Why Anesthesiologists Matter

A middle aged man is brought to the emergency department for a fall and loss of consciousness. A stat CT scan of the brain shows a severe brain bleed, probably from uncontrolled high blood pressure. His neurologic exam is deteriorating; he doesn't wake up to voice or touch, and he cannot protect his windpipe, so the emergency physician determines that a breathing tube is necessary. As they make this determination, they call me as the ICU fellow and say they are going to admit the patient to my service.

Even though the emergency physicians have formulated an appropriate plan, I rush down because this will be my patient. When I arrive, the medications to ensure the patient is asleep for intubation have already been given. The ED physicians have used their standard agents for intubation, but they are absolutely not the ones I would choose. The medications they use are ideal for overwhelming infection, trauma, and massive bleeding because they maintain the blood pressure. But this person was bleeding into his head; as an anesthesiologist, I would have chosen medications that prevented a hypertensive crisis. Unfortunately, I arrived moments before I could give them feedback.

In this situation, everyone in the room was tense and stressed about getting the breathing tube in. But as an anesthesiologist, when I glanced at the patient, I was fairly confident I could do it without trouble. I kept my focus on the main thing that would kill this patient: his blood pressure, especially with the forceful ED laryngoscopy, would go through the roof, and this would dramatically worsen the bleeding. I grabbed propofol and labetalol, two agents to lower the blood pressure, but it took me several minutes to get the blood pressure into an acceptable range. I was the only one focused on those vital signs, and if I had not been there, critical time would have been lost. Here is a situation where an anesthesiologist matters.

Many people can put in breathing tubes. Emergency doctors, intensive care physicians, neonatologists, even emergency medical technicians can do the physical action. But I spent three years learning the nuances: how to minimize trauma, what medications to choose, what complications to expect, how to manage the whole patient while focused on one small task. No matter how good a non-anesthesiologist is, his training is simply not as focused on these critical few minutes, sending a patient to sleep and securing the windpipe. In this case, I think it mattered. I have a lot of respect for other specialties because they do things I know little about. I write this blog not to criticize them, but to say that as an anesthesia-trained ICU fellow, there are situations, procedures, and medical decisions I feel very confident about, and I hope we are recognized for those instances of expertise.