General vs. regional anesthesia not an arbitrary decision

Scenario: How should health workers handle fear of HIV transmission?

An anesthesia resident decides to administer regional anesthesia by way of epidural catheter to a patient about to undergo exploratory laparotomy. Although he has used this approach for the same surgery in the past, the attending tells the resident that they will be using only general anesthesia this time. When the resident asks why, the attending says, "The patient is HIV positive. Why expose yourself?" The resident wonders whether avoidance of regional anesthesia in HIV-positive patients is appropriate.

Reply:

The obvious question this consult raises is, what has happened to medical professionalism? Physicians are supposed to put the welfare of patients above their own.

Physicians have exposed themselves since ancient times to a variety of hazards to care for the sick, injured and dying. In return for working long hours, possibly contracting diseases and knowingly exposing themselves to other hazards, physicians theoretically and practically enjoy spiritual satisfaction, the privilege of self-regulation and high social regard. The scenario also raises the importance of role modeling and the "informal curriculum" that shapes the beliefs and attitudes of residents.

Clinical issues also come to mind when reflecting on this case. Is there valid evidence that central neuraxial or regional anesthetic techniques offer any benefit over general anesthesia? What do patients typically know about these matters, and what decision-making skills and attitudes do they bring to the discussion? What are the real exposure risks to physicians? What underlying forces might shape difficult decisions? Given what we are learning in health care about highly reliable industries, should we be giving worker safety a closer look in the drive to improve patient safety? While in-depth analysis of these issues is beyond the limits of this forum, further discussion of several points follows.

Serious complications of general and regional anesthesia are so uncommon in completely healthy patients and in patients with well-controlled health problems that do not interfere with their activities of daily living, that the choice of anesthetic technique is typically influenced by factors other than statistically known serious risks. Clinician and patient preference and experience, for example, may support one approach versus the other. That said, physicians have a moral obligation not to alter their practice pattern based on patients' ability to pay, social status, religion, or race or other arbitrary reasons. In addition, evidence does exist indicating that regional anesthesia results in lower rates of nausea, vomiting and oral/parenteral pain medication use and in earlier return of bowel function after abdominal surgery. One would expect that any patient, AIDS patients included, who would clearly benefit from having a regional anesthetic should be offered that option with an adequate explanation of the risks and benefits.

Typically, patients are unaware of the scientific rationale for choosing general or regional anesthesia. If the physician does not advocate regional anesthesia, and the patient has not had an experience that leads him or her to choose regional or a firm recommendation from a trusted personal source, general anesthesia is often the default mode. Even with the recent trend of increased patient decision-making and improved health literacy due to the Internet, it is still unlikely that a patient who is not offered regional anesthesia would know enough to pursue that option for its possible benefit. Much, therefore, still rests on the physician 's shoulders.

One has to question the rationality of a physician's decision to avoid regional anesthesia in an HIV-infected patient. The action speaks more of a fear-based dread than a logically reasoned conclusion. The prevalence of hepatitis B and C is greater than HIV, and more easily transmissible to clinicians. Why not treat these patients differently as well? The administration of general anesthesia, with its associated need for multiple intravenous medications and airway manipulations, is not completely without risk to clinicians when treating patients with transmissible diseases.

Finally, one should consider the nature of safety in complex systems. Patients will achieve the highest levels of safe care when caregivers' well-being is included in the task and goal calculus as well. This last point may seem to run counter to traditional notions of professionalism, but is aligned with increasingly accepted theories of ecological systems design.

Alcoa's focus on worker safety as a code word for respect and an invitation to intense process analysis to achieve the goal of zero worker injuries in a huge risky multinational industry has become a well-known corporate success story. Based on the Toyota Production System, Alcoa's method is now the basis for an ongoing study with the goal of reducing nosocomial infections and adverse drug events to zero. Providing the safest care to patients is inextricably linked in systems analysis terms to understanding and managing interrelationships between people (physicians and other professionals), tasks (patients, goals) and the environment (tools, approaches, facilities).

One could make a strong case for systematically notifying all caregivers at risk that a patient has "x" problem, and that he or she should be treated with extra caution to reduce the risk of transmission. Although universal precautions are espoused, busy clinicians balance competing elements and prioritize boundary protections in cases that get their attention. Physicians and other caregivers experience needless personal risks when engaging poorly designed systems for lifting heavy patients, handling sharps, managing paranoid psychotics or even reporting safety hazards.

Although reporting near misses and preventable adverse events is the critical first step in recognizing where problems lie in processes of care, good intentions and theory are blocked by a culture of secrecy and resistance in which front-line caregivers do not receive feedback from reports and do not trust how the information will be used.

The message here is that patients cannot receive the safest care unless clinicians are safe to the extent that systems design, including technical, social, organizational, political and legal factors, allow and are aligned with safety goals.

In speculating a bit further on the erosion of professionalism in the context of this case, it might be worth considering what the effects of market forces and attendant conflicts of interest, shorter "touch time," the third liability crisis in as many decades and fragmentation of care have had on the physician-patient relationship. These issues cut both ways.

To rebuild trust on each side of the equation, a true systems perspective is needed that takes into account the concerns of each party, whether those concerns are rational or fear-based. The solutions lie in technical and work design that lead to adoption of best practices, transparency among all parties and a climate that fosters honest dialogue.

--Stephen D. Small, MD, and Bobbie Jean Sweitzer, MD University of Chicago Dept. of Anesthesiology and Critical Care and University of Chicago Developing Center for Patient Safety. The center is supported by grant P20 HS11553 from the Agency for Healthcare Research and Quality.