Last year Dr. Ron Miller was in a hospital pre-op unit doing what he has done every week for more than three decades: administering an anesthetic to a patient headed for surgery. Miller served as an anesthesiologist in the Vietnam War and now chairs the department of anesthesia at the University of California, San Francisco, School of Medicine; it's hard to imagine someone with more experience or better credentials. Even so, he was taken by surprise when he gave a low dose of a moderate sedative called midazolam, designed to put the patient into a semiconscious state, somewhere between sleep and wakefulness--and the man stopped breathing. "There is no way of predicting that a patient would have responded that way," he says. "I've been doing this for years, so I was prepared." He managed to revive the man.
But just imagine, says Miller, what might have happened if that had taken place outside a hospital, without a trained anesthesiologist present. A decade or two ago, such a scenario would have been farfetched because most surgery was done in hospital O.R.s.
Not anymore. "What we call outside-the-operating-room anesthesia is exploding," says Dr. Orin Guidry, president of the American Society of Anesthesiologists. It's not that doctors are doing heart bypasses or hip replacements or radical mastectomies on an outpatient basis. "If you're going to take a person apart," says Dr. Warren Zapol, anesthetist in chief at Boston's Massachusetts General Hospital, "you need to control the airways, paralyze the muscles and do things that amateurs don't want to do."
But there has been an enormous increase in less drastic procedures. Cardiologists are performing many more angiograms and other invasive tests than they did a couple of decades ago. Plastic surgeons are doing more liposuction procedures and partial face-lifts. Gastroenterologists are doing more colonoscopies and endoscopies--snaking a tube in from one end or the other of the digestive tract to take pictures. "Where 15 years ago endoscopy was a rare procedure," says Guidry, "now everybody's expected to have one periodically. There's tons of stuff that just wasn't done before."
There is simply no way trained anesthesiologists can meet the demand--especially since the increase in surgeries has been accompanied by a simultaneous increase in what anesthesiologists are asked to do. "At UCSF," says Miller, "we manage all of the post-op pain, we run all of the recovery rooms, and we man all of the preoperative evaluative clinics."
That helps explain why, at a rough guess, some doctors estimate that 45% of all sedation today is handled by people other than anesthesiologists. "There are tens of thousands, maybe millions, of sedation procedures done satisfactorily by other physicians," Guidry says. Still, a 2003 study published by Dr. Hector Vila, chief of anesthesiology at the University of South Florida's College of Medicine, showed 10 times the risk of death or permanent injury for surgery performed in doctors' offices rather than in ambulatory surgery centers. The difference, Vila concluded, was largely due to lax anesthesia procedures. In an extreme example, he says, "one plastic surgeon had his girlfriend giving the anesthesia. It didn't take long for something to go bad."