Guess Who's Putting You Under

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In the wake of that study, Florida has stricter training and certification rules for people administering office-based anesthesia; 21 other states have some sort of guidelines. Some individual health-care systems have created their own tighter rules. And the anesthesiologists' society released new guidelines last fall to help hospitals and clinics establish credentialing processes for nonanesthesiologists who provide sedation.

Since each patient's response to anesthesia can be different, as San Francisco's Miller was reminded last summer, the guidelines are intended to ensure that whoever administers the drugs should be able to rescue a patient from one level of sedation deeper than the level intended (see chart). "Our job is flying in bad weather," says Zapol. "A fair number of hearts stop in operating rooms, or people stop breathing. The key thing in training is to make people confident at resuscitation."

As for the type of sedation a doctor will aim for in a given operation, there are no hard-and-fast rules. In general, operating on the extremities offers more options than operating on the body's core, but the dividing lines between levels of anesthesia can be blurry. Once you get away from major surgery, pain control and sedation are often mixed and matched according to patient preference. Says Dr. Ronald Pearl, chairman of the department of anesthesia at Stanford: "It's not uncommon when we do a spinal anesthetic, say for knee surgery, to ask the patients whether they want to be awake or asleep for it." Those who choose sleep do so not because they want to avoid the pain--they won't be feeling it in either case--but because they just don't want to know they're under the knife.

But choosing to stay awake doesn't mean a patient is free of the risks of anesthesia. "We can get in trouble with a local anesthetic," says Zapol. "We can get in trouble with a spinal anesthetic," which keeps pain signals from getting to the brain but doesn't make the patient sleepy. "We can overdose you in all of those places." Someone, whether it's an anesthesiologist, another physician or a fully trained nurse, has to be ready to deal with that possibility. "Surgeons are experts at kidneys and ureters and coronary arteries and lungs. They're skillful people," Zapol says. But someone has to keep the rest of the body going while they operate.