Re: "If You're Thinking of Buying...Anesthesia Services" (March, page 66). I want to comment on Dr. Adam Dorin's statement regarding anesthesia care by physicians alone or in a team approach with certified registered nurse anesthetists. Dr. Dorin implies CRNAs working as sole providers are a rarity. But according to the American Association of Nurse Anesthetists, CRNAs are the sole anesthesia providers in about two-thirds of all rural hospitals in the United States, enabling these healthcare facilities to offer obstetrical, surgical and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100 percent of the rural hospitals. CRNAs administer 65 percent of anesthetics in the United States, according to the AANA (writeOutLink("www.aana.com",1)).

My other concern is Dr. Dorin's caution to the administrators of smaller facilities using a CRNA as the lone anesthesia provider. He intimates this might be a problem if there is a rare but potential emergency situation in which an additional pair of qualified, anesthesia-trained hands is absent. But the same situation is possible with the lone anesthesiologist. If Dr. Dorin were insinuating worse outcomes for the patient based on anesthesia provider, I would like to cite a study done by Michael Pine et al., "Surgical Mortality and Type of Anesthesia Provider" (AANA Journal, 2003; 71:109-116), which found that mortality rates were similar for CRNAs and anesthesiologists working individually. Also, there was no difference between anesthesiologists working alone versus anesthesiologists and CRNAs working as a team. Further, hospitals using CRNAs as sole anesthesia providers had results similar to hospitals where anesthesiologists were involved in the care.

Timothy P. Kostura, CRNA, MSNA
Carilion Health System
Roanoke, Va.
writeMail("[email protected]")

Dr. Dorin replies: I have no problem defending the position that a medical license should not be obtained by legislative fiat. The American Society of Anesthesiologists has equally compelling data to support the notion that MDs are superior and safer than CRNAs. Frankly, I don't care either way. I'm an MD. Despite having worked with some good and bad MDs and CRNAs alike, I will always come down on the side of the MDs.

Save Our Specialty Hospitals
Re: "Bracing for Medicare's Upcoming Changes" (March, page 10). You refer to the Medicare Modernization Act's imposing an 18-month moratorium on physician referrals to specialty hospitals in which physicians have financial interests. To be accurate, the MMA imposed the 18-month moratorium on any new specialty hospitals in which physicians have financial interests. The American Surgical Hospital Association has embarked on a campaign to reveal the truth about the specialty hospital industry. ASHA's No. 1 priority is seeing the moratorium sunset. The American Hospital Association and other large, well-funded hospital lobbies are attacking the specialty hospital industry and would like to see the moratorium extended or expanded to an outright ban of specialty hospitals and physician referral to facilities in which they have a financial interest. The hospital lobbies are jeopardizing all physician-owned specialty hospitals. ASHA urges all who are at risk to reach out to the elected officials on Capitol Hill to inform them about the many benefits associated with specialty hospitals.

Jim Grant
President
American Surgical Hospital Association
writeMail("[email protected]")

Measuring Sedation
Re: "5 Strategies for Better Airway Management" (April, page 49). Dr. Marco's admirable article would have been more complete had he included the concept of measuring as a way to avoid over-sedation. While we have no hard data on what percentage of anesthesia providers employ benzodiazepines (diazepam or midazolam) versus propofol for sedation, we know the bispectral index and other level of consciousness monitors measure propofol. BIS-monitored titration of propofol lets the anesthesia provider dial up whatever level of sedation is desired for a particular procedure. At BIS 78-85, you can produce minimal sedation for dental work that requires the patient to open and close his mouth on command. At BIS 70-78, you can produce moderate or so-called conscious sedation. At BIS 60-70, you can produce deep sedation. A differentiating point between moderate and deep sedation hinges on whether passive or active airway intervention is required to maintain the airway. Passive maneuvers include extending and laterally rotating the patient's head as well as placing a liter IV bag under the patient's shoulders to increase the degree of jaw extension. Active airway maneuvers include the LMAs described by Dr. Marco as well as nasal airways. Patient movement at BIS 60-75 (with a zero EMG) means the patient is receiving adequate propofol and is an indication for more local. The ability to provide adequate local analgesia is critical to opioid avoidance.

Barry L. Friedberg, MD
Corona del Mar, Calif.
writeMail("[email protected]")