So, Who's Responsible for Clearing Patients for Anesthesia?
Re: "A Case of Inadequate Informed Consent" (April, page 25). It should have been clear to the anesthesiologist that this patient with significant cardiac and pulmonary morbidity and an undefined degree of obesity wasn't a candidate for interscalene block. Not only did the block have to be converted to general anesthesia, but it also complicated the course of general anesthesia, as this patient would certainly need post-operative ventilator support because of the successful interscalene block. The shortness of breath and restlessness is a symptom of phrenic nerve paralysis, which is typical in a successful interscalene block. Of course, this patient needed rescue as he had longstanding COPD, coronary artery disease and heart failure with cardiomyopathy. The anesthesiologist should not have been left off the hook on this one. Poor choice!

Michael Wolf, CRNA
Renaissance Surgery Center
Oshkosh, Wis.
[email protected]

The medical clearance, anesthetic technique and informed consent all raise important issues. The surgeon should have requested medical clearance for the surgical procedure itself, not for a "procedure with local anesthesia." Local anesthesia is a service provided by the surgeon without an anesthesia provider. At our surgery center, it's the surgeon's responsibility to clear the patient for surgery. The anesthesiologist is the expert in perioperative medicine and anesthesia and as such is the physician responsible for ensuring patients are fit for anesthesia using information provided by the primary physician or other consultants. The anesthesiologist is also responsible for identifying the appropriate type of anesthesia for a given patient considering the patient's health and the needs of the surgeon. In this case, the surgeon probably intended for the procedure to be performed with an interscalene block, for which this patient is unfortunately not a candidate because of his underlying pulmonary compromise. The patient must be cleared for general anesthesia as regional techniques can fail and general anesthesia may be required to complete the procedure. The anesthesiologist should obtain informed consent for his procedures. Our anesthesia consent form encompasses all types of anesthesia, and we note in the anesthesia record which plans were discussed with the patient. Whenever a patient doesn't consent to the plan and possible complications, investigate alternatives and discuss the case further with the patient, surgeon and cardiologist before proceeding. Ultimately, it is the anesthesiologist's duty to clear the patient for anesthesia and not the task of the surgeon or cardiologist.

Hugh L. Preas II, MD
Medical Director and Chief of Anesthesia
The Surgery Center of Chevy Chase
Chevy Chase, Md.
[email protected]

Do CRNAs Really Cost Less?
Re: "CRNAs Represent a Cost-effective Alternative" (May, page 11). As much as CRNAs have helped to fill a void in providing anesthesia services, make no mistake that this role should be done only under the supervision of an anesthesiologist. The CRNA is certainly a safer alternative to the gastroenterologist supervising a nurse giving drugs while also monitoring the patient, but I must disagree with Mr. Green's statement that CRNAs are a less expensive alternative. Many anesthesiologists who provide their expertise in GI centers don't bill the centers or the patients, but do their own billing. This costs the GI center practically nothing and gives the center the ability to market the presence of another physician trained in the specialty of anesthesiology.

Let us not be misled by a perception that CRNAs cost half as much as anesthesiologists. As far as I know, CRNAs will cost the center in salary and won't work over 40 hours without overtime, not to mention the cost of malpractice and retirement.

Michael Peck, MD
First Colonies Anesthesia Associates
Rockville, Md.
[email protected]

The Right Furniture Shows You're Considerate of Overweight Patients
Re: "The Not-so-little Touches" (March, Manager's Guide to Overweight Patients, page 37). Thank you for putting into print what so many people in health care rarely consider: the inadequacies of facility readiness with regard to bariatric patients.

You mention that it is prudent to include furniture with a weight capacity of at least 750 pounds. I believe that this amount is insufficient for many practices. My reasoning is simple. When a person sits down, he exerts 1.5 times his own body weight in force. This means that a person weighing 500 pounds is exerting 750 pounds of force, the limit of the recommended furniture. What happens when a person exceeding this weight limit arrives in your facility? Suddenly, there is a legitimate chance of product failure.

Your article states that, "Placing oversized chairs alongside standard furniture is key to tastefully accommodating overweight patients." I could not agree more. There is another thought to consider here. Several companies are now manufacturing furnishings that are the size of standard furniture, but have much higher weight capacities. We've found these chairs to be quite useful in that they allow greater confidence, regardless of which chair the larger patients choose. Let's face it, some folks suffering from morbid obesity simply do not want to be herded into the large chairs. These smaller models allow peace of mind for facility managers without making patients who don't want to sit in the larger chairs feel uncomfortable.

Ben Hubbard
Carstone Seating
Somerset, Ky.
[email protected]