Reader response

Myron Yaster MD

From Jacob Karlsson, Consultant Pediatric Anesthetist, Associate Professor, Karolinska University Hospital, Stockholm Sweden on CO₂ and bronchoscopy. My research group has been working with CO₂ in various settings in pediatric anesthesia for more than 10 years. If I had to choose between low and moderately high CO₂, I’d go for high CO₂ any day!

Have a look at these additional publications as well:

Karlsson J, Wallin M, Hallbäck M, Lönnqvist PA. Carbon dioxide: A stronger driver of cardiac output than oxygen? Acta Anaesthesiol Scand. 2023 Nov;67(10):1439-1440. doi: 10.1111/aas.14310. Epub 2023 Jul 18. PMID: 37463848.

Kaiser, H.A., Bauer, T., Riva, T. et al. Carbon dioxide and cardiac output as major contributors to cerebral oxygenation during apnoeic oxygenation. Sci Rep 14, 3617 (2024). https://doi.org/10.1038/s41598-023-49238-3

From Myron: I just did a quick read of these articles and will post a PAAD reviewing them in the near future. And to our readers: If you find an article you think we should review in the PAAD please send me the pdf or citation and I’ll do my best to review.

From Sparticus on toxic leadership

Thanks to PAAD and the PAAD authors for attacking a critical issue in all of medicine and of particular concern in pediatric anesthesia…leadership. While the article is insightful, I fear 2 major contributing factors in toxic leadership are not given enough attention: 1) the rise of operational leadership and 2) apathy among us, the pediatric anesthesiologists who work under leadership.

The PAAD refers to clinical and academic merits in the path to leadership, with an implication that these strengths do not translate to success as a leader. However, these criteria have existed over many decades, and I worry that alternative criteria such as operational merit may contribute to the culture deficits we observe. Clinical and academic leaders may lack competence in operational demands, but should operational optimization be our primary goal? The financial pressures of meeting OR and out-of-OR staffing strains, improving time in the OR, minimizing workforce expenditures, and staffing with trainees/CRNAs/AAs have slowly taken the mantle of primary concerns rather than traditional academic missions. The “operational” leader has emerged in some traditional academic centers. Having worked under such leadership, I’ve come to think of the operational leader as being hyper-focused on putting warm bodies in rooms on time, improving billing practices, passing JCAHO requirements, minimizing legal or public relations issues, managing all clinical issues top-down, and generally pleasing the c-suite…perhaps with the intention to join them. These deviations from the traditional primary missions of clinical excellence, research, education, and quality have been harmful to the culture of my group. When our leaders care primarily about efficient staffing and meeting hospital billing expectations, why should we sacrifice for the academic missions? You know, those things we all wrote about once upon a time in medical school applications. Show me the incentive and I’ll show you the outcome. I fear we have incentivized money, out times, and performing well on checkbox metrics rather than clinical exceptionalism, innovation, and pushing boundaries to improve patient care.

This leads to another possible contributor to toxic leadership…the rest of us. I’m frequently dismayed at the state of ongoing education and dedication to the profession. Since COVID, my division has had nearly exclusively virtual divisional meetings. I, along with most colleagues, scan email, get breakfast ready, get the kids dressed, and finish a workout while the phone or computer drones on. This is how our new staff and fellows were trained. We enjoy the extra time and sacrifice the tradition of debating ideas, sharing knowledge. Surveying friends elsewhere, I know we aren’t the only place who have accepted this new normal. We clamor for work-life balance, and what this means in most instances is we want the least work possible with the most recognition. We seek to be valued rather than to be valuable.

In short, I agree that toxic leadership is terribly harmful to the culture of an anesthesia group. However, assuming the cause of toxic leadership to be clinical or academic merits without “operational” leadership traits may be a faulty assumption. When leaders fail, we should carefully assess our own motivations, behaviors, and value creation in our group and the profession.

From Anders Svedmyr, MD, Consultant pediatric anesthetist, Department of pediatric anesthesia and intensive care, Stockholm, Sweden.

I follow the PAAD with great interest but haven't so far contributed any reader response. However, when I read the recent comment regarding the editorial by von Ungern et al (PAAD 14th April), I felt deeply concerned. Not because of the editorial itself - which I don't find the least provocative and completely agree with - but because you articulate a need to be anonymous when discussing it. If debating, or agreeing with a completely sensible text like von Ungern's could be seen as problematic for pediatric anesthetists in the US, I find this quite disheartening. I do hope this small sign of a potentially stifled debate does not signal a broader trend.

From Judit Szolnoki MD

Thank you for highlighting the importance and issues with M&Ms. I strongly believe in the power of sharing events within a group (and even wider: APSF, WUS) and learning together for a better outcome. I agree with you though, that involving patients or families in the M&M process might not be the best idea. After all, we do not have them watch surgery either: in an M&M we are dissecting the events and trying to diagnose problems. Concurrently, it is also a place where we “treat” our second victim (for the better or worse, depending on the culture). However, there is a way to involve the patients/families. That is through the disclosure process. I am calling it a process as it is not a one-and-done event. It involves several discussions and allows the opportunity for the patient/family to add their perspective and ask questions. Communication and Optimal Resolution (CANDOR) is a process that provides tools for such discussions. The CANDOR is patient-centered and emphasizes early disclosure of adverse events and proactive methods to achieving an amicable and fair resolution for the patient/family and involved health care providers. Here is a link for more information: https://www.ahrq.gov/patient-safety/settings/hospital/candor/index.html.

From Dr Nick Marsden, Anaesthesia Fellow, The Royal Children's Hospital Melbourne

I'd disagree that the M&M is only a century old, I think they have probably existed for as long as doctors have been causing harm I.e. as long as medicine has existed. An M&M is merely a form of reflective practice, which we're all familiar with I'm sure. The difference now of course is that your reflection may well be done for you, by people in authority or gradients of power, in unforgiving departments that imply this is the first time something like this has ever happened. Spoiler alert! ITS NOT! All our leaders and seniors have made the same mistakes as us, and probably worse. If someone says 'I wouldn't have done it like that' they're most likely being untruthful, and equally, unkind. These events can humiliate and embarrass those brave enough to stand up and present their errors, but they don't have to, they can be tools for collective learning if done well, but to be done well we need a clear goal for what we want the meeting to achieve. Before we invite patients in, perhaps we need to know why we are attending ourselves?