Reader response

Myron Yaster MD

From Dudley E. Hammon MD, Wake Forest University School of Medicine on error traps in scoliosis surgery

Thank you for your positive words regarding our article on error traps for anesthesia in adolescent scoliosis correction. I particularly enjoyed your comment on utilizing the EEG to guide the depth of anesthesia.  I find myself talking to the neuromonitoring specialist more and more about the EEG and how our anesthetic is affecting it. One area that has been of great use was helping to guide me while performing a wake-up test.  Instead of talking blindly to the patient wondering when(or if) they might respond, the IOM tech let us know when they were close to emerging, and it worked like a charm.  I am kicking myself for not mentioning that in our article.

From Branden M. Engorn, MD, Pediatric Critical Care Medicine, Pediatric Anesthesiology, Pediatric Cardiac Anesthesiology, Director of Quality and Safety, Anesthesiology, Rady Children's Hospital San Diego

I was hoping to share our experience at Rady Children's Hospital San Diego and our history of extubating patients in the PACU by PACU nurses. This was our culture for many years. In some clinical scenarios the anesthesiologist would choose to extubate the patient in the operating room. 

We published data showing the practice was safe and improved operating room efficiency for a cohort of patients including children who underwent inguinal hernia repair, laparoscopic appendectomy, and pyloromyotomy.

Oviedo P, Engorn B, Carvalho D, Hamrick J, Fisher B, Gollin G. The impact of routine post-anesthesia care unit extubation for pediatric surgical patients on safety and operating room efficiency. J Pediatr Surg. 2022 Jan;57(1):100-103. doi: 10.1016/j.jpedsurg.2021.09.019. Epub 2021 Sep 20. PMID: 34688493. 

Our practice of extubating in the PACU stopped during COVID. In the post COVID environment our nurse staffing in the PACU has had significant turnover. We are currently undergoing a QI project to assess safety and if we should re-implement this practice. Furthermore, we are undergoing a communication project focused on surgical services team member communication. In particular, we are looking at critical time points during the anesthetic and surgery and opportunities for improved communication.

From Lynnie R. Correll MD PhD, FASA, FAAP, ABOIM, Pediatric Anesthesiologist, British Columbia Children’s Hospital

I really enjoyed the PAAD about extubation and “landing the plane.” I am in total agreement that the end of the case is just as important as the beginning (or even more so as the patient may remember more of it!) and love the suggestions about possible options. 

The part about “extubation checklists” really piqued my interest as I was recently lucky enough to be involved in a multidisciplinary project regarding unplanned intubations - when it became clear that many of these intubations were “RE”-intubations after an extubation that occurred without any real structured plan. Among other things, our group developed a formal checklist for extubations (in this case in the NICU) which we designed to be very similar to the one we use in the OR.

Juviler P, Meyers JM, Levatino E, Axford J, Barker E, Correll L, Decker AS, Faria J, Gloff M, Loria A, McKenna M, Schriefer J, Stevens TP, Verna S, Wegman S, Wolcott K, Wakeman D. Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project. J Pediatr Surg. 2023 Sep 22:S0022-3468(23)00566-3. doi: 10.1016/j.jpedsurg.2023.09.029. PMID: 37845122. 

From Anonymous on CF: cure found

Thank you so much for shedding the spotlight on cystic fibrosis. I was positively delighted and relieved to see that you also marveled at this miracle. I have followed this disease closely, even before I entered medical school. CF hits a little closer to home for me as my best friend from high school died of this disease at age 19. Throughout my 18 years of practicing anesthesia, I’ve seen fewer and fewer of these patients in the OR. None of them looked nearly as sick as my friend, Pat. No wasting, no repeated hospitalizations for pneumonia, and less and less of that unique sputum that had been so characteristic of patients with this disease.

A few years ago, I got a front row seat into why cystic fibrosis looks so vastly improved. I began serving on the board of a charitable organization (ALK Positive, Inc) that helps patients with a type of cancer driven by the Anaplastic Lymphoma Kinase (ALK) oncogene. In adults, ALK-rearrangements lead to NSCLC. Since I had a connection to leadership in the cystic fibrosis foundation (CFF), I was tasked with reaching out to the CFF for mentorship. ALK Positive wanted to learn from the CFF about venture philanthropy. Around 1998, the CEO of the CFF, Robert J. Beall, developed the idea of venture philanthropy to break through the pharmaceutical industry’s reluctance to get involved in cystic fibrosis research.

The CFF was the first nonprofit organization to provide funding to a for-profit company to de-risk the investment. This was an entirely new approach that became wildly successful.  Fortunately, the CFF now mentors other similar organizations to help them on their paths to success.

The reason I bring this to your attention is because I do think that C.F. meaning “cure found,” might be troublesome to some readers, especially those personally impacted by cystic fibrosis. While we as clinicians are justified in celebrating how well this disease has been tamed, patients still struggle with this disease in ways we might not be aware.  Especially later in life, CF patients struggle with fatigue and other symptoms while no longer bearing the physical stigmata of disease. They don’t look ill. The CFF was started by parents who wanted to stop their children from dying. Parents are still fundraising to help improved care for people with CF. To imply “cure” almost suggests that all that advocacy work is no longer necessary. The CFF is still working toward a cure.

The only way I am able to write this at all is because I am now an oncology patient. I’ve spent 18 years thinking like a physician, but only 5 thinking like a patient. As a patient, I can tell you advocacy work is very hard work.  For example, many oncologists consider ALK-driven NSCLC no longer worthy of research funding since “those patients are doing ok.” They refer to the miracle of tyrosine kinase inhibitors (TKIs), that allow some of us to live up to 7 years, even longer in some cases. While we are grateful for those 7 years,  we strive for much more by fundraising, creating documentaries, sharing deeply personal stories of survival.

This is the part of patient lives that clinicians don’t always see. Often, our young patient’s parents are tirelessly doing advocacy work around their children’s care.  I think it is important to recognize the tremendous efforts of the families with CFF that lead to venture philanthropy. They are by far the most successful of all the patient advocacy groups and inspiration to so many others.  As clinicians, I do hope that w