A continuum for using placebo interventions in regional anesthesia and analgesia studies.

The anesthesiologist Henry K. Beecher is commonly associated with his crusade for informed consent for research. Less recognized is his contribution to the development of principles of randomized controlled trials through his emphasis on surgery as placebo to minimize bias. This article reviews Beecher's contribution and how it should be applied to modern studies of perioperative analgesia.

The role of World War II and the European theater of operations in the development of anesthesiology as a physician specialty in the USA.

World War II was a time of growth and development of anesthesia as a physician specialty. Wartime training exposed neophyte physician-anesthetists to role models who showed the potential of anesthesiology and to the richness of practicing anesthesia. Wartime anesthesia required dexterity, imagination, and pluck, and surgeons and other physicians were suitably impressed. Drawing historical conclusions about cause and effect is hazardous. Recognized and unrecognized biases, preconceived notions, and the quality and type of resources available affect writers. With this in mind, consider how the effects of World War II on the growth of physician anesthesia loosely parallel the growth of anesthesia in Great Britain during the 19th century. Anesthesia became a medical profession in Great Britain because of the interest and support of physicians and the complexity of administering chloroform anesthesia. Similarly, World War II physician-anesthetists showed they could provide complex anesthesia care, such as pentothal administration, regional anesthesia, and tracheal intubation, with aplomb and gained the support of surgical colleagues who facilitated their growth within a medical profession. They returned to a medium ready to support their growth and helped to establish the medical profession of anesthesiology in the United States.

Activities of an ethics consultation service in a Tertiary Military Medical Center.

The Joint Commission on Accreditation of Healthcare Organizations requires hospitals to have a mechanism to address issues of medical ethics. Most hospitals, especially those in the military, have an ethics committee composed solely of members who serve as an additional duty. To enhance the ethics consultation service, the 59th Medical Wing created a position under the chief of the medical staff for a full-time, fellowship-trained, medical ethicist. After establishment of this position, the number of consultations increased, a systematic program for caregiver education was developed and delivered, and an organizational presence was achieved by instituting positions on the institutional review board, the executive committee of the medical staff, and the credentials committee. Issues in medical care are becoming increasingly complicated, due in large part to financial stresses and technological advancements. Ethics consultation can help prevent and resolve many of these problems. This report discusses the activities of the first year of a full-time ethicist in a tertiary military medical center.

Perioperative do-not-resuscitate orders.

Recent advances in perioperative refusal of resuscitation center on goal-directed orders. Goal-directed orders permit patients to define perioperative resuscitation in terms of outcomes rather than procedures. A typical goal-directed order may state 'The patient desires resuscitative efforts during surgery and in the postoperative care unit only if the adverse events are believed to be both temporary and reversible, in the clinical judgment of the attending anesthesiologists and surgeons.' This review also discusses ways to use the ability to withdraw care as a way of honoring patients' wishes.

Regional anesthesia equipment checkout recommendations: a case report and discussion.

The use of an apparatus checkout list is common in medicine and anesthesia. After being involved in a case in which the separation of a spinal introducer hub from its shaft during subarachnoid block required surgical removal of the retained shaft, a search for related cases was undertaken. The Medline database from 1966 to 1997 was used to identify defects and problems related to centroneuraxis equipment. Using these data, a regional anesthesia equipment checkout list of six recommendations was created in the spirit of other anesthesia checkout lists. The recommendations are to (1) ensure the proper fit and length between the needle and its stylet (particularly if using resterilized needles), (2) check for defects in the needle hub and shaft union by applying axial traction to the hub, (3) flush the needle with the distal end occluded, checking for defects in the hub-shaft junction or in the shaft itself, (4) check for malalignment between the needle hub and shaft, (5) examine the catheter for consistency in diameter and ensure the catheter can be introduced into the needle, and (6) flush the catheter, checking for the presence, patency, and location of distal holes. These recommendations must undergo further review before they are accepted as a practice standard.

Recall of risks following labor epidural analgesia.

STUDY OBJECTIVE: To ascertain patients' recall of the risks of labor epidural analgesia from a discussion of informed consent during active labor. DESIGN: Survey analysis following an intervention. SETTING: Labor and delivery unit of a tertiary-care teaching hospital. PATIENTS: 101 ASA physical status I and II parturients in active labor. INTERVENTIONS: Patients were given a standardized discussion of the risks of labor epidural analgesia. MEASUREMENTS AND MAIN RESULTS: Within 24 hours of the informed consent discussion, patients were first asked to recall risks, and then asked to identify risks from a true and false list. Patients recalled 2.0 +/- 1.3 risks (mean +/- SD), with 12% recalling at least four risks, 37% recalling at least three risks, 66% recalling at least two risks, and 87% recalling at least one risk. There was no difference in level of recall between primiparas and multiparas, or in patients with mild and moderate pain scores versus those patients with severe pain scores. CONCLUSIONS: Recall of risks by parturients is similar to the recall of risks by other patients, and it does not appear to be affected by parity or the reported level of pain.

Field block for cranial surgery in World War II.

During World War II, physicians with minimal training were often thrust into the role of anesthetist. To educate these men, experts in anesthesia taught simple, conservative, and effective anesthetic techniques, such as the field block. Field blocks are the ideal "no frills" anesthetic because they are low-risk procedures that require minimal equipment. Unfortunately, many of the field blocks used during World War II are no longer taught. We present one technique that has fallen from favor, the field block for cranial surgery, both to educate about anesthesiology during World War II and to provide knowledge for the practicing military physician. The modern military anesthesiologist must be capable of anesthetizing patients under any conditions. First response care teams may find the technique of field block for cranial surgery useful in providing emergency anesthesia care.

The benefits of the explanation of the risks of anesthesia in the day surgery patient.

STUDY OBJECTIVE: To ascertain the benefits of the preoperative discussion of the risks of anesthesia with parents of ASA status I or II pediatric day surgery patients. DESIGN: Survey analysis. SETTING: Pediatric day surgery unit. PATIENTS: 54 parents of ASA status I or II pediatric day surgery patients between the ages of 7 months and 16 years. INTERVENTIONS: After informed consent for the anesthetic was obtained by a member of the anesthesiology team, the parent(s) were given a questionnaire on their feelings about the explanation of the risks of anesthesia. MEASUREMENTS AND MAIN RESULTS: The questionnaire evaluated how parents felt about their understanding of the risks of anesthesia, the effect of hearing the risks of anesthesia on their anxiety levels, and the benefits of hearing the risks of anesthesia. Over 90% of the parents felt that they understood the risks of anesthesia, that the discussion of the risks would have no effect on their decision to proceed with surgery, and that the explanation of the risks is desirable; 92% considered the explanation desirable either out of a sense of responsibility or because they welcomed better understanding. CONCLUSIONS: Our study suggests the benefits of the explanation of the risks of anesthesia appear to be rooted in satisfying parental responsibility and understanding, and not in providing information for decision making or anxiety relief. Anesthesiologists should not feed compelled to always detail all the risks, but should seek to satisfy individual parental needs.

The cardiopulmonary resuscitation-not-indicated order: futility revisited.

This paper reviews the advent of unilateral do-not-resuscitate orders. Unilateral do-not-resuscitate policies presume that cardiopulmonary resuscitation is a medical therapy and that physicians have no obligation to undertake a medical therapy that does not offer achievable and appropriate goals. Four do-not-resuscitate policies from U.S. hospitals and some of the significant published proposals are reviewed. We conclude that anything other than a physiologic definition of futility is indefensible because of imposed value judgments, imprecise definitions of quantitative and qualitative futility, inexact data, lack of certitude of economic benefit, and the role of autonomy for the patient and physician.