key: cord-0772754-5hbe4bg8 authors: van Klei, Wilton A.; Hollmann, Markus W.; Sneyd, J Robert title: The value of anaesthesiologists in the COVID-19 pandemic – a model for our future practice? date: 2020-08-20 journal: Br J Anaesth DOI: 10.1016/j.bja.2020.08.014 sha: 0ff84695c9e7d87b5542a6e519968ad96dd3913e doc_id: 772754 cord_uid: 5hbe4bg8 nan The COVID-19 pandemic places healthcare systems under extreme pressure. As the infection spread, the number of infected patients requiring hospital admission was often overwhelming, displacing care for other groups. Many required ICU admission. 1 In places, the (expected) number of patients requiring ICU admission far exceeded the number of ICU beds and care providers normally available. Hospitals therefore doubled or tripled their ICU capacity by decreasing or halting elective surgery and establishing ICU beds in empty operating rooms and postoperative anaesthesia care units. 1 Historically and currently, the majority of physicians practicing intensive care have trained in anaesthesia and a high proportion continue some anaesthetic practice. Whilst mono-specialty intensivists form an important component of the ICU workforce and are well represented in specialty leadership, their numbers are small. Therefore, anaesthesiologists, usually redeployed from the operating rooms, have provided most of the medical care in temporary COVID-19 ICUs. Thus, the COVID-19 pandemic has showcased the skills of anaesthesiologists as team workers, consultant physicians for the critically ill and as medical managers, strategists and leaders. 5 Unusually, our specialty has caught the public eye including the appearance of an anaesthesiologist on the cover of an April 2020 issue of Time magazine. However, before we become too pleased with ourselves, we should reflect on our specialty's journey and develop strategies for our future development. Although anaesthesiologists dominated the emergence of intensive care, 6 a significant proportion of us are careful to avoid the ICU. Whether this reflects anxiety around care of the critically ill or the attractions of private practice and diminished out-of-hours working remains uncertain. As with both dinosaurs and mammals, intensive care medicine has evolved differently on different continents. The European model has always been interdisciplinary and is today profoundly competency based. 7, 8 Anaesthesiologists remain at the centre but do so as part of a specialist intensivist community which is well organised and confident. In the US, few anaesthesiologists train in or practise critical care and surgical leadership of ICU management is commonplace, although an intensivist model may improve outcomes whilst reducing costs. 9 Perhaps we could fall back to the operating rooms? We would do so at our peril. Almost every aspect of anaesthetic practice is under challenge by new technologies and alternative providers. Our equipment is becoming smarter and fluids, hypnotics, analgesics and muscle relaxants can all be delivered by closedloop systems. 12 Laryngeal mask airways service the vast majority of spontaneously breathing patients, bypassing the traditional bag and mask skills. Videolaryngoscopes and other devices facilitate tracheal intubation and we are well on the way to deployable robotic intubation of the trachea. 13 These technologies subtract from the 'craft' dimension of the anaesthesiologist's traditional skill set. New drugs with shorter durations of action, cleaner profiles and easier use and titration have simplified the mission, thus paralysis is easier to manage with atracurium than using curare or pancuronium. Sevoflurane is easier to use than halothane. Attempts by anaesthesiologists to restrain the use of 'their' drugs by emergency physicians 14 or nurse sedationists 15 come across as self-interested and financially motivated rather than patient-centred and evidence-based. 16 American anaesthesiologists find their operating room practice challenged by nurse anaesthetists who appear to work as safely as their medically qualified colleagues when embedded in mixed care teams. 17 Liberalization of supervisory requirements may markedly expand nurse anaesthetists' scope of practice. Nonmedical anaesthesia is well established in several continental European counties, 18 slowly developing in the UK 19 and is routine in much of the third world. In short, the core specialty of operating room anaesthesia is under threat. What to do? What are we left with? The pandemic has been an opportunity for anaesthesiologists to showcase their skills. These skills were used successfully in the process of distributing care in the COVID-19 pandemic, both to COVID and non-COVID patients. For the moment we have the eye of all of the hospital and much of the general public. We have a moment (arguably a brief one…) to exploit this as an opportunity to reposition our specialty for the future. Anaesthesiologists should head towards the challenges. Giving a few mL of propofol for sedation during colonoscopy in healthy patients is not the work of a specialist -it can be safely managed by a nurse. Anaesthesiologists are specialized generalist physicians, with extensive knowledge of the (patho)physiology of organ systems both under normal and stress conditions and are trained to mechanically and pharmacologically influence these systems. We should use that knowledge. Likewise, within and beyond the operating rooms we should be going the 'hard yards', working as perioperative physicians managing complex patients at each stage of their perioperative journey. Anaesthesiologists, as team players with little distance between physician and non-physician care givers, as efficient planners and controllers, should facilitate multidisciplinary collaborations outside the operating room. If anaesthesia is going to redefine its position (as it must) then it all has to be earned, none of it will be given. The failure of the 'Perioperative Surgical Home' concept attempted by the American Society of Anesthesiologists is something to learn from. If surgeons and administrators are going to share leadership of perioperative care with anaesthesiologists, in its broadest sense, then it will be because we have demonstrated that it is the way to produce better quality patient care (measurably), cheaper care, faster care and more satisfying (to all parties) care. No one else is going to do this for us. Recently, the European Society of Anaesthesiologists announced a name change to embrace intensive care and is now in the preliminary skirmishes of a battle with the European Society of Intensive Care Medicine. (www.esahq.org/esanews/esa-2020-general-assembly-message-from-the-presidents/). The outcome of such boundary disputes will be resolved by evidence and not by rhetoric. Intensive care was once an anaesthesiologists hegemony, but those days are long gone. If anaesthesiologists are to call ourselves intensivists and perioperative physicians then we have to earn the right to do so by generating respect from our colleagues in medicine, surgery and management. The scope and versatility that anaesthesiologists have demonstrated during the COVID-19 pandemic has to become daily routine practice. We can take responsibility for healthcare delivery processes and use our broad knowledge outside operating room care and planning. In that sense, the COVID-19 pandemic should be a wake-up call. If we respond, we can stand on the shoulders of iconic anaesthesiologists like John Snow and Bjørn Ibsen who took on responsibilities outside the operating room during the cholera and polio pandemics to define the specialty. 20 Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region Sevoflurane for outpatient anesthesia: a comparison with propofol Risk to health from COVID-19 for anaesthetists and intensivists-a narrative review Vital Signs Monitoring with Wearable Sensors in Highrisk Surgical PatientsA Clinical Validation Study Role of anaesthesiologists during the COVID-19 outbreak in China Intensive care medicine is 60 years old: the history and future of the intensive care unit An international survey of training in adult intensive care medicine Models for intensive care training. A European perspective The impact of an intensivist-model ICU on traumarelated mortality The Anesthesiologist in Critical Care Medicine: Past, Present, and Future Report from the task force on future paradigms of anesthesia practice Anesthetic Management Using Multiple Closed-loop Systems and Delayed Neurocognitive Recovery: A Randomized Controlled Trial Embracing the robotic revolution into anaesthetic practice Propofol for adult procedural sedation in a UK emergency department: safety profile in 1008 cases Morbidity and mortality of endoscopist-directed nurse-administered propofol sedation (EDNAPS) in a tertiary referral center Making sense of propofol sedation for endoscopy Anesthesia Care Team Composition and Surgical Outcomes Swedish-registered nurse Anesthetists' evaluation of their professional self Leading the integration of physician associates into the UK health workforce Beyond the operating room: the roles of anaesthesiologists in pandemics The authors declare that they have no conflict of interest.