You are in the operating room taking care of a patient as an anesthesia provider. Before surgery, you or your colleagues, as well as the surgeon, have seen and optimized the patient. Everything has already been planned and prepared for a safe and smooth surgery and perioperative care. However, while the patient is anesthetized and is under your care, an unexpected event happens. Something goes wrong and your patient’s condition starts to deteriorate. What you see, hear and feel indicate that the patient’s well-being is at serious risk.
Depending on the urgency of the situation, you may need to fix the problem and re-stabilize the patient in seconds to minutes. Although the common scenario is that you are able to manage the patient’s condition very well on your own, the issue at hand is totally different from what you have ever experienced. You either have no idea what is going on or do not know how to manage the situation as it is the first time that you are facing such a problem. You want to do everything you can for the patient, so you try hard to remember everything that you once knew; everything that might help with the management of the patient’s problem. However, the more you try the less you remember. You may even remember less than your norm as you are under a significant amount of stress. You may look for the operating room crisis checklists while hoping it includes a guideline for the problem you are facing. (1-3) Still, you realize that nothing can replace timely guidance provided by anesthesia experts. So, you check if there is any colleague available for help. Fortunately, there is. So, you get some relief as you are almost certain that you will get better results than when you work on your own. Your colleague manages to come help and make a big difference in the outcome by assisting with the diagnosis and/or management of the patient’s condition.
Does this scenario sound familiar to you? It probably does if you have been in anesthesia practice for some time, and especially if you have worked at different locations.
Fortunately, anesthesia colleagues are available in most operating rooms to assist with such anesthesia emergencies. However, the following points are in favor of a potential need for an organization that could connect anesthesia providers to off-site anesthesia experts in order to favorably manage critical incidents that happen intraoperatively.
In intraoperative critical incidents where seconds count, on-site anesthesia colleagues may not be available timely.
On-site anesthesia colleagues are usually busy with their own cases and can only be available for a short period of time and intermittently. In some cases, that might be sufficient to solve the problem, but in other cases a continuous presence of a helpful expert is needed to improve the outcome of the incident.
In some areas, no anesthesia colleague is available on-site to help with those situations.
Even if on-site colleagues are available to help consistently, they might not be as knowledgeable and experienced as off-site experts in diagnosis and management of rare incidents. Expertise requires significant repetitive practice, so none of the anesthesia providers are experts in every emergency. (4) The current information overload in anesthesia and other areas of medicine also supports this.
Neither on-site nor off-site knowledgeable and experienced colleagues are available locally in some medical centers.
In some areas of the world, because of the limited resources intraoperative critical incidents might be more common and their diagnosis and management might be more difficult.
If there existed an organization that could connect anesthesia providers to off-site anesthesia experts, there would be a potential for improvement of patient safety and outcome of intraoperative critical incidents. Our research shows that the only organization that brings the expertise of anesthesia consultants to intraoperative incidents in real time is the Malignant Hyperthermia Association of the US (MHAUS), which specifically supports management of cases suspected of having Malignant Hyperthermia (MH). Although there are some reports of anesthesia conducted and guided from a distance, there is no established organization for assisting anesthesia providers with intraoperative critical incidents other than MH. (5-8)
That is why the idea of establishing such an organization called “Relief Anesthesia Hotline Association”℠ or RAHA℠ has emerged. One might say that the incidence of perioperative and anesthesia-related mortality and morbidity is low, so there is no need for such an organization. Indeed, the incidence of perioperative mortality and morbidity reported in different studies has been variable, and has declined significantly over the past 50 years. (9-17) However, due to the large number of procedures performed everyday, critical incidents still occur intraoperatively. (14) Considering the severity of the critical events that occur intraoperatively, and the large impact they can have on the patient and everyone involved in the situation, every effort to prevent these incidents from happening or to improve their outcome is worthwhile. (18) The Anesthesia Patient Safety Foundation’s vision statement clearly points to this idea by stating that “no patient shall be harmed by anesthesia”. (19)
Since it is not clear how much need exists for RAHA, a survey has been designed to assess the opinion and need of anesthesia providers in different areas of the world. If the survey shows there is a need for such an organization, the feasibility of the establishment of RAHA will be explored further in the next stage. At that phase, another survey will probably be distributed to anesthesia providers to assess their interest in serving in or directing the organization. The preliminary research shows that RAHA should be established as a non-profit (like MHAUS). If the second stage shows establishment of RAHA is feasible, it will be established. There will be other stages in the development of RAHA that have been designed and will be followed based on the results of each stage. RAHA, when established, will start operating in a small scale and as a pilot first. If the results are promising, it will expand its activities to operate worldwide. Eventually, RAHA aims to benefit from the help of surgeons in different specialties as some of the intraoperative critical incidents are related to surgery and could only be solved by surgery experts. It is also aimed to use the information obtained from the activities of RAHA to expand its operations to preventive measures in order to decrease the incidence of intraoperative critical incidents.
With the current telecommunication devices, it is possible to easily, securely and confidentially transfer audiovisual medical information over the internet. If RAHA is established, the anesthesia provider experiencing a critical incident intraoperatively could either call a hotline or go to a secure web link and start a video conference with an anesthesia expert in real time and around the clock. After receiving the required information and details, the anesthesia consultant could provide advice instantly, ask other experts to get involved or review up-to-date medical information before providing advice. Evidence-based medicine or clinical guidelines, where available, will be used for the advice provided by anesthesia consultants. If not, expert opinion serves as advice. The patient’s anesthesia provider will consider all the information and opinions and will make the final decisions.
If the survey shows there is a need for RAHA and if it could be established, it could have widespread and life-saving benefits worldwide for both present and future generations. Therefore, your contribution to this survey can have a huge impact on the future of the profession and the safety of patients during the intraoperative period. Even if the survey results show there is no need for this system, the results themselves are valuable and could be used for further global or local planning to improve the safety of patients. If you find value in this initiative, please complete the relevant 7-minute survey and share it with your colleagues. Your contributions to this effort and to the profession are greatly appreciated. All responses are anonymous and are kept confidential. Only the aggregate data will be used to determine the need for the proposed organization. The results of this survey will be published on RAHA’s website. It will also be emailed to those who subscribe to RAHA’s newsletter. The initiator of this project hopes that the results of the survey could lead to the involvement of major anesthesia societies and world-class anesthesiologists in the next stages of the development of RAHA.
If you do not want to miss the results of this survey or any upcoming news about the development of RAHA, you may want to consider subscribing to our newsletter. If you are interested in contributing further to this project, please do not hesitate to contact us.