ANESTHESIA REPORT. FOR THE ---Is SURGICAL EXECUTIV'd COWITTEE STAFF The Anesthesia Service is administered jointly by a staff of graduate physicians and nurse anesthetists, under the direction of Dr. Apgar and Idiss Penl.and. The total number of anesthetists em- ployed for the past five years has been fourteeq, which has been adequate for the averzge operating schedule. During vacations, and at times of aaximum demands, this number has not b2en enough. Also, dur- ing the last six years, the total number of cnesthcsias administered hzs increased by two thousmd. This does not include the newly ac- quired Neurological Service. BeIx~w is c? table showing in more detail this increase in cases. 1933 Pr e s byt E r i an Ho spit c.,l 4459 Sloane Hospital 1117 Bzbies Hospital 443 Eye Institute 4.36 Vanderbilt Clinic 1085 Wards 242 Cystoscopies 62 7849 1.934 1932 4377 4.451 1136 1253 1434 1653 559 553 1066 1139 194 267 75 6 3. -_I II_ 8842 9380 1936 4654 1215 1543 670 1093 299 49 3523 I_c 1937 1,749 1299 1600 739 1263 273 22 _I_ 9945 1938 441 5 1344 1687 860 1053 279 34 9672 - 1939 4866 1290 1633 765 1042 313 35 3944 Other fpctors also contribute to the need for some increase in staff. i 1. We believe that for the patimt's welfare, rmd for the training of anesthetists, that it is not on1.y desirnble but necessary to make a preoperative arid postoperative study of the patient. takes a certain zmount of time, c?nd limits the cctual number of anes- This thesias one person can administer. -2- 2. The Obstetrical Service has frsquently suggested that we assist in teaching its residents, or t3ke over entirely its Znesthesia problems. This would be desirable from both our points of view, but we have been unable to do anything because of insufficient staff. With the teaching program for residents and medical students quite well under way, we me awaiting the opportunity to 3. start the research program. It has been impossible becmse of a short- age of both staff and time. 4. Since July, 1938 we have supplied one full-time anesthe- tist for Welfare Hospital, assigned to the Colrunbia University Surgi- cnl Division. to work on his own responsibility beforc going into practice, and to work with a group of poor risk patients which present so many anes- thesia problems. This position offers an opportunity for the resident 5. The presence of medic21 anesthetists on the staff has occasioned requests for service other than for surgical anesthesia. Among these procedures are treatment for intrectable pain, diagnostic and therzpeutic nerve blocks, aifflcult sedative problems and resusci- tation, 211 important parts of an anesthetist's training. These again trke time from surgical anesthesia. The proportion of resident physicirns to nurse anesthetists, we believe should be a labile one. At present we have vacancies, salaries md teaching material for two more greduate physicians, but we cannot fill thc vacancies because of housing conditions. Thorough investigation reveals no hope for more than four rooms now occupied by anesthesia residents. In view of the great demand for specialists in anesthesia, and the excellent clinical material available at the * Medical Center for teaching, it is unfortunate that training in anes- thesia is limited by housing conditions. BUDGET We welcome the news that the Anesthesia Department is to be presented with a budget. Such a. step will eneble us to determine accurately the cost per patient for an anesthesia, and to suggest -3- measures for economy, as well as to simplify the maintenance of the department. However, it should be a truly unified budget. It should include all the types of anesthetic agents used by the staff, i.e., inhalation, intravenous, rectal, local and regional drugs, in any part of the Medical Center, i.e., Presbyterian Hospital, Sloane, Babies, Vanderbilt Clinic, I.O.P.H., and Neurological Institute. Psychiatric Institute and the Dental School are excepted. The same applies for anesthesia equipment, which includes machines and their maintenance, stationery end store room supplies. The analeptic drugs, such as cora- mine and ephedrine, belong more properly on the anesthesia budget than on the operative budget. CHARGES This problem will be considered in detail by the Charges Committee, but we wish to record here r3. few impressions. 1. We believe the prevailing ward, semi-private and private charges for use of operating room to be just. It is desirable to de- termine how much of the fee can be credited to the Anesthesia Depart- ment budget. thesia expenditures. We suggest that about 40% of the fee would cover iines- 2. We feel that a charge should be made to two other groups of patients. (a) Wzrd patients anesthetized in thc: treatment rooIil. In Harkness, the charge for the use of the treatment room would cover this. The sum of one dollar would probably cover the cost of gzses. (b) Harkness patients anesthctized in their om rooms. ' This should be a.bout the same 2s the trectment room fee. 3. The VmderSilt Clinic rate seems correct. 4. The advent of physician mesthetists permanently em- ployed by the hospital raises i? new question, c? charge for professional services. Anesthesia in most hospitcls is considered a consulting service on a par with Radiology or Pathology. Khen anesthesia. scrvice is requested, whether actual administration or consultation, c7 profes- sional fee is submitted. It is a detriment to the development of the -IC- specisrlty here that such a ferj cannot be charged. past two years, privcte ptients have asked regarding their anesthesir Miny times these fee (when anesthetized by physicians), and have been surprisec! to find that there would be no charge. whether we vclue the professional service. Such an answer leaves one wondering It has always been a privilegc: of the surgeons to bring i.n an outside anesthetist if he SO desires. In this case, the znesthe- tist always submits a fee. It is suggested that any physician employed by the hospital, who is qualified by the Americas Boar6 of Am?sthesiology, be allowed to charge a professional fee. This is naturally on a sliding scale, and practically amounts to 10% of the sixrgcon's fee. money collected would be applied to the anesthetist's salary, an Anesthesia Research Fund, or to the budget can be decided later. Whether the USE OF EXPLOSIVE AGENTS The Anesthesia Service feels that the medical and physio- logical advantages of the explosivc anesthetic agents (especially cyclopropane and ether) far outweigh the possible explosive hazard. We are acutely aware of the problem and are making every effort to acquaint the surgical and anesthesia staffs with the hazard and to teach ways to minimize it. EQUIPMENT Until 1935, the equipment for inhalction anesthesia was quite adequate. Since then, f'undxaentzl improvements hcve been made * in gas mzchines. The inprovemcnts lead to 2 more accurete, safer End more economica.1 administration of the 9.gcnts. Sime Mzy, 1936 when cyclopropane was introduced, the demanr? for this gzs/been f;ir 3hcz.d of our epparatus to adninister it. Of the sixteen gas machines in daily use, only seven can be used for cyclopropane. Five obsolete inodels need urgently to be replaced. has I The equipment for regional, intrnvcnous and rectnl mss- thesia is sufficient. Submitted by: Jxiuary 10, 194.0