Con: cardiac anesthesia and elitism: where does SIGMA end and ROA begin?

0 NE OF OUR faculty, who wishes to remain anonymous, invented an acronym, namely “SIGMA” to stand for “Society for Isolation and Glorification of Myocardia1 Anesthesiologists.” The other acronym used in this communication, namely ROA, stands for “regular old anesthesiologist.” With that as background, please consider the following scenario, which takes place at 3:00 AM. Mr Smith, who is 63 years old, has undergone a quadruple-vessel CABG during yesterday’s surgical schedule, and is bleeding. The decision has been made to re-operate. His blood pressure briefly dipped to 87/67 mmHg and a tentative diagnosis of “tamponade” is being entertained. The ROA on cal1 in the hospita1 does not have SIGMA credentials. There is a SIGMA member on cal1 at home. From an anesthesia standpoint, what is actually involved with this re-operation for bleeding? Differential diagnosis of hypotension, airway management, fluid, blood and electrolyte replacement, arrhythmia control, blood gas management, obliteration of awareness, analgesia, and muscle relaxation are some of the most likely elements involved. ROAs work quite effectively in al1 these arenas daily. The cardiac anesthesiologist who believes that he or she somehow has a priori extra expertise in these areas is naive (and wrong). A true blue SIGMA member presented with the above argument wil1 solemnly intone, “Ah, but what if this patient needs to go back on cardiopulmonary bypass?” Can an ROA provide competent and safe care for such a case, which suddenly needs CPB? During cannulation, severe bleeding andior hypotension can occur. Hemodynamic and fluid management are again required. During CPB, the argument goes that a SIGMA member is needed because he or she wil1 know the proper arterial pressures at each stage of the procedure. Actually, that knowledge does not yet exist. Can the ROA remember to give heparin‘? Usually the perfusionist (1) calculates the dose; (2) fills the syringe; and (3) measures activated coagulation time (ACT) and wil1 keep track of when the heparin was given, as wel1 as the effects of the heparin on the ACT. What about the all-important period during emergence from CPB? How many cardiac anesthesiologists actually make independent decisions to start specific inotropes without at least consulting with the surgeon during this crucial period? Not many. How many cardiac anesthesiologists actually merely follow pharmacologic orders from the surgeon during this critical period? If an anesthesiologist claims to be a “cardiac anesthesiologist” but simply awaits surgical orders for dopamine, isoproterenol, epinephrine