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Behind the masks: pediatric anesthetists
| As children's physicians, they're not known for saving lives; they don't diagnose; they don't give practical advice on how to look after a toddler's persistent cold or reassurance that you're doing the right thing about the baby's eczema.
PHOTO: OWEN EGAN
But we couldn't make do without them.
Pediatric anesthetists are the ones who manage the panoply of drugs and gases required to relax, sedate, induce amnesia during an operation and relieve acute and chronic pain. Without their minutely timed and measured labour, surgery couldn't take place, chronic pain couldn't be addressed and local and temporary pain, such as that caused by a bone marrow aspiration, for instance, would make such potentially life-saving procedures impossible. They're also the ones to explain the process of anesthetics and pain relief to children or their parents.
Yet these key players in the hospital care of so many children are in short supply in Montreal and across the country.
Dr. Francesco Carli, chair of McGill's Department of Anesthesia and acting chair of pediatric anesthesia, says that with 10 pediatric anesthetists at the Montreal Children's Hospital (who also serve Shriners' Hospital for Children), the situation is better than it was a year ago, when the hospital had only four to five, leaving many children deprived of surgery or treatment.
"We had to stop teaching residents because the anesthetists were [always] needed in the operating rooms," he says.
But even at 10 staff members, says Carli, there is much that can't be done. Given the variety of demands on McGill's pediatric anesthetists, there simply aren't enough bodies to do the clinical (operating room) work, pain management (for children with leukemia, for instance), anesthetizing of children for such potentially harrowing experiences as magnetic resonance imaging, teaching, research and administrative duties. Never mind having the time and brain space to devise new services and approaches to anesthesia and pain management.
Ideally, Carli says, the department would have 14 staff members and three fellows (there are usually one or two now). "We should be able to staff seven operating rooms, not the current three to four," says Carli, adding that the ORs are only at 50 per cent of their capacity. "The emergencies are looked after; it's the tonsils that have to wait a year."
What to do? Create an endowed chair, suggested Carli's wife, Loretta Carli. The idea appealed to the weathered anesthetist. The chair would be the only one of its kind in Canada.
"The Department of Anesthesia at the Montreal Children's Hospital needs a forceful and dynamic leader, with high academic credentials, who would be able to attract graduates for speciality training and keep them in Montreal," wrote Carli in a fundraising letter he sent last year to private donors and foundations.
Once you have such a person, he explains over the phone, "you will have more fellows and staff, because renown attracts people. In genetics, for instance, people come from all over the world to study with [human genetics professor] Charles Scriver."
Unlike genetics, pediatric anesthesia — indeed, anesthesia in general — has an image problem. Widely perceived by the public as mere technicians, and by debutante medical students as being less-than-glorious specialists, the "men and women behind the mask" have neither the status of the lifesaver nor the recognition of the medical scientist. It would be the job of the chair holder to change that.
Dr. Josée Lavoie looks forward to seeing that happen.
She's a pediatric anesthetist who loves her work and would like nothing better than to have more people in her field.
Like many who made her choice of specialization, Lavoie stumbled into first, anesthesia then cardiac anesthesia, then pediatric cardiac anesthesia.
While in her fourth year at the Université de Sherbrooke, Lavoie opted to specialize in family medicine but a rotation in anesthesia turned her head. "What I liked about anesthesia when I first got into it was how complete it was. You have to know pharmacology, all the different body systems, how each functions normally and in a diseased state and how the disease can affect anesthesia.
"For a patient with kidney disease, for instance, you can't use a drug that must be eliminated by the kidney."
Anesthetists, especially pediatric ones, must also be exacting technicians, having to insert catheters and intravenous tubing into, sometimes, the tiniest of vessels and make the most careful of measurements.
"You have to be very anal about certain things," says Lavoie with a laugh. "With adults, when calculating the amount of medication needed, you can round off their weight to the nearest kilogram; with children you can't; it's to the milligram!"
For those who like to use their hands, "[anesthesia] is a nice combination of the intellectual and the technical," she continues.
That shows. On this December morning, for instance, Dr. Lavoie is preparing the 20 types of medication she will need for a tiny little girl who is being operated on to correct a heart defect known as Tetrology of Fallot.
Soon, she and an operating room nurse will go to take the two-month-old from her parents down the hall. It's a wrenching moment for them.
Dealing with patients, or their parents, explaining the operation and the process of anesthesia or pain management is an aspect of her job Lavoie particularly likes. "There's a very intense human side; you have very little time to make a patient trust you. You have to inspire confidence so that the patient goes to sleep relaxed and at peace."
Once the crying baby arrives in the OR, Lavoie quickly puts her to sleep using gas then tapes her eyes shut to prevent them from being damaged by the bright surgical lights. Next, she intubates the infant so that she may be artificially respirated.
For the next two hours, she and the respiratory technologist seem to work non-stop administering one medication or another and monitoring the numerous machines. This is an operation where the baby's heart is stopped and her blood is pumped through a heart-lung machine while surgeon Christo Tchervenkov repairs the defective right ventricular septum and exit so that the heart may properly circulate the blood to the lungs.
Watching Lavoie work, an observer can understand why it takes five years to specialize in anesthesia, a further year in pediatric anesthesia and a further year to complete the cardiac subspecialty.
This lengthy training may be one of the deterrents to attracting graduate anesthetists to pediatrics, she suggests.
"By the time you've finished your residency in anesthesia, you're close to 30, you have lots of debt and one less year to start paying back your loans."
Furthermore, she continues, even though there is a shortage of pediatric anesthetists, budding anesthetists usually opt to work with adult patients because there are far more adult hospitals than children's hospitals.
If there's one thing Lavoie finds hard in her job it's dealing with "very, very sick children. It's hard to accept that a one-year-old, a three-year-old has a chance of dying before you do."
But she is buoyed by the fact that there is a very low mortality rate in the hospital and she has seen cardiac surgery do much good. The two-month-old baby, for instance, left the hospital two weeks later, breathing on her own, her repaired heart pumping perfectly.
For more information about the Academic Chair of Pediatric Anesthesia's Appeal, phone 842-1231 ext. 5345 or e-mail firstname.lastname@example.org.