No pain, all gain

There will be a growing shortage of specialists giving anesthesia due to the aging of populations, says leading University of Iowa obstetric anesthesiologist Prof. Cynthia Wong in Israel.

PROF. CYNTHIA WONG (photo credit: Courtesy)
(photo credit: Courtesy)
Blame the serpent in the Garden of Eden for persuading Eve to eat fruit from the Tree of Knowledge, condemning women forever to pain in childbirth. The pain of giving birth is probably the most severe pain most women will endure in their lifetimes.
But, fortunately, women were given a reprieve by doctors and scientists, and labor pain was not forever. The modern era of childbirth analgesia began in 1847 when Dr James Young Simpson gave ether to a woman in labor. Chloroform was available the same year, and the colorless chemical later made it possible for England’s Queen Victoria to enjoy a pain-free delivery of her eighth child.
Doctors developed various types of nerve blocks for women in childbirth in the first decades of the 20th century. In 1943, the first epidural anesthesia – in which a hollow needle and a small, flexible catheter are inserted into the space between the spinal column and the outer membrane of the spinal cord (epidural space) in the middle or lower back – was introduced. The catheter is taped onto the back so it can be reused if more anesthesia is needed.
Today, some 46% of Israeli women have epidural anesthesia for childbirth (more wanted it, but an anesthesiologist was not available or they delivered too fast for it to be administered). The epidural anesthesia rate in the US has climbed in recent years to half or more of all deliveries.
I myself know what it’s like, as one of my sons, a four-kilo baby, was born in Jerusalem’s Misgav Ladach Hospital during the Gulf War, with me wearing a gas mask. The anesthesia from the epidural was a great relief.
A relative recently was given epidural anesthesia at the capital’s Shaare Zedek Medical Center for a normal labor. But when the alert and adroit midwife noted a rare umbilical cord prolapse that threatened the fetus’s life, she rushed her to the operating room, and the baby was born by cesarean within three minutes of her noticing the problem. The epidural anesthesia in place made it possible to do the operation immediately and save the baby without inducing general anesthesia, a more risky anesthetic.
THE TWO-DAY annual international conference of the Israel Society of Anesthesiologists held recently in Tel Aviv to discuss the latest advances in the field was attended by hundreds of specialists from here and abroad. Outgoing society chairman Prof.
Benjamin Drenger, who heads the orthopedic anesthesia unit at Hadassah University Medical Center in Jerusalem’s Ein Kerem, completed six years as head of the society.
He noted that the conference was aimed at bringing outstanding anesthesiologists to Israel to meet with their Israeli counterparts and discuss “this fascinating field in the heart of medicine.” They discussed the field of obstetrical anesthesia, as well as anesthesia in complicated surgery, pediatric anesthesia, pain medicine and other subjects.
Drenger noted that anesthesia is vital not only in the operating room; without it, many procedures in other hospital departments, including catheterization, pain clinics, radiology and intensive care, cannot be carried out.
Prof. Idit Matot, director of the anesthesia, pain and intensive care division at Ichilov Hospital at Tel Aviv Sourasky Medical Center, was elected as the new chairman of the society. She urged patients and their families to get to know the anesthesiologist who will be involved in their surgery and procedures, discuss their concerns and give details on chronic diseases so as to prevent complications.
ONE OF the visiting speakers at the conference was Prof. Cynthia Wong, a leading world expert in obstetric anesthesia and chairman of the anesthesiology department at the University of Iowa’s Carver College of Medicine. It was her first-ever visit to Israel.
“I have great Israeli colleagues with whom I am in touch,” she said in an interview with The Jerusalem Post while attending the conference.
“They are all very smart people.”
Her mother-in-law was head of a Hadassah Women’s Zionist Organization of America chapter. Now that Wong has been here, she would like to come back and see more. Her husband Lawrence, a businessman, has relatives who have visited here often.
They have four children – two adopted – and she herself has undergone epidural anesthesia. Three of the grown children are at university, and none wants to be a physician.
“Their talents lie elsewhere,” she said with a smile.
Her Chinese-American father worked at IBM; her mother was a nurse and an aunt was a psychiatrist, who was a role model for going into medicine. She spent her teens in Rochester, Minnesota, which is home to the Mayo Clinic – “a very medical town.”
Wong earned her bachelor’s degree in biology and chemistry at Indiana University, did a fellowship at the Institute for Immunobiology and Immunochemistry at the University of Wuerzburg in Germany and then earned her medical degree at the University of Chicago’s Pritzker School of Medicine. She did her internship, residency and specialty in anesthesiology at Chicago’s Rush-Presbyterian-St. Luke’s Medical Center.
Although she is present at deliveries numerous hours a day, she never wanted to be an obstetrician.
“Anesthesiology is an entirely different style of medicine. It gives instant gratification and requires detailed knowledge of pharmacology and physiology. There is no time to get bored. It is fast-paced and you do things with your hands. I can see the results of my work instantaneously.”
Although most patients don’t ask or even care who is going to put them under, anesthesiologists are “as important as surgeons, as without us, surgery is impossible, and we make sure the patient remains alive and stable.”
She noted that just as there is a shortage of doctors in her specialty in the Israel, there is one in the US as well.
“The manpower situation will only get worse because of the aging of the population” said Wong. “More people will need surgery and other treatments requiring anesthesia and pain relief. There aren’t enough training positions. Also, only 36% of anesthesiologists in the US today are women; they tend less than men to go into the specialty.”
To cope with the shortage of doctors in the field, certified registered nurse anesthetists have been licensed in the US.
“These are advanced-practice nurses who do a couple of years in intensive care nursing and then go back to school for a master’s degree or a doctorate in nurse anesthesia,” she added. There are many of these in the US (but none yet in Israel), and “in general, they give good care. But anesthesiologists believe that nurse anesthetists should work with them and not independently. In an emergency, one should have an extra pair of hands. The team model is best.”
As state laws differ, nurse anesthetists can work independently without a physician or dentist in 17 of the 50 states, but in the rest they cannot. This situation, said Wong, is very controversial.
“A nurse anesthetist is less expensive than an anesthesiologist. This makes for cheaper health care, and is safe for routine surgery in healthy patients.” She is aware of the fact that most Israeli infants are delivered by well-trained midwives, with obstetricians intervening only in risky pregnancies. In the US, midwives deliver only a third of the babies. Men are still obstetricians, but as many women prefer to be treated by women for gynecological cases, male specialists in the field are “becoming oddities.”
Her hospital is in a rural state. In many smaller hospitals, anesthesiologists may not be immediately available to provide an epidural, especially at night. “They have to be called from home,” Wong said. “It’s an economic issue. General anesthesiologists know how to do epidurals, and they provide care to most women, but for high-risk women, anesthesiologists with expertise in obstetrical anesthesia are best.”
Surprisingly, in the US, midwives are generally “less in favor of epidurals; they take care of more lower-risk women than obstetricians do. A growing number of older women with chronic illnesses give birth, and there is a lot of obesity, diabetes and heart disease. So there are fewer lowrisk cases and more cesarean sections that require epidural or spinal anesthesia.”
Spinal anesthesia, used for elective cesarean sections, is performed in a similar way to epidurals, but the anesthetic medicine is injected using a much smaller needle – directly into the cerebrospinal fluid that surrounds the spinal cord. The area where the needle will be inserted is first numbed with a local anesthetic. Then the needle is guided into the spinal canal and the anesthetic is injected, usually without the use of a catheter. This numbs the body, usually from the chest level down. Unlike an epidural injection, more anesthesia cannot be added because the needle is removed after the injection.
Wong said that one can use combined spinal/epidural anesthesia – first giving a small spinal dose and leaving a catheter in the epidural space. “This works much faster than epidural anesthesia, and one can give a small dose of spinal anesthetic initially, with more through the epidural catheter if needed.
Although people may fear spinal or epidural anesthesia because of complications, becoming permanently paralyzed as a result is “so rare that these are virtually uncountable. Maybe it would happen 40 or 50 years ago, but today it is extremely unlikely,” said the anesthesiologist. Anesthesia can cause blood pressure to drop, so we have to keep our eyes on that. The medication may cause some patients to itch, and women who have had epidural or spinal anesthesia may develop an headache that, untreated, can last for a week to 10 days because spinal fluid leaks out of the sac.
General anesthesia is not used in the developed world for regular deliveries except in emergencies. In many parts of the developing world, however, putting women completely out with a general anesthetic is still the norm.
The C-section rate in the US is about 33%, considerably higher than most Israeli hospitals. While the rate of vaginal births after cesarean is lower there than in Israel, there is a major push in the US to increase it, she said. Many Asian women, especially, prefer cesareans.
Wong was interested to hear that in Israel, because religious Jewish women have more babies and are fearful of their productivity being limited by cesareans, there are obstetricians who are experts in external cephalic version; they spend all their time trying, through manipulation of the fetus by pressing on the abdomen, to bring it down from a breech position.
“We also turn babies, and epidural anesthesia is often used to make it less painful,” she said. “Babies who are turned successfully can flip back in the other direction.
About 4% of all pregnancies are breech.”
IN HER talk to the anesthesiology conference, Wong focused on maternal death from sepsis, hemorrhaging, preeclampsia and other causes, especially common for women in the Third World. For most women and their families, childbirth is a joyous occasion. However, across the world, approximately two pregnant women die every minute, and even in high-resource countries such as the US and Israel, some women die during or after childbirth.
“Israel,” she said, “has one of the lowest rates of maternal death in the world; however, the rate among their neighboring countries is significantly higher. Causes of death include hemorrhage, hemorrhagic stroke in women with preeclampsia/ eclampsia, sepsis and indirect deaths in women with preexisting diseases, such as heart disease.”
Research, Wong concluded, “has shown that a team approach to care can markedly decrease the risk of bad outcomes. Team members include not only the obstetrician and midwife, but also the anesthesiologist, among others. Anesthesiologists, by virtue of their expertise in caring for other critically ill patients, both in the operating room and intensive care units, have the training and expertise to play an essential role in helping to rescue the critically ill obstetric patients.”