In Reply:--We appreciate the thoughtful comments made by Allen and Murray. We agree that the consent issue is an important one and was well presented by Allen and Murray. We do not ask the patients who will be anesthetized by the airway rotation residents for special consent to perform airway maneuvers because all of the airway methods we use are well established/accepted, and our teaching methods greatly minimize risk. However, we stress that experienced faculty must be present during performance of the airway maneuvers and that the judgment of the faculty be strictly followed at all times. One very important element regarding faculty judgment is the absolute avoidance of inappropriate force or roughness at any time. In addition, the supervising faculty continually evaluates the impact of the teaching process on the patient; this means that all teaching plans are inherently flexible and may be aborted/changed at any time. We estimate that approximately 10% of the time, the teaching plan is altered, based on online observation of the teaching process/patient response (the observations may indicate increased risk or, conversely, the observations may indicate that the procedure is simply too easy and there is little learning benefit to be gained by following the procedure to completion).
In 4 yr, (approximately 1,000 faculty/airway rotation resident cases), we have had only three adverse outcomes, and two of the three adverse outcomes were the same. In two cases, intubation through the self-sealing fiberoptic bronchoscope diaphragm on an intubating anesthesia mask caused a piece of the blue diaphragm to be carried into the trachea. In both cases, the complication was recognized immediately by the faculty, and the blue piece of diaphragm was removed from the trachea by an alligator clamp passed through the working channel of a fiberoptic bronchoscope. We no longer intubate through the self-sealing fiberoptic diaphragm just for teaching purposes. In the third case, an improperly sterilized laryngeal mask airway (cleaned in Cidex) caused perilaryngeal edema, necessitating emergent conventional laryngoscopic intubation. The patient suffered no long-term morbidity, and the improper LMA cleaning procedure was identified and rectified immediately.
It is possible that new complications with new equipment may occur in the future, but this possibility applies to all clinical situations. We believe we use accepted methods very carefully, so that the risk of these methods does not require special consent.
Jonathan L. Benumof, MD; Professor of Anesthesia, Sheila D. Cooper, MD; Assistant Clinical Professor of Anesthesia, UCSD Medical Center, Department of Anesthesiology, 402 Dickinson Street, Mail Code 8812, San Diego, California 92103–8812.
(Accepted for publication May 2, 1996.)