Meet the people who help sedate you
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Hey, it's me, Michael Bublé. You hear that? That's the sound of the Junos, the biggest party in Canadian music. I'll be there hosting. Some 41 will be rocking out on stage for the last time, plus a whole lineup of amazing performances. And guess what? You're all invited. I'll bring the tux, you bring the snacks. Let's make it a night to remember. Don't miss the Junos, live from Vancouver. March 30th at 8 Eastern on CBC and CBC Gem.

This is a CBC Podcast. I'm Dr. Brian Goldman. This is White Coat Blackheart. In Canada, one of the reasons why your upcoming operation might be postponed is a chronic shortage of anesthesiologists. As we told you on the show a while back, some have suggested that Canada consider filling the gap with certified registered nurse anesthetists, registered nurses with advanced training in anesthesia.

We got a lot of pushback from anesthesiologists who say one way Canada has already addressed the shortage is by recruiting and training anesthesia assistants, providers who come from the ranks of respiratory therapists and nurses. McKenzie Health, a hospital just north of Toronto, invited us to tag along with a veteran anesthesia assistant or AA named Rob Bryan. So this is endoscopy suite number four. We have five endoscopy suites for a very big endoscopy center.

And today we have a full list. We have 15 patients that we're going to put through just in this room. Rob Bryan readies endoscopy suite number four for a busy day. As an AA, Rob is much more critical to caring for patients in this room than you might imagine. So then I just spend the time getting my room set up before the first patient comes in. So it usually takes me about 20 minutes to set up for the day. And without you, it would be the anesthesiologist doing all of this? Yeah, they do the same thing in their own rooms.

Right. Correct. You're the extender. You're the extra pair of hands for the anesthesiologist that allows them to do more things than they would be able to do by themselves. Yes. Absolutely. So the role of an anesthesia assistant...

is to extend the care and the service of the physician specialist in anesthesia in the anesthesia department. Often dramatically? Yeah, often dramatically. Unlike nurse anesthetists who can practice anesthesia independent of doctors, AAs like Rob work under the direct supervision of anesthesiologists. We apply that knowledge under medical direction of an anesthesiologist as part of the anesthesia service. So we are definitely acting in a role as a physician extender. Physician is always in charge

of the patient's care and they're always directing the patient's care. So now I'm just going to prepare some of my emergency drugs for the day as well as my routine sedation drugs for the day. Note that Rob refers to his sedation drugs for the day. Rob works under the supervision of an anesthesiologist who empowers him to sedate patients and much more. So how much do you think

The average Canadian knows about what anesthesia assistants do. I don't think the average Canadian knows a lot about the anesthesia department, how anesthesia care is delivered. Why do you think that is, that they don't know much about what you do? I think it's a culture of health care where we're not always in the media and displaying to people about how care is delivered. I think we're very much patient advocates, nose to the grindstone type of culture. How much airway management do you do? Well, I do a lot. Okay.

I would say on an average day, I probably manage maybe a half a dozen to a dozen airways. Now, the thing that's kind of unique about my practice is that we're kind of like a tactical airway response team, so to speak.

where there may be seven operating rooms or 14 operating rooms going. If there's a difficult airway and the anesthesiologist wants a second set of skilled hands, I may be bouncing from room to room. So in a short period of time, I get a lot of exposures to difficult airways. Are you observing or doing?

Both my scope and skill set is quite broad and allows the anesthesiologist to choose what particular part of my scope and skill set is important to them at that time so that they can prioritize where they want to focus. So you're not just increasing efficiency, that you're definitely doing that. You're also...

helping anesthesiologists cope with complexity in patients. A hundred percent. So one of the advantages of the anesthesia care team and having an a CCAA working with an anesthesiologist, it allows them to multitask.

with either high acuity or in a very emergent situation where you have to do multiple things simultaneously. You have to do it proficiently and competently to make sure the patient survives or has the best possible outcome. Just a quick note, Rob referred to himself as a CCAA, which stands for Certified Clinical Anesthesia Assistant. It's a designation given by the Canadian Society of Respiratory Therapists to RTs like Rob who have got additional training.

In Canada, not all AA's are CCAA's like Rob. What's a day looking like?

Well, today we have a day of procedural sedation that we're going to do. So we're up in endoscopy, so we're going to be doing colonoscopies and gastroscopies all under deep sedation. We're about to witness that dynamic between AA and anesthesiologists that Rob mentioned and what it means for patients. At a nearby monitoring station just outside Endoscopy Suite 4.

Anesthesiologist Dr. Chris Farlinger briefs Rob on their first patient of the day, a woman with recent gastrointestinal bleeding who's here for a colonoscopy. Hey, Rob.

First lady, Carol, 55. She was here a couple of weeks ago because she had some malina stools, so she had an upper scope done. It was unremarkable, so now she comes back for the lower portion. She had no problems with her anesthetic last time. Airway looks fine. Don't have any concerns with that. All right. Thank you very much. Sounds good. You're okay with the routine? Yeah, yeah. Yeah, absolutely. Yeah, and she had a good experience last time. Excellent. Thank you.

So tell me about that exchange you just had. Yes, so that's a pretty typical exchange that we have between an anesthesia assistant and anesthesiologist. So again, it's a review of the patient's past medical history, current medical history.

any particular anesthesia considerations. Sometimes we look at other things like, do they have sleep apnea? Do they have other problems with their breathing while they're sleeping? So it's really important that I get all this information from the anesthesiologist. Briefing with the anesthesiologist complete, Rob gets the sedation meds ready and meets Carol Haim, the patient. Just on the side. Hello. I'm Dr. Brian Goldman. I recognized your voice immediately. Oh, there you go. Big fan. There you go. Yes.

Hi, my name is Rob Ryan, I'm one of the registered respiratory therapists and certified clinical anesthesia assistants. I'm going to look after you today. You spoke to a colleague of mine outside, Dr. Farlinger. I did. Okay, and we reviewed your chart together, so you spelled me in on your history. Just a couple quick questions for you. Do you have any problems with snoring or...

Sleep apnea? No. Okay. The exchange Rob has with Carol is the exact same kind of pre-procedure assessment that an anesthesiologist would have with her. Now, it's time to sedate Carol for her colonoscopy. Looking forward to the nap because I've been up since 4. Well, that's my specialty. You'll have a nice, restful sleep. Pleasant dreams. Thank you. Just everybody be careful. You are my sole focus. Okay, so...

The first medication that's going in is a little bit of numbing medicine so you won't feel the rest of it going. Okay, let that sit there for a second. Okay, it gives you a nice dream. So I want you to think of a nice place you want to go on vacation. Oh my gosh, that would be awesome. Where would you like to go if you could go anywhere? Literally anywhere with my husband. It's just, you know, we can leave. And the children too, yeah. Oh yeah, the children. Let's take them with us too. Well, it's your dream. You can go with whoever you like.

It takes about 10 to 15 seconds to kick in. Oh, you're getting foggy. There we go. Oh, yeah. All right. You're getting foggy. All right, enjoy your sleep. While Carol sleeps, Rob keeps watch on her vital signs and gives her small doses of medication to keep her sedated. Early during the colonoscopy, Carol's oxygen level dips briefly. Rob quickly determines that Carol's larynx or voice box has gone into spasm. He fixes the problem without any fuss.

As Rob keeps a close eye on Carol, he answers some of my questions. She seems quite comfortable right now. She's tolerating the procedure well. Have you ever had to intubate a patient in a room like this? Yeah, for sure. So I think that one of the reasons why anesthesia is here, providing this type of service, is that there are risks that are associated with it.

So in addition to providing the sedation, we also have an expanded skill set that could increase the type of anesthesia that we have to deliver. So for example, we got into bleeding, right? And I need to deepen the anesthetic care. I would call Dr. Farlinger in and prepare to intubate the patient and then possibly transfer down to the operating room. We had that type of a misadventure or, you know, again, it's an unprotected airway.

And sometimes with sedation, people can spit up a little bit and they can trigger what's called a laryngospasm. Usually you can break it pretty quickly, but sometimes they don't respond as fast. Again, I would call in Dr. Farlinger and we would work together to secure the airway and protect the patient's life from any misadventures. Rob mentioned some hypothetical examples in which he might need to call in the anesthesiologist to help deal with an unexpected emergency.

I note that during Carol's colonoscopy, Dr. Farlinger never needed to enter the room, but he was always steps away at a hub close by where he monitored Carol's vital signs on a remote monitor. Now what I'm doing is just sort of catching up on some of the charting. So the nice thing that we have here is we have electronic charting so I can go back to different periods where I started the care. So after the rundown you got from Dr. Farlinger,

He's not here at all, just here. That's right. That's right. And he's close by though. If I have a concern or if I need a hand, he's literally outside the door in the anesthesia hub and I can pull him in if I need a second set of hands. So he's screening and interviewing the next set of patients.

So, and again, this is one of the advantages of having an anesthesia care team model where number one, we could expand the reach of that one anesthesiologist to cover multiple rooms. That anesthesiologist can properly assess and screen every single patient that's coming through the rooms to make sure that we're prepared for any clinical presentation or any unexpected event. So it adds a layer of safety.

as well as it creates efficiency so that we can actually serve 30 patients versus that one anesthesia being only to do 15. What Rob just said is worth repeating. Dr. Farlinger supervises Rob and a second AA in another endoscopy suite. That enables one anesthesiologist to care for twice as many patients, meaning twice as many endoscopies get done.

While interviewing Rob, Dr. Jared Gallant steps into the colonoscopy suite. As chief of the Department of Anesthesiology at McKenzie, Gallant was instrumental in bringing AAs into the hospital. So tell me how many AAs, how many anesthesia assistants work in the department now and how that's grown. Yeah, absolutely. So we've grown from two originally, maybe about 10 to 15 years ago, all the way up to 13 right now.

And any plans for it to grow some more? Absolutely. How? So within the last few years, we've been able to put through RT students who showed an interest in expanding their career and their scope of practice. And we've been able to home grow them into AAs. So we're going to continue that process as well. So RTs, respiratory therapists, what's special about respiratory therapists that they're the ideal candidates to become anesthesia assistants?

I think naturally what they do in the intensive care unit with the neonatals in the family birthing, they have the skill set both technically as well as the knowledge about the airway equipment, the respiratory system, the cardiovascular system. So they're the perfect blend of mixing pharmacology with physiology and applying it to the everyday practice. Where do you think you'd be in terms of efficiency without anesthesia assistance?

Absolutely. We would be worlds up far. We would have to shut down operating rooms. We wouldn't have that care team model up in endoscopy. Our patients would be lacking the efficiencies and we would just not be able to give them the same care.

speed of care that they're receiving. And overall, the system, this would mean more patients in beds, more patients in hallways in emergencies, all these different things back up in a health care system. So they've afforded us that opportunity to move patients through the operating room in a safe and efficient manner. Dr. Jared Gallant, thank you so much for speaking with me. It's been a pleasure.

Carol's colonoscopy is finished and the sedation is wearing off. Hi Carol, all done. You're just waking up. You're in the recovery room now, okay? You did great. You're welcome. Okay, perfect. Yes, all right. Give me a shout if you need anything. All right.

This was a typical patient for you? No bumps? No bumps. She had a little bit of a laryngospasm at the beginning, which she kind of relieved quickly. And how did you relieve it? So I just did a little jaw thrust. So I know that the level of the anesthetic I gave wasn't too deep. I think she had a little secretions there. She was able to clear it. I felt her swallow get rid of it when I was doing a little jaw thrust.

And then, you know, within seconds she was back up to her baseline and coasting. Yeah, her oxygen level went down for a while. Yeah, like seconds. Seconds, yeah. And that's pretty typical. So a lot of times when you first give the anesthetic, there's usually about a 10-second period where the brain is sort of shocked for a second and then it sort of restarts itself.

And that's why it's a safe way to give them medication so you're not committed and it doesn't take a long time. Like I said, but normally, it doesn't usually happen all the time. But, you know, some patients, they...

That's why we're there, right? She did her underwhelming. Great. No concerns. She's awake and talking in the recovery room now. Perfect. Your next guy is... One colonoscopy in the books, 14 more to go. Dr. Jared Gallant told me that before AAs joined the team, this hospital routinely had to postpone procedures because there weren't enough anesthesiologists. Now they don't, and he says AAs are a big reason why. We'll be right back.

I'm Katie Boland. And I'm Emily Hampshire, who didn't want to be here. On our new podcast, The Whisper Network, we want to speak out loud about all the stuff that we usually just whisper about, like our bodies, our cycles, our sex lives. Basically everything I text to you, Katie. So this is like your intimate group chat with your friends. And we can't wait to bring you into The Whisper Network. This journey is a nightmare for me. I'm doing it for all of us. So you're welcome.

You're listening to White Coat Blackheart. This week, how anesthesia assistants are making anesthesiologists more efficient at hospitals in many parts of Canada. Most AAs were once respiratory therapists. A smaller number come from the ranks of registered nurses. Most have prior operating room and critical care experience. What AAs are permitted to do varies with the province. AAs are becoming part of the anesthesia team in more and more parts of Canada. That includes Nova Scotia.

Dr. Matthew Kybert is a pediatric cardiac anesthesiologist at IWK Health Center in Halifax. Dr. Sally Bird is a pediatric anesthesiologist and associate chief of the hospital's pediatric anesthesia department at the IWK. Dr. Sally Bird, Dr. Matthew Kybert, welcome to White Coat Blackheart. Thank you. Are you

Great to be here. Sally, let's start with you. We're doing this show in part because our program on certified registered nurse anesthetist generated a very strong negative reaction among anesthesiologists in Canada. Sally, help us understand why that is.

I think there's a few reasons for it. I'd like to back up a little bit and say that while we had a strong negative reaction to the idea of importing sort of the CRNA system into Canada, we're very supportive about looking at creative solutions to extending access, increasing access to anesthesia care and to extending, using some physician extenders, not

Just see RNAs. We've both worked in the U.S. We both have the utmost respect for, you know, the nurse anesthetist colleagues that we've worked with. But we see it in the U.S. as an adversarial system and not necessarily one that would be fitted to our Canadian health care system. And we believe that we already have a homegrown solution here that we can add to and extend and expand within Canada without importing an American solution to our Canadian problem.

Matthew, I want to get you into this conversation. Any thoughts on the negative reaction that our show generated among anesthesiologists in Canada? Yeah, I think there's a couple reasons why it could be viewed so negatively. I agree that whenever there's a parallel system, it can create animosity between the two groups when they're not under one umbrella or one

care team model. I think that's part of it, but I think there's another part of it too, which is the recognition that physicians

in anesthesia have done a really good job at making anesthesia very safe. And yet we've been, as a profession, relatively resistant to opening up in Canada to non-physician anesthesiologists or alternate types of providers because of a fear of kind of taking a backwards track on some of that process. But there's an emotional component to this.

We train very hard to become anesthesiologists and to kind of agree that there could be another provider that perhaps isn't as highly trained as we are doing the same job is kind of emotionally difficult for people. So I think that's part of the reason why it perhaps generated such a negative response.

I really want to get to the major reason why you wrote to us, you and Sally wrote to us after that episode and made the case for anesthesia assistants to have a bigger role during procedures needing anesthesia. And you're passionate about it. I want to hear why you're passionate about that, Sally.

Oh, I'm very passionate about this because we're doing this at the IWK and we're extremely proud of it. Initially, when they started, they would do things like help us out with putting patients off to sleep, help out in the recovery room. But, you know, we slowly realized that these are pretty incredible people with a lot of expertise to offer. And so our anesthesia assistants now, within collaboration with us,

are doing independent procedural sedations. They are doing vascular access, so they're putting lines into people's veins, into tiny babies' veins. And we've really managed, with no extra money from the government and no extra people, to start to provide...

greater access to the care that the children need at our hospital and it's been really revolutionary. And it's just the beginning you know it's a really cool job to be an AA these days I think because you may be one day helping me out with a complicated cardiac anesthesiologist it's really a two-person job to get one of these sick babies off to sleep and ready for surgery and

That might be one day. The next day, you may be providing breaks, relief. Then another day, you might be on the PIC team. Matt, can you explain what a PIC line is? Yeah, absolutely. It's one of my favorite things. So say, for example, you have a regular intravenous in your

Those only last in kids for about two days or so. So if you needed six weeks of intravenous antibiotics, you'd be getting poked a lot of times over that six period of time, and you'd basically be stuck in a hospital. If you put a PICC line in, which is basically a really long intravenous that sits, a line that sits basically on top of the heart, that will last easily for six weeks, maybe three months. And it used to be that it was more of a nurse practitioner job or interventional radiology job, but because we had a need here,

We've made it more of an anesthesia assistant job. So,

We're the only people in Canada that are doing this as a primary anesthesia assistant service. And we recently did a study that we hope to publish in the next coming months that show that our complications are no different, in fact, a little bit better. And our number of attempts in time it takes us to do the procedure is quite a bit shorter compared to other types of providers. Matt, what else do the AAs in your department specifically do that most don't do elsewhere right now?

On pediatrics, they are doing things like sedation for chest tube insertions, a lot of burn dressing changes, for example. That is a major source of our sedations for kids that have recurrent burns. This is something that we did a horrible job of before the anesthesia assistance, and kids would really suffer through these burn dressing changes. And now they have a great pathway forward to get high-quality sedation care done.

procedures. Lumbar punctures for chemotherapy, for example, in our oncology kids are now largely done by our anesthesia assistant teams. Biopsies, those sorts of things are being done right now. But the next step, of course, is to hopefully expand their role into even more areas.

So this is really interesting because you're talking about a set of procedures that we have depended on anesthesiologists providing that you're saying can be provided under supervision of anesthesiologists, of course, that are being provided by anesthesia assistants. Sally, how innovative is this?

I think it's fairly innovative. We've just kind of gone ahead and done this. To expand on what Matt is talking about, the cancer services, the anesthesia assistants are now providing that sedation independently. And that means that the anesthesiologist could be doing something else. So it means that we're able to get other things done. And I think I also wanted to sort of expand or clarify and say many of the things that

used to have to go on an operating room list, on a surgical list and take up time, which meant that less surgery could happen. And so part of our move here and innovation has been if we can move the things that don't need to be on an operating room list, we

and can be done by an anesthesia-assisted sedation, then we have more space on the operating room list for surgeries to happen. And I think almost everyone in Canada who's paying any attention to healthcare knows that our surgical wait list is a massive problem across the country. So I think we're being quite innovative in trying to increase access to both sedation services, vascular access services, and operating room procedures by using anesthesia assistance to help with all of those things.

Last question I want to ask each of you in turn. You've been talking about what's going on in Halifax. You have a story to tell for the rest of the country, for other provinces and how they can use anesthesia assistance. Matthew, let's start with you. Yeah, I think the first part is to recognize that they have really good training and they have really good potential.

to expand their services. And I think they are profoundly underutilized in our healthcare system. And I think in a situation where we have an access to surgical care issue, we have to think about creative solutions.

to move forward and get people the care they need. Sally, last word to you. Oh, I agree with everything that Matt has said. And I think the main point here is what you haven't asked us is couldn't CRNAs do this too? So I'm going to ask myself that question and say, yes, probably CRNAs could fulfill this role in Canada as well, but we don't have them now. And we already have anesthesia assistance programs

integrated into our departments and we speak the same language and we have mutual respect and collaboration and we work so well together as a team and there's already a high level of trust and I think to expand

Their role, it really does require this trust that we have built with each other on both sides. And so, like Matt said, I think that they already exist in many hospitals and where they're underused. And with some creative thought and some extra mentoring and training, they could do so much more, which would benefit really everyone in the system, patients, healthcare providers, and anesthesiologists.

Well, Dr. Sally Bird, Dr. Matthew Kybert, I want to thank you for coming on to White Coat Blackheart to talk about anesthesia assistance and how you're using them, where you practice. Thank you for having us. Thanks so much for having us on. Dr. Sally Bird and Matthew Kybert said the priority is to provide safe anesthesia care. Safety and fewer cancelled operations sound like a big win for patients, no matter who provides the care.

That's our show this week. White Coat Blackheart was produced this week by Stephanie Dubois with help from Jennifer Warren and Samir Chhabra. Our digital producer is Ruby Buiza, and our digital writer this week is Brandi Whiteley. Our senior producer is Colleen Ross. I'm Brian Goldman, and I'm proud to bring you medicine from the Canadian side of the gurney. See you next week. For more CBC Podcasts, go to cbc.ca slash podcasts.