A healthcare company executive is shot in the back, murdered in cold blood; an angry populace chafes at the rising costs of health insurance and denials in coverage; and a privately held insurance company schemes to fatten its bottom line by restricting reimbursement for anesthesia services. In the parlance of that god-awful, hackneyed expression, “there’s a lot to unpack.”

A few things stand out that seemingly most Americans can agree upon. Things cost too damned much. It is truly difficult to get a timely appointment with a primary care physician, and the wait is worse if you need a specialist. And profits for many health insurers soar while patients get denied vital coverage, and reimbursement to physicians tanks. There’s a lot of well-deserved anger and frustration out there, and one has to ask: When and how will any of this end?

From never-ending staffing shortages to a myriad of financial challenges from the COVID-19 pandemic, the past several years have been exceptionally difficult on the United States' healthcare system. Although many institutions have weathered the storm, some have resorted to private equity, some are on life support and others have closed their doors. Now, hospitals and health systems (and our country at large) are facing another unforeseen obstacle: tariffs on imports into this country. The presidential order imposes a 10% tariff on all countries, as well as individualized higher tariffs on the countries “with which the United States has the largest trade deficits.”

As the vast majority of supplies that hospitals depend upon to safely operate are imported (such as gloves, gowns, machines, medicines and IV supplies), the tariffs will undoubtedly increase costs at every level. Additionally, the tariffs are likely to have a significant harmful impact on the country’s pharmaceutical supply chain, particularly in the generic space, and could exacerbate existing drug shortages. A significant portion of active pharmaceutical ingredients (APIs) and finished medications are manufactured abroad, with a substantial percentage of APIs originating from India and China—countries that are being hit with major increases in tariffs. 

The Los Angeles wildfires have destroyed thousands of homes and stores, and left entire communities in ash and rubble. And while lives have already been lost, experts are now discussing the long-term health impact for those who lived or worked in the area.

"The general practitioners, the anesthesiologists, the entire medical community needs to be educated in occupational medicine and the lessons that we've learned in occupational medicine in dealing with massive exposure," said Peter J. Papadakos, MD, a professor of anesthesiology and perioperative medicine, and the director of critical care medicine at the University of Rochester Medical Center, in New York.  

"I think that when I look at this that it’s one of the largest environmental and health catastrophes that has befallen our country─if not the world─in terms of the amount of people that may have been contaminated, and those who may become contaminated once they go back to where their homes were."

The number of senior citizens is growing rapidly; individuals aged 65 and older increased from 39.6 million in 2009 to 54.1 million in 2019 (a 36% increase) and is projected to reach 94.7 million by 2060. However, over the last few years, the usual respect and care of our aging population is decaying into a growing incidence of neglect and abuse.

Prior to  COVID-19, one in 10 elderly adults in the U.S. experienced elder abuse. A major review in 2017 of 52 studies from 28 nations reported that 15.7% of people over 60 were subjected to some form of abuse. In 2020, this number doubled to one in five—a nearly 84% increase. A study by the Administration for Aging stated that hundreds of thousands of seniors were abused, neglected and exploited by family and others.

The following is an excerpt from a related Time Magazine article:

"What is even more disturbing is that in 90% of cases, the abuser is a member of the family, based on findings in the study. In fact, two-thirds of the abusers were adult children or spouses. We, of course, find this to be a shocking statistic; since the dawn of recorded history the elderly have been given great respect and were cared for by both the family and the community as a whole."

There has been a marked increase in mass casualty events in our society. Targets have included schools, malls, houses of worship, and yes, hospitals. Our staffing crisis unfortunately has negatively affected even our most robust trauma system and emergency rooms; there has also been the closure of many hospitals in rural areas, which has created healthcare deserts. The inability of many towns and small cities to care for “terror event” patients’ issues, of course, will affect how we deliver trauma care.

As such, it’s critical that anesthesia providers in small hospitals and ambulatory surgery centers receive training in Advanced Trauma Life Support to augment the local response. Additionally, communities need to develop a response plan that includes all of the local medical resources, such as ambulatory centers and urgent care facilities, in the event of an attack.

Finally, we should advocate for the public at large to participate in the American Red Cross’s STOP THE BLEED program to increase the pool of first responders who are able to treat severe bleeding. We should stockpile bandages and tourniquets in all potential target areas. Working together, we may be more able to respond to these horrific events in a more effective way, and ultimately save more lives.  

The American healthcare system is experiencing a growing crisis: How do we adequately staff our operating rooms, hospitals, clinics and offices with healthcare professionals? The lack of staff crosses all professional lines, from physicians to nurses to lab technologists—all levels of staff are in short supply. To deal with this challenge, health administrators have resorted to using temporary contract workers known as locums. These temporary, stop-gap employees are usually paid multiple times more than permanent staff. This practice not only undervalues full-time employees, but also exacerbates the crisis because it robs staff from other facilities to staff another. Finally, the increase in locums, and its associated costs, has undeniably harmed the bottom line with many services and facilities closing down, further decreasing access to healthcare for the public.

We as health professionals need to address this crisis. To do so, the causes must be analyzed and solutions developed. Some issues, such as salary lines and child care, can easily be addressed. Others, such as professional burnout due to electronic medical record systems, which have taken professionals away from patient care—essentially making them data entry clerks—should be addressed, and jointly with technology companies. The bottom line is that all of us must focus on this crisis or it will lead to a marked decline of the American healthcare delivery system.

At the 2023 spring meeting of the American Society of Regional Anesthesia and Pain Medicine, Rajnish Gupta, MD, a professor of anesthesiology at Vanderbilt University Medical Center, in Nashville, Tenn., discusses how podcasting can be a way for anesthesiologists to highlight their academic work and communicate with other like-minded professionals in the specialty.

“The beauty of podcasting is that it allows the speaker to talk on a specific topic to a narrow audience. That way you can expand on a topic that may not be appropriate for a large population of people, but in that small niche, there is a lot of enthusiasm.” 

Barbara Orlando, MD, PhD, an associate professor of anesthesiology and the division chief of obstetric anesthesiology at McGovern Medical School at the University of Texas Health Science Center, in Houston, discusses several ways to reduce morbidity and mortality in pregnant patients. She also addresses high-risk pregnant patients with various comorbidities, such as obesity and those with a lack of prenatal care.

“This podcast is about my personal journey as an anesthesiologist in gaining understanding and being more involved with societies and committees in charge of maternal mortality and morbidity. My interest was sparked by my passion for obstetric anesthesia, and my new role as a division chief of OB anesthesia at UT Houston. Reviewing bad outcomes and thinking of ways of reducing such events was very eye-opening to me, and I hope to inspire others as well.”

Obstructive sleep apnea (OSA) affects 20% of U.S. adults, of whom about 90% are undiagnosed. The major risk factors for OSA include obesity, male sex and a family history of OSA. There is a large body of literature showing that OSA is an independent risk factor for hypertension, heart disease, type 2 diabetes and stroke.  This case illustrates how a patient presented for elective admission for surgery and suffered a stroke.  

A 55-year-old man with obesity presented for elective surgery for a chronic nonhealing ankle fracture. The patient reported a long history of loud snoring and type 2 diabetes. He was administered a general anesthetic and had no issues during the case. The patient recovered and was admitted to the hospital overnight, and it was noted that he had marked bouts of hypertension overnight while sleeping; the patient had no past history of hypertension. The staff also noted evidence of sleep apnea patterns of sleep and snoring. The patient was then discharged home. Three weeks later, the patient presented with a large embolic stroke and was admitted to the neuro-ICU. He was discharged to a rehabilitation facility with marked cognitive issues.  

This case illustrates how important it is for anesthesia providers to screen patients for OSA and educate patients about the major risks of OSA. There were also some key incidents during this admission that support the need for staff education. The episodes of hypertension during sleep and not while awake are a key sign of the cyclic sympathetic outflow that occurs during OSA. This also supports cyclic release of mediators that occurs during severe OSA that can affect the endothelium and cause activation of coagulation cascade. The snoring can also cause direct vibratory trauma to the carotid blood vessels, and also cause endothelium damage on the interior of those vessels that can generate a clot.  

We as anesthesia providers should be at the forefront of identification of OSA and have a protocol to educate patients and refer them to sleep specialists for testing and proper treatment. This can be a major public health contribution of our specialty.  

Cancer is a major global public health concern that affects all citizens and communities around the world. Globally, the incidence of cancer is predicted to increase by 50% by the year 2030; and during the same period, cancer-related mortality is projected to increase by 60% to 13.1 million deaths worldwide. This increasing trend in cancer-related mortality exists despite a slow but steady decline in cancer-related death rates since the early 1990s in the United States and the Western world.

Citizens 65 years of age or older have a cancer incidence rate that is 10 times higher than among younger people, while the mortality rate among older cancer patients is 16 times greater than among younger patients. However, cancer is no longer considered a terminal disease. With the implementation of effective cancer prevention education programs, widely available screening programs leading to early diagnosis, and the advent of effective biologic and immunotherapeutic modalities, the profile of cancer is changing to a chronic medical condition.

There are more than 20 million cancer survivors currently living in the United States alone. Of the nearly 20 million new cancer cases worldwide in 2021, more than 80% of cases will need surgery, some several times as curative resection is essential for global cancer control, particularly for patients with solid tumors. It is estimated that by 2030, over 45 million surgical procedures will be needed globally for cancer control. Furthermore, both patients with cancer and cancer survivors will continue to need the services of our specialty in the perioperative setting well beyond their primary cancer care.  

As most of the diagnostic and interventional procedural care for patients with cancer is provided in the community setting around the world, this textbook, “Perioperative Care of the Cancer Patient,” will serve the educational needs of anesthesia providers in all settings globally. Each of the chapters is authored by international experts in the field and discusses the current understanding and practices, current controversies and unanswered questions, and the direction for future studies.  

I believe this is an exciting time for anesthesiology and perioperative medicine as we continue to partner with oncology and other specialties to break down silos and work together to improve postoperative outcomes and increase disease-free survival.