The thoughts must be pretty loud, because within seconds the guy in 6A clears his throat.

"Well," my partner in the seat next to me begins, "would your rather have the co-pilot flying? He only has a couple of years flying experience. The co-pilot wasn't a transport pilot for the army flying large cargo planes on a regular basis, and he hasn't got the 12 years of experience the pilot has."

"Of course not," I answer.

"Well what do you want?" he rejoins.

"Ideally, I want a couple of good pilots in each plane."

"That's too expensive," he notes.

"OK, I want a senior and a junior pilot on each plane, then."

My interlocutor wonders this: "Is it OK if the co-pilot flies the plane while the pilot is back in the galley schmoozing with the stewardesses?"

"Well as long as he checks in frequently, is there for take-off and landing, and is immediately available, I suppose that while autopilot is engaged, there's no harm."

"Would you feel better if we simply ditched the co-pilot, who's more apt to make a mistake, and just have the pilot there?" he inquires.

"Depends on whether the more frequent mistakes a co-pilot makes can be rectified more easily by the senior pilot, resulting in fewer crashes, or whether the mistakes a solo pilot makes are more likely to plunge me to my doom, even though it occurs more rarely."

The barbed questioner asks, "What about having a fully trained commercial airliner co-pilot versus a former fighter pilot who is now in training for commercial flights, and who will eventually be chosen to be a lead pilot?"

I consider. "Well, the former fighter pilot is still learning, and might have more skills, but he or she is not yet fully developed. He or she might think things through with a little more knowledge base, but hasn't necessarily had to pull a commercial jet out of a dive, even though they understand the theory. Could be a wash, in my mind."

HMMMMMMM. We pause. We are inside a metal tube, hurtling at supersonic speeds 35,000 feet above a Jersey Turnpike tollbooth.

That's this study. The investigators found that, with more CRNAs, fewer residents, fewer solo anesthetics, more care team concurrent anesthetics, higher rates of critical incidents, there were lower rates of patient injury. This study bears out my anecdotal experience and opinion that two heads are better than one. They don't have to have equal experience, they don't have to be equal in knowledge, and they don't have to have equal authority as long as each brings their talents to the rescue of patients. As in the above example, although the pilot is clearly in charge, a good recommendation the co-pilot makes can still be valuable.

At the one academic center in which this retrospective study was done, over five years, as resident numbers (and, perhaps, quality) decreased, more CRNAs were added to the staff and the number of cases done by CRNAs doubled to about 30%. Attendings did not have the luxury of sitting in a room giving solo anesthesia. The MD did a much higher concurrency rate (going from 1.6 to 2.2 rooms on average), and so the top guy paid less attention to any one patient, and more critical incidents where anesthesia was primarily involved, occurred. But the patient injury rate went DOWN. Seems like a resounding endorsement of the anesthesia care team as a reasonable approach to doing the work. There are huge political implications here (which I will neither address nor respond to), but collaborative team approaches with skilled doctors and nurses, in my mind, make more economic sense now than ever before. If physicians can learn to leverage their skill set, and provide their value by greater rescue of patients from harm, then that seems a good thing. The involvement of board certified anesthesiologists has been noted as an associated factor in the rescue from critical events in other studies as well.

The paper did not note in which type of cases (solo MD, MD plus CRNA, MD plus resident) the critical incidents occurred, nor at what rate, nor did they report whether the level of resident or years of CRNA training had some association. That would have been quite interesting. They only reported overall practice rates of problems. The point is that increased concurrency and use of CRNAs in a care team in a tertiary care center was associated with better patient outcomes. That's where we should all want to be, regardless of philosophy! It would be very interesting if similar data on practice incidents/outcomes could be obtained from tertiary care centers that went in the opposite direction, using more solo anesthesiologist care to make up for decreased residency numbers.

This paper suggests that critical incidents are NOT the indicator to be used to determine anesthesia safety, but the ultimate outcome - patient harm. How correct can you get!!! Bad things happen; how you respond is the key. Anytime we use intermediate outcomes, rather than final outcomes (i.e. how a patient feels or what he experiences) means we may come to the wrong conclusions. The authors are to be commended for their efforts in this regard.