History of Canadian Anesthesia

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The first reported anesthesia in a territory that would become part of Canada (in 1867) was in the British colonial province of New Brunswick, in January 1847. In the late 19th century, Canadian anesthesia was linked primarily with that in the UK, leading to a physician-based practice, which continues to the present. In the early 20th century, US influence increased. By the 1930s a true Canadian identity began to emerge and, in time, to dominate. The Canadian Society of Anaesthetists formed in 1920, but lapsed in 1929 with the start of the Anaesthesia Section of the Canadian Medical Association. The Montreal Society of Anaesthetists, established in 1930, became the Canadian Anaesthetists' Society (CAS) in 1943. The CAS was renamed the Canadian Anesthesiologists' Society in 1993. The CAS began a medical journal in 1954, an international education fund in 1967, and a research foundation in 1979.

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Since anaesthesia, unlike medical or surgical specialties, does not constitute treatment, this study sought to determine if methods used to assess medical or surgical outcomes (that is the determination of adverse outcome) are applicable to anaesthesia. Anaesthetists collected information on patient, surgical and anaesthetic factors while data on recovery room and postoperative events were evaluated by research nurses. Data on 27,184 inpatients were collected and the analysis of outcomes determined for the intraoperative, post-anaesthetic care unit and postoperative time periods. Logistic regression was used to control for differences in patient populations across the four hospitals. In addition, a random selection of 115 major events was classified by a panel of anaesthetists into anaesthesia, surgical and patient-disease contributions. Across the three time periods, large variations in minor outcomes were found across the four hospitals; these variations ranged from two-to five-fold after case-mix adjustment (age, physical status, sex, emergency versus elective and length of anaesthesia). The rates of major events and deaths were similar across three hospitals; one hospital had a lower mortality rate (P < 0.001) but had a higher rate of all major events (P < 0.0001). Of major events assessed by physician panels, 18.3% had some anaesthetic involvement and no deaths were attributable partially or wholly to anaesthesia. Possible reasons to account for these variations in outcome include compliance in recording events, inadequate case-mix adjustment, differences in interpretation of the variables (despite guidelines) and institutional differences in monitoring, charting and observation protocols. The authors conclude that measuring quality of care in anaesthesia by comparing major outcomes is unsatisfactory since the contribution of anaesthesia to perioperative outcomes is uncertain and that variations may be explained by institutional differences which are beyond the control of the anaesthetist. It is suggested that minor adverse events, particularly those of concern to the patient, should be the next focus for quality improvement in anaesthesia. Puisque l’anesthésie, contrairement aux spécialités médicales ou chirurgicales, ne constitue pas un traitement, cette étude a cherché à déterminer si les méthodes utilisées pour évaluer les issues des actes médicaux ou chirurgicaux (soit la détermination d’une issue défavorable) sont applicables en anesthésie. Les anesthésistes ont colligés l’information concernant les facteurs reliés aux patients, à la chirurgie et à l’anesthésie, alors que les données concernant la salle de réveil et les événements post-opératoires étaient évaluées par des infirmières de recherche. Des données concernant 27,184 patients hospitalisés ont été colligées et l’analyse des issues déterminée pour les périodes intra-opératoire, de salle de réveil et postopératoire. Une régression logistique a été utilisée pour contrôler les différences entre les populations de patients des quatre hôpitaux. De plus, une sélection au hasard de 115 événements majeurs a été classifiée par un groupe d’anesthésistes selon la contribution de l’anesthésie, de la chirurgie et de la maladie du patient. Pour les trois périodes considérées, de grandes variations dans les issues défavorables d’importance mineure ont été trouvées entre les quatre hôpitaux; ces variations s’étendaient de deux à cinq fois après ajustement pour la variété des cas (âge, condition physique, sexe, cas d’urgence versus cas électif, et durée de l’anesthésie). Les taux d’événements défavorables majeurs et de mortalité étaient similaires pour trois hôpitaux; un hôpital avait un taux de mortalité plus faible (P = 0,0004) mais avait un taux plus élevé pour tous les événements majeurs (P < 0,0001). Parmi les événements majeurs évalués par les groupes de médecins, 18,3% avaient un certain lien avec l’anesthésie et aucune mortalité n’était attribuable en partie ou en totalité à l’anesthésie. Les raisons pouvant expliquer ces variations dans l’issue des soins anesthésiques incluent la compliance à enregistrer les événements, un ajustement inadéquat pour la variété des cas, des différences dans l’inteprétation des variables (malgré les directives) et des différences institutionnelles dans les techniques de surveillance et les protocoles d’observation et d’inscription au dossier. Les auteurs concluent que mesurer la qualité des soins en anesthésie en comparant les issues défavorables majeures est non satisfaisant puisque la contribution de l’anesthésie à ces issues péri-opératoires est incertaine et que les variations peuvent etre expliquées par des différences institutionnelles sur lesquelles l’anesthésiste n ’a pas de contrôle. Il est suggéré que les événements difavorables mineurs, particulierement ceux qui intéressent le patient, devraient être le prochain point d’intérêt pour améliorer la qualité en anesthésie.
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To review the effectiveness of the Research Grants, Career Scientist Award and Fellowship Program (RGCSFP) of the Canadian Anesthesiologists' Society (CAS)/Canadian Anesthesia Research Foundation (CARF) by surveying past recipients. The CAS Research Committee database of past RGCSFP recipients was reviewed to identify all past award recipients from the time of program inception in 1985 until the year 2005. A questionnaire was mailed to all past recipients with retrievable addresses. The questionnaire asked specific questions regarding past and current research, publications, grant procurement and mentoring of trainees. In addition, opinions regarding the program's effectiveness were solicited. Of the 100 mailed survey forms, 66 (66%) were completed and returned. The number of original published articles per respondent was 30.1 +/- 28.5 (mean +/- SD) at the time of the survey, and the life-time number of all publication types was 38.5 +/- 34.6. Cumulative research funding increased in relation to the number of years in research, and amongst past recipients with > 15 years in research, individual research funding from all sources was $585,747 +/- $773,716. Ninety-six percent of respondents agreed or strongly agreed that the program was valuable. The RGCSFP has supported a large number of new and established anesthesia investigators in Canada, and these individuals have demonstrated high research productivity. The program is considered to be very valuable according to past recipients.
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Conclusion It is apparent that, despite the earlier use of ether by a country practitioner (Crawford Long) and dentists (William Clark and Horace Wells), the influence of a pair of distinguished surgeons (John C. Warren and Henry Bigelow) was required to promote the widespread use of ether following William Morton’s demonstration of its efficacy at the Massachusetts General Hospital. The accounts that Drs. Warren and Bigelow wrote for theBoston Medical and Surgical Journal were widely reported in many countries. Dr. Bigelow’s father, Professor Jacob Bigelow, wrote a personal letter to a friend in England, Dr. Francis Boott, telling him of the discovery. Two days after receiving this letter, Dr. Boott was present when ether was first administered in England (on December 19, 1846), and two days after this Robert Liston used ether for a leg amputation at University College Hospital in London. Thus the future of surgical anaesthesia in England was assured. The abortive attempts by Morton to conceal the nature of the anaesthetic agent and to patent the process of its application little delayed the spread of the use of ether. The news of ether anaesthesia was received in Upper Canada during December 1846. In fact, the country practitioners of Brockville or Chatham heard of this discovery before Francis Boott or Robert Liston in England. Upper Canada in the 1840s was a country of pioneers: country doctors were accustomed to managing all aspects of medical care, so it is not surprising that it was these practitioners who read of ether anaesthesia and were among the first to apply it.* The use of ether for tooth extraction and surgical operations was probably widespread throughout rural Upper Canada within six months of Morton’s original demonstration — as illustrated in Fig. 3, an excerpt from theChatham Gleaner of Tuesday, May 25, 1847.
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To examine the supply of physician anesthesia providers necessary to accommodate the previously described clinical and non-clinical service volume needs throughout Canada. The Canadian Medical Association (CMA) physician database provided baseline specialist anesthesiologists numbers and ages as of January 1, 2000. The Royal College of Physician and Surgeons of Canada (RCPSC) provided annual anesthesia certificant numbers for the period 1971-2000. Combining these data with the separately reported estimates of anesthesia provider needs for the years 1999 and 2016, the matching of anesthesia provider supply and demand during the period 2000-2016 was examined. The CMA database included 2,287 anesthesiologists in Canada on January 1, 2000. The needs assessment (clinical and non-clinical) identified the requirement for 2,495 full time equivalent (FTE) anesthesiologists in 1999 and 3,265 in 2016 (31% increase). Taking into account the ages of current anesthesiologists, the increased future requirements and the current rate of graduation from RCPSC-approved training programs in Canada a deficit of at least 656 FTEs is identified for the period 2000-2016 (average 41 per year). Canada has a current shortage of anesthesiologists. Based on the assessment of future needs in Quebec and extrapolated to all provinces, this shortage will worsen, unless Canadian training programs are expanded or other steps are taken to augment the numbers of anesthesia practitioners. Ongoing studies in each province are required to validate and update these conclusions.
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A human resource planning model for anesthesiology is described. The model uses 'per capita' expenditure for anesthesiologists in Quebec, as a measure of clinical services provided to different age/gender groups. The future demand for anesthesia services is calculated as the product of 'per capita' expenditure and the population projections to a future date. Future demand was converted into full-time equivalent (FTE) providers required, by dividing by the annual 'units of service' optimally delivered by one FTE anesthesiologist. The pattern of age/gender (demographic) consumption of anesthesia services in Quebec was compared with data from Ontario to validate its use in a planning model. The model was then applied to all provinces and territories. The 'per capita' expenditures on anesthesia services in Quebec and Ontario showed a regular pattern. Using the model, the estimated 1999 demand for FTE anesthesiologists to provide clinical services in Quebec is 546 and 669 for 2016. When non-clinical demands were included, we estimated that Quebec's total demand will increase to approximately 730 FTEs in 2016. Similar estimates are made for all provinces. The population increase anticipated is 17.9% but the increase in FTE demand in Canada is 30.9%. The model showed that the cause of the increased FTE demand for anesthesiologists is a combination of increased population and its demographic composition. The relative impact of each of these factors varies in different provinces. Effective specialty-specific planning models can be designed but they need ongoing committed resources and personnel for their usefulness to be maximized.
Trm CANADIAN MEDICAL PROFESSION has more than one reason for celebrations during 1967. The Centennial of Confederation is a fact already known. But 1967 also marks the one-hundredth anniversary of the foundation of the Canadian Medical Association, the centenary of the discovery of antisepsis by Lister, and the one-hundred-and-twentieth year of the first use of anaesthetics in Canada. Historical facts transmitted verbally soon become legends because they quickly begin to lack authenticity. Historical facts reported in writing and not invalidated or refuted at the time they took place are certainly nearer to veracity. Browsing among old books and old medical journals, gleaning from old newspapers, I finally found a reliable answer in my search for the first physicians who used and administered anaesthetics in Canada. As a starting point, let us remember that sulphuric ether was first used clinically on October 16, 1846, by William Thomas Green Morton (1819-1868) at the Massachusetts General Hospital in Boston, when Dr. J. C. Warren removed a
Charles Robson (Figure 1) was born in New Westminster, British Columbia (now a suburb of Vancouver), in 1884 and graduated in medicine from McGill University in Montreal in 1913. Having interned and with some anesthesia training at the Royal Victoria Hospital in Montreal, he was sent overseas to work in a Canadian Army Hospital where he founded a school to train military anesthetists. Returning to Canada in 1919, he joined the staff of the Hospital for Sick Children in Toronto as chief anesthetist, a position he held until 1951 (1). During most of this time, he was the sole full-time anesthetist at the hospital; administration of anesthesia at this hospital was not limited to staff anesthetists until 1950 (1). Figure 1. Dr Charles Robson. Download figure to PowerPoint
Since 1847 anaesthesia in Canada has evolved through six phases. In the first (1847-1898), it was a craft without an academic and professional base. The second (1899-1919) was marked by the first academic appointments and by Canadians' wartime experiences of anaesthesia. The third phase (1920-1929) evidenced the professional satisfaction of anaesthesia and included the founding of the Canadian Society of Anaesthetists. In the fourth phase (1930-1943) the growth of the Royal College of Physicians and Surgeons of Canada, the introduction of certification and the founding of the definitive professional society--the Canadian Anaesthetists' Society--fostered the evolution of what was now becoming a recognizable specialty. The fifth phase (1944-1971) was one of resolution of problems affecting the status of anaesthesia: the first autonomous department of anaesthesia in a Canadian university was founded (at McGill in 1945), the Royal College Fellowship was approved for anaesthesia (in 1951), the Canadian Anaesthetists' Society Journal was launched (in 1954) and a single standard for certification of specialists was finally established (in 1971). In the sixth (1972-1989), the main elements were the assumption of responsibility for residency training by the universities and by the renaming of the journal as the Canadian Journal of Anaesthesia. Through these years of increasing professionalism, it has, however, been the accomplishments of individual Canadian physicians, facing many challenges, that have made the specialty in Canada recognizably Canadian.
Using a radiologic technique, the position and pattern of movement of the diaphragm have been evaluated in three adult volunteers, both awake and anesthetized, during spontaneous ventilation and with muscle paralysis and mechanical ventilation. Studies were made with the subjects in supine and left lateral decubitus positions with tidal and large volume breaths. Positive end expiratory pressure (PEEP) was added in studies of two subjects. During spontaneous ventilation awake or anesthetized, because of regional mechanical advantages, the dependent part of the diaphragm had the greatest displacement despite the higher intra abdominal pressure in this region. Paralysis, awake or anesthetized, caused a cephalad shift of the end expiratory position of the diaphragm that was disproportionately large in dependent regions. It also reversed the pattern of diaphragmatic displacement. The passive diaphragm was displaced preferentially in nondependent zones where abdominal pressure is least. Consequently, PEEP could not restore the diaphragm to its awake functional residual capacity position, and large breaths also could not duplicate the pattern of displacement achieved spontaneously.
In a recent demonstration in anesthetized dogs normal gas exchange was maintained over prolonged periods of time by applying at the airway very high frequency (15 Hz) sinusoidal oscillations with a volume less than half that of the physiologic dead space. Now, 12 patients have been ventilated in this way for as long as 1 hour. All were being mechanically ventilated either following major vascular surgery or for treatment of respiratory failure. Their ages varied from 3 days to 74 years; weights ranged from 2.5 to 100 kg. Oscillatory volumes of 1.5 to 3.0 ml/kg of body weight were delivered using a piston pump operating at a frequency of 15 Hz. Baseline cardiorespiratory data obtained during standard mechanical ventilation were compared to the means of four to six observations obtained during the period of oscillation. The calculated shunt fraction decreased significantly from 12.5 ± 9.1 during mechanical ventilation to 8.2 ± 6.8 during oscillation with no change in either arterial CO2 tensions (37.7 ± 5.0 torr during mechanical ventilation; 37.6 ± 5.4 torr during oscillation) or cardiac output (6.1 ± 2.1 L/min during mechanical ventilation; 6.0 ± 2.3 L/min during oscillation). Two patterns of response were evident. Patients with predominantly right to left shunting (e.g., septic shock) showed little change in calculated Qs/Qt with oscillation. In patients with chronic obstructive lung disease in whom one would expect to have extensive V/Q mismatch, oscillation resulted in large decreases in Qs/Qt ratio (e.g., 25.0 → 13.0). Oscillatory ventilation appears to be a promising new way of achieving gas exchange with minimal risk of barotrauma to the lung.
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