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November 15, 2009

アウェースコープ

10月くらいから仕事が忙しい。多忙の時は誰でも,自分が仕事を失う日のことなど想像しない。それどころか,「もう少し楽させて欲しい」と願ったりする。自分もそのひとり。しかし贅沢を言ってはいけない。商売繁盛と喜ぶべき。「フリーの麻酔科医がやっていけるのはここ数年」が的外れでない保証はない。

IMIがエアウェイスコープのキャンペーンを行っている。噂では定価の半額近くになるらしい。さてはいよいよ第二世代の発売が予定され,旧型の在庫一斉処分か? そもそも今のAWSは重たくてでかい。肥満患者ではイントロック挿入時に本体が胸部につかえてしまう。パイルダーオンとかいう方法もあるが,確かにイントロック単体では口に入れやすいものの,そのあとに大きくて重たい本体を乗っけるのは少し抵抗がある。本体にイントロックを固定する際に余計な力がかかって歯を損傷する恐れもある。それに,私はマジンガーZが好きではない。

本体が患者の胸につかえないような工夫が施され,さらに小児用やDLT用のイントロックが発売されたなら,AWSはもっと普及するかもしれない。しかし,実は私はこれの普及を密かに恐れている。
外科医たちがAWSを色モノ,マニアックな麻酔科医のオモチャ,ブラードやトラキライトに続く“いつもの”趣味の小道具と見ている間は心配ないが,彼らが「これを使えば俺たちも気道確保を恐れずにすむのではないか」と変な気を起こされると困る。AWSの成功を参考に,光学系が得意な企業がこぞって同系統の挿管用具の開発に乗り出すかもしれない。3Dのデジタルカメラさえ市販されている今日,AWSよりも進化した挿管用具が明日世に出ても不思議ではない。

麻酔科医としては「気管挿管をなめるな。器具が進化しても挿管はそんなに簡単ではない」と言い切りたいところだが,所詮はノドの奥にある2本の管の一方にチューブを入れるだけのこと。声門という,口から十数センチ奥の暗くて狭い箇所が鮮明に(特に曇らず)見えるよう液晶画面と光源を備え,チューブ先端が声門に向けて進むような仕組み(これが一番難しい?)があればいい。

外科医たちがAWSもしくはこれに準ずる挿管用具に習熟し気道確保を恐れなくなったなら,私はお払い箱になる可能性がある。麻酔科医のレーゾンデートルというか,気むずかしい(?)フリーの麻酔科医を外科医がわざわざ雇うのは,自分たちで全身麻酔を行いたくないから。なぜ自科で麻酔をしたくないかというと,気道確保に失敗すると患者の死亡や脳死につながるから。では外科医にとって気管挿管が難しい手技でなくなったとき,彼らはどうするか? 「外科医も少なくなっているので,さらに麻酔に人手をとられたくない」と,やはり麻酔科医を雇い続けてくれるか。それとも,小うるさい麻酔科医をばっさり切り捨てるか。

「AWSでの挿管に失敗したとき,外科医たちは自力でリカバリーできるか」という指摘もあるだろう。しかし現在,挿管困難が予想されない患者においてAWSで挿管に失敗した場合,その原因の大半はイントロックのサイズが1種類しか存在しないことに起因すると思う。イントロックのバリエーションが増えればAWSでの挿管不能は格段に減るのではないか。確かに我々麻酔科医はAWSで挿管に失敗しても他の引き出しを持っている。しかしAWSを使い始めた頃はともかく,何百例もAWSで挿管している熟練者がAWSで挿管できない場合,麻酔科医がその後打てるリカバリーショットも限られてくるに違いない。スガマデックスが発売される日も近い。外科医たちが「我々がAWSで挿管できないということは麻酔科医にとっても難しいはずだから,無理に挿管するのはやめよう。エスラックスをスガマデックスでリバースして手術を中止。マスク換気も難しいなら即気管切開」と割り切ってしまうことも考えられる。

もちろん麻酔科医の仕事は気道確保だけではない。循環のコントロールや術後鎮痛,悪性高熱に代表される地雷的イベントへの対処などなど…。しかし,「何年も挿管したことがない」という外科医はいても,「ドーパミンやペルジピンを使ったことがない」外科医はおそらくいない。自分たちでルンバールを施行しているなら,急激な血圧低下にもしょっちゅうお目にかかっているだろう。気道確保に比べて,循環コントロールのハードルはそれほど高くないと思われる。術後鎮痛に関しては,麻酔科医が硬膜外カテーテルや末梢神経ブロックを駆使して創部痛を完全に抑えれば,確かに外科医は術後管理が楽になる。では外科医が自分たちでプレーンな全麻だけして術後に患者が痛がればどうなるか? どうということはない。ボルタレン坐薬,ペンタジン筋注,ロピオンDIVの回数が増えるだけ。なかには「術後は痛がるぐらいがちょうどいい。まったく痛がらずにいると呼吸が止まらないか不安になる」という外科医もいる。そして地雷的イベントへの対処だが,悪性高熱症の治療に慣れている麻酔科医は少ないどころか,見たこともない麻酔科医がほとんど。経験がないという点では外科医と変わらない。アナフィラキシーショックに至っては麻酔薬以外でも発生するので,むしろ外科医の方が経験豊富かも知れない。

杞憂である可能性も高い。「俺はそこらへんの麻酔科医より挿管がうまい」と公言もしくは内心思っていた外科医は昔からいたが,彼らが麻酔することはなかった。病棟でサーボは使えても,麻酔器には触れることもできない外科医も多く見てきた。外科医の仕事だけで充分忙しいのに,わざわざ麻酔の仕事まで新たに引き受けるようなことはしないだろう。その麻酔科医のことがよほど嫌いでなければ。

とにかく,気道確保は外科医にとってホームではなく,アウェーであって欲しい。

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Comments

私は、脊椎の手術でも、ほとんど普通に挿管してます。ファイバー使えないわけでもありませんが、普通にできるものをわざわざファイバー使うなんて研修医の練習の時だけでいいじゃないかという気持ちからですが。
で、ほとんど急患は自前でやってもらうようにしてますけど、やっぱりできるだけ自前麻酔はしたくなようですよ。

Posted by: タカ派の麻酔科医 | November 16, 2009 at 11:34 AM

外科医では挿管は普通にやっているイベントなんで、べつだんやることに抵抗はないです。とくにわれわれはawakeの人に挿管するんで、筋弛緩かかっている人ばかり挿管する麻酔医よりもスキルが劣っていることはないと思います。
外科医が当科麻酔を嫌がるのは、手術に集中できないからと、なにかあったときの責任の追及が嫌だからなのが主でしょう。ゆえに、挿管がいかに容易になろうが、麻酔科の出番はまったく減らないと確信します。

Posted by: 地方外科医 | November 16, 2009 at 12:29 PM

管理人様
「患者の胸につかえないような工夫」ですが、わたくしはいわゆるramp positionを採用しています。肩枕をいれて背中から徐々に高くしていき、外耳孔と胸骨が同じ高さに…というアレです。ただし、あまりにこれをやると、チューブやGEBが前交連・輪状軟骨に衝突してしまい、声門が見えてもうまく挿管できなくなる危険性があるかもしれません。

地方外科医様
まったくおっしゃるとおりだと思います。
「筋弛緩かかっている人ばかり挿管する麻酔医」も多いかもしれませんね。
わたくしは手術室でもAWSあるいはファイバースコープによる意識下挿管を積極的に施行していますが、最近では、挿管するのに麻酔導入・筋弛緩薬投与は必要ないのでは…?、とも思うようになりました。

いずれにしても、誰にでも安全に麻酔が行えるのだったら、世の中にとってはハッピーなのではないでしょうか。

Posted by: くるたん | November 16, 2009 at 08:49 PM

タカ派の麻酔科医様,地方外科医様,コメントをありがとうございます。

私の仕事が奪われることはないとのこと,少し安心しました。

Posted by: 管理人 | November 16, 2009 at 09:32 PM

くるたん様,コメントをありがとうございます。

>いずれにしても、誰にでも安全に麻酔が行えるのだったら、世の中にとってはハッピーなのではないでしょうか。

まったくその通りです。自分の仕事が減ることばかり気にしている私は恥じ入るばかりです。

Posted by: 管理人 | November 16, 2009 at 09:40 PM

 麻酔科医が挿管出来ないときによく内視鏡ガイドで挿管してあげます。早めに替わってあげた方が結局時間短縮になるし、CVCも麻酔がかかったらすぐに自分で入れます。それでも自前の麻酔は(他科の麻酔をすることはあっても)かけません。

Posted by: 私立病院外科医 | November 21, 2009 at 08:41 AM

当分は麻酔科医の仕事がなくなることはなさそうそのこと,安心しました。

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