White Coat Black Art26:30Meet the people who help sedate you
One solution to a critical shortage of anesthesiologists in Canada could lie with increasing the ranks of anesthesia assistants, advocates say.
“In a situation where we have a serious … access to surgical care issue, we have to think about creative solutions to move forward and get people the care they need,” Dr. Sally Bird, pediatric anesthesiologist and chief of pediatric anesthesia at IWK Health Centre in Halifax, told Dr. Brian Goldman, host of CBC Radio’s White Coat, Black Art.
Although many Canadians may not yet be familiar with their work, the anesthesia assistant profession was established more than 50 years ago in Quebec and about 15 years ago in most other provinces. However, they are not yet available everywhere.
As the name suggests, anesthesia assistants (AAs) work under the direct supervision of anesthesiologists.
Rob Bryan, a veteran AA at Mackenzie Health in Richmond Hill, Ont., just north of Toronto, said that “the role of an anesthesia assistant is to extend the care and the service of the physician specialist in anesthesia in the anesthesia department.”
“A physician is always in charge of the patient’s care,” said Bryan, who was working in an endoscopy room providing anesthesia for colonoscopy patients on the day White Coat, Black Art visited the hospital.
In contrast, specially trained nurses called nurse anesthetists can practise anesthesia independent of doctors in the United States, but they have not been able to do so in Canada since the end of the Second World War.
Nurse anesthetists, also called certified registered nurse anesthetists, can have their own practice similar to the way a nurse practitioner can provide primary care in the absence of a family doctor. That means they can fill a gap in rural and remote areas of the U.S., for example, providing sedation in places where it wouldn’t otherwise be possible to even get an epidural for labour and delivery.
Duties of AAs vary among provinces
Canadian anesthesiologists say it doesn’t make sense to launch a new program to certify nurse anesthetists, given that Canada already has an established system with AAs that could be scaled up — not just in numbers but in scope of practice.
“We work so well together as a team, and there’s already a high level of trust,” IWK’s Bird said.
That’s also the official stance of the Canadian Anesthesiologists’ Society, which came out with a position statement the last time there was a push in British Columbia to introduce nurse anesthetists, saying the organization “firmly rejects” nurse anesthetists in Canada. Instead, its plan to address surgical wait times includes, among other things, increasing the number and availability of trained AAs.
Most anesthesia assistants have backgrounds as respiratory therapists (RTs), although some come to it from the ranks of registered nurses and all have additional training in anesthesia.
Mackenzie Health’s Bryan has a designation called Certified Clinical Anesthesia Assistant, or CCAA, given by the Canadian Society of Respiratory Therapists to RTs like him who received that additional training. In Canada, not all anesthesia assistants are CCAAs like him.
While what anesthesia assistants are permitted to do varies from province to province, they’re becoming part of anesthesia teams in more and more parts of Canada.
New data from the Canadian Institute for Health Information shows patients in all provinces are waiting longer than before the pandemic for some priority orthopedic and cancer surgeries, but it’s not all bad news — overall more surgeries are being performed than ever.
‘Pretty incredible people with a lot of expertise’
Dr. Jerod Gollant, chief of the department of anesthesiology at Mackenzie Health, said that before AAs joined the hospital’s staff, it routinely had to postpone procedures because there weren’t enough anesthesiologists.
That doesn’t happen now, he said, because anesthesia assistants have allowed the department to be more efficient and see more patients.
For example, having multiple AAs working in the endoscopy unit under the supervision of one anesthesiologist allows another anesthesiologist to be freed up to work elsewhere in the hospital, Gollant said.
“So we’re able to provide the therapeutic diagnostic and screening endoscopic procedures for all of our community while not cancelling any surgeries downstairs in the main operating room.”
At IWK in Halifax, the scope of practice for AAs has expanded gradually starting in 2021, said Bird, the hospital’s chief of pediatric anesthesia.
“Initially, when they started they would do things like help us out with putting patients off to sleep, help out in the recovery room,” she said. “But we slowly realized that these are pretty incredible people with a lot of expertise to offer, and so our anesthesia assistants now, in collaboration with us, are doing independent procedural sedations.”
Sami Jreige is one of the certified clinical anesthesia assistants who works with Bird.
“We are a little unique in terms of what the AAs can do…. We can provide deep sedation to patients to have procedures done that would otherwise require an anesthesiologist to do,” he said.
“That’s probably my favourite part of my job is being able to go off and clear a waitlist or schedule elective cases specifically for the AAs, where we can get things done in a more timely and efficient manner.”
Limited training capacity
An editorial in the Canadian Journal of Anesthesia in September 2024 said not only is there a relative lack of awareness of the profession as a career option, but training capacity is too low.
The editorial points out that there are only four accredited AA training programs in Canada — two in Ontario and two in British Columbia, as well as one provisionally accredited program in Alberta.
“I don’t think we’re a very well-known profession, to be honest,” Jreige said, noting that even among health-care workers, those who don’t work in operating rooms or with anesthesia departments may not have heard of AAs.
Carolyn McCoy, director of professional practice for the Canadian Society of Respiratory Therapists, which represents certified clinical anesthesia assistants, said it takes one to two years to complete the additional training required to become a CCAA.
“Typically, because the education to become an anesthesia assistant is not funded, in order to pay the bills … the vast majority continue to work full time while they’re taking this additional education on the side.”
The editorial in the Canadian Journal of Anesthesia said training subsidies could be part of increasing the number of AAs, as could better pay. A more robust supply of trained AAs is also key to avoiding burnout among existing anesthesiologists, it said.
Bird said she firmly believes AAs can make for a stronger anesthesia workforce in Canada, especially given that anesthesia assistants are already in place in many hospitals.
“With … some extra mentoring and training, they could do so much more, which would benefit really everyone in the system: patients, health-care providers and anesthesiologists.”
