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Address correspondence to: D. John Doyle MD PhD FRCPC; New Media Editor, Canadian Journal of Anesthesia, Department of Anesthesia, The Toronto Hospital, 200 Elizabeth Street, Toronto, Ontario Canada M5G 2C4 Voice pager: (416) 375-0565; Fax: (416) 340-3698; E-mail: djdoyle{at}home.com

1. Airway Resources on the Internet: Part 1

UNIVERSITY OF WISCONSIN AIRWAY RESOURCES

Adult vs Pediatric Airway

http://www.anesthesia.wisc.edu/Topics/Airway/inf_vs_adult.html

Indications for Double Lumen ETTs

http://www.anesthesia.wisc.edu/Topics/Airway/double_lumen_ett.html

High-Frequency Jet Ventilation

http://www.anesthesia.wisc.edu/Topics/Airway/hf_ventilation.html

Complications of Nasotracheal Intubation

http://www.anesthesia.wisc.edu/Topics/Airway/nasotrachintub.html

Pressure Support Ventilation

http://www.anesthesia.wisc.edu/Topics/Airway/presssuppvent.html

Superior Laryngeal Nerve Block

http://www.anesthesia.wisc.edu/Topics/Airway/sup_laryngl_nerve.html

Transtracheal Jet Ventilation

http://www.anesthesia.wisc.edu/Topics/Airway/transtrach_jet.html

Apneic Oxygenation

http://www.anesthesia.wisc.edu/Topics/Airway/apneic_oxygenation.html

EMERGENCY AIRWAY MANAGEMENT GUIDE

The following sets of notes are from lectures presented as part of the annual Emergency Airway Management Course sponsored by Anesthesiology and Emergency Medicine at Vanderbilt University.

Evaluation of the Emergency Airway (John Barwise MD)

http://anesthesiology.mc.vanderbilt.edu/resweb/eamg/Eamg2.htm

Controlled Ventilation (Ahmed Badr MD)

http://anesthesiology.mc.vanderbilt.edu/resweb/eamg/Eamg3.htm

Indirect Tracheal Intubation (Mehmood Durrani MD)

http://anesthesiology.mc.vanderbilt.edu/resweb/eamg/EAMG4.htm

Direct Laryngoscopy and Endotracheal Intubation (Richard Levitan MD)

http://anesthesiology.mc.vanderbilt.edu/resweb/eamg/Eamg5.htm

Flexible Fiberoptic Laryngoscopy and Endotracheal Intubation (Charles Beattie MD PhD)

http://anesthesiology.mc.vanderbilt.edu/resweb/eamg/EAMG6.HTM

Use of Pharmacologic Agents (Garry Walker MD)

http://anesthesiology.mc.vanderbilt.edu/resweb/eamg/EAMG7.htm

Confirmation of Endotracheal Intubation (Steven White MD)

http://anesthesiology.mc.vanderbilt.edu/resweb/eamg/EAMG8.htm

Management of the Pediatric Airway (Jayant Deshpande MD)

http://anesthesiology.mc.vanderbilt.edu/resweb/eamg/EAMG9.htm

Evaluation of a Child with Inspiratory Stridor (Gail E. Rasmussen MD)

http://anesthesiology.mc.vanderbilt.edu/resweb/eamg/RASMUS.htm

LARYNGEAL MASK AIRWAY WEB PAGES

Insertion of a Laryngeal Mask Airway (video)

http://www.ispub.com/journals/IJA/Vol1N3/lmavdogo.htm

Laryngeal Mask Airway

http://gasbone.herston.uq.edu.au/teach/su602/docs/c13laryg.html

Toronto LMA Web Site

http://doyle.ibme.utoronto.ca/lma/index.htm

LMA Publications List

http://www.saga.nl/lma/lmapubl.html

Laryngeal Mask Airway: Uses in Anesthesiology

http://www.sma.org/smj/96jun1.htm

Effects of Laryngeal Mask Insertion on Intracranial Pressure

http://www.ispub.com/journals/IJA/Vol1N3/case.htm

LMA Company Web Site

http://www.lmaco.com/company/index.htm

AIRWAY TEXTBOOK IN PROGRESS

Doyle, D. John. The Airway Casebook (Working Title)

(Word for Windows 97 format)

http://canmed.net/50cases.doc

2. GASNet Anesthesia Resource

http://gasnet.med.yale.edu

This is perhaps the best known of anesthesia resources on the Internet, and comes highly recommended. It is run by Dr. Keith Ruskin at Yale University. The site includes a large variety of worthwhile offerings. Some samples:

Virtual Anesthesia Textbook

http://gasnet.med.yale.edu/mirror/vat/

The Virtual Anaesthesia Textbook is a collaborative effort by people from around the world to provide a comprehensive textbook style listing of Web Pages relating to the practice of anesthesia.

Anesthesia Discussion Forum

http://gasnet.med.yale.edu/discussion/anesthesiology/

Subscription is available free of charge to any anesthesiology professional.

RealVideo G2 Video on Demand Server

http://gasnet.med.yale.edu/theater/videos/videos.html

Medicolegal Case Discussions. Example:

http://www.gasnet.org//journals/amp/1999/january/judge/judge.html

Digital Echocardiography Reference Library

http://www.gasnet.org/reference/echolib/

This resource uses VDOLive technology to deliver high-quality echocardiogram videos over a 28.8 kb or faster modem connection. You will need a VDOLive player (available by download free of charge).

3. Running a Virtual Office or Laboratory from the Internet

Most anesthesiologists have an office of some sort. I have two physical offices (one at home) and a new virtual office which I operate for the Society for Airway Management (SAM), where I primarily serve as editor of the society newsletter (the Airway Gazette) but also serve as an unofficial technical advisor. (Of interest, the newsletter name was suggested by Microsoft Publisher when I used this program to produce the inaugural edition!).

My two physical offices are overfilled with box after box of files, random documents, half-finished papers and reviews, along with a considerable number of unsorted papers. The sheer volume of stuff, and not having a secretary to help with filing, both contribute substantially to my chaotic offices. Nevertheless, everything gets sorted out annually, in time for filing income taxes. Still, important files sometimes remain lost for months at a time.

Efficiency experts have been on to this problem for some time and bookstores abound with titles dealing with solutions. A number of computer companies offer technical solutions for business offices involving corporate networks, groupware applications such as Lotus Notes, and systems that scan paper documents for archiving.

My approach to this problem is simple, convenient and free: I started a free Hotmail account (www.hotmail.com) to serve as a virtual post office for SAM. I used that e-mail address (samnotes{at}hotmail.com) to send private and group messages dealing with SAM administrative matters as well as to archive key documents (such as submitted manuscripts for the newsletter). Low cost, ease of access and ease of organization are the key advantages. Finally, the office is easily accessed from almost anywhere a personal computer can be found.

There are two potential drawbacks: (1) If the Hotmail site crashes, the office is closed, and (2) It would be prudent to assume that, despite password protection, Hotmail addresses can be hacked by individuals willing to spend enormous time or money. There is also the possibility that you will need more than your allocated space (in which case more space to store documents may be obtained at www.freedrive.com as well as at several other sites.)

I take a similar virtual approach with some research projects. A student collaborator and I share a virtual laboratory notebook which she periodically updates as she carries out certain experiments under my supervision. She reports on new developments by short e-mail messages containing the link to a page at a free web hosting site (such as geocities.com) where the full report, complete with text and graphics, can be found. I then write back with comments or with instructions for the next phase of the project. (We still occasionally meet face-to-face though. I prefer to have more than a virtual relationship with my collaborators).

It is because of developments such as these that the traditional concepts of libraries, offices and laboratories will change for ever.

4. Death Prediction Software Raises Difficult Issues

From the time of Hypocrites physicians have been concerned with the prognosis of their patients, that is, in determining the likely outcome following disease or injury in a given individual. Related to this goal are scoring systems, often implemented in software, that can be clinically useful in estimating the severity of an injury or disease. Such scoring algorithms have proven to be useful in managing patients with asthma, burns, cancer, heart attacks, liver disease, trauma and other life-threatening conditions. In particular, the steadily rising costs of intensive care medicine and the ability of intensive care specialists to prolong the life of critically ill patients for extended periods creates a need (at least in the mind of some individuals) to identify early those patients who will die regardless of treatment.

One well-studied scoring system known as APACHE II (Acute Physiological and Chronic Health Evaluation) has proven to be particularly useful in predicting the outcome of patients with multi-organ failure cared for in hospital intensive care units. For example, in a study by Atkinson et al. [Atkinson S, Bihari D, Smithies M, Daly K, Mason R, McColl I. Identification of futility in intensive care. Lancet 1994; 344: 1203–6] the APACHE II scoring algorithm was studied with a view to predicting when further care would be futile. The authors found that their algorithm had the potential "to indicate the futility of continued intensive care but at the cost of one in 20 patients who would survive if intensive care were continued."

Many would regard a 5% error rate as excessive when human life is concerned. But can anyone identify what might be an acceptable rate? Or should the use of such prognostic software be abandoned on philosophical grounds? In particular, in publicly funded medical systems with limited resources (such as exists in Canada) can one afford to ignore prognostic information that would help guide medical resource allocation? (For instance, many individuals would argue that money spent on futile therapy would be better spent on shortening waiting lists for heart or cancer surgery.)

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