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Kindness is the foundation of positive human relationships. Kindness is also the foundation of quality anaesthesia, framing not just the goals of care but the paths we tread to reach them: kindness to our patient, kindness to one's team, and kindness to oneself. Kindness is the oxygen that sustains our practice.

"[Kindness is] helpfulness towards someone in need, not in return for anything, nor for the advantage of the helper himself, but for that of the person helped." – Aristotle, Book II of Rhetoric

Like many anaesthetists, I often fixate on outcomes. Yet for patients, the journey often matters as much as the destination. While modern medicine makes successful outcomes the lowest bar, the hospital experience shapes the patient's entire perception of care, sometimes turning a medical success into a perceived failure. When we centre our practice on kindness, we elevate both process and outcome, giving them equal weight.

Too often we equate quality anaesthesia with technical excellence: precise techniques, rapid turnover, stable vitals, adherence to best practices. We audit hard markers like pain scores and discharge times. Yet this reductionist approach misses the cornerstone of healthcare: kindness.

When we view our practice through the lens of kindness – not empathy, for it helps no one for the anaesthetist to experience the same pains and fears as their patient – we reorient our decisions around "how can I help this person?" with a clarity of purpose unburdened by personal gain. This perspective expands our care to embrace the whole person under our care.

Patient fears before anaesthesia and surgery become just as important to address as the technical aspects of care. Technique choices are no longer made for the convenience of the anaesthetist or hospital, but rather for the needs of the patient. Perioperative care rooted in kindness recognises the interconnection between patient experience and patient outcomes – the two factors that truly matter to those under our care.

This practice of kindness extends beyond the patient. It reshapes and reorients the way we engage with our team and ourselves.

Kindness to our team means fostering a culture of supportive communication: listening to concerns, acknowledging contributions, and responding to mistakes with constructive compassion. How often do you thank your assistant and surgical team at the end of a list?

Kindness becomes even more critical in moments of crisis. The stress you feel is likely shared by everyone in the room, and they look to you for both professional and emotional leadership. Maintaining calm, staying composed, and offering reassurance transforms a team’s performance under pressure. By contrast, a moment of sharp anger can unravel team cohesion, leaving lasting damage. In a crisis, anger is a poison that corrodes collective resilience.

Kindness to oneself may be the hardest form of kindness to practice. In a field where the bar is set so high, self-compassion is essential as we struggle to accept imperfect outcomes or personal errors. We must see mistakes not as failures but as opportunities for growth. The long hours, the high-intensity work, a sometimes-capricious health system, and the unpredictability of anaesthesia all contribute to burnout. It’s easy to get lost in our vocation, but we must recognise that life cannot be all work. Our families, our friendships, and our health must take priority. Kindness to ourselves is not indulgence; it is self-preservation.

In our demanding profession, perhaps the best advice is simple:

"Be a little kinder than you have to." – Emily Jenkins.

When we practice with kindness – to our patients, our team, and ourselves – we create an environment where care is more than just a technical exercise. We cultivate a virtuous cycle: supported team members provide better patient care; well-cared-for patients make our work more fulfilling.

And when we are kind to ourselves, we have the emotional resources to extend that kindness to others. In anaesthesia, as in life, kindness is not just a virtue – it's the vital sign that reflects the health of our practice. Kindness is an act of compassion that elevates routine care, benefiting everyone involved.

We are now two and a half years into the COVID pandemic, and just beginning to see yet another case surge with the arrival of the BA.5 Omicron sub-variant. The good news just keeps coming! 😉

Along with new variants, 30 months has also given us a lot of research and data. Metajournal alone has indexed almost 39,000 COVID-related publications relevant to anaesthesia, pain, critical care and emergency medicine.

Of course that's a crazy volume of research to manage, with a pretty low signal-to-noise ratio. Sifting through that for quality and relevant studies is exactly what metajournal was designed for.

Here's a quick round-up of interesting COVID-related research...

RAT tests & infectiousness

As good quality, locally validated RAT tests become increasingly available, we are also collecting more data showing they are a good indicator of individual infectiousness at the moment in time the test is performed.

The article collection 'Does a COVID RAT-negative result mean non-infectious?' explores several of these studies, suggesting that a negative RAT is likely a reliable indicator of being non-infectious.

The bottom line...

A correctly-performed adequately-validated RAT, is likely a sensitive indictor of individual infectiousness at that specific moment in time. The reliability of a negative RAT will be improved if using the same manufacturer and technique as a previously positive test, and more so if there are several subsequent negative RATs.

Return to exercise after COVID?

A recent J Sci Med Sport editorial (Hughes 2022) from Australian elite sport, exercise medicine and sports cardiology experts, provides reassuring encouragement when returning to exercise after COVID recovery.

Read on for more on exercise after COVID...

A very interesting study in JAMA Surgery from Wallis et al. received a lot of press coverage. The research team showed that female patients treated by male surgeons not only more commonly experienced post-operative complications, but also suffered a higher mortality, than when treated by female surgeons.

What did they do?

This big-data study covered 12 years of the 20-most-common surgical procedures performed in Ontario, Canada. Wallis and team investigated how patient-surgeon sex discordance correlated to a composite for adverse postoperative outcomes. (A deeper investigation of the earlier Wallis 2017 study).

And they found?

While ~15% of all patients experienced an adverse post-operative outcome, female patients treated by a male surgeon experienced significantly higher odds of a composite of adverse events (OR 1.15 [1.10-1.20]), 30-day complications (OR 1.16 [1.11-1.22]), readmissions (OR 1.11 [1.04-1.19]), and death (OR 1.32 [1.14-1.54]) compared to when treated by female surgeons.

Yet male patients treated by female surgeons experienced either lower odds (death 0.87 [0.78-0.97]) or statistically-similar odds of complications (composite end-point, readmission or post-op complications).

The hot-take

Women once again receive the metaphorical short-end of the medical-stick. Whether societal or elsewhere in the health industry value-chain, long established gender inequity reveals itself in worse surgical outcomes for female patients.

Hang on a sec…

But this cannot just be written off as a consequence of existing social gender inequity, but rather a disquieting causal loop between this as a cause and the result then perpetuating further inequity.

If some part of a surgeon’s ’professional success’ is wrapped-up in the ability to achieve positive outcomes for patients while minimising the adverse, then male surgeons are failing their female patients when compared to either female surgeons, or to the care they provide their male patients.

And yet the same discordance cost is not true for female surgeons.

Read on for the take-home & more medical-gender influences...

In anaesthesia, sitting at the point where the ideal meets reality, is compromise.

Compromise is the practical, real-world necessity that allows a health system to function in the face of competing demands. Every point of care in a hospital is a balance of compromises, frequently between safety and the many other flavours of medical quality.

For anaesthesiology the most common compromise is balancing safety with the quality of the patient experience: pain, distress, cost, delays, efficiency, levels of intervention, seniority of care… (Though let’s acknowledge, suffering injury because of a safety compromise is also a pretty poor patient experience.)

In a dynamic world of external stressors (<cough>pandemic<cough>) compromise becomes both more important and more fraught. How do we balance conflict between the needs and priorities of care? Compromises are then a pragmatic necessity, recognising the fractal complexity of patients and hospitals that the inherently reductive nature of best practice and theory struggles to accomodate.

A great example of this is found within the Zero Harm safety movement, aspiring to the worthy (though naive) goal of reducing healthcare staff & patient injury to zero. Zero Harm’s mistake is to build an entire ideology upon an unachievable goal, for as Thomas points out in 'The harms of promoting Zero Harm':

“...some harms are inevitable and impossible to eliminate.”
– Thomas (2020)

Zero Harm is itself a compromise, deprioritising other components of care in service to absolute safety. Only by recognising the natural compromises at every level of the health system can we make informed decisions about the risk-price we are willing to pay for compromise.

Many years ago as a junior resident, a senior colleague dropped some wisdom about compromise that sticks with me today. He made the observation in the setting of one of the commonest and discrete medical interventions: intravenous cannulation. Sometimes you have a cannula that is smaller or not flowing as well as you would prefer. Depending on the circumstance, this is often tolerable and we grudgingly accept it.

"But beware”, he said, “never allow more than one compromise.”

Although imperfect intravenous access may be a small compromise, it represents an increased-risk point of failure. Perhaps you now feel compelled to accept a ‘minor’ airway compromise (LMA over an ETT?), or a fasting compromise, or location, or the presence (or not) of a parent at induction? While each step may be justifiable, stacking compromises increases points of failure and risk in a non-linear way.

Stacked compromises increase risk geometrically.

Stacked compromises are fragile.

While there may be no true hard rules in anaesthesia, we need to appreciate that risk exists on a dynamic spectrum. The adolescent ideology of Zero Harm may have near Zero Place in anaesthesia, yet the primacy of risk management and harm minimisation always requires considering how our compromises interact and compound to alter the risk profile of the care we provide. Our goal in managing risk in complex systems should be to reduce risk where we can, and build resilience where we cannot.

You may still feel it necessary to stack your compromises, but by the Gods of Anaesthesia, if you do then you better make sure you know the price being paid – and who is ultimately paying it.

• Explore more in the metajournal knowledge collection: Reducing health-system harm: Safety I vs Safety II.

GA caesarean section & post-partum depression

This large study (Guglielminotti 2020) of 428,204 New York caesarean section records (2006-2013), including 34,356 general anaesthetics (8%), investigated the association between mode of anaesthesia and post-partum depression (PPD). Other studies have shown an association between caesarean section (emergency > elective) and PPD. (Sun 2021, Xu 2017, and others), though this is the first to look specifically at general anaesthesia as a PPD risk factor.

Guglielminotti and Li found that general anaesthesia increased the odds of severe PPD by 54% (aOR 1.54, 1.21-1.95), and suicidal ideation by a massive 91% (aOR 1.91, 1.12-3.25), though not a significant increase in anxiety or PTSD.

The researchers discuss many potential causative factors, particularly known associations between GA CS & poor pain control, and subsequent pain & PPD – while also acknowledging the obvious potential for confounders. Of note patients receiving GA were older, more often non-Caucasian, had more co-morbidities, neonatal complexity, and lower socio-economic levels – also all independently associated with PPD risk.

In order to quantify the potential confounding contribution of emergency vs elective status, the researchers employed the novel E value:

To assess the impact of emergent cesarean delivery on our results, we calculated the E value associated with the aOR for the risk of PPD and suicidality. This relatively new metric takes into consideration 2 associations: (1) that between the confounder (emergent cesarean delivery) and the outcome (PPD); and (2) the association between the confounder (emergent cesarean delivery) and the exposure (general anesthesia).

An E value of 1.7 for the unmeasured confounder emergent cesarean delivery indicates that to explain away the association between general anesthesia and depression, either: (1) emergent cesarean delivery increases the risk of depression by at least 70%; or (2) emergent cesarean delivery is at least 70% more prevalent among general anesthesia than among neuraxial anesthesia. Either association is clinically plausible.

Keep it in perspective...

We already know that general anaesthesia for CS is suboptimal: it compromises both maternal experience and safety, but it should (hopefully) only ever be a chosen mode of anaesthesia when there is a true contraindication to regional anaesthesia – even at the modestly-high 8% GA rate among this New York cohort.

Looking at it from the other end, bear in mind that the modestly-faster time-to-incision for GA over regional is also of questionable neonatal benefit.

The take-home:

Just another reason to avoid GA CS when possible – but you already knew that, right?

"...general anesthesia is a potentially modifiable risk factor for PPD. This finding provides further supporting evidence favoring neuraxial over general anesthesia in cesarean delivery whenever possible."

Supraglottic airway training and manikins

Interesting prospective simulation & equipment study by way of the University of Freiburg. Schmutz et al. investigated how effective five different second generation supraglottic airway devices (SADs) performed in two common airway manikins: the TruCorp AirSim® and the crowd favourite, Laerdal's Resusci Anne® Airway Trainer™.

While ventilation was achieved in all SAD-manikin combinations, the Resusci Anne® Airway Trainer™ was associated with better and more consistent performance for SAD position, participant subjective assessment and ease of gastric tube insertion for most of the SADs. The TruCorp AirSim® did however achieve better leak pressures across most of the SADs (LMA® Supreme™, Ambu® AuraGain™, i-gel®, KOO™-SGA & LTS-D™).

But then, what are the implications for airway simulation training? The researchers correctly note that:

The most important quality of a manikin is the ability to simulate the real-world conditions and thus to give the trainee an authentic feedback.

The bottom line for SAD manikins?

While considering how manikin choice and SAD availability match with your aims for simulation training, the bigger picture is that the primary goal of any manikin-SAD coupling is real-life fidelity – and for that reason, participant subjective assessment is king. And so in this study at least, the Resusci Anne® Airway Trainer™ wins.

Read on for head rotation with LMAs & COVID vaccine persistence...