Airway management training for electroconvulsive therapy psychiatrists.

Sir,

We read with great interest Andrade et al.'s, “Position statement and guidelines on unmodified electroconvulsive therapy.”[1] While in full agreement that unmodified ECT should be used only under “exceptional circumstances,” we would like to add a suggestion about training of physicians that could improve patient care. We have previously expressed our opinion[2] about benzodiazepine-modified ECT, noting that the safety of the procedure could be enhanced by oxygen via mask and intravenous anti-hypertensive medication, when needed.

We propose a certificate training course for ECT psychiatrists that would teach them the basic skills of airway management. The aim of such a course would be to allow the use of modified ECT in selected patients, even when a trained anesthesiologist was not available. Patient selection would be critical, and treatment of those with complex medical conditions would be deferred until an anesthesiologist was available. The course, given over a 1-2 day period, would cover the following areas: Airway assessment, identification of features which would make the patient an unacceptable candidate for modified ECT without an anesthesiologist, basic airway management (including the proper use of rescue devices), and clinical pharmacology of the anesthetic and anti-hypertensive agents commonly used by anesthesiologists caring for patients during ECT.

If formal recognition of the official nature of such training were granted, liability issues might be satisfactorily mitigated. In an era of increasing specialization in medicine, this proposal, to allow one specialist to encroach on the “turf” of another seems, at first glance, regressive. Indeed, if adequate resources were available for specialty care at all times, we would not be making such a proposal. It is worth noting that for many decades some psychiatrists provided the entirety of ECT care, including the anesthesia and airway management, with a satisfactory record of safety.[34] A certificate course in airway management for psychiatrists (or other member of the ECT healthcare team) would seem a helpful step in providing safer, more humane ECT in countries around the world where there is a shortage of trained anesthesia personnel.