 Thank you, Joe. Ladies and gentlemen, good morning. It's an honor and a pleasure for me to be here with you today. As you already heard, my name is Steve DeHert. I'm a professor of anesthesiology at the Ghent University Hospital, and I'm very proud to serve as president of the European Society of anesthesiology for the upcoming two years. This meeting is for me a great opportunity to share with all of you some of the contributions my specialty anesthesiology and for the different societies of anesthesiologists have made to patient safety, and more specifically, perioperative patient safety. Indeed, anesthesiology is not just about putting a patient to sleep. Anesthesiologists actually are key players in perioperative patient safety. OK, just to give you a number, a few numbers, thanks to our continuing efforts we were capable of reducing mortality related to anesthesia, to anesthetic events by 97%. We are about at 3,000 in the 1950s, and now we are about at one in a million. This is a tremendous advance in patient safety. And why has this occurred? Well, I will quote here the Helsinki Declaration on Patient Safety in Anesthesiology. This is because anesthesiologists safeguard the patient's best interest whenever they are at the most vulnerable period, beat in anesthesia, intensive care, medicine, pain, or critical emergency medicine. These are the things we are dealing with as anesthesiologists. If I ask you the question, what does an anesthesiologist do, the first thing you will probably think about is putting patients to sleep and hopefully getting the patients awake again. This is, of course, true. This is part of the job. But I hope to convince you that we do much, much more than just putting patients to sleep. That's one part. We are also very much involved in the preoperative period. This means a period before anesthesia. We look at the patients, we discuss with the patients, and based on the entire picture, the physical condition of the patient, the circumstances where the patients live, we develop an anesthetic strategy, a perioperative strategy that will make sure that this patient has the safest procedure that one can imagine and deserve, of course. And even more important, we are also responsible for the postoperative phase. The trajectory is not finished after that the patient has undergone surgery and has waken up. There is a whole period, at least 24 to 48 hours, where we need to take control of the patient. I will show you a few examples later on, where you will see that this is a very important part of our profession as anesthesiologist. But let's start with the pre-interoperative phase, the phase of the operation and the anesthesia itself. Let me tell you a brief story of a young guy that came in our day clinic a few months ago. Let's call him Mr. F. Mr. F is a 30-year-old male who suffers from a condition which we called chronic hydranitis superativa, which means that there are separating boards in his skin and they need to be removed. Mr. F has already undergone this operation a few times before, so we can know his condition. And you might be interested to know that Mr. F has become the proud father of a little girl two weeks before and he has also another child, a two-year-and-a-half boy. So here is this young guy, father of two children, happy at home, and he comes in the operating theater for what we call a completely routine operation. Everything goes smoothly. There are no delays, so from administrative point of view, we are completely clear for a routine operation without any problems. Takeoff, landing, without any problems. So the guy, the man, is brought in the operating theater where the attending anesthesiological team is waiting for him. The attending anesthesiology team is myself, a supervising anesthesiologist, a young trainee, third year, so he's already capable of doing things, and the nurse assistant. Of note, the nurse had already been present at two previous operations of Mr. F, so she knows a patient and they discuss with each other, talk with each other. We do the preoperative checklist, nothing wrong to see, everything is OK, and we start the induction, because it's a routine case. I tell my assistant, my trainee, it's good, you're capable of doing it. I leave it up to you, and I will be here looking at you and sitting next to you, and it starts. Give the injection, what we expect, all to be normal, and then almost immediately after the administration of the anesthetic drugs, Mr. F develops big, big problems. And because if Mr. F develops problems, this means that we, as anesthesiological team, are also in trouble. What is happening, it starts to convulse. As the blood pressure drops, there is nothing we can imagine what happened. We use completely the same drugs as have been used before, so we rule more or less out an allergic reaction to these drugs. But what is the cause? Is it a cardiac arrest? Possibly. But the problem is that because it's convulsions, we cannot rely on the monitoring, on the blood pressure, on the ECG, on the pulse oximeter, so we really don't know what is happening. And here you are with a complete anesthetic team dealing with a catastrophe in this young man without knowing what to do, so-called without knowing what is the cause. Well, luckily for us, we have, thanks to the anesthesiological societies, we have guidelines, we have sending operating procedures. Here's an example of such an algorithm that helps you to react to such situations, even complete unexpected situations. You just follow the situations, you just follow the guidelines, and you know what to do. And here, that's what we did. What is the first direction in the guidelines? It's say, call for help. And that's what we did. Call for help, and then we started the resuscitation. Now, I will leave you the story of Mr. Ref for a few minutes and tell you later on what happened with him. What do I want to underscore with this example? Well, no matter how many times you check and you recheck the equipment, the condition of the patient, it's not you can never exclude that at a certain moment a complete routine scenario turns out into a disaster scenario. Some people like to compare what is happening in anesthesia with what is happening in the aviation industry. That's okay. We know that from the aviation industry, the introduction of a very rigorous checklist have resulted in a dramatic decrease in airplane crashes and airplane accidents. And actually, we do more or less the same. We have our checklist. We control everything and we can diminish the incidents occurring by wrong medication, by equipment failure, and so on. But what people tend to forget is that a patient is not a machine. Biological systems are infinitely more complicated and more unpredictable than machines, than planes. So you cannot make the entire parallel with the aviation industry. Okay. You know that we are dealing with perioperative problems and anesthesiologists, by definition, are trained. We are really very well trained to deal with these acute catastrophes during the operation and during surgery. The problem is that this knowledge of a catastrophe that hangs above you is present, is an important psychological burden to the entire team. And therefore it's very important that the team, but also the patient and also the relatives of the patient know that anesthesiologists are trained doctors and that the anesthesiology team is a trained team. So they are capable of dealing with all potential catastrophes. Now, let me go back to Mr. F. What is a thing you probably remind you of, Mr. F? For all the details I have given you, probably the sole thing that you remember is the fact that he's a young father of two children. This gives some kind of recognizability, not also for you, but also for the team that is dealing with Mr. F. You need to take into account that my nurse and my assistant had the same age. So for them, it's a really psychological burden to see that this guy is developing problems. They could be in the same situation. They can easily imagine that they are in the same situation. This is a kind of very important psychological burden. And then again, it's good to know that you have a trained anesthesiologist with years and years of experience under his belts. So at this stage, you might be interested to know what an anesthesiology team is, what an anesthesia team is. Well, at least in Europe, they mostly consist such teams with a physician anesthesiologist, trained physician anesthesiologist. Sometimes a trainee, if you are in a situation of an education hospital, and an assistant, always, almost always an assistant, be it a nurse or a technician. Now, what does this anesthesiological team do? The role is, first of all, to evaluate the patient before you start or before we start the operation, the anesthesia, we know the patient. We know all the medical history of the patients. We know the diseases of the patients, the medication, and so on. Based on this information, strategic plan is developed and is administered during the operation and after the operation, of course, there is continuous diagnosis, monitoring of the patient to prevent any problems to occur or if they occur to treat them as good as possible. So, you have this team. This team is, of course, very good to treat the patients, but it also is a unique opportunity to give education and training to the next generation of anesthesiologists. We will not live forever. After us, there need to be anesthesia also. So, we train these anesthesiologists and you need to know that anesthesiology, training to anesthesiology is rather arduous and takes a long time. People really need the training. And the training is given by us, senior anesthesiologists, who have thousands and thousands of anesthesias under our belt. But in addition to this training, to this demonstration on how to work, to this education at bedside, there is also need for continuous medical education. We need to be sure that our colleagues remain up to date, that they know the recent advances, that they know about recent changes and adaptations. And there is a place where anesthesiological societies can play an important role, not can play, play indeed a very important role. Perhaps you are now wondering what a professional scientific society could be. Well, let me give you an example close by, which is our society, the European Society of Anesthesiology. What is our task, generally, is to promote and coordinate the scientific, educational and professional activities across Europe, and this in order to continually improve. This is an important point, improve the standards of practice and as a consequence, improve patient safety. There are several pillars by which we can do this. One of the pillars is research. We develop our own clinical studies. We administer research grants. We publish the results of our studies in different publications, in different scientific papers, among others, our own journal, the European Journal of Anesthesiology. We disseminate the knowledge to all our members, all over the world, via the website, via the newsletter, and so on. Another important part of a scientific society is to give an education, to provide a tool to the members to have continuing medical education by e-learning, for instance, simulation classes, master classes, and so on. And a very important also, and I already mentioned this, is a production of guidelines. Guidelines help the individual doctors to know how to treat the different issues that may occur. Let's go back for a minute to the case of Mr. F. What Mr. F developed was a very rare condition, so rare that a lot of anesthesiologists will never encounter this in their daily professional life. So they cannot rely on their own experience. They need to rely on standing orders that are given by the scientific societies. And it's thanks to these guidelines, the following of these standard operating procedures, that people, persons like Mr. F, for instance, can survive a disaster like what's happening in the case. I will come back to Mr. F later on. What I want to do now is to give you a little story to demonstrate you that a role as anesthesiologist goes beyond the intraoperative phase. You're also responsible for the preoperative and the postoperative period like I already said before. The case I want to give you is the case of Mrs. K. Mrs. K is an 80-year-old lady who needs to undergo a second hip replacement because of atrosis. She's scheduled for an elective operation. She lives together with her husband, but her husband has been diagnosed with Alzheimer's disease a few months ago. So actually, she's the one who needs to take care of her husband. The couple is capable of still living at home. They have some domestic help, some social help twice a week, but they can live more or less independently at home. They have a daughter living abroad, so not available, and there are also no other relatives to take care of them or to help them if there is a problem. Like almost all persons of about 80 years, Mrs. K has some additional comorbidities, other diseases that are present. She's hypertensive, she has type 2 diabetes, hypercholesterolemia, and because of all these conditions, she needs to take a lot of medication, what we call polypharmacy. So Mrs. K, even if she's independent living, she's still a rather person which is significantly at risk. And because of this, the increased risk and the age of the patient, she's referred to the preoperative anesthesiology clinic. And what does she see? Do we see there? Mrs. K has also an additional problem which is anemia, not sufficient red blood cells. This makes this elective operation very dangerous, even more dangerous than it's normal. We don't want to operate an old lady for a hip replacement when she's anemic. So the anesthesiologist takes a very wise decision, says I will postpone this operation for six weeks and we will try to optimize Mrs. K by giving her some iron to increase the red blood cell count. This is done after six weeks. It appears that it appears that blood tests are completely normal and Mrs. K gets her operation without any problem. Sorry about that. So Mrs. K gets her operation. And now I want you to imagine two different scenarios. Think about it as a DVD game where you have, depending on the circumstances, a complete different outcome when you have different circumstances. So in the first universal, let's say, Mrs. K is admitted in a high-care hospital. This high-care hospital has a facilities for continuous monitoring, has a facilities of sufficient staff. So Mrs. K is controlled after the operation, is very closely controlled and very closely monitored. Now in the middle of the night, Mrs. K develops bleeding, heavy bleeding at the level of the operation wound. What happens? She starts to bleed, she gets hypertensive, saturation decrease and the consequences because she's monitored that the monitors go in alarm. Immediately there is the attending staff. Mrs. K is treated promptly and there is no problem at all. Everything is okay. She can leave the ward the day after and the hospital a week later back to her husband to take care of him. Now we mentioned an alternative parallel universe where Mrs. K is not in the high-care hospital but she's in a low-care hospital. This hospital or this situation has no resources or very little resources. No money for monitoring, no money for staff. And there Mrs. K after the operation goes immediately to the ward, develops the same story in the middle of the night, she starts to bleed, gets hypertensive, gets hypoxic. Now nobody sees it, there is no monitoring. It's only the morning after when the nurses are around that she discovered that Mrs. K is in big trouble. At that time she's completely exsanguinated and she needs resuscitation. She's resuscitated, brought to the intensive care unit where fortunately she develops pneumonia due to antibiotics resistant strain. And she lingers between life and death for weeks and weeks. So what do I want to prove? Or what do I want to underscore with this example? First of all preoperatively there is the importance of the highly tailored care. I've shown you that Mrs. K has a lot of comorbidities and that these comorbidities need to be taken into account. We decided to postpone the operation to optimize her blood count to prevent any transfusion to occur. So this is an active action taken by an anesthesiologist. But Mrs. K is not only Mrs. K as a patient. She lives together with her husband and her husband depends on her. So the longer Mrs. K is absent from home, the more strain this will put on a familial and social situation. And certainly the situation of Mr. K. So we need to take into account that certainly for this type of persons we need to make the hospital stay as short as possible. What is the second message I want to give you? There is an absolute need for appropriate human and financial resources. You have seen in the high care hospital, Mrs. K is promptly treated and there is no complication afterwards. In the low care hospital, if we cannot monitor our patient, if we cannot treat our patients, there is a big problem because these patients will die or at least develop important morbidities. So you might be curious to know what happened to the two patients I presented to you. Well, Mr. F, Mr. F survived. He was diagnosed, we resuscitated him successfully. And apparently from the clinical picture and the blood values it appeared that he has developed an anaphylactic shock. So he had the fourth time that the medication was used. He had developed one of the agents that we use, an anaphylactic shock. He could leave the hospital the day after and he's living happy with his family and with his two children. What happened to Mrs. K? Well, Mrs. K is a little bit a composite character. You have seen that the outcome of Mrs. K critically depends and of patients like Mrs. K critically depends on the resources that are present to treat, to monitor and to follow these patients. So I come back to my initial point. What is the role of anesthesiologist in perioperative safety, in perioperative patient safety? Well, I have convinced you that we play a role preoperatively, interoperatively and postoperatively. And it is this integrated approach that makes it possible for us as anesthesiologists to take care of the patients and to give the patients a safe perioperative course. And societies try to continue to even improve this patient safety by working together with other anesthesiological societies, other anesthesiology group, healthcare professionals, institutions, patient associations and with you, the public. And it's only in this way that we are capable of improving perioperative patient safety for the sake of all of future patients. Thank you very much.