This is what the anesthesia experience is like for most patients: You show up for surgery, and some anesthesia professional you’ve never met or talked to appears 10 minutes before you are to be wheeled into the operating room. The anesthesia professional might be an MD, a CRNA, or both a MD and a CRNA might be involved. At an academic/university hospital, the anesthesiologist might be a resident MD in his or her first, second, or third year of anesthesia training, and that resident will then be supervised by a faculty member who is responsible for either one operating room or two.
It doesn’t have to be this way. Anesthesiologists in our practice telephone their patients the night before to discuss the anesthesia care. Some hospitals have an anesthesia preoperative clinic where patients are interviewed and examined one day or more prior to surgery. Patient questions are answered at such a clinic, but it’s uncommon for you to meet the person who actually anesthetize you at such a clinic visit.
I’m going to put on my patient advocate hat. Let’s say you’re going to have surgery six weeks from now.
- What can you do to make your anesthesia experience safer?
- What can you do to otherwise optimize the anesthesia care you’re about to receive?
Here’s my list of 11 things you can do:
- Don’t choose to schedule your surgery at a teaching hospital in July or August. On June 30th every year, each intern and resident physician advances one year in his or her training. An intern who finished a 12-month rotating internship suddenly becomes an anesthesia trainee as of July 1st. An anesthesia resident who trained for 12 months and performed perhaps 700 anesthetics, is now a second year resident. An anesthesia resident who trained for 24 months and performed perhaps 1400 anesthetics, is now a third year resident. Each of these residents is completely inexperienced in their new level. The curriculum for residents is more complex each year, with 2nd and 3rd year residents covering progressively more complex cases such as open heart, brain, chest, or neonatal surgeries. A faculty member will supervise each resident, but often the supervision is one faculty member covering two operating rooms concurrently. The individual who monitors you minute-to-minute during your surgery will be a relatively inexperienced resident. If you’re scheduled for surgery at an academic medical center in July or August, I’d advise you to move up your surgery to May or June instead.
- Using the Internet, check the roster of anesthesia physicians at the facility where you’re about to have surgery. Virtually every medical center has a list of staff anesthesiologists posted on their website, and most websites will provide a summary of each physician’s academic training. Peruse the list. Are the majority of anesthetists MDs or CRNAs, or is the staff a mix of both? Did the MDs train at reputable universities, or were they trained at hospitals you’ve never heard of? Is there a phone number you can call if you wish to speak to an anesthesiologist prior to your week of surgery if you have a special concern?
- Talk to your surgeon about the proposed anesthesia. He or she will usually know whether your case requires a general anesthetic, with or without a regional anesthetic (such as a spinal, an epidural or a nerve block). Ask your surgeon if they have an anesthesiologist colleague they recommend for your specific case, and ask whether you can request a specific anesthesiologist prior to the surgery date.
- If you have chronic health issues (e.g. heart problems, lung problems, high blood pressure, diabetes, neurologic problems, kidney failure, obesity, or sleep apnea) you can expect the surgical/anesthesiologist team to require a clearance note from your primary care physician (PCP) prior to the surgery. The purpose of this clearance is to document that no further diagnostic or treatment interventions are necessary prior to your anesthetic and surgery. This is important. Planning a visit to your PCP in the month or two prior to surgery is strongly recommended.
- Are you unusually sensitive to drugs, sedatives, or alcohol? Tell your anesthesiologist when you meet him or her. Without question, certain individuals are unusually sensitive to normal doses of narcotics, sedatives, and general anesthetics. These individuals are often female, petite (under 120 pounds), geriatric, or persons who rarely expose themselves to central nervous system depressants such as alcohol. Armed with this information, your anesthesiologist will administer adequate doses of drugs, but no more than the minimum necessary.
- The standard of care is for your anesthesiologist to explain the alternate anesthesia techniques for your surgery, as well to explain the risks and benefits of each alternative. I’d advise you to listen, ask questions, and consider the KISS principle (Keep It Simple Stupid). The correct anesthetic is usually the simplest technique that works for the surgeon, the anesthesiologist, and for you. You get a vote. Use it, and choose wisely when alternatives are explained to you.
- If you have a family history of a blood relative who died under anesthesia, share this information with your anesthesiologist. The rare but serious malady Malignant Hyperthermia (MH) is an inherited disease which causes intense fevers, muscle rigidity, and hypermetabolism, and is triggered by specific anesthetic drugs such as sevoflurane, desflurane, isoflurane, or succinylcholine. The disease is rare (1 out of 100,000 anesthetics), but if your family has a history suggestive of MH, or if any of your family died under anesthesia, the anesthesiologist needs to know.
- You must stop eating and drinking prior to an elective anesthetic. The purpose is to keep your stomach empty at the induction of anesthesia. If you vomit or regurgitate stomach contents while you are unconscious, the food can be inhaled into your lungs, and you could acquire a serious pneumonia that could require an Intensive Care Unit stay, a prolonged hospitalization, or even loss of life. American Society of Anesthesiologists guidelines are nothing to eat after midnight the night before surgery, except clear liquids may be ingested up until 2 hours prior to surgery. Here’s an anecdote to relate how a patient can break this rule: Several years ago an anesthesiologist colleague of mine was scheduled to anesthetize a professional athlete for knee surgery. When this patient was asked if he’d followed the protocol and had nothing to eat or drink after midnight, the patient said yes, he had followed the rules. The surgery and anesthesia were performed without complication. In the post-anesthesia recovery room the patient boasted, “I knew it wouldn’t make any difference. I had bacon, eggs, and toast for breakfast this morning before surgery. I didn’t tell anyone because I knew it was a bogus rule.” It’s not a bogus rule. Don’t be like this local sports legend/difficult patient. Listen to the fasting rules and follow them.
- Sleep well the night before your surgery. For the majority of surgeries in the United States, a patient sleeps at home in their own bed the night before surgery. It’s rare to be sick enough to require inpatient admission to the hospital the day before surgery. Many patients are nervous regarding the impending anesthetic, and a wild array of thoughts and fears swirl through their brain regarding anesthesia and surgery. Many patients are too wired on their own adrenaline to sleep normally the evening prior to their surgery. What about sleeping pills? Are they safe the night prior to anesthesia? Yes, they are almost never unsafe. Common sleep medications such as Ambien, Ativan, or Valium taken at 10 pm won’t complicate the anesthetic course which begins 9 hours or more into the future on the following day. Because your anesthesiologist hasn’t personally met you and examined you, they cannot prescribe these medicines the night before for you. Your surgeon may prescribe sleep meds when he or she examines you. What about a glass of wine or an alcoholic beverage to aid sleepiness? Is this safe? Yes. If you’re an occasional wine drinker, there’s no serious harm to imbibing one glass of wine the night before surgery to help you relax and sleep.
- Trust your anesthesiologist as you would your airline pilot. When you board a commercial airplane, do you cast a glance into the cockpit to see what your pilots look like? I do. I’m reassured to see a touch of gray. It’s possible that a pilot in his or her 30s is outstanding, but the experience of a midcareer, gray-sideburned pilot is more reassuring to me. During your surgery you’ll be unconscious and unable to control your fate. You’re dependent on the anesthesiologist and his or her training and experience. The overwhelming majority of physician anesthesiologists are well trained and excellent. Calm yourself and trust your doctor.
- Read theanesthesiaconsultant.com as well as other reputable anesthesia sources on the Internet, such as the American Society of Anesthesiologists website, or Pubmed. Can you find misinformation on some healthcare websites? Yes. You’ll need to be careful regarding the source of your Internet education. But knowledge is a powerful tool, and I’d encourage you to expand your understanding of what anesthesiologists do to prepare for your upcoming surgery. Good luck!
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
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