CARDIAC ARREST DURING A PEDIATRIC TONSILLECTOMY

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

A 12-year-old boy and his mother walk into a surgery center. The child is scheduled for a tonsillectomy, and is otherwise healthy. The anesthesiologist induces general anesthesia, and ten minutes later the patient has ventricular arrhythmias which descend into a cardiac arrest. Advanced Cardiac Life Support (ACLS) measures are applied, but the child cannot be resuscitated, and is declared dead. What caused this cardiac arrest during a pediatric tonsillectomy?

This is an actual closed malpractice case which I was asked to review. The anesthesiologist induced general anesthesia with propofol and a paralytic drug called succinylcholine (sux-in-ol-KOH-leen), and then inserted a breathing tube successfully into the patient’s windpipe. All vital signs were normal. Sevoflurane, nitrous oxide, and 50% oxygen were ventilated into the patient’s lungs. The surgeon began the tonsillectomy. One minute later the cardiac arrest occurred. The anesthesiologist followed ACLS guidelines, but standard ACLS treatments and hyperkalemia (elevated potassium concentration) treatments were unsuccessful.

Succinylcholine is an intravenous muscle relaxant (paralytic) drug commonly used in the United States. Succinylcholine is an old drug—available since 1951—which has the distinction of being the most rapid-acting intravenous muscle relaxant, and also the shortest-acting muscle relaxant. Succinylcholine is an important drug in an anesthesiologist’s toolkit. When an airway emergency threatens a patient’s life, such as the unexpected occurrence of laryngospasm, succinylcholine is the emergency drug of choice to paralyze the patient, relax the spasm of the vocal cords, and enable the anesthesiologist/emergency room physician/acute care physician to insert a life-saving breathing tube into the trachea.

But succinylcholine can be a dangerous drug. The Food and Drug Administration (FDA) placed a Black Box Warning on succinylcholine in 1994. The current succinylcholine warning in the PDR (Prescribers’ Digital Reference) reads:

Succinylcholine is contraindicated in patients with a personal or familial history of malignant hyperthermia and/or skeletal muscle myopathy. Malignant hyperthermia may be precipitated by succinylcholine; concomitant use of volatile anesthetics may further increase this risk. 

In neonates, infants, children, and adolescents, reserve the use of succinylcholine for emergency intubation or instances where immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach, or lack of intravenous access). 

There have been rare reports of ventricular dysrhythmias and fatal cardiac arrest secondary to rhabdomyolysis with hyperkalemia, primarily in healthy-appearing pediatric patients who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne’s muscular dystrophy. 

Affected pediatric patients are typically, but not exclusively, males 8 years or younger. Although some patients have no identifiable risk factors, a careful history and physical exam may identify developmental delays suggestive of myopathy, and a preoperative creatinine kinase could identify patients at risk. 

Closely monitor body temperature, expired CO2, heart rate, blood pressure, and electrocardiogram in pediatric patients to help detect early signs of malignant hyperthermia and/or hyperkalemia. 

The rhabdomyolysis syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes of succinylcholine administration. If cardiac arrest occurs immediately after succinylcholine administration, institute treatment for hyperkalemia (e.g., intravenous calcium, bicarbonate, glucose with insulin, hyperventilation). If malignant hyperthermia is suspectedinitiate appropriate treatment (e.g., dantrolene, supportive care) concurrently.”

Per the Black Box warning, succinylcholine has the potential for inducing life threatening hyperkalemia in children with undiagnosed skeletal muscular dystrophies. Severe hyperkalemia and ventricular arrhythmias followed by cardiac arrest may occur in apparently healthy children who have an occult muscular dystrophy (usually Duchenne’s muscular dystrophy). An occult muscular dystrophy is a rare inherited disease. The global prevalence of Duchenne’s muscular dystrophy is 7.1 cases per 100,000 males, and 2.8 cases per 100,000 in the general population. The Black Box warning on succinylcholine recommends to “reserve use in children for emergency intubation or need to immediately secure the airway.”

The Black Box warning applies to neonates, infants, children and adolescents. No parent wants their son or daughter under the age of 18 to electively receive a drug which has an FDA Black Box Warning for use in adolescents. No parent wants their neonate, infant, child, or adolescent to have a risk of sudden cardiac arrest under general anesthesia for a common elective surgery.

In 1994 the Anesthesia Patient Safety Foundation (APSF) published a sentinel article about the risks of succinylcholine in pediatric anesthesia. The article reviews the history of the succinylcholine warning: “In 1992, Drs. H. Rosenberg and G. Gronert published a letter in Anesthesiology briefly reviewing four deaths in male children under the age of eight who had received halothane and then succinylcholine. These cases were identified through the Malignant Hyperthermia (MH) Hotline. Reference was also made to ‘11 similar cases’ identified through the German MH Hotline. Their letter concluded with the statement: ‘We have notified the Food and Drug Administration of this potential problem and recommended that anesthesiologists carefully consider the indications for use of succinylcholine in young children.’ This letter was accepted for publication August 24,1992.” The article goes on to emphasize “the need for prompt and appropriate treatment should hyperkalemic arrest occur. This treatment involves the intravenous administration of calcium. With proper treatment, approximately 50% of patients have survived this catastrophic hyperkalemia.” The Black Box warning specifically states, “If cardiac arrest occurs immediately after succinylcholine administration, institute treatment for hyperkalemia (e.g., intravenous calcium, bicarbonate, glucose with insulin, hyperventilation).”

Despite the Black Box warning, how often is succinylcholine still used for non-emergency pediatric anesthetics in the United States? No one knows. I can attest that during a recent Quality Assurance review in the Northern California, I saw anesthetic records from a board-certified anesthesiologist who administered succinylcholine to a 14-year-old boy for elective ear surgery. I discussed this with the anesthesiologist, who was unaware they were doing anything dangerous.

There is an excellent alternative to the elective use of succinylcholine. For most cases, pediatric or adult, the muscle relaxant rocuronium is a superior alternative to succinylcholine. Succinylcholine is the IV muscle relaxant with the most rapid onset, but large doses (0.9 mg/kg) of rocuronium are nearly as rapid as succinylcholine, without any of succinylcholine’s risks.   Succinylcholine is also the IV muscle relaxant which wears off the fastest, but since the year 2015 FDA approval of the muscle relaxant reversal drug sugammadex (Bridion), an intubating dose of rocuronium can be rapidly reversed within 3 minutes by administering 16 mg/kg of sugammadex

Succinylcholine remains an important drug for the treatment of airway emergencies. I would never begin a general anesthetic if I did not have a vial of succinylcholine immediately available in case of an airway emergency. In addition, succinylcholine is important because it can be administered intramuscularly (in a patient who has no IV). For example, if a child is undergoing an inhalational induction of general anesthesia with sevoflurane vapor prior to a surgery, and the child suddenly goes into laryngospasm before any IV can be started, (this does occur, not uncommonly, and is a true emergency), the appropriate treatment is an intramuscular injection of 4 mg/kg of succinylcholine. The child will become paralyzed within minutes, and the anesthesiologist can then insert a life-saving breathing tube. (The mean onset of paralysis with 4 mg/kg intramuscular succinylcholine in children ages 1 to 10 ranges from 2.9 to 3.9 minutes.)

I’ve written about the advantages and risks of succinylcholine previously in the article, “Succinylcholine: Vital Drug or Obsolete Dinosaur?”  

I also refer you to the published article, “Is There Still a Role for Succinylcholine in Contemporary Clinical Practice?

The take home messages from this case study of a cardiac arrest during a pediatric tonsillectomy are:

  • If you’re an anesthesia provider, do not administer succinylcholine to a neonate, infant, child, or adolescent for an elective surgery. The Black Box warning on succinylcholine recommends to “reserve use in children for emergency intubation or need to immediately secure the airway.”
  • If you’re a parent, prior to your son or daughter’s surgery, be empowered to ask your child’s anesthesiologist if they’re aware of the Black Box warning on succinylcholine. 
  • Nobody wants a death brought on by an elective anesthetic.

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ARTIFICIAL INTELLIGENCE IN THE OPERATING ROOM . . . (THE PREMISE OF DOCTOR VITA) . . . DISCUSSED IN THE JOURNAL ANESTHESIOLOGY

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997
HAL from the movie 2001:A Space Odyssey

In 2004 I began writing Doctor Vita, a novel describing the encroachment of Artificial Intelligence (AI) into medical care. Fifteen years later, in 2019, Doctor Vita was published. The story described Artificial Intelligence in medicine as a perceived panacea that descended into a chaotic dystopian reality.

In recent years, engineers have developed closed-loop AI machines that can administer appropriate doses of anesthetics without human input, as described in The Washington Post article, “We Are Convinced the Machine Can Do Better Than Human Anesthesiologists.”

This month’s issue of Anesthesiology, our specialty’s leading journal, contains two studies on further incremental Artificial Intelligence in Medicine advances in the operating room. Both studies reveal machines that control a patient’s blood pressure automatically during surgery, by the administration of fluids and/or vasopressors (Joosten, et al. and Maheswari et al. 

Closed-loop anesthesia computer controllers for AI titration of anesthesia level

Two editorials accompany these publications. In the first editorial, titled “Computer-assisted Anesthesia Care: Avoiding the Highway to HAL,”  author Dr. David Story writes, “Among the cautionary tales of computer-assisted human activity, 2001:A Space Odyssey is a standout. On a journey to Jupiter, HAL the computer kills most of the crew, forcing the survivor to deactivate HAL. Like space travel, while computer-assisted health care has great potential it also contains the full Rumsfeld range of knowns and unknowns.” Dr. Story concludes his editorial with, “As our pilot counterparts are doing in aviation,anesthesiologists should anticipate training in crises while using computer-assisted technologies, as well as maintaining the skills to ‘fly’ manually.  . . . None of us wants to manage a deteriorating patient by trying to deactivate a malfunctioning computer-assisted anesthesia system, only to have it respond, ‘I’m sorry . . . I can’t do that.’

The second editorial in the same issue of Anesthesiology is titled “Back to the OR of the Future: How Do We Make It a Good One?”  Author Dr. Martin London writes, “The classic 1985 science fiction film Back to the Future transports the erstwhile protagonist (Marty McFly, played by a young Michael J. Fox) 30 years backwards into the past in the eccentric ‘Doc’ Brown’s custom DeLorean time machine, to deal with a series of comedic yet moral quandaries regarding his future existence. A notable quote by Doc Brown is, ‘The future is whatever you make it, so make it a good one.’  Dr. London goes on to say, “The use of artificial intelligence–derived controllers clearly signals a new era in intraoperative hemodynamic management. . . . It does seem inevitable that software control of hemodynamics and anesthetic depth will become routine. Thus, we might ask, ‘What happens to the operator/clinician involved?’ Will it be more appropriate for a busy anesthesiologist covering multiple operating rooms to be supervising the admittedly extreme scenario of ‘information technology experts’ ensuring the machines are functioning properly or actual healthcare providers monitoring the patient and not the machine? And what happens when the “computers go down”? Who will rush in to fill the gap? Will the process be ‘good’ or will it be ‘dystopic?’

Artificial intelligence in medicine is not the stuff of science fiction. AI in medicine is here. Will Artificial Intelligence in medicine assist doctors in compassionate care of their patients, or will AI present one more set of computers obstructing the relationships between healing professionals and those who need healing?

Medical journals like Anesthesiology reveal the future of medicine, as published data unfolds. A novel like Doctor Vita reveals a fictional future of medicine, based on the very trends that are going on today. 

Do you want a computer to care for you when your life is on the line? Do you want an algorithm, or a human, to be your doctor?  

Will you have a choice?

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HOW THE INTERNET CHANGED ANESTHESIOLOGY FOREVER

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Anesthesia is a hands-on specialty. We use our manual skills daily to place breathing tubes, insert intravenous and intra-arterial catheters, and place needles for spinal punctures, epidural catheters, and regional nerve blocks. The Merriam-Webster dictionary defines the internet as “an electronic communications network that connects computer networks and organizational computer facilities around the world.” This definition seems to have has very little to do with inserting breathing tubes, catheters, or needles, yet the internet changed anesthesiology forever.

The internet is the biggest change in anesthesiology since the FDA approvals of propofol in 1989, the laryngeal mask airway in 1991, and sevoflurane in 2002.

Picture this: your job requires you to spend the majority of your day in a windowless room with four other people. You cannot leave the room, and if you make a serious error in your work, someone can die. There is a telephone on the wall. You’re allowed to bring along a briefcase or a backpack. 

This was the description of the anesthesiology workplace prior to the internet. Vigilance regarding a sleeping patient’s vital signs was always paramount, but the constant effort to be vigilant could be mind-numbing. No one can stare at an ECG/oximeter/blood pressure monitor for hours without interruption. Anesthesiologists could chat with the surgeons and/or nurses, make an occasional phone call, and at times read materials they brought with them into the operating room. Major adverse events seldom occur during the middle of a general anesthetic of long duration on a healthy patient. A comparison would be a commercial pilot flying an airplane from San Francisco to New York. The flight lasts 5 hours, but there would likely be only minor adjustments in course or altitude during the middle 4 hours. Anesthesia is said to be “99% boredom and 15 panic,” because 99% of the time patients are stable, yet 1% of the time, especially at the beginning and the end of anesthetics, urgent or emergency circumstances could threaten the life of the patient.

Since the development of the internet, anesthesia practice has changed forever. Every hospital operating room is equipped with a computer connected to the internet. Every anesthesia provider carries a smartphone connected to the internet. Many anesthesia providers carry a laptop or a tablet in their briefcases. These devices enable an anesthesiologist to remain connected to the outside world during surgery. Let’s look at the specific ways the internet has changed anesthesia practice:  

Electronic Medical Record anesthesia intraoperative vital signs record
  • Electronic medical records (EMRs). Love it or hate it, the EMR is here to stay. The EMR requires a computer terminal and screen in every operating room, and every hospital operating room must be connected to the internet. A patient’s EMR combines information from previous clinic visits, emergency room visits, laboratory and test results, and all data from the preoperative, intraoperative, and postoperative course on the day of surgery. Anesthesiologists type information into the EMR multiple times during each case.
AN EXAMPLE PUBMED SEARCH SCREEN
  • Immediate access to medical search engines. A major advantage of internet connectivity is the ability to immediately research any medical question or problem. Abstracts of every published medical study are available on Pubmed. For those of us on the faculty of a university hospital, hundreds of medical textbooks are immediately available online as reference sources. The entire catalog of FDA-approved drugs is listed on the PDR (Physician’s Desk Reference) website, or on the PDR app on our smartphones. These are all invaluable tools which empower a physician anesthesiologist and improve care to every patient.  
  • Connectivity to other anesthesia providers is a third important advantage of the internet. We’re now able to immediately contact a colleague by cell phone, text message, or email if we have a question or a problem. In anesthesia care team models, in which a Certified Nurse Anesthetist (CRNA) is physically present in the operating room while being supervised by an attending physician anesthesiologist, the MD anesthesiologist can be summoned to return to the operating room in seconds if a problem arises. You can also imagine a future vision of telemedicine in which an experienced physician anesthesiologist, who lives many miles or time zones away, can supervise a CRNA or an inexperienced anesthesiologist performing in-person patient care via Zoom conferencing. 

A 2010 publication in the journal Anaesthesia and Intensive Care stated, “Experienced anesthetists are skilled at multi-tasking while maintaining situational awareness, but there are limits. Noise, interruptions and emotional arousal are detrimental to the cognitive performance of anesthetists. While limited reading during periods of low task load may not reduce vigilance, computer use introduces text-based activities that are more interactive and potentially more distracting.”

From what I observe of anesthesia practice in the year 2021, intermittent use of the internet during anesthesia duty is not uncommon. The windowless confines of the operating room are now connected to the world.

Further scholarly research regarding computers, tablets, cell phones, and internet use in the operating room will no doubt be forthcoming. Stay tuned.

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HOW LONG DOES GENERAL ANESTHESIA LAST?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

“I’m going to have surgery to have my gall bladder out. How long will the anesthesia last?”

The query “How long does general anesthesia last?” is a common question before surgery. Modern anesthetics wear off quickly after surgery, but the answer to your question is “It depends.” It depends on: (1) which drugs were administered, (2) the length of the anesthetic time, (3) the type of surgery you had, (4) how much pain you have following the surgery, and (5) how healthy you are.

Let’s look at each of these factors:

  • WHICH DRUGS WERE ADMINISTERED.

The main classes of general anesthetic drugs are intravenous (IV) and inhalational.

IV DRUGS. The most common IV drugs include propofol and narcotics. 

Propofol is a hypnotic drug that renders people unconscious in seconds. A single dose of propofol wears off quickly, within minutes, because the molecules of propofol redistribute throughout the body, to wherever the bloodstream takes the propofol. Organs such as the brain, heart, liver, and kidneys receive high blood flow. Muscle and fat receive less blood flow. If propofol is continuously infused into your IV by a pump or a drip, propolol levels can remain nearly constant. When the infusion is stopped, the propofol concentration in the bloodstream drops, and the drug redistributes back from the brain, heart, live, and kidneys into the bloodstream once again. As the propofol concentration in the brain drops, you begin to awaken. When a propofol infusion is stopped, for most patients, within 10-15 minutes the propofol concentration in the bloodstream will decrease to 10-20% of its previous concentration. Intravenous anesthesia is well discussed in the textbook Miller’s Anesthesia, Ninth Edition, Chapter 23.

SEE ABOVE: For a bolus of propofol at time 0, the concentration peaks in less than one minute, and drops below the Therapeutic range by 8 minutes, meaning the patient will awaken.

Fentanyl is the most common IV narcotic used in surgery in the United States. Narcotics blunt pain, but will not keep you asleep unless administered in very high doses. When fentanyl or any IV narcotic is administered, its blood level is at its highest immediately, and then the blood concentration decreases just like propofol did, by redistributing throughout the rest of the body.

SEVOFLURANE VAPORIZER

INHALATIONAL DRUGS. Sevoflurane is the most commonly used potent inhalational anesthetic. Sevoflurane has both a quick onset and a quick offset time when ventilated into or out of your body. When your surgery ends, your anesthesiologist will turn off the sevoflurane in your inhaled gas mixture, and 90% of the sevoflurane is typically ventilated away in the first 10-15 minutes. Inhalational anesthesia is well discussed in the textbook Miller’s Anesthesia, Ninth Edition, Chapter 20.

Per the left graph, 80-90% of sevoflurane or N2O concentration is exhaled after 10 minutes time

Nitrous Oxide (N2O) is a commonly used anesthetic gas of modest potency. By itself, N2O cannot produce a general anesthetic. It is typically used in a concentration of 50%, as an adjunct to sevoflurane or narcotics. The advantages of N2O are that it is inexpensive, it wears off quickly, and it has a reliable safety record. Dentists sometimes use N2O to bring on inhaled sedation when they are doing office procedures such as filling a cavity.

Balanced anesthesia: Most general anesthetics include balanced doses of propofol, sevoflurane and a narcotic. How fast you wake at the end of your general anesthetic after a surgery depends on the sum total of how much propofol, sevoflurane, fentanyl (or other narcotic) you were given. Higher drug doses –> slower wakeup. Lower drug doses –> faster wakeup.

  • THE LENGTH OF THE ANESTHETIC TIME.

If you have a brief thirty-minute anesthetic to repair a tendon defect in your hand, you’ll wake up quickly, because the doses of the IV and inhalational drugs discussed above will be lower than if you had an eight-hour surgery.

  • THE TYPE OF SURGERY YOU HAD.

Surgeries differ in terms of the amount of anesthetic required. A colonoscopy, for example, is technically not a surgery, but rather an endoscopic examination of the inside of your colon. There is no incision, there is usually only moderate discomfort, and there is no significant postoperative pain. The only anesthetic required may be an infusion of propofol alone, and when that infusion is stopped, you’ll wake in 5 minutes. In contrast, if you have an open heart surgery, such as coronary artery bypass grafting (CABG), the anesthetic plan may be to keep you asleep for several hours after the surgery in the ICU, or even overnight, while your heart, lungs, blood pressure, and temperature recover from the surgery. For the gall bladder excision surgery you’re scheduled for, the typical anesthetic and surgery duration is about two hours. The anesthetic plan would be to turn off the IV and inhaled anesthetic drugs at the conclusion of the surgery, leaving just enough narcotic concentration in your bloodstream so you will awaken with excellent pain control. The duration of this wakeup from when the anesthetics are turned off until you are awake and talking will be 10 – 20 minutes for most patients.

  • HOW MUCH PAIN YOU HAVE AFTER THE SURGERY.

Some surgeries do not hurt. For example, a small breast biopsy is relatively painless. In contrast, an intraabdominal operation such as removal of a portion of your colon will cause much more pain in the hours and days following surgery. Even though 90% of the propofol and sevoflurane will wear off in the first two hours after abdominal surgery, you’ll require ongoing doses of narcotics such as morphine or Dilaudid to be comfortable. Ongoing narcotics cause sedation, and you’ll be sleepy for the duration of time that you require IV narcotics for pain relief.

  • HOW HEALTHY YOU ARE.

All else being equal, patients with normal heart and lung function, and normal body weight, will awaken sooner than patients with decreased heart function, decreased lung function, and/or obesity.

***THE ROLE OF LOCAL ANESTHETICS***

One last topic is the role of local anesthetics to speed anesthetic wakeup and recovery. Local anesthetics such as lidocaine, ropivicaine, or bupivacaine can be injected via needles to effect pain relief. There are several ways this can be done:

  1. Local infiltration of the anesthetic into the skin incision, into the joint if you’ve had an arthroscopy, or into the tissues surrounding the surgical site. Local infiltration directly decreases pain in that region, and therefore decreases the amount of general anesthesia drugs needed or narcotic drugs needed. 
  2. Spinal or epidural blocks, administered by the anesthesiologist into the low back, cause the loss of sedation in the abdomen, pelvis, and lower extremities. This directly decreases pain, and therefore decreases the amount of general anesthesia drugs or narcotic drugs needed. 
  3. Ultrasound directed regional nerve blocks administered by the anesthesiologist, can effect numbness in a shoulder, upper extremity, knee, leg, or foot enervated by a specific nerve. This decreases the amount of general anesthesia drugs or narcotic drugs needed. 

Some examples of how long it takes to wake up, if you’re healthy, after general anesthesia for common procedures:

Colonoscopy                                                    5 minutes

Knee arthroscopy                                            5-10 minutes

Tonsillectomy                                                  5-15 minutes

Breast augmentation                                      10-15 minutes

Abdominal/flanks liposuction                        10-15 minutes

Rhinoplasty/nose surgery                               10-15 minutes

Laparoscopic abdominal surgery                  10-20 minutes

Total knee/hip replacements                         10-20 minutes

Brain surgery/craniotomy                              15-25 minutes

Open heart surgery                                        2 – 12 hours

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The most popular posts for laypeople on The Anesthesia Consultant include:
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

DYING UNDER GENERAL ANESTHESIA

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

You’re an anesthesiologist and you’re contacted by a patient who is dying of cancer. He wants an end of life anesthetic so that he will be unconscious and die without pain and suffering. What do you do? Will you enable dying under general anesthesia?

A recent article from the United Kingdom discussed this topic of end of life anesthesia, otherwise known as “terminal anesthesia.” Terminal anesthesia refers to a situation when a patient has a terminal illness such as end-stage cancer and is suffering through their last days. They request to have a general anesthetic so they are unconscious throughout the process of dying under general anesthesia.

Is anyone doing terminal anesthesia anywhere? The Journal of Medical Ethics reported that in 2016, France passed a law granting terminally ill patients the right to continuous deep sedation until death. This right was proposed as an alternative to euthanasia and was presented as the ‘French response’ to problems at the end of life. The law draws a distinction between continuous deep sedation and euthanasia.” 

Euthanasia, or the ending of life through pharmacologic intervention, is illegal in the United States, the United Kingdom, and most nations. In the 1980s and 1990s, Dr. Jack Kevorkian of the United States  infamously created a euthanasia machine that injected lethal doses of sodium pentothal (a hypnotic sleep drug), potassium chloride (an overdose of potassium which caused cardiac arrest), and pancuronium (a paralyzing drug) into terminal patients who requested a pharmacologic suicide. Dr. Kevorkian was convicted of second degree murder, and served 8 years of a 10-to-25-year prison sentence.

Dr. Jack Kevorkian and his euthanasia machine

Dying patients may have an interest in terminal anesthesia. In a survey of 500 individuals in the United Kingdom regarding end-of-life options, 88% of the respondents said they would like the option of a general anesthetic if they were dying.  

What would terminal anesthesia look like? Medication(s) would be administered through an intravenous line to bring on unconsciousness without hastening death. These last three words are key, because terminal anesthesia is specifically not to be euthanasia. Terminal patients are frail, and their cardiac and respiratory systems will be sensitive to oversedation. Terminal anesthesia is not to directly stop the patient from breathing, stop their hearts from beating, or put them at risk from aspirating food into their lungs. The duration of the IV sedation/anesthesia must be maintained until the patient’s heart eventually stops because of their underlying terminal medical illness. Because of the danger of food aspiration into the windpipe (trachea), tube feedings to the stomach during the time of this terminal anesthetic would not be allowed. 

What drugs could be used for terminal anesthesia? Propofol (an IV hypnotic drug) and midazolam (an IV benzodiazepine also known as Versed) are the most likely agents. The initial infusion of these drugs must be gradual, because bolus doses of these powerful agents into the bloodstream of a frail, end of life patient, could easily halt their breathing and hasten death. No pulse oximetry or other monitors would be used, and the person administering the drug would not remain in constant attendance with the patient. These two facts—the lack of monitoring and the lack of being physically present to attend to the patient—are boldly in defiance of what anesthesiologists do when they administer general anesthesia to patients. The motto of the American Society of Anesthesiologists is “Vigilance.” Terminal anesthesia implies minimal vigilance, and for this reason I cannot imagine the practice being approved in the United States.

An April 2021 publication in the journal Anaesthesia disagrees. The authors describe end of life anesthesia as “an impending development for which the specialty should prepare.” Co-author Jaideep Pandit, MD, professor of anesthesia at Oxford University, said, “Ethically, it is the right thing to do to make this offer to dying patients where it is technically feasible and the literature says it is. The desire to be unconscious in times of great adversity is understandable—it isn’t surprising or wrong to want to be unconscious in adverse situations. We as physicians are here to help, and if we have the means to help and meet the patient’s desire and it is ethical to do so, then we should strive to make this option feasible.” This article described the first use of end of life anesthesia as occurring over 25 years ago: “The first description of using general anesthesia in end‐of‐life care was in 1995 by John Moyle, a consultant anesthetist and palliative care physician. Moyle recognized the limitations of conventional approaches . . . Moyle developed a protocol for infusing the then relatively new anesthetic agent propofol and described its use in two patients, who died peacefully after 4 and 9 days of continuous infusion. . . . Moyle and others recommended very slow intravenous infusion by a pump at a carefully titrated dose (e.g. just 5 mg.h‐1 vs. the 100–200 mg typically used as a bolus) The depth of anesthesia achieved was inadequate for a surgical procedure, but was ideal for an undisturbed dying patient.” 

A study from Sweden described their experience with propofol for end of life sedation. Two indications for using propofol were identified. The first was refractory nausea and vomiting, and the second was the need for palliative sedation due to refractory anxiety or agitation, with or without intractable pain. Monitoring of the patient was as follows: “During the first hour of treatment, the patients were checked repeatedly by both the nurse and the physician caring for the patient. Then, evaluation was performed after 2, 6, and 12 hours. These assessments were preferably made by the physician, but when symptom control had been established, the evaluation was made by the nurse. Patients on continuous treatment with propofol were thereafter evaluated at least twice daily by the nurse in addition to their daily routine care. The physician visited the patient at least once daily for evaluation.” The mean dose range of propofol during treatment was between 0.90 and 2.13 mg/kg/h, (or for an average 70-kilogram patient, between 70 and 150 mg of propofol per hour). The length of treatment with propofol varied between 2 hours and 44 days. The study reported “All but three patients died at the unit, and the median survival was 38 days, compared with the usual median survival of 14 days at the unit.” 

Euthanasia is illegal, but general anesthesia is legal. Could general anesthesia really be approved so that individuals do not have to experience the suffering of dying? What if the United States passed a law, similar to the 2016 law in France, that granted terminally ill patients the right to continuous deep sedation until death? Will this type of terminal sedation/anesthesia ever happen in the United States? It’s currently common to utilize anesthesia/deep sedation for patients who are on ventilators in an intensive care unit (ICU). If such a patient has an untreatable illness, they may die while they are in the ICU under deep sedation, but the application of terminal anesthesia outside of an ICU is not seen in the United States today.

There are other ethical, medicolegal and practical implications to utilizing terminal anesthesia. Who would give the IV sedation/general anesthesia? The Hippocratic Oath states, “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan,” so it’s unlikely any American physician would administer the anesthetic. Would the medical malpractice court system litigate that cases of terminal anesthesia were indeed euthanasia, and therefore illegal? If the American Society of Anesthesiologists opposed the idea, could continuous deep sedation at end-of-life ever come to fruition? What if some medical professional with a license to administer anesthesia decided to open up a practice of administering terminal anesthetics? Could such an individual collect cash payments or insurance payments for administering general anesthesia to patients who were on hospice, and thereby earn a large quantum of money for each case? 

Everyone fears dying, and no one wants to have a painful or torturous death. Expect to hear more discussion about this topic in years to come, but don’t expect physician anesthesiologists in the United States to prescribe or administer terminal anesthesia any time soon. 

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The most popular posts for laypeople on The Anesthesia Consultant include:
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WILL CRNAs REPLACE MD ANESTHESIOLOGISTS?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Who is responsible for your anesthetic? A doctor or a nurse? On March 28, 2021 the anesthesia world in the United States was rocked by the headline: “Wisconsin Hospital Replaces All Anesthesiologists With CRNAs.“  

The hospital was Watertown Regional Medical Center, located in Watertown, Wisconsin,  population 23,861, midway between Milwaukee and Madison. The medical center previously had an anesthesia staff that included both MDs and CRNAs (Certified Registered Nurse Anesthetists).  Why did this change happen? The article didn’t say. The article did say that “Envision, a large medical staffing agency that works with the hospital . . . will oversee the anesthesiology team. A quote from the Medscape article read: “Adam Dachman, MD, a surgeon at the hospital, speaking for himself, said he has no problem using nurse anesthetists. (He said) ‘It’s a misconception that physicians are required to administer anesthesia.’” 

Is this a watershed moment for the profession of physician anesthesiologists? Are CRNAs going to replace MD anesthesiologists all over America, changing the profession forever?

In a word, no. 

Will certified registered nurse anesthetists (CRNAs) will be major factor in anesthesia care in the 21st century? Yes. See this link. There are roles for both CRNAs and physician anesthesiologists in the 21st century. 

Let’s step back and look at healthcare practitioners from the view of a patient. Let’s say you’re a patient, and you enter a medical clinic for a checkup. An individual who is not a doctor interviews you, it’s usually quite clear by their nametag and by their verbal introduction whether they are a physician, a nurse, a physician assistant, or a nurse practitioner. Each of these job titles has a different educational background, a different duration of training, and a differing level of autonomy and responsibility. If a physician assistant or a nurse practitioner presents themselves as your healthcare provider in a clinic, you realize you are not being attended to by a physician.

When you enter a hospital or surgery center for a surgery and an anesthesia professional approaches you prior to your surgery, that professional could be a physician anesthesiologist, a Certified Registered Nurse Anesthetist, or an Anesthesia Assistant (AA). Each of these job titles has a different educational background, a different duration of training, and a differing level of autonomy and responsibility. If a CRNA presents themselves as the sole anesthesia professional responsible for evaluating you and making the anesthesia plan and carrying out all the anesthesia care,  you realize you’re not being attended to by a physician.

Are CRNAs and anesthesiologists equals? No, they are not. The difference in training is profound. CRNAs are registered nurses with a minimum of one year experience as a critical care nurse followed by, on the average, an anesthesia training period of three years. Anesthesiologists are medical doctors, and their training of four years of medical school followed by a minimum of four years of anesthesia residency following makes them specialists in all aspects of anesthesia care and perioperative medicine.

Physician anesthesiologists frequently employ CRNAs to assist them in the anesthesia care team model. In this model, an MD anesthesiologist supervises up to four CRNAs who work in up to four different operating rooms simultaneously. The responsibility for the anesthesia care in this model resides with the supervising MD anesthesiologist. 

The American Society of Anesthesiologists STATEMENT ON THE ANESTHESIA CARE TEAMAnesthesiology is the practice of medicine including, but not limited to, preoperative patient evaluation, anesthetic planning, intraoperative and postoperative care and the management of systems and personnel that support these activities. . . . This care is personally provided by or directed by the anesthesiologist.”

Governors in 19 primarily Western states (Wisconsin, Arizona, Oklahoma, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, California, Colorado, and Kentucky) have signed legislation allowing CRNAs to opt out of physician supervision and practice anesthesiology alone. The primary motivation for this change was the fact that hospitals in rural communities had inadequate numbers of physician anesthesiologists. Empowering CRNAs to work alone made surgery more accessible to patients in these rural areas. I have no personal connection to or communication with the Watertown Regional Medical Center, but a small community like the one in Watertown Wisconsin likely was unable to recruit or retain a full lineup of MD anesthesiologists, so they were forced to staff with CRNAs. The Watertown Regional Medical Center website, under “Find a Doctor,” as of April 25, 2021 listed 3 MDs and 10 CRNAs.  

Is there any data that CRNA anesthesia care is less safe than MD anesthesia care?  There is. Doctor J H Silber’s landmark study from the University of Pennsylvania documented that both 30-day mortality and failure-to-rescue rates were lower when anesthesia care was supervised by anesthesiologists, as opposed to anesthesia care by unsupervised nurse anesthetists. This study has been widely discussed. The CRNA community dismissed the study’s conclusions, citing that the Silber study was a retrospective study. 

An anesthesia blog, Great Z’s, recently posted a column titled CRNAs Take Over AmericaThe column said, the anesthesia care team model will be the end of physician anesthesiologists. With the ACT model, anesthesiologists’ roles become more like physician assistants. We’re outside the operating rooms, dealing with preop history taking, starting IV’s, making sure the patients are ready for their surgeries. Meanwhile, the CRNAs are the ones that are administering the anesthesia. They are the ones the surgeons will interact with 90% of the time. Our interactions with surgeons diminish to the point where they feel the CRNAs are doing all the work and no physician anesthesiologist is needed. This makes the hospital administration’s decision to save money by firing all the anesthesiologists that much easier and less controversial with the staff.” 

I disagree that MD anesthesiologists will be pushed out the doors nationwide. Easy anesthetic cases can be done by either MDs or CRNAs, but complex cases (open heart surgery, brain surgery, neonatal surgery, surgery on patients with multiple medical comorbidities) will nearly always require physician anesthesiologists. I believe surgeons will support the role of physician anesthesiologists in their operating rooms. Surgeons have no incentive to replace physician anesthesiologists with CRNAs. Patients have no incentive to replace physician anesthesiologists with CRNAs. Would CRNA anesthesia care be less expensive? There is a paucity of data to support that, with only one study to date, published in a nursing journal (Journal of Nursing Economics) which concluded that, “CRNAs acting as the sole anesthesia provider cost 25 percent less than the second lowest cost model.” 

In California where I live and work, Governor Arnold Schwarzenegger signed the independent practice for CRNAs into law in 2009. California physician anesthesiologists were angry and concerned about the legislation change at the time, but in the 12+ years since 2009, the penetration of unsupervised CRNA practice in California was been minimal. The traditional old models of physician-only anesthesia or the anesthesia care team are still the dominant modes of practice in California. 

One threat that remains troubling is the specter that national staffing companies (see the Watertown story above) may force out MDs and hire predominantly CRNAs, collect the standard anesthesia fees for each case, pay the CRNAs less than they paid MD anesthesiologists, and therefore increase profit to the shareholders of the parent company. What can anesthesiologists do about this problem? Don’t sell your anesthesia practice to a national company. But if your hospital CEO makes an exclusive contract with such a company, it’s possible you could be forced out without any choice.

CRNAs will have a significant role in American healthcare in the future. The most significant role will be played with an MD anesthesiologist at their right hand supervising them. Non-supervised CRNAs will be found mainly at rural hospitals. I don’t see a significant number of unsupervised CRNAs working in Palo Alto, Manhattan, or Boston anytime soon.

The future for physician anesthesiologists still looks bright.

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WAS TIGER WOODS DRIVING UNDER THE INFLUENCE?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Was Tiger Woods driving under the influence (DUI) on the morning of February 23rd, 2021 when he was injured in a single car accident? 

Perhaps his anesthesiologist knows. 

Tiger Woods underwent surgery at Harbor-UCLA Medical Center just hours after his single car rollover vehicle crash. Surgeons performed a pinning of a tibia (shin bone) fracture and pinning of an ankle fracture. Prior to administering an anesthetic, it would be important for the anesthesiologist to know the toxicology screen results in any patient who just survived such an accident. The anesthesiologist needs to know what other drugs, if any, were present in the patient’s system at the time of the crash, because this fact could influence anesthesia management. Drug use could mean central nervous system depressants (opioids, alcohol, sedatives, hypnotics, sleeping pills) or stimulants (cocaine, amphetamines). If sedative drugs were present, there can be a synergistic effect between the drugs and the anesthetic medications. If stimulant drugs were present, the patient may have tolerance and/or increased anesthetic dose requirements. 

A 2017 anesthesia study stated that “for optimal patient care through the perioperative period, it is critical to obtain information about patient drug use and other associated treatment in order to construct an appropriate anesthetic plan, including specific considerations during surgery, emergence, and in the post anesthesia care unit.” 

In a study from Nature, 1007 consecutive patients undergoing emergency surgery were screened for illicit drug use (IDU). Seventy-five patients (7.45%) were found to be positive for IDU, even though zero patients admitted a positive history of illicit drug use. Of the 75 patients, 50 tested positive for morphine, 22 tested positive for methamphetamine, 13 tested positive for ketamine, 6 tested positive for two drugs, and 2 tested positive for all three drugs. The study concluded, “Knowledge of illicit drug users (IDUs) is important because of the comorbidity related to drug use.”

Miller’s Anesthesia (9th edition, 2020, Chapter 31, Preoperative Evaluation, authored by Wijeysundera and Finlayson) states, “A patient with a history of current or previous alcohol or drug addiction presents special challenges for the perioperative team. . . . Addictive disease should be considered permanent even in patients who have had long periods of abstinence. . . . Substance abuse disorders are risk factors for poor outcomes in the perioperative setting.”

The 1996 Health Insurance Portability and Accountability Act (HIPAA) prohibits a patient’s doctors from divulging any private healthcare information (PHI) to anyone who is not caring for that patient. The anesthesiologists may know whether a motor vehicle accident patient was part of a DUI incident, but they will not release the results of such a tox screen to the press. 

The sheriff who arrived at the Woods crash scene stated there was no evidence that Woods was impaired or intoxicated at the time of the crash in Rolling Hills Estates, California. The police said they “did not issue a citation for Woods . . . To issue a ticket for reckless driving would require evidence that Woods had committed multiple violations before the crash, such as unsafe lane changes, or passing other cars unsafely, according to investigators. . . . Woods had no recollection of the collision, investigators said at the press conference.” 

I’m not a lawyer, but I presume that tox screen results could be subpoenaed if a crime had been committed. For example, if an automobile collides with a school bus and kills someone, then I presume the driver’s medical test results would be part of a criminal investigation. 

According to the forensic report, Tiger Woods was speeding as fast as 75 miles per hour, or more than 45 mph faster than the legal speed limit before his SUV crashed. Investigators said the accident was “the result of Woods driving in an unsafe manner for road conditions. . . . The evidence suggested the golfer didn’t brake or steer out of the emergency for nearly 400 feet after striking an eight-inch curb in the median.” 

Per Golfweek magazine: “forensic experts say the evidence suggests Woods was not conscious when he left his lane and kept going in a straight line before crashing. Instead of staying with the downhill road as it curved right, he went straight over the curb in the median to the left, hit a wooden sign and kept going in a straight line into opposing traffic lanes before leaving the road, hitting a tree and rolling over. Jonathan Cherney, an accident reconstruction expert and former police detective who walked the scene, told USA TODAY Sports it was ‘like a classic case of falling asleep behind the wheel, because the road curves and his vehicle goes straight.’ There were no skid marks on the road, Villanueva said. Instead, Woods’ Genesis SUV kept going straight for several hundred feet. Woods later told sheriff’s deputies he couldn’t remember how the crash occurred and didn’t remember even driving.” 

Per USA Today: “’The report doesn’t deal with the underlying cause of the crash,’ said Charles Schack, a former New Hampshire state police trooper who is now president of Crash Experts, which analyzes traffic accidents for law firms and insurance companies. ‘It addresses the data superficially with no apparent curiosity as to why Tiger drove for hundreds of feet without adjusting his steering, braking, or speed. Taking away the high-profile aspect of this crash and looking at the data and roadway, it appears that the driver made no attempt to follow the roadway during the moments leading to the crash. This is typical of a driver who was incapacitated due to a medical issue, falling asleep or being impaired.’” 

Can an individual take a sleep medication prescribed by a physician, such as Ambien, at nighttime and still have drowsiness from the medication which impairs their driving ability the next morning? Yes. In 2013 the Food and Drug Administration released the following Safety Communication regarding zolpidem (Ambien):

The U.S. Food and Drug Administration (FDA) is notifying the public of new information about zolpidem, a widely prescribed insomnia drug. FDA recommends that the bedtime dose be lowered because new data show that blood levels in some patients may be high enough the morning after use to impair activities that require alertness, including driving. Today’s announcement focuses on zolpidem products approved for bedtime use, which are marketed as generics and under the brand names Ambien, Ambien CR, Edluar, and Zolpimist.

FDA is also reminding the public that all drugs taken for insomnia can impair driving and activities that require alertness the morning after use. Drowsiness is already listed as a common side effect in the drug labels of all insomnia drugs, along with warnings that patients may still feel drowsy the day after taking these products. Patients who take insomnia drugs can experience impairment of mental alertness the morning after use, even if they feel fully awake. 

FDA urges health care professionals to caution all patients (men and women) who use these zolpidem products about the risks of next‐morning impairment for activities that require complete mental alertness, including driving. 

There appears to be a public safety concern that individuals who take Ambien for sleep may be impaired when driving a vehicle the following morning. 

Was Tiger Woods impaired on the morning of his single car accident? I don’t know, and it’s not my intent to accuse him in any way. I wish him a speedy and complete recovery, and hope we can all watch him play golf at a high level once again. The purpose of this column is to inform readers that: 1) anesthesiologists need to know the results of blood and/or urine toxicology screens before they are administer general anesthesia to an automobile trauma victim; 2) sleeping aids such as Ambien (zolpidem) carry an FDA warning that they can impair activities such as driving the morning after administration; and 3) HIPAA law prevents physicians from disclosing the medical records of patients to the media.

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The most popular posts for laypeople on The Anesthesia Consultant include:
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

ALCOHOL AND ANESTHESIA

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

You’re a patient scheduled for elective surgery tomorrow. You’re nervous and you’d like to drink a glass of wine (or two) at dinner the night before the surgery. Is this OK? What’s the relationship between alcohol and anesthesia?

Alcohol use is common in the United States—fourteen percent of the United States adult population suffers from alcohol addiction.  Surgery is common in the United States—there were more than 17 million surgeries performed in America in 2014. The intersection of an alcohol-addicted patient and surgery is therefore common. How much alcohol consumption is too much? The thresholds for defining high-risk alcohol consumption are 5 or more drinks in one day (>14 drinks per week on average) for males under 65 years of age, and 4 or more drinks in a day (>7 drinks per week on average) for all females and males 65 or more years of age. (Miller’s Anesthesia, 9th edition, Chapter 31, Preoperative Evaluation) All adults and adolescents should be questioned regarding their history of alcohol use prior to anesthesia. 

Let’s look at the risks for an acutely alcohol intoxicated patient first. Hospital emergency rooms have no shortage of drunken individuals who’ve been involved in motor vehicle trauma, motorcycle accidents, gang violence, or domestic violence. Acute intoxication with alcohol is usually diagnosed by history or by the smell of a patient’s breath. If an individual requires an acute surgical procedure, their level of intoxication is documented by measuring the alcohol concentration in their blood prior to surgery. Extreme levels of acute alcohol intoxication can cause coma or stupor, because alcohol is a central nervous system depressant, but other causes of decreased mental status must also be considered. An altered mental status in a trauma victim who smells of alcohol may be secondary to the central nervous system depressant effect of alcohol, or it may also be secondary to intracranial trauma. A CT scan of the head is indicated. High levels of alcohol intoxication alter a patient’s tolerance to anesthetic medications, because many anesthetics are central nervous system depressants just like alcohol, and there can be an additive effect between the alcohol and the anesthetic doses. Polydrug abuse is common, and blood tests are done on intoxicated patients to determine if other central nervous system depressants (opioids or sedatives), stimulants (cocaine, amphetamines), or other psychotropic substances (e.g. cannabis REF) are present. During surgery, anesthesiologists titrate medications to the desired effect by adding doses cautiously and following the effects on the patient’s vital signs of blood pressure and heart rate. Following surgery, anesthesiologists are vigilant symptoms of acute alcohol withdrawal syndromes. Chronic heavy alcohol use is associated with a two-fold to five-fold increase in postoperative complications, including higher rates of admission to intensive care units and increased lengths of hospital stay. (Chapman R, Plaat F, et al, Alcohol and Anaesthesia, Continuing Education in Anaesthesia, Critical Care and Pain, Volume 9, number 1, 2009, pp 10-13)

For elective scheduled surgeries, patients are seldom intoxicated, but the issue  of their chronic alcohol intake is important. Doctors and nurses question each patient regarding the history of alcohol consumption prior to surgery, and are aware that patients often downplay the quantity of their alcohol consumption. A patient who admits to one or two drinks per day may very well consume twice that amount. Chronic alcohol use can increase the dose requirements for general anesthetics, either because of induction/stimulation of the microsomal ethanol-oxidizing system (cytochrome P-450 system), or through the development of cross tolerance to other central nervous system drugs. (Chapman R, Plaat F, et al, Alcohol and Anaesthesia, Continuing Education in Anaesthesia, Critical Care and Pain, Volume 9, number 1, 2009, pp 10-13)

In contrast, chronic heavy alcohol use can cause cirrhosis and depress liver function. Certain anesthetic drugs, especially narcotics, are cleared by the liver, and decreased liver metabolism of narcotics can lead to relative overdoses. Chronic heavy alcohol use can also lead to cardiomyopathy with depressed ejection of blood from the heart, causing low blood pressures during and after anesthesia. Chronic alcohol dependence can cause central nervous system, gastrointestinal system,  hematological, metabolic, and musculoskeletal disorders. Because of the contrasting pharmacologic and physiologic effects of chronic alcohol dependence in a surgical patient, anesthesiologists will titrate the administration of  medications by monitoring the patient’s vital signs of blood pressure and heart rate, and adjusting the anesthetic depth required.

As a patient, what should you do? 

Be honest with yourself and your doctors if you drink daily. Alcohol dependence can and will affect your anesthetic and your body’s reaction to anesthetic drug dosing. Your anesthesiologist will be your consultant, and will administer anesthetic medications and doses in a range that is safe for you. In a perfect world, patients with heavy alcohol dependence should be identified before elective surgical procedures and referred to alcohol counseling services.

Does mild alcohol consumption of one to two glasses of wine or one to two beers per day increase anesthetic risk prior to surgery? Your risks will ultimately depend on the complexity of the surgery and the number of other medical problems that you have, but for most patients it’s unlikely you’ll have any anesthetic or surgical complication based only on this amount of alcohol consumption. One glass of wine with dinner may very well help you relax and get adequate sleep the night before your anesthetic.

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popular posts for laypeople on The Anesthesia Consultant include:
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

A DAY IN THE LIFE OF AN ANESTHESIOLOGIST

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

One of my readers asked me to describe a day in the life of an anesthesiologist, as he was considering a career in anesthesiology. To aid you in visualizing yourself in the hospital, I’m substituting the pronoun “you” instead of “I” in the narrative below.

Your day is as follows, Doctor:

0530 hours – Your alarm goes off, awakening you and starting your morning. (Anesthesia is not the career for you if you like to sleep late—surgery always begins at 0730 hours). You complete your morning bathroom and breakfast routines, and leave your residence at 0630 hours for the hospital.

0645 hours—You arrive at the hospital, use your ID to open the gate to the parking lot, and walk one hundred yards from the parking lot to the hospital entrance. You take the elevator to the third floor and proceed to the locker room. The scrubs are enclosed in a device not dissimilar to a soda machine, and you need your ID to operate it. The machine opens and you extract a scrub top and scrub bottom in your size. You leave your street clothes in your locker. Because anesthesiologists do not scrub in a sterile fashion, it’s OK to wear your watch and ring., and to bring your cell phone with you.

Empty Operating Room

0655 hours—You don a bouffant hat and a facemask, and enter your operating room. Your hospital contains multiple operating rooms, and today you are in room #10. Your briefcase contains your personal medical equipment and office items you need for the day. Inside the operating room, the scrub tech is already dressed in a sterile gown and gloves, and is preparing the instruments the surgeon will use to operate on the first patient. The first surgery today is a procedure devised to treat obstructive sleep apnea, a procedure called a maxillary-mandibular osteotomy. An ear, nose, and throat (ENT) specialist will saw through the patient’s upper and lower facial bones, extend their bite forward to open the back of the throat further, and then fixate the bones in their new positions. The surgery will take approximately three hours. 

Your station in the operating room consists of an anesthesia machine; a bevy of vital signs monitors; a computerized pharmacy cart; a cart full of syringes and equipment; and the computer which handles the hospital’s electronic medical record (EMR).

Anesthesia Workstation

You log into the EMR system, and then you log into your first patient’s chart. You’ve looked over the patient’s information the night before, and you now review everything in detail, including the history, physical findings, vital signs, height, weight, body-mass index (BMI) from this morning, and any laboratory results.  

            Next you log into the patient’s file on the computerized pharmacy cart, and extract the controlled substances/drugs (Versed and fentanyl) that you will use for this case. The lower drawers to the computerized pharmacy cart unlock, and you’re able to access the propofol you’ll use to induce anesthesia. You fill a 20-milliliter syringe with 20 ml of propofol, and set it on the countertop. You remove a plastic breathing endotracheal tube (ETT) from its wrapper and set it next to the propofol syringe. You remove a lighted laryngoscope from a drawer and set it next to the ETT. You prepare several empty syringes which you’ll use to inject medications into your patient’s intravenous (IV) line.

Labelled anesthetic syringes

            Next you turn to the anesthesia machine and run through a checklist to assure it is connected to oxygen, full of the liquid form of the general anesthetic sevoflurane, and that all the hoses and valves are airtight and operational. You check the suction catheter system to document there is negative pressure should you need to suck saliva or vomitus out of the patient’s airway. You reach into your briefcase and pull out the stethoscope and peripheral nerve stimulator you’ll use during the case. 

Pre-Anesthesia Room

0700 hours—It’s time to meet your first patient. You walk into the pre-operative area, where your patient is wearing a hospital gown and is lying on a gurney. At this point every patient is apprehensive and anxious. You do your best to reassure him as you introduce yourself and sit down at the foot of the bed. Rather than launching immediately into medical questions, you begin by asking him what he would normally be doing on this day if he wasn’t at the hospital. This way you and the patient can connect on a human level before beginning the anesthetic proceedings. The patient will probably already have an IV in their arm, placed by a registered nurse. (To the contrary, in our practice we physician anesthesiologists start the IVs ourselves. We do this because we’re skilled at placing IVs painlessly and successfully, it doesn’t take that much time, and it gives the patient confidence that we’ll continue to take care of them at the highest level.)

            You ask the patient questions that are pertinent regarding their medical history. For example, if a patient has a history of asthma you’ll ask him if he has ever had an asthma attack severe enough to require treatment in an emergency room. If the patient was older than 50 years, you’ll ask him if he gets shortness of breath when he climbs two flights of stairs.

            Once your questions are answered, you’ll do a pertinent physical exam of the patient’s airway, heart, and lungs. Then you’ll explain the sequence of the anesthetic, as well as the anesthetic alternatives and risks. Your monologue goes as follows: “I’ll begin by giving you a medication in your IV which will make you feel less anxious. Then we’ll roll down the hallway into the operating room. There I’ll give you a medication which makes you lose consciousness. You’ll be asleep for the entire surgery. I’ll be with you that entire time, and you won’t feel any pain, or experience any awareness. During the time you’re asleep, there’s an airway tube in place. I’ll remove the tube when you wake up. You may have a sore throat from the tube. You may have nausea after general anesthesia. You’ll wake up reasonably comfortable, but as the general anesthesia wears off you’ll likely experience the onset of pain. There’ll be a nurse standing right next to you in the Recovery Room, and he or she will administer pain relieving medication to you if and when you need it. Do you have any questions?”

            After the patient gives verbal consent, you administer 2 ml of Versed (midazolam), a Valium-like benzodiazepine, into the IV. Within a minute or two, the patient feels the relaxing effect of the Versed, and you roll his gurney down the hallway toward the operating room.

Moving a patient from the gurney to the operating room table.

0715 hours—You roll the gurney in to the operating room. The patient moves himself from the gurney to the operating room table. You and the operating room nurse work to connect the patient to the standard vital signs monitors: the pulse oximeter on his fingertip, the three (or five) electrocardiogram stickers across his chest, and a blood pressure cuff on his arm. You turn to the EMR computer, and with a series of clicks you document the start of anesthesia time; begin data collection from the vital signs monitors; and identify which device (anesthesia machine/monitors in which operating room) you are connected to and receiving input from. You inject two prophylactic anti-nausea drugs, Zofran (ondansetron) and Decadron (dexamethasone) into the IV, and inject 2 ml (100 micrograms) of the narcotic fentanyl. You place an oxygen mask over the patient’s face so that the room air (21% oxygen and 78% nitrogen) that he has been breathing is replaced by 100% oxygen prior to going to sleep.

0725 hours—It’s time to begin anesthesia induction. You inject 40 mg of lidocaine, a local anesthetic, into the IV to blunt the burning sensation that propofol can cause. Then you inject 20 ml (200 mg) of propofol into the IV. Propofol is an opaque white liquid which disappears from the IV line as it enters the vein in the patient’s arm. Within 20 – 30 seconds the patient is unconscious. You ventilate the patient with oxygen for two breaths via the facemask to document that the airway is open and patent, and then you inject 4 ml (40 mg) of the paralyzing drug rocuronium into the IV. You continue to ventilate the patient via the facemask as the patient becomes paralyzed and unable to breathe for himself. You monitor the progression toward paralysis with a small battery-powered nerve stimulator device which you hold against the facial nerve area lateral to his eyebrow on the side of his face. 

Nasotracheal Endotracheal Tube

This surgery requires a specialized ETT which enters through the nose, courses through the back of the throat, and then passes between the vocal cords into the trachea (windpipe). You remove the facemask so the surgeon can insert cotton swaths soaked in local anesthetic into each nostril. Once all motor twitch activity is absent on the facial nerve monitor, you insert the nasal breathing tube, coated with a lubricating jelly, into the right nostril. You advance the tube through the nose until the tip appears in the oral cavity. At this point, you insert the lighted laryngoscope into the patient’s mouth, visualize the vocal cords, and push the ETT from outside the nose through the vocal cords into the trachea. You use a syringe to inflate air into the balloon cuff on the distal end of the ETT, and connect the proximal end of the ETT to the hoses on your anesthesia machine. You inflate the lungs via the breathing system, and listen with your stethoscope to document there are appropriate breath sounds in both the left and right lungs. You turn on your anesthetic vaporizer to administer a concentration of 1.5% sevoflurane gas to the patient. You tape the patients eyes closed so that they do not dry out under general anesthesia. Next you unlock the bed so that it can be rotated 180 degrees, so you are near the patient’s feet and the surgeon has the head of the bed to himself.

            While the surgeon, the nurse, and the scrub tech prepare the patient for the surgical incisions, you administer the antibiotic Kefzol (cephazolin) into the IV. Then you spend 10 minutes of time on the EMR, documenting every drug you injected and all the procedures you performed.

Maxillary surgery

0800 hours—Surgery begins. You titrate the depth of anesthetic drugs to match the degree of surgical stimulus. You do this by monitoring the blood pressure and heart rate, and use a variety of IV drugs to keep the vital signs from straying too high or too low from their pre-operative values. By 0830 hours you are finally able to sit down. The EMR inputs the vital signs automatically from the patient monitors into the medical record. You are vigilant regarding the surgical procedure, the IV infusing into the patient, the ventilator, and the inhaled and injectable anesthetics administered. At certain times during the case, when the surgeon is sawing into  the facial bones, he will ask you to lower the patient’s blood pressure in order to minimize bleeding from the bone. You do this by adding intravenous anti-hypertensive injections, and/or by deepening the level of general anesthetic drugs. As you near the end of this first case, you log into the second case of your anesthetic list on the EMR, and begin information gathering and EMR documentation as you did for your first case.

1130 hours—The surgery ends. You supervise the rotating of the operating room table 180 degrees, so the patient’s head and airway are adjacent to the anesthesia equipment again. You discontinue all anesthetic drugs and wait for the patient to regain consciousness. This can take from 5 to 15 minutes, and is a potentially hazardous time. Like landing an airplane, you need the patient to arrive at consciousness smoothly, without disruption in the vital signs. Most importantly you need him to be breathing safely through his newly remodeled face and airway.

1140 hours—The patient opens his eyes. You remove the ETT and place the oxygen facemask back over his nose and mouth. Once you’ve confirmed that he’s ventilating himself safely, you call for the gurney again. Together with the orderlies, the nurse, and the surgeon, you slide the patient back over to the gurney, and begin to transport him out of the operating room.

Post Anesthesia Care Unit

1145 hours—You push the gurney into the Post Anesthesia Care Unit (PACU), and into a parking berth staffed by a different registered nurse and another battery of vital signs monitors. You and the nurse connect the patient to the same monitors you used in the operating room, and document that the vital signs within safe limits. Then you give the nurse a verbal report of the patient’s preoperative medical problems and the pertinent surgical and anesthetic details. You proceed to the charting room, where you log into the EMR again and finish documenting all the data from the anesthetic. Throughout the time the patient is recovering in the PACU, the nurse follows medical orders you’ve written, and you’re responsible for the patient’s safety and well-being. The PACU nurse will call you for any questions or problems.

1155 hours—You find lunch somewhere. At my hospital there is no doctor’s cafeteria, and there is insufficient time to wait in line at the regular cafeteria. You may bring a sandwich from home, or you may subsist on protein bars, a bagel, a banana, or some yogurt you find in the operating room lounge. For anesthesiologists, the interval between surgeries is a time when the surgeons, nurses, and the empty operating room are waiting for you to get things going again. No surgery can proceed without anesthesia, so your between-case time is to be minimized. In some models of anesthesia care, a certified registered nurse anesthetist (CRNA) may break you out during the anesthetic or between cases, but when there is 100% physician anesthesia staffing, everyone is waiting for you between cases to get the next patient asleep.

1225 hours—You meet your second patient and go through the steps outlined beginning at 0700 hours above once again.

Depending on the length of your anesthetic list, you may be finished by 1400 hours (a 7-hour day), or you may be finished at 1700 hours (a 10-hour day), or if you are on-call you may work all night, until 0700 the next morning. The good news is that your pay is proportional to the duration of time and the number and complexity of the cases you do. When you are on overnight call as an anesthesiologist, you will usually have the next day entirely off.

Ambulatory Surgery Center

On certain days you may work at an outpatient ambulatory surgery center (ASC) instead of at a hospital. At an ASC the surgical procedures are simpler, and medical problems are screened beforehand so that no sick patients are allowed. Many ASCs have no EMR, and the charting is done by writing on paper with a ballpoint pen, which is less time-consuming than the current sluggish and expensive EMR systems used at hospitals. During an ASC day you may do one 8-hour anesthetic, or you may do eight 1-hour anesthetics. An ASC often provides food for their staff and their doctors, and you will be finished at a reasonable and predictable time, usually between noon and 1700 hours.

How are your emotions during your day as an anesthesiologist? It depends on how experienced you are. Even veteran anesthesiologists are on edge during the induction of anesthesia and the placement of breathing tubes. The maintenance phase of anesthesia, during the middle of the surgery, is predictably stable most of the time. Are you bored during this time period? Not likely, as there is enough going on with the surgical procedure, its effects on the patient’s physiology, and the pharmacology you are commanding. The end of each surgery increases the vigilance and anxiety level of the anesthesiologist once again until the patient is safely transferred to the PACU. Some cases are more stressful than others. Emergency surgeries, patients at the extremes of age (very young or very old), trauma surgeries, cardiac surgeries, lung surgeries, and neurosurgeries are among the most stressful. Anesthesiologists who practice these subspecialties are often adrenaline junkies themselves, and enjoy the challenge of more difficult cases.

After your work day you’ll drive home and enjoy a free evening. You typically won’t have any phone calls regarding the day’s patients. Once a patient leaves the PACU without complications, it’s unlikely there will be ongoing any issues for the anesthesiologist. For these reasons, anesthesiology is often considered a “quality lifestyle” medical specialty. I’d agree. Your evenings and weekends are usually free unless you are on call, which makes anesthesiology appealing. 

On each work evening you’ll receive your list for the following day’s cases. In our practice, we telephone each patient the night before to go over essential questions. Hopefully then you can go to sleep when you please. In my career I’ve had quite a few nights where the next day’s difficult cases gave me cause for concern or worry. Concerns and worries can lead to insomnia, a not-uncommon stressor for a practicing anesthesiologist. You might be worrying about a re-do heart valve replacement anesthetic on an 80-year-old woman, a throat surgery on a 340-pound man, or a list of 3-year-olds with obstructive sleep apnea who are having tonsillectomies. 

A career in anesthesia is not for the faint at heart. Mistakes or complications in our specialty can lead to bad outcomes in a matter of minutes. That said, a career in anesthesia is a fascinating and complex lifetime passion, during which you can help tens of thousands of patients undergo surgery safely.

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THE TEN MOST SIGNIFICANT ADVANCES IN ANESTHESIOLOGY IN THE PAST DECADE

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

What were the ten most significant advances in anesthesiology in the past decade, 2010 – 2020? Here are my picks:

  • Sugammadex. Sugammadex was FDA-approved in December 2015, and the practice of chemically paralyzing surgical patients and reversing their paralysis has been forever changed. For my non-medical readers, sugammadex is an intravenous drug which reverses the paralysis of rocuronium, the most commonly used anesthetic paralytic drug, in approximately one minute. Sugammadex replaced the decades-old practice of injecting a combination of neostigmine and glycopyrrolate to reverse paralysis. Neostigmine and glycopyrrolate were slow to act (a wait of up to nine minutes), and could not reverse paralysis if zero twitches were present on a nerve stimulator monitor. In addition, 16 mg/kg of sugammadex IV can reverse an intubating dose of rocuronium, which makes rocuronium more quickly reversible than succinylcholine for rapid sequence intubation. Sugammadex is not cheap (a cost of $100 per 200 mg vial), but since the availability of sugammadex, no anesthesia practitioner should ever have an awake and still-paralyzed patient at the conclusion of an anesthetic. A terrific advance. Five stars.
  • Use of Zoom. In the era of COVID, Zoom videoconferencing made person-to-person communication involving anesthesiologists possible. During the early days of the COVID outbreak, the American Society of Anesthesiologists was able to keep its members informed and educated via Zoom conferencing. At the present time, almost all anesthesia continuing medical education (CME) is conducted effectively via Zoom. I attend the Stanford anesthesia Grand Rounds each Monday morning via Zoom, and the educational value is as high as it was when I attended in person. Expect Zoom CME to continue as a major vector in the years to come. Although Zoom may adversely affect in-person attendance at medical meetings forever, I believe widespread videoconferencing education is a tremendous advance. Five stars.
  • The Stanford Anesthesia Emergency Manual. See this link.  The algorithms set out in the red laminated ring-bound Stanford Anesthesia Emergency Manual filled a fundamental need in acute care medicine. When perioperative emergencies arise, a delay in treatment can result in death or irreversible brain damage. The presence of this Stanford book of checklists assures that every operating room is equipped with the cognitive aids needed for standard of care treatment. The manual is available at https://emergencymanual.stanford.edu. The authors chose not to glean profits from the publication of the Stanford Emergency Manual, but instead made it available for physicians and nurses everywhere for free. Five stars.
  • Safer care. Anesthesia care has become safer and safer. Deaths and adverse outcomes continue to decrease because of improved monitoring, vigilance, education, and training. The Cleveland Clinic writes, “In the 1960s and 1970s, it wasn’t uncommon to have a death related to anesthesia in every one of every 10,000 or 20,000 patients. Now it’s more like one in every 200,000 patients—it’s very rare.” The continuing advances in anesthesia safety are a bellwether for other specialties, who must envy the progress made in anesthesiology quality assurance. The Anesthesia Patient Safety Foundation is a hub of all advances. Five stars.
  • Pubmed/Internet/the Cloud. This past decade saw an explosion of handheld mobile devices and phones, as well as an expansion in the use of the cloud and the internet. Anesthesiology benefited from these technological advances. Information regarding anesthesia care is immediately available to any anesthesia provider anywhere in the world, if they have internet access. The ability to do a Google search on any topic is outstanding and immediate. Pubmed is a National Library of Medicine website which catalogs an abstract on every medical publication. Pubmed is an essential tool for every physician who is investigating previously published medical knowledge. Five stars.
  • Closed loop TIVA (total intravenous anesthesia).  Anesthesiologists and pharmacologists have been working on the pharmacokinetics of automated administration of intravenous anesthetics for years. Utilizing EEG monitoring data (BIS monitor levels) to titrate the depth of anesthesia shows promise. For a typical anesthetic, TIVA requires more work than vapor anesthesia with sevoflurane, because the anesthesiologist must load a syringe with propofol and/or remifentanil, attach an infusion line, load the syringe into the infusion pump, and program the pump to the correct infusion rate. In contrast, a sevoflurane vaporizer is already loaded with liquid anesthetic, is easy to use, and merely requires the pushing of one button and turning of one dial. Closed loop TIVA is not in clinical use at this time, but you can expect that the future, anesthesia recipes will include automated sedation/anesthetic depth titration via computer administration. The TIVA research of the past ten years has paved the way for this advance. Three stars.

The ultrasound-guided regional anesthesia boom. In the past ten years the number of ultrasound guided regional anesthesia blocks has mushroomed. Regional nerve blocks decrease the need for postoperative narcotics. Evidence shows that ultrasound guidance reduces the incidence of vascular injury, local anesthetic systemic toxicity, pneumothorax and phrenic nerve block for interscalene blocks, but there has not been consistent evidence that ultrasound guidance is associated with a reduced incidence of nerve injury. The ultrasound-guided regional anesthesia boom has led to tens of thousands of additional nerve blocks, and an unfortunate fact is that a small but non-zero number of these patients develop permanent nerve damage in their arms or legs after their blocks. Regional anesthesia specialists who publish in the medical literature have made little effort to quantify or report these complications. Prospective data on nerve injuries is needed. Honest verbal informed consent to each patient before a nerve block is needed. See this link. Three stars.

Point of care ultrasound (POCUS). In recent years, anesthesiologists began to aim their ultrasound probes at the abdomen, thorax, and airway, to gain real-time information and immediate knowledge of the anatomy and pathology beneath the skin and to better manage and treat critically ill patients. POCUS is proving useful in trauma , chest examination, and pediatric anesthesia. Because POCUS is a recent development, the majority of anesthesiologists do not have the training, skills, or knowledge needed to use this new technique. Recent graduates of residency and fellowship programs will lead the way as the anesthesia workforce transitions toward mastery of POCUS. Three stars.

  • ASA Monitor/Dr. Steven Shafer. I list this development last, but my enthusiasm for the ASA Monitor and its Editor-in-Chief Steven Shafer is extremely high. The American Society of Anesthesiologists revamped their ASA Monitor publication into a monthly newsletter reporting up-to-date information regarding our specialty. The ASA hired Steven Shafer MD PhD as the editor. Dr. Shafer is a Professor of Anesthesiology at Stanford, and is an outstanding scientist, author, and humorist. I’ve known Steve for nearly forty years, since he was a medical student. He has authored more than 200 peer-reviewed publications in the field of anesthesiology, and was the Editor-in-Chief for Anesthesia and Analgesia from 2006-2016. Dr. Shafer possesses a razor-sharp intellect and a flippant sense of humor seldom seen in scientific writing. His lead editorial in each month’s issue of the ASA Monitor is required reading for every anesthesia professional. Dr. Shafer also personally authors a daily update on COVID research and statistics—a Google group which you can personally subscribe to as an email offering. See this link. Five stars.

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The most popular posts for laypeople on The Anesthesia Consultant include:
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

HOW DO PANDEMICS END? EXAMINING THE 1918 SPANISH FLU PANDEMIC

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

How do pandemics end? Now that COVID-19 vaccines have been approved, we’re all hoping this is the beginning of the end of this coronavirus pandemic. What about a history lesson—how did the last large respiratory viral pandemic end? The 1918 Spanish flu pandemic killed between 50 million and 100 million people, and was the third worst pandemic in the past 1000 years. (Number one was the bubonic plague/Black Death in the 1300s which killed 75 to 200 million people, up to 70% of Europe’s population.1 Number two is the HIV/AIDS pandemic which has killed 32 million people from 1981 to the present.2) How did the Spanish flu pandemic end? There was no vaccine technology in 1918. There were no intensive care units, there were no ventilators, and there wasn’t even a microscope powerful enough to see or identify the virus. There were no anti-viral drugs such as remdesivir or Regeneron’s monoclonal antibodies, and there were no antibiotics to treat the bacterial pneumonias that developed as complications of the flu. When people got a severe case of the Spanish flu, they died. 

H1N1 influenza virus

Novel coronavirus

The difference between the 1918 pandemic and the 2020 pandemic is the fact that the Spanish flu was an influenza virus, and COVID is caused by a novel coronavirus. Both are respiratory viruses, but influenza and coronavirus are two very different entities. Influenza is a seasonal infection which usually runs from autumn until spring. In a typical year, 200,000 Americans are hospitalized for flu-related complications. Over the past thirty years there have been between 3,000 to 49,000 influenza-related U.S. deaths every year. The 1918 Spanish flu pandemic was caused by an H1N1 influenza virus A. It lasted from 1918 to 1920, and infected 500 million people, more than one-third of the world’s population. REF https://www.cdc.gov/flu/pandemic-resources/1918-commemoration/1918-pandemic-history.htm  ). The pandemic killed between 50 million and 100 million people, including 675,000 in the United States. The pandemic occurred during World War I. The press in the United States and much of Europe censored early death tallies from the disease to minimize global panic. Spain was a neutral country in the war, and their newspapers were free to report on the disease, especially since their King Alfonso XIII  contracted the disease. Early stories from Spain created the impression that Spain was hard hit by the disease, and because of this the pandemic was named “Spanish flu.” 

The first wave of the Spanish flu began in the spring of 1918. The second wave began in August, and was more lethal than the first wave. In the United States the peak number of deaths were reported between September and December of 1918.  Infected individuals experienced typical flu symptoms such as sore throat, headache and fever. In January 1919 a third wave of the Spanish flu spread in Europe. The troop deployments and trench warfare of World War I facilitated disease transmission. Death was often caused by bacterial pneumonia  due to common upper respiratory-tract bacteria which invaded the lungs by infecting the viral-damaged airway cells.

Ninety-nine percent of Spanish flu deaths in the United States occurred in people younger than age 65, and fifty percent of the deaths were in young adults 20 to 40 years old. As in the COVID-19 pandemic, the entertainment and service industries suffered heavy economic losses. Public policy on curbing the spread of the Spanish flu was similar to the advice offered in the COVID pandemic: social distancing and masks-earing were encouraged. Frequent hand-washing, quarantining of patients, and closure of schools, public spaces and non-essential businesses were all utilized to minimize the spread of the disease.

How did the Spanish flu pandemic end? Individuals who were infected either died of influenza or survived and developed immunity. In the middle of 1920, the Spanish flu faded away enough on its own so that the pandemic ended.

Let’s compare this to the current novel coronavirus pandemic. As of this week there have been 300,000 COVID-19 deaths in the United States and 1.7 million deaths worldwide. So far less than 1 percent (74 million infected/7.8 billion total world population = .0095) of the world’s population is known to have been infected with the novel coronavirus. While the Spanish flu eventually faded away, as annual seasonal influenza usually fades away, the novel coronavirus has so far showed no signs of weakening. We are nowhere near herd immunity. Herd immunity is defined as “when a large portion of a community (the herd) becomes immune to a disease, making the spread of disease from person to person unlikely. As a result, the whole community becomes protected — not just those who are immune.”  

Doctors don’t expect the current COVID-19 pandemic to end until a significant percentage of the world’s population is vaccinated. According to Dr. Anthony Fauci, “Let’s say we get 75 percent, 80 percent of the population vaccinated. If we do that, if we do it efficiently enough over the second quarter of 2021, by the time we get to the end of the summer, i.e., the third quarter, we may actually have enough herd immunity protecting our society that . . . we can approach very much some degree of normality that is close to where we were before.”

Between twenty and forty percent of Americans say they will not take the COVID vaccine. This is a high number, and it strikes me as lunacy. The health consequences of you, your family members, or your friends developing a severe case of COVID-19 are well documented. Both the Pfizer and the Moderna vaccines showed minimal side effects in their clinical trials. Be smart. Get vaccinated as soon as you can. Herd immunity to the COVID-19 virus will only develop if we vaccinate the populace. Hopefully vaccine-induced immunity will curb the COVID-19 pandemic so the world can once again return to the lifestyles and freedoms we enjoyed in 2019.

For further information regarding influenza pandemics, I recommend The History Of Influenza Pandemics By The Numbers.

References:

  1. Austin Alchon, Suzanne (2003). A pest in the land: new world epidemics in a global perspective. University of New Mexico Press. p. 21. ISBN 978-0-8263-2871-7. Archived from the original on 2019-04-01. Retrieved 2016-04-22.
  2. “UNAIDS report on the global AIDS epidemic 2010”. UNAIDS. UNAIDS. 2010. Retrieved 5 September 2020.


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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
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Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

SUFFOCATING ALONE

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997
Dr. Shirlee Xie, Minneapolis

This week Dr. Shirlee Xie, Associate Director of Hospital Medicine at Hennepin Healthcare in Minneapolis, Minnesota, taped an interview in which she described her personal experiences caring for COVID inpatients. I encourage you to watch the video on this link. Dr. Xie was highly emotional as she made the following remarks regarding COVID: (beginning at 2:53 of the video)

“I don’t think that people can really comprehend how horrific this disease is, unless they’ve been personally touched by it. I mean, people are literately suffocating inside our hospitals, and they are dying alone. And truly, my heart breaks for everybody who has lost their jobs or their housing, and for kids that aren’t able to go to school, and for people that aren’t able to see their families. And they don’t get the luxury to complain about COVID fatigue, and their families don’t get the luxury to complain about it, because they’re living in, like, COVID hell.”

I’d like to emphasize two words that Dr. Xie chose: suffocating and alone.

We’re all going to die someday. There are terrible ways to exit this life, and there are dignified, tranquil exits. 

As a physician, regarding end of life matters I prefer to see people die without pain and without suffering. Gasping for your next breath is a terrible way to exit this world. I place breathing tubes for a living, and I’ve seen patients gasping for their last breaths in emergency rooms, intensive care units, and other hospital settings. These patients are terrified and panicked. It’s an awful way to die. When I was in college and medical school I smoked Marlboros and enjoyed every puff. When I began my internal medicine residency I worked at the Palo Alto VA hospital, where I first saw veterans dying of emphysema and chronic obstructive pulmonary disease (COPD). Many World War II veterans smoked from the 1940s until the 1080s, and had destroyed their lungs. At their baselines they were unable to walk up one flight of stairs. When one of these patients acquired a respiratory viral infection, they would become acutely ill and need to be admitted to the hospital. These patients were gasping for breath and had to be supported in the ICU on ventilators. Being a patient on a ventilator is an ordeal. When you have a breathing tube in your windpipe, you can no longer talk. When you have a breathing tube in your windpipe, the stimulus of that plastic in your trachea is extreme (your reflex is to cough hard and reject the plastic tube from your airway). When you have a breathing tube in your windpipe, you need to be sedated so that you don’t panic, cough, buck, or pull the tube out of your body. After I’d seen a dozen formerly brave soldiers on ventilators, I quit smoking cigarettes for good. I hope never to die that way—sucking for my last breath.

In the intensive care unit, intubated and ventilated
In the intensive care unit, on a ventilator

When it’s time to die, most of us hope to die with someone we love near us at the bedside. I’ve stood witness to hospice deaths, where family members surround the bed as their loved one drifts off to sleep under the cloak of narcotic sedation and breaths their last. This is a calm, honorable death. No one wants to die alone, staring up at some white ceiling with an array of fluorescent lights as our last image of this world. No one wants to die alone, listening to ICU alarm bells chiming instead of the sound of our spouse’s voice or our children’s voices. Because of social distancing, family members and loved ones are not allowed inside hospital intensive care units during this time of COVID. When you’re dying of COVID, you’re alone, and you may never see the people you love ever again.

Hospice

Listen to what Doctor Xie says about COVID deaths. Suffocating alone. No one wants to die a premature COVID death. As doctors, we are well aware that the economic downturn of the COVID pandemic is affecting millions of people. An economic downturn such as this is awful. Hopefully Congress will seek to soften the hardship for those without jobs or housing. 

But when you’re dead, you’re dead. You don’t want “COVID hell.” You don’t want to die a COVID death. You don’t want your loved ones to die a COVID death. You don’t want your friends to die a COVID death. You don’t even want people you don’t like to die a COVID death.

Hang in there for a few more months. Do what the CDC and Dr. Fauci advocate: Socially distance, wear masks, and stay home as much as possible unless you’re exercising outside with social distance. 

Vaccines are on their way. This is just one year of our lives. Long lives, we hope. 

Without suffocating alone.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

WHAT ANESTHESIOLOGISTS DO… AN EXAMPLE ANESTHETIC

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Most patients have no real idea what anesthesiologists do. Most college premed students have no real idea what anesthesiologists do. Most medical students have no real idea what anesthesiologists do.

Anesthesiologists are responsible for your medical care before, during, and after surgeries. At Stanford University we’re called the Department of Anesthesiology, Perioperative and Pain Medicine. “Perioperative” means “around the time of operations.” Today I’ll walk you through an example anesthetic which shows how an anesthesiologist approaches the challenges of a difficult surgical problem: emergency non-cardiac surgery in a patient with heart disease.

John Doe is a 58-year-old man with an acute inflammation of his gallbladder (acute cholecystitis), who needs to have his gallbladder removed (cholecystectomy). For the past 24 hours, Mr. Doe has suffered fever and acute right upper quadrant abdominal pain. His general surgeon advises surgery as soon as possible. Mr. Doe’s past medical history is positive for obesity (six feet tall, 240 pounds, BMI=32.5), coronary artery disease, and a history of stable angina.

PREOPERATIVE WORK: Anesthesiologist Dr. A reviews the chart and learns that Mr. Doe has had chest pain (angina) with exercise for the past two years. His cardiologist dida heart catheterization one year ago and discovered that Mr. Doe has small vessel coronary artery narrowing. His narrowed  vessels were too small to treat with coronary stents, and Mr. Doe received only medical therapy for his angina, in the form of isosorbide nitrate pills, diltiazem (calcium channel blocker pills), and nitroglycerin tablets as needed for chest pain. 

Mr. Doe takes a nitroglycerin tablet about once a week. This medical regimen has been effective in avoiding unstable angina and preventing heart attacks. Mr. Doe also takes atorvastatin (Lipitor) to control his hypercholesterolemia. Dr. A speaks with the cardiologist and asks two questions: “Are there any other diagnostic tests needed before surgery, and are there any other therapeutic measures needed before surgery?” The cardiologist answers that a preoperative echocardiogram is indicated, and he orders the test. The echocardiogram shows Mr. Doe’s heart is contracting normally (ejecting 60% of its volume with every beat). The cardiologist also measures the patient’s blood troponin level. Troponin levels are elevated when a patient is having an acute heart attack. Mr. Doe’s troponin levels are within normal limits, therefore no heart damage has occurred so far. Regarding therapeutic intervention, the cardiologist advises a continuous infusion of nitroglycerin to help prevent cardiac ischemia/heart attack damage during the anesthetic. 

An anesthesia machine, with the vital signs monitor screen on the left, and the electronic medical records computer screen on the right.

Dr. A meets Mr. Doe and interviews him. Mr. Doe is currently having moderately severe abdominal pain, nausea, fever, and chills. He has not had any chest pain for the past two weeks, and has no shortness of breath. His vital signs are heart rate = 100, BP = 150/80, respiratory rate =  20 breaths/minute, oxygen saturation 95% on room air, and temperature 100.2 degrees. Dr. A examines the patient and finds that the airway looks normal, the lungs are clear, the heart sounds are normal, and the abdomen is tender over the area of the gallbladder. Dr. A explains the general anesthetic plan to Mr. Doe, and informs the patient that his risk of heart complications for this acute surgery is higher than average because of the past cardiac history. Dr. A then records all pertinent preoperative information into the electronic medical record (EMR) via a computer keyboard and screen located just to the right of his anesthesia machine.

IN THE OPERATING ROOM: Mr. Doe will be asleep for the surgery, and Dr. A will be present the entire time. Mr. Doe has a preexisting intravenous (IV) line in his left arm. Prior to the surgery, Dr. A sedates the patient with 2 milligrams of IV midazolam (Versed) a benzodiazepine anxiety-reducing drug, and 100 micrograms of IV fentanyl, a narcotic.  

He then inserts a second catheter into the patient’s radial artery in its location at the right wrist. (I’ll use the male pronoun “he” for Dr. A in this example case, but be aware that as of 2017, 40% of anesthesiologists under the age of 36 years are female. This arterial line is connected to an electronic monitor which shows the blood pressure wave and blood pressure value continuously throughout the anesthetic. Dr. A places five ECG monitoring stickers on the patient’s chest, and a pulse oximeter on the third finger of the patient’s right hand. Dr. A notes the pre-anesthetic vital signs are heart rate = 80 beats/minute, blood pressure (BP) = 130/80, and oxygen saturation = 96% on room air, increasing to 100% on mask oxygen. This data is automatically entered into the chart of the electronic medical record.

MONITORING SCREEN with vs

After the patient breathes oxygen via a mask for two minutes, Dr. A performs a rapid sequence induction of anesthesia by injecting propofol (a hypnotic sleep drug) and succinylcholine (a muscle paralyzing drug) into the IV. The operating room nurse presses down on Mr. Doe’s cricoid cartilage in his neck, to compress the esophagus and prevent any stomach contents from regurgitating upward into the airway. 

Ten seconds after the propofol injection the patient is asleep. Forty seconds after the succinylcholine injection the patient is paralyzed. At this time Dr. A inserts a laryngoscope into the patient’s mouth and visualizes the patient’s vocal cords and the opening into the larynx or windpipe.

Under direct vision, Dr. A inserts a hollow plastic endotracheal tube (ET tube) into the patient’s windpipe, and then withdraws the laryngoscope. The cuff on the distal end of the ET tube is located just below the vocal cords, and Dr. A injects 3 milliliters of air into the cuff to inflate it and to secure the tube with a seal at the level of the windpipe. 

Dr. A then uses his anesthesia machine apparatus to squeeze breaths through the ET tube into the lungs, and listens to both sides of Mr. Doe’s chest with a stethoscope to document that breath sounds are present in both lungs. Dr. A glances at his anesthesia monitoring screen, which includes a row for the carbon dioxide detected in the exhaled breathing gas. The monitor screen traces a square wave vs. time, indicating that the ventilation of carbon dioxide (CO2) is now occurring out of the lungs with each ventilation. 

Dr. A secures the ET tube to the upper lip with adhesive tape, so the critical breathing tube cannot dislodge during the surgery. He sets the ventilator to deliver a volume of 800 milliliters into the lungs, nine times every minute. He sets the mixture of the inhaled gas as 50% oxygen and 50% air, with a resultant oxygen concentration of 60% oxygen. Dr. A turns on the sevoflurane vaporizer at this point, which releases a 1.5% concentration of sevoflurane vapor into the breathing mixture. 

Sevoflurane vaporizer (see yellow knob) on anesthesia machine

Sevoflurane, a potent inhaled general anesthetic drug, travels from the lungs via the blood stream to the patient’s brain, where sevoflurane molecules move from the bloodstream into the brain. This continuous delivery of sevoflurane molecules to the brain assures both sleep and amnesia. Dr. A injects an IV dose of 40 milligrams of rocuronium, a second paralyzing drug which will keep the patient motionless for approximately 30-40 minutes.

Dr. A prepares to start a central intravenous line into the right internal jugular vein. He preps the right side of the patient’s neck with Betadine iodine soap, and drapes the right neck with sterile towels. He places a probe on the patient’s neck from a device called an ultrasound machine. The ultrasound machine bounces soundwaves off the contents inside the neck, and generates a two-dimensional black and white image of the veins, arteries, muscles, and nerves found there. 

Dr. A inserts a needle into the right jugular vein under ultrasound visualization, and then inserts a wire through the needle into the lumen (center) of the vein. Seconds later, Dr. A slides a hollow intravenous catheter over the wire 14 centimeters into the center of the right internal jugular vein. 

Dr. A removes the wire and connects an intravenous drip to the central line catheter. He then connects a preprepared drip of nitroglycerin to a stopcock located on the central line IV, and turns on a preprogramed machine which infuses a small amount of nitroglycerin into the patient’s internal jugular vein continuously.

Dr. A steps back and surveys the patient’s vital signs. The BP is 100/50. The BP machine’s computer calculates a mean arterial blood pressure (MAP) as ((2 X diastolic BP) + systolic BP)/all divided by 3. The mean arterial pressure is thus ((2 X 100) + 50)/divided by 3 = 250/3, or 83. 

The desired range of the mean arterial pressure for this case will be from 65-90, and it will be Dr. A’s job to control the blood pressure within this range. The pulse rate is 60 beats per minute, and it will be Dr. A’s job is to keep the pulse rate from getting too high or too low (60 – 80 beats per minute is a desired goal). The oxygen saturation is 100%, and it will be Dr. A’s job is to keep the oxygen saturation, or O2sat, between 90-100%.

Dr. A administers an IV dose of an intravenous antibiotic prior to the surgical incision, and also administers two IV antinausea drugs, ondansetron (Zofran) and metoclopropamide (Reglan) prophylactically. He tapes the patient’s eyes shut so the corneas will not dry out and become scratched at any time during the surgery. 

Dr. A inserts an oral gastric tube through the mouth into the patient’s stomach, and suctions out any stomach contents. He inserts a temperature probe into the patient’s nose and connects it to a temperature monitor. He assists the nurses in positioning and padding the patient’s arms adjacent to the sides of his abdomen. He then wraps a plastic Bair Hugger blanket over the patient’s upper chest and head, and connects a Bair Hugger device which blows heated air through the bag to warm the patient if necessary during the anesthetic. 

The patient is now ready for the surgery to begin.

A nurse preps the abdomen by painting the skin with an antiseptic solution. The scrub technician and the surgeon drape sterile paper barriers over the perimeter of the abdomen, as well as a sterile paper vertical barrier (ether screen) between the anesthesiologist and the abdominal surgical site. 

The surgeon calls for a Time Out, at which time the operating room personnel review the patient’s name, the planned surgery, the patient’s allergies, and the estimated time for the surgery. Once the Time Out has been accepted, the surgeon begins the surgery. Almost all gallbladder excisions are done through a laparoscopic approach without opening the abdomen. The surgeon inserts a sharp trocar into the abdomen, removes the central core of this device, and then inflates carbon dioxide gas through the device into the interior of the abdomen. 

Once the interior of the abdomen is expanded like a balloon, an instrument with a camera on its tip is inserted into the abdomen, and the two-dimensional image of the interior of the abdomen is viewed on multiple video screens. The surgeon makes multiple small incisions and inserts additional surgical tools inside the abdomen.

The stimulus of the surgical incisions causes the blood pressure to increase. The mean arterial pressure (MAP) rises from 70 to 95. Dr. A deepens the anesthetic by injecting an additional two milliliters (100 micrograms) of IV fentanyl, which returns the MAP to 80 within two minutes. The insufflation of the abdomen with carbon dioxide is stimulating as well, because is stretches the lining of the abdomen (the peritoneum), and the MAP rises to 95 again. 

This time Dr. A increases the infusion rate of the nitroglycerin drip. Nitroglycerin dilates the venous blood vessels in the body which lowers the blood pressure, and also dilates the coronary arteries. He also begins a constant infusion of propofol via an intravenous pump to deepen the anesthetic level and lower the blood pressure further. The MAP decreases to 80 once again.

The surgeon requests the operating room table be tilted so the patient’s head is higher than the feet, and the right side of the patient’s body is higher than the left. Dr. A accomplishes this positioning by pushing buttons on the table controls. 

The purpose of this positioning is for gravity to move the intestines and abdominal contents downward toward the patient’s feet and toward the left side, thereby clearing the view of the gallbladder area in the right upper quadrant of the abdomen. 

There are hemodynamic (blood pressure and heart rate) consequences to this change in positioning. The MAP drops to 55 and the heart rate drops to 55. Dr. A treats the heart rate drop with an IV injection of atropine, an anticholinergic medication which blocks slow heart rates, and the pulse rate climbs back to 65. He chooses to treat the low MAP by injecting a small amount (5 milligrams) of a medication called ephedrine, which acts to increase both blood pressure and heart rate. The MAP returns to 70.

There is minimal bleeding during the gallbladder resection, and the experienced surgeon completes the surgery in 45 minutes. During this time Dr. A continues the maintenance anesthesia of sevoflurane and propofol, and injects further doses of the paralyzing drug rocuronium 20 milligrams (to keep the patient paralyzed ) and the narcotic fentanyl 100 micrograms (to provide ongoing pain relief).

As the surgeons close the final incisions, Dr. A removes the oral gastric tube and weans off the anesthesia drugs. The propofol infusion is discontinued. The sevoflurane is discontinued. The operating room table is returned to a level position. The rocuronium paralysis is reversed by the IV injection of a medication called sugammadex. As the anesthesia lightens, a predictable increase in blood pressure and pulse rate occurs, as the patient’s body begins to sense the stimulation of the breathing tube within the trachea and the sensation of the completed surgical repair. Once the patient is awake enough to breathe on his own, Dr. A removes the ET tube and places an oxygen mask over the patient’s nose and mouth. 

All critical care medicine is an effort to maintain Airway-Breathing-Circulation, in that order. Dr. A confirms that the patient’s airway is open in the absence of the ET tube, and that the patient is breathing adequately. 

Dr. A rechecks the vital signs and sees that the oxygen saturation is 98%, the pulse rate is 110, and the MAP is 110. The elevated pulse rate and blood pressure are dangerous in terms of this patient’s known coronary artery disease. The elevated high heart rate increases the cardiac oxygen consumption and lowers the time for the coronary arteries to fill between beats. The elevated blood pressure also increases the cardiac oxygen consumption, and puts the patient at a higher risk for heart damage or a heart attack. Dr. A treats both the elevated heart rate and blood pressure by injecting 10 milligrams of labetalol (an intravenous beta-blocker drug) which lowers the heart rate to 90 and lowers the MAP to 90 within two minutes. A second dose of IV labetalol brings the heart rate to 70 and the MAP to 80 within another two minutes. At this point Dr. A is satisfied that the patient is stable, and the staff prepares to transfer the patient to the post anesthesia care unit (PACU). A hospital bed is stationed to the side of the operating room table, and the monitors are disconnected from the patient. 

The orderlies, nurses, and doctors slide a roller device under the patient, and on the count of three they roll the patient onto the hospital bed. Dr. A secures an oxygen mask over the patient’s face, elevates the patient’s head to 30 degrees, and makes sure the IV line, the arterial line, and the internal jugular line tubings are all intact and not tangled for the transfer to the PACU. The baseline infusion of the nitroglycerin is continued throughout, as the cardiologist requested.

POSTANESTHESIA:  In the PACU, nurses reconnect the patient to the same monitoring devices worn during the anesthetic. A registered nurse personally attends to the patient in the PACU. The anesthesiologist writes all the orders for pain medications, cardiac medications, and anti-nausea medications.

The patient will stay in the PACU for approximately one hour, before he is transferred to the intensive care unit (ICU) for continued observation of his vital signs, cardiac condition, and for ongoing administration of the IV nitroglycerin. Once the patient is transferred to the ICU, Dr. A contacts both the ICU team and the cardiologist and signs off responsibility for the patient to them. In the ICU the cardiologist orders troponin levels once again, to determine whether or not the patient suffered a heart attack during surgery. The troponin levels are found to be low, indicating no heart damage occurred. The patient wakes up in a satisfactory status, with resolution of his abdominal pain. His vital signs remain normal.

Post Anesthesia Care Unit (PACU)

On the next day the patient’s nitroglycerin infusion is discontinued, his oxygen therapy is discontinued, and he’s discharged to a post-surgical ward bed. On the following day he’s discharged home.

This describes what an anesthesiologist does in performing a moderately difficult anesthetic. This model case is not unique to a university hospital—it could occur as described in any community hospital near you. Gallbladder surgery is not without risks, and not all gallbladder surgeries end well. In 5-10% of laparoscopic gallbladder surgeries, technical difficulties with the anatomy require the surgeon to switch to an open surgical method which requires a larger incision, and results in more postoperative pain. 

Open gallbladder surgery incision

As in any intraabdominal surgery, gallbladder surgery can lead to surgical complications such as:

  • Infection
  • Bleeding
  • Swelling
  • Bile leakage
  • Damage to the bile duct
  • Damage to the intestine, bowel, or blood vessels

Laparoscopic gallbladder surgery can lead to postoperative medical complications such as heart attacks, sepsis, pneumonia, pulmonary embolus (blood clot to the lungs), or rarely death. In 1987 pop icon Andy Warhol, age 58,  died just hours after gallbladder surgery in a prominent New York City hospital.  

No one ever disclosed what went wrong in Mr. Warhol’s case, but the anesthesia challenges for that surgery would have been similar to what was outlined above. 

This is what an anesthesiologist does. Your physician anesthesiologist is much more than a “sandman” or a “gas man.” Your physician anesthesiologist is your protector when you lose consciousness and go under the knife. While your surgeon attends to the surgical repair, your anesthesiologist will attend to your heart, brain, lungs, and the rest of your body . . .  before, during, and after your surgery.

Additional information on the profession of anesthesiology is available at the American Society of Anesthesiologists website.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

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WHY IS THERE AN ANESTHESIOLOGIST ON PRESIDENT TRUMP’S WALTER REED MEDICAL TEAM?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Why is there an anesthesiologist on President Trump’s Walter Reed medical team? Why would the president need an anesthesiologist?

This morning Dr. Sean Conley, the White House Physician, introduced President Trump’s medical team of seven doctors. Dr. Conley spoke to the nation from the approach to Walter Reed National Military Medical Center in Bethesda, Maryland. He introduced the team behind him with these words:

“Behind me are some of the members of the president’s medical team, whom I’d like to introduce. Dr. Sean Dooley, pulmonary critical care doctor. Brian Garibaldi, pulmonary critical care. Dr. Robert Browning, pulmonary critical care. Dr. Jason Blaylock, infectious disease. Dr. Wes Campbell, infectious disease. Dr. John Hodgson, anesthesia. Major Kurt Klein, Army Nurse. Commander Megan Nasworthy, Navy Nurse. Lieutenant Julianna Lavopa, Navy Nurse. Lieutenant Commander John Shea, clinical pharmacist. And not present with us are Lieutenant Beth Carter, Lt.. Maureen Meehan, both Navy nurses and Dr. Jesse Schonau, director Executive Medicine Program.”

The tally of these seven doctors reads:

3 Pulmonary and Critical Care doctors

2 Infectious Disease doctors

1 Anesthesiologist

1 Emergency Room doctor, (this is Dr. Conley, a doctor of osteopathic medicine, or D.O.)

Why an anesthesiologist? President Trump is diagnosed with COVIE-19. Details of his illness are few. We were told that as of today, Saturday, October 3rd 2020, President Trump has no fever, no trouble breathing, is not currently on oxygen therapy, and has an oxygen saturation of 96% (normal = 90-100%).

COVID-19 is an infectious disease, so it makes sense that two infectious disease doctors are attending to him.

COVID-19 most commonly causes serious illness by lung infection, so it makes sense that two pulmonary and critical care doctors are attending to him.

But why does President Trump need an anesthesiologist on his medical team at Walter Reed Medical Center?

The answer: Airway Management.

If a patient with COVID-19 becomes acutely ill and his respiratory status declines so much that he cannot keep a safe oxygenation level merely by breathing oxygen through a supplementary mask or an oxygen tent, then that patient needs to be placed on a ventilator.

Ventilators pump oxygen in and out of a patient’s lungs via a breathing tube placed in the patient’s windpipe (trachea). This is called an endotracheal tube, and every anesthesiologist places hundreds of these tubes each year. The placement of an endotracheal tube into a COVID-19 patient who is gasping for breath is an acute procedure which requires an expert. A general anesthetic drug and a paralytic drug would be injected into the patient’s intravenous line, and then an anesthesiologist (wearing a space suit of extensive personal protective gear) would use a device called a laryngoscope to place the tube into the trachea under direct vision of the patient’s voice box.

If you’re a patient and you begin gasping for breath because of respiratory failure secondary to COVID-19, you don’t want your anesthesiologist to be far away. That’s why there’s an anesthesiologist on President Trump’s current medical team. The next few days will be telling. The president may remain stable and have only minimal or mild illness, but there is a nonzero chance that he will decompensate and become acutely ill.

Placing an endotracheal tube into Donald Trump would probably be an uneventful task for an expert, but the president is overweight and he does have a thick neck. Patients whose airway looks like his can prove difficult for an anesthesiologist to intubate the trachea. The attending anesthesiologist would most likely use a video laryngoscope, which has a camera on the tip of the scope that is inserted into the patient’s throat. This technology allows the anesthesiologist to “see around the corner” into the patient’s larynx or voice box. The image of the patient’s airway appears on a video screen.

Regarding President Trump’s treatment to date: he has already been treated with Remdesivir, an antiviral therapy which is administered via an intravenous line. There is data that Remdesivir is effective in animals for COVID viral prophylaxis or immediately following viral inoculation.

 It appears he also received an antibody cocktail yesterday, REGN-COV2, developed by Regeneron. The development of this cocktail was described in the journal Science in August

No one knows how President Trump’s medical course will proceed. As a medical doctor, I can only wish him the best of health, the best of medical care, and the best medical outcome that is possible. I hope no anesthesiologist has to place a breathing tube.

Stay tuned in these interesting and difficult times.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

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THE TWO LAWS OF ANESTHESIA (ACCORDING TO SURGEONS)

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

There are Two Laws of Anesthesia, according to surgeon lore. They are:

  1. The patient must not move.
  2. The patient must wake up (when the surgery is over).

Surgeons work with physician anesthesiologists, with certified nurse anesthetists (CRNAs), or with an anesthesia care team that includes both physician anesthesiologists and CRNAs. Most surgeons’ comprehension of what anesthesiologists are doing is limited. Most surgery residencies have zero months of anesthesia training out of their sixty months of total residency. No matter who supplies the anesthesia services, to our surgical colleagues the critical requirements of anesthesia include 1. and 2. above. 

Period.

Physician anesthesiologists finish medical school and complete at a minimum four additional years of training. Surgeons finish medical school and complete at a minimum five additional years of training. There’s not much difference there. Anesthesiologists typically spend 90+% of their working hours in the operating room. A busy surgeon will spend 50% of their time in the operating room, and the other 50% in preoperative clinic, postoperative clinic, or rounding on patients in the hospital. Anesthesiologists win the tally for most operating room hours per week. Anesthesiologists take care of a patient’s heart, lungs, brain, and kidney function before, during, and after surgery. Surgeons perform a specific operation on one organ system, e.g. heart surgeons operate on the heart, orthopedic surgeons operate on a bone or a joint, and ear surgeons operate on ears.

Yet in all the surgical specialties, Two Laws describe the surgeons’ lofty expectations of anesthesia professionals:

  1. The patient must not move.
  2. The patient must wake up (when the surgery is over).

Physician anesthesiologists learn to perform anesthesia for all types of surgery, including cardiac, vascular, trauma, neurosurgery, pediatrics, eye, ear nose and throat, urology, and obstetrics. Physician anesthesiologists attend to patients of all ages, from newborns to centenarians. Physician anesthesiologists develop an extensive understanding of physiology as well as the pharmacology of hundreds of medications. Physician anesthesiologists regularly insert breathing tubes, venous catheters, arterial catheters, and stomach tubes, and inject regional anesthetic blocks into the spinal fluid, the epidural space, and learn nerve blocks of every major peripheral nerve.

Yet to our surgical colleagues, Two Laws describe an excellent anesthesiologist’s work:

  1. The patient must not move.
  2. The patient must wake up (when the surgery is over).

Let’s examine the Two Laws:

  1. The patient must not move. This Law is important because a surgeon must not be distracted by motion within the surgical field. If a patient coughs or bucks on the breathing tube, movement will occur. The surgeon must stop, sometimes for 60 seconds or more, while the anesthesiologist administers additional drugs to the patient. During these 60 seconds, it’s important that the surgeon sighs, crosses his or her arms, or otherwise expresses what a major inconvenience this loss of 60 seconds has been. Has a patient ever been harmed by an episode of brief movement? In the overwhelming majority of surgeries there is no harm whatsoever. In a perfect anesthesia world, patients will not move. But in the majority of anesthetics the patient is not chemically paralyzed, and it is possible for movement to occur. An overly deep level of anesthesia will help prevent movement, but has the adverse consequence of requiring a longer time to wake the patient at the end of the surgery. Which brings us to Law #2:
  2. The patient must wake up. When the surgeon finishes suturing the skin incision and  concludes the surgery, he or she will remove their gloves and gown and wait for the anesthesiologist to wake the patient. Modern anesthetics wear off quickly, and for most surgeries the duration of time from the end of surgery to the patient waking and talking is approximately 10 – 15 minutes. But these are minutes during which the surgeon must watch and wait. These are minutes during which the surgeon’s valuable time is ticking by, and seemingly wasted. In the overwhelming majority of surgeries, anesthesiologists successfully wake the patient and remove the breathing tube. At this time the surgeon can leave the operating room to meet with the patient’s family and discuss the successful operation. None of this could happen if the anesthesiologist was not competent with Law #2. 

If you’re a medical student considering a surgical specialty, it’s important you understand the Two Laws. If you become an anesthesiologist or a surgeon, you will be on one side or the other of the Two Laws. 

If you’re a patient, consider that it’s your surgeon’s job to cut and cure while it’s your anesthesiologist’s job to keep you from moving and to wake you up. Of course, your vigilant physician anesthesiologist will also assure that you’re safe, asleep, and unaware. Your vigilant physician anesthesiologist will also assure that you’re as stable and as healthy as possible after surgery. Trust your anesthesiologist  and realize that while these Two Laws come from the lips of surgeons, the genesis of the Two Laws perhaps occurred with a tongue in cheek. I’ve had excellent relationships with hundreds of surgeons over decades, and despite these Two Laws, the majority of surgeons are wonderful doctors and healers who are not condescending toward their anesthesia colleagues whatsoever.

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The most popular posts for laypeople on The Anesthesia Consultant include:
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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

TOXIC MARIJUANA SYNDROME YOU’VE NEVER HEARD OF: CANNABINOID HYPEREMESIS SYNDROME

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Cannabinoid Hyperemesis Syndrome. Chances are you’ve never heard of it, but one of your patients, or someone you know, may develop this syndrome in the coming years. Cannabis use is common. According to The Washington Post, in 2017 more than half of American adults had tried marijuana at least once in their lives, and a total of 55 million Americans currently used the drug. This number approaches the total of 59 million cigarette smokers in America. Each year 2.6 million Americans become new cannabis users. The majority of marijuana users are male, earn under $50,000 a year, and lack a college degree. The 18–25 year old age group has the highest prevalence of marijuana use. 

Emesis is the medical word for vomiting. Hyperemesis means excessive vomiting. The number of people affected with Cannabinoid Hyperemesis Syndrome is estimated at about 2.7 million people in the United States per year. Cannabinoid Hyperemesis Syndrome (CHS) presents as a triad of chronic cannabis use, cyclic episodes of nausea and vomiting, and frequent hot bathing. If the patient withholds the history of chronic cannabis use, it’s difficult to impossible to make the correct diagnosis. Despite months of cyclical symptoms and thousands of dollars of Emergency Room visits and lab tests, the syndrome may not be correctly diagnosed or treated.

Let’s look at a case study of CHS to learn how it may present, and why it is uncommonly recognized:

A 25-year-old male presents for a diagnostic upper gastrointestinal endoscopy. He has a three-month history of persistent nausea, vomiting, and weight loss. His laboratory tests and CT scans of his abdomen and chest are normal. He carries a presumptive diagnosis of GERD (gastroesophageal reflux disease), and treatment with anti-acid drugs such as proton-pump inhibitors and H2-blockers have not improved the symptoms. The young man has been afraid to eat because of nausea and retching. He has been unable to work, and his sleep has been significantly impaired. He has lost weight from 150 pounds to his current weight of 135 pounds. On exam he appears well. His vital signs are normal, and his abdominal exam is negative for tenderness. He is scheduled for general anesthesia for the endoscopy procedure. He was referred for the upper GI endoscopy by his primary care doctor, and the gastroenterologist has yet to meet the patient.

Twenty minutes before his procedure, the anesthesiologist asks the patient if he takes any medicine or drugs. “Only the stomach pills my doctor prescribed,” he replies. “They aren’t working at all. I also use marijuana to decrease the nausea, but it’s not working either.”

“How frequently do you use marijuana?” the anesthesiologist asks. 

“Promise not to tell my parents?” he says. “I use a vape pen about 8 – 10 times a day.” 

“For how long have you been doing that?”

“About five years. I’ve increased my use over the past few months, because it’s supposed to be helpful for nausea, but it’s not working anymore.”

The anesthesiologist excuses himself, and sets off to find the gastroenterologist scheduled to do the procedure.  The anesthesiologist shares the cannabis history, and the gastroenterologist immediately says, “No one ever told me this patient was a chronic marijuana user. This changes everything. His history is classic for Cannabinoid Hyperemesis Syndrome.”

The gastroenterologist interviews the patient and confirms the correct clinical diagnosis. The treatment is immediate cessation of marijuana use, and the endoscopy is cancelled.

One week after stopping all cannabis use, the patient’s symptoms have completely resolved. He is eating well without nausea or vomiting, and has gained back 8 pounds.

Cannabinoid Hyperemesis Syndrome was first described in 2004 in a series of 9 patients from Australia.  In all of the cases, chronic cannabis abuse preceded the onset of a cyclical vomiting illness. Stopping cannabis led to cessation of the vomiting in seven cases. Three cases did not abstain and continued to have recurrent vomiting. Three other cases rechallenged themselves after a period of abstinence and relapsed to the same illness. Two of these cases abstained again, and remain well. The third case did not abstain, and remained ill. The majority of the patients displayed abnormal washing behavior during episodes of active nausea, in which they took repeated hot showers or baths, which temporarily relieved their symptoms.

Δ9-tetrahydrocannabinol (THC) is the principle psychoactive compound in cannabis. There are two distinct cannabinoid receptors, CB1 and CB2, in the human body, located predominately in the central nervous system and also in the gastrointestinal tract. THC stays in the body for a prolonged time, with an elimination plasma half-life of 20–30 hours. THC accumulates within body fat, and body fat serves as a long-term storage site. Typically THC can be used for its antiemetic (anti-nausea) property, and has been used to blunt nausea in cancer chemotherapy patients. With chronic use THC can induce a paradoxical nausea-inducing effect by unknown mechanisms on the central nervous system and the gastrointestinal system, causing the Cannabinoid Hyperemesis Syndrome. Patients with Cannabinoid Hyperemesis Syndrome are chronic users of cannabis who likely have large lipid reservoir stores of THC. 

CHS patients are typically young adults with a long history of marijuana use. There is usually a delay of several years following the onset of the chronic marijuana habit before the onset of symptoms. CHS patients often remain misdiagnosed. Erroneous diagnoses considered included a broad range of conditions affecting the gastrointestinal tract. In one study the average duration of cannabis use prior to onset of the recurrent vomiting was 19.0 ± 3.4 years, and had an average of 7.1 ± 4.3 emergency room visits, 5.0 ± 2.7 clinic visits, and 3.1 ± 1.9 admissions for the CHS syndrome. Daily marijuana use was typical, often exceeding 3 – 5 times per day. 

The three phases of CHS are prodromal, hyperemetic, and recovery. In the prodromal phase patients develop early morning nausea, a fear of vomiting, and abdominal pain. The hyperemetic phase includes episodes of intense and persistent nausea and vomiting. Patients vomit profusely, and can vomit or retch multiple times per hour. In the original 2004 Australian study, 70% of patients reported weight loss of at least 5 kg (11 pounds). Symptomatic patients typically undergo extensive diagnostic work ups, including laboratory and imaging studies, which are all normal or nondiagnostic. The recovery phase can last for days, weeks, or months. It occurs after the cessation of cannabis consumption, and is associated with return to normal eating patterns and original body weight.

The diagnosis of CHS must be made entirely by clinical history. The history of extensive previous cannabis use is universal, but may be unrealized if the patient withholds the information for personal reasons. A Mayo Clinic study in 2012 which included 98 patients, was the largest study to date. Characteristics of the Mayo CHS patients are shown in this table:

The Mayo series of 98 CHS patients helped establish these  diagnostic criteria. These criteria include: 

  • Essential for diagnosis: Long-term cannabis use. 
  • Major features: Severe cyclic nausea and vomiting, Resolution with cannabis cessation, relief of symptoms with hot showers or baths, abdominal pain epigastric or periumbilical, weekly use of marijuana. 
  • Supportive features: age less than 50 years, weight loss of > 11 pounds (5 kg), morning predominance of symptoms, normal bowel habits, negative laboratory, radiographic, and endoscopic tests.

Acute medical treatment for severe CHS episodes includes IV fluids for dehydration and supportive care. Traditional anti-emetic drugs such as Zofran have been largely ineffective. The only reliable long term treatment is the cessation of cannabis. The percentage of patients who relapse has not been quantified to date. The case series data in the medical literature currently document that many of the patients who return to cannabis use have recurrent CHS.

Voters have legalized the recreational use of cannabis in 11 states (California, Colorado, Washington, Oregon, Nevada, Maine, Alaska, Michigan, Illinois, Massachusetts, and Vermont). Because cannabis was legalized through popular vote and not via the usual Food and Drug Administration (FDA) channels, the drug did not undergo government scrutiny regarding toxicities and long term health effects. I discussed this topic in an earlier column.  

Cannabinoid Hyperemesis Syndrome should be considered as a plausible diagnosis in anyone with recurrent severe vomiting and a strong history of cannabis abuse. 

Because of recent legalization of recreational and medical cannabis use in many states, expect the incidence of Cannabinoid Hyperemesis Syndrome to increase. If your patient, or someone you know and love, develops recurrent severe vomiting in the setting of a strong history of cannabis abuse, the diagnosis may very well be Cannabinoid Hyperemesis Syndrome. 

The good news is that once the diagnosis is made, the syndrome is curable with cannabis abstinence.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
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What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
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Advice For Passing the Anesthesia Oral Board Exams
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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

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QUALITY ASSURANCE IN ANESTHESIA

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997
This image has an empty alt attribute; its file name is 2444107_orig.jpg

Case study #2020: A healthy 48-year-old woman is anesthetized for a hysterectomy. As the surgery is ending, her blood pressure skyrockets to 220/160 and her pulse rate rises to 165 beats per minute. She is resuscitated and transferred to the Intensive Care Unit (ICU).

What happened? The hospital’s Quality Assurance (QA) program, also known as a Quality Improvement (QI) program, is charged with investigating this adverse event.  

Mistakes happen in medicine.

In 1999 the Institute of Medicine published the landmark “To Err is Human” report, which described that adverse events occurred in 3 – 4% of all hospital admissions, and that over 50% of the adverse events were due to preventable medical errors. Approximately 10% of the adverse events led to deaths. The report estimated that 44,000 – 98,000 Americans died each year due to medical errors. The report estimated that medical errors were the 8th leading cause of death in the United States. The report recommended that instead of blaming individuals, to instead prevent future errors by designing safety into the system. 

My experience in Quality assurance/Quality improvement programs includes:

  • Stanford University Hospital QA Committee (Care Review Committee), 1997 – 2009
  • Stanford University Anesthesia QA Committee, 2002 – 2009, and
  • Waverley Surgery Center QI Committee (Chairman), 2002 – present.

The analysis of complications is one of the most interesting aspects of medicine. Every complication has an opening event, a story line, and a conclusion. Using Case study #2020 above, let’s trace through the steps involved in improving medical quality:

  1. CAPTURE THE CASES. The first task is to find out about all adverse events. This can be harder than it sounds. Ideally the involved MDs and nurses will fill out an Incident Report or an Adverse Event Report, which includes the details of what happened to their patient. But many clinicians are reluctant to hang out their dirty laundry, and it’s possible for adverse events to be hidden, buried, or ignored. This hampers care improvement. We can’t fix problems we haven’t identified. At a large hospital, Adverse Event Reports are digitally entered into a computer site. At a smaller facility such as a surgery center, Adverse Event Reports are filed on paper forms. In either case, once the case is captured, the QA system can analyze the event. Case study #2020: The attending surgeon and the operating room nurse each filed digital Adverse Event documents because of their patient’s extremely high blood pressure and heart rate, and her unplanned admission to the ICU.
  2. ANALYZE ADVERSE INCIDENT REPORTS FOR SIGNIFICANT NEGATIVE CLINICAL OUTCOMES, OR THE NEAR MISS OF A NEGATIVE OUTCOME. Some Adverse Events reports are more significant than others. Some reports reveal only minor issues such as prolonged post-operative nausea and vomiting, or a prolonged Post Anesthesia Care Unit stay. An MD or specially trained RN will sift through the stack of Adverse Event Reports and choose those problems which require attention. Case study #2020: The chairperson of the QA Committee notes the elevated BP and heart rate and the unplanned ICU admission, and flags this case for immediate committee evaluation.
  3. ROOT CAUSE ANALYSIS . . . RETRIEVE AND REVIEW ALL RELEVANT MEDICAL RECORDS FOR COMMITTEE: Root Cause Analysis (RCA) is an organized approach to ferreting out the causes for any adverse medical event. The goal of RCA is to find out what happened, why it happened, and what can be done to prevent it from happening again. After a hospital complication, all electronic medical records (EMRs) pertinent to the incident are reviewed to discern what happened. A time line is formulated, with the goal of finding a cause and effect relationship that led to the complication. The hospital EMR may be hundreds of pages long, depending on the complexity of the case. At an outpatient surgery center where medical records are usually kept on paper, the review process is faster and easier, as the entire case may be documented in twenty pertinent pages or less. Case #2020: Review of the case shows that the BP and heart rate increases occurred within minutes after the anesthesiologist administered an intravenous dose of the drug atropine.
  4. INTERVIEW THE CLINICIANS: Members of the committee are charged with interviewing the individuals present at the time of the complication. Case #2020: The surgeon, operating room nurse, and the anesthesiologist are interviewed. The initial interviews with the clinicians are done prior to the QA Committee meeting on the case, although key clinicians may be interviewed at the actual QA Committee meeting. The pertinent revelation was that the anesthesiologist administered an intravenous dose of 4 mg of Zofran, and charted that the dose was administered. After the case was over, he said he looked for the empty atropine ampoule, and discovered that it was instead an empty 1 mg epinephrine ampoule.
  5. ASSESS WHAT HAPPENED: In Case #2020: The unintended intravenous bolus injection of 1 mg of epinephrine into a stable patient caused life-threatening hypertension and elevated heart rate. Epinephrine is adrenaline, and a dose of 1 mg IV bolus is only appropriate if a patient is in cardiac arrest situation, such as ventricular fibrillation, asystole (flat line), or pulseless electrical activity. The administration of a wrong medicine by human error is called “syringe swap” or “ampoule swap.”  It’s a preventable human error. In this case the atropine and epinephrine ampoules were nearly identical in size, color, and shape. The two different ampoules were stored in the same drawer in the anesthesiologist’s drug cart, and the distance between the two storage areas was only 2 inches.
  6. REVIEW THE RELEVANT MEDICAL LITERATURE: Using PUBMED.com,     it’s easy to search for similar incidents in the medical literature. The committee found an example of the very same epinephrine ampoule swap occurring previously.  In this published case report, an epinephrine ampoule was erroneously injected instead of a similar appearing neostigmine ampoule at the conclusion of a hysterectomy. The patient had an immediate cardiac arrest. The patient survived, but required an ICU stay. The neostigmine and adrenaline ampoules were very similar and were stored in adjacent compartments in the anesthesia cart.
  7. THE QA COMMITTEE DISCUSSES THE CASE: The committee consists of MDs from multiple specialties. Case #2020: These MDs  discuss the case and the probable cause of the adverse event, and discuss possible system improvements to prevent repeat of the error in the future. These suggestions are based on the education, experience, and training of the committee members, as well as from input from the relevant medical literature. Note that the committee does not criticize or blame the anesthesiologist for making the error, and does not make a point of singling out the individual physician as the culprit. 
  8. MAKE SYSTEM CHANGES TO AVOID FUTURE SIMILAR COMPLICATIONS: Case #2020: The committee decides to remove all 1 mg  epinephrine ampoules from the readily accessible anesthesiologist drug drawers in all operating rooms, to prevent the inadvertent administration of another dangerous bolus of epinephrine when it could be mistaken for Zofran or any other drug. (Epinephrine is an important medication to be administered during cardiac arrests, allergic reactions, or for cardiac patients whose blood pressure is falling precipitously, so the medication must be available.) The committee recommends that the only formulation of epinephrine included in the anesthesia drug drawer be the clearly labeled cardiac arrest epinephrine bolus syringes, which are packaged in individual cardboard  boxes. The dangerous 1-milliliter epinephrine ampoules are moved out of the operating room. The recommended policy and procedure is for anesthesiologists to request the 1-milliliter ampoules to be retrieved for them from pharmacy storage, by the operating room nurse, only when needed. This is expected to be a rare occurrence.
  9. SOME PEER REVIEW OUTCOMES REQUIRE REPORTING TO THE CALIFORNIA STATE MEDICAL BOARD: QA/QI work is part of peer review, and cannot be subpoenaed during any legal malpractice litigation. In California, a QA investigation triggers a obligated report to the state Medical Board when the following may have occurred: (A) Incompetence, or gross or repeated deviation from the standard of care involving death or serious bodily injury to one or more patients, to the extent or in such a manner as to be dangerous or injurious to any person or to the public; (B) The use, prescribing, or administration to himself or herself of any controlled substance, or the use of any dangerous drug or of alcoholic beverages, to the extent or in such a manner as to be dangerous or injurious to the licentiate, any other person, or the public, or to the extent that such use impairs the ability of the licentiate to practice safely; (C) Repeated acts of clearly excessive prescribing, furnishing, or administering of controlled substances or repeated acts of prescribing, dispensing, or furnishing of controlled substances without a good faith effort prior examination of the patient and medical reason therefor; or (D) Sexual misconduct with one or more patients during a course of treatment or an examination
  10. ONGOING METRICS ARE TRENDED TO TRACK CHANGES IN COMPLICATION RATES: The QA Committee must collect follow up data to determine if the suggested system change improved future outcomes. If the data indicates worsening trends, then the committee will investigate and consider further Quality Improvement measures. Case #2020: for two years following the new epinephrine policy there were zero ampoules swaps involving epinephrine. In addition, zero other episodes of ampoule swap of any other drugs occurred. 

Mistakes happen. The role of a QA Committee is to prevent them from happening again. This method of making system changes so that Hazards are less likely to become Losses, is depicted in the Swiss Cheese model below:

The Swiss Cheese Model was originally designed to eliminate errors in the oil industry, and was later adopted by the airline industry. Visualize the pieces of Swiss Cheese as barriers between Hazards and Losses. Each single Swiss Cheese barrier isn’t perfect and isn’t sufficient to prevent a hazard. Each additional barrier is designed so that the error that penetrated through the first barrier is stopped by the second barrier. Designing different barriers at different stages of medical care, with different strengths and weaknesses, makes it more difficult for a Hazard (mistake) to lead to a Loss (serious injury or death). The Swiss Cheese model is designed to make it difficult for a straight line to exist from Hazard to Losses.

The Quality Assurance process is summarized in the article Overview of the Quality Assurance Movement in Health Care.  Hospitals and surgery centers in your area are following Quality Assurance processes similar to those discussed above, so that when you or your loved ones are admitted for medical care, the chances of a serious complication will be as close to zero as possible.

Note: The Anesthesia Patient Safety Foundation (APSF) is the national organization that deals with safety issues in anesthesiology practice. The monthly APSF newsletters are available online at https://www.apsf.org, and serve as valuable educational material for every anesthesiologist regarding safety issues in our specialty.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

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SURGEON GENERAL, WHERE ART THOU?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Picture this: You’re a highly qualified, board-certified physician anesthesiologist with a Master’s Degree in Public Health from Berkeley. President Donald Trump appoints you to be the Surgeon General of the United States. Then the COVID-19 pandemic rears its head, and you can’t speak out regarding appropriate public health measures without crossing your President. Such is the plight of Dr. Jerome Adams, the 20th Surgeon General of the United States, stuck between supporting medical science or avoiding conflict the President he works for.

Dr. Adams is the first anesthesiologist to hold the office of Surgeon General when he was appointed in 2017. Dr. Adams’ area of public health expertise is the prevention and management of opioid abuse. In 2014 then-Governor of Indiana Mike Pence appointed Dr. Adams to be the Indiana Health Commissioner. Under Dr. Adams’ guidance, Indiana counties created syringe exchanges to contain the spread of AIDS throughout the state.

As an anesthesiologist, I’m a fan of Jerome Adams. We’re separated by only one degree: Dr. Adams is an acquaintance of Dr. Michael Champeau, who is the President of my anesthesia group in California. Dr. Adams is highly respected within the anesthesia world, and was a lead speaker at the 2019 American Society of Anesthesiologists National Meeting.

Dr. Adams was the subject of an article in The Washington Post on July 12, 2020, titled “Surgeon General Jerome Adams may be the nicest guy in the Trump Administration. But is that what America needs right now?” The article states, “Adams came to Washington three years ago to tackle another problem —  the raging opioid crisis — by drawing from a painful personal history with a brother who has struggled with substance abuse. Yet he has been thrust into the role of the pandemic surgeon general.” The article describes Jerome Adams as a fine man, experienced in tackling the opioid problem, but now confronted with the difficult public health reality of the coronavirus.

Most people don’t understand the office of the Surgeon General, a position often referred to as “The Nation’s Doctor.”The Surgeon General of the United States is the head of the United States Public Health Service Commissioned Corps, and is the leading spokesperson on matters of public health in the United States. In contrast, the Attorney General of the United States is the head of the United States Department of Justice, the chief lawyer of the United States government, and a member of the President’s Cabinet. Compared to the Attorney General, the Surgeon General has historically been an office with little power.

Dr. Adams’ legacy as Surgeon General will likely be clouded by our nation’s public health response to the COVID-19 virus. At the time of this writing, COVID case numbers and death rates are peaking in the United States, five months after the onset of the outbreak. Dr. Adams is in a precarious position: he was appointed to the office of Surgeon General by a President who has spent much of 2020 ignoring the advice of medical experts and advisors. If Dr. Adams publicly emphasizes the medical facts regarding battling the COVID pandemic (6-foot social distancing, wearing masks, avoiding crowded indoor settings) he risks contradicting the President who appointed him to the office. If Dr. Adams remains mute on the appropriate public health approach to battling the COVID pandemic, he risks marring his reputation as the lead public health officer in the United States.

Dr. Adams’ early response to the COVID pandemic in February 2020 included advice for the general public to not wear masks:

On Feb. 29, 2020, Adams tweeted: 

In an interview with “Fox & Friends” on March 2, 2020, Dr. Adams said: “One of the things (the general public) shouldn’t be doing is going out and buying masks. . . . It has not been proven to be effective in preventing the spread of coronavirus amongst the general public. . . . Folks who don’t know how to wear them properly tend to touch their faces a lot, and actually can increase the spread of coronavirus. You can increase your risk of getting it by wearing a mask if you are not a healthcare provider.”

This advice was contrary to the now-accepted public health strategy of requiring masks on everyone. The fact that the Surgeon General made the opposite recommendation in February 2020 was unfortunate. He meant well, as his advice was given at a time when there were inadequate amounts of PPE (personal protective equipment) for healthcare workers who were battling COVID on the hospital frontlines. Adams did not want an inadequate supply of masks to be redirected away from hospitals. When the public health recommendation later pivoted 180 degrees to wearing masks publicly, Adams’ February admonition seemed to have been bad advice.

In the spring of 2020, Adams appeared daily on television as part of President Trump’s Coronavirus Task Force, along with Dr. Anthony Fauci and Dr. Deborah Birx. When the Trump administration was facing criticisms about its COVID-19 response in hard-hit minority communities, Dr. Adams’ remarks at a April 10, 2020 daily press briefing were designed to address those concerns. Critics believed several comments made by Adams played into racial stereotypes. “Avoid alcohol, tobacco and drugs,” Adams said. He urged communities of color to “step up” to fight the disease. “We need you to do this, if not for yourself, then for your abuela. Do it for your granddaddy. Do it for your Big Mama. Do it for your Pop-Pop.” Representative Alexandria Ocasio-Cortez (Democrat-N.Y.) said the comments amplified claims about minority populations engaging in risky behaviors.

In the weeks following April 10th, 2020, Dr. Adams’ appearances with the Coronavirus Task Force became limited, and his role in COVID-19 public health policy was minimized.

The website of the Surgeon General (see above) has a paucity of information about the pandemic. There is one link for COVID-19 Updates. The website has general information about the Office of the Surgeon General (OSG), but very little medical information. There are links to Advisories on Marijuana and the Developing Brain, E-Cigarettes, and Naloxone and Opioid Overdose.

In the midst of the greatest public health crisis in one hundred years, the Surgeon General has remained—or the government has kept him—on the sidelines. At the current time the administration has distanced itself from both Dr. Fauci and Dr. Adams. The medical community sees this as unfortunate, as both physicians are respected and honest experts. 

Most Surgeons General have negligible legacies after their term is concluded. Notable past Surgeons General include:

Surgeon General Luther Terry MD (1961 – 1965), who was previously the Chief of General Medicine and Experimental Therapeutics at the National Heart Institute. Dr. Terry’s committee report issued on March 7, 1962 indicated that cigarette smoking was a cause of lung cancer and bronchitis, and probably a risk factor for cardiovascular disease as well.  

This report led to the familiar warning on all packages of cigarettes in the United States:

Surgeon General C. Everett Koop MD (1982-1989), was a pediatric surgeon from the University of Pennsylvania School of Medicine faculty. Dr. Koop released a paper which called for AIDS education in the early grades of elementary school, and he gave full support for using condoms for disease prevention. He also resisted pressure from the President Reagan to report that abortion was psychologically harmful to women. He believed abortion was a moral issue rather a public health issue.

Surgeon General Antonia Novello MD (1990-1993) was a pediatrician and the first female Surgeon General. She was a graduate of the University of Puerto Rico School of Medicine. 

Surgeon General Joycelyn Elders MD (1993-1994) is currently a professor emeritus of pediatrics at the University of Arkansas. Dr. Elders once spoke at a United Nations conference on AIDS, and when asked whether it would be appropriate to promote masturbation as a means of preventing young people from engaging in riskier forms of sexual activity she replied, “I think that it is part of human sexuality, and perhaps it should be taught.”  She was fired by President Bill Clinton that year.

What will Jerome Adams’ legacy be? We’ll only know after his term has ended and the chronicle of the COVID-19 pandemic is recorded into history books. As the top public health doctor in the United States at the time of our worst public health nightmare in a century, his feats, achievements, and non-achievements will be on the record for years to come. 

I support Dr. Jerome Adams, and urge him to use his platform, education, and experience to be a leader in America’s public health response to COVID-19.

Would President Trump fire his Surgeon General if Dr. Adams publicly disagreed with the President? Perhaps. But I believe Jerome Adams’ legacy will grow to the degree he speaks out on the side of medical science regarding the containment of the coronavirus, and to the degree the United States has a successful public health response to the COVID-19 pandemic.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
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Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

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BLACK MAN DIES AFTER A CONFRONTATION WITH POLICE AND INJECTION OF THE ANESTHETIC KETAMINE BY PARAMEDICS. WHAT WENT WRONG?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997
Elijah McClain

Elijah McClain was a 23-year-old Black man who was detained by police just after 10:30 pm on August 24, 2019 while on his way home from picking up an iced tea for his brother. The Aurora, Colorado Police Department received a call about a “suspicious person” wearing a mask and waving his hands. 

An account of the events of that night appeared on the website thecut.com:     

Elijah McClain

The 23-year-old had made a quick trip to the convenience store to pick up an iced tea for his brother. His sister later told a local ABC affiliate  that McClain was wearing an open-face ski mask because he “had anemia and would sometimes get cold.” And although he was unarmed, simply walking home and, his sister said, listening to music, police say “a struggle ensued.” One officer accused McClain of reaching for his gun, and one put him in a carotid hold, which involves an officer applying pressure to the side of a person’s neck in order to temporarily cut off blood flow to the brain. “Due to the level of physical force applied while restraining the subject and his agitated mental state,” officers then called Aurora First Responders, who “administered life-saving measures,”  according to a local NBC affiliate. Paramedics injected McClain with what they said was a “therapeutic” amount of ketamine to sedate him, while officers held him down.

McClain went into cardiac arrest on the way to the hospital, and was taken off life support on August 30. His family said at the time that he was brain dead, and covered in bruises. . . .

Elijah McClain in ICU

Body-cam footage of the arrest does exist, although the Aurora Department of Police did not release it to the public until late November, months after McClain’s death. In the footage, an officer can be heard admitting McClain had done nothing illegal prior to his arrest; another accuses McClain of reaching for one of their guns. McClain, meanwhile, can be heard asking the officers to stop, explaining that they started to arrest him as he was “stopping [his] music to listen.” He gasps that he cannot breathe. He tells them his name, says he has ID but no gun, and pleads that his house is “right there.” He sobs, and vomits, and apologizes: “I wasn’t trying to do that,” he says. “I just can’t breathe correctly.” One of the officers can also be heard threatening to set his dog on McClain if he “keep[s] messing around,” and claiming he exhibited an extreme show of strength when officers tried to pin back his arms. . . .

An autopsy initially listed McClain’s cause of death as “undetermined.”

McClain’s autopsy also raised questions. The Adams County Coroner announced in early November that it wasn’t clear whether his death had been an accident, or carotid hold–related homicide, or the result of natural causes. The coroner listed McClain’s cause of death as “undetermined,” but points to hemorrhaging in his neck and abrasions on different parts of his body. Noting that “an idiosyncratic drug reaction (an unexpected reaction to a drug even at a therapeutic level) cannot be ruled out” in reference to the ketamine dosage, the report’s wording seemed to pin responsibility on McClain himself.”

A July 3, 2020 story by NBC news described the ketamine administration in this case as follows: 

The officers took McClain to the ground using a carotid control hold, a type of chokehold meant to restrict blood to the brain to render a person unconscious. . . .

McClain “briefly went unconscious,” according to a report the local district attorney, Dave Young, completed last fall. McClain could also be heard in the police video telling the officers, “I can’t breathe, please,” and he vomited while he was on the ground.

A medic told officers that “when the ambulance gets here, we’re going to go ahead and give him some ketamine.”

The officers responded, “Sounds good,” and they told the medic that McClain appeared to be “on” something and that he had “incredible strength.”

An Aurora Fire Rescue medic injected McClain with 500 milligrams of ketamine, according to the district attorney’s report.

The coroner found that McClain’s death was due to “undetermined causes,” . . . The medic at the scene estimated that McClain weighed 220 pounds, Young’s report said. But the coroner said he was 5 feet, 6 inches tall and weighed 140 pounds.

According to documents shared by Aurora Fire Rescue, the standard dose of ketamine is 5 milligrams per each kilogram of a person’s weight. That would mean that instead of 500 milligrams of ketamine, McClain should have received about 320 milligrams.

The use of ketamine by Emergency Medical Technicians (EMT) was reviewed in the paper Prehospital Use of IM Ketamine for Sedation of Violent and Agitated Patients in the Western Journal of Emergency Medicine. Regarding the indications to use ketamine in the pre-hospital setting, the paper stated: “Violent and agitated patients pose a serious challenge for emergency medical services (EMS) personnel. Rapid control of these patients is paramount to successful prehospital evaluation and also for the safety of both the patient and crew. Sedation is often required for these patients, but the ideal choice of medication is not clear.” In this retrospective review of prehospital ketamine use, 50 of the 52 patients studied were rapidly sedated, and only three patients had negative side effects. But these three side effects were significant, including the requirement for an endotracheal tube (ETT) in two patients, and the requirement for bag valve mask (BVM) ventilation in one patient. ETT or BVM are indicated when airway or breathing cease to be adequate. The publication included the following algorithm to guide the pre-hospital usage of ketamine:

What probably happened to cause Elijah McClain’s death? 

As an anesthesiologist I’ve administered ketamine safely to hundreds of patients. It’s a potent drug but poses life-threatening risks if given by personnel who are not airway experts. I have no access to the medical records or police records from Elijah McClain’s death. But based on reading the media coverage, here’s my interpretation regarding the administration of ketamine to Elijah McClain:

Ketamine is a potent injectable drug used by anesthesiologists to provide sedation or general anesthesia. (Reference: Elsevier Clinical Key Monograph, Lane Medical Library online, Stanford University Medical Center) It can be injected via an intravenous line, or injected into a muscle (intramuscularly, or IM) as it was to Elijah McClain. Ketamine produces an anesthetic state characterized by profound pain relief with minimal depression of breathing. Ketamine brings on a trancelike state of unconsciousness, but also produces undesirable psychological reactions during awakening which are called emergence reactions. Common symptoms of emergence reactions are vivid dreams, a sense of floating out of body, and illusions which seem to be misinterpretations of a real, external sensory experience. (Reference: Miller’s Anesthesia, 9th edition, Chapter 23, Intravenous Anesthetics)

For anesthesiologists the primary indication intramuscular/IM ketamine is to induce general anesthesia in uncooperative patients, young children, or adolescents who will not remain still and allow the elective placement of an intravenous/IV catheter. An intramuscular injection of ketamine into the deltoid muscle of the shoulder or the quadraceps muscle of the thigh will bring on the onset of anesthesia in 3 to 5 minutes. Per the chart below, the general anesthesia induction dose of ketamine is 4-6 mg/kg when used IM:

Uses and Doses of Ketamine

From Reves JG, Glass P, Lubarsky DA, et al. Intravenous anesthetics. In: Miller RD, Eriksson LI, Fleischer LA, et al, eds.  Miller’s Anesthesia,  7th ed. Philadelphia: Churchill Livingstone; 2010: 719–768.

Induction of general anesthesia  ∗ 0.5-2 mg/kg IV  
4-6 mg/kg IM
Maintenance of general anesthesia0.5-1 mg/kg IV with N  2  O 50% in O  2  
15-45 μg/kg/min IV with N  2  O 50%-70% in O  
30-90 μg/kg/min IV without N  2  O
Sedation and analgesia0.2-0.8 mg/kg IV over 2-3 min
2-4 mg/kg IM
Preemptive or preventive analgesia0.15-0.25 mg/kg IV

McClain’s demise may have been caused by the effects of ketamine, combined with inadequate management/resuscitation of a ketamine-anesthetized adult by non-anesthesia professionals:

  1. McClain was not NPO prior to his anesthetic. Nothing by mouth (nil per os, or NPO) is the standard of care prior to elective surgery. Vomiting stomach contents after the induction of general anesthesia can lead to aspiration of these stomach contents into the windpipe and/or lungs, which can cause death. Patients for elective surgery who receive ketamine always have an empty stomach. It’s dangerous for a paramedic to induce general anesthesia in an individual who is not NPO, because any vomiting could obstruct the airway and breathing. According to Elsevier Clinical Key Monograph, Lane Medical Library online, Stanford University Medical Center: “Vomiting has been reported following ketamine administration. Intact laryngeal-pharyngeal reflexes may offer some protection, however the possibility of aspiration must be considered.”
  2. Ketamine causes increased airway secretions, and the accumulation of these secretions on the vocal cords can cause laryngospasm (the clamping of the vocal cords together which blocks off all airflow). Ketamine causes increased production of saliva and increased secretions in the trachea and bronchial passages. Drugs called antisialagogues which block the production of these excess secretions are routinely given together with ketamine to prevent this complication. Atropine is the treatment most commonly used, with glycopyrrolate being an alternative drug. Laryngospasm is the most feared complication of intramuscular ketamine sedation, and laryngospasm is more common in the presence of increased secretions. Laryngospasm causes immediate cessation of all airflow through the voice box and will cause death within minutes if not treated. Medical treatment of laryngospasm in this setting would be pharmacologic paralysis of the vocal cords using a drug named succinylcholine, followed rapid sequence induction (RSI) of anesthesia and endotracheal tube (ETT) placement.    
  3. An overdose of ketamine can impair respirations, and Elijah McClain received an overdose of ketamine. He weighed 140 pounds (64 kilograms). He received a dose of 500 mg, or 7.8 mg/kilogram. This exceeded the general anesthetic dose of 4 – 6 mg/kg for intramuscular use. Respiratory depression and apnea can occur after rapid administration or high doses of ketamine. (Reference: Elsevier Clinical Key Monograph, Lane Medical Library online, Stanford University Medical Center) An overdose of ketamine, administered by a non-anesthesiology professional, could lead to loss of airway and death if McClain stopped breathing and was not properly resuscitated by either bag valve mask (BVM) ventilation or ETT placement.

The mnemonic Airway-Breathing-Circulation, or A-B-C, describes the order of acute medical care to an emergency patient, and the failure of Airway or Breathing likely caused McClain’s death by one or more of the three possibilities listed above.

It’s possible that the police officer’s choke hold/carotid hold contributed to or caused McClain’s death as well. If this police maneuver obstructed blood flow to one or both carotid arteries, McClain was at risk of becoming unconscious from lack of oxygen to his brain. If the police maneuver obstructed his trachea/windpipe, then McClain was at risk to lose his airway and be unable to breathe.  

Was there any indication for the paramedics, accompanied by police officers, to induce general anesthesia to Elijah McClain under the circumstances above? Based on what has been published regarding of the facts of the case, I don’t think so.

This case received a modest amount national publicity when it occurred. Now, in the context of the amplified Black Lives Matter movement, the case has become very relevant. A Change.org petition demanding “Justice for Elijah McClain” has garnered nearly two million signatures. 

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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COMPUTER SCIENCE VS. MEDICAL SCHOOL

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997
Computer code
medical school

You’re a high school or college student with proficiency in science and math, and you’re wondering about your eventual career path. Two of the most ambitious career choices would be to go to medical school, or to go into some form of computer science/software/hardware engineering.

Which road is the correct road for you? 

It depends.

I’ve been a medical doctor for 40 years, practiced three different specialties, and worked on a top medical school faculty for 30 years. I understand the pathway of a medical career very well. I live and work in Silicon Valley. I have many friends and many patients who work in the tech/computer world, so I understand the life of a high tech career.

I have three sons, all of whom are skilled in science and math. I’ve discussed the pros and cons of being a physician with them since they were in elementary school, and they’ve observed my lifestyle. The career choices of my sons so far: one businessman, one computer scientist, and one 9th grader who is yet undecided (but leaning toward computer science).

Why are none of them pursuing medicine? They’ve listened to me and have made their own choices. What follows is the advice I give to young students skilled in science and mathematics who are trying to decide between medical school and a computer science career:

MEDICAL SCHOOL:

Positives:

  1. There is a high demand for MDs. You will have a job. As the Baby Boomer generation ages, they’re all requiring an increased level of health care intervention.
  2. You will be well paid. The average salary varies by specialty from $230,000/year for pediatrics to $480,000/year for orthopedic surgery.
  3. You’ll help people get healthy. That feels good. 
  4. Respect. Most people respect physicians.
  5. You can work into your 70s if you want to. There is minimal age discrimination.
  6. You’ll be a lifelong student. An emersion into medical knowledge makes you both an interested and interesting person your whole life. 

Negatives:

  1. Deferred gratification: it takes a long time to become an MD. You’ll be 30 years old at a minimum when you finish training. At that age you’ll have a negative net worth, and you’ll be financially years behind your friends who went to work immediately out of college
  2. You’ll work ong hours, including sleeping overnight in hospitals during your training. 80-hour work weeks are common.
  3. You’ll acquire significant debt that will take you many years to repay. An October 2019 report from the Association of American Medical Colleges stated that 73% of medical students graduate with a mean debt of $201,490 and 18% with a mean debt exceeding $300,000.
  4. Medicine isn’t what it was in the 1960s-2000s, when MDs hung out their own shingle, thrived in private practice, and had significant autonomy. At the present time many young MDs are settling for a salary as an employee of a large organization. 
  5. Burnout is a constant risk. Electronic medical records require a significant portion of your work time, you may be required to see patients in 10-minute production-pressure clinic visits, and you’ll be on call during nights and weekends. Answering phone calls or being summoned into the hospital at 3 a.m. gets old.

COMPUTER SCIENCE/SOFTWARE/HARDWARE ENGINEER

Positives:

  1. You’ll be employable right out of college at age 22, with a good salary. The average income for a computer scientist is listed as $84,796, with a range from $69,000 – $114,000.
  2. High demand exists. You’ll get a job.
  3. You’ll have less educational debt, because you only went to four years of school after high school.
  4. Many students find computer science challenging and interesting.
  5. Computer science is changing the world we live in.
  6. It’s possible to work from home.

Negatives:

  1. Your salary will likely max out at less than an MD would earn. 
  2. It can be a lonely work life—just you and your computer. Computer science is rarely described as a social job.
  3. It’s possible your job will age-out in later years as you compete with younger, cheaper graduates with the same degree.
  4. You’ll probably have little autonomy. Most computer scientists work as a cog in some giant company. Think Google, Facebook, Apple, or Amazon.
  5. Competition exists. It’s difficult to be accepted into computer science programs at quality colleges—but it’s not as competitive as medical school acceptance. 

Listing the pros and cons of each career as I’ve done above will not make your decision for you. I recommend you make the decision between computer science and medical school with your gut, based on the following thought process:

Computer science and medical school are two appealing careers for students with strong science and mathematics backgrounds, BUT THE TWO JOBS ARE SO DIFFERENT. Medical doctors take care of people. We listen to patients, we hold their hands, we comfort them, and we attempt to heal them. Computer scientists work with code, chips, software, or hardware. The emotional milieu of these two careers could not be more different. 

Search your heart and you’ll know whether you’d rather spend decades working with people, or whether you’d rather spend decades working in a tech job. Search your heart and you’ll know whether you’d rather spend decades in an operating room/clinic setting, or whether you’d rather spend decades staring at a computer.

Then follow your heart based on those two images, and you’ll wind up where you need to be.

If you’re a real go-getter, you can complete undergraduate training in computer science and then go to medical school. Reference my column on How to Make a Billion Dollars in Healthcare to learn why a combined degree might be the educational pathway of choice for super-ambitious science and math students.

Good luck!

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The most popular posts for laypeople on The Anesthesia Consultant include:
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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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REOPENING 2020. . . DARWINISM WILL RULE

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

In Charles Darwin’s book On the Origin of Species he theorized that organisms best adjusted to the environment are the most successful in surviving and reproducing. In the Great Reopening after the COVID pandemic of 2020 we will see Darwinism in action.

The five basic pillars of safe reopening are eloquently described by Harvard surgeon Atul Gawande in his article “Amid the Pandemic, a Regimen for Reentry” in the May 13, 2020 edition of The New Yorker. They are:

  1. Wearing masks.
  2. Social distancing to 6 feet away or greater.
  3. Frequent handwashing and avoiding touching your face.
  4. Screening individuals for COVID symptoms, or better yet screening individuals with the nasal swab test.
  5. Culture. If a population understands 1-4 above and collectively adheres to these behaviors, reopening will be as safe as possible.

I awoke this Memorial Day morning to television videos showing groups of mask-less people in certain states across America enjoying the holiday weekend by walking shoulder to shoulder on beaches and boardwalks, malls pools, and parks.

The five tenets above were blatantly ignored. I was aghast. Why? Denial is at play. “I deny the risk of COVID” people were out in public.

These individuals convinced themselves that the virus threat is not real, and that COVID-19 was some boogieman that invaded New York City like Godzilla in a B-movie. Protesters around America have raged against coronavirus restrictions and governments that administer them.

Protesters around America have been toting guns and waving “Don’t tread on me” flags. 

What will happen to reopening without individuals following the five rules above? Asymptomatic carriers will pass the virus on to others. Multiple others. And what will happen to these others? Pursuant to what we’ve learned in these past months, roughly 80% of their contacts will have no significant symptoms. If these contacts also go to beaches, parks, boardwalks, pools, and malls without social distancing or masks, they will pass the virus on as well.

Five percent of those who newly contract the virus from the “I deny the risk of COVID” individuals will get very sick, and approximately 1% of the newly infected individuals will die. Ironically, young healthy “I deny the risk of COVID” people will probably not die, but one percent of those who were ignorant enough to stand within 6 feet of them will die. Survival of the fittest? Yes. Individuals who ignore points 1-5 above will find that death will follow their actions. If you choose to ignore points 1-5 above, you and your genes stand a higher chance of following the dinosaurs and the wooly mammoths into the abyss of extinction.

What if you’re not ignorant and you follow points 1-5 above? One of my colleagues is a University of California at San Francisco MD-PhD virologist and immunologist. He confirms that the five points above will keep reopening safe. He’s highly educated and careful in his behaviors. We were standing outside in an open space, and not only was he keeping greater than 6 feet of distance away from me, he repeatedly maneuvered to stand upwind of me so that any water vapor that I exhaled would be carried away from him rather than in his direction.

Are PhDs and MDs more likely to follow 1-5 above? I don’t have any data, but my guess is “yes.” Are less educated people and people who don’t read the news more likely to be “I deny the risk of COVID” individuals? Again I don’t have any data, but my guess is “yes.” You don’t need a graduate degree to observe points 1-5 above, you only need common sense. If you see a group of people who are within less than six feet of each other without wearing masks, you need to avoid them at all costs. Will less adaptive genes like the ones who ignore the risk of catching COVID die out? Only time will tell.

Unfortunately Darwinism will not be limited to killing off the “I deny the risk of COVID” individuals. People with health risk factors such advanced age, diabetes, obesity, and hypertension, and elderly people crowded together indoors in nursing homes are also at high risk of dying from COVID-19. These deaths will be a different kind of Darwinism, a survival of the fittest based on preexisting physical ailments.

The Great Reopening of 2020 can be very safe. Be smart. Reopen with glee, enjoy the great outdoors, hang out with friends, and walk in beautiful settings, but don’t pretend that the masks, the 6-foot distancing, and the hand hygiene are fairy tales. 

They aren’t. 

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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PATIENTS: IS IT SAFE FOR YOU TO HAVE SURGERY DURING THE COVID PANDEMIC AS OF MAY 2020?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

An important question for many Americans is, “Is it safe for me to have surgery during this COVID pandemic?”

It depends. 

In the San Francisco Bay Area where I work, the answer as of today, May 13th, 2020, is “yes.”

This is a key point: Healthcare professionals are more concerned with catching COVID-19 from you, the patient, than you should be concerned with catching COVID-19 within the healthcare facility. Read on to learn why.

The main questions as to whether a hospital or an ambulatory surgery center can resume elective surgery as of May 2020 are:

  1. What is the incidence of COVID-19 in your geographic area?
  2. Is testing for the virus that causes COVID-19 available in your area?
  3. Is there adequate personal protective equipment (PPE) at the facility?
  4. If you are having a major surgery in a hospital, will there be an adequate number of ICU and non-ICU beds, ventilators, medications, anesthetics and medical surgical supplies at the facility?

Your state health department will have statistics regarding the incidence of COVID-19 in your area. In Palo Alto, California, where I work at Stanford, the percentage of asymptomatic patients who have a positive COVID posterior nasal swab is quite low at 0.4%, or only 1 out of 250 people. The incidence of positive COVID antibody tests, indicating a prior exposure to the disease, is only 3%. Our county and state health administrations have noted a decline in the incidence of COVID cases, and have authorized a reopening of elective surgery. 

The American College of Surgeons, the American Society of Anesthesiologists, the American Association of periOperative Registered Nurses, and the American Hospital Association issued a joint statement on April 17th2020, stating that for reopening to occur, “there should be a sustained reduction in the rate of new COVID-19 cases in the relevant geographic area for at least 14 days and the facility shall have appropriate number of intensive care unit (ICU) and non-ICU beds.”

The joint statement also said that “facilities should use available testing to protect staff and patient safety whenever possible and should implement a policy addressing requirements and frequency for patient and staff testing.” Most facilities are interpreting this to mean that patients should have a negative COVID virus screening test prior to surgery. Most of these swab specimens are taken from the posterior aspect of the nose, although some tests only require an anterior nasal swab or a sputum/saliva sample. 

When you enter the healthcare facility, a nurse will question you regarding virus symptoms, and will screen you by taking your temperature. The inside of the healthcare facility will be cleaned prior to any patient care, and will be recleaned after each patient leaves an operating room. Everyone in the healthcare facility will be wearing masks. Everyone will be practicing social distancing of 6 feet unless they need to be closer to you to do their duty. All the precautions you’ve heard about multiple times from TV news reporters over the past weeks are strictly practiced inside healthcare facilities. When I’m at Stanford Hospital or the surgery centers in our area I’m confident the environment is safe.

Changes in the care of surgical patients during the time of COVID are best discussed in terms of preoperative care, intraoperative care, and postoperative care:

Preoperative care: No visitors are allowed into the perioperative region. At Stanford, if you have not had a COVID test prior to elective surgery, a nasal swab is taken on admission, and a rapid COVID test is done with the result available within about 2 hours. Healthcare workers take respiratory precautions with all patients as if that patient was COVID positive, whether the COVID test result has come back yet or not. You will wear a mask in the preoperative room, and that mask will remain on your face until just prior to the induction of anesthesia.

Intraoperative care: The American Society of Anesthesiologists states that “virus-carrying droplet particles become aerosolized into finer particles by airway procedures such as laryngoscopy, intubation, extubation, suctioning, and bronchoscopy, as well as by coughing and sneezing. These airway procedures and exposures carry a higher risk of infection for anesthesia professionals and other healthcare workers and require the use of rigorous PPE and environmental protection.” This means that when you are going to sleep or when you are waking up, airway procedures such as placing and removing a breathing tube are high-risk times for you to cough and project virus-carrying droplets into the atmosphere around you. The anesthesiologist wears full PPE (N95 mask, face shield, gown, two pair of gloves) during these times, and all other healthcare professionals (surgeons, nurses, techs) are to be at least 6 feet away or preferably outside of the operating room entirely. This is what your anesthesiologist will be wearing immediately prior to the time you go to sleep:

Postoperative care: When you awaken and your breathing tube is removed, the anesthesiologist once again places a paper surgical facemask over your mouth and nose to prevent you from coughing virus-containing droplets into the atmosphere of the operating room or the post-anesthesia care unit (PACU). If the procedure was an outpatient surgery, you will leave the facility and return home after you’ve recovered from anesthesia. Outpatient surgeries have the advantage of not requiring a hospital bed or an ICU bed/ventilator, which leaves these supplies available if a resurgence of COVID occurs in the community.

Which surgeries are commonly done as of May 13th, 2020? 

Each hospital or ambulatory surgery center is supposed to establish a prioritization policy committee consisting of surgery, anesthesia and nursing leadership, to develop a strategy to screen which surgical cases are appropriate to proceed with or not.

What do you, the patient, do with all this information? 

The timing of scheduling a surgery is always a balance of benefits and risks. Your surgeon will perform an essential surgery for you whenever a delay could cause harm. Your surgeon will weigh the risk of delay against the benefit that can be achieved by moving forward with your surgery. If your surgeon says your surgery is appropriate at this time, and you are willing to consent to the surgery, then you can move forward with the procedure. 

Healthcare professionals will adhere to the high quality standards as outline above, and surgery and anesthesia should be safe for you. 

References: 

Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic. (The American College of Surgeons, the American Society of Anesthesiologists, the American Association of periOperative Registered Nurses, and the American Hospital Association) 

Anesthesia Patient Safety Foundation, COVID-19 and Anesthesia FAQs

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ANESTHESIOLOGY IN THE TIME OF COVID

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

On April 17, 2020 I delivered a lecture for InternetMedicine.com entitled “Anesthesiology in the Time of COVID.” The material covered is directed at both healthcare professionals and laypersons. You can access the lecture on YouTube at:

OUTLINE: 

  1. ICU/INTUBATING ANESTHESIA DUTY
  2. ANESTHESIA MACHINES as VENTILATORS
  3. RATIONING VENTILATORS, and the ICU SOFA SCORE
  4. BAY AREA VS NEW YORK. DIFFERENCES IN COVID RATES
  5. UNDEREMPLOYED ANESTHESIOLOGISTS NOW
  6. REOPENING ANESTHESIOLOGY AFTER THE SURGE

The lecture identifies the most famous anesthesiologist in the world, discusses highlights of the last three American Society of Anesthesiologists COVID Town Hall Zoom webinars, and looks forward to how currently underemployed anesthesiologists, who are waiting on the sidelines because of the COVID cancellations of elective surgery, can and will return to work safely in the near future.

Access the lecture here.

UNDEREMPLOYED: AMERICAN SURGEONS, ANESTHESIOLOGISTS AND NURSES

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

During this COVID crisis, intensive care unit and emergency room doctors and nurses in hotspots like New York City have dangerous, exhausting jobs keeping coronavirus patients alive. But the American medical response to the COVID crisis is bimodal. A minority of doctors and nurses are saddled with these dangerous around-the-clock jobs battling the disease in ICUs and ERs. The majority of doctors and nurses are on the sidelines, waiting for a return to work, just like many other workers in the United States. 

This has especially affected surgical teams. COVID-19 is a terrible medical tragedy, but it is not a surgical disease. In the United States as a whole, surgery has ground to a halt. Surgeons, anesthesiologists, certified nurse anesthetists, and operating room nurses are barely working at all now, for the fourth consecutive week.

The Center for Medicare and Medicaid Services (CMS) issued an edict on March 18, 2020 that all elective surgery be cancelled. The logic was sound and was twofold: 1) to keep doctors, nurses, masks, gowns, ventilators, ICU beds and hospitals unused for non-urgent care, therefore freeing up these assets to fight the coronavirus pandemic; and 2) to keep healthcare workers away from each other in a social distancing strategy to stop the spread of the virus.

The shelter-in-place orders that shuttered the economy have sidelined workers in multiple industries: the airlines, resorts, cruise ships, arenas, concerts, churches, retail, education, sports, etc. You can add elective medical care to this list.

According to CMS, what kind of surgery can be done during this pandemic? The CMS document says to “postpone non-essential surgeries and other procedures. This document provides recommendations to limit those medical services that could be deferred, such as non-emergent, elective treatment, and preventive medical services for patients of all ages.” 

Ambulatory surgery centers have been almost entirely shut down. The document “Additional Guidance on the ASC Community’s COVID-19 Response” reads:

Examples of cases that might still need to proceed with surgery at this time include:

  • Acute infection
  • Acute trauma that would significantly worsen without surgery
  • Potential malignancy
  • Uncontrollable pain that would otherwise require a hospital admission
  • A condition where prognosis would significantly worsen with a delay in treatment

Greater that 95% of the surgical cases for my anesthesia group have been cancelled for four weeks running. A Bay Area contingent of the California Society of Anesthesiologists held a Zoom conference last week, and the majority of attendees voiced that they were not seeing COVID duty, but their anesthetic workload had plummeted. 

Should these surgical specialists be moved into roles fighting COVID? In Northern California there has been no need. The existing ICU beds, ventilators, and ICU/ER staffing has largely been adequate for the number of COVID patients. Elective surgery has been cancelled at the hospital I work at, Stanford University Hospital, per the CMS edict. According to the Internal Medicine Grand Rounds lecture from April 8, 2020, Stanford Hospital currently had only 13 COVID patients, with 5 of those in the ICU on ventilators. The total overall number of COVID deaths at Stanford Hospital as of April 8, 2020 was 2 patients, and there were 54 unused ICU beds. 

The cessation of elective surgery is a source of economic hardship for many medical entities, including healthcare companies, hospital systems, surgeons, anesthesia professionals, and nurses. We’re all waiting for elective, non-urgent surgery to resume when it’s safe for the medical personnel and for the patients. Expect this to occur when widespread testing tells us that the medical personnel and the patients either test negative for the COVID virus or positive for the COVID antibody. Everybody is waiting on the tests. We don’t need thousands of tests, we need millions of tests in the United States.

Unemployed and underemployed Americans from multiple industries, including healthcare, hope this widespread testing will happen within weeks from this date, not months.

LIFE AFTER THE PANDEMIC: 14 PREDICTED TRENDS

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Eventually the peak of the COVID pandemic will ease off and the number of cases and death rates will plateau. What about life after the pandemic? Will everyone go back to living like they did in February 2020 before the crisis arrived?

No.

Remember how airline travel was forever changed after 9/11? We adapted to the TSA screening. We adjusted to taking off our shoes, belts, and removing toiletries and electronics before every flight. In a similar way, this COVID-19 event in American history will change the way we live.

I’m a busy anesthesiologist and internist. I’ve been reading opinions and data from infectious disease experts regarding the COVID crisis for weeks. I foresee 14 medically-related trends on life and medical care in America occurring after the pandemic, but before the vaccine is available. Pondering these issues will help us prepare to find solutions. Here they are:

Testing, testing, testing. As soon as COVID testing is widely available, you’ll see skyrocketing numbers of individuals being tested. A test for COVID infection is necessary to discern who actually has the disease and is contagious. When we do not have adequate diagnostics we are forced to social distance everyone blindly. We don’t know which febrile patients with a cough to quarantine. We don’t know which asymptomatic patients are carrying the COVID virus and are contagious. The availability of a COVID test which is a) accurate, b) mass-produced, and c) inexpensive, will be the first game changer. Scientists have also developed a test for COVID antibody, which diagnoses which individuals have previously had the infection. We don’t know for certain that these individuals are immune to reinfection, but scientists are hopeful that is the case. Once we know who has had the disease already (positive antibody test), or those who are currently not contagious for the virus (negative COVID virus test), we can divide our workforce into safe employees and quarantined employees. Then people can come out of shelter and trickle back to work. But because you could test negative for the virus and then become infected the next day, testing would have to be cheap enough and available enough to be repeated frequently.

Gathering of large numbers of people will continue to be discouraged or banned. That means music concerts, sporting events, movies, cruise ships, casinos, or churches full of hundreds or thousands of individuals will be an ongoing bad idea. Until you know that person next to you is COVID negative, you won’t want to be sitting two feet away from them. This issue will plague the entertainment and sporting industries until there is a vaccine which eliminates the disease.

Scant air travel. Do you really want to sit two feet away from multiple strangers for several hours without knowing they are COVID negative? The airline industries and the travel/vacation/resort industries will be severely curtailed until there is a vaccine, widespread testing, or a cure.

Continued high usage of videoconferencing, including telemedicine clinic visits and remote schooling. Most physicians never used Zoom or WebEx prior to the COVID shutdown. Now we’re all using some form of videoconferencing every day. It’s an excellent way to interact and conduct lectures, meetings, or patient interviews, although it limits the ability to perform physical examination of the patient. Most teachers never taught using videoconferencing prior to the COVID shutdown. Now many are using it every day. Zoom and its brethren will be a major part of American life for years to come.

Ongoing delays in elective medical care. The majority of my anesthetic practice deals with elective, non-emergency surgery. All elective surgery has stopped with the COVID crisis. When will it begin anew? See #1 above. When we know a surgical patient is COVID negative and the patients know that all the medical staff is COVID negative, we can proceed with non-urgent cases. What about in-person medical office visits? Physicians will want to know that patients are COVID negative or antibody positive. I see a model where a patient must either have a certificate that documents a positive COVID antibody test, or have a negative COVID test (done one day prior to surgery) before their non-urgent surgery can be done. Likewise for in-person clinic visits.

Concerns that COVID will resurge in the fall of 2020 and/or in the spring of 2021. This fear will keep our country’s leadership on edge until there is a vaccine which eliminates the disease. Social distancing edicts may be withdrawn this summer, but the fear of another surge in the autumn will keep the specter of shelter-in-place on every politician’s mind until they are assured it is not needed.

14-day quarantining for anyone who enters the U.S. from abroad should disappear once available COVID testing is available. Accurate testing before an individual boards an international flight will reveal the whether that incoming individual is contagious.

Voting by absentee ballot will be mandated, or at least be very prevalent. Why would America choose to convene thousands of individuals at voting booths or voting sites on November 3rd 2020, thereby increasing the risk of respiratory disease spread? I’ve voted absentee ballot for decades. I’m usually too busy at work to get to the polling location before it closes. Absentee voting is easy, takes far less time, and will be medically safer than traveling to polling locations.

Lawsuits will abound. American is a litigious country. Expect families who experienced a COVID death to look for someone to sue—someone who didn’t close their gym, didn’t close their music festival, or didn’t order shelter-in-place soon enough—because that delayed decision caused their family member to contract COVID and die.

Finger pointing like you’ve never seen. Every politician will look toward politicians in the other party and blame them for not acting quickly enough. We’re seeing some of this already, but it’s drowned out by the mortality going on. After the smoke settles look for amplified criticism directed towards China for not telling the world the crisis was coming, federal political leadership for not being prepared for the pandemic, governors for not shutting down their state soon enough, legislators for not sending enough money to all the unemployed citizens, etc.

Eventually we’ll all pay higher taxes to replace the money given away by the CARES (Coronavirus Aid, Relief, and Economic Security) Act, which is funding two trillion dollars to Americans who are not working due to the COVID medical crisis. It’s also possible there will be a CARES II and CARES III at some point in the future depending on the duration of the economic crisis. The aid is necessary and wise. We’ll all have to pay for it someday.

Ongoing financial problems for workers in the depressed industries of airlines, vacation/resorts, cruise ships, theme parks, hotels, entertainment, and arena/stadium based sporting leagues.

On a positive note, adequate federal stockpiles of both ventilators and personal protective equipment (PPE) will be readied for any future pandemics.

Again on a positive note, there will be increased federal funding regarding vigilance and preparation for future viral outbreaks.

If the present crisis was a Hollywood movie (e.g. Outbreak, Contagion, or The Andromeda Strain), scientists would find a cure just when things were looking most dire. Will the COVID-19 crisis end happily like a Hollywood screenplay? Will COVID just fade away as the weather gets warm again? Nobody knows. Many intelligent researchers around the world are working on medical therapies against the COVID-19 virus. I’m hopeful that a cure will come. 

Many intelligent researchers around the world are working on a vaccine against the COVID-19 virus. Dr. Anthony Fauci of the National Institutes of Health (NIH) estimates it will be 12-18 months before experts develop the ultimate game changer, a vaccine.  I’m hopeful and optimistic that a vaccine will come. 

President Trump expects the United States to reopen its economy “sooner than people think.” Experts disagree. See The New York Times story, U.S. is Nowhere Close to Reopening the Economy, Experts SayDr. Fauci states that “the United States might never get entirely back to where it was before the novel coronavirus outbreak, especially without a vaccine.” Until that time, I foresee the changes listed above. Don’t be surprised to see them arrive after the peak of the current pandemic is in our rear view mirror.

I welcome discussion from my readers as to their viewpoints and predictions on life in America after the pandemic.

WHEN IS THE END OF THE COVID SURGE IN YOUR STATE?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

When is the end of the COVID surge in your state? It varies from state to state. 

This website shows projections of when the coronavirus surge will peak in your state, and when coronavirus cases will finally decline. The graph above is for the entire 50 states, and shows the peak of the surge on April 16th, with an estimated 2,644 deaths that day. The data is clearly displayed in a graph of the calendar date vs. total deaths for each of the 50 states.

On a morning when the Surgeon General stated, “This week will be like a ‘Pearl Harbor’ and a ‘9/11’ moment,” and a day after the President said, “there will be a lot of death,” what is the true estimate for where you live?  

There is considerable variation amongst the states. New York looks like this, with the peak projected for April 11th, with a peak of 852 deaths per day:

California, where I live, looks like this, with the peak coming later on April 28th, and with a lower peak of 119 deaths per day:

These graphs are a reality check. When I share them with friends, the first things I hear are, “Oh my, I’d better stay inside, because the amount of cases is still increasing daily,” and “Oh my, the whole curve doesn’t go away until well into late June. How long will I have to shelter in place?”

The good news is, every one of the graphs shows an eventual decline, when the peak of the pandemic will be over.

NUMBER OF HOSPITALIZED CORONAVIRUS PATIENTS IN SANTA CLARA COUNTY CALIFORNIA

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

SANTA CLARA COUNTY, CALIFORNIA

Questions I’m frequently asked are, “What is the coronavirus census in your hospital?” or “How full is your hospital with COVID patients?”

I work in Santa Clara County, California, in the San Francisco Bay Area. The six counties of the Bay Area were placed in shelter-at-home relatively early, on March 16th during the COVID-19 outbreak.

The answer to the hospital COVID-19 census question is shown in the graph below, available to the public as part of a video lecture on Coronavirus (COVID-19) Grand Rounds-Stanford Department of Medicine, posted on YouTube on April 1, 2020.

This data is from March 30, 2020. The magnified picture is fuzzy, but please squint hard and examine the three circles. The good news is the total numbers are not high. The first green circle highlights that Stanford Hospital had a total of 15 COVID patients, and there were only 8 COVID patients in the ICU. Regional Hospital in San Jose had the highest numbers, with a total of 38 COVID patients and 20 COVID patients in the ICU. The total for all nine hospitals listed in Santa Clara County was 154 COVID patients, with 72 COVID patients in the ICU. The population of Santa Clara County is 2 million.

These numbers are in contrast to the situation in New York City, where there are 11,739 COVID patients hospitalized. The population of New York City is 8.6 million.

Why are Santa Clara County’s numbers so low? Part of the reason is that the six counties of the San Francisco Bay Area, which includes Santa Clara County, ordered shelter-in-place early, on Monday March 16th, 2020.  

New York City ordered shelter in place on March 20th, 2020.

Another reason may be that California population is less dense than in New York City. Santa Clara County’s area is 1304 square miles, compared to 302 square miles for New York City. Most people in Santa Clara County live in houses. Open spaces abound between most residences. In New York City the populace lives in tighter quarters, with many residences in vertical apartments or condominiums. It’s likely easier to share virus contact in New York City. But no doubt there are other reasons for the magnitude of the outbreak in New York City which are not clear at this time.

From the White House, Dr. Deborah Birx praised California and Washington state for their prompt response to the COVID crisis, and commented that New York and New Jersey had lagged in their response.

Stay tuned, but right now in Santa Clara County, in the southern part of the San Francisco Bay Area, hospitalized COVID-19 numbers are magnitudes lower than New York City.

CORONAVIRUS AND THE SOFA SCORE

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

When you read the words “coronavirus and the sofa score” during a period of shelter-in-place for COVID-19, your first thought will be “laying on a sofa watching Netflix.”

Wrong. SOFA is a medical metric called the SOFA score.

This column is about rationing of ICU care and ventilators. If/when hospital intensive care units (ICUs) become overwhelmed with too many coronavirus patients requiring ventilators, then ethical choices may need to be made. If there are “n” number of ventilators and “n+10” patients who need one, who gets a ventilator and who does not? Which patients have an excellent prognosis to live and which do not?

Will ICU beds and ventilators need to be rationed in the COVID-19 crisis?

In crisis areas like New York City and Italy’s Lombardy region, anxiety and fear abound. I’ve previously posted this video showing the stress at an Italian COVID-19 ward.

This week I was contacted by a reader in his 70s who had a history of heart disease. His anxiety regarding the coronavirus epidemic was so high he asked me if he purchased a ventilator for the local university hospital, could he be guaranteed it would be available for him if he needed it? 

What data are available specifically for COVID-19 to address the question of which patients will have the highest ICU mortality?

Fei Zhou, MD et al published a retrospective study regarding COVID-19 patients from the Wuhan, China area in the medical journal Lancet. 191 patients were included in this study. 137 were discharged and 54 died in hospital.

Zhou measured data on each patient at the time of admission to the ICU. He discovered that the odds of dying in the hospital increased with: 

A) increasing age, 

B) a D-dimer level exceeding 1 mcg/L on admission, and 

C) a higher SOFA score on admission to the ICU.

Of these three criteria:

  1. We’ve already heard that a higher age is a risk factor for dying from COVID-19. See chart above
  2. A high D-dimer level indicates that increased blood clotting is occurring. The D-dimer is not specific, and can correlate with a deep venous thrombosis, a pulmonary embolus, or other diagnoses which include increased blood clotting. 
  3. What is a SOFA score? Read below:

SOFA stands for Sequential Organ Failure Assessment, and it quantifies the extent of a patient’s organ function or failure in six different organ systems: the lungs (respiratory), the heart (cardiac), the kidney (renal), the brain (neurological), the liver (hepatic), and the blood clotting system (coagulation). It’s used to predict ICU mortality based on lab results and clinical data. The higher the score, the worse the prognosis.

Let’s look at how each organ system is rated, first for a normal person like yourself, and secondly for a sick COVID-19 patient in the ICU:

RESPIRATORY:

Lung or respiratory failure is the most common failing system in sick COVID-19 patients. The SOFA respiratory score is based on the ratio of:  your blood oxygen level (PaO2) divided by the percentage of oxygen that you’re breathing. Right now your blood oxygen level is approximately 90 mm Hg, and the percentage of oxygen in room air that you are breathing is 21%, or 0.21 as a decimal. Divide 90/0.21 = 428. From the chart above, you earn 0 points, which is good. A COVID-19 patient sick with pneumonia may have a low blood oxygen level of 50 mm Hg on 100% oxygen, or 1.0 as a decimal (100% oxygen is the most a ventilator can deliver). 50/1.0 = 50, which earns that patient a respiratory score of +4 points.

CARDIAC:

The cardiac score is based on how high or low your blood pressure is, and on what concentration of adrenaline-like medication is required to keep your blood pressure up to a safe level. The blood pressure metric used is the mean arterial pressure (MAP), which is your average blood pressure. Right now your blood pressure may be 120/80, which equates to a mean arterial pressure of 93. Because you require no medications to keep your mean blood pressure > 70, you earn 0 points. A sick COVID-19 patient with heart failure might require a high concentration of an epinephrine (adrenaline) drip to maintain their blood pressure. This would earn them a cardiac score of +4.

RENAL:

The renal score is based on now much urine a patient produces per day, or how high their blood creatinine level rises to. Normal urine output is at least of 0.5 milliliters/kilogram of body weight per hour. A 70 kilogram (154-pound) human makes a minimum of 840 milliliters of urine/day, which earns them 0 renal points. A sick COVID-19 ICU patient with renal failure may make less that 200 milliliters of urine per day, which earns them a renal score of +4 points.

LIVER:

The liver score is based on how high the bilirubin concentration is in the blood. Bilirubin increases as a liver fails. Your bilirubin is a normal concentration of 1.0 mg/dL, and you earn 0 points. A sick ICU patient with a failing liver may have a buildup of bilirubin in the blood. An elevation to a concentration of > 204 mg/dL earns them a liver score of +4 points.

NEUROLOGICAL:

The Glasgow Coma Scale (GCS) quantifies the level of consciousness. Because you are awake and reading this, let’s assume you have a perfect GCS of 15. This earns you 0 points. A comatose patient on a ventilator may have a score of < 6, which earns them a neurological score of +4 points.

COAGULATION:

The normal concentration of platelets in the bloodstream is > 150,000, or (150 X 103 microL), and if you’re normal individual you will earn a score of 0. A sick COVID-19 patient in the ICU may be bleeding for a variety of reasons, and be consuming platelets trying to cease bleeding. A low platelet count of (20 X 103 microL) earns them a coagulation score of +4 points.

Zhou wrote: “Older age, elevated D-dimer levels, and high SOFA score could help clinicians to identify at an early stage those patients with COVID-19 who have poor prognosis.” 

What about rationing ICU care? Will older age or a higher SOFA score on admission impact a rationing of ICU care, that is, will older patients or patients with a very high SOFA score be denied a ventilator or an ICU stay? Will famous people or rich people score the last ventilators? I am doubtful this will happen in the ethical practice of medicine in the United States. But if the number of ICU patients greatly exceeds the number of ICU beds with ventilators, difficult choices may have to be made. Some patients may receive ventilators while others are denied ventilators. The Zhou data supports the premise that older patients and those with elevated organ failure scores on admission to the ICU have a worse prognosis. If ethical decisions are made, these two numbers (as well as an elevated D-dimer level) may be criteria which guide these difficult decisions.

Further research and data collection on COVID-19 patients in the hospitals and ICUs will give more detailed answers to these questions. Stay tuned.

I refer you to a fine and pertinent article written by Dr. Robert Truog, of the Harvard Center for Bioethics, entitled, “The Toughest Triage – Allocating Ventilators in a Pandemic,” published in the New England Journal of Medicine March 23, 2020.

The April 1, 2020 issue of The New York Times discusses the issue of rationing ICU care in New York City.

The Atlantic explores the issue of rationing of care in the era of COVID-19 in this March 28,2020 article.

VIDEO FROM AN ITALIAN HOSPITAL COVID-19 WARD

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Today I’m posting a link to a video from an Italian hospital COVID-19 ward. For those of you who may doubt the severity or the danger of this pandemic, please watch this video which illustrates the crisis in Italy, and what could occur in the United States in the weeks to come:

If you’re wondering if the American response to the COVID-19 threat is over-exaggerated, this video should convince you that every measure of social distancing, personal protective equipment for healthcare workers, and expansion of ventilator/ICU availability is warranted.

WORLDOMETER CORONAVIRUS . . . ENCOURAGING DATA FROM ASIA

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Today I’m forwarding a link to Worldometer Coronavirus, a valuable big data scoreboard for hour-by-hour numbers on the pandemic worldwide. Data from the United States shows an escalating case load, but the data from China and South Korea shows flattening of the case load curve already.

Does social distancing work? Check out these two graphs of the case rates in China and South Korea:

This is the first encouraging data I’ve seen regarding this pandemic. Chinese case numbers went from roughly 0 to 40,000 in nine days from January 22 to February 9th, then went from 40,000 to 80,000 in seventeen days from February 9th to February 28th. Remarkably, from February 28th to March 16th, over the course of seventeen days, the curve flattened in China. That’s exactly what we’re praying for in the United States. A similar flattening of the curve occurred in South Korea:

The total coronavirus cases in the United States are still increasing exponentially at this date as shown in the graph below. The United States is still on the upswinging portion of the case curve. We expect/hope our social distancing will bring about the same flattening of the case count curve that has already occurred in China and South Korea.

Total case data by country are listed below. The USA has the 8th highest number of cases to date. The encouraging information in this table is in the “NEW CASES” column, where CHINA and SOUTH KOREA have only 36 and 74 new cases, respectively. Most likely this is because of the social distancing measures put into place early in those countries.

Additional data from the United States as of today are copied below. This data is updated hour-by-hour on the Worldometer Coronavirus website:

If you read down this far, you’re flooded with information. If you follow Worldometer Coronavirus regularly, you’ll know exactly how the pandemic is progressing or fading. Worldometer Coronavirus is not on the App Store for your phone, but you can do this: a) open the Worldometer Coronavirus website on Safari on an iPhone; click on the SEND icon (the square with the upward arrow) at the bottom of the screen; and c) select ADD TO HOME SCREEN. This will enable you to follow Worldometer Coronavirus on your smartphone.

Remember how the case number curves flattened in China and South Korea, and be encouraged by the probability of the same eventually occurring in the United States in the weeks to come. Until that time, practice social distancing as advised by national health leadership.

Information is power. I hope you’ll be empowered to make the right choices for yourself and your family in these historic and difficult days.

CAN WEARING A FACE MASK SAVE YOUR LIFE?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

During the COVID-19 pandemic we’ve been told not to wear a face mask if we don’t have viral symptoms.

Is this a mistake? Can a face mask save your life? I’m not talking about an N-95 mask, which blocks virus entry into your nose and mouth, and which are in short supply even for health care professionals during this pandemic, but a typical surgical mask, as pictured above.

Today I’m forwarding excellent information from a post by American viral specialist, James Robb MD, Fellow of the College of American Pathologists, a former Professor of Pathology at the University of California San Diego, and one of the first molecular virologists in the world to work on coronaviruses in the 1970s.

Dr. Robb is a proponent of individuals wearing surgical masks in public during a pandemic. He writes: 

“Stock up now with disposable surgical masks and use them to prevent you from touching your nose and/or mouth (We touch our nose/mouth 90X/day without knowing it!). This is the only way this virus can infect you – it is lung-specific. The mask will not prevent the virus in a direct sneeze from getting into your nose or mouth – it is only to keep you from touching your nose or mouth.

“The virus is on surfaces . . . This virus only has cell receptors for lung cells (it only infects your lungs). The only way for the virus to infect you is through your nose or mouth via your hands or an infected cough or sneeze onto or into your nose or mouth.”

This is a controversial recommendation. There are currently not enough surgical masks for everyone in the United States to be wearing one, but a face mask forms an effective blockade to an individual touching their own mouth and nose. The most common form of transmission of COVID-19 is likely autoinoculation of the virus from our hands to our nose, mouth, and eyes.

Dr. Jerome Adams, the Surgeon General of the United States, an anesthesiologist himself, and a professional I have tremendous respect for, tweeted this advice on February 29th, 2020:

“Seriously people- STOP BUYING MASKS! 
They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!”

It’s true that a typical surgical mask will not prevent you from inhaling the COVID-19 virus. And it’s also true that the medical teams in the United States need to have an adequate supply of surgical masks. But during this pandemic the facts are:  a) those doctors and nurses who are actually caring for or screening for coronavirus patients are wearing specialized N-95 masks, not regular surgical masks; and b) the need for surgical masks in the hospital has markedly declined because elective surgery in the United States is grinding to a halt during the current shutdown. Santa Clara County, where I practice in California, received a CDC recommendation that all elective and non-urgent surgical procedures be cancelled, and we are complying with this shutdown.

What if everyone in the United States started wearing a surgical mask all day? I’m not talking about an N-95 mask, which has twin elastic bands and forms a tight seal where the edges meet your skin. I’m talking about the looser version commonly worn in operating rooms. A tight N-95 mask is uncomfortable and will be often adjusted, necessitating multiple touching of the mask with your hands, which is could transmit the virus to the surface of the mask:

A looser fitting surgical mask is not uncomfortable, and is both a barrier to touch and a reminder not to touch one’s nose and mouth:

Is there any data that the barrier to touching their noses and mouths would slow the spread of COVID-19? No, there is no data, and there will not be anytime soon because no one has time to do such a study right now. But it’s common sense, as Dr. Robb recommends above, that preventing hand to face transmission is a vital part of curbing the spread of the virus.

On February 28th, 2020 a surgical colleague of mine who had just returned from Asia came to work and did surgery in one of our outpatient operating rooms here in California. One week later he was diagnosed with COVID-19 infection, and he was hospitalized. All the nurses, doctors, and techs who were present at work that day were placed on 14-day surveillance for the onset of COVID-19 symptoms, i.e. fever, cough, or shortness of breath. Sixteen days later, none of them have developed any symptoms of COVID-19. One of the reasons we attribute this positive outcome to is that all the doctors, nurses, and techs, as well as the infected surgeon, were wearing face masks. Almost no one will touch their nose and mouth if they are wearing a mask, and no one who is scrubbed in for surgery can touch their nose or mouth.

On March 12, 2020, in coverage of the COVID-19 pandemic, Time Magazine published an article Why Wearing a Face Mask is Encouraged in Asia, But Shunned in the U.S.” In Asia it became commonplace for individuals to wear face masks after the COVID-19 outbreak. They don’t have any data. They’re just worried.

We all should be worried at this point. If you cannot stop touching your mouth, nose, and face, and you can acquire a face mask, then consider wearing it. You don’t have to have a clean one each day. It’s not to prevent you from coughing on others, it’s to prevent you from touching your own face.

Is there any harm to wearing a face mask if you have one? I don’t think so. The benefit/risk ratio is high. Protect yourself and your family.

INFORMATION FROM THE BIOHUB PANEL on COVID-19, UCSF

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

I’m forwarding these excellent notes from the University of California San Francisco (UCSF) Medical Center on COVID-19. The most sobering data:

  • 40-70% of the US population will be infected over the next 12-18 months.  After that level you can start to get herd immunity.  Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.
  • We used their numbers to work out a guesstimate of deaths— indicating about 1.5 million Americans may die.  The panelists did not disagree with our estimate.  This compares to seasonal flu’s average of 50K Americans per year.  

  • Panelists
    • Joe DeRisi:  UCSF’s top infectious disease researcher.  Co-president of ChanZuckerberg BioHub (a joint venture involving UCSF / Berkeley / Stanford).  Co-inventor of the chip used in SARS epidemic.
    • Emily Crawford:  COVID task force director.  Focused on diagnostics
    • Cristina Tato:   Rapid Response Director.  Immunologist.  
    • Patrick Ayescue:   Leading outbreak response and surveillance.  Epidemiologist.  
    • Chaz Langelier:   UCSF Infectious Disease doctor

What’s below are essentially direct quotes from the panelists.  Sections bracketed are the few things that are not quotes.

  • Top takeaways 
    • At this point, we are past containment.  Containment is basically futile.  Our containment efforts won’t reduce the number who get infected in the U.S.  
    • Now we’re just trying to slow the spread, to help healthcare providers deal with the demand peak.  In other words, the goal of containment is to “flatten the curve,” to lower the peak of the surge of demand that will hit healthcare providers.  And to buy time, in hopes a drug can be developed. 
    • How many in the community already have the virus?  No one knows.
    • We are moving from containment to care.  
    • We in the US are currently where at where Italy was a week ago.  We see nothing to say we will be substantially different.
    • 40-70% of the US population will be infected over the next 12-18 months.  After that level you can start to get herd immunity.  Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.
    • [We used their numbers to work out a guesstimate of deaths— indicating about 1.5 million Americans may die.  The panelists did not disagree with our estimate.  This compares to seasonal flu’s average of 50K Americans per year.  Assume 50% of US population, that’s 160M people infected.  With 1% mortality rate that’s 1.6M Americans die over the next 12-18 months.]
      • The fatality rate is in the range of 10X flu.
      • This assumes no drug is found effective and made available.
    • The death rate varies hugely by age.  Over age 80 the mortality rate could be 10-15%.  [See chart by age Signe found at the top of this column.] 
    • Don’t know whether COVID-19 is seasonal but if is and subsides over the summer, it is likely to roar back in fall as the 1918 flu did
    • I can only tell you two things definitively.  Definitively it’s going to get worse before it gets better.  And we’ll be dealing with this for the next year at least.  Our lives are going to look different for the next year.
  • What should we do now?  What are you doing for your family?
    • Appears one can be infectious before being symptomatic.  We don’t know how infectious before symptomatic, but know that highest level of virus prevalence coincides with symptoms.  We currently think folks are infectious 2 days before through 14 days after onset of symptoms (T-2 to T+14 onset).
    • How long does the virus last?
      • On surfaces, best guess is 4-20 hours depending on surface type (maybe a few days) but still no consensus on this
      • The virus is very susceptible to common anti-bacterial cleaning agents:  bleach, hydrogen peroxide, alcohol-based.
    • Avoid concerts, movies, crowded places.
    • We have cancelled business travel.  
    • Do the basic hygiene, eg hand washing and avoiding touching face.
    • Stockpile your critical prescription medications.  Many pharma supply chains run through China.  Pharma companies usually hold 2-3 months of raw materials, so may run out given the disruption in China’s manufacturing. 
    • Pneumonia shot might be helpful.  Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
    • Get a flu shot next fall.  Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
    • We would say “Anyone over 60 stay at home unless it’s critical.” CDC toyed with idea of saying anyone over 60 not travel on commercial airlines.
    • We at UCSF are moving our “at-risk” parents back from nursing homes, etc. to their own homes.  Then are not letting them out of the house.  The other members of the family are washing hands the moment they come in.
    • Three routes of infection
      • Hand to mouth / face
      • Aerosol transmission
      • Fecal oral route

  • What if someone is sick?
    • If someone gets sick, have them stay home and socially isolate.  There is very little you can do at a hospital that you couldn’t do at home.  Most cases are mild.  But if they are old or have lung or cardio-vascular problems, read on.
    • If someone gets quite sick who is old (70+) or with lung or cardio-vascular problems, take them to the ER.
    • There is no accepted treatment for COVID-19.  The hospital will give supportive care (eg IV fluids, oxygen) to help you stay alive while your body fights the disease.  ie to prevent sepsis.
    • If someone gets sick who is high risk (eg is both old and has lung/cardio-vascular problems), you can try to get them enrolled for “compassionate use” of Remdesivir, a drug that is in clinical trial at San Francisco General and UCSF, and in China.  Need to find a doc there in order to ask to enroll.  Remdesivir is an anti-viral from Gilead that showed effectiveness against MERS in primates and is being tried against COVID-19.  If the trials succeed it might be available for next winter as production scales up far faster for drugs than for vaccines.  
    • Why is the fatality rate much higher for older adults?
      • Your immune system declines past age 50
      • Fatality rate tracks closely with “co-morbidity,” i.e. the presence of other conditions that compromise the patient’s hearth, especially respiratory or cardio-vascular illness.  These conditions are higher in older adults.   
      • Risk of pneumonia is higher in older adults.  
  • What about testing to know if someone has COVID-19?  
    • Bottom line, there is not enough testing capacity to be broadly useful.  Here’s why.
    • Currently, there is no way to determine what a person has other than a PCR test.  No other test can yet distinguish “COVID-19 from flu or from the other dozen respiratory bugs that are circulating”.
    • A Polymerase Chain Reaction (PCR) test can detect COVID-19’s RNA.  However they still don’t have confidence in the test’s specificity, ie they don’t know the rate of false negatives. 
    • The PCR test requires kits with reagents and requires clinical labs to process the kits. 
    • While the kits are becoming available, the lab capacity is not growing.  
    • The leading clinical lab firms, Quest and Labcore have capacity to process 1000 kits per day.  For the nation.
    • Expanding processing capacity takes “time, space, and equipment.”  And certification.   ie it won’t happen soon.
    • UCSF and UC Berkeley have donated their research labs to process kits.  But each has capacity to process only 20-40 kits per day.  And are not clinically certified.
    • Novel test methods are on the horizon, but not here now and won’t be at any scale to be useful for the present danger.
  • How well is society preparing for the impact?
    • Local hospitals are adding capacity as we speak.  UCSF’s Parnassus campus has erected “triage tents” in a parking lot.  They have converted a ward to “negative pressure” which is needed to contain the virus.  They are considering re-opening the shuttered Mt Zion facility.
    • If COVID-19 affected children then we would be seeing mass departures of families from cities.  But thankfully now we know that kids are not affected.
    • School closures are one the biggest societal impacts.  We need to be thoughtful before we close schools, especially elementary schools because of the knock-on effects.  If elementary kids are not in school then some hospital staff can’t come to work, which decreases hospital capacity at a time of surging demand for hospital services.  
    • Public Health systems are prepared to deal with short-term outbreaks that last for weeks, like an outbreak of meningitis.  They do not have the capacity to sustain for outbreaks that last for months.  Other solutions will have to be found.
    • What will we do to handle behavior changes that can last for months?
      • Many employees will need to make accommodations for elderly parents and those with underlying conditions and immune-suppressed.
      • Kids home due to school closures
    • Dr. DeRisi had to leave the meeting for a call with the governor’s office.  When he returned we asked what the call covered.  The epidemiological models the state is using to track and trigger action.  The state is planning at what point they will take certain actions.  ie what will trigger an order to cease any gatherings of over 1000 people.  
  • Where do you find reliable news?
    • The John Hopkins Center for Health Security site.   Which posts daily updates.  The site says you can sign up to receive a daily newsletter on COVID-19 by email.  
    • The New York Times is good on scientific accuracy.

  • Observations on China
    • Unlike during SARS, China’s scientists are publishing openly and accurately on COVID-19.  
    • While China’s early reports on incidence were clearly low, that seems to trace to their data management systems being overwhelmed, not to any bad intent.
    • Wuhan has 4.3 beds per thousand while US has 2.8 beds per thousand.  Wuhan built 2 additional hospitals in 2 weeks.  Even so, most patients were sent to gymnasiums to sleep on cots. 
    • Early on no one had info on COVID-19.  So China reacted in a way unique modern history, except in wartime.  
  • Every few years there seems another:  SARS, Ebola, MERS, H1N1, COVID-19.  Growing strains of antibiotic resistant bacteria.  Are we in the twilight of a century of medicine’s great triumph over infectious disease?
    • “We’ve been in a back and forth battle against viruses for a million years.”  
    • But it would sure help if every country would shut down their wet markets.  
    • As with many things, the worst impact of COVID-19 will likely be in the countries with the least resources, eg Africa.  See article on Wired magazine on sequencing of virus from Cambodia.

HOW CORONAVIRUS PRESENTS CLINICALLY . . . NOTES FROM THE 2020 INFECTIOUS DISEASE ASSOCIATION OF CALIFORNIA MEETING

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

I’m forwarding this important healthcare news about the most common presentation of coronavirus. It was obtained from a colleague who took notes from a meeting of the Infectious Disease Association of California dated March 7, 2020:

1. The most common presentation of COVID-19 was a one week prodrome of myaglias (muscle pain), malaise, cough, and low grade fevers gradually leading to more severe trouble breathing in the second week of illness. It is an average of 8 days to development of shortness of breath and average 9 days to onset of pneumonia/pneumonitis. This is not like influenza, which has a classically sudden onset. Fever was not very prominent in several cases. The most consistently present lab finding was lymphopenia (a low level of lymphocytes). The most consistent radiographic finding was bilateral interstitial/ground glass infiltrates on chest X-ray. Aside from that, the other markers (c-reactive protein, procalcitonin) were not as consistent.

2. Co-infection rate with other respiratory viruses like influenza or respiratory syncytial virus (RSV) is <=2%, interpret that to mean if you have a positive test for another respiratory virus, then you do not test for COVID-19. This is based on large dataset from China.

3. So far, there have been very few concurrent or subsequent bacterial infections, unlike influenza where secondary bacterial infections are common and a large source of additional morbidity and mortality.

4. Patients with underlying cardiopulmonary disease seem to progress with variable rates to Acute Respiratory Distress Syndrome (ARDS) and acute respiratory failure requiring Bilevel Positive Airway Pressure (BiPAP) then intubation. There may be a component of cardiomyopathy from direct viral infection as well. Intubation is considered “source control” equal to patient wearing a mask, greatly diminishing transmission risk. BiPAP is the opposite, and is an aerosol generating procedure and would require all going into the room to wear Powered Air-Purifying Respirators (PAPRs).

5. To date, patients with severe disease are most all (excepting those whose families didn’t sign consent) getting Remdesivir from Gilead through compassionate use. However, the expectation is that avenue for getting the drug will likely close shortly. It will be expected that patients would have to enroll in either Gilead’s randomized controlled trial (RCT) . . . (5 vs 10 days of Remdesivir) or the NIH’s “Adaptive” RCT (Remdesivir vs. placebo). Others have tried Kaletra, but didn’t seem to be much benefit.

6. If our local lab ran out of test kits we could use Quest labs to test. Their test is 24-48 hour turn-around-time. Both Quest and ordering physician would be required to notify Public Health immediately with any positive results. Ordering physician would be responsible for coordinating with the Health Department regarding isolation. Presumably, this would only affect inpatients though since we have decided not to collect specimens ordered by outpatient physicians.

7. At facilities that had significant numbers of exposed healthcare workers they did allow those with low and moderate risk exposures to return to work well before 14 days. Only healthcare workers (HCWs) with highest risk exposures were excluded for almost the full 14 days. After return to work, all wore surgical masks while at work until the 14 days period expired. All had temperature check and interview with employee health prior to start of work, also only until the end of the 14 days. Obviously, only asymptomatic individuals were allowed back.

8. Symptom onset is between 2-9 days post-exposure with median of 5 days. This is from a very large Chinese cohort.

9. Patients can shed RNA from 1-4 weeks after symptom resolution, but it is unknown if the presence of RNA equals presence of infectious virus. For now, COVID-19 patients are “cleared” of isolation once they have 2 consecutive negative RNA tests collected >24 hours apart.

10. All suggested ramping up alternatives to face-to-face visits, telemedicine, “car visits,” and telephone consultation hotlines.

11. Sutter Health and other larger hospital systems are using a variety of alternative respiratory triage at the Emergency Departments.

12. Health Departments (e.g. California Department of Public Health) state the Airborne Infection Isolation Room (AIIR) is the least important of all the suggested measures to reduce exposure. Contact and droplet isolation in a regular room is likely to be just as effective. One heavily affected hospital in the San Jose, California area is placing all “undifferentiated pneumonia” patients not meeting criteria for COVID testing in contact+droplet isolation for 2-3 days while seeing how they respond to empiric treatment and awaiting additional results.

As an internal medicine doctor and anesthesiologist, I see the information above as remarkable for several reasons:

How quickly the symptoms progress in susceptible patients from malaise and cough to respiratory failure and intubation; how difficult it may be to staff adequate numbers of nurses, physicians, and respiratory therapists if the ICU case numbers grow because these healthcare workers will be both at risk and deserving of quarantine themselves; the risk that healthcare workers will stay home because of fear, thus depleting the staff of hospitals; and the paucity of specific medical information the Centers for Disease Control and Prevention (CDC) has has chosen to release either to the medical community or to the public to date.

CORONAVIRUS AND ICU VENTILATORS

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

The question isn’t how many people in the United States will contract the coronavirus COVID-19. The key question is how many of these coronavirus cases will become extremely ill and wind up in an ICU. Authorities tell us two criteria define the threat of a virus: how quickly it can spread, and how severe or virulent the cases are.

How many of the infected patients will develop respiratory failure, and how many will require admission to an Intensive Care Unit (ICU) to be kept alive by a ventilator? To date there have been 90,000 coronavirus cases in the world and 3,000 have died, for a mortality rate of 3.33%. To date there have been 127 coronavirus cases in the United States and 9 have died, for a mortality rate of 7%. This statistic deserves an asterisk, because the denominator is likely too low. We don’t have data as to how many patients have contracted coronavirus, because testing has been limited to date.

We also have no information the numerator, the people who died. The Center for Disease Control (CDC) has released minimal information on the fatalities. For example, how many of the Kirkland, Washington deaths were elderly patients who were Do Not Resuscitate (DNR) status? That is, they were to be denied ICU treatment, ventilator support, and cardiopulmonary resuscitation (CPR) if they became seriously ill? How many of the deaths were vigorous adults who succumbed despite a full ICU effort to keep them alive?

What would the cause of these deaths be in a coronavirus-infected patient? The coronavirus is a respiratory virus which primarily infects respiratory tissues, much like the influenza virus does.  Symptoms could include sudden onset of fever, cough, headache, muscle pain, severe malaise (feeling unwell), sore throat, and a runny nose. With influenza illness may range from mild to severe and even death, but hospitalization and death occur mainly among high risk groups such as elderly patients or those with preexisting chronic illnesses.

A severe coronavirus infection would infect the lungs, and cause progressively increasing shortness of breath and dropping oxygen levels in a patient’s bloodstream. The medical treatment would be supportive, that is, a breathing tube would be placed in the patient’s windpipe (trachea) by an anesthesiologist, an ICU doctor, or an emergency room doctor, and the tube would be connected to a mechanical breathing machine, called a ventilator.

As of 2015, there were 94,837 ICU beds in the United States. Many or most of these beds are already filled by patients who need ICU support. If the new coronavirus were to become a pandemic which caused thousands or tens of thousands of cases of respiratory failure in the United States, each of these new coronavirus patients would require an ICU bed and a ventilator. This could quickly overrun our ICU capacity in America. 

That is the real scare of the coronavirus issue—the fear that our hospitals could not handle the volume of severe infections. Could temporary ICU beds be set up? Each bed would require a ventilator, a set of monitors, and around-the-clock nursing staffing. The supplies of each of these is finite. In addition, with an infectious disease such as coronavirus, each of these ICU beds would ideally be an isolation bed, which kept that patient quarantined from other patients and staff.

Can an anesthesia machine in an operating room be used as an ICU ventilator? Yes. Read more about that topic here. An operating room can be converted into an ICU room with the anesthesia machine ventilator keeping the patient alive.

In week one of the pandemic in California, I went grocery shopping at my local Safeway. The parking lot was full. When I arrived at the front door there were no shopping carts. Inside the store I saw hundreds of shoppers elbow to elbow in all the aisles. I asked an employee why the store was so busy, and she said, “This is nothing. You should have seen it yesterday—even busier!” “Why is it?” I asked. 

Her answer was two words: “The virus.”

She went on to say that customers were buying cleansing wipes, Advil, Tylenol, water, and food provisions that they could survive on for months. On my way out of the store, I saw my own primary care physician in the parking lot, and we discussed the shopping mayhem. He validated my views with the remarks, “It’s not if, but when, people will get infected. It’s just  too soon to know how many severe cases there will be.”

The Safeway customers buying Advil and Tylenol are worried. If you have a severe infection, Advil and Tylenol are not going to save you. What you would need is an intensive care bed with a ventilator, equipment to support your vital signs, and doctors and nurses to care for you 24 hours around the clock.

I hope and pray the overwhelming majority of coronavirus infections in the United States will be mild and self-limiting. A search for a vaccine and/or useful treatment drugs are underway. But because American medical systems need to be prepared, those in charge of health care administration are no doubt preparing contingency plans on how they can manage thousands of new patients in respiratory failure if needed. For more information on this topic see Stockpiling Ventilators for Influenza Pandemics.



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The most popular posts for laypeople on The Anesthesia Consultant include:
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ARE DOCTORS THE CULPRITS IN THE RISING COST OF HEALTHCARE?

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Are doctors the culprits in the rising cost of healthcare? In a word, no. 

Does this story sound familiar? Your health insurance premiums are increasing by 12% each year. You or your employer pays this amount directly to Anthem, United Healthcare, or one of the other major health insurance companies. A drawback is  your health insurance policy comes with a $5000 deductible per person insured, so that you are paying out of pocket to get the first $5000 of each family member’s medical care each year. Because of this deductible cost, you choose to utilize as little health care as possible each year.

The result of this scenario? The insurance company wins in two ways:

1) The insurance company is collecting all time high premiums

2) You and the rest of the insured population are utilizing your insurance less, and choosing less health care visits and procedures because you have to pay cash for the initial expenses. 

Health insurance companies are primary culprits in the rising costs of healthcare.

I’m writing this from the viewpoint of a father who pays for the health insurance for a family of four. I currently pay $2000/month, or $24,000/year, for my group’s Anthem PPO (Preferred provider organization) coverage. My family’s in-network deductible is $5000/person, and our out-of-network deductible is $10,000/person. With this $5000 deductible per person, I may pay $20,000 in deductible payments before I gain any significant insurance coverage. If my family remains healthy, we are paying deductibles all year and gaining very little coverage for our insurance dollars. Our insurance is, in essence, catastrophic coverage in case we incur a major illness. 

I’m also writing this from the viewpoint of a working MD who sees declining payment and increasing difficulty contracting with these same healthcare organizations as a provider. 

The majority of health insurance companies are for-profit, and they are making record profits at this time. Forbes magazine reported that the health insurance industry “is enjoying a Golden Age of growth, sales and profits. ”

The top eight for-profit health insurance companies and their revenue for 2018, as reported by Forbes and Becker’s Hospital Review are listed below:

1. UnitedHealth Group
Membership: 49.5 million 
Revenue: $201 billion 

2. Anthem
Membership: 40.2 million
Revenue: $90 billion 

3. Aetna
Membership: 22.2 million 
Revenue: $60.6 billion

4. Cigna
Membership: 15.9 million
Revenue: $41.6 billion 

5. Humana
Membership: 14 million
Revenue: $53.7 billion

6. Centene
Membership: 12.2 million 
Revenue: $48.3 billion

7. Molina Healthcare
Membership: 4.4 million 
Revenue: $18.8 billion 

8. WellCare Health Plans 
Membership: 4.37 million
Revenue: $16.9 billion

The five largest health insurance or pharmacy benefit management (PBM) companies (Anthem, Cigna, CVS Health, Humana and UnitedHealth Group) in the United States collect revenues as large as the five dominant tech companies (Facebook, Amazon, Apple, Netflix and Google). 

Data: Company filings and FactSet; Chart: Naema Ahmed/Axios

  Data: Company filings and FactSet; Chart: Naema Ahmed/ 

These five health insurance/pharmacy companies had revenue of almost $787 billion in 2019, compared with $783 billion of projected revenue for the five largest tech companies. (Note: health insurers and pharmacy benefit managers pay much of their revenues to hospitals, doctors and drug companies, but these five companies are still recording billions in profit.) TheBest’s Market Segment Report stated that “through third-quarter 2018, health insurers’ net income grew by 19% to $25.8 billion compared with the same prior-year period.”

Los Angeles Times article said, “The truth is that private health insurers have contributed nothing of value to the American healthcare system. Instead, they have raised costs and created an entitled class of administrators and executives who are fighting for their livelihoods, using customers’ premium dollars to do so.”  The same article quoted Wendell Porter who said, “Health insurers have been successful at two things: making money and getting the American public to believe they’re essential.” 

The article went on to say, “The most perplexing aspect of our current debate over healthcare and health coverage is the notion that Americans love their health insurance companies. The increasingly prevalent mode of health coverage in the group and individual markets is the narrow network, which shrinks the roster of doctors and hospitals available to enrollees without heavy surcharges.  . . . Private insurers don’t do nearly as well as Medicare in holding down costs, in part because the more they pay hospitals and doctors, the more they can charge in premiums and the more money flows to their bottom lines. They haven’t shown notable skill in managing chronic diseases or bringing pro-consumer innovations to the table. . . . In reality, Americans don’t like their private health insurance so much as blindly tolerate it. That’s because the vast majority of Americans don’t have a complex interaction with the healthcare system in any given year, and most never will. As we’ve reported before, 1% of patients account for more than one-fifth of all medical spending and 10% account for two-thirds. Fifty percent of patients account for only 3% of all spending.”

(Image source: NIHCM)

Why do Americans want to keep their present healthcare insurers? Because the vast majority of Americans have very little need for medical care in any given year. That’s why most people are satisfied with their coverage. 

When will we see new models for private health insurance? The joint venture of Amazon, Berkshire Hathaway and JPMorgan Chase hired Harvard’s Atul Gawande MD, MPH as their CEO of their medical partnership. Many believe this organization will attempt to contract directly with major health systems, thereby bypassing traditional health insurance companies, in a quest to bring down costs. 

What can Congress do? What if they stipulate that health insurers pay out, for example, 97% of the premiums they collect? This concept, called a “medical loss ratio,” was part of the Affordable Care Act for plans sold on the federal health exchange to people under the age of 65. The Senior Citizens League webpage said, “The medical loss ratio sounds good in theory, but can contribute to rising healthcare costs due to ‘perverse incentives.’ . . If the insurance company has accurately built high costs into the premium, it can make more money.  Here’s how:  Let’s say administrative expenses eat up about 17 percent of each premium dollar and around 3 percent is profit.  Making a 3 percent profit is better if the company spends more.  It’s as if a mom told her son he could have 3 percent of a bowl of ice cream.  A clever child would say, ‘Make it a bigger bowl.’”

I’m not a socialist. I don’t support Medicare-for-all.  I’ve always believed capitalism and free enterprise would solve most economic problems. The current monopolies of health care insurance by a small number of for-profit health insurers is hardly a free market. There is inadequate competition against the Big 8 for-profit insurers, all of whom charge high premiums and bank massive profits. Health insurance companies are well represented in Washington D.C. Healthcare companies spent $3.9 billion dollars lobbying over the past 20 years.  

I encourage voters to pay careful attention to the issue of health insurance profits, and to pay careful attention to where presidential hopefuls and Congressional candidates stand on the issue. If politicians seem to be mouthpieces for the big business of health insurance industry, don’t vote for them. If they are advocates for change that help Americans gain affordable healthcare, I encourage you to vote for them.

As a physician, I’m particularly critical of the argument that doctors are causing the rising healthcare costs in American. The United States has the most expensive healthcare delivery system in the world, and it’s not because doctors make too much money. The administration of each healthcare dollar includes a syphoning off of huge profits by the insurance industry. A fine column by former President of the California Society of Anesthesiologists and UCLA professor Karen Sibert MD cites sources that physician are a mere 8% of America’s healthcare bill.  

Some journalists criticize physicians as an overpaid contingent who are inflating the cost of healthcare in America. Doctors are an essential profession in America. Physicians are suffering from high incidences of student debt, burnout, and premature retirement. As Karen Sibert MD wrote in another excellent column, “Keep up the insults, and good luck finding a physician in 10 years.”

Be informed and wary about the rising cost of health insurance and rising profits of the health insurance industry.

And I hope you stay healthy and don’t need to utilize your health insurance this year. 



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The most popular posts for laypeople on The Anesthesia Consultant include:
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ROBOTIC ANESTHESIA REALLY IS COMING

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

The February 2020 edition of Anesthesiology, our specialty’s preeminent journal, published an article on robotic anesthesia.1

The accompanying editorial by Dr. Thomas Hemmerling was titled “Robots Will Perform Anesthesia in the Near Future.2 The author wrote: 

I have no doubt that closed-loop (i.e. robotic) anesthesia is at least as good as the best human anesthesia. And that, for me, would be good enough to use it every day.”

The primary study by Joosten1 looked at the performance of multiple closed-loop systems for administration of anesthesia in 90 patients undergoing major noncardiac surgery in a single center in Belgium. The conclusion of the study was that the automated system outperformed manual control, as there was minimal but significantly better cognitive function in the patients one week after surgery when the closed loop control was used. 

A BIS monitor

The depth of anesthesia was measured using a BIS (bispectral index) monitor. A BIS electrode was applied to each patient’s forehead and temporal regions to capture the frontal electroencephalogram (EEG) from the brain. 

three Base Primea infusion pumps

In the closed-loop (automated, or robotic) group, two infusion pumps were used to deliver target-controlled intravenous infusions of the hypnotic drug propofol and the narcotic remifentanil, in order to maintain BIS values between 40 and 60. BIS values between 40 and 60 have been shown to correlate with adequate anesthesia depth.

In his editorial, Dr. Hemmerling wrote:

“Robotic anesthesia, defined as anesthesia delivered by an automated control system, will soon be available. It is my opinion that closed loop devices will become available in the United States . . .  

One of the changes our profession has gone through is an ever-increasing demand to multitask, be it by running more than one operating room, or by simultaneously performing administrative or teaching tasks. In addition, the number of parameters to monitor has also increased. It is therefore not surprising that one of the common denominators of studies comparing closed loop control versus manual control is the finding that humans change a given target infusion rate far less frequently than closed loop devices do.

I have no doubt that the practice of running more than one operating room, common in the United States but less so elsewhere, will soon be an international standard. Closed loop devices will allow us to maintain a high standard of quality independent from the amount of physical presence.

Robotic anesthesia delivered in Washington by Dr. Smith would essentially be the same as robotic anesthesia performed in Chicago by Dr. Miller. . . . 

I think technology will advance similar to what we have seen and see in the car manufacturing industry. First, there was manual transmission, then automatic transmission, double clutch systems, navigation systems, all sorts of safety assist systems…soon, there will be self-driving cars.

How will we do anesthesia in the future? It is 2030 and I am scheduled to supervise anesthesia for a 40-yr-old patient undergoing laparoscopic cholecystectomy.

In the operating room, I tell my robot—let’s call it A-bot—about the surgery, the patient, and the type of anesthesia I would like performed. “Can I get a propofol, remifentanil-based anesthesia? Can we target 45 as a Bispectral Index? A-bot, can you maintain mean arterial pressure around 65? Can you maintain cardiac index during surgery of more than 2.5 l · min–1 · m–2? A-bot, I would like to use rocuronium, bolus application is good enough, but please keep neuromuscular blockade lower than 25% at all times. Please choose a respiratory rate of 12 and adjust tidal volumes to maintain end-tidal carbon dioxide of 32 mmHg in 50% air! Let’s provide preemptive analgesia using morphine and ketorolac—usual dosages, A-bot, you know.”

A-bot answers: “Sure will, Tom—you keep me informed about surgical progress?”

“Yep.”

When I look at all the literature, including the fine work by Joosten et al.,1  I have no doubt that closed loop anesthesia is at least as good as the best human anesthesia. And that, for me, would be good enough to use it every day.”2

In 2019 I wrote an editorial that robotic anesthesia was coming.3 And as I wrote the novel Doctor Vita 4 over a 15-year span from 2004-2019, I became more and more convinced of the role technology will play, for better or for worse, in replacing the human element in patient care. The premise of the novel is valid.

Will artificial intelligence in medicine provide the world with healthcare workers who work simply by plugging them in? Will some form of Doctor Vita populate future operating rooms?

An editor in the world’s leading anesthesia journal has predicted it. 

References:

  1. Joosten, A, Rinehart, J, et al. Anesthetic management using multiple closed-loop systems and delayed neurocognitive recovery: A randomized controlled trial. Anesthesiology. 2020; 132:253–66.
  2. Hemmerling TM. Robots will perform anesthesia in the near future. Anesthesiology 2020: 132:219-220.
  3. Novak R. “Artificial Intelligence in Anesthesia and Perioperative Medicine is Coming.” EC Anaesthesia 5.5 (2019): 112- 114. 
  4. Novak R. Doctor Vita. All Things That Matter Press, 2019.




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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
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Will I Be Nauseated After General Anesthesia?
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
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CANNABIS AND ANESTHESIA

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

You use cannabis products. 

You’re about to have an anesthetic. 

Should you tell your anesthesiologist or not? Read on . . . 

PREVALENCE OF MARIJUANA USAGE

Cannabis, or marijuana, is used by approximately 2.7-4.9% of the world’s population, making it the most widely used illicit drug on Earth. Cannabis is also one of the most widely used drugs in the United States, where an estimated 22 million people over the age of 12 use cannabis products each year. 

SCHEDULE 1 DRUG 

Fifty years ago, in 1970, the Drug Enforcement Agency (DEA) regulated all cannabis products in the United States to Schedule 1 classification. Schedule 1 drugs have no accepted medical use and have a high potential for abuse. Other Schedule I drugs include heroin, LSD, mescaline, psilocybin, and ecstasy.  This classification of cannabis as a Schedule I drug made it impossible for American-based researchers to conduct research studies on cannabis products on humans. Typically a new medication must clear specific hurdles with the DEA before it is approved for public usage. At present the recreational use of marijuana is legal in 11 states: Alaska, California, Colorado, Illinois, Maine, Massachusetts, Michigan, Nevada, Oregon, Vermont and Washington, and also in Washington, D.C.

A problem exists because cannabis is categorized as an abuse drug that was not able to be studied, and has now been legalized without appropriate research. The physiology and pharmacology of cannabis in humans is also difficult to study because a) there are many different cannabinoids present in marijuana products, each with variable effects, and b) the drug can be either inhaled or ingested orally. If the DEA eventually removes cannabis from the DEA Schedule I list, then scientific prospective clinical trials can be done to better evaluate the implications of cannabis use.

WHAT WE DO KNOW

The most potent psychoactive product in the marijuana plant is delta-9-tetrahydrocannabinol, or THC.

THC is found in the flowering buds of the plant, and to a lesser degree in the leaves, stems, and seeds. The half-life of THC in the body is 5-13 days. Modern cultivation improvements have increased the THC content of cannabis. The average marijuana cigarette in the 1970s contained 1 – 3% THC, the average marijuana cigarette in the 1990s contained 6 – 20% THC, and some currently available strains have up to 33% THCButane hash oil extracts may have a THC concentrations as high as 90%.  The effects of cannabis are difficult to predict because the THC concentration in any delivered dose depends on both the THC concentration of the product, and the route of delivery.

CBD, short for cannabidiol, is a product marketed for antianxiety and chronic pain problems. CBD is not psychoactive, meaning it doesn’t have a strong effect on cognitive brain activity and doesn’t cause the central nervous system high associated with THC. Like all cannabis products, CBD is still classified as a Schedule 1 drug by the DEA. To date I’m unaware of any data that CBD interacts with anesthetics in any important way. 

ACUTE AND CHRONIC EFFECTS OF CANNABIS

To an anesthesiologist, a patient’s three most important physiologic systems are the brain, the heart, and the lungs. These are also the systems most effected by cannabis. Inhaled cannabinoids are rapidly distributed within the vessel-rich group of organs in the human body (the brain, lungs, heart, kidney, and liver), and effects are seen within seconds to minutes after an inhaled dose. The effects of orally ingested cannabinoids may be delayed up to 1 to 2 hours. 

CENTRAL NERVOUS SYSTEM/BRAIN

The most well known effects of marijuana involve the central nervous system, and include euphoria, sedation, and relaxation. Adverse side effects include apathy and lack of motivation.  Some users report reduced anxiety with cannabis use, but there are reports of worsened anxiety leading to paranoia or psychosis with cannabis use.There have also been case reports of acute psychosis after rapid ingestion of high doses of oral THC. Due to the central nervous system effects of cannabis, marijuana use has been implicated in motor vehicle accidents. Studies have shown a dose-dependent effect of acute cannabis administration on slowing the reaction time of drivers, and causing them to weave between traffic lanes. This is worsened by co-administration of marijuana with ethanol.These marijuana-plus-or-minus alcohol users may present to anesthesiologists for emergency surgical procedures related to traffic accidents. 

CARDIAC

The acute cardiac effects of cannabis administration include rapid heart rates (tachycardia) and the peripheral dilation of blood vessels, which causes low blood pressure.  A study showed that tobacco smokers with stable angina who never smoked cannabis developed angina with exercise significantly faster after smoking cannabis.  A second study showed a 5-fold increased risk of a heart attack (myocardial infarction or MI) in the first hour following cannabis smoking, compared to a 24-fold increased risk of MI in the hour following cocaine ingestion. The elevated risk of heart attack in cannabis users is thought to be due to a combination of the increased heart rate, the lower blood pressure, and the increase in cardiac work.  In the United States, cannabis use disorder has not been associated with any change in overall perioperative morbidity, mortality, length of hospital stay or costs, but cannabis use disorder is associated with an increased risk of postoperative myocardial infarction

LUNGS

Studies show bronchodilation and decreased airway resistance with either inhaled or ingested THC, but marijuana smoking can also result in airway hyperreactivity similar to that seen with tobacco smoking. Marijuana can be more irritating to airways because it burns at a higher temperature than tobacco. Cannabis is commonly smoked in hand-rolled and unfiltered cigarettes, or “joints,” introducing high concentrations of carcinogenic chemicals and irritants into the airways and lungs. Vaping cannabis oil promotes the inhalation of respiratory carcinogens and irritant compounds which can cause lung injury. Characteristics of cannabis smoking such as prolonged and deep inhalation, a shorter joint butt, and the higher combustion temperature, may result in greater carboxyhemoglobin  levels and tar retention in the airways. The chronic effects of inhaled marijuana include cough, bronchitis, and emphysema similar to those seen in chronic tobacco smokers.

WITHDRAWAL SYNDROME

The cannabis withdrawal syndrome is validated as a clinical entity in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as well as in the International Classification of Diseases (ICD) systems. Cannabis withdrawal syndrome can develop within a day after stopping high-dose chronic cannabis use. The symptoms include irritability, aggression, anxiety, insomnia, disturbed dreams, depressed mood, weight loss, abdominal cramping, sweating, fevers and chills.  

BEFORE SURGERY

In every cannabis using patient, the anesthesia preoperative evaluation should include assessment of the psychologic, cardiac, and pulmonary systems in order to minimize any risk of a perioperative complication. 

It’s important for the anesthesiologist to know the duration, frequency, and route of their patient’s cannabis use, as well as the time of most recent intake. Anesthesiologists should seek to identify patients as new or chronic cannabis users. If a patient exhibits any central nervous symptoms of acute cannabis intoxication, it’s important to assess the patient for symptoms of escalating anxiety, paranoia, or psychosis, as these symptoms may predict a violent emergence from anesthesia. The current lab testing methods assaying for plasma or urine cannabis levels do not provide effective quantitative data on cannabis intoxication. The history and physical examination by a physician are more important than a toxicology screen. Drug screening for cannabis is not currently a standard of care in preoperative medical evaluation.

Prior to urgent anesthetics on a patient with acute cannabis intoxication, the anesthesiologist will 1) consider delaying the induction of anesthetic induction until the resolution of tachycardia and/or low blood pressure, and 2) conduct a preoperative evaluation for chronic marijuana smokers similar to that used for chronic tobacco smokers. This includes questioning the patient regarding exercise tolerance, shortness of breath, chest pain, and listening to the lungs for evidence of chronic bronchitis or emphysema. 

ANESTHESIOLOGIST CONCERNS 

When attending to a cannabis user, the anesthesiologist must be aware that:  a) cannabis consumers may have an increased tolerance to anesthetics,  b) cannabis consumers have an unknown cross-tolerance to the anesthetic agents, c) cannabis consumers have an increased risk of myocardial infarction (MI or heart attack) within one hour after use, and d) cannabis consumers may have increased airway reactivity (i.e. wheezing, coughing, shortness of breath, or asthma symptoms).

In a prospective, randomized, single-blinded study, thirty male patients using cannabis more than once per week and 30 nonusers aged 18-50 years had anesthesia induced with propofol. The dose of propofol required for successful placement of a laryngeal mask airway (LMA) tube was significantly higher in the cannabis group than in nonusers

Researchers studied 27 patients undergoing elective orthopedic surgery who were randomly allocated to high dose cannabis (6 patients), low dose cannabis (8 patients), active placebo (6 patients) and placebo (7 patients). The cannabis drugs were administered 20 minutes before induction of general anesthesia in a double-blind fashion. During inhaled anesthesia, the researchers examined the patient’s bispectral index (BIS index, i.e. an intraoperative brain EEG level that measures depth of  general anesthesia). The average BIS values were significantly higher (i.e. the patients were not as deeply anesthetized) in the high dose cannabis treatment group. The researchers concluded that for cannabis consuming patients, one cannot rely on the EEG-BIS monitoring for the purpose of determining the patient’s anesthetic depth. An inference from this data is that cannabis patients were more tolerant of maintenance inhaled general anesthesia doses than non-cannabis users.

Because cannaboids are Schedule I drugs, and the effects of cannabis have been more thoroughly studied in animals. Studies in mice and rats showed cannabinoid-induced analgesic tolerance to morphine. There have been no similar studies in humans published to date. 

POSTOP:  INCREASED PAIN AND POSSIBLE WITHDRAWAL SYNDROME:

Following surgery, cannabis users report higher pain scores, worse sleep, and require more narcotics than non-cannabis users.  In Jamaica, a prospective randomized study was carried out on 73 patients who underwent elective surgery. There were 42 cannabis users and 31 non-users. The cannabis users required significantly higher supplemental Demerol (meperidine) doses after surgery.  (J Psychoactive Drugs. 2013 Jul-Aug;45(3):227-32)

As discussed previously, after surgery physicians should remain vigilant to cannabis withdrawal symptoms in chronic cannabis users.

AS THE PATIENT, WHAT SHOULD YOU DO?

If you are the patient, when you present for surgery and anesthesia, will the nurses and doctors specifically ask you if you use cannabis or marijuana? Perhaps not. Current routine preoperative evaluation usually includes the question “Do you use any street drugs?” Nearly 100% of patients answer “No.” As discussed above, 22 million people in the U.S. use cannabis, yet very few will admit this on a preoperative questionnaire. Why? I believe most people do not want to be identified as using a drug which is still deemed illegal by the federal government. Most people do not want “marijuana user” to be part of their medical history problem list. They may fear the moniker of “marijuana user” following them onto some digital database, damning them in future insurance applications or legal actions. I believe most people do not believe identifying themselves as cannabis users makes any difference to their doctors and nurses. Per the discussions above, there are important reasons for an anesthesiologist to know if you use cannabis. But if you are a cannabis user, will you reveal the truth?

Cannabis is currently legal and commonly used in multiple states in America. The drug has specific effects on the brain, heart, and lungs which can affect your health during or after an anesthetic. 

For your own welfare, be honest and discuss your cannabis use with your anesthesiologist prior to surgery. 



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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
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Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
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ROBOT SURGERY . . . A VIEW FROM THE ANESTHESIOLOGY COCKPIT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
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Almost every anesthesiologist in America has experience with surgery using the da Vinci robot system. Is robot surgery a miraculous futuristic device that advances surgery to a higher plain? Or is it an expensive gadget for hospitals and surgeons to market and attract potential patients?

To answer these questions let’s first review some history. Until the 1990s most abdominal surgery was done through an open incision. To remove a gall bladder or an appendix, the surgeon made an incision into the abdomen, inserted his hands and instruments, cut out the tissue under direct vision, and then sewed the abdomen together again. A gall bladder incision might be five inches long. An appendix incision might be 2½ inches long. The surgical times were short—a private practice surgeon could complete an open gall bladder surgery in 30 – 40 minutes, or an open appendectomy in 20 – 25 minutes. A disadvantage was that the patient had pain from the incision, and the recovery time was days to weeks before the patient could return to normal activities.

Laparoscopy

Enter laparoscopy, a true major advance in surgery. The first video laparoscopic gall bladder resection (cholecystectomy)  was performed in 1987. A quantum advance occurred in the 1990s when video laparoscopic surgery became widespread. Laparoscopy required only small incisions in the abdomen, through which slender instruments were inserted. The interior of the abdomen was insufflated (blown up like a balloon) and one of the slender instruments held a camera. The image of the inside of the abdomen was visualized on a video screen while the surgeon manipulated instruments seen on that two-dimensional view. My colleague and Stanford clinical faculty member Camran Nezhat, the author of multiple textbooks on the topic, was a leading pioneer in the development of video laparoscopy. Laparoscopic surgery took longer than open surgery—a laparoscopic gall bladder or laparoscopic appendectomy usually lasted about twice as long as an open surgery—but the significant advantage was the lack of a painful open incision, which led to significantly less postoperative pain and a shorter postoperative recovery time. Many patients could be discharged the same day as their surgery, and most returned to normal activities sooner than if they had open surgery.  Video laparoscopy surgical equipment and the longer operating times were increased expenses, but the advantages of outpatient surgery and quicker recovery made the new technique the standard of care for many surgeries within the abdomen.

Anesthesia for laparoscopy was similar to the anesthetic for open abdominal surgery. Patients were asleep and paralyzed, and their breathing is done by a ventilator. The laparoscopy patient had a tense abdomen—it was essentially a balloon full of carbon dioxide—that usually required smaller volume breaths from the ventilator, but in most ways the two anesthetics were alike. 

da Vinci robot

Using the da Vinci robot for abdominal surg