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?
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
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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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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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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:
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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
phone 650-465-5997

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 surgery is an extension of laparoscopic techniques, but the instruments are connected to robot arms rather than held by surgeons. The da Vinci surgeon sits at a console in the corner of the operating room, with his back to the patient and his face in a 3-D viewer, which gives a high-definition, magnified view of the surgical site. Assistant surgeon(s) and techs stand at the patient’s side, watch the surgery on video screens, and assist during the operation. The surgeon manipulates handles on the da Vinci device, which move the instruments within the patient’s body. The three-dimensional view within the abdomen is superior to a two-dimensional view on a video screen. I’ve personally had the opportunity to look through the 3-D viewer into the abdomen, and it’s a remarkable phenomenon. It’s as if you were a microscopic insect inside the patient, and looking around at the intestines, liver, arteries and veins that surround you. Another touted advantage of the robot is the ability for the surgeon to make precise movements via the robot’s mechanism. 

surgeon (at left) with his back to the operating room table and patient

The non-profit SRI (Stanford Research Institute) developed the early da Vinci system in the late 1980s with funding from the National Institutes of Health. The system was thought to have promise in allowing surgeons to operate remotely on surgeons wounded on battlefields. (When you read on you’ll realize how improbable this application would be.) 

In the 1990s, John Freund negotiated an option to acquire SRI’s intellectual property, and started a company named Intuitive Surgical Devices, Inc. The company’s prototype was ready for clinical testing in 1997. In 2000 the Federal Drug Administration (FDA) approved use of the da Vinci Surgical System for laparoscopic surgery, and Intuitive raised $46 million in an initial public offering. One year later the FDA approved use of the system for prostate surgery. In subsequent years the FDA approved the system for thoracoscopic surgery, cardiac procedures, and gynecologic procedures.

The da Vinci Surgical System spread slowly at first. Sixty hospitals in the United States used the system in 2002, but this number grew to 431 hospitals by 2014. Approximately 1,500 United States  hospitals now have the da Vinci Surgical System, according to Modern Healthcare. The system costs approximately $2 million, and there are costs for maintenance and for the non-reusable instruments held by the arms during surgery. A robotic surgery generally costs anywhere from $3,000 to $6,000 more than traditional laparoscopic surgery.  In 2016 Healthline wrote, “To justify its price — roughly 10 times that of a traditional laparoscopic surgery — da Vinci would need to do a lot better overall.” 

For abdominal surgery, use of the robot is as follows: The assembled robot is draped in sterile plastic and positioned distant to the patient, while the anesthesiologist induces general anesthesia and inserts an endotracheal breathing tube into the patient’s windpipe. The circulating nurse then preps the patient’s abdomen with antiseptic solution and the scrub tech surrounds the patient’s abdomen with sterile drapes. The surgeons insert a trocar to inflate the abdomen with carbon dioxide gas, and then make the incisions required for the insertion of the instruments into the patient’s body. When the robot is finally moved in over the patient and the instruments are connected to the robot arms, the anesthesiologist has limited access to the patient’s head, neck, and chest, due to the size, breadth and girth of the robot. The anesthesiologist’s station is within 4 – 6 feet of the patient’s head. At least one surgical assistant and one scrub tech stand at the patient’s side throughout the surgery. At a university teaching hospital, this number could be significantly greater. 

anesthesiologist (at right) during robotic surgery

The anesthetic for robotic abdominal surgery is no different than the technique for laparoscopy, except for one important feature. Robotic surgeries take longer than the same surgery done via traditional laparoscopy—a fact that makes most robotic procedures tedious for anesthesia personnel. Robot surgeries take up more of an operating room’s most precious resource—time. Hospital operating room resources—nurses, techs, orderlies, and administrative staff—are paid by the hour. Longer surgeries mean longer staffing hours and greater expense.

Do anesthesiologists prefer, enjoy, or feel challenged by these robotic surgery cases? In a word—no. There is little that is unique or challenging after one has done a few of these cases. In general anesthesiologists prefer surgery that is fast, efficient, safe, and effective.

1248 papers on “robot surgery” in 2019 to date

What does the world’s medical literature have to say about robotic surgery? When I entered the keywords “robot surgery, 2019” into the Pubmed search engine today, I discovered 1,248 papers published on robot surgery in the first 11 months of 2019. This is an exceptionally large number of publications. Robot surgery is a hot topic in the community of academic surgery. Multiple surgical specialties, including general, gynecology, cardiac, thoracic, cancer, and head and neck surgeons, are writing about their experiences with the da Vinci robot. You’ll find individual case reports, series of cases, meta-analyses, and comparison of current outcomes/complications to historical controls. 

Pertinent studies include the following:

Gall bladder surgery: In a 2019 study in the American Journal of Surgery, a national databank review of gall bladder resections (cholecystectomy) showed that the direct cost of robotic cholecystectomy was significantly higher than laparoscopic cholecystectomy, with no added benefit. The conclusion of the study was that “routine use of the robotic platform for cholecystectomy should be discouraged until costs are reduced.” 

Prostatectomy: A randomized controlled trial compared robotic surgery with open surgery for patients with localized prostate cancer, and showed that both robotic and open surgery achieved similar results in terms of key quality of life indicators at three months. 

Kidney surgery: A study published in the Journal of the American Medical Association (JAMA) showed the percentage of radical nephrectomies using the robot increased from 1.5% in 2003 to 27.0% in 2015. There were no significant differences between robot-assisted vs laparoscopic radical nephrectomy in major postoperative complications. The robot-assisted procedures had both longer operating times and higher direct hospital costs. 

Gynecology: The mortality in benign minimally invasive gynecologic surgery was low, and the mortality for laparoscopic vs robotic approaches was similar. 

Rectal surgery: JAMA publication showed that for patients with rectal carcinoma, robot-assisted laparoscopic surgery did not significantly reduce the risk of conversion to open laparotomy, when compared with conventional laparoscopic surgery. These findings suggested that robot-assisted laparoscopic surgery did not confer an advantage in rectal cancer resection. 

What will be the future direction of robotic surgery? Currently Intuitive Surgical and the da Vinci Surgical System have a monopoly. No other company has any significant market share. In 2017 Intuitive Surgical had $3.12 billion in total revenue, with a net income of $660 million. Their stock price is currently $549/share, up 300% from $178/share in January of 2016. The volume of robotic surgeries continues despite a paucity of published data that robotic surgery is any better. The cost of these procedures is high, and most hospitals are losing money on robot cases. Hospital executives seem to see the robot as a loss leader. No administrator wants to lead an old-fashioned hospital that doesn’t have a robot, while their competitor hospital across town is advertising robotic surgery on the side of buses traveling down Main Street.

Robotic surgery is a technology looking for a reason to exist, and a solution looking for a problem. Robotic surgery is not nearly the advance that laparoscopy was. Technology is pervasive and is changing healthcare. Enter any hospital today and you’ll see doctors and nurses peering into computer screens. They are pointing, clicking, entering information, and typing in findings on their patients. Where are the patients? Often they’re looking at the backs of these same doctors and nurses who are sitting at the computer terminals. Medicine, as I was taught in the 20th Century, was a profession dedicated to caring for and healing people. Modern medicine is increasingly pushing the hands of doctors and nurses toward keyboards and gadgets.

a doctor charting on electronic medical records
a da Vinci surgeon at work

The surgeon with his face in a robot console’s 3-D viewer, while his back is to his patient, is a powerful metaphor for the technologic trend in medical care. I believe patients want to see our faces, and we need to look into their eyes. I doubt that great American physicians from our past—William Osler, Harvey Cushing, the Mayo Brothers, or Norm Shumway—would be fans of robotic surgery.


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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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ANESTHESIOLOGISTS, DON’T BE AFRAID TO CUT INTO A PATIENT’S NECK

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. You’ve lost the airway on your obese anesthetized gynecology patient, your multiple attempts to intubate the trachea have failed, you cannot mask ventilate the patient, and insertion of a laryngeal mask airway did not help. Your patient’s skin and lips are purple and you are terrified. What do you do?

  1. Call a surgeon stat to do a tracheostomy
  2. Ask the gynecologist to cut an airway into the patient’s neck
  3. Keep trying to intubate the trachea yourself
  4. Insert a needle into the cricothyroid membrane, and begin jet ventilation
  5. Cut an airway into the neck yourself.

A study in the October 2019 issue of Anesthesiology showed that when a “can’t intubate, can’t oxygenate” crisis occurred, there were delays finding someone prepared to cut a surgical airway into the front of the neck in time to save the patient’s life. The study looked at malpractice closed claims and found: 1) Outcomes remained poor in malpractice closed claims related to difficult tracheal intubation; 2) The incidence of brain damage or death at induction of anesthesia was 5.5 times greater in the years 2000 – 2012 than in the years 1993 – 1999; 3) Inadequate planning and judgement errors contributed to the bad outcomes; and 4) Delays in placing a surgical airway during “can’t intubate, can’t oxygenate” emergencies were a major issue.

A closed claims study is akin to a large mortality and morbidity (M & M) conference. A closed claims study tells us which complications led to malpractice settlements. Each malpractice closed claim marks a negligent practice which caused an adverse outcome.

I’d like to focus on one specific aspect of this important study: anesthesiologists need to lose their reluctance to cut a surgical airway into a patient’s neck in a “can’t intubate, can’t oxygenate” airway emergency. A surgical airway is an invasive airway via the front of the patient’s neck into their trachea. Waiting for a surgeon to cut a surgical airway, or fearing to cut a surgical airway yourself, could cost your patient his or her life. Delay or failure in placing a surgical airway was described in 10 of the specific 12 cases listed in the Appendix of this Anesthesiology closed claims study, as follows:

Case 1: “Eventually a surgical airway was performed after the patient arrested.”

Case 2: “A surgical airway was performed after the patient arrested.”

Case 3: “The surgeon was called to the room to perform an emergency surgical airway, but there were not any instruments available in the room. The patient sustained anoxic brain injury and later died.”

Case 4: “Ventilation was difficult and the patient arrested. The surgeon arrived and attempted to perform an emergency surgical airway, at which time the anesthesiologist successfully intubated the patient’s trachea as the hematoma was drained. The patient was resuscitated but later died of anoxic brain damage.”

Case 5: “The anesthesiologist asked the surgeon to perform an emergency cricothyrotomy. However, the surgeon insisted that an electrocautery to be set up first. Nine minutes after cardiac arrest, a surgical airway was secured by the surgeon. The patient was resuscitated but remained in a persistent vegetative state.”

Case 6: “An ear-nose-throat surgeon was called to perform a surgical airway, who suggested a supraglottic airway be inserted instead. After the supraglottic airway was placed, the patient became impossible to ventilate and went into cardiac arrest. The surgical airway was placed with some difficulty. The patient sustained severe hypoxic brain and died.”

Case 8: “The surgeon performed a cricothyrotomy after the patient had marked bradycardia and hypotension.”

Case 10: “A surgeon was called to place a cricothyrotomy. The patient was resuscitated but had severe anoxic brain damage and died.”

Case 11: “Multiple intubation attempts and supraglottic airway insertion were made for more than an hour before a surgical airway was performed. At that time, the patient was asystolic and had a tension pneumothorax. The patient died.”

Case 12: “The patient had a hypoxic cardiac arrest. The surgeon arrived 22 min after induction and secured an emergency surgical airway. The patient was resuscitated but sustained hypoxic brain damage requiring assistance with activities of daily living.”

It’s tragic that 10 of the 12 listed cases involved delayed or failed front of neck access to the airway. In an editorial in the same issue of Anesthesiology, authors Takashi and Hillman wrote, “Decision to provide a surgical airway was frequently delayed by repeated attempts at tracheal intubation, anesthesia care providers being hesitant to initiate surgical procedures, or surgeons being reluctant to perform tracheostomy or simply not available.”

The American Society of Anesthesiologists Difficult Airway Algorithm, shown below, clearly describes invasive airway (i.e. surgical airway) access via the front of the neck when attempts to intubate the trachea and oxygenate the patient both fail.

“Can’t intubate, can’t oxygenate” events are rare, but they do occur with a published incidence of 1 in 50,000 anesthetics, per the fourth national audit project in the United Kingdom.  

The brain can be permanently damaged following episodes in which the brain sees no oxygen for five minutes or longer.

Approaches to front of neck access include either cannula techniques or surgical techniques, with significant differences:

Cannula Technique:

This involves inserting a large bore IV catheter through the cricothyroid membrane.

Because the lumen of a 14-gauge IV catheter is small, ventilation requires a high-pressure jet oxygen delivery system. In a publication from 2016, the failure rate with cannula techniques was 42% in “can’t intubate, can’t oxygenate” emergencies. Failure can occur because of kinking, malposition, or displacement of the needle/cannula. Because of the high failure rates, use of the cannula technique is discouraged.

Surgical Technique:

Most surgeons are trained to perform tracheostomies during their residencies, but when a “can’t intubate, can’t oxygenate” emergency occurs, tracheostomy is not the preferred procedure.

Tracheostomy – tube is inserted between tracheal rings

  Cricothyroidotomy, a technique which is faster and requires less surgical skill, can be performed by anesthesiologists, and is the preferred procedure.

In a cricothyroidotomy, the cricothyroid membrane is divided by a surgical incision made with a wide scalpel (#10 scalpel).

a cricothyrotomy is inserted in the cricothyroid space, cephalic to the trachea

Using the scalpel, bougie, tube (SBT) technique,

a bougie is inserted into the trachea through the incision. A lubricated 6.0 mm cuffed endotracheal tube is advanced over the bougie into the trachea, and the bougie is removed as demonstrated in this video link: 

This technique has been specifically endorsed in the United Kingdom in the algorithm from their Difficult Airway Society.  The British Difficult Airway Society guideline for a Can’t Intubate, Can’t Oxygenate crisis follows: 

How to train anesthesiologists to perform SBT cricothyroidotomy:

Are anesthesiologists trained to perform cricothyroidotomy? Not really. Even though the procedure is the last safety valve on the Difficult Airway Algorithm, most anesthesiologists have minimal or no experience in this life-saving procedure. How can we train anesthesiologists to perform cricothyroidotomies? 

In my residency in the 1980s we were trained to do cricothyroid injections of cocaine prior to awake fiberoptic intubation procedures. Each resident performed dozens of these injections, and I became extremely comfortable locating and piercing the cricothyroid membrane with a needle. In 35 years and 25,000+ anesthetics, I’ve never needed to place a surgical airway through that same membrane, but I feel confident I could do so with the scalpel, bougie, tube technique. 

The problem is that most anesthesiologists have never had to perform this front of neck access procedure on a patient. The stakes are high, because there is little time for failure. After several minutes of “can’t intubate, can’t oxygenate,” someone needs to take a scalpel to the cricothyroid membrane. That someone can and often should be the anesthesiologist.

In the October 2013 American Society of Anesthesiologists Monitor we read, “Perhaps the most important problem encountered in “can’t intubate, can’t oxygenate”  is a delay in recognition or institution of emergency airway management. . . . While someone clearly needs to make the decision to obtain a surgical airway, both the surgeons and the anesthesiologist may feel uncomfortable in this role. Retrospective studies, including closed claims analysis, demonstrate that most patients are already in cardiac arrest before emergency invasive airway attempts are performed. While decisive and timely action is clearly needed, the decision to pursue a surgical airway is not an easy one; . . . In fact, there is little legal risk from a surgical airway attempt – no matter how messy – if the patient survives, but enormous liability if the procedure is not attempted.”

In a study from Great Britain, 104 anaesthetists received a structured training session on performing cricothyrotomy. These anaesthetists then took part individually in a simulated “can’t intubate, can’t oxygenate” event using simulation and airway models, to evaluate how well they could perform front‐of‐neck access techniques. First‐pass tracheal tube placement was obtained in 101 out of the 104 cricothyroidotomies (p = 0.31). They concluded that anaesthetists can be trained to perform surgical front of neck access to an acceptable level of competence and speed via simulator training

What needs to happen? Anesthesiology residents need to be trained to do front of neck access, and they need to be trained not to delay if the procedure is indicated. This training needs to be a requirement for all anesthesia professionals. Mid-career anesthesiologists pay for weekend Continuing Medical Education courses on subjects such as ultrasound-directed regional blocks or transesphogeal echocardiography. While these topics are important, they are not life-saving skills such as front of neck access. Anesthesiologists in training, practicing anesthesiologists, and Certified Registered Nurse Anesthetists (CRNAs) must receive hands-on education on performing front of neck access, as well as the reasoning behind not delaying the procedure. 

You’re an anesthesiologist or a CRNA. What should you do now?

  1. Familiarize yourself with the anatomy of the cricothyroid membrane on each of your patients.
  2. Have a scalpel, bougie, tube kit containing a #10 scalpel, a bougie, and a #6 cuffed endotracheal tube included with each difficult airway cart at each facility you anesthetize at.
  3. I now carry a scalpel, bougie, tube kit in my briefcase which I take with me every day at work. In the current model of private practice in California, where we work at multiple different freestanding surgery centers and surgeon offices, this is a reliable means to assure that I have front of neck access equipment with me wherever I anesthetize patients.
  4. Review and rehearse the anatomy and skills necessary to perform front of neck surgical cricothyroidotomy.
  5. Work to avoid “can’t intubate, can’t oxygenate” events. Evaluate each airway prior to surgery. If a significant concern exists regarding a difficult intubation, a difficult mask ventilation, or difficult front of neck access, use your judgment and perform an awake intubation. Securing an airway prior to anesthesia induction is a reliable way to avoid “can’t intubate, can’t oxygenate” disasters.

The closed claims study on difficult tracheal intubation in the October 2019 issue of Anesthesiology should serve as a bellwether for our profession. The practices of waiting for surgeons to arrive to do front of neck access, or of anesthesiologists delaying front of neck access in a “can’t intubate, can’t oxygenate” emergency must cease. Emergency front of neck access must be a core skill that all anesthesiologists are both willing and able to perform when a patient is turning purple before their eyes. 

We owe it to our patients to be ready to save their lives.


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The most popular posts for laypeople on The Anesthesia Consultant include:
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Why Did Take Me So Long To Wake 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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EXTUBATION IS RISKY BUSINESS. WHY THE CONCLUSION OF GENERAL ANESTHESIA CAN BE A CRITICAL EVENT

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
preparing to remove an endotracheal tube from a patient

Every general anesthetic has risk. In the immortal words of Forrest Gump, “Sh*t happens.” The conclusion of most general anesthetics requires the removal of a breathing tube. The removal of this airway tube, an event called “extubation,” is a critical and sometimes dangerous event. Extubation is risky business.

The most invasive type of airway tube used in anesthesia is called an endotracheal tube, or ET tube. At the onset of general anesthesia anesthesiologists place an ET tube through the mouth, past the larynx (voice box), and into the trachea (windpipe). The ET tube is a conduit to safely transfer oxygen and anesthesia gases into and out of the lungs.

After a surgery is finished, anesthetic gases and intravenous anesthesia drugs are discontinued, and the patient wakes up within 5 to 15 minutes. If the patient has an ET tube, it is usually removed. Anesthesiologists are vigilant during extubation. In contrast, other operating room professionals are usually relaxed and winding down at this time, because the surgical procedure is finished. Extubation is not a time to relax. The incidence of respiratory complications (e.g. low oxygen saturations or airway obstruction) occurred at a significantly higher rate following extubation than during induction of anesthesia (P < 0.01).

The Difficult Airway Society Guidelines for the Management of Tracheal Extubation state that “tracheal extubation is a high-risk phase of anesthesia. The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in injury or death.”

Let’s examine five actual post-extubation scenarios that caused death, complications, or a near-miss: 

  1. During my first month of anesthesia training at a county hospital in San Jose, California, I chose to try to wake up a healthy patient without the presence of my faculty member. When I removed the endotracheal tube, the patient was unable to breathe and his oxygen level dropped acutely. I didn’t know what to do, and in a panic I paged my faculty member. He entered the operating room, elbowed me aside, assessed the diagnosis of laryngospasm, applied an anesthesia mask over the patient’s face, and began a chin-lift maneuver while forcing positive pressure oxygen into the patient via the mask. Within ten seconds the patient coughed, began breathing, and the oxygen level rose to safe levels. I was aghast with the acute deterioration I had neither predicted nor known how to remedy. The faculty member looked me in the eye and said, “Don’t take out the endotracheal tube until the patient opens his eyes.” I took that endotracheal tube out too early because I was inexperienced—still years away from finishing my anesthesia training. Laryngospasm occurs when the vocal cords clamp together following removal of the ET tube. This is usually caused by saliva or blood on the vocal cords during an intermediate phase of anesthesia. Laryngospasm is a vocal cord reflex which closes the cords to protect the trachea from aspirating fluid into the lungs. When the vocal cords remain closed, no oxygen can pass and an individual can die. The Difficult Airway Society Guidelines for the Management of Tracheal Extubation (see below), published in 2012, recommend to “wait until awake, eye opening/obeying commands,” just as my faculty member advised me in 1986.
Difficult Airway Society Guidelines “low risk” algorithm
NOTE: “Wait until awake (eye opening/obeying commands)”
  • A 40-year-old male presented for outpatient surgery on his nose. His past medical history was positive for obesity (220 pounds, 5 feet 6 inches tall) and hypertension. Anesthesia was induced with propofol, fentanyl, and rocuronium, and an ET tube was easily placed. The surgery concluded 2 hours later and the anesthetics were discontinued. The patient began to cough. The anesthesiologist decided to extubate the trachea at that time. After extubation the patient continued to make respiratory efforts, but no airflow was noted. The blood oxygen saturation dropped to a dangerous level of 78%. The anesthesiologist was unable to reintubate the trachea due to poor visibility. The oxygen saturation dropped to 50%. Seven minutes later, the anesthesiologist was finally able to replace the ET tube. Copious secretions were suctioned out of the tube, ventilation remained difficult, and the oxygen saturation level remained in the 50% range. The patient’s ECG deteriorated into a cardiac arrest. He was resuscitated, and 20 minutes later his oxygen saturation finally rose to 94%. A chest x-ray showed pulmonary edema, meaning that the lungs were full of fluid. The diagnosis was laryngospasm leading to negative pressure pulmonary edema. When a patient powerfully attempts to inhale against the obstructed vocal cords of laryngospasm, the negative pressure of each inhale moves fluid from blood vessels into the airway spaces of the lungs, a phenomenon is called negative pressure pulmonary edema. This patient was eventually declared brain dead due to prolonged his prolonged low oxygen levels.
Chest X-ray showing increased lung water in negative pressure pulmonary edema
  • A 40-year-old male presented for a routine elective upper GI endoscopy procedure. He was morbidly obese, with a weight of 380 pounds and a height of 5 feet 4 inches. The anesthesiologist induced anesthesia with propofol and paralyzed the patient with rocuronium in order to place the ET tube prior to the procedure. The procedure lasted only 15 minutes. The paralysis was reversed by the drug combination of neostigmine 5 mg and Robinul 1 mg, and patient was extubated awake. In the first minute it became clear that the patient was still partially paralyzed and unable to ventilate himself. The blood oxygen level dropped acutely to life-threatening levels. The anesthesiologist then performed an emergency reintubation to replace the ET tube to again ventilate oxygen into the patient’s lungs to save his life. (Note- this case occurred in 2015, prior to the availability of sugammadex, a new intravenous drug which rapidly and reliably reverses rocuronium paralysis in a minute or less.) 
  • An 80-year-old female presented for elective right elbow surgery. She was obese (220 pounds, 5 feet tall), had a past history of congestive heart failure, and had her aortic valve replaced two years earlier. She had a history of shortness of breath climbing one flight of stairs. The anesthesiologist induced anesthesia with propofol and rocuronium, and placed an ET tube. At the conclusion of surgery, the anesthetics were discontinued. While the ET tube remained in place, her blood pressure climbed to a high of 200/120, her heart rate climbed to 120 beats per minute, and white froth began to occlude the inside of the ET tube. This fluid was pouring out of her lungs due to acute congestive heart failure caused by marked hypertension. During extubation, 10 – 30 % increases in both heart rate and blood pressure can occur. Hypertension and increased heart rate must be monitored and treated during the extubation of patients with cardiac disease. The patient was ventilated with 100% oxygen, an arterial line was placed in the radial artery in her wrist to continually monitor her elevated blood pressure, and an emergency infusion of an ICU antihypertensive drug called nitroprusside was started. The nitroprusside decreased the blood pressure to 150/80, she was re-sedated with propofol, and she was transferred to an ICU with the ET tube still in place. A myocardial infarction was ruled out by blood tests. The ET tube was removed in the ICU the following morning. She walked out of the hospital two days later. 
  • A healthy 4-year-old female had a general anesthetic for elective surgery to reconstruct her middle ear. After a ninety-minute surgery, the anesthetics were discontinued. Five minutes later she opened her eyes. Just seconds prior to the planned extubation, the patient vomited 100 milliliters of brown solid and liquid material which overflowed from her mouth. The anesthesiologist inserted a suction catheter into her mouth to remove the vomitus. The lung examination with a stethoscope confirmed normal breath sounds. The patient’s vital signs remained normal and the ET tube was removed. The patient suffered no respiratory distress, and the lungs were free from of the stomach contents. The cuffed ET tube prevented aspiration of the vomitus into her lungs. If her ET tube had been removed at any point prior to the vomiting, it’s likely the solid and liquid stomach contents would have descended into her lungs, clogged and obstructed her lower airways, and required insertion of a new ET tube and transfer to an ICU for treatment of aspiration of stomach contents into the lungs. 

My advice to anesthesia professionals regarding extubation is to:

  • Review the Difficult Airway Society Guidelines for the Management of Tracheal Extubation. The guidelines advise awake extubation. My advice, in line with this publication, is: The ET tube is your friend. Don’t pull it out until you’re certain you don’t need it any more. Prior to extubation, many patients will struggle and move prior to the time they open their eyes or can obey commands. An onlooking surgeon will at times say, “can you take the tube out now? The patient is going to rip their sutures out or have bleeding from the surgical site.” At times anesthesiologists will comply and remove the ET tube earlier at this request. Most of the time there will be no serious complication, but there will at times be complications of airway obstruction, laryngospasm, or low oxygen levels. If a bad outcome occurs, the anesthesiologist will own the complication. No one will blame the surgeon.
  • Pass the American Board of Anesthesiologists oral board examination, and become board-certified in anesthesiology. The time spent studying for the oral boards will make you a safer and smarter anesthesiologist who is better prepared to handle emergency situations. A study in Anesthesiology showed rates for death and failure to rescue from crises were greater when anesthesia care was delivered by non-board certified midcareer anesthesiologists. In the Stanford Department of Anesthesiology, we administer mock oral board examinations to the residents and fellows twice a year. Managing a sudden hypoxic episode is a common question during the oral exam. If you can think well in a room in front of two examiners, you are more likely to think well in a true emergency when your patient’s life is at stake.
  • If you have access to anesthesia simulator sessions, enroll yourself. Like the flight simulator training that commercial pilots are required to complete, anesthesia simulators hone the emergency skills of individual anesthesiologists.

What if you’re a patient and you’re contemplating surgery? How can you optimize your chances to avoid an anesthetic complication? I offer these suggestions:

  • Choose to have your surgery at a facility that is staffed with American Board of Anesthesiology board-certified physician anesthesiologists.
  • Ask a knowledgeable medical professional to recommend a specific anesthesiologist at your facility, and request that specific anesthesiologist for your care.
  • Inquire about who would manage your crisis if you have one during or after your surgery. Will your anesthesia professional be a physician anesthesiologist, a Certified Registered Nurse Anesthetist (CRNA), or an anesthesia care team made up of both? If an anesthesia care team is attending to you, how many rooms is each physician anesthesiologist supervising? How far away or how many minutes away will your physician anesthesiologist be while you are asleep?
  • In the future, quality of care data will be available on facilities and physicians, including anesthesiologists. These metrics will allow patients to compare facilities and physicians. Do your homework with whatever data is publicized. Research the facility you are about to be anesthetized in.
  • You are a higher risk patient if you have: significant obesity, obstructive sleep apnea, heart problems, breathing problems, age > 65, if you’re having regular dialysis, emergency surgery, abdominal surgery, chest surgery, major vascular surgery, cardiac surgery, brain surgery, regular dialysis, a total joint replacement, or a surgery involving a high blood loss. Be aware you’re at a higher risk, and ask more questions of your surgeon and your anesthesia provider. 

Neither anesthesia providers nor patients want to be victims of an anesthetic emergency that leads to a bad outcome.

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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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DOCTOR VITA 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
artificial_intelligence_ai_healthcare

My name is Rick Novak, and I’m a double-boarded anesthesiologist and internal medicine doctor and a writer of medical fiction. I’m here to talk about Doctor Vita, a vision of the future of Artificial Intelligence in Medicine.

I’m an Adjunct Clinical Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford and the Deputy Chief of the department. I don’t tout myself as an expert in AI technology, but I am an expert in taking care of patients, which I’ve done in clinics, operating rooms, intensive care units, and emergency rooms at Stanford and in Silicon Valley for over 30 years.

AI is already prevalent in our daily life. Smartphones verbally direct us to our destination through mazes of highways and traffic. Self-driving cars are in advanced testing phases. The Amazon Echo brings us Alexa, an AI-powered personal assistant who follows verbal commands in our homes.Artificial intelligence in medicine (AIM) will grow in importance in the decades to come and will change anesthesia practice, surgical practice, perioperative medicine in clinics, and the interpretation of imaging. AI is already prevalent in our daily life. Smartphones verbally direct us to our destination through mazes of highways and traffic. Self-driving cars are in advanced testing phases. The Amazon Echo brings us Alexa, an AI-powered personal assistant who follows verbal commands in our homes. AIM advances are paralleling these inventions in three clinical arenas:

Surgical Robot

1. Operating rooms: Anesthesia robots fall into two groups: manual robots and pharmacological robots. Manual robots include the Kepler Intubation System intubating robot:

designed to utilized video laryngoscopy and a robotic arm to place an endotracheal tube, the use of the DaVinci surgical robot to perform regional anesthetic blockade, and the use of the Magellan robot to place peripheral nerve blocks.

Magellan robot for placing regional anesthetic blocks

Pharmacological robots include the McSleepy intravenous sedation machine, designed to administer propofol, narcotic, and muscle relaxant:

McSleepy anesthesia robot

and the iControl-RP machine, described in The Washington Post as a closed-loop system intravenous anesthetic delivery system which makes its own decisions regarding the IV administration of remifentanil and propofol. This device monitors the patient’s EEG level of consciousness via a BIS monitor device as well as traditional vital signs. One of the machine’s developers, Mark Ansermino MD stated, “We are convinced the machine can do better than human anesthesiologists.” The current example of surgical robot technology in the operating room is the DaVinci operating robot. This robot is not intended to have an independent existence, but rather enables the surgeon to see inside the body in three dimensions and to perform fine motor procedures at a higher level. The good news for procedural physicians is that it’s unlikely any AIM robot will be able to independently master manual skills such as complex airway management or surgical excision. No device on the horizon can be expected to replace anesthesiologists. Anesthetizing patients requires preoperative assessment of all medical problems from the history, physical examination, and laboratory evaluation; mask ventilation of an unconscious patient; placement of an airway tube; observation of all vital monitors during surgery; removal of the airway tube at the conclusion of most surgeries; and the diagnosis and treatment of any complication during or following the anesthetic.

IBM Watson AI Robot

2. Clinics: In a clinic setting a desired AIM application would be a computer to input information on a patient’s history, physical examination, and laboratory studies, and via deep learning establish a diagnosis with a high percentage of success. IBM’s Watson computer has been programmed with over 600,000 medical evidence reports, 1.5 million patient medical records, and two million pages of text from medical journals. Equipped with more information than any human physician could ever remember, Watson is projected to become a diagnostic machine superior to any doctor. AIM machines can input new patient information into a flowchart, also known as a branching tree. A flowchart will mimic the process a physician carries out when asking a patient a series of increasingly more specific questions. Once each diagnosis is established with a reasonable degree of medical certainty, an already-established algorithm for treatment of that diagnosis can be applied. Because anesthesiology involves preoperative clinic assessment and perioperative medicine, the role of AIM in clinics is relevant to our field.

Artificial Intelligence and X-ray Interpretation

3. Diagnosis of images: Applications of image analysis in medicine include machine learning for diagnosis in radiology, pathology, and dermatology. The evaluation of digital X-rays, MRIs, or CT scans requires the assessment of arrays of pixels. Future computer programs may be more accurate than human radiologists. The model for machine learning is similar to the process in which a human child learns–a child sees an animal and his parents tell him that animal is a dog. After repeated exposures the child learns what a dog looks like. Early on the child may be fooled into thinking that a wolf is a dog, but with increasing experience the child can discern with almost perfect accuracy what is or is not a dog. Deep learning is a radically different method of programming computers which requires a massive database entry, much like the array of dogs that a child sees in the example above, until a computer can learn the skill of pattern matching. An AIM computer which masters deep learning will probably not give yes or no answers, but rather a percentage likelihood of a diagnosis, i.e. a radiologic image has a greater than a 99% chance of being normal, or a skin lesion has a greater than 99% chance of being a malignant melanoma. In pathology, computerized digital diagnostic skills will be applied to microscopic diagnose. In dermatology, machine learning will be used to diagnosis skin cancers, based on large learned databases of digital photographs. Imaging advances will not directly affect anesthesiologists, but if you’re a physician who makes his or her living by interpreting digital images, you should have real concern about AIM taking your job in the future.

There’s currently a shortage of over seven million physicians, nurses and other health workers worldwide. Can AIM replace physicians? Contemplate the following . . . 

All medical knowledge is available on the Internet:

Most every medical diagnosis and treatment can be written as a decision tree algorithm:

Voice interaction software is excellent:

The physical exam is of less diagnostic importance than scans and lab tests which can be digitalized:

Computers are cheaper than the seven-year post-college education required to train a physician:

versus an inexpensive computer:

There is a need for cheaper, widespread healthcare, and the concept of an automated physician is no longer the domain of science fiction. Most sources project an AIM robot doctor will likely look like a tablet computer. For certain applications such as clinical diagnosis or new image retrieval, the AIM robot will have a camera, perhaps on a retractable arm so that the camera can approach various aspects of a patient’s anatomy as indicated. Individual patients will need to sign in to the computer software system via retinal scanners, fingerprint scanners, or face recognition programs, so that the computer can retrieve the individual patient’s EHR data from an Internet cloud. It’s possible individual patients will be issued a card, not unlike a debit or credit card, which includes a chip linking them to their EHR data.

What will be the economics of AI in medicine? Who will pay for it? America spends 17.8% of its Gross National Product on healthcare, and this number is projected to reach 20% by 2025. Entrepreneurs realize that healthcare is a multi-billion dollar industry, and the opportunity to earn those healthcare dollars is alluring.

It’s inevitable that AI will change current medical practice. Vita is the Latin word for “life.” I’ve coined the name “Doctor Vita” for the AI robot which will someday do many of the tasks currently managed by human physicians.

These machines will breathe new life into our present healthcare systems. In all likelihood these improvements will be more powerful and more wonderful than we could imagine. A bold prediction: AI will change medicine more than any development since the invention of anesthesia in 1849. Doctor Vita from All Things That Matter Press describes a fictional University of Silicon Valley Medical Center staffed by both AI doctors and human doctors. How physicians interact with these machines will be a leading question for our future. AI in medicine will arrive in decades to come. Michael Crichton wrote Jurassic Parkin 1990, 29 years ago, and we still do not see genetically recreated dinosaurs roaming the Earth. But we will see AI in medicine within 29 years. You can bet on it.

Here’s a dilemma: In 2018 and 2019 autopilots drove two Boeing 737 Max airplanes to crashes despite the best efforts of human pilots to correct their course. To date there have been 3 deaths of drivers in self-driving Tesla automobiles. What will happen when AI intersects with medicine and we have machines directing medical care? In the spirit of Jules Verne, this century’s trip around the world, to the center of the earth, to the moon, or beneath the ocean’s surface is the coming of Artificial Intelligence in Medicine.

For the bibliography click here.

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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?

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

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ANESTHESIOLOGIST BURNOUT

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

Regarding anesthesiologist burnout: What if I told you 50% of physician anesthesiology trainees suffer burnout, and those trainees average $220,000 in educational debt by the age of 32? 

The term “burnout” was coined in the 1970s by American psychologist Herbert Freudenberger, who used the term to describe the consequences of severe stress and high ideals in helping professions such as doctors and nurses, who sacrifice themselves for others.

The symptoms of physician burnout are recognized as: 

  • Exhaustion
  • Emotional detachment, i.e. feeling alone in the world
  • Self-doubt
  • Feeling helpless, trapped, and defeated
  • Increasingly cynical and negative outlook
  • Decreased satisfaction and sense of accomplishment

Our specialty’s premiere journal Anesthesiology recently published a study by Dr. H. Sun titled, “Repeated Cross-sectional Surveys of Burnout, Distress, and Depression among Anesthesiology Residents and First-year Graduates.” The study reported that “Based on survey data from 2013 to 2016, the prevalence of burnout, distress, and depression in anesthesiology residents and first-year graduates was 51%, 32%, and 12%, respectively. More hours worked and student debt were associated with a higher risk of distress and depression, but not burnout. Perceived institutional and social support and work-life balance were associated with a lower risk of burnout, distress, and depression.”

I completed two residencies in the 1980s at Stanford University Hospital, the first in internal medicine and the second in anesthesiology. The internal medicine residency required 100-hour weeks of service. I worked 30-hour shifts in the hospital every third night on most rotations, without a day off afterwards. The anesthesia residency was 80 hours per week with in-hospital night call.

Were residents burned out in the 1980s? I believe they were, but no one was publishing data on burnout then. Fellow residents I knew committed suicide, became addicted to fentanyl and overdosed, or dropped out of their residencies. We had a battlefield mentality—everyone was stressed, but we marched onward with the goal of finishing our training and entering the early career years. The plot of a popular 1970s medical novel, The House of God by Samuel Shem, involved a cohort of Boston medical interns who had burnout symptoms, and began to cynically dislike their patients and their own lives. In the end these young doctors dropped out of their internal medicine residencies to join cushier specialties such as radiology, dermatology, pathology, ophthalmology, and (gasp) anesthesiology. 

Now we learn that anesthesiology residents have a 50% incidence of burnout. In the Sun study the mean physician age was 32 years, the mean number of hours worked per week was 61, the mean number of night calls/night shifts per month was 5, and 37% of the doctors were females. Females were more likely than males to suffer from burnout (54% vs. 49%, P = 0.002). Seventy-eight percent of the respondents reported having student loan debt, with a median amount of $220,000. 

In 1980 I graduated from the University of Chicago School of Medicine with $23,000 in student debt. In 1984 the average debt for students who graduated from a private medical school was $27,000. Per Consumer Price Index data, $1 in 1980 equaled $3.11 in 2019. Adjusting for inflation, the average student debt from 1984 calculates to $83,970 in 2019 dollars, or roughly 40% of what today’s students are borrowing.  

Among medical specialties studied, anesthesiology has a higher rate of burnout (approximately 48%) than the all-physician average (46%).  Anesthesiology ranks seventh on the list of burnout by specialty, with emergency medicine, internal medicine, neurology, and family medicine having the four highest rates.  

Medical school application rates remain high. In 2019 there were 849,678 applications to U.S. medical schools, and 21,622 students matriculated. The average student applied to 16 schools. It’s terrific that bright students are still interested in becoming physicians. Are they driving themselves toward the twin brick walls of physician burnout and six-figure educational debt? Yes, many of them are.  

The current political healthcare debate includes the prospect of Medicare for All. How would Medicare for All affect anesthesiology? Medicare pays anesthesiologists approximately 20% of what commercial insurance pays anesthesiologists. If Medicare for All ever becomes a reality, those young anesthesiologists who already own $220,000 in student debt will see their income plummet. Paying off their debt will take significantly longer, adding stress to an already stressed young physician’s life. 

If you’re a patient reading this, you might wonder how all this might affect you. Consider this: we all want our doctors to be emotionally and physically healthy. We all want our caretakers to be content, well-reimbursed, non-burned out professionals rather than stressed-out MDs in chronic debt. 

What can be done about physician burnout? Per the Sun article, “Perceived institutional and social support and work-life balance were associated with a lower risk of burnout, distress, and depression,” and “those who believed they maintained an appropriate balance between personal and professional lives and who were satisfied with the level, accessibility, and acceptability of workplace resources were much less likely to suffer from burnout, distress, and depression.” Stanford Medical Center recently hired Tait Shanafelt MD as their first Chief Wellness Officer, in an effort to provide programs with a supportive medical center environment for Stanford physicians. 

I still recommend a career path toward medical school for motivated and qualified students, with these reservations: 

1. It’s important that your medical school and your residency training program have intact resources to support psychologically stressed/burned out/depressed enrollees; and 

2. You need to carefully examine your projected economic stress, i.e. the debt you will incur in your medical training vis-à-vis your expected income in the medical specialty you hope to enter.   

Anticipate psychological stress and debt in your medical training. You’ll need to be well informed and supported in your journey to become a physician in 21st Century America.

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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?


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THE ELECTRIC CHAIR AND 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

What do the electric chair and anesthesiology have in common? The pertinent Venn diagram includes capital punishment, death by lethal injection, electrocution, and anesthesiology ethics. Anesthesiologists inject intravenous drugs to keep people alive during surgery. No anesthesiologist would be involved in lethal injection procedures or in recommending methods for killing another human being. Lethal injection requires someone to administer anesthetic medications in high concentrations without supporting breathing or cardiac function. On August 15, 2019 the state of Tennessee executed Steven West by electrocution for raping a 15-year-old girl and then killing both her and her mother in 1986. 

When given the option of lethal injection or the electric chair, West chose the chair. Uncertainties regarding current lethal injection drug regimens may have played a part in a recent inmate execution via the electric chair. Let’s look at the issues.

lethal injection table

Capital punishment by lethal injection is a relatively recent development. In 1982 Texas became the first state in the United States to use lethal injection to carry out capital punishment. The three intravenous drugs usually involved in lethal injection were (1) sodium thiopental, a barbiturate drug that induces sleep, (2) pancuronium, a drug that paralyzes all muscles, making movement and breathing impossible, and (3) potassium chloride, a drug that induces ventricular fibrillation of the heart, causing cardiac arrest.  

A barrier to lethal injection arose in January 2011 asHospira Corporation, the sole manufacturer of sodium thiopental, announced that they would stop manufacturing the drug. Hospira had planned to shift production of thiopental from the United States to Italy, but theEuropean Union also banned the export of thiopental for use in lethal injection.

Several death-row inmates have brought courtroom challenges claiming lethal injection violated the ban on “cruel and unusual punishment” found in the Eighth Amendment to the United States Constitution. There are drug regimen factors and technical factors regarding lethal injection problems. Regarding drug regimen factors, alternative sedative drugs such as midazolam, fentanyl, Valium, or hydromorphone have been considered to replace sodium thiopental, but there have been legal challenges as to whether inmates are indeed unconscious under these newer lethal injection recipes. The potential of cruel and unusual punishment can occur if the sedative combination does not reliably induce sleep, so that the individual to be executed is awake and aware when the paralyzing drug freezes all muscular activity. About ten years ago I was contacted by the Deputy Attorney General of a Southern state, who asked me if I would testify that a massive overdose of a single-drug intravenous anesthetic would reliably render an individual unconscious and anesthetized. The Deputy AG sent me the position paper authored by the opposition’s expert for the abolitionist argument. That paper was a massive treatise authored by an MD-PhD anesthesiologist-pharmacologist. The paper was approximately 80 pages long with hundreds of references. The abolitionist movement against capital punishment is strong. I declined to testify in support of the state’s lethal injection protocol. 

There are also technical factors involved with intravenous injection. A 100-fold overdose of a sedative should render an inmate asleep, correct? Not necessarily. What if the intravenous catheter or needle is incorrectly positioned, and the drug does not enter the vein in a reliable fashion? Is this a possibility? It is. If the catheter is not inserted by a trained medical professional it’s possible that the catheter will be outside of the vein, and the intended medications will spill into the soft tissues of the arm. The intended site of action of intravenous anesthetic drugs is the brain. To reach the brain the drug must be correctly delivered into a vein. Cases in which failure to establish or maintain intravenous access have led to executions lasting up to 90 minutes before the execution was complete. Thus the role of a medical professional to insert the intravenous catheter and administer the lethal injection is critical. The dilemma is that medical professionals are trained to save lives, not to execute people. The Hippocratic Oath clearly states that physicians must “do no harm” to their patients.

The American Medical Association states, “A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.”

The American Society of Anesthesiologists states, “Although lethal injection mimics certain technical aspects of the practice of anesthesia, capital punishment in any form is not the practice of medicine . . . The American Society of Anesthesiologists continues to agree with the position of the American Medical Association on physician involvement in capital punishment. The American Society of Anesthesiologists strongly discourages participation by anesthesiologists in executions.”

The American Nurses Association states, “The American Nurses Association is strongly opposed to nurse participation in capital punishment. Participation in executions is viewed as contrary to the fundamental goals and ethical traditions of the profession.”

Without a trained medical professional to administer the intravenous catheter and inject the drugs in a reliable fashion, the practice of lethal injection has stalled in the State of California. Since 2006 there have been no death penalty executions by lethal injection in the state of California. In February 2006, U.S. District Court Judge Jeremy D. Fogel blocked the execution of a convicted murderer because of concerns that if the three-drug lethal injection combination was administered incorrectly it could lead to suffering for the condemned, and potential cruel and unusual punishment. This led to a moratorium of capital punishment in California, as the state was unable to obtain the services of a licensed medical professional to carry out an execution. There are currently over 700 inmates on death row in California.

Death by electrocution reentered the news this month. In the electrocution method, the condemned inmate is strapped to a wooden chair and high levels of electric current are passed through electrodes attached to the head and one leg. Lethal injection has been considered a more humane method of capital punishment than the electric chair. Tennessee provided inmates with a choice of the electric chair or lethal injection, and inmate Steven West chose the electric chair. Will electrocution replace lethal injection as the most common form of capital punishment in the United States? There is no current trend to support this. In 2018 there were 23 capital punishment executions by lethal injection, and only 2 by the electric chair. In 2019 there have been 10 capital punishment executions by lethal injection, and only one by electrocution.

Challenges to lethal injection are ongoing, and are in the domain of lawyers and courtrooms. If current lethal injection methods are ruled cruel and inhumane or if they are ruled unconstitutional, and states cling to the goal of capital punishment, we may see more headlines like this month’s electric chair execution from Tennessee. 

For previous columns regarding lethal injection procedures, see

JANUARY 2014 LETHAL INJECTION WITH MIDAZOLAM AND HYDROMORPHONE . . AN ANESTHESIOLOGIST’S OPINION, and

APRIL 2014 LETHAL INJECTION IN OKLAHOMA . . . AN ANESTHESIOLOGIST’S VIEW.

LETHAL EXECUTION USING FENTANYL . . . AN ANESTHESIOLOGIST’S OPINION https://wordpress.com/post/theanesthesiaconsultant.com/2738

APRIL 2014 LETHAL INJECTION IN OKLAHOMA – AN ANESTHESIOLOGIST’S VIEW

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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?

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DO DOCTORS EVER RIDE IN AMBULANCES?

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

Do doctors ever ride in ambulances? Ambulances are a territory usually staffed by Emergency Medical Technician (EMT) personnel, but yes, in certain emergencies doctors do ride in ambulances.

In the process of doing 30,000 anesthetics, I’ve taken several rides in the back of an ambulance with my patients. Why? Sixty-six percent of surgeries in the United States take place as an outpatient, and many of these surgeries are performed at freestanding facilities distant from hospitals. When a patient decompensates emergently at a freestanding ambulatory surgery center or in an operating room at a doctor’s office, the facility will call for an ambulance staffed with EMT personnel. If the patient is unstable, a physician, usually an anesthesiologist, will need to accompany the patient and the EMTs to the hospital emergency room.

The following are examples of cases in which I or my colleagues have ridden in ambulances from freestanding surgery centers to the Stanford Emergency Room and Stanford Hospital in Palo Alto, California:

  1. A 3-year-old girl developed negative pressure pulmonary edema with plummeting pulse oximetry readings 10 minutes after a tonsillectomy. Her breathing tube had been removed, but she developed upper airway obstruction in the Post Anesthesia Care Unit (PACU) and needed urgent reintubation. She was extubated one hour later at the surgery center after treatment with diuretic, oxygen, and ventilation via the tube. She was then transferred to the hospital for overnight observation of her airway, pulmonary function, and oxygenation. The duty in the ambulance included monitoring her oxygenation, her airway and her breathing.  The presence of an anesthesiologist was reassuring to the stunned parents who had no expectation of a complication after a common surgery such as a tonsillectomy. The patient was discharged the following day without further complication.
  2. A 75-year-old female underwent lateral epicondylitis release surgery on her right elbow, and developed acute pulmonary edema with failing oxygen saturation levels at the conclusion of surgery. The patient had a past history of aortic stenosis, and had her aortic valve replaced with a small metal valve two years earlier. She was active, although she did experience mild shortness of breath on walking stairs. She was obese with a BMI=35. She received a general anesthetic with an endotracheal tube. The surgery was simple and the surgical duration was only 17 minutes. When the anesthetics were discontinued at the end of surgery, her blood pressure climbed to markedly high levels, and her heart failed to pump effectively against the elevated blood pressure. Pulmonary edema fluid filled her lungs and filled the hoses of the anesthesia machine. Her oxygenation returned to normal after titrating her BP down with a nitroprusside drip, and her blood pressure needed to be monitored continuously by an arterial line inserted into her radial artery at the wrist. The duty in the ambulance included ventilating the patient via the Ambu bag, keeping the patient sedated, watching the arterial line pressure continuously, and titrating the level of the vasodilating nitroprusside infusion. She remained intubated overnight in the hospital and was extubated the next day. She survived without any further complication and did not have a myocardial infarction. 
  3. A healthy 45-year-old woman developed acute hypotension 6 hours following a laparoscopic hysterectomy. The surgery was done in a small community hospital where there was no ICU, blood bank, or emergency room. The patient had multiple low-normal blood pressure readings over the first 5 hours postoperatively, and was being observed by the nursing staff. At hour 6 her blood pressure dropped to a dangerously low level and her hematocrit level on a portable device came back as 9.9%, indicative of a severe acute anemia. She was transferred urgently to the hospital. The duty in the ambulance included resuscitation with IV fluids, and observation of her airway and breathing as her level of consciousness dropped. She required repeat surgery at the hospital to control the intraabdominal bleeding, as well as preoperative transfusion to treat her anemia and hypovolemic shock.

These three cases are examples of surgical patients who became acutely ill miles from the nearest hospital. Each case illustrates how a failure of airway, breathing, or circulation can lead to an emergency. The problem in the first case was airway obstruction leading to pulmonary edema. The problem in the second case was lungs filled with fluid which made normal breathing impossible. The problem in the third case was bleeding which caused the normal circulation of blood within the body to be inadequate.

Why did an anesthesiologist travel with each patient? 

  1. Each patient was extremely sick and required acute monitoring and treatment, and medical decisions needed to be made during the trip to the hospital. EMTs are trained in resuscitation, but EMT training is only a fraction of anesthesiologist training. Having the anesthesiologist who was already resuscitating the patient continue to care for the patient en route to the hospital was the wisest course.
  2. Acute medical emergencies are defined by resuscitation of Airway-Breathing-Circulation. Anesthesiologists are the physicians with the highest level of airway skills, as well they are experts in acute resuscitation. If any physician is to travel with the patient, an anesthesiologist is the wisest choice to manage Airway-Breathing-Circulation in ongoing emergencies.
  3. Medical-legal risk is minimized if the most highly trained physician involved in the case continues to manage the case. The handoff or transfer of medical care from one practitioner to another is a high risk time for errors. The anesthesiologist  is responsible for the safety and care of his or her patient, and the highest continuity of care occurs when the anesthesiologist who managed the emergency attends to the patient during the transfer to the hospital.

I’ve been the Medical Director at a freestanding surgery center near Stanford for the past 17 years. Surgery centers strive to minimize the potential of emergencies in outpatient surgeries. Medical Directors work to limit the types of cases performed in a freestanding surgery center. This includes avoiding procedures that cause major pain, bleeding, or disruption of physiology. Typical surgeries performed in freestanding centers include:

  • Arthroscopic orthopedic surgeries
  • Simple ear nose and throat surgeries
  • GI endoscopies and colonoscopies
  • Simple general surgery procedures
  • Simple ophthalmologic surgeries
  • Plastic surgeries

Surgery centers also strive to operate on healthier patients who lack major comorbidities. Surgery centers are reluctant to approve general anesthesia in a freestanding outpatient setting to patients who have: 

  • Severe sleep apnea
  • Severe cardiac problems such as shortness of breath or ongoing chest pain
  • Severe morbid obesity or super-morbid obesity
  • Renal dialysis
  • Severe abnormal airways
  • Markedly abnormal blood pressures, heart rates, or blood oxygen levels

Regarding ambulance rides, no one is going to advocate that MDs take over EMTs roles regarding riding in ambulances. But when surgery or anesthesia leads to an acute event at a site distant from a hospital, the anesthesiologist involved in that patient’s care is responsible for that patient’s safety and for the ongoing care and resuscitation. The anesthesiologist will be riding in the ambulance and doing what anesthesiologists routinely do–managing Airway-Breathing-Circulation.

If any anesthesia professionals have stories regarding their own emergency ambulance rides resuscitating patients, I invite you to share them with my readers. 

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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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REGARDING THE FRENCH ANESTHESIOLOGIST ACCUSED OF MURDER

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
RMJAPURVG5IFIP5JZYX75LU3QY A French anesthesiologist was accused of poisoning patients to trigger cardiac arrests during surgery. Nine patients died. Dr. Frédéric Péchier is apparently suspected of injecting lethal doses of potassium chloride or anesthetics into intravenous bags either prior to or during simple surgeries. This allegedly caused patients to have cardiac arrests, giving Dr. Péchier  a setting to arrive on scene quickly after the event and “rescue” the patients. It is alleged that this gained him the respect of fellow doctors and the admiration of his victims. The 47-year-old physician denied the charges. Prosecutors said Péchier was the only medical doctor present during all the incidents where traces of poison were found or when the overdoses were diagnosed. Frederic Pechier was arrested and now stands charged in twenty-four cases, nine of which resulted in death. He worked as an anesthesiologist in the eastern French city of Besançon. I have no inside knowledge on the cases except for what has been reported in the lay press, but I can present a possible and plausible explanation for what the prosecutors are theorizing. Let’s begin with a discussion of intravenous (IV) potassium injection. In the 1990s Dr. Jack Kevorkian devised an assisted-suicide machine for patients who wanted to end their lives. The machine gave three sequential IV injections. The first drug was sodium pentothal, which induced sleep. The second drug was pancuronium, which paralyzed the muscles and stopped movement and breathing. The third drug was potassium chloride, which caused cardiac arrest and stopped the heartbeat. IV potassium in high doses is lethal. I authored a chapter on Disorders of Potassium Balance in Complications in Anesthesia, 3rdEdition, 2017, edited by Drs. Lee Fleisher and Stanley Rosenbaum. Potassium plays an important role in the chemistry of excitable cells such as cardiac muscle cells. Potassium is the principal cation or element inside the cells, and disorders of potassium balance can cause life-threatening arrhythmias. More than 98% of total body potassium is located inside cells, rather than in the bloodstream. The normal serum potassium concentration in the bloodstream is 3.5-5.3 mEq/L, but the potassium concentration inside a cell is about 30-40 times higher. When the serum potassium level rises acutely, cardiac arrythmias result. A high index of suspicion is required to diagnose an elevated concentration of potassium in the bloodstream (hyperkalemia). Acute hyperkalemia presents with electrocardiogram (ECG) changes including  narrowed peaked T waves, widening of the QRS complex, and progression to ventricular tachycardia, fibrillation, or a cessation of the heartbeat. Normal healthy patients almost never have hyperkalemia. Dialysis patients who are without functioning kidneys are at the highest risk for hyperkalemia. Other causes of hyperkalemia are massive transfusion due to the potassium accumulated in blood bags during preservation, episodes of massive cell damage such as major trauma or third-degree burns, or accidental iatrogenic injections of intravenous potassium in a medical  setting. The treatment of hyperkalemia is very specific. The cardiac effects of hyperkalemia are reduced by calcium gluconate or calcium chloride, which antagonize the effect of the elevated potassium concentration on heart cell membranes. As well, administration of intravenous glucose and insulin decreases the serum potassium concentration by shifting potassium from the bloodstream into cells.   If the French patients had acute hyperkalemia due to a massive overdose of potassium injected into an IV bag, an initial presentation would likely be cardiac rhythm disturbances which deteriorated into ventricular fibrillation and a cardiac arrest. This would not respond to traditional therapy such as shocking the patient or administering IV adrenalin, because the etiology of the problem—hyperkalemia—would remain untreated. If a physician somehow guessed that the serum potassium was elevated and administered IV calcium followed by IV insulin and glucose, this could lead to successful resuscitation. However, we must note that there is no time to measure the blood potassium level in an acute setting such as a cardiac arrest, and there would be no reason at all for a healthy patient undergoing a routine surgery to have an acute hyperkalemic episode. If a healthy patient had a cardiac arrest and a doctor guessed that calcium, insulin, and glucose would revive the patient, and if the potassium concentration in the patient’s blood was assayed later and found to be markedly elevated, then this would be a very suspicious set of circumstances. Let’s move on to the discussion of an overdose of IV local anesthetic drug.  An IV injection of the local anesthetic bupivacaine (Marcaine) in a high concentration is known to cause cardiac arrest. There is only one reliable and specific antidote for an overdose of IV bupivacaine, and that is the IV injection of intralipid. If a healthy patient had a cardiac arrest and a doctor guessed that an injection of intralipid would revive the patient, and if the bupivicaine concentration in the patient’s blood was assayed later and found to be markedly elevated, then this would also be a very suspicious set of circumstances. How could these drugs—potassium or bupivacaine—ever wind up in a patient’s IV? I am forced to speculate, but consider this:  Prior to surgery all patients have an IV placed in their arm and a liter bag of fluid—either sodium chloride or Lactated Ringer’s solution—is attached to that IV. The IV line is the route in which anesthesiologists inject drugs into the patient’s bloodstream to induce sleep. The contents of the plastic IV bag of 1000 milliliters of normal saline or Lactated Ringer’s solution drips into the patient’s bloodstream over the first hour of surgery. If an individual injected a toxic dose of potassium or bupivacaine into the liter bag, in an undetected fashion in a preoperative setting, then that toxic dose would be infused over the first hour of the anesthetic when the individual who introduced the toxin is not present in the operating room at all. When the cardiac arrest predictably occurs, the individual could arrive on scene with the antidote of either calcium-insulin-glucose or intralipid, and be cited as a hero. Once again, at this time I have no specific knowledge about the medical evidence from France, But let’s hope none of the facts point to murder. I’m a great believer in the professionalism of physicians, and I would prefer that nothing illegal, immoral, or unethical happened with these cases. Stay tuned in the months to come to learn what evidence is presented, and eventually we’ll all learn what happened in the trial of Dr. Frédéric Péchier. * * 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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INTRAVENOUS CAFFEINE FOLLOWING 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

Data exists that intravenous caffeine may be effective in assisting the awakening of patients following general anesthesia. Will future anesthesiologists routinely use caffeine to wake patients after surgery? Will a shot of IV espresso be the stimulus for you to return to consciousness after your general anesthetic? Perhaps. 

Caffeine is the most popular and commonly used psychoactive drug in the world.In 2014 85% of American adults consumed some form of caffeine daily, 164 mg/person/day on the average.1A cup of coffee contains from 80 to 120 mg of caffeine.A 12-ounce cola contains from 30 to 50 mg. Currently intravenous caffeine is marketed as a three milliliter ampule that contains only 20 mg/ml of caffeine, or 60 mg total. Multiple commercial energy drinks include significantly higher doses of caffeine per the chart below

The safety of caffeine has been well established, and the energy drink market is expected to reach 83.4 billion dollars by 2024.

The market share for leading energy drink brands is shown below.

 

Intravenous caffeine post-surgery is not a new idea. When I first went into the private practice of anesthesia in 1986, gray-haired anesthesiologists at our community hospital in Fremont, California occasionally injected 100 mg of caffeine into a patient’s IV after a surgery if the patient was slow to wake. “It helps a lot!” my fellow anesthesiologists reported. I tried it on several of my patients who had prolonged awakening after general anesthesia. It seemed to speed the time to eye opening, but I had no metrics or data to evaluate whether this was a bona fide finding. Now we have more information.

The Department of Anesthesia and Critical Care at my alma mater the University of Chicago School of Medicine published two landmark papers on IV caffeine and anesthesia awakening. The first studies were conducted on rats.2Researchers placed rats in a gas-tight anesthesia box where the animals were exposed to 3% isoflurane until they became unconscious. The rats were then removed from the box, 2% isoflurane was delivered to them via an anesthesia nose cone, an intravenous line was inserted into their tails, and the rats were returned to the anesthesia box. After a total of 45 minutes of exposure to isoflurane, either IV caffeine 25 mg/kg or a placebo was injected into the IV. Anesthesia was terminated 5 minutes later and the rats were placed on their backs on a table. The recovery time was the time from when the animals were removed from the anesthesia box until they stood with four paws on the table. Rats who received IV caffeine doses awakened more quickly (in as quick as only 40% of the time) compared to those who received placebo.

In a second experiment they exposed rats to propofol anesthesia. The researchers placed the rats in a gas-tight anesthesia box where they were exposed to 3% isoflurane until they became unconscious. The rats were then removed from the box, an intravenous line was inserted into their tails, and they were allowed to wake up. A bolus of 4 mg/kg propofol was injected into the IV along with either 25 mg/kg caffeine or a placebo. Those treated with caffeine woke within an average of 6 minutes compared to 9.8 minutes for controls. There were no vital signs differences between the groups treated with caffeine or placebo in either rat experiment.

The Chicago researchers followed the rat studies with a randomized controlled study on human volunteers.3Eight healthy males each underwent two general anesthetics, one with IV caffeine and one without. The induction was with IV propofol, a laryngeal mask airway (LMA) was placed, and anesthesia was continued with isoflurane for one hour. Ten minutes before the termination of each anesthetic, the subjects were randomized to receive either IV caffeine 15 mg/kg or a saline placebo. (Note that this dose approximates 1000 mg of caffeine for a 70 kg adult, a large dose.) The recovery time was charted as the time from when the isoflurane was discontinued until the time the patient first gagged on the LMA. The average recovery time in the caffeine group was 9.6 minutes versus 16.5 minutes in the control group (P=0.002), a 42% reduction in time. Once again, there were no vital signs differences between the subjects treated with caffeine or with placebo.

Why does caffeine accelerate awakening from anesthesia? The Chicago researchers cited two mechanisms: caffeine acts by inhibiting phosphodiesterase to elevate intracellular cAMP, and it also antagonizes adenosine receptors A1and A2A. Caffeine reversibly blocks the action of adenosine on its receptors and consequently prevents the onset of drowsiness induced by adenosine.

Currently the only medical uses for caffeine are to treat neonatal apnea and to treat migraine or postdural puncture spinal headaches. Despite the fact that caffeine is considered safe,caffeine overdose can result in a central nervous system overstimulation called caffeine intoxication which typically occurs only after ingestion of large amounts of caffeine, (e.g. more than 400–500 mg at a time).4This is only half the dose that Chicago researchers administered in their human study. Symptoms of caffeine intoxication include restlessness, anxiety, a rambling flow of thought and speech, irritability, and irregular or rapid heartbeat.5Massive overdoses of caffeine can result in death. The LD50(lethal dose in 50% of cases) of caffeine in humans is estimated to be 150–200 mg per kilogram of body mass (i.e. 100-130 cups of coffee for a 70 kilogram adult).6

It’s too soon for caffeine use to become routine in the operating room. The Chicago researchers did not envision caffeine as a routine reversal agent for all general anesthetics. Anesthesiologists are skilled at weaning their patients from anesthetics for timely wakeups after the conclusion of most surgeries, but there are always outliers who are slow to wake. For these patients, a dose of IV caffeine may be helpful without introducing any increased risk. The Chicago researchers wrote, “the judicious use of caffeine could provide a tool to accelerate emergence in those individuals who manifest unanticipated prolonged emergence times and populations, such as the elderly, that are prone to prolonged emergence and recovery. . . . Further work is needed, and will follow, to extend these findings to other anesthetics including common IV agents like propofol, as well as demonstrating that these results are reproducible in patient populations, including females, older individuals, and those with chronic medical conditions undergoing operative procedures who receive multiple classes of pharmacologic agents in the course of a normal anesthetic.”

We may see intravenous caffeine following general anesthesia in the future for selected patients. Those private anesthesiologists I worked with in 1986 may have been correct when they injected IV caffeine into their sleepy patients after surgery and judged that “It helps a lot!”

References:

  1. Mitchell DC, et al (January 2014). “Beverage caffeine intakes in the U.S”. Food and Chemical Toxicology. 63: 136–42.
  2. Wang Q, et al. Caffeine accelerates recovery from general anesthesia, J Neurophysiol, 2014 Mar;111(6), 1331-1340.
  3. Fong R, et al. Caffeine accelerates emergence from isoflurane anesthesia in humans, Anesthesiology. 2018 Nov;129(5):912-920.
  4. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). American Psychiatric AssociationISBN 978-0-89042-062-1.
  5.  “Caffeine (Systemic)”. MedlinePlus. 25 May 2000. 
  6.  Holmgren P, Nordén-Pettersson L, Ahlner J (January 2004). “Caffeine fatalities–four case reports”. Forensic Science International. 139 (1): 71–3.

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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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DOCTOR BY DAY, SCI-FI WRITER BY NIGHT

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 week the Palo Alto (California) Weekly ran a feature story on Rick Novak and Doctor Vita

Doctor by day, sci-fi novelist by night

Longtime Atherton resident spotlights AI and medicine in books

Dr. Rick Novak poses for a portrait at Stanford Hospital in Palo Alto on May 23. Photo by Magali Gauthier/The Almanac

Between his time in the operating room, teaching, and raising his three sons, Atherton resident Dr. Rick Novak has found time to write two novels.

Novak, 65, an anesthesiologist at the Waverley Surgery Center in Palo Alto, recently published his latest, “Doctor Vita,” a story about an artificial intelligence (AI) physician module that goes awry.

It’s a science fiction novel that explores how technological breakthroughs like artificial intelligence and robots will affect medical care — and already have.

The Almanac, an Embarcadero Media publication which serves Menlo Park, Atherton, Woodside, and Portola Valley California, featured a story “Fiction or the Future?” on Rick Novak and Doctor Vita the same week.

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SURGICAL CASES IN FOREIGN LANDS—INTERPLAST

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

Interplast1-750x403

International Plastic Surgery

Imagine . . . rare unrepaired surgical cases in foreign lands, coupled with surgeons in America who rarely have the opportunity to operate on such cases. A win-win situation would be to fly American medical teams overseas to help these patients. This model for plastic and reconstructive surgery was born at Stanford University Medical Center in the 1960s in an organization named Interplast. During my anesthesia training at Stanford in the 1980s I was present through the growth years of Interplast, when traveling teams were dispatched to countries around the world to perform reconstructive surgeries on cleft lip and palate patients. Interplast was founded by Donald Laub MD, who was the Chief of the Division of Plastic and Reconstructive Surgery at Stanford from 1968-1980.

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Donald Laub MD

The idea for Interplast grew from the surgical history of Antonio Victoria, a 13-year-old with cleft lip and palate deformities that made him a social outcast in his home country of Mexico. Antonio arrived at Stanford University Medical Center in 1965. Dr. Robert Chase restored the boy’s appearance with three operations. Dr. Laub witnessed Antonio’s transformation and the idea for Interplast germinated.

In 1969 Dr. Laub founded Interplast (now called ReSurge International) with a mission statement to transform lives through the art of plastic and reconstructive surgery. Dr. Laub chronicles his history on his website Many People, Many Passports. Dr. Laub was the first academic to develop and lead multidisciplinary teams on humanitarian surgical trips to developing countries. The teams included plastic surgeons, anesthesiologists, pediatricians, and nurses experienced in the care of cleft palate reconstructions. The first trip to Mexicali was financed with a mere $500 of donations. Through contact with the governments and medical authorities in four countries, initial trips were scheduled to Mexico, Guatemala, Honduras, and Nicaragua. Seven hundred and fifty patients received treatment during the first five years, and an additional 150 were transported to Stanford for reconstructions in California. Through the 1970s and 1980s Interplast made trips to multiple other countries. The teams were made up of volunteers, and the trips were financed by charity donations.

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Cleft lip deformity before and after reconstruction

Cleft lip and cleft palate deformities were common in Mexico and Central America, and the chances for surgical repair in the poor areas of these countries were minimal. Individuals with other deformities such as extensive burn scars were also social pariahs because of their appearance. Interplast made it a humanitarian goal to reconstruct these patients as well.

In addition to reconstructing patients, Interplast doctors educated local physicians in modern techniques. This was the medical equivalent of “give a man a fish and he eats for a day, but teach a man to fish and he will eat for a lifetime.” The opportunity to reconstruct patients with deforming diagnoses uncommon in the United States was life-changing for the American doctors as well. In the United States, the specialty of plastic surgery was seen as one concerned with enhancing the cosmetic appearance of cash-paying customers who desired a more youthful or beautiful appearance. In the third world, helping change a deformed child’s appearance was a unique emotional reward for American physicians who traveled there.

The administration of the Stanford University School of Medicine understood the value of the program. Stanford lent financial support to Interplast and financed Interplast rotations as part of the residency training programs in plastic surgery and anesthesiology. In our final year of anesthesia residency, each resident was assigned to a one week Interplast trip to perform anesthetics overseas. The week was not a vacation—we were paid during that week and the expenses of our airfare were covered by Interplast. Trip members typically lodged with members of the local community.

In 1986 I was assigned to San Pedro Sula, Honduras for my Interplast experience. Two weeks before we were to depart, our team assignment was changed to Montego Bay, Jamaica. I asked my faculty member if that was a positive change and he remarked, “You just traded the dusty streets of San Pedro for a Caribbean resort city. What do you think?”

Each Interplast anesthesia team included one faculty member and one or more resident. For my trip the anesthesia staff consisted only of myself and one Stanford attending—thus I received both an introduction to international pediatric anesthesia and one-on-one teaching from an experienced professor.

A striking difference between Interplast anesthesia and American anesthesia was the lack of sophisticated equipment overseas. Interplast members carried no narcotic medications across borders, for obvious political reasons. All postoperative pain was treated with local anesthesia injections from the surgeons (if local anesthetics were available), or by verbal reassurance from the nurses in the Post Anesthesia Recovery Unit (PACU). The PACU was often full of children screaming in pain after their palate surgeries. There are many nerve endings in the human palate, and after cleft palate reconstruction the pain is roughly equivalent to the pain of a tonsillectomy without any narcotic analgesia. It was difficult to listen to the children crying, but in time their pain would subside.

In the 1980s Interplast teams carried halothane, a potent liquid general anesthetic, as well as a halothane vaporizer to convert the drug into an inhaled gas. General anesthetics were initiated by holding a mask over a child’s face while they inhaled halothane vapor until they fell asleep. We started intravenous lines after the induction of anesthesia, but we had very few medications to inject into those IVs. Because there were dozens of cases to be done, the anesthesia attending and the anesthesia resident each did their cases alone and independently, in adjoining operating rooms. The rooms were primitive and usually had piped in oxygen, but lacked nitrous oxide availability.

Complications were rare, but their incidence was not zero. The combination of tiny patients, a paucity of medical drugs, a relatively inexperienced (i.e. not fully trained yet) anesthesia resident working alone, no ICU, no laboratory, and no emergency backup made every case an adventure. We had no complications on our trip, but there were a few anecdotes of cardiac or respiratory arrests from my colleagues who went to other countries.

As a partially-trained resident, I’d anesthetized less than 20 children in my life by the time of my Interplast trip. I was nervous during every anesthetic induction and every anesthetic wakeup. There were no American lawyers or malpractice suits to worry about in Montego Bay, but my job required me to accept responsibility for a child’s life. I’d take a child from his or her parents prior to the surgery and I didn’t want anything but a happy ending for that child, his parents, or me at the end of the day. We performed anesthetics from dawn until dusk. The lines of patients awaiting surgery were long, and each family clamored for the opportunity for their child to receive life-changing free surgeries from the American team.

Dr. Laub set the tone for Interplast. He made 159 trips and personally performed over 1500 operations overseas. He was and is a giving, confident, warm, and intellectual visionary. HIs office was decorated with a 1986 photograph of himself and President Reagan in Washington DC, marking the 1986 Private Sector Initiatives award Dr. Laub received for the creation of Interplast.In 2000 Dr. Laub was diagnosed with an aggressive intravascular central nervous system lymphoma. He survived the malignancy but retired from active clinical practice. I admire him for his surgical skills, entrepreneurial skills and positive attitude. No matter what difficulties arose in one’s life, Dr. Laub was ready to listen, quick to smile, and in closing he’d say, “May the wind always be at your back.”

Dr. Laub recently authored Second Lives, Second Chances: A Surgeon’s Stories of Transformation, a book describing his life, his founding of Interplast, and his pioneer work in trans-gender surgery. The link to the book can be found here.

I’ve continued to anesthetize children throughout my career. Anesthetizing toddlers by yourself is not like riding a bike. Once you learn to do it, the skills must be retained with frequent repetition or else you run the risk of being unsafe. The majority of anesthesiologists cease anesthetizing children soon after residency, and choose not to build on the pediatric anesthesia skills they learned as trainees. I feel fortunate that my practice still includes anesthetizing children every week. In part I owe this to Interplast for introducing me to my early pediatric anesthesia experiences.

A medical career requires years of memorizing facts as well as tireless nights and days attending to sick patients to learn the art and science of healing. Interplast taught more—the doctors and nurses who journeyed to foreign lands to improve the lives of poor children reaped the emotional benefits of being a medical professional. Nothing in our job feels better than helping a sick child become healthier or helping a family gain a new lease on that child’s future.

Interplast has now become Resurge International (REF https://www.resurge.org). To date Resurge has performed 95,000 operations in 15 countries. The times are different, but the issues are still the same. Opportunities with Resurge are described on their website.

We’re lucky in America. Despite criticisms of our medical system and its costs, the availability of outstanding medical care is just a few miles down the road for most of us. Interplast patients were elated to benefit from American medicine abroad.

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The most popular posts for laypeople on The Anesthesia Consultant include:

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MEDICARE FOR ALL and 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

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Multiple Democratic candidates for President of the United States are advocating Medicare for All. Medicare for All would decimate the specialty of physician anesthesiologists in America. Medicare for All would cause an exodus from the specialty of anesthesiology.

I’m an independent voter—neither a Democrat nor a Republican, and this column is not in opposition to Democratic candidates or in any way supportive to a Republican agenda. My aim is to inform my readers, both anesthesia professionals and laypersons, that if Medicare for All becomes reality, there will be a dire consequence regarding anesthesia staffing and services to patients.

The Medicare pay rate for anesthesiologists is a mere fraction of the current insurance pay rate. Based on the 2018 American Society of Anesthesiologists report, the national average insured conversion factor for anesthesia (the amount paid for a 15-minute time period of service) was $76.32. The current national Medicare conversion factor for anesthesia is $22.18, or only 29% of the 2018 overall mean commercial conversion factor.

Anesthesia practices have varying ratios of insured patients, Medicare patients, Medicaid patients (which pay slightly less than Medicare), and patients with no insurance (who often pay zero). What happens if every anesthesia patient pays only Medicare rates in a Medicare for All future? Let’s look at some examples.

If a practice currently has 75% insured patients and 25% Medicare/Medicaid patients, the income for that practice would be (.75 X $76) + (.25 X $22) = $62.50 per unit. Under Medicare for All, their income would be $22.18 per unit. This is a pay cut of $40.32 per unit, or a decrease in pay to 35% of their prior income.

If a practice currently has 50% insured patients and 50% Medicare/Medicaid patients, the income for that practice would be (.50 X $76) + (.50 X $22) = $49 per unit. Under Medicare for All, their income would be would be $22.18 per unit. This is a pay cut of $26.82 per unit, or a decrease in pay to 45% of their prior income.

If a plumber, an accountant, a truck driver, an attorney, or a fast-food worker was forced to take a pay cut to 35%-45% of their previous income, they would be upset. Would they be looking for another career? Probably.

If a physician anesthesiologist is forced to take a pay cut to 35%-45% of their previous income, they will be upset too. Will they be looking for another career? Probably.

Expect the exodus from physician anesthesiology to look like this:

  • Older anesthesiologists would simply retire, rather than work for 35%-45% of their prior income.
  • Medical students who are evaluating different specialties for their lifetime vocation would look at anesthesiology and flee. Even prior to its arrival, it’s possible that the specter of Medicare for All in the near future will drive students away from careers in anesthesiology. Medicare pay rates for anesthesiology are significantly lower than Medicare pay rates for all other specialties. See the graph below, which shows the ratio of commercial pay rates/Medicare rates for various services. For most medical services, the ratio of the average insured payment/Medicare payment is between 1.0 and 2.0. This means that, at the lowest, the average Medicare rates are about 50% of insured rates. You’ll recall that the Medicare anesthesia rate is only 29.1% of insured rates.

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The declining number of the oldest and the youngest physician anesthesiologists would radically decrease the census of anesthesiologists in the United States. This likely would lead to an increased role for certified nurse anesthetists (CRNAs), and an eventual increase in the number of schools training CRNAs, but in the short term there would be no way to staff adequate numbers of anesthesia professionals. It’s possible the U.S. may increase immigration of anesthesiologists from other countries where, their pay rate is less than the new Medicare for All pay rate is in America.

Might Medicare for All be forced to quickly increase anesthesiology payment rates to secure an adequate number of physician anesthesiologists? Perhaps, but I wouldn’t bet on it. Medicare has always been a zero-sum system. If anesthesiologists are going to be paid more, then someone else would be paid less, and it would be hard to predict which specialties would be on the end of that further pay cut.

But take a deep breath and relax. Medicare for All will be debated for some time. Even if a liberal Democrat wins the presidency and Congress gains a majority of Democrats in both the Senate and the House, they will all have to overcome multiple powerful lobbies, including the medical insurance industry, hospitals, the pharmacology industry, and organized physician groups. Currently there are so many jobs and so much money involved in the health care systems in American that the battle of Medicare for All will be a true war. Patients would have a significant transition as well. David Brooks wrote in The New York Times on March 4, 2019, “Right now, roughly 181 million Americans receive health insurance through employers. About 70 percent of these people say they are happy with their coverage. Proponents of Medicare for All are saying: We’re going to take away the insurance you have and are happy with, and we’re going to replace it with a new system you haven’t experienced yet because, trust us, we’re the federal government!”

If you’re a layperson, you may think Anesthesiologists are overpaid right now, that’s the true problem with what you’re discussing in this column. Keep in mind that anesthesiologists must complete four years of college, four years of medical school, and at least four years of post-medical school internship and residency training to become board-eligible for work as a physician anesthesiologist. LINK. This means they are at a minimum 30 years old, have borrowed hundreds of thousands in student loans to pay for their training, and have endured significant delayed gratification compared to others they went to college with. Procedural specialties such as surgery and anesthesiology are higher paying than primary care specialties such as internal medicine or pediatrics. Why? The work of procedural physicians requires specialized skills, and their work incurs more risk than interviewing and examining patients in a clinic. I have worked as both an internal medicine doctor and an anesthesiologist, and I can attest that it is almost impossible to harm a patient in an internal medicine clinic, while it is possible to lose a patient to anoxic brain damage in five minutes in an operating room as an anesthesiologist if you err. Risk during an anesthesia career is omnipresent.

As I stated on the home page of my blog, “The profession of medicine offers a lifetime of fascination, and no specialty is more fascinating than anesthesiology.” In addition, freeing patients from pain and ushering them through surgery safely is a wonderful vocation. But if anesthesiology jobs someday pay 35%-45% of their current income, the exodus of anesthesiologists will occur despite the fascination and emotional rewards of the profession.

Life will go on, there will just be less anesthesiologists, which will be OK unless you need one for your upcoming surgery.

Further information on proposed Medicare for All is available at their home page at http://www.medicareforall.org/pages/Know.

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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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FREE SOLO

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

Every anesthesia provider must learn to free-solo anesthesia early in his or her career. The 2018 movie Free Solo showcases Alex Honnold as he became the first person to free solo climb the 3000-feet high El Capitan wall of granite in Yosemite National Park without ropes or safety gear. This has been called the greatest feat in rock climbing history, and the movie is nominated for a 2019 Academy Award in the Feature Documentary category.

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FREE SOLO movie poster 2018

Believe it or not, but Free Solo could have been an anesthesiologist’s movie. How can that be? “Free-soloing” describes the most anxiety–producing event in every anesthesiologist’s life: the transition from anesthesia training when your faculty member is backing up your every move and every mistake, to the real world of anesthesia when you have to do scary cases alone without assistance.

During the dayshift, working alone is seldom an issue for any anesthesiologist. A typical hospital will have dozens of other anesthesia providers working in the same building. Within seconds or minutes, any anesthesiologist can be assisted or bailed out by a colleague.

Unlike Alex Honnold, the anesthesiologist is not putting their own life at risk—rather it is their patient who is at risk. The degree of risk is variable. For healthy patients undergoing elective surgery the anesthetic risks are minimal, and are similar to the risks of driving on a freeway in an automobile. For emergency surgeries, cardiac surgeries, chest surgeries, brain surgeries, or for anesthetics on patients with significant heart, lung, blood pressure, or airway problems, the risks of anesthesia are higher. The patient is totally dependent on their anesthesiologist to return them to consciousness safely.

Commercial aviation is sometimes compared to anesthesia practice. When commercial pilots take off in airliners, their passengers are totally dependent on the pilot to return them to the ground safely. But in commercial aviation there is one important difference: by law there must be a second pilot in the cockpit.

In anesthesia there is no guaranteed second anesthesiologist. There are multiple different models of anesthesia care. In an anesthesia care team, a physician anesthesiologist supervises up to four operating rooms and each operating room is staffed with a certified registered nurse anesthetist (CRNA). In a university hospital, a faculty member may supervise two operating rooms each with a resident anesthesiologist-in-training in attendance. In many hospital operating rooms, a solitary physician anesthesiologist attends to his or her patient alone. In seventeen “opt-out” states in America a solitary CRNA can attend to a patient without any physician anesthesiologist backup. Working alone may be less safe. A 2019 study from Europe reported an outcome advantage for anesthesiologist working in teams: The study showed that anesthesia given by teams of anesthesiologists and anesthesia nurses was associated with decreased 30-day postoperative mortality and a shorter length of stay when compared with solo anesthesiologists. There was no evidence for the specific cause of the decreased mortality.

Because of manpower necessities, there will never be a law mandating a second anesthesiologist for every surgery as there is in commercial aviation. There will always be emergencies at 2 a.m. or on weekend afternoons when all other anesthesiologists are elsewhere. As well, there are tens of thousands of freestanding surgery centers and office operating rooms where only one anesthesia professional is present.

Is there any data in the medical literature documenting that inexperienced anesthesia professionals have a greater incidence of adverse outcomes? Per Pubmed, there is no such publication. But there is no publication that denies the truth of this correlation. There is a paucity of data on the topic. The issue has not been rigorously studied in a scientific basis.

I review malpractice legal cases, and I can attest that inexperienced anesthesia personnel (who are less than board-certified physician anesthesiologists) are involved in many cases. I believe recent graduates are at particular risk when they work alone. In most cases with severe complications, the anesthesia professional (an MD or a CRNA) was managing the anesthetic alone until it was too late to save the patient.

During physician anesthesia training, a faculty member teaches, supervises, advises, and bails out each resident should there be a mishap. Following their three years of residency, a graduate is free to take a job as an attending anesthesiologist in any hospital system, multi-specialty clinic, or anesthesia group who will hire him or her. This is when the free-soloing begins.

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Let me cite some examples of anesthesia free-soloing:

  1. The new graduate is on duty at 2 a.m., and a three-hundred-pound man arrives at the emergency room with the abdominal emergency of a dying, obstructed intestine. The surgeon decides the case is an emergency and cannot wait until morning. The typical anesthetic for this surgery is a rapid-sequence induction of intravenous general anesthesia, followed by the placement of a hollow breathing tube through the mouth into the patient’s windpipe. This sounds easy enough, except when it isn’t. Morbidly obese patients can be very difficult to intubate, and without a properly placed breathing tube these patients can be difficult to keep oxygenated. Five minutes without oxygen causes irreversible brain death. Sound scary? It is.
  2. The new graduate is on duty at 3 p.m. at a community hospital. A two-year-old girl arrives at the emergency room gasping for breath, crowing with each inspiration, febrile, drooling, and barely conscious. Both the emergency room physician and the anesthesiologist quickly make the diagnosis of acute epiglottitis, a rare bacterial infection which causes the epiglottis (the flap which covers the windpipe when you swallow) to become inflamed and swollen. This causes a severe obstruction during each inhaled breath. The patient needs a breathing tube within minutes, before the swollen epiglottis cuts off all passage for air inflow into the lungs. I had this very case during my first year in private practice. I’d read about the proper management, but I’d never seen acute epiglottitis myself. The appropriate treatment is to bring the patient to the operating room urgently, and to staff an experienced head and neck surgeon at the bedside. The anesthesiologist’s job is to induce sleep with an inhaled anesthetic (sevoflurane) via a mask, while carefully supporting the airway and facilitating the passage of oxygen and anesthesia gas in and out of the lungs until the patient falls asleep. Once the patient is asleep, a physician or nurse must place an IV catheter in the patient’s arm, and then the anesthesiologist must insert a lighted scope into the patient’s mouth, locate the swollen epiglottis and the opening to the windpipe below it, and insert a tiny hollow plastic breathing tube into the windpipe. If anything goes wrong and the breathing tube cannot be inserted before the child turns blue, the surgeon must immediately slice into the child’s neck and insert a breathing tube through the skin. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.
  3. The new graduate is on duty alone at a dental office, anesthetizing a 17-year-old male for wisdom teeth removal. After the induction of general anesthesia but before the beginning of surgery, the anesthesiologist administers a requested dose of intravenous antibiotic. Minutes later, the patient’s blood pressure drops from 120/80 to 60/30, the heart rate climbs from 80 to 160 beats per minute, and the normal lung sounds convert to tight wheezes. Hopefully the anesthesiologist will make the correct diagnosis of an anaphylactic allergic reaction—most likely due to the antibiotic. The effective treatment requires perfect management of the patient’s airway, breathing, and circulation. The specific treatment for anaphylaxis requires intravenous injection of epinephrine (adrenaline). A misdiagnosis leading to the omission of epinephrine can be fatal. If the blood pressure remains low and the lungs continue to deteriorate, there will be a lack of oxygen delivery to the brain. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.

What can be done to make free-soloing safer for patients? In my opinion, the best safety ropes are these:

  1. Most hospitals have an emergency room physician on duty at all hours. These MDs are multi-talented and have the acute care skills necessary to assist an anesthesiologist in an emergency. Rather than waiting until a patient has a cardiac arrest or until an airway is lost and the patient’s brain is losing oxygen, an anesthesia professional can consult the ER doctor in advance, e.g. requesting them to assist with a difficult induction of anesthesia on a morbidly obese adult or with a child with a difficult airway.
  2. Even if no experienced anesthesiologist is present in the hospital, there is always an experienced physician anesthesiologist colleague available on the other end of a phone call. Young or inexperienced anesthesia professionals can telephone senior anesthesiologists prior to the anesthetic, whenever a situation arises in which they are doubtful, insecure, or uncomfortable. It’s difficult to admit a lack of confidence, but it’s better to do this than to review a terrible complication with the senior anesthesiologist the next day, like two firefighters gazing over the burned basement remains of a previously preserved house.
  3. Most American anesthesia training programs are now utilizing simulation training facilities to prepare residents for severe acute care scenarios. A simulator lab has a surrogate patient and a full battery of vital sign monitors under the control of a teacher. The teacher can dial in a variety of emergencies and observe the pupil’s response to the emergencies. Feedback is given afterward regarding observed errors and any needed improvements in management. If a young physician anesthesiologist has faced emergencies in the simulator, we believe the anesthesiologist will be better prepared to free-solo following their training.
  4. The Stanford Anesthesiology department authored the Stanford Cognitive Aid Emergency Manual, a booklet of itemized recipes and checklists for all common dire emergencies one might see in an operating room. A PDF of this booklet is available for free of charge download here. Using the Stanford Cognitive Aid Emergency Manual in the operating room will help prevent medical errors, even by inexperienced anesthesia professionals.
  5. Whenever possible, solo anesthesiologists should have already passed the American Board of Anesthesiologists written and oral examinations, and therefore be board-certified. It’s a fact that one can practice anesthesiology in the United States without being board certified, but the ABA oral examination forces graduates to answer difficult questions in the pressure cooker of an oral exam room. Board-certified anesthesiologists will be better prepared for the pressure cooker of an operating room emergency as well.

If you’re a patient, should you worry about your anesthetist free-soloing during your surgery?

Let me reassure you. If you’re having an elective surgery in a hospital in the daytime, there are usually multiple backup anesthesia providers to assist with any problems. But for emergencies in the middle of the night, on weekends, or at freestanding surgical facilities with only one anesthesiologist present, your anesthesia care and outcome will be solely dependent on the skills, training, and experience of the solitary individual who is attending to you.

I’ve stood at the bottom of El Capitan in Yosemite National Park and looked upward at the vertical granite face with awe. I could never climb El Capitan, with or without ropes. I respect what Alex Honnold did at the highest level. He is brave beyond measure and he was willing to put his life on the line. Anesthesiologists, particularly junior anesthesiologists, must free-solo as well. No Hollywood cameras will be rolling, but the adrenaline will be pumping through their veins just as if they themselves were climbing El Capitan.

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The most popular posts for laypeople on The Anesthesia Consultant include:

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8-YEAR-OLD CONGOESE BOY DIES FROM ANESTHESIA. WHAT HAPPENED?

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

8-year-old Matadi Sela Petit, who journeyed from the Democratic Republic of Congo to Los Angeles for surgery, died at Cedars-Sinai Hospital on December 16, 2018, from what has been described as “a rare genetic reaction to the anesthesia.” Matadi was born with a cleft lip and a tumor on the left side of his face/cheek that grew into the size depicted in this photograph:

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Matadi Sela Petit

The Dikembe Mutombo Foundation, created by retired National Basketball Association star Dikembe Mutombo, sponsored the boy to come from Congo to the United States for the surgery. Matidi’s cleft lip was treated earlier with help from the foundation.

According to The Washington Post, “The Dikembe Mutombo Foundation . . . headed by the former NBA star said that during the delicate surgery on Dec. 16, the boy suffered a rare and unexpected genetic reaction to anesthesia.”

This was a tragic outcome, and my sympathies go out to the patient’s family, to the Foundation, and also to the physicians who treated the boy. Cedars-Sinai is an outstanding medical center—one of the finest in the United States—and has a reputation of having an outstanding medical staff.

What “genetic reaction” could have occurred during the anesthetic? No details have been released in the press, and readers are left to puzzle over what went wrong. As a practicing pediatric anesthesiologist, I’m interested in what happened. I have no access to medical records, nor any inside information on the case, but based on my education and experience my impressions follow below.

Regarding “a rare and unexpected genetic reaction to anesthesia,” the phrase used in the press release to describe the event, I see these possibilities:

  1. Malignant Hyperthermia. Malignant Hyperthermia (MH) is a disease in which a severe reaction occurs during general anesthesia, only among patients who are genetically susceptible. Symptoms include hypermetabolism, muscle rigidity, high fever, acidosis, sudden high blood potassium levels, and a risk of cardiac arrest. MH can only occur in patients who have the genetic predisposition to the disease, and who are then exposed to a potent anesthetic gas (e.g. sevoflurane, desflurane, or isoflurane), or the intravenous muscle relaxant succinylcholine. The treatment for MH involves emergency intravenous injection of the antidote dantrolene, immediate cooling of the patient, and immediate treatment for acidosis and elevated potassium concentration. The treatment for MH is usually effective if the diagnosis is made promptly. The quoted mortality rate for MH is now less than 5%. A potent anesthetic gas such as sevoflurane is commonly used in most pediatric anesthetics, and could have been used in Matidi’s case. Succinylcholine carries a Black Box Warning from the U.S. Food and Drug Administration regarding its use in pediatric patients, and it was unlikely to be used in this Matidi’s anesthetic. Even if Matidi had a previous surgery for his cleft palate, it is not unheard of for a patient to fail to develop MH on their first exposure to potent inhaled anesthetics, and yet develop MH on a later exposure.
  2. An occult muscular dystrophy. A patient who has an undiagnosed genetic muscular dystrophy can develop a sudden cardiac arrest after the administration of the muscle relaxant succinylcholine. Administration of succinylcholine to a patient with an occult muscular dystrophy can cause sudden cardiac arrhythmias, and for this reason succinylcholine carries a Black Box Warning from the U.S. Food and Drug Administration, restricting its use in pediatric patients to emergencies. Because of the Black Box Warning against using succinylcholine in pediatric anesthesia, it is unlikely succinylcholine was used in this patient’s anesthetic.
  3. The mass effect of the tumor in this patient’s face. If one can assume Matidi was born with this tumor, then the existence of this congenital mass lesion next to his airway and breathing passages is a genetic issue. From the photograph of Matidi, the tumor dominated his face. The tumor pushed his mouth to the right, and likely encroached on breathing anatomy. Once general anesthesia is induced, large tumors like this can compress the airway further. Every general anesthetic requires safe management of A-B-C, or Airway-Breathing-Cardiac, in that order. A child such as Matidi with markedly abnormal facial anatomy brings the risk of the loss of control of the airway at any point during the anesthesia or surgery. Loss of airway means there is no clear path for oxygen to traverse from the anesthesia machine through the head and neck to the lungs. Lack of oxygen to the lungs can lead to lack of oxygen to the brain and heart. Five minutes of oxygen depletion to the brain can cause anoxic brain damage. Oxygen depletion to the heart can cause cardiac arrest. Airway problems related to congenital diseases are discussed in the article Specific Genetic Diseases at Risk for Sedation/Anesthesia Complications, in the journal Anesthesia & Analgesia.

After scouring the world’s anesthesia literature and textbooks, I can find no other plausible “genetic reaction to anesthesia” to explain this patient’s death.

This patient’s care will be discussed in peer review and quality assurance committees at the hospital where the event occurred. There is always an autopsy on any unexpected death in an operating room, and more information may come from that. But whenever there is an adverse patient outcome, for medical-legal reasons, do not expect the healthcare professionals to reveal the specifics of what happened to the outside world.

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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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DOCTOR VITA AND THE BS IN 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

Last week Lawton Burns PhD and Mark Pauly PhD of the Wharton School of Business at the University of Pennsylvania published a landmark economic article entitled, “Detecting BS in Health Care.” Yes, you did not read that wrong—the academic paper used the abbreviation “BS” to describe the bull—- in the healthcare industry.

BS in Health Care

 

As a practicing physician, I find it to be a fascinating paper, and I recommend you click on the link and read it. The authors begin with a discussion of the art and value of BS detection. They mention that Ernest Hemingway was once asked, “Is there one quality needed to be a good writer, above all others?”

Hemingway replied, “Yes, a built-in, shock-proof, crap detector.”

The authors write, “While flat-out dishonesty for short term financial gains is an obvious answer, a more common explanation is the need to say something positive when there is nothing positive to say. . . . The incentives to generate BS are not likely to diminish—if anything, rising spending and stagnant health outcomes strengthen them—so it is all the more important to have an accurate and fast way to detect and deter BS in health care.”

The authors list their Top 10 Forms of BS in Health Care. The first four forms of BS weave a common theme:

  1. Top-down solutions: High-level executives and top management in the health care industry are supposed to engineer alternative payment models, but nothing has worked to date.
  2. One-size-fits-all, off-the-shelf: Leadership of industry and government assume one solution will work for multiple organizations, without customization.
  3. Silver-bullet prescriptions: A “silver bullet” is described as something that will cure all ills, and must be implemented because it been “decided that it is good for you,” Electronic health records (EHRs) are a prime example of a silver-bullet prescription. The federal government pushed the use of EHRs, claiming the systems would reduce costs and improve quality—but Burns and Pauly argue EHRs “eventually raised costs and only mildly touched a few quality dimensions.”
  4. Follow the guru: We must follow a visionary guru with a mystical revelation about what needs to be done. The authors describe how, in health care, Harvard professor Michael Porter and former CMS (Center of Medicare and Medicaid) administrator Don Berwick launched theories based on population health, and per-capita cost, to little success.

The current U.S. healthcare market is dominated by large corporations, led by businessmen who outline a yellow brick road for physicians to lead patients along. There is minimal effective policy-making from physicians. Healthcare stocks consistently grow in value, with little relationship to an improvement in clinical care, value, or cost. The government is involved as well, as in their mandate for Electronic Health Records (EHRs), a technology change that cost a lot of money, while forging a barrier between clinicians and the patients we are trying to interview, examine, and care for.

Where will the current trends take us? Will businessmen and/or the government prescribe health care? Will more and more computers and machines dominate health care?

Self-driving cars, Siri, Alexa, automated checkouts at Safeway, and IBM’s Watson are technologic realities. Will we someday see a self-driving physician with the voice of Siri and the brains of Watson?

Call that device “Doctor Vita.”

The saga of Doctor Vita arrives in 2019 from All Things That Matter Press.

 

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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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IS SUBLINGUAL SUFENTANIL DANGEROUS?

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

Is sublingual sufentanil dangerous? The United States Food and Drug Administration (FDA) voted to approve the narcotic sufentanil for sublingual use in November of 2018. Sublingual sufentanil is 5-10 times more potent than fentanyl, and dissolves under the tongue in seconds.

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In an era of opioid overdose crisis, we now have a new, even more potent pill form of opiate.

Opioid deaths 1999-2017Sublingual sufentanil is approved for use only in medical settings, for the treatment of moderate to severe acute pain. But it is also possible that sublingual sufentanil will become the most dangerous street opiate ever known. This column reviews the arrival of sublingual sufentanil, from the viewpoint of a practicing anesthesiology attending.

Raeford Brown, Jr., MD, chair of the Anesthetic and Analgesic Drug Products Advisory Committee, and professor of anesthesiology and pediatrics at the University of Kentucky, disagreed with the FDA approval for sublingual sufentanil, citing the drug’s risk for “diversion, abuse, and death.” He cited the possible harms of such a “dangerous” drug — estimated to be 500-600 times more potent than morphine — coming to market in a tablet form. He warned of the risks of diversion of sufentanil by anesthesiologists and other medical personnel. He was quoted, “Sufentanil is a very potent opioid that is in a preparation that will be easily divertible. In the IV formulation, it has been a drug of abuse for health care providers.”

I agree with Dr. Brown. Sublingual sufentanil raises dangerous concerns. Sublingual sufentanil has the potential become the hydrogen bomb of all opiates—the mother of all lethal street drugs.

I have extensive experience administering intravenous sufentanil to patients. Intravenous sufentanil was FDA-approved in 1984. Its original primary use was as an anesthetic for cardiac surgery. I practiced cardiac anesthesia from 1985 until 2000. In the 1980s, cardiac anesthesia was achieved by high dose narcotic techniques, specifically with high dose fentanyl (100 micrograms/kg) techniques. For a 70-kilogram patient, this required injecting 7000 micrograms of fentanyl, or 140 ml of fentanyl (nearly two and an half sixty-milliliter syringes full of fentanyl) at the time of anesthetic induction. When intravenous sufentanil was approved at the same 50 mcg/ml concentration as fentanyl, but with a potency of 10 X of fentanyl, the narcotic induction only required 14 ml of sufentanil total. I can still remember my wide-eyed professors saying, “With sufentanil, the entire cardiac anesthetic is here in one syringe.” The use of sufentanil for cardiac anesthesia faded as anesthesiologists began using lower doses of narcotic as part of early-extubation techniques in the late 1990s.

We also used intravenous sufentanil to supplement anesthesia for non-cardiac surgeries. The most common method was to dilute the sufentanil 10:1 with saline, to a concentration of 5 mcg/ml. At this concentration, sufentanil was indistinguishable from fentanyl at 50 mcg/ml. After several years it became apparent that there was no advantage of using sufentanil IV over fentanyl IV in non-cardiac anesthesia, and the administration of IV sufentanil dwindled. The intravenous sufentanil form of the drug was also approved for epidural anesthesia. Over time, the use of sufentanil for epidural anesthesia also decreased, also supplanted by fentanyl.

Just when it looked like sufentanil was a drug nobody really neededà enter AcelRx Pharmaceuticals, a San Francisco Bay Area company which manufactured and tested a sublingual sufentanil product designed to melt under a patient’s tongue. Pamela Palmer, the founder and Chief Medical Officer of AcelRx, received her MD and PhD at Stanford, and is an acquaintance of mine. Dr. Palmer is an anesthesiologist who is brilliant and well informed regarding the pharmacology of sufentanil and the use of sufentanil in anesthetic practice.

Because sufentanil is highly lipid (fat) soluble, it is quickly absorbed into the bloodstream through the mucosal lining of the mouth. AcelRx will market the drug under the name Dsuvia, in a sublingual sufentanil tablet system (SSTS) which consists of a single-dose applicator prefilled with a single 3-mm-diameter 30-mcg tablet, administered by a healthcare professional no more frequently than hourly.

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A radio frequency identification (RFID) cartridge, requiring the patient’s thumbprint, helps reduce unauthorized dosing. The device is tethered to the patient’s bed to reduce risk of product loss. Each tablet is pre-loaded into a single-dose applicator within a pouch so it is suitable for field/trauma use. Both the fixed drug and dose and lockout time interval eliminate the end-user programming error risk associated with Patient Controlled Analgesia (PCA) intravenous narcotic pumps.

Studies documented the efficacy and safety of the SSTS in the treatment of postoperative pain in patients following open abdominal surgery compared with placebo.

SSTS was rated a success by significantly more patients when compared to intravenous PCA morphine. There was a faster onset of analgesia and both higher patient and nurse satisfaction scores with the SSTS as measured by validated questionnaires.

Dsuvia will be marketed as “postoperative, sublingual, patient controlled analgesia.” Once administered under the tongue, the sufentanil tablets typically dissolve within 5  minutes. The FDA approved the drug to be used in hospital settings only, for the treatment of moderate-to-severe acute pain, where a narcotic is needed and rapid onset is desired, but the route of administration does not require intravenous access. Typical settings would be the surgical wards after major orthopedic or general surgery procedures. The chief competition for Dsuvia will likely be Patient Controlled Analgesia (PCA) intravenous narcotic pumps, a commonly used analgesic method in which patients push a bedside button and self-administer intravenous narcotic (e.g. morphine, fentanyl, or Dilaudid) on demand through their IV line.

The most significant risk involving sublingual sufentanil is its potency, specifically its extreme potency as a respiratory depressant. The product description by AcelRx states that sufentanil has a “high therapeutic index” of 26,716. The Therapeutic Index is the ratio that compares the blood concentration at which a drug becomes toxic and the concentration at which the drug is effective. The larger the therapeutic index (TI), the safer the drug is. The TI affirms that sufentanil toxicity starts at a concentration of 26716 times its therapeutic concentration, but this ignores the risk of respiratory depression at much, much lower doses. A patient treated with an overdose of sufentanil will stop breathing at a dose only slightly greater, i.e. in the ballpark of only 2 – 4 times greater, than its therapeutic concentration. Like all opiates, sufentanil has side effects of respiratory depression, sedation, nausea and constipation. Respiratory depression is the reason why opiate overdose patients die. Opiate overdoses do not cause death because of an inherent “toxicity” of the drug concentration in the blood, but rather because of respiratory depression. People simply stop breathing.

Regarding sufentanil, the National Institute of Health website states: WARNINGS: Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Sufentanil Citrate injection should be administered only by persons specifically trained in the use of anesthetic drugs and the management of the respiratory effects of potent opioids, including respiration and cardiac resuscitation of patients in the age group being treated. Such training must include the establishment and maintenance of a patent airway and assisted ventilation. Adequate facilities should be available for postoperative monitoring and ventilation of patients administered anesthetic doses of Sufentanil Citrate Injection. It is essential that these facilities be fully equipped to handle all degrees of respiratory depression. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status.

There is also hope that sublingual sufentanil will have battlefield applications. A statement from FDA Commissioner Scott Gottlieg, MD on November 2, 2018 read: “(Sublingual sufentanil) has some unique features in that the drug is delivered in a stable form that makes it ideally suited for certain special circumstances where patients may not be able to swallow oral medication, and where access to intravenous pain relief is not possible. This includes potential uses on the battlefield. For this reason, the Department of Defense (DoD) worked closely with the sponsor on the development of this new medicine. This opioid formulation, along with Dsuvia’s unique delivery device, was a priority medical product for the Pentagon because it fills a specific and important, but limited, unmet medical need in treating our nation’s soldiers on the battlefield. The involvement and needs of the DoD in treating soldiers on the battlefield were discussed by the advisory committee . . . The FDA has made it a high priority to make sure our soldiers have access to treatments that meet the unique needs of the battlefield, including when intravenous administration is not possible for the treatment of acute pain related to battlefield wounds.”

In conclusion, will sublingual sufentanil be dangerous or not?

My assessment of sublingual sufentanil, based on the information above, is as follows:

  1. Sublingual sufentanil (SS) can be useful in hospitalized post-operative patients following major, painful surgeries such as orthopedic total joint replacements or intra-abdominal surgeries. SS could replace PCA intravenous morphine or fentanyl.
  2. The market share, or prevalence of SS use will largely depend on its cost versus intravenous PCA units. AcelRx will market the drug beginning in early 2019, at a wholesale price of $50 to $60 per dose.
  3. SS will not be frequently used in Post Anesthesia Care Units, Intensive Care Units, or the Emergency Department, because patients in these settings all have intravenous lines in place, and can receive traditional IV narcotics as needed. There is no need or demand for a sublingual narcotic product in these settings.
  4. If SS tablets are diverted or stolen and are taken outside of medical settings, they can cause death. Overdoses as low as two to four times a therapeutic dose could cause respiratory depression and death. If hospital personnel divert the drug for recreational use, these personnel will be at high risk for mortality.
  5. If SS ever reaches the streets as a recreational drug or heroin substitute, users will achieve opiate overdose and death at a very high rate. If anyone naively believes the drug will not reach the streets, consider that manufactured forms of all the other pill forms of opiates, i.e. Percocet, Vicodin, and Oxycodone, eventually reached the streets. What will prevent this new drug from doing the same?
  6. Efforts to educate street users regarding the dangers of this new drug will likely fail. There can be no safe use of SS outside a medical setting. People will likely overdose and die.
  7. Regarding battlefield use: In military settings where IVs are not common, the capacity to administer potent sublingual narcotic may become standard. But misuse and abuse in the military and on the battlefield are also possible. Tales of rampant drug abuse by soldiers in the Vietnam War are part of the lore of that conflict. Access to sublingual sufentanil in the military would need to be strictly confined and monitored.
  8. An added note: An intentional overdose with SS is probably an outstanding drug for physician-aided suicide.

I have no crystal ball, but the bottom line is this:

If sublingual sufentanil use is confined to acute care hospital settings, it will be useful and not dangerous. But if sublingual sufentanil reaches the streets as a drug of abuse, it will be lethal.

Time will tell which of these fates is the truth.

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The most popular posts for laypeople on The Anesthesia Consultant include:

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How Safe is Anesthesia in the 21st Century?

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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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