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

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

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

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

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

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

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

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

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

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

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

Will you have a choice?

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

HOW LONG DOES GENERAL ANESTHESIA LAST?

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

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

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

Let’s look at each of these factors:

  • WHICH DRUGS WERE ADMINISTERED.

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

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

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

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

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

SEVOFLURANE VAPORIZER

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

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

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

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

  • THE LENGTH OF THE ANESTHETIC TIME.

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

  • THE TYPE OF SURGERY YOU HAD.

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

  • HOW MUCH PAIN YOU HAVE AFTER THE SURGERY.

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

  • HOW HEALTHY YOU ARE.

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

***THE ROLE OF LOCAL ANESTHETICS***

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

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

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

Colonoscopy                                                    5 minutes

Knee arthroscopy                                            5-10 minutes

Tonsillectomy                                                  5-15 minutes

Breast augmentation                                      10-15 minutes

Abdominal/flanks liposuction                        10-15 minutes

Rhinoplasty/nose surgery                               10-15 minutes

Laparoscopic abdominal surgery                  10-20 minutes

Total knee/hip replacements                         10-20 minutes

Brain surgery/craniotomy                              15-25 minutes

Open heart surgery                                        2 – 12 hours

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DYING UNDER GENERAL ANESTHESIA

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

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

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

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

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

Dr. Jack Kevorkian and his euthanasia machine

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

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

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

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

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

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

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

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

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

WILL CRNAs REPLACE MD ANESTHESIOLOGISTS?

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

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

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

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

In a word, no. 

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

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

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

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

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

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

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

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

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

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

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

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

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

The future for physician anesthesiologists still looks bright.

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

WAS TIGER WOODS DRIVING UNDER THE INFLUENCE?

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

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

Perhaps his anesthesiologist knows. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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A MORBIDLY OBESE PATIENT WITH MEAT STUCK IN HIS ESOPHAGUS

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 the anesthesiologist on call on a Saturday night. A patient arrives at the Emergency Room complaining that he ate piece of steak one hour ago, and the meat got stuck in his throat. He is morbidly obese patient who stands six feet tall and weighs 350 pounds, for a BMI of 47.

The attending general surgeon wants to do an upper GI endoscopy to extract the piece of meat from the patient’s esophagus or push it through into the stomach. He’s called on you to do the anesthetic. 

What do you do?

You examine the patient and find he has a short neck, a small mouth, and a large tongue. You cannot see his soft palate at all, and you rate him as a Mallampati 4.

Mallampati Class IV airway

The patient is alert, and is an excellent historian. He cannot even swallow his saliva. He has no difficulty breathing or significant chest pain. His hospital chart shows no past anesthetics, and he has no medical problems except hypertension which is treated with lisinopril. His vital signs are normal, and his oxygen saturation is 96% on room air.You are six months out of anesthesia training and new to this hospital. The surgeon—a 60-year-old male with the brash confidence of General Patton—is an iconic and respected figure at this medical center. He wants to proceed at once. It’s 8 pm on a Saturday night. He requests “just a little sedation” so he can insert the endoscope past the gag reflex and into the esophagus.

You bring the patient into the endoscopy suite, attach the standard vital signs monitors, and administer oxygen via a Procedural Oxygen Mask (POM, made by Mercury Medical).

You administer 2 mg of Versed and 100 micrograms of fentanyl IV. The surgeon sprays Cetacaine into the patient’s mouth for topical anesthesia and inserts a bite block. After five minutes time the patient is still wide awake. The surgeon looks at you and says, “I need him a little deeper than this.” You administer another 1 mg of Versed and 50 micrograms of fentanyl. After another five minutes time, the patient is still wide awake. The surgeon looks at you and repeats, “I need him a little deeper than this.” He says this in an impatient condescending tone, and you feel pressured. You administer 50 mg of propofol, and the patient’s eyes begin to drift closed. The surgeon inserts the gastroscope, after which the patient coughs, gags, and vomits into his airway. His oxygen saturation which had been 100% quickly plummets to 75%. You move to the head of the bed, suction the patient’s mouth, and attempt bag-mask ventilation without success. His oxygen saturation drops to 60%. You reach for a Miller 3 laryngoscope and attempt to intubate the trachea, but you cannot visualize his vocal cords. You are panicked. The surgeon is screaming at you to do something. You tell the surgeon he needs to do a tracheostomy. In the meantime you insert a laryngeal mask airway into the patient’s throat, but are still unable to ventilate the lungs. The ECG rhythm converts to ventricular fibrillation, and you call a Code Blue.

After thirty minutes of CPR and ACLS, the patient is declared dead.

What went wrong here? A patient who walked into the hospital is now dead. The basic problem was that the anesthesiologist proceeded to deeply sedate a patient with a full stomach (a known aspiration risk) without first controlling the airway by inserting an endotracheal tube. This morbidly obese patient with a thick neck, a small mouth, and a large tongue was always going to be difficult to intubate, but a successful intubation was most likely to occur under controlled circumstances with the patient awake prior to any endoscopy. The issue of a domineering surgeon pushing an inexperienced anesthesia provider into doing the wrong anesthetic is a key problem. This can and does happen, and once the case has concluded with a bad outcome, that same surgeon will deny any culpability, step back and say “I don’t do anesthesia. The decisions and actions of the anesthesiologist caused the problem, not me.”

How should the anesthetic have been done? 

In a parallel universe, an experienced anesthesiologist would do the following:

  • Explain to the surgeon and the patient that the meat stuck in the esophagus presents a dire risk of aspiration into the lungs and loss of airway, and explain to them that the case must be done either entirely awake without sedation (unlikely to be successful), or as a general anesthetic with an endotracheal tube placed prior to any endoscopy intervention.
  • This case is best done in an operating room, rather than in an endoscopy suite.
  • The anesthesiologist will assemble all emergency airway equipment, including a Glidescope, a fiberoptic laryngoscope, the entire difficult airway cart, and the scalpel, bougie, tube equipment for an emergency cricothyrotomy. 
  • The anesthesiologist will likely call in a second pair of experienced hands, either a second anesthesiologist or perhaps the in-house emergency room physician most experienced with intubating patients.
  • A rapid sequence intubation with propofol, succinylcholine, and cricoid pressure is a possible approach, but runs the risk that if the airway is so difficult that the endotracheal tube cannot be passed on the first attempt, the patient will be difficult to ventilate, difficult to oxygenate, and the meat and saliva from the esophagus could aspirate into the airway, leading to a hypoxic emergency.
  • A safer approach is an awake oral intubation using a fiberoptic laryngoscope. The back of the operating room table is inclined upward into a sitting position. Topical anesthesia and local nerve blocks of the airway are performed. See the footnote below (referenced from Miller’s Anesthesia) for a detailed description of the airway anesthesia.A Moderate sedation with Versed and fentanyl is administered, but the patient is kept awake. There’s still a risk that the topical anesthesia will blunt the cough reflex if the patient regurgitates the meat, so suction and a MaGill forceps are immediately available.
  • The anesthesiologist inserts the fiberoptic scope through an endotracheal tube (ET tube) and advances the scope into the mouth until he or she is able to visualize the vocal cords. This can be difficult and may take time, but there is no acute emergency, so an unhurried approach is warranted. Once the fiberoptic scope is threaded through the vocal cords, the patient will most likely cough violently and will require some restraint by two individuals, one on each side of the bed. The ET tube is threaded over the scope quickly and the balloon on the ET tube is inflated. The tube is connected to the anesthesia machine circuit and end-tidal CO2 is confirmed. At this point an IV bolus of propofol and rocuronium is administered to induce general anesthesia. 
  • Once the ET tube is taped securely in place, the surgeon can position the patient as he desires for the upper GI endoscopy. Anesthesia is maintained with sevoflurane and oxygen. When the surgeon is finished, the patient is awakened using sugammadex as necessary to reverse the muscle relaxation. When the patient opens his eyes, he can be safely extubated.

What are the lessons to be learned from this case study?

  • Don’t be intimidated or pushed into an unsafe anesthesia plan. Do what you were trained to do in residency, and stick to safe anesthesia practice. If an adverse outcome occurs, claiming the surgeon made you do something unsafe will not help you one bit. You are in charge of all anesthesia decisions.
  • In anesthesia practice and all acute medicine care, you must manage Airway-Breathing-Circulation (A-B-C) in that order. Anesthesiologists are trained as airway experts, and for this reason we are the most vital acute care physicians in a medical emergency. The airway must managed first.
  • Take great care when anesthetizing a morbidly obese patient. They are at higher risk for anesthetic complications. They are also at greater risk for surgical and perioperative medical problems. See the lay press coverage in U.S. News and World Report, and also another post from this blog.
  • Maintain your skills in awake intubation. No anesthesiologist uses awake intubation often. For nearly every patient the appropriate sequence is to induce anesthesia first and intubate the trachea afterwards. But some patients: e.g. those with ankylosing spondylitis, congenital airway deformities like Treacher Collins syndrome, or certain patients with morbidly obesity or super morbidly obesity (BMI > 50), awake intubation is indicated. One of my professional partners, a former Senior Examiner for the American Board of Anesthesiologists, told me that during national anesthesia oral board examinations, when a patient presented with severe airway abnormalities for a surgical case, it was very common for successful examinees to state they would perform an awake intubation. Why? Because an awake intubation burns no bridges. The patient is unharmed by general anesthesia until the ET tube is already in place, and thus is unlikely to have a Cannot Intubate-Cannot Ventilate situation that can lead to life-threatening hypoxia. And as well, in an oral exam the examinee doesn’t have to actually perform the procedure—they only have to state they could do it successfully.
  • How do you maintain your skill in awake intubation? This is the tough question. When I was in residency training, Dr. Phil Larson, a former Chairman of Anesthesia at Stanford and former Editor-in-Chief of the journal Anesthesiology, taught us elective awake intubation on patients with normal airways, who did not require an awake intubation, so we could hone the skill. Each patient was sedated with IV narcotics. Local lidocaine nerve blocks were done, and an injection of local anesthetic was administered through the cricothyroid membrane, all prior to us performing the awake fiberoptic intubation successfully. Did this take extra time? It did. The intubation and anesthesia induction took ten minutes instead of one minute. Did the surgeons mind? They didn’t, because they respected Dr. Larson, they were glad an excellent anesthesiologist was attending to their cases, and they realized that nine minutes of time was no big deal. Am I recommending you do this in your practice? No, but in this age of the Glidescope, many anesthesiologists have forgotten how to utilize a fiberoptic intubation. I recommend you practice fiberoptic intubation on asleep patients, and maintain the skill.

You may need it to save someone’s life one day.

Footnote:

A. (From Chapter 44, Airway Management in Adults, Miller’s Anesthesia, Ninth edition, pp 1373-1412)  “Topical application of local anesthetic to the airway should, in most cases, be the primary anesthetic for awake airway management. Lidocaine is the most commonly used local anesthetic for awake airway management because of its rapid onset, high therapeutic index, and availability in a wide variety of preparations and concentrations. Benzocaine and Cetacaine (a topical application spray containing benzocaine, tetracaine, and butamben; Cetylite Industries, Pennsauken, NJ) provide excellent topical anesthesia of the airway, but their use is limited by the risk of methemoglobinemia, which can occur with as little as 1 to 2 seconds of spraying. . . .  A mixture of lidocaine 3% and phenylephrine 0.25%, which can be made by combining lidocaine 4% and phenylephrine 1% in a 3:1 ratio, has similar anesthetic and vasoconstrictive properties as topical cocaine and can be used as a substitute. Topical application of local anesthetic should primarily be focused on the base of the tongue (pressure receptors here act as the afferent component of the gag reflex), the oropharynx, the hypopharynx, and the laryngeal structures; anesthesia of the oral cavity is unnecessary. . . . Before topical application of local anesthetic to the airway, administration of an anticholinergic agent should be considered to aid in the drying of secretions, which helps improve both the effectiveness of the topical local anesthetic and visualization during laryngoscopy. Glycopyrrolate is usually preferred because it has less vagolytic effects than atropine at doses that inhibit secretions and does not cross the blood-brain barrier. It should be administered as early as possible to maximize its effectiveness. “. . . Oropharyngeal anesthesia can be achieved by the direct application of local anesthetic or by the use of an atomizer or nebulizer. Topical application of local anesthetic to the larynx can be achieved by directed atomization of a local anesthetic or by the  spray-as-you-go (SAYGO) method, which involves intermittently injecting local anesthetic through the suction port or working channel of a flexible intubation scope (FIS) or optical stylet, as it is advanced toward the trachea.“Topical application of local anesthetic to the airway mucosa using one or more of these methods is often sufficient. If supplemental anesthesia is required, then a variety of nerve blocks may be used. Three of the most useful are the glossopharyngeal nerve block, superior laryngeal nerve block, and translaryngeal block. The glossopharyngeal nerve supplies sensory innervation to the posterior third of the tongue, vallecula, the anterior surface of the epiglottis, and the posterior and lateral walls of the pharynx, and is the afferent pathway of the gag reflex. To block this nerve, the tongue is displaced medially, forming a gutter (glossogingival groove). A 25-gauge spinal needle is inserted at the base of the anterior tonsillar pillar, just lateral to the base of the tongue, to a depth of 0.5 cm. After negative aspiration for blood or air, 2 mL of 2% lidocaine is injected. The process is then repeated on the contralateral side. The same procedure can be performed noninvasively with cotton-tipped swabs soaked in 4% lidocaine; the swabs are held in place for 5 minutes.”     

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ALCOHOL AND ANESTHESIA

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

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

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

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

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

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

As a patient, what should you do? 

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

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

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A DAY IN THE LIFE OF AN ANESTHESIOLOGIST

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

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

Your day is as follows, Doctor:

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

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

Empty Operating Room

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

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

Anesthesia Workstation

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

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

Labelled anesthetic syringes

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

Pre-Anesthesia Room

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

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

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

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

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

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

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

Nasotracheal Endotracheal Tube

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

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

Maxillary surgery

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

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

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

Post Anesthesia Care Unit

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

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

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

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

Ambulatory Surgery Center

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

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

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

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

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

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

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

THE PHYSICIAN ANESTHESIOLOGIST JOB MARKET LOOKS EXCELLENT

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 physician anesthesiologist job market looks excellent. Medical students, college pre-med students, and academically successful high school students, are you wondering if anesthesiology is a great career for you? The current demand for anesthesiologists is high. If you’re geographically mobile and willing to relocate to where the demand for anesthesiologists is maximal, you’ll have little problem securing a solid job.

Career Explorer reports, “There are currently an estimated 33,000 anesthesiologists in the United States. The anesthesiologist job market is expected to grow by 15.5% between 2016 and 2026.” Over the next 10 years, it is expected that America will need 6,200 anesthesiologists. That number is based on 5,100 additional anesthesiologists, and the retirement of 1,100 existing anesthesiologists.

Anesthesiology News reports a shortage in the anesthesia job market, which is fueling high job demand in the field.

The American Society of Anesthesiologists surveyed the job market in 2016. Their study reported: “At the time of the survey, almost all the (anesthesia resident) respondents had received job offers, with 97 percent having confirmed jobs. Among the geographic regions, percent of residents having a confirmed job ranged from a 93 percent (Midwest) to 100 percent (Northeast and West). Nationwide, a majority (55 percent) of residents were joining anesthesiology groups with plans to become a partner, while 45 percent accepted employed positions. The mean starting salary was $299,605 with a standard deviation of $77,000, reflecting considerable regional differences. Residents were asked to rank factors most important in choosing a job. The three most important factors included geography, job description and monetary compensation.” 

In just the past 7 days, I received the following unsolicited job offers via personal email. Seeing is believing, so peruse these requests for anesthesiologists and see what you think:

Here’s my advice:

Anesthesiology is a fascinating, challenging, adrenaline-charged career choice with a burgeoning job market. If you’re a student considering a career as a physician, The Anesthesia Consultant website strongly recommends a career as a physician anesthesiologist. For further information, I recommend the following columns from this blog:

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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?

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

THE TEN MOST SIGNIFICANT ADVANCES IN ANESTHESIOLOGY IN THE PAST DECADE

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

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

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

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

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

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

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

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

HOW DO PANDEMICS END? EXAMINING THE 1918 SPANISH FLU PANDEMIC

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

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

H1N1 influenza virus

Novel coronavirus

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

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

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

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

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

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

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

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

References:

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


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

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

SUFFOCATING ALONE

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

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

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

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

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

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

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

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

Hospice

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

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

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

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

Without suffocating alone.

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

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

WHAT ANESTHESIOLOGISTS DO… AN EXAMPLE ANESTHETIC

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

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

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

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

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

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

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

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

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

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

MONITORING SCREEN with vs

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

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

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

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

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

Sevoflurane vaporizer (see yellow knob) on anesthesia machine

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

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

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

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

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

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

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

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

The patient is now ready for the surgery to begin.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Post Anesthesia Care Unit (PACU)

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

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

Open gallbladder surgery incision

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

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

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

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

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

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

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

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

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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:
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.

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?
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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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:
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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HILARIOUS GUFFAW-OUT-LOUD MEDICAL SATIRE BY TWO STANFORD PROFESSORS

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

Publish, Don’t Perish is a hilarious guffaw-out-loud medical satire written by two Stanford anesthesia professors, Dr. Jay Brodsky and Dr. John Brock-Utne. Not since The House of God have I read a book that spoofed the medical world in such accurate detail—absurd but almost believable.

The premise of the book relates to the truism than university medical faculty must “publish or perish.” Indeed the path of promotion to tenured professor status requires academic physicians to publish original clinical or laboratory research in reputable journals. Brodsky’s and Brock-Utnes’ book focuses on the new phenomenon of “predatory internet medical journals,” which will publish nearly anything if the author pays them a fee. 

An example email a doctor will receive from one of these predatory internet journals would be a poorly worded offer such as:  “Greetings. I hope you are well and trust you are doing splendidly. I’m Editorial Manager of The New American Journal of Medicine. We have seen your recent published articles and they seem to be very fascinating and it will be grateful if you accept to contribute a manuscript to our journal . We’ll accept anything. I really hope you won’t deny my mail and will surely submit a paper to the journal. We’ll publish it within two weeks.”

Publish, Don’t Perish presents fictional examples of medical studies that these new internet journals would be happy to publish. The parody examples from Publish, Don’t Perish include:

Study: Face Masks Can Alleviate Surgical Stress. Results:

Study: The Body Habitus of Miss America Contestants Have Shown an Ominous Decrease. “Since the iconic beauty pageant was established in the 1920s, the average BMI of the Miss America winner has now dropped to < 18 kg/m2. At the current rate of decline Miss America will have a BMI of Zero by the year 2300.”

Study: The Ideal PPE (Personal Protective Equipment) for the Operating Room. “To minimize exposure in the COVID-19 crisis, . . . we have provided all our physicians and nurses with atmospheric diving suits.” See below:

Letter: Orthopedic Surgeon Presents Alternative to Tracheostomy for ICU Patient. “An orthopedic surgeon was called to perform a tracheostomy in a COVID-19 patient with respiratory failure, . . . but the surgeon was unfamiliar with that procedure and decided to proceed with the only surgical airway management operation he was comfortable with.”

News: All Ancient Women Were Obese. “In a stunning announcement by several prominent anthropologists, the scientific and medical communities were shocked to hear of a new insight into human history. ‘We believe, rather than being the exception, that all Neolithic women were obese, and in most instances they were morbidly obese. . . . At excavations of sites twenty thousand years old, just a few examples of our finds are shown below.’”

The conclusion of this stunning announcement is, “Contrary to current teaching, it is obvious that the female body is meant to be obese.”

New Nursing Journal Announced. “The American Nurses Association is proud to announce the publication of our newest nursing journal, called ‘Anecdotes, not Science, Involving Nurses In New Environments,’ or ASININE.”

Case Report: Alexa Wakes Patient Up From Surgery. “When the surgeon told me he had ten minutes left in the case, I asked Alexa to set an alarm for thirty minutes because as you know, it always takes them about three times as long to finish.”

Other laugh-out-loud faux examples include:

Study Finds That Having Sex Without a Condom May Lead to Pregnancy.

Hospital News: Hospital CEO Accidentally Visits Operating Rooms: Finds Visit Productive

Case Report: Every Hospital Service Consulted on One Patient. 

120-Year-Old Doctor Called Out of Retirement to Fight COVID-19.  “As a young physician Dr. Tuttle sherperded Washington state through the devastating 1918 Spanish Flu influenza epidemic, and Dr. Fauci is listening to his recommendations.”

News: Anesthesia Blamed for Everything.

Nurse Earns Final Degree: Now Has the Entire Alphabet Behind His Name. “Richard R. Whitaker has recently completed his advanced degree in zoophobia, and thus became the first nurse to have every single letter of the alphabet listed behind his name.” example: Richard Whitaker, RN, PhD, CNP, CNM, ADP, AARP, . . . ZD.

Dr. John Brock-Utne and Dr. Jay Brodsky

Doctors Brodsky and Brock-Utne are distinguished experts in genuine medical writing. Between them they have published over 500 articles in the peer-reviewed medical literature. Publish, Don’t Perish, an 8 X 10- inch paperback, 80 pages long, is their first full-length book of satire. In a parallel universe both authors could have made a solid living as Saturday Night Live comedy writers, or perhaps they could have penned an R-rated comedy movie or two.

Five stars. This reviewer recommends you order a copy from Amazon right now. Make sure to order a gift copy or two for your orthopedic surgeon, hospital CEO, or favorite nurse as well.

Back Cover of Publish, Don’t Perish

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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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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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.

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.

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.

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

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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:
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 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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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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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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GRADY HARP REVIEWS DOCTOR VITA. “A SPLENDID AND TIMELY NOVEL”

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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Grady Harp, Amazon Hall of Fame Top 100 Reviewer

April 20, 2019

Once again Rick Novak serves up a virulent novel that addresses an ongoing change in medicine that worries most of us – the growing dependence on robotics in surgery and the dehumanization of medicine: doctor patient interaction is altered by EMR and IT reporting of visits to insurance companies and the warmth of communication suffers. Rick takes this information to create a story about the extremes of AI in the form of a glowing globe that is Dr Vita and the struggle computer scientist/anesthesiologist Dr Lucas assumes as he tries to save medicine from the extremes of the ‘new age’ called FutureCare. As expected, Rick’s recreation of the tension in the OR and in interaction of the physicians is on target: his own experiences enhance the veracity of the story’s atmosphere.

Rick Novak writes so extremely well that likely has answered the plea of his readers to continue this `hobby’. He is becoming one of the next great American physician authors – think William Carlos Williams, Theodore Isaac Rubin, Oliver Wolf Sacks, Richard Selzer, and also the Brits Oliver Wendell Holmes et al. Medicine and writing can and do mix well in hands as gifted as Rick Novak. Highly Recommended. Grady Harp, April 19

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THE FIRST CHAPTER OF DOCTOR VITA BY RICK NOVAK

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

robotic-procedures

The first chapter of Doctor Vita by Rick Novak opens with a scene unlike any you’ve ever read before.

Chapter 1    THE BRICKLAYER

Alec Lucas’s first contact with FutureCare came in operating room #19 at the University of Silicon Valley Medical Center, where his patient Elizabeth Anderson blinked into the twin suns of the surgical lights hanging from the ceiling. A clear plastic oxygen mask covered Elizabeth’s nose and mouth, her cheeks were pale and tear-stained, and a strand of gray hair protruded from a blue paper bonnet. Her hand trembled as she reached up to remove the mask.

“I’m scared,” she said.

“I’m not,” said Dr. Lucas, who was her anesthesiologist. A green paper mask covered his face, but his pale blue eyes sparkled at her. He hummed to himself as he injected a dose of midazolam into Elizabeth’s IV to relax her.

“Am I crazy to go through this?” she said. “A 78-year-old lady with cancer?”

“We’re hoping your cancer can be cured with surgery,” Alec said. “Right now you’re doing great. Everything is perfect. Have a wonderful dream.” Elizabeth had cancer of the stomach, and presented today for robot-assisted laparoscopic surgery to remove half her stomach. It was a huge surgery—a risky surgery. Alec wondered why they were doing this operation on this lady. He questioned the aggressive strategy for a woman this old, but his job was to anesthetize, not to philosophize.

He’d seen presurgery anxiety like hers hundreds of times. The best way to cure her fears was to get her off to sleep. He injected doses of propofol and rocuronium into her intravenous line. The drugs flowed into Elizabeth’s arm, and within ten seconds her eyes closed. He inserted the lighted blade of a laryngoscope into her mouth, and visualized the white and shining upside-down “V” of her vocal cords, hovering in a sea of pink tissue. He slid a hollow plastic tube between the cords and into the blackness of the trachea beyond. Then he activated the ventilator, which blew a mixture of oxygen and sevoflurane through the tube into her lungs.

“I haven’t worked with you before, Dr. Lucas,” said the circulating nurse, who stood at the patient’s side. “My name is Maggie.”

“Of course you’ve never worked with me,” he said. “I told the nursing supervisor I never wanted to work with Maggie.” Then he winked at her and said, “We haven’t worked together because today is my first day on staff here. I’ve been at the University of Chicago since my first day of medical school. After fifteen years of shoveling snow, it was time to give California a try.”

Alec looked up as the surgeon, Xavier Templeton, entered the room. A tall scrawny man, Templeton had pale hairless matchstick arms that looked better hidden within a surgical gown. His bushy eyebrows met in the midline, and his left eye squeezed in an involuntary tic. Templeton’s hands wouldn’t touch Elizabeth Anderson’s skin or stomach today. His hands would control two levers on a console worthy of a spacecraft, and each move he made would be translated into the movement of a five-armed machine named the Michelangelo III, also known as The Bricklayer.

The five slender mechanical arms of The Bricklayer, dull gunmetal gray in color, dangled like the legs of a giant spider above Elizabeth Anderson’s abdomen. Each arm was draped in clear plastic to keep The Bricklayer sterile when it entered her body through tiny incisions.

Alec accepted his role of goaltender at the Pearly Gates. His assignment was to keep Elizabeth Anderson asleep and alive, while Templeton and The Bricklayer resected her tumor.

Twenty minutes into the surgery, Xavier Templeton sat on a chair in the corner of the room with his back to the operating table, and peered into a binocular stereo viewer. His hands maneuvered two levers on the console before him. On the operating table, the five robot arms reached into the abdomen though five one-centimeter incisions. One of the arms held a camera on a thin metal rod, movable at the surgeon’s control. A seventh-year resident worked as a surgical assistant, and attached appropriate operating instruments to the other 18-inch-long robot arms.

The two surgeons murmured to each other in quiet voices. Alec watched the surgery on a large flat screen video monitor that hung above him. He saw pink tissues, robot fingers moving, and a lot of irrigating and blunt dissection. The surgery was going well, and Alec made only minor adjustments in his drug doses and equipment as needed.

Then one thing changed.

One of the robot fingers on the video screen convulsed in staccato side-to-side slicing movements of its razor-sharp tip. A clear plastic suction tube exiting from the patient’s abdomen lurched and became an artery of bright red blood. The scarlet tube emptied into a bottle two feet in front of Alec. In sixty seconds the three-liter bottle was full of blood. Fifty-eight seconds prior to that, Alec was on his feet and both hands were moving. A flip of a switch sent a stream of fluid through the biggest IV into the patient. He turned off all the anesthesia gases and intravenous anesthetic medications.

“Big time bleeding, Dr. Templeton,” Alec shouted to the surgeon.

As fast as he could infuse fluid into two IVs, Alec could not keep up with the blood loss draining into the suction tube. The blood pressure went from normal to zero, and a cacophony of alarms sounded from the anesthesia monitoring system.

Templeton descended from his perch on the far side of the room, and put on a sterile gown and gloves. He took a scalpel from the scrub tech, and in one long stroke made an incision down the midline of the abdomen from the lower end of the breastbone to the pubic bone. With two additional long swipes, the left and right sides of Elizabeth Anderson parted. A red sea rose between them. The surgical resident and the scrub tech held suction catheters in the abdomen, but the stream of blood bubbled upward past the catheters. Templeton cursed and reached his right hand deep to the posterior surface of the abdominal cavity, feeling for the blood vessel on the left side of the spinal column. He found it, and squeezed the empty and pulseless aorta.

Alec looked at the monitors. The blood pressure was zero, and the electrocardiogram showed the heart was whipping along at a rate of 170 beats per minute. His patient had one foot in the grave. “Have you got control up there?” he screamed at Templeton.

“God damn it! I’m squeezing the aorta between my fingers,” Templeton answered. “As soon as I can see, I’ll put a clamp on the vessel. The bleeding is everywhere. I can’t see a damn thing.” Templeton’s face, mask, hat, and gown were drenched with the blood of Elizabeth Anderson. His unibrow was a red and black dotted line.

“Fire up the Maytag,” Alec said to Maggie. “Call the blood bank and activate the massive transfusion protocol.” Alec bent over the Maytag, a rapid blood infusion device with a bowl the size of a small washing machine. He turned the Maytag to its top flow rate. The machine hummed and spun, and the basin of IV fluid emptied into Elizabeth Anderson through a hose as wide as a small hot dog.

Despite the infusion of fluid, her blood pressure peaked at a dismal 65/40. “Have you found the hole yet?” he said to Templeton.

“Torn aorta. There are multiple holes—the aorta’s leaking like a sprinkler hose,” Templeton said without looking up. His left eye was blinking and squeezing repeatedly as he worked. “It’s terrible. The inferior vena cava is shredded and the blood from the lower half of her body is pouring out into her abdomen. The blood is everywhere.” Blink, squeeze. “Her vessels are falling apart like tissue paper.”

An orderly ran into the operating room carrying a red plastic beer cooler. Alec grabbed the cooler and popped off the top. Inside were six units of packed red blood cells, six units of fresh frozen plasma, and six units of platelets from the blood bank. “Check all the units and let’s get them flowing,” he said to Maggie.

Maggie picked up each bag and double-checked the patient’s name and the unit numbers with a second nurse, and then she handed the entire cooler to Alec. He drained each of the units of blood products into the basin of the Maytag, and the bowl hummed and pumped the blood into Elizabeth Anderson. The blood pressure began to climb, but one look at the crimson suction tubes exiting the patient’s stomach told Alec they were still in trouble. The bleeding wasn’t slowing. Blood was exiting faster than he could pump it in.

“We need a second cooler of blood products stat!” he said. Maggie picked up a telephone and relayed the order to the blood bank.

Alec looked at the surgical field, and the patient’s blood was everywhere—on Templeton’s face, hands, gown, on the surgical drapes and on the floor. It was everywhere but where it needed to be—inside her blood vessels. Templeton’s resident was jamming a suction catheter into the abdomen next to Templeton’s fingers, trying to salvage as much blood as he could.

“Damn it,” Templeton said. “She’s still bleeding, and now she’s bleeding pink piss water. I can see through her blood, it’s so dilute. How much fluid have you given her?”

“Six units of blood, six units of plasma, six units of platelets, and eight liters of saline.”

Alec glanced at the monitors and saw that her blood pressure had plateaued at a near-lethal level of 40/15.

“Her blood isn’t clotting anymore,” Templeton said. “The blood’s oozing and leaking everywhere I place a suture.”

Alec palpated her neck, and there was no pulse. “She has no blood pressure and no pulse,” he said. “We need to start CPR.”

Templeton’s resident placed the palms of his hands on Elizabeth Anderson’s breastbone and began chest compressions. The patient’s heart rate of 180 beats per minute slowed to 40 beats per minute, with premature beats and pauses between them. After twenty seconds of a slow irregular rhythm, her heartbeat tracing faded into the quivering line diagnostic of ventricular fibrillation.

Alec injected 1 milligram of epinephrine, and screamed, “Bring in the defibrillator.”

A second nurse pushed the defibrillator unit up to the operating room table. Templeton charged the paddles, applied them to the patient’s chest, and pushed the buttons. Elizabeth Anderson’s body leapt into the air as the shock of electrical energy depolarized every muscle of her body. All eyes turned to the ECG rhythm, and it was worse than ever.

Flat line.

“Damn it. Give me the scalpel back,” Templeton said. He carved a long incision between the ribs on the left side of Elizabeth Anderson’s chest, and inserted his hand into her thorax.

“I have her heart in my hand and I’m giving her direct cardiac massage,” he said. Alec looked at the monitors, and the direct squeezing of the heart was doing nothing. The blood pressure was still zero, and now blood was oozing from the skin around her IV sites, as well as from the surgical wounds in her abdomen.

Elizabeth Anderson’s heart was empty. Her blood vessels were empty. Her blood pressure had been near-zero for twenty-five minutes.

“What do you think, sir, should we call it?” Templeton’s resident said.

Templeton pulled his hand out of Elizabeth Anderson’s chest, and looked at the clock. “I pronounce her dead, as of 8:48 a.m. Damn, damn, damn it!”

Alec reached over and turned off the ventilator. The mechanical breathing ceased, and there was nothing left to do. He looked down at Elizabeth Anderson’s bloated face. Two strips of clear plastic tape held her eyes fastened shut, and her cheeks were as white as the bed sheet she rested on. A length of pink tape held the breathing tube fixed to her upper lip, and blood oozed from her nose and from the membranes between her teeth. This lady walked into the University of Silicon Valley Medical Center today hoping for a surgical miracle, and instead she was going to the morgue looking like this.

Xavier Templeton peeled his gloves off. “Goddamn it! The fricking robot went berserk. Sliced into the artery like a goddamned hedge trimmer. Now I have to tell the family she’s dead. Goddamn damn it!” He scowled in Alec’s direction. “Are you coming with me, Dr. Lucas?”

Alec nodded a yes. He looked at the gloomy outline of The Bricklayer’s arms, and then back at Templeton. Templeton was a fool to blame the medical device for his own ineptitude. The machine could do no wrong on its own.

This was the surgeon’s fault. Alec had heard it all before. Accept compliments and deflect all blame—it was an adage as old as the profession of surgery.

Templeton commanded The Bricklayer. And The Bricklayer was no better than the human hands that led it.

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WHICH ANESTHESIA FELLOWSHIPS ARE MOST POPULAR?

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

Which anesthesia fellowships are most popular? How many anesthesia residents choose further subspecialty fellowship education at the end of their residency, and which subspecialties are those graduates choosing?

The grid below, published in the California Society of Anesthesiologists Vital Times 2018, lists the fellowship choices from the last five years of Stanford anesthesia resident graduates:

IMG_7419.jpg

The totals from most popular to least popular fellowship choices from this grid are as follows:

SUBSPECIALTY:

Cardiac anesthesia                17

Regional anesthesia              14

Pediatric anesthesia              12

ICU/critical care                        10

Pain medicine                             8

Research                                         8

Obstetric anesthesia               2

Neuro anesthesia                      1

ENT/airway                                    1

Transfusion medicine            1

Palliative care                              1

TOTAL                                             75

Approximately 28 residents graduate from Stanford each year, for a total of 140 graduates over five years. If 75 out of 140 graduates pursued fellowships, then approximately 53% of residents chose fellowships, while 47% entered the workforce without further fellowship training.

I’m a private practice/community anesthesiologist who also practices in a major university medical center at Stanford, and I have some reflections on this data. The fact that 47% of the graduates do not pursue subspecialty fellowship training doesn’t surprise me. If an anesthesiologist proceeds directly through college, medical school, internship, and then a three-year residency, he or she will be at a minimum 30 years old. Twelve years of post-high school education is enough for many graduates, and the desire to earn a paycheck can trump any desire to complete any more training. A board-eligible anesthesiologist without a fellowship can find a job in most geographical areas without difficulty. In a competitive marketplace such as the San Francisco Bay Area, I believe an anesthesiologist with fellowship training gains an advantage in the search for a plum job over someone who did not complete a fellowship.

Let’s look at the fellowships Stanford graduates chose, and discuss the merits of each subspecialty as of 2019:

220px-Cvt_anesthesologist

Cardiac anesthesia continues to be popular. Stanford has outstanding cardiac surgery and cardiac anesthesia departments. The technology and challenges of cardiac anesthesia tend to draw ambitious residents into this subspecialty. I practiced cardiac anesthesia for 15 years. Those years were notable for very early morning arrival at the hospital (circa 6 a.m.), lots of invasive anesthesia preoperative procedures (arterial lines, central venous pressure catheters, pulmonary artery catheters, and transesophageal echocardiography), long complicated surgeries, sick patients, takebacks for bleeding in the middle of the night, and several surgeons with demanding difficult personalities. The field of cardiac surgery has changed dramatically since the 1980s and 1990s, when one of my surgical colleagues then lamented, “What’s the difference between a cardiac surgeon and a dinosaur?” His answer was, “Nothing.” In the 1980s invasive cardiologists began inventing techniques to apply balloons and stents in the coronary arteries to replace the open-chest coronary artery bypass grafting that cardiac surgeons used to do. Today even valve replacements can be done by cardiologists. Today cardiac surgeries are primarily difficult tertiary cases and revision procedures, i.e. cases that cardiologists cannot fix via intravascular access.

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Regional anesthesia is a growing field. Both academic and community anesthesia groups need individuals with expertise in ultrasound-guided regional blocks. Regional anesthesia specialists should have no trouble finding jobs.

pediatricanesthesia

Pediatric anesthesia specialists are found in every large anesthesia department. Pediatric hospitals need fellowship-trained graduates on their staff, but for private/community groups, the role of fellowship-trained pediatric anesthesiologists depends on the volume of pediatric surgery. Community groups often expect multiple anesthesiologists to cover routine pediatric cases (e.g. age 1 and over) when they are on call. If only 10% of cases are pediatric and those cases sometimes occur on weekends or at night when an on call anesthesiologist will staff the cases, it’s unlikely the group will hire a specialist pediatric anesthesiologist to be on call every night. For a large group, this may be possible, but for a smaller group, it may not.

Respiratory_therapist

ICU/critical care medicine fellowships have always been popular at Stanford. For years the anesthesia department ran the intensive care units at Stanford, and these anesthesia/ICU attendings were outstanding role models. I decided to follow my internal medicine residency at Stanford with an anesthesia residency because I was so impressed with the ICU attendings and their training. The current Stanford anesthesiologist department chairman, Ron Pearl MD PhD, was initially a Stanford internal medicine resident who then completed the Stanford ICU fellowship, and after all that enrolled in and graduated from the Stanford anesthesia residency program. The unique value of an ICU fellowship is that you attend to sick patients of every type, and you become comfortable managing the most demanding medical situations day and night. ICU/critical care graduates are become outstanding clinical anesthesiologists who add value in either an academic or a community setting. Note that in a private/community practice setting, the clinical work in an ICU setting often becomes secondary to operating room anesthesia work, because there have always been superior financial reimbursements for the time anesthesiologists spend in the operating room versus the time they spend in the ICU.

epidural-injections

Pain medicine is a vast frontier for anesthesiology. The anesthesia department at Stanford renamed itself the Department of Anesthesiology, Perioperative and Pain Medicine to emphasize the inclusion of pain medicine within our specialty. While the clinical features of operating room anesthesia care have changed very little in recent decades, the possibilities for research and growth in pain medicine are limitless. As an internal medicine doctor, I can tell you that almost everyone hurts in some part of their body, and the treatments for pain, especially for chronic pain, are still in their infancy. Opioid medications work for a while, but patients can become tolerant and addicted to the drugs. More specific pain treatments without the opioid side effects of respiratory depression, addiction, constipation, and nausea are desperately needed. The potential for basic science research in pain medicine is unequaled in any other field of anesthesia. In either community or academic practice, pain doctors staff pain clinics where other physicians can refer their most difficult and unhappy patients. Pain clinic waiting rooms are rarely empty.

2-laboratory-test-tubes-in-science-research-lab-olivier-l-studio

Research fellowships are a launching pad to an academic career. Selecting an outstanding mentor is a key factor. If a mentor is known to publish extensively, he or she can teach their fellow how to select important projects, design experiments and studies, write grants, write research papers, and get those papers published. Basic science laboratory research is becoming the domain of investigators with PhDs. Significant clinical research is done primarily by MD anesthesia faculty members at universities. The reputation of a professors is judged by the extent of their publishing and research. Research fellowships are not an important step to a career in private/community clinical medicine.

obanesth

Obstetric anesthesia is a valid subspecialty in academic centers. In private/community jobs, it’s expected that all anesthesiologists who are on call on weekends and nights can handle both routine and emergency obstetric cases. Completing an OB fellowship isn’t a direct link to landing a graduate an outstanding community job—almost every community anesthesiologist will be expected to have to have OB skills.

2-craniotomy-brain-surgery-dr-p-marazziscience-photo-library

Neuro anesthesia training will prepare a graduate for a wide array of brain surgery cases. This specialty will be valued in an academic practice or in a private/community group that does a large amount of neurosurgery.

Awake-Intubation.001

In Ear, nose and throat/airway subspecialty training, a graduate will gain expertise in managing difficult airway cases. This field will appeal to graduates seeking an academic job doing complex head and neck surgical cases.

I don’t have access to national data on the distribution of fellowships in graduates of anesthesia programs other than Stanford. While it’s possible that Stanford is an atypical peer group, I hope this analysis of the fellowships Stanford graduates choose gives you a better idea of the career choices available to anesthesia residents.

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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:

Matadi-Sela-Petit

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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