NERVE BLOCKS AND NERVE INJURY

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Let’s discuss an elephant in the room of operating room anesthesia–the association between peripheral nerve blocks and nerve injury.

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The use of peripheral nerve blocks has crescendoed in anesthesia practice, stimulated by the use of ultrasound-guided visualization of nerves. There are growing economic industries in ultrasound machines, ultrasound block needles, and in anesthesia personnel who bill for this additional optional procedure on orthopedic patients.

Ultrasound allows us to visualize the nerves, but there are no data demonstrating a lower neurologic complication rate with this ultrasound technique.(Liu SS, et al. A prospective, randomized controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg. 2009;109:265-271).

The incidence of nerve injury following peripheral nerve block is low, but not zero. Per Gadsden, the mechanism of permanent nerve injury is felt to be either needle trauma, or toxicity of local anesthetics. In a review article by David Hardman MD MBA, of the University of North Carolina, the incidence of permanent injury rates, as defined by a neurologic abnormality present at or beyond 12 months after the procedure, ranges from 0.029% to 0.2%. This reviewed data came from old studies, dating from 2001 – 2012. There are no more recent published studies of large populations. Multiplying this 1/3000 to 1/500 incidence by the tens of thousands of nerve blocks performed yearly leads to a significant number of permanently damaged nerves.

This is a problem.

I would never agree to have an ultrasound-guided brachial plexus, femoral or popliteal nerve block performed on me.

Why not? Because I need my hands and upper extremities to function normally in order to earn a living as an anesthesiologist. Because I’m also active in a number of sports, and I need my legs and lower extremities to function normally in order to walk, run, and function in athletics.

For me, the acceptable incidence of permanent nerve injury to my limbs is zero. The incidence of permanent nerve injury with general anesthesia should be zero. Of course, if the surgical team is negligent and positions me in a dangerous posture during general anesthesia, there could be a compression or traction nerve injury, but this is exceedingly rare in competent hands. Of course, if an orthopedic surgeon is negligent and compresses, stretches or damages a nerve, there could be nerve injury, but again this is exceedingly rare in competent hands.

If I’m wary of having a peripheral nerve block performed on myself, then I must be wary for my patients as well. Every individual needs their upper and lower extremities to function normally to perform every day tasks, to perform their jobs, or to enjoy their leisure or athletic activities.

I contend that, as of 2018, the incidence and number of permanent nerve injuries during this era of ultrasound-guided nerve blocks looms larger than any medical literature confirms. Why is this? I believe there are several reasons for the under-reporting of nerve injury following peripheral nerve blocks:

  1. Time lag in published data. The data in the medical literature regarding peripheral nerve injury following nerve block is old. In a lecture on this topic by David Hardman MD MBA at the American Society of Anesthesiologists (ASA) national convention in San Francisco, none of the data regarding nerve injury complication was more recent that 2007. Recent data is still unreported, and remains to be analyzed.
  2. Time lag in Closed Claims data. The ASA Closed Claims data always lags behind the occurrence of complications. A typical malpractice lawsuit takes a long time (e.g. 4 – 7 years) to come to a conclusion. The ASA Closed Claim database may be 10 years or more in arrears before it is finally published.
  3. Some peripheral nerve injuries never get reported to anyone. Either the patient never informs the physician, the case never gets tallied in any database, the physician never informs any quality assurance (QA) committee, or the case meets its termination in a QA committee discussion that goes no further.
  4. No one publishes case reports of their complications. Do you think an anesthesiologist is motivated to publish a case report in which they had permanent nerve injury of the brachial plexus following an interscalene nerve block for shoulder surgery? Of course not. He or she wants that case buried deeply, with as few people as possible knowing. No one publishes their dirty laundry, hence the medical literature is lacking in adverse case reports.
  5. Academic professors specializing in regional anesthesia have little interest in publicizing data that could damn or minimize the importance of their chosen subspecialty. A physician who makes his or her living performing, teaching, and writing about a hammer has a conflict of interest when it comes to speaking out on the dangers of wielding that hammer.

In my role as a peer review physician, quality assurance committee member, expert legal witness, and simply as a physician in a busy medical system, I’m aware of more than a dozen patients who already have permanent nerve injury following an ultrasound-guided peripheral nerve block. None of their case histories has been published, and none of their cases have appeared in a published series of nerve injury complications.

Is there a cover-up ongoing regarding permanent nerve injury? There is certainly no publicizing of these complications.

Let me give you an example of another anesthesia technique that was associated with permanent nerve injury: In the 1990’s we routinely used hyperbaric 5% lidocaine for spinal anesthesia. Lidocaine had the advantage of supplying short (1 – 1 ½ hour) spinal anesthesia for simple cases such as cytoscopies, urethral surgeries, perineal surgeries, and inguinal hernias. Case reports of cauda equina syndrome emerged, in which some lidocaine spinal anesthetics were associated with inflammation of the distal spinal cord (cauda equina), which caused permanent lower extremity nerve injury. Because of this risk, the use of lidocaine spinal anesthesia disappeared. The risk of nerve injury was real, and the risk was too daunting to continue using that anesthesia technique.

Expect a similar story to evolve over the coming years regarding the current burgeoning practice of peripheral nerve blockade. “Complications of Peripheral Nerve Block,” an article published in the British Journal of Anaesthesia in 2010, stated that “complications of peripheral nerve blocks are fortunately rare, but can be devastating for both the patient and the anaesthesiologist.” Indeed, for the patients whose nerve injury does not resolve it can be a tragedy.

In his lecture on nerve injury complications of peripheral nerve block delivered at the 2018 ASA national convention in San Francisco, speaker David Hardman, MD MBA told a standing room only crowd of anesthesiologists that if your patient develops a permanent nerve injury following a peripheral nerve block, “you will be sued.” Why was there a huge crowd for this particular lecture? I believe it’s because many anesthesiologists are aware of the occurrence of nerve injury, and aren’t sure what to do about the incidence of ultrasound-guided nerve blocks in their practice.

No one wants to be sued, but per the Hippocratic Oath we must first do no harm. The real crisis is not that an anesthesia provider gets sued, but that the patient will go the rest of their lives without the normal use of their arm or leg.

General anesthesia has risks. Adding a regional anesthetic to a general anesthetic adds a second set of risks. At times regional anesthesia is indicated. I still perform peripheral nerve blocks on select patients, and I believe peripheral nerve blockade still has utility in anesthesia practice. I believe ultrasound-guided peripheral nerve blocks are indicated:

  1. If the scheduled procedure will cause significant post-operative pain, e.g. a total shoulder replacement.
  2. If parenteral narcotics are unlikely to relieve the pain satisfactorily, e.g. a total shoulder replacement, or you are doing a painful procedure on a patient who consumes chronic narcotics, and who will be tolerant to narcotic analgesia.
  3. If I explain the non-zero risk of permanent nerve injury, e.g. a risk of 1 in 3000 patients, and the patient both understands this risk and consents to proceed.

Seducing a patient into accepting a peripheral nerve block by minimizing the chance of permanent nerve injury with phases such as, “nerve injury is very, very rare,” or “nerve injury is very uncommon, and it usually resolves,” is deceptive medical practice. If that patient later develops permanent nerve injury, you can expect to be sued. A 2007 survey of academic regional anesthesiologists indicated that nearly 40% of respondents did not disclose the risks of long-term and disabling neurologic injury prior to performing peripheral nerve blocks.( Brull R, et al. Disclosure of risks associated with regional anesthesia: a survey of academic regional anesthesiologists. Reg Anesth Pain Med. 2007;32:7-11)

It’s better to tell the patient the truth, and risk the following dialogue:

Anesthesiologist: “The risk of permanent nerve injury after this nerve block is very low, but it’s not zero. A ballpark incidence of the chance of permanent nerve injury to your arm (or leg) is one patient in 3,000.”

 Patient: “A one in 3000 chance that I could have permanent nerve injury? I don’t want to take that chance. Skip the block.”

Yes, you might lose the opportunity to do the block, but that’s what informed consent is all about. It’s your duty to explain the risks, the benefits, and the alternatives. In Hardman’s article, the author states that he circles the words “nerve injury” on the anesthesia consent for peripheral nerve block, and he has the patient write their initials next to it, to document that they have read it and understand the risks.

 

REFERENCES:

  1. https://www.anesthesiologynews.com/Review-Articles/Article/07-15/Nerve-Injury-After-Peripheral-Nerve-Block-nbsp-Best-Practices-and-Medical-Legal-Protection-Strategies/32991/ses=ogst
  2. Liu SS, et al. A prospective, randomized controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg. 2009;109:265-271).
  3. Brull R, et al. Disclosure of risks associated with regional anesthesia: a survey of academic regional anesthesiologists. Reg Anesth Pain Med. 2007;32:7-11.
  4.  http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1948033
  5. https://www.nysora.com/neurologic-complications-of-peripheral-nerve-blocks
  6. https://academic.oup.com/bja/article/105/suppl_1/i97/235950   

 

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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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ABOUT THE ANESTHESIA CONSULTANT

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Greetings. My name is Dr. Richard Novak, the author of About The Anesthesia Consultant. The Anesthesia Consultant exists to increase your knowledge about anesthesia and the practice of medicine before, during, and after surgery. The Anesthesia Consultant is designed to inform and entertain both laypeople and medical specialists, and provides answers not found in traditional textbooks.

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I’m a Stanford-trained physician, double-boarded in internal medicine and anesthesiology, and I’ve personally anesthetized over 25,000 patients over 34+ years. I’m currently an Adjunct Clinical Professor in the Stanford Department of Anesthesiology, Perioperative and Pain Medicine.

I’ve learned a lot over these years, and my intent is to share my knowledge with my readers, who include anesthesia professionals and lay people. This anesthesia blog contains more than 180 distinct pages and posts, all written by me. About half the columns are directed to the general public, so that they can understand anesthesia practice and the life of an anesthesia professional. The other half are detailed, well-referenced articles aimed at physician anesthesiologists, nurse anesthetists, and anesthesia assistants the world over.

I began my writing career in 2001, when I was the Deputy Chief of Anesthesia at Stanford University Hospital. Stanford is a mixed hospital, with both full time faculty and private practice faculty. I have been in the private practice of anesthesia since 1986, and my viewpoints are unique because very few private practice physician anesthesiologists have worked in a major university hospital for over thirty years.

Private practice anesthesia differs from academic anesthesia in important ways, and I began writing monthly Deputy Chief Columns in the Stanford Anesthesiology Department newsletter in 2001, to articulate these differences.

Once the total number of columns exceeded sixty, I created The Anesthesia Consultant website in 2010 to share my writing with readers outside Stanford. I continue to write 1 – 1 columns per month, in addition to maintaining a full time job as a clinical anesthesiologist.

In 2018, The Anesthesia Consultant was rated the #7 anesthesia blog in the world by Feedspot.

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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?

 

Click on the Pages of The Anesthesia Consultant for an overview of important topics, or browse through the 160+ Posts listed in the sidebar. If you don’t find the answer to your anesthesia questions, you can contact me at:

rjnov@yahoo.com.

 

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

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Thanks, and good luck reading!

Richard Novak, MD

 

ANESTHESIA EXPERT WITNESS

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Dr. Richard Novak, an Adjunct Clinical Professor of Anesthesiology at Stanford University Medical Center, is available for anesthesia expert witness consultation.

Dr. Novak is a clinician who administers anesthesia and directs perioperative medical care at Stanford University Hospital and multiple outpatient surgery centers in and around Palo Alto, California. Dr. Novak has personally performed more than 25,000 anesthetics since 1984, and is uniquely qualified because he works in an academic medical center but is also a community private practice anesthesiologist.  In addition to providing clinical care, Dr. Novak is available for experienced medical-legal expert witness consultation, case review, or testimony in the specialties of anesthesiology and perioperative internal medicine.

Dr. Novak is board certified by both the American Board of Anesthesiology and the American Board of Internal Medicine.

CONTACT EMAIL:  RJNOV@yahoo.com

 

CURRICULUM VITAE

OFFICE ADDRESS

Associated Anesthesiologists Medical Group

2237 Alma Street

Palo Alto, California 94601

telephone (650) 323-0617

 

Education:

1972-76                        B.A., Chemistry, Magna Cum Laude, Carleton College

1976-80                        M.D., University of Chicago Pritzker School of Medicine

 

Postgraduate Education:

1980-81                        Internship in Internal Medicine, Stanford University Hospital

1981-83                        Residency in Internal Medicine, Stanford University Hospital

1984-86                        Residency in Anesthesiology, Stanford University Hospital

 

Awards and Honors:

 Phi Beta Kappa, Carleton College

AOA, University of Chicago School of Medicine

 

Professional Experience:

1983-84  Physician Specialist, Department of Internal Medicine, Stanford Emergency Room, Stanford University School of Medicine

1986   Attending Anesthesiologist, Santa Teresa Kaiser Hospital, San Jose, CA

1986-88   Attending Anesthesiologist, Washington Hospital, Fremont, California

1989 to Present    Attending Anesthesiologist, Stanford University Hospital, Associated Anesthesiologists Medical Group, Inc., Palo Alto, California

 

Medical Licensure:  California

 

Medical Staff Privileges:

Stanford University Hospital, Palo Alto, California

Plastic Surgery Center, Palo Alto, California

Menlo Park Surgical Hospital, Menlo Park, California

Waverley Surgery Center, Palo Alto, California

California Ear Institute, Palo Alto, California

 

Board Certification:

1981       Diplomate, National Board of Medical Examiners

1983       Diplomate, American Board of Internal Medicine

1987       Diplomate, American Board of Anesthesiology

 

Academic Appointments:

1983-84    Physician Specialist, Department of Internal Medicine, Emergency Room Attending, Stanford University School of Medicine.

1988-1993    Clinical Instructor, Stanford University Department of Anesthesiology

1993- 2000    Adjunct Clinical Assistant Professor, Stanford University Department of Anesthesiology.

2000 to August 2018    Adjunct Clinical Associate Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine.

September 2018 to present   Adjunct Clinical Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine.

 

Teaching Experience:

1983  Instructor, Advanced Trauma Life Support, Instructor, Advanced Cardiac Life Support

1984   Lecturer, Emergency Management of Overdose,  Stanford Hospital Pharmacy Symposium

1988 to Present  Examiner, Practice Oral Board Exams, Stanford Department of Anesthesia

1992  Lecturer, Preoperative Assessment of Internal Medicine Patients,

Internal Medicine Resident  Conference, Stanford University Hospital

1993  Lecturer, Anaphylaxis on Induction of General Anesthesia,, Stanford Anesthesia Grand Rounds

1995  Lecturer, Electrolyte Disturbance during Hysteroscopy, Stanford Anesthesia Grand Rounds

2001 Lecturer, Anaphylaxis during Liposuction, Stanford Anesthesia Grand Rounds

2001 to Present  Author, Deputy Chief Column, Anesthesia Gas Pipeline, Department of Anesthesia, Stanford, CA.

2003  Lecturer, Hypovolemic Shock in Gynecologic Laparoscopy, Stanford Anesthesia Grand Rounds

2004 Lecturer, Neurologic Complications following Total Joint Replacement, Stanford Anesthesia Grand Rounds

2005 Lecturer, Preoperative Screening at an Freestanding Ambulatory Surgery Center, Stanford Anesthesia Grand Rounds

2007 Lecturer, Awareness During General Anesthesia, Stanford Anesthesia Grand Rounds

2009 Lecturer, Medical Director Management of a Freestanding Ambulatory Surgery Center, Stanford Anesthesia Grand Rounds

2011 Lecturer, Pulmonary Edema in a 3-Year-Old Following Tonsillectomy, and 75 Cases of 10-Hour Outpatient General Anesthetics for Atresia/Microtia Pediatric Surgery, Stanford Anesthesia Grand Rounds

2015 Lecturer, Pediatric Anesthesia in a Freestanding Ambulatory Surgery Center, Stanford Anesthesia Grand Rounds

2016  Invited Lecturer, The Transition From Anesthesia Residency to Community Practice, University of New Mexico, Albuquerque, New Mexico, July 14, 2016

2016  Invited Lecturer, Pediatric Anesthesia at Freestanding Ambulatory Facilities, University of New Mexico Anesthesia Grand Rounds, Albuquerque, New Mexico, July 15, 2016

2017  Lecturer, Expert Witness Testimony in Anesthesia, Stanford Anesthesia Grand Rounds

 

Offices Held:

1991 to Present  Vice President, Associated Anesthesiologists Medical Group, Inc.

1995 to 1998   Alternate Delegate, District 4, California Society of Anesthesiologists

1996 to 2000  Medical Advisory Board, Palo Alto Surgecenter

2001-2015  Deputy Chief of Anesthesia, Stanford University Medical Center

2002-Present  Medical Director, Waverley Surgery Center, Palo Alto, California

2005-2014  Delegate, District 4, California Society of Anesthesiologists

2006-Present Expert Reviewer, Medical Board of California

 

Medical Committees:

1997 to 2009   Care Improvement QA Committee, Stanford Univ. Hospital

1998 to Present   Quality Assurance Committee, Stanford Dept. of Anesthesia

1997 to Present   Quality Assurance Committee, Associated Anesthesiologists Medical Group

1996 to 2000    Medical Advisory Board, Palo Alto Surgecenter

2002 to 2009   Stanford University Hospital Anesthesia QA Committee

2002 to Present  Chairman, Waverley Surgery Center QA Committee

 

Publications:

Novak RJ, Gaeke R, Kirsner JB. Chronic Daily Narcotic Use in Patients with Crohn’s Disease:   Gastroenterology May 1980;  78(5): Part 2, p 1331.

Novak  RJ, Hill BB, Schubart PJ, Fogarty TJ, Zarins CK.  Endovascular Aortic Aneurysm Repair in a Patient with Prohibitive Cardiopulmonary Risk:  Anesthesiology 1999;  91:  1542 – 45.

Novak RJ, Dental Anesthesia for Autistic Children, letter to the editor:   Autism Research Review International 2000, Vol 14, No. 4, page 7.

Novak RJ, The Metronome, Anesthesiology, Mind to Mind Section 2012: 117:417.

Novak RJ, Vascular Access Made Easy, Outpatient Surgery Magazine Manager’s Guide to Ambulatory Anesthesia, July 2013, pages 10-19.

Novak RJ, Lessons in Medication Labeling, Outpatient Surgery Magazine Manager’s Guide to Ambulatory Anesthesia, October 2013, pages 22-25.

Author, Deputy Chief Columns, January 2001 – 2015, Anesthesia publication Gas Pipeline, circulated internationally by the Department of Anesthesia, Stanford, CA.

Author, The Anesthesia Consultant website, http://theanesthesiaconsultant.com

Novak RJ, The Doctor and Mr. Dylan, a novel, Pegasus Books, 2014, and Montelago Press, 2017, (second edition).

Novak, RJ, Best Practices in Drug Safety, Manager’s Guide to Staff and Patient Safety Supplement to Outpatient Surgery Magazine, October 2015, pages 34-40.

Novak RJ, Book Chapter, Disorders of Potassium Balance, in Complications in                        Anesthesia, 3rd Edition, 2017, edited by Lee Fleisher and Stanley Rosenbaum,                        Elsevier Press, Philadelphia.

Novak RJ, Book Chapter: Management of Insulin Overdose; in Advanced                         Perioperative Crisis Management, 2017, edited by Matthew McEvoy                                          and Cory Furse, Oxford Press.

Novak RJ, Book Chapter, Anesthesia Considerations in Ear Reconstruction, in Modern Microtia Reconstruction: Art, Science, and New Clinical Techniques, edited by Reinisch J and Tahiri Y, Springer Press, New York (In Press).

Novak RJ, Ideas That Work: Anesthesiologists Start Their Own IVs to                                     Build Rapport With Patients, Outpatient Surgery Magazine, April 2017.

Novak RJ, Doctor Vita, a novel, All Things That Matter Press, 2019 (In press).

 

Volunteer Activities:

 1992 to 2000    Internal Medicine Physician, RotaCare Clinic of East Palo Alto

2007 to 2009     Internal Medicine Physician, Samaritan House Clinic, Redwood City

2015 to present  Editor for SafeSpace mental health non-profit organization, Menlo Park, CA

 

Professional Societies:

American Society of Anesthesiologists

California Society of Anesthesiologists

California Medical Association

Santa Clara County Medical Association

 

All expert witness testimony follows the Guidelines For ExpertWitness Qualifications and Testimony, as set forth by American Society of Anesthesiologists:

GUIDELINES FOR EXPERT WITNESS QUALIFICATIONS AND TESTIMONY (Approved by the ASA House of Delegates on October 15, 2003, and last amended on October 22, 2008) PREAMBLE The integrity of the litigation process in the United States depends in part on the honest, unbiased, responsible testimony of expert witnesses. Such testimony serves to clarify and explain technical concepts and to articulate professional standards of care. The ASA supports the concept that such expert testimony by anesthesiologists should be readily available, objective and unbiased. To limit uninformed and possibly misleading testimony, experts should be qualified for their role and should follow a clear and consistent set of ethical guidelines. A. EXPERT WITNESS QUALIFICATIONS 1. The physician (expert witness) should have a current, valid and unrestricted license to practice medicine. 2. The physician should be board certified in anesthesiology or hold an equivalent specialist qualification. 3. The physician should have been actively involved in the clinical practice of anesthesiology at the time of the event. B. EXPERT WITNESS ETHICAL GUIDELINES 1. The physician’s review of the medical facts should be truthful, thorough and impartial and should not exclude any relevant information to create a view favoring either the plaintiff or the defendant. The ultimate test for accuracy and impartiality is a willingness to prepare testimony that could be presented unchanged for use by either the plaintiff or defendant. 2. The physician’s testimony should reflect an evaluation of performance in light of generally accepted standards, reflected in relevant literature, neither condemning performance that clearly falls within generally accepted practice standards nor endorsing or condoning performance that clearly falls outside accepted medical practice. 3. The physician should make a clear distinction between medical malpractice and adverse outcomes not necessarily related to negligent practice. 4. The physician should make every effort to assess the relationship of the alleged substandard practice to the patient’s outcome. Deviation from a practice standard is not always causally related to a poor outcome. 5. The physician’s fee for expert testimony should relate to the time spent and in no circumstances should be contingent upon outcome of the claim. 6. The physician should be willing to submit such testimony for peer review.

 

 

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?

 

Coming in 2019, from All Things That Matter Press: DOCTOR VITA, Rick Novak’s second novel

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

ai-medical-1-orig

 

How do you imagine the future of medical care? Cherubic young doctors holding your hand as you tell them what ails you? Genetic advances or nanotechnology gobbling up cancerous cells and banishing heart disease? Rick Novak describes a flawed future Eden where the only doctor you’ll ever need is Doctor Vita, the world’s first artificial intelligence physician, endowed with unlimited knowledge, a capacity for machine learning, a tireless work ethic, and compassionate empathy.

artificial-intelligence-in-medicine

In this science fiction saga of man versus machine, Doctor Vita blends science, suspense, untimely deaths, and ethical dilemma as the technological revolution crashes full speed into your healthcare.

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Set on the stage of the University of Silicon Valley Medical Center, Doctor Vita is the 1984 of the medical world– a prescient tale of Orwellian medical advances.

 

FIVE MINUTES . . . TO AVOID ANOXIC BRAIN INJURY

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Anoxic brain injury. These three words make any anesthesiologist cringe. In layman’s terms, anoxic brain injury, or anoxic encephalopathy, means “the brain is deprived of oxygen.”

Five minutes stopwatch

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In an anesthetic disaster the brain can be deprived of oxygen. Without oxygen, brain cells die, and once they die they do not regenerate. If something dire goes wrong during anesthesia and surgery and the flow of oxygen to the brain is cut off, an anesthesia practitioner has about five minutes to diagnose the cause of the problem and treat it. Some brain cells start dying within five minutes after the oxygen supply disappears, and brain hypoxia can rapidly cause severe brain damage or death. (1,2)

In malpractice cases I’ve consulted on, a five-minute window is an accepted duration for low blood oxygen levels to cause permanent brain damage.

The good news is that catastrophic events causing sudden drops in oxygen levels are very rare during anesthesia. I’ve reviewed the risks of anesthesia in the 21st Century in a previous column, which I refer you to.

Miller’s Anesthesia is the premier textbook in anesthesiology. I respect Miller’s Anesthesia as an outstanding reference, but a keyword search for “anoxic encephalopathy” in Miller’s Anesthesia only links to two chapters: one on temperature regulation, and second on pediatric intensive care. The topic of anoxic encephalopathy as related to anesthesia disasters and brain death—a issue that can ruin both a patient’s life and an anesthesiologist’s career—is not specifically covered in Miller’s Anesthesia.

Anesthesiologists are human, and human error is known to seep into anesthesia care. Miller’s Anesthesia, Chapter 7 on Human Performance and Patient Safety,3 makes several statements pertinent to human error:

“. . . anesthesia professionals themselves, both as a profession and as individuals, have strengths and vulnerabilities pertaining to their work environment. The performance of human beings is incredibly flexible and powerful in some aspects but very limited in others. Humans are vulnerable to distractions, biases, and errors.”  

“The stakes are high because even for elective surgery in healthy patients, there is an ever-present and very real risk of injury, brain damage, or even death. A catastrophe is often the end result of many pathways that begin with seemingly innocuous triggering events. . . .”

“Because more than 70% of all errors in medicine can be attributed to problems with human factors rather than problems with knowledge or practical skills, the impact of human factors cannot be overestimated.

My impression, based on 34 years in an anesthesia career, is that some anesthesia practitioners perform better under pressure. Just like Joe Montana had the knack for doing the right thing on a football field when the pressure was on, and just like Sully (Chesley Sullenberger) made correct decisions when the jet engines of US Airways Flight 1549 were knocked out by collisions with birds shortly after takeoff, some anesthesia practitioners perform well under intense pressure . . . and some don’t.

Let me present two examples, inspired by real cases, of relatively healthy young patients who had unexpected hypoxic (low oxygen) episodes. These patients had drastically different outcomes due to different anesthetic care:

CASE 1.

A 40-year-old male presented for outpatient septoplasty surgery. His past medical history was positive for obesity (weight=100 kg with a BMI=32) and hypertension. His preoperative vital signs were normal with an oxygen saturation of 98%.

Anesthesia was induced with propofol 250 mg, fentanyl 100 micrograms, and rocuronium 50 mg IV. An endotracheal tube was easily placed, and breath sounds were equal bilaterally. Anesthesia was maintained with oxygen, nitrous oxide, and sevoflurane 1.5%, and incremental doses of 50 micrograms of fentanyl.

The surgery concluded 2 hours later, and the nitrous oxide and sevoflurane were discontinued. The patient began to cough, and reached up to try to pull out his endotracheal tube. The anesthesiologist decided to extubate the trachea. After extubation the patient was making respiratory efforts, but no airflow was noted. A jaw thrust attempt to break suspected laryngospasm was ineffective. The oxygen saturation dropped to 78%.

  • Succinylcholine 40 mg was administered. There was no improvement in the oxygenation or airway.
  • Two minutes later a second dose of succinylcholine 60 mg was administered. There was continued inability to move oxygen.
  • Two minutes later, a #4 LMA was placed, with continued inability to move oxygen.
  • Two minutes later the anesthesiologist attempted to reintubate the trachea. The first attempt was unsuccessful due to poor visibility. The oxygen saturation dropped to 50%.
  • Seven minutes after the initial oxygen desaturation to 78%, a second laryngoscopy using a GlideScope was successful, and a 7.0 ET tube was placed. Copious secretions were suctioned out of the ET tube. Ventilation remained difficult and peak inspiration pressures were high. The patient continued to be hypoxic. The patient’s ECG deteriorated into pulseless electrical activity (PEA), and chest compressions were initiated. Epinephrine 1 mg was administered IV twice, the peripheral pulses returned, and chest compressions were stopped.
  • Twenty minutes after the oxygen desaturation to 78%, the oxygen saturation finally rose to 94%. A chest x-ray showed pulmonary edema. The diagnosis was laryngospasm leading to negative pressure pulmonary edema. Furosemide 20 mg was administered IV. The patient remained on a ventilator in the ICU for seven days, at which time he was declared brain dead.

 

CASE 2.

A 30-year-old male was scheduled for maxillary and mandibular osteotomies for obstructive sleep apnea. He was otherwise healthy. He weighed 80 kg and had a BMI=26. His preoperative vital signs were normal.

Anesthesia was induced with propofol 250 mg and rocuronium 50 IV, and a right cuffed nasal endotracheal tube was placed. Breath sounds were bilateral and equal. Anesthesia was maintained with sevoflurane 1.5%, nitrous oxide 50%, propofol 50 mcg/kg/hr, and incremental doses of 50 mcg fentanyl. The surgery concluded 4 hours later. The surgeons wired the upper and lower teeth together. The propofol, sevoflurane, and nitrous oxide were discontinued.

The patient opened his eyes ten minutes later, and responded appropriately to conversation. The endotracheal tube was removed, and the patient’s airway was patent. He was moved to the gurney, the back of the gurney was elevated 30 degrees, and a non-rebreather mask with a 10 liters/minute flow rate of oxygen was strapped over his face. The anesthesiologist then transported the patient down the hallway to the PACU. En route the patient became more somnolent and developed upper airway obstruction resistant to jaw thrust maneuvers.

  • On arrival at the PACU the patient was nonresponsive, and his initial oxygen saturation was 75%. The anesthesiologist began mask ventilation via an Ambu bag, and the oxygen saturation rose to 90%. The patient was making ventilatory efforts without significant air movement.
  • The wires fixating the maxilla and mandible together were severed with a wire cutter.
  • The anesthesiologist attempted laryngoscopy with a Miller 2 blade, and was unable to visualize the larynx because of frothing fluid bubbling in the oropharynx. A presumptive diagnosis of negative pressure pulmonary edema was made, and a GlideScope was called for. The oxygen saturation was 88%.
  • After suctioning the frothy fluid which filled the oropharynx, a second laryngoscopy attempt with the GlideScope yielded successful placement of a 7.0 oral endotracheal tube. Pulmonary edema fluid was suctioned from the lumen of the endotracheal tube, and furosemide 20 mg was injected IV. The oxygen saturation rose to 98% on 100% oxygen.

The duration of time from when the patient’s oxygen level was discovered to be 75% until his oxygen level rose above 90% was two minutes. The duration of time from when the patient’s oxygen level was discovered to be 75% until the trachea was successfully reintubated was four minutes.

The patient remained intubated in the ICU for two nights, with diagnoses of upper airway edema post maxillary-mandibular osteotomies and negative pressure pulmonary edema. He was extubated on post-op day #3, when he successfully passed a cuff-leak test. His oxygen saturations were normal and his brain was undamaged. He walked out the hospital alive and well.

Case #1 and Case #2 were similar in that both patients were young relatively healthy men having head and neck surgery. The expected risk of serious complication for each procedure was low. The expected risk of death, or of brain death, was extremely small. Yet one man died and the other survived.

Why?

In Case #1, a case study based on a closed claim malpractice settlement, the delays in anesthesia care led to prolonged low oxygen levels, and these prolonged low oxygen levels caused anoxic brain damage. The deviations from the standard of care included:

  1. The patient was extubated too early, at a time when he was still partially anesthetized, in a transitional phase of anesthesia, and not yet awake. The safest technique for extubation is awake extubation, when the patient is an awake state of eye opening and obeying commands. Per the Difficult Airway Society Guidelines for the Management of Tracheal Extubation, an awake intubation is when “the patient’s eyes are open and the patient is responsive to commands.”4 This patient had head and neck surgery, and was at risk for post-operative airway problems. Extubating before the patient opened his eyes and obeyed verbal commands was a deviation from the standard of care.
  2. Once the patient developed post-extubation laryngospasm, the standard of care was for the anesthesiologist to act immediately to relieve airway obstruction and correct hypoxemia. Laryngospasm can lead to hypoxia, as it did in this case. The order of treatment is A-B-C, or Airway–Breathing–Circulation. When the immediate application of jaw thrust and continuous positive airway pressure via facemask was unsuccessful, and the oxygen saturation dropped into the 70’s, the standard of care was to immediately paralyze the patient with an intubating dose of succinylcholine (1 mg/kg IV) and to reinsert an endotracheal tube. Per Difficult Airway Society Guidelines for the Management of Tracheal Extubation, “If laryngospasm persists and/or oxygen saturation is falling: (administer) succinylcholine 1 mg/kg intravenously. Worsening hypoxia in the face of continuing severe laryngospasm with total cord closure . . . requires immediate treatment with intravenous succinylcholine. The rational for 1 mg/kg is to provide cord relaxation, permitting ventilation, re-oxygenation and intubation should it be necessary.”4 The entire time from the onset of laryngospasm to the successful control of the airway and ventilation of the lungs in Case #1 exceeded 20 minutes.

When a bad outcome like this occurs in a hospital or surgery center, a facility’s Quality Assurance Committee examines the details of the case—not to assign blame—but to identify flaws in patient care systems which must be improved in the future.

When a patient’s family hires a lawyer to investigate a bad outcome, the same analysis of the medical record and the medical details occurs, but the stakes are different. Physicians and facilities carry malpractice insurance with limits in the millions of dollars. If a physician or a facility is found to have performed below the standard of care, and if that negligent performance is found to have caused patient damage, they may well lose a malpractice settlement. The minute-by-minute pulse oximetry data will be scrutinized during any ensuing malpractice trial or deposition, with an aim to document how many minutes the oxygen saturation was critically low. A time frame of five minutes or greater of hypoxia in the medical record can be damning for the anesthesiologist’s case.

In the Miller’s Anesthesia chapter titled Human Performance and Patient Safety, Drs. Rall and Gaba describe 15 Key Points of Crisis Resource Management (CRM).3 Highlights of the Key Points include:

  • CRM Key Point 2. Anticipate and Plan. “Anesthesia professionals must consider the requirements of a case in advance and plan for the key milestone. They must imagine what could go wrong and plan ahead for each possible difficulty. Savvy anesthesia professionals expect the unexpected, and when it does strike, they then anticipate what could happen next and prepare for the worst.”
  • CRM Key Point 3. Call for Help Early.
  • CRM Key Point 4. Exercise Leadership and Followership With Assertiveness. “A team needs a leader. Someone has to take command, distribute tasks, collect information, and make key decisions. . . . Followers are key members of the team who listen to what the team leader says and do what is needed.”
  • CRM Key Point 8. Use All Available Information. “Information sources include those immediately at hand (the patient, monitors, the anesthesia record), secondary sources such as the patient’s chart, and external sources such as cognitive aids (see later) or even the Internet.”
  • CRM Key Point 11. Use Cognitive Aids. “Cognitive aids—such as checklists, handbooks, calculators, and advice hotlines—come in different forms but serve similar functions. They make knowledge “explicit” and “in the world” rather than only being implicit, in someone’s brain.” An example cognitive aid is the Stanford Emergency Manual, which I recommend.5

Dr. David Gaba, one of the authors of this chapter, is a longtime friend of mine and a pioneer in the fields of anesthesia simulator design and crisis management. I respect this list of 15 CRM Key Points, but I also know that when the clock is ticking on those five minutes of patient hypoxia, there is no time to think through 15 items. There is no time for any wasted effort or motions. The anesthesia provider must captain the ship and restore oxygenation without delay. The anesthesia provider needs a plan embedded in his or her brainstem that allows them to keep the patient safe.

Based on my experience as both a practicing anesthesiologist for over 30 years and an expert witness for over 15 years, when your patient’s oxygen level drops acutely, these are the things you need to DO:

  1. First off, turn your oxygen supply to 100% oxygen. Turn off all nitrous oxide or air input.
  2. Call for help.
  3. Think A-B-C, or Airway-Breathing-Circulation, in that order.
  4. Examine the patient, particularly their airway and lungs.
  5. If the patient is not already intubated, and you cannot mask ventilate the patient to a safe oxygen level, intubate the trachea immediately to deliver 100% oxygen via controlled ventilation. Use succinylcholine, the fastest emergency paralytic drug.
  6. If you cannot intubate the patient with a traditional Miller 2 or Mac 3 blade, request a GlideScope videoscope ASAP. (Have the American Society of Anesthesiologists Difficult Airway Algorithm committed to memory.)
  7. Have the Stanford Emergency Manual5 in your operating room suite, and ask a registered nurse to recite the Cognitive Aid Checklist for HYPOXEMIA to you, to make sure you haven’t missed something.
  8. If the patient is still not improving, reaffirm your assessments of A-B-C. Fix the Airway, fix the B, then fix the Circulation.
  9. Remember: ACLS (Acute Cardiac Life Support) is important, but ACLS is C, and if A and B are faulty, the cardiac care of ACLS will not save the brain.

Other advice to anesthesiologists:

  • Before a hypoxic emergency occurs in your practice, do yourself and your patients a favor by passing the American Board of Anesthesiologists oral board examination. The time spent studying for the oral boards will make you a safer and smarter anesthesiologist who is better prepared to handle emergency situations. A study in the journal Anesthesiology showed rates for death and failure to rescue from crises were greater when anesthesia care was delivered by non-board certified midcareer anesthesiologists.6 In the Stanford Department of Anesthesiology, Perioperative and Pain Medicine, we administer mock oral board examinations to the residents and fellows twice a year. Presenting an examinee with a sudden hypoxic episode is a common occurrence during the exam. If you can think well in a room in front of two examiners, you are more likely to think well in a true hypoxemic emergency when your patient’s life is at stake.
  • A second tip: If you have access to anesthesia simulator sessions, enroll yourself.

What if you’re a patient reading this? What if you’re contemplating surgery? How can you optimize your chances to avoid an anesthetic disaster?

I offer these suggestions:

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

None of us, anesthesia providers or the families of patients, want to be sitting in a courtroom for a malpractice trial because there were five bad minutes without oxygen.

References:

  1. https://medlineplus.gov/ency/article/001435.htm
  2. https://medlineplus.gov/ency/article/000013.htm
  3. Rall M, Gaba D, et al. Human Performance and Patient Safety. Miller’s Anesthesia, Chapter 7, Eighth Edition, p 106-166.
  4. Popat M, Mitchell V, et al. Difficult Airway Society Guidelines for the management of tracheal extubation, Anaesthesia 2012, 67, 318-340.
  5. Stanford Anesthesia Cognitive Aid Group. Emergency Manual: Cognitive aids for perioperative clinical events. *Core contributors in random order: Howard SK, Chu LK, Goldhaber-Fiebert SN, Gaba DM, Harrison TK http://emergencymanual.stanford.edu/
  6. Silber JH et al. Anesthesiologist Board Certification and Patient Outcomes. Anesthesiology.2002 May;96(5):1044-52.

 

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?

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How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

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12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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LETHAL EXECUTION USING FENTANYL . . . AN ANESTHESIOLOGIST’S OPINION

the anesthesia consultant

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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Lethal injection using fentanyl occurred for the first time in the death penalty execution of Carey Dean Moore in Nebraska August 14th, 2018.

lethal-injection-0000-1503512440

Per CBS News, “The Nebraska drug protocol called for an initial IV dose of diazepam, commonly known as Valium, to render the inmate unconscious, followed by the powerful synthetic opioid fentanyl, then cisatracurium besylate to induce paralysis and stop the inmate from breathing and potassium chloride to stop the heart.

Diazepam and cisatracurium also had never been used in executions before.”

From an anesthesiologist’s point of view:

  1. Valium (diazepam), an antianxiety drug, is seldom used in current surgical anesthesia practice, as it has been replaced by Versed (midazolam), which has a faster onset and causes less stinging on intravenous injection.
  2. Fentanyl, a powerful morphine-type narcotic, given in very high doses, brings on sedation, respiratory depression, and unconsciousness. The combination of Valium and high doses of fentanyl (typically 100 micrograms per kilogram) was the standard anesthetic used for open heart surgery in the 1980s. High doses of fentanyl can cause chest wall rigidity, which would add to any agonal respiratory efforts during a lethal injection, hence the necessity of a muscle relaxant (see below).
  3. Cisatracurium, a muscle relaxant or paralyzing drug, blocks all muscle movement and breathing. The paralyzing drug is used to both stop respiration and to eliminated any writhing and agonal movements during the dying movements.
  4. Potassium chloride, in high concentrations, causes the heart to fibrillate and cease beating.

Beginning in the 1970s, initial lethal injection recipes in the United States included 1) sodium thiopental (a barbiturate) to induce sleep, 2) pancuronium (a muscle relaxant) to paralyze the individual, and 3) potassium chloride to fibrillate the heart. In the 1970s-1990s, thiopental and pancuronium were commonly used anesthetic drugs. (In recent decades, propofol has replaced thiopental as the hypnotic of choice for general anesthesia for surgery, and the drugs rocuronium and vecuronium have replaced pancuronium as muscle relaxants for surgery.)

The European Union banned the export of thiopental for lethal injection in 2011, and a search for available alternate sedatives and intravenous anesthetics ensued. By 2016, more than twenty American and European pharmaceutical manufacturers had blocked the sale of their drugs for use in lethal injections, effectively making most FDA-approved unavailable for any potential lethal execution drug.1

This use of fentanyl, diazepam, and cisatracurium in Nebraska is the latest chapter in the recipe for lethal injection story. Stay tuned to see whether the manufacturers of these drugs choose to ban their sale for use in capital punishment.

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.

Note: As a physician who took the Hippocratic Oath to never harm patients, I neither approve of nor would assist in any way in the lethal injection of a prisoner.

 

References:

  1. Eckholm, Erik “Pfizer Blocks the Use of Its Drugs in Executions”The New York Times. May 16, 2016.

 

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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ANESTHETIC FACTS FOR NON-MEDICAL PEOPLE: ANESTHETIC RISKS IN CHILDREN

the anesthesia consultant

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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What are the anesthetic risks for children? What should you do if your 2-year-old son or daughter requires surgery and anesthesia? Should you consent to proceed? Should you wait until he or she is 3 years old?

The answer to all these questions is: “It depends.”

am_150605_child_anesthesia_800x600

Let’s look at recommendations as they exist in 2018.

On December 14, 2016, the United States Food and Drug Administration (FDA) issued a Drug Safety Communication Drug Safety Communication Warning that general anesthesia and sedation drugs used in children less than 3 years of age who were undergoing anesthesia for more than 3 hours, or repeated use of anesthetics, “may affect the development of children’s brains.”

The text of this December 2016 FDA statement reads:

The U.S. Food and Drug Administration (FDA) is warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains. . . . Consistent with animal studies, recent human studies suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning. However, further research is needed to fully characterize how early life anesthetic exposure affects children’s brain development. . . . Health care professionals should balance the benefits of appropriate anesthesia in young children and pregnant women against the potential risks, especially for procedures that may last longer than 3 hours or if multiple procedures are required in children under 3 years. Discuss with parents, caregivers, and pregnant women the benefits, risks, and appropriate timing of surgery or procedures requiring anesthetic and sedation drugs.”

This FDA warning resulted in a labeling change for these 11 common general anesthetics drugs and sedative agents:

  • Propofol
  • Sevoflurane
  • Midazolam
  • Isoflurane
  • Desflurane
  • Halothane
  • Pentobarbital
  • Etomidate
  • Ketamine
  • Lorazepam
  • Methohexital

Of these, sevoflurane and propofol are mainstay drugs used in pediatric anesthetics. Anesthesia for infants and children is most frequently initiated with an inhalation induction of sevoflurane vapor, because most infants and children do not have an IV line prior to induction. The primary intravenous hypnotic drug for children is propofol.

Because of this FDA statement, the propofol package insert warning label now reads:

Pediatric Use; ANIMAL TOXICOLOGY AND/OR PHARMACOLOGY). Some published studies in children suggest that similar deficits may occur after repeated or prolonged exposures to anesthetic agents early in life and may result in adverse cognitive or behavioral effects. These studies have substantial limitations, and it is not clear if the observed effects are due to the anesthetic/sedation drug administration or other factors such as the surgery or underlying illness. Anesthetic and sedation drugs are a necessary part of the care of children needing surgery, other procedures, or tests that cannot be delayed, and no specific medications have been shown to be safer than any other. Decisions regarding the timing of any elective procedures requiring anesthesia should take into consideration the benefits of the procedure weighed against the potential risks.”

For sevoflurane, the package insert warning label now reads:

Repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in neonates, infants, and children younger than 3 years, including in utero exposure during the third trimester, may have negative effects on brain development. Consider the benefits of appropriate anesthesia in young children against the potential risks, especially for procedures that may last more than 3 hours or if multiple procedures are required during the first 3 years of life. It may be appropriate to delay certain procedures if doing so will not jeopardize the health of the child. No specific anesthetic or sedation drug has been shown to be safer than another. Human studies suggest that a single short exposure to a general anesthetic in young pediatric patients is unlikely to have negative effects on behavior and learning; however, further research is needed to fully characterize how anesthetic exposure affects brain development.

There are no real alternatives to these 11 general anesthetic drugs regarding pediatric anesthesia. Dexmedetomidine and narcotics are not on the FDA list, but dexmedetomidine and narcotics are not sufficient to provide general anesthesia by themselves.

What does this mean to physicians and parents regarding anesthetics on children under the age of 3 years?

The most common indications for infants and toddlers to be placed under general anesthesia are for short procedures such as ear tubes for chronic ear infections, hernia repair, or removal of the adenoids. At times infants or toddlers require general anesthesia or sedation so they will stay still during a procedure, such as when they need an MRI or a CT scan.

There are an estimated 1.5 -2 million children under 3 years of age who undergo anesthesia annually in the United States. Prior to the FDA statement, Texas Children’s Hospital performed more than 43,000 cases each year. Approximately 13,000 of these cases involved patients under 3 years of age, and more than 11,000 of these anesthetics lasted more than 3 hours. Nearly all of the prolonged anesthetics were for serious congenital conditions for which treatment could not be delayed until the patient reached 3 years of age. Because of the FDA warning, the hospital adopted the warning’s recommendation that a discussion occur among parents, surgeons and other physicians, and anesthesiologists regarding the duration of anesthesia, any plan for multiple general anesthetics for multiple procedures, and the possibility that the procedure could be delayed until after 3 years of age.1

Dr. Constance Houck, chair of the American Academy of Pediatrics’ Surgical Advisory Panel and an Associate Professor of Anesthesia at Harvard Medical School said, “two recently published studies examining short-term anesthesia exposure for hernia repair did not show neurobehavioral differences between those who had received a general anesthetic and those who had not. . . . Most surgeries are less than one hour, but some infants and children with significant congenital defects require more prolonged surgery. . . Examples would include such defects as cleft lip and palate and malformations of the urinary or gastrointestinal tract.” Postponing major reconstructive surgery until children are older is generally not an option. “There is no evidence to suggest that short procedures should be postponed, but parents should always discuss with their child’s pediatrician and surgeon the risks and benefits of timing of procedures.2

The American Society of Anesthesiologists response to the FDA statement read: “the accumulated human data suggest that one brief anesthetic is not associated with cognitive or behavioral abnormalities in children. Most but not all studies in children do however suggest an association between repeated and or prolonged exposure and subsequent difficulties with learning or behavior.”3

In addition to the FDA drug recommendations, there are well documented surgical concerns with operating on children under age 3. For example, the recommendations for pediatric tonsillectomy are to delay until age 3, based on a high degree of evidence for increased respiratory complications at ages younger than 3.4

An overriding important consideration regarding pediatric anesthetics is: Who will be doing the anesthesia? It’s important to inquire regarding the experience and training of the physician anesthesiologist who is about to anesthetize your child. (See my related column Pediatric Anesthesia: Who is Anesthetizing Your Child?)

Some anesthesiologists do specialty fellowship education for one or two years in pediatric anesthesia, usually at an academic pediatric hospital, and are therefore well-trained to attend to your child. In community hospitals, experienced physician anesthesiologists who have attended to children since their residency training commonly do pediatric anesthetics. My practice fits this model: I am not a fellowship-trained pediatric anesthesiologist, but I have anesthetized thousands of children safely over 33+ years since my Stanford residency.

Let’s return to the question of whether your 2-year-old should have anesthesia and surgery.

My family had a personal experience with this question. My oldest son fell and cracked his upper right incisor when he was 1½ years old. He had three general anesthetics in the following nine months for dental surgeries: the first surgery to place a cap on the fractured tooth, the second surgery to extract the tooth because it died, and a third surgery to place a prosthetic incisor to replace the lost tooth. These three surgeries were performed in 1998 and 1999 when my son was between 1½ and 3 years of age. He suffered no apparent developmental delays secondary to anesthesia, but in the present day, following the FDA statement, both the physicians and the parents would be unlikely to proceed with three repeated anesthetics on such a young child.

The answer for you depends on whether your child’s surgery is elective and can wait until he or she is 3 years old, whether it is a one-time surgery, whether the surgery is brief, whether it is an emergency or whether it is to remedy a congenital deformity and can not be delayed. You’ll need to have an informed consent discussion with the surgeon, the physician anesthesiologist, and perhaps your pediatrician. If your child’s surgery is a one-time anesthetic for a common short procedure such as ear ventilation tubes or an inguinal hernia repair, it’s likely that proceeding with anesthesia and surgery will be the correct answer. If the surgery is urgent or if delaying surgery will cause an adverse outcome, then proceeding with anesthesia and surgery will be the correct answer. Trust your surgeon and physician anesthesiologist as consultants, and you’ll make the correct choice.

Be reassured. The Society for Pediatric Anesthesiology states that “complications are extremely rare. In the United States, the chance (risk) of a healthy child dying or sustaining a severe injury as a result of anesthesia is less than the risk of traveling in a car.”5

 

References:

  1. Andropoulos DB, Greene MF. Anesthesia and Developing Brains — Implications of the FDA Warning. N Engl J Med 2017; 376:905-907
  2. https://www.forbes.com/sites/ritarubin/2016/12/17/fda-has-ordered-new-label-warnings-but-its-not-clear-that-anesthesia-is-risky-in-pregnancy-kids/#45afde9138c9
  3. https://www.asahq.org/advocacy/fda-and-washington-alerts/washington-alerts/2016/12/asa-response-to-the-fda-med-watch
  4. Lescanne E, et al. Pediatric tonsillectomy: clinical practice guidelines. Eur Ann Otorhinolaryngol Head Neck Dis. 2012 Oct;129(5):264-71.
  5. http://www2.pedsanesthesia.org/patiented/risks.iphtml

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

 

 

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

The anesthesiaconsultant.com, copyright 2010, Palo Alto, California

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

HOW NEW ARE “MODERN ANESTHESIA” TECHNIQUES?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

1990s-moodboard

Point/Counterpoint: Modern anesthesia techniques are radically different from the methods of twenty years ago. True or false?

POINT: False. Twenty-first century general anesthetics are nearly identical to the anesthetic techniques of the late 1990s. Consider this list of the most commonly administered anesthetic drugs in the United States in the present day (2018):

Medication                        Year introduced

Propofol                              1989

Sevoflurane                        1995

Nitrous oxide                     1846

Fentanyl                               1959

Versed                                   1985

Rocuronium                        1994

Succinylcholine                  1952

Zofran                                  1991

Bupivicaine                          1957

 

I review hundreds of anesthesia records each year from California and multiple other regions of America. I can attest that these nine medications are still the mainstays of most anesthetics. A typical standard general anesthetic includes Versed as an anti-anxiety premed, propofol as the hypnotic, sevoflurane +/- nitrous oxide as the maintenance vapor(s), fentanyl as the narcotic, Zofran for nausea prophylaxis, rocuronium or succinylcholine for muscle paralysis, and bupivicaine injected (usually by the surgeon) for long-lasting pain relief.

How can it be that general anesthesia has ceased to evolve? In this brave new world of the Internet, iPhones, iPads, and personal computers, how could anesthesiology have stalled out with 20th-century pharmacology? My colleague Donald Stanski, MD PhD, former Chairman of Anesthesiology at Stanford and now an executive in pharmacology business, explained it to me this way: The existing anesthesia drugs are cheap and work well. The cost of research and development for each new anesthesia drug is prohibitively expensive, and for pharmaceutical companies there is no certainty that any new anesthesia drug would control a sufficient market share to make a profit.

I believe we would benefit from a new narcotic drug that would promise less side effects than the fentanyl/morphine analogues, i.e. less respiratory depression, nausea, and sedation. I believe we would benefit from a new ultra-short onset paralyzing drug without the side effects of succinylcholine, i.e. without the risks of muscle pain, hyperkalemic arrests, triggering of malignant hyperthermia, increased intracranial and intraocular pressure, or bradycardia. Someone may discover these products someday, but for the present time the older drugs enjoy the market share.

What about regional anesthesia? When a patient needs a spinal anesthetic, the recipe of bupivicaine +/- morphine is unchanged from the 1990s. When a patient needs an epidural for surgery, the recipe of bupivicaine or lidocaine +/- narcotic is unchanged from the 1990s.

What about monitors of vital signs? The standard monitoring devices of pulse oximetry, end-tidal CO2 monitoring, and other essential anesthesia vital sign monitors were developed and in use by the 1990s. I can think of no specific reason why a general anesthetic administered in 2018 would be safer than a general anesthetic administered in the 1990s.

 

COUNTERPOINT: True. Anesthesia in 2018 is markedly different from anesthesia in the 1990s. Most of the drugs in use haven’t changed, but current-day anesthesia providers practice in a cockpit surrounded by computers. Each operating room anesthesia location is the epicenter of computerized medical record-keeping machines, computerized Pyxis-style drug storage systems, computerized labeling machines, and bar-code reading billing machines. If you don’t understand how to command these high-tech devices, you’ll be unable to initiate an anesthetic at a university hospital. The adage that “the patient comes first” is sometimes lost in an array of LED displays, passwords, and keyboards.

There have been other significant changes in anesthesia practice since the year 2000:

  • The most significant advance is the video laryngoscope, a vital tool for intubating difficult airways, which has facilitated endotracheal intubation in thousands of patients where 20th-century rigid laryngoscope blades were not effective.
  • Ropivicaine was released in the year 2000, and has the distinct advantage of long-lasting local anesthetic nerve blockade with less motor block than bupivicaine.
  • Sugammadex is a remarkable advance, allowing for the reliable reversal of neuromuscular paralysis in only seconds. Sugammadex is the single most important new medication in the toolbox of the 21st-century anesthesiologist.
  • Ultrasound-guided regional anesthesia was developed in 1994, but became popular in the past ten years. Administering local anesthetic injections adjacent to major nerves grants non-narcotic pain relief to thousands of patients following orthopedic surgeries.
  • Acute pain services utilize nerve blocks and other adjuncts to relieve post-operative discomfort. Pain service teams were available only in primitive forms in the 1990s. In fact, at Stanford we changed our name from the “Department of Anesthesiology” to the “Department of Anesthesiology, Perioperative and Pain Medicine” since the turn of the millennium.

 

In closing:

At a wedding a bride is advised to wear something old, something new, something borrowed, and something blue.

In the world of anesthesia we use some things old, some things new, nothing borrowed, and . . . we make sure our patients never turn blue.   🙂

 

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?

 

*
*
*
*

Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

 

 

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

The anesthesiaconsultant.com, copyright 2010, Palo Alto, California

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

THE JOY OF BEING A DOCTOR

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

My greatest joy of being a doctor comes immediately after the conclusion of a pediatric anesthetic.

maxresdefault

I stay with the child until the anesthetic depth has dissipated, the breathing tube is removed, and the child is awake and safe with the recovery room nurse in the Post Anesthesia Care Unit. At that point I walk out to the waiting room to find the parents so I bring them back to see their child. I invariably have a bounce to my step, and I’m a bit choked up with anticipation. I’ve done this enough times to know what to expect. The mother and father are waiting with wide eyes and worried looks on their faces. I give them a reassuring smile and my first words are, “Everything went perfectly. Your son (or daughter) is safe. Follow me.” The three of us return to the bedside in the recovery room, where the mother and child reunion occurs (cue up the Paul Simon soundtrack). The parents fawn over their child, the child reaches out his or her arms, the relief is palpable, and I’m proud to have contributed to the positive outcome.

Why go to medical school? Bright, hard-working college students have choices to make. Many ambitious young people wonder if they should apply to medical school. It’s difficult to get into med school, the journey is long (four years of medical school followed by three to seven years of residency), and the tuition can be high.

Why go to medical school? The daughter of one of my friends is an undergraduate business school student, and her last summer internship was with Proctor and Gamble working in the sales and marketing force selling Clorox. Selling bleach is a career choice radically different from going to medical school.

Do you want to sell bleach, or do you want to help people? The answer to “Why do you want to go to medical school?” is almost that simple. So many jobs in America are related to selling some product, some service, or some commodity. Becoming a physician is about helping people, and it’s also about making your own life have a greater purpose.

“Why do you want to be a doctor?” is the first question asked at most medical school interviews. Answers vary. Why do young men and women choose to become doctors nowadays? One guiding factor might be economics. The average salary for a physician in the United States is in excess of $250,000. To a 22-year-old, that high salary is alluring. Non-medical students who pursue careers in teaching, engineering, or business will start at lower annual salaries, but the future income of a physician is balanced against the deferred gratification of the years involved in their education. The student must pay for four years of medical school tuition and living expenses, and then work for meager wages for 3-7 years afterwards as a resident. The medical student delays the onset of their “real world” employment until age 30-32.

Non-medical students who go to work straight out of college at age 22 may already have families, mortgages, multiple cars, and perhaps a vacation home, while the 32-year-old physician has an 80-hour-a-week job, $250,000 of student loans, and the obligation to take care of sick patients at 3 a.m. It’s not an easy life, it’s not all fun, and most doctors wonder at one time or another whether they made the right choice. Making a lot of money is not the right answer to the question of why you want to go to medical school.

So why do we go to medical school? Young men and women who have a physician parent are in the best position to reply from the heart—they’re aware that their parent works long hours, reads incessantly to stay well informed, and gets out of bed in the middle of the night to handle emergencies. A doctor’s son or daughter has heard all the good and bad stories that describe a physician’s lifestyle. But most college students don’t have a doctor for a parent, and most college students have a little idea what the lifestyle of a physician would feel like. My father was a welder. I had no family experience to guide my career choice. For students like me, without a physician parent, it’s important to work medical volunteer jobs and/or research jobs to test the waters before applying to medical school, to decide whether the life of a doctor would appeal to them.

Why go to medical school? Each new patient I meet treats me with respect—a respect I don’t get if I’m outside of the hospital walking down the street or shopping at a grocery store. Years ago I shared this impression with my wife, and she said, “Of course your patients treat you with respect. You’re about to take their lives into your hands. They’re nervous, they’re scared, and the last thing they want to do is to get you in a bad mood!” This may be true, but the respect your patients give you is bona fide, and it’s a feeling few other jobs can offer.

Why go to medical school? I don’t think you’ll ever get equivalent joy out of selling bleach (or some other commodity) that you’ll gain helping other human beings with their health problems. Medicine is a profession. A career in medicine is an opportunity to entwine your work life with other people’s lives in a meaningful and remarkable way. You might make more money as a CEO or a venture capitalist, but few other jobs bring the potential to change lives for the better to the degree that being a physician does.

When you go to your medical school interview and the professor asks you “Why do you want to be a doctor,” the answer from your heart must be five words long:

“I want to help people.”

Your reward for becoming a doctor will arrive years later, when you feel what I feel when I reunite parents with their child after surgery. You’ll feel the joy and satisfaction of a purposeful life.

 

P.S. In 2012 the journal Anesthesiology published my poem “The Metronome,” which describes a scene from my life as a pediatric anesthesiologist:

 

The Metronome

 

To Jacob’s mother I say,

“The risk of anything serious going wrong…”

She shakes her head, a metronome ticking without sound.

“with Jacob’s heart, lungs, or brain…”

Her lips pucker, proving me wrong.

“isn’t zero, but it’s very, very close to zero…”

Her eyes dart past me, to a future of ice cream and laughter.

“but I’ll be right there with him every second.”

The metronome stops, replaced by a single nod of assent.

She hands her only son to me.

 

An hour later, she stands alone,

Pacing like a Palace guard.

Her pupils wild. Lower lip dancing.

The surgery is over.

Her eyebrows ascend in a hopeful plea.

I touch her hand. Five icicles.

I say, “Everything went perfectly. You can see Jacob now.”

The storm lifts. She is ten years younger.

Her joy contagious as a smile.

The metronome beat true.

 

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?

 

*
*
*
*

Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota.

The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode.

In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.”

Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

 

 

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

The anesthesiaconsultant.com, copyright 2010, Palo Alto, California

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

 

FENTANYL AND THE OPIOID CRISIS: AN ANESTHESIOLOGIST’S PERSPECTIVE

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

The United States is in the midst of an opioid epidemic. The crisis consists of two separate threats. One is the increased presence of powerful illicit street drugs such as fentanyl. The second threat is the increasing use of oral prescription painkillers like Oxycontin, Percocet, and Vicodin. This column addresses fentanyl—its medical aspects and the on-the-street abuses of this powerful narcotic.

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MEDICAL USE OF FENTANYL

I’ve administered fentanyl to over 20,000 patients in my career, and can vouch for the medical utility and import of this drug. Fentanyl is the most commonly administered narcotic during surgery in the United States. If you’ve had a surgical anesthetic, or even a colonoscopy, you’ve likely received fentanyl with few ill effects. Fentanyl is an essential ingredient in the pharmaceutical armamentarium of acute care medicine in hospitals, surgery centers, intensive care units, and emergency rooms throughout the United States. On the streets, fentanyl is killing people. In our hospitals and surgery centers, fentanyl is a useful adjunct as omnipresent as Tylenol.

Fentanyl was first synthesized by Dr. Paul Janssen of Janssen Pharmaceuticals in the 1960s, and was then introduced into anesthetic practice under the brand name Sublimaze.1 Fentanyl is a rapid-onset narcotic drug usually administered by intravenous injection. Compared to morphine, fentanyl is more lipid (fat) soluble, which means the drug crosses into the central nervous system more quickly and works faster than morphine. The termination of the effect of low doses of fentanyl results from decreased concentration, as the drug redistributes from the bloodstream to other organ tissues.

The elimination of higher doses of fentanyl from the body depends on elimination by the liver. Morphine, Demerol, and Dilaudid are other common intravenous medical narcotics, which have slower onset and longer duration of action. When injected into an intravenous line, fentanyl reaches its peak analgesic effect in minutes, significantly faster than morphine. This quicker onset makes fentanyl an easier drug for anesthesiologists to titrate to a desired effect., which makes fentanyl superior when timing for a patient’s awakening from anesthesia. As outpatient and ambulatory surgery blossomed, a short-acting narcotic such as fentanyl, which wore off promptly, became the narcotic of choice.

The most daunting feature of fentanyl is its potency. Most drugs used by anesthesiologists are in doses of milligrams (mgs) or grams (gms). Fentanyl is approximately 100 times more potent than morphine, so a typical 5 mg (5 mg = 5000 microgram) dose of morphine is equivalent to a mere 50 microgram dose of fentanyl. A typical intravenous incremental dose of fentanyl to an adult patient is a mere 50-100 micrograms. The drug is marketed as one milliliter = 50 micrograms for this reason, so 1 – 2 milliliters is an appropriate dose. This potency and the need to be packaged in micrograms is unique to fentanyl and its analogues sufentanil and remifentanil, and requires medical personnel to become comfortable with the low ranges of the appropriate microgram doses.2

Medical fentanyl can be administered in several ways:

  • Intravenous fentanyl, as described above, is the most common medical usage of the drug.
  • Rarely, fentanyl is added to the spinal fluid as part of a spinal anesthetic block prior to surgery, or to the epidural space as part of an epidural block prior to surgery or prior to labor for childbirth.
  • Transdermal drug delivery of fentanyl via an adhesive skin patch is also possible, because of the drug’s high solubility in both water and oil, low molecular weight, high potency, and its lack of skin irritation. Fentanyl transdermal patches (Durogesic or Duragesic) are useful in chronic pain management. The patches work by slowly releasing fentanyl through the skin into the bloodstream over 48 to 72 hours, allowing for long-lasting pain management. Dosage is based on the size of the patch.
  • Oral transmucosal fentanyl citrate (OTFC) is a solid dosage form of fentanyl that consists of fentanyl incorporated into a sweetened lozenge on a stick. A commercially available fentanyl product for oral administration, the fentanyl lollipop Actiq, is an application of this technology. The lollipop provides a means by which the drug can dissolve slowly in the mouth. The lollipop is only FDA approved for providing analgesia to patients with chronic pain or cancer pain, and the fentanyl lollipop is not FDA-approved for analgesia after surgery.

Narcotics suppress pain by their action in the brain and spinal cord, but they cause their adverse side effects in multiple organ systems, including the respiratory and cardiovascular systems. The principal danger from narcotics is respiratory depression. The respiratory rate is usually markedly slowed in narcotic overdose, as excessive doses of narcotics make people stop breathing. If there’s an anesthesiologist present to support a person’s breathing, respiratory depression is not a problem. On the streets, with no medical personnel present, respiratory depression from a narcotic overdose can be fatal.

The anesthesia world is well aware of the risks of fentanyl addiction. Narcotic addiction has struck down many anesthesia providers who found themselves vulnerable to sampling the potent euphoria-inducing fentanyl doses they were administering to their patients. Stanford authors described fentanyl addiction in anesthesiologists in 1980.3 More than a dozen of my personal friends and colleagues died anesthetic drug-related addiction deaths in the 1980s and 1990s.

For some of these physicians the first sign of their addiction was death by overdose. In others the addiction was uncovered, they were sent to rehabilitation programs, and they are still alive today. Anesthesiologists graduating from narcotic rehab programs are still known to have a risk to relapse. The relapse rate for anesthesiologists after drug abuse treatment is greatest in the first 5 years and decreases as time in recovery increases. The positive news is that 89% of anesthesiologists who complete treatment and commit to aftercare remain abstinent for longer than 2 years. However, death is still the primary presenting sign of relapse in opiate-addicted anesthesiologists.

 

FENTANYL AS A STREET DRUG

The current battle against fentanyl as a street drug has little or nothing to do with American medical practice. Most of the fentanyl found on the streets is not diverted from hospitals, but rather is sourced from China and Mexico. Dealers sought a narcotic product cheaper and even stronger than heroin, and that product is fentanyl. In 2016 there were more than 60,000 fatal overdoses in America. More than half were due to opioids, and the newest and most potent street narcotic was fentanyl.

Fentanyl-related overdose deaths increased nearly 600 percent from 2014 to 2016. “If anything can be likened to a weapon of mass destruction in what it can do to a community, it’s fentanyl,” said Michael Ferguson, a special agent in charge of the Drug Enforcement Administration’s New England division. “It’s manufactured death.” Illicit fentanyl is imported directly from China or Mexico, where the drug is manufactured. Dealers then mix the powder into other drugs, making for imprecise potency in sometimes-lethal doses.4 The IV street drug fentanyl is believed to be manufactured in China or Mexico, and is smuggled across the borders. Highly organized drug cartels are spreading the drug throughout the country. Its street nickname is “China White” or “China Girl,” referring at where most of the drug is thought to be coming from. The DEA estimates that drug traffickers can buy a kilogram of fentanyl powder for $3,300 and sell it on the streets for more than 300 times that, generating nearly a million dollars.5

As a street drug, fentanyl can be injected intravenously, taken orally, or snorted nasally. Each of these routes poses a threat:

  • Intravenous fentanyl as a street drug – Prior to fentanyl, heroin was the injectable street drug of choice. Because of the extremely high strength and potency of pure fentanyl powder, it’s difficult to dilute appropriately. The diluted mixture may be far too strong and, may cause respiratory depression and death. Some heroin dealers mix fentanyl powder with heroin to increase potency or compensate for low-quality heroin. Because fentanyl is more potent than heroin, the presence of even small quantities of fentanyl in injected heroin can result in respiratory depression. The fentanyl sold on the streets is likely made in a non-pharmaceutical lab, and is less pure than the medical version anesthesiologists administer. Its effect on the body can be hard to predict. Heroin and fentanyl look identical, and with drugs purchased on the street, addicts don’t know what they’re taking. An intravenous fentanyl overdose can cause a person to cease in breathing within minutes of injection, and result in death. Narcan, or naloxone, is a specific antagonist of narcotic overdose. Administration of Narcan as a fentanyl overdose antidote is a potential acute rescue remedy. 
  • Oral fentanyl as a street drug – Fentanyl is also sold as an oral street drug. Ten people died in just twelve days from fentanyl-laced pills in Sacramento County, California in March of 2016. In San Francisco, fentanyl showed up in pills labeled as Xanax, which turned out to be pure fentanyl. After 26 years in a Orange County crime lab south of Los Angeles, forensic scientist Terry Baisz said, “I was shocked the first time I tested this stuff and it came back as fentanyl. We hadn’t seen it before 2015.” Dealers were describing their pills as Xanax or Oxycodone. The tablets looked nearly identical to products manufactured by commercial pharmaceutical companies, although the pills sold on the streets contained fentanyl.6 The singer Prince’s death in 2016 was due in part to an overdose of fentanyl, likely in a pill form of counterfeit hydrocodone-acetaminophen (Vicodin) tablets.7
  • Intranasal fentanyl as a street drug – If fentanyl is supplied to the addict in powder form, and the powder is confused with cocaine and is snorted intranasallly, the addict may die. A hospital in New Haven, Connecticut treated twelve overdoses, three of them fatal, in just an eight-hour period in June 2016 among addicts who were snorting a white powder they purchased on the city’s streets. 8The powder they believed was cocaine turned out to be fentanyl. The absorption of a nasal dose of fentanyl can lead to immediate respiratory depression and death.

U.S. Surgeon General Jerome Adams, an anesthesiologist, has suggested distributing the narcotic antagonist Narcan freely, so that onlookers can quickly treat fentanyl-overdosed individuals.9 I respect Dr. Adams at the highest level, but I’m skeptical of this approach. An addict injecting fentanyl while he or she is alone is still at high risk of dying, and I’m not aware of any statistics documenting whether addicts reliably have company present while they are injecting themselves.

First response Emergency Medical Technicians should carry Narcan. Treatment of patients who are discovered comatose for unknown reasons has long included an empiric injection of Narcan to reverse possible narcotic overdose. The public needs to be aware of the existence of fentanyl powder, its ultra-high potency, and the danger of a fatal overdose immediately after the intravenous injection, oral ingestion, or intranasal inhalation of any street drug. There’s a real threat that any dose of street fentanyl can be lethal.

In our operating rooms, hospitals, surgery centers, and intensive care units, fentanyl is used safely. On the streets, fentanyl poses nothing but problems. Education, prevention, and DEA enforcement will have key roles in addressing the crisis of fentanyl in non-medical settings.

 

References:

  1. Fentanyl, Chemical and Engineering News, https://pubs.acs.org/cen/coverstory/83/8325/8325fentanyl.html
  2. Kazuhiko F, Opioid Analgesics, Miller’s Anesthesia, 8th Edition, Chapter 31, 864-914.
  3. Spiegelman WG, Saunders L, Mazze Ri, Addiction and anesthesiology, Anesthesiology 1984 Apr;60(4):335-41.
  4. Lewis N et al. Fentanyl linked to thousands of urban overdose deaths, Washington Post, August 15, 2017.
  5. https://www.washingtonpost.com/graphics/2017/national/fentanyl-overdoses/?utm_term=.8c722ada39be Nazarenus C. The opioid fentanyl: the new heroin, but deadlier. Medical Marijuana 411, May 11, 2016.
  6. https://medicalmarijuana411.com/opiod-fentanyl-new-heroin-deadlier/Sidner S. The opioid fentanyl: the new heroin, but deadlier. ClickonDetroit.com, May 10, 2016. https://www.clickondetroit.com/health/fentanyl-the-new-heroin-but-deadlier
  7. Kroll D, Prince’s Death From Fentanyl May Have Been Due To Counterfeit Generic Drugs, Pharma and Healthcare, Aug 22, 2016. https://www.forbes.com/sites/davidkroll/2016/08/22/princes-death-from-fentanyl-may-have-been-due-to-counterfeit-generic-drugs/#52096f902b17
  8. Bebinger M, Fentanyl-laced cocaine becoming a deadly problem among drug users, Health News from NPR, March 29, 2018. https://www.npr.org/sections/health-shots/2018/03/29/597717402/fentanyl-laced-cocaine-becoming-a-deadly-problem-among-drug-users
  9. Surgeon General Urges More Americans To Carry Opioid Antidote, NPR Public Health, April 5, 2018. https://www.npr.org/sections/health-shots/2018/04/05/599538089/surgeon-general-urges-more-americans-to-carry-opioid-antidote

 

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INTRAVENOUS ACETAMINOPHEN: AN IMPORTANT NON-OPIOID THERAPY, OR AN EXORBITANTLY PRICED VERSION OF AN OVER-THE-COUNTER MEDICATION?

the anesthesia consultant

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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Intravenous acetaminophen was introduced in Europe in 2002. The United States Food and Drug Administration approved IV acetaminophen (Ofirmev, Cadence Pharmaceuticals) in 2010 for management of mild to moderate pain, moderate to severe pain with adjunctive opioid analgesics, and reduction of fever.

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IV acetaminophen (Ofirmev)

 

 

Acetaminophen (Tylenol) has been available in oral and rectal forms for decades. 

tylenol-tylenol-extra-strength-500-mg-150-units

Oral acetaminophen

 

Healthcare costs continue to skyrocket in the United States. In 2016 Americans spent $435 billion on prescription drugs.1 This month the Trump administration released a 44-page blueprint for executive action on drug pricing entitled “American Patients First.” Their goal is to drive prescription drug costs down by increasing competition. At this time it’s too early to tell how effective these efforts will be.

Anesthesiologists are the only physicians who prescribe and then directly administer medications themselves. CRNAs are the only nursing professionals who prescribe and then directly administer medications themselves. Because anesthesiologists and CRNAs typically don’t pay for the medications, there can be a disconnect regarding costs and value.

If you were in charge of pharmaceutical purchasing at a hospital or an ambulatory surgery center, and you had an identical acetaminophen molecule available for either 5 cents per dose or $42 per dose, which would you choose? The answer is obvious, but as an administrator you are not prescribing the drug.

A 2014 study showed that patients who received IV acetaminophen reported superior satisfaction with pain control compared to patients who received placebo.2 In inpatient and postoperative settings, intravenous acetaminophen became a route of choice for rapid analgesia, and appeared to reduce the need for other analgesics such as opioids. Disadvantages of IV acetaminophen included the time and equipment needed for IV drug administration, as well as increased costs.

In a publication from the Canadian Journal of Hospital Pharmacy, Jibril wrote, “The study drug (acetaminophen, either oral or IV) was given when patients first awakened after surgery, and additional doses were given every 6 h until 0900 the next morning. . . . The use of opioids was significantly lower in the group receiving acetaminophen by the IV route than in the group receiving acetaminophen by the oral route (p < 0.05). However, this difference did not translate into a significant difference in rates of postoperative nausea and vomiting or any significant difference in pain scores on a 100-mm visual analogue scale (VAS) at any time. . . . A major finding of this review was the absence of strong evidence suggesting superiority of IV acetaminophen administration over oral routes. . . . IV acetaminophen may be useful for opioid-sparing in postoperative pain. To date, no strong evidence exists that IV acetaminophen should replace any form of standard care. At most, the evidence indicates that this formulation could function as an adjunctive agent in patients unable to take oral forms. . . . . In the United States, there has been great debate regarding use of this formulation, which has led many hospitals to adopt policies and procedures that restrict use for a limited period or for patients not able to take medications by mouth. These restrictions are required because of the cost of the product, in addition to other administration-related inconveniences. Canadian hospitals and formulary committees should be aware of the available efficacy and safety data if the formulation is marketed in Canada and its use becomes widespread. Given the high cost and the lack of superiority over oral forms, Canadian hospitals may need to restrict use of the IV formulation, as their US counterparts have already done.”3

In a study of IV acetaminophen use in neurosurgical ICU patients at Virginia Commonwealth University, Gretchen Brophy, PharmD, of the departments of pharmacy and neurosurgery wrote, “We and every institution I’ve spoken to have restricted its use, because we don’t have data saying it’s more effective. At $33 a dose” – recently up from $10 – “it’s harder to justify. At least in the 0-3 hour window, it didn’t have any additional benefit over oral. It might still be better at 1 hour; kinetically, that would make sense, but there’s nothing yet to say from what we did that it’s better.”4 VCU restricted intravenous acetaminophen use to one dose per patient.

Mallinckrodt purchased Cadence Pharmaceuticals in 2014, and increased the price of Ofirmev from $17.70 to $42.48 per vial. (A full case of Ofirmev includes 24 vials.) Sales increased to $71 million during their fiscal first quarter, double the amount for the same period the previous year. Hospitals noted the rise in expenses and sought alternatives such as oral acetaminophen, and the volume of sales dropped. Robert Press, chief of hospital operations at NYU Langone, which anticipated $1 million in additional costs because of Ofirmev, was quoted to say, “We found out a lot of the use was really not necessary and we found we could give alternative products.”5

Some hospitals removed Ofirmev from their formularies after the price went up. Others simply switched to alternatives such as oral acetaminophen. Others increased their budgets to cover the cost of the drug, but the net effect of Mallinckrodt’s price hike was to reduce the doses of Ofirmev prescribed. Mallinckrodt’s U.S. headquarters are located in Missouri. Senator Claire McCaskill (D-Missouri) wrote a letter to Mallinckrodt CEO Mark Trudeau demanding information about pricing and revenue numbers. In the letter she also suggested that Ofirmev, expensive as it was, might actually be saving hospitals money because of opioid-sparing. Senator McCaskill wrote, “Any obstacle to prescribing non-opioid alternatives, even those used solely in a hospital setting, is cause for concern.” It should be noted that McCaskill received $2,500 in campaign financing from Mallinckrodt during the 2016 election cycle.6

Mallinckrodt released a statement that read, “One recent analysis of health economic data on the use of Ofirmev coupled with a one-level reduction in opioid use was linked to decreasing hospital stays, potential opioid-related complications and related costs for the treatment of acute surgical pain. . . . The study showed a potential of $4.7 million in annual savings for a typical, medium-sized hospital.”6

The clinical benefit of reduced opioid consumption with Ofirmev has not been evaluated nor demonstrated in prospective, randomized controlled trials. In a review in the journal Pharmacotherapeutics, Yeh wrote, “Although use of intravenous acetaminophen has reduced other postoperative resource utilization (e.g., hospital length of stay) in some studies outside the United States in patients undergoing abdominal surgery, a full economic evaluation in the United States has yet to be undertaken.”7

The research study anesthesiologists would like to read is a prospective, randomized, double-blind trial of 1000 mg of preoperative oral acetaminophen, versus 1000 mg of IV acetaminophen administered just prior to the end of surgery. Will this research ever be performed? I hope so, but you can bet Mallinckrodt is never going to fund that study.

I repeat Jibril’s conclusion to sum up the answer to our initial question above:“An absence of strong evidence suggesting superiority of IV acetaminophen administration over oral routes. . . . To date, no strong evidence exists that IV acetaminophen should replace any form of standard care. At most, the evidence indicates that this formulation could function as an adjunctive agent in patients unable to take oral forms. . . . Therefore, on the basis of current evidence, if a patient has a functioning gastrointestinal tract and is able to take oral formulations, IV formulations are not indicated.”3

And what is the solution regarding anesthesia providers who frequently choose to prescribe IV acetaminophen despite these recommendations? The hospital I work at, Stanford University Hospital, restricts Ofirmev usage to patients who are NPO (nothing by mouth), and each Ofirmev order has a hard stop after 24 hours, eliminating further usage. The owners of the surgery center I medically direct have an even more decisive solution: Ofirmev is not on the facility formulary at all.

 

References:

  1.  Cortez J. Prescription Drug Spending Hits Record $425 Billion in U.S. Bloomberg, April 13, 2016.                                                https://www.bloomberg.com/news/articles/2016-04-14/prescription-drug-spending-hits-record-425-billion-in-u-s
  2. Apfel CC et al. Patient satisfaction with intravenous acetaminophen: a pooled analysis of five randomized, placebo-controlled studies in the acute postoperative setting. J Healthc Qual. 2014 Jan 16.
  3. Jibril F, et al. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making, Can J Hosp Pharm. 2015 May-Jun; 68(3): 238–247.
  4. Otto MA et al. No pain benefit found for IV acetaminophen vs. oral in the neuro ICU. Clinical Neurology News. January 30, 2015.
  5. Staton T. Price hikes aren’t always sustainable: Just ask Mallinckrodt about Ofirmev. Fierce Pharma. Oct 12, 2015. https://www.fiercepharma.com/pharma/prie-hikes-aren-t-always-sustainable-just-ask-mallinckrodt-about-ofirmev
  6. Staton T. Mallinckrodt’s pain med Ofirmev gets scrutiny in Senate—but this pricing probe has a twist. Fierce Pharma. May 30, 2017. https://www.fiercepharma.com/pharma/mallinckrodt-s-pain-med-ofirmev-gets-scrutiny-senate-but-pricing-probe-has-a-twist
  7. Yeh Y et al. Reviews of Therapeutics: Clinical and Economic Evidence for Intravenous Acetaminophen. Pharmacotherapeutics. 08 May 2012.

 

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

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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

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Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

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LEARJET ANESTHESIA – THE EARLY DAYS OF HEART TRANSPLANTATION

the anesthesia consultant

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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Learjet anesthesia? Yes, anesthesia can be a glamorous specialty. During my Stanford training in 1984-1986 I flew on Learjets more times than I can count, during missions to harvest donor hearts from throughout the western United States.

learjet-lear-60

Norman Shumway MD PhD, a Stanford surgical professor and legend, invented the heart transplantation procedure and performed the first heart transplant in the USA on January 6, 1968 in operating room 13 of Stanford University Hospital. Survival rates for heart transplantation patients increased markedly in 1983 with the adoption of cyclosporine as an effective anti-rejection drug. During the 1980’s Stanford was the only prominent heart transplantation program in the western United States, and the quantity of brain dead heart donors was modest. In order to expand their volume of transplants, Stanford created a fixed-wing aircraft harvesting and transportation program to bring donor hearts to Palo Alto from distant locations.

One registered nurse had a fulltime job locating appropriate brain dead heart donors within a 60-90 minute Learjet trip from Stanford. A separate team of physicians and nurses was responsible for assembling a waitlist of prospective heart transplant recipients, and for arranging housing for them within the San Francisco Bay Area.

When Stanford learned of a brain dead donor with a normal heart at a distant location, the following choreography occurred: 1) a matching donor was identified and told to come to Stanford Medical Center immediately; 2) a team of surgeons, anesthesiologists, nurses, and a heart-lung perfusionist was paged to Stanford Medical Center immediately to prepare the recipient patient for his or her transplant surgery; and 3) a transport team of two surgeons (a chief resident in cardiac surgery and a second surgical resident), one anesthesia fellow or resident, one scrub nurse, one circulating nurse, and the nurse in charge of the transport team were all paged to the Stanford Medical Center immediately.

Note that the anesthesia transport team member was only an anesthesia fellow or a resident. The eligible residents were second-year residents (anesthesia residency training was only two years in duration during the 1980’s). As a second-year resident, I was a partially trained anesthesiologist who had done only 800-1000 anesthetics at that time, and was not yet eligible to sit for the American Board of Anesthesia exam.

An ambulance transported our team to the Moffett Field Air Force Base, 10 miles southeast of the Stanford campus, where we boarded a Learjet for the flight to the donor hospital. The donor harvesting catchment area was as far north as Seattle, as far south as Las Vegas, and as far east as Boise. We had no medical tasks to do in flight, and we spent our time looking out the windows and small talking. Upon arrival at the airport in the donor city, an ambulance transported us to the hospital.

At the hospital we proceeded to the intensive care unit where we found the donor’s brain dead body connected to a ventilator and ICU monitors. At this point my work began. Even though the patient was brain dead, it was imperative to maintain his or her vital signs and oxygenation at optimal levels to preserve the cardiac function for the eventual recipient. My first tasks were to insert an arterial line in the radial artery to monitor blood pressure, and to insert a central venous pressure catheter in the internal jugular vein to administer medication infusions as needed to decrease or increase the blood pressure during the upcoming surgery. We would then transport the patient through the hallways of this foreign hospital, accompanied by the surgeons, and directed by staff of that hospital who knew the floor plan. I’d be squeezing an Ambu bag full of oxygen to ventilate the patient, all the while vigilant of the vital signs displayed on a portable monitor during the transport.

We’d arrive in the operating room—a room we’d never seen or worked in before—and prepare the patient for surgery. My job was to connect the patient to the operating room ventilator and the standard cardiac surgery monitors: ECG, oximeter, arterial line, and central venous pressure. The manufacturers of the monitoring equipment varied from hospital to hospital, and it was not unusual for the equipment to be different than machines I’d worked with before. My next task was to prepare vasoactive drips such as nitroprusside and connect them to the central venous pressure IV line. No anesthetic drugs were used, because the donor was brain dead, but surgical stimulus always caused increases in blood pressure and heart rate. It was critical that pumping against a high resistance or pumping at a high rate not tax the donor heart. I also had to fill out a written anesthesia medical record to document what I was doing to the patient.

The scrub tech, nurse, and the two surgeons prepped and draped the patient for surgery, and the initial incision was made over the sternum. A power saw was used to cut the breastbone down the midline to enter the chest. A rib-spreader was used to widen the cavity and improve visualization. The surgeons inspected the heart in terms of its general appearance, size, contractility, and the state of the coronary arteries. Once they’d determined the heart was indeed normal, the transplant nursing coordinator made a phone call to the Stanford operating room in California to inform them it was a green light to anesthetize the heart recipient there.

In our operating room, the two surgeons clamped off the aorta and all other blood vessels leading into and out of the heart, and injected a cardioplegic solution into the coronary arteries via the root of the aorta. This solution preserved the heart function during the upcoming trip when the heart would no longer be beating. The surgeons then cut the heart out of the body, placed it in a sterile bag, and placed the bag into an Igloo chest full of ice. I turned off the ventilator, the surgeons removed their gloves and gowns, and our whole cast scurried out of the operating room with the Igloo and its precious cargo in hand.

It was always a bizarre sight to see that human carcass with an empty thorax lying on an operating room table when we left the operating room. In the later months of my Learjet experiences, a second transplant team was sometimes present to harvest the kidneys or corneas after we departed.

The original ambulance met us at the Emergency Room entrance, and we sped back to the airport Code 3 with alarms blaring. We drove onto the tarmac next to the Learjet and climbed inside. The doors closed, engines flared, and wheels up . . . we were on our way back to Palo Alto.

The flight home was relaxing. We’d spent an intense period of time at the hospital, and we had no work to do except to ride and look out the windows. Beverages and food were always supplied for the trip home. The mood was jubilant—the feeling you get with medical jobs when you realize you’ve accomplished something. We were helping the recipient patient in their journey back to health, and experiencing private jet travel at 35,000 feet at the same time.

On arrival to Moffett Field, an ambulance awaited us on the tarmac. We’d climb in and ride at top speed back to Stanford. We stopped in front of the Emergency Room, and the surgeons and the nurse coordinator ran through the doorway and up the stairs to operating room 13, where the anesthetized recipient patient lay, his or her chest open, ready to receive the new heart at once.

At this point I went home. An anesthesia resident colleague and an anesthesia faculty member were upstairs attending to the recipient. Caring for the recipient patient was their job for today—mine was finished.

How stressful was the entire journey to harvest the new heart? Pretty stressful, to be honest. At that point, I’d done less than two years of anesthesia training, and I was relatively inexperienced. During my training, a faculty member always stood right next to me during every anesthesia induction and a faculty member was immediately available at all times. On the Learjet trips I was without faculty backup for the first time. The setting at the destination hospital was always unfamiliar. The equipment on hand at the destination hospital was often unfamiliar. The cardiac chief resident surgeon was typically an intense 39-year-old who’d been training for decades and who had little interest in waiting any longer than possible while an anesthesia resident-in-training toiled to insert an arterial line and a central venous catheter. Even though the patient was brain dead, there was no tolerance for errors in ventilation or medical management, it was imperative to keep the vital signs stable throughout the donor surgical procedure, and there was time pressure to keep the process moving.

Prior to my anesthesia residency I’d completed three years as an internal medicine resident at Stanford and one year as an attending in the Emergency Room at Stanford. All my experience in internal medicine and emergency medicine was useful on those heart-harvesting trips—but I knew how lucky I was. Internal medicine residents don’t get to ride Learjets, and ER attendings don’t get to ride Learjets either.

An added motivation: We were paid $35/hour for our time, a princely sum in 1986.

Alas, none of this would happen nowadays. Currently there are hundreds of cardiac transplantation programs in the United States, and each program procures their donor hearts from close geographic proximity.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

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12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too.

Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?”

The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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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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THE ANESTHESIA CONSULTANT IS NAMED ONE OF THE WORLD’S TOP ANESTHESIA BLOGS

the anesthesia consultant

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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Today theanesthesiaconsultant.com was named one of the world’s top anesthesia blogs by Feedspot.

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I’m grateful to Feedspot for this honor, and to my readers for making this possible.

See the link here to view the complete list of the world’s top anesthesia blogs. Theanesthesiaconsultant.com was ranked #7, behind such high-powered professional websites such as Anesthesiology News, the Journal of the Association of Anaesthetists of Great Britain and Ireland, and Reddit Anesthesiology,

Keep reading, and I’ll keep writing!

 

Thanks,

Richard Novak, MD

 

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?

ARE SURGERY CENTERS SAFE?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Are surgery centers safe? This column is in response the Kaiser Health News story “How a push to cut costs and boost profits at surgery centers led to a trail of deaths” published on USAToday.com this week. The article set off a firestorm of controversy in the surgery center industry. The Kaiser article cites anecdotal information and allegations from ongoing litigation cases of patients seemingly harmed by their care at outpatient ambulatory surgery centers.

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The quantity of ambulatory surgery centers has greatly increased over the past forty years for three primary reasons: Technologic advances made surgery easier, anesthetic care is safer, and healthcare payment policies encourage ambulatory surgery. I’ve been the Medical Director at a busy freestanding ambulatory surgery center in Northern California for a decade and a half. I’m a Stanford University-trained anesthesiologist and internist, and I’m uniquely qualified to answer the question: Are American surgery centers safe?

Yes, they are safe.

A review of the medical literature on Pubmed shows no peer-reviewed studies or data that surgery centers provide less safe care than hospitals.

Surgery and anesthesia are never 100% safe, no matter where procedures are done. There are always risks. The roles of anesthesiologists and surgeons at surgery centers are to minimize the risks.

There are four key questions regarding safe patient care at surgery centers:

  1. Is the scheduled procedure appropriate for an outpatient surgery center?
  2. Is the patient healthy enough to tolerate the scheduled procedure as an outpatient?
  3. Are the healthcare professionals at that center practicing at the standard of care?
  4. Is the surgery center accredited by an organization such as the Accreditation Association for Ambulatory Health Care (AAAHC)?

 

Question #1.

The most important screening question for a surgery center is, “What is the scheduled procedure?” Knee arthroscopies, tonsillectomies, inguinal hernia repairs, and colonoscopies are standard surgery center procedures. You cannot do large cases such as craniotomies, open heart surgeries, or an aortic vascular surgeries at a surgery center. The necessary backups of an intensive care unit, a blood bank, respiratory therapy, and a clinical laboratory are lacking. The job of a Medical Director is to survey the schedule each week, and decide if any planned cases are outside the usual comfort zone for that center. If there is any question, the Medical Director must gather more information on the procedure and the patient, usually by talking directly to the surgeon, and decide whether or not to give the case a green light. If the verdict is a red light, the surgeon needs to do the case in a hospital.

In recent years, some surgery centers have expanded their scope. Procedures such spine surgeries, total joint replacements, and bariatric surgeries are performed as ambulatory or short stay procedures at some outpatient centers. As the USAToday.com article points out, one motivation is money. A surgery center can extract well-insured cases from hospitals in order to increase profits for the surgery center. Is it better for a patient to have these procedures in a freestanding facility detached from a hospital? There is a paucity of research in peer-reviewed medical literature regarding the performance of these cases outside of hospitals. The USAToday.com article lists multiple spine surgery patients who died after surgery at an ambulatory surgery center. Medicare has only approved payment for spinal surgery at ambulatory centers since 2015. To my knowledge, no one has published the overall statistics regarding complications from spinal surgery in surgery centers and compared this to the complications from similar procedures in hospital settings.

What about the claim from the USAToday.com article that 911 calls from a surgery center are a problem? If a patient unexpectedly becomes acutely ill at a surgery center, calling 911 and transferring the patient to a hospital is routine policy and appropriate medical care.

 

Question #2.

How does a facility decide whether a patient is fit enough to undergo a given surgery at an outpatient center? At a surgery center, it’s the Medical Director’s job to screen every patient prior to scheduling. It’s the Medical Director’s job to prevent patients who are too sick from having a procedure at a surgery center. Different systems exist for preoperative assessment. Large university hospitals staff preoperative anesthesia clinics for their patients, and patients are required to physically visit the clinic to be examined and assessed prior to inpatient surgery. This system is not always practical in outpatient community medicine. Patients are usually assessed by their primary care physicians as indicated before surgery. A typical preoperative screening protocol at a surgery center is as follows: a preoperative assessment professional from the surgery center will telephone each patient several days before surgery, ask a series of pertinent screening medical questions, and fill out a standardized form. Any outlying answers are referred to the Medical Director, who decides if the patient is fit for the surgery. If the patient is too sick, the Medical Director will cancel the case, and tell the surgeon that the surgery needs to be done in a hospital.

 

Question #3.

When a complication occurs, anesthesiologists and surgeons in the operating room have a responsibility to correctly diagnose the problem and apply the correct therapy. The legal term for this is that physicians must adhere to the “standard of care.” The standard of care is defined as “what a reasonably trained physician would do in the same circumstance.” Deviating from the standard care is called negligence, and is part and parcel to medical malpractice lawsuits. If a bad outcome occurs in a surgery center because of negligence, i.e. malpractice, this is not a fault of the surgery center system. This concept is a central flaw in the USAToday.com article. The article cites multiple bad outcomes from surgery center cases, and in many of these cases the central issue seems to be negligent, below the standard of care decisions and actions by the health care professionals involved. Negligence is not specific to surgery centers.

 

Question #4.

Most surgery centers provide care to Medicare patients, and must meet standards approved by the federal government. To obtain Medicare certification, a surgery center must have an inspection conducted by a representative of an organization that the government has authorized to conduct that inspection, such as the Accreditation Association for Ambulatory Health Care (AAAHC). Inspectors will physically visit the surgery center to verify that the center meets established standards. Most surgery centers have passed such an inspection. The surgery center I work at is recertified every three years. If you’re uncertain whether your local surgery center is safe, request documentation that the facility has been certified by an organization such as AAAHC.

Nearly 60% of all surgical procedures in the United States are performed as outpatient surgery. Tens of millions of Americans receive care in ambulatory surgery centers each year. I’ve personally had two arthroscopic surgeries and three colonoscopies, and I chose to have all five procedures at a freestanding outpatient surgery center. The USAToday.com article cited anecdotal adverse outcomes from patients who were cared for at outpatient ambulatory surgery centers. Adverse outcomes will occur, but the frequency of these events (adverse events vs. total number of cases) is extraordinarily small. America’s surgery centers are by and large very safe. I reaffirm that no peer-reviewed data documents that ambulatory surgery centers are unsafe.

The key issues regarding surgery center safety will always be the four questions posed above. Is a given procedure safe and appropriate for an outpatient surgery center? Is a given patient fit enough to have their particular procedure in an outpatient surgery center? Are the healthcare professionals at that center practicing at the standard of care? And is the surgery center accredited by an organization such as the AAAHC?

In the overwhelming majority of America’s surgery centers, the answers to these three questions will be “Yes, yes, yes, and yes.”

 

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MYOCARDIAL INJURY AFTER NONCARDIAC SURGERY . . . COMMON, SILENT, AND DEADLY. WHAT CAN WE DO?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

You’re a 55-year-old man with hypertension, scheduled for surgery for a right colon removal for colon cancer. How likely is your death within 30 days after surgery?

Higher than you would think.

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Your 30-day morality following this inpatient surgery is 1.2%. What can we do to improve myocardial injury after noncardiac surgery? Read on…

Dr. Daniel Sessler, Chairman of the Department of Outcomes Research at the Anesthesia Institute of the Cleveland Clinic, spoke at the Stanford Anesthesia Grand Rounds last week. His lecture, titled “Perioperative Myocardial Injury,” answered the questions above. Let me share what Dr. Sessler had to say:

  1. Myocardial injury after noncardiac surgery, abbreviated as MINS, is a common, silent, and deadly problem. Dr. Sessler described mortality related to surgery as the third leading cause of death in America, behind cardiovascular disease and cancer, and he cited myocardial injury as the leading cause of death after surgery.
  2. Devereaux, Sessler, and colleagues measured postoperative hsTnT (high sensitive troponin T) in 21,842 patients over the age of 45 who had inpatient noncardiac surgery at 23 medical centers in 13 countries.1 (For my nonmedical readers: hsTnT or cardiac troponin is a biomarker for acute myocardial infarction, i.e. heart attack.) Two hundred sixty-six patients died within 30 days after surgery, for an overall mortality rate of 1.2%. A total of 3904 patients had elevated hsTnT, diagnostic for MINS, for an overall incidence of tropinin elevation = 18% of the patients. Ninety-three percent of these patients had no ischemia-related symptoms, and would not have been detected without the hsTnT measurements.
  3. Puelacher published similar data in an older population (all patients over the age of 65).2 He studied postoperative hsTnT levels in 2018 consecutive inpatients and found perioperative myocardial injury (PMI) occurred in 397 (16% of the patients). Only 24 (6% of the patients) had typical chest pain, and only 72 (18% of the patients) had ischemic symptoms. The 30-day mortality was 8.9% for patients with PMI, compared to 1.5% for patients without PMI.
  4. hsTnT isn’t commonly measured in current practice, which means the majority of MINS patients go undiagnosed. Sessler recommended that all patients diagnosed with MINS be seen by a cardiologist, to consider further diagnostic or therapeutic intervention. He specifically mentioned the possibilities of statin and/or aspirin therapy, as well as smoking cessation and weight loss.
  5. Sessler suggested that a future approach to MINS detection would be to measure postoperative hsTNT for three days in every inpatient noncardiac surgery patient over 65 years old, and in those over 45 with one or more cardiovascular risk factor.
  6. What about preoperative clearance for noncardiac surgery? Sessler described exercise tolerance and the echocardiogram cardiac stress test as two inaccurate screening tools. He rated the two most effective screening tools as the Revised Cardiac Risk Index (see below), and the preoperative measurement of BNP (Brain Natriuretic Peptide).
  7. The Revised Cardiac Risk Index (RCRI) evaluates these 6 patient factors:

■ High-Risk Surgery – the following surgeries are deemed high risk for perioperative cardiac complications:

-­ Intraperitoneal

– Intrathoracic

– Suprainguinal vascular

■ History of ischemic heart disease – characterized by either a history                                     of a positive test, a diagnosed MI, current chest pain suspicion of                                                 myocardial ischemia, nitrate therapy, or evidence of                                                             pathological Q waves on electrocardiogram.

■ History of congestive heart failure – described as the presence of                                     either:

– Pulmonary edema, bilateral rales or S3 gallop;

– Paroxysmal nocturnal dyspnea;

– A CXR showing pulmonary vascular redistribution.

■ History of cerebrovascular disease – e.g. a prior TIA or stroke.

■ Pre-operative insulin treatment.

■ Pre-operative creatinine more than 2 mg/dL.

 

Positive findings of these factors define 4 classes of postoperative                                     cardiac complication percentage rates:

■ 0 factors – Class I – risk 0.4%;

■ 1 factor – Class II – risk 0.9%;

■ 2 factors – Class III – risk 6.6%;

■ 3 to 6 factors – Class IV – risk 11%. 

  1. Preoperative BNP concentration is a powerful independent predictor of perioperative cardiovascular complications.3 At best, clinicians can utilize both a low score in the preoperativeRevised Cardiac Risk Index plus a low value of the BNP or the N-terminal proB-type natriuretic peptide (NT-proBNP) plasma level.4 Sessler stated that a BNP test costs 1/20th as much as an echo stress test, and is more accurate in predicting postoperative cardiac mortality. He stated that a NT-proBNP level of < 300 ng/mL correlated well with a safe perioperative cardiovascular course.
  2. Elevated preoperative troponin or hsTnT concentrations were also significantly associated with postoperative MI and long-term mortality after noncardiac surgery.5
  3. Metoprolol, aspirin, and clonidine all failed as preoperative interventions to decrease cardiac risk. Metoprolol decreased postoperative myocardial infarction, but there were more deaths and an increased rate of stroke in the metoprolol group than in the placebo group.6 Aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of death or nonfatal myocardial infarction, and increased the risk of major bleeding.7 Low-dose clonidine did not reduce the rate death or nonfatal myocardial infarction, and increased the risk of clinically important hypotension and nonfatal cardiac arrest.8
  4. Eliminating nitrous oxide from the anesthetic regimen had no effect in decreasing myocardial injury.9
  5. Intraoperative hypotension correlated with postoperative myocardial injury. Mascha studied the time-weighted average intraoperative mean arterial pressure (TWA-MAP), and found that lower mean arterial pressure strongly correlated with mortality.10 Sessler stated that a mean blood pressure of 50 torr for even one minute was a risk factor for postoperative myocardial injury. Targeting a specific systolic blood pressure reduced the risk of postoperative organ dysfunction.11
  6. Sessler stated that 1/3 of intraoperative hypotension occurred during the time between induction of anesthesia and time of the surgical incision. By analyzing large databases from electronic anesthesia recording systems, hypotension was documented during this time period when general anesthesia lacked any surgical stimulus to keep blood pressure elevated. Sessler’s recommendation was to maintain the MAP > 65 torr throughout noncardiac surgery.
  7. The use of vasopressors to treat hypotension was safe.
  8. Tachycardia was not a risk factor. “It hardly matters,” Sessler said.
  9. Preoperative angiotensin-converting-enzyme inhibitors (ACE inhibitors), e.g. lisinopril, Lotensin, or Altace, and Angiotensin II receptor blockers (ARBs), e.g. Diovan or Cozaar, were risk factors for intraoperative hypotension and cardiovascular morbidity. Roshanov studied data from 14,687 patients aged 45 years or older for inpatient noncardiac surgery.12 Four thousand eight hundred and two of these patients were taking ACE inhibitors or ARBs preoperatively. The patients who withheld their ACE inhibitors/ARB drugs in the 24 hours before surgery were less likely to suffer the outcomes of death, stroke, or myocardial injury. The authors recommended that patients withhold these drugs for 24 hours before surgery.

 

Dr. Sessler closed his lecture with the following recommendations:

  • In the future, clinicians should measure high-sensitivity troponin (hsTnT) for three days postoperatively on inpatient surgery patients of age > 65, or patients age >45 with one cardiovascular risk factor. Elevated shTnT will identify patients who with MINS, and these MINS patients should be referred for cardiology/internal medicine follow up.
  • In the future, clinicians should screen for preoperative cardiovascular risk by a combination of the BNP and hsTnT assays prior to surgery.
  • There is no known preoperative medical prophylaxis against MINS.
  • Maintain intraoperative mean arterial pressure > 65.
  • Hold ACE inhibitors/ARBs for 24 hours prior to surgery.

One of our professors asked Dr. Sessler if the current practice at the Cleveland Clinic included measuring preoperative BNP and three-day postoperative hsTnT. Sessler’s answer was, “not yet, but we’re working on it.”

What about your practice and mine?

This is a new topic and a cutting edge issue to most anesthesiologists, with the key studies only published in the last year. I’m impressed by the MINS data, and I don’t want any patient of mine joining the MINS mortality list. I already withhold ACE inhibitors/ARBs for 24 hours preoperatively. I will continue to be vigilant to maintain MAP > 65, using vasopressors as necessary. I currently use the Revised Cardiac Risk Index as well as cardiology consultations as indicated to screen patients preoperatively. At the present time both the cardiologists and I depend on exercise tolerance history and echo treadmill tests for preoperative cardiac clearance. I expect in the near future our healthcare systems will adopt the standards of checking BNP preoperatively and hsTnT for three days postoperatively for inpatient surgery patients of age > 65, or patients age >45 who have one cardiovascular risk factor. Stay tuned for future recommendations.

References:

  1. Devereaux PJ et al. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. 2017Apr 25;317(16):1642-1651.
  2. Puelacher C et al. Perioperative Myocardial Injury After Noncardiac Surgery. Circulation. 2018;137, 1-12.
  3. Rodseth RN et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol.2014 Jan 21;63(2):170-80.
  4. Vetrugno L et al. The Possible Use of PreoperativeNatriuretic Peptides for Discriminating Low Versus Moderate-High Surgical Risk Patient. Semin Cardiothorac Vasc Anesth. 2018 Jan 1.
  5. Nagele P et al. High-sensitivity cardiac troponin T in prediction and diagnosis of myocardial infarction and long-term mortality after noncardiac surgery. Am Heart J.2013 Aug;166(2):325-332.
  6. Devereaux PJ et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. 2008 May 31;371(9627):1839-47.
  7. Devereaux PJ et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med.2014 Apr 17;370(16):1494-503.
  8. Devereaux PJ et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med.2014 Apr 17;370(16):1504-13.
  9. Myles PS et al. The safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): a randomised, single-blind trial. Lancet. Volume 384, No. 9952, October 2014, 1446-1454.
  10. Mascha EJ. Intraoperative Mean Arterial Pressure Variability and 30-day Mortality in Patients Having Noncardiac Surgery. 2015 Jul;123(1):79-91.
  11. Futlier E et al. Effect of Individualized vs Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients Undergoing Major Surgery: A Randomized Clinical Trial. 2017Oct 10;318(14):1346-1357.
  12. Roshanov PS et al. Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort. 2017Jan;126(1):16-27.

 

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CARTOON FROM THE 1999 AMERICAN SOCIETY OF ANESTHESIOLOGISTS ART CONTEST

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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The year was 1999, the technology stock market was exploding, and businessmen in Silicon Valley were getting richer by the hour. Meanwhile, back at the metaphor, anesthesiologists practiced their essential healing profession, and hoped HMOs and hospital administrators would not decrease their anesthesia quantum wage any further.

The cartoon won an Honorable Mention award at the ASA national meeting in 1999.

The original is a 24 inch X 36 inch panel which hangs in the office at my home.

Rick Novak, MD

 

P.S. I do believe it’s healthy for physicians to express themselves in print, in art, and via the spoken word.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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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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MERITS OF PHYSICIAN ANESTHESIOLOGY

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Some people have difficulty seeing the outstanding merits of physician anesthesiology. I understand where these opinions come from, but the phenomenon still bothers me.

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Today I read a thoughtful and well-written essay in Anesthesiology News titled, Anesthesiologists-The Utility Players of the Medical Field written by anesthesiologist David Stinson MD from my native state of Minnesota. His thesis is that, like utility players on a baseball team, we are valuable but suffer an identity crisis. He writes, “Our specialty, anesthesia, has suffered an identity crisis for decades. Are we the ‘captain of the ship’ or is the surgeon? . . . It is never quite clear and the answer changes with location and context. Are we physicians or are we glorified advanced practice nurses?”

To me, the appropriate headline should read, “Anesthesiologists—the Most Valuable Players of the Medical Team.” I’d like to see an anesthesiologist saying, “I’m going to Disney World” at the end of the Super Bowl before picking up his (or her) MVP trophy.

Why would I say this? Two anecdotes will illustrate why I understand the problem. In the late 1970’s I was a third-year medical student at a prominent Midwestern medical school, where an unspoken rank system existed in the operating room. The surgical attendings were the kings, the students were the peasants, the nurses and techs were serfs, and the anesthesiologists were the whipping boys for the surgeons. I witnessed consistent verbal abuse, bullying, condescending barking commands, and lack of respect directed from surgeons toward anesthesiologists. One day I was scrubbed in as a retractor-holding medical student on a 12-hour esophagectomy, and at the conclusion of the procedure the attending surgeon removed his gloves and gown and left the room to talk to the family. Five minutes later, the patient had a cardiac arrest. The resuscitation was not successful, and the patient died. Afterward the surgeon bellowed his disapproval regarding how the anesthesia team had failed to keep the patient alive after he had spent all day “curing” the patient. It was an unforgettable experience to me, and one of the take-home messages was that I never wanted to be an anesthesiologist.

Fast-forward three years into the future, when I was an internal medicine resident at Stanford serving my medical intensive care unit rotation. The anesthesiology department ran the ICUs at Stanford during the 1980’s. The ICU attendings were charismatic, smart, decisive, impressive role models. The ICU attendings had respectful peer relationships with all the surgeons, including the private-practice cardiac surgeons whose post-operative patients were housed in the ICU. Morning rounds, evening rounds, and the eight hours in between were filled with action, procedures, upbeat emotions, and encouraging talk about the specialties of anesthesiology and critical care medicine. The Stanford anesthesia residents boasted of weekdays off after their nights on call, Learjet trips to harvest donor hearts for Dr. Norm Shumway’s cardiac transplant patients, weeklong trips to third-world countries to perform anesthetics on cleft lip and palate patients, and best of all, the excitement of inserting endotracheal tubes, arterial lines, central lines, Swan Ganz catheters, spinal and epidural needles into patients of all sizes and surgical needs. This was alluring to internal medicine residents. Each year a significant number of internal medicine residents applied for admittance to anesthesiology residencies, which is what I did. Were surgeons hollering at the anesthesiologists at Stanford? In a word . . . no. The department had the respect of the surgeons. This was the environment I grew up in, and the professional spirit we all should aspire to.

Here are 10 reasons why anesthesiologists should hold their heads high and never have a molecule of low self esteem around their medical center:

  1. All of acute care medicine is based on A-B-C, or Airway-Breathing-Circulation. Operating room medicine, intensive care medicine, emergency room medicine, trauma helicopter medicine, and battlefield medicine are all based on A-B-C, or Airway-Breathing-Circulation. Who are the experts of the A, or Airway? Anesthesiologists are the experts. There can be no acute care resuscitation without someone managing the airway, usually with an endotracheal tube. It’s true that other medical professionals have abilities to place endotracheal tubes, but none of them have the breadth of skills, techniques, and volume of attempts as anesthesiologists do. Hold your heads high. Read my column on bullying in the operating room. Don’t put up with condescending behavior from a surgeon. Surgeons know how to wield a scalpel. You know how to wield the most valuable tool of all medical equipment, the laryngoscope.78432-7985650
  2. It’s true that surgeons bring the patients to the operating room for surgery. It’s just as true that none of those patients would agree to the operations without having an anesthetic. The anesthesiologist’s role is vital.
  3. Clinic doctors are important. They manage primary care as well as outpatient specialty care. They make diagnoses and prescribe therapeutic medicines. Anesthesiologists also partake in clinic care in preoperative clinics and pain clinics. An anesthesiologist’s knowledge of internal medicine isn’t as comprehensive as a board-certified internist, but the consider the flip side: None of the internists can administer general anesthesia, regional anesthesia, or manage the A of the A-B-Cs like an anesthesiologist can. I was an internal medicine doctor who lacked these skills and then acquired them during anesthesia residency. Trust me—internists envy the skills of anesthesiologists.
  4. Anesthesiologists deal with life and death situations on a regular basis. Clinic doctors, including surgeons on their days in clinic, listen to and talk to patients. There is no peril in outpatient clinic medicine. On any given day at your job as an anesthesiologist you could be attending to a morbidly obese adult, a tiny child, a frail geriatric patient, or an emergency thoracic case. Your heart rate will climb as high as the patient’s, and you’ll manage the circumstances. Anesthesiologists are goalies at the Pearly Gates, and we should be proud of it.
  5. Physician anesthesiologists have a fascinating job. Anesthesiologists administer anesthetics to virtually every specialty: general surgery, cardiac surgery, neurosurgery, obstetrics, gynecology, otolaryngology, orthopedic surgery, podiatry, ophthalmology, plastic surgery, psychiatry for electroshock therapy, invasive radiologists, cardiologists, oral surgeons, dentists, and pediatric surgeons. The breadth of knowledge across specialties is unrivaled by any other physician.
  6. Who is the captain of the ship in the operating room? Is it the surgeon or is it the anesthesiologist? My advice is: don’t concede the role to your surgical colleague alone. He or she knows how to do the operation. You know how to do the anesthetic. It is a symbiotic relationship. Do not lay yourself down on the ground in reverence. In the words of the Eagles song “Peaceful Easy Feeling,” “she can’t take you anywhere you don’t already know how to go.” If you see and feel yourself as the servant, second in command, that’s where you’ll find yourself . . . as the servant, second in command. Step up. Be an equal. Be in control of your domain, a critical domain.
  7. Physician anesthesiologists are well paid. Per U. S. News and World Report, an anesthesiologist is the highest paying job in America. Think about that. There are 325 million people in our country, and there are thousands of different job descriptions. Your profession is the highest paid. Be proud of that.
  8. Physician anesthesiologists are in demand. As I write this in 2018, I receive multiple emails per day seeking attending anesthesiologists for jobs around the USA. If you’re willing to relocate and be mobile, you’ll find numerous suitors competing for your services as an attending anesthesiologist. Per U.S. News and World Report, the unemployment rate for anesthesiologists is a paltry 0.5%.
  9. Physician anesthesiologists help people every day. You could be selling Coca Cola or cell phones or cell phone data networks or stocks. Would you be serving humanity as well if you were working in some business job? You have the opportunity to change lives for hundreds of patients per year.
  10. Maybe you’re worried that nurse anesthetists will take your job away. I have no crystal ball to foretell the future, but consider these things: (a) Most CRNAs work in anesthesia care team models with our physician anesthesiologist colleagues, and this MD-CRNA relationship is a well accepted model of patient care that will persist into the future; (b) Physician anesthesiologists are needed for leadership roles in clinical care, administration, committees, and quality assurance; and (c) Remember that you are a physician and CRNAs are not. Keep up your skills. The large medical systems of the future will tier their anesthesia coverage. Complex cases will always require MD anesthesiologists. It’s likely that simple cases such as cataracts, lymph node biopsies, and knee arthroscopies can be safely done with CRNA anesthesia. Continue to seek out and perform difficult anesthetic cases only an MD would feel comfortable doing. If you find yourself attending to only ASA I an ASA II patients for straightforward surgeries, you may indeed find your job taken by someone with less training. Instead, step up. Be proud of your training, your unique skills, the heritage of your profession, and the esteem of your standing among your fellow physicians.

 

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PHYSICIAN ANESTHESIOLOGIST LISTED AS THE #1 BEST PAYING JOB BY U.S. NEWS AND WORLD REPORT

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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For years I’ve extolled the intellectual and emotional virtues of a career in anesthesiology.

This week U.S. News and World Report credited anesthesiologist with another honor: the highest paying job in their 2018 Best Paying Jobs survey. Regarding the #1 job, physician anesthesiologist, the article states, “the breadth of the profession has dramatically expanded in the last decade. Anesthesiologists still work in hospital operating rooms, but their expertise is also needed in other places, including invasive radiology, gastrointestinal endoscopy, electrophysiology and more. In fact, the profession is expected to grow by 18 percent through 2026, with 5,900 new jobs.” The median salary for a physician anesthesiologist was listed as $208,000, and the unemployment rate as 0.5%.

The article also states, “The journey to becoming an anesthesiologist is a long one. After obtaining an undergraduate degree, hopefuls need to take the Medical College Admission Test (MCAT) and attend medical school. After graduation, they will then have to pass the United States Medical Licensing Examination (USMLE) to undergo a one-year internship followed by a three-year residency in anesthesiology. Most anesthesiology residents go on to do a one- to two-year fellowship program to learn a subspecialty, such as critical care or obstetric anesthesia. After completing residency and taking an exam, anesthesiologists may also receive their board certification through the American Board of Anesthesiology. It’s not required, but it does demonstrate advanced skill and knowledge and many help with getting more professional opportunities or a higher salary. However, all anesthesiologists have to obtain state licensure, the requirements for which vary by state. By the time an anesthesiologist is through residency and a fellowship, he or she will have completed anywhere from 12,000 to 16,000 hours of clinical training, according to the American Society of Anesthesiologists.”

The job of a certified nurse anesthetist was listed as #11 on the Best Paying Jobs list. The article states, “health care reform and the aging baby boom population are precipitating the demand for more health care providers. And indeed, the BLS (Bureau of Labor Statistics) predicts that the profession is poised to grow by about 16 percent by the year 2026, which translates into 6,700 new job openings.” The median salary of nurse anesthetists was listed as $160,270, and the unemployment rate as 2.7%.

Careers in anesthesia are intellectually stimulating, emotionally gratifying, and have high median salaries and ultra-low unemployment. Expect the demand for acceptance into physician anesthesiologist and nurse anesthetist training programs to remain high. I see both careers to remaining attractive and secure for the foreseeable future.

 

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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WHEN SURGEONS, OR PATIENTS, TRY TO TELL THE ANESTHESIOLOGIST WHAT TO DO — 14 EXAMPLES

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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You’re a board-certified anesthesiologist. You’ve graduated from a residency program in which you learned the nuances of preoperative, intraoperative, and postoperative anesthesia practice. Yet at times, surgeons or patients will try to coerce you to do something counter to your professional judgment.

Individuals would never board a Boeing 787 aircraft and tell the pilot what to do, but individuals will try to influence their anesthesiologist.

Let’s look at some examples:

 

WHEN SURGEONS TRY TO TELL THE ANESTHESIOLOGIST WHAT TO DO:

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  1. “This patient’s not too sick. You’re wrong to cancel his surgery.” In an example of this scenario, an orthopedic surgeon tries to convince you that the 65-year-old obstructive sleep apnea patient with a BMI of 40 who never walks further than the distance from his couch to his kitchen table is “not that sick,” and that you should not cancel the patient’s rotator cuff repair at a freestanding outpatient surgery center. Trust your training and your intuition. You believe the patient is high risk in terms of his airway, his breathing, his cardiac status, and his potential for post-operative complications. You’re trained in perioperative medicine. The orthopedic surgeon is trained in the management of joint and bone disorders. Tell the surgeon that the patient needs to have cardiac clearance prior to any general anesthetic, and that the case needs to be done in a hospital setting rather than at a freestanding surgery center.
  2. “Just do MAC (Monitored Anesthesia Care) anesthesia for this case, but make sure he’s asleep. My patient doesn’t want to hear anything.” In an example of this scenario, a surgeon schedules an inguinal hernia repair as a MAC anesthetic. The surgeon intends to supplement your intravenous (IV) sedation with local anesthetic at the surgical site. The surgeon told the patient to expect “a twilight sleep during the surgery.” You discuss this with the surgeon, who requests you, “Just give the patient sedation with propofol.” Per the American Society of Anesthesiologists Continuum of Depth of Sedation, if a patient is unarousable even with painful stimulation, that is a general anesthetic. In contrast, if a patient shows purposeful response following repeated or painful stimulation, that is deep sedation. It’s possible to infuse propofol and keep a patient purposefully responsive, but very few of us do this. Propofol infusions are typically used to make our patients sleep, and most propofol infusions cross the American Society of Anesthesiologists line into general anesthesia. If there is a complication or a bad outcome after the surgery, and you delivered general anesthesia when the operating room schedule said MAC and your preoperative anesthesia note stated the anesthesia plan was MAC, then you’re at medical-legal risk for delivering a deeper anesthetic than what was documented on the schedule and on your anesthetic plan.
  3. “Can you do an axillary block for this finger surgery?” In an example of this scenario, the surgeon requests an axillary block for a debridement of a finger surgery. You’re comfortable placing ultrasound-assisted regional anesthetic blocks, but you’re not confident with this particular block. You discuss other options with the surgeon, and suggest he places a digital block, which is more specific and incurs less risks than the axillary block. He pushes back, wanting you to do the axillary block. But if you don’t want to do the block, you don’t have to. You’re in charge of the anesthetic. You make the decision. The case proceeds with intravenous sedation, the surgeon complies with your request and blocks the base of the finger with local anesthesia, and the patient does fine.
  4. “This patient doesn’t need an arterial line (or a central venous pressure line).” In an example of this scenario, an 70-year-old woman with aortic stenosis is about to undergo an exploratory laparotomy for a perforated bowel. You’re concerned about maintaining her cardiac output, blood pressure, and blood volume during the surgery, and decide she needs an arterial line prior to induction and an internal jugular CVP after induction. The surgeon, in a hurry to proceed with the laparotomy, tells you neither of these lines is necessary. Your answer? Because you’re the expert in perioperative medicine, you tell him you need those lines and you will put them in. If there is a death or a dire cardiovascular complication, you’ll be the physician who will face the criticism if you did not place the lines. Blaming the surgeon will not protect you.
  5. After the conclusion of a surgery, the surgeon says, “What are you waiting for? Extubate the patient. She is bucking and coughing. Extubate the patient!” In an example of this scenario, after the conclusion of a tonsillectomy, you turn off the anesthetics. The patient eventually coughs and bucks on the endotracheal tube, but has not opened her eyes. When you open her eyelids, you note that her gaze is dysconjugate. You’re concerned that if you extubate the trachea, this still-emerging patient could develop laryngospasm. The surgeon then says, “When are you going to extubate? All this coughing is raising the blood pressure, and will cause bleeding and I’ll have a complication.” What should you do? Anesthesia practice must always follow the priorities of A-B-C, or Airway-Breathing-Circulation. You’re in charge of the airway. The endotracheal tube is your friend until the patient opens her eyes, is awake and responsive, and can maintain her own airway. Take out the breathing tube when you’re ready, not when the surgeon asks you to.
  6. Near the conclusion of surgery the surgeon says, “I’d like you to please extubate this patient deep.” In an example of this scenario, a patient has just received a five-hour general anesthetic for a facelift. As in the example above, the surgeon is concerned that coughing or bucking on the endotracheal tube at emergence will elevate the blood pressure and cause increased postsurgical bleeding. What should you do? Again, follow your training and experience. Anesthesia practice must always follow the priorities of A-B-C, or Airway-Breathing-Circulation. You’re in charge of the airway. The endotracheal tube is your friend until your patient opens her eyes, is awake and responsive, and can maintain her own airway. Certain slender, healthy patients are safe to extubate deeply, but this author is unconvinced of the benefit/risk analysis of deep extubation. You may make the surgeon happy, and you may continue to have a safe airway under general anesthesia in the absence of the endotracheal tube, but what if you don’t? What if the airway is poorly maintained in this patient after this five-hour surgery, when her entire head and jaw are wrapped up in a bulky facelift dressing? My advice is to take out the breathing tube when you’re ready, not when the surgeon asks you to.
  7. “Just give the patient a little bit of anesthesia, because my procedure will only last 10 minutes.” In an example of this scenario, the surgeon requests you sedate a 210-pound woman with a Body Mass Index (BMI) = 36 for a 15-minute egg retrieval. Because of the brief and seemingly trivial nature of the procedure, the gynecologist requests an anesthetic free of any airway tubes. You assess the patient and her airway, and decide you’ll need to use a laryngeal mask airway (LMA), with an endotracheal tube ready to go if the woman’s ventilation on the LMA is suboptimal. You explain to the surgeon that you’re doing what is safe, despite the requests the surgeon made. On obese, elderly, pediatric, or sicker patients, there are simple surgeries, but there are no simple anesthetics. Rely on your experience and training, and do the anesthetic by the standard of care.
  8. “I’d like to do this procedure in my office operating room, not in a surgery center or the hospital.” In an example of this scenario, the surgeon has a patient he’d only like to operate on in his office. You’ve worked at his office before, and you know his office operating room does not have an anesthesia machine. Your technique there is limited to IV sedation without any airway tubes or ventilation. You discover that the patient is an obese 45-year-old woman with a BMI = 32, and the planned procedure is implantation of a maxillary bone graft. Your concern is that you will not be able to safely sedate or anesthetize this woman for this oral surgery without a breathing tube or an anesthesia machine. The surgeon objects, and says that the woman does not have enough money to pay for the procedure to be done at the local outpatient surgery center, and that’s why he needs to do it in the office. You stand firm, and kindly refuse to do the anesthetic in his office.

 

 

WHEN PATIENTS TRY TO TELL THE ANESTHESIOLOGIST WHAT TO DO:

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  1. “I don’t want a breathing tube into my windpipe and voice box because I’m a singer and I don’t want my voice ruined.” In an example of this scenario, a 35-year-old 250-pound man with a BMI of 34 who sings in a rock ‘n roll band is about to have a lumbar laminectomy. He does not want to be intubated. He read about anesthesia on the Internet, and he wants you to use an LMA instead of an endotracheal tube. Your response? You advise him that per your experience and training, his only safe airway management is with an endotracheal tube, not with an LMA. You tell him that yes, he will have a sore throat after surgery, and the irritation to his vocal cords may cause a temporary hoarse voice. You advise him that the duration of the hoarse voice should be no more than several days or a week or two, and that it’s rare for any voice change to be permanent. You advise him that he can consent to the endotracheal tube with these risks, or he can refuse. If he refuses the appropriate airway tube management, you will decline to give him anesthesia today.
  2. “I want to be awake for my surgery, so I can watch and talk to the surgeon.” In an example of this scenario, a 55-year-old woman scheduled for a knee arthroscopy wants to be awake for the surgery. She is visibly nervous, and tells you she wants to be awake because she is afraid of dying during a general anesthetic. You discuss the options with the patient, which include spinal anesthesia, epidural anesthesia, or regional blocks, each accompanied by intravenous sedation if necessary, which will permit her to be comfortable and awake. She declines each of these. She just wants “some medicine in the IV to take the edge off while I’m still awake, just like I did with my last colonoscopy.” You discuss with her that knee surgery is more painful than a colonoscopy. You discuss with her that she will need more anesthesia than she is requesting. You leave the bedside and talk to the surgeon about the options. The surgeon is agreeable with injecting local anesthesia into the knee, as a supplement to the intravenous sedation you will administer. The patient, the surgeon, and you all agree with this plan. You also give the patient informed consent that if she is not comfortable, she may need more anesthesia medications from you and she may have to go to sleep. Begrudgingly, she consents. Five minutes into the surgery, despite 200 micrograms of IV fentanyl, 6 milligrams of IV midazolam, and appropriate 2% lidocaine injections into the knee joint by the surgeon, the patient is uncomfortable, crying, and in a state of panic. You begin an infusion of propofol, she goes to sleep, and the ordeal is over. She awakens in the PACU without complications and without complaints. In my experience, many patients who demand or insist on being awake during surgery are patients who hope to control circumstances in the middle of surgery, rather than trusting their anesthesiologist and surgeon. Don’t be surprised if these patients wind up requiring general anesthetics. Make sure you have preoperative informed consent for general anesthesia as a back up, because it’s likely you’ll need to administer it.
  3. A patient who’s been in the PACU (Post Anesthesia Care Unit) for an hour tells you, “I want more intravenous narcotics.” In an example of this scenario, a patient who had an arthroscopic anterior cruciate ligament (ACL) reconstruction is complaining of 8/10 pain ninety minutes postoperatively. He’s received 300 micrograms of fentanyl and two Percocet in the PACU, and says he is still uncomfortable. You go to his bedside, and witness that he is in no acute distress. His vital signs are normal, with a respiratory rate of 12 breaths per minute. He refused a femoral nerve block prior to surgery. Because he’s been medicated, the option of having him sign a consent and performing a femoral nerve block now is out of the question. Your assessment is that his pain score is inflated. One man’s 8/10 may be another’s 3/10. His respiratory rate is already low normal, and he’s received the adjunct of 30 mg of IV Toradol, as well as the Percocet. At this point in my practice I have the following conversation with the patient: I tell them, “You’ve already had the standard pain-relieving medications, including the oral medication the surgeon prescribed for home use. One option now would be to hospitalize you so that you can continue to receive IV narcotics, but we don’t hospitalize healthy patients after routine ACL reconstruction. A second option is for you to stay here in the PACU and continue to receive IV narcotics, but that makes little sense because you cannot continue IV narcotics at home. So the remaining option is for you to be discharged on the oral medication Percocet that the surgeon prescribed.” There’s a point after routine outpatient surgeries where there’s no rationale for the continued administration of IV narcotics, and the patient needs to be discharged home on their oral medications.
  4. Your awake patient in the PACU says, “I’m so anxious. Can I have more of that Versed you gave me before surgery?” In an example of this scenario, a patient with chronic anxiety wakes up from an uneventful anesthetic with complaints of nervousness. The role of the PACU staff is to monitor Airway-Breathing-Circulation while tending to common postsurgical complaints such as pain and nausea until the anesthetics wear off sufficiently for discharge. In my residency, my professors taught me that benzodiazepines were valuable preoperatively but have no role in the PACU, and I still follow this principle. The PACU is a temporary destination prior to discharging a patient home or to their hospital room. Sedating these patients with Versed or any other benzodiazepine in the PACU will prolong their recovery and is not indicated. The best treatment for PACU anxiety is often to discharge the patient out of the PACU.
  5. Your next patient is a child. His parent tells you, “I want to be in the operating room when my son goes to sleep. He needs me.” In an example of this scenario, the mother of a 3-year-old patient wants to accompany her son into the operating room to emotionally support the boy during a mask induction with sevoflurane. The scheduled procedure is bilateral ear pressure-equalizing tubes surgery. This author believes that parent(s) can be a distraction during the potentially dangerous time of mask induction of anesthesia. I’ve done thousands of pediatric inductions without parental presence, and I never wished I had a layperson there at my elbow while I was trying to assure safe airway management. Letting the child watch an iPad as they separate from their parents and engage in the anesthesia induction is a modern solution to this problem.
  6. A preoperative patient with a dangerous airway problem (think ankylosing spondylitis or Treacher Collins syndrome) tells you, “I refuse to have an awake intubation. I need the general anesthesia first before you put in that breathing tube.” In an example of this scenario, an 18-year-old boy with Treacher Collins syndrome and a very abnormal airway refuses awake intubation for an emergency appendectomy. Your assessment of his airway is that you will not be able to visualize the vocal cords with either traditional laryngoscopy or video laryngoscopy. You’re uncertain you can mask ventilate the patient if he is asleep either. You tell him he can be sedated and relaxed for an awake intubation, but you cannot administer general anesthetic prior to his intubation, for safety reasons. Per a study on this very topic, you decide to use dexmedetomidine , which has minimal respiratory depression, to sedate him, and you acquire the assistance of a second anesthesiologist to monitor the patient and manage the sedation while you apply topical anesthesia to the airway and drive the fiberoptic scope. After thirty minutes of work, the two of you manage to successfully insert the endotracheal tube, and the surgery can begin.

 

The overwhelming majority of anesthesiologist-surgeon and anesthesiologist-patient interactions are positive. But when conflicts such as these examples occur, the take-home messages are:

  1. YOU ARE THE BOARD-CERTIFIED SPECIALIST IN ANESTHESIA. IT IS YOUR JOB TO MAKE THE ANESTHESIA DECISIONS.
  2. SURGEONS ARE SPECIALISTS IN SURGERY. THEY ARE NOT SPECIALISTS IN ANESTHESIA OR PERIOPERATIVE MEDICINE.
  3. YOU PAY YOUR OWN MALPRACTICE INSURANCE, AND YOU HAVE TO ANSWER TO THE CONSEQUENCES IF YOU GET SUED. IF YOU ARE SUED, THE KEY QUESTION WILL BE “DID THE ANESTHESIOLOGIST PRACTICE AT THE STANDARD OF CARE?” REPLYING THAT THE SURGEON OR THE PATIENT TALKED YOU INTO A SUB-STANDARD PRACTICE IS NO DEFENSE. IT IS YOUR JOB TO MAKE THE ANESTHESIA DECISIONS.
  4. THE CORRECT ANESTHETIC PLAN IS THE SIMPLEST ANESTHETIC PLAN THAT ALL THREE PARTIES (THE SURGEON, THE PATIENT, AND YOU) AGREE TO.

 

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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LOOKING FOR A NEW ANESTHESIA JOB? CHECK OUT BLOCHEALTH.COM                       

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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Are you unhappy with your current anesthesia job? Are you considering finding a new job, relocating, changing your case mix, payer mix, or increasing your income? Are you a resident or fellow or a nurse anesthetist looking for your first job?

Every week thousands of anesthesiologists and nurse anesthetists are looking for new employment. Individuals are seeking a new geographic location, a higher income, or more autonomy. Clients (healthcare systems/employers) are seeking candidates (physician anesthesiologists or CRNAs) for locum tenens help, part time help, or as fulltime employees.

The best job opportunities are usually spread via word of mouth. For example, alumni of your training program will seek out fellow graduates of the same program. You interview with their group, and ideally you’re offered a job. But what if you aren’t hearing about any job opportunities which interest you?

Internet websites post job advertisements for anesthesia professionals. Many of the advertised jobs are salaried positions, at a modest pay range, in locations which may or may not be popular. At the current time you will find thousands of job openings for full time, part time, and locum tenens anesthesiologists on Internet listings.

The American Society of Anesthesiologists website http://careers.asahq.org/jobs posts job openings, many of them for academic positions.

Current healthcare staffing websites listing anesthesia positions include Gasworks.com, Indeed.com, or Glassdoor.com.

Finding a promising job listing on these sites is only the beginning, to be followed by a complex process of applying to the listing company and/or the listing client healthcare system, and waiting to see if you are hired.

An innovative new medical staffing company named BlocHealth has entered the business of matching anesthesia candidates with client hospitals/healthcare systems. BlocHealth shows promise to be a game changer for physicians or nurse anesthetists looking to relocate, or physicians or nurse anesthetists looking for their first job. When you click on Blochealth.com you aren’t greeted with random listings of multiple job offerings—you’ll be matched with jobs based on your preferences.

The definition of a “bloc” is a combination of parties or groups sharing a common purpose. BlocHealth’s proposes to redefine the healthcare staffing industry by enabling providers to find staffing opportunities that uniquely match their talent, experience, and lifestyle. BlocHealth aims to do this without the complicated fees and back and forth processes of preexisting staffing companies.

BlocHealth aims to work with candidates to get you the highest rates possible, all the while keeping in mind the client/healthcare system’s bottom line. BlocHealth is “candidate-centric,” which means physician anesthesiologists and CRNAs have more control over the process and the pay rate they will accept. BlocHealth’s goal is to make the process of finding a position much more efficient, whether you are looking for locum tenens, part time, or permanent positions anywhere in the United States.

The BlocHealth website (www.blochealth.com) promises innovation in healthcare staffing via three specific strategies:

  1. Cost savings. BlocHealth’s profit is an industry-low percentage of the transaction amount. Existing staffing companies often charge a 30% profit off the top. This decreased cost to employers/clients promises significant cost savings to employers, and encourages them to list with BlocHealth.
  2. Transparency is a BlocHealth core value. Candidates will be kept in the loop with all details of the job search from start to finish.
  3. The BlocHealth process is unique. The website does not initially present a listing of anesthesia job offerings. Instead, each candidate physician anesthesiologist or CRNA fills out a brief form which primarily asks where you want to work, what dollar amount per hour you want to be paid, and then asks you to upload your curriculum vitae. A BlocHealth representative will then contact you via email or phone to discuss further specifics.

With BlocHealth:

  1. You, the candidate, have the control. You can search for opportunities by specialty, case types, availability, and pay rate.
  2. You, the candidate, set the pay rate you want. There are no recruiters pressuring you to lower your rate to inflate an agency’s profit margin.
  3. It’s a quicker process. There is less dealing with recruiters, and more finding the positions you want.
  4. You’ll have access to easy-to-view hospital profiles.
  5. You’ll have access to extremely detailed job descriptions.
  6. You can directly message hospitals with interest.
  7. You can be matched to high quality jobs. Candidates will be notified when their profile matches 90%+ with a job. Case types, location, shifts, dates, etc. will be taken into consideration when matching.
  8. Candidates can see what clients have checked out their profile pages.

BlocHealth is different from the preexisting companies. Older companies:

  1. Offered the candidate little control of the process. Recruiters at agencies presented which opportunities they believed the candidate should consider.
  2. Controlled too much of the price negotiation. Recruiters were motivated to convince candidates to take less money so they and their company can earn more money.
  3. Require too many steps, instead of the shorter smoother BlocHealth process, before successfully matching a candidate with a new job opportunity.

I recommend you check out BlocHealth—it’s a new way of doing business.

Uber presented a new model which had significant price and access advantages over taxis. BlocHealth aims to similarly slash the market share of other Internet healthcare staffing companies, and help find you a new job in the process.

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

 

AVOIDING PREVENTABLE ERRORS IN ANESTHESIA – 14 TIPS

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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One goal of theanesthesiaconsultant.com is to make the practice of anesthesia safer.

The practice of anesthesia on healthy patients is quite safe. The safety of anesthesia on ASA I and II patients has been compared to the safety record of commercial aviation. Few passengers board an airplane and worry they will die before they land at their destination. But planes do crash, and so do anesthetized patients.

In August 2107 the journal Anesthesiology published the study “Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage,” authored by Christian M. Schulz MD et al. . This was an important study which documented what experienced anesthesiologists already know—although our specialty has never been safer, preventable deaths still occur.

The study analyzed the United States Anesthesia Closed Claims Project database of 10,546 malpractice claims between 2001-2013. A total of 266 cases of brain damage or death during anesthesia care in the operating room under the care of a solo anesthesiologist occurred. Of these 266 cases, 198 (74%) had a situational error by the solo anesthesia provider. Malpractice payments were made in 85% of these situational error cases, compared to only 46% in other cases. The total of 198 patients in 12 years averaged more than16 preventable deaths per year.

What was the definition of a situational error? The article sited three types: perception, comprehension, and projection.

PERCEPTION ERROR. A failure to gather information via history, the patient’s chart, physical exam, diagnostic tests, imaging, or monitors, including the absence of monitors.

COMPREHENSION ERROR. The information was available, but there was a failure to understand and diagnose the significance of information obtained from history, physical exam, diagnostic tests, imaging findings, or monitors.

PROJECTION ERROR. A failure to forecast future events or scenarios based on a high-level understanding of a problematic situation.

Of the 198 situational errors, perception errors were most common (42% of the cases), followed by comprehension errors (29%) and projection errors (29%).

72% of the errors occurred during general anesthetics, 23% occurred during monitored anesthesia care, and 5% occurred during regional anesthetics.

The primary damaging event differed in the 198 error cases vs. the 68 other cases. In the 198 situational error cases, respiratory events were the dominant category (p<.001), including inadequate oxygenation/ventilation (24%), difficult intubation (11%), and pulmonary aspiration (10%). In the 68 non-error cases, cardiovascular events were the dominant category. All the anesthesiologists were single practitioners, that is, they were not part of an anesthesia care team with a nurse anesthetist.

The authors of the study made the following points in their discussion of the findings:

  1. Many perception errors stemmed from lack of or lack of attention to respiratory monitoring. Key respiratory monitors were pulse oximetry and end-tidal CO2 monitors.
  2. Other common perception errors were missing preoperative information, which led to inadequate preoperative evaluation.
  3. The most common comprehension error was failure to comprehend an ongoing clinical difficulty related to respiratory problems.
  4. Many projection errors involved lack of appreciation of difficult airways.
  5. Projection errors also included procedures taking place in inappropriate environments, such as very sick patients having surgery in an office or an outpatient surgery center.

The authors made the following suggestions to decrease preventable errors:

  1. Perception errors may be prevented by regular scanning and processing of all the information available prior to and during every anesthetic.
  2. A “call for help” and the use of cognitive aides (e.g. emergency checklists or an emergency manual) may help when a patient deteriorates.
  3. Situational awareness training can be addressed in anesthesia crisis resource management education, including simulation training.

There were limitations to the Schulz study. The assembled data was retrospective and nonrandom. The Anesthesia Closed Claims Project may not reflect the true incidence of situational errors in anesthesia practice in the United States. As well, the 198 patients found in this study are only those countable via the closed malpractice claims. The true number of uncaptured cases of preventable deaths is unknown.

I have a busy practice of medical-legal consultation. I evaluate 8-10 cases per year of preventable death or brain death, and I’m just one person with one medical-legal practice. I believe there are far more cases that exceed my reach.

The Schulz study listed 11 specific patient case examples of preventable errors. Based on these 11 cases, the multiple legal cases referred to me, my 31 years of practice, and my 25,000 personally administered anesthetics for all types of surgeries and patients, I’m qualified to give advice on how to decrease preventable errors in anesthesia. My advice follows:

  1. I see uninformed preoperative workups leading to errors. Be an outstanding preoperative physician. Your preoperative assessment of each patient needs to be complete and pertinent. Pay special attention to cardiac, respiratory, neurologic, and any other significant medical issues. If you’re uncomfortable with any lack of information, you must acquire that information before you begin an anesthetic. If you need a consultant such as a cardiologist, cancel the case and get a cardiac consult before you proceed.
  2. As part of your preoperative workup, ask every patient if they can climb two flights of stairs. Be wary when administering general anesthesia to any patient who cannot walk up two flights of stairs. If a patient develops shortness of breath at this modest exertion, this is evidence of a lack of cardiac or respiratory reserve. This requires preoperative workup to determine the diagnosis and to apply treatment prior to general anesthesia. Any patient who has significant knee, hip, foot, or back pain or who has claudication that prevents him or her from walking up two flights of stairs has not proven to you that they have adequate cardiac and/or respiratory reserve. A referral to a cardiologist/pulmonologist/internist for preoperative clearance testing may be indicated prior to surgery.
  3. Don’t let surgeons talk you into anesthetizing patients you believe are inadequately worked up for anesthesia. Don’t let surgeons talk you into anesthetizing patients using anesthesia techniques or anesthesia plans you’re not comfortable with. We give mock oral board exams to residents at Stanford, and a common exam question is to try to dupe the resident into doing something unsafe because the surgeon demanded it. The surgeon is not trained in anesthesiology. The surgeon does not pay your malpractice insurance, and he or she will not have to endure your malpractice lawsuit if the anesthetic goes awry.
  4. Don’t let surgeons talk you into anesthetizing patients in inappropriate locations or settings. Be careful anesthetizing sicker patients in offices or in freestanding outpatient surgery centers. These facilities lack ICUs, clinical labs, blood gases, respiratory therapists, radiology, and backup anesthesia professionals. Be wary of performing procedures which are too invasive or too extensive in these settings. Twenty years ago one of our orthopedic surgeons attempted to schedule an 80-year-old female for a total knee replacement in a freestanding outpatient surgery facility which had overnight capabilities. I refused to staff the case, and told him, “Cases like this—that’s why we have hospitals.” He hung up on me, but there were no further requests to schedule similar patients at that facility. There are pressures to perform increasingly difficult procedures on increasingly sicker patients in non-hospital settings. Resist these pressures. There can be no surgery without an anesthetic. Be consistent with the values you learned in your university residency program. These values haven’t changed—they’re called the standards of care—and they reflect what an adequately trained physician will do in any give situation. Stay within these standards of care, and you’re unlikely to ever lose a malpractice lawsuit.
  5. The highest number of malpractice cases I review involve airway disasters. Do not screw up airway management. This includes intubation, extubation, and mask ventilation. I’ve previously written on this topic, and I can’t emphasize it enough.
  6. Because the highest number of malpractice cases I review involve airway disasters, I’d advise you to commit the ASA Difficulty Airway Algorithm to memory. I recommend Dr. Phillip Larson’s approach to the difficulty airway, as presented in the Appendix to Richard Jaffe’s Anesthesiologists Manual of Surgical Procedures. Patients with airway emergencies deteriorate in minutes. Have a plan in mind before you begin.
  7. Because the highest number of malpractice cases I review involve airway disasters, I recommend you always have a videoscope available. All well-stocked hospital operating rooms will have a Glidescope or equivalent, but many freestanding outpatient surgery centers or office-based operating rooms will not. It’s not always possible to predict the difficulty of endotracheal intubation. If you work at facilities or offices without a videoscope, I recommend you carry a disposable single-use Airtraq in your briefcase. The devices are single-use, and can be invaluable or lifesaving when conventional laryngoscopy is unsuccessful.
  8. Keep a reference book of checklists for dealing with anesthesia disasters available in every anesthetizing location. My recommendation is the Stanford Anesthesia Cognitive Aid Group Emergency Aid. Should a disaster occur, all the steps to appropriate treatment are listed so that you can follow those steps.
  9. Review the Stanford Anesthesia Cognitive Aid Group Emergency Manual regularly, and memorize the steps to each algorithm. The checklists exist so that in a disaster clinicians will not forget any steps, but a solid anesthesiologist will know this information by heart. You had to learn all this information to pass your oral anesthesia board exam, so why would you allow yourself to forget them as your career proceeds? Why would you want to be anything less than the safest practitioner you can be?
  10. A high percentage of the malpractice cases I review involve obese patients. Be extra wary when attending to obese patients. Obese patients present multiple difficulties in terms of airway management, placement of anesthesia lines, safety of oxygenation and ventilation both in the operating room and postoperatively, and they also present increased challenges for your surgeon. Anesthetics on patients with a BMI > 30 are more difficult, and anesthetics on patients with a BMI >40 or >50 are always challenging. I refer you to a previous column on the risks of obese patients for anesthesia.
  11. If you’re ever wondering whether or not to place an arterial line for a non-cardiac case, I’d recommend you place one. I was a cardiovascular anesthetist at Stanford for 15 years, and during that time I placed countless radial arterial lines prior to induction. The procedure is relatively painless, and for the sickest patients the benefit/risk ratio is high. The second-to-second feedback regarding hypotension or hypertension can be essential in patients with limited cardiac reserve, in trauma patients, or in patients with shock. An arterial line will be much more difficult to place if you wait until your patient is already hypovolemic, vasoconstricted, or hypotensive. And if the patient’s arms are tucked or if the patient is in a position other than supine, you’ll have restricted access to the radial artery intraoperatively. My advice: if you’re pondering whether or not to place an arterial line prior to inducing a sick patient, just do it.
  12. Be vigilant. The maintenance phase of anesthesia can at times be long, tedious, and boring, but it’s mandatory we stay vigilant for developing problems. Scan all patient monitors and all aspects of the patient during anesthesia care. Look for trends, e.g. increases or decreases in blood pressure or heart rate. Note any decrease in oxygen saturation, airway pressures, or end-tidal CO2 patterns. Diagnose and treat any abnormalities early in their development.
  13. Don’t struggle alone. Call for help early if your patient deteriorates. In anesthesia residency programs, each resident has multiple faculty members and other residents to assist him or her if a patient becomes acutely ill. In community practice there is almost always a second anesthesiologist or a second acute care physician in the facility to help. A second pair of hands can be invaluable in assisting airway or vascular procedures. A second mind is useful in confirming diagnoses and therapies are correct. An anecdote from my own anesthesia practice: an 80-year-old patient developed severe hypertension leading to frothing pulmonary edema just prior to extubation at the conclusion of a twenty-minute elbow surgery. My colleague in the next operating room left his stable anesthetic, arrived in my room, and placed an arterial line while I tended to the heart and lung emergency. Once the arterial line was placed, I was able to acutely titrate a sodium nitroprusside drip to normalize the blood pressure, decrease the afterload, and regain adequate oxygenation. The patient recovered fully. Without my partner’s help, it’s likely the patient would have died of hypoxemia.
  14. I’ve seen several cases of undetected hemorrhagic shock. Don’t be afraid to speak up to your surgeon. If your surgeon is working in the abdomen or the chest and your patient develops an increasing heart rate and a decreasing blood pressure, this could be the presentation of hemorrhage. The surgeon needs to know if the vital signs are deteriorating. If major hemorrhage occurs, you’ll need to insert a second large-bore IV line, get help, and order a Massive Transfusion Pack from the blood bank.

The Schulz study was an important publication. Preventable errors do occur in anesthesia. It’s up to us to do everything we can to make the incidence of preventable errors in our practice approach zero. You’ll keep your patients safe, and you’ll stay away from bad outcomes and malpractice lawsuits.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

 

ARTIFICIAL INTELLIGENCE IN MEDICINE

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

I’m fascinated by the topic of artificial intelligence in medicine. This is the third column in a series regarding robots in medicine. (See Robot Anesthesia and Robot Anesthesia II)

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AI already influences our daily life. Smartphones verbally direct us to our destination through mazes of highways and traffic. Computers analyze our shopping habits and populate our Internet screens with advertisements for products we’ve ogled in the past. Smartphones perform voice-to-text conversions by pattern recognition of human vocal sounds. Fingerprint scanners learn and then recognize the image of our thumbprints with exacting accuracy. Amazon’s Alexa is an AI-powered personal assistant that accepts verbal commands in our homes.

What about AI in medicine (AIM)? AIM is a bold enterprise on the horizon in clinical medicine. Hundreds of AIM scientific publications appear in medical journals each year. I’m not an AIM researcher, but I’m an expert clinician and I love to read. I’ve worked in almost every scenario of medical practice, and because my base is at Stanford University Medical Center in Silicon Valley, many of the advances of the high-tech industry are right here in my backyard. My medical board certifications are in internal medicine and anesthesiology—two fields which have significant overlap in their knowledge base but radically different practice settings. Internal medicine doctors work in clinics, where most diseases are chronic and the most valuable tools for doctors are excellent listening and diagnostic skills. Anesthesiologists work in operating rooms and intensive care units—acute care settings which demand vigilance, steady hands, and quick thinking.

Based on my experience and my reading, I foresee AIM/robots populating three clinical arenas in radically different roles. These arenas will be: 1) diagnosis of images, 2) clinics, and 3) operating rooms/intensive care units. Let’s look at each of these in turn.

  1. Diagnosis of images    This will be the first major application of AIM. We already have electrocardiogram (ECG) machines which interpret a patient’s ECG tracing with high accuracy, and print out the diagnosis for the physician to read. This application debuted in the 1980s and is now the industry standard, although confirmation of diagnosis by a physician is important for some diagnoses such as ST-elevation myocardial infarction (STEMI). More than a few physicians have already lost the skill of reading an ECG themselves because of this device. Future applications of image analysis in medicine will be machine learning for diagnosis in radiology, pathology, and dermatology. The evaluation of digital X-rays, MRIs, or CT scans is the assessment of arrays of pixels. Expect that future computer programs will be as accurate or more accurate than human radiologists. The model for machine learning is similar to the fashion in which a human child learns. A child is not given a list of criteria which define what a dog looks like. Instead, the 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. Machine learning is a subset of deep learning, a concept that makes automated decision-making possible. Deep learning is a radically different method of programming computers. It requires massive database entry, much like the array of dogs that a child sees in the example above, so that the computer can learn the skill of pattern matching. The program repetitively teaches a machine the identity of certain images, and the system hones this algorithm and becomes faster and more accurate in recognizing similar images. An AI computer which masters machine learning and deep learning will probably not give yes or no answers, but rather a percentage likelihood of a diagnosis, i.e. a radiologic image has greater than a 99% chance of being normal, or a skin lesion has greater than a 99% chance of being a malignant melanoma. At the present time the Food and Drug Administration (FDA) does not allow machines to make formal diagnoses, and such AI computer applications are only prototypes. But if you’re a physician who makes his or her living by interpreting digital images, there’s real concern about AI taking your job in the future. Some experts believe AIM devices will not replace radiologists, but rather will make their work more efficient and accurate. For example, AI computers can identify MRI or CT scans which are normal, freeing human radiologists to concentrate on scans where an abnormality exists. In this scenario, radiologists would not lose their jobs to AIM computers, instead radiologists who don’t use AIM machines may lose their jobs to radiologists who do use the AIM technology. In pathology, computerized digital diagnostic skills will be applied to microscopic diagnosis. In dermatology, machine learning will be used to diagnosis skin cancers, based on large learned databases of digital photographs. Dermatologists must rely on years of experience to learn to discern various skin lesions, but an AI computer can ingest hundreds of thousands of images in a period of months.
  2. Clinics  In the clinic setting, the desired AI application would be a computer that could input information on a patient’s history, physical examination, and laboratory studies, and via machine learning and deep learning, establish the patient’s diagnoses with a high percentage of success. AI computers will be stocked with information from multiple sources, including all known medical knowledge published in textbooks and journals, as well as the electronic health records (EHR)/ clinical data from thousands of previous hospital and clinic patients. AI machines can remember this vast array of information better than any human physician. AI machines will organize the input of 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 questions. The flowchart program contains a series of “if . . . then . . .” branches that depend on the patient’s answers. AI will input the information sources from each new patient, and arrive at diagnoses. Once each diagnosis is established with a reasonable degree of medical certainty, an already-established algorithm for treatment of that diagnosis can be applied. For example, if the computer makes a diagnosis of asthma, then an established textbook treatment regimen of bronchodilators will be activated. It’s projected that AIM applications in clinic settings will decrease unnecessary diagnostic tests, lower therapeutic costs, and reduce the manpower needed for outpatient medicine.
  3. Operating rooms  The best current example of robot technology in the operating room is the da Vinci operating robot, used primarily in urology and gynecologic surgery. 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. In my previous essays Robot Anesthesia and Robot Anesthesia II, I described models of robots designed to perform intravenous sedation or intubation of the trachea, products which are futuristic but currently have no market share. The good news for procedural physicians such as anesthesiologists or surgeons is this: it’s unlikely any AI computer or robot will be able to independently replace the manual skills such as airway management, endotracheal intubation, or surgical excision. Regarding anesthesiology, I expect future AIM robots will be hyperattentive monitoring devices which follow the vital signs of anesthetized patients, and then utilize feedback loops to titrate or adjust the depth of anesthetic drugs as indicated by these vital signs. Such a robot would not replace a human anesthesiologist, but could serve as an autopilot analogue during the maintenance or middle phase of long anesthetics, freeing up the anesthesia professional so that he or she need not be physically present. This parallels the original genesis of the role of a nurse anesthetist—to be present during stable phases of anesthetic management—so that the physician anesthesiologist could roam to other operating rooms as needed.

What will an AIM robot doctor look like? It’s unlikely it will look like a human. Most sources project it will look like a smartphone. I’d expect the screen to be bigger than a smartphone screen, so an AIM robot doctor will likely look like a tablet computer. For certain applications such as clinic 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—this will be done via tools such as retinal scanners, fingerprint scanners, or face recognition programs—so that the computer can retrieve that 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.

How will we define if these medical computers are truly intelligent? The accepted test for machine intelligence is the Turing test, as described by computer scientist Alan Turing in 1950. In the Turing test, a human evaluator interacts with two players via a computer keyboard. One of the players is a human and the other a machine. If the evaluator cannot reliably tell the machine from the human, the machine is said to have passed the test, and is deemed intelligent.

What will be the economics of AIM? Who will pay for it? Currently America spends 17.6% 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 a seductive lure. Companies are looking to merge increasing computing power available at steadily decreasing costs, big data from large EHR patient populations, and artificial intelligence with an aim to drive down the costs of health care while increasing effectiveness. Expect to see the development of increasingly cheaper AIM devices to augment the skills of human physicians, or maybe replace them in some job descriptions. The government’s medical costs may decrease if work currently done by expensive-to-train physicians is instead performed by nurse practitioners or nurses aided by artificial intelligence machines, supervised by relatively few human physicians. Google is working on an AIM project in the United Kingdom entitled DeepMind. DeepMind is using machine learning to analyze eye scans from more than a million patients, with the aim to create algorithms which can detect early warning signs of eye diseases that human physicians might miss. Google researchers have also developed an AIM computer to screen for and analyze the spread of breast cancer cells in lymph node tissue on pathology slide images. Scientists at the Memorial Sloan-Kettering Cancer Center in New York have programmed over 600,000 medical evidence reports, 1.5 million patient medical records, and two millions of pages of text from medical journals into IBM’s Watson computer. Equipped with more information than any human physician could ever remember, Watson is projected to become a diagnostic machine superior to any doctor.

There’s a worldwide shortage of physicians. The earliest a human physician can enter the workforce is age 29, after completing 4 years of college, 4 years of medical school, and 3 years of the shortest residency (e.g. internal medicine, pediatrics, or family practice residency). A major advantage of AIM is that the machines won’t require 24 years of education. Can America afford to train people for almost three decades to then sit in a clinic and perform histories and physicals on patients who have chronic illnesses such as hypertension, hyperlipidemia, and obesity? Shifting these jobs to allied healthcare providers such as physician assistants or nurse practitioners is a cheaper alternative, but what could be cheaper than an AIM machine module which either assists one physician to evaluate a vast number of patients, or an AIM module of the future which replaces the physician entirely?

When can we expect to see new AIM tools adopted in clinical practice? Web-based smartphone apps such as Your.MD and Babylon already exist to assist physicians in diagnosis. You can anticipate the application of machine learning in the diagnosis of digital images soon. The DeepMind and Watson computers are blazing a trail toward machine learning in clinical medicine. Expect the FDA to assess the new technologies, and when it is safe and appropriate, to approve machine diagnosis as part of the practice of medicine. Remember how fast we advanced from a cell phone the size of a breadbox to the powerful smartphone that fits in the palm of your hand today. In the ten years since the introduction of the iPhone in 2007, who could have imagined the vast array of applications we carry in our pocket or purse in 2017?

AIM is coming. It will arrive be sooner than we think, and in all likelihood it will be more powerful and more wonderful than we could imagine. A brave prediction: AIM will change medicine more than any development since the invention of anesthesia in 1849.

I can’t wait to see it.

 

Recommended reading:

Hsieh, Paul. AI in Medicine: Rise of the Machines, Forbes, April 30, 2017. 

Mukherjee, Siddhartha. A.I. vs M.D. What Happens When Diagnosis is Automated? The New Yorker, April 3, 2017. 

Manney, Kevin. How Artificial Intelligence Will Heal America’s Sick Healthcare System. Newsweek, May 24, 2017. 

Omni staff. Artificial Intelligence in Medicine. Omni, 2016.

Bhavsar N, Norman A. Artificial Intelligence is Completely Transforming Healthcare. Futurism, April 3, 2017.

Dickson B. How Artificial Intelligence is Revolutionizing Healthcare, TheNextWeb.com, May 2017.

Russell S, Norvig P. Arificial Intelligence, A Modern Approach, 3rd Edition, 2010, Prentice Hall.

 

NOTE:

Coming in 2019, DOCTOR VITA, Dr. Novak’s second novel, an Orwellian science fiction tale of how Artificial Intelligence in Medicine will change the world we live in forever.

 

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?

How do you imagine the future of medical care? Cherubic young doctors holding your hand as you tell them what ails you? Genetic advances or nanotechnology gobbling up cancerous cells and banishing heart disease? Rick Novak describes a flawed future Eden where the only doctor you’ll ever need is Doctor Vita, the world’s first artificial intelligence physician, endowed with unlimited knowledge, a capacity for machine learning, a tireless work ethic, and compassionate empathy.

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In this science fiction saga of man versus machine, Doctor Vita blends science, suspense, untimely deaths, and ethical dilemma as the technological revolution crashes full speed into your healthcare.

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Set on the stage of the University of Silicon Valley Medical Center, Doctor Vita is the 1984 of the medical world– a prescient tale of Orwellian medical advances.

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

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11 THINGS YOU CAN DO TO MAKE YOUR ANESTHETIC SAFER

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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This is what the anesthesia experience is like for most patients: You show up for surgery, and some anesthesia professional you’ve never met or talked to appears 10 minutes before you are to be wheeled into the operating room. The anesthesia professional might be an MD, a CRNA, or both a MD and a CRNA might be involved. At an academic/university hospital, the anesthesiologist might be a resident MD in his or her first, second, or third year of anesthesia training, and that resident will then be supervised by a faculty member who is responsible for either one operating room or two.

It doesn’t have to be this way. Anesthesiologists in our practice telephone their patients the night before to discuss the anesthesia care. Some hospitals have an anesthesia preoperative clinic where patients are interviewed and examined one day or more prior to surgery. Patient questions are answered at such a clinic, but it’s uncommon for you to meet the person who actually anesthetize you at such a clinic visit.

I’m going to put on my patient advocate hat. Let’s say you’re going to have surgery six weeks from now.

  • What can you do to make your anesthesia experience safer?
  • What can you do to otherwise optimize the anesthesia care you’re about to receive?

 

Here’s my list of 11 things you can do:

  1. Don’t choose to schedule your surgery at a teaching hospital in July or August. On June 30th every year, each intern and resident physician advances one year in his or her training. An intern who finished a 12-month rotating internship suddenly becomes an anesthesia trainee as of July 1st. An anesthesia resident who trained for 12 months and performed perhaps 700 anesthetics, is now a second year resident. An anesthesia resident who trained for 24 months and performed perhaps 1400 anesthetics, is now a third year resident. Each of these residents is completely inexperienced in their new level. The curriculum for residents is more complex each year, with 2nd and 3rd year residents covering progressively more complex cases such as open heart, brain, chest, or neonatal surgeries. A faculty member will supervise each resident, but often the supervision is one faculty member covering two operating rooms concurrently. The individual who monitors you minute-to-minute during your surgery will be a relatively inexperienced resident. If you’re scheduled for surgery at an academic medical center in July or August, I’d advise you to move up your surgery to May or June instead.
  2. Using the Internet, check the roster of anesthesia physicians at the facility where you’re about to have surgery. Virtually every medical center has a list of staff anesthesiologists posted on their website, and most websites will provide a summary of each physician’s academic training. Peruse the list. Are the majority of anesthetists MDs or CRNAs, or is the staff a mix of both? Did the MDs train at reputable universities, or were they trained at hospitals you’ve never heard of? Is there a phone number you can call if you wish to speak to an anesthesiologist prior to your week of surgery if you have a special concern?
  3. Talk to your surgeon about the proposed anesthesia. He or she will usually know whether your case requires a general anesthetic, with or without a regional anesthetic (such as a spinal, an epidural or a nerve block). Ask your surgeon if they have an anesthesiologist colleague they recommend for your specific case, and ask whether you can request a specific anesthesiologist prior to the surgery date.
  4. If you have chronic health issues (e.g. heart problems, lung problems, high blood pressure, diabetes, neurologic problems, kidney failure, obesity, or sleep apnea) you can expect the surgical/anesthesiologist team to require a clearance note from your primary care physician (PCP) prior to the surgery. The purpose of this clearance is to document that no further diagnostic or treatment interventions are necessary prior to your anesthetic and surgery. This is important. Planning a visit to your PCP in the month or two prior to surgery is strongly recommended.
  5. Are you unusually sensitive to drugs, sedatives, or alcohol? Tell your anesthesiologist when you meet him or her. Without question, certain individuals are unusually sensitive to normal doses of narcotics, sedatives, and general anesthetics. These individuals are often female, petite (under 120 pounds), geriatric, or persons who rarely expose themselves to central nervous system depressants such as alcohol. Armed with this information, your anesthesiologist will administer adequate doses of drugs, but no more than the minimum necessary.
  6. The standard of care is for your anesthesiologist to explain the alternate anesthesia techniques for your surgery, as well to explain the risks and benefits of each alternative. I’d advise you to listen, ask questions, and consider the KISS principle (Keep It Simple Stupid). The correct anesthetic is usually the simplest technique that works for the surgeon, the anesthesiologist, and for you. You get a vote. Use it, and choose wisely when alternatives are explained to you.
  7. If you have a family history of a blood relative who died under anesthesia, share this information with your anesthesiologist. The rare but serious malady Malignant Hyperthermia (MH) is an inherited disease which causes intense fevers, muscle rigidity, and hypermetabolism, and is triggered by specific anesthetic drugs such as sevoflurane, desflurane, isoflurane, or succinylcholine. The disease is rare (1 out of 100,000 anesthetics), but if your family has a history suggestive of MH, or if any of your family died under anesthesia, the anesthesiologist needs to know.
  8. You must stop eating and drinking prior to an elective anesthetic. The purpose is to keep your stomach empty at the induction of anesthesia. If you vomit or regurgitate stomach contents while you are unconscious, the food can be inhaled into your lungs, and you could acquire a serious pneumonia that could require an Intensive Care Unit stay, a prolonged hospitalization, or even loss of life. American Society of Anesthesiologists guidelines are nothing to eat after midnight the night before surgery, except clear liquids may be ingested up until 2 hours prior to surgery. Here’s an anecdote to relate how a patient can break this rule: Several years ago an anesthesiologist colleague of mine was scheduled to anesthetize a professional athlete for knee surgery. When this patient was asked if he’d followed the protocol and had nothing to eat or drink after midnight, the patient said yes, he had followed the rules. The surgery and anesthesia were performed without complication. In the post-anesthesia recovery room the patient boasted, “I knew it wouldn’t make any difference. I had bacon, eggs, and toast for breakfast this morning before surgery. I didn’t tell anyone because I knew it was a bogus rule.” It’s not a bogus rule. Don’t be like this local sports legend/difficult patient. Listen to the fasting rules and follow them.
  9. Sleep well the night before your surgery. For the majority of surgeries in the United States, a patient sleeps at home in their own bed the night before surgery. It’s rare to be sick enough to require inpatient admission to the hospital the day before surgery. Many patients are nervous regarding the impending anesthetic, and a wild array of thoughts and fears swirl through their brain regarding anesthesia and surgery. Many patients are too wired on their own adrenaline to sleep normally the evening prior to their surgery. What about sleeping pills? Are they safe the night prior to anesthesia? Yes, they are almost never unsafe. Common sleep medications such as Ambien, Ativan, or Valium taken at 10 pm won’t complicate the anesthetic course which begins 9 hours or more into the future on the following day. Because your anesthesiologist hasn’t personally met you and examined you, they cannot prescribe these medicines the night before for you. Your surgeon may prescribe sleep meds when he or she examines you. What about a glass of wine or an alcoholic beverage to aid sleepiness? Is this safe? Yes. If you’re an occasional wine drinker, there’s no serious harm to imbibing one glass of wine the night before surgery to help you relax and sleep.
  10. Trust your anesthesiologist as you would your airline pilot. When you board a commercial airplane, do you cast a glance into the cockpit to see what your pilots look like? I do. I’m reassured to see a touch of gray. It’s possible that a pilot in his or her 30s is outstanding, but the experience of a midcareer, gray-sideburned pilot is more reassuring to me. During your surgery you’ll be unconscious and unable to control your fate. You’re dependent on the anesthesiologist and his or her training and experience. The overwhelming majority of physician anesthesiologists are well trained and excellent. Calm yourself and trust your doctor.
  11. Read theanesthesiaconsultant.com as well as other reputable anesthesia sources on the Internet, such as the American Society of Anesthesiologists website, or Pubmed. Can you find misinformation on some healthcare websites? Yes. You’ll need to be careful regarding the source of your Internet education. But knowledge is a powerful tool, and I’d encourage you to expand your understanding of what anesthesiologists do to prepare for your upcoming surgery. Good luck!

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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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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11 MEDICAL INACCURACIES IN FAMOUS MOVIE SCENES . . . AN ANESTHESIOLOGIST’S ANALYSIS

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

I love the movies, but it can be painful to watch medical scenes where the facts are distorted, sometimes so much that the storyline is implausible. Let’s take a look at 11 famous Hollywood movies, and at the inaccuracies of medically mistaken surgical/anesthetic/critical care scenes in those films:

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  1. Million Dollar Baby (2004). This film is my Hollywood medical pet peeve, and the movie that motivated me to write this column. Million Dollar Baby won the Academy Award for Best Picture in 2004, yet the concluding scenes vital to the movie’s plot are both medically impossible and unrealistic. The female lead, Maggie Fitzgerald (Hilary Swank) is seriously injured in a $1 million World Boxing Association welterweight title match. Maggie is paralyzed from the neck down— a ventilator-dependent quadriplegic—and is hospitalized in a private room. Her coach and trainer, Frankie Dunn (Clint Eastwood) visits her. He sits next to her bedside and they discuss her fallen health. She tells Clint she doesn’t want to go on living like this, a paralyzed invalid. What’s the problem with this scene? It’s impossible for Maggie to talk if she’s on a ventilator. Maggie has a tracheotomy, with the breathing tube inserted in the front of her neck, below the level of the vocal cords. A patient cannot speak with a tracheotomy tube in place because all ventilation takes place below the vocal cords. If Maggie can’t speak, she can’t utter her lines, and she can’t partake in the dialogue with Clint. Somehow the movie’s medical consultants let the movie be filmed with this medical impossibility.                   But wait—there’s another medical impossibility. In a later scene, Clint returns to the same room and kills Maggie. First he turns off the ventilator and disconnects Maggie’s breathing hose at the tracheotomy site. Then he injects her IV with a syringe of adrenaline, and leaves the vital signs monitor on. The vital signs monitor shows her heart rate suddenly change to zero as she dies. That’s not how adrenaline works—it’s not a euthanizing drug. Adrenaline causes the heart rate and blood pressure to rise higher and higher—think heart rates in the range of 200 beats per minute and a blood pressure of 250/180. This may or may not kill someone over time, but it will not kill them in seconds. An injection of potassium chloride could kill Maggie in seconds, but where would Frankie obtain potassium chloride? He could not. As this scene ends, Frankie walks out of the room leaving Maggie to die behind him. The vital signs monitor continues to emit a soft high-pitched tone, but there’s no one else around to hear it. In reality the vital signs monitor would be emitting a loud alarm, signaling to everyone that the vital signs are gone and the patient is trying to die. These alarms would bring a fleet of nurses and/or doctors into the room to try to save the patient. But if they saved Maggie, Million Dollar Baby would’ve had a different ending, and Clint Eastwood wouldn’t have had his bold moment of stopping Maggie’s suffering—the bogus version of Million Dollar Baby that won Best Picture.

 

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  1. Pulp Fiction (1994). In a famous scene Mia Wallace (Uma Thurman) snorts a large dose of heroin and collapses in either a cardiac arrest or a sudden coma. Vincent Vega (John Travolta) brings the unconscious Mia to his dealer’s house. The dealer hands Travolta a syringe of adrenaline connected to a 6-inch-long needle. Travola plunges the needle into the front of Mia’s chest with a prodigious swing of his arm. He doesn’t even have time to push the plunger and inject the adrenaline before Mia immediately screams and wakes up. This scene, as entertaining as it is, could never occur. No layperson would understand where in the body to inject intra-cardiac adrenaline. The chance of puncturing a lung or lacerating the heart or great vessels of the chest would be high. In a cardiac arrest the preferred route of epinephrine injection is into an arm vein, concurrent with chest compressions which move the drug through the circulatory system and into the heart. I’ve practiced acute care medicine for over three decades, and I’ve never found a need to inject epinephrine into a patient’s heart directly.                                                                                             And it’s unlikely Mia Wallace would wake up instantly. If her diagnosis was stupor from the combination of alcohol and heroin, then perhaps the pain of the injection would wake her. If she was suffering from a heroin/narcotic overdose, the specific antidote would be Narcan, not adrenaline, and it should be injected into one of her arm veins. If her diagnosis was a cardiac rhythm disorder such as ventricular fibrillation or ventricular fibrillation which caused sudden death, the only therapy likely to immediately revive her would be cardiac defibrillation, e.g. by an ACD (automatic cardiac defibrillator) similar to the machines found in public areas like airports or arenas. But if she had ventricular fibrillation or tachycardia for the entire duration it took to transport her across town to Travolta’s dealer’s house, then Mia would be dead after that prolonged time and she could never recover. Director/writer Quentin Tarantino scored bigger points by having his two biggest stars connect via a 6-inch needle to the chest. The result was memorable, laughable, and outrageous entertainment, but without plausibility.

 

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  1. Casino Royale. (2006). James Bond realizes he’s consumed a poison drink while at a baccarat table in a casino. He knows he’s about to die, and stumbles to his car in the parking lot outside. He removes some sort of cell phone device from the glove compartment and contacts M’s headquarters in London. Bond rests the cell phone on his radial pulse at his wrist, and miraculously his vital signs are revealed to London. The doctor in London assesses that Bond is in ventricular tachycardia, a dangerous heart rhythm, and tells Bond to take the defibrillator out of the glove compartment and connect it to his chest. Within another minute, the electronic device resting on Bond’s pulse miraculously transmits to London the diagnosis: the poison is digitalis. The doctor tells Bond to inject the blue syringe from the glove compartment to “counteract the digitalis.” Bond stabs himself in the neck with the syringe, and then passes out before he can activate the defibrillator. Bond’s lady friend arrives on the scene in the nick of time and pushes the red button on the defibrillator to shock Bond, and he wakes up . . . all cured! None of this could happen. There’s no electronic device over your wrist pulse that can tell you anything more than your heart rate. Such a device could not make a specific diagnosis such as ventricular tachycardia, and such a device could not make a specific diagnosis such as digitalis poisoning. Luckily for Bond, his woman friend arrives in time to defibrillate his heart, and he survives. Somehow you had a feeling James Bond wouldn’t die, didn’t you?             An academic medical paper examined the phenomenon of cardiac arrest survival rate in the movies. The article studied thirty-five cardiac arrest scenes in 32 movies from 2003 to 2012 (including Casino Royale, Mission Impossible 3, Inception, and Spider Man 3) for accuracy and credibility. (Ofole UM et al, Defibrillation in the movies: a missed opportunity for public health education, Resuscitation. 2014 Dec; 85(12): 1795–1798.) This medical study concluded that in the movies, defibrillation and cardiac arrest survival outcomes were often portrayed inaccurately. In 8 scenes of in-hospital cardiac arrest, 7 of the 8, or 88% of the patients survived, compared to survival rates of 23.9% reported in the medical literature. In 12 movie scenes involving out-of-hospital cardiac arrest, 8 of 12, or 67% of the patients survived, compared to survival rates of 7.9-9.5% reported in the medical literature. In summary, too many patients survived in the movies. I presume that’s because writers, directors, producers, and audiences all prefer to see their movie stars wake up and live. See #4 below for another example of the same in a blockbuster Hollywood movie.

 

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  1. Jurassic Park (1993). Tim Murphy, the middle-school-aged grandson of the park’s inventor, is electrocuted on the perimeter fence of a dinosaur pen. He collapses to the ground and Dr. Alan Grant (Sam Neill) says, “He’s not breathing.” Dr. Grant proceeds to give Tim mouth-to-mouth resuscitation and chest compressions, and in exactly 26 seconds Tim coughs several times and wakes up. Remarkable! Per the medical publication in Resuscitation above, this sort of recovery from out-of-hospital cardiac arrest . . . only happens in the movies.

 

  1. Coma (1978). The 1977 novel Coma by Robin Cook, MD from Harvard was the first outstanding medical thriller, and one of the books that inspired me to become a writer. A successful movie version of Coma followed the book. The premise of Coma was that healthy young patients were developing brain death after general anesthesia, for no apparent reason. The protagonist Dr. Susan Wheeler (Genevieve Bujold) uncovers the root cause of the evil scheme: patients are breathing carbon monoxide instead of oxygen during general anesthesia, because some diabolical doctors have spliced a pipeline of carbon monoxide into the oxygen pipeline. The brain-dead patients are then harvested to a secret room and suspended by wires from the ceiling in a supine posture until their bodies can be sold and transported off as organ donors.                                                                                                                   In the 1970’s when the screenplay was written this plot may have seemed plausible, but in the 21st century it’s impossible. The anesthetic gases you breathe are now monitored on a second-to-second basis, and if the mixture does not contain adequate oxygen, multiple alarms sound off instantly. In addition, you wear a pulse oximeter on your fingertip. If the blood in your finger does not contain adequate oxygen, the oximeter reads a low result and alarms instantly so the anesthesiologist can remedy the situation. As well, extra oxygen tanks are present in every operating room as a safety back up, in the rare instance that the piped-in wall oxygen source is stopped or is inadequate. You can relax. Coma could not happen in this manner in the 21st

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  1. Split (2016). The villain in this film suffers from multiple personality disorder, or dissociative identity disorder (DID). In more than one scene, the villain Kevin Wendell Crumb (James McAvoy) sprays an aerosol into the face of his victims. Within seconds these individuals collapse in unconsciousness. Crumb lives and works at a zoo, where the audience is led to believe such a spray tranquilizer is used as needed to tranquilize the animals. As an anesthesiologist who induces unconsciousness in my patients every day, I can tell you that no such immediate coma-inducing spray gas exists. The potent inhaled anesthetics we anesthesiologists use are sevoflurane, desflurane, and isoflurane. Veterinarians these same anesthetic vapors for their surgical anesthetics as well. Each of these drugs is a liquid, which is then vaporized by special equipment to deliver inhaled anesthesia gas. These vaporizers are metal cylinders about the size of half-gallon milk carton. The fastest and most pleasant smelling of these vapors is sevoflurane. Inhaled sevoflurane can induce anesthesia in ten to thirty seconds if a high concentration of the drug is inhaled deeply into the lungs, but there is no drug that works in one second, like the aerosol that the villain used in Split.

 

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  1. Old School (2003). This movie portrays another version of the instant sedative. In a scene at a youth birthday party, Frank Ricard (Will Farrell) picks up a tranquilizer gun which is designed to inject “the most powerful animal tranquilizer in the world” into any of the ponies or farm animals on display at the party. Frank accidentaly shoots himself in the neck, and the dart remains sticking out of the left side of his neck at a perpendicular angle. The owner of the gun, an animal tamer, comments that Frank has injected himself “in the jugular.” Within the next 30 seconds, Frank becomes increasingly wobbly and stuporous, and eventually falls face first into the swimming pool. Could this happen? Almost certainly not.                 Ketamine is the quickest injectable drug anesthesiologists have in their arsenal to anesthetize a patient by a non-intravenous injection. Ketamine is an injectable general anesthetic which is effective in inducing general anesthesia within 30-120 seconds after an intramuscular injection. If injected directly into a vein, e.g. an arm vein, ketamine can induce general anesthesia in 10-15 seconds. But the stab to Frank’s neck at the 90-degree perpendicular angle is unlikely to hit the exact location of the internal jugular vein, which is only about 1/2 an inch in diameter. And Will Farrell’s dart didn’t land in any big muscle like the buttock or the deltoid muscle at the shoulder, either. Powerful injectable animal tranquilizers such as etorphine or xylazine or tiletamine exist which can subdue a beast in a short time after intramuscular injection, but none of them will work as fast as the drug does in this scene. Movies are about entertainment, and it’s not entertaining to watch an actor spend five slow minutes becoming sedated enough to pass out so the plot can move onward.

 

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  1. Awake (2007). Young billionaire Clay Beresford (Hayden Christensen, or Anakin Skywalker from the Star Wars movies) needs a heart transplant, and it turns out that he is awake and aware during the general anesthetic for his heart surgery. While he is awake he overhears the surgeon’s plan to murder him. Producer Joana Vicente told Variety that Awake “will do to surgery what Jaws did to swimming in the ocean.” The movie trailer aired a statement that states, “Every year 21 million people are put under anesthesia. One out of 700 remain awake.” Awake was not much of a commercial success, with a total box office of only $32 million, but the film did publicize the issue of intraoperative awareness under general anesthesia, a topic worth reviewing.                                                                                                              If you have a general anesthetic, do you have a 1 in 700 chance of being awake? If you’re a healthy patient undergoing routine surgery, the answer is no.  If you’re extremely sick and you’re having a high-risk procedure, the answer is yes. A key publication on this topic was the Sebel study. (The incidence of awareness during anesthesia: a multicenter United States study, Sebel, PS et al, Anest. Anal.  2004 Sep;99(3):833-9, Department of Anesthesiology, Emory University School of Medicine.) The Sebel study was a prospective, nonrandomized study, conducted on 20,000 patients at seven academic medical centers in the United States. Patients were scheduled for surgery under general anesthesia, and then interviewed in the postoperative recovery room and at least one week after anesthesia. A total of 25 awareness cases were identified, a 0.13% incidence, which approximates the 1 in 700 incidence quoted in the Awake movie trailer. Awareness was associated with increased American Society of Anesthesiologists (ASA) physical status, i.e. sicker patients.  Assuming that approximately 20 million anesthetics are administered in the United States annually, the authors postulated that approximately 26,000 cases of intraoperative awareness occur each year.                                                                         Healthy patients are at minimal risk for intraoperative awareness. Patients at higher risk for intraoperative awareness include: 1) patients with a history of substance abuse or chronic pain, 2) ASA Class 4 patients (patients with a severe systemic disease that is a constant threat to their life) and others with limited cardiovascular reserve, 3) patients with previous history of intraoperative awareness, 4) patients requiring the use neuromuscular paralyzing drugs during the anesthetic, and 5) patients undergoing certain surgical procedures which are higher risk for intraoperative awareness, including cardiac surgery, Cesarean sections under general anesthesia, trauma cases, or emergency cases.

 

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  1. Vertigo (1958). Vertigo has no surgical/anesthetic/critical care gaffes, but I’ll comment on the film because the leading lady (Kim Novak) and I have the same last name (alas, we’re not related) and because it’s always been one of my favorite movies. The physical symptom known as vertigo is defined as, “a medical condition where a person feels as if they or the objects around them are moving when they are not. It often it feels like a spinning or swaying movement. This may be associated with nauseavomiting, sweating, or difficulties walking. It is typically worsened when the head is moved. Vertigo is the most common type of dizziness.In key scenes from Vertigo, Scottie Ferguson (Jimmie Stewart) suffers from attacks of acrophobia. His symptoms are presented as a whirling sensation when he looks downward from a height.                                                                                                           The symptom complex Jimmie Stewart suffers from in this movie would more accurately be described as acrophobia than vertigo. Acrophobia is “an extreme or irrational fear or phobia of heights, Acrophobia sufferers can experience a panic attack in high places and become too agitated to get themselves down safely.” Jimmie’s character is incapable of functioning at heights, and contributes to his inability to save Kim Novak from falling to her death in the film’s final minute. Vertigo is a catchy title—no doubt a more nuanced and debatable title than Acrophobia. In 2012 Sight & Sound granted Vertigo first place in their poll of the greatest films of all time. Imagine if the number one movie of all time had been correctly named Acrophobia after it’s medically accurate diagnosis.

 

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  1. The Doctor (1991). In the movie’s opening scene, surgeon Jack MacKee (William Hurt) is shown in the operating room completing a heart surgery. As the final crucial stage of the operation is completed successfully, he asks for his “closing music.” The Jimmy Buffett song “Why Don’t We Get Drunk (And Screw)” begins to play, and the three male surgeons and the male anesthesiologist all sing the chorus together. William Hurt says to his scrub nurse, “Nancy, I want to hear you sing for me.” The photo above is the scene just before the singing begins. William Hurt is the surgeon, second from the right, and Nancy is on the far right. The anesthesiologist is in the center, in the immediate background. Why is this scene inaccurate? One answer is that the singing anesthesiologist is not separated from the sterile surgical field by the usual vertical barrier of sterile drapes known as the “ether screen.” Anesthesiologists don’t stand inches from the surgical field next to the surgeons. But how about singing the sexual song in the operating room? Many surgeons have their favorite closing music, and an occasional surgeon will sing along with their closing music. Could this scene of sexual harassment occur in 1991 when this movie was made? It could—back in the 1980s and 1990s I saw actions as bold as portrayed by William Hurt’s character, and worse. But this wouldn’t occur in 2017. There’s no tolerance for sexual harassment in the medical workplace nowadays.

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  1. Get Out (2017). An excellent thriller with absurd characters and shocking scenes, Get Out faltered badly regarding surgical and medical science. (Spoiler Alert) The plot hinges on brain transplantation, a far-fetched fiction in itself. To make the movie’s depiction even worse, the brain transplantations are performed in the basement of the neurosurgeon’s house, with the two patients side-by-side, and there is no anesthesia equipment or anesthesiologist. The first patient seems to be dozing, without any breathing tube or ventilator, while the surgeon (above) slices off the top of his skull. There are also no nurses or scrub techs, the only assistant being the neurosurgeon’s son, who is a medical student. An entertaining movie, right up until this scene, which is so absurd that no one could possibly believe it. Get Out received a Rotten Tomatoes score of 99%, so the critics (none of whom are doctors) still loved the movie.

There they are: my 11 favorite examples of medical inaccuracies from major film studios. Will there be more in the future? Don’t doubt it. Hollywood directors and writers aren’t likely to let mere medical science stand in the way of entertainment. 🙂

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

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IS PRIVATE PRACTICE ANESTHESIA DOOMED?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

What is the future of private practice anesthesiology?

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First off, let’s define “private practice.” The Merriam-Webster online dictionary defines private practice as: “a professional business (such as that of a lawyer or doctor) that is not controlled or paid for by the government or a larger company (such as a hospital).”

In my community the dentists are all in private practice, as are most of the accountants, psychologists, and attorneys. Why should anesthesiologists be any different? Let’s look at the issues.

A private practice single-specialty anesthesia group will usually provide anesthesia for similarly self-employed surgeons who are in private practice. How does the business work? When a single-specialty anesthesia group provides a service, the group decides the cost of that service, and the group sends a bill to the patient’s insurance company or to Medicare or Medicaid for that amount. How much will they get paid? It depends. Medicare and Medicaid cap their payments at a small fraction of an anesthesiologist’s typical fee. For insured patients, the anesthesia group collects whatever the insurance company pays, along with the deductible or co-pay the patient owes through their insurance plan. The collected amount, minus the group’s overhead (office employee salaries, office rent, office supplies, malpractice insurance, and health insurance for their own families) equals the anesthesia group’s profit.

A private practice anesthesia group needn’t be a physician-only group. In many private practice anesthesia groups, physician anesthesiologists supervise multiple nurse anesthetists in multiple operating rooms. These groups are still single specialty anesthesia groups. Physician anesthesiologists pay their nurse anesthetists as employees as well as their other expenses, and then divide the profit.

In recent years the prevalence of the private practice model is decreasing. The model is being replaced by jobs where the anesthesiologists are employees. Employees of whom?

One employee model is the multispecialty group model, in which all medical specialties work in parallel under one umbrella organization. Examples of this are the Permanente Medical Group (of Kaiser Permanente), Sutter Health in California, Mayo Clinic, and university groups such as Stanford Health Care in my neighborhood. The essence of this model is physicians are salaried, and income is divided amongst the different specialties. Surgical specialties such as anesthesiology and all surgeons earn less than they would in a self-employed private practice model, with some of the income from their services going to primary care specialists like family practitioners, internists, and pediatricians. It’s a symbiotic system since the referrals to the surgical specialists commonly originate from the primary care doctors in the first place. In this model an anesthesiologist will earn less money per case, but may increase his or her income by doing more cases.

A second employee model is the for-profit national physician corporation. The national corporation may purchase anesthesia private practice groups to gain access to their hospital and/or surgery center contracts. The corporation pays an up-front payment to the current anesthesiologists of each smaller group at the time of purchase. The parent corporation collects all future anesthesia bills, and pays out a decreased fee to the anesthesiologists who are now employees. The difference between the collected fee and the anesthesia pay-out equals the profit bottom line of the purchasing corporation, which may be a publically traded company.

A third employee model occurs when a single anesthesiologist or a smaller company attains an exclusive contract for a hospital or a surgery center. This solitary anesthesiologist or smaller company then employs other anesthesiologists at a lower set rate or salary, then contracts to have all billing and collecting done, and keeps the difference between the collected rate and the rate paid to the employees as profit.

One of the reason employee models are increasing in frequency is that the private practice of primary care medicine and the private practice of surgery are both shrinking. If more and more primary care doctors join large multispecialty groups or a national company, and if more and more surgeons join large multispecialty groups or a national company, there will be a paucity of patients for a freestanding anesthesia group to attend to. These trends are not going away.

As a result, today’s graduates from anesthesia residencies and fellowships are finding decreasing opportunities in true private practices, and increased offers to become someone’s employee. This means some of the anesthesia income will be shared with or siphoned off by other people.

Can young anesthesiologists do anything to reverse this trend? It depends. Private practice opportunities still exist in many geographic areas of the United States, if a new anesthesiologist is flexible about where he or she is willing to live. If you’re determined to stay in an overcrowded, underpaying marketplace, you may find nothing better than a salaried job at a modest income.

What is a modest income? Is $250,000 a year a modest income? That number sounds like a large income to most Americans. However if the doctor worked 60 hours per week and was awake all night performing anesthetics every fifth night, and if the collected fees for that individual’s anesthesia work that year totaled $750,000, then that individual was being paid significantly less than they earned.

How can you tell if your employer is paying you less than you earned? Find out what they are collecting per anesthesia unit of time, and do the math. Compare that number to what they are paying you. See my article on anesthesia billing as a reference for this.

Many private practice groups will survive. In the words of Charles Darwin, it will be survival of the fittest. Private practice groups will have to change and adapt to maximize their chances for survival. They will have to provide a higher level of service, and become more involved outside the operating room, in perioperative leadership, and in their local hospital politics and economics.

The anesthesia job market is part of the free marketplace in America, and Adam Smith’s invisible hand will drive individuals toward the best and highest paying opportunities. If you’re a young anesthesiologist, can you do anything to avoid the trend toward low salaried jobs? You can refuse to settle for poorly-paying jobs. Move to a marketplace that pays you well for your time. You may choose to not settle for a salary which is a mere fraction of what you are earning, especially if you are keeping patients alive at 3 a.m. while healthcare businessmen and stockholders are sleeping.

Medscape lists the best states for doctors to practice in. Flexibility in geography may yield a superior opportunity for you.

Medscape recently reported the average yearly income for anesthesiologists in the United States as $364,000. If your yearly income is $250,000 (this would be $114,000 under the average), then somewhere in the United States there are anesthesiologists with an income of $364,000 + $114,000 = $478,000, to maintain the average yearly income that Medscape reported.

When you input “private practice anesthesiologist” into Indeed.com, you’ll find multiple job offers. The private practice of anesthesia may be shrinking, but it’s far from gone.

 

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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PREANESTHESIA CLEARANCE FROM PRIMARY CARE DOCTORS: TWO QUESTIONS

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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Many patients require preoperative clearance prior to surgery, especially patients with significant medical problems or at extremes of age. Preanesthesia evaluation reduces surgical and medical complications. Some health care systems run preoperative anesthesia clinics, where anesthesia professionals evaluate these patients prior to surgery. Such clinics can increase operating room efficiency and decrease day-of-surgery cancellations and delays, and are especially important prior to major inpatient surgeries such as brain surgeries, chest surgeries, abdominal surgeries and major transplants. In many health care systems there are no anesthesia clinics, and primary care doctors (internal medicine specialists, family practitioners, or pediatricians) do the preoperative assessments.

The surgeon may request the clearance or an anesthesiologist may request the clearance, but it will ultimately be the anesthesiologist who must care for the heart, lungs, brain, and blood pressure during the surgery and in the recovery room after the surgery.

Let’s choose an illustrative example. A 60-year-old man is scheduled to have a laparoscopic gallbladder removal (cholecystectomy). He takes lisinopril for hypertension and metformin for diabetes. He weighs 240 pounds, has a Body Mass Index of 38, and never exercises. What do anesthesiologists want to see in the internal medicine preoperative clearance consult?

We want to know the answer to two questions:

  1. Does the patient require any additional diagnostic workup prior to the surgery?
  2. Does the patient require any additional therapeutic changes prior to the surgery?

I’m Stanford-trained and board-certified in both internal medicine and anesthesiology, so I’m uniquely qualified to discuss this topic. Let’s look at what the process of an internal medicine preoperative consult looks like.

Let’s assume the internist has not seen the patient in the past year. The patient will be seen at the internist’s office, where the internist does a history and a physical, followed by an assessment and plan. The history includes a documentation of the past medical history, a review of current symptoms, a list of medications, allergies, past surgical history and family history. The physical exam includes the height, weight, vital signs, and documentation of any abnormal findings on exam of the entire body. The internist’s assessment will include a list of medical problems and a plan for each problem. For the patient above, the problem list would include:

  1. Hypertension
  2. Type 2 diabetes
  3. Obesity
  4. Sedentary lifestyle
  5. Preoperative assessment for upcoming general anesthesia for gallstones

An assessment and plan for each medical problem would be listed as follows:

  1. BP= 140/85 today. Plan: currently adequately controlled. Continue lisinopril.
  2. Plan: Check fasting glucose and hemoglobin A1c. Continue metformin.
  3. Plan: Weight loss counseling and consult with dietician.
  4. Sedentary Lifestyle. Plan: Advised initiation of exercise program.
  5. Preoperative assessment. Plan: cleared for general anesthesia providing ECG and labs are normal.

The labs are ordered, and the results accompany the history and physical. All the lab tests are normal. The ECG is abnormal, and shows diffuse ST wave abnormalities suspicious for ischemia (inadequate blood flow to the heart muscle). At this point the primary care physician can answer the two questions above:

  1. Does the patient require any additional diagnostic workup prior to the surgery? Answer: Yes. The patient requires referral to a cardiologist for workup of the abnormal ECG, especially in context of his sedentary lifestyle and risk factors of hypertension and diabetes.
  2. Does the patient require any additional therapeutic changes prior to the surgery? Answer: Dependent on the cardiologist’s assessment.

The surgery is delayed pending the cardiologist assessment. The cardiologist sees the patient, and recommends an exercise stress echocardiographic. The test is done, and is abnormal—the patient has abnormal decreased movement of the left anterior wall of his heart with exercise. Because of this abnormality, the cardiologist recommends a cardiac catheterization. The cardiac cath is done, and the patient has a 90% narrowing of his left anterior descending coronary artery. The cardiologist places a stent across this narrowing, and the patient is discharged home.

Because of the primary care doctor’s work, the patient had the necessary diagnostic tests done (blood work, ECG, and referral to cardiology), and the patient had a necessary therapeutic intervention done (a coronary stent). The gall bladder surgery is scheduled for one month hence.

Let’s discuss what a primary care doctor’s not should NOT be. The primary care doctor should not recommend what form of anesthesia is safe, e.g. “medically cleared for spinal anesthesia,” or “medically cleared for local anesthesia plus sedation.,” or “medically cleared for regional block anesthesia.” The primary care doctor should not recommend what drugs are safe to use. The primary care doctor should not recommend where the surgery should or should not be done, e.g. in a hospital, a surgery center, or in a doctor’s office. The primary care doctor should not estimate the percentage of survival or morbidity for the scheduled procedure.

Primary care doctors are very smart and highly trained professionals, but primary care doctors don’t work in operating rooms. They don’t know which anesthetic technique to recommend, which drugs to utilize, or the different strengths and weaknesses of different anesthetizing locations. What they do know is the outpatient condition of their patient.

Anesthesiologists need the answers to #1 and #2 above. If you’re an anesthesiologist, you now know exactly what questions to ask. If you’re a patient about to undergo surgery, you now know how important the preoperative medical assessment is to your anesthesiologist.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

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THE ANESTHESIOLOGIST ON THE NATIONAL FOOTBALL LEAGUE SIDELINES

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

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The National Football League (NFL) of American football is a multibillion-dollar industry which dominates the sports airwaves and press headlines from the first preseason game each August until the Super Bowl each February.

Did you know there is an intersection between anesthesiology and NFL game day?

There is.

At each and every NFL game there must be one Airway Management Physician on the sideline. This Airway Management Physician is most commonly an anesthesiologist or an emergency medicine physician. My anesthesia company had the contract for the San Francisco 49ers Airway Management Physician during the 2005-2006 season, and I worked in this role. It was a fascinating job, and in this column I’ll fill you in on the experience.

Why must every NFL game have an Airway Management Physician on the field? Football is a violent sport played by young men of unprecedented speed and size. When these men collide there is always the risk of injury. The NFL Physicians Society (NFLPS) mandates a 27-person game-day medical staff.

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Each sideline includes 2 orthopedists, 2 primary care physicians, 4 athletic trainers, 1 unaffiliated neurotrauma consultant, and 1 chiropractor. In addition, the Stadium Medical Team includes 1 dentist, 1 ophthalmologist, 1 Airway Management Physician, 2 Emergency Medical Technicians, 2 independent athletic trainers, 1 radiology technician, and 1 visiting team medical liaison.

During the game, common football injuries to the knee, ankle, foot, shoulder, elbow, or hand are matters for the team orthopedic specialists, the athletic trainers, and perhaps the chiropractor. Injuries to the head activate a concussion protocol in which the neurological examination is carried out with the aid of the neurotrauma consultant.

The Airway Management Physician is present in case of a severe medical complication. This would include a cardiac arrest, a respiratory arrest, a cervical spine injury, or an airway injury which impairs breathing. In these situations the acute medical management must follow the standard sequence of Airway, Breathing, and Circulation. The player’s airway must be open and secured prior to any effective breathing or cardiac care. If the player’s airway is not open, the Airway Management Physician is responsible for placing a breathing tube through the player’s mouth into his windpipe so oxygen can be effectively ventilated in and out of the lungs. The absence of oxygen to a patient’s brain for 3-5 minutes can cause permanent brain damage.

The NFL game day Airway Management Physician will be an experienced anesthesiologist or emergency room doctor, because these are the two specialties which deal with the placement of urgent breathing tubes in hospital operating rooms, emergency rooms, or intensive care units.

The urgent placement of an airway tube is called a Rapid Sequence Intubation, or RSI. Anesthesiologists routinely use RSI technique to place a breathing tube into a patient’s windpipe prior to emergency surgery. Emergency surgery patients are always classified as “full stomach” patients, meaning that they have not fasted for the required 8 hours prior to elective surgery. Patients who have full stomachs are at risk for vomiting their stomach contents into their lungs. This can be a lethal complication. In my 30+-year career as an anesthesia attending, I’ve placed thousands of RSI breathing tubes prior to surgeries. Emergency room physicians place RSI breathing tubes for various causes including trauma, cardiac arrests, or respiratory arrests.

To perform a RSI, the anesthesiologist or emergency room doctor will administer a hypnotic drug (such as propofol or ketamine) if the patient is conscious, followed by a paralyzing drug (such as succinylcholine or rocuronium). At the same time, a medical colleague (a surgeon or a nurse) will press down on the cricoid cartilage at the anterior aspect of the patient’s voice box. This is called a Sellick maneuver or cricoid pressure, and this serves to compress cricoid cartilage (which circles the windpipe) downward against the esophagus to reduce the chance of stomach contents regurgitating into the mouth and/or lungs.

Next the anesthesiologist or emergency room doctor inserts a lighted instrument called a laryngoscope into the patient’s mouth, to identify and visualize the opening to the trachea or windpipe. The physician then inserts a hollow plastic breathing tube called an endotracheal tube (ET tube) into the windpipe. The ET tube has an inflatable balloon near its tip. Once the ET tube is in place, the physician inflates the balloon to secure a tight fit within the windpipe. Oxygen can then be ventilated in and out of the tube via a breathing bag.

A RSI is a stressful acute medical procedure in which there is little room or time for error. If the physician has difficulty inserting the breathing tube and the patient has no oxygen entry, the patient can suffer anoxic brain damage within 3-5 minutes. In a hospital setting, even when the physician has all the necessary equipment at his or her fingertips, a RSI can be a harrowing experience. Trying to execute a RSI on the 50-yard-line of a football field, on a 300-pound athlete with a thick neck and who is wearing bulky shoulder pads and perhaps a football helmet, under national television audience scrutiny, would be stressful to the extreme.

No NFL player to date has ever had a cardiac or respiratory arrest on the football field during a game. On August 20th, 2005, San Francisco 49ers offensive lineman Thomas Herrion collapsed and died the locker room after a preseason game in Denver. Per a personal account from a physician present in the locker room at the time, the team had gathered around and closed their eyes to say the Lord’s Prayer, and during that prayer they heard a loud thump. They opened their eyes to see Herrion lying on the ground unconscious and seizing. No anesthesiologist or emergency room physician was present. The physicians who were present attempted to revive Herrion. He was transported to St. Anthony’s Central Hospital where he was pronounced dead.

Per coroner Amy Martin, a forensic pathologist in Denver, Herrion weighed 335 pounds and was 6 feet 3 inches tall. His autopsy was positive for significant blockage of the right coronary artery, and his cause of death was listed as heart disease. His blood tests were negative for any steroids or performance-enhancing drugs. He entered the game for about 20 plays near the end of the game, and he appeared to be in normal physical condition prior to entering the locker room.

In the weeks following Herrion’s death, my anesthesia company was hired to be the Airway Management Physicians for the remainder of that 49ers season. I was the Airway Management Physician for the September 25, 2005 game between the 49ers and the Dallas Cowboys at Candlestick Park in San Francisco. Prior to the game we dressed in team medical polo shirts in the team locker room with the other members of the medical team. Some physicians were engaged in pregame consultations with the trainers regarding players with injuries or ailments. Before the game I joined a group of physicians who walked to the opposing sideline to introduce ourselves to members of the Cowboys medical team. Just prior to kickoff, when the 49ers ran out of their locker room onto the field, we physicians walked just behind them. The soundtrack to our stadium entrance was the same roaring ovation that the sellout crowd gave their football heroes—it was an unforgettable experience.

I was given a small, 10 X 4 X 4-inch pouch labeled “RSI equipment.” Inside were the necessary items: the laryngoscope, the syringes, and the drugs necessary for a routine Rapid Sequence Intubation. I must confess that for multiple reasons I was praying I would not intubating a 335-pound lineman with the contents of that pouch on that day. Along with the other members of the medical team, I was instructed to remain between the 30-yard-line and the goal line on either end of the field, and not to enter the team bench area between the 30-yard-lines. I was given a red hat to wear so I could be easily identified in an emergency situation. I remained in the immediate vicinity of the other team doctors so I was ready for a team approach should an emergency occur. I watched the game vigilantly so I would be ready should an emergency occur.

There were no cardiac arrests or fractured cervical spines, and my services were not required on that Sunday. Following that season the 49ers contracted with the full-time faculty of Stanford Medical Center to be their Airway Management Physicians, and I never had the opportunity to reprise the experience of that one 49ers-Dallas game.

I was left with several lasting impressions regarding the NFL anesthesiologist experience:

  1. The sheer size of the linemen makes their airways potentially difficult to manage. I performed anesthetics on multiple San Francisco 49ers players for orthopedic surgeries over 15 years time. Their cardiovascular fitness was never in question, but their bulk was striking. A Body Mass Index (BMI) table states that a 335 pound, 6 foot 3 inch patient has a BMI=41. A BMI over 40 is defined as Morbid Obesity, and this is always a significant anesthesia concern. Morbid Obesity carries a risk classification of American Society of Anesthesiologists Class 3, which is defined as “a patient with a severe medical disease which is currently stable.” A professional athlete is more healthy than an inactive couch potato fan who watches the NFL on television, but nonetheless anesthetizing gigantic men requires skill and entails risk.
  2. A second lasting impression is that the RSI pouch I was given in 2005 would be woefully inadequate in 2017. An essential tool to intubate a 300-pound giant wearing football gear is a portable video laryngoscope, such as the McGrath 5: hqdefaultThis is a handheld tool with a camera on one end and a video screen on the other. The video laryngoscope allows the physician to see around the curves of a large man’s tongue and jaw, and to visualize the opening to the windpipe without moving or extending the cervical spine (which in some football injuries must be suspected of having an unstable fracture). I’m certain that modern day RSI equipment at NFL games includes not only a portable videoscope but also a larger array of breathing tubes and airway management tools such as you’d find in a difficult airway cart in an operating room or an emergency room. The American Society of Anesthesiologists Difficult Airway Algorithm references the optimal approach to any airway difficulty, and an airway emergency on an NFL playing field would be best managed per this Algorithm.
  3. My third profound recollection is how cool it felt to be on the sideline for an NFL game, and how memorable it was to witness the spectacle up close. My own football skills never advanced past 3-on-3 touch football, but I’m a fan, and I’ll always remember my adventure as a member of the medical team for America’s number one sports attraction.

 

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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THEANESTHESIACONSULTANT HITS ONE MILLION VIEWS – MARCH 2, 2017

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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I want to thank my readers, as theanesthesiaconsult.com reached the landmark of 1,000,000 all-time views this week. The website was born in 2010 when I posted multiple columns I originally wrote for the Stanford Anesthesia Department publication The Gas Pipeline. Over the following months I added a series of columns aimed at laypeople, answering frequently asked questions about anesthesia.

The website reached only a few thousand viewers the first year, but I kept writing and the readership grew. By 2017 the number of columns grew to the current total of 148 pages. The crescendo in traffic was progressive, with a recent boom to a level of approximately 11,000 views per week, and a pace to reach over 500,000 readers per year. Thirty-five percent of the clicks are on columns aimed at anesthesia/medical professionals, and 67% of the clicks are on columns aimed at the public. My readers reside in over 100 countries from around the world.

The website has been an adventure for me. I write and control everything as a one-man production. The platform is a WordPress.com template, and my only expense is $18 per year to WordPress for website hosting. I’ve never paid a penny for Internet search engine optimization, or for efforts to rise toward the top on Google search lists.

I enjoy corresponding with readers, and I frequently write columns in response to a request or question from a reader. In addition to writing about my own experience and training, I rely heavily on Pubmed.com as my source of knowledge of the peer-reviewed medical literature, which I frequently summarize and refer to for my readers.

Three sets of editors have contacted me to write chapters for their anesthesia/surgical textbooks on topics I’ve written about on my website. A leading university anesthesia program invited me to travel to their hospital and lecture as a Visiting Professor. Attorneys from 20 states have contacted me for opinions on legal cases.

Writing is a passion, but my primary job is still clinical anesthesia. I attend to patients before, during, and after surgery, five days a week. I’ve personally administered more than 25,000 anesthetics over 33 years, and have no plans to retire soon.

The success of theanesthesiaconsultant.com would not be possible without my readers, and I thank you all. I’ll keep writing, and I invite you to keep reading.

Thanks a million!

Rick Novak, MD

 

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?

HOW TO DO CLINICAL RESEARCH

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

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Dr. John Brock-Utne’s Clinical Research, Case Studies of Successes and Failures is a unique and valuable addition to the medical literature, and a must-have handbook for medical school faculty members of all ages and seniority.

Dr. Brock-Utne is a Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University, and an experienced and accomplished academician. His book is a treatise on how to create significant clinical research studies, and how to get those studies published.

Faculty members in academic medical centers have long been evaluated by a “Publish or Perish” mentality. Publishing significant papers in prominent medical journals is expected if a faculty member wants to solidify his or her job security, or to gain tenure at a university.

A Google search for “Clinical research guidebooks” reveals a paucity of competing books. Brock-Utne’s Clinical Research, Case Studies of Successes and Failures is to date the only manual written by a medical professor for this purpose. Just as many prominent business and law schools teach by the case study method, Brock-Utne follows the same technique. Each book chapter presents a question regarding clinical research, posed in Socratic manner, based on the author’s actual experience,. A discussion of the answer follows. This format makes for easy and thoughtful reading, and effective assimilation of the desired knowledge.

Dr. Brock-Utne speaks from experience. A PubMed search documents that he has 271 publications to date, spanning 46 years from 1971-2017.

The three appendixes at the conclusion of the book sum up the major content in concise form. Appendix A (Review of the Clinical Research Process From Beginning to End), Appendix B (The Future of Clinical Research), and Appendix C (Summary Pearls) deserve reading and rereading until the pages are dog-eared.

This book is an essential addition to the library of faculty members of any department or medical specialty. The future of medicine requires the grooming of well-informed, talented researchers. Hopeful researchers need a how-to guide of the outstanding caliber of John Brock-Utne’s Clinical Research, Case Studies of Successes and Failures.

 

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

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12 TIPS ON BECOMING AN OUTSTANDING ANESTHESIOLOGIST

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

What qualities define an outstanding anesthesiologist? The bell-shaped normal curve describes the random distribution of many things. A bell-shaped curve exists for the abilities of anesthesia doctors as well.

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I’ve been practicing anesthesia since the mid 1980s. I’ve met and worked alongside hundreds of anesthesia colleagues from all corners of the globe. Some were academic professors, some were trainees at a university, and some were community anesthesiologists either in my group or in other anesthesia companies.

We’re entering an era of metrics for physicians, in which the government and hospital systems will collect data to monitor quality and performance. Because the outcomes of most surgical anesthetics are overwhelmingly uneventful, the occurrence of negative metrics for anesthesia performance will be rare—too rare to quantitate whether one doctor is “better” than another.

Rather, I’m choosing to list the qualities I’ve witnessed that make physician anesthesiologists stand out as leaders.

To be an outstanding anesthesiologist, you must:

  1. Be smarter than other anesthesiologists. Certain anesthesiologists pride themselves on keeping up with the new developments in medicine. They also repeatedly review the essential knowledge base they learned as a trainee. Their pursuit of knowledge is multifaceted, and includes reading journals, attending lectures, attending conferences, and habitually reading textbooks, Pubmed, or Internet searches when they see an opportunity to learn. Interaction with other smart anesthesiologists is essential. I’ve seen instances where an isolated company of anesthesiologists tells themselves, “We are the best anesthesiologists,” when they rarely interact with the anesthesia world outside their group. This can be a vain conceit. Only by engaging the greater community of anesthesiologists outside your tiny geographic domain can you exchange information and grow as a doctor.
  2. Be prepared. The Boy Scouts of America motto is “Be Prepared.” Anesthesiologists must abide by the same value, because an anesthesia complication that goes sour can cost a patient’s life within minutes. Every anesthetic is an opportunity to care for a patient at the highest level, and an opportunity to err. Planning anesthesia care, based on your training, experience, and knowledge, is critical. You also need to be ready to manage a difficult airway, hypotension, hypertension, or the myriad of acute respiratory and cardiac complications that can occur before, during, or after a surgical anesthetic. Pay attention at every Quality Assurance meeting, every Mortality and Morbidity conference, and to every tale of a near-miss anesthesia calamity. Remember the circumstances of other doctors’ complications, and utilize the information to be a safer doctor yourself.
  3. Be friendly and personable. You have to get along well with surgeons, the nursing staff, the scrub techs, administrators, and the patients. If your medical colleagues look forward to working with you because you’re a pleasant individual with a positive attitude, this bodes well. If your medical colleagues find you brash, moody, or easily angered, the opposite is true. Anesthesiologists aren’t typically known to be verbose. A pathologist friend of mine, commenting on the lack of verbal skills in his profession, one said, “The extroverted pathologist looks at your shoes instead of his own shoes when he talks to you.” Don’t be like that pathologist. Polish your interpersonal skills.
  4. Learn how to wake up patients promptly. It sounds elementary, but I still see mid-career anesthesiologists whose patients take too long to wake up. Their patients are obtunded on arrival to the Post Anesthesia Care Unit (PACU) after surgery, and they rely on the PACU nursing staff to complete the job of anesthesia wake up. Surgeons, nurses, and other anesthesiologists notice this, and the reputation of a practitioner who can’t wake a patient on time is no secret within a surgical suite.
  5. Learn to perform medical procedures at the highest level. Anesthesiologists are hands-on doctors. We earn our living placing breathing tubes, IVs, arterial lines, central lines, epidural catheters, spinal blocks, and ultrasound-guided regional blocks. Some anesthesiologists are wizards with their hands. Some are not. Reputations are built and lost based on the manual skills of physician anesthesiologists. The nurses, surgeons, and techs know which anesthesiologists to recommend, and they won’t recommend you if you’re inept.
  6. Enjoy your 10 minutes with each patient prior to surgery. The preoperative evaluation is a medical interview to review the history, physical examination, and laboratory tests, and the evaluation is followed by a discussion of the anesthetic alternatives and risks—but those 10 minutes are much more than that. It’s your chance to get to know this person you’re about to render unconscious. You have an opportunity to converse about their heritage, the geographical course of their life to date, or their hobbies. The patient wants to like you and trust you, because you’re about to take his or her life into your hands. Take the time to connect with your patient before the anesthetic, and you won’t regret it. In our anesthesia company’s practice, we MDs have always inserted our own preoperative IVs. This gives us more face time with the patient to converse with them and comfort them, and perhaps make them laugh prior to rendering them unconscious. Many hospitals and surgical centers prefer to have an RN place the preoperative IVs. This may save 3-5 minutes of time. I’m all for efficiency, but this time is better spent with the doctor applying his or her skills at IV insertion while chatting and putting the patient at ease.
  7. Avoid letting surgeons boss you around. Many surgeons are excellent co-professionals to work with, and some are not. Some surgeons are bullies, and are condescending in their remarks and attitudes toward the anesthesia provider they’re working with. I implore you to never submit to this abuse. The most important value in the operating room is to care for the patient, but this value is never best served with a surgeon intimidating the operating room staff. Stick up for yourself. Stick up for the circulating nurse and the scrub tech as well, if necessary. In the long run this will result in excellent care for more patients. The other medical professionals in the operating room will respect you for it.
  8. Cultivate your speaking and writing skills. It’s difficult to rise among the ranks of your fellow physicians unless you’re a superior communicator. Speaking skills are essential in every doctor-patient conversation. You’re selling yourself to the patient and their family as a confident practitioner. They’re nervous, they’ve never met you, and they’re forming their first impression of the individual who will soon be responsible for keeping them alive. Your abilities to communicate with surgeons, nurses, and techs before, during, and after a surgical anesthetic are also important. To rise to leadership roles, you must eventually speak at committee meetings, clinical conferences, administrative meetings, and possible at community, county, or state level medical meetings. Likewise, the ability to express yourself via the written word is critical. Some physicians will find themselves authoring peer-reviewed publications in scientific journals or chapters in textbooks. Others will author columns or opinion pieces in hospital, community, county, or state newsletters. Even routine communications via email are opportunities to produce eloquent, well-organized thoughts to your medical colleagues.
  9. Avoid being a “locker-slammer.” In anesthesia jargon, a locker-slammer is a practitioner who finishes his or her day of operating room anesthetics, goes directly to the locker room, changes out of his or her scrubs, slams the locker shut, and goes home. A locker-slammer will shun hospital politics, meetings, and out-of-the-operating room medical interactions. A true locker-slammer may practice at a given hospital for years and be unknown to anyone outside of the operating room suites. To avoid this fate, get involved. Anesthesiologists are vital on hospital committees such as the Quality Assurance Committee, Pharmacy Committee, Critical Care Committee, Emergency Room Committee, Medical Executive Committee, and many more.
  10. Trust your gut, and choose a line of work you love. The saying goes, “If you love what you do, you’ll never work a day in your life.” Outstanding anesthesiologists love their career. If you don’t love managing Airway, Breathing, and Circulation in surgical patients at all hours of the night and day, perhaps you’ve chosen the wrong specialty.
  11. Avoid complaining about long days or short days in the operating room. In my first year of private practice I used to moan about days with little or no work, because I wasn’t making any income that day. Two days later I’d have a 30-hour shift where I was working constantly without sleep, and I’d grouse about that. A senior anesthesiologist took me aside and said, “Richard, don’t complain about the short days. Get out there and enjoy your free time. And don’t complain about the long days. Those are the days you’re making money, and be happy about that fact, too.” He was right, and I share his advice with you as well.
  12. Understand the economics of anesthesia practice, billing, and reimbursement. I knew very little about these topics when I finished my residency training. Graduating residents in the 21st Century still know very little about these topics, which puts them at high risk to accepting low-paying jobs with little upside for leadership. Anesthesiologists earn solid money, but different job descriptions pay markedly different wages. Shop around. Attend the American Society of Anesthesiologists Practice Management Conference. If you’re ambitious, why would you take a job as a 40-hour per week employee for a large corporation, if that corporation is billing high fees for your service and then paying you 50% of what they collect? Physician anesthesia leaders must become skilled businessmen and businesswomen as well as clinicians.

These are a dozen traits I see in outstanding anesthesia colleagues. How many of these traits do you have? If there are traits you lack, I hope this column inspires you to gain them. Be patient with yourself. A career in anesthesia is a marathon, and these 12 tips are guideposts for your journey.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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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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A PEDIATRIC ANESTHESIA EMERGENCY: THE CHILD WITH AN OPEN EYE INJURY AND A FULL STOMACH

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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A 3-year-old boy is eating a McDonalds Happy Meal on the lawn of the restaurant. A lawn mower approaches, and a rock is ejected from the mower, hitting the child in the eye. The boy suffers a penetrating open eye injury, and is taken to the nearest hospital. You are on call for the repair. You’re are an experienced practitioner, but not a pediatric anesthesia specialist. What do you do?

Discussion: There are two issues. One is how to safely perform the open-eye, full stomach anesthetic, and the other is the performance of pediatric anesthesia by non-pediatric anesthesia specialists.

Your goals for this anesthetic are to protect the airway and to avoid increases in intraocular pressure (IOP). Sudden increases in IOP in patients with an open globe injury can lead to vitreous loss and blindness. The list of things that increase IOP and risk further eye damage includes crying, coughing, the Valsalva maneuver, vomiting, firm pressure with an anesthesia face mask, laryngoscopy, and endotracheal intubation. Ketamine and succinylcholine also increase IOP. Trying to start an IV without causing crying and the attendant increase in IOP in a 3-year-old can be difficult.

True ophthalmic emergencies (e.g. central retinal artery occlusions or chemical burns) must be treated within minutes to avoid blindness or permanent vision loss. A penetrating open globe injury is usually urgent, rather than emergent. At times urgent procedures are delayed until the patient has been fasting for 6 hours, and has an appropriate NPO status.

Let’s assume your surgeon is determined to operate urgently, and doesn’t want to wait 6 hours after the patient’s meal. In his judgment delaying the surgery would increase the patient’s risk of loss of vision.

No single approach to this patient is ideal, but a proposed approach is:

  1. Apply EMLA cream with an occlusive dressing over several potential IV sites 45-60 minutes before the IV attempt. Next give the boy an oral midazolam premedication (0.67 mg/kg), and wait until he becomes sedated enough to start an intravenous line.
  2. Once the IV is in place, a modified rapid sequence induction is done with cricoid pressure, using rocuronium as the muscle relaxant. A dose of 1-1.5 mg/kg is used to speed the pace of neuromuscular blockade. With the availability of sugammadex to reverse deep rocuronium motor block, the risks of a high dose of rocuronium in this setting are minimal. A nerve stimulator is used to confirm that depth of muscled blockade is adequate, to avoid any coughing during laryngoscopy. The FDA black box warning regarding pediatric use of succinylcholine allows for its use for emergency intubation or for patients with a full stomach, but this author prefers to avoid it if alternatives exist. Succinylcholine causes a transient tonic increase (4-20 minutes) in extraocular muscle tone, which causes an increase in IOP of 10 to 20 mm Hg.
  3. If the child has chubby arms, hands, ankles and feet, and you are not able to place the IV despite adequate oral sedation, you may proceed with an inhalation induction. Utilize sevoflurane with cricoid pressure maintained throughout. Once the child is asleep, the IV can be placed, relaxant given, and the endotracheal tube inserted.
  4. An oral gastric tube is used to suction out the stomach.
  5. Controlled ventilation is recommended, to insure the field is quiet for the surgeon.
  6. At the conclusion of surgery, because of the full stomach, the patient is extubated awake. For tips on a smooth emergence, see my column on Smooth Emergence from Anesthesia.
  7. Postoperative nausea and vomiting can increase IOP. Prophylactic IV ondansetron is recommended.
  8. Postoperatively, a pain-free child will cry less and have fewer increases in IOP. The surgeon should consider a regional block of the eye to decrease the need for postoperative narcotics.

The second issue in this case is that you’re not a pediatric anesthesiologist. A children’s hospital or a university hospital will have a team of pediatric anesthesiologists with specialized training on call for emergencies. Call schedules and staffing are different in community hospitals, where a smaller team of anesthesiologists shares night call. Unless the hospital is very large, it’s uncommon to have anesthesiologists of multiple specialties on call each day, e.g. one for pediatrics, one for cardiac cases, one for trauma, one for obstetrics, and one for the general operating rooms. It’s common for general anesthesia practitioners to cover many or all specialties when they’re on call. If the on-call anesthesiologist is not comfortable with an individual case, he or she can seek out and call in a better-trained anesthesiologist, if one is available. The goal of producing a specialist anesthesiologist for every type of case at all hours of the night and weekend is a difficult one to staff. The decision to care for this patient at a community hospital at all is a judgment as to whether standards of care can be met with the physicians who are available. I’m double-boarded in internal medicine and anesthesiology, and have no extra post-graduate training in pediatric anesthesia, yet I have cared for children age 10 months and over for over 30 years. I consider myself expert and confident in the anesthesia care of children of these ages in a community setting.

In my opinion, neonates and younger infants need anesthesiologists with specialized pediatric training. Whether specialized training should be mandated when anesthesiologists care for older children is debatable. Policies to define a minimum age limit for patients of general anesthesiologists may be a hot topic in the future.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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

DSC04882_edited

 

 

THE ART OF ANESTHESIA—A NEW TEXTBOOK, HIGHLY RECOMMENDED

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

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Imagine if Yoda and Obi-Wan Kenobi wrote a book called, “The Art of Jedi Practice.”

In the anesthesia world that book is now available, and it’s called Practical Anesthetic Management—The Art of Anesthesiology,  authored by C. Philip Larson and Richard Jaffe. Drs. Larson and Jaffe are both professors who taught me in the Stanford University Department of Anesthesiology, Perioperative and Pain Medicine.

Their book contains a series of chapters designed to teach the anesthesia professional how to perform our craft at a higher level. There are alternate textbooks, e.g. Miller’s Anesthesia, which contain an encyclopedic knowledge of our specialty, but the new Larson and Jaffe book will teach you how to improve and enhance your patient care. Between them, Larson and Jaffe have supervised tens of thousands of anesthetics in a university practice. Between them, Larson and Jaffe have taught hundreds of anesthesia residents the finer points of clinical care. Now, because of this book, readers can find on the printed page what the authors taught in the preoperative forum, in the operating room, and in the post-anesthesia recovery room.

The authors clearly state the philosophy of the book in the Preface: “As a result of the importance given to evidence-based anesthesia, practices based on experience or common sense are suspect and often denigrated. Further, some clinical practices do not lend themselves to scientific validation, as examples in this textbook will show. This is where the art of anesthesia plays an important role in maintaining the highest quality of anesthetic care. This book is not intended to be a comprehensive textbook of anesthesiology. Rather, we have selected key topics in the specialty where we believe the art of anesthesiology has generally been overlooked, misunderstood, or forgotten.”

Representative chapter titles include: Role of the Laryngeal Mask Airway in Airway Management, Essentials of Airway Management, Laryngospasm: the Silent Menace, Cricothyrotomy: A Lesson to Be Learned, Nitrous Oxide: Yea or Nay, Meperidine: A Forgotten Jewel, Sevoflurane: The Most Versatile Anesthetic Ever Developed, and The Bariatric Challenge.

Dr. Larson was the Chairman of Anesthesia at Stanford during the 1980’s, and the Editor-In-Chief of Anesthesiology, the world’s foremost anesthesia journal, during that same time period. He was my neuroanesthesia professor at Stanford. I was fortunate enough to spend hundreds of hours with him, learning the craft of anesthesia from a true legend. He loved to teach during the maintenance phase of a surgical case, and always utilized the Socratic method. He’d say, “The intake valve on your anesthesia machine is stuck in the open position. What’s the worst thing that could happen?” Then he’d stare at me while the gears churned in my head, as I searched and searched for the answer to a question I’d never considered. Dr. Larson also taught residents his hands-on method for awake intubation. He’d utilize this technique on all patients scheduled for lumbar disc surgeries: We’d sedate the patient, perform an awake oral fiberoptic intubation, and then have the patient roll themselves over into the prone position while awake, with the endotracheal tube already in their trachea! It was a remarkable technique, and representative of the pearls of wisdom present in this new textbook.

Dr. Jaffe is a Professor of Anesthesia at Stanford, and the lead author of Anesthesiologist’s Manual of Surgical Procedures. Next to Miller’s Anesthesia, the Anesthesiologist’s Manual of Surgical Procedures is the most essential textbook for any anesthesia trainee. At first glance, Jaffe’s first book appears to be a “cookbook” which gives recipes for nearly every anesthetic procedure, but it is much more. The textbook includes both the surgical and the anesthetic details for all common surgical procedures anesthesiologists will face.

Together, Drs. Larson and Jaffe own decades of anesthesia wisdom. The new compilation of their knowledge, Practical Anesthetic Management—The Art of Anesthesiology, is a must-have for the library of every anesthesia teaching program in the world, and is highly recommended for every resident, fellow, and practitioner of the art of anesthesia as well.

May the force, and the art, of anesthesia be with you.

 

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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HOW DO ANESTHETICS WORK?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

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I commonly hear two questions from my patients: “How does anesthesia work?” and “How do the anesthetic drugs make me fall asleep?”

The short answer to both questions is, “We’re not sure.”

This column is designed as a brief tutorial for non-anesthesiologists who wish to better comprehend how anesthetic drugs work.

General anesthesia is the sum of hypnosis (sleep), amnesia, analgesia (pain relief), and the lack of any motion response to pain. Propofol and barbiturates cause hypnosis. Versed and other benzodiazepines cause amnesia. Narcotics such as morphine and fentanyl cause analgesia. Paralyzing drugs such as rocuronium, vecuronium and succinylcholine cause muscle relaxation and lack of motion.

The potent inhaled anesthetics sevoflurane, desflurane, and isoflurane produce all four of the effects of hypnosis, amnesia, analgesia, and lack of motion.

The molecules of anesthetic drugs have great diversity. Some are very small, such as nitrous oxide, while others such as propofol or barbiturates have complex formulas. Some are gases and some are injected liquids. This diversity leads investigators to postulate that there are multiple mechanisms of action for anesthetic drugs on the brain.

Drugs such as propofol and Versed are injected into the bloodstream and are circulated to the central nervous system, where they carry out their effect on brain cells. Inhaled anesthetics such as sevoflurane and desflurane traverse from the lungs into the bloodstream and are circulated to the central nervous system, where they carry out their effect on brain cells.

Once in the brain, it’s not clear how anesthetic drugs work. Most anesthetic drugs are hydrophobic, which literally translates to “water fearing.” This means their molecules are more soluble in fat than in water. Anesthetic drugs exhibit a correlation between their potency and how hydrophobic they are. The entry of any drug into a brain cell must be via the outer lining, or membrane, of that cell. Investigators believe anesthetics must move through, or bind to, the fat-soluble aspects of the membranes of brain cells. The drugs likely then bind to proteins within the cell membranes, and cause their anesthetic effect by changing the characteristics of ion channels within the cell membranes. There is no unifying theory as to how this occurs, but it is known that anesthetic agents have effects on brain cell membrane proteins, which depend on the hydrophobic, electrostatic, and size properties of the individual drug.

Specific examples in our understanding of anesthetic actions include:

(1) Barbiturate drugs, propofol, and inhalational anesthetics are known to act by potentiating a brain chemical called gamma-aminobutyric acid, or GABA. GABA is an inhibitory neurotransmitter, meaning it’s a brain chemical which inhibits other brain activity. This inhibition in some way promotes unconsciousness.

(2) The anesthetics nitrous oxide and ketamine are known to antagonize an excitatory Nmethyl-d-aspartate (NMDA) subtype of neurotransmitter. By blunting this excitatory process, the drugs work to promote unconsciousness.

The takeaway message is that no specific premise exists to explain how all the different general anesthetic drugs work on the brain. A variety of mechanisms likely results in similar effects on the brain, each eliminating the transmission of sensory messages to the brain and initiating unconsciousness.

Anesthesiologists administer other types of drugs, including narcotics, paralyzing drugs, and local anesthetics. The mechanisms of action of these medications are better understood.

fentanyl

Narcotics such as morphine, fentanyl, Demerol, or Dilaudid cause pain relief by binding to opioid receptors in the brain (or the spinal cord). The most common narcotic side effects, e.g. sleepiness and nausea, also arise from the direct effect of the narcotics on the brain. Narcotics bind to three specific receptors in the central nervous system: the mu, delta, and kappa receptors. The mu receptor is primarily responsible for the pain-relieving and euphoria-inducing effects of narcotics. Investigators are searching for new narcotics to specifically target the mu receptor, with the aim of reducing side effects of sedation and nausea.

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Muscle relaxants (muscle paralyzing drugs) such as rocuronium, vecuronium, and succinylcholine act on the body’s peripheral skeletal muscles. Muscles normally contract when a neurotransmitter molecule named acetylcholine travels from a nerve ending and binds to a receptor on the neuromuscular junction on the muscle. This binding causes the muscle to contract. Succinylcholine paralyzes muscles by binding to and activating the acetylcholine receptor, first by causing a muscle contraction and then by rendering the muscle flaccid. Rocuronium and vecuronium paralyze muscles by competitively binding to the receptor and blocking the normal access of acetylcholine, which renders the muscle flaccid.

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Local anesthetic drugs such as lidocaine, bupivicaine (Marcaine), and ropivicaine temporarily block the function of nerves outside the central nervous system. These local anesthetic drugs block the peripheral nerve from conducting of the feeling of pain to the brain. Nerve conduction is dependent on the opening of sodium channels in nerve cell membranes, allowing an influx of sodium ions into the nerve. The blocking of sodium transport renders the nerve incapable of transmitting the pain message.

Modern anesthetic care can involve all the drugs discussed above. For example, in a general anesthetic for an abdominal surgery, the anesthesiologist may inject Versed into the IV as a premedication to reduce anxiety, then inject propofol into the IV to initiate sleep, and inject rocuronium into the IV to induce muscle relaxation/paralysis prior to inserting an endotracheal breathing tube. General anesthesia is then maintained by the administration of a potent inhaled anesthetic gas such as sevoflurane, supplemented by the intravenous injection of a narcotic such as fentanyl to assure post-operative pain relief.

Physician anesthesiologists must master the diverse anesthetic drug repertoire of injectable hypnotics, narcotics, muscle relaxants, as well as the inhaled general anesthetics. The selection of the proper anesthetic drugs and doses for each individual patient makes anesthesiology both fun and fascinating.

Reference:  Mantilla CB, Wong GY, Molecular and cellular mechanisms of anesthesia, Faust’s Anesthesiology Review, Elsevier, 2013, Chapter 60, 139-41.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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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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NEAR MISS COMPLICATIONS IN THE OPERATING ROOM . . . LESSONS LEARNED REGARDING SUGAMMADEX

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

8-2040-01

I’m aware of two cases of residual neuromuscular blockade which occurred during the past year. Both cases involved obese patients who required emergency reintubation. Both cases were near misses for brain death. Both of these near misses would never have occurred if sugammadex was available and if sugammadex had been used.

The first case was a 50-year-old, 120 kilogram male for an endoscopic retrograde cholangiopancreatography (ERCP). The procedure was to be done in the prone position, and required endotracheal intubation. The intubation was easily performed, and was facilitated with 60 mg of rocuronium for paralysis. The patient was turned prone, and the procedure commenced. After only 15 minutes of operating time, the gastroenterologist announced that the procedure was over. Electrical nerve stimulation of the train of four (TOF) at the facial nerve with a Life Tech Mini Stim showed one twitch. The anesthesiologist injected 5 mg of neostigmine and 1 mg of glycopyrrolate IV, and the patient was turned supine. After ten minutes, the TOF nerve stimulation of the facial nerve showed four equal twitches, and the sevoflurane anesthesia was discontinued. The patient was allowed to return to spontaneous breathing, and he opened his eyes. The trachea was extubated. Within the first two minutes, the patient had inadequate strength for spontaneous respiration. On 100% oxygen via mask, his oxygen saturation dropped from 100% to 80%. 120 mg of succinylcholine was injected IV, and an emergency reintubation was performed. The repeat intubation was more difficult than the original intubation, and required two looks before the trachea was visualized. The nadir oxygen saturation was 60%. The patient was kept asleep for thirty additional minutes, until nerve stimulation at the ulnar nerve showed both TOF and sustained tetany without fade. At that point the trachea was extubated. The patient had no brain damage, and he was discharged home ninety minutes later.

The second case was a 45-year-old, 120 kilogram male with obstructive sleep apnea for a uvulopalatopharyngoplasty (UPPP) and tonsillectomy. The endotracheal intubation was easily done, and was facilitated with 70 mg of rocuronium for paralysis. The surgery lasted 60 minutes. The anesthesiologist injected 5 mg of neostigmine and 1 mg of glycopyrrolate IV fifteen minutes prior to the end of surgery. At the conclusion of surgery, electrical nerve stimulation of the facial nerve with a Life Tech Mini Stim showed four equal twitches in the TOF, and the sevoflurane anesthesia was discontinued. The patient was allowed to return to spontaneous breathing, and opened his eyes. The trachea was extubated. Within the first minute, the patient was awake and breathing, but had jerky breathing pattern and was unable to ventilate himself effectively. On 100% oxygen via mask, his oxygen saturation dropped from 100% to 70%. 200 mg of propofol and 120 mg of succinylcholine were injected IV, and an emergency reintubation was performed. The repeat intubation was more difficult than the original intubation because of blood in the mouth and the oral surgery, and required two looks before the trachea was visualized. The nadir oxygen saturation was 49%. The patient was kept asleep for thirty additional minutes until nerve stimulation at the ulnar nerve showed both TOF and sustained tetany without fade. At that point the trachea was extubated. The patient had no brain damage. He was a planned admission to the hospital, and the remainder of his hospital course was uncomplicated.

Several teaching points are warranted:

  1. If succinylcholine been used for the intubations, the large intubating doses of rocuronium would have been avoided, and the inadequate reversal of the rocuronium intubating doses would likely not have occurred.
  2. If smaller doses of rocuronium been used for intubation, the inadequate reversal of the rocuronium intubating doses would likely not have occurred.
  3. These two cases were done prior to sugammadex availability. In the era of sugammadex, beginning now in 2016, these two near misses should never occur. Sugammadex is a modified γ-cyclodextrin which shows a high affinity for rocuronium and vecuronium. Sugammadex forms a tight inclusion complex with either rocuronium or vecuronium, resulting in rapid reversal of neuromuscular blockade. Sugammadex is able to reverse a moderate profound neuromuscular blockade with a dose of 2.0 mg/kg, and a profound neuromuscular blockade with a dose of 4.0 mg/kg.(1) In my experience, these doses of sugammadex completely reverse rocuronium paralysis within 30-40 seconds. Inadequate neuromuscular blockade reversal should never occur in the era of sugammadex. The past practice of administering neostigmine plus glycopyrrolate to reverse neuromuscular blockade, and then waiting up to ten minutes, is an inferior pharmacologic measure when compared to sugammadex. Reversal with neostigmine plus glycopyrrolate is slow, unreliable, and at times incomplete. While it’s true that a 200 mg ampoule of sugammadex costs approximately $100, that sum of money is trivial when compared to the cost of the lawsuit that would have occurred if either of the two case studies above had resulted in brain death due to delayed or unsuccessful reintubation. In my medical-legal consulting practice I see multiple cases of failed or delayed endotracheal intubations that result in brain death and multimillion-dollar closed malpractice claims.
  4. Residual neuromuscular blockade cannot always be reliably excluded by using qualitative monitoring such as a Life Tech MiniStim device to monitor TOF. The TOF is monitored by comparing the amplitude of the fourth (T4) to the first (T1) evoked mechanical response at the facial nerve or the ulnar nerve. The T4/T1 ratio, or the TOF ratio, coincides with symptoms of peripheral muscle weakness.At a TOF ratio less than 0.60, signs of muscle weakness and ptosis are easily observed. When TOF ratios recover to 0.70, the majority of patients are able to sustain head lift and eye opening. A very low TOF ratio between 0.1 and 0.5 is easily detected by a qualitative nerve stimulator. However, TOF ratios between 0.5 and 1.0 can be difficult to discern visually. Many clinicians are unable to detect fade when TOF ratios exceed 0.30 to 0.4.(1) Qualitative neuromuscular monitoring of the facial nerve twitch can be deceiving. Applying the peripheral nerve stimulator to the ulnar nerve at the adductor pollicis is the gold standard, and this site must be used for the pre-reversal assessment even when the ulnar nerve and thumb are not accessible intraoperatively. Recovery from neuromuscular paralysis should be present when a TOF count without fade has been confirmed at the adductor pollicis.(2) In a partially paralyzed patient, a visually undetectable fade of the TOF at the facial nerve may coincide with a visually detectable fade in TOF when the ulnar nerve is tested. When a patient’s arms are tucked during surgery, or when the ulnar nerve area is distant from the anesthesiologist’s location, it may be impossible to test ulnar nerve stimulation intraoperatively. Prior to extubation, when the ulnar nerve is accessible, ulnar nerve stimulation will convey a more accurate assay of the level of neuromuscular reversal.
  5. Immediate reversal of neuromuscular blockade induced by rocuronium is possible with a larger dose of sugammadex of 16 mg/kg. To facilitate intubation, a dose of succinylcholine (1 mg/kg) will cause a neuromuscular blockade of 4 – 5 minutes in duration. If an airway is found to be difficult or if the intubation is found to be impossible, the anesthesiologist has no way to return the patient to spontaneous breathing until these 4 – 5 minutes elapse. To facilitate intubation, a dose of rocuronium (0.5 – 1 mg/kg), if immediately reversed by sugammadex 16 mg/kg, will cause a shorter duration of paralysis than if succinylcholine were used. It remains to be seen whether this fact will lead to increased use of rocuronium rather than succinylcholine in difficult endotracheal intubations in which a potential early return to spontaneous ventilation is deemed prudent.

 

Healthcare systems are likely to promote selective or infrequent utilization of the new neuromuscular paralysis antidote sugammadex because of its cost. For your practice, and for mine, use the drug when you need it. You’re not personally paying the $100 price for the dose of sugammadex. If you have a serious patient complication because of inadequate neuromuscular reversal by the old drug neostigmine, the adverse patient outcome and the resulting lawsuit may cost you a whole lot more than that $100.

For the record, I have no financial interest or investment in sugammadex. I just know a good product when I see one.

References:

  1. Murphy GS et al, Reversal (Antagonism) of Neuromuscular Blockade, Chapter 35, Miller’s Anesthesia, 8th Edition, 2015.
  2. Thilen SR, Qualitative Neuromuscular Monitoring: How to Optimize the Use of a Peripheral Nerve Stimulator to Reduce the Risk of Residual Neuromuscular Blockade, Curr Anesthesiol Rep. 2016;6:164-169.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

 

AN ANESTHESIOLOGIST’S SALARY

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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How much money does an anesthesiologist earn?

Let me begin by offering two anecdotes:

  • I was an invited visiting anesthesia professor at a major university this year, and following one of my lectures an anesthesiology resident approached me for a discussion. During our conversation he revealed that his student loan debt was $300,000. In 2014 the published average student loan debt for a physician was $183,000. I believe a higher estimate is not unusual, particularly if the student doctor attended private medical school and/or college.
  • I recently received an email from a medical student who was considering anesthesia as a career specialty, but his concern was: is the bottom about to fall out for anesthesiologists’ salaries? Should he perhaps avoid a career in anesthesiology?

Each anecdote concerns the issue of how much anesthesiologists earn, and what will that number be in the future?

The good news for the future of anesthesia careers is that the number of surgeries in the United States is expected at increase as the Baby Boomers age. The demand for anesthesia services will grow. Who will provide these services, and what will they be paid?

How much money do anesthesiologists currently make?

It depends.

If you do a Google search on this question, most of the published answers vary from $275,000 to $360,000 per year.

This sounds like a lot of money, but recall that to reach that salary, an anesthesiologist must finish 4 years of medical school and a 4-year anesthesia residency. At a minimum these young anesthesiologists are 30 years old. The deferred gratification is significant. Had they gone to work after college at age 22 and been promoted in a business job for 8 years, that individual might own a home, be saving for their children’s college educations, and would not have the debt from 4 years of medical school.

Let’s assume an individual does persevere and finish their anesthesia residency at age 30, and is now seeking an anesthesia job with that aforementioned average salary of $275,000 to $360,000 per year.

The first question: is that advertised salary a number prior to deductions for the big three of pension plan, health insurance, and malpractice insurance? If an anesthesiologist earns $300,000 per year, but must subtract these three expenses (let’s estimate pension plan at $45,000, health insurance at $24,000, and malpractice insurance at $20,000) then the income drops to $300,000 minus $89,000 = $211,000 per year, or $17,583 per month before taxes. Subtract again for student loan payments, and the income level continues to decrease. So a critical first question to ask is if the big three benefits are/are not part of the promised salary.

What specific factors determine how high the anesthesiologist’s salary will be? An operating room anesthesia practice is somewhat akin to being a taxi cab driver. You earn income for each ride/anesthetic, and your income depends on how many rides/anesthetics and how long they last. More complex anesthetics such as cardiac cases pay more, but the largest determiner is the duration of time one spends giving the anesthesia care. If you work in a physician anesthesiology practice where an MD stays with each surgical patient 100% of the time, then the only way to increase income is to do more cases or more hours. If you work in a practice which utilizes an anesthesia care team, where one physician anesthesiologist may supervise, for example, 4 Certified Registered Nurse Anesthetists (CRNAs), then a physician’s income is increased because he or she is billing for and supervising care for multiple concurrent surgeries.

Different payers pay different sums per unit time. The top payers are insured patients of less than Medicare age (<65 years old). Among the lowest payers are uninsured patients (who often pay zero), Medicaid and Medicare patients, and Worker’s Compensation patients. Medicare patients routinely pay only 13-20 cents on the billed dollar, and Medicaid pays even lower, so a practice heavy with Medicare and Medicaid patients will compensate their anesthesiologists poorly. Insurance companies (i.e. Blue Cross, Blue Shield, Aetna, United Healthcare) pay whatever rate they have contracted with that anesthesia group. If a particular insurance company pays a low rate, an anesthesia group may refuse to sign a contract with that insurance company. This leaves the anesthesiologist out-of-network with that company, which can mean a higher payment or co-payment for the patient as a result of the insurance company’s refusal to negotiate a fair reimbursement.

Just as taxi cab drivers are being supplanted by Uber and Lyft, cheaper models of anesthesia care are popping up, and the penetration of these models into the future marketplace is unknown. One model is having a CRNA do the anesthetic independently without any physician anesthesiologist present. This is currently legal in 27 states (see map). At the current time, in my home state of California, independent CRNA practice is legal, but the penetration of this model in the marketplace is very minimal. The Veterans Affairs hospitals are currently pondering a move to allow CRNAs to practice independently without any physician anesthesiologist present. You can expect to see a higher penetration of the anesthesia care team, where one physician anesthesiologist may supervise, for example, 4 CRNAs, and a decrease in practices where an MD anesthesiologist stays with each patient 100% of the time.

To be blunt, my impression is that the future marketplace is unlikely to pay for a physician anesthesiologist to do solo anesthesia care for each and every surgical patient.

In the current marketplace a young graduate anesthesiologist may enter one of several different models of anesthesia practices. Each has a different level of salary expectation. The various models are listed below, in roughly a higher-income-per-anesthesiologist to lower-income-per-anesthesiologist order:

  1. A single-specialty anesthesia group that shares income fairly. This group may be as small as 5 or as large as hundreds of physician anesthesiologists, with or without additional CRNAs. Such a group usually has an exclusive contract with a hospital or hospitals to provide all anesthesia services, which can include trauma, obstetrics, and 24-hour emergency room coverage. A very large single-specialty anesthesia group may contract with many hospitals in a geographic area. In a single-specialty model, that single-specialty group receives all the anesthesia billings, and the income is divided, usually in some form of “eat-what-you-provided” formula. Those MDs who worked the most receive a proportional increase in their income. A new MD may have a one-year try-out before they become a partner, after which they are entitled to an equal income per unit time. This model where anesthesiologists are partners, is typically more lucrative than models where the anesthesiologists are employed by another entity. A survey by Medscape on anesthesiologists’ salaries in 2016 showed that male self-employed anesthesiologists (model #1) earned an average income of $413,000, while male anesthesiologist employees (see models #2 – #8 below) earned an average income of $336,000.
  2. A single-specialty anesthesia group in which a chairman (or a small oligopoly of MDs) collect the money, and then employ and grant a salary to everyone below them in the company. New hires are paid less, often with no potential to increase their income. This type of system preys on junior anesthesiologists.
  3. A multispecialty medical group. A multispecialty medical group has a bevy of primary care physicians who refer internally to their specialist surgeons, who then utilize their internal group of anesthesiologists. This is a secure job for anesthesiologists because the stream of cases is guaranteed by the physicians within their multispecialty group. A disadvantage is that incomes from lower paying specialties (primary care MDs) and higher paying specialties (i.e. cardiologists, surgeons, and anesthesiologists) are pooled. The lower paying specialists usually have their salaries raised, and the anesthesiologists will be subsidizing them.
  4. An HMO. In California the Health Maintenance Organization (HMO) Kaiser Permanente has a large share of the marketplace. The entity known as the Permanente Medical Group is the multispecialty integrated medical group which works at the Kaiser hospitals and clinics. The reimbursement model will be similar to that described in #3 above.
  5. University anesthesia groups. A university employs MDs as a multispecialty medical group, and the model is similar to #3 above. A difference is that university groups have various taxes and fees on their income that go to the betterment and growth of the medical school and the university hospital system. In addition, some university hospitals provide care to indigent populations that may have higher percentage of poor payers such as Medicaid or uninsured patients.
  6. National anesthesia companies. In this model, a national company obtains the anesthesia contract for a hospital or multiple facilities, and then that national company hires and employs anesthesiologists. The company bills for the anesthesia services provided, pays their employee anesthesiologists whatever sum they’ve agreed to pay them, and the difference between the received monies and the owed salaries is profit that goes to stockholders of the national company. This model is problematic for our specialty, because a percentage of the anesthesia fees goes to stockholders who had zero to do with performing the professional service.
  7. Veteran’s Affairs (VA) hospital anesthesia groups. At the present time, VA hospitals are staffed by anesthesiologists who are employees of the VA system. As mentioned above, there are politicians pushing for the VA to allow CRNAs to practice independently, unsupervised by physician anesthesiologists. The American Society of Anesthesiologists is opposed to this change, believing that our veterans deserve physician anesthesiologists.
  8. Locum tenens assignments. These are part-time, week-long, or month-long anesthesia duties, paid for at a daily rate. A typical fee for a full day’s work may be a pre-tax payment of $1200/day (not including the big three of pension, health or malpractice insurance).

As stated above, the good news for the future of anesthesia careers is that the number of surgeries in the United States is expected at increase as the Baby Boomers age. The demand for anesthesia services will grow. The unknown fiscal factors for the future of our specialty are:

  1. What will insurers/Medicare/Medicaid/the Affordable Care Act pay for these anesthesia services? Will a single payer government health plan ever arrive, and if it does what will anesthesiologists be paid?
  2. Who will be giving these services? Physician anesthesiologists, anesthesia care teams involving physician anesthesiologists plus CRNAs, anesthesia care teams involving physician anesthesiologists plus Anesthesia Assistants, or independent CRNAs?
  3. The American Society of Anesthesiologists is attempting to rebrand the practice of anesthesiology with the concept of the Perioperative Surgical Home (PSH), in which physician anesthesiologists are responsible for all aspects of preoperative, intraoperative, and postoperative medical care for patients around the time of surgery. This expanded role includes preoperative clinics and postoperative pain control and medical management. To what degree can/will the PSH change the job market for graduating anesthesiologists?

In any case, as I wrote on the Home Page of theanesthesiaconsultant.com website, “the profession of medicine offers a lifetime of fascination, and no specialty is more fascinating than anesthesiology.” If a college student or a medical student is truly interested in a career in anesthesia, I remain encouraging to them, regardless of these uncertainties regarding the future.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Check out . . . THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

 

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

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DENTAL ANESTHESIA DEATHS . . . GENERAL ANESTHESIA FOR PEDIATRIC PATIENTS IN DENTAL OFFICES

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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GENERAL ANESTHESIA FOR PEDIATRIC PATIENTS IN DENTAL OFFICES

 

CASE PRESENTATION:

A 5-year-old developmentally delayed autistic boy has multiple dental cavities. The dentist consults you, a physician anesthesiologist, to do sedation or anesthesia for dental restoration. What do you do?

DISCUSSION:

Children periodically die in dental offices due to complications of general anesthesia or intravenous sedation. Links to recent reports include the following:

3-year-old girl dies in San Ramon, CA after a dental procedure in July 2016.

A 14-month-old child, scheduled to have 2 cavities filled, dies in an Austin, TX dental office. The dentist and an anesthesiologist were both present.

A 6-year-old boy, scheduled to have teeth capped at a dental clinic, has anesthesia and dies after the breathing tube is removed.

Another 6-year-old boy, scheduled to have a tooth extracted by an oral surgeon, dies after the oral surgeon administers general anesthesia.

Pediatric dentists use a variety of tactics to keep a typical child calm during dental care. The child is encouraged to view a movie or cartoon while the dental hygienist or dentist works. The parent or parents are encouraged to sit alongside their child to provide emotional support. If a typical child requires a filling for a cavity, the dentist can utilize nitrous oxide via a nasal mask with or without local anesthesia inside the mouth.

These simple methods are not effective if the child has a developmental delay, autism, behavioral problems, or if the child is very young. Such cases sometimes present to a pediatric hospital for anesthetic care, but at times the child will be treated in a dental office. Possible anesthesia professionals include a physician anesthesiologist, a dental anesthesiologist, or an oral surgeon (who is trained in both surgery and anesthesia).

 

HOW WOULD A PHYSICIAN ANESTHESIOLOGIST ANESTHETIZE A CHILD IN A DENTAL OFFICE?

There are a variety of techniques an anesthesiologist might use to sedate or anesthetize a young child. The correct choice is usually the simplest technique that works. Alternative methods include intramuscular sedation, intravenous sedation, or potent inhaled anesthetics.

 

ANESTHESIA INDUCTION:

The first decision is how to begin the anesthetic on an uncooperative child. Options for anesthesia induction include:

  1. Intramuscular sedation. A typical recipe is the combination of 2 mg/kg of ketamine, 0.2 mg of midazolam, and .02 mg/kg of atropine. These three medications are drawn up in a single syringe and injected into either the deltoid muscle at the shoulder or into the muscle of the anterior thigh. Ketamine is a general anesthetic drug that induces unconsciousness and relieves pain. Midazolam is a benzodiazepine which induces sleepiness and decreases anxiety. Ketamine can cause intense dreams which may be frightening. Midazolam is given because it minimizes ketamine dreams. Atropine offsets the increased oral secretions induced by ketamine. Within minutes after the injection of these three drugs, the child will become sleepy and unresponsive, and the anesthesiologist can take the child from the parent’s arms and bring the patient into the operating room. Most anesthesiologists will insert an intravenous catheter into the patient’s arm at this point, so any further doses of ketamine, midazolam, or propofol can be administered through the IV.
  2. Oral sedation with a dose of 0.5-0.75 mg/kg of oral midazolam syrup (maximum dose 20 mg). If the child will tolerate drinking the oral medication, the child will become sleepy within 15- 20 minutes. At this point, the anesthesiologist can take the patient away from the parent and proceed into the operating room, where either an intravenous anesthetic or an inhaled sevoflurane anesthetic can be initiated.

 

MONITORING THE PATIENT:

  1. The patient should have all the same monitors an anesthesiologist would use in a hospital or a surgery center. This includes a pulse oximeter, an ECG, a blood pressure cuff, a monitor of the exhaled end-tidal carbon dioxide, and the ability to monitor temperature.
  2. The anesthesiologist is the main monitor. He or she will be vigilant to all vital signs, and to the Airway-Breathing-Circulation of the patient.

 

MAINTENANCE OF ANESTHESIA:

  1. Regardless of which anesthetic regimen is used, oxygen will be administered. Room air includes only 21% oxygen. The anesthesiologist will administer 30-50% oxygen or more as needed to keep the patient’s oxygen saturation >90%.
  2. Intravenous sedation: This may include any combination of IV midazolam, ketamine, propofol, or a narcotic such as fentanyl.
  3. Local blocks by the dentist. The dentist may inject local anesthesia at the base of the involved tooth, near the superior alveolar nerve to block all sensation to the upper teeth, or near the inferior alveolar nerve to anesthetize all sensation to the lower jaw.
  4. Inhaled nitrous oxide. The simplest inhaled agent is nitrous oxide, which is inexpensive and rapid acting. Used alone, nitrous oxide is not potent enough to make a patient fall asleep. Nitrous oxide can be used as an adjunct to any of the other anesthetic drugs listed in this column.
  5. Potent inhalation anesthesia (sevoflurane). Most dental offices will not have a machine to administer sevoflurane. (Every hospital operating room has an anesthesia machine which delivers sevoflurane vapor.) Portable anesthesia machines fitted with a sevoflurane vaporizer are available. A colleague of mine who worked full time as a roving physician anesthesiologist to multiple pediatric dental offices leased such a machine and used it for years. The advantages of sevoflurane are: i) few intravenous drugs will be necessary if the anesthesiologist uses sevo, and ii) the onset and offset of sevo is very fast—as fast as nitrous oxide. The administration of sevoflurane usually requires the use of a breathing tube, inserted into the patient’s windpipe.
  6. The anesthesiologist will be present during the entire anesthetic, and will not leave.

 

AWAKENING FROM ANESTHESIA:

  1. With intramuscular and/or intravenous drugs, the wake-up is dependent on the time it takes for the administered drugs to wear off or redistribute out of the blood stream. This may take 30-60 minutes or more following the conclusion of the anesthetic.
  2. With inhaled agents such as sevoflurane and nitrous oxide, the wake-up is dependent on the patient exhaling the anesthetic gas. The majority of the inhaled anesthetic effect is gone within 20-30 minutes after the anesthetic is discontinued.
  3. The patient must be observed and monitored until he or she is alert enough to be discharged from the medical facility. This can be challenging if a series of patients are to be anesthetized in a dentist’s office. The medical staff must monitor the post-operative patient and also attend to the next patient’s anesthetic care. It’s imperative that the earlier patient is awake before the anesthesiologist turns his full attention to the next patient.

 

THE ANESTHETIC FOR OUR CASE PRESENTATION ABOVE:

  1. The anesthesiologist meets the parents and the patient, and explains the anesthetic options and procedures to the parent. The parent then consents.
  2. The anesthesiologist prepares the dental operating room with all the necessary equipment in the mnemonic M-A-I-D-S, which stands for Monitors and Machine, Airway equipment, Intravenous line, Drugs, and Suction.
  3. The anesthesiologist injects the syringe of ketamine, midazolam, and atropine into the child’s deltoid muscle. The child becomes sleepy and limp within one minute, and the anesthesiologist carries the child into the operating room.
  4. All the vital sign monitors are placed, and oxygen is administered via a nasal cannula.
  5. An IV is started in the patient’s arm.
  6. The dentist begins the surgery. He or she may inject local anesthesia as needed to block pain.
  7. Additional IV sedation is administered with propofol, ketamine, midazolam, or fentanyl as deemed necessary.
  8. When the surgery is nearing conclusion, the anesthesiologist will stop the administration of any further anesthesia. When the surgery ends, the anesthesiologist remains with the patient until the patient is awake. The patient may be taken to a separate recovery room, but that second room must have an oxygen saturation monitor and a health care professional to monitor the patient until discharge.

CHALLENGES OF DENTAL OFFICE ANESTHESIA:

  1. You’re do all the anesthesia work alone. If you have an airway problem or an acute emergency, you’ll have no other anesthesia professional to assist you. Your only helpers are the dentist and the dental assistant.
  2. The cases are difficult, otherwise you wouldn’t be there at all. Every one of the patients will have some challenging medical issue(s).
  3. You have no preop clinic, so you don’t know what you’re getting into until you meet the patient. I’d recommend you telephone the parents the evening before, so you can glean the past medical and surgical histories, and so you can explain the anesthetic procedure. Nonetheless, you can’t evaluate an airway over the phone, and on the day of surgery you may encounter more challenge than you are willing to undertake.
  4. It’s OK to cancel a case and recommend it be done in a hospital setting if you aren’t comfortable proceeding.
  5. The anesthesiologist usually has to bring his or her own drugs. The narcotics and controlled substances need to be purchased and accounted for by the anesthesiologist with strict narcotic logs to prove no narcotics are being diverted for personal use. All emergency resuscitation drugs need to be on site in the dental office or brought in by the anesthesiologist.
  6. If a sevoflurane vaporizer is utilized, dantrolene treatment for Malignant Hyperthermia must be immediately available.

 

BENEFITS OF DENTAL OFFICE SEDATION AND GENERAL ANESTHESIA:

  1. The parents of the patients are grateful. The parents know how difficult dental care on their awake child has been, and they’re thankful to have the procedures facilitated in a dental office.
  2. The dentist and their staff are grateful. They don’t have a method to safely sedate such patients, and are thankful that you do.
  3. Most cases are not paid for by health insurance, rather they are cash pay in advance.

 

HOW SAFE IS ANESTHESIA AND SEDATION IN A DENTAL OFFICE?

No database can answer the question at present. In 2013 the journal Paediatric Anesthesia published a paper entitled Trends in death associated with pediatric dental sedation and general anesthesia. (1) The paper reported on children who had died in the United States following receiving anesthesia for a dental procedure between1980-2011. Most deaths occurred among 2-5 year-olds, in an office setting, and with a general or pediatric dentist (not a physician anesthesiologist or dental anesthesiologist) as the anesthesia provider. In this latter group, 17 of 25 deaths were linked with a sedation anesthetic.

Another study analyzed closed claims databases of 17 malpractice claims of adverse anesthesia events in pediatric patients in dental offices from 1992 – 2007. (2) Thirteen cases involved sedation, 3 involved local anesthesia alone, and 1 involved general anesthesia. 53% of the claims involved patient death or permanent brain damage. In these claims the average patient age was 3.6 years. Six cases involved general dentists as the anesthesia provider, and 2 involved local anesthesia alone. The adverse event occurred in the dental office in 71% of the claims. Of the 13 claims involving sedation, only 1 claim involved the use of vital sign monitoring. The study concluded that very young patients (≤ 3-years-old) were at greatest risk during administration of sedative and/or local anesthetic agents. The study concluded that some practitioners were inadequately monitoring patients during sedation procedures. Adverse events had a high chance of occurring at the dental office where care is being provided.

If general anesthesia or deep sedation are performed in a dental office, the anesthetist must practice with the same vigilance and standards of care as they would in a hospital or surgery center. Either a physician anesthesiologist, an oral surgeon (acting as both the dental surgeon and the anesthetist), or a dental anesthesiologist may perform the anesthesia. There are no data at this time to affirm that a physician anesthesiologist is the safest practitioner in this setting.

Note: This column addressed the office practice of pediatric dental anesthesia as seen from a physician anesthesiologist’s point of view.

References:

(1) Lee HH et al, Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-6.

(2) Chicka MC et al, Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent.2012 May-Jun;34(3):231-8.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

 

WHAT’S NEW UNDER THE ANESTHESIA SUN? LETTER GRADES FOR 13 MAJOR CHANGES IN THE LAST TEN YEARS OF OUR PROFESSION

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

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SUGAMMADEX – The long awaited reversal agent for neuromuscular paralysis reached the market in 2016, and by my review, the drug is wonderful. I’ve found sugammadex to reverse rocuronium paralysis in less than a minute in every patient who has at least one twitch from a nerve stimulator. The dose is expensive at about $100 per patient, but at this time that’s cheaper than the acquisition costs for neostigmine + glycopyrrolate. The acquisition cost of neostigmine + glycopyrrolate at our facilities exceeds $100, and this combination of drugs can take up to 9 minutes to reverse rocuronium paralysis. Sugammadex reversal can make the duration of a rocuronium motor block almost as short acting as a succinylcholine motor block, and sugammadex can also eliminate complications in the Post Anesthesia Care Unit due to residual postoperative muscle paralysis. Grade = A.

 

SHORTAGES OF GENERIC INTRAVENOUS DRUGS – Over the last five years we’ve seen unexpected shortages of fentanyl, morphine, propofol, ephedrine, neostigmine, glycopyrrolate, meperidine, and atropine, to name a few. These are generic drugs that formerly cost pennies per ampoule. In the current marketplace, generic manufacturers have limited the supplies and elevated the prices of these medications to exorbitant levels. I wish I’d had the foresight and the money ten years ago to invest in a factory that produced generic anesthetic drugs. Grade = F.

 

THE PERIOPERATIVE SURGICAL HOME – The American Society of Anesthesiologists has been pushing this excellent concept for years now—the idea being that a team of physician anesthesiologists will manage all perioperative medical care from preoperative clinic assessment through discharge, including intraoperative care, postoperative care and pain management in the PACU, the ICU, and the hospital wards. The goal is improved patient care with decreased costs. It’s not clear the idea has widespread traction as of yet, and the concept will always be at odds with the individual aspirations of internal medicine doctors, hospitalists, intensivists, surgeons, and certified nurse anesthetists, all who want to make their own management decisions, and all who desire to be paid for owning those decisions. Grade = B-.

 

MULTIMODAL PAIN MANAGEMENT FOLLOWING TOTAL JOINT REPLACEMENTS – The development of pain management protocols which include neuroaxial blocks, regional anesthetic blocks, local anesthetic infiltration by surgeons, oral and intravenous pain medications, have advanced the science of pain relief for total knee and total hip replacements. The cooperation between surgeons, anesthesiologists, and internal medicine specialists to develop the protocols has been outstanding, the standardized checklist care has been well accepted, and patients are benefiting. Grade = A.

 

ULTRASOUND GUIDED REGIONAL ANESTHESIA – Regional anesthetic blocks are not new, but visualizing the nerves via ultrasound is. The practice is becoming widespread, and the analysis of economic and quality data is ongoing. Ultrasound guided regional anesthesia is a major advance for painful orthopedic surgeries, but I worry about overuse of the technique on smaller cases for the economic benefit of the physician wielding the ultrasound probe. A second concern is the additive risk of administrating two anesthetics (regional plus general) to one patient. I’ve reviewed medical records of patients with adverse outcomes related to regional blocks, and I’m concerned ultrasound guided regional anesthesia may be creating a new paradigm of postoperative complications, e.g. prolonged nerve damage or intravascular injection of local anesthetics. In the future I look forward to seeing years of closed claims data regarding this increasing use of regional anesthesia. Grade = B.

 

VIDEOLARYNGOSCOPY – The invention of the GlideScope and its competitors the C-MAC, King Vision, McGrath and Airtraq videolaryngoscopes was a major advance in our ability to intubate patients with difficult airways. My need for fiberoptic intubation has plummeted since videolaryngoscopy became available. I’d recommend that everyone who attempts traditional laryngoscopy for endotracheal intubation have access to a video scope as a backup, should traditional intubation prove difficult. Grade = A.

 

ANESTHESIOLOGIST ASSISTANTS (AAs) – The American Society of Anesthesiologists is championing the idea of training AAs to work with physician anesthesiologists in an anesthesia care team model. A primary reason is to combat the influence and rise in numbers of Certified Registered Nurse Anesthetists (CRNAs) by inserting AAs as a substitute. Not a bad idea, but like the Perioperative Surgical Home, the concept of AAs is gaining traction slowly, and the penetration of AAs into the marketplace is minimal. To date there are only ten accredited AA education programs in the United States. Grade = B-.

 

CHECKLISTS – We now have pre-incision Time Outs, pre-induction Anesthesia Time Outs, and pre-regional anesthesia Block Time Outs. It’s hard to argue with these checklists. Even if 99.9% of the Time Outs change nothing, if 0.1% of the Time Outs identify a miscommunication or a laterality mistake, they are worth it. Grade = A.

 

ANESTHESIA ELECTRONIC MEDICAL RECORDS (EMRs)– The idea is sound. Everything in the modern world is digitalized, so why not medical records? The problem is the current product. There are multiple EMR systems, and the systems cannot communicate with each other. Can you imagine a telephone system where Sprint phones cannot communicate with AT&T phones? The current market leader for hospitals is Epic, a ponderous, expensive system that does little to make the pertinent information easier to find in medical charts. For acute care medicine such as anesthetic emergencies, the medical charting and documentation in Epic gets in the way of hands-on anesthesia care. In the past, when I administered 50 mg of rocuronium, I simply wrote “50” in the appropriate space on a piece of paper. In Epic I have to make at least 4 mouse clicks to do the same thing. This Epic entry cannot be made on a touch screen because the first rocuronium window on the touch screen is a three-millimeter-tall box, too small for a finger touch. I’d like to see Apple or Google develop better EMR software than we have at present. Perhaps the eventual winning product will be voice activated or will involve easy touch screen data entry and data access. And all EMR systems should interact with each other, so patient privacy medical information can be portable. Grade = C-.

 

THE ECONOMICS OF ANESTHESIA – When I began in private practice in 1986, most successful anesthesiologists joined a single-specialty anesthesia group. This group would cover a hospital or several hospitals along with nearby surgery centers and offices. The group would bill for physician services, and insurance companies would reimburse them. Each physician joining the group would endure a one or two-year tryout period, after which he or she became a partner. Incomes were proportional to the number of cases an individual attended to. The models are changing. Smaller anesthesia groups are merging into larger groups, better equipped to negotiate with healthcare insurers and ObamaCare. More and more healthcare systems are employing their own anesthesiologists. In a healthcare system, profits are pooled and shared amongst the varying specialists. This model is not objectionable. Anesthesiologists share the profits with less lucrative specialties such as internal medicine and pediatrics, but the anesthesiologists are assured a steady flow of patients from the primary care physicians and surgeons within the system. The end result is less income than in a single-specialty anesthesia group, but more security. Grade = B.

 

THE SPECTER OF A BAN ON BALANCE BILLING – In a perfect world all physician groups would be contracted with all health insurance companies, at a monetary rate acceptable to both sides. Unfortunately there are insurance company-physician group rifts in which an acceptable rate is not negotiated. In these instances, the physician provider for a given patient may be out of network with the patient’s insurer, not because of provider greed (as portrayed by some politicians and insurers) but because the insurance company did not offer a reasonable contracted rate. Some politicians believe physician out-of-network balance billing should be outlawed. This would give unilateral power to insurance companies. Why would an insurance company offer a reasonable rate to a physician provider group, if the insurance company can pay the physicians a low rate and the new law says the physicians have no alternative but to accept it as payment in full? The no-balance-billing politicians will portray patients as victims, but if they succeed in changing the laws, physicians will become victims. Physicians as well as consumers must unite to defeat this concept. Grade = F.

 

CORPORATE ANESTHESIA – National companies are buying multiple existing anesthesia groups and changing the template of our profession in America. The current physician owners of a practice can sell their group to a publically traded national company for a large upfront payoff. The future salaries of anesthesiologists of that group are then decreased, and the rest of the profit formerly garnered by the physicians goes instead to the bottom line of the national company’s shareholders. If this model becomes widespread, the profession of anesthesiology will morph into a job populated by moderately reimbursed employees. Grade = D.

 

INDEPENDENT PRACTICE FOR CRNAs – Anesthesiology is the practice of medicine. In a two-year training program, an ICU nurse can learn to administer propofol and sevoflurane, and how to intubate most patients, and become a CRNA. It takes a physician anesthesiologist to manage complex preoperative medical problems, intraoperative complications, and postoperative medical complications. I understand rural states such as Montana and the Dakotas cannot recruit enough physician anesthesiologists to hospitals in their smallest towns, but for states like California to legalize independent anesthesia practice for CRNAs is unconscionable. Grade = D.

 

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

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

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ANESTHESIA ERRORS AND COMPLICATIONS: MALPRACTICE OR NOT?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

medical-malpractice-anesthesia-errors-1-638

 

If a patient suffers a bad outcome after anesthesia, did the anesthesiologist commit malpractice?

Not necessarily. There are risks to every anesthetic and every surgery, and if a patient sustains a complication, it may or may not be secondary to substandard anesthesia care.

Let’s look at the most common reasons for anesthesia malpractice claims. In a study by Ranum,(1) researchers examined a total of 607 closed claims from a single national malpractice insurance company over five years between 2007 and 2012. The most frequent anesthesia-related injuries reported were:

  1.   Teeth damage — 20.8 percent of the anesthesia medical malpractice claims
  2.   Death — 18.3 percent
  3.   Nerve damage — 13.5 percent
  4.   Organ damage — 12.7 percent
  5.   Pain — 10.9 percent
  6.   Cardiopulmonary arrest — 10.7 percent

When the minor claims for teeth damage are omitted, claims for death and cardiopulmonary arrest account for nearly one in four closed claims for anesthesiologists. This shows the severe nature of anesthesia bad outcomes.

How can we discern whether a bad patient outcome is a risk for a malpractice claim?

There are four elements to a medical malpractice claim. They are as follows (2):

  1. Duty to care for the patient. The anesthesiologist must have made a contract to care for the patient. The anesthesiologist meets the patient, takes a history, reviews the chart, does a pertinent physical exam, and discusses the options for anesthetic care. The anesthesiologist then obtains informed consent from the patient to carry out that plan, and the duty to care for the patient is established.
  2. Negligence occurs if the anesthesiologist failed in his or her duty to care, that is, he or she performed below the standard of care. The standard of care is defined as the level of care expected from a reasonably competent anesthesiologist. If a lawsuit is eventually filed, anesthesiology expert witnesses will testify for both the defense and the plaintiff as to what the standard of care was for this case. If the defendant anesthesiologist performed below the standard of care, they are vulnerable to losing the lawsuit.
  3. The plaintiff must prove the negligence was a proximate cause of the injury to the patient. If a lawsuit is eventually filed, expert witnesses will argue how and why the negligence was linked or was not linked to the adverse outcome.
  4. The injury or loss can be measured in monetary compensation to the plaintiff.

Let’s look at two fictional case studies to demonstrate how a bad outcome may or may not be related to anesthesia malpractice:

CASE ONE: A 70-year-old man is scheduled to have laparoscopic abdominal surgery for a partial colectomy to remove a cancer in his large intestine. Prior to his surgery he has a complete history and physical by his internal medicine doctor, and the results of that workup are in the medical chart. The patient medical history is positive for hypertension, hyperlipidemia, and obesity. His Body Mass Index, or BMI, is elevated at 32. His blood pressure is 140/85, and his physical exam is otherwise unremarkable. Prior to the surgery, the anesthesiologist requests clearance from a cardiologist. The cardiologist performs an exercise stress echocardiogram, which is read as normal. The anesthesiologist plans a general anesthetic, and obtains informed consent from the patient. During the informed consent, the anesthesiologist tells the patient that risks involving the heart, the lungs, or the brain are small but not zero. The patient accepts these risks.

The surgery and anesthesia proceed uneventfully. The patient is awakened from general anesthesia and taken to the Post Anesthesia Care Unit. The patient is drowsy and responsive, with a blood pressure of 100/60, a heart rate of 95, a respiratory rate of 16, a temperature of 36.0 Centigrade, and an oxygen saturation of 96% on a face mask delivering 50% oxygen. A Bair Hugger blanket is applied to warm the patient, and morphine sulfate 2 mg IV is given for complaint of abdominal pain.

Thirty minutes later, the patient develops acute shortness of breath, and his oxygen saturation drops to 75%. The anesthesiologist sees him and evaluates him. The cause of the shortness of breath and drop in oxygen level are unclear. The concentration of administered oxygen is increased to 100%, but the patient acutely becomes unresponsive. The anesthesiologist intubates the patient’s trachea, and begins ventilating him through the breathing tube. The patient is still unresponsive and has a cardiac arrest. Despite all Advanced Cardiac Life Support treatments, the patient dies.

An expert witness later reviews the chart, and finds the anesthesia management to be within the standard of care prior to, during, and after the surgery. There was no negligence that caused the cardiac arrest. Why did the patient die? The post-mortem exam, or autopsy, in a case like this could show a pulmonary embolism or a myocardial infarction, either of which can occur despite excellent anesthesia care. The patient was elderly, overweight, and hypertensive. Abdominal surgery and general anesthesia in this patient population are not without risk, even with optimal anesthetic care.

CASE TWO: A 55-year old female is scheduled for a facelift at a freestanding plastic surgery center operating room. Her history and physical examination are normal except that she is 5 feet tall and weighs 200 pounds, for a BMI=39. The anesthesiologist plans a general anesthetic, and obtains informed consent from the patient. After the induction of general anesthesia with propofol and rocuronium, the anesthesiologist is unable to place the endotracheal tube in the patient’s windpipe. He tries repeatedly in vain, and during this time the woman’s oxygen saturation drops to dangerous levels below 70%, and remains low for over five minutes. He eventually places the tube successfully. The surgery is cancelled, and the woman fails to wake up. She is transferred to a local hospital and admitted to the intensive care unit. A neurologic workup confirms that she has anoxic brain damage, or brain death.

This is a case where an overweight but otherwise healthy woman walked into a surgery center for an elective surgery, and emerged brain dead. Per the donor card in the patient’s wallet, the family agreed to donate the patient’s organs. Was this outcome due to malpractice? Yes. The anesthesiologist performed below the standard of care, because he failed to keep the patient oxygenated during the multiple attempts to place the breathing tube. An expert witness for the plaintiff testifies that a reasonably competent anesthesiologist would understand and follow the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm, and use alternate techniques to keep the patient oxygenated should the endotracheal tube placement be technically difficult. (These techniques include bag-mask ventilation, placement of a laryngeal mask airway, or use of a video laryngoscope). The failure to keep the airway open and the failure to keep the patient oxygenated led to the anoxic brain damage. An expert witness for the defense concurs with this opinion, and the anesthesiologist’s malpractice insurance company settles the case by paying the patient’s family.

Complications can occur before, during, or after anesthesia. The overwhelming majority of physician anesthesiologists manage their patients at or above the standard of care. When an adverse outcome occurs there may very well be no negligence or malpractice, and one should expect the legal system to award little or no malpractice award payments.

Does that mean that if the standards of care are adhered to, then there will be no malpractice payment following a bad outcome? Unfortunately, the data say no.

The ASA Closed Claims Project collects closed anesthesia malpractice claim results from the 1970s to the present. From 1975-79, 74% of anesthesia lawsuits resulted in payment. From 1990-99 this proportion declined to 58%. Much of this positive change may be explained by improvements in standards of care, i.e. the change to the routine monitoring of pulse oximetry and end-tidal carbon dioxide levels. In the 1970s, 51% of the lawsuits in which standards of care were met resulted in payment. In the 1990s only 40% of the lawsuits in which standards of care were met resulted in payment, but 40% is not zero.(3)

Other facts about medical malpractice lawsuits: About 93% of malpractice claims close without going to a trial. The average claim that goes to trial involves a 3 to 5 year process.(4) Of the cases that go to trial, 79% of verdicts are for the defendant physician.(5)

Medical errors do occur. Physicians are human. How common are medical errors in anesthesiology? It’s hard to quantitate. Medical errors that do not result in closed malpractice claims are not tabulated.

The issue of medical errors is currently a hot topic. A report published in the The British Medical Journal this week stated that if medical error was a disease, it would rank as the third leading cause of death in the United States, trailing only heart disease and cancer. Medical error was defined as an unintended act of either omission or commission, or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient. The authors calculated a mean rate of death from medical error of 251 ,454 cases per year. The authors pointed out that death certificates in the U.S., used to compile national statistics, currently have no facility for acknowledging medical error. The ICD-10 coding system has limited ability to record or capture most types of medical error. The authors recommended that when a medical error resulted in death, both the physiological cause of the death and the related problem with delivery of care should be captured.(6)

Do anesthesiologists commit any of these medical errors? Undoubtedly. What does this mean if you are a patient scheduled for surgery and anesthesia? You should have every expectation your board-certified physician anesthesiologist will practice at or above the standard of care. The chances that you will become an adverse outcome statistic are small, but those chances are not zero.

See my column Do Anesthesiologists Have the Highest Malpractice Insurance Rates? to learn more about malpractice risks and anesthesiologists.

 

References:

  1. Ranum D, et al, Six anesthesia-related medical malpractice claim statistics. Analysis of patient injury based on anesthesiology closed claims data from a major malpractice insurer, Journal of Healthcare Risk Management Volume 34,Issue 2,pages 31–42,
  2. Tsushima WT, Nakano KK, Effective Medical Testifying: A Handbook for Physicians, 1998, Butterworth-Heinemann.
  3. Posner KL: Data Reveal Trends in Anesthesia Malpractice Payments. ASA Newsletter68(6): 7-8 & 14, 2004.
  4. Chesanow N, Malpractice: When to Settle a Suit and When to Fight. Medscape Business of Medicine, Sept 25, 2013.
  5. Jena AB,, Outcomes of Medical Malpractice Litigation Against US Physicians. Arch Intern Med.2012 Jun 11;172(11).
  6. Makary MA, Daniel M, Medical Error—the Third Leading Cause of Death in the U.S., BMJ, 2016;353:i2139.

 

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?

 

 

*
*
*
*

Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

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

DSC04882_edited

 

 

LARGE-VOLUME LIPOSUCTION: IS IT SAFE?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

 

liposuction-fat

I work in a private practice setting in Palo Alto, California, and liposuction is one of the most common plastic surgery procedures performed. The accepted definition of a “large-volume” liposuction is a total aspirate of greater than 4 liters. Seventy percent of the total aspirate is fat, so if a total volume of 4 liters is harvested, the total volume of fat is 0.7 X 4, or 2.8 liters. Each liter of liposuction fat weighs approximately 2 pounds, so the weight removed in a 4-liter total-aspirate liposuction is 2.8 liters X 2 pounds/liter = 5.6 pounds.

The current accepted upper limit for fat removed in an outpatient liposuction is 5 liters, so the maximum weight of fat removed would be 5 liters X 2 pounds/liter = 10 pounds.

Early in my career, in the late 1980’s, liposuction was a bloody procedure. Prior to surgery healthy outpatients donated their own autologous blood, which they received intraoperatively to treat the expected hemorrhage which accompanied liposuction.

In the late 1980’s, American dermatologist Jeffery Klein introduced the tumescent technique for liposuction, in which dilute solutions of epinephrine and lidocaine were injected into the subcutaneous tissues prior to liposuction. This technique induced vasoconstriction and resulted in decreased blood loss, and made transfusion and post-operative anemia rare.

The volume of tumescent solution injected by the surgeon is roughly equivalent to the total volume expected to be aspirated from the patient. For a large-volume liposuction, 4 – 7 liters of tumescent solution may be injected into the body areas to be suctioned. The tumescent solution includes 1 mg of epinephrine and 20 ml of 1% lidocaine (200 mg lidocaine) per one liter of Lactated Ringers. The complication of local anesthetic toxicity from lidocaine is rare. The maximum dose of lidocaine should be kept < 35 mg/kg, or < 2450 mg for a 70 kg (154 pound) patient. If the surgeon injects six liters, this will total only 1200 mg of lidocaine. Symptoms of epinephrine toxicity are also rare.

Preanesthetic assessment and patient selection are key for safe large-volume liposuction procedures. All patients are ASA I or II, and have stable medical histories. Our facility requires each patient to weigh less than 250 pounds, or to have a BMI < 36. Preoperative labs and ECGs are done only as needed, per standard Ambulatory Surgery Center policies. The procedures are done under general endotracheal anesthesia, and can last from 3 to 8 hours. Our facility, the Plastic Surgery Center in Palo Alto, has two operating rooms. At times the second room is not occupied, and a solo anesthesiologist is the only anesthesia professional present on site and must be prepared to handle any and all emergencies.

A protocol for large-volume liposuction at our facility is as follows:

  1. General anesthesia is induced. An endotracheal tube rather than a supraglottic airway is used. Many procedures involve both supine and prone positioning because anterior and posterior parts of the body are liposuctioned. A Foley catheter is inserted into the bladder.
  2. After prepping and draping, the surgeon injects the tumescent solution into the areas to be liposuctioned. The total volume of the injectate must not exceed 10 liters. In most cases, the total volume of the injectate does not exceed 6 liters.
  3. The liposuction proceeds. The typical aspirate is a mixture of fat and tumescent fluid, with minimal bloody or reddish tinge. The total volume of fat aspirated is not to exceed 5 liters. The ratio of fat/total aspirate in each container is 0.7. If a total of 7 liters of liposuction aspirate is harvested, the total volume of fat is 7 X 0.7, or 4.9 liters.
  4. Fluid intake and output must be balanced. The total intake includes 6 liters of tumescent Lactated Ringers, plus intravenous fluids. Usually the volume of intravenous fluid is kept to less than 1 liter. The output equals the total aspirate volume of 7 liters in this case, plus the urine output. If the urine output is less than 0.5 ml/kg/hour, the diuretic furosemide 10 mg can be administered IV.
  5. Maintaining normothermia is challenging. Large-volume liposuction usually requires exposure of the patient’s body surface from the lower thorax to the knees to room air temperature. Twin Bair Huggers are used to warm both the lower and upper non-operative fields of the patient’s body.
  6. At the conclusion of surgery, constricting garments are applied to the patient’s body to reduce edema and bleeding. General anesthesia is continued until these garments are applied.
  7. Patients are discharged home after a typical PACU time of 75-120 minutes.

 

How safe is large-volume liposuction?

Palo Alto plastic surgeon George Commons and anesthesiologist Bruce Halperin published a retrospective review on 631 consecutive patients from 1986–1998 who underwent liposuction procedures of at least 3 liters total aspirate.(1) Total aspirate volumes ranged from 3 to 17 liters. Complications consisted of minor skin injuries and burns, allergic reactions to garments, and postoperative seromas. Only four patients of 631 (0.6%) developed serious complications, including four patients with mild pulmonary edema and one patient who developed pneumonia postoperatively. These patients were treated appropriately and had uneventful recoveries.

A retrospective study from Germany reported on 2275 large-volume liposuction patients from 1998-2002 in which there were 72 cases of severe complications (3.1%), including 23 deaths.(2) The most frequent complications were bacterial infections (necrotizing fasciitis, gas gangrene, and sepsis), hemorrhage, perforation of abdominal viscera, and pulmonary embolism. Fifty-seven of the 72 complications were clinically evident within the first 24 postoperative hours. Risk factors for the development of severe complications were insufficient standards of hygiene, infiltration of multiple liters of tumescent solution, permissive postoperative discharge, selection of unfit patients, and lack of surgical experience, especially regarding the identification of complications. The striking 1% mortality rate of this series documents that liposuction was dangerous in Germany between 1998 and 2002.

A review of 127,961 cosmetic surgery cases in the U.S. in 2016 showed a 0.9% complication rate in liposuction patients. Overweight patients (BMI = 25-29.9) and obese patients (BMI ≥ 30) were both independent risk factors for post-operative infection and venous thromboembolism.

In a series from Illinois, 69 of 4534 (1.5 percent) of liposuction patients in experienced a postoperative complication.(4) Both the liposuction volume and the patient’s BMI were significant independent risk factors. Liposuction volumes in excess of 100 ml per unit of body mass index were an independent predictor of complications (p < 0.001).

In experienced hands, the major morbidity of large-volume liposuction should be low—no more than the complication rates of 0.6 – 1.5% reported from the United States above. As long as there are patients who desire less fat in their thighs, hips, buttocks, abdomen, knees, arms, or necks, there will be a demand for liposuction. Large-volume liposuction requires an anesthesia professional who’s comfortable managing the perioperative medicine. If you’re considering this surgical procedure, my recommendation is to seek both a surgeon and an anesthesia team who are well trained and experienced.

 

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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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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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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