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THE ANESTHESIA CONTROL TOWER: BIG BROTHER OR FRIEND?

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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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

The Barnes Jewish Hospital, Washington University, St. Louis

Imagine this: You’re an anesthesiologist in the operating room at a busy hospital. Your patient is in mid-surgery, and you receive a call from the Anesthesia Control Tower that the patient’s blood pressure is too low, your blood transfusion replacement is inadequate, and that the patient is in danger. What do you do? How do you feel about all this?

Anesthesiologists at Barnes Jewish Hospital at Washington University in St. Louis, Missouri are studying a novel system they call the Anesthesia Control Tower (ACT). The ACT is a telemedicine-based intraoperative clinical support system.  A team led by an attending anesthesiologist uses remote monitoring to provide evidence-based support to anesthesia colleagues in all the operating rooms. The ACT is similar in concept to an air traffic control tower. The clinicians in the Anesthesiology Control Tower, called ACTors, monitor operating rooms (ORs) in real time by following the electronic health records. Just as an air traffic control tower monitors aircraft and delivers information and alerts to the pilots, the ACT communicates with anesthesia providers to assist them in providing safe care.

A press article describing the ACT states: “Surgery is a big insult to the human body. A lot can go wrong. In fact, it does. An estimated 10 to 20 percent of patients who undergo major inpatient surgery experience major complications such as heart attacks, unremitting pain, infections, and blood clots in the weeks to months following their procedures; about two percent are dead within 30 days of surgery. Some of this morbidity and mortality may be preventable through early identification of risk factors and better communication to mitigate risks during the surgery. . . . Air traffic control concepts can predict high risks for healthcare complications and improve decision making.”

The Washington University ACT provides a watchful eye over 60 operating rooms at Barnes-Jewish Hospital, watching over nearly 1,000 patients per week.  

A software program used in the ACT is called AlertWatch®. The ACT anesthesiologist (ACTor) watches a monitor displaying the Tower Mode census view (Figure 1 below), which shows an overview of all the patients in the ORs. Alerts or abnormal vital signs and laboratory results are represented by squares and triangles, respectively. Checkmarks indicate alerts that must be addressed by the ACT. The Tower Mode view looks like this (Figure 1):

 

Figure 1   Census View, Anesthesia Tower

 

The Tower Mode includes a display for each individual patient (Figure 2 below). The organ systems are labeled with relevant physiologic variables and values. Colors outline each organ, and include normal (green), marginal (yellow), or abnormal function (red). The left side of the display shows patient case information. Information regarding the patient’s medical problems can be accessed by selecting the organ system or laboratory study of interest. The black checkmark at the bottom of the left panel indicates that there is an active alert for the ACT clinicians to address (Figure 2 below):

Figure 2 Individual Patient Display, Anesthesia Tower 

 

Clicking on the checkmark opens the case review dialogue, which looks like this (Figure 3):

Figure 3, Case Review Dialogue, Anesthesia Tower

The Anesthesia Control Tower is physically located within the hospital complex, but is remote from the operating rooms. Washington University has expanded the ACT to include the Recovery Control Tower, which provides similar surveillance over patients in the Post Anesthesia Care Unit (PACU).

This photograph below depicts the Anesthesia Control Tower manpower at work at Barnes Jewish Hospital at Washington University in St. Louis:

Monitoring surgeries from the Anesthesiology Control Tower (left to right): Omokhaye M. Higo, MD, vice chair for innovation, Thaddeus Budelier, MD, program manager for the Perioperative Innovation Center, and Bradley A. Fritz, MD, assistant professor of anesthesiology, Washington University Medical School.

 

Some anesthesiologists were initially skeptical about the ACT idea. But Washington University Anesthesia Chairman Dr. Michael Avidan stated, “Most of the skepticism has evaporated over time as clinicians have perceived that innovation and technology are not threats, but rather enhancements. The conceptualization of our Perioperative Innovation Center is more akin to ‘phone a friend’ than it is to a sinister ‘big brother.’”

Current staffing levels of anesthesia professionals in the United States are inadequate. The shortage of anesthesia professionals, particularly in rural areas, may someday be remedied by a telemedicine system which resembles the ACT.  We may someday see anesthesia managed by less highly trained persons in the OR, with an ACTor backing them up by watching from on high.

Anesthesiologists who supervise Certified Registered Nurse Anesthetists (CRNAs) or Anesthesia Assistants (AAs) in an anesthesia care team model often have to provide care for multiple patients simultaneously. These attending anesthesiologists cannot physically be present in multiple operating rooms at all times. These anesthesiologists may be aided by Anesthesia Control Tower technology, which continually assesses patients for signs of deterioration and alerts the attending anesthesiologist when an adverse event is brewing.

If the Anesthesia Control Tower is to become a standard in hospital care, we need to know if the ACT changes medical outcomes. Washington University is conducting a study randomizing thousands of adult surgical patients in their operating rooms to an intervention group (ACT) or to a control group without ACT. An estimated 10,000 patients will be enrolled per year, and over four years  approximately 40,000 total patients will be enrolled. Data from this study are as yet unavailable.

The goals of this clinical trial are 1) to develop machine-learning algorithms for forecasting perioperative adverse events; 2) to develop a clinical decision support system that suggests interventions based on the algorithms, and 3) to change the paradigm of perioperative care.

Will physicians and patients see the ACT model in the near future? Significant issues regarding the adoption of Anesthesia Control Tower technology include:

  1. Documenting that ACT provides an improvement. A critical barrier for anesthesiologists, hospitals, and policy makers nationwide will be documenting that the ACT demonstrates an improvement in costs, patient outcomes, or patient experience. None of these things are apparent at this time.
  2. Paying for the ACT equipment and the ACTor on duty will be an issue. Additional hardware and software would be required at each hospital. An in-person anesthesiologist is already being paid to do each case, and the ACTor is another level of anesthesia staffing someone is going to have to pay for.
  3. Anesthesiologist opposition. A challenging barriers will be how anesthesiologists perceive systems like the ACT. Anesthesiologists are trained to be vigilant and manage their patients themselves. Having the ACT peering into the operating room, perhaps with a video camera watching the operating room, will likely be unpopular with the anesthesiologists being observed. There may also be concern that data from the ACT could be used against physicians in the event of a malpractice lawsuit. When the topic of the Anesthesia Control Tower was breached, one of my physician anesthesiologist colleagues remarked, “If that system becomes standard, I’m quitting.”
  4. Lack of need for an ACT in ambulatory settings. According to a 2017 study by the Centers for Medicare and Medicaid Services, the majority of surgical procedures in the United States, fully 70 percent, occur in ambulatory surgery centers or offices outside of hospitals. These outpatient procedures are predominantly smaller surgeries conducted on healthier patients. These smaller ambulatory facilities would have no use for the ACT, both because patients are healthier and because the surgical procedures incur less risk and fewer complications. The costs of an ACT in these smaller settings would be unlikely bring any benefit.
  5. Flawed analogy. Air traffic controllers exist to coordinate takeoffs and landings, so planes do not collide with each other in the air or on the runways. In anesthesiology, operating room patients will not collide with each other and do not have traffic issues with each other. Instead, the Anesthesia Control Tower will scrutinize each patient’s data for abnormalities that will predict a pending complication.
  6. The ACT and the algorithms developed through the ACT will likely be a transitional technology. Having one anesthesiologist (the ACTor) overseeing multiple operating rooms will likely be a steppingstone to Artificial Intelligence technology in which a computer oversees the data from each operating room, with the aim to detect and prevent adverse outcomes from developing. The arrival of ChatGPT foreshadows the AI technology about to bloom in healthcare. In the future the anesthesia provider in each operating room will likely be backed up by AI technology enforcing algorithms, rather than being backed up by a human in a control tower. I described this healthcare evolution in my 2019 book Doctor Vita, in which Artificial Intelligence in the form of inexpensive, internet-connected computers took over a California medical center and changed the face of medicine forever.

Improving vigilance and improving outcomes is the ultimate goal of ACT technology. Further data on the Anesthesia Control Tower will be forthcoming. We’ll await the prospective controlled studies, and then we’ll all learn whether or not this technology is an advance to help patients and physicians.

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The most popular posts for laypeople on The Anesthesia Consultant include: How Long Will It Take To Wake Up From General Anesthesia? Why Did Take Me So Long To Wake From General Anesthesia? Will I Have a Breathing Tube During Anesthesia? What Are the Common Anesthesia Medications? How Safe is Anesthesia in the 21st Century? Will I Be Nauseated After General Anesthesia? What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include: 10 Trends for the Future of Anesthesia Should You Cancel Anesthesia for a Potassium Level of 3.6? 12 Important Things to Know as You Near the End of Your Anesthesia Training Should You Cancel Surgery For a Blood Pressure = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

AUDIT TRAILS = THE BIG BROTHER OF MEDICAL CARE  

THE ANESTHESIA CONSULTANT Leave a comment
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)
The Audit Trail in the Electronic Medical Record

A spy lurks within every Electronic Medical Record (EMR), and most doctors have no idea that sentry exists. Every time a healthcare provider clicks his or her mouse on an EMR, that click is recorded by the Orwellian Big Brother of Medical Care, the audit trail. An audit trail can be defined as a “record that shows who has accessed a computer system, when it was accessed, and what operations were performed.” Virtually all EMRs in the United States now track at least four pieces of information about every instance a healthcare provider accesses a patient: 

  1. Who accessed, 
  2. Which patient record,
  3. At what time, and 
  4. The action they performed. 

The audit trail is NOT part of the EMR printout, and it’s not visible on the EMR patient care screen that we healthcare providers see. Lawyers can subpoena the audit trail in malpractice legislation, and the hospital must provide the audit trail if the court decides that the audit trail is relevant. An audit trail will look like an Excel document, with the provider’s name in one column and the information about each click listed in other columns:

In any malpractice legislation, an attorney will most likely have to hire an expert to interpret this audit trail for the judge and jury to understand what the document illustrates.

The audit trail was mandated by the 2005 Security Rule of the Health Insurance Portability and Accountability Act (HIPAA), which required all healthcare organizations to “implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information.”  Any organization that works with electronic protected health information—which includes patient names, addresses, social security numbers, and other pieces of sensitive personal information—must use audit trails. The purpose of the audit trail was to detect inappropriate viewing of the EMR by someone who was not directly caring for the patient. For example, preventing a healthcare provider from clicking on the EMR of someone else’s patient who is a neighbor, a previous girlfriend, a celebrity athlete, politician, or entertainer. But an audit trail is a roadmap to a physician’s EMR use, and in the case of a malpractice lawsuit, the audit trail can be either redeeming or damning.

Back in the era of handwritten medical records, Samuel Shem described “buffing the chart” in his medical satire novel “The House of God.” 

“Buffing the chart” was a dishonest means of writing medical notes in a patient’s chart to make the patient look well-treated, without the doctor providing that treatment. Buffing the chart, or any other dishonesty, is impossible with EMRs. The audit trail will document whether you provided standard medical care in real time or not. If your patient has a significant complication or an adverse outcome, a lawyer can subpoena the audit trail and hire an expert to interpret it. 

Indeed, the most common use of audit trails is in medical malpractice actions. Let’s look at some hypothetical examples:

  • A 36-year-old woman is scheduled for emergency surgery at 3 a.m. for an ectopic pregnancy. The patient weighs 250 pounds and is 5 feet tall, for a Body Mass Index (BMI) = 48.8. On induction of general anesthesia, the anesthesiologist working alone is unable to successfully place an endotracheal breathing tube and is unable to ventilate oxygen into the patient. The patient develops anoxic brain damage. The family sues the anesthesiologist, and the plaintiff attorney orders an audit trail. The audit trail documents that the anesthesiologist never clicked on an available old anesthetic record which documented that this patient had a difficult airway, in which it took two anesthesiologists twenty minutes to successfully insert an endotracheal breathing tube using both a GlideScope and a fiberoptic laryngoscope. The audit trail also documents that one day after the surgery, the anesthesiologist added a paragraph to his preoperative note claiming that he was aware of the previous difficult airway diagnosis. Once the audit trail results were revealed, the anesthesiologist and his defense lawyer realize that they cannot win, and they pay a malpractice settlement out of court.  
  • A 55-year-old man is scheduled for a left hip replacement. His past medical history is significant only for hyperlipidemia. The EMR shows standard of care anesthetic management for the surgery, but in the Post Anesthesia Care Unit (PACU) the patient develops shortness of breath, chest pain, and needs to be reintubated and sent to the Intensive Care Unit. Cardiologists diagnose an acute myocardial infarction (MI) and congestive heart failure. The patient survives, but the MI leaves the patient with reduced cardiac output and chronic heart failure. The patient sues, and the plaintiff attorney orders an audit trail. The audit trail reveals that the anesthesiologist never looked at the preoperative ECG which showed ischemic changes. The standard of care following this abnormal ECG required a cardiology consult prior to the elective surgery. The plaintiff wins the case as the anesthesiologist and the primary care doctor failed to make the required referral to a cardiologist prior to the hip surgery.
  • A 55-year-old patient on chronic dialysis is scheduled for revision of a left forearm dialysis fistula. The patient receives general anesthesia for the case and has a cardiac arrest mid-surgery. The patient’s family sues, and the plaintiff attorney orders an audit trail. The audit trail shows that the patient’s potassium level prior to surgery was markedly elevated at 8.1, and this lab value was available on the chart 30 minutes prior to the induction of anesthesia, and the anesthesiologist never clicked on the laboratory value to check what the result was prior to the surgery. The plaintiff wins the malpractice lawsuit.

The following are quotations from a legal review article titled “A Pandora’s Box: The EMR’s Audit Trail.”

  1. A subpoena for audit trail information must be for legitimate reasons.  
  2. There is no clear precedent currently on the issue of whether a defendant health care provider must produce an audit trail as a matter of standard course as if it were the medical record itself. Courts surprisingly are deciding the issue primarily on relevance grounds.
  3. Once the audit trail is produced and counsel has had a chance to review it to the care rendered, plaintiff’s counsel may seek to make an issue regarding the truthfulness of the information contained in the EMR at trial including allegations of alteration or wrongdoing.
  4. Simple conjecture or inferences that an EMR record was altered based on a review of the audit trail is not enough, and expert testimony to support that position may be required. Absent expert testimony, a plaintiff patient was not permitted to present evidence to the jury.

The following are quotations from a legal publication “The Utility of Audit Trails Analysis in Medical Malpractice Actions” :

  1. Each time a patient’s EMR is opened, regardless of the reason, the audit trail documents this detail. The audit trail cannot be erased, and all events related to the access of a patient’s EHR are permanently documented in the audit trail. Providers cannot hide anything they do with the medical record. No one can escape the audit trail. It’s easy to see how and why an audit trail could serve as an important piece of evidence in a medical malpractice action. 
  2. In printed form, [audit trails] can look like gibberish to the untrained eye. Fortunately, there’s a simple solution to these problems: the use of an expert trained in understanding and navigating EMR systems and interpreting and explaining audit trails.

The take-home message: the era of “buffing the chart” is over. Whenever we healthcare providers click on any item on the EMR, or whenever we don’t click on an item on the EMR, a Big Brother Audit Trail is watching and permanently recording who accessed the EMR, which patient item was accessed, at what time, and what action was performed.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

HOW THE INTERNET CHANGED ANESTHESIOLOGY FOREVER

THE ANESTHESIA CONSULTANT Leave a comment
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

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

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

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

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

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

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

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

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

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

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

13 MAJOR CHANGES IN ANESTHESIOLOGY IN THE LAST TEN YEARS

THE ANESTHESIA CONSULTANT 2 Comments
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

Let’s look at 13 major changes in the last ten years of anesthesiology, and give a letter grade to mark the significance of each advance:

final_ten_year_graphic_gif

 

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:

DSC04882_edited

 

 

ZDoggMD MUSIC VIDEO TRASHES ELECTRONIC MEDICAL RECORDS

THE ANESTHESIA CONSULTANT 1 Comment
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

I’m not a fan of the current state of Electronic Health Records (EHR), also known as Electronic Medical Records (EMR). Particularly in acute care, the computer keyboard and screen have no place between an anesthesiologist and his patient, an emergency room physician and his patient, an ICU doctor and his patient, or an ICU nurse and her patient. In a past column I identified the EHR as the most overrated advance affecting anesthesia practice in the past 25 years. ZDoggMD trashes EHR in his powerful and humorous You Tube video An EHR State of Mind, in which he raps about Electronic Health Records to the tune of Jay Z’s and Alicia Key’s hit single An Empire State of Mind.

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ZDoggMD is a former Stanford physician known for his music videos, parodies, and comedy sketches regarding contemporary medical issues and work in the medical field. ZDoggMD is played by Dr. Zubin Damania, CEO and Founder of Las Vegas-based Turntable Health. Dr. Damania attended UC Berkeley in the early 1990s, followed by medical school at UCSF and residency at the Stanford University School of Medicine.

Check out his website at http://zdoggmd.com. Links exist to multiple equally funny satiric videos. You’re sure to be entertained.

I agree with him that the current cumbersome EHRs come between doctors and patients during hospital care. My criticisms include:

  1. Different EHRs at different hospitals are unable to communicate with each other.
  2. If you work at different hospitals with different EHRs, you have to be trained and retrained in multiple EHR platforms.
  3. With an EHR it takes at least 5 clicks to chart “atropine 0.4 mg.” In the past with a paper record you would merely write “0.4” on the atropine line.
  4. Nurses consistently have their backs to patients as they type, type, type data into computer terminals. In an operating room, the circulating nurse’s job is analogous to that of a court reporter/stenographer. Florence Nightingale would have had a stroke.
  5. As ZDoggMD points out in his video, the current EHR is a “glorified billing platform with some patient stuff tacked on.” Hospitals spend hundreds of millions of dollars to install the EHR, and then tell us that the EHR will help them bill and collect money at a superior rate. The economics don’t add up, and have nothing to do with patient care.
  6. With an EHR, instead of writing a pertinent note at each patient encounter, health care providers copy and paste previous notes, altering the minimal differences at each encounter. This habit makes it difficult to ferret out the pertinent information in, for example, a six-page copied template.

ZDoggMD challenges us as healthcare providers. On his website he writes, “We on the front lines of healthcare need to stand up and demand that our organizations, government, and tech vendors stop letting the unintended consequences of legislation and technology wreck our sacred relationship with patients while destroying our ability to do what we do without having to tell our kids to stay as far away from medicine as they can. Great technology [insert Steve Jobs fanboy comments here] can be the glue that connects us…”

Indeed, I wish Apple Computers would create an EHR which was as intuitive and easy as their iPad software.

Perhaps in the future the state of mind of an EHR will be superior. As of now, as ZDoggMD points out, it is not.

 

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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*
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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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

WHAT ONE QUESTION SHOULD YOU ASK TO DETERMINE IF A PATIENT IS ACUTELY ILL?

THE ANESTHESIA CONSULTANT 3 Comments
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

What one question should you ask to determine whether a patient has a serious medical problem? What one question must you ask to determine whether urgent intervention is required?

Imagine this scenario: You’re an anesthesiologist giving anesthesia care in the operating room to your second patient of the day. The Post Anesthesia Care Unit (PACU) nurse calls you regarding your first patient who is in the PACU following appendectomy. The nurse says, “Your patient Mr. Jones is still nauseated and very sleepy. I’ve medicated him with ondansetron and metoclopramide as ordered, but he’s still nauseated and sleepy.”

That one question would be: “What are his vital signs?”(This is a bit of a trick question, since you are asking not one question, but four or five. It’s as if you’re down to your last request from the Genie from Aladdin’s lamp, and you’re wishing for more wishes. As Robin Williams’ Genie character said in Disney’s Aladdin, “Three wishes, to be exact. And ixnay on the wishing for more wishes. That’s all. Three. Uno, dos, tres. No substitutions, exchanges or refunds.” )

The traditional four vital signs are the blood pressure, heart rate, respiratory rate, and temperature. For anesthesiologists, surgeons, emergency room physicians, and ICU doctors, the fifth vital sign is the oxygen saturation or O2 sat. Some publications tout the pain score (on a 1-10 scale) as a fifth vital sign. While I subscribe to the pain score’s importance, it’s of less value in most acute care situations than the O2 saturation.

Let’s return to the patient scenario. You ask the nurse, “What are the patient’s vital signs?”

The nurse answers, “His heart rate is 48, his blood pressure is 88/55, his O2 sat is 100, and his respiratory rate is 16.”

You answer, “His heart rate is too low and so is his blood pressure. Let’s give him 0.5 mg atropine IV now.”

Five minutes later the nurse calls back. The heart rate increased to 72 and the blood pressure is 110/77. The patient’s symptoms resolved as the vital signs normalized.

Let’s look at a second scenario. You drop off a 48-year-old hysterectomy patient in the PACU. The patient is awake, and her initial vital signs are BP 120/64, pulse 100, respirations 18, and O2 saturation 99%. You return to the operating room to initiate care for your next patient for a laparoscopy. Thirty minutes later, the PACU nurse calls you to report your first patient has increasing abdominal discomfort. Her repeat vital signs are: BP 110/80, pulse 130, respirations 26, and O2 saturation 99%. You’re concerned an intra-abdominal complication is brewing. Five minutes later, the nurse reports a third set of vitals. The patient’s heart rate continues to rise to 140. Her blood pressure is now 82/40, her respirations are 30, and her skin has become cold and moist to the touch. She’s unable to speak coherently and is losing consciousness. You can not leave the patient you are anesthetizing, but you call a fellow anesthesiologist to evaluate the patient in person, and prepare her for emergent re-operation.

The patient’s initial vital signs were stable, but the downward trend of her vital signs were a harbinger of the serious complication. Eventually the symptoms of abdominal pain and decreasing consciousness appeared, and confirmed the diagnosis of intra-abdominal hemorrhage and impending shock. The increased heart rate, decreased blood pressure, and increased respiratory rate were red flags early on.

Abnormal vital signs can indicate that a patient is acutely ill. Equally important to the value of each vital sign is the temporal trend in the vital signs. A vital sign trend increasing or decreasing from the normal range can validate that the patient is becoming acutely ill.

You may be thinking, why is Dr. Novak telling me vital signs are important? Everybody know vital signs are, well … vital.

My message to you is to seek out the vital signs, all of them, as essential clues in all patients.

As anesthesiologists, we spend our entire intraoperative clinical career staring at a patient’s vital signs on a video screen. When the blood pressure goes up, we act. When the blood pressure goes down, we act. When the heart rate goes up, we act, and when the heart rate goes down, we act. When oxygen saturation trends downward, we act. Because most intraoperative patients are unconscious, the patient’s verbal history—the traditional clues regarding acute illness—are unavailable. We can not ask our patient questions to determine whether vital sign changes are associated with symptoms of chest pain, shortness of breath, or neurologic deficits. We’re accustomed to treating patients by normalizing their vital signs.

Other healthcare providers lack this perspective. Nurses and non-acute-care physicians such as family practitioners and internists can fill a patient’s history chock full of other details so thick that the vital signs are buried. The five or six vital sign numbers are often obscured in pages of text. Most physician and nursing notes in an electronic medical record (EMR) are lengthy, and are many are copied and pasted from previous encounters. Each patient interview is a quiz bowl of medical history answers. The five or six vital sign numbers are a needle in the haystack of a modern medical history. The EMR in a clinic or a hospital can serve to worsen this plight, as vital signs are recorded by nurses and entered into nursing documents on the computer, and treating physicians may have to dig to find the correct page that lists vital signs. One possible benefit of an EMR is a proposed safety system that requires, for any abnormal vital sign entered into the computer, the nurse to document they have verbally informed a physician of that abnormal value. This system would assure that abnormal values are never ignored, and that an MD will assess whether further diagnostic or therapeutic steps need to be taken.

Ferret out the vital signs. In my career as a clinical anesthesiologist and anesthesia expert witness, I can’t recall one significant complication that wasn’t foretold by an increased or decreased heart rate, blood pressure, respiratory rate, or temperature, a decreased O2 saturation, or an increased pain score.

Keep your eye on the vitals, and keep your patients out of trouble.

 

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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

THE TOP TEN MOST USEFUL ADVANCES AND THE FIVE MOST OVERRATED ADVANCES AFFECTING ANESTHESIA IN THE PAST 25 YEARS

THE ANESTHESIA CONSULTANT 2 Comments
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

In 1986 the American Society of Anesthesiologists adopted pulse oximetry and end-tidal CO2 monitoring as standards of care.  These two monitors were our specialty’s major advances in the 1980’s, and made anesthesia safer for everyone. What are the most significant advances affecting anesthesia since that time? As a clinician in private practice, I’ve personally administered over 20,000 anesthetics in the past quarter century.  Based on my experience and observations, I’ve assembled my list of the Top Ten Most Useful Advances Affecting Anesthesia from 1987-2012.  I’ve also assembled my list of the Five Most Overrated Advances Affecting Anesthesia from 1987-2012.

THE TOP TEN MOST USEFUL ADVANCES AFFFECTING ANESTHESIA IN THE PAST 25 YEARS (1987- 2012):

#10. The cell phone (replacing the beeper).  Cell phones changed the world, and they changed anesthesia practice as well.  Before the cell phone, you’d get paged while driving home and have to search to find a payphone.  Cell phones allow you to be in constant contact with all the nurses and doctors involved in your patient’s care at all times.  No one should carry a beeper anymore.

#9. Ultrasound use in the operating room.  The ultrasound machine aids peripheral nerve blockade and catheter placement, and intravascular catheterization.  Nerve block procedures used to resemble “voodoo medicine,” as physicians stuck sharp needles into tissues in search of paresthesias and nerve stimulation.  Now we can see what we’re doing.

#8.  The video laryngoscope.  Surgeons have been using video cameras for decades.  We finally caught up.  Although there’s no need for a video laryngoscope on routine cases, the device is an invaluable tool for seeing around corners during difficult intubations.

#7.  Rocuronium.  Anesthesiologists long coveted a replacement for the side-effect-ridden depolarizing muscle relaxant succinylcholine.  Rocuronium is not as rapid in onset as succinylcholine, but it is the fastest non-depolarizer in our pharmaceutical drawer.  If you survey charts of private practice anesthesiologists, you’ll see rocuronium used 10:1 over any other relaxant.

#6.  Zofran.  The introduction of ondansetron and the 5-HT3 receptor blocking drugs gave anesthesiologists our first effective therapy to combat post-operative nausea and vomiting.

#5. The ASA Difficult Airway Algorithm.  Anesthesia and critical care medicine revolve around the mantra of “Airway-Breathing-Circulation.”  When the ASA published the Difficult Airway Algorithm in Anesthesiology in 1991, they validated a systematic approach to airway management and to the rescue of failed airway situations.  It’s an algorithm that we’ve all committed to memory, and anesthesia practice is safer as a result.

#4.  The internet.  The internet changed the world, and the Internet changed anesthesia practice as well.  With Internet access, clinicians are connected to all known published medical knowledge at all times.  Doctors have terrific memories, but no one remembers everything.  Now you can research any medical topic in seconds. Some academics opine that the use of electronic devices in the operating room is dangerous, akin to texting while driving.  Monitoring an anesthetized patient is significantly different to driving a car.  Much of O.R. monitoring is auditory.  We listen to the oximeter beep constantly, which confirms that our patient is well oxygenated.  A cacophony of alarms sound whenever vital signs vary from norms.  An anesthesia professional should never let any electronic device distract him or her from vigilant monitoring of the patient.

#3.  Sevoflurane.  Sevo is the volatile anesthetic of choice in community private practice, and is a remarkable improvement over its predecessors.  Sevoflurane is as insoluble as nitrous oxide, and its effect dissipates significantly faster than isoflurane.  Sevo has a pleasant smell, and it replaced halothane for mask inductions.

#2.  Propofol.  Propofol is wonderful hypnotic for induction and maintenance.   It produces a much faster wake-up than thiopental, and causes no nausea.  Propofol makes us all look good when recovery rooms are full of wide-awake, happy patients.

#1.  The Laryngeal Mask Airway.  What an advance the LMA was.  We used to insert endotracheal tubes for almost every general anesthesia case.  Endotracheal tubes necessitated laryngoscopy, muscle relaxation, and reversal of muscle relaxation.  LMA’s are now used for most extremity surgeries, many head and neck surgeries, and most ambulatory anesthetics.

THE FIVE MOST OVERRATED ADVANCES AFFECTING ANESTHESIA IN THE PAST 25 YEARS (1987-2012):

#5.   Office-based general anesthesia.  With the advent of propofol, every surgeon with a spare closet in their office became interested in doing surgery in that closet, and they want you to give general anesthesia there.  You can refuse, but if there is money to be earned, chances are some anesthesia colleague will step forward with their service.  Keeping office general anesthesia safe and at the standard of care takes careful planning regarding equipment, monitors, and emergency resuscitation protocols.  Another disadvantage is the lateral spread of staffing required when an anesthesia group is forced to cover solitary cases in multiple surgical offices at 7:30 a.m.  A high percentage of these remote sites will have no surgery after 11 a.m.

#4.  Remifentanil.  Remi was touted as the ultra-short-acting narcotic that paralleled the ultra-short hypnotic propofol.  The problem is that anesthesiologists want hypnotics to wear off fast, but are less interested in narcotics that wear off and don’t provide post-operative analgesia.  I see remi as a solid option for neuroanesthesia, but its usefulness in routine anesthetic cases is minimal.

#3.  Desflurane.  Desflurane suffers from not being as versatile a drug as sevoflurane.  It’s useless for mask inductions, causes airway irritation in spontaneously breathing patients, and causes tachycardia in high doses.  Stick with sevo.

#2.  The BIS Monitor.  Data never confirmed the value of this device to anesthesiologists, and it never gained popularity as a standard for avoiding awareness during surgery.

#1.  The electronic medical record.  Every facet of American society uses computers to manage information, so it was inevitable that medicine would follow. Federal law is mandating the adoption of EMRs.  But while you are clicking and clicking through hundreds of Epic EMR screens at Stanford just to finish one case, anesthesiologists in surgery centers just miles away are still documenting their medical records in minimal time by filling out 2 or 3 sheets of paper per case. Today’s EMRs are primitive renditions of what will follow. I’ve heard the price tag for the current EMR at our medical center approached $500 million.  How long will it take to recoup that magnitude of investment?  I know the EMR has never assisted me in caring for a patient’s Airway, Breathing, or Circulation in an acute care setting.  Managing difficulties with the EMR can easily distract from clinical care.  Is there any data that demonstrates an EMR’s value to anesthesiologists or perioperative physicians?

Your Top Ten List and Overrated Five List will differ from mine.  Feel free to communicate your opinions to me at rjnov@yahoo.com.

As we read this, hundreds of companies and individuals are working on new products.  Future Top Ten lists will boast a fresh generation of inventions to aid us in taking better care of our patients.

 

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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*
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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 ricknovak.com by clicking on the picture below:  

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