IS ANESTHESIA A CUSHY SPECIALTY?

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

Is anesthesia worthy of the House of God‘s assessment that it’s a cushy medical specialty? My answer, after thirty years of anesthesia practice, is … it depends.

Cover image of The House of God

Samuel Shem’s classic novel/satire of medicine, The House of God (published in 1978, more than two million copies sold), follows protagonist Dr. Roy Basch as he struggles through his year as an internal medicine intern. A second physician recommends Basch switch careers to one of six no-patient-contact specialties: Rays, Gas, Path, Derm, Eyes, or Psych. These names translate to radiology, anesthesia, pathology, dermatology, ophthalmology, and psychiatry. These specialties are touted as lower stress choices with superior lifestyles, where time with sick patients is minimized and the physician is more likely to be happy.

Is this true? Is anesthesia worthy of Samuel Shem’s assessment that it’s a cushy specialty?

My answer, after thirty years of anesthesia practice, is … it depends.

Let’s examine each of the six specialties regarding their perceived advantages:

• Radiology involves a career of peering at digital images of X-rays, MRIs, CT scans, or ultrasound studies. Patient contact is minimal. Because many of these tests are ordered in emergency rooms at all hours of the night, on-call radiologists work long hours and endure sleepless nights. As well, the subspecialty of Invasive Radiology has become a hands-on field that requires as much patient contact as most surgical specialties.
• Pathology involves a career of peering through a microscope, running a clinical lab to determine blood and urine chemistry results, or performing autopsies. Most of pathology requires zero contact with living patients. Most pathology work is done in daylight hours, and loss of sleep is unusual.
• Dermatology involves a career of seeing a multitude of patients (think 80 – 100 per day) in a busy clinic practice. Patient volume and patient contact are high. Each clinic visit is brief because only the specific skin lesions in question are fair game for physician-patient interrogation. Hospitalized patients are uncommon, there are few emergencies, and loss of sleep is unusual.
• Ophthalmology involves an office practice of examining the vision and eyes of patients, as well as an operating room practice of performing cataract, retinal, or corneal surgeries. Other than an occasional eye trauma surgery at a late hour, loss of sleep for ophthalmologists is unusual.
• Psychiatry involves an outpatient practice of verbal therapy and/or prescribing oral medications (e.g. antidepressants, anti-anxiety, or attention deficit hyperactivity disorder meds). Inpatient psychiatry is usually limited to patients with severe depression and psychotic diseases. Most emergencies are limited to patients with after-hours suicidal ideation or attempts. Loss of sleep is unusual.
• Anesthesiology involves providing unconsciousness and medical management to patients during all types of surgical interventions. Surgeries occur at all hours of the day and night. Loss of sleep is common, and job stress during select cases can be extreme. Let’s examine lifestyle issues of anesthesia practice in more detail:

An anesthesiologist and his or her awake surgical patient are only together for only 15 minutes prior to induction of anesthesia, during which time they exchange information on medical history and informed consent. This brief duration doesn’t exactly qualify for The House of God’s no-patient-contact list, but anesthesia does qualify as very-little-awake-patient contact. Minimal time with conscious patients appeals to physicians who don’t relish prolonged face-to-face patient interaction.

An image of your anesthesiologist playing tennis or golf and then waltzing into the operating room at leisure to do a simple surgery is mistaken. The presence of an anesthesiologist is imperative for nearly every emergency procedure. All emergency medical care follows the guideline of A-B-C, or Airway-Breathing-Circulation, and anesthesiologists are airway specialists nonpareil. Emergency room attendings and head and neck surgeons have certain airway skills, but no other specialty has the depth of airway expertise that anesthesiologists own. An anesthesiologist provides care for 500–1000 patients per year, and every one of these patients requires acute management of the airway to assure safe oxygenation and breathing.

Trauma surgery, childbirth, acute surgical disease from the emergency room, and organ transplant surgery are as common at night as in the daytime. An on-call anesthesiologist at a busy community hospital may arrive at 6:30 a.m., do seven or eight surgical anesthetics which last until dusk, and then remain in the hospital all night to perform several epidural anesthetics on laboring women, anesthetize an 80-year-old woman for surgery to relieve a bowel obstruction, and replace an endotracheal tube in a struggling patient in the intensive care unit as the sun comes up the following day. An on-call anesthesiologist at a university hospital may arrive at 6:30 a.m. and attend to a complex liver-transplant surgery which lasts 20 hours and concludes at 3 a.m. A cushy specialty? Hardly.

A lifestyle advantage for anesthesiologists is that we can work hard and play hard. It’s possible for an anesthesiologist to take weeks or months off at a time if their employer or anesthesia group approves. There’s no chronic patient care/patient follow up, no clinic overhead, and no clinic employee overhead. For these reasons an anesthesiologist can schedule multiple weeks without work or income more easily than a clinic doctor can. For these reasons it’s also possible for an anesthesiologist to work part time, i.e. two or three days each week. This scheduling flexibility is an excellent lifestyle advantage, and for this reason my answer to whether anesthesia is a cushy specialty is … it depends.

Some anesthesiologists choose to spend their career outside the operating room. Some specialize in pain management and see patients in outpatient pain clinics—selected patients are taken to the operating room non-urgently to receive pain-injection procedures such as epidural steroid injections, nerve blocks, or pain pump insertions. A small number of anesthesiologists run preoperative assessment clinics where they assess the medical status of patients prior to surgery. A small number of anesthesiologists supervise intensive care units and manage critically patients who require ventilators, cardio-active medications, and anesthesia sedation infusions.

I’d like to leave you with one image imprinted in your mind—that of an anesthesiologist toiling over an ill patient at 2 a.m. in a hospital. The patient may have survived a car crash, suffered a ruptured appendix, be delivering twin babies, or be the recipient of a lung transplant. Wherever there’s a sick patient who needs acute supervised unconsciousness, there’s an anesthesiologist present. In words John Steinbeck wrote at the conclusion of The Grapes of Wrath, Tom Joad tells his mother,

“I’ll be all around in the dark – I’ll be everywhere.
Wherever you can look – wherever there’s a fight, so hungry people can eat, I’ll be there.
Wherever there’s a cop beatin’ up a guy, I’ll be there.
I’ll be in the way guys yell when they’re mad.
I’ll be in the way kids laugh when they’re hungry and they know supper’s ready, and when the people are eatin’ the stuff they raise and livin’ in the houses they build – I’ll be there, too.”

This prompts me to pen parallel text regarding my specialty, entitled
Tom Joad the Anesthesiologist:

I’ll be all around in the dark—I’ll be everywhere.
Wherever you can look—wherever there’s a motorcycle accident, a Cesarean section, a heart transplant, I’ll be there.
Wherever there’s a cop dragging a knifed-up gang member into the E.R., I’ll be there.
I’ll be there when the surgeon screams and when the new mother laughs,
When the 100-year-old gets his hernia mended and when the 4-year-old gets his tonsils out—I’ll be there, too.
Ma, it’s just what I do.
It’s what we all do.

 

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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

AWARENESS UNDER GENERAL ANESTHESIA

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

How common is awareness under general anesthesia? In 2007, Hollywood released the movie Awake, in which the protagonist, played by Hayden Christensen (Anakin Skywalker from Star Wars) is awake during the general anesthetic for his heart surgery, and 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 airs 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 undergo general anesthesia, do you have a 1 in 700 chance of being awake?  If you are a healthy patient undergoing routine surgery, the answer is no.  If you are sick and you are having a high-risk procedure, the answer is yes.

A key publication on this topic was the Sebel study. 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. American Society of Anesthesiologists (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. The use of neuromuscular paralyzing drugs during the anesthetic.

5. Certain surgical procedures are higher risk for intraoperative awareness.  These procedures include cardiac surgery, Cesarean sections under general anesthesia, trauma or emergency cases.

The causes of intraoperative awareness include:

1. Intentionally light anesthesia administered to patients who are hypotensive or hypovolemic, or those with limited cardiovascuar reserve.

2. Intentionally light anesthesia administered to obstetric patients, in the attempt to avoid neonatal respiratory depression.

3. Efforts to expedite operating room turnover and minimize recovery room times.

4. Some patients have higher anesthetic requirements, due to chronic alcohol or drugs.

5. Equipment and provider errors:

Empty vaporizers with no potent anesthetic liquid inside

Syringe pump malfunction

Syringe swap, or mislabeling of a syringe

6. Difficult intubation, in which the anesthesia provider forgets to give supplementary IV doses of hypnotics.

7. Choice of anesthetic.  In multiple trials, the use of neuromuscular blockers is associated with awareness.

8. Some studies show a higher incidence of awareness with total intravenous anesthesia or nitrous-narcotic techniques.

What are the legal implications of intraoperative awareness?

The Domino study reported that cases of awareness represented 1.9% of malpractice claims against anesthesiologists. Deficiencies in labeling syringes and vigilance were common causes for awake paralysis. The patients’ vital signs were not classic clues:  hypertension was present in only 15% of recall cases, and tachycardia was present in only 7%.

What are the consequences of intraoperative awareness?

The following consequences have been reported from the Samuelsson study:

1. Recollections of auditory perceptions and a sensation of paralysis.  Anxiety, helplessness, and panic.  Pain is described less frequently.

2. Up to 70% of patients develop Post-Traumatic Stress Disorder (PTSD), i.e. late psychological symptoms of anxiety, panic attacks, chronic fear, nightmares, flashbacks, insomnia, depression, or preoccupation with death.

What about BIS Monitoring?

Bispectral Index monitoring, or BIS monitoring, uses a computerized algorithm to convert a single channel of frontal EEG into an index score of hypnotic level, ranging from 100 (awake) to 0 (isoelectric EEG).

The BIS monitor was FDA-approved in 1996.  A BIS level of 40 – 60 reflects a low probability of consciousness during general anesthesia.  BIS measures the hypnotic components of anesthesia (e.g. effects of propofol and volatile agents), and is relatively insensitive to analgesic components (e.g. narcotics) of the anesthetic.  The BIS monitor is neither 100% sensitive nor 100% specific.

The B-Aware Trial was a randomized, double-blind, multi-center controlled trial using BIS in 2500 patients at high risk for awareness (cardiac surgery, C-sections, impaired cardiovascular status, trauma, chronic narcotic users, heavy alcohol users).   Explicit recall occurred in 0.16% (2 patients) when BIS used, vs. 0.89% (11 patients) when no BIS was used. This was a significant finding (p=0.022).

A significant paper published in the world’s leading anesthesia journal concluded that the predictive positive and negative values of BIS monitoring were low due to the infrequent occurrence of intraoperative awareness.  In addition, the cost of BIS monitoring all patients undergoing general anesthesia is high. Because there have been reported cases of awareness despite BIS monitoring, the authors concluded that the effectiveness of the monitor is less than 100%. The authors concluded that the contention that BIS Index monitoring reduces the risk of awareness is unproven, and the cost of using it for this indication is currently unknown.

In 2005, the American Society of Anesthesiologists published its Practice Advisory for Intraoperative Awareness.  The anesthesia practitioner is advised to do the following:

1. Review patient medical records for potential risk factors. (Substance use or abuse, previous history of intraoperative awareness, history of difficult intubation, chronic pain patients using high doses of opioids, ASA physical status IV or V, limited hemodynamic reserve).

2. Determine other potential risk factors. (Cardiac surgery, C-section, trauma surgery, emergency surgery, reduced anesthetic doses in the presence of paralysis, planned use of muscle relaxants during the maintenance phase of general anesthesia, planned use of nitrous oxide-opioid anesthesia).

3. Patients considered to be at increased risk of intraoperative awareness should be informed of the possibility when circumstances permit.

4. Preinduction checklist protocol for anesthesia machines and equipment to assure that the desired anesthetic drugs and doses will be delivered.  Verify IV access, infusion pumps, and their connections.

5. The decision to administer a benzodiazepine prophylactically should be made on a case-by-case basis for selected patients.

6. Intraoperative monitoring of depth of anesthesia, for the purpose of minimizing the occurrence of awareness, should rely on multiple modalities, including clinical techniques (e.g., ECG, blood pressure, HR, end-tidal anesthetic gas analyzer, and capnography)…. Brain function monitoring is not routinely indicated for patients undergoing general anesthesia, either to reduce the frequency of intraoperative awareness or to monitor depth of anesthesia…. The decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner of selected patients (e.g. light anesthesia).

Published suggestions for the prevention of awareness include:

1. Premedication with an amnestic agent.

2. Giving adequate doses of induction agents.

3. Avoiding muscle paralysis unless totally necessary.

4. Supplementing nitrous/narcotic anesthesia with 0.6% MAC of a volatile agent.

5. Administering 0.8 – 1.0 MAC when volatile agent is used alone.

6. Confirming delivery of anesthetic agents to the patient

In 2006, the California Society of Anesthesiologists released the following Statement on Intraoperative Awareness:

“ . . . Anesthesiologists are trained to minimize the occurrence of awareness under general anesthesia.  It is recognized that on rare occasions, usually associated with a patient’s critical condition, this may be unavoidable.  Furthermore, it is commonplace in contemporary anesthetic practice to employ a variety of techniques using regional nerve blocks and varying degrees of sedation.  Patients often do not make an distinction between these techniques and general anesthesia, yet awareness is often expected and anticipated with the former.  This may have led to a misunderstanding of ‘awareness’ during surgery by many patients.”

In 2011, the New England Journal of Medicine, arguably the most prestigious medical journal in the world, published a study looking at using the BIS monitor for the prevention of intraoperative awareness. Prevention of intraoperative awareness in a high-risk surgical population). The researchers tested the hypothesis that a protocol incorporating the electroencephalogram-derived bispectral index (BIS) was superior to a protocol incorporating standard monitoring of end-tidal anesthetic-agent concentration (ETAC) for the prevention of awareness. They randomly assigned 6041 patients at high risk for awareness to either BIS-guided anesthesia or ETAC-guided anesthesia. Results showed that a total of 7 of 2861 patients (0.24%) in the BIS group, as compared with 2 of 2852 (0.07%) in the ETAC group, had definite intraoperative awareness.  The superiority of the BIS protocol was not established.  Contrary to expectations, fewer patients in the ETAC group than in the BIS group experienced awareness.

To conclude, intraoperative awareness is a real but rare occurrence, with certain patient populations at higher risk. The BIS monitor is no panacea. Specific pharmacologic strategies can minimize the incidence of awareness. If you are a healthy patient undergoing a routine procedure, intraoperative awareness should be very rare.

The best defense against intraoperative awareness will always be the presence of a well-trained and vigilant physician 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 ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

WHEN THE ER CALLS YOU ABOUT A RUPTURED AORTIC ANEURYSM

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

Clinical Case:  The Emergency Room physician calls you to see a 70-year-old man with severe abdominal pain and a known abdominal aortic aneurysm.  The patient’s BP is 80/40, and his heart rate is 120.  What do you do?

Discussion:  Prior to my anesthesia residency I was an Emergency Room attending at Stanford University Hospital.  I witnessed patients such as this one managed well, and mismanaged.  Difficulties were system problems coordinating the ER, the OR, patient transport, the surgical team, and the anesthesia team.

Let’s look at this case.  Assume it is 10:00 p.m., and the patient is in a private hospital setting.  When you get the call from the ER, you are at home, 20 minutes from the hospital.  You jump into your car and streak toward the hospital.   You telephone the OR from your car, to make sure the room is ready, and the anesthesia techs (or nurses, as some hospitals do not employ anesthesia techs) have the equipment that you want ready in the OR. You request two Level 1’s, IV lines, an arterial line and pulmonary artery catheter, 3 transducers, a four-channel drug infusion pump, a TE echo, and a tray of syringes.  Next you call any other anesthesiologist who is already in the hospital.  This will usually be your colleague or partner in OB anesthesia.  You present the case to him or her, and make a plan.   Your colleague  will go to the ER, and transport the patient to the OR.  You also re-telephone the ER to make certain that a surgeon is there, or en route.  You instruct the ER physician to put the patient on oxygen, to attempt 2 large bore peripheral  IV’s, to get blood stat from the blood bank (probably O negative given the acute nature of the bleeding), and to attach a portable monitor.  You instruct both your partner and the ER staff to not waste time on arterial line attempts or CVP attempts.  They need to transport the patient to the OR as soon as possible.

When you arrive at the hospital, the patient is rolling into the OR, stuporous and  moaning.  Your partner helps you attach routine monitors.  The blood pressure and heart rate are the same as they were  minutes ago when the ER physician called you.  The surgeon scrubs and gowns, and the nurses prep as they would for a stat cesarean section.  You leave both arms out for line access. You do a rapid sequence induction with etomidate  and succinylcholine,  and intubate the trachea.  You also give .4 mg scopolamine IV for amnesia.  The surgeon makes the incision and clamps the aorta in minutes.  The bleeding is retroperitoneal.   There is no blood in the abdomen.  After aortic clamping, the BP rises to 100 systolic.  You continue volume resuscitation with O-negative blood.  Your partner places a radial arterial line and sends a blood gas, while you place a TE echo to monitor left ventricular volume.   You consider adding a pulmonary artery catheter as quickly as possible, to give cardiac output and systemic vascular resistance data.  Maintenance anesthesia may be either inhalation or narcotic, if the patient’s BP will tolerate any anesthetic.

For patients with ruptured abdominal aortic aneurysm, the overall mortality rate is up to 90%, with the time from onset of symptoms to control of bleeding being the key to outcome.  65–75% of patients die before they arrive at hospital and up to 90% die before they reach the operating room.  (Brown LC, Powell JT, Annals of Surgery 230 (3): 289–96, September 1999).  An abdominal aortic aneurysm will usually rupture into the retroperitoneum, which permits tamponade of the hemorrhage.  About 25% of abdominal aortic aneurysms  rupture into the peritoneal cavity, and these cases have a greater amount of bleeding, at a greater pace. In select cases, if the patient is stable enough, the surgical team may elect to treat the ruptured aorta by an endovascular approach to the abdominal aorta.  Either way, your role as the anesthesiologist is to get the patient into an OR, and put an endotracheal tube in without delay, so the surgeon can clamp the proximal aorta and control bleeding.  Common mistakes are:  (1)  Delays in the ER to put in IV’s or invasive monitoring lines.  A 14-gauge IV will not keep up with blood lost from an aorta;  and  (2)  Delays in transport to the OR.  You can not rely on traditional hospital transport systems.  Physicians need to “scoop and run”, much like a trauma helicopter team in the field, and get their patient into an OR.

The remainder of the anesthetic management is familiar territory, discussed in textbook chapters on abdominal aortic repair.  Management will involve transfusion of the appropriate amount of blood products, optimizing cardiac function, acid-base status, respiratory status, temperature, and urine output.  The patient is taken to ICU sedated and ventilated for postoperative care.

This patient was an “ASA 5” classification who survived surgery because you were swift and wise.

Take this advice from a former ER doc:  Know when and how to get out of the ER fast.

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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

 

 

CAN YOU LEAVE YOUR ANESTHETIZED PATIENT IN AN EMERGENCY?

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

Clinical Case of the Month:  You are in an operating room in a freestanding plastic surgery center giving general anesthesia to Patient A, and you are called by the PACU nurse because Patient B in the PACU is having stridor.  The PACU Patient B is a healthy 39-year-old female, one hour status-post liposuction, and her anesthesiologist has signed out to you.  Patient B is now cyanotic.  You are the only anesthesiologist for miles, and both Patient A and B need you.  What do you do?

Discussion:  You perch the circulating R.N. from your O.R. in front of the monitors, tell her to let you know if anything changes, and you leave the O.R. to attend to the patient in the PACU.  Is there any alternative?  Are you going to stand there with stable Patient A while Patient B dies of airway obstruction thirty feet away from you?

When you arrive in the PACU, you see a young woman sitting up in bed making loud crowing sounds with every inspiration.  Her oxygen saturation is 89% on 4 liters of nasal oxygen, and her heart rate is 110.  Her husband is standing at the bedside, and his eyes are bugging out of his head watching his wife gasp for air.  The PACU nurse is standing on the other side of the patient, and her eyes are bugging out almost as far as the husband’s.

You ask the nurse to open an Ambu bag and connect it to the oxygen source.  You ask the husband to leave the room while you evaluate and treat his wife.  A second nurse escorts him out.  You listen to the patient’s lungs, and her breath sounds are normal except for upper airway stridor.  The exam of her mouth and neck is normal.  You take additional history, and learn that she had a three hour intubation for a prone liposuction, and was extubated without complication.  She received 20 mg of meperidine 45 minutes earlier, and no other medication was given in PACU.  The stidor started two minutes earlier, when her oxygen saturation decreased from 100% to the high 80’s.

Your diagnosis is laryngospasm of unclear etiology.  You apply an anesthesia mask over her face, deliver 100% oxygen via the Ambu bag, and attempt to apply continuous positive airway pressure (CPAP) to break her laryngospasm.  You ask her to cough hard to clear secretions that may be lodged on her vocal cords.  Within a minute the stridor passes, and her oxygen saturation returns to 100%.  Her other vital signs are normal, and her skin is free of urticaria.  You review her anesthesia record, and it is unremarkable.  The patient feels significantly better, and you return to the OR to check on your patient who is still under general anesthesia.  The OR circulating nurse reassures you that Patient A is fine, and nothing changed during your absence.

Two minutes later, the PACU nurse calls in a panic again, because Patient B is having stridor again.  You run to the PACU, and repeat the assessment and therapeutic moves you made in the paragraphs above.  Your diagnosis is post-intubation laryngospasm.  You can not rule out post-intubation vocal cord paralysis.  You treat with 8 mg of IV dexamethasone.  There is no vaporized racemic epinephrine in the facility.  The patient is moving air well, but intermittently crowing with stridor.  You call 911 for an ambulance, and call the ER attending at the nearest hospital to tell him you are coming over.  You place a third call to the Respiratory Therapy service at the hospital, and tell them to meet you at the ER with a racemic epinephrine treatment for the patient.

Patient A’s surgery  ends in the next 10 minutes, as the ambulance crew arrives and prepares Patient B for transport.  You extubate Patient A and deliver her in stable condition to the PACU just in time to join the Emergency Medical Techs as they load Patient B into the ambulance.  You load your pockets with vials of propofol and succinylcholine, a laryngoscope, and two syringes, and follow her into the ambulance.  The siren blares, and the ambulance drives Code 3 to the ER.  The patient’s intermittent stidor continues, with oxygen saturation in the low 90’s on a 100% non-rebreather mask.

In the first twenty minutes in the ER, the Respiratory Therapist arrives and gives a nebulized racemic epinephrine treatment to Patient B.  Within the next twenty minutes her symptoms resolve.  Her husband arrives, and he looks a lot happier than the first time you saw him, too.

You make a phone call.  Minutes later, one of the nurses from the freestanding plastic surgery center drives up in their car to give you a ride back to where your automobile is parked back at the surgery center.

Sound impossible?  Guess again.  This entire scenario occurred three months ago, a mile or two from Stanford hospital.

The diagnosis of post-extubation stridor is more common in newborn infants after prolonged or multiple intubations, but it occurs in adults as well.  In one series of 112 extubations of adults in an ICU in France, the prevalence of post-extubation stridor was 12% (Jaber S, Intensive Care Med. 2003 Jan;29(1):69-74).  Occurrence after extubation post-surgery is less common.  When laryngospasm occurs in the OR immediately post-intubation, we are all taught to treat the patient with 100% oxygen and CPAP by face mask.  The laryngospasm usually clears as the patient awakens from anesthesia and mounts a strong cough to clear secretions from the larynx.

When stridor occurs in the PACU of a hospital, the established medical therapy is nebulized racemic epinephrine (Vaponefrin), .5 ml of a 2.25%solution q 3-4 hours given by Respiratory Therapy, and a dose of dexamethasone 4 – 8 mg IV (Miller, Anesthesia, 2005, pp 2817, 2538).   Nebulized epinephrine acts as both an alpha and beta adrenergic agonist, and has both vasoconstrictor and bronchodilator properties.

The lack of Respiratory Therapy in freestanding surgery centers is another of the issues that differentiates them from in-hospital ambulatory surgery centers.  The plastic surgery center that suffered through this episode has now purchased the equipment to deliver nebulized epinephrine post-op.  It may be years, or decades, before they get an opportunity to use it.  A more important lesson is that the perioperative care of surgical patients is multi-faceted, and no one is better prepared to diagnose or treat problems than an anesthesiologist.  If you practice anesthesia in freestanding surgery centers long enough, you too will experience a ride in an ambulance to the ER.  Hopefully your story will have a happy ending, as our Clinical Case of the Month did.

Our patient was discharged home from the ER after a stable four hour observation period, and she had no further problems at home.

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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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WHAT IF YOUR SON NEEDS AN EMERGENCY APPENDECTOMY ON VACATION?

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

Clinical Case for Discussion:  You, your spouse, and your 5-year-old son are vacationing in Montana when your son develops acute abdominal pain and fever.  You take him to the largest medical center around, the community hospital in a town with a population of 20,000.  The surgeon there makes the diagnosis of an acute abdomen, and plans on operating.  You meet the anesthesia provider, and it is an unsupervised certified registered nurse anesthetist (CRNA). What do you do?

Discussion: Circa 1985, one of my anesthesia Stanford mentors told me this:  “If you’re on vacation in some rural place like Montana, and you need emergency surgery, let the anesthetist do the case whatever way he usually does it–if the only way he knows how to do things is open drop ether technique, you need to let him do it the way he knows.  It’s not the time to educate him into trying something new and different.”

Now you are in a rural hospital with a sick kid, and you feel nervous.  You ask the CRNA about his clinical experience, and he tells you he’s been out of training for 10 years, and has anesthetized hundreds of children without a single complication.

Your spouse (a non-medical professional) speaks up first, declaring that you are an anesthesiologist, and that he or she (the spouse) is adamantly opposed to the child having an anesthetic by a unsupervised nurse.  Your spouse asks how far it is to the nearest major medical center that would have pediatric anesthesia care supervised or performed by an MD?  The answer: a two-and-a-half hour drive.  Your child is moaning in the bed in front of you, and you realize that delaying the surgery for hours is a bad idea.

Your spouse tells you he/she wants you to do the anesthetic.  There are several problems with this solution.  Number one:  you do not have a state license in Montana.  Number two:  the hospital has a policy that family members are not allowed into the operating rooms during surgery.  Number three:  you have always been advised by your mentors and peers that physicians who take anesthetize or operate on their own family members have a difficult time being either objective or professional if some unfortunate complication arise.

You pull the surgeon aside and ask his views on the CRNA and the pediatric anesthetic assignment.  The surgeon reports that he has been working with this CRNA for 12 months, but has yet to see the CRNA anesthetize anyone under the age of 18 for him.  He confirms that on this weekend evening, there are no other anesthesia professionals within sixty miles.

Your son continues to moan.  Your spouse is pacing, and continues to fret about the CRNA not touching the child.  Your head is spinning.  What do you do?

As a father and an anesthesiologist, on 4 occasions I have handed one of my kids over to another anesthesiologist for surgery.  Each time I selected the anesthesiologist myself, I knew the anesthesiologist well, and trusted their skills under any circumstances.  Each surgery went well, but I can attest that every parent is on edge until they see their child awake and well after the conclusion of the surgery.  You, as a parent, will feel intensely protective of your child.

You realize that surgical emergencies likely occur somewhere in Montana every day, and that unsupervised nurse anesthetists are conducting many of these anesthetics.  You haven’t heard or read of an epidemic of anesthetic disasters in “opt out” states, where governors have decided that CRNA’s can conduct anesthesia without MD supervision.

You reason that your son is probably on safe ground, but . . . if something went wrong, you’d feel guilty for not being more involved. You know you’d feel uncomfortable sitting in the waiting room while the surgeon and CRNA do their best work in the OR.  Can  you convince the surgeon and CRNA that you want to be in the OR with them as an observer, although this is against hospital policy?  Can you convince them to telephone the Chief of Staff to make an exception in this one case?

What if the story played out as follows:  You call the Chief of Staff, you present your request is a cordial fashion, she empathizes, and allows you to observe in the OR.

You watch the anesthetic induction proceed uneventfully.  After intubation, the anesthetist inserts an oral gastric tube to suction out the stomach.  The surgery begins, and the diagnosis is a perforated appendix.  The surgeon performs the required surgery.  On anesthetic emergence, the CRNA untapes the endotracheal tube before your son’s eyes open, and begins letting air out of the cuff with a syringe.  Your heart rate quickens, and you blurt out, “Can you wait until he’s more awake before extubating him?”  The anesthetist answers, “I like to extubate deep, so there is less bucking.  I suctioned the oral gastric tube, so I know his stomach is empty now.”  While the two of you are debating, your son wretches forcefully and vomits a large volume of bilious fluid.  The good news is that the endotracheal tube was still in place, with the cuff inflated.  The good news is that none of the vomitus was aspirated.  Flustered, the anesthetist suctions out the mouth, and waits until the patient is wide awake before extubating him.  Minutes later, your son is awake and safe, but your hands are still shaking.

Fiction?  Sure, but the issue and question is whether or not unsupervised CRNA anesthesia is a good idea.  If your son had aspirated due to poor anesthetic judgment, would that event have shown up as a vital statistic anywhere?  I doubt it.

J H Silber’s landmark study from the University of Pennsylvania (Anesthesiologist direction and patient outcomes, Anesthesiology. 2000 Jul;93(1):152-63) documented that both 30-day mortality and failure-to-rescue rates were lower when anesthesia care was supervised by anesthesiologists, as opposed to anesthesia care by unsupervised nurse anesthetists.  This study was widely discussed.  The CRNA community dismissed the conclusions, citing that it was a retrospective study.   In a letter to the editor published in Anesthesiology, Dr. Bruce Kleinman wrote regarding the Silber data, “this study could not and does not address the key issue: can CRNAs practice independently? In fact, the negative outcomes in this retrospective study may be related to the medical direction of nonanesthesiologists and may not be related in any way to the practice of CRNAs per se.” (Anesthesiology: April 2001 – Volume 94 – Issue 4 – p 713)

Governor Schwarzenegger stunned California anesthesiologists in July 2009 by signing a document opting California out of the requirement for CRNA’s to be supervised by an MD.  An important conflict is the fact that California law rules that an MD must supervise the medical practice of CRNA’s.  The outcome for California is still undetermined, but the threat of CRNA’s replacing larger subsets of anesthesiologist’s work in future years is a crucial and daunting issue that all of us will follow with interest and intensity. Your delegates and lobbyists in the California Society of Anesthesiologists and the American Society of Anesthesiologists are working on the issue of unsupervised CRNA anesthesia care.  It’s a battle that needs to be fought, for the patients and their families, as much as for the careers of present and future anesthesiologists.

Back to the Clinical Case–if you are vacationing in Yellowstone or Glacier National Parks next summer, hopefully your family will stay out of the operating room and you never have the ponder any of these  problems.

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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