THE TWO LAWS OF ANESTHESIA (ACCORDING TO SURGEONS)

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

There are Two Laws of Anesthesia, according to surgeon lore. They are:

  1. The patient must not move.
  2. The patient must wake up (when the surgery is over).

Surgeons work with physician anesthesiologists, with certified nurse anesthetists (CRNAs), or with an anesthesia care team that includes both physician anesthesiologists and CRNAs. Most surgeons’ comprehension of what anesthesiologists are doing is limited. Most surgery residencies have zero months of anesthesia training out of their sixty months of total residency. No matter who supplies the anesthesia services, to our surgical colleagues the critical requirements of anesthesia include 1. and 2. above. 

Period.

Physician anesthesiologists finish medical school and complete at a minimum four additional years of training. Surgeons finish medical school and complete at a minimum five additional years of training. There’s not much difference there. Anesthesiologists typically spend 90+% of their working hours in the operating room. A busy surgeon will spend 50% of their time in the operating room, and the other 50% in preoperative clinic, postoperative clinic, or rounding on patients in the hospital. Anesthesiologists win the tally for most operating room hours per week. Anesthesiologists take care of a patient’s heart, lungs, brain, and kidney function before, during, and after surgery. Surgeons perform a specific operation on one organ system, e.g. heart surgeons operate on the heart, orthopedic surgeons operate on a bone or a joint, and ear surgeons operate on ears.

Yet in all the surgical specialties, Two Laws describe the surgeons’ lofty expectations of anesthesia professionals:

  1. The patient must not move.
  2. The patient must wake up (when the surgery is over).

Physician anesthesiologists learn to perform anesthesia for all types of surgery, including cardiac, vascular, trauma, neurosurgery, pediatrics, eye, ear nose and throat, urology, and obstetrics. Physician anesthesiologists attend to patients of all ages, from newborns to centenarians. Physician anesthesiologists develop an extensive understanding of physiology as well as the pharmacology of hundreds of medications. Physician anesthesiologists regularly insert breathing tubes, venous catheters, arterial catheters, and stomach tubes, and inject regional anesthetic blocks into the spinal fluid, the epidural space, and learn nerve blocks of every major peripheral nerve.

Yet to our surgical colleagues, Two Laws describe an excellent anesthesiologist’s work:

  1. The patient must not move.
  2. The patient must wake up (when the surgery is over).

Let’s examine the Two Laws:

  1. The patient must not move. This Law is important because a surgeon must not be distracted by motion within the surgical field. If a patient coughs or bucks on the breathing tube, movement will occur. The surgeon must stop, sometimes for 60 seconds or more, while the anesthesiologist administers additional drugs to the patient. During these 60 seconds, it’s important that the surgeon sighs, crosses his or her arms, or otherwise expresses what a major inconvenience this loss of 60 seconds has been. Has a patient ever been harmed by an episode of brief movement? In the overwhelming majority of surgeries there is no harm whatsoever. In a perfect anesthesia world, patients will not move. But in the majority of anesthetics the patient is not chemically paralyzed, and it is possible for movement to occur. An overly deep level of anesthesia will help prevent movement, but has the adverse consequence of requiring a longer time to wake the patient at the end of the surgery. Which brings us to Law #2:
  2. The patient must wake up. When the surgeon finishes suturing the skin incision and  concludes the surgery, he or she will remove their gloves and gown and wait for the anesthesiologist to wake the patient. Modern anesthetics wear off quickly, and for most surgeries the duration of time from the end of surgery to the patient waking and talking is approximately 10 – 15 minutes. But these are minutes during which the surgeon must watch and wait. These are minutes during which the surgeon’s valuable time is ticking by, and seemingly wasted. In the overwhelming majority of surgeries, anesthesiologists successfully wake the patient and remove the breathing tube. At this time the surgeon can leave the operating room to meet with the patient’s family and discuss the successful operation. None of this could happen if the anesthesiologist was not competent with Law #2. 

If you’re a medical student considering a surgical specialty, it’s important you understand the Two Laws. If you become an anesthesiologist or a surgeon, you will be on one side or the other of the Two Laws. 

If you’re a patient, consider that it’s your surgeon’s job to cut and cure while it’s your anesthesiologist’s job to keep you from moving and to wake you up. Of course, your vigilant physician anesthesiologist will also assure that you’re safe, asleep, and unaware. Your vigilant physician anesthesiologist will also assure that you’re as stable and as healthy as possible after surgery. Trust your anesthesiologist  and realize that while these Two Laws come from the lips of surgeons, the genesis of the Two Laws perhaps occurred with a tongue in cheek. I’ve had excellent relationships with hundreds of surgeons over decades, and despite these Two Laws, the majority of surgeons are wonderful doctors and healers who are not condescending toward their anesthesia colleagues whatsoever.

*

*

*

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

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

CAN ANESTHESIA MACHINES BE USED FOR ICU VENTILATORS?

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

Can anesthesia machines be used as ICU ventilators for COVID-19 patients?

Yes, they can. 

Every anesthesia machine has a ventilator attached to it. The ventilator is not as complex a device as what is found in the ICU, but an anesthesia machine ventilator is fully capable of ventilating sick COVID-19 patients, who have the severe pneumonia known as Acute Respiratory Distress Syndrome (ARDS). For years physician anesthesiologists have transported sick patients from the intensive care unit (ICU) to the operating room (OR) when patients needed a surgical procedure. These sick patients have been successfully maintained on the anesthesia machine ventilator, and physician anesthesiologists have attended to them.

The most practical way to utilize an anesthesia machine as a ventilator would be to convert the existing operating room into a temporary ICU in this time of the COVID-19 pandemic, when we face a threat of inadequate numbers of ICU beds and ventilators. Who would staff these additional temporary ICUs? It could possibly be the customary staff of the operating room, i.e. a circulating nurse and an anesthesiologist. Ideally there would need to be consultation and care by a critical care attending physician, to make sure the proper management is applied to all of a patient’s physiologic systems, e.g. their heart, kidneys, lungs, their antibiotics and their nutrition.

The American Society of Anesthesiologists (ASA) held an online Town Hall meeting last Thursday night, March 19th, 2020 to discuss anesthesiology information pertaining to the COVID-19 pandemic. The question of using anesthesia machines for ICU ventilators was specifically discussed. ASA President Dr. Mary Dale Peterson said she’d already participated in a conference call with government leadership, including President Trump, regarding the pandemic. She said she’d suggested the use of anesthesia machines as ventilators for COVID-19 patients, as well as an increased role for physician anesthesiologists in the ICU care of infected patients.

A typical anesthesia machine is pictured above. The ventilator aspect of the machine is magnified below:

Anesthesia machine ventilators are capable of delivering variable amounts of oxygen, from room air 21%, to a full 100% oxygen if necessary. Most anesthesia machines are capable of delivering increasing amounts of Positive End Expiratory Pressure (PEEP) up to 20 cmH20, which is often necessary to oxygenate patients with severe ARDS. Anesthesia ventilators can function in volume control mode (by delivering a set volume of a tidal breath), or pressure control mode (by delivering a present inspiratory pressure of each tidal breath).

Anesthesia machines would need to be equipped with an inline bacterial/viral filter on the expiration limb of the disposable breathing hoses, to keep viruses from infecting the machine. This is easily done.

Will anesthesiologists be called to step forward at this time of crisis to man temporary operating rooms that are converted to ICUs? Perhaps. It will depend on the number of critical care MDs who are already available, and whether additional staffing is needed. It will depend on the supply of Personal Protective Equipment (PPE) available. (Asking anyone to step into a COVID-19 ICU without the required PPE is a dangerous request. The ongoing search for more N95 masks, face shields, gowns, and gloves is critical.) It will depend on the ages of the available anesthesia personnel. The death rate for COVID-19 infection increases markedly after age 60, so older anesthetists would be less than ideal. Is there a role for Certified Registered Nurse Anesthetists if ORs are converted into ICUs? Yes.

You can also read an earlier column I wrote on Coronavirus and ICU ventilators.

For more details on anesthesia machines and ventilators, this link will connect you to the website of North American Draeger, a leading manufacturer of anesthesia machines.

Specific information on Draeger anesthesia ventilators can be found here.