THE DIFFERENCE BETWEEN A PHYSICIAN ANESTHESIOLOGIST AND A NURSE ANESTHETIST

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

What’s the difference between a physician anesthesiologist and a nurse anesthetist? After the first 3 – 4 years in the workforce, either one can master the manual skills of anesthesia. That is, either one can display excellence in intubating the trachea, performing a spinal or an epidural anesthetic, performing a nerve block, inserting an arterial line, or inserting a central venous pressure catheter. There is no fork in the career path that makes a busy Certified Registered Nurse Anesthetist (CRNA) automatically inferior to a medical doctor anesthesiologist in hands-on skills. So what really is the difference between a physician anesthesiologist and a nurse anesthetist? The answer: internal medicine.

All physician anesthesiologists graduate from medical school, where they rotate through clerkships in surgery, pediatrics, obstetrics-gynecology, internal medicine, emergency medicine and psychiatry, as well as electives in surgical or medicine subspecialties of their choice.

By contrast, CRNAs are registered nurses experienced in intensive care or emergency room nursing, who then enter a 2 – 3 year program of learning the skills to anesthetize patientsCRNAs can now administer anesthesia independent of any physician anesthesiologist supervision in the majority of the United States

The difference between a physician anesthesiologist and a nurse anesthetist is that the former has a depth of knowledge of 1) the physiology of the human body, 2) the pathophysiology of diseases, 3) the breadth of pharmacology, and 4) the ability to make diagnoses and prescribe treatment. In short, the physician anesthesiologist has extensive training in the internal medicine essentials of 1), 2), 3), and 4) above.

Nurse anesthetists are valuable and integral cogs in American healthcare. It’s not my intention to demean or minimize the role of CRNAs. My goal is to point out the most specific difference between a physician anesthesiologist and a nurse anesthetist.

At Stanford our department is named the Department of Anesthesiology, Perioperative and Pain Medicine. What is Perioperative Medicine? Perioperative Medicine is all the medical care before, during, and after surgery. Is Perioperative Medicine a subspecialty of internal medicine? In a way, it is. Following an internal medicine residency, graduates may subspecialize in cardiology, oncology, pulmonary medicine, kidney medicine, infectious disease, critical care, or . . . perioperative medicine. When I finished my Stanford internal medicine residency, the top four choices among my colleagues for the next step were: #1 a cardiology fellowship, #2 general internal medicine private practice, #3 an anesthesia residency, or #4 an oncology fellowship.

Stanford University now offers a combined internal medicine/anesthesiology residency, with the goal of training leaders in anesthesiology. The PGY1 year is spent entirely on medicine rotations.  The PGY2 year consists of all anesthesia rotations.  During PGY3-5 years, the resident alternates between 3 months of medicine rotations and 3 months of anesthesia rotations.

The outgoing Chairman of Anesthesiology, Perioperative and Pain Medicine at Stanford is Ronald Pearl MD PhD, an outstanding clinician and scientist who led our department for twenty-two years. In addition to board-certification in internal medicine and anesthesiology, Dr. Pearl is also board certified in critical care medicine. Dr. Pearl is one of the smartest clinicians I’ve ever met. His extensive internal medicine knowledge raises him above other anesthesia providers. 

Currently, anesthesiology residency programs are three years in duration, beginning after a resident has completed at least one year of internship. During those three years of anesthesia residency (PGY2 – PGY4) the resident rotates through

  • two one-month rotations in: obstetric anesthesiology, pediatric anesthesiology, neuro anesthesiology, and cardiothoracic anesthesiology
  • a minimum of one month in the adult intensive care unit during each of the three years 
  • three months of pain medicine, including one month in acute perioperative pain, one month in chronic pain, and one month of regional analgesia/peripheral nerve blocks
  • one-half month in a preoperative evaluation clinic 
  • one-half month in a post anesthesia care unit, and one-half month in out-of-OR locations.  

These rotations of an anesthesia resident develop the young doctor into a clinician comfortable in preoperative assessment and management, in the intraoperative administration of anesthesia, and in the postoperative evaluation and treatment of patients. 

Currently, internal medicine residency programs are three years in duration, including a one-year internship in internal medicine. During those three years (PGY1 -PGY3) a resident rotates through: 

  • a minimum of 4 months of critical care (medical ICU or cardiac care unit) rotations
  • a minimum of 1/3 of Internal Medicine training occurs in an ambulatory setting
  • a minimum of 1/3 of Internal Medicine training occurs in an inpatient setting
  • a longitudinal continuity clinic of 130 one-half-day sessions over the course of training, including one clinic per month. The continuity clinic includes evaluation of performance data for resident’s panel of patients.
  • exposure to each of the internal medicine subspecialties and to neurology
  • an assignment in geriatric medicine
  • an emergency medicine experience of four weeks
  • electives available in psychiatry, allergy/immunology, dermatology, medical ophthalmology, office gynecology, otorhinolaryngology, non-operative orthopedics, palliative medicine, sleep medicine, and rehabilitation medicine

These rotations of an internal medicine resident develop the young doctor into a broadly trained clinician experienced in multiple areas.

I’m not advocating that anesthesia departments be folded under the umbrella of their institution’s department of internal medicine. Instead, what I am recognizing is that the field of anesthesiology is more than putting in breathing tubes, arterial catheters, IV lines, or nerve block needles in a variety of different surgical settings. The field of anesthesiology is understanding and managing medical problems before, during, and after surgery, i.e., Perioperative Medicine. Describing our specialty with the word “Anesthesia” is an oversimplification of what we do. If our specialty was newly named today, it would be called Perioperative Medicine, period.

What about pediatric perioperative medicine? Doesn’t pediatric perioperative medicine involve the knowledge base of pediatricians, instead of the knowledge base of internal medicine? Yes. Deep knowledge of pediatric medicine instead of internal medicine (on adult patients) applies to pediatric perioperative medicine. No doubt a pediatrician who then completes an anesthesia residency will likely be an outstanding pediatric perioperative doctor, but only 5.4 % of anesthesia care in the United States is on pediatric patients less than 15 years old. The majority of the knowledge base for anesthesia care pertains to adult patients, i.e. the knowledge base for internal medicine physicians.

Several examples will illustrate why internal medicine forms the backbone of perioperative anesthesia practice. Before surgery, a patient who presents with insulin dependent diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea is an example of the kind of patient an internal medicine doctor sees regularly in his or her outpatient clinic. During surgery, a patient who develops atrial fibrillation or marked hypertension is an example of the kind of events an internal medicine doctor sees in an intensive care unit. After surgery, a patient who presents with chest pain or shortness of breath is an example of the kind of patient an internal medicine doctor sees in the emergency room or in the intensive care unit. Wait . . . you can argue that a CRNA has previous experience working as a registered nurse in an ICU or an emergency room before beginning nurse anesthetist training. But a registered nurse in an ICU or an emergency room does not independently diagnose and treat medical conditions. A registered nurse in an ICU or an emergency room follows written orders from a medical doctor. There is a world of difference between a medical doctor commanding diagnosis and treatment in an ICU/emergency room versus a registered nurse who follows orders.

Should all anesthesia residency training follow the Stanford optional model of combining internal medicine and anesthesia residencies into one program? No. Prolonging the training of every physician anesthesiologist in the United States makes little sense, but those who desire to be leaders will consider this double-residency option. 

Recent years brought an attempt to rename the territory of anesthesiologists as the “Perioperative Surgical Home.”  The Perioperative Surgical Home is defined as “a patient-centered, team-based, and coordinated perioperative care setup, composed of the head anesthesiologist-perioperativist in tandem with dedicated nurse practitioners and other PSH team doctors.” This is a move in a positive direction, with the intent of better patient care coordinated by an anesthesiologist-led team. There is an economic barrier to the Perioperative Surgical Home, in that the PSH may appear to be a coup attempt for anesthesia departments to take over jurisdictions from preoperative and postoperative internal medicine doctors. Any adoption of the PSH will likely be gradual, as the battle for patients plays out in each medical center.

Instead, a first step is that anesthesia departments redefine themselves as Departments of Perioperative Medicine, and that the academic training for these departments involve increasing time spent expanding the internal medicine knowledge base of residents in medical intensive care units, cardiac intensive care units, medicine wards, and medicine clinics. Performing month after month of repetitive intraoperative anesthesia care has a decreasing return on expanding a resident’s fund of knowledge, and can serve to make the role of a physician anesthesiologists and the role of a nurse anesthetist close to being the same.

It’s important that physician anesthesiologists create perceivable differences between themselves and CRNAs. The role of Perioperative Medical Doctors is a more broad and more specific identity when compared to what nurse anesthetists do. Let’s make our young physician anesthesiologist trainees into Perioperative Medicine Specialists, instead of confusing them with other anesthesia professionals who can also administer propofol, sevoflurane, and rocuronium.

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

THE TOP 20 DOCTORS IN THE HISTORY OF ANESTHESIA

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

Important advances in the history of anesthesia changed medicine forever. Humans have inhabited the Earth for 200,000 years, yet the discovery of surgical anesthesia was a relatively recent development in the mid-1800s. For thousands of years most surgical procedures were accompanied by severe pain, and the only strategies available to decrease pain were to give patients alcohol or opium until they were stuporous. How did our specialty advance from prescribing patients two shots of whiskey to administering safe modern anesthesia? In chronologic order, my choices for the most important doctors in the history of anesthesia are:

1842. Dr. Crawford Long, Georgia, USA. THE CO-DISCOVERER OF ETHER AS A GENERAL ANESTHETIC.  Dr. Long was an American surgeon recognized for introducing the use of inhaled ether as a general anesthetic. Dr. Long administered ether for the first time on March 30, 1842, to remove a tumor from the neck of patient James Venable. Dr. Long dripped ether on a towel through which Mr. Venable inhaled. Dr. Long performed multiple surgeries using this technique, but did not publish his findings until seven years later in 1849 in The Southern Medical and Surgical Journal. As a result, there is a dispute whether Dr. Crawford Long or Dr. William Morton (below) discovered ether anesthesia first. 

1846. Dr. William Morton, Boston, USA. THE FIRST PUBLIC DEMONSTRATION OF ETHER AS A GENERAL ANESTHETIC.  Dr. Morton performed the first public demonstration of general anesthesia at Harvard’s Massachusetts General Hospital on October 16, 1846. Morton, a local dentist, utilized inhaled ether to anesthetize patient Gilbert Abbott for removal of a tumor on the patient’s neck. According to surgeon John Collins Warren’s account of the operation, “(the patient) said that he had felt as if his neck had been scratched; but subsequently, when inquired of by me, his statement was, that he did not experience pain at the time, although aware that the operation was proceeding. Morton was unaware of Dr. Crawford Long’s prior work which began four years earlier in 1842. Morton published his accomplishment in the December 1846 issue of Medical Examiner. Comment: Both Dr. Long and Morton deserve recognition for the discovery and eventual application of ether as a general anesthetic drug. The invention of ether changed medical care forever, making painless surgery a reality.

1853.  Dr. Alexander Wood, Scotland. THE DISCOVERY OF THE HYPODERMIC NEEDLE, THE SYRINGE, AND THE INJECTION OF MORPHINE. Dr. Wood invented a hollow needle that fit on the end of a piston-style syringe, and used the syringe and needle combination to successfully treat pain by injections of morphine.  Comment: Most anesthetic drugs today are injected intravenously. Such injections would be impossible without the invention of the syringe.

1885. Dr. William Halsted, Baltimore, USA. THE DISCOVERY OF INJECTABLE COCAINE AND LOCAL ANESTHESIA.  Cocaine was the first local anesthetic discovered. Dr. Halsted of Johns Hopkins University first injected 4% cocaine into a patient’s forearm and concluded that cocaine blocked sensation. The patient’s arm was numb below but not above the point of injection. Halstead became addicted to cocaine, and later to morphine.  Comment: The discovery of local anesthesia gave doctors the power to block pain in specific locations. The improved local anesthetics procaine (Novocain) and lidocaine were later discovered in 1905 and 1948, respectively.

1899. Dr. August Karl Gustav Bier, Germany. THE FIRST TO PERFORM SPINAL ANESTHESIA, AND ALSO THE INVENTOR OF THE BIER BLOCK (AN INTRAVENOUS REGIONAL ANESTHESIA TECHNIQUE FOR HAND OR FOOT SURGERY).  Dr. Bier was a German surgeon before the concept of an anesthesia specialist was invented. He performed the first surgery under spinal anesthesia in 1899. Dr. Bier injected cocaine through a spinal needle, which paralyzed the lower half of his patient. Dr. Bier was able to perform painless ankle surgery. The patient was fully conscious during the operation. Comment: Dr. Bier was the father of regional anesthesia, an important tool in the repertoire of a modern anesthesiologist.

Dr. Nikolai Korotkov

1905. Dr. Nikolai Korotkov, Russia. THE DISCOVERY OF THE MEASUREMENT OF BLOOD PRESSURE BY BLOOD PRESSURE CUFF. Dr. Korotkov described the sounds produced during auscultation with a stethoscope over a distal portion of an artery as a blood pressure cuff was deflated. These Korotkoff sounds resulted in an accurate determination of systolic and diastolic blood pressure. Comment: Anesthesiologists monitor patients repeatedly during every surgery. A patient’s vital signs are the heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature. It would be impossible to administer safe anesthesia without blood pressure measurement. Low blood pressures may be evidence of anesthetic overdose, excessive bleeding, or heart dysfunction. High blood pressures may be evidence of inadequate anesthetic depth or uncontrolled hypertension.

The cuffed endotracheal tube
Dr. Aurthur Guedel

1932. Dr. Arthur Guedel, Wisconsin, USA. DEVELOPMENT OF THE CUFFED ENDOTRACHEAL BREATHING TUBE. Dr. Guedel added an inflatable cuff to the distal end of a breathing tube to be inserted into a patient’s trachea. This advance allowed the use of positive-pressure ventilation into a patient’s lungs. Comment: Surgery within the abdomen and chest would be impossible without controlling the airway and breathing with a tube in the trachea. Advanced cardiac life support (ACLS) of Airway-Breathing-Circulation depends on the insertion of a cuffed endotracheal tube.

1927. Dr. Ralph Waters, University of Wisconsin, USA. THE FIRST ANESTHESIA RESIDENCY PROGRAM. Before Dr. Waters, a variety of individuals administered anesthesia. He developed the first department of anesthesia at a medical school, and established the first resident training program in anesthesia. He is considered the “father of academic anesthesia.” Dr. Waters also introduced the anesthetic gas cyclopropane into clinical use, the carbon dioxide absorption method on the anesthesia machine, and endobronchial anesthesia for thoracic surgery. Comment: Every university anesthesia residency program owes a debt to the legacy of Ralph Waters. 

Dr. John Lundy

1934. Dr. John Lundy, Mayo Clinic, Minnesota, USA. THE INTRODUCTION OF INTRAVENOUS THIOPENTAL AND INJECTABLE BARBITURATES.  Dr. Lundy of the Mayo Clinic in Rochester, Minnesota introduced the intravenous anesthetic sodium thiopental into medical practice. In 1934, Dr. Ernest Volwiler and Dr. Donnalee Tabern synthesized Pentothal, the first intravenous general anesthetic. Pentothal was first used in humans on 8 March 1934 by Dr. Ralph Waters. Three months later, Dr. John Lundy started clinical trials of thiopental at the Mayo Clinic at the request of Abbott Laboratories. Injecting Pentothal provided a more pleasant induction of anesthesia than inhaling pungent ether. Comment: This was a huge breakthrough. Almost every modern anesthetic begins with the intravenous injection of an anesthetic drug. (Propofol has now replaced Pentothal.)

1941, Dr. Robert Miller, Texas, USA. INVENTION OF THE MILLER INTUBATING LARYNGOSCOPE BLADE. The Miller straight laryngoscope blade was used to elevate the epiglottis and enabled anesthesiologists to directly view the vocal cords and the laryngeal opening in an anesthetized patient, so they could directly place an endotracheal breathing tube into the trachea. Comment: The Miller straight laryngoscope blade is the second most common blade used for direct laryngoscopy today, and my personal favorite.

Dr. Harold Griffith

1942. Dr. Harold Griffith, Montreal, Canada. THE DISCOVERY OF CURARE, THE FIRST INJECTABLE MUSCLE RELAXANT.  Dr. Griffith injected the paralyzing drug curare to 25 patients during cyclopropane general anesthesia to induce muscular relaxation. Although the existence of curare was known for many years—it was used on poison arrows by South American Indians—it was not used in surgery to deliberately cause muscle relaxation until this time. Comment: Paralyzing drugs are necessary to enable the easy insertion of endotracheal tubes into anesthetized patients, and paralysis is also essential for many abdominal and chest surgeries.

1943, Dr. Robert Macintosh, England.  INVENTION OF THE MACINTOSH INTUBATING LARYNGOSCOPE BLADE. The Macintosh curved laryngoscope blade enabled anesthesiologists to indirectly elevate the epiglottis and view the vocal cords and the laryngeal opening in an anesthetized patient, so they could directly place an endotracheal breathing tube into the trachea. Comment: The Macintosh curved laryngoscope blade is the most common blade used for direct laryngoscopy today.

ventilating the lungs by bag-ventilation via a tracheostomy

1953. Dr. Bjorn Ibsen, Denmark. THE DEVELOPMENT OF THE FIRST INTENSIVE CARE UNIT (ICU).  The origin of the ICU followed the Copenhagen polio epidemic of 1952, which caused respiratory failure in hundreds of patients. Hundreds of patients required ventilation for weeks. Dr. Ibsen organized over a thousand medical students who positive-pressure-ventilated the lungs of these patients by bag-ventilation via tracheostomies. This gathering uniting of physicians and medical students to manage sick patients led to Ibsen being considered the “father of intensive care.” Comment: In the ICU, the Airway-Breathing-Circulation management perfected in the operating room was extended to critically ill patients who were not undergoing surgery.

1956. Dr. Charles Suckling. THE DISCOVERY OF HALOTHANE, THE FIRST MODERN INHALED ANESTHETIC. British chemist Charles Suckling synthesized the inhaled anesthetic halothane. Halothane had significant advantages over ether or cyclopropane. Halothane had a more pleasant odor, a higher potency, faster onset, and was nonflammable. Halothane gradually replaced older anesthetic vapors and achieved worldwide acceptance. Comment: Halothane was the forerunner of our modern inhaled anesthetics isoflurane, desflurane, and sevoflurane. These drugs have faster onset and offset times, cause less nausea, and are not explosive like ether was. The discovery of halothane changed inhalation anesthesia forever.

Dr. John Severinghaus and the first blood gas analyzer

1957. Dr. John Severinghaus, UCSF, California, USA. THE FIRST MEASUREMENT OF ACID/BASE CHEMISTRY OF HUMAN BLOOD.  Dr. Severinghaus developed the first blood gas analyzer, now on display in the Smithsonian Museum, which measured the pH, pCO2, and pO2 in a sample of arterial blood. https://www.mlo-online.com/continuing-education/article/13008466/blood-gas-testing-a-brief-history-and-new-regulatory-developments  He also developed the initial methods for measuring end-tidal gas concentrations in anesthetized patients in the mid-1970s, and he worked with Dr. Eger (below) on the discovery of minimum alveolar concentration of inhaled anesthetics. He died in 2021 at the age of 99 years. Comment: Measuring blood gases in an acutely ill patient is a cornerstone of all ER and ICU medicine. Measuring blood gases is also routine in cardiac, neurosurgical, and trauma anesthesia, and the measurement of end-tidal gas concentration is a standard in general anesthetics today.

1960s. Dr. Ted Eger, UCSF, California, USA. DISCOVERY OF THE MINIMUM ALVEOLAR CONCENTRATION OF POTENT INHALED ANESTHETICS. Dr. Eger defined the science of inhaled anesthesia uptake and concentration when he characterized the Minimum Alveolar Concentration (MAC) of every gaseous anesthesia drug. Per Dr. Eger’s New York Times obituary when he died at the age of 86 in 2017, he was “a leader in the development of a now universally used technique to determine the proper dose of anesthetic gas administered in operating rooms.” Comment: Almost every general anesthetic today includes some form of an inhaled anesthetic such as sevoflurane, desflurane, or nitrous oxide. Dr. Eger’s work defined the principles of how much gas to administer to each patient.

A pulse oximeter probe
Dr. William New

1983. Dr. William New, Stanford University, California, USA. THE DEVELOPMENT OF PULSE OXIMETRY MONITORING. The Nellcor pulse oximeter, co-developed by Stanford anesthesiologist Dr. William New, was the first commercially available device to measure the oxygen saturation in a patient’s bloodstream. The Nellcor pulse oximeter had the unique feature of lowering the audible pitch of the pulse tone as the oxygen saturation dropped, giving anesthesiologists an audible early warning that their patient’s heart and brain were in danger of low oxygen levels. Comment: The Nellcor changed patient monitoring forever. Oxygen saturation is now monitored before, during, and after every surgery. Prior to Nellcor monitoring, the first sign of low oxygen levels was often a cardiac arrest. Following the invention of the Nellcor, oxygen saturation became the fifth vital sign, along with pulse rate, respiratory rate, blood pressure, and temperature.

1987. Dr. Archie Brain, England. DEVELOPMENT OF THE FIRST COMMERCIAL LARYNGEAL MASK AIRWAY. The Laryngeal Mask Airway (LMA) replaced the endotracheal tube as the airway device for many general anesthetics. The LMA can be inserted blindly into a patient’s mouth, does not require the patient to be paralyzed for insertion, is an easy method for securing the airway, and does not require a laryngoscope. The LMA was introduced to the United States market in 1992. Comment: The LMA revolutionized the general anesthetic technique for most extremity surgeries, some head and neck surgeries, and is used as a rescue technique in the American Society of Anesthesiologists Difficult Airway Algorithm (see below).

1990s. Dr. Jonathan Benumof, UCSD, San Diego, California, USA.  DEVELOPMENT OF THE DIFFICULT AIRWAY ALGORITHM. Dr. Benumof was the main originator of the American Society of Anesthesiologists Difficulty Airway Algorithm, first published in 1996. The Difficult Airway Algorithm describes pathways to safe airway management, and its application has saved countless lives. Comment: The Difficult Airway Algorithm is the standard of care for managing patients who are difficult to intubate and/or oxygenate. All anesthesiology providers commit the algorithm to memory, because when airway disasters occur there is simply no time for them to Google the correct order of rescue procedures.

The GlideScopy
Dr. John Pacey

2001. Dr. John Pacey, vascular and general surgeon, University of British Columbia, Canada. INVENTION OF THE GLIDESCOPE, THE WORLD’S FIRST VIDEOLARYNGOSCOPE. Dr. Pacey introduced the GlideScope (Verathon) as the first commercially available video laryngoscope in 2001. The GlideScope combined two new technologies: the video laryngoscope and the hyper-angulated laryngoscope blade, and enabling doctors and CRNAs to “see around the corner” of the airway to place endotracheal tubes into the trachea of  patients with difficult airways. Comment: Note that Dr. Pacey and several other doctors on this Top 20 List invented improvements in airway management. Failed airway management remains the most dreaded complication in anesthesia practice, as it can lead to anoxic brain damage. We are thankful to Drs. Arthur Guedel, Ralph Waters, Robert Miller, Robert Macintosh, Archie Brain, Jon Benumof, and John Pacey, whose inventions made intubation of the difficult airway . . . less difficult. 

These are the top 20 doctors who made major advances in the history of anesthesia as I see them. Who will be the next successful inventor to advance our specialty? At Stanford University our department is titled the Department of Anesthesiology, Perioperative and Pain Medicine. A key question for the future of Anesthesiology is “How do anesthetics work on the brain?” A key question for the future of Pain Medicine is “How can we more effectively block pain?” In 2016 an estimated 20.4% of the adults in the United States had chronic pain, and the relief of pain remains a key unsolved problem. Anesthesiologists or scientists who develop answers to these questions will likely join The Top Doctors in the History of Anesthesia list.

AUTHOR’S NOTE: The ultimate chronicle of anesthesia history is The Wondrous Story of Anesthesia, edited by Dr. Ted Eger, Dr. Laurence Saidman, and Dr. Rod Westhorpe. It’s available on Amazon and deserves to be on the bookshelf of every medical library in the world.

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

WHEN INTERNS AND RESIDENTS UNIONIZE

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

On May 2, 2022, residents and fellows (medical doctors in their first years of educational work after medical school) at Stanford University Health Care voted to unionize. In an email to medical staff, the Graduate Medical Education administration wrote: “Stanford Health Care (SHC) residents and fellows voted in favor of having The Committee of Interns and Residents (CIR), a local of Service Employees International Union (SEIU), serve as their collective bargaining representative. The votes cast in the election represent the sentiment of 1,049 residents and fellows who participated, out of the 1,478 employed by SHC. Ultimately, 835 voted ‘yes’ to unionization; 214 voted ‘no.’ . . . While we believe that the best relationship with our employees is a direct one without a union, we respect the results. . . . When the results are certified in the coming days, the first stages of the collective bargaining process will begin. . . . We will negotiate with the union in good faith to reach an agreement that reflects your priorities, while maintaining the best parts about training at Stanford.”

Stanford residents and fellows are not alone in choosing to unionize. A total of 1450 residents and fellows at UCSF (University of California San Francisco) recently voted to join the same Committee of Interns and Residents (CIR) union. The UCSF residents stated, “By joining CIR, UCSF residents will be able to negotiate their contracts for the first time, including bargaining for better salaries, benefits, time off, and other provisions that will improve resident life and well-being.” 

A total of over 20,000 residents and fellows at hospitals around the U.S. have voted to join this CIR union. What will this development mean to healthcare in the United States? I respect residents and fellows at the highest level. I spent five years as a medical resident, and I can empathize with the demands of their workload. From my current perspective as an attending physician at an academic medical center, how will this unionizing of housestaff (MDs who are residents and fellows) play out? 

First off, why form a union? The main reasons are a lack of bargaining power regarding:

  1. Burnout and staffing. Housestaff work up to 80 hours per week, a number that is twice the 40-hour workweek considered standard in the United States, and they do this for a duration of 3 to 7 years, depending on their specialty.  The rate of burnout is known to be high in medical doctors, and despite nods to wellness programs at most university hospitals, improvements have been slow in coming. An online survey of doctors finds an overall physician burnout rate of 42%, and the highest percentage of burnout occurred in these six specialties: urology: 54%, neurology: 50%, nephrology: 49%, diabetes and endocrinology: 46%, family medicine: 46%, and radiology: 46%.
  2. COVID. The long hours and risks of acquiring COVID while working with sick COVID patients from 2020 -2022 made many residents and fellows feel vulnerable and angry. While hospital administrators and many faculty returned to the safe havens of their homes each night, interns and residents staffed intensive care units, wards, and emergency rooms, caring for patients with this terrifying new contagious disease. When University of Massachusetts interns and residents joined the CIR union, they stated, “When the pandemic struck, securing better conditions became even more urgent, as the inequities in our healthcare system were laid bare — and in light of the rapid changes that left residents scrambling to keep up within traumatizing and sometimes dangerous practice conditions.”
  3. Higher pay. Residents and fellows are paid a salary. They do not earn an hourly wage. When their salary is divided by 80 hours of work per week, 50 weeks per year, most residents and fellows are making less than minimum wage. When University of Massachusetts interns and residents joined the CIR union, they stated, “UMass Memorial residents are willing to work 80 hours per week because we know exceptional care is critical to community well-being, but we are significantly underpaid for doing so.” 
  4. Better benefits. Residents and fellows will desire more vacation time, top-notch health insurance benefits, and perhaps even retirement contributions.

If residents and fellows don’t receive what they seek during negotiations with the administration, what consequence can residents and fellows turn to? Will they go on strike? In May 2019, interns and residents at UCSF staged a 15-minute “Unity Break” strike as a show of solidarity and power. The Committee of Interns and Residents, which represented 1,100 of UCSF’s resident and fellow population at that time, said that management had not properly recognized the contributions of their resident and intern members and offered a package that left them underpaid and underrepresented. “UCSF has failed to meet some of the very basic demands that we have been fighting for at the table,” said Kim Carter, director of the union. 

Can doctors strike? Is it ethically OK for doctors to strike? I think the answer is no. To leave patients without healthcare while doctors strike for better hours, wages, and benefits is a violation of the ethics of our healing profession. I don’t believe young doctors should be abused or squeezed into unacceptable hours, low wages, and/or poor benefits, but doctors staging a labor walkout would be a mistake. And if a union will never strike, will it ever have any real negotiating power? The CRONA (Committee for the Recognition of Nursing Achievement) nursing union at Stanford staged a strike beginning April 25, 2022, just days ago. Negotiations were successful after only one week of the strike, with the nurses gaining a tentative agreement for significant base wage increases of 5% on April 1, 2022, 2% on December 1, 2022, 5% on April 1 2023, and 5% on April 2024, in addition to other improvements in benefits, staffing, and scheduling. 

I have firsthand experience with strikes. I was a laborer during three United Steelworkers of America strikes in Northern Minnesota during summer employment in taconite mines while I was in college and medical school. Blue-collar strikes are not pretty. The picket lines were brutal, and no one dared cross them. Both sides lost money as the strikes wore on, and interpersonal conflicts simmered for a long time afterward. 

The idea of residents and fellows joining a union is not a new one. In 2001 The Los Angeles Times reported a story on this topic. The article stated, “Striking will disrupt the educational progression of classes, clinical practice and testing. A student wants to come in and have some certainty that his or her three-year residency will take three years. How would they feel if suddenly they were told they wouldn’t finish on time and, whether a strike is a good idea or a bad one, that they’re not going to be able to take a board exam?” One of the doctors who joined the union at that time stated, “Change won’t come overnight, but I think it will happen. We have to stop that cowboy attitude: ‘It’s always been this way, we’re tough, we don’t complain.’ Many residents want to complain, but they’re in an environment where if they do, they’re punished. Residents have to fight for all these things and, without a union, they don’t have any legs to stand on.”  

The ”cowboy attitude” refers an old-school medical education argument that sounds like this: “There’s no other way to educate doctors. It takes at least 80-100 hours per week. Even if you stay in-house every other night you miss half the good cases. When I was a resident, back in the (fill in the blank . . . 1950s, 1960s, 1970s, or 1980s), we slept in the hospital every other night and worked 120 hours per week. Now residents are complaining that 80 hours per week is too much.”

When I was an internal medicine resident in the 1980s, we stayed in the hospital on-call every third night and worked approximately 100 hours per week. My salary during my first year of residency was $16,000. On an hourly basis, this equated to $3.33 per hour. Adjusted for inflation, my 1980 salary would be $55,826, or $11.63 per hour, less than the current minimum wage. 

If medical centers shorten the workweek of interns and residents to 40 hours per week from the current limit of 80 hours per week, the medical center may need to hire twice as many interns and residents or other physician surrogates to do the workload. And if the union negotiates a 10-20% increase in annual salary, the cost for interns and resident would increase further. Where will all this money come from? Most of the salaries of residents and fellows are paid for by billions of dollars of federal tax money, as medical education is subsidized by the United States government. The publication Congressional Research Sources states, “Federal support for medical residency training (a.k.a., graduate medical education [GME]) is the largest source of federal support for the health care workforce. Although the health workforce includes a number of professions, the size of the federal investment in GME—estimated at $16 billion in 2015—makes it a policy lever often considered to alter the health care workforce and impact health care access.” 

Labor unions in the United States are organizations that represent workers in many industries. Labor unions grew afterCongress passed the National Labor Relations Act (NLRA) in 1935 to protect the rights of both employees and employers, to encourage collective bargaining, and to eliminate certain private sector labor and management practices which could harm the welfare of workers, businesses and the economy.

The Ailing Labor Rights of Medical Residents, by Sarah Geiger, published in 2006, describes the legal history of medical resident labor law and the attempts to legalize unionization among medical residents. I quote the following excerpts directly from Geiger’s paper: 

“From 1947 to 1974, hospital staff members did not have the right to unionize. . . . Congress then amended the NLRA in 1974 to include non-profit hospitals. The Committee on Labor and Public Welfare report on the amendments stated that it could find no acceptable reason why 1,427,012 employees of these non-profit, non-public hospitals, representing 56% of all hospital employees, should continue to be excluded from the coverage and protections of the Act. . . . One source of confusion involved the dubious supervisory status of professional health care providers. . . . health care professionals exercised supervisory roles and were thus excluded from the right to unionize. . . .

In Cedars-Sinai Medical Center, the NLRB held that the residents, interns, and clinical fellows of Cedars-Sinai were not ‘employees’ within the meaning of the NLRA. Thus, they had no right to unionize. . . . The Board thus concluded that interns, residents, and clinical fellows were primarily students, noting the relationship between residents and Cedars-Sinai was primarily educational, and not an employment relationship. . . .  The decision remarked that interns ‘participate in these programs not for the purpose of earning a living; instead they are there to pursue the graduate medical education that is a requirement for the practice of medicine. This statement implies that residents do not actually ‘practice medicine,’ but merely are training to do so. . . . 

“In response to staunch legal criticism, the Board reversed Cedars- Sinai.  Boston Medical, an oft-quoted case, involved a unit of housestaff at the Boston Medical Center (BMC) that attempted to unionize. . . .  The Board overruled its precedent in Cedars-Sinai and held that medical interns and residents were both students and employees and thus were entitled to unionize. . . . The NLRB recognition of housestaff’s plight has done little to encourage unionization among medical interns and residents. . . . The residents’ dual roles, however, present extra-legal barriers to unionization which are not present in other industries. Residents spend an inordinate number of hours in the hospital and often are directly serving patients for twenty-four hours at a time. . . .  the fears of Congress (and earlier fears of the American Medical Association) that unionization may compromise the doctor-patient relationship or the quality of health care residents adds another layer of complication. . . .   

“The Association of American Medical Colleges (AAMC), the representative body of all accredited medical schools in the United States and Canada, as well as over 400 teaching hospitals, vehemently opposed all resident unionization efforts. . . . Offering more labor rights to medical residents would cost academic hospitals inordinate amounts of money. The cost of replacing one surgical resident with a “physician extender,” or other physician, is $210,000 to $315,000 a year. . . . the federal government is by no means an objective observer in the matter of medical residency funding and regulations. Currently, the federal government is the main financier of graduate medical education, ‘contributing $6.8 billion through Medicare, plus additional sums through the Departments of Defense and Veteran Affairs.’ The federal government is constantly looking to reduce the cost of medical care. Offering residents more control over their working conditions would likely lead them to demand more money, money that would have to come from the federal government or from private university hospitals. Thus, the government and academic hospitals are appropriate bedfellows in opposing resident labor rights. 

“The Boston Medical decision made it clear that little legal basis exists to deny medical residents unionization rights or any NLRA specified rights for that matter. Thus, unless Congress amends the NLRA, no legal barriers exist to housestaff unionization.  Many other internal barriers, however, hinder medical residents from acquiring labor rights. Unionization takes more effort than residents have time for and many fear unions will compromise their goals as physicians. A national survey of residents found that residents’ willingness to get involved in forming a union or serving as a member of union management was inversely proportional to the difficulty and amount of time their specialty required them to be in the hospital. Residents are accountable to their superiors for their future careers and would rather endure a few years of grueling working conditions than do anything which might compromise their careers. . . . Hospitals should give residents a real opportunity to unionize. . . . An informed, inclusive dialogue will serve to clarify legal and extra-legal barriers to accomplishing these congressional goals as well as to alleviate medical residents’ labor burdens.”

As described above, a crucial issue which complicates union negotiations for medical residents and fellows is that their jobs are part work and part education. Each intern or resident is a medical worker, a student of the specialty he or she is training in, and a teacher to the interns and residents who are junior to them in the hierarchy. Residents and fellows are learning as they are paid to work. Their learning is both valuable and necessary for progression to their eventual career. The U.S. News and World Report’s listing of the “Best Paying Jobs in America” lists specialties of Medical Doctors as 7 of the 10 highest paying jobs in the United States. 

No discussion of intern and resident salaries would be complete without a disclosure of the average debt these young doctors carry. Because of the high costs of medical school and college tuition, the average medical school graduate owes $241,600 in education debt. The average medical school graduate owes six times as much as the average college graduate. You can’t blame student doctors for wanting to maximize their income as medical interns, residents, and fellows.

If there’s a silver lining in all this, it’s best described in this anecdote from my training years: After completing a 3-year residency in internal medicine, I applied for and was accepted to a second 2-year residency in anesthesiology, a field I was passionate to learn about. In the first weeks of my anesthesia residency, a former chairman of the Stanford anesthesiology department gave us a lecture and tutorial on how to intubate the trachea of a patient with the highest level of skill and ease. I hung on every word he said. I was getting a lesson from a legend, and I was collecting a salary while I was learning this craft. Image a young golf professional getting paid while he received a lesson from Jack Nicklaus. I was earning a salary while I bettered my education and became more marketable in the medical marketplace. Could I have been paid more as a resident? Perhaps. But the primary gain I made during five residency years was the investment of my time in the labor and learning which made it possible for me to work as a board-certified anesthesiologist for the past 36 years . . . and still counting.

I’m confident Stanford Healthcare and the CIF union will negotiate a successful compromise agreeable to both sides. Until that time, stay tuned, as the intersection of physician labor unions and academic medical centers will generate headlines in the days ahead.

I offer this question to my readers: Do you think it’s acceptable for unionized doctors to strike?

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REMIMAZOLAM: NEW WONDER ANESTHETIC DRUG OR MEDICAL WHITE ELEPHANT?

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

In July 2020 the Food and Drug Administration (FDA) approved the intravenous benzodiazepine remimazolam (Byfavo, Acacia Pharma) for use in sedation for procedures of 30 minutes or less. Will anyone utilize this new drug, or is it an expensive addition to our arsenal with few significant advantages over current agents?

Remimazolam differs from midazolam (Versed), the current most commonly used IV benzodiazepine, in that remimazolam is rapidly converted to an inactive metabolite by tissue esterases, resulting in an ultra-short onset/offset profile. Remimazolam is marketed as a powder which must be reconstituted into a liquid within its vial prior to administration.

remimazolam
propofol

For use in procedural sedation, remimazolam will not replace Versed, but rather will aim to replace propofol. The proposed advantages of remimazolam over propofol include:

  1. Remimazolam can be completely reversed by the benzodiazepine antagonist flumazenil (Romazicon) whereas there is no reversal agent or antagonist for propofol. The only way to end the sedative effects of propofol is for an anesthesia professional to support the airway, breathing, and circulation of the patient until the drug effects of propofol wear off in time.
  2. Remimazolam has minimal cardiac or respiratory depression. Sicker ASA III and IV patients maintain their breathing and circulation status while under remimazolam sedation.
  3. There is no accumulative effect of remimazolam over time. Its elimination by an esterase does not slow during lengthy administration of remimazolam, as in the prolonged sedation of an intensive care unit (ICU) patient on a ventilator.
  4. There is no burning sensation upon injecting remimazolam into a patient’s intravenous line as there is with propofol.
  5. A non-anesthesia-professional can administer remimazolam, whereas an anesthesia professional/airway expert must administer and monitor propofol administration.

Are these advantages important? Items 1 – 5 are discussed as follows:

  1. Non-anesthesiologists can reverse the effects of remimazolam with flumazenil if they overdose a patient, but this advantage is less important for anesthesia professionals. Anesthesiologists can manage the airway of a patient over-sedated with a benzodiazepine without need to administer a reversal agent. I’ve never administered a dose of flumazenil in my entire career, nor have most of my anesthesia colleagues. 
  2. Propofol has cardiac and respiratory depression, but in most cases these effects are minimal. Per the PDR (Physician’s Digital Reference), patients with compromised myocardial function, intravascular volume depletion, or abnormally low vascular tone (e.g. septic patients) are more susceptible to hypotension. When an anesthesiologist is present these risks are routinely managed. 
  3. For a long operating room anesthesia case (e.g. of 8 – 10  hours duration), there is no clinically significant accumulation of propofol in the bloodstream. Propofol Infusion Syndrome (PRIS), which can be potentially fatal, is a risk with prolonged propofol sedation in the ICU (See ICU Sedation below).
  4. The burning sensation upon injecting propofol can be blunted by intravenous lidocaine. A 2016 meta-analysis showed that both lidocaine pretreatment and mixing lidocaine with the propofol were effective in reducing pain on propofol injection. In addition, a preanesthetic dose of Versed prevents a patient from remembering any burning sensation from a propofol injection that follows. 
  5. The most important advantage of remimazolam is that non-anesthesiologists can safely administer remimazolam. Propofol administration requires an experienced clinician, e.g. either an anesthesiologist, a certified registered nurse anesthetist (CRNA), or an emergency medicine physician. Per the American Society of Anesthesiologists: “The practitioner administering propofol for sedation/anesthesia should, at a minimum, have the education and training to identify and manage the airway and cardiovascular changes which occur in a patient who enters a state of general anesthesia.” 

The disadvantages of remimazolam compared to propofol include:

  1. Expense. The cost of a 20 ml (200 mg) vial of propofol is $9.20. The cost of a 20 mg vial of powdered remimazolam is $41.67
  2. Remimazolam is sold as a powder and must be reconstituted into a liquid before it can be injected intravenously.

Remimazolam is currently approved as an anesthesia drug in Japan and South Korea, for intensive care unit sedation in Belgium, but only for procedural sedation in the United States, China, and Europe. In total, there are four possible applications for remimazolam. Let’s examine the pros and cons of using remimazolam in these four applications:

  1. Preoperative sedation. Since midazolam (Versed) was approved in 1982, a standard anesthesia practice has included a 2 mg dose of  Versed prior to surgery to calm a patient’s anxiety. In the 1980s my anesthesia chairman at Stanford received a letter from a postoperative patient in which she complained of being awake and very anxious in the operating room prior to the anesthetic for her breast cancer surgery. Our chairman lectured to us, “Do you know many patients are nervous prior to their anesthesia and surgery? Every one of them. We have an excellent drug for relieving preoperative anxiety, and that drug is Versed. Use it! Give your patient a dose of Versed before they enter the operating room. There are few significant side effects of one dose of Versed. Use it!” Will remimazolam replace Versed for this application? No. There is no advantage of the new, shorter acting, more expensive remimazolam over Versed for preoperative sedation.
  2. Sedation for short procedures. This is the FDA-approved application for remimazolam in the United States. An example procedure would be a colonoscopy. Will remimazolam be widely used for colonoscopies in the near future? No, I doubt it. The cost increase is the main disadvantage. See the typical drug acquisition costs for three alternative sedation recipes for colonoscopy below:

            $18.40 for 400 mg of propofol; or 

$5.17 for fentanyl+Versed ($4.35 dollars for 6 mg of Versed  plus $0.82 for 200 micrograms of fentanyl); or

$41.67 for 20 mg of remimazolam

The increased cost per case is $23.27 for remimazolam over propofol

The increased cost per case is $36.50 for remimazolam over fentanyl+Versed.

If a busy endoscopy center does 100 colonoscopies cases per week, the cost increase is $2327 per week for remimazolam over propofol, or $3650 per week for remimazolam over fentanyl+Versed. These are a prohibitive cost increases with no clear added benefits. The only way remimazolam could result in cheaper sedation costs would be if a healthcare system was looking to eliminating the cost of paying for an anesthesia provider for these procedures. The pairing of remimazolam+gastroenterologist sedation rather than propofol+anesthesiologist sedation could afford significant cost savings for a healthcare system.

3. Total intravenous anesthesia (TIVA). TIVA could include a continuous infusion of the ultra-short-acting narcotic remifentanil plus a continuous infusion of the ultra-short-acting remimazolam. An alleged advantage of this technique could be the fast offset time of these two TIVA anesthetic agents. I doubt this technique will gain market share. It’s far easier to turn on the knob of a sevoflurane vaporizer than to load and manage two TIVA-syringe pumps. As well, the added expense of a prolonged infusion of remimazolam will be prohibitive.

4. ICU sedation. Remimazolam has the advantage of ongoing first-degree elimination, meaning that no matter how long the drug is infused, it will always have reliable elimination by esterase and will not accumulate in the plasma. Prolonged ICU sedation with propofol can lead to the Propofol Infusion Syndrome (PRIS). PRIS occurs predominantly in patients receiving high doses of propofol for a prolonged period. Risk factors for the development of PRIS include a critical illness such as sepsis, head trauma, use of vasopressors, and carbohydrate depletion (liver disease, starvation, or malnutrition). PRIS commonly presents as a high anion gap metabolic acidosis, with rhabdomyolysis, hyperkalemia, acute kidney injury, elevated liver enzymes, and decreased cardiac output. Because of the risk of PRIS,  the duration of propofol infusion administration should not exceed 48 hours and the administered dose should not be higher than 4 mg/kg/hour.

This potential advantage of remimazolam over propofol will be offset by the increased expense of hours or days of remimazolam utilization in an ICU sedation situation. ICU sedation with fentanyl and older benzodiazepines such as Ativan will have the advantage of a lower cost. 

In the hands of an anesthesiologist, propofol is an elegant and almost ideal intravenous sedative, with the advantages of rapid onset, rapid offset, inexpensive generic pricing, minimal cardiovascular/respiratory depression, and lack of nausea. Propofol administration does carry the risks of upper airway obstruction, hypoventilation, and low oxygen saturation, but when an anesthesiologist is present these risks are minimal. 

If a healthcare organization doesn’t want to employ an anesthesiologist or a CRNA for a case which requires procedural sedation, then remimazolam may be an excellent sedative choice. Will gastroenterologists prefer to sedate patients with remimazolam plus fentanyl without an anesthesiologist? Or will they prefer to have an anesthesiologist present to administer propofol? Expect gastroenterologists to prefer the latter, because they are not only off-loading the task of sedating the patient, they are also off-loading the risks of managing the patient’s medical co-morbidities, which can be significant if a patient has lung disease, cardiac disease, morbid obesity, or obstructive sleep apnea.

The remimazolam story suggests one of my favorite anecdotes: A former Stanford Chairman of Anesthesiology and friend of mine who left the university in 2006 to become a pharmaceutical company executive, first at Novartis and then at AstraZeneca. Ten years ago, when I asked him what new anesthesia drugs were in the pipeline, he answered, “None, and there probably will be very few new ones. The drugs you have now are inexpensive generic drugs, and they work very well. The research and development costs to bring a new anesthetic drug to market are prohibitively expensive, and unless that new drug is markedly better, it will not push the inexpensive generic drugs out of use.”

Remimazolam will capture a very small market in the United States. Until remimazolam becomes an inexpensive generic drug, I see it as a medical white elephant rather than a wonderful anesthetic advance.

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

ROBOTIC ANESTHESIA 

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

How soon will we see robotic anesthesia in our hospitals and surgery centers? In the past three decades the high-tech revolution introduced the internet, the laptop computer, the iPhone, Google, and global positioning satellites. Most of these discoveries originated in Silicon Valley, just miles outside Stanford University Hospital where I’ve been working for the past 42 years. Our medical world inside the hospital has changed more slowly. We’ve seen advances in noninvasive surgery, fiberoptic scopes, transplantation science, cancer therapeutics, and mega healthcare delivery companies. But what’s new in anesthesia the last 30 years? Relatively little. The Glidescope, sugammadex, ultrasound-guided blocks, and the time-consuming Electronic Medical Record arrived, but we typically administer the same medications, use the same airway tubes, and watch the same vital signs monitors as we did in the 1990s. 

Why have there been no new anesthetics? Let me tell you a story: A former Stanford Chairman of Anesthesiology and friend of mine left the university in 2006 to become a pharmaceutical company executive, first at Novartis and then at AstraZeneca. Ten years ago, when I asked him what new anesthesia drugs were in the pipeline, he answered, “None, and there probably will be very few new ones. The drugs you have now are inexpensive generic drugs, and they work very well. The research and development costs to bring a new anesthetic drug to market are prohibitively expensive, and unless that new drug is markedly better, it will not push the inexpensive generic drugs out of use.”

Is the same true for anesthesia devices? Are proposed anesthetic robots too expensive to design, test, and manufacture? Can they be brought to market to assist current anesthesia providers? Can they be brought to market to replace any anesthesia providers? Keep these economic questions in mind as we review the current science of robotic anesthesia.

vanished and vanishing jobs

Jobs have already disappeared in many industries. ATMs replaced bank tellers. Automated garbage trucks replaced garbage men. In the near future automated cars and trucks will replace drivers. In medicine, computerized artificial intelligence for the analysis of digital images is superior to the human eye, placing the jobs of radiologists, pathologists, and dermatologists in peril. 

Will we live to see anesthesiologists replaced by technology? The following three pictures depict fictional anesthesia robots:

fictional medical robots

But this is what real anesthesia robots look like:

real anesthesia robots

An outline of the types of robotic anesthesia is as follows:

  1. PHARMACOLOGIC ROBOTS
  2. MECHANICAL ROBOTS PERFORMING PROCEDURES
  3. DECISION SUPPORT ROBOTS

  1. PHARMACOLOGIC ROBOTS:

In 2012 a United States national marketing firm contacted me to seek my opinion regarding an automated device to infuse propofol. The device was the Sedasys®-Computer-Assisted Personalized Sedation System, developed by Johnson and Johnson/Ethicon. The system incorporated an automated propofol infusion device, along with standard ASA monitors, including end-tidal CO2, into a device to be used to provide conscious sedation for GI endoscopy.

The SEDASYS system

The Sedasys unit infused an initial dose of propofol (typically 30 – 50 mg in young patients) over 3 minutes, and then began a maintenance infusion of propofol at a pre-programmed rate (usually 50 mcg/kg/min).  If the monitors detected signs of over-sedation, that is, falling oxygen saturation, depressed respiratory rate, or a failure of the end-tidal CO2 curve, then the propofol infusion was stopped automatically.  In addition, the machine talked to the patient, and at intervals asked the patient to squeeze a hand-held gripper device.  If the patient was non-responsive and did not squeeze, the propofol infusion was automatically stopped.

The planned strategy was to have gastroenterologists complete a weekend educational course to learn: that Sedasys was not appropriate if the patient is ASA 3 or 4 or had severe medical problems; that Sedasys was not appropriate if the patient had risk factors such as morbid obesity, a difficult airway, or sleep apnea; and gastroenterologists were taught the airway skills of chin lift, jaw thrust, oral airway use, nasal airway use, and bag-mask ventilation. 

I did not recommend the device be FDA-approved, as I saw the potential of inappropriate patients with obesity or sleep apnea slipping through the screening process, as well as the risk that an over-sedated patient could lose their airway and the gastroenterologist would not be able to rescue them, seeing as propofol has no reversal agent. 

With only one prospective clinical trial, the United States Food and Drug Administration did approve the device in 2013. There was limited clinical use of Sedasys, and Ethicon announced in March 2016 that it was pulling Sedasys from the market. 

The failure of Sedasys was attributed to three factors:

  1. If a patient became too “light” during a procedure, the Sedasys system was not capable of increasing the depth of the sedation.
  2. Both patients and endoscopists expected deep general anesthesia, not moderate sedation. 
  3. Gastroenterologists were ill-equipped to shoulder the responsibility of general anesthesia and airway management. 

From the failure of Sedasys it was clear that further refinement in technology and drug use was needed. That refinement was the development of closed-loop devices. A closed-loop control system is a set of mechanical or electronic devices that automatically regulates a process variable to a desired state or set point without human interaction. The cruise-control on your automobile is an example of closed-loop feedback control of driving speed.

In anesthesia, closed-loop devices can infuse the medications propofol and remifentanil, with the rate of the infusions guided by a bispectral (BIS) monitor of EEG (electroencephalography) activity.  Propofol is an ultra-short-acting hypnotic drug, and remifentanil is an ultra-short-acting narcotic. Administered together, these drugs induce total intravenous anesthesia (TIVA).

A closed-loop system can infuse these two drugs automatically. A BIS monitor calculates a score between 0 and 100 for the patient’s level of unconsciousness, with a score of 100 corresponding to wide awake and 0 corresponding to a flat EEG. A score of 40 – 60 is considered an optimal amount of anesthesia depth. A computer controls the infusion rates of two automated infusion pumps containing propofol and remifentanil. The infusion rates depend on whether the measured BIS score is higher or lower than the 40- 60 range. Researchers in Vancouver, Canada expanded this technology into a device called the iControl-RP, where the initials RP stand for remifentanil and propofol. In addition to the BIS monitor, the iControl-RP monitored the vital signs of blood oxygen level, heart rate, respiratory rate, and blood pressure to determine how much anesthesia to deliver.

iControl-RP robot

In a single-blind randomized study published in Anesthesiology in 2015, 42 patients were randomized to the closed-loop iControl-RP group or to a manual group. The results showed the percentage of time with BIS40-60 was greater in the closed-loop group (87%) vs. the manual group (72%). The number of perioperative adverse events and the length of stay in the postanesthesia care unit were similar. The conclusion of the study was that automated control of hypnosis and analgesia guided by the BIS was clinically feasible.

This study led to an article in the The Washington Post in 2015,  in which one of the machine’s co-developers, Dr. Mark Ansermino said, “We are convinced the machine can do better than human anesthesiologists.” The device had been used on 250 patients at that time. The iControl-RP team struggled to find a corporate backer for its project. Dr. Ansermino told The Washington Post, “Most big companies view this as too risky.” He believed a device like this was inevitable. “I think eventually this will happen,” Ansermino said, “whether we like it or not.”

A second pharmacologic robot named McSleepy used three syringe pumps to control the three components of general anesthesia (hypnosis, analgesia, and neuromuscular block) in an automated closed-loop anesthesia drug delivery system. Each component had specific monitoring: BIS; AnalgoScore (an-AL-go-score = a pain score derived from the heart rate and mean arterial pressure) which was used as the control variable to titrate the effective dose of remifentanil; and the train of four (TOF), which was a measure of the twitch strength of a muscle when its peripheral nerve was electrically stimulated.

McSleepy robot

A 2013 study in the British Journal of Anaesthesia  looked at 186 patients managed by McSleepy, in which the McSleepy system showed better control of hypnosis than manually administered anesthesia (see graphs below). 

The control of depth of anesthesia under McSleepy (blue) or manual (green)

The McSleepy system also showed faster extubation times than manually administered anaesthesia. 

A second McSleepy study in the British Journal of Anaesthesia in 2013 showed an application in telemedicine.  The remote control of general anesthetics was successfully performed between two different countries (Canada and Italy). Twenty patients underwent elective thyroid surgeries, with a master-computer in Montreal and a slave-computer in Pisa, demonstrating the feasibility of remote telemedicine control of anesthesia administration.

II.  MECHANICAL ANESTHESIA ROBOTS

Ma’s mask ventilation robot

The first example is a machine designed to provide mask ventilation, as described in the paper “Novel Anesthesia Airway Management Robot for Robot Assisted Non-invasive Positive Pressure Mask Ventilation,” Published by Dr. Ma et al, from China. Ma designed a robot equipped with two snake arms and a mask-fastening mechanism to facilitate trachea airway management for anesthesia. (PIC) The two snake arms were designed to lift a patient’s jaw. The mask-fastening mechanism was used to fasten and hold the mask onto a patient’s face. A joystick control unit managed both the lifting and fastening force. To date this system has not been used on humans, but the device was proposed as a method to perform non-invasive mask positive pressure ventilation via a robotic system.

The Kepler Intubating System

In 2012 Dr. Hemmerling at McGill University in Montreal published a paper in Current Opinions in Anaesthesiology, describing the Kepler Intubation System. The Kepler Intubation System consisted of a remote-control joystick and intubation cockpit, linked to a standard videolaryngoscope via a robotic arm. (PIC) Ninety intubations were performed on a mannequin with this device. The first group of 30 intubations was performed with the operator in direct view of the mannequin. The second group of 30 intubations was performed with the operator unable to see the mannequin. The third group of 30 intubations were performed via semiautomated intubations during which the robotic system replayed a tracing of a previously recorded intubation maneuver. All intubations were successful on the first attempt, with the average intubation times between 41 and 51 seconds for all three groups. The study concluded that a robotic intubation system can complete successful remote intubation within 40 to 60 seconds.

The Magellan Nerve Block System

In 2013 Dr. Hemmerling published the study “First Robotic Ultrasound-Guided Nerve Blocks in Humans Using the Magellan System” in Anesthesia & Analgesia. The Magellan system consisted of three main components: a joystick, a robotic arm, and a software control system. After localization of the sciatic nerve by ultrasound, 35 ml of bupivacaine 0.25% was injected by the robot. Thirteen patients were enrolled. The nerve blocks were successful in all patients. The nerve performance time was 164 seconds by the robotic system, and 189 seconds by a human practitioner. The Magellan System was the first robotic ultrasound-guided nerve block system tested on humans.  

III.  DECISION SUPPORT ROBOTS

A decision-support robot can recognize a crucial clinical situation that requires human intervention and, when allowed by the attending clinician, may administer treatment. It seems likely that cognitive robots which follow algorithms can increase patient safety.

In August 2021 Dr. Alexandre Joosten, an anesthesia professor in Brussels, Belgium and Paris, France, published “Computer-assisted Individualized Hemodynamic Management Reduces Intraoperative Hypotension in Intermediate- and High-risk Surgery: A Randomized Controlled Trial” in Anesthesiology.  This study tested the hypothesis that computer-assisted hemodynamic management could reduce intraoperative low blood pressure in patients undergoing intermediate- to high-risk surgery. This prospective randomized single-blinded study included 38 patients undergoing abdominal or orthopedic surgery. All patients had an indwelling radial arterial catheter to monitor blood pressure continuously. A closed-loop system titrated a norepinephrine infusion based on the blood pressure, and a second separate decision support system infused mini-fluid challenges when low blood pressures were recorded. Results showed the time of intraoperative hypotension was 1.2% in the computer-assisted group compared to 21.5% in the manually adjusted goal-directed therapy group (P < 0.001). The incidence of minor postoperative complications was the same between groups (42 vs. 58%; P = 0.330). The mean stroke volume index and cardiac index were both significantly higher in the computer-assisted group than in the manually adjusted goal-directed therapy group (P < 0.001). The study’s conclusion was that this closed-loop system resulted in a significant decrease in the percentage of intraoperative time with a low mean arterial pressure.

VOICE-ACTIVATED DEVICES

Voice-activated devices are gaining traction in healthcare. The story “Amazon’s Alexa Is Now a Healthcare Provider” was published by Medscape on February 17, 2022.

Alexa at bedside

The article described how thousands of Alexa-enabled devices are in use in hundreds of hospitals in America. Amazon’s Alexa functions as a digital personal assistant whose voice-powered innovation connects patients with their healthcare team members. Patients who are confined to bed can use their voice to communicate directly to a nurse’s smartphone. An Alexa device is positioned near the bed at Cedars-Sinai Medical Center in Los Angeles, making it easy to call for nursing help. (PIC) Alexa can also connect healthcare providers to their patients. Doctors or nurses can appear virtually in a patient’s room on the Alexa Show’s video screen and assess the needs of that patient. I expect voice-activation to link healthcare providers with medical robots in the future.

PROBLEMS WITH ROBOTS REPLACING ANESTHESIA

The medical publications referenced above demonstrate that robotic anesthesia devices exist, yet none of them are in common use at this time. The current and proposed robotic devices are only small steps toward replacing anesthesiologists, because anesthetizing patients requires far more expertise than merely titrating drug levels or performing a solitary mechanical procedure. 

Anesthesia management consists of a wide variety of skills:

  • preoperative assessment of a patient’s medical problems 
  • successful mask ventilation of an unconscious patient (in most cases) followed by placement of an airway tube
  • diagnosis and treatment of any medical complication that occurs as a result of the anesthesia or the surgical procedure
  • removal of the airway tube at the conclusion of most surgeries, and 
  • the diagnosis and treatment of postoperative medical complications

Successful robotic anesthesia devices may eventually eliminate the repetitive aspects of anesthesia management. You may see robots assisting anesthesia providers in the coming decades, depending on the economic viability of the technology. 

Will the intrusion of a robot into anesthesia care be a welcome event? When you’re a patient, do you desire a caring, empathetic human attending to you, or do you desire an algorithm? 

Or in the future, will you desire both?

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

THE RESCUE: UNDERWATER ANESTHETICS EXPLAINED

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

Underwater general anesthetics of 3 hours duration? See it in The Rescue, a new National Geographic Documentary Film directed by Jimmy Chin (winner of the 2018 Academy Award for Best Documentary Feature for Free Solo)The Rescue details the miraculous extraction of 12 boys and their coach from a flooded Thailand cave in June and July of 2018. The Rescue required 13 underwater general anesthetics delivered by an anesthesiologist and maintained by non-medical cave divers during their 3-hour swim to the mouth of the cave. How did this once-in-history anesthetic tour de force come about? You can watch the movie—a favorite for this year’s Oscar for Best Documentary—on Disney+ for their $7.99 monthly fee. This column explains the specifics as to how anesthesiology innovation saved thirteen lives in The Rescue.

The site of The Rescue was the Tham Luang Nang Non cave in Chiang Rai Province in northern Thailand. Twelve boys of ages 11 – 16 from the Wild Boar soccer team and their coach entered the cave for a birthday celebration. June monsoon rains hit and flooded the entrance of the cave, trapping all thirteen inside. 

The boys were trapped at the left of this diagram. The entrance to the cave is at the right.

The synopsis of The Rescue follows this timeline:

Day 1 – Trials of gas-powered generators to pump the water out of the cave fail to lower the water level.

Day 2 – The Thai Navy Seals arrive on site. They attempt scuba diving into the cave but abort their efforts because of low visibility and difficult access. They were only able to advance 200 meters into the cave. None had experience diving into dark narrow caves. John Volanthen, an information technology consultant who does cave diving as a hobby, shows them a map of the long tortuous cave route, and surmises that the boys are trapped about 2 kilometers into the cave. Richard Stanton, a retired middle-aged British firefighter who is also an expert in cave diving, is alerted to the predicament, and flies to Thailand to help. 

Day 5 – Stanton assembles a collection of his friends who are fellow cave divers. These men have real world jobs such as electricians, contractors, mechanics, and consultants, but are experienced in underwater cave exploration. At first, the Thai Navy Seals will not allow the cave divers to attempt a rescue because they deem it is too dangerous. Eventually the Thai Seals consent to let the cave divers proceed. Stanton describes their passage as scuba diving against a raging river of white water, with the added problem of poor visibility. They surface at the first air-filled chamber inside the cave, and instead of finding the boys they find four pump workers who were unknowingly trapped inside the cave. The cave divers swim the pump workers out, sharing their scuba regulators as they swim, but find the pump workers are easily panicked in the dark cold underwater conditions, and the passage out is very difficult. Their entire swim rescue of these men takes only 30 to 40 seconds, yet Stanton describes the ordeal as “an underwater wrestling match.” 

Day 7 –Rain continues and the water levels rise. Hundreds of people surround the mouth of the cave, and worldwide media coverage is ongoing.

Day 10 – The cave divers continue their attempts to explore the length of the cave. They extend a rope behind them to trace their route back to the outside world. After several hours of traversing the narrow route, including passing through several air chambers above water, they reach a chamber where the atmosphere smells pungent. They fear they have located the rotting flesh of decomposing bodies. Instead they shine a light into the chamber and see 13 people—the Thai boys and their coach—sitting on the rocky floor. They are skinny and frightened, but alive. They’ve had no food for 10 days and have existed by drinking the water from the cave. The cave divers return to the mouth of the cave and announce that the boys are alive. 

Day 12 – The divers follow the rope back to the boys and bring them power gel food and foil blankets. Their plan going forward is unclear. There appears to be no way to swim the boys out for the 3-hour underwater journey to the mouth of the cave. One option is to wait until October (four months) until the monsoon season is over, and the cave is no longer flooded. A second option is to somehow drill down to where the boys are trapped. A third option is to pump out millions of gallons of water out of the cave, but this is also deemed impossible. Another cave diver friend of Stanton’s is Dr. Richard Harris, who lives and works in Australia. Dr. Harris is an anesthesiologist. The team of cave divers telephone him and ask if the boys can be anesthetized for 3 hours to be extracted underwater. His initial answer is no, that this would be impossible.

At the same time, the divers bring an oxygen analyzer into the cave and discover that there is only 15% oxygen left in the atmosphere where the boys are trapped. Normal room air contains 21% oxygen, and 15% oxygen is considered an eminent threat to life for the boys. Immediate action is necessary.

Day 14 – Dr. Harris arrives at the cave. He and his cave diver colleagues come up with a plan to anesthetize and extract the boys, but there is a new problem: The Thai government does not want them to attempt the rescue. The government fears the boys will all die in the futile attempt. Enter Josh Morris,   a cave diver who speaks Thai. He explains the facts and the threat of the low oxygen atmosphere to the government authorities, and convinces them there is no time to waste and that there is no other workable plan. The government agrees to let the cave divers proceed.

Day 15 – The rescue plan is as follows: Divers will swim into the cave to the chamber where the boys are located. The divers will transport an extra oxygen cylinder, a full-face dive mask and regulator, and a dive suit for each boy. They will also carry three medications: 1) Xanax, an oral anti-anxiety pill in the Valium family of benzodiazepines; 2) ketamine, an injectable general anesthetic drug, carried in a syringe-and-needle setup; and 3) atropine, an injectable drug which dries up oral secretions (necessary because ketamine can cause excessive salivation significant enough to choke off breathing). When the cave divers arrive at the chamber where the boys are situated, they dress the first boy in a dive suit complete with a rubber head-covering. Dr. Harris then administers the Xanax pill and the intramuscular injections of ketamine and atropine. After the boy loses consciousness, they tie the boy’s hands behind the boy’s back and apply the full-face oxygen dive mask to keep the water out. The boy is placed in the water atop a full oxygen cylinder, and a diver guides the boy and the cylinder under the water. This diver clings to the rope as he begins the 3-hour journey back toward the cave entrance. There are multiple air chambers on the route back to the entrance. At each air chamber, the diver surfaces and assesses if the boy is still alive and breathing, and whether the boy is anesthetized deeply enough. If the boy is twitching, the diver injects more ketamine. Keep in mind this diver is not a doctor—he has been taught by Dr. Harris to inject more drug if the boy seems to need more sedation. This process is repeated for four boys the first day and is successful. All four reach the surface, alive and anesthetized, and are transported to a nearby hospital.

Day 17 – The process is repeated and four more boys are successfully extracted.

Day 18 – A heavy monsoon rainstorm is expected, so all five remaining individuals are extracted before the cave is totally flooded. The cave divers are hailed as civilian heroes as the last of the boys is rescued. The rescue effort involved more than 10,000 people, including divers, rescue workers, 900 police officers, 2,000 soldiers representatives from 100 governmental agencies, 10 police helicopters, more than 700 diving cylinders, and the pumping of more than a billion liters of water from the caves. 

In the aftermath, Richard Stanton returns to England and receives a George Medal, the second highest award for civilian gallantry, in a regal ceremony at Buckingham Palace. 

The Rescue is riveting and suspenseful, and ultimately worth the one hour 45 minutes and the $7.99 you’ll invest in it.

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Here’s the Anesthesia Consultant analysis of the medical circumstances in The Rescue:

  • In an operating room, anesthesia is typically delivered as a gas (e.g. sevoflurane), or intravenously. Neither gas anesthesia nor intravenous anesthesia is possible in an underwater cave rescue. Ketamine is the only general anesthetic drug which can be injected. Ketamine can be injected either into an IV (e.g. in an operating room by an anesthesiologist) or into a muscle (e.g. in a cave in Thailand). Ketamine has the advantages of quick onset and a lack of respiratory depression—that is, ketamine will not stop a patient’s breathing. But if a patient becomes over-sedated it’s possible they will have upper airway obstruction which can lead to inadequate ventilation, so ketamine administration typically needs to be administered by an anesthesia professional who monitors the patient’s breathing—unless you’re rescuing kids in a cave. Ketamine also has theses disadvantages: It results in a relatively slow wake up (compared to propofol and/or sevoflurane gas); it causes markedly increased saliva production (which is why we need to administer atropine, a secretion-blocking anticholinergic drug—along with ketamine); and ketamine can cause vivid bad dreams—for this reason we routinely give an IV benzodiazepine such as Versed along with ketamine. Re-dosing of ketamine was required because the drug’s half-life (the time it takes for the total amount of ketamine in the body to be reduced by 50%) is about 2.5 hours in adults. Dr. Harris couldn’t be with every boy en route, which is why he had to train the other cave divers how to inject ketamine for redosing.
  • Dr. Harris could have chosen to use an injection of intramuscular Versed instead of Xanax (the oral benzodiazepine used in The Rescue). A disadvantage with oral Xanax is its slow onset time. It’s unlikely the Xanax began to work until it was absorbed from the stomach and carried by the bloodstream to the brain, which likely took thirty minutes or more.
  • The choice of full-face dive masks (FFMs), capable of maintaining constant positive airway pressure (CPAP) during the anesthetics, was brilliant. All acute medical care, be it in an operating room, an intensive care unit, an emergency room, a battlefield, or a cave, follows the priority order of A-B-C, or Airway- Breathing-Circulation. The problems of keeping the airway open, as well as keeping oxygenation and ventilation intact, were daunting challenges underwater. There were no research articles and no textbooks to tell the cave divers how to deal with this situation. They used their best strategy and made their best guess, and it was successful. If excessive water had leaked into the mask, a boy could drown. 
full face dive mask

  • Fortunately all the boys and their coach were slender (per the video footage) and had low body-mass-indexes (BMIs). A patient with a low BMI typically has an easy airway, and would have a lower chance of obstructing their upper airway during a 3-hour underwater general anesthetic. An overweight patient would probably not have survived a 3-hour underwater general anesthetic. As well, all the boys and their coach were young and healthy with normal hearts and lungs. If they had been older, with any abnormal cardiac or respiratory function, they may not have survived the 3-hour underwater general anesthetic.
The Thai boys in the cave

  • It’s striking that the boys could survive for two weeks with only water and no food. Hydration is critical—no one can survive two weeks without water—but food was not imperative for this length of time. They survived without calories for two weeks, but humans can only survive for about three days without water.
  • Hypothermia, or low body temperature, was a risk during the underwater rescue. Anesthetized patients have no muscle movement and are unable to generate any body heat in the cold water. The scuba suits and hoods were aimed at minimizing the temperature drop while the boys were anesthetized.
  • No one monitored the vital signs of the boys during their 3-hour underwater general anesthetics. General anesthetics always require monitoring of these parameters: heart rate, oxygen saturation, blood pressure, ECG, respiratory rate, temperature, and end-tidal carbon dioxide expiration. In an underwater cave anesthetic, none of this was possible. Luckily the ketamine anesthesia as administered must have kept all the vital signs within acceptable limits.
  • The oxygen concentration in the atmosphere of the cave was only 15%, far lower than the normal room air concentration of 21% we’re all breathing right now. This oxygen concentration of 15% is roughly equivalent to the oxygen concentration atop a mountain at 10,000 feet of altitude. The boys tolerated the gradual decrease of the oxygen level within the cave from 21% to 15% over 12 days without any brain damage or any damage to a vital organ system. An acute decrease from 21% to 15% may have caused low blood oxygen—hypoxia—and organ damage. During anesthetics in an operating room, anesthesiologists commonly administer at least 40-50% oxygen—a higher concentration than in room air—as an extra margin of safety.

The film The Rescue documents a remarkable feat of emergency medicine and emergency anesthesia care. I recommend you see the movie, and I hope you’ll understand the medical care better because of the discussion presented above. 

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

THE TOP 10 LIVING ANESTHESIOLOGISTS 2022

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

TheAnesthesiaConsultant.com presents its 2022 ranking of The Top 10 Living Anesthesiologists. These individuals made significant original contributions to the practice and/or education of anesthesiologists throughout the world. As a physician anesthesiologist who has attended to patients in the 1980s, 1990s, 2000s, 2010s, and now the 2020s, in both university and community settings, I’m uniquely qualified to identify and honor the leaders in our field over this time. 

Here’s the list:

David Gaba MD

#10. David Gaba MD, Stanford University School of Medicine. Dr. Gaba developed the anesthesia crisis simulator, and his group developed the Stanford Anesthesia Emergency Manual. Both are landmark contributions toward reducing medical errors by anesthesia providers and improving patient outcomes. Dr. Gaba has authored 242 publications in major medical journals.  He is a Professor at the Stanford University Department of Anesthesiology, Perioperative and Pain Medicine, and the Associate Dean for Immersive and Simulation-Based Learning at the Stanford University School of Medicine

James Eisenach, MD

#9. James Eisenach MD, Wake Forest University.  Dr. Eisenach served as Editor-in-Chief of Anesthesiology for 10 years from 2007-2016, and in 2016 became the President and CEO of the Foundation for Anesthesia Education and Research (FAER), a key organization supporting research in our field. Dr. Eisenach has authored 562 publications in major medical journals and is nationally renowned for his research on the mechanisms of pain.  Dr. Eisenach is a Professor of Anesthesia at Wake Forest University.

Robert Stoelting MD

#8. Robert Stoelting MD, University of Indiana. https://patientsafetymovement.org/speaker/robert-k-stoelting-md/   Dr. Stoelting is the author of the textbook Pharmacology and Physiology in Anesthetic Practice, co-author of the textbooks Basics of Anesthesia and Anesthesia and Co-Existing Disease, and co-editor of the textbook Clinical Anesthesia. During his 19 years as President of the Anesthesia Patient Safety Foundation, Dr. Stoelting was instrumental in developing and expanding the APSF as a leading publication in the anesthesia literature.  Dr. Stoelting is a Professor Emeritus and Past Chair, Department of Anesthesia, Indiana University School of Medicine (1977-2003).

Richard Jaffe MD

#7. Richard Jaffe MD PhD, Stanford University. Dr. Jaffe is the lead author/editor of the premier anesthesia textbook Anesthesiologist’s Manual of Surgical Procedures, first published in 1994. This textbook presented a new and original format, with surgeon authors describing all the common surgical procedures followed by anesthesiologist authors describing the preoperative, interoperative, and postoperative approaches to each type of case. This was the first anesthesia “recipe book,” and with each new edition (there have been six editions to date) it remains one of the best-selling anesthesia textbooks. Dr. Jaffe has also authored 130 publications in major medical journals. Dr. Jaffe is a Professor, Stanford University Department of Anesthesiology, Perioperative and Pain Medicine, and by courtesy, of Neurosurgery. 

Jonathan Benumof MD

#6. Jonathan Benumof MD, University of California San Diego.  Dr. Benumof was the main originator of the American Society of Anesthesiologists Difficulty Airway Algorithm, first published in 1996. The Difficult Airway Algorithm described pathways to safe airway management, and its application has saved countless lives that might have been lost to mismanaged airway disasters. He also single-authored the textbook Anesthesia for Thoracic Surgery as well as 311 publications in major medical journalsDr. Benumof is an Emeritus Professor of Anesthesiology at the University of California San Diego School of Medicine

Dr. Steven Shafer testifying at the Michael Jackson manslaughter trial

#5. Steven Shafer MD PhD, Stanford University.  Dr. Shafer’s area of expertise is the pharmacology of intravenous anesthetic drugs. He was the Editor-in-Chief of Anesthesia and Analgesia for 10 years and authored 293 publications in major medical journals, many of them the initial studies on the pharmacokinetics of propofol. He is currently the Editor-in-Chief of The ASA Monitor. Dr. Shafer appeared as an expert witness in the Michael Jackson manslaughter trial, in which Dr. Conrad Murray was convicted of the inappropriate administration of propofol in Jackson’s bedroom. Dr. Shafer is a Professor Emeritus at the Stanford University Department of Anesthesiology, Perioperative and Pain Medicine

Lee Fleisher MD

#4. Lee Fleisher MD, University of Pennsylvania.  Dr. Fleisher authored the textbooks Anesthesia and Uncommon Diseases, and Complications in Anesthesia, as well as 421 publications in major medical journals, with a concentration in the preoperative evaluation of the surgical patient. His most noteworthy contribution was the classic paper Preoperative Cardiac Evaluation for Noncardiac Surgery, published in 1992 in Anesthesia and Analgesia. This paper set the standards for how anesthesiologists should approach the preoperative cardiac evaluation of their patients. Dr. Fleisher was the long-term Chair of the Department of Anesthesiology and Critical Care (2004-2020), and the Robert Dunning Dripps Professor of Anesthesia at the University of Pennsylvania Health System. He is currently the Chief Medical Officer and Director of The Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), a part of the Department of Health and Human Services (HHS). 

Daniel Sessler MD

#3. Daniel Sessler MD, Cleveland Clinic. Dr. Sessler has authored an astounding total of 1089 publications in major medical journals, and has raised total extra-mural research funding of $65 million so date. Dr. Sessler is an editor for Anesthesiology and serves as a reviewer for more than 50 journals. He has given invited lectures at more than 350 institutions.  His papers have been cited more than 37,000 times, making him the world’s most published and cited anesthesiologist. Dr. Sessler is currently Professor and Chairman, Department of Outcomes Research, Anesthesiology Institute at the Cleveland, and Clinical Professor of Anesthesiology at Case Western Reserve University. 

Dr. Archie Brain and his invention, the LMA

#2. Archie Brain MB, London Hospital, Whitechapel, England. Dr. Brain is the British anesthesiologist who invented the laryngeal mask airway (LMA), which he patented in 1982. Dr. Brain’s objectives for the LMA were to provide a better method of maintaining a patient’s airway than by face mask, with the benefit that the LMA was less hemodynamically stressful than the insertion of an endotracheal tube. The LMA has been used over 300 million times worldwide in elective anesthesia and emergency airway management, and is one of the most significant anesthesia inventions in the last 50 years. The LMA Classic was sold by LMA International NV, a company which sold to Teleflex Inc in 2012 for $276 million.

Ronald Miller MD

#1. Ronald Miller MD. University of California San Francisco. Dr. Miller is best known as the initial lead author of Miller’s Anesthesia, the most widely used textbook of anesthesiology in the world, first published in 1981 and now in its Ninth Edition. https://anesthesia.ucsf.edu/news/ronald-d-miller-distinguished-professorship  Dr. Miller was the Chairman of Anesthesia at UCSF from 1983-2009,  and built what was arguably the finest anesthesiology department in the world, with a particular focus on research, as well as expanding the role of anesthesiologists in the pain clinic and in the intensive care unit.

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NOTE: This list does not include the inventor of the GlideScope, the first commercial video laryngoscope (developed in 2001 and an outstanding contribution to the field of anesthesiology), because Dr. John Allen Pacey, the inventor of the GlideScope, was not an anesthesiologist but a vascular and general surgeon at the University of British Columbia. 

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NOTE: This list of The Top 10 Living Anesthesiologists does not contain any females or diversity. All ten nominees are white males. Such was the state regarding the advances in our specialty over the past five decades. Future lists may honor females or diversity, depending on the state of career achievements over the coming years.

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

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

Three days ago, I was giving anesthesia for six consecutive colonoscopy patients. Following my first case, I checked my phone and discovered that the President of the United States Joe Biden was having a colonoscopy at Walter Reed Medical Center that very morning. The headlines stated that for the first time, temporary acting presidential power was being turned over to a woman, Vice President Kamala Harris, during the time of President Biden’s colonoscopy anesthesia.

I mentioned this to the gastroenterologist I was working with that day, and he asked, “How long do you think he will be unable to make decisions as the President? We tell our patients not to drive the rest of the day, and not to make any important life decisions after their general anesthetic. Biden has the most difficult and most important job on Earth. When can he return to duty?”

I answered, “My guess is that he’ll have the same propofol anesthetic we’re administering today. The procedure will last thirty minutes, he’ll begin to awaken five minutes after the propofol is discontinued, and within an hour he’ll feel clear-headed.” The gastroenterologist was dubious that the leader of the free world would be alert enough to resume power only one hour after receiving propofol. Joseph Biden was one day short of his 79th birthday when the colonoscopy took place. Later that morning the news services reported that the President had transferred presidential powers to Kamala Harris at 10:10 a.m. EST and resumed his presidential powers at 11:35 a.m., a mere 1 hour and 25 minutes later. 

The evening after the colonoscopy, comedian Colin Jost of Saturday Night Live joked about Biden’s colonoscopy.  During Weekend Update, Jost reported on Biden’s resumption of all his presidential responsibilities immediately following the colonoscopy, and noted that Biden had just turned 79. “Half the country already thinks he’s senile,” Jost said. “You can’t drop all that on him the second he comes out of the gas.”

A note from an anesthesiologist to the comedy writers: No one uses “gas” for anesthesia for a colonoscopy. The anesthetic is solely from intravenous (IV) drug(s).

I have no specific knowledge of what anesthetic drug regimen the President received for his colonoscopy, but more likely than not he received propofol. Anesthesia for colonoscopy is typically administered so that patients have no awareness during this procedure, a procedure which does not involve surgical pain, but rather involves the uncomfortable entrance of a 66-inch-long flexible hose, one-half-inch in diameter, into their anus, rectum, and colon. 

For the quickest recovery after colonoscopy, one option is no anesthesia at all. Very few patients sign up for a colonoscopy without any intravenous anesthesia. The press reports about Biden’s colonoscopy stated that he had anesthesia, so let’s discount the option that he had the procedure while awake. 

Colonoscopy sedation is typically done with one of two recipes: 1) conscious sedation with a combination of intravenous Versed (generic name midazolam, a benzodiazepine in the Valium family) plus intravenous fentanyl, such that the patient has no memory of the procedure; or 2) intravenous general anesthesia with propofol by continuous infusion or by intermittent boluses so that the patient is unresponsive. The combination of Versed and fentanyl leads to a slower wakeup and recovery than with propofol. The duration of effect of Versed is approximately 30 to 45 minutes after a single dose, with a recovery time of 2 to 6 hours. The duration of effect of IV fentanyl begins within minutes and lasts for 30 to 60 minutes after a single dose. 

Propofol for colonoscopy leads to a quicker wakeup, a quicker discharge home, and less hangover. Virtually every surgical general anesthetic in the United States includes propofol, and anesthesiologists are experts at the administration and pharmaceutical properties of the drug. Propofol is an intravenous nonbarbiturate anesthetic which induces anesthesia quickly and provides a rapid emergence from anesthesia. The onset of action is within 20 – 40 seconds. The anesthesia provider for a colonoscopy will continue administering IV propofol until the procedure is over. A typical colonoscopy will last 20 – 40 minutes, depending on whether the gastroenterologist needs to take extra time to remove any colonic polyps. In Biden’s case, a single 3 mm benign-appearing polyp was identified and removed.

Propofol’s pharmacokinetics are described by two phases:

In the first phase (red curve), the plasma concentration decreases rapidly because the drug redistributes, or spreads, out of the bloodstream into other tissues of the body. The halflife of this fast redistribution is only 2 – 8 minutes, meaning the concentration of propofol in the bloodstream is halved every 2 to 8 minutes. This first phase explains the quick transition to wakefulness up after the drug is stopped. The second phase (black curve) is the elimination of propofol from the body. The half-life time of this elimination from the body is 4 – 7 hours (reference: MILLER’S ANESTHESIA, 9thedition, chapter 23 on Intravenous Anesthetics).

The graph below depicts the timeline after propofol is discontinued. After a one-hour infusion, the concentration of propofol in the blood drops to near zero within 30-40 minutes.

THE PROPOFOL CONCENTRATION APPROACHES ZERO 40 MINUTES AFTER THE END OF INFUSION

The website PDR.net affirms this, stating that “Recovery from anesthesia is rapid (8 to 19 minutes for 2 hours of anesthesia) and is associated with minimal psychomotor impairment.” The PDR also states that “The elimination half-life of 3 to 12 hours is the result of slow release of propofol from fat stores. About 70% of a single dose is excreted renally (by the kidneys) in 24 hours.”

While the President would be awake one hour after receiving 30 minutes of propofol, and the blood concentration would be minimal, it still takes 24 hours for 70% of a single dose of propofol to be excreted by the kidneys. Therefore, one hour after the propofol was discontinued, even though the blood concentration was minimal, a significant amount of the drug would still be in the President’s body.

I’ve had propofol anesthesia for a colonoscopy, and I can attest that I woke up promptly and was in an automobile heading home within 45 minutes after the end of the procedure. I felt alert, albeit a bit woozy, after 60 minutes of recovery time. Did I feel it would have been safe for me to resume my duties administering general anesthetics to patients at that time? No. Would a major American airline allow one of its pilots to fly passengers at that time? No. Would the U.S. Army allow a general to command thousands of soldiers at that time? I doubt it.

One hour after a propofol colonoscopy anesthetic, the President would be awake enough to converse and give a “thumbs up.” Would he be alert enough at that point to make decisions regarding the nuclear football, a potential attack on Taiwan by mainland China, or a terrorist attack on a major United States city? Was this nearly 79-year-old man safe to make all the acute decisions the United States President could have to make, only one hour after discontinuing propofol? 

The Mayo Clinic website states that, “After the exam (colonoscopy), it takes about an hour to begin to recover from the sedative. You’ll need someone to take you home because it can take up to a day for the full effects of the sedative to wear off. Don’t drive or make important decisions or go back to work for the rest of the day.” 

Was Biden fit to run the country 55 minutes after his colonoscopy anesthetic? 

Hmmm. The decision as to whether he was recovered enough to resume running the country . . . was a decision made by President Biden’s doctors on that day.

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THE NEW 2022 ASA DIFFICULT AIRWAY ALGORITHM

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

The American Society of Anesthesiologists (ASA) just published a 2022 update on their ASA Difficult Airway Algorithm Guidelines. The 2022 document is a revision of the 2013 publication “Practice guidelines for management of the difficult airway: A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.” The 2022 ASA Difficult Airway Algorithm Guidelines are 51 pages in total.

The most important changes are identified by examining the 2013 and the 2022 algorithms side by side. Let’s look at the 2013 flow chart algorithm and compare it to the 2022 flow chart algorithm below:

THE 2013 ASA DIFFICULT AIRWAY ALGORITHM

THE 2022 ASA DIFFICULT AIRWAY ALGORITHM

Note these major changes from 2013 to 2022:

  1. The top third of the 2022 algorithm lists factors which direct the anesthesiologist to perform awake intubation. The reason for this change is undoubtably the wisdom of utilizing awake intubation when a significant risk of a difficulty airway exists. There are minimal airway risks when a patient is awake, and the benefit of placing the endotracheal tube in a difficult airway patient while the patient is awake is immense. When we give mock oral board examinations to anesthesia residents at Stanford, and we describe to the examinee that the patient has a difficult airway, the answer of “I’d do an awake intubation” is hard to criticize and almost never leads to a catastrophe. In contrast, inducing general anesthesia prior to intubation in these patients can lead to a “Can’t intubate-can’t oxygenate” emergency, which can lead to a cardiac arrest and possible anoxic brain damage.
  2. The text highlighted in red in the 2022 document is both new and vital. The first of these is “OPTIMIZE OXYGENATION THROUGHOUT,” under the pathway INTUBATION ATTEMPT WITH PATIENT AWAKE, with the footnote 2Low- or high-flow nasal cannula, head elevated position throughout procedure. Noninvasive ventilation during preoxygenation. The message is to keep oxygen flowing via nasal cannula throughout airway management attempts to minimize hypoxia, and to keep the head elevated to maximize the functional residual capacity (FRC), which is the reservoir of oxygen in the patient’s lungs.
  3. LIMIT ATTEMPTS, Consider calling for help” is new and printed within a red box in the INTUBATION ATTEMPT AFTER GENERAL ANESTHESIA –> FAILED pathway. This is an effort to prevent repetitive unsuccessful intubation attempts from soaking up precious time, during which the brain is poorly oxygenated.
  4. LIMIT ATTEMPTS AND CONSIDER AWAKENING THE PATIENT” is new and printed in red in the NON-EMERGENCY PATHWAY under the “Ventilation adequate/intubation unsuccessful” pathway. This is again an effort prevent repetitive unsuccessful intubation attempts from soaking up precious time, during which the brain is poorly oxygenated.
  5. LIMIT ATTEMPTS AND BE AWARE OF THE PASSAGE OF TIME, CALL FOR HELP/FOR INVASIVE ACCESS” is new and printed in red in the EMERGENCY PATHWAY under the MASK VENTILATION NOT ADEQUATE, SUPRAGLOTTIC AIRWAY NOT ADEQUATE pathway. This is again an effort to prevent repetitive unsuccessful intubation attempts from soaking up precious time, during which the brain is poorly oxygenated.

These changes, printed or boxed in red, emphasize that the pace of difficult airway decisions is important. The duration of elapsed time is vital. When an anesthesia provider cannot intubate the patient and then cannot ventilate the patient, the oxygen level in the blood can plummet. There is a significant danger of anoxic brain damage within minutes. I’ve previously reviewed this topic in a 2019 Anesthesia Grand Rounds Lecture at Stanford, summarized in my article “Five Minutes to Avoid Anoxic Brain Damage.” The U.S. Library of Medicine website states that “Brain cells are very sensitive to a lack of oxygen. Some brain cells start dying less than 5 minutes after their oxygen supply disappears. As a result, brain hypoxia can rapidly cause severe brain damage or death,” and “Time is very important when an unconscious person is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 to 6 minutes later.”

The sentence “Be aware of the passage of time, the number of attempts, and oxygen saturation” appears more than once in the 2022 Difficult Airway Algorithm Guidelines article, and is a key point for all anesthesia providers who encounter a difficulty airway emergency.

In my roles as an anesthesia quality assurance reviewer or a medical-legal expert consultant, I’ve seen this issue arise multiple times. Even though anesthesia providers believe they are following the Difficult Algorithm accurately, they are doing things too slowly, and they waste too much time. Once it’s clear that a “Cannot intubate-cannot oxygenate” scenario is occurring, the time clock is running, and the anesthesia provider must not only do the correct thing but he or she must do the correct thing without undue delay. The necessary procedure may be as invasive as a cricothyroidotomy/front of the neck access via the scalpel-bougie-endotracheal tube approach.  

The five points listed above are the major changes in the algorithm. In addition, the new 2022 article includes a Pediatric Difficult Airway Algorithm and an approach to Extubation of the Trachea in a Difficult Airway Patient. Other important quotes from the 2022 article include (bold emphasis added):

  1. “The consultants and members of participating organizations strongly agree with recommendations to perform awake intubation, when appropriate, if the patient is suspected to be a difficult intubation and difficult ventilation (face mask/supraglottic airway) is anticipated.”
  2. “Meta-analyses of randomized controlled trials comparing video-assisted laryngoscopy with direct laryngoscopy in patients with predicted difficult airways reported improved laryngeal views, a higher frequency of successful intubations, a higher frequency of first attempt intubations, and fewer intubation maneuvers with video-assisted laryngoscopy.”
  3. The footnote (7) for alternative difficult intubation approaches states: 7Alternative difficult intubation approaches include but are not limited to video-assisted laryngoscopy, alternative laryngoscope blades, combined techniques, intubating supraglottic airway (with or without flexible bronchoscopic guidance), flexible bronchoscopy, introducer, and lighted stylet or lightwand. 
  4. “A randomized controlled trial comparing a videolaryngoscope combined with a flexible bronchoscope reported a greater first attempt success rate with the combination technique than with a videolaryngoscope alone.”
  5. When appropriate, refer to an algorithm and/or cognitive aid.” 

AUTHOR’S NOTE: I’d suggest that the Stanford Emergency Manual of cognitive aid algorithms for anesthesia and ACLS emergencies be onsite at all anesthetizing locations. 

I’d also recommend that the 2022 ASA Difficult Airway guideline algorithm be onsite at all anesthetizing locations.

Every anesthesia professional will encounter patients with difficult airways—this is one of the most important and most feared situations in our specialty. Commit the 2022 ASA Difficult Airway Algorithm to memory. Use awake intubation when you’re concerned about the potential of a “Cannot intubate-cannot oxygenate” scenario. And if you’re in the middle of a difficult airway emergency, call for help and be aware of the passage of time, the number of attempts, and the oxygen saturation. Don’t let an excessive number of minutes elapse without regaining oxygenation of your patient.

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

PHYSICIAN TRAINING: TWO FORKS IN THE ROAD

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

You’re in the middle of your medical school years, and wondering what specialty to pursue. There are two major forks in the road when trying to choose the career that suits your emotional make-up and work ethic. The sooner you understand these two forks in the road, the better off you’ll be. 

CLINIC DOCTOR OR ACUTE CARE DOCTOR?

The first major fork in the road is whether you’re best suited for a career as a clinic doctor or as an acute care doctor. The main specialties for clinic doctors are internal medicine, family practice, pediatrics, and psychiatry. The main specialties for acute care doctors are surgery, anesthesiology, emergency medicine, and obstetrics-gynecology.

Internal medicine and pediatrics include subspecialties. The subspecialties of endocrinology, oncology, nephrology (kidney specialist), and allergy-immunology are primarily clinic doctors. Cardiologists are hybrid clinic/acute care doctors who must first complete a residency in internal medicine, and then subspecialize with 3-4 additional years of fellowship training. Pulmonologists (lung specialists) are also hybrid clinic/acute care doctors who must first complete a residency in internal medicine, and then subspecialize with 2 additional years of fellowship training.

Pursue a career as a clinic doctor if you enjoy sitting in a room, listening to patients and talking to patients. Most clinic doctors rarely place a tube or a needle into a patient after their residency training is completed. Most clinic doctors work daytime hours, but have weekend call and night call, which may include phone consultations or emergency room visits. Clinic doctors see multiple patients per day, perhaps 4-8 patients per day for psychiatrists, and up to 30 patients or more for some specialists such as allergists.

Pursue a career as an acute care doctor if you prefer adrenaline-charged arenas such as the operating room, the intensive care unit, the labor and delivery suite, or the emergency room. The pace will be much faster than in a clinic, and the stress level will be higher. You’ll perform surgeries, deliver babies, or run trauma Code Blues. If you become an anesthesiologist, you’ll routinely put your patients into pharmaceutical comas and then reverse that status.

These are some of the significant differences between the clinic path and the acute care path:

  1. Sudden risks are almost unknown in clinics. In a clinic setting, doctors make diagnoses, order tests, and prescribe oral medications. In an acute care setting, health care interventions involve scalpels, tubes, IVs, intravenous medications, breathing tubes and ventilators. Malpractice events are less likely to occur in clinic settings. It’s difficult to harm a patient in a clinic. Clinic errors may involve the failure to make the correct diagnosis or the failure to follow up on the result of an important test. Acute care errors can include failure to manage the A-B-Cs of airway, breathing, and circulation safely.
  2. Income differences. Physicians who do procedures, and who incur the risks of procedures gone wrong, earn more money. Physicians who staff clinics usually earn less. This fact may be concealed from medical students. Once students become aware of the income differences, the invisible hand of capitalism tends to drive them into the acute care specialties which are higher paying. The financial numbers are pertinent, because the median debt for an American medical school graduate was $200,000 in 2019. The average four-year cost for a public medical school education was $250,222, and the average four-year cost for a private medical school education was $330,180.  Medical school graduates need to earn a significant income to repay their student loans.
  3. Long-term relationships with patients. Primary care clinic doctors often attend to the same patients for decades, and form long-term cordial relationships with their patients. Acute care doctors typically see a patient once, for a surgery, an anesthetic, a childbirth, or an emergency room visit. Acute care doctors rarely develop lasting interactions with any of their patients. Clinic doctors may receive holiday cards or presents from their patients; acute care doctors will not.
  4. Lifestyle differences. Clinic doctors mainly work daytime hours, although they may receive afterhours phone calls regarding patient health problems. If one of their patients becomes acutely ill, a primary care doctor may see that patient in the emergency room. Some acute care specialists work as shift labor, especially emergency room doctors, anesthesiologists, or hospitalists. Acute care doctors may also have schedules in which they can take blocks of weeks or even months off at a time, giving them the option to pursue longer vacations or travel. Primary care doctors are rarely able to take long blocks of time away from their patients.

ACADEMIC DOCTOR OR COMMUNITY DOCTOR?

A second fork in the road during physician training is the choice whether to become an academic physician or a community physician. An academic physician is a faculty member at a medical school. Their job description includes teaching younger doctors and mentoring younger doctors in patient care. Academic physicians work in university hospitals, Veterans Administration (VA) hospitals, and county hospitals—any setting where medical students and resident physicians are training. Ambitious medical students often plan to become academic physicians, because they admire the academic professors who are training them. Ambitious medical students may profess that they want to become academic professors, because it may appear this career path is what the finest university training programs are looking for. The gambit seems to look like this: if you want to be admitted to a famous university residency program, tell them you want to be a famous professor just like the individual who is interviewing you for that program. I can only advise you to tell the truth about your career ambitions.

Most physicians eventually drift away from academic intentions, and become community physicians. Community physicians are individuals who work at your local clinic, your local hospital, or your local health maintenance organization. A 2017 article stated that “Although 45 percent of graduating medical students aspire to work in an academic setting, only about 16 percent will do so. Of those who do work in academic settings, up to 38 percent will leave academia within 10 years.” 

These are some of the significant differences between the between the academic path and the community path:

  1. Income. Academic physicians usually earn less money than community physicians. Academics spend part of their time teaching young doctors, instead of seeing additional patients. Academics may also spend part of their time doing laboratory science or clinical studies, instead of seeing additional patients. Academic departments also typically pay a “Dean’s tax” to the medical school dean, as part of their agreement within the medical school. 
  2. Housestaff back-up. Academic physicians have a team of housestaff physicians—interns, residents, and fellows—to do many of the mundane tasks of patient care for them. These housestaff physicians may sleep in the hospital and handle middle-of-the night issues while the academic faculty member sleeps at home. This is a significant benefit. I can attest that as you age, you’ll have less and less desire to get out of bed to handle urgent medical issues. Community physicians must function like interns. They set up call schedules to share night duty with other community physicians in the same specialty, but if there’s an issue at night when you’re on call, you will have to drive to the hospital to handle it.
  3. Tenure for professors. If academic professors have a productive career of publishing significant research, their university may award them with tenure, defined as lifetime job security at that university. Tenure guarantees a distinguished professor academic freedom and freedom of speech by protecting him or her from being fired no matter how controversial or nontraditional their research, publications, or ideas are. This benefit is usually only an option for basic science research doctors who are specifically hired to “tenure-track” appointments.

A THIRD FORK:

A small minority of medical school graduates shun either academic or community practice, and instead take their MD degree and go directly to work in industry either as a researcher at a medical company, or a consultant in a medical industry. Consider this path if you believe you’re not suited to taking care of patients.

My Journey:

I had personal experience with each of these forks in my medical education road. During medical school I was having a difficult time deciding between surgery and internal medicine. During my final summer quarter break, I returned to my hometown and joined the local general surgeon to observe him performing a gall bladder surgery. After the procedure, I questioned him about his satisfaction with his career in general surgery. He told me, “I’m very happy with general surgery, but if I had to do the 7-year residency over again, I could never do it. It was that difficult.” The look on his face told me what I needed to know, so I opted for a career in internal medicine. I matched at Stanford and began my three-year residency. During my second year, while I was spending my afternoons in the internal medicine clinic, I realized I preferred acute care to clinic care. That same year I’d spent one month in the Stanford intensive care unit (ICU) rotation. The Stanford anesthesia department ran the ICU, and I met multiple faculty and resident anesthesiologists who loved their specialty and were excellent role models. I made an appointment to meet with the ICU physician-in-chief, and told him I wanted to become an ICU specialist like him. He told me, “If you want to be an ICU doctor, I’d advise you to do an anesthesia residency first, because ICU care involves airway-breathing-circulation, and anesthesiologists are the airway experts. But once you finish your anesthesia residency, you’ll never come back to see me, because you’ll love anesthesia so much you’ll probably just do anesthesiology as a career.” I followed his advice. I applied to anesthesia residencies, and was eventually accepted to begin my anesthesia training, albeit three years into the future.

During those three years, I finished my internal medicine training. Then I hovered at the fork in the road between academic and community medicine during my one-year gap between my internal medicine and anesthesia residencies. The Stanford Department of Internal Medicine hired me for a twelve-month position as a faculty member in the emergency room. My role was to be the attending in the ER from 9 a.m. to 5 p.m. Monday through Friday, and to give a lecture to the residents each morning at 8 a.m. I was thrilled to be on the faculty at Stanford at the young age of 29. I discovered during that year that if you’re an academic doctor/clinician/educator who doesn’t do research, that you have minimal respect within your department. That same year I met many community doctors on their ER duty who were very happy with their work. My conclusion from my one-year academic appointment was that if you enjoyed clinical care, then it was better to just graduate from your training program and go out there and do clinical care in the community. If I’d had the skillset to become a tenure-track academic professor, perhaps I would have pursued a university career, but I did not.

THE BIG PICTURE:

There is tremendous competition to become a physician. Applications to medical school are at an all time high. According to the American Association of Medical Colleges (AAMC), applications increased 18% from 2020 to 2021. Stanford University School of Medicine received 11,000 applications for an admission class of 90 spots.

It’s an honorable and a wonderful career to heal and take care of sick and suffering as a medical doctor. If you’re admitted to an American medical school, you’ll have the choice whether to become a primary care doctor or an acute care doctor. You’ll have the choice to become an academic physician or a community physician. But you’ll have made the most important choice already—to become a medical doctor in the first place. 

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

EMERGENCY AT A SURGERY CENTER

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

You’re the anesthesiologist assigned to a freestanding ambulatory surgery center (ASC). Are you and the facility prepared for an emergency at a surgery center? Let’s examine this case study:

You meet your first patient of the morning, a 75-year-old female scheduled for lateral epicondylitis release surgery on her right elbow.  You review her medical record and interview her. You discover she had her aortic valve replaced with a small metal valve two years earlier. She is active, although she does experience mild shortness of breath on walking stairs. She is obese, weighing 200 pounds, with a BMI=35. She is on no medications. On physical exam, her vital signs are normal, her lungs are clear, and her heart exam is positive for the clicking sound of a mechanical valve and a 2/6 systolic murmur. She has a thick neck and a large tongue. The surgeon says he will only need to operate for 15 minutes. The patient refuses a regional nerve block, so she’ll need to be asleep.

You attach the standard vital sign monitors, preoxygenate the patient, and induce anesthesia with 150 mg of propofol, 50 micrograms of fentanyl, and 40 mg of rocuronium. You intubate her trachea with a 7.0 tube without difficulty, and place her on a ventilator delivering 1.5% sevoflurane and 50% nitrous oxide.

The patient’s arm is prepped and draped. The surgeon injects 2% lidocaine at the skin incision site, and the surgery begins. Vital signs remain normal with BP=110/70, P=80, and oxygen saturation=99%. The surgery concludes after 17 minutes. You discontinue the sevoflurane and reverse the paralysis with sugammadex. The patient’s blood pressure increases to 150/100 within three minutes. Three minutes later the oxygen saturation drops to 80% and thick frothy fluid bubbles into the endotracheal tube and the circle breathing hoses which connect the patient to the anesthesia machine. The blood pressure is now BP=180/120.

You call for help and attempt to suction the frothy fluid out of the breathing tubes. You listen to the lungs and hear loud rattling rales. You assess that you’re dealing with pulmonary edema (excess fluid in the lungs). The patient’s oxygen saturation drops to 70%. 

A second anesthesiologist responds to your call for help and arrives in the room. You explain what is going on, and while you do, the oxygen saturation becomes unmeasurable and the blood pressure machine fails to give any reading. Your colleague suggests you administer 20 mg of Lasix (furosemide) as a diuretic, and he injects this for you. You continue to ventilate the patient with 100% oxygen, and continue to suction copious fluid out of the patient’s lungs. The ECG monitor descends into a slow agonal rhythm, and when you check the carotid artery at the patient’s neck, there is no pulse. You call a Code Blue and begin CPR compressions on the patient’s chest. After thirty minutes of Advanced Cardiac Life Support (ACLS) drug administration, the pulses have not returned. You have no other therapies to offer, and the patient is declared dead.

Acute pulmonary edema on a chest X-ray

Did this have to happen? No, it did not. In a parallel universe with more competent clinicians, let’s look at how this patient should have been handled:

  1. First off, this case was inappropriate for a freestanding outpatient surgery center. This freestanding outpatient surgery center was located miles from the local hospital, and the hospital resources of an intensive care unit (ICU), respiratory therapists, arterial blood gas analysis, and chest X-rays were not available. The surgery was trivial enough—a brief procedure on the elbow—but the patient had a medical history which was too complex to approve a general endotracheal anesthetic at a freestanding ASC. Typically patients who have had a successful cardiac valve replacement are much improved after their surgery, and complaints of shortness of breath or extreme fatigue—symptoms of inadequate cardiac function—are absent. A 75-year-old patient who complains of shortness of breath on exertion was a poor candidate for anesthesia at an ASC. A pre-operative cardiology consult was indicated, and would likely include an echocardiogram and a stress test. In our parallel universe, the echocardiogram ordered by the cardiologist revealed a small aortic valve diameter—less that one centimeter—and a dilated left ventricle with an ejection fraction (LVEF) of 35% (a severely abnormal value, as the normal left ventricle can eject more than 50% of its volume). This patient with a low LVEF needed to have her surgery postponed until her cardiac function was improved via medications or a further surgical cardiac intervention was done. After that, when and if this elbow surgery ever does occur, it would need to be done in a hospital setting.
  2. What if the anesthesiologist did not adhere to #1 above, and the anesthetic led to pulmonary edema as described above? How could the anesthesiologist better manage the emergency? All acute medical care is managed by A-B-C, or Airway-Breathing-Circulation. In this case the Airway tube was in place. The Breathing was being done by the ventilator, but the breathing tube was occluded by pulmonary edema fluid. The treatment to improve the Breathing was both active suctioning to clear the airway of fluid and medical treatment to reverse the cause of the increased fluid. Diagnosis of the Breathing and Cardiac problems was as follows: discontinuation of anesthesia in this patient, who still had a breathing tube in her trachea as she awakened, stimulated markedly increased blood pressure –> the left ventricle could not eject against this high pressure –> this led to acute left heart failure with resulting backup of fluid into the lungs –> this caused pulmonary edema and dropping oxygen saturation. (Because of her airway anatomy, she was not a candidate for a deep extubation.) Treatment for both the Breathing problem and the Cardiac problem was an emergency afterload reducing drug such as nitroprusside. Every ASC must have a Code Blue cart with emergency drugs and equipment, and the anesthesiologist must call for the cart. He or she instructs one of the RNs to prepare a 250 ml bag of nitroprusside and to attach it to an intravenous infusion pump.
  3. We anesthesiologists are only as good as our monitoring devices. When the oximeter reports very low readings and the BP cuff stops working, we are in big trouble. Anesthesiologists cannot safely administer a potent intravenous infusion such as nitroprusside without an accurate second-to-second monitor of the patient’s blood pressure. One of the anesthesiologists quickly places an arterial line catheter in the left radial artery at the wrist. The arterial line is connected to the monitoring equipment, to reveal that the blood pressure is 240/140, for a mean blood pressure (MAP) of 173 mm Hg. The anesthesiologists connect the nitroprusside drip to the peripheral intravenous line, and infuse the drug to decrease the blood pressure to 140/80 (MAP=100) within minutes. The frothing fluid in the breathing tubes clears, and the oxygen saturation returns to 100%. 
  4. The anesthesiologists then place a central venous catheter in the right internal jugular vein and transfer the nitroprusside infusion to the central line. They titrate small doses of fentanyl and Versed into the peripheral IV line to sedate the patient because immediate extubation is not appropriate, and prepare to transfer the patient via ambulance to the nearest hospital ICU. The original anesthesiologist accompanies the patient in the ambulance to the ICU, while continuing to monitor the patient’s vital signs and manage the blood pressure, sedation, ventilation, and oxygenation.
  5. The patient’s sedation is discontinued the next morning in the hospital ICU, and she is extubated safely. She has no brain damage or cardiac damage. The anesthesiologist visits her that afternoon, and converses with her as she eats her lunch. She has questions about how this could have happened, and he answers each question honestly.

There are multiple take-home messages from this case study:

  1. The preoperative screening of patients at a freestanding ASC is crucial. No one wants to have a Code Blue or a near-Code Blue, miles away from any hospital. Surgery centers manage preoperative screening in various ways, but most community ASCs do not run an in-person preoperative anesthesia clinic. At our ASC, a preoperative caller contacts each patient two days prior to their scheduled surgery, and fills out a comprehensive history form based on the patient’s answers and any medical tests and/or consults available on that patient. If there are positive answers regarding important medical issues such as shortness of breath, chest pain, heart disease, obstructive sleep apnea, morbid obesity, chronic kidney or liver disease, cancer, or previous transplants, then the preoperative caller refers the case to the Medical Director. The Medical Director makes the decision whether the patient is appropriate for the scheduled surgery. If the patient is not appropriate, the case is cancelled two days ahead of time.
  2. If an acute respiratory or cardiac emergency occurs at an ASC, the first move is to call for help from a second anesthesiologist. Two minds and four hands are a better solution. The registered nurses bring a copy of the Stanford Emergency Manual into the room, as well as the code cart which includes the emergency drugs and monitoring equipment.
  3. In a true emergency, diagnosis and treatment must occur within minutes. No anesthesiologist wants to be the doctor who “draws a blank” when their patient is trying to die right in front of them. Stanford’s Dr. David Gaba pioneered acute anesthesia simulator training to improve anesthesiologist performance in emergency settings. You may inquire whether such simulations are available in your geographic area.  
  4. Always manage acute medical emergencies as A-B-C, or Airway-Breathing-Circulation, in that order. In this case the improvement in Breathing required suctioning and afterload reduction, and the improvement Cardiac required arterial line monitoring and afterload reduction.
  5. Realize that short simple surgeries exist, but some short simple surgeries on sick patients present significant anesthetic risks. The anesthesiologist must assess all medical risks and not be swayed by a surgeon who insists this will be “just a short simple case.” If an anesthesiology complication occurs, that surgeon will not likely be blamed, nor will he or she come to your defense. It will be “the anesthesiologist’s fault.”
  6. Every ASC must be prepared for acute unexpected emergencies. The code cart must be stocked with ACLS medications and monitoring equipment for arterial and/or central lines. The ASC should ideally have a copy of the Stanford Emergency Manual, and all drugs and equipment listed in that manual should be available, even though it is not a hospital setting.
  7. It’s important for ASCs to conduct mock-Code-Blue drills on a yearly basis so that staff is prepared when a real emergency occurs.
  8. Depending on cost, an ASC may choose to stock a nitroglycerin drip or a newer potent vasodilator medication such as Cleviprex (clevidipine) rather than nitroprusside in their code cart.
  9. Ideally, anesthesiologists who work at ASCs should also have medical staff privileges at an acute care setting in a hospital, and be performing anesthetics on sicker hospitalized patients there. If an anesthesia provider’s practice is reduced to only healthy patients for outpatient surgeries, that anesthesia provider may become less than competent if a patient develops an emergency in a surgery center.
  10. In case of an emergency at a surgery center, your goal is to stabilize the patient and transfer the patient to the nearest hospital as soon as it is safely possible. The hospital resources of an ICU, respiratory therapists, radiology, cardiology consultation, and a full laboratory service including arterial blood gas analysis are invaluable.

For those readers who are surgical patients, let me reassure you that the vast majority of patients cared for at freestanding ASCs have no anesthesia complications, and many ASCs are staffed by competent anesthesiologists and nurses prepared to save you in the rare event that something goes awry before, during, or after your outpatient surgery.

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

SMART GLASSES IN THE OPERATING ROOM

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

A South Korean group led by Dr. Y.E. Jang published a study in this month’s issue of Anesthesiology describing the use of a head-mounted smart glasses display during radial arterial line placement in patients younger than 2 years. Placing a catheter into the tiny radial artery in a child’s wrist is one of the most difficult procedures in our specialty. The average internal diameter of the radial artery is 1.2 ± 0.3 millimeter in children aged less than 2 years. Wearing smart glasses improved the anesthesiologist’s first-attempt success rate, and reduced the procedure time and complication rates. This was an important study, and important information.

In the control group of this study, each anesthesiologist would use a traditional ultrasound screen to visualize the artery. 

The anesthesiologist must look up to see the ultrasound machine, while he is working on the patient’s wrist.

In the smart glasses group, the ultrasound machine was located behind the operator, and the smart glasses were paired with the ultrasound machine. The smart glasses used were a binocular Moverio BT-35E unit,  connected to an ultrasound machine by a HDMI cable. The smart glasses displayed a simultaneous replica of the ultrasound screen image in front of the anesthesiologist’s eyes, so the operator could easily see both the procedure field (the radial artery at the wrist) and the ultrasound screen simultaneously without any head and eye movement. 

The anesthesiologist can see the ultrasound image while he is looking at the patient’s wrist

One hundred sixteen children were included in the study. The smart glasses group had a higher first-attempt success rate than the control group: 87.9% (51 of 58) vs. 72.4% (42 of 58) in the control group, with p = 0.036. The smart glasses group also had a shorter first-attempt procedure time (median 33 seconds) than the control group (median 43 seconds), with p = 0.007.

An accompanying editorial in the same issue of Anesthesiology stated, “This elegant prospective trial offers objective insight into the potential impact of head-mounted displays on the overall success and provider ergonomics in anesthetic care during technically complex procedures. Head-mounted displays and augmented reality devices have been evaluated in various settings, including placement of ultrasound-guided peripheral nerve blocks, for use in intraoperative patient monitoring and placement of central venous catheters.”

What will be the role of smart glasses in medicine? We all remember the original hype surrounding the 2013 release of Google Glass, a product which failed to capture a significant market of users. 

Google Glass

Problems with Google Glass included: “The unit overheated frequently with use and shut itself down, the battery life wasn’t long enough (less than an hour), the apps were great demos but limited in scope, and the user interface — tapping, swiping, blinking, head gestures, and the voice recognition after saying ‘Ok Glass’ — was not always smooth.” 

A 2014 study looked at using Google Glass to aid central venous catheter insertion in adults. This study failed to show any positive effects on success rate, procedure time, or number of attempts. These results most likely were due to the fact that larger central blood vessels in adults are easier to locate than the diminutive radial artery in the pediatric population.

Smart glasses are being studied in aviation. Both anesthesiologists and pilots have occupations where the slightest miscalculation or mistake can cost lives. Any step which enhances safety can be seen as a valuable change. A new product called AEROGLASS (Augmented reality aerial navigation for a safer and more effective aviation) attempts to put augmented reality in front of pilots’ eyes.

AEROGLASS in aviation

A recent review states, “The AEROGLASS turnkey smart glass solution provides general aviation pilots a true 3D, 360° view of navigation and safety features. One of the largest challenges for aviation professionals is accurately and safely navigating an aircraft. Current studies show that pilot error accounts for up to 70 % of all aviation accidents. Piloting an aircraft requires translating complex readings from the control panel displayed in 2D into a 3D environment and 360° reality. Accessing this information also requires pilots to take their eyes off the sky, thereby making them more prone to errors and increasing their stress levels. With a headset on, pilots will now be able to have digital 3D information appearing naturally in their field of vision, helping them make faster and better decisions. ‘Our product is an AR solution based on smart glasses. When pilots wear them, they will continue to see the scenery around them, but in addition to that, relevant safety and navigation information will be overlaid transparently within their field of view. . . . At first, the newly developed technology targets professional general aviation, but after some time AEROGLASS plans to utilize its technology in other transportation domains such as automotive and maritime or even for passengers.”

There are two potential uses for smart glasses in anesthesiology. The first is for performing invasive procedures which require ultrasound technology, such as the placement of peripheral nerve blocks or the placement of catheters into arteries and veins. This use makes sense, because it can make some procedures easier, as shown in the Jang study. But the placement of pediatric arterial lines, as in the Jang study, is a small marketplace (e.g. including pediatric open heart surgery, and pediatric surgery involving major blood loss). Ultrasound imaging for the placement of peripheral nerve blocks would be a bigger market, but to date there is no data supporting the use of smart glasses in the placement of peripheral nerve blocks.

Anesthesia vital signs monitor display

A second and more compelling use for smart glasses would be the display of a patient’s vital sign monitoring in real time on the smart glass screen, so that an anesthesiologist is in constant contact with the images of the vital sign electronic monitors. In 2021 a nurse anesthetist publication looked at the use of Google Glass by seven nurse anesthetists for display of the vital signs monitor, but there were no quantitative data to examine the significance of the technology. The physician medical literature has not studied the issue. 

Advantages of using smart glasses for real time patient vital signs monitoring would include:

  • The electrocardiogram, oximeter, and end-tidal CO2 waveforms would be displayed front and center in the anesthesiologist’s sight. The vital signs of heart rate, blood pressure, oxygen saturation, end-tidal gas values, and temperature would be constantly visualized no matter where the anesthesiologist was looking. 
  • This is a futuristic technology, and its use may connote that the hospital or surgery center is at the cutting edge of monitoring and safety equipment (despite the lack of any data to confirm this advantage at this time).

Disadvantages of using smart glasses for patient vital signs real time monitoring would include:

  • The cost of the head-mounted display (Moverio BT-35E, glasses in the current study) is approximately $800. This is not a large amount of money, but multiplied times every anesthetizing site, the expense rises.
  • The requirement for reliable and constant Bluetooth connection between the smart glasses and the electronic monitor.
  • The weight of the smart glasses (119 grams, or 0.43 pounds) is 4 – 8 times heavier than usual glasses (25 – 50 grams, or 0.05 – 0.1 pounds). Many individuals may object to wearing this product. 
  • If an anesthesiologist wears prescription glasses of his or her own, there would be two pairs of glasses needed.
  • The question of whether smart glasses are necessary in every routine anesthetic.

Let’s look at this last point. During most routine anesthetics the constant beep-beep-beep note and tone of the pulse oximeter gives the anesthesiologist real-time audible monitoring of both the heart rate and the ballpark oxygen saturation, without having to look at the display. The anesthesiologist still has to look up at the vital signs screen intermittently to note the blood pressure, end-tidal gas values, and temperature, but this intermittent look is part of the vigilance all anesthesiologists must do anyway. A left-to-right scanning gaze at the patient, the surgical field, the IV lines, any IV infusions, the airway tubing, the anesthesia machine, and the vital signs monitor screen is standard procedure in anesthesiology. If adopted, the use of smart glass technology for routine vital signs monitoring would indeed be a large market. Would the addition of smart glasses for routine monitoring be an overdose of technology in the operating room cockpit? Does excessive technology distract us from the actual patient?

Let me give you a historical perspective. As recently as the year 2000 there were zero computers in the anesthesia workstation. Our equipment included an anesthesia gas machine, a vital signs monitor, and carts which contained breathing tubes, airway equipment, syringes, needles, and drugs. Now we are encumbered by an electronic medical record (EMR) system screen + keyboard, and a narcotic-dispensing computerized drug cart in every hospital anesthetizing location. 

EPIC anesthesia electronic medical record (EMR) computer
Anesthesia drug cart
Anesthesia bar code reader/label printer computer

Add in some smart glasses with Bluetooth connection, and you’ve got an armada of gadgets to both aid the anesthesiologist and to distract him or her from the actual patient, who is three feet away and in need of vigilant care. Is anesthesia care any safer with all the computers: the EMR, and the narcotic-dispensing computerized drug cart? There is no data that these devices have made anesthesia any safer—it is only more complicated.

If smart glasses are ever to become a standard of care, I believe it would require data and proof that anesthesia complications were reduced and anesthesia outcomes were improved with such a device.

Technology in medicine tends to come between the patient and his or her doctor, a theme explored in my 2019 editorial, and in my novel Doctor Vita. View the future of medical technology with care. Think of that computer terminal between you and your doctor during a clinic visit. Now imagine a parallel situation with that computer terminal between you and your anesthesiologist, between you and your emergency room doctor, or between you and your ICU nurse. Will adding more electronic devices lead to safer care or more convoluted care? 

Put it another way: Do we need smart glasses, if we have smart anesthesiologists?

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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
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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.

NURSE ANESTHESIOLOGY?

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

 

Who is responsible for your safety before, during, and after your surgery? Will it be a nurse or will it be a physician? This is an important question. Perioperative mortality is the third leading cause of death in the United States after heart disease and cancer. This statement appeared in the July 2021 issue of Anesthesiology, our specialty’s leading journal.  We’re all aware of the threats from heart disease or cancer, but most people know next to nothing about “perioperative mortality.” What is perioperative mortality? 

The word “perioperative” means “around the time of surgery.” It’s officially defined as the 30-day time period following surgery. “Mortality” means a patient death. Any patient who dies within 30 days of their anesthetic qualifies as a perioperative mortality. Very few patients die in the operating room, but significant numbers die in the weeks that follow. 

Why do patients die? A 2013 study in Anesthesiology states, “Despite the fact that a surgical procedure may have been performed for the appropriate indication and in a technically perfect manner, patients are threatened by perioperative organ injury. For example, stroke, myocardial infarction, acute respiratory distress syndrome, acute kidney injury, or acute gut injury are among the most common causes for morbidity and mortality in surgical patients.”  

The same article states, “a 30-day death rate of 1.32% in a U.S.-based inpatient surgical population for the year 2006. This translates to 189,690 deaths in 14.3 million (1 in 75) admitted surgical patients in one year in the United States alone. For the same year, only two categories reported by the Center for Disease Control—heart disease and cancer—caused more deaths in the general population.” Note this data was for inpatient surgeries.

The practice of anesthesiology is currently defined as “perioperative medicine.” At Stanford University, we’re called the Department of Anesthesiology, Perioperative, and Pain Medicine. Perioperative medicine refers to the care of patients before surgery (preoperative), during surgery (intraoperative), and after surgery (postoperative). Each of these three areas is critical in assuring the lowest rate of complications. The American Board of Anesthesiology requires each candidate for board certification to pass an oral exam with clinical questions pertaining to preoperative, intraoperative, and postoperative management. A board-certified physician anesthesiologist is therefore validated as an expert in all areas of perioperative medicine.

Who will make YOUR anesthetic decisions? Who will take care of you before, during, and after YOUR surgery? 

Most anesthetics are conducted by physician anesthesiologists. At times, physician anesthesiologists employ certified registered nurse anesthetists (CRNAs) to assist them in what is called the anesthesia care team (ACT) model. In this model, an MD anesthesiologist supervises up to four CRNAs who work in up to four different operating rooms simultaneously. All the responsibility in the ACT model resides with the supervising MD anesthesiologist.  

In a minority of states (19 of the 50 states) in America, governors made it legal for an unsupervised CRNA to provide anesthesia care. Are CRNAs and anesthesiologists equals? No, they are not. The difference in training is profound. CRNAs are registered nurses with a minimum of one year experience as a critical care nurse followed by, on the average, an anesthesia training period of three yearshttps://www.aana.com/membership/become-a-crna/minimum-education-and-experience-requirements  Physician anesthesiologists have to graduate from a four-year medical school or osteopathic  school, and then complete four additional years of internship and residency to become board-eligible anesthesiologists. The initial rationale for unsupervised CRNA care was that some rural communities had inadequate supplies of MD anesthesiologists, so governors made the decision to let nurses supply the anesthesia care unsupervised. These states include Arizona, Oklahoma, Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, Wisconsin, California, Colorado, and Kentucky. If you live in one of these 19 states, there’s no guarantee a perioperative physician anesthesiologist will care for you. 

Does the lack of a perioperative physician—an anesthesiologist—make a difference? Yes. 

Doctor J H Silber’s landmark study from the University of Pennsylvania documented that both 30-day mortality and failure-to-rescue rates were lower when anesthesia care was supervised by anesthesiologists, as opposed to anesthesia care by unsupervised nurse anesthetists. Silber wrote, “These results suggest that surgical outcomes in Medicare patients are associated with anesthesiologist direction, and may provide insight regarding potential approaches for improving surgical outcomes.”

In 2009, in California where I live and work, Governor Arnold Schwarzenegger signed a law permitting independent practice for CRNAs. California physician anesthesiologists have been angry and concerned about this legislation change, but in the 12+ years since the law went into effect, the penetration of unsupervised CRNA practice in California was been minimal. This is despite the fact that there is an oversupply of CRNAs in the western United States.   

The traditional older models of physician-only anesthesia or the anesthesia care team are still the dominant modes of practice in California. 

Anesthesiology is the practice of medicine. Perioperative medicine is the practice of medicine. Anesthesiology and perioperative medicine are the domains of physicians. 

When you are a patient in an intensive care unit (ICU), all orders and decisions are made by physicians. Nurses are an essential part of ICU care, but management is by physicians. 

When you are a patient in an emergency room (ER), all orders and decisions are made by physicians. Nurses are an essential part of ER care, but management is by physicians.    

Why should your perioperative medicine be managed by non-physicians?

A major conflict is playing out in American medicine at this time. Beginning in 2025, all CRNAs will need a doctorate in nurse anesthesia to enter the field. Expect these nursing graduates to introduce themselves to you as “Doctor.” This new degree, called a “Doctor of Nursing Anesthesia Practice (DNAP),” is not a medical school diploma, and by no means is equivalent to the Medical Doctor (MD) degree held by physician anesthesiologists. Medical school admission in America is extremely competitive. For the 2020-2021 year there were 53,030 medical school applicants, and 22,239 applicants were admitted, meaning only 42% of medical school applicants matriculated. 

The American Association of Nurse Anesthetists (AANA) has made the decision to deceive patients by formally changing its name to the American Association of Nurse Anesthesiology, confusing the distinction between an MD anesthesiologist and a nurse anesthetist by adopting the word “anesthesiologist” to describe themselves. 

The American Society of Anesthesiologists (ASA) released this statement: “The American Society of Anesthesiologists condemns AANA’s organizational name change and encouragement of its members’ use of the term “nurse anesthesiologist,” which will confuse patients and create discord in the care setting, ultimately risking patient safety.” The ASA statement also said:

  • ASA, the American Board of Anesthesiology, the American Board of Medical Specialties and the American Medical Association affirm that anesthesiology is a medical specialty and professionals who refer to themselves as “anesthesiologists” must hold a license to practice medicine.
  • The New Hampshire Supreme Court upheld a ruling in March 2021 by the New Hampshire Board of Medicine to limit the use of the term “anesthesiologist” to individuals licensed to practice medicine.
  • The Council on Accreditation of Nurse Anesthesia Educational Programs defines “anesthesiologist” as a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who has successfully completed an approved anesthesiology residency program.
  • The World Health Organization views “anesthesiology as a medical practice” that should be directed and supervised by an anesthesiologist.

Who will be taking care of YOU before, during, and after your surgery? As patients, you deserve to know, and you also deserve a physician managing your perioperative medicine. 

Before your surgery, you deserve a medical doctor.    

After your surgery, you deserve a medical doctor.    

And yes . . . during your surgery, you deserve a medical doctor of anesthesiology as well.

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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.

CARDIAC ARREST DURING A PEDIATRIC TONSILLECTOMY

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

A 12-year-old boy and his mother walk into a surgery center. The child is scheduled for a tonsillectomy, and is otherwise healthy. The anesthesiologist induces general anesthesia, and ten minutes later the patient has ventricular arrhythmias which descend into a cardiac arrest. Advanced Cardiac Life Support (ACLS) measures are applied, but the child cannot be resuscitated, and is declared dead. What caused this cardiac arrest during a pediatric tonsillectomy?

This is an actual closed malpractice case which I was asked to review. The anesthesiologist induced general anesthesia with propofol and a paralytic drug called succinylcholine (sux-in-ol-KOH-leen), and then inserted a breathing tube successfully into the patient’s windpipe. All vital signs were normal. Sevoflurane, nitrous oxide, and 50% oxygen were ventilated into the patient’s lungs. The surgeon began the tonsillectomy. One minute later the cardiac arrest occurred. The anesthesiologist followed ACLS guidelines, but standard ACLS treatments and hyperkalemia (elevated potassium concentration) treatments were unsuccessful.

Succinylcholine is an intravenous muscle relaxant (paralytic) drug commonly used in the United States. Succinylcholine is an old drug—available since 1951—which has the distinction of being the most rapid-acting intravenous muscle relaxant, and also the shortest-acting muscle relaxant. Succinylcholine is an important drug in an anesthesiologist’s toolkit. When an airway emergency threatens a patient’s life, such as the unexpected occurrence of laryngospasm, succinylcholine is the emergency drug of choice to paralyze the patient, relax the spasm of the vocal cords, and enable the anesthesiologist/emergency room physician/acute care physician to insert a life-saving breathing tube into the trachea.

But succinylcholine can be a dangerous drug. The Food and Drug Administration (FDA) placed a Black Box Warning on succinylcholine in 1994. The current succinylcholine warning in the PDR (Prescribers’ Digital Reference) reads:

Succinylcholine is contraindicated in patients with a personal or familial history of malignant hyperthermia and/or skeletal muscle myopathy. Malignant hyperthermia may be precipitated by succinylcholine; concomitant use of volatile anesthetics may further increase this risk. 

In neonates, infants, children, and adolescents, reserve the use of succinylcholine for emergency intubation or instances where immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach, or lack of intravenous access). 

There have been rare reports of ventricular dysrhythmias and fatal cardiac arrest secondary to rhabdomyolysis with hyperkalemia, primarily in healthy-appearing pediatric patients who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne’s muscular dystrophy. 

Affected pediatric patients are typically, but not exclusively, males 8 years or younger. Although some patients have no identifiable risk factors, a careful history and physical exam may identify developmental delays suggestive of myopathy, and a preoperative creatinine kinase could identify patients at risk. 

Closely monitor body temperature, expired CO2, heart rate, blood pressure, and electrocardiogram in pediatric patients to help detect early signs of malignant hyperthermia and/or hyperkalemia. 

The rhabdomyolysis syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes of succinylcholine administration. If cardiac arrest occurs immediately after succinylcholine administration, institute treatment for hyperkalemia (e.g., intravenous calcium, bicarbonate, glucose with insulin, hyperventilation). If malignant hyperthermia is suspectedinitiate appropriate treatment (e.g., dantrolene, supportive care) concurrently.”

Per the Black Box warning, succinylcholine has the potential for inducing life threatening hyperkalemia in children with undiagnosed skeletal muscular dystrophies. Severe hyperkalemia and ventricular arrhythmias followed by cardiac arrest may occur in apparently healthy children who have an occult muscular dystrophy (usually Duchenne’s muscular dystrophy). An occult muscular dystrophy is a rare inherited disease. The global prevalence of Duchenne’s muscular dystrophy is 7.1 cases per 100,000 males, and 2.8 cases per 100,000 in the general population. The Black Box warning on succinylcholine recommends to “reserve use in children for emergency intubation or need to immediately secure the airway.”

The Black Box warning applies to neonates, infants, children and adolescents. No parent wants their son or daughter under the age of 18 to electively receive a drug which has an FDA Black Box Warning for use in adolescents. No parent wants their neonate, infant, child, or adolescent to have a risk of sudden cardiac arrest under general anesthesia for a common elective surgery.

In 1994 the Anesthesia Patient Safety Foundation (APSF) published a sentinel article about the risks of succinylcholine in pediatric anesthesia. The article reviews the history of the succinylcholine warning: “In 1992, Drs. H. Rosenberg and G. Gronert published a letter in Anesthesiology briefly reviewing four deaths in male children under the age of eight who had received halothane and then succinylcholine. These cases were identified through the Malignant Hyperthermia (MH) Hotline. Reference was also made to ‘11 similar cases’ identified through the German MH Hotline. Their letter concluded with the statement: ‘We have notified the Food and Drug Administration of this potential problem and recommended that anesthesiologists carefully consider the indications for use of succinylcholine in young children.’ This letter was accepted for publication August 24,1992.” The article goes on to emphasize “the need for prompt and appropriate treatment should hyperkalemic arrest occur. This treatment involves the intravenous administration of calcium. With proper treatment, approximately 50% of patients have survived this catastrophic hyperkalemia.” The Black Box warning specifically states, “If cardiac arrest occurs immediately after succinylcholine administration, institute treatment for hyperkalemia (e.g., intravenous calcium, bicarbonate, glucose with insulin, hyperventilation).”

Despite the Black Box warning, how often is succinylcholine still used for non-emergency pediatric anesthetics in the United States? No one knows. I can attest that during a recent Quality Assurance review in the Northern California, I saw anesthetic records from a board-certified anesthesiologist who administered succinylcholine to a 14-year-old boy for elective ear surgery. I discussed this with the anesthesiologist, who was unaware they were doing anything dangerous.

There is an excellent alternative to the elective use of succinylcholine. For most cases, pediatric or adult, the muscle relaxant rocuronium is a superior alternative to succinylcholine. Succinylcholine is the IV muscle relaxant with the most rapid onset, but large doses (0.9 mg/kg) of rocuronium are nearly as rapid as succinylcholine, without any of succinylcholine’s risks.   Succinylcholine is also the IV muscle relaxant which wears off the fastest, but since the year 2015 FDA approval of the muscle relaxant reversal drug sugammadex (Bridion), an intubating dose of rocuronium can be rapidly reversed within 3 minutes by administering 16 mg/kg of sugammadex

Succinylcholine remains an important drug for the treatment of airway emergencies. I would never begin a general anesthetic if I did not have a vial of succinylcholine immediately available in case of an airway emergency. In addition, succinylcholine is important because it can be administered intramuscularly (in a patient who has no IV). For example, if a child is undergoing an inhalational induction of general anesthesia with sevoflurane vapor prior to a surgery, and the child suddenly goes into laryngospasm before any IV can be started, (this does occur, not uncommonly, and is a true emergency), the appropriate treatment is an intramuscular injection of 4 mg/kg of succinylcholine. The child will become paralyzed within minutes, and the anesthesiologist can then insert a life-saving breathing tube. (The mean onset of paralysis with 4 mg/kg intramuscular succinylcholine in children ages 1 to 10 ranges from 2.9 to 3.9 minutes.)

I’ve written about the advantages and risks of succinylcholine previously in the article, “Succinylcholine: Vital Drug or Obsolete Dinosaur?”  

I also refer you to the published article, “Is There Still a Role for Succinylcholine in Contemporary Clinical Practice?

The take home messages from this case study of a cardiac arrest during a pediatric tonsillectomy are:

  • If you’re an anesthesia provider, do not administer succinylcholine to a neonate, infant, child, or adolescent for an elective surgery. The Black Box warning on succinylcholine recommends to “reserve use in children for emergency intubation or need to immediately secure the airway.”
  • If you’re a parent, prior to your son or daughter’s surgery, be empowered to ask your child’s anesthesiologist if they’re aware of the Black Box warning on succinylcholine. 
  • Nobody wants a death brought on by an elective anesthetic.

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The most popular posts for laypeople on The Anesthesia Consultant include:
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Why Did Take Me So Long To Wake From General Anesthesia?
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How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
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Should You Cancel Surgery For a Blood Pressure = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

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

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

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

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

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

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

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

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

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

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

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

Will you have a choice?

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The most popular posts for laypeople on The Anesthesia Consultant include:
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Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
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Should You Cancel Surgery For a Blood Pressure = 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 LONG DOES GENERAL ANESTHESIA LAST?

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

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

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

Let’s look at each of these factors:

  • WHICH DRUGS WERE ADMINISTERED.

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

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

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

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

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

SEVOFLURANE VAPORIZER

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

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

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

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

  • THE LENGTH OF THE ANESTHETIC TIME.

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

  • THE TYPE OF SURGERY YOU HAD.

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

  • HOW MUCH PAIN YOU HAVE AFTER THE SURGERY.

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

  • HOW HEALTHY YOU ARE.

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

***THE ROLE OF LOCAL ANESTHETICS***

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

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

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

Colonoscopy                                                    5 minutes

Knee arthroscopy                                            5-10 minutes

Tonsillectomy                                                  5-15 minutes

Breast augmentation                                      10-15 minutes

Abdominal/flanks liposuction                        10-15 minutes

Rhinoplasty/nose surgery                               10-15 minutes

Laparoscopic abdominal surgery                  10-20 minutes

Total knee/hip replacements                         10-20 minutes

Brain surgery/craniotomy                              15-25 minutes

Open heart surgery                                        2 – 12 hours

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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?
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How Safe is Anesthesia in the 21st Century?
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Should You Cancel Surgery For a Blood Pressure = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

DYING UNDER GENERAL ANESTHESIA

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

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

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

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

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

Dr. Jack Kevorkian and his euthanasia machine

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

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

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

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

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

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

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

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

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

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
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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.

WILL CRNAs REPLACE MD ANESTHESIOLOGISTS?

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

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

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

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

In a word, no. 

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

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

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

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

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

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

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

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

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

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

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

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

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

The future for physician anesthesiologists still looks bright.

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

WAS TIGER WOODS DRIVING UNDER THE INFLUENCE?

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

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

Perhaps his anesthesiologist knows. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A MORBIDLY OBESE PATIENT WITH MEAT STUCK IN HIS ESOPHAGUS

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

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

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

What do you do?

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

Mallampati Class IV airway

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

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

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

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

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

How should the anesthetic have been done? 

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

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

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

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

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

Footnote:

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

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

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

ALCOHOL AND ANESTHESIA

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

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

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

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

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

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

As a patient, what should you do? 

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

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

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

A DAY IN THE LIFE OF AN ANESTHESIOLOGIST

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

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

Your day is as follows, Doctor:

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

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

Empty Operating Room

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

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

Anesthesia Workstation

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

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

Labelled anesthetic syringes

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

Pre-Anesthesia Room

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

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

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

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

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

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

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

Nasotracheal Endotracheal Tube

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

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

Maxillary surgery

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

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

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

Post Anesthesia Care Unit

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

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

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

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

Ambulatory Surgery Center

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

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

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

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

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

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

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
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12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

THE PHYSICIAN ANESTHESIOLOGIST JOB MARKET LOOKS EXCELLENT

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

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

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

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

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

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

Here’s my advice:

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

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

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

THE TEN MOST SIGNIFICANT ADVANCES IN ANESTHESIOLOGY IN THE PAST DECADE

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

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

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

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

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

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

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The most popular posts for laypeople on The Anesthesia Consultant include:
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Why Did Take Me So Long To Wake From General Anesthesia?
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Will I Be Nauseated After General Anesthesia?
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
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Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

HOW DO PANDEMICS END? EXAMINING THE 1918 SPANISH FLU PANDEMIC

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

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

H1N1 influenza virus

Novel coronavirus

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

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

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

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

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

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

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

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

References:

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


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The most popular posts for laypeople on The Anesthesia Consultant include:
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Why Did Take Me So Long To Wake From General Anesthesia?
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How Safe is Anesthesia in the 21st Century?
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

SUFFOCATING ALONE

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

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

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

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

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

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

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

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

Hospice

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

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

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

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

Without suffocating alone.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
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How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
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Advice For Passing the Anesthesia Oral Board Exams
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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

WHAT ANESTHESIOLOGISTS DO… AN EXAMPLE ANESTHETIC

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

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

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

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

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

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

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

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

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

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

MONITORING SCREEN with vs

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

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

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

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

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

Sevoflurane vaporizer (see yellow knob) on anesthesia machine

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

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

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

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

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

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

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

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

The patient is now ready for the surgery to begin.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Post Anesthesia Care Unit (PACU)

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

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

Open gallbladder surgery incision

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

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

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

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

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

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

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

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

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WHY IS THERE AN ANESTHESIOLOGIST ON PRESIDENT TRUMP’S WALTER REED MEDICAL TEAM?

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

Why is there an anesthesiologist on President Trump’s Walter Reed medical team? Why would the president need an anesthesiologist?

This morning Dr. Sean Conley, the White House Physician, introduced President Trump’s medical team of seven doctors. Dr. Conley spoke to the nation from the approach to Walter Reed National Military Medical Center in Bethesda, Maryland. He introduced the team behind him with these words:

“Behind me are some of the members of the president’s medical team, whom I’d like to introduce. Dr. Sean Dooley, pulmonary critical care doctor. Brian Garibaldi, pulmonary critical care. Dr. Robert Browning, pulmonary critical care. Dr. Jason Blaylock, infectious disease. Dr. Wes Campbell, infectious disease. Dr. John Hodgson, anesthesia. Major Kurt Klein, Army Nurse. Commander Megan Nasworthy, Navy Nurse. Lieutenant Julianna Lavopa, Navy Nurse. Lieutenant Commander John Shea, clinical pharmacist. And not present with us are Lieutenant Beth Carter, Lt.. Maureen Meehan, both Navy nurses and Dr. Jesse Schonau, director Executive Medicine Program.”

The tally of these seven doctors reads:

3 Pulmonary and Critical Care doctors

2 Infectious Disease doctors

1 Anesthesiologist

1 Emergency Room doctor, (this is Dr. Conley, a doctor of osteopathic medicine, or D.O.)

Why an anesthesiologist? President Trump is diagnosed with COVIE-19. Details of his illness are few. We were told that as of today, Saturday, October 3rd 2020, President Trump has no fever, no trouble breathing, is not currently on oxygen therapy, and has an oxygen saturation of 96% (normal = 90-100%).

COVID-19 is an infectious disease, so it makes sense that two infectious disease doctors are attending to him.

COVID-19 most commonly causes serious illness by lung infection, so it makes sense that two pulmonary and critical care doctors are attending to him.

But why does President Trump need an anesthesiologist on his medical team at Walter Reed Medical Center?

The answer: Airway Management.

If a patient with COVID-19 becomes acutely ill and his respiratory status declines so much that he cannot keep a safe oxygenation level merely by breathing oxygen through a supplementary mask or an oxygen tent, then that patient needs to be placed on a ventilator.

Ventilators pump oxygen in and out of a patient’s lungs via a breathing tube placed in the patient’s windpipe (trachea). This is called an endotracheal tube, and every anesthesiologist places hundreds of these tubes each year. The placement of an endotracheal tube into a COVID-19 patient who is gasping for breath is an acute procedure which requires an expert. A general anesthetic drug and a paralytic drug would be injected into the patient’s intravenous line, and then an anesthesiologist (wearing a space suit of extensive personal protective gear) would use a device called a laryngoscope to place the tube into the trachea under direct vision of the patient’s voice box.

If you’re a patient and you begin gasping for breath because of respiratory failure secondary to COVID-19, you don’t want your anesthesiologist to be far away. That’s why there’s an anesthesiologist on President Trump’s current medical team. The next few days will be telling. The president may remain stable and have only minimal or mild illness, but there is a nonzero chance that he will decompensate and become acutely ill.

Placing an endotracheal tube into Donald Trump would probably be an uneventful task for an expert, but the president is overweight and he does have a thick neck. Patients whose airway looks like his can prove difficult for an anesthesiologist to intubate the trachea. The attending anesthesiologist would most likely use a video laryngoscope, which has a camera on the tip of the scope that is inserted into the patient’s throat. This technology allows the anesthesiologist to “see around the corner” into the patient’s larynx or voice box. The image of the patient’s airway appears on a video screen.

Regarding President Trump’s treatment to date: he has already been treated with Remdesivir, an antiviral therapy which is administered via an intravenous line. There is data that Remdesivir is effective in animals for COVID viral prophylaxis or immediately following viral inoculation.

 It appears he also received an antibody cocktail yesterday, REGN-COV2, developed by Regeneron. The development of this cocktail was described in the journal Science in August

No one knows how President Trump’s medical course will proceed. As a medical doctor, I can only wish him the best of health, the best of medical care, and the best medical outcome that is possible. I hope no anesthesiologist has to place a breathing tube.

Stay tuned in these interesting and difficult times.

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The most popular posts for laypeople on The Anesthesia Consultant include:
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How Safe is Anesthesia in the 21st Century?
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:
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Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

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THE TWO LAWS OF ANESTHESIA (ACCORDING TO SURGEONS)

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

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

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

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

Period.

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

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

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

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

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

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

Let’s examine the Two Laws:

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

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

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

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

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

TOXIC MARIJUANA SYNDROME YOU’VE NEVER HEARD OF: CANNABINOID HYPEREMESIS SYNDROME

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

Cannabinoid Hyperemesis Syndrome. Chances are you’ve never heard of it, but one of your patients, or someone you know, may develop this syndrome in the coming years. Cannabis use is common. According to The Washington Post, in 2017 more than half of American adults had tried marijuana at least once in their lives, and a total of 55 million Americans currently used the drug. This number approaches the total of 59 million cigarette smokers in America. Each year 2.6 million Americans become new cannabis users. The majority of marijuana users are male, earn under $50,000 a year, and lack a college degree. The 18–25 year old age group has the highest prevalence of marijuana use. 

Emesis is the medical word for vomiting. Hyperemesis means excessive vomiting. The number of people affected with Cannabinoid Hyperemesis Syndrome is estimated at about 2.7 million people in the United States per year. Cannabinoid Hyperemesis Syndrome (CHS) presents as a triad of chronic cannabis use, cyclic episodes of nausea and vomiting, and frequent hot bathing. If the patient withholds the history of chronic cannabis use, it’s difficult to impossible to make the correct diagnosis. Despite months of cyclical symptoms and thousands of dollars of Emergency Room visits and lab tests, the syndrome may not be correctly diagnosed or treated.

Let’s look at a case study of CHS to learn how it may present, and why it is uncommonly recognized:

A 25-year-old male presents for a diagnostic upper gastrointestinal endoscopy. He has a three-month history of persistent nausea, vomiting, and weight loss. His laboratory tests and CT scans of his abdomen and chest are normal. He carries a presumptive diagnosis of GERD (gastroesophageal reflux disease), and treatment with anti-acid drugs such as proton-pump inhibitors and H2-blockers have not improved the symptoms. The young man has been afraid to eat because of nausea and retching. He has been unable to work, and his sleep has been significantly impaired. He has lost weight from 150 pounds to his current weight of 135 pounds. On exam he appears well. His vital signs are normal, and his abdominal exam is negative for tenderness. He is scheduled for general anesthesia for the endoscopy procedure. He was referred for the upper GI endoscopy by his primary care doctor, and the gastroenterologist has yet to meet the patient.

Twenty minutes before his procedure, the anesthesiologist asks the patient if he takes any medicine or drugs. “Only the stomach pills my doctor prescribed,” he replies. “They aren’t working at all. I also use marijuana to decrease the nausea, but it’s not working either.”

“How frequently do you use marijuana?” the anesthesiologist asks. 

“Promise not to tell my parents?” he says. “I use a vape pen about 8 – 10 times a day.” 

“For how long have you been doing that?”

“About five years. I’ve increased my use over the past few months, because it’s supposed to be helpful for nausea, but it’s not working anymore.”

The anesthesiologist excuses himself, and sets off to find the gastroenterologist scheduled to do the procedure.  The anesthesiologist shares the cannabis history, and the gastroenterologist immediately says, “No one ever told me this patient was a chronic marijuana user. This changes everything. His history is classic for Cannabinoid Hyperemesis Syndrome.”

The gastroenterologist interviews the patient and confirms the correct clinical diagnosis. The treatment is immediate cessation of marijuana use, and the endoscopy is cancelled.

One week after stopping all cannabis use, the patient’s symptoms have completely resolved. He is eating well without nausea or vomiting, and has gained back 8 pounds.

Cannabinoid Hyperemesis Syndrome was first described in 2004 in a series of 9 patients from Australia.  In all of the cases, chronic cannabis abuse preceded the onset of a cyclical vomiting illness. Stopping cannabis led to cessation of the vomiting in seven cases. Three cases did not abstain and continued to have recurrent vomiting. Three other cases rechallenged themselves after a period of abstinence and relapsed to the same illness. Two of these cases abstained again, and remain well. The third case did not abstain, and remained ill. The majority of the patients displayed abnormal washing behavior during episodes of active nausea, in which they took repeated hot showers or baths, which temporarily relieved their symptoms.

Δ9-tetrahydrocannabinol (THC) is the principle psychoactive compound in cannabis. There are two distinct cannabinoid receptors, CB1 and CB2, in the human body, located predominately in the central nervous system and also in the gastrointestinal tract. THC stays in the body for a prolonged time, with an elimination plasma half-life of 20–30 hours. THC accumulates within body fat, and body fat serves as a long-term storage site. Typically THC can be used for its antiemetic (anti-nausea) property, and has been used to blunt nausea in cancer chemotherapy patients. With chronic use THC can induce a paradoxical nausea-inducing effect by unknown mechanisms on the central nervous system and the gastrointestinal system, causing the Cannabinoid Hyperemesis Syndrome. Patients with Cannabinoid Hyperemesis Syndrome are chronic users of cannabis who likely have large lipid reservoir stores of THC. 

CHS patients are typically young adults with a long history of marijuana use. There is usually a delay of several years following the onset of the chronic marijuana habit before the onset of symptoms. CHS patients often remain misdiagnosed. Erroneous diagnoses considered included a broad range of conditions affecting the gastrointestinal tract. In one study the average duration of cannabis use prior to onset of the recurrent vomiting was 19.0 ± 3.4 years, and had an average of 7.1 ± 4.3 emergency room visits, 5.0 ± 2.7 clinic visits, and 3.1 ± 1.9 admissions for the CHS syndrome. Daily marijuana use was typical, often exceeding 3 – 5 times per day. 

The three phases of CHS are prodromal, hyperemetic, and recovery. In the prodromal phase patients develop early morning nausea, a fear of vomiting, and abdominal pain. The hyperemetic phase includes episodes of intense and persistent nausea and vomiting. Patients vomit profusely, and can vomit or retch multiple times per hour. In the original 2004 Australian study, 70% of patients reported weight loss of at least 5 kg (11 pounds). Symptomatic patients typically undergo extensive diagnostic work ups, including laboratory and imaging studies, which are all normal or nondiagnostic. The recovery phase can last for days, weeks, or months. It occurs after the cessation of cannabis consumption, and is associated with return to normal eating patterns and original body weight.

The diagnosis of CHS must be made entirely by clinical history. The history of extensive previous cannabis use is universal, but may be unrealized if the patient withholds the information for personal reasons. A Mayo Clinic study in 2012 which included 98 patients, was the largest study to date. Characteristics of the Mayo CHS patients are shown in this table:

The Mayo series of 98 CHS patients helped establish these  diagnostic criteria. These criteria include: 

  • Essential for diagnosis: Long-term cannabis use. 
  • Major features: Severe cyclic nausea and vomiting, Resolution with cannabis cessation, relief of symptoms with hot showers or baths, abdominal pain epigastric or periumbilical, weekly use of marijuana. 
  • Supportive features: age less than 50 years, weight loss of > 11 pounds (5 kg), morning predominance of symptoms, normal bowel habits, negative laboratory, radiographic, and endoscopic tests.

Acute medical treatment for severe CHS episodes includes IV fluids for dehydration and supportive care. Traditional anti-emetic drugs such as Zofran have been largely ineffective. The only reliable long term treatment is the cessation of cannabis. The percentage of patients who relapse has not been quantified to date. The case series data in the medical literature currently document that many of the patients who return to cannabis use have recurrent CHS.

Voters have legalized the recreational use of cannabis in 11 states (California, Colorado, Washington, Oregon, Nevada, Maine, Alaska, Michigan, Illinois, Massachusetts, and Vermont). Because cannabis was legalized through popular vote and not via the usual Food and Drug Administration (FDA) channels, the drug did not undergo government scrutiny regarding toxicities and long term health effects. I discussed this topic in an earlier column.  

Cannabinoid Hyperemesis Syndrome should be considered as a plausible diagnosis in anyone with recurrent severe vomiting and a strong history of cannabis abuse. 

Because of recent legalization of recreational and medical cannabis use in many states, expect the incidence of Cannabinoid Hyperemesis Syndrome to increase. If your patient, or someone you know and love, develops recurrent severe vomiting in the setting of a strong history of cannabis abuse, the diagnosis may very well be Cannabinoid Hyperemesis Syndrome. 

The good news is that once the diagnosis is made, the syndrome is curable with cannabis abstinence.

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

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

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