THE ANESTHESIOLOGIST AND THE NFL

the anesthesia consultant

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

the anesthesia consultant

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

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

 

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

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

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

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

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

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

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

#4.  The ASA Difficult Airway Algorithm.  Anesthesia and critical care medicine revolve around the mantra of “Airway-Breathing-Circulation.”  When the ASA published the Difficult Airway Algorithm in Anesthesiology in 2003, they validated a systematic approach to airway management and to the rescue of failed airway situations.  It’s an algorithm that we’ve all committed to memory, and anesthesia practice is safer as a result.

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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