THE MOST IMPORTANT TECHNICAL SKILL FOR AN ANESTHESIOLOGIST?

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

Latest posts by the anesthesia consultant (see all)

What’s the most critical technical skill for an anesthesiologist? I ask this question when I’m teaching anesthesia residents and medical students. Their most frequent answer is . . . the ability to place an endotracheal tube. This is the wrong answer. The most critical technical skill for an anesthesiologist is . . . facemask ventilation. Why?

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All acute medical care follows the sequence of A-B-C, or Airway, Breathing, Circulation. Control of the airway is the most important clinical priority in anesthesia care. Placement of an endotracheal tube to establish an airway is an essential skill, but at times it’s difficult or near impossible to intubate the trachea on the first attempt.

The American Society of Anesthesiologists  Difficult Airway Algorithm addresses this issue. The Algorithm recommends, “Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management. Opportunities for supplemental oxygen administration include (but are not limited to) oxygen delivery by nasal cannulae, facemask, or LMA, insufflation; and oxygen delivery by facemask, blow-by, or nasal cannulae after extubation of the trachea.”

In emergency situations, maintenance of oxygen delivery by facemask can be critical.

The INTUBATION AFTER INDUCTION OF GENERAL ANESTHESIA section of the Difficult Airway Algorithm is bifurcated into two pathways. The left side is labeled FACE MASK VENTILATION ADEQUATE. The right side is labeled FACE MASK VENTILATION NOT ADEQUATE.

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The left side FACE MASK VENTILATION ADEQUATE leads to a NONEMERGENCY PATHWAY algorithm. The right side FACE MASK VENTILATION NOT ADEQUATE begins with CONSIDER/ATTEMPT SGA (Supraglottic Airway), but if SGA placement is unsuccessful, the right side FACE MASK VENTILATION NOT ADEQUATE pathway leads directly to an EMERGENCY PATHWAY algorithm subtitled “Ventilation not adequate, intubation unsuccessful.”

“Ventilation not adequate, intubation unsuccessful” is a circumstance every anesthesiologist dreads, and every anesthesiologist hopes to avoid. Failure to keep a patient oxygenated can lead to hypoxia and brain death in as short a time as three minutes.

One way to spend less time on the right side of the ASA Difficult Airway Algorithm is to be expert and proficient in facemask ventilation.

In my practice, I’d estimate 1 – 2 patients out of every 100 patients, or 7 – 10 patients per year, present an unexpected difficult intubation. In my preoperative assessment I believe their intubation will be routine or only moderately difficult. After I induce general anesthesia and paralyze the patient, I find their larynx is anterior and difficult to visualize by direct laryngoscopy. In these patients in which my initial attempt(s) are unsuccessful, repeat laryngoscopies are required, and facemask ventilation between laryngoscopies to maintain oxygenation and ventilation is critical.

A second intubation attempt may involve a change in head and neck positioning, oropharangeal suctioning, or a different laryngoscope. If these modifications are unsuccessful, video laryngoscopy is indicated. A recent study in Anesthesiology showed video laryngoscopy to be the most successful technique to achieve successful tracheal intubation after failed direct laryngoscopy, with a 92% rescue rate. Video laryngoscopy is known to be associated with improved visualization of the larynx , although placement of the tube into the trachea may still require repeated attempts, requiring alteration in curve of the stylet or repositioning of the laryngoscope.

Some might argue that the use of video laryngoscopy for the first attempt at endotracheal intubation will eliminate this problem. But as described above, for difficult airways or obese patients, even video laryngoscopy can require repeated attempts because of difficulty advancing the tube into the trachea. No data exists to support that initial video laryngoscopy is safer or more effective than direct laryngoscopy when used by anesthesiologists in operating rooms.

Airway and Breathing must be maintained by facemask ventilation until an endotracheal airway or supraglottic airway is established. The manual skill of maintaining a seal between the mask and the patient’s face requires strength. The four fingers hold the caudal aspect of the mask firmly against the chin, and also serve to extend the patient’s neck. The thumb presses down on the cephalad aspect of the mask against the bridge of the nose. The right hand squeezes the ventilation bag on the anesthesia machine.

An anesthesiologist with an injured or impaired left hand is unable to safely ventilate a patient via facemask, especially an overweight patient or a patient with a beard or abnormal facial anatomy. Because of this, an anesthesiologist with an injured or impaired left hand should not be administering general anesthesia. Anesthesiologists would be wise to avoid hand or wrist injuries which could make them unemployable. Anesthesiologists would be wise to avoid falling on their outstretched hands. The pastimes of bicycle riding, skateboarding, rollerblading, climbing ladders, and rock climbing are all fraught with hand-injury danger. Should anesthesiologists avoid these activities? At the very least, anesthesiologists need to be overly careful with these activities.

Operating room practice requires anesthesiologists to perform multiple additional technical procedures, including the placement of IVs, arterial lines, central venous catheters, spinal blocks, epidural blocks, and ultrasound-guided regional nerve blocks. Each of these skills is important, but none of them are as critical as the ability to keep a patient oxygenated, first with a facemask, and second by placing an airway tube.

In a previous column, I described a case in which an anesthesiologist lost the airway on a pregnant woman following induction of general anesthesia for Cesarean section. The acute situation led to the anesthesiologist’s unrelenting focus on repeat laryngoscopies, at the expense of the facemask ventilation needed to return the oxygen saturation to a level greater than 90%. Failure to keep the patient oxygenated through repeated intubation attempts can lead to hypoxia and brain death.

The full list of the intellectual, technical, and personal qualities necessary to succeed in the profession of anesthesiology are summarized in my column On Becoming an Anesthesiologist – What Personal Characteristics are Essential.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

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13 MAJOR CHANGES IN ANESTHESIOLOGY IN THE LAST TEN 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

Latest posts by the anesthesia consultant (see all)

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

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SUGAMMADEX – The long awaited reversal agent for neuromuscular paralysis reached the market in 2016, and by my review, the drug is wonderful. I’ve found sugammadex to reverse rocuronium paralysis in less than a minute in every patient who has at least one twitch from a nerve stimulator. The dose is expensive at about $100 per patient, but at this time that’s cheaper than the acquisition costs for neostigmine + glycopyrrolate. The acquisition cost of neostigmine + glycopyrrolate at our facilities exceeds $100, and this combination of drugs can take up to 9 minutes to reverse rocuronium paralysis. Sugammadex reversal can make the duration of a rocuronium motor block almost as short acting as a succinylcholine motor block, and sugammadex can also eliminate complications in the Post Anesthesia Care Unit due to residual postoperative muscle paralysis. Grade = A.

 

SHORTAGES OF GENERIC INTRAVENOUS DRUGS – Over the last five years we’ve seen unexpected shortages of fentanyl, morphine, propofol, ephedrine, neostigmine, glycopyrrolate, meperidine, and atropine, to name a few. These are generic drugs that formerly cost pennies per ampoule. In the current marketplace, generic manufacturers have limited the supplies and elevated the prices of these medications to exorbitant levels. I wish I’d had the foresight and the money ten years ago to invest in a factory that produced generic anesthetic drugs. Grade = F.

 

THE PERIOPERATIVE SURGICAL HOME – The American Society of Anesthesiologists has been pushing this excellent concept for years now—the idea being that a team of physician anesthesiologists will manage all perioperative medical care from preoperative clinic assessment through discharge, including intraoperative care, postoperative care and pain management in the PACU, the ICU, and the hospital wards. The goal is improved patient care with decreased costs. It’s not clear the idea has widespread traction as of yet, and the concept will always be at odds with the individual aspirations of internal medicine doctors, hospitalists, intensivists, surgeons, and certified nurse anesthetists, all who want to make their own management decisions, and all who desire to be paid for owning those decisions. Grade = B-.

 

MULTIMODAL PAIN MANAGEMENT FOLLOWING TOTAL JOINT REPLACEMENTS – The development of pain management protocols which include neuroaxial blocks, regional anesthetic blocks, local anesthetic infiltration by surgeons, oral and intravenous pain medications, have advanced the science of pain relief for total knee and total hip replacements. The cooperation between surgeons, anesthesiologists, and internal medicine specialists to develop the protocols has been outstanding, the standardized checklist care has been well accepted, and patients are benefiting. Grade = A.

 

ULTRASOUND GUIDED REGIONAL ANESTHESIA – Regional anesthetic blocks are not new, but visualizing the nerves via ultrasound is. The practice is becoming widespread, and the analysis of economic and quality data is ongoing. Ultrasound guided regional anesthesia is a major advance for painful orthopedic surgeries, but I worry about overuse of the technique on smaller cases for the economic benefit of the physician wielding the ultrasound probe. A second concern is the additive risk of administrating two anesthetics (regional plus general) to one patient. I’ve reviewed medical records of patients with adverse outcomes related to regional blocks, and I’m concerned ultrasound guided regional anesthesia may be creating a new paradigm of postoperative complications, e.g. prolonged nerve damage or intravascular injection of local anesthetics. In the future I look forward to seeing years of closed claims data regarding this increasing use of regional anesthesia. Grade = B.

 

VIDEOLARYNGOSCOPY – The invention of the GlideScope and its competitors the C-MAC, King Vision, McGrath and Airtraq videolaryngoscopes was a major advance in our ability to intubate patients with difficult airways. My need for fiberoptic intubation has plummeted since videolaryngoscopy became available. I’d recommend that everyone who attempts traditional laryngoscopy for endotracheal intubation have access to a video scope as a backup, should traditional intubation prove difficult. Grade = A.

 

ANESTHESIOLOGIST ASSISTANTS (AAs) – The American Society of Anesthesiologists is championing the idea of training AAs to work with physician anesthesiologists in an anesthesia care team model. A primary reason is to combat the influence and rise in numbers of Certified Registered Nurse Anesthetists (CRNAs) by inserting AAs as a substitute. Not a bad idea, but like the Perioperative Surgical Home, the concept of AAs is gaining traction slowly, and the penetration of AAs into the marketplace is minimal. To date there are only ten accredited AA education programs in the United States. Grade = B-.

 

CHECKLISTS – We now have pre-incision Time Outs, pre-induction Anesthesia Time Outs, and pre-regional anesthesia Block Time Outs. It’s hard to argue with these checklists. Even if 99.9% of the Time Outs change nothing, if 0.1% of the Time Outs identify a miscommunication or a laterality mistake, they are worth it. Grade = A.

 

ANESTHESIA ELECTRONIC MEDICAL RECORDS (EMRs)– The idea is sound. Everything in the modern world is digitalized, so why not medical records? The problem is the current product. There are multiple EMR systems, and the systems cannot communicate with each other. Can you imagine a telephone system where Sprint phones cannot communicate with AT&T phones? The current market leader for hospitals is Epic, a ponderous, expensive system that does little to make the pertinent information easier to find in medical charts. For acute care medicine such as anesthetic emergencies, the medical charting and documentation in Epic gets in the way of hands-on anesthesia care. In the past, when I administered 50 mg of rocuronium, I simply wrote “50” in the appropriate space on a piece of paper. In Epic I have to make at least 4 mouse clicks to do the same thing. This Epic entry cannot be made on a touch screen because the first rocuronium window on the touch screen is a three-millimeter-tall box, too small for a finger touch. I’d like to see Apple or Google develop better EMR software than we have at present. Perhaps the eventual winning product will be voice activated or will involve easy touch screen data entry and data access. And all EMR systems should interact with each other, so patient privacy medical information can be portable. Grade = C-.

 

THE ECONOMICS OF ANESTHESIA – When I began in private practice in 1986, most successful anesthesiologists joined a single-specialty anesthesia group. This group would cover a hospital or several hospitals along with nearby surgery centers and offices. The group would bill for physician services, and insurance companies would reimburse them. Each physician joining the group would endure a one or two-year tryout period, after which he or she became a partner. Incomes were proportional to the number of cases an individual attended to. The models are changing. Smaller anesthesia groups are merging into larger groups, better equipped to negotiate with healthcare insurers and ObamaCare. More and more healthcare systems are employing their own anesthesiologists. In a healthcare system, profits are pooled and shared amongst the varying specialists. This model is not objectionable. Anesthesiologists share the profits with less lucrative specialties such as internal medicine and pediatrics, but the anesthesiologists are assured a steady flow of patients from the primary care physicians and surgeons within the system. The end result is less income than in a single-specialty anesthesia group, but more security. Grade = B.

 

THE SPECTER OF A BAN ON BALANCE BILLING – In a perfect world all physician groups would be contracted with all health insurance companies, at a monetary rate acceptable to both sides. Unfortunately there are insurance company-physician group rifts in which an acceptable rate is not negotiated. In these instances, the physician provider for a given patient may be out of network with the patient’s insurer, not because of provider greed (as portrayed by some politicians and insurers) but because the insurance company did not offer a reasonable contracted rate. Some politicians believe physician out-of-network balance billing should be outlawed. This would give unilateral power to insurance companies. Why would an insurance company offer a reasonable rate to a physician provider group, if the insurance company can pay the physicians a low rate and the new law says the physicians have no alternative but to accept it as payment in full? The no-balance-billing politicians will portray patients as victims, but if they succeed in changing the laws, physicians will become victims. Physicians as well as consumers must unite to defeat this concept. Grade = F.

 

CORPORATE ANESTHESIA – National companies are buying multiple existing anesthesia groups and changing the template of our profession in America. The current physician owners of a practice can sell their group to a publically traded national company for a large upfront payoff. The future salaries of anesthesiologists of that group are then decreased, and the rest of the profit formerly garnered by the physicians goes instead to the bottom line of the national company’s shareholders. If this model becomes widespread, the profession of anesthesiology will morph into a job populated by moderately reimbursed employees. Grade = D.

 

INDEPENDENT PRACTICE FOR CRNAs – Anesthesiology is the practice of medicine. In a two-year training program, an ICU nurse can learn to administer propofol and sevoflurane, and how to intubate most patients, and become a CRNA. It takes a physician anesthesiologist to manage complex preoperative medical problems, intraoperative complications, and postoperative medical complications. I understand rural states such as Montana and the Dakotas cannot recruit enough physician anesthesiologists to hospitals in their smallest towns, but for states like California to legalize independent anesthesia practice for CRNAs is unconscionable. Grade = D.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited