The Ether Way

Impaired Physicians

The public imagines that doctors protect each other. The reality is far more complicated. Medicine, at least hospital medicine, is a fishbowl. If Doctor Y turns up for rounds with a black eye on the fifth floor, we are likely to hear about it (in gossipy tones) in the OR that same morning. Think of a hospital as a big cubicle barn without the barriers. Nevertheless, disciplining physicians is tricky business.

First, my credentials. I have served as Chief of Staff at two hospitals, and have been in hospital leadership for two decades. I have had death threats against me and my children, almost certainly as a consequence of physician disciplinary activities during my time as chief of staff. I have been involved in dozens of disciplinary actions at all levels, and in retrospect, I've been generally satisfied with outcomes for patients and physicians.

"There's a lot of stuff goes on."

  -Tony La Russa


A favorite anesthesia blogger, T of Anesthesioboist, recently compared anesthesia to cooking. Not an inapt comparison, but I've always thought anesthesia was most like...baseball. There are the obvious reasons (I'm a guy, I was a baseball fan, baseball is like all of life..); no, wait-hear me out on this one.

Anesthesia is like playing right field.

Firstly, batting is like an anesthesia induction or emergence (or like coming off bypass); it is an acutely intense activity which requires complete concentration on multiple rapidly changing variables in the midst of distraction, if one is to be successful. It is an intensely physical activity (go ahead-try to manage a cardiac induction with a broken finger or sprained ankle) with relatively narrow tolerances. Hitting and anesthesia are completely honest activities; there is no pretend, and little that is relative; either you got it right or you didn't.

The maintenance phase of anesthesia is like playing right field; although it looks relaxed, it's anything but; peering in for signals as to positioning, scrutinizing the batter's stance for clues to his intentions. Examining the baserunner's positions; who's fast enough to tag up and beat a throw, who's slow. Ignoring or engaging the crowd. Preparing to move to a hit ball...every pitch is an exercise in focused watchfulness and pre-positioning. That's the price of playing in the big leagues. And being a "gold glover" means virtually never committing an error; One mistake in a thousand plays is barely good enough. The chances that any given pitch will result in the need for decisive action by the right fielder are low; maybe routine fly balls two or three times a game. Once every five or ten games maybe a big move; shag a fly and a long accurate throw to the cutoff man. Once or twice a season, the game hinges on your move; hero or goat? And if you get it right, the pitcher might come by in the locker room and thank you for saving the game; or, more likely, he might be too busy talking to the press about "his" win.

We’re from the government, and we’re here to help.

   Everyone knows that this statement is generally untrue. It’s a whopper, right up there with “the check is in the mail” and “I’ll respect you in the morning”?   When is this true? Ironically, most often, when members of the armed forces are conducting operations ordered by their Commander-in-Chief (humanitarian or combat missions).  When is this not true? Well….

    As a group, proponents of health care reform advocate a greater government role in the provision of health care.  The more limited proposals advocate some combination of greater regulation and more extensive participation (e.g. expanding Medicaid).  More ambitious proposals would produce explicitly or functionally socialized health care. As we deliberate about the options, it is worth remembering that the US government in already in the business of health care,

    Not only is the US government already in the business of health care, it in fact runs 3 large health care systems in parallel.  The first is the military health care system, which in fact is a hybrid system of military hospitals specializing in the care of combat casualties and an HMO that specializes in procuring care from the lowest bidder (and if you have any friends in the service, you can ask them how it works).  The second is the Veteran’s Administration, which is one of the largest, if not the largest, vertically and horizontally integrated providers of health care on the planet.  The third is of course the Medicare system, which has been a growing force and shaping healthcare since its inception.  Only a few visionaries predicted the role that Medicare would have in shaping health care when it was proposed.

 

Patient Safety in Anesthesia...A success story

December 7, 1941  Pearl Harbor.... Lots of casualties. Patient safety routine efforts primarily consist of finger on the pulse, eyes on the chest, observation of skin color. The recently released drug, thiopental, is employed. Some of the soldiers die…of anesthesia (1-3). Anesthesia-related death rate reported at 1 in 450 (2).

September 1979 – September 1981 (WAK residency time). The operating surgeon calmly notes blood’s dark.  WAK’s reaction: BLOOD'S DARK!!! Dr. Todres says the first 3 things to check for with any problem in the OR is, first airway, then the airway, and finally the airway. So he checks it and finds a disconnect which somehow was not able to be heard with the esophageal stethoscope over the orthopedists’ hammers and drills. No oxygen analyzer, no disconnect alarm, no pulse oximeter, no automated blood pressure monitor; by today’s standards, no nothing, although we did have manual blood pressure cuffs, EKG machines,  and the beginnings of advanced hemodynamic monitoring. WAK’s attendings were fond of saying “when I was a resident…” followed by some parable of how he managed with no monitors other than his five senses.  It seemed like at least once a year at M&M there was discussion about an intraoperative death by undetected disconnect. Anesthesia death rate said to be about 1 in 10,000.

 

Whack-a-mole!

No mysticism today, but a meditation nonetheless. I have in mind the once-again confused state of matters for the patient with cardiac disease presenting for non-cardiac surgery. When I left off in my thinking, snug (and smug) in my self-assurance, it was January 2005. Life was good! Eagle and Fleischer (and all the rest..) had published, in 2002, a lovely practice guide stratifying risk by extent of procedure, severity of risk factors, and had even published a sexy little flow chart suggesting how to proceed. To make matters even better, intervening publications highlighted the protective effects of Beta-blockers, statins (who knew they had an acute protective effect?), and the interesting observation that many post-op MI's smolder (elevated i-troponins for hours or days) before they burst forth. (At least, that's one of the off-hypothesis impressions I took from this data.) McFalls et al did their remarkable study (CARP) in the VA system (where else in America could such a thing be done?) where they took a bunch of veterans with known coronary artery disease of sufficient severity to warrant intervention (CABG or PCI), and randomized them to either have their hearts fixed before abdominal or thoracic aneurysm surgery, or after. No kidding-you can look it up! Here. No differences in outcomes! No differences!(They eliminated critical aortic stenotics (Duh!) and Left mains (hmmm.) Lots of letter-to-the-editor chatter about this study, as befits a work of this breathtaking hypothesis and conclusion. You'll have to read them yourself...

Patients are not Customers!

Link through Kevin MD's July 26th post to a good (and important) op-ed about a long time pet peeve of mine; hospitals calling patients "customers."

Brain Damage From Anesthetics

Say it aint so.....

So far no one has shown a direct effect of anesthetics to produce brain damage in people.  However, there are some disturbing reports about post operative cognitive dysfunction after surgery, especially in the elderly.  The Mayo group published data suggesting a link between age of onset of alzheimers and cumulative lifetime anesthetic exposure.  Moreover, Monk's group has shown an association between depth of anesthesia by BIS and one year mortality.  So what's up?

Pretty much every category of anesthetic has been impugned:

Opioids.

I am pretty sure I (and my colleagues) published the first papers showing histologic injury from a clinically used anesthetic drug (Anesth Analg 75:953‑964, 1992.   see fig).  We showed that high doses of alfentanil in paralyzed ventilated rats produced seizures and limbic system  brain damage in paralyzed ventilated physiogically controlled rats.  The doses were about ten times higher than analgesic, a dose range commonly used in cardiac surgery.  Similar results were produced with sufentanil, fentanyl, and remifentanil.  Given to monkeys in a PET scanner we saw FDG temporal lobe activation with fentanyl.  We gave brief high dose remifentanil to five humans fully paralyzed and ventilated also showing limbic system activation.  I just published another paper reporting limbic system activation at low doses of remifentanil in 29 volunteers with a variation in the activation pattern according to apolipoprotein E genotype.  Kearse and Tempelhoff have shown limbic epileptiform activity from fentanyl in humans.  Sullivan et al and Augoustides et al have shown that the proconvulsant properties of  remifentanil make for easier ECTs.  I had one patient seize from a remi injection before ect (do we shock or not?) and another developed post remi-ect status epilepticus.

     So the evidence seems overwhelming that opioids can produce limbic activation and in the right setting   produce brain damage, but we still don't know about people.(NB: when i suggested to several NIH study sections and the AHA in the early 90's that what we were seeing in rats might be relevant they returned non scored critiques...real visionaries there...)

Gabergic drugs

Drugs like barbiturates and benzodiazepines have been long considered to be protective.  Thus the chagrin from many quarters when todorovic, olney and colleagues showed that neonatal exposure to midazolam and nitrous oxide produced later histologic damage and cognitive dysfunction. 

General Anesthesia is really a drug induced coma

I am very particular that patients understand enough about anesthesia to be appropriately concerned regarding what they are about to agree to undergo. In my youth, I supervised an anesthetist who routinely minimized what she said so as to not "upset" the patients. ("you are going to take a little nap while Dr Smith does your surgery...") Nonsense. That's not what we do, and it's not the way patients ought to think about what we do (and what they are agreeing to endure...)  This little conceit creates a false basis for informed consent and trivializes what we do. (we're not just "passing gas" here...) Patients don't believe it, anyway; they know that surgery and anesthesia involve risk and pain, and that anyone who says differently is just selling something.

Grandpa:  ...I'm explaining to you because you look nervous.
Grandson: I wasn't nervous. Maybe I was a little bit "concerned" but that's not the same thing.

    The Princess Bride

Everyone does it, but no one writes about it

What the heck am I doing here?  Why am I here?  More specifically, why have I agreed to participate in a blog?

    Because in medicine, there are a large number of subjects that everyone thinks about and talks about, but no one writes about.  As a group, these subjects are too social for our journals, and too political for our organizational newsletters.  The scientific front-story of medicine receives excellent coverage in our journals, as do the explicit economic issues in our various societal newsletters.

The back-story, the issues surrounding the social construction of health care at the individual, group, hospital, and societal level, has no venue for conversation.  We all wonder: where is this going? We talk about it, but there is nowhere to read about it.  The result is highly local, mostly poorly informed and poorly formulated discussion.  So what? It matters.  The truly radical changes in medicine today are in its social structure as much as in its scientific underpinnings and clinical practice.  As a group, physicians are uninformed about these social issues.  Worse, we are untrained to think and write about them.  There’s a lot to know about the social construction of health care, and physicians don’t even know where to begin.
   

Sleep and Death are Brothers...

In anesthesiology, it is all too easy to lose oneself in the mechanics of placing an endotracheal tube, and to forget that, in the extraordinary act of inducing a trance-like state barely distinguishable from death in a fellow human being, you are acting squarely within the realm of myth. "Sleep and death are brothers" is an ancient Greek proverb, and from the mythologic perspective, is quite literally true. The god of Sleep,  Hypnos is the younger brother of the god of death, Thanatos; both children of Nyx, the goddess of night. And therein lies a glimpse at the beauty of mythology and archetype; the blurring of the distinction between what is real, and what is metaphorically and romantically true or essential (containing the essence of a thing). Our Western penchant for deconstruction and de-mystification has the unfortunate and unintended consequence of driving the essence of things out of our daily lives. We slay beauty, the essence, with the real. A beautiful fragrant climbing rose becomes trivialized and "understood" as a biological device that uses sunlight to fix atmospheric carbon as growth substrate, and the flower is an attractant to promote cross pollination; we have killed the essence of the rose and replaced it with reality, to our great aesthetic detriment; in so doing, we fall out of grace; we lose the Tao.  Just so have we trivialized the stupendous act of conjuring a near death stupor in our fellow man, and than at our will, performing a veritable resurrection; an Anastasis, in greek; αναστασις;  ανα (ana) up and στασις (stasis) standing. This word, anastasis, by the way, bears a striking similarity to anesthesia, and would have been familiar to a classically educated scholar such as Oliver Wendell Holmes...