Archive for the ‘Advice’ Category

No, I’m not talking about putting fentanyl into my own veins — a remarkably bad idea. I’m questioning the habitual, reflex use of fentanyl, a synthetic opioid, in clinical anesthesiology practice.

I’ve been teaching clinical anesthesiology, supervising residents and medical students, in the operating rooms of academic hospitals for the past 18 years. Anesthesiology residents often ask if I “like” fentanyl, wanting to know if we’ll plan to use it in an upcoming case. My response always is, “I don’t have emotional relationships with drugs. They are tools in our toolbox, to be used as appropriate.”

But I will say that my enthusiasm for using fentanyl in the operating room, as a component of routine, non-cardiac anesthesia, has rapidly waned. In fact, I think it has been months since I’ve given a patient fentanyl at all.

Here’s why.

What is fentanyl?

Fentanyl is an opioid pain-killer in the same class as morphine or Demerol, meaning that it acts on the same receptors in the brain to lessen the subjective experience of pain. It appeared on the market in 1960, and quickly gained wide use in anesthesia practice.

Fentanyl is potent and works fast, which makes it very effective in treating the intense stimulus of surgical pain, and its peak effect lasts only a short time. It’s also inexpensive, which makes it attractive in an era of cost containment in healthcare.

When I started my anesthesia residency, we assumed that since fentanyl’s analgesic and euphoric effects were so brief, short-term exposure to the drug wouldn’t increase a patient’s risk of long-term narcotic abuse. For the first few years, fentanyl was kept in unsecured medication carts in the operating rooms along with Benadryl, lidocaine, and other commonly used medications.

But anesthesiology departments quickly learned that fentanyl did indeed have high abuse potential. Its pleasurable “high” and rapid onset proved irresistible to some people, and deaths from overdose occurred all too often among medical personnel. Now, we track every microgram of fentanyl used or discarded during surgery.

Fentanyl stayed quietly under the radar for decades as an IV drug useful primarily in anesthesiology practice. But it began to see more use in the treatment of chronic pain — as transdermal patches, or “lollipops” for absorption by mouth. And with its increased availability came a higher risk of abuse. The well-publicized death of the musician Prince in 2016 from an accidental overdose propelled fentanyl into fame.

Today fentanyl is making headlines as the drug responsible for an ever-increasing number of opioid overdose deaths. Cheap to synthesize, it’s being laced into heroin and illegally made into pills that look just like oxycodone. People don’t have any way of knowing how much they are taking, and they die because they stop breathing.

Of course, illegal fentanyl abuse is the polar opposite of administering fentanyl responsibly as a licensed anesthesia professional who is monitoring the patient’s every breath. But we’ve learned that opioids, even when legally and carefully administered with the best intentions, may have unintended consequences.

Pain relief can lead to more pain

The key fact, often poorly understood by physicians — let alone the general public — is that treating pain with opioids can lead to more pain, a phenomenon known as “opioid-induced hyperalgesia”.

This is different from tolerance to the pain-relieving effects of opioids. Most people understand that if you start taking any narcotic — whether morphine, oxycodone, or fentanyl — over time you will become “tolerant” to the drug’s effect and will need more of it to achieve the same level of pain relief.

Opioid-induced hyperalgesia, or “OIH”, is a different problem. The definition of hyperanalgesia is abnormally heightened sensitivity to pain. OIH is defined as hypersensitivity to pain that occurs as a result of opioid use. When surgical patients receive opioids while under anesthesia, several studies have demonstrated increased opioid requirements after surgery, and worse, not better, pain scores.

An excellent 2016 review article in the journal Anesthesiology pointed out that the potential onset of OIH “should be considered when opioids are administered” to patients under anesthesia. It may well be that short-acting opioids such as fentanyl are worse offenders in terms of provoking OIH than longer-acting ones, as OIH increases when pain relief wears off and opioid doses must be repeated.

Do we need to use opioids during anesthesia?

Actually, we don’t. That has been the most surprising fact I’ve learned in recent years, as I’ve modified my practice in light of America’s lethal opioid epidemic.

There’s little reason to use fentanyl to block the unconscious patient’s blood pressure and heart rate responses during surgery, or the discomfort of having a breathing tube inserted. Other non-opioid anesthesia medications can do that just as well, without the risk of OIH.

In fact, a recent editorial from UCLA suggested that we don’t need to give opioids during surgical anesthesia at all, and that we would be better off reserving them for postoperative pain control. We can use other techniques — inhaled anesthetics, regional nerve blocks, epidurals, non-opioid pain medications — in a multimodal approach to treating painful stimuli during and after surgery. We can change our public image from “the docs with good drugs” to “proactive healers of our national opioid addiction epidemic.”

In light of all this information, I’m not sure I want my anesthesia practice associated with the use of fentanyl at all. I may be paranoid, but I suspect it’s only a matter of time until some clever plaintiff’s attorney sues anesthesia providers, claiming that a patient’s addiction was spawned by a first exposure to fentanyl during surgery. Who needs that misery?

As Joseph Heller wrote in Catch 22, “Just because you’re paranoid doesn’t mean they aren’t after you.” Enough said.

Emory University held graduation ceremonies on August 5 for the 2017 Class of Anesthesiologist Assistants (AAs), who received Masters of Medical Science degrees. While the traditional academic regalia can’t fail to evoke Harry Potter in the minds of many of us, there is some magic in the processional and the music that always makes graduation a moving, meaningful event. I had the honor of delivering the commencement address, reprinted here.

Distinguished faculty, graduates, honored guests:

It is a great pleasure and an honor to be here, and to congratulate all the graduates of the Emory University Class of 2017 on your tremendous accomplishment. Just think about all you have learned in the past two years! You’ve transformed yourselves into real anesthesia professionals, able to deliver first-class care to patients at some of the most critical times in their lives.

Today is a great time to become an anesthesiologist assistant. Just two days ago, Dr. Jerome Adams was confirmed as our country’s Surgeon General. He is the first-ever physician anesthesiologist to have that honor. Even better, he is from Indiana, where he was the State Health Commissioner, and of course Indiana is among the states where CAAs are licensed to practice. We know that Dr. Adams understands the principles of the anesthesia care team. Dr. Adams gets it – who AAs are, what you do, and how well qualified you are to care for your patients.

Another happy thought – the Secretary of Health and Human Services today is Dr. Tom Price from Georgia, an orthopedic surgeon, and a former Representative in Congress. His wife, Betty, is a physician anesthesiologist who currently serves in the Georgia state legislature.

Whatever your opinions about politics (and believe me, we’re not going there today), whether your blood runs red or blue, I think we can all celebrate the fact that we now have people in key positions who understand anesthesia; whose presence in Washington is great for AAs, for patients, and for the practice of safe, team-based anesthesia care.

All About Great Medical Discoveries

As I thought about what to say to you today, the first thing that occurred to me is that this summer marks 30 years since I finished my anesthesia training. You might be curious to know if I ever had any second thoughts, any regrets about that career choice. My answer is a resounding “no”.

I was lucky enough to get interested in anesthesia at an early age. I brought something to show you. This book was published in 1960. It’s called All About Great Medical Discoveries, and I read it when I was a little girl about 8 or 9 years old, in Amarillo, Texas. Here’s what it had to say about anesthesia, in a chapter called “The Conquest of Pain”:

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How reporter Jan Hoffman and the New York Times manage to insult female physicians and get their facts about anesthesia so wrong all at the same time.

My husband and I, both anesthesiologists, enjoy our Sunday mornings together — coffee, the New York Times, a leisurely breakfast. No rush to arrive in the operating room before many people are even awake.

Today, though, seeing reporter Jan Hoffman’s front-page article in the Times — “Staying Awake for Your Surgery?” — was enough to take the sparkle out of the sugar. Her article on how much better it is to be awake than asleep for surgery reminded me why I left a plum job as a reporter for The Wall Street Journal to go to medical school — because reporters have to do a quick, superficial job of covering complex issues. They aren’t experts, but seldom admit it.

Physician anesthesiologists across the country are likely to face patients on Monday morning who wonder if they ought to be awake for their surgery. The answer to that question may well be “no”. But according to Ms. Hoffman, that answer reflects “physician paternalism”, and makes us opponents of the “patient autonomy movement”, because a patient should have the right to choose to be awake.

It’s not that simple.

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Is there a direct connection between communication skills and the art of successful leadership? Most of us would agree that there is. But is there a direct connection between blogging and leadership? That may be more of a reach.

Can the process of writing a blog help to develop communication skills that will prove useful in leadership? In my opinion the answer is yes, but a qualified yes. Writing a blog won’t help anyone become a good writer who never learned to write competently in the first place. Perhaps even more important, writing a blog won’t help anyone become a thought leader who hasn’t developed any original thoughts.

Communicating a vision

To make a real mark in history, a leader has to communicate a vision that people understand. The vision must be powerful enough to motivate them to follow. In decades past, for instance, the men who became President of the United States typically were graduates of liberal arts education, trained in the arts of debate, oratory, and essay composition. They knew how to make their points.

No matter which end of the political spectrum you favor, most of us would agree that Presidents John F. Kennedy and Ronald Reagan were gifted communicators. Though obviously they benefited from the help of speechwriters behind the scenes, both were skillful writers on their own, as proved by their private documents and letters.

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This column ran first in the online magazine for medical students, “in-Training”

In case you were wondering — robots won’t replace anesthesiologists any time soon, regardless of what the Washington Post may have to say. There will definitely be a place for feedback and closed-loop technology applications in sedation and in general anesthesia, but for the foreseeable future we will still need humans.

I’ve been practicing anesthesiology for 30 years now, in the operating rooms of major hospitals. Since 1999 I’ve worked at Cedars-Sinai Medical Center, a large tertiary care private hospital in Los Angeles.

So what do I think today’s medical students should know about my field?

A “lifestyle” profession?

For starters, I have to laugh when I hear anesthesiology mentioned with dermatology and radiology as one of the “lifestyle” professions. Certainly there are outpatient surgery centers where the hours are predictable and there are no nights, weekends, or holidays on duty. The downside? You’re giving sedation for lumps, bumps, and endoscopies a lot of the time, which can be tedious. You may start to lose your skills in line placement, intubation, and emergency management.

Occasionally, though, if you work in an outpatient center, you’ll be asked to give anesthesia for inappropriately scheduled cases on patients who are really too high-risk to have surgery there. These patients slip through the cracks and there they are, in your preoperative area. Canceling the case costs everyone money and makes everyone unhappy. Yet if you proceed and something goes wrong, you can’t even get your hands on a unit of blood for transfusion. To me, working in an outpatient center is like working close to a real hospital but not close enough — a mixture of boredom and potential disaster.

The path I chose is to focus on high-risk inpatient cases. I especially enjoy thoracic surgery, with the challenges of complex patients and one-lung ventilation. You can bring me the sickest patient in the hospital setting — where I have all the monitoring techniques, resuscitation drugs, blood products, bronchoscopes, and anything else I might need — and I’ll be perfectly happy. The downside: a practice like mine tends to be stressful and tiring, and I never know the exact time that the day will end. Hospitals that offer Level I trauma and high-risk obstetric care are required to have anesthesiologists in house 24 hours a day, 365 days a year. There’s no perfect world.

What type of person is happy as an anesthesiologist?

Even though women comprised 47% of the US medical school graduates in 2014, only about 33% of the applicants for anesthesiology residency were women. I’d be interested to hear from all of you as to why fields such as pediatrics and ob-gyn tend to be so much more attractive to women, because I genuinely don’t understand it. But I do have a few thoughts as to the type of person who is happy or unhappy as an anesthesiologist.

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