Posts Tagged ‘Anesthesiology’

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 caller “The Conquest of Pain”:

“It is almost impossible for us to imagine the horror of surgical operations before the discovery of methods for putting the patient to sleep.

Operating rooms were usually located in separate buildings or in towers so that the other patients in the hospital would not hear the screams of the patient. It sometimes took as many as six husky men to hold the patient still. Because of the terrible pain, the surgeon had to operate as swiftly as possible. But speed made for poor surgery.

Modern surgery was impossible until a way had been found to protect the patient from the pain.”

Think about that. Modern surgery was impossible before anesthesia. I suppose I was a peculiar sort of little girl, but I found this fascinating. The book went on to talk about Dr. Crawford Long, who in 1842 was the first surgeon to perform an operation under ether anesthesia, in the town of Jefferson, Georgia, about 60 miles northeast of here. The author wrote about new anesthesia gases like – wait for it – cyclopropane, and explained how anesthesia gases are safer if oxygen is mixed with them. Good to know!

Fast forward about 20 years. When I went to medical school, although I enjoyed nearly all my clinical rotations, there wasn’t any doubt in my mind by the end of the third year that I wanted to go into anesthesia.

It really is a great profession! For anyone who might not be familiar with our field, we can sum it up by saying that in anesthesia we take care of patients while surgeons try to fix them. It’s not only a matter of preventing pain and awareness. We take care of the high blood pressure, diabetes, asthma, or any other medical problems our patients may have. We have to know a fair amount about internal medicine, and pediatrics, and birthing babies. And we must learn about each different kind of surgery, and how to tailor the anesthesia to the operation as well as to the patient.

People often think that anesthesia sounds sort of dry and technical. It’s true that there is a great deal of detail to learn, about drugs and techniques. You might even think that there’s not a lot of human interaction, or connection with patients.

But let’s take a closer look. This year I have the honor of being the president of the California Society of Anesthesiologists.  Our tagline is “Physicians for Vital Times.” Because in anesthesia, we are with patients at the most vital times of their lives – childbirth, surgery, intensive care, and sometimes even at the moment of death.

Think about the parents whose child needs surgery. The problem may not be that serious – maybe the surgeon needs to fix crossed eyes or take out tonsils. But the parents know, deep down, that though the surgery may be minor, the anesthesia is not. And when we take that child into the operating room, we must always remember the trust those parents are placing in us, to keep their child safe to the very best of our ability.

It’s humbling, too, to think of the times that patients are looking up at us just before they go under anesthesia.  Think of the terrified young mother in labor, who knows that her baby is in distress, and that she needs general anesthesia for an emergency C-section. Think of the patient who’s been in a terrible accident, or a victim of violence. There may be times ahead – and I hope there will be mercifully few of them – when your voice may be the last voice a patient hears on this earth. It matters what we say, and even more, it matters how we say it.

When I started my anesthesia training, most patients came into the hospital for surgery the night before, and we would do preoperative visits without any time pressure. Those days are over!  Today we’re lucky to have 10 minutes to complete a preoperative history, examine the patient, discuss anesthesia, and document it all in the computer! Yet those 10 minutes are vitally important to that patient. How we handle that interaction makes all the difference in whether our patients feel safe putting their lives in our hands.

We’ve made anesthesia very safe, and we’ve made it look easy – maybe too easy. People can forget that when anesthesia goes wrong, the results can be deadly. In my role as CSA President, I have been sounding the alarm for better anesthesia care for children in dental offices. You might have seen me on TV last month, with NBC reporter Kate Snow, talking about tragic cases of children who died, or suffered permanent brain damage, caused by anesthesia gone horribly wrong in the dentist’s office.

Can you imagine taking your child in for a dental procedure, not knowing that the dentist would be giving general anesthesia while doing the dental procedure? That there would be no anesthesia professional there who could rescue your child’s airway in an emergency?  It seems inconceivable, but it happens every day.

One of the keys to safe anesthesia is the concept of the anesthesia care team, where physician anesthesiologists work together with residents, nurses, anesthesiologist assistants, and technicians. Two heads often are better than one, and there certainly are times when you need way more than two hands! That is one reason why I’ve been such a strong supporter of CAA practice for years, because I know you believe in the care team concept as much as I do.

There are so many of us in California who would love to have CAAs working with us every day. We are working to make it happen! Unfortunately, it’s tough in the blue states, where politicians tend to be in the pockets of unions, and nurses’ unions are powerful. But we’re not giving up! Right now, we are starting plans for the first AA training program in California. We have every hope that this will be the pathway to educate our lawmakers about AAs, and to demonstrate the quality of AA training. Ultimately, we will move California toward the goal of full CAA licensure.

And on that note, let me emphasize a message that I know you’ve heard before:  Money is the mother’s milk of politics. I am so happy to hear that the AA students here at Emory understand this fundamental truth:  that no advocacy effort can succeed without money and hard work at the grass roots level to back it up. Please continue to be involved. Keep up your AAAA membership. It’s your professional association, and it has your back. Get involved in committee work. Donate to your political action fund. That is the only way we can continue to expand CAA practice, in California, and across the entire United States.

What advice should I leave with you?

Let’s start with the Golden Rule – treat your patients as you would wish to be treated.  Use plenty of local anesthesia before any needle stick, and if your patient says ouch, use more. The most difficult patients are nearly always that way because they’re deeply unhappy, or in pain, or frightened. Our challenge is always to be kind, no matter what.

At the same time, be professional.  Use your first and last name when you introduce yourself.  I cringe when I hear any medical professional introduce herself to a patient as “Suzy”. That may be fine at the Waffle House, but not at the hospital. Instead, say, “My name is Suzy Smith. I’m a Certified Anesthesiologist Assistant, and I’ll be working with Dr. Jones today taking care of you.”

Please don’t go up to the bedside of patients 30 or 40 years your senior, and start calling them by their first name. They weren’t brought up that way, and they may not like it.  Say Mr. or Ms. unless the patient specifically asks you to do otherwise.  Saying “Yes sir” or “Yes ma’am” doesn’t hurt either. Now that I think about it, you probably already have good manners because we’re in the South, but I can assure you that in Los Angeles this is not always the case.

When you meet your patient in the preop area, after you’ve properly introduced yourself, what’s the first thing you should do?  Please don’t say “put on gloves”. First, wash your hands. Then, touch your patient. Make human contact. Shake hands, or touch your patient’s arm. Listen carefully to the patient’s heart and lungs. You don’t need to wear gloves for any of this. Even the World Health Organization says you should NOT wear gloves for contact that doesn’t involve blood, or mucous membranes, or body fluids. You just need to wash your hands before you start and again when you’re finished.  Human contact is such an important part of anesthesia care, no matter how brief it may be. It matters to your patients, and you may be surprised how much it will mean to you over time.

Learn to enjoy the company of surgeons. Many jokes are made about surgeons. “Often wrong, but never unsure” is one of the more repeatable ones. Some of the more malignant and abusive traditions of past surgical training have eased up, so they’ve become less arrogant. But a surgeon still needs to have a sense of confidence and a certain amount of nerve. Male or female, they often think of themselves as the captain of the ship. The way to deal with that sort of personality is with grace and a bit of humor. In anesthesia, we need the right balance of backbone and flexibility.

Don’t worry too much about work-life balance, whatever that is. The term doesn’t even make sense to me. The opposite of work is leisure. The opposite of life is death.  If you feel that you’re only living when you’re off duty, then I would respectfully suggest that you need to find another job! Anesthesia is a great profession – endlessly interesting, always evolving. Of course, you need time for family, for exercise, for leisure. Especially in the years when children are small, it can be tough to juggle all your responsibilities. But satisfying work is a fundamental component of a life well lived. It’s OK to lean in to your career!

Always keep learning. That’s what keeps it interesting. Go to a workshop and learn a new technique. Make yourself learn to use the next new drug – that’s the only way you can decide how and when it’s worth using.

It just amazes me what I’ve seen in my lifetime. To go from using a slide rule in high school chemistry to having a phone with more capacity than a whole room full of IBM mainframe computers used to have – that’s phenomenal. When I started in anesthesia, there was no pulse oximetry, or end-tidal CO2, or ultrasound. It makes me want to stick around for another 30 years just to see what will happen next. Imagine what you’ll see in your lifetimes!  Techniques that are state-of-the-art today – 30 years from now you may look back and think, “I can’t believe we used to do it that way!”

In giving anesthesia, in taking care of our patients, we have the opportunity and the responsibility to be part of the whole cycle of life, to look beyond ourselves. What we have in common as human beings will always be more important than our differences. I wish you great joy and every success in your years ahead, and I thank you all for the great pleasure of being here today.

The art of deep extubation

Fair warning — this post is likely to be of interest only to professionals who administer anesthesia or may have to deal with laryngospasm in emergency situations.

There are two schools of thought about how to extubate patients at the conclusion of general anesthesia:

Allow the patient to wake up with the endotracheal tube in place, gagging on the tube and flailing like a fish on a line, while someone behind the patient’s head bleats, “Open your eyes!  Take a deep breath!”


Remove the endotracheal tube while the patient is still sleeping peacefully, which results in the smooth emergence from anesthesia like waking from a nap.

It will not require much subtlety of perception to guess that I prefer option 2. It is quiet, elegant, and people who’ve seen it done properly often remark that they would prefer to wake from anesthesia that way, given the choice.

There is art and logic to it, which I had the pleasure of learning from British anesthesiologists at the Yale University School of Medicine years ago.

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I wish I knew who coined the term “DRexit” so I could send flowers or a bottle of whiskey as a thank-you gift. There couldn’t be a more perfect term to describe the growing exodus of physicians from our beloved profession, which is turning into a morass of computer data entry and meaningless regulations thought up by people who never touch a patient.

The one bright note on the horizon for me is that physicians are starting to wake up to the trap of MOC, or mandatory maintenance of certification. It’s surprising that the Federal Trade Commission hasn’t recognized already that this is quite a racket, forcing physicians to do CME activities dictated by monopolistic certification boards which profit handsomely.

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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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Six-year-old Caleb Sears:  His death was preventable

I’m not a pediatric anesthesiologist. Most of us in anesthesiology – even those who take care of children in the operating room or the ICU every day – probably will never give anesthesia to a child in a dentist’s or oral surgeon’s office. So why should we care what happens there? Dental anesthesia permits and regulations, after all, are under the authority of state dental boards, not medical boards.

The reason we should care is that healthy children have died under anesthesia in dental office settings, children like Marvelena Rady, age 3, and Caleb Sears, age 6. Unfortunately, they aren’t the first children to suffer serious complications or death in our state after dental procedures under sedation or general anesthesia, and unless California laws change, they won’t be the last.

In 2016, officers and past presidents of the California Society of Anesthesiologists (CSA) have made multiple trips to meetings of the Dental Board of California (DBC) to discuss pediatric anesthesia. We’ve provided detailed written recommendations about how California laws concerning pediatric dental anesthesia should be updated and revised. We’ve explained in testimony before the Dental Board, and in meetings with lawmakers, why we believe so strongly that the single “operator-anesthetist” model (currently practiced by dentists and oral surgeons in many states) cannot possibly be safe.

The DBC on December 30 published new recommendations for revision of California laws pertaining to pediatric dental anesthesia, posted them on its website, and sent them to the Senate Committee on Business, Professions, and Economic Development. But these recommendations ignored many of our concerns, and don’t go nearly far enough to protect children.

Further, the DBC cites statistics claiming that pediatric dental anesthesia is currently safe. But there is no database! The Dental Board has admitted to discarding records after review. They have reported on “only nine” recent cases involving death, ignoring other tragic cases of permanent brain damage and prolonged ICU admissions. Pediatricians in California recently surveyed 100 of their members and found that 29 of them — nearly one-third — knew of patients in their practices who had experienced adverse events in a dental office.

What is a single “operator-anesthetist”?

You may never have heard of a single “operator-anesthetist” because such a thing doesn’t exist in medical practice.

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