Archive for the ‘Anesthesiology’ Category

Tell me your cosmetic secrets

I live and work in Los Angeles, one of the plastic surgery capitals of the world. Quite a few of my patients have “had a little work done” — the blandly euphemistic term you’ll hear for plastic surgery makeovers of all kinds. That’s fine. Plastic surgeons have children to feed too.

The problem is this: many of my patients want to convince everyone that their “look” is entirely natural. They don’t want to admit that they’ve had a tummy tuck, an eyelid lift, or breast implants. One patient tried to tell me that the perfectly matched scars behind her ears were the result of a car accident, not a face lift. In front of family members, patients will even deny having dentures. That’s understandable, but unwise from a medical point of view.

The fact is that plastic surgery has implications for future medical care. Your anesthesiologist needs to know about it, and your surgeon does too. It may be cosmetic, but it’s still a bigger deal than getting your eyebrows waxed.

Here’s why we need to know the cosmetic secrets our patients may NOT want to tell us.

Why does a tummy tuck matter?

One of the worst complications I’ve seen after plastic surgery happened to a lovely patient who, years before, had an abdominoplasty, popularly known as a “tummy tuck”, with a very good cosmetic result. Many women request this procedure once they’ve finished having children, to tighten up the skin and smooth out the appearance of the abdomen. The incision is similar to the one for a cesarean section, across the lower abdomen, though it extends further to each side. Once it’s well healed, it may barely be visible.

Years later, the patient needed major surgery on her liver, and the surgeon made an incision known as a “chevron” or “rooftop” – an incision across the upper abdomen, just below the ribcage. The surgical team didn’t realize she’d had a prior abdominoplasty, and the patient never thought to mention it.

The blood supply to her abdominal wall had been interrupted from below by the abdominoplasty incision, and now was interrupted from above by the chevron incision. The skin and soft tissue of the patient’s whole abdominal wall essentially died and turned black from lack of blood flow and oxygen, a condition called tissue necrosis. The patient needed extensive skin grafting and several surgical procedures for reconstruction.

What about breast implants?

For the most part, breast implants don’t matter much in terms of subsequent surgery – unless you need an operation that involves your chest. Surgery on the lungs or esophagus often is done today with a minimally invasive technique called video-assisted thoracoscopy, where the surgeon inserts slender instruments and a tiny camera through small incisions in the chest wall. It would be easy to rupture a breast implant unless the surgeon knows it’s there and can work around it.

Chin enhancement?

Chin enhancement surgery, or genioplasty, may involve inserting a small plastic implant to improve the appearance of a receding or “weak” chin. It may seem like a trivial procedure, and the tiny scar beneath the chin may be hard to spot. But please tell your anesthesiologist if you have a chin implant! A receding chin is a facial feature that can alert the anesthesiologist to possible trouble inserting a breathing tube. It’s important for us to know if a patient’s chin didn’t always look the way it does today.

(As an aside, it’s not uncommon for men to grow beards as a cheaper, easier way to conceal a receding chin. An experienced anesthesiologist knows to look for this feature when evaluating the patient’s airway prior to surgery.)

Eyelid lifts? False eyelashes?

Eyelid lift, or blepharoplasty, is done to remove excess or sagging skin from the eyelids. It’s also popular among East Asian patients (both men and women) who want to alter the shape of their eyelids for a more “western” look.

After a blepharoplasty, the eyes may not close completely if a patient is sedated or unconscious during another operation. If the eyes aren’t fully shut, they may dry out because the patient isn’t blinking normally. The delicate corneas may develop micro-cracks, which cause pain when the patient wakes up just like any other corneal scratch or injury. Oxygen from a face mask blowing past partially open eyes may also cause the corneas to dry out and become red and painful. If we know that you’ve had a blepharoplasty, we can take extra precautions to protect your eyes and keep them moisturized.

False eyelashes or eyelash extensions can easily be damaged during surgery. This is because the anesthesiologist usually protects the patient’s eyes from corneal scratches by putting tape or a transparent dressing over the eyelids. When the tape comes off at the end of surgery, the eyelashes can come with it. If you’ve just paid $150 or more for a full set of lashes, I can understand why you’d be upset. If you mention that you have them on, we can use goggles to protect your eyes and leave the eyelashes undisturbed.

We promise not to tell

The take-home message to patients? Please tell us your cosmetic secrets. Send your family members off to get coffee before you talk to us if you don’t want them to know. But what we – your anesthesiologist and your surgeon – DON’T know about your cosmetic history, unfortunately, can hurt you. We promise not to tell.

If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

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“Each man or woman is ill in his or her own way,” Dr. Abraham Verghese told the audience at the opening session of ANESTHESIOLOGY 2019, the annual meeting of the American Society of Anesthesiologists. In his address, titled “Humanistic Care in a Technological Age,” Dr. Verghese said, “What patients want is recognition from us that their illness is at least somewhat unique.”

Though we in anesthesiology have only limited time to see patients before the start of surgery, Dr. Verghese reassured listeners that this time has profound and immense value. He pointed out that there is “heightened drama around each patient” in the preoperative setting. “Everything you do matters so much,” he said. What patients look for are signs of good intentions and competence, and the key elements are simple: “the tone of voice, warmth, putting a hand on the patient.”

Dr. Verghese, a professor of internal medicine at Stanford University and the acclaimed author of novels including the best-selling Cutting for Stone, believes that patient dissatisfaction and physician burnout are the inevitable consequences of today’s data-driven healthcare system, where physicians seldom connect with patients on a personal level or perform a thoughtful, unhurried physical examination. “Our residents average 60 percent of their time on the medical record,” he said.

“It’s the ‘4000 clicks’ problem,” Dr. Verghese said, citing a study in which emergency room physicians averaged 4000 mouse clicks over a 10-hour shift, and spent 43 percent of their time on data entry but only 28 percent in direct patient contact.

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When adjectives obfuscate

A few years ago, at the misguided recommendation of a public relations consultant, many of us in America started referring to ourselves as “physician anesthesiologists”. That was a silly move. The term is cumbersome and does not flow trippingly on the tongue. It is also redundant. You don’t hear our colleagues referring to themselves as “physician cardiologists” or “physician urologists”.

There was never any need of an adjective to modify “anesthesiologist”.

Anesthesiology is a medical specialty, practiced by physicians who have completed residency training in anesthesiology. To become board-certified, we undergo a rigorous examination program conducted by the American Board of Anesthesiology.

In England, comparably trained physicians are called “anaesthetists”. In England, they also refer to their subway system as “the underground”, and to the hood of the car as the “bonnet”. It’s confusing, but we muddle through.

The term “nurse anesthesiologist” is an oxymoron.

I’m all done with the term “physician anesthesiologist”. I am the immediate past president of the California Society of Anesthesiologists, and a 30+ year member of the American Society of Anesthesiologists. I am a physician who is immensely proud to practice anesthesiology. My patients know I am a physician because I make it clear to them when I introduce myself and give them my business card.

Dr. Virginia Apgar was an anesthesiologist. It is an honor to follow in her footsteps, even if most of us will never match her achievements. That is all.

We’re very fortunate in anesthesiology. We’re seldom the physicians who have to face families with the terrible news that a patient has died from a gunshot wound.

But all too often we’re right there in the operating room for the frantic attempts to repair the bullet hole in the heart before it stops beating, or the blast wound to the shattered liver before the patient bleeds to death.

Despite all the skills of everyone in the operating room – surgeons, anesthesiologists, nurses, technicians – and all the blood in the blood bank, we’re not always successful. A death on the OR table is a traumatic event and a defeat; we remember it decades later.

So yes, this is our lane too. Memories haunt me of the times when mine was the last voice a gunshot victim heard on this earth, telling him he was about to go to sleep as he went under anesthesia for the last-ditch, futile attempt to save him.

I use the pronoun “he” intentionally, as every one of those cases in my professional life has been a young man. My experience is representative; most gunshot victims aren’t the random targets of mass shootings. They are overwhelmingly male (89 percent), under the age of 30 (61 percent), and over half are from the lowest income quartile.

The National Rifle Association (NRA) is way off base in telling physicians to mind their own business as it did in its infamous November 7 tweet. Human life is our business. Pediatricians have every right to remind parents that gun security, and keeping guns out of the hands of children, are vital to their well-being right up there with getting them vaccinated.

At my house, we’ve always kept our guns padlocked in a safe that our children couldn’t have broken into with a crowbar. We’re not NRA members, but we enjoy going to a shooting range on occasion. I learned gun safety during my officer training in the Army Reserve Medical Corps. My husband and I are firmly in the category of gun-owners who take both the right and the responsibility with the utmost seriousness.

Physician opinions on gun control and gun ownership vary just as much as the opinions of the rest of the population. What doesn’t vary is our collective sense of responsibility for public health and our support for better, more readily available, mental health care.

The solutions to America’s horrific rate of gun-related deaths aren’t easy or obvious. But the NRA isn’t helping matters with its thoughtless and incendiary social media message.

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