Archive for the ‘Safety’ 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.

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.

Keep calm and give the Ancef

A true allergic reaction is one of the most terrifying events in medicine. A child or adult who is highly allergic to bee stings or peanuts, for instance, can die within minutes without a life-saving epinephrine injection.

But one of the most commonly reported allergies — to penicillin — often isn’t a true allergy at all. The urgent question that faces physicians every day in emergency rooms and operating rooms is this:  How can we know whether or not the patient is truly allergic to penicillin, and what should we give when antibiotic treatment is indicated?

It’s time for us to stop making these decisions out of fear, and look squarely at the evidence. Withholding the right antibiotic may be exactly the wrong thing to do for our patients. Here’s why.

Can’t we just prescribe a different antibiotic?

When we hear that patients are “PCN-allergic”, we’ve been trained from our first days as medical students to avoid every drug in the penicillin family. We’re also taught to avoid antibiotics called “cephalosporins”, which include common medications like Keflex. This is because penicillin and cephalosporin molecules have some structural features in common, raising the odds that a patient allergic to one may also be allergic to the other.

What does it matter? Can’t physicians just prescribe a different antibiotic?

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When you tell anyone in healthcare that “sedation” to the point of coma is given in dentists’ and oral surgeons’ offices every day, without a separate anesthesia professional present to give the medications and monitor the patient, the response often is disbelief.

“But they can’t do that,” I’ve been told more than once.

Yes, they can. Physicians are NOT allowed to do a procedure and provide sedation or general anesthesia at the same time – whether it’s surgery or a GI endoscopy. But dental practice grew up under a completely different regulatory and legal structure, with state dental boards that are separate from medical boards.

In many states, dentists can give oral “conscious” sedation with nitrous oxide after taking a weekend course, aided only by a dental assistant with a high school diploma and no medical or nursing background. Deaths have occurred when they gave repeated sedative doses to the point that patients stopped breathing either during or after their procedures.

Oral surgeons receive a few months of education in anesthesia during the course of their residency training. They are legally able to give moderate sedation, deep sedation or general anesthesia in their offices to patients of any age, without any other qualified anesthesia professional or a registered nurse present. This is known as the “single operator-anesthetist” model, which the oral surgeons passionately defend, as it enables them to bill for anesthesia and sedation as well as oral surgery services.

Typically, oral surgeons and dentists alike argue that they are giving only sedation – as opposed to general anesthesia – if there is no breathing tube in place, regardless of whether the patient is drowsy, lightly asleep, or comatose.

The death of Caleb Sears

Against this backdrop of minimal regulation and infrequent office inspections, a healthy six-year-old child named Caleb Sears presented in 2015 for extraction of an embedded tooth. Caleb received a combination of powerful medications – including ketamine, midazolam, propofol, and fentanyl – from his oral surgeon in northern California, and stopped breathing. The oral surgeon failed to ventilate or intubate Caleb, breaking several of his front teeth in the process, and Caleb didn’t survive.

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The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

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