Did anyone see the Diane Sawyer segment on AUA?

[UTSouthwestern]

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Allow me to barf on the anesthesiologist representing all of us in response to the need to put the BIS in EVERY OR in America. If anyone else saw that segment this AM and knows who that anesthesiologist was, please let me know.

 

[serenity]

Allow me to barf on the anesthesiologist representing all of us in response to the need to put the BIS in EVERY OR in America. If anyone else saw that segment this AM and knows who that anesthesiologist was, please let me know.

She was Carol A.Warfield, Chief of anesthesia and critical care at BID, New york

http://www.bidmc.harvard.edu/display.asp?leaf_id=1692

Awareness during anesthesia is surely spreading some awareness amongst the patients,thats for sure,what do ya say!!!!

 

[apellous]

Allow me to barf on the anesthesiologist representing all of us in response to the need to put the BIS in EVERY OR in America. If anyone else saw that segment this AM and knows who that anesthesiologist was, please let me know.

He must have either developed that piece of $hit or owns a ton of stock ini the company. What a WASTE of money. I dont need a monitor to tell me I forgot to turn the gas back on after repositioning the pt. You know those few people that suffered are do to human error. either machine not spitting out the right amount of gas, operater error(GAS OFF OR NOT ENOUGH), or these people that claim these accounts are nuts and maybe having a hallucination from the special K. Real probably all three of these

 

[UTSouthwestern]

It's ridiculous how far the brain monitor makers are going to try to force these useless monitors to be bought everywhere. What happens when you get a trauma patient that can't tolerate vapor, versed, etc. and you have that wonderful BIS monitor on telling you the obvious - the patient MAY be awake? You dutifully give the scopolamine, the BIS says everything's A OK, and the patient wakes up two days later and says "I remember everything about the surgery!" Will the doctors then be allowed to sue the makes of the BIS? Will the patients? Of course not. Tucked into the packaging insert of the little BIS monitor is a little statement saying that the BIS is not a foolproof device.

I am also suprised no one has talked about overanesthetizing patients and the consequences of doing so, especially in elderly patients.

As for Carol Warfield, if you aren't up the task of arguing against unproven and expensive monitors like the BIS, KEEP YOUR MOUTH SHUT AND FIND SOMEONE ELSE TO DO THE INTERVIEW. Her responses really made us look unaware and uncaring of the situation and the background of the topic.

 

[toughlife]

Allow me to barf on the anesthesiologist representing all of us in response to the need to put the BIS in EVERY OR in America. If anyone else saw that segment this AM and knows who that anesthesiologist was, please let me know.

Do you have a link to where this clip can be watched?

 

[jetproppilot]

It's ridiculous how far the brain monitor makers are going to try to force these useless monitors to be bought everywhere. What happens when you get a trauma patient that can't tolerate vapor, versed, etc. and you have that wonderful BIS monitor on telling you the obvious - the patient MAY be awake? You dutifully give the scopolamine, the BIS says everything's A OK, and the patient wakes up two days later and says "I remember everything about the surgery!" Will the doctors then be allowed to sue the makes of the BIS? Will the patients? Of course not. Tucked into the packaging insert of the little BIS monitor is a little statement saying that the BIS is not a foolproof device.

I am also suprised no one has talked about overanesthetizing patients and the consequences of doing so, especially in elderly patients.

As for Carol Warfield, if you aren't up the task of arguing against unproven and expensive monitors like the BIS, KEEP YOUR MOUTH SHUT AND FIND SOMEONE ELSE TO DO THE INTERVIEW. Her responses really made us look unaware and uncaring of the situation and the background of the topic.

Remind me, UT never to piss you off. Thats some Jedi-Gangsta-Sh1t you just spewed.

Well said. 👍

 

[jwk]

Dr. Cottrell (past ASA president) was on the Today Show yesterday talking about this as well. The patient was supposedly awake during part of her EMERGENCY hip surgery. Dr Cottrell pointed out that she was in a group of patients where the anesthesiologist had to make a decision between her possibly being awake and her brain being dead from hypotension, (excellent response) and that much larger studies needed to be done before we know whether any awareness monitor is actually useful or not. Matt "BIS-boy" Lauer tried to pin him down on the BIS, even with a question along the lines of "...doesn't every patient deserve this WHETHER IT WORKS OR NOT?" He went on to ask the patient if she was going to make sure there was a BIS monitor used when she goes back in for more surgery, and of course she said yes. Dr. Cottrell pointed out that she would be going back in for ELECTIVE surgery and is in much better physical condition now than after her initial trauma, and that just because she had awareness before, it was highly unlikely she would have it again given the different situations.

I'm surprised the interview wasn't followed by a commercial for Aspect Medical. Hey, if it's good for Clarinex and Levitra, why not BIS?

 

[redstorm]

Hey if i had a choice between having a bis monitor or a vigilant (pain in the ass, pay attention to every detail) anesthesiologist, I would pick the latter.

That being said, the BIS monitor is just another thing to look at that offers you information abou t awareness. so i would not be so quick in discounting it. BUt the bis needs to be looked at in context of the situation and other information such as RR, temp, heart rate and blood pressure.

In short, it has its uses.

 

[C.P.]

the bis is an interesting machine, with a good concept, but not so solid functionality.
Take a look at recent studies on people paralyzed, but not anesthetized, where the BIS actually showed they were "asleep," and other studies that showed bodies in the process of an organ harvest actually showed "awareness" according to the BIS after being declared brain dead.
The BIS is a good idea, but is still not reliable. . . yet.
There's a lot of confounders based on the presence of EMG noise (even though the new four lead BIS is supposed to filter that out).
Regardless, anytime someone stands up on national television and advocates for a technology, you can be guaranteed that every patient is going to be asking/demanding for it. . . even if it's a MAC or regional case.

 

[jwk]

Hey if i had a choice between having a bis monitor or a vigilant (pain in the ass, pay attention to every detail) anesthesiologist, I would pick the latter.

That being said, the BIS monitor is just another thing to look at that offers you information abou t awareness. so i would not be so quick in discounting it.

In short, it has its uses.

I'll agree 100% with your first statement.

And I'll disagree with the others - a lot.

 

[Gator05]

I'll state up front that I'm uncomfortable with the idea of using BIS purely for awareness monitoring. Aside from the above arguments, there is also another well-studied point: titrating your anesthetic to the BIS can INCREASE your risk of awareness!

As a research lead, however, it's a pretty awesome topic. Rampil has written a fantastic article (1998) concerning detection and processing of the EEG. An impressive synchrony of research on consciousness theory, anesthetic action, and consciousness monitors is allowing each to help validate the other.

That said, I'm sure that a simpe, 4-lead spectral analysis of the EEG could also produce the same results as the BIS.

 

[MAC10]

I used a bis monitor once during an ortho case out of sheer bordem. I thought it was way late telling me what I already knew. You know when the patient is getting light, you get that sick oh*hit feeling, then the heart rate goes up, then you grap the propfol (3sec), then the bis goes up. Vigilance.

 

[Noyac]

I seem to recall somewhere that there was a study (I know no particulars of the study ; power; randonized or any of that) that looked at the BIS monitor not for awareness but for M&M. They stated in the conclusion that keeping the BIS value above 40 ( I think) showed a decrease in the morbidity as far as a year out. Did anyone else see that sudy?

Also you can be fooled by ketamine with the BIS. I did a D&C in the middle of the night under ketamine sedation for retained products. I thought what the hey, lets see what this BIS says. The pt was teetering b/t deep sedation and general. She was NPO and we could go on about the risks of this form of sedation but to get to the point, she would not respond at times and the BIS read 98. The next day she had no recall. Thank you versed.

If we are going to use BIS on everyone, whats the cost going to be to the pt. that I feel doesn't need BIS monitoring? Do we need to throw in any extra costs in todays healthcare system? Especially,, when it is unnecessary?

 

[jwk]

I seem to recall somewhere that there was a study (I know no particulars of the study ; power; randonized or any of that) that looked at the BIS monitor not for awareness but for M&M. They stated in the conclusion that keeping the BIS value above 40 ( I think) showed a decrease in the morbidity as far as a year out. Did anyone else see that sudy?

Also you can be fooled by ketamine with the BIS. I did a D&C in the middle of the night under ketamine sedation for retained products. I thought what the hey, lets see what this BIS says. The pt was teetering b/t deep sedation and general. She was NPO and we could go on about the risks of this form of sedation but to get to the point, she would not respond at times and the BIS read 98. The next day she had no recall. Thank you versed.

If we are going to use BIS on everyone, whats the cost going to be to the pt. that I feel doesn't need BIS monitoring? Do we need to throw in any extra costs in todays healthcare system? Especially,, when it is unnecessary?

OMG - cost? We have to worry about cost?

How many millions of dollars are people perfectly willing to throw away on technology such as BIS without knowing whether it even works, just because they're scared of a potential lawsuit about awareness?

Here's the deal -Two main classes of patients have awareness - the group that can't tolerate anesthesia (trauma, stat C/S, etc.) or the group where the anesthesia provider is careless (read incompetent) or is diverting the meds to themselves. In the first group, awareness can be defended. In the second group, it can't be defended, and the provider who allows it to happen under those circumstances should have their ass handed to them as they're tossed out the door.

 

[etherRN]

I wonder if Carol has ever seen the BIS placed on jello. This has been done, with a BIS reading showing in the 60's.

 

[Epidoodle]

Deleted

 

[chillindrdude]

another indication that anesthesiologists need to educate the lay-public more...hows about a PR campaign? i find that many folks (both the public AND other doctors) have a grossly inaccurate view of what anesthesiology is and what we do.

 

[bigdan]

I wonder if Carol has ever seen the BIS placed on jello. This has been done, with a BIS reading showing in the 60's.

I'd love to see it if this is true. Wonder how she'd explain it.

It does, however, seem like we've gotten into BIS-bashing. Is BIS worthless, or is it potentially helpful but just not yet proven? If the latter is true, I think it important not to throw "the baby out with the bath water" and trash the BIS.

But it would be nice to see if Dr. Warfield would like to explain herself to an informed anesthesia audience (admittedly, not me), in a forum where her equals can seek clarification of what was said. Just seems a bit weird that someone with a big title from a reputable center would just go and "sell out" anesthesia.

What do y'all think?

dc

 

[VolatileAgent]

i will say this about the bis...

one of my attending's gave me a break, and when i came back to the room (we were running a neuro propofol/fentanyl tiva) everything looked hunky-dory. just so happens we were using the bis. now, i don't regularly use it to run a case, but since it was a prone cervical spine with neuromonitoring i thought, whatdaheck and threw one on before we flipped this lady.

anyway...

so, i get back to the room and i think everything's cool. because i don't normally use the bis i don't normally look at it (an inherent problem with adding technology and "monitor overload" namely forgetting to look at patient cues). just so happens i glance up and the thing says '90' with a sharp uprise timed at about the time i took my break. i say outloud, "hol s*%&#" and turn to my attending who's walking out of the room and say, "do you think that's real?" then, i glance over and notice that he'd refilled the propofol syringe and forgotten to turn the pump back on.

essentially, the bis saved our ass in this instance. later i asked the lady if she'd remembered anything and she told me she hadn't.

in summary, there may be a use for this device. granted, it is often a result of human error. but, at least in this case, it saved us from a potential AUA (and a lawsuit).

jury is still out for me. do i think they are using emotional scare tactics in the lay-public to promote it and get it sold? sure as hell. but, they also sold a sh*tload of viagra doing essentially the same thing, maybe a little subtler.

 

[militarymd]

I hate the BIS....It is a piece of s h i t. They initially marketed it to help you wake up patients faster, and when they couldn't sell it that way...because experienced anesthesia providers don't need it....they try to sell it with scare tactics.

Everytime the Aspect rep comes, I make fun of him or her....unless they're bringing lunch.

 

[jetproppilot]

I hate the BIS....It is a piece of s h i t. They initially marketed it to help you wake up patients faster, and when they couldn't sell it that way...because experienced anesthesia providers don't need it....they try to sell it with scare tactics.

Everytime the Aspect rep comes, I make fun of him or her....unless they're bringing lunch.

Have to differ with you on some cases.

Do agree its ability to prevent awareness is unproven.

I do believe, like SWAN numbers, that trends can be clinically useful...I think traditionally anesthetics are done too "deep"...keep your BIS numbers in the 50s during a CABG, for example, and you won't need the empirically "deep" anesthetic for this "big" case. May improve extubation times, lower ICU stay, etc. Again, just an opinion.

Also believe that empirically too-deep anesthetics reduce efficiency (getting patients in and out of your surgery center), and BIS may have a role here.

Again, not really proven useful for what the media is hyping it for (ABSOLUTELY preventing awareness), but don't discount its potential usefuleness for an adjunct against awareness, and giving the clinician an extra tool to monitor anesthetic depth.

Clinicians that say they can tell when a patient is "light" by hemodynamics reminds me of pilots that say they can fly without visual reference to the ground by "feel".

Can't be done consistently.

Try and fly in instrument conditions by feel and you will become the next lawn dart.

 

[militarymd]

Have to differ with you on some cases.

Do agree its ability to prevent awareness is unproven.

I do believe, like SWAN numbers, that trends can be clinically useful...I think traditionally anesthetics are done too "deep"...keep your BIS numbers in the 50s during a CABG, for example, and you won't need the empirically "deep" anesthetic for this "big" case. May improve extubation times, lower ICU stay, etc. Again, just an opinion.

Also believe that empirically too-deep anesthetics reduce efficiency (getting patients in and out of your surgery center), and BIS may have a role here.

Again, not really proven useful for what the media is hyping it for (ABSOLUTELY preventing awareness), but don't discount its potential usefuleness for an adjunct against awareness, and giving the clinician an extra tool to monitor anesthetic depth.

Clinicians that say they can tell when a patient is "light" by hemodynamics reminds me of pilots that say they can fly without visual reference to the ground by "feel".

Can't be done consistently.

Try and fly in instrument conditions by feel and you will become the next lawn dart.

OK. a difference in opinion.

 

[BostonGas]

I am a new member here and I am sorry to have to start my first thread in this manner:

First of all it is Dr. Carol Warfield, Chief of Anesthesia, at Beth Israel Deaconess Medical Center, BOSTON , not NY and she is my chief.

UTSW-Your comments are pretty rude and inaccurate. I wonder if you actually would tell a Harvard chairman to "keep your mouth shut" to their face? Did you actually watch the whole clip? Why don't you shoot your venom at the major anesthesia figure who supports use of the device in every anesthestic, Dr. "Real Age" Michael Roizen, Anestehsia Chair at The Cleveland Clinic and who was featured on the same clip?

Dr Warfield's presentation was very PC. Did you want her to come out and say the device is a total piece of crap when there is some literature that supports it? Especially when there are patients (probably paid for by Aspect Technology) also on the piece saying what a horrible experience they had being paralyzed, in pain and not able to scream? She was very PC about it, quoting the ASA statement on AUA and cerebral monitoring. The statement can be seen on this page of the ASA website.

http://www.asahq.org/patientEducation.htm

The statement says that although the current brain wave monitors may prove to be useful one day, they currently are not proven yet and still need to undergo more rigorous review. It says that nothing replaces an experienced, vigiliant anesthesiologist

You don't get too far in life by being from being too outspoken and controversial (UTSW-take note), especially when you have upset, emotional patients on the other side of a split screen. I'm sorry that she did not use her time on national TV to bash a BIS monitor with a baseball bat.

The fact the matter is we here in Boston know that this technology is all about aggressive marketing by a local company. They love the spotlight of traumatized patients on news shows and use every opportunity to market their devices, before they are completely scientifically proven. It is a vile marketing tactic and actually makes anesthesiologists not want to be forced to use it especially with the expense that goes along with it. The proof in the pudding is that we don't use these monitors standardly in our program. It is used for educational purposes (You don't have a problem with that UTSW-do ya?) and no one believes they should be standard of care.

Dr. Warfield is a national leader in our field and in no way deserves the derision that she has received here. You should be lucky if one day you should work for her.

 

[militarymd]

As a leader in the field, Dr. Warfield had the opportunity to set things straight and put Aspect in its place...instead she spouts PC propaganda.

That is sad.

BIS is an interesting piece of technology trying to find an indication. Not the cure all that Aspect claims it is while marketing to a scared public.

 

[Gimlet]

Was flipping through the channels late last night and ran across a piece about the BIS monitors on "Paula Zahn Now." It really looks like this is going to be the issue du-jour, isn't it? They had an MGH anesthesiologist, Dr. Carl Rosow (who is also a consultant for Aspect) on the show demonstrating the BIS monitor, and some lady relating her experience of being awake throughout her hysterectomy.

I'll refrain from commenting on the piece as I'm only an M1 and really don't feel that I'm knowledgable enough to evaluate it. I've attached a transcript copied from CNN.com for anyone who would like to see what they had to say.

It's a shame that the media is swooping in on this issue and totally ignoring all of the unprecedented advances anesthesiologists made for the safety of patients undergoing anesthesia in the mid '90s. Hopefully all that work to better the reputation of this specialty won't be undone by this intraoperative awareness issue.

 

[UTSouthwestern]

I am a new member here and I am sorry to have to start my first thread in this manner:

First of all it is Dr. Carol Warfield, Chief of Anesthesia, at Beth Israel Deaconess Medical Center, BOSTON , not NY and she is my chief.

UTSW-Your comments are pretty rude and inaccurate. I wonder if you actually would tell a Harvard chairman to "keep your mouth shut" to their face? Did you actually watch the whole clip? Why don't you shoot your venom at the major anesthesia figure who supports use of the device in every anesthestic, Dr. "Real Age" Michael Roizen, Anestehsia Chair at The Cleveland Clinic and who was featured on the same clip?

Dr Warfield's presentation was very PC. Did you want her to come out and say the device is a total piece of crap when there is some literature that supports it? Especially when there are patients (probably paid for by Aspect Technology) also on the piece saying what a horrible experience they had being paralyzed, in pain and not able to scream? She was very PC about it, quoting the ASA statement on AUA and cerebral monitoring. The statement can be seen on this page of the ASA website.

http://www.asahq.org/patientEducation.htm

The statement says that although the current brain wave monitors may prove to be useful one day, they currently are not proven yet and still need to undergo more rigorous review. It says that nothing replaces an experienced, vigiliant anesthesiologist

You don't get too far in life by being from being too outspoken and controversial (UTSW-take note), especially when you have upset, emotional patients on the other side of a split screen. I'm sorry that she did not use her time on national TV to bash a BIS monitor with a baseball bat.

The fact the matter is we here in Boston know that this technology is all about aggressive marketing by a local company. They love the spotlight of traumatized patients on news shows and use every opportunity to market their devices, before they are completely scientifically proven. It is a vile marketing tactic and actually makes anesthesiologists not want to be forced to use it especially with the expense that goes along with it. The proof in the pudding is that we don't use these monitors standardly in our program. It is used for educational purposes (You don't have a problem with that UTSW-do ya?) and no one believes they should be standard of care.

Dr. Warfield is a national leader in our field and in no way deserves the derision that she has received here. You should be lucky if one day you should work for her.

Take note BostonGas, I would be more than happy to speak to Carol face to face. I will be in Boston in April and I will be happy to look you and Carol up. I did watch the clip and if being PC was all that was required in a debate, we could have sent you instead of a chairman to read off a statement of cautious endorsement. Had she delved more specifically into the specific cases in which AUA is most common, it may have lent a balancing perspective to the issue instead of purely fear mongering that the rate of AUA is equal among ALL cases done with anesthesia.

Since that clip aired, almost every patient of mine including my 23 year old lap chole patient today has asked me if we have that monitor available to use and in one case, a patient stated somewhat jokingly, "Well I guess I can sue you for not having it right?"

This was a great opportunity for Carol to give a BALANCED PERSPECTIVE of the issue with explanations of scenarios where AUA is more probable (trauma, cardiac, OB/GYN under regional with sedation, orthopedic outpatient surgery with regional and sedation, etc.) and the reasons we sometimes purposefully risk AUA to keep a patient ALIVE. Instead, the anesthesiologists and surgeons with whom I was watching this clip couldn't believe how demure and almost apologetic she came across as. Three of the surgeons flat out stated that "she just made you guys look really stupid and obstructive" to new technology.

So what now BostonGas? With Aspect throwing all their financial support into a media blitz on AUA, do we now have to use the BIS for EVERY case, instead of just in cases when it's information yield would be highest? That distinction was conveniently omitted by the media. Do you use it to possibly shave off 5-10 minutes of recovery time at the risk of AUA in outpatient surgery as Paul White and Dajun Song have suggested?

http://www.anesthesiology.org/pt/re/anes/abstract.00000542-200404000-00010.htm;jsessionid=Dj92qLoKW5MHK8M3qj7JKJvvZARRskSZIUkKk44JtRmMuLYNGvyC!-2035160892!-949856144!9001!-1

For those of us who ARE diligent and attentive to our patients and can fastrack patients without looking at a BIS, will we now have to use it and add another cost to the healthcare system?

No one said Carol had to bash the crap out of the BIS (BostonGas-take note), but a more detailed and balanced perspective might have given the general public a better understanding of the entire issue of AUA, instead of essentially letting the media whip the public into a frenzy without a thorough understanding of all aspects of the issue. The ball is in your court.

 

[Noyac]

Wait, whats wrong with you guys? She is from Boston, Beth Whatever nodoubt, she and Bostongas "must" be right. Why don't you all conform and do as our superiors say to do?
Give me a F*ckin Break.

 

[militarymd]

Wait, whats wrong with you guys? She is from Boston, Beth Whatever nodoubt, she and Bostongas "must" be right. Why don't you all conform and do as our superiors say to do?
Give me a F*ckin Break.

You're right.....Ivory towers do know it all and have done it all...as opposed to us poor stupid slobs who have to turn cases to make a living.

 

[BostonGas]

You guys are absolutely incredible.

UTSW, everything you say about BIS is completely valid, but how exactly do you get all of that across in less than 5 minutes, where all you get is time for 15 second sound bites? As you can see from this thread, how controversial this technology is, with some people swearing by it and others mocking the industry reps who show up at their hospitals. We (you and I) agree that this technology is unproven and in no way merits use in every case. We agree that the marketing of the device, based on patient fear, is reprehensible. I for one, as well as most in my program, have no use for it. Where we do differ is in my objection to the nasty attack on the messenger. I am sorry Dr. Warfield did not convey your message in a manner that was satisfactory to you. Maybe one day you'll be in a position to speak to a national audience and do what you feel is a better job. Please take the opportunity to meet with her when you are here in April. I hope that you will be more respectful when you are face to face than you are in an anonymous forum. Why don't you attack major figures in the field who are funded by Aspect who advocate the monitor as a standard of care?

As for the other comments, noyac and militarymd-Did you even see the piece? If you knew anything about my program, the phrase "ivory towers" would never enter into play. In contrast to our sister programs, the staff and chair here are as laid back and approachable as they come. Sounds like there may be a bit of an inferiority complex when it comes to Boston anesthesia? Why? People who train and practice anesthesia here are just like everyone else. No better, no worse. Who is asking anyone to conform?

I think a more important question is why do anesthesiologists who have finished, or are well into their residency, spend so much time on a medical student forum? There was always a group at my high school of people who graduated that would still hang out with those who were still in high school. You need to move on. You post several times a day, every day. When someone disagrees with what you have to say it turns into a concerted, sarcastic attack. I have seen this on other forums where certain posters take on the role of "board mafioso" by virtue of the fact they post so much and, all must pay hommage to them.

I'm done debating this. Slam me all you want. I'll be enjoying all my program has to offer. Outta here.

 

[jetproppilot]

I think a more important question is why do anesthesiologists who have finished, or are well into their residency, spend so much time on a medical student forum? There was always a group at my high school of people who graduated that would still hang out with those who were still in high school. You need to move on. You post several times a day, every day. When someone disagrees with what you have to say it turns into a concerted, sarcastic attack. I have seen this on other forums where certain posters take on the role of "board mafioso" by virtue of the fact they post so much and, all must pay hommage to them.

I reap satisfaction from being able to provide a picture of "the real world" to people who arent there yet. As I said on another thread, there were absolutely no resources available when I was a resident, other than finishing, joining a group, and learning by mistakes.

I also enjoy interacting with other clinicians across the country about life, both professional and personal. I get a kick out of Mil's avatars. I enjoy debating over different ways to do cases. Etc. Gotta problem with that?

If you are implying by your condescending "high school group" comment that we have unfulfilled lives and therefore seek "mafioso" status here at sdn, you are sadly mistaken.

Sounds like you are the one that needs to move on with all your bullsh&t.

BTW, you are the FIRST person to bash UTSW, out of however many thousands have read his informative posts. That tells me you are the one with the problem.

 

[VolatileAgent]

I think a more important question is why do anesthesiologists who have finished, or are well into their residency, spend so much time on a medical student forum? There was always a group at my high school of people who graduated that would still hang out with those who were still in high school. You need to move on. You post several times a day, every day. When someone disagrees with what you have to say it turns into a concerted, sarcastic attack. I have seen this on other forums where certain posters take on the role of "board mafioso" by virtue of the fact they post so much and, all must pay hommage to them.

very lame and a cheap shot. when someone can't talk to the facts, they talk to the person.

if you don't like opinions (be they on people, places, or things), then you might want to stay out of internet forums altogether. if you don't like it here, be a man of your word and don't come back.

by the way, there is way too much marketing passed off as "editorial" in the pharmaceutical/device industry. didn't see the piece, but seems like the best thing your girl could've done is not to have agreed to appear in the first place. hey, we all have our egos and sometimes an appearance on gma (or other show) is too enticing. sounds like she could've been better prepped. utsw was well within his right to criticize. it can become dangerous when one "expert" of a discipline presents him/herself in the scientifically illiterate lay media. people (i.e., the end-users, in this case patients) often don't get better informed, just more confused.

 

[bigdan]

Well...

I can't fault Boston for defending his program. He obviously has pride in it, and in that there is no wrong (in my mind). And maybe UTSW and the chief at BID will meet, and an appropriate exchange of ideas will take place. Again, nothing wrong with that.

But, Mr. Gas, I am one of the many up-and-comers that benefit from UTSW (who, btw, was recently a resident), MilMD, Jet, Tenesma, etc. that do offer up opinions, experience, counsel, and advice that I simply CANNOT get elsewhere. They're like the OTHER group of graduates that hang out with students - I call them "teachers". I'm glad they're here, and I'm glad I can glean info from them.

dc

 

[bullard]

What bigdan said. Many of the other forums lack attending participation. We're lucky.

Well...

I can't fault Boston for defending his program. He obviously has pride in it, and in that there is no wrong (in my mind). And maybe UTSW and the chief at BID will meet, and an appropriate exchange of ideas will take place. Again, nothing wrong with that.

But, Mr. Gas, I am one of the many up-and-comers that benefit from UTSW (who, btw, was recently a resident), MilMD, Jet, Tenesma, etc. that do offer up opinions, experience, counsel, and advice that I simply CANNOT get elsewhere. They're like the OTHER group of graduates that hang out with students - I call them "teachers". I'm glad they're here, and I'm glad I can glean info from them.

dc

 

[militarymd]

No, no....

I'm a loser...a BIG loser....My wife and children hate me, I can barely intubate MP1 airways....the nurses at work make fun of me ..... so I hang out here.

 

[jetproppilot]

You guys are absolutely incredible.

UTSW, everything you say about BIS is completely valid, but how exactly do you get all of that across in less than 5 minutes, where all you get is time for 15 second sound bites? As you can see from this thread, how controversial this technology is, with some people swearing by it and others mocking the industry reps who show up at their hospitals. We (you and I) agree that this technology is unproven and in no way merits use in every case. We agree that the marketing of the device, based on patient fear, is reprehensible. I for one, as well as most in my program, have no use for it. Where we do differ is in my objection to the nasty attack on the messenger. I am sorry Dr. Warfield did not convey your message in a manner that was satisfactory to you. Maybe one day you'll be in a position to speak to a national audience and do what you feel is a better job. Please take the opportunity to meet with her when you are here in April. I hope that you will be more respectful when you are face to face than you are in an anonymous forum. Why don't you attack major figures in the field who are funded by Aspect who advocate the monitor as a standard of care?

As for the other comments, noyac and militarymd-Did you even see the piece? If you knew anything about my program, the phrase "ivory towers" would never enter into play. In contrast to our sister programs, the staff and chair here are as laid back and approachable as they come. Sounds like there may be a bit of an inferiority complex when it comes to Boston anesthesia? Why? People who train and practice anesthesia here are just like everyone else. No better, no worse. Who is asking anyone to conform?

I think a more important question is why do anesthesiologists who have finished, or are well into their residency, spend so much time on a medical student forum? There was always a group at my high school of people who graduated that would still hang out with those who were still in high school. You need to move on. You post several times a day, every day. When someone disagrees with what you have to say it turns into a concerted, sarcastic attack. I have seen this on other forums where certain posters take on the role of "board mafioso" by virtue of the fact they post so much and, all must pay hommage to them.

I'm done debating this. Slam me all you want. I'll be enjoying all my program has to offer. Outta here.

Funny how people defend the Big-Name-Academic-Programs....but when we, the private practice milleau dudes proclaim, from experience, that our observations are as good as the Published Ones, there is resistance.

Heres the scoop.

BTW, I have nothing to gain by posting stuff like this. Noone knows who I am (except Mil, UT, and Trinity Alumnus).

AND I have no envy and no desire to compete with the Big-Gun-Published-Anesthesia-Dudes.

What I HAVE learned, being, at some point in my career, in both academic and private practice environments, is that the academic-published dudes proclaim their view as gospel .

Anesthesia is a career where the gospel way to do a case is few and far between.

Unless you are naive, if you have any knowledge, it is hard to watch/listen to a proprietary pitch without pessism. Hence the large, conflictive thread on the BIS monitor.

One of my partners is a paid spokesman for Desflurane...so when the Sevoflurane people show up at our site, he shuns them....

IS THERE A CLINICIAN OUT THERE THAT CAN SAY DESFLURANE IS SO MUCH BETTER THAN SEVOFLURANE THAT IT WARRANTS SUPERIORITY OVER SEVOFLURANE???

Gimme a fuc*ing break. Both are revolutionary volatiles. The best clinical sites have both available, able to exploit both of their advantages.

SOO, when a "RESPECTED" clinician appears on national TV advocating a proprietary device as STANDARD OF CARE through media sympathy, when the proprietary-care-in-question hasnt been exclusively proven,

YOURE GONNA GET DUDES LIKE UT CALLING THEM TO THE CARPET .

Why Bostongas cant see the forest through the trees shows how naive BOSTONGAS is.

 

[ear-ache]

But, Mr. Gas, I am one of the many up-and-comers that benefit from UTSW (who, btw, was recently a resident), MilMD, Jet, Tenesma, etc. that do offer up opinions, experience, counsel, and advice that I simply CANNOT get elsewhere. They're like the OTHER group of graduates that hang out with students - I call them "teachers". I'm glad they're here, and I'm glad I can glean info from them.

dc

Amen.

 

[jetproppilot]

BTW, I have nothing to gain by posting stuff like this. Noone knows who I am (except Mil, UT, and Trinity Alumnus).

Sorry. And Noyac.

 

[UTSouthwestern]

Boston, that segment didn't have to be 5 minutes if Carol had brought up the salient issues that were being bypassed by the media. If you have that opportunity to educate the lay public about items that Aspect is avoiding, you will force a debate that more than likely will expand beyond the preset 5 minute interval simply because it is something that no one has expected to hear.

As for criticizing those who support the BIS, that isn't the issue. They support the BIS and you know it and they defend their point of view. Carol was supposed to provide the academic viewpoint that balanced the hysteria that the media and Aspect are trying to create and to find either a neutral ground or counterpoints to the routine use of the BIS. It seemed that she was a proponent for the BIS, not a neutral expert. What has gotten me upset is that patients are now asking it of me for even basic cases. Patients that I am just sedating for pain procedures are asking me to use a BIS even though they are SUPPOSED to be awake for certain procedures or certain times of other procedures. That is just a total waste of their money, but they don't understand what the BIS MIGHT provide and when it is appropriate. They only hear "BIS prevents awareness under anesthesia and should be used at all times."

I have spoken at conferences before and I was a radio DJ for a daily evening talk show and more, so I would be happy to take that opportunity should one present itself. As for my identity, it's no secret. I would bet that at least half of the regular posters here and many who have only lurked but have contacted me by PM, know who I am by first name and last.

I thank the rest of the posters who have spoken on my behalf and I normally do not get irate at any one or any issue, but when I see trusting patients coming to the OR now with elevated levels of fear that may have been attenuated by a respected professor's words, it bugs me.

 

[Noyac]

October 25, 2005

FOR IMMEDIATE RELEASE
Tuesday, October 25, 2005
Contact:
ASA Annual Meeting Press Office
Georgia World Congress Center
(404) 222-5612, 5613, 5614, 5615

Or after October 26:
Gina Steiner
ASA Communications Department
(847) 825-5586

REPORT ON AWARENESS UNDER GENERAL ANESTHESIA SAYS ANESTHESIOLOGISTS HAVE MULTIPLE TOOLS AND APPROACHES FOR MINIMIZING RISKS

ATLANTA—At its annual meeting today, the House of Delegates of the American Society of Anesthesiologists (ASA) approved the final report of ASA’s Task Force on Intraoperative Awareness. The report, “Practice Advisory for Intraoperative Awareness and Brain Function Monitoring,” represents the most thorough document to date to assist anesthesiologists and hospitals in minimizing the risks of awareness under general anesthesia.

The purpose of a practice advisory is to provide ASA members with the most up-to-date information possible to assist them in making treatment decisions for individual patients. A practice advisory is not a standard or guideline, and does not serve to identify a particular treatment or approach as a standard of care.

Unintended awareness under general anesthesia is rare, and involves the patient having some recollection of events during his or her surgery, including possibly hearing sounds and feeling sensations or pain. It is more likely to occur in patients whose condition is unstable, or in emergency or trauma situations.

The incidence of intraoperative awareness has been reported as 1 to 2 cases per 1,000 surgeries under general anesthesia. Although many cases are brief, some are more significant or traumatic for the patient. It is not possible to eliminate episodes of awareness in all cases, as anesthesiologists must sometimes opt for lighter anesthesia to keep the patient safe.

Though cases of unintended awareness are unusual and sometimes unavoidable, this phenomenon has been highly publicized in recent years.

The report reviews several processes, approaches and tools that anesthesiologists can consider in their treatment plans for individual patients, with the goal of reducing the incidence of unintended awareness under general anesthesia.

In the report, the task force makes several recommendations and statements related to monitoring of patients for intraoperative awareness.

First, it states that physicians should rely on “multiple modalities, including clinical techniques (e.g., checking for clinical signs such as purposeful or reflex movement) and conventional monitoring systems (e.g., electrocardiograms, blood pressure monitors, heart-rate monitors, end-tidal anesthetic analyzers and capnographs).”

Second, the report states that “the decision to use a brain function monitor should be made on a case-by-case basis by the individual practitioner for selected patients.” This group may include patients undergoing trauma surgery or cesarean section who cannot tolerate a deep anesthetic. Providing a lighter than normal anesthetic to at-risk patients may be a necessary step taken by anesthesiologists, the possibility of which is generally discussed with the patient in advance of surgery, if circumstances permit.

“The most important monitor in the operating room is the anesthesiologist, who has 12 years of medical training and a wealth of experience to draw on when deciding what is appropriate for each individual patient,” said Orin Guidry, M.D., newly installed ASA president.

In a separate but related action, the ASA House of Delegates passed a recommendation that ASA study funding further research into the usefulness of brain function monitoring technology in minimizing the risk of intraoperative awareness.

The American Society of Anesthesiologists has been educating its members about awareness for more than a decade through its NEWSLETTER and educational meetings. Its Practice Advisory on Intraoperative Awareness and Brain Function Monitoring represents the most comprehensive examination of the subject to be undertaken in the health care arena.

ASA encourages patients to discuss any concerns about awareness under general anesthesia with their anesthesiologist. It also advises that anesthesiologists continue to treat any patient who reports awareness with compassion and respect, and to refer them for counseling as appropriate. More information for patients is available at: http://www.asahq.org/patientEducation/Awarenessbrochure.pdf.

“We spend our entire career working to make sure that every patient is kept safe, and is protected from pain and fear. This is what we do,” Dr. Guidry said.



Additional Background

American Society of Anesthesiologists

Practice Advisory for Intraoperative Awareness and Brain Function Monitoring

The Task Force and its Report

ASA’s Task Force on Intraoperative Awareness, appointed in 2004, was charged with producing a practice advisory that would identify risk factors associated with intraoperative awareness, provide decision tools to enable the clinician to reduce the frequency of unintended intraoperative awareness, stimulate the pursuit and evaluation of strategies to prevent or reduce the frequency of intraoperative awareness, and provide guidance for the intraoperative use of brain function monitors as they relate to this phenomenon.

As part of its work, the Task Force reviewed more than 150 studies. The group sought comments on several preliminary drafts of the report from ASA members and other interested parties earlier this year. Members, technical experts and manufacturers of brain function monitors (devices marketed to measure the depth of a patient’s sedation) submitted comments.

The final report examines the latest medical and scientific information on intraoperative awareness, including factors that increase a patient’s risk. It summarizes the research on brain function monitoring, reports on multiple approaches for minimizing risks, and recommends appropriate followup for patients who report awareness during surgery. It also reports on the opinions of members and consultants about the usefulness of brain function monitoring in minimizing the risk of intraoperative awareness.

Brain Function Monitoring

Brain function monitoring devices, made by a handful of companies, use processed electroencephalographic data to assign a numeric value to a patient’s depth of sedation. One application for which they are marketed is to help minimize the risk of intraoperative awareness.

The report recognizes the devices as a possible tool for monitoring selected patients, but concludes that the decision to use this emerging technology should be made on a case-by-case basis by the individual practitioner.

“There is still much to be discovered about how these devices work, and in which situations they are best applied,” Dr. Guidry said. “We are interested in following their continued evolution and to conducting further research in this area. Meanwhile, brain function monitors are an option to be used when the anesthesiologist deems it appropriate, just as he or she makes choices about specific drugs, dosages, warming devices, and other types of monitors depending on the individual patient.”

From an historical perspective, ASA’s approach to these monitors is consistent with its approach to other types of equipment used by anesthesiologists. For example, capnographs and pulse oximeters are widely used today to monitor surgical patients’ breathing and blood oxygen levels. Yet language encouraging their use in ASA standards and guidelines did not happen overnight; it was strengthened gradually as the devices’ usefulness, reported by anesthesiologists and researchers, became more evident.

END of Statement
........................................................................................................


However, thanks to the media and those that help the media, whether intentionally or not, every pt is going to want one of these monitors.

 

[jwk]

Boston, that segment didn't have to be 5 minutes if Carol had brought up the salient issues that were being bypassed by the media. If you have that opportunity to educate the lay public about items that Aspect is avoiding, you will force a debate that more than likely will expand beyond the preset 5 minute interval simply because it is something that no one has expected to hear.

As for criticizing those who support the BIS, that isn't the issue. They support the BIS and you know it and they defend their point of view. Carol was supposed to provide the academic viewpoint that balanced the hysteria that the media and Aspect are trying to create and to find either a neutral ground or counterpoints to the routine use of the BIS. It seemed that she was a proponent for the BIS, not a neutral expert. What has gotten me upset is that patients are now asking it of me for even basic cases. Patients that I am just sedating for pain procedures are asking me to use a BIS even though they are SUPPOSED to be awake for certain procedures or certain times of other procedures. That is just a total waste of their money, but they don't understand what the BIS MIGHT provide and when it is appropriate. They only hear "BIS prevents awareness under anesthesia and should be used at all times."

I have spoken at conferences before and I was a radio DJ for a daily evening talk show and more, so I would be happy to take that opportunity should one present itself. As for my identity, it's no secret. I would bet that at least half of the regular posters here and many who have only lurked but have contacted me by PM, know who I am by first name and last.

I thank the rest of the posters who have spoken on my behalf and I normally do not get irate at any one or any issue, but when I see trusting patients coming to the OR now with elevated levels of fear that may have been attenuated by a respected professor's words, it bugs me.

The solution? Don't have BIS available. We don't have it, and if patients ask, they get a quick education about awareness (actually, they're getting that anyway) and awareness monitors. If patients get a little huffy, then we might even pull out the anecdotes about awake paralyzed volunteers with a BIS that says they're asleep, or that Jello gives a reading on the BIS.

 

[Disse]

This is from 10/14/03

http://www.asahq.net/news/Today ShowApfelbaumtranscript.pdf

I'd cut and paste it so it was easier to read but I can't figure out how ( 😳 )

 

[Gimlet]

This is from 10/14/03

http://www.asahq.net/news/Today ShowApfelbaumtranscript.pdf

I'd cut and paste it so it was easier to read but I can't figure out how ( 😳 )

Wow, reading that made me realize that that Matt Lauer truly is a f#$%ing dickhead. I hate it when these media personalities "interview" someone and continuously interrupt them in order to railroad the interviewee into conceding a point they weren't trying to make.

 

[adleyinga]

Wow, reading that made me realize that that Matt Lauer truly is a f#$%ing dickhead. I hate it when these media personalities "interview" someone and continuously interrupt them in order to railroad the interviewee into conceding a point they weren't trying to make.

WOW I am surprised at some of the vulgarity posted here by practicing anesthesiologists or residents- since med students know nothing about this device.

I too started as a non-believer in BIS and called is junk. However now that I have been forced to use it I have started using it as an additional piece of information that can be helpful. Do I rely on it -NO but do I use to help in some situations- YES.

I think anybody that is so cocky to say that it is a piece of garbage should go back to using Vernitrol anesthesia machines, pentothal and curare. I did many perfect anesthetics with those drug and halothane of course.

I will try all new toys, drugs etc and then decide if I like them.

Wether you like it or not- BIS or other brain monitoring is coming. JCAHO talks about it, ASA talks about it and the media. There is more to this method of monitoring than just PR. I know many of the people invovled in pushing this device and they are decent smart people who truly believe in it and they do not all live in Ivory Towers.

As the ASA statment says- the jury is still out on BIS but it is something to consider.

A Former BIS hater

 

[Noyac]

WOW I am surprised at some of the vulgarity posted here by practicing anesthesiologists or residents- since med students know nothing about this device.

I too started as a non-believer in BIS and called is junk. However now that I have been forced to use it I have started using it as an additional piece of information that can be helpful. Do I rely on it -NO but do I use to help in some situations- YES.

I think anybody that is so cocky to say that it is a piece of garbage should go back to using Vernitrol anesthesia machines, pentothal and curare. I did many perfect anesthetics with those drug and halothane of course.

I will try all new toys, drugs etc and then decide if I like them.

Wether you like it or not- BIS or other brain monitoring is coming. JCAHO talks about it, ASA talks about it and the media. There is more to this method of monitoring than just PR. I know many of the people invovled in pushing this device and they are decent smart people who truly believe in it and they do not all live in Ivory Towers.

As the ASA statment says- the jury is still out on BIS but it is something to consider.

A Former BIS hater

And which one of us said it was "junk"?

Now if the anesthesia provider to the patient in the Matt Lauer interview had a BIS would that pt not have had recall? Well if the provider didn't bother to chart for 3 hrs then he/she probably wouldn't have been paying attention to the BIS as well. That is if he/she would have even bothered to hook it up. Yes, this technology is coming but do we need to scare the lay public into demanding something that isn't proven as of yet. As we all know, nothing can replace a vigilant anesthesia provider.

 

[jetproppilot]

WOW I am surprised at some of the vulgarity posted here by practicing anesthesiologists or residents-

Geez. Another judgmental individual.

Lets see...this week we've been compared to High School students since we're "holding on" and posting on SDN, and now we cuss too much.

WOW I am surprised at the plethora of All-Knowing, Judgmental, Arrogant, Sinless people out there.

 

[jetproppilot]

WOW I am surprised at some of the vulgarity posted here by practicing anesthesiologists or residents- since med students know nothing about this device.

I too started as a non-believer in BIS and called is junk. However now that I have been forced to use it I have started using it as an additional piece of information that can be helpful. Do I rely on it -NO but do I use to help in some situations- YES.

I think anybody that is so cocky to say that it is a piece of garbage should go back to using Vernitrol anesthesia machines, pentothal and curare. I did many perfect anesthetics with those drug and halothane of course.

I will try all new toys, drugs etc and then decide if I like them.

Wether you like it or not- BIS or other brain monitoring is coming. JCAHO talks about it, ASA talks about it and the media. There is more to this method of monitoring than just PR. I know many of the people invovled in pushing this device and they are decent smart people who truly believe in it and they do not all live in Ivory Towers.

As the ASA statment says- the jury is still out on BIS but it is something to consider.

A Former BIS hater

Hey AD, BTW, do you know the 7 cusswords you never hear on television? (George Carlin)

1)S
2)P
3)F
4)C
5)CS
6)MF
7)T


HAHAHAHHAHAHAHAHHAHAHAHAHAHHAHAHAHAHAHHAAHHAHAHAHAHAHAHAHAH

 

[militarymd]

And which one of us said it was "junk"?

Now if the anesthesia provider to the patient in the Matt Lauer interview had a BIS would that pt not have had recall? Well if the provider didn't bother to chart for 3 hrs then he/she probably wouldn't have been paying attention to the BIS as well. That is if he/she would have even bothered to hook it up. Yes, this technology is coming but do we need to scare the lay public into demanding something that isn't proven as of yet. As we all know, nothing can replace a vigilant anesthesia provider.

It was me. I called it a piece of s h i t. I was introduced to it. I found it interesting. I used it, and I found that it impaired me from doing a case that way I would want. Frequently, the BIS is high when I felt no additional hypnotic was needed, and other times very low when I felt hypnotics were needed.

So I called it an expensive random number generator....after giving it due chance to impress me.

If the mortality data on low BIS scores bear out, then I will use to improve 6 month and 1 year mortality in the elderly.

 

[DarksideAllstar]

since med students know nothing about this device

Thanks for generalizing. A s s.

 

[jwk]

WOW I am surprised at some of the vulgarity posted here by practicing anesthesiologists or residents- since med students know nothing about this device.

I too started as a non-believer in BIS and called is junk. However now that I have been forced to use it I have started using it as an additional piece of information that can be helpful. Do I rely on it -NO but do I use to help in some situations- YES.

I think anybody that is so cocky to say that it is a piece of garbage should go back to using Vernitrol anesthesia machines, pentothal and curare. I did many perfect anesthetics with those drug and halothane of course.

I will try all new toys, drugs etc and then decide if I like them.

Wether you like it or not- BIS or other brain monitoring is coming. JCAHO talks about it, ASA talks about it and the media. There is more to this method of monitoring than just PR. I know many of the people invovled in pushing this device and they are decent smart people who truly believe in it and they do not all live in Ivory Towers.

As the ASA statment says- the jury is still out on BIS but it is something to consider.

A Former BIS hater

So you've been "forced to use it". Maybe that colors your opinion a little. I tried it at a place where I do some freelance work. It's not "forced" on anyone. I tried it - not worth the effort or the expense, and it doesn't change the way I do my anesthesia.

That's not to say I can't change though. I'm probably one of the oldest farts on here, and I actually used vernitrols (and even copper kettles) and curare, and still use pentothal on occasion. I know, to you these are just concepts - to me they were everyday practice. And I could still go in to work tomorrow and put a patient to sleep with a vernitrol vaporizer (if I could find one) and curare (if I could find any) and pentothal (still in our Pyxis machine), and they would stay asleep for the case and wake up at the end, just like they did in 1979.

I've seen drugs and technology that were incredible advances - and I've seen plenty of dogs as well. As it stands right now, BIS is a dog. Maybe some of these awareness monitors will pan out. And I'll make this prediction - Aspect Medical, because of it's sleazy marketing tactics, questionable science, and even more questionable "experts", will be at the bottom of the pile IF we ever consider buying an awareness monitor.

 

[adleyinga]

Geez. Another judgmental individual.

Lets see...this week we've been compared to High School students since we're "holding on" and posting on SDN, and now we cuss too much.

WOW I am surprised at the plethora of All-Knowing, Judgmental, Arrogant, Sinless people out there.

NO not calling you names BUT

""Matt Lauer truly is a f#$%ing dickhead.""

is vulgar for a professional BB