All I know is that this dude's website has some of the most hilarious items on a CV that I have ever seen.
I mean who includes this????
letter to editor in Outpatient Surgery Magazine...
"It never ceases to amaze me how many times patients remark that no one has ever bothered to numb their skin before IV insertion. My routine has evolved from using a 25g needle with plain lidocaine to using a 30g needle with lidocaine buffered with sodium bicarbonate to reduce the sting of the lidocaine. (Plain saline will also suffice.) We also now have the availability of EMLA cream and pressurized, needleless systems."
Wow, that was worthy of publication.
I also enjoyed your new definition of GA..."GA is a state defined by bispectral index (BIS) values from 40 to 60 on a 100-point scale."
Really? Not even Aspect has the balls to claim that the BIS number defines what a general anesthetic is. From the same "article"...
"Since December 26, 1997, I have routinely monitored my patients with the BIS brain monitor. My patients have their propofol titrated between 60 and 75. This level of sedation is either moderate or deep sedation depending on whether passive or active airway intervention is required to maintain the airway. Clearly PK MAC sedation at BIS 60 to 75 is not GA at BIS 40 to 60! Patients receive the 'illusion' of GA (BIS 40 to 60) with the lesser trespass of sedation (BIS 60 to 75)."
So what exactly is passive or active airway intervention? I'll buy that perhaps sticking in a nose hose does not make it a GA, but if you are having to put in an LMA you are definitely giving a GA regardless of your BIS score.
Again from
Outpatient Surgery Magazine...
"Re: Preventing Surgical Fires (December 2003). Your otherwise excellent story failed to mention the advantages of using BIS-monitored propofol ketamine (PK) anesthesia as a pre-emptive solution. Essential to PK technique, which provides the illusion of general anesthesia to the patient, is the avoidance of opioids, which eliminates the requirement of oxygen, an ignition source for fires."
So you can provide something other than a GA that involves airway manipulation and doesn't require oxygen? Are your patients just smoking a #4 on room air?
From
Outpatient Surgery...
"Once youve observed loss of both lid reflex and verbal response, administer 50 mg ketamine bolus and wait 2-3 minutes before injecting the local analgesic. Without the BIS monitor, administer ketamine after loss of both lid reflex and verbal response. With BIS, wait until a level of 70-75 before giving the ketamine. Think of propofol as the martini, says Dr. Friedberg, and ketamine as the olive."
What? You're basically admitting that your patients are nonresponsive but spontaneously breathing and that's not a GA? I can do the same thing with a mask and 4% sevoflurane and I don't think I'd get away with calling it anything other than a GA.
You are certainly free to practice anesthesia however you so choose. However, your claims regarding your technique border on ridiculous across the board. I mean a PONV rate of essentially zero? Not happening, and I use plenty of regional techniques with no opioid. No oxygen required? Unlikely in most scenarios, particularly when sedated. And did I read correctly that you don't even have an anesthesia machine in the room? Interesting choice.
Congrats on the website, though, looks like you spent some money on having it designed well.
Dude,
Very pleased you took the time to read my thoughts and share your response with the list.
Cognitive dissonance is when you read or see something that is so at variance with your belief system that you cannot accept it. You are a classic case. Many share your skepticism even after they witness the technique first hand. First question - what was the trick? - what did you give that we did not see?
"All I know is that this dude's website has some of the most hilarious items on a CV that I have ever seen.
I mean who includes this????
letter to editor in Outpatient Surgery Magazine..."
Sorry to burst your bubble, but my CV is
not posted on my web site. If you would like a copy, I 'd be happy to email it to you.
The page to which you refer is the 'Doctors Only' page which lists some of my publications. The page does not say peer-reviewed or scholarly publications, just 'publications.'
Outpatient Surgery Magazine is a trade journal devoted primarily to managers of outpatient facilities. Since you read it, I am very happy to have reached you.
" I also enjoyed your new definition of GA..."GA is a state defined by bispectral index (BIS) values from 40 to 60 on a 100-point scale."
"...your patients are nonresponsive but spontaneously breathing and that's not a GA? "
You missed this previous post or chose to ignore it:
From
Anesthesia in Cosmetic Surgery Cambridge University Press 2007
Chapter 1 Propofol ketamine with bispectral (BIS) index monitoring,
Table 1-4 BIS Level of Sedation/Anesthesia
98-100 Awake
78-85 Minimal sedation ('anxiolysis')
70-78 Moderate ('conscious') sedation
60-70 Deep sedation
45-60
with systemic analgesia General anesthesia
<45 OVERDOSED
Minimally invasive anesthesia(MIA)® is BIS 60-75 or moderate to deep sedation with adequate
local analgesia.
Non-responsiveness with the dissociated state in my paradigm is limited to 10-20 minutes. After that, the patients responsive to painful stimuli.
This non-responsiveness does not extend to the glottic chink. Saliva on the cords will provoke laryngospasm, not aspiration. That's the basis for the routine glycopyrrolate prior to induction.
"So what exactly is passive or active airway intervention?"
The ASA talks about 'intervention' (moderate sedation) and 'assistance' (deep sedation) in their description of levels of sedation/anesthesia but doesn't define those terms. I at least attempted to.
Passive airway intervention (for moderate sedation) includes head positioning (facelift position - head extended and rotated laterally) and placement of a 1,000 cc IV bag under thee patient's shoulders. Both maneuvers increase the force on the genioglossus muscle, maintaining a patent airway.
Active intervention include the insertion of a SUPRA-glottic device to maintain the airway. Could be a nasal airway, oral airway, or (gasp) yes, an LMA.
😱 If BIS doesn't drop into the 45-60 range and no systemic analgesia is given, its sedation, not GA.
Also, you missed (or chose to ignore) "
If you need to call MIA to get paid, by all means do so with my blessing" in another previous post.
"if you are having to put in an LMA you are definitely giving a GA regardless of your BIS score."
You sound like a shill for the AAAASF, the plastic surgeon's certifying body.
If the BIS doesn't go below 60 with the insertion & maintenance of MIA, it is still sedation, not GA. Sorry, dude, I will have to politely disagree with you.
"You are certainly free to practice anesthesia however you so choose."
I am overwhelmed by your graciousness and generosity.
"I mean a PONV rate of essentially zero? Not happening..."
Maybe not in your practice.
My patients will complain if their IV insertion hurt. Have you always used a 30G needle for the skin wheal prior to IV insertion?
Cosmetic surgery patients are also not shy in reporting PONV in the least nor are my nurses or surgeons.
Unlike your institutional practice, there is no place to hide from one's outcomes in an office based practice.
Published in
Dermatol Surg 0.6% PONV in 1,264 pts. & in
Internat Anesthesiol Clin 0.5% in 2,683 pts. Both references appear in my CV. I guess you missed them.
If you follow my paradigm, you, too, will reproduce an essentially zero PONV but you obviously prefer cognitive dissonance.
Just because you don't understand the paradigm shift, doesn't make it untrue or non-reproducible.
FWIW, my book was just reviewed in A&A Dec. 2007 issue. I received permission from Dr. Shafer (editor-in-chief) to reprint it for my well designed web site. It should be up tomorrow along with today's press release.
Here is the concluding paragraph:
The text (
Anesthesia in Cosmetic Surgery) is a suitable addition to the library of those who anesthetize patients for cosmetic surgery. The reader is urged to use the described techniques as guidelines rather than
de facto rules and to
disregard the bravado of the editor (my italics). Also, keep in mind that the dosage guidelines for local anesthetic are "generous." Putting these issues aside, the textbook serves as a useful primer in the practice of anesthesia for cosmetic surgery and
deserves a place on ones sub-specialty bookshelf.(my bold)
The review also states that I am a 'self promoter.'
😱
What do you think was said about Drs. Morton & Wells in 1846? (Hint: you know the ether & nitrous public demonstrations in Boston)
Probably that they were self-promoters.
How about Archie Brain and his LMA?
Another self-promoter.
In fact, I think anyone who has offered the profession something
new,
different,
safer and
better has to endure the sobriquet of 'self-promoter.'
Would it help you if I repeated "Gentlemen, this is no humbug."
😀
"No oxygen required? Unlikely in most scenarios, particularly when sedated."
My patients are ASA 1 & 2 who receive an incremental propofol induction with 83 micrograms per (mini)drop titrated to BIS < 75. That is one drop from a 5mg/cc propofol infusion bag with a 60 gtts/cc IV set. Numbers for pumps are available in my book, Ch. 1, Table 1-6 Clinical pathway.
Oxygen is rarely required in my paradigm because of
minimal trespass to the patient. Like 'MIA.' Less is more. Don't slam dunk the pts. to sleep and you can do this, really.
Just because you can't do this, doesn't make it unachievable.
It appears the US military doesn't have a problem reproducing this approach in the field hospitals in Iraq & Afghanistan. see
Anesthesia in Cosmetic Surgery Ch. 7 PK beyond cosmetic surgery: implications for military medicine & mass-casualty anesthesia. They have adopted my technique
because they don't need an anesthesia machine or large quantities of O2 and, of course, because it's simpler and safer.
As far as you and your posting buddy that followed, if you don't want to replicate my outcomes, it will not affect me one iota. However, it will affect your patients, surgeons, nurses, and maybe even your pocketbook.
The choice is completely yours.
I wish you every success in your practice(s).
Best regards from SoCaal,
aghast1
, for the same effect. 
