NYT: "Going Under the Knife, With Eyes and Ears Wide Open"

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Dr. Karen Sibert wrote a short but nice response letter, should be published tomorrow. She sent out an advanced copy by email today.
 
The article highlights another reason why regional and MAC skills are more important than ever. (And why CRNAs will become the dominant anesthesia providers in this country for more and more surgeries.)

Only the naïve would believe that a longer GA does not affect the IQ or has similar risks with a regional technique. Most general anesthetics are less than perfect because the providers are not anal, and we still don't know enough about the mechanisms of action of the substances we use.
 
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rakotomazoto said:
Dr. Karen Sibert wrote a short but nice response letter, should be published tomorrow. She sent out an advanced copy by email today.
Click to expand...

It was a nice and to the point response.


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rakotomazoto said:
Dr. Karen Sibert wrote a short but nice response letter, should be published tomorrow. She sent out an advanced copy by email today.
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Watch out who you call “paternalistic”

I don't agree with her. Like one of the commenters, I would say that the truth lies somewhere in the middle. We are somewhat paternalistic, as we don't usually discuss alternative anesthetic plans. We tend to do things mostly the way we and the surgeons like them.
 
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FFP said:
Only the naïve would believe that a longer GA does not affect the IQ or has similar risks with a regional technique.
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In the developing brain I wouldn't argue with this, although the jury's still out. But in the adult brain, you really think the IQ is permanently effected? I don't know the answer, but I'm not convinced a GA doesn't have completely reversible effects on a healthy, adult brain in the long run.

The effects of surgery, with micro-emboli, pro-inflammatory effects, hemodynamics effects... that might be another story.

If I was considering a completely elective surgery, even a potentially long surgery, the long term effects of anesthesia wouldn't weigh in my choice at all. And I ain't looking to lose IQ points.
 
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Unless under the care of a known and trusted anal solo attending, I will never have GA if I have a choice. I chose not to have an elective surgery years ago, because it would have been in an ACT academic place. Some people consistently overanesthetize their patients (and lie about it on the paper record), because it's much easier than a carefully-titrated customized balanced anesthetic, or using pressors every time they are needed.

People should be educated that choosing one's in-room anesthesia provider is (at least) as important as choosing one's surgeon.
 
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VS

Medical-Cannabis1.jpg


The "adult" Brain can handle a lot of abuse so I'm not nearly as concerned by a 3-4 hour general anesthetic with Isoflurane vs years of smoking weed.
 
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BLADEMDA said:
Years of puffing on a joint might cause memory troubles when you’re older, researchers believe. A new study says that the effects of marijuana use can last for decades, particularly when it comes to your memory.

The Scary Way Long-Term Marijuana Use May Impact Memory | The Huffington Post
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Long term high dose use of just about anything is bad for the organ it effects and potentially other organs. The data might be interesting, but I don't need data to know that.
 
I'm curious about the demographics of Bensalem, PA where 80% of Dr. Ilyas patients choose to be awake for their procedures. I practice in Trump voting territory with minimally educated patients that overwhelmingly smoke are overweight and have as little insight into their own health as possible. When presented with options for anesthesia I'm usually told "Just knock me out doc, I don't want to know or see anything" Of course these are the sickest patients with the most comorbidities.
This article applies mostly to elite well educated patients who are able to comprehend the risks of anesthesia and might actually have some *gasp* curiosity about how their bodies work. Based on the results of the last election I don't believe this represents an increasing trend in the general population of the US
 
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Colba55o said:
I'm curious about the demographics of Bensalem, PA where 80% of Dr. Ilyas patients choose to be awake for their procedures. I practice in Trump voting territory with minimally educated patients that overwhelmingly smoke are overweight and have as little insight into their own health as possible. When presented with options for anesthesia I'm usually told "Just knock me out doc, I don't want to know or see anything" Of course these are the sickest patients with the most comorbidities.
This article applies mostly to elite well educated patients who are able to comprehend the risks of anesthesia and might actually have some *gasp* curiosity about how their bodies work. Based on the results of the last election I don't believe this represents an increasing trend in the general population of the US
Click to expand...

The flip side to that "elite well educated" bit leads straight to another shade of "western rich white hippie woman syndrome" that mostly rears its pretentious ugly head in OB.

Think about the crazy women who want to deliver their babies naturally, at home, in the bathtub. They ain't gonna take no lip from no doctor, trying to boss them around and do unnatural things to them. Women been makin' babies fer millions of years! But you ask any poor woman in a 3rd world country if she'd prefer to deliver at home or in a modern hospital and of course she'll choose the hospital. She's known and seen mothers and neonates die. The risk of childbirth is just an abstract thought to the western home birth hippie. She thinks her imagined idealized spiritual birth experience is the most important thing because she can't fathom the notion of bleeding to death in her home. She's an idiot.

FTFA said:
a patient’s decision to remain awake during an operation also reflects a growing suspicion, generally, of authority figures
Click to expand...

Yep, there it is.


Some of the procedures described in the article are done under local, or with minimal sedation from a sedation nurse (not a CRNA), everywhere. Nobody gets general anesthesia for carpal tunnels or vasectomies. Patients get spinals for procedures all the time. Often supplemented with some sedation because that's what most patients want. But there's nothing special or revolutionary about being awake for some procedures.

So much stupid in this article.

FTFA said:
“Sometimes I’ll go overboard and say, ‘That’s perfect!’ or ‘It came together exactly the way we wanted!’
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Yeah, let's BS our patients and exaggerate to make them feel better. Now that's truly paternalistic and insulting.

FTFA said:
“When I had a vasectomy I had the awake option. But I said, ‘Nope! I’d rather be asleep. I’m good, thanks.’”
Click to expand...

Oh FFS. I guess some people do.

(A hospital I used to work at would book vasectomies in the main OR just to falsely inflate utilization numbers. But they didn't get GA.)
 
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pgg said:
Nobody gets general anesthesia for carpal tunnels or vasectomies
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We have a surgeon that will only do his open carpal tunnels under GA. Not once have any of his patients batted an eyelash when I tell them they are going to sleep for this.

Interestingly I had dinner with a very well educated PhD buddy of mine tonight who said he wants to be asleep for any type of surgical procedure and is terrified of being aware of anything even if it is painless. I think this article is BS and the trend toward regional is not fueled by patients but by physicians
 
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We have a hand surgeon that cannot seem to put local in the right spot ever, so many of us have found that it's just easier to place an LMA and run then at 0.6 MAC (she also takes about 45 minutes). Our other one is very good about localizing the surgical site for a lot of his procedures, while leaving the patient able to move their fingers so he can check things like his tendon repairs actively intraop. His patients get virtually nothing, and do well, partly because he preps them for this.

We almost never do vasectomies in the OR, but when we do, it's because they're refusing local in the clinic, and demand a GA (usually also command interest patients), or its a prima dona surgeon that wants GA, with exparel for local.

I prefer to be wide awake for my own procedures, mostly because I get really bad PONV and don't want to be disinhibited around my co-workers.

Regarding education level, political affiliation, and desire for GA vs other technique, I can't say that I see a correlation with my patient population. I offer regional when appropriate, and most patients refuse, stating that they just want to be asleep as know nothing about what's going on (that includes several surgeons, and a few of the other anesthesiologists at my shop).

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FFP said:
Unless under the care of a known and trusted anal solo attending, I will never have GA if I have a choice. I chose not to have an elective surgery years ago, because it would have been in an ACT academic place.
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Dude.

You have issues.
 
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Aren't carpal tunnels becoming office procedures by you guys?

They rapidly are shifting in my area over past 2 years. We still do some, but not many.


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psychbender said:
We have a hand surgeon that cannot seem to put local in the right spot ever, so many of us have found that it's just easier to place an LMA and run then at 0.6 MAC (she also takes about 45 minutes). Our other one is very good about localizing the surgical site for a lot of his procedures, while leaving the patient able to move their fingers so he can check things like his tendon repairs actively intraop. His patients get virtually nothing, and do well, partly because he preps them for this.

We almost never do vasectomies in the OR, but when we do, it's because they're refusing local in the clinic, and demand a GA (usually also command interest patients), or its a prima dona surgeon that wants GA, with exparel for local.

I prefer to be wide awake for my own procedures, mostly because I get really bad PONV and don't want to be disinhibited around my co-workers.

Regarding education level, political affiliation, and desire for GA vs other technique, I can't say that I see a correlation with my patient population. I offer regional when appropriate, and most patients refuse, stating that they just want to be asleep as know nothing about what's going on (that includes several surgeons, and a few of the other anesthesiologists at my shop).

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Click to expand...

OK, it's been a little while...

What is a command interest patient? Is that a patient that requires "extra attention" because they think they are better or more deserving than others?
 
sethco said:
OK, it's been a little while...

What is a command interest patient? Is that a patient that requires "extra attention" because they think they are better or more deserving than others?
Click to expand...

No, it's a military term meaning that the patient is of some interest to the hospital commander and/or deputies. Technically, any active duty patient undergoing surgery has to have command approval for the procedure, but command interest is usually isolated to officers in some position of authority in the hospital or physicians. It's basically our way of saying a VIP patient.



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Colba55o said:
Based on the results of the last election I don't believe this represents an increasing trend in the general population of the US
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Don't get out much, do you?
 
psychbender said:
Wait, I forgot that you were military, too. Did they not have this in the Air Force? Is it just an Army and Navy thing?

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Click to expand...

Oh, we had it.

But, it was a non-flattering expressment we gave to "difficult" patients. For example, if a patient was in a car accident while intoxicated and killed other passengers in the vehicle and we were seeing them for an unrelated issue. Hence, command interest...
 
Shimmy8 said:
Dude.

You have issues.
Click to expand...
Listen, "dude".

I work with CRNAs every day. I see even the "best" of them do dumb things on a weekly basis. Like keeping the 90 year-old grandma on 2 of Sevo and BP of 85/40 for an hour. Or running 3 of Sevo with no opiates on board for hours. Or lying in the paper chart about the real vitals (or omitting the pressors). Or transporting patient with aortic aneurysm to the ICU, without taking any vasodilator with them, not even propofol, so you can start praying when the patient wakes up on the way and the BP shoots up to 220+. Or not calling for help even when the sat is in the 60's in a healthy patient. I see imperfections on a daily basis. I see them texting, I see them doing crosswords etc. Count yourself lucky if you have never seen stuff that would make you think twice before letting them play with your brain, or take care of a dear one. I am sure these examples apply to a lot of MDs, too. Since quality of anesthesia is tough to quantify, and the human body is resilient, one can get away with a lot before doing macroscopic harm.

P.S. It takes a special kind of human quality to insult somebody anonymously and gratuitously on the Internet. Same goes for those who liked your post. One can disagree without the ad hominem.
 
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I'm sorry, @FFP, that you have a tough working environment. You've referenced it several times. I don't really share the absolute negatives and haven't seen them to this degree in our academic center. You are a little more distrusting than others on this forum, to be blunt.

I didn't blink an eye when I needed emergency surgery at my institution and my anesthetic was done by a CRNA. He's a colleague and he worked to assuage my fears of the surgery. I woke up feeling great, actually. I don't have permanent cognitive issues (to my knowledge, maybe my coworkers think otherwise!) or other implied issues with a possible "high MAC" anesthetic. Mine was a simple, straightforward case and I'm heathy. Doesn't change some of my other thoughts about practice guidelines of course.

Also, liking a post is hardly a personal assault on the internet... relax.
 
You seriously have never "insulted" someone on here. Considering your tone and 4500 posts, I find that hard to believe.

I think no matter how you feel, refusing an elective procedure because of the ACT model is IMO a little extreme and says more about your control freak mindset than anything else.
 
I am sure I have insulted many, some even intentionally. I am also sure I have apologized in many cases.

Sorry to disappoint, I am not a control freak, just cautious. I pay attention to details, but I accept that humans are less than perfect. I just don't like playing Russian roulette with my body and my future, if I don't have to. I don't think only pediatric brains get affected by GA. And I still have to meet a high IQ person with many general anesthetics in his/her past.

I would accept being anesthetized by a person I know and trust, CRNA or MD, just not by people I don't know, regardless of credentials. All patients should be as selective with their anesthesia providers as with their surgeons and other doctors.
 
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FFP said:
And I still have to meet a high IQ person with many general anesthetics in his/her past.
Click to expand...

Not to get too far off topic but.....

I recently had a patient, a young man born with hypoplastic left heart who had a Fontan, a baffle revision, multiple caths, a pacemaker, and several other procedures who by report is a successful student at a top university. I also have a partner who's son had multiple surgeries to correct scoliosis and is also a stellar student.

I'm not saying GA has no effect but we don't know when and to what extent. At my age I'd have no hesitation about GA if I needed it. In my late 70s or 80s I'd think about it.
 
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FFP said:
Listen, "dude".

I work with CRNAs every day. I see even the "best" of them do dumb things on a weekly basis. Like keeping the 90 year-old grandma on 2 of Sevo and BP of 85/40 for an hour. Or running 3 of Sevo with no opiates on board for hours. Or lying in the paper chart about the real vitals (or omitting the pressors). Or transporting patient with aortic aneurysm to the ICU, without taking any vasodilator with them, not even propofol, so you can start praying when the patient wakes up on the way and the BP shoots up to 220+. Or not calling for help even when the sat is in the 60's in a healthy patient. I see imperfections on a daily basis. I see them texting, I see them doing crosswords etc. Count yourself lucky if you have never seen stuff that would make you think twice before letting them play with your brain, or take care of a dear one. I am sure these examples apply to a lot of MDs, too. Since quality of anesthesia is tough to quantify, and the human body is resilient, one can get away with a lot before doing macroscopic harm.

P.S. It takes a special kind of human quality to insult somebody anonymously and gratuitously on the Internet. Same goes for those who liked your post. One can disagree without the ad hominem.
Click to expand...

Definitely agree there are a lot of terrible CRNAs who are piss poor technicians and only get by because the patients are resilient enough to withstand the assault.
 
nimbus said:
Not to get too far off topic but.....

I recently had a patient, a young man born with hypoplastic left heart who had a Fontan, a baffle revision, multiple caths, a pacemaker, and several other procedures who by report is a successful student at a top university. I also have a partner who's son had multiple surgeries to correct scoliosis and is also a stellar student.

I'm not saying GA has no effect but we don't know when and to what extent. At my age I'd have no hesitation about GA if I needed it. In my late 70s or 80s I'd think about it.
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Kids are actually much more resilient than adults. That's how they are built, regardless of species. They are not small adults. They have much better regenerative potential. That's why they get all those cancers, too. And that's probably why we don't see the in vivo effects of anesthetics that we see in the lab.

At the same time, we have all seen post-anesthetic cognitive disfunction in elderly. It's real. So my guess is that GA does cause damage regardless of age; the outcome depends on how well the body can recover (and what other damage did the in room-provider cause personally).

During my time in the ICU, I have seen so much OR anesthetic mismanagement by less-knowledgeable providers. Many anesthesiologists and CRNAs don't see or care for the big picture for a patient. (Even of this forum many people say that they don't want to learn or be involved in perioperative care.) They never ask themselves: If I do this today, what will the long-term effects be on this patient? Is it really worth giving that unit of blood or fluid? What's the best MAP for the brain? How about the kidneys? Does it matter whether the patient pees or not? What are the basic important things that I can do for this patient today, to make sure I caused no/minimal harm? Every single little thing we do to patients has risks.

Of course, for young and healthy individuals it matters much less, but do enough harm to a patient and it will stick, even if we can't always quantify it. We get away with stuff because the harm is not detectable and/or the body recovers and/or nobody is really interested in seriously financing such long-term prospective studies. Not because there was no harm in the first place. That's my point, I guess. Plus that I am a natural born optimist. :)
 
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If the "harm" is undetectable, was there really any harm done??

 
dr doze said:
Detecting harm in part depends on hard you look and our ability to look.
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Yes, I know what you are saying, and I don't disagree. But, if the "harm" is only detectable when you look with a scanning electron microscope or put the patient through a 827 point neuropsychiatric eval - well then it is even worth talking about?
 
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nimbus said:
Not to get too far off topic but.....

I recently had a patient, a young man born with hypoplastic left heart who had a Fontan, a baffle revision, multiple caths, a pacemaker, and several other procedures who by report is a successful student at a top university. I also have a partner who's son had multiple surgeries to correct scoliosis and is also a stellar student.

I'm not saying GA has no effect but we don't know when and to what extent. At my age I'd have no hesitation about GA if I needed it. In my late 70s or 80s I'd think about it.
Click to expand...

Imagine how smart they would be if they never had anesthetics
 
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