The Ether Way

Patient Safety in Anesthesia...A success story

December 7, 1941  Pearl Harbor.... Lots of casualties. Patient safety routine efforts primarily consist of finger on the pulse, eyes on the chest, observation of skin color. The recently released drug, thiopental, is employed. Some of the soldiers die…of anesthesia (1-3). Anesthesia-related death rate reported at 1 in 450 (2).

September 1979 – September 1981 (WAK residency time). The operating surgeon calmly notes blood’s dark.  WAK’s reaction: BLOOD'S DARK!!! Dr. Todres says the first 3 things to check for with any problem in the OR is, first airway, then the airway, and finally the airway. So he checks it and finds a disconnect which somehow was not able to be heard with the esophageal stethoscope over the orthopedists’ hammers and drills. No oxygen analyzer, no disconnect alarm, no pulse oximeter, no automated blood pressure monitor; by today’s standards, no nothing, although we did have manual blood pressure cuffs, EKG machines,  and the beginnings of advanced hemodynamic monitoring. WAK’s attendings were fond of saying “when I was a resident…” followed by some parable of how he managed with no monitors other than his five senses.  It seemed like at least once a year at M&M there was discussion about an intraoperative death by undetected disconnect. Anesthesia death rate said to be about 1 in 10,000.

 

Whack-a-mole!

No mysticism today, but a meditation nonetheless. I have in mind the once-again confused state of matters for the patient with cardiac disease presenting for non-cardiac surgery. When I left off in my thinking, snug (and smug) in my self-assurance, it was January 2005. Life was good! Eagle and Fleischer (and all the rest..) had published, in 2002, a lovely practice guide stratifying risk by extent of procedure, severity of risk factors, and had even published a sexy little flow chart suggesting how to proceed. To make matters even better, intervening publications highlighted the protective effects of Beta-blockers, statins (who knew they had an acute protective effect?), and the interesting observation that many post-op MI's smolder (elevated i-troponins for hours or days) before they burst forth. (At least, that's one of the off-hypothesis impressions I took from this data.) McFalls et al did their remarkable study (CARP) in the VA system (where else in America could such a thing be done?) where they took a bunch of veterans with known coronary artery disease of sufficient severity to warrant intervention (CABG or PCI), and randomized them to either have their hearts fixed before abdominal or thoracic aneurysm surgery, or after. No kidding-you can look it up! Here. No differences in outcomes! No differences!(They eliminated critical aortic stenotics (Duh!) and Left mains (hmmm.) Lots of letter-to-the-editor chatter about this study, as befits a work of this breathtaking hypothesis and conclusion. You'll have to read them yourself...

Patients are not Customers!

Link through Kevin MD's July 26th post to a good (and important) op-ed about a long time pet peeve of mine; hospitals calling patients "customers."

Brain Damage From Anesthetics

Say it aint so.....

So far no one has shown a direct effect of anesthetics to produce brain damage in people.  However, there are some disturbing reports about post operative cognitive dysfunction after surgery, especially in the elderly.  The Mayo group published data suggesting a link between age of onset of alzheimers and cumulative lifetime anesthetic exposure.  Moreover, Monk's group has shown an association between depth of anesthesia by BIS and one year mortality.  So what's up?

Pretty much every category of anesthetic has been impugned:

Opioids.

I am pretty sure I (and my colleagues) published the first papers showing histologic injury from a clinically used anesthetic drug (Anesth Analg 75:953‑964, 1992.   see fig).  We showed that high doses of alfentanil in paralyzed ventilated rats produced seizures and limbic system  brain damage in paralyzed ventilated physiogically controlled rats.  The doses were about ten times higher than analgesic, a dose range commonly used in cardiac surgery.  Similar results were produced with sufentanil, fentanyl, and remifentanil.  Given to monkeys in a PET scanner we saw FDG temporal lobe activation with fentanyl.  We gave brief high dose remifentanil to five humans fully paralyzed and ventilated also showing limbic system activation.  I just published another paper reporting limbic system activation at low doses of remifentanil in 29 volunteers with a variation in the activation pattern according to apolipoprotein E genotype.  Kearse and Tempelhoff have shown limbic epileptiform activity from fentanyl in humans.  Sullivan et al and Augoustides et al have shown that the proconvulsant properties of  remifentanil make for easier ECTs.  I had one patient seize from a remi injection before ect (do we shock or not?) and another developed post remi-ect status epilepticus.

     So the evidence seems overwhelming that opioids can produce limbic activation and in the right setting   produce brain damage, but we still don't know about people.(NB: when i suggested to several NIH study sections and the AHA in the early 90's that what we were seeing in rats might be relevant they returned non scored critiques...real visionaries there...)

Gabergic drugs

Drugs like barbiturates and benzodiazepines have been long considered to be protective.  Thus the chagrin from many quarters when todorovic, olney and colleagues showed that neonatal exposure to midazolam and nitrous oxide produced later histologic damage and cognitive dysfunction. 

General Anesthesia is really a drug induced coma

I am very particular that patients understand enough about anesthesia to be appropriately concerned regarding what they are about to agree to undergo. In my youth, I supervised an anesthetist who routinely minimized what she said so as to not "upset" the patients. ("you are going to take a little nap while Dr Smith does your surgery...") Nonsense. That's not what we do, and it's not the way patients ought to think about what we do (and what they are agreeing to endure...)  This little conceit creates a false basis for informed consent and trivializes what we do. (we're not just "passing gas" here...) Patients don't believe it, anyway; they know that surgery and anesthesia involve risk and pain, and that anyone who says differently is just selling something.

Grandpa:  ...I'm explaining to you because you look nervous.
Grandson: I wasn't nervous. Maybe I was a little bit "concerned" but that's not the same thing.

    The Princess Bride

Everyone does it, but no one writes about it

What the heck am I doing here?  Why am I here?  More specifically, why have I agreed to participate in a blog?

    Because in medicine, there are a large number of subjects that everyone thinks about and talks about, but no one writes about.  As a group, these subjects are too social for our journals, and too political for our organizational newsletters.  The scientific front-story of medicine receives excellent coverage in our journals, as do the explicit economic issues in our various societal newsletters.

The back-story, the issues surrounding the social construction of health care at the individual, group, hospital, and societal level, has no venue for conversation.  We all wonder: where is this going? We talk about it, but there is nowhere to read about it.  The result is highly local, mostly poorly informed and poorly formulated discussion.  So what? It matters.  The truly radical changes in medicine today are in its social structure as much as in its scientific underpinnings and clinical practice.  As a group, physicians are uninformed about these social issues.  Worse, we are untrained to think and write about them.  There’s a lot to know about the social construction of health care, and physicians don’t even know where to begin.
   

Sleep and Death are Brothers...

In anesthesiology, it is all too easy to lose oneself in the mechanics of placing an endotracheal tube, and to forget that, in the extraordinary act of inducing a trance-like state barely distinguishable from death in a fellow human being, you are acting squarely within the realm of myth. "Sleep and death are brothers" is an ancient Greek proverb, and from the mythologic perspective, is quite literally true. The god of Sleep,  Hypnos is the younger brother of the god of death, Thanatos; both children of Nyx, the goddess of night. And therein lies a glimpse at the beauty of mythology and archetype; the blurring of the distinction between what is real, and what is metaphorically and romantically true or essential (containing the essence of a thing). Our Western penchant for deconstruction and de-mystification has the unfortunate and unintended consequence of driving the essence of things out of our daily lives. We slay beauty, the essence, with the real. A beautiful fragrant climbing rose becomes trivialized and "understood" as a biological device that uses sunlight to fix atmospheric carbon as growth substrate, and the flower is an attractant to promote cross pollination; we have killed the essence of the rose and replaced it with reality, to our great aesthetic detriment; in so doing, we fall out of grace; we lose the Tao.  Just so have we trivialized the stupendous act of conjuring a near death stupor in our fellow man, and than at our will, performing a veritable resurrection; an Anastasis, in greek; αναστασις;  ανα (ana) up and στασις (stasis) standing. This word, anastasis, by the way, bears a striking similarity to anesthesia, and would have been familiar to a classically educated scholar such as Oliver Wendell Holmes...

Axe Handles...

...I am an axe
And my son a handle, soon
To be shaping again, model
And tool, craft of culture,
How we go on.    

 

from Axe Handles, Gary Snyder.

 

 

I recall two mantras that circulated through the residents from my years at Wisconsin; "run silent, run deep," and more importantly, "do the right thing." "Do the right thing" was our constant reminder not to take shortcuts, not to be lazy, not to leave things half done. Those were the days before pulse oximeters and gas monitors, and we all cruised along much closer to the dimly perceived edge of the cliff. It was a time when bradycardia was BAD (it meant hypoxia, and not beta-blockade), and the surgeons would alert us that "the blood looks dark" as a precautionary warning. It is so long ago, we mostly didn't think to worry about tachycardia induced ischemia (yikes!) and we mostly didn't wear gloves (yikes again!) As a resident and fellow, I was surrounded by men and women who knew what they were; Anesthesiologists, capital A, and who were both proud and humble at the same time. These were people who taught me how to live in the often brutish world of the OR and maintain my self-respect and discipline. They taught me how to manage a patient and an operating room. No big fuss; just do the right thing.

The Wisconsin Anesthesia department was very close; it was as tight a team as I have ever been on, although there was the usual (and perpetual) faculty bickering that is an invariable (and endearing) feature of academic departments; that bickering was like the roar of the surf, waxing and ebbing by turns, but never absent. I miss that agitation, which encompassed everything, from anesthesia technique to the chairman's latest pronouncement. It was all very clubby. Private practice is lonely by comparison. The attitude is "I do it all day, why do I want to talk about it?" The Wisconsin anesthesia residents of that era saw themselves as, well, sort of better than other residents. It wasn't an arrogant thing, exactly... It was more of a (smug) self-assurance; the department taught us how to put in tubes and lines right away, so we all weren't afraid of procedures. We were the go-to people in a code. During our rotating internship, the faculty kept a close eye on us as we served on various medical and surgical services. We were family. Various medical and surgical residents were allowed into our fraternity. More than one switched to anesthesia, I suspect, because we had so much esprit and fun. We knew who we were.

The Nature of Anesthesia Judgment

Neo: What are you trying to tell me? That I can dodge bullets?
Morpheus: No, Neo. I'm trying to tell you that when you're ready, you won't have to.

Judgment in anesthesia, as in all of life, takes unusual forms. While you might think that drug selection/technique are the  essence of anesthesia judgment, I believe after thirty years that these choices matter rather less than we think. I am reminded of old studies of psychotherapy that concluded that good therapeutic outcomes correlated with individual therapists more than theoretical "schools" of therapy; that talk therapy is personal. So, perhaps surprisingly, is anesthesia. In my memory, some of the most knowledgeable anesthesiologists were the least capable in the OR. Sometimes it was because they were crippled by their encyclopedic cognitive sets, and sometimes it was because they had no damn common sense. There are two countervailing aphorisms that apply in anesthesia, both taught to most anesthesia residents. First, "if you don't know where you are going, you'll probably end up somewhere else." You have to have a plan going into an anesthetic with a specific set of therapeutic goals and indications (where are you going and why are you going there). The second is "No plan survives first contact with the enemy."  You've got to be willing to modify/abandon your first plan when circumstances don't support it. Let me give an example.

I am presented with a truly unfortunate hypotensive late middle aged patient with bad generalized vascular disease who requires anesthesia for an abdominal catastrophe; probably bowel infarct. He has suffered a stroke some years earlier and is institutionalized. He is aphasic, and does not follow commands, but is vigilant and appears scared. Per telephone conversation with daughter, a previous anesthetic one year earlier at another institution presented unclear airway difficulties ("they said they had trouble with the tube" - when will we ever get electronic records!?) Textbook plan A; awake fiberoptic intubation with mild sedation and appropriate limited topicalization. Start out. Midazolam. Clenched teeth; door shut tight. OK. Plan B; NG decompression, rapid sequence induction. Hmmm; succinylcholine contraindicated for peritonitis, but seems unwise to use rocuronium in case matters become ugly. Ditto more midazolam v etomidate. Sux it is. Reassuring words, 2 suckers, NG out, cricoid pressure, a touch of etomidate, 40 of sux. Mouth barely opens; skin/tmj contractures. No direct laryngoscopy here. Push on? Back out? Easy mask airway (don't like this, but a man's gotta do...) no regurgitation past cricoid. Plan C. Flexible fiberoptic/Ovassapian airway. Chin lift (assistant B) cricoid maintained (assistant A). Easy access, tube passes clean... Another victory for the home team. Elapsed time; about 6 minutes. Lowest sat; 96% Changes of plan- hmmm, two, I guess. Aspiration zero. Perspiration zero. Might it have gone different? Sure. If he'd refluxed, I would have fought it off, backed out and regrouped. Plan D? Awake cricothyrotomy or trach, maybe.

Hours of Boredom, Moments of Terror...

"Hours of boredom, moments of terror"  What a load of bullshit. Anesthesia only seems boring to people who believe that if you are not constantly fiddling with instruments, you can't be doing anything meaningful. (do we know anybody like that?) Moments of terror? I guess that refers to the feeling of loss of control you might have when you realize that the problem at hand (i.e. airway) is something that you don't know a thing about, and so you have to rely on (and trust) the skill and competence of your colleague while you stand by and watch.

"passing gas."

You know you are just "passing gas" when:

-you don't know the difference between an ACE inhibitor and an ARB.

-when somebody calls the ether screen the "blood brain barrier," you don't get it.

-you can't list the drugs that predispose to torsades in a patient with a long QTC (or you don't know your current patient's QTC!)

-you're not as comfortable with a flexible fiberscope as a direct laryngoscope.

-you don't know what "open lung concept" ventilation is.

-you don't look at the heart while coming off bypass.

-you cancel patients for "cardiac clearance" (Egads!)

-you didn't auscultate for undiagnosed aortic stenosis before you induced.

You're just "passing gas:"

-if you didn't set your alarms.

-if you don't know which nerve roots form the phrenic nerves.

-if you can't conduct a resuscitation "by the book" and you don't know when it's appropriate to "throw the book out"

-If you don't know that the most important member of the surgical team is... everybody, because if the $12/hour person in sterile processing doesn't get it right, the whole thing is a disaster...

-if you can't clearly articulate what differentiates you from a CRNA, and why it matters.

I could go on forever...feel free to chime in; I'll compile them all and re-post the complete list sometime...