Good Anesthesia Matters!

The anesthesia world is spinning up to a tizzy over the upcoming theatrical release of the movie "Awake." For those of you living "off the grid", Awake is a story about a poor victim who has the extraordinary misfortune to be subjected to cardiac surgery awake/paralyzed. None of us have seen this movie, but advanced word is the anesthesia folks aren't favorably depicted.

I am really, really looking forward to its release. For a lifetime, I have wholly devoted myself to my craft; medicine and anesthesiology. While I have not minded being in the background behind my surgeons, I have, over thirty years, grown tired of the surgical attitude that what I do is trivial; of course it is, because if it weren't, well, they'd be doing it themselves, wouldn't they?  And if I and my colleagues had been made of better stuff, we would have gone into surgery.  What a load of nonsense.

One slip of the surgeon's knife, and a patient's meaningful life is over. Just so, one mistake with a syringe of vecuronium, and a patient is dead, or perhaps, worse than dead... The truth is, if I don't practice smartly and on form, patients will suffer and perhaps die in ways both obvious (aka "Awake") and subtle (ie high blood glucose leading to higher post-op infection rates) It's about time everybody understood it. It doesn't help when colleagues (especially CRNA's, I note over the years) minimize what they and we do; "oh you're going to take a little nap while your (big strong) surgeon operates on you." I even avoid the use of the word sleep to describe what I do. I usually say "sleep is what you do at night. It is free and natural, but if your surgeon were to attempt to operate while you are asleep, you would wake up in great pain. What I provide is drug induced unconsciousness, not unlike a temporary coma. You will not wake up until I reverse the process. It is a safe procedure in my hands, and I will stay with you the entire time to maintain this state and see you safely through." I have no tolerance for anybody who suggests that I am scaring patients like this; it is simple truth, which is the stuff of informed consent.

For every patient that  says "oh, doctor, anesthesia is soooo important," I have ten patients who believe that I belly up to the table with a syringe of clear stuff, inject it, and walk on to the next room, or out for a cup of coffee... ("who was that masked man? I don't know, but he left this bill pinned to my dickie...")

A little patient apprehension about their upcoming anesthetic is a good thing-it's appropriate.  And if the patients get the idea that who is giving their anesthetic; their education, dedication, compassion and diligence,  matter to their outcome, well, then, so much the better. Because it's true.

Where I come from, there' was a saying; "a good surgeon deserves good anesthesia. A bad surgeon needs it." I can't remember all the times I've had to hold a patient together physiologically while the surgeon tried to work his way out of a nasty situation. I have auscultated the hearts of 20000 patients to avoid missing that once-in-a-lifetime patient with critical aortic stenosis who would otherwise die on anesthesia induction (I've found 2). I've sniffed around thousands of diabetics for a whiff of the coronary artery disease that might progress to a fatal perioperative MI. I've sat on the floor of the holding area hundreds of times looking up at anxious three year olds and their parents, quickly forging a rapport that I could leverage into a less scary induction.

I can deal with healthy patient fear; it just takes a little time, some patience and explanation. I hope that every patient for the rest of my career has the good sense to ask me what I'm going to do to keep them alive, and how I'm going to prevent the excruciating agony of their being awake "under the knife", and then I hope they look me in the eye as I explain it all, to be sure they see a soul they can trust.

And if anesthesia leadership on both sides of the aisle (AANA and ASA) settle for some bland reassurances about anesthesia diligence and try to undermine the message of "AWAKE"  by pointing out the inevitable inaccuracies they will find in the movie, than they (and we) ought rightly to be banished to the back benches of the medical pecking order.

And if Aspect medical makes a few more bucks on their BIS monitors along the way, so be it; their box isn't perfect, but it isn't bad, either...

I say, "bring it!" I'll be there on opening night with a big bag of popcorn to assuage my vicarious anxiety...

Comments

[shomama]

great post. i love your attitude towards the movie, it is really what we should all be thinking. Instead of being afraid we should see this as an opportunity. In looking through old Anesthesiology articles from the 1940's I came upon a speech given at the NYC world's fair in July 1940 by Howard Haggard a doctor and researcher from Yale. He spoke about "the place of the anesthetist in american medicine." It was amazing because it was as if it was written today. He presented the same issues and conflicts we face in that the better we do our job the less noticeable we end up appearing. If you haven't, I definitely recommend reading it. His main solution to this "problem" is in reshaping public opinion to understand the gravity of our work. He gives examples from other fields (i.e. surgery) that were once considered irrelevant and how by working to shape public perception they are now perceived with such stature. I think this movie is a great opportunity to work with the public, educate them about the realities of anesthesia and how amazing our work is that we can keep them both alive and free of pain while the surgeon messes around with their insides. The ASA, instead of sending out forboding emails to its members about this movie should be out there engaging the public. (July 1940, Volume 1, Issue 1)
Here is the link: http://www.anesthesiology.org/pt/re/anes/pdfhandler.00000542-194007000-00001.pdf;jsessionid=HvpJy71Kvsvq3Tnt2pM2fCLNWTD19G6b0yFcXGc9YR23Nntj7TwQ!1821113646!181195629!8091!-1

[mkeamy]

yup. the pdf file of that article sits on the desktop of my old I-book for inspiration; I've been thinking about writing a post about it for a bit, but you just beat me to it! It's fun, too, to go through those old issues, eh? Thanks for stopping by; nice to hear from you.

Mitch

[Heart Valve Surgery]

Thanks for this. As a double heart valve surgery patient, I'm always on the lookout for intersting information. This definitely qualifies.

Cheers,
Adam

[rlbates]

Love this post. Please submit it to the next SurgeXperience (http://surgexperiences.wordpress.com/2007/11/02/surgexperiences-108-to-be-hosted-at-aggravated-docsurg/)

[Felix Kasza]

> [..] I have ten patients who believe that I belly up to the table with a syringe of clear stuff [...]

... which is clearly wrong -- everybody knows that it's a syringe of White Stuff.

:-)

Cheers,
Felix.

[mkeamy]

hmmm...would you believe I use a lot of etomidate? Thanks for stopping by.

[Sid Schwab]

In the flip-side of your good surgeon/bad surgeon idea, it's easy to appreciate the difference between good and bad anesthesia as well.
And, as a result, to recognize that there's a lot more to it than big syringe/small syringe. I've been lucky to have worked with by far more excellent anesthesiologists than the other kind. I think I've let them know how much I appreciate it. I hope I have. Surgery is much easier when patients hold still; more gratifying when they wake up.

[RichardH]

Yes, it is difficult that the patient is unconscious during our care, and after all goes well they wake up feeling fine and thinking that nothing significant happened. I think it is important that we take the time to develop a rapport with our patients before and after their anesthesia.

[mkeamy]

I absolutely agree. I wrote about the preop interview early in the blog; you can find it here; http://mkeamy.typepad.com/anesthesiacaucus/2007/06/seeing-patients.html

Thanks for stopping by!

Mitch