The anesthesia consultant | Designed to inform both laypeople and medical..
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine. Dr. Novak is an Adjunct Clinical Associate Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in California.
My editorial “Artificial Intelligence in Anesthesia and Perioperative Medicine is Coming” was just published in EC Anaesthesia. I refer you to the direct link here.
Highlights from the paper follow:
Artificial intelligence in medicine (AIM) will grow in importance in the decades to come and will change anesthesia practice, surgical practice, perioperative medicine in clinics, and the interpretation of imaging. AI is already prevalent in our daily life. Smartphones verbally direct us to our destination through mazes of highways and traffic. Self-driving cars are in advanced testing phases. The Amazon Echo brings us Alexa, an AI-powered personal assistant who follows verbal commands in our homes. AIM advances are paralleling these inventions in three clinical arenas:
1. Operating rooms: Anesthesia robots fall into two groups: manual robots and pharmacological robots. Manual robots include the Kepler Intubation System intubating robot, designed to utilized video laryngoscopy and a robotic arm to place an endotracheal tube , the use of the DaVinci surgical robot to perform regional anesthetic blockade , and the use of the Magellan robot to place peripheral nerve blocks [3,4]. Pharmacological robots include the McSleepy intravenous sedation machine, designed to administer propofol, narcotic, and muscle relaxant , and the iControl-RP machine, described in The Washington Post as a closed-loop system intravenous anesthetic delivery system which makes its own decisions regarding the IV administration of remifentanil and propofol . This device monitors the patient’s EEG level of consciousness via a BIS monitor device as well as traditional vital signs . One of the machine’s developers, Mark Ansermino MD stated, “We are convinced the machine can do better than human anesthesiologists.” The current example of surgical robot technology in the operating room is the DaVinci operating robot. This robot is not intended to have an independent existence, but rather enables the surgeon to see inside the body in three dimensions and to perform fine motor procedures at a higher level. The good news for procedural physicians is that it’s unlikely any AIM robot will be able to independently master manual skills such as complex airway management or surgical excision. No device on the horizon can be expected to replace anesthesiologists. Anesthetizing patients requires preoperative assessment of all medical problems from the history, physical examination, and laboratory evaluation; mask ventilation of an unconscious patient; placement of an airway tube; observation of all vital monitors during surgery; removal of the airway tube at the conclusion of most surgeries; and the diagnosis and treatment of any complication during or following the anesthetic.
2. Clinics: In a clinic setting a desired AIM application would be a computer to input information on a patient’s history, physical examination, and laboratory studies, and via deep learning establish a diagnosis with a high percentage of success. IBM’s Watson computer has been programmed with over 600,000 medical evidence reports, 1.5 million patient medical records, and two million pages of text from medical journals . Equipped with more information than any human physician could ever remember, Watson is projected to become a diagnostic machine superior to any doctor. AIM machines can input new patient information into a flowchart, also known as a branching tree. A flowchart will mimic the process a physician carries out when asking a patient a series of increasingly more specific questions. Once each diagnosis is established with a reasonable degree of medical certainty, an already-established algorithm for treatment of that diagnosis can be applied. Because anesthesiology involves preoperative clinic assessment and perioperative medicine, the role of AIM in clinics is relevant to our field.
3. Diagnosis of images: Applications of image analysis in medicine include machine learning for diagnosis in radiology, pathology, and dermatology. The evaluation of digital X-rays, MRIs, or CT scans requires the assessment of arrays of pixels. Future computer programs may be more accurate than human radiologists. The model for machine learning is similar to the process in which a human child learns–a child sees an animal and his parents tell him that animal is a dog. After repeated exposures the child learns what a dog looks like. Early on the child may be fooled into thinking that a wolf is a dog, but with increasing experience the child can discern with almost perfect accuracy what is or is not a dog. Deep learning is a radically different method of programming computers which requires a massive database entry, much like the array of dogs that a child sees in the example above, until a computer can learn the skill of pattern matching . An AIM computer which masters deep learning will probably not give yes or no answers, but rather a percentage likelihood of a diagnosis, i.e. a radiologic image has a greater than a 99% chance of being normal, or a skin lesion has a greater than 99% chance of being a malignant melanoma. In pathology, computerized digital diagnostic skills will be applied to microscopic diagnose. In dermatology, machine learning will be used to diagnosis skin cancers, based on large learned databases of digital photographs. Imaging advances will not directly affect anesthesiologists, but if you’re a physician who makes his or her living by interpreting digital images, you should have real concern about AIM taking your job in the future.
There’s currently a shortage of over seven million physicians, nurses and other health workers worldwide . Can AIM replace physicians? Contemplate the following: All medical knowledge is available on the Internet; most every medical diagnosis and treatment can be written as a decision tree algorithm; voice interaction software is excellent; the physical exam is of less diagnostic importance than scans and lab tests which can be digitalized; and computers are cheaper than the seven-year post-college education required to train a physician. There is a need for cheaper, widespread healthcare, and the concept of an automated physician is no longer the domain of science fiction. Most sources project an AIM robot doctor will likely look like a tablet computer. For certain applications such as clinical diagnosis or new image retrieval, the AIM robot will have a camera, perhaps on a retractable arm so that the camera can approach various aspects of a patient’s anatomy as indicated. Individual patients will need to sign in to the computer software system via retinal scanners, fingerprint scanners, or face recognition programs, so that the computer can retrieve the individual patient’s EHR data from an Internet cloud. It’s possible individual patients will be issued a card, not unlike a debit or credit card, which includes a chip linking them to their EHR data.
It’s inevitable that AIM will change current medical practice. In all likelihood these changes will be more powerful and more wonderful than we can imagine. A bold prediction: AIM will change medicine more than any development since the invention of anesthesia in 1849. How physicians interact with these machines will be a leading question for the twenty-first century.
Imagine . . . rare unrepaired surgical cases in foreign lands, coupled with surgeons in America who rarely have the opportunity to operate on such cases. A win-win situation would be to fly American medical teams overseas to help these patients. This model for plastic and reconstructive surgery was born at Stanford University Medical Center in the 1960s in an organization named Interplast. During my anesthesia training at Stanford in the 1980s I was present through the growth years of Interplast, when traveling teams were dispatched to countries around the world to perform reconstructive surgeries on cleft lip and palate patients. Interplast was founded by Donald Laub MD, who was the Chief of the Division of Plastic and Reconstructive Surgery at Stanford from 1968-1980.
Donald Laub MD
The idea for Interplast grew from the surgical history of Antonio Victoria, a 13-year-old with cleft lip and palate deformities that made him a social outcast in his home country of Mexico. Antonio arrived at Stanford University Medical Center in 1965. Dr. Robert Chase restored the boy’s appearance with three operations. Dr. Laub witnessed Antonio’s transformation and the idea for Interplast germinated.
In 1969 Dr. Laub founded Interplast (now called ReSurge International) with a mission statement to transform lives through the art of plastic and reconstructive surgery. Dr. Laub chronicles his history on his website Many People, Many Passports. Dr. Laub was the first academic to develop and lead multidisciplinary teams on humanitarian surgical trips to developing countries. The teams included plastic surgeons, anesthesiologists, pediatricians, and nurses experienced in the care of cleft palate reconstructions. The first trip to Mexicali was financed with a mere $500 of donations. Through contact with the governments and medical authorities in four countries, initial trips were scheduled to Mexico, Guatemala, Honduras, and Nicaragua. Seven hundred and fifty patients received treatment during the first five years, and an additional 150 were transported to Stanford for reconstructions in California. Through the 1970s and 1980s Interplast made trips to multiple other countries. The teams were made up of volunteers, and the trips were financed by charity donations.
Cleft lip deformity before and after reconstruction
Cleft lip and cleft palate deformities were common in Mexico and Central America, and the chances for surgical repair in the poor areas of these countries were minimal. Individuals with other deformities such as extensive burn scars were also social pariahs because of their appearance. Interplast made it a humanitarian goal to reconstruct these patients as well.
In addition to reconstructing patients, Interplast doctors educated local physicians in modern techniques. This was the medical equivalent of “give a man a fish and he eats for a day, but teach a man to fish and he will eat for a lifetime.” The opportunity to reconstruct patients with deforming diagnoses uncommon in the United States was life-changing for the American doctors as well. In the United States, the specialty of plastic surgery was seen as one concerned with enhancing the cosmetic appearance of cash-paying customers who desired a more youthful or beautiful appearance. In the third world, helping change a deformed child’s appearance was a unique emotional reward for American physicians who traveled there.
The administration of the Stanford University School of Medicine understood the value of the program. Stanford lent financial support to Interplast and financed Interplast rotations as part of the residency training programs in plastic surgery and anesthesiology. In our final year of anesthesia residency, each resident was assigned to a one week Interplast trip to perform anesthetics overseas. The week was not a vacation—we were paid during that week and the expenses of our airfare were covered by Interplast. Trip members typically lodged with members of the local community.
In 1986 I was assigned to San Pedro Sula, Honduras for my Interplast experience. Two weeks before we were to depart, our team assignment was changed to Montego Bay, Jamaica. I asked my faculty member if that was a positive change and he remarked, “You just traded the dusty streets of San Pedro for a Caribbean resort city. What do you think?”
Each Interplast anesthesia team included one faculty member and one or more resident. For my trip the anesthesia staff consisted only of myself and one Stanford attending—thus I received both an introduction to international pediatric anesthesia and one-on-one teaching from an experienced professor.
A striking difference between Interplast anesthesia and American anesthesia was the lack of sophisticated equipment overseas. Interplast members carried no narcotic medications across borders, for obvious political reasons. All postoperative pain was treated with local anesthesia injections from the surgeons (if local anesthetics were available), or by verbal reassurance from the nurses in the Post Anesthesia Recovery Unit (PACU). The PACU was often full of children screaming in pain after their palate surgeries. There are many nerve endings in the human palate, and after cleft palate reconstruction the pain is roughly equivalent to the pain of a tonsillectomy without any narcotic analgesia. It was difficult to listen to the children crying, but in time their pain would subside.
In the 1980s Interplast teams carried halothane, a potent liquid general anesthetic, as well as a halothane vaporizer to convert the drug into an inhaled gas. General anesthetics were initiated by holding a mask over a child’s face while they inhaled halothane vapor until they fell asleep. We started intravenous lines after the induction of anesthesia, but we had very few medications to inject into those IVs. Because there were dozens of cases to be done, the anesthesia attending and the anesthesia resident each did their cases alone and independently, in adjoining operating rooms. The rooms were primitive and usually had piped in oxygen, but lacked nitrous oxide availability.
Complications were rare, but their incidence was not zero. The combination of tiny patients, a paucity of medical drugs, a relatively inexperienced (i.e. not fully trained yet) anesthesia resident working alone, no ICU, no laboratory, and no emergency backup made every case an adventure. We had no complications on our trip, but there were a few anecdotes of cardiac or respiratory arrests from my colleagues who went to other countries.
As a partially-trained resident, I’d anesthetized less than 20 children in my life by the time of my Interplast trip. I was nervous during every anesthetic induction and every anesthetic wakeup. There were no American lawyers or malpractice suits to worry about in Montego Bay, but my job required me to accept responsibility for a child’s life. I’d take a child from his or her parents prior to the surgery and I didn’t want anything but a happy ending for that child, his parents, or me at the end of the day. We performed anesthetics from dawn until dusk. The lines of patients awaiting surgery were long, and each family clamored for the opportunity for their child to receive life-changing free surgeries from the American team.
Dr. Laub set the tone for Interplast. He made 159 trips and personally performed over 1500 operations overseas. He was and is a giving, confident, warm, and intellectual visionary. HIs office was decorated with a 1986 photograph of himself and President Reagan in Washington DC, marking the 1986 Private Sector Initiatives award Dr. Laub received for the creation of Interplast.In 2000 Dr. Laub was diagnosed with an aggressive intravascular central nervous system lymphoma. He survived the malignancy but retired from active clinical practice. I admire him for his surgical skills, entrepreneurial skills and positive attitude. No matter what difficulties arose in one’s life, Dr. Laub was ready to listen, quick to smile, and in closing he’d say, “May the wind always be at your back.”
I’ve continued to anesthetize children throughout my career. Anesthetizing toddlers by yourself is not like riding a bike. Once you learn to do it, the skills must be retained with frequent repetition or else you run the risk of being unsafe. The majority of anesthesiologists cease anesthetizing children soon after residency, and choose not to build on the pediatric anesthesia skills they learned as trainees. I feel fortunate that my practice still includes anesthetizing children every week. In part I owe this to Interplast for introducing me to my early pediatric anesthesia experiences.
A medical career requires years of memorizing facts as well as tireless nights and days attending to sick patients to learn the art and science of healing. Interplast taught more—the doctors and nurses who journeyed to foreign lands to improve the lives of poor children reaped the emotional benefits of being a medical professional. Nothing in our job feels better than helping a sick child become healthier or helping a family gain a new lease on that child’s future.
Interplast has now become Resurge International (REF https://www.resurge.org). To date Resurge has performed 95,000 operations in 15 countries. The times are different, but the issues are still the same. Opportunities with Resurge are described on their website.
We’re lucky in America. Despite criticisms of our medical system and its costs, the availability of outstanding medical care is just a few miles down the road for most of us. Interplast patients were elated to benefit from American medicine abroad.
Once again Rick Novak serves up a virulent novel that addresses an ongoing change in medicine that worries most of us – the growing dependence on robotics in surgery and the dehumanization of medicine: doctor patient interaction is altered by EMR and IT reporting of visits to insurance companies and the warmth of communication suffers. Rick takes this information to create a story about the extremes of AI in the form of a glowing globe that is Dr Vita and the struggle computer scientist/anesthesiologist Dr Lucas assumes as he tries to save medicine from the extremes of the ‘new age’ called FutureCare. As expected, Rick’s recreation of the tension in the OR and in interaction of the physicians is on target: his own experiences enhance the veracity of the story’s atmosphere.
Rick Novak writes so extremely well that likely has answered the plea of his readers to continue this `hobby’. He is becoming one of the next great American physician authors – think William Carlos Williams, Theodore Isaac Rubin, Oliver Wolf Sacks, Richard Selzer, and also the Brits Oliver Wendell Holmes et al. Medicine and writing can and do mix well in hands as gifted as Rick Novak. Highly Recommended. Grady Harp, April 19
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The first chapter of Doctor Vita by Rick Novak opens with a scene unlike any you’ve ever read before.
Chapter 1 THE BRICKLAYER
Alec Lucas’s first contact with FutureCare came in operating room #19 at the University of Silicon Valley Medical Center, where his patient Elizabeth Anderson blinked into the twin suns of the surgical lights hanging from the ceiling. A clear plastic oxygen mask covered Elizabeth’s nose and mouth, her cheeks were pale and tear-stained, and a strand of gray hair protruded from a blue paper bonnet. Her hand trembled as she reached up to remove the mask.
“I’m scared,” she said.
“I’m not,” said Dr. Lucas, who was her anesthesiologist. A green paper mask covered his face, but his pale blue eyes sparkled at her. He hummed to himself as he injected a dose of midazolam into Elizabeth’s IV to relax her.
“Am I crazy to go through this?” she said. “A 78-year-old lady with cancer?”
“We’re hoping your cancer can be cured with surgery,” Alec said. “Right now you’re doing great. Everything is perfect. Have a wonderful dream.” Elizabeth had cancer of the stomach, and presented today for robot-assisted laparoscopic surgery to remove half her stomach. It was a huge surgery—a risky surgery. Alec wondered why they were doing this operation on this lady. He questioned the aggressive strategy for a woman this old, but his job was to anesthetize, not to philosophize.
He’d seen presurgery anxiety like hers hundreds of times. The best way to cure her fears was to get her off to sleep. He injected doses of propofol and rocuronium into her intravenous line. The drugs flowed into Elizabeth’s arm, and within ten seconds her eyes closed. He inserted the lighted blade of a laryngoscope into her mouth, and visualized the white and shining upside-down “V” of her vocal cords, hovering in a sea of pink tissue. He slid a hollow plastic tube between the cords and into the blackness of the trachea beyond. Then he activated the ventilator, which blew a mixture of oxygen and sevoflurane through the tube into her lungs.
“I haven’t worked with you before, Dr. Lucas,” said the circulating nurse, who stood at the patient’s side. “My name is Maggie.”
“Of course you’ve never worked with me,” he said. “I told the nursing supervisor I never wanted to work with Maggie.” Then he winked at her and said, “We haven’t worked together because today is my first day on staff here. I’ve been at the University of Chicago since my first day of medical school. After fifteen years of shoveling snow, it was time to give California a try.”
Alec looked up as the surgeon, Xavier Templeton, entered the room. A tall scrawny man, Templeton had pale hairless matchstick arms that looked better hidden within a surgical gown. His bushy eyebrows met in the midline, and his left eye squeezed in an involuntary tic. Templeton’s hands wouldn’t touch Elizabeth Anderson’s skin or stomach today. His hands would control two levers on a console worthy of a spacecraft, and each move he made would be translated into the movement of a five-armed machine named the Michelangelo III, also known as The Bricklayer.
The five slender mechanical arms of The Bricklayer, dull gunmetal gray in color, dangled like the legs of a giant spider above Elizabeth Anderson’s abdomen. Each arm was draped in clear plastic to keep The Bricklayer sterile when it entered her body through tiny incisions.
Alec accepted his role of goaltender at the Pearly Gates. His assignment was to keep Elizabeth Anderson asleep and alive, while Templeton and The Bricklayer resected her tumor.
Twenty minutes into the surgery, Xavier Templeton sat on a chair in the corner of the room with his back to the operating table, and peered into a binocular stereo viewer. His hands maneuvered two levers on the console before him. On the operating table, the five robot arms reached into the abdomen though five one-centimeter incisions. One of the arms held a camera on a thin metal rod, movable at the surgeon’s control. A seventh-year resident worked as a surgical assistant, and attached appropriate operating instruments to the other 18-inch-long robot arms.
The two surgeons murmured to each other in quiet voices. Alec watched the surgery on a large flat screen video monitor that hung above him. He saw pink tissues, robot fingers moving, and a lot of irrigating and blunt dissection. The surgery was going well, and Alec made only minor adjustments in his drug doses and equipment as needed.
Then one thing changed.
One of the robot fingers on the video screen convulsed in staccato side-to-side slicing movements of its razor-sharp tip. A clear plastic suction tube exiting from the patient’s abdomen lurched and became an artery of bright red blood. The scarlet tube emptied into a bottle two feet in front of Alec. In sixty seconds the three-liter bottle was full of blood. Fifty-eight seconds prior to that, Alec was on his feet and both hands were moving. A flip of a switch sent a stream of fluid through the biggest IV into the patient. He turned off all the anesthesia gases and intravenous anesthetic medications.
“Big time bleeding, Dr. Templeton,” Alec shouted to the surgeon.
As fast as he could infuse fluid into two IVs, Alec could not keep up with the blood loss draining into the suction tube. The blood pressure went from normal to zero, and a cacophony of alarms sounded from the anesthesia monitoring system.
Templeton descended from his perch on the far side of the room, and put on a sterile gown and gloves. He took a scalpel from the scrub tech, and in one long stroke made an incision down the midline of the abdomen from the lower end of the breastbone to the pubic bone. With two additional long swipes, the left and right sides of Elizabeth Anderson parted. A red sea rose between them. The surgical resident and the scrub tech held suction catheters in the abdomen, but the stream of blood bubbled upward past the catheters. Templeton cursed and reached his right hand deep to the posterior surface of the abdominal cavity, feeling for the blood vessel on the left side of the spinal column. He found it, and squeezed the empty and pulseless aorta.
Alec looked at the monitors. The blood pressure was zero, and the electrocardiogram showed the heart was whipping along at a rate of 170 beats per minute. His patient had one foot in the grave. “Have you got control up there?” he screamed at Templeton.
“God damn it! I’m squeezing the aorta between my fingers,” Templeton answered. “As soon as I can see, I’ll put a clamp on the vessel. The bleeding is everywhere. I can’t see a damn thing.” Templeton’s face, mask, hat, and gown were drenched with the blood of Elizabeth Anderson. His unibrow was a red and black dotted line.
“Fire up the Maytag,” Alec said to Maggie. “Call the blood bank and activate the massive transfusion protocol.” Alec bent over the Maytag, a rapid blood infusion device with a bowl the size of a small washing machine. He turned the Maytag to its top flow rate. The machine hummed and spun, and the basin of IV fluid emptied into Elizabeth Anderson through a hose as wide as a small hot dog.
Despite the infusion of fluid, her blood pressure peaked at a dismal 65/40. “Have you found the hole yet?” he said to Templeton.
“Torn aorta. There are multiple holes—the aorta’s leaking like a sprinkler hose,” Templeton said without looking up. His left eye was blinking and squeezing repeatedly as he worked. “It’s terrible. The inferior vena cava is shredded and the blood from the lower half of her body is pouring out into her abdomen. The blood is everywhere.” Blink, squeeze. “Her vessels are falling apart like tissue paper.”
An orderly ran into the operating room carrying a red plastic beer cooler. Alec grabbed the cooler and popped off the top. Inside were six units of packed red blood cells, six units of fresh frozen plasma, and six units of platelets from the blood bank. “Check all the units and let’s get them flowing,” he said to Maggie.
Maggie picked up each bag and double-checked the patient’s name and the unit numbers with a second nurse, and then she handed the entire cooler to Alec. He drained each of the units of blood products into the basin of the Maytag, and the bowl hummed and pumped the blood into Elizabeth Anderson. The blood pressure began to climb, but one look at the crimson suction tubes exiting the patient’s stomach told Alec they were still in trouble. The bleeding wasn’t slowing. Blood was exiting faster than he could pump it in.
“We need a second cooler of blood products stat!” he said. Maggie picked up a telephone and relayed the order to the blood bank.
Alec looked at the surgical field, and the patient’s blood was everywhere—on Templeton’s face, hands, gown, on the surgical drapes and on the floor. It was everywhere but where it needed to be—inside her blood vessels. Templeton’s resident was jamming a suction catheter into the abdomen next to Templeton’s fingers, trying to salvage as much blood as he could.
“Damn it,” Templeton said. “She’s still bleeding, and now she’s bleeding pink piss water. I can see through her blood, it’s so dilute. How much fluid have you given her?”
“Six units of blood, six units of plasma, six units of platelets, and eight liters of saline.”
Alec glanced at the monitors and saw that her blood pressure had plateaued at a near-lethal level of 40/15.
“Her blood isn’t clotting anymore,” Templeton said. “The blood’s oozing and leaking everywhere I place a suture.”
Alec palpated her neck, and there was no pulse. “She has no blood pressure and no pulse,” he said. “We need to start CPR.”
Templeton’s resident placed the palms of his hands on Elizabeth Anderson’s breastbone and began chest compressions. The patient’s heart rate of 180 beats per minute slowed to 40 beats per minute, with premature beats and pauses between them. After twenty seconds of a slow irregular rhythm, her heartbeat tracing faded into the quivering line diagnostic of ventricular fibrillation.
Alec injected 1 milligram of epinephrine, and screamed, “Bring in the defibrillator.”
A second nurse pushed the defibrillator unit up to the operating room table. Templeton charged the paddles, applied them to the patient’s chest, and pushed the buttons. Elizabeth Anderson’s body leapt into the air as the shock of electrical energy depolarized every muscle of her body. All eyes turned to the ECG rhythm, and it was worse than ever.
“Damn it. Give me the scalpel back,” Templeton said. He carved a long incision between the ribs on the left side of Elizabeth Anderson’s chest, and inserted his hand into her thorax.
“I have her heart in my hand and I’m giving her direct cardiac massage,” he said. Alec looked at the monitors, and the direct squeezing of the heart was doing nothing. The blood pressure was still zero, and now blood was oozing from the skin around her IV sites, as well as from the surgical wounds in her abdomen.
Elizabeth Anderson’s heart was empty. Her blood vessels were empty. Her blood pressure had been near-zero for twenty-five minutes.
“What do you think, sir, should we call it?” Templeton’s resident said.
Templeton pulled his hand out of Elizabeth Anderson’s chest, and looked at the clock. “I pronounce her dead, as of 8:48 a.m. Damn, damn, damn it!”
Alec reached over and turned off the ventilator. The mechanical breathing ceased, and there was nothing left to do. He looked down at Elizabeth Anderson’s bloated face. Two strips of clear plastic tape held her eyes fastened shut, and her cheeks were as white as the bed sheet she rested on. A length of pink tape held the breathing tube fixed to her upper lip, and blood oozed from her nose and from the membranes between her teeth. This lady walked into the University of Silicon Valley Medical Center today hoping for a surgical miracle, and instead she was going to the morgue looking like this.
Xavier Templeton peeled his gloves off. “Goddamn it! The fricking robot went berserk. Sliced into the artery like a goddamned hedge trimmer. Now I have to tell the family she’s dead. Goddamn damn it!” He scowled in Alec’s direction. “Are you coming with me, Dr. Lucas?”
Alec nodded a yes. He looked at the gloomy outline of The Bricklayer’s arms, and then back at Templeton. Templeton was a fool to blame the medical device for his own ineptitude. The machine could do no wrong on its own.
This was the surgeon’s fault. Alec had heard it all before. Accept compliments and deflect all blame—it was an adage as old as the profession of surgery.
Templeton commanded The Bricklayer. And The Bricklayer was no better than the human hands that led it.
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Which anesthesia fellowships are most popular? How many anesthesia residents choose further subspecialty fellowship education at the end of their residency, and which subspecialties are those graduates choosing?
The grid below, published in the California Society of Anesthesiologists Vital Times 2018, lists the fellowship choices from the last five years of Stanford anesthesia resident graduates:
The totals from most popular to least popular fellowship choices from this grid are as follows:
Cardiac anesthesia 17
Regional anesthesia 14
Pediatric anesthesia 12
ICU/critical care 10
Pain medicine 8
Obstetric anesthesia 2
Neuro anesthesia 1
Transfusion medicine 1
Palliative care 1
Approximately 28 residents graduate from Stanford each year, for a total of 140 graduates over five years. If 75 out of 140 graduates pursued fellowships, then approximately 53% of residents chose fellowships, while 47% entered the workforce without further fellowship training.
I’m a private practice/community anesthesiologist who also practices in a major university medical center at Stanford, and I have some reflections on this data. The fact that 47% of the graduates do not pursue subspecialty fellowship training doesn’t surprise me. If an anesthesiologist proceeds directly through college, medical school, internship, and then a three-year residency, he or she will be at a minimum 30 years old. Twelve years of post-high school education is enough for many graduates, and the desire to earn a paycheck can trump any desire to complete any more training. A board-eligible anesthesiologist without a fellowship can find a job in most geographical areas without difficulty. In a competitive marketplace such as the San Francisco Bay Area, I believe an anesthesiologist with fellowship training gains an advantage in the search for a plum job over someone who did not complete a fellowship.
Let’s look at the fellowships Stanford graduates chose, and discuss the merits of each subspecialty as of 2019:
Cardiac anesthesia continues to be popular. Stanford has outstanding cardiac surgery and cardiac anesthesia departments. The technology and challenges of cardiac anesthesia tend to draw ambitious residents into this subspecialty. I practiced cardiac anesthesia for 15 years. Those years were notable for very early morning arrival at the hospital (circa 6 a.m.), lots of invasive anesthesia preoperative procedures (arterial lines, central venous pressure catheters, pulmonary artery catheters, and transesophageal echocardiography), long complicated surgeries, sick patients, takebacks for bleeding in the middle of the night, and several surgeons with demanding difficult personalities. The field of cardiac surgery has changed dramatically since the 1980s and 1990s, when one of my surgical colleagues then lamented, “What’s the difference between a cardiac surgeon and a dinosaur?” His answer was, “Nothing.” In the 1980s invasive cardiologists began inventing techniques to apply balloons and stents in the coronary arteries to replace the open-chest coronary artery bypass grafting that cardiac surgeons used to do. Today even valve replacements can be done by cardiologists. Today cardiac surgeries are primarily difficult tertiary cases and revision procedures, i.e. cases that cardiologists cannot fix via intravascular access.
Regional anesthesia is a growing field. Both academic and community anesthesia groups need individuals with expertise in ultrasound-guided regional blocks. Regional anesthesia specialists should have no trouble finding jobs.
Pediatric anesthesia specialists are found in every large anesthesia department. Pediatric hospitals need fellowship-trained graduates on their staff, but for private/community groups, the role of fellowship-trained pediatric anesthesiologists depends on the volume of pediatric surgery. Community groups often expect multiple anesthesiologists to cover routine pediatric cases (e.g. age 1 and over) when they are on call. If only 10% of cases are pediatric and those cases sometimes occur on weekends or at night when an on call anesthesiologist will staff the cases, it’s unlikely the group will hire a specialist pediatric anesthesiologist to be on call every night. For a large group, this may be possible, but for a smaller group, it may not.
ICU/critical care medicine fellowships have always been popular at Stanford. For years the anesthesia department ran the intensive care units at Stanford, and these anesthesia/ICU attendings were outstanding role models. I decided to follow my internal medicine residency at Stanford with an anesthesia residency because I was so impressed with the ICU attendings and their training. The current Stanford anesthesiologist department chairman, Ron Pearl MD PhD, was initially a Stanford internal medicine resident who then completed the Stanford ICU fellowship, and after all that enrolled in and graduated from the Stanford anesthesia residency program. The unique value of an ICU fellowship is that you attend to sick patients of every type, and you become comfortable managing the most demanding medical situations day and night. ICU/critical care graduates are become outstanding clinical anesthesiologists who add value in either an academic or a community setting. Note that in a private/community practice setting, the clinical work in an ICU setting often becomes secondary to operating room anesthesia work, because there have always been superior financial reimbursements for the time anesthesiologists spend in the operating room versus the time they spend in the ICU.
Pain medicine is a vast frontier for anesthesiology. The anesthesia department at Stanford renamed itself the Department of Anesthesiology, Perioperative and Pain Medicine to emphasize the inclusion of pain medicine within our specialty. While the clinical features of operating room anesthesia care have changed very little in recent decades, the possibilities for research and growth in pain medicine are limitless. As an internal medicine doctor, I can tell you that almost everyone hurts in some part of their body, and the treatments for pain, especially for chronic pain, are still in their infancy. Opioid medications work for a while, but patients can become tolerant and addicted to the drugs. More specific pain treatments without the opioid side effects of respiratory depression, addiction, constipation, and nausea are desperately needed. The potential for basic science research in pain medicine is unequaled in any other field of anesthesia. In either community or academic practice, pain doctors staff pain clinics where other physicians can refer their most difficult and unhappy patients. Pain clinic waiting rooms are rarely empty.
Research fellowships are a launching pad to an academic career. Selecting an outstanding mentor is a key factor. If a mentor is known to publish extensively, he or she can teach their fellow how to select important projects, design experiments and studies, write grants, write research papers, and get those papers published. Basic science laboratory research is becoming the domain of investigators with PhDs. Significant clinical research is done primarily by MD anesthesia faculty members at universities. The reputation of a professors is judged by the extent of their publishing and research. Research fellowships are not an important step to a career in private/community clinical medicine.
Obstetric anesthesia is a valid subspecialty in academic centers. In private/community jobs, it’s expected that all anesthesiologists who are on call on weekends and nights can handle both routine and emergency obstetric cases. Completing an OB fellowship isn’t a direct link to landing a graduate an outstanding community job—almost every community anesthesiologist will be expected to have to have OB skills.
Multiple Democratic candidates for President of the United States are advocating Medicare for All. Medicare for All would decimate the specialty of physician anesthesiologists in America. Medicare for All would cause an exodus from the specialty of anesthesiology.
I’m an independent voter—neither a Democrat nor a Republican, and this column is not in opposition to Democratic candidates or in any way supportive to a Republican agenda. My aim is to inform my readers, both anesthesia professionals and laypersons, that if Medicare for All becomes reality, there will be a dire consequence regarding anesthesia staffing and services to patients.
The Medicare pay rate for anesthesiologists is a mere fraction of the current insurance pay rate. Based on the 2018 American Society of Anesthesiologists report, the national average insured conversion factor for anesthesia (the amount paid for a 15-minute time period of service) was $76.32. The current national Medicare conversion factor for anesthesia is $22.18, or only 29% of the 2018 overall mean commercial conversion factor.
Anesthesia practices have varying ratios of insured patients, Medicare patients, Medicaid patients (which pay slightly less than Medicare), and patients with no insurance (who often pay zero). What happens if every anesthesia patient pays only Medicare rates in a Medicare for All future? Let’s look at some examples.
If a practice currently has 75% insured patients and 25% Medicare/Medicaid patients, the income for that practice would be (.75 X $76) + (.25 X $22) = $62.50 per unit. Under Medicare for All, their income would be $22.18 per unit. This is a pay cut of $40.32 per unit, or a decrease in pay to 35% of their prior income.
If a practice currently has 50% insured patients and 50% Medicare/Medicaid patients, the income for that practice would be (.50 X $76) + (.50 X $22) = $49 per unit. Under Medicare for All, their income would be would be $22.18 per unit. This is a pay cut of $26.82 per unit, or a decrease in pay to 45% of their prior income.
If a plumber, an accountant, a truck driver, an attorney, or a fast-food worker was forced to take a pay cut to 35%-45% of their previous income, they would be upset. Would they be looking for another career? Probably.
If a physician anesthesiologist is forced to take a pay cut to 35%-45% of their previous income, they will be upset too. Will they be looking for another career? Probably.
Expect the exodus from physician anesthesiology to look like this:
Older anesthesiologists would simply retire, rather than work for 35%-45% of their prior income.
Medical students who are evaluating different specialties for their lifetime vocation would look at anesthesiology and flee. Even prior to its arrival, it’s possible that the specter of Medicare for All in the near future will drive students away from careers in anesthesiology. Medicare pay rates for anesthesiology are significantly lower than Medicare pay rates for all other specialties. See the graph below, which shows the ratio of commercial pay rates/Medicare rates for various services. For most medical services, the ratio of the average insured payment/Medicare payment is between 1.0 and 2.0. This means that, at the lowest, the average Medicare rates are about 50% of insured rates. You’ll recall that the Medicare anesthesia rate is only 29.1% of insured rates.
The declining number of the oldest and the youngest physician anesthesiologists would radically decrease the census of anesthesiologists in the United States. This likely would lead to an increased role for certified nurse anesthetists (CRNAs), and an eventual increase in the number of schools training CRNAs, but in the short term there would be no way to staff adequate numbers of anesthesia professionals. It’s possible the U.S. may increase immigration of anesthesiologists from other countries where, their pay rate is less than the new Medicare for All pay rate is in America.
Might Medicare for All be forced to quickly increase anesthesiology payment rates to secure an adequate number of physician anesthesiologists? Perhaps, but I wouldn’t bet on it. Medicare has always been a zero-sum system. If anesthesiologists are going to be paid more, then someone else would be paid less, and it would be hard to predict which specialties would be on the end of that further pay cut.
But take a deep breath and relax. Medicare for All will be debated for some time. Even if a liberal Democrat wins the presidency and Congress gains a majority of Democrats in both the Senate and the House, they will all have to overcome multiple powerful lobbies, including the medical insurance industry, hospitals, the pharmacology industry, and organized physician groups. Currently there are so many jobs and so much money involved in the health care systems in American that the battle of Medicare for All will be a true war. Patients would have a significant transition as well. David Brooks wrote in The New York Times on March 4, 2019, “Right now, roughly 181 million Americans receive health insurance through employers. About 70 percent of these people say they are happy with their coverage. Proponents of Medicare for All are saying: We’re going to take away the insurance you have and are happy with, and we’re going to replace it with a new system you haven’t experienced yet because, trust us, we’re the federal government!”
If you’re a layperson, you may think Anesthesiologists are overpaid right now, that’s the true problem with what you’re discussing in this column. Keep in mind that anesthesiologists must complete four years of college, four years of medical school, and at least four years of post-medical school internship and residency training to become board-eligible for work as a physician anesthesiologist. LINK. This means they are at a minimum 30 years old, have borrowed hundreds of thousands in student loans to pay for their training, and have endured significant delayed gratification compared to others they went to college with. Procedural specialties such as surgery and anesthesiology are higher paying than primary care specialties such as internal medicine or pediatrics. Why? The work of procedural physicians requires specialized skills, and their work incurs more risk than interviewing and examining patients in a clinic. I have worked as both an internal medicine doctor and an anesthesiologist, and I can attest that it is almost impossible to harm a patient in an internal medicine clinic, while it is possible to lose a patient to anoxic brain damage in five minutes in an operating room as an anesthesiologist if you err. Risk during an anesthesia career is omnipresent.
As I stated on the home page of my blog, “The profession of medicine offers a lifetime of fascination, and no specialty is more fascinating than anesthesiology.” In addition, freeing patients from pain and ushering them through surgery safely is a wonderful vocation. But if anesthesiology jobs someday pay 35%-45% of their current income, the exodus of anesthesiologists will occur despite the fascination and emotional rewards of the profession.
Life will go on, there will just be less anesthesiologists, which will be OK unless you need one for your upcoming surgery.
Every anesthesia provider must learn to free-solo anesthesia early in his or her career. The 2018 movie Free Solo showcases Alex Honnold as he became the first person to free solo climb the 3000-feet high El Capitan wall of granite in Yosemite National Park without ropes or safety gear. This has been called the greatest feat in rock climbing history, and the movie is nominated for a 2019 Academy Award in the Feature Documentary category.
FREE SOLO movie poster 2018
Believe it or not, but Free Solo could have been an anesthesiologist’s movie. How can that be? “Free-soloing” describes the most anxiety–producing event in every anesthesiologist’s life: the transition from anesthesia training when your faculty member is backing up your every move and every mistake, to the real world of anesthesia when you have to do scary cases alone without assistance.
During the dayshift, working alone is seldom an issue for any anesthesiologist. A typical hospital will have dozens of other anesthesia providers working in the same building. Within seconds or minutes, any anesthesiologist can be assisted or bailed out by a colleague.
Unlike Alex Honnold, the anesthesiologist is not putting their own life at risk—rather it is their patient who is at risk. The degree of risk is variable. For healthy patients undergoing elective surgery the anesthetic risks are minimal, and are similar to the risks of driving on a freeway in an automobile. For emergency surgeries, cardiac surgeries, chest surgeries, brain surgeries, or for anesthetics on patients with significant heart, lung, blood pressure, or airway problems, the risks of anesthesia are higher. The patient is totally dependent on their anesthesiologist to return them to consciousness safely.
Commercial aviation is sometimes compared to anesthesia practice. When commercial pilots take off in airliners, their passengers are totally dependent on the pilot to return them to the ground safely. But in commercial aviation there is one important difference: by law there must be a second pilot in the cockpit.
In anesthesia there is no guaranteed second anesthesiologist. There are multiple different models of anesthesia care. In an anesthesia care team, a physician anesthesiologist supervises up to four operating rooms and each operating room is staffed with a certified registered nurse anesthetist (CRNA). In a university hospital, a faculty member may supervise two operating rooms each with a resident anesthesiologist-in-training in attendance. In many hospital operating rooms, a solitary physician anesthesiologist attends to his or her patient alone. In seventeen “opt-out” states in America a solitary CRNA can attend to a patient without any physician anesthesiologist backup. Working alone may be less safe. A 2019 study from Europe reported an outcome advantage for anesthesiologist working in teams: The study showed that anesthesia given by teams of anesthesiologists and anesthesia nurses was associated with decreased 30-day postoperative mortality and a shorter length of stay when compared with solo anesthesiologists. There was no evidence for the specific cause of the decreased mortality.
Because of manpower necessities, there will never be a law mandating a second anesthesiologist for every surgery as there is in commercial aviation. There will always be emergencies at 2 a.m. or on weekend afternoons when all other anesthesiologists are elsewhere. As well, there are tens of thousands of freestanding surgery centers and office operating rooms where only one anesthesia professional is present.
Is there any data in the medical literature documenting that inexperienced anesthesia professionals have a greater incidence of adverse outcomes? Per Pubmed, there is no such publication. But there is no publication that denies the truth of this correlation. There is a paucity of data on the topic. The issue has not been rigorously studied in a scientific basis.
I review malpractice legal cases, and I can attest that inexperienced anesthesia personnel (who are less than board-certified physician anesthesiologists) are involved in many cases. I believe recent graduates are at particular risk when they work alone. In most cases with severe complications, the anesthesia professional (an MD or a CRNA) was managing the anesthetic alone until it was too late to save the patient.
During physician anesthesia training, a faculty member teaches, supervises, advises, and bails out each resident should there be a mishap. Following their three years of residency, a graduate is free to take a job as an attending anesthesiologist in any hospital system, multi-specialty clinic, or anesthesia group who will hire him or her. This is when the free-soloing begins.
Let me cite some examples of anesthesia free-soloing:
The new graduate is on duty at 2 a.m., and a three-hundred-pound man arrives at the emergency room with the abdominal emergency of a dying, obstructed intestine. The surgeon decides the case is an emergency and cannot wait until morning. The typical anesthetic for this surgery is a rapid-sequence induction of intravenous general anesthesia, followed by the placement of a hollow breathing tube through the mouth into the patient’s windpipe. This sounds easy enough, except when it isn’t. Morbidly obese patients can be very difficult to intubate, and without a properly placed breathing tube these patients can be difficult to keep oxygenated. Five minutes without oxygen causes irreversible brain death. Sound scary? It is.
The new graduate is on duty at 3 p.m. at a community hospital. A two-year-old girl arrives at the emergency room gasping for breath, crowing with each inspiration, febrile, drooling, and barely conscious. Both the emergency room physician and the anesthesiologist quickly make the diagnosis of acute epiglottitis, a rare bacterial infection which causes the epiglottis (the flap which covers the windpipe when you swallow) to become inflamed and swollen. This causes a severe obstruction during each inhaled breath. The patient needs a breathing tube within minutes, before the swollen epiglottis cuts off all passage for air inflow into the lungs. I had this very case during my first year in private practice. I’d read about the proper management, but I’d never seen acute epiglottitis myself. The appropriate treatment is to bring the patient to the operating room urgently, and to staff an experienced head and neck surgeon at the bedside. The anesthesiologist’s job is to induce sleep with an inhaled anesthetic (sevoflurane) via a mask, while carefully supporting the airway and facilitating the passage of oxygen and anesthesia gas in and out of the lungs until the patient falls asleep. Once the patient is asleep, a physician or nurse must place an IV catheter in the patient’s arm, and then the anesthesiologist must insert a lighted scope into the patient’s mouth, locate the swollen epiglottis and the opening to the windpipe below it, and insert a tiny hollow plastic breathing tube into the windpipe. If anything goes wrong and the breathing tube cannot be inserted before the child turns blue, the surgeon must immediately slice into the child’s neck and insert a breathing tube through the skin. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.
The new graduate is on duty alone at a dental office, anesthetizing a 17-year-old male for wisdom teeth removal. After the induction of general anesthesia but before the beginning of surgery, the anesthesiologist administers a requested dose of intravenous antibiotic. Minutes later, the patient’s blood pressure drops from 120/80 to 60/30, the heart rate climbs from 80 to 160 beats per minute, and the normal lung sounds convert to tight wheezes. Hopefully the anesthesiologist will make the correct diagnosis of an anaphylactic allergic reaction—most likely due to the antibiotic. The effective treatment requires perfect management of the patient’s airway, breathing, and circulation. The specific treatment for anaphylaxis requires intravenous injection of epinephrine (adrenaline). A misdiagnosis leading to the omission of epinephrine can be fatal. If the blood pressure remains low and the lungs continue to deteriorate, there will be a lack of oxygen delivery to the brain. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.
What can be done to make free-soloing safer for patients? In my opinion, the best safety ropes are these:
Most hospitals have an emergency room physician on duty at all hours. These MDs are multi-talented and have the acute care skills necessary to assist an anesthesiologist in an emergency. Rather than waiting until a patient has a cardiac arrest or until an airway is lost and the patient’s brain is losing oxygen, an anesthesia professional can consult the ER doctor in advance, e.g. requesting them to assist with a difficult induction of anesthesia on a morbidly obese adult or with a child with a difficult airway.
Even if no experienced anesthesiologist is present in the hospital, there is always an experienced physician anesthesiologist colleague available on the other end of a phone call. Young or inexperienced anesthesia professionals can telephone senior anesthesiologists prior to the anesthetic, whenever a situation arises in which they are doubtful, insecure, or uncomfortable. It’s difficult to admit a lack of confidence, but it’s better to do this than to review a terrible complication with the senior anesthesiologist the next day, like two firefighters gazing over the burned basement remains of a previously preserved house.
Most American anesthesia training programs are now utilizing simulation training facilities to prepare residents for severe acute care scenarios. A simulator lab has a surrogate patient and a full battery of vital sign monitors under the control of a teacher. The teacher can dial in a variety of emergencies and observe the pupil’s response to the emergencies. Feedback is given afterward regarding observed errors and any needed improvements in management. If a young physician anesthesiologist has faced emergencies in the simulator, we believe the anesthesiologist will be better prepared to free-solo following their training.
The Stanford Anesthesiology department authored the Stanford Cognitive Aid Emergency Manual, a booklet of itemized recipes and checklists for all common dire emergencies one might see in an operating room. A PDF of this booklet is available for free of charge download here. Using the Stanford Cognitive Aid Emergency Manual in the operating room will help prevent medical errors, even by inexperienced anesthesia professionals.
Whenever possible, solo anesthesiologists should have already passed the American Board of Anesthesiologists written and oral examinations, and therefore be board-certified. It’s a fact that one can practice anesthesiology in the United States without being board certified, but the ABA oral examination forces graduates to answer difficult questions in the pressure cooker of an oral exam room. Board-certified anesthesiologists will be better prepared for the pressure cooker of an operating room emergency as well.
If you’re a patient, should you worry about your anesthetist free-soloing during your surgery?
Let me reassure you. If you’re having an elective surgery in a hospital in the daytime, there are usually multiple backup anesthesia providers to assist with any problems. But for emergencies in the middle of the night, on weekends, or at freestanding surgical facilities with only one anesthesiologist present, your anesthesia care and outcome will be solely dependent on the skills, training, and experience of the solitary individual who is attending to you.
I’ve stood at the bottom of El Capitan in Yosemite National Park and looked upward at the vertical granite face with awe. I could never climb El Capitan, with or without ropes. I respect what Alex Honnold did at the highest level. He is brave beyond measure and he was willing to put his life on the line. Anesthesiologists, particularly junior anesthesiologists, must free-solo as well. No Hollywood cameras will be rolling, but the adrenaline will be pumping through their veins just as if they themselves were climbing El Capitan.
8-year-old Matadi Sela Petit, who journeyed from the Democratic Republic of Congo to Los Angeles for surgery, died at Cedars-Sinai Hospital on December 16, 2018, from what has been described as “a rare genetic reaction to the anesthesia.” Matadi was born with a cleft lip and a tumor on the left side of his face/cheek that grew into the size depicted in this photograph:
Matadi Sela Petit
The Dikembe Mutombo Foundation, created by retired National Basketball Association star Dikembe Mutombo, sponsored the boy to come from Congo to the United States for the surgery. Matidi’s cleft lip was treated earlier with help from the foundation.
According to The Washington Post, “The Dikembe Mutombo Foundation . . . headed by the former NBA star said that during the delicate surgery on Dec. 16, the boy suffered a rare and unexpected genetic reaction to anesthesia.”
This was a tragic outcome, and my sympathies go out to the patient’s family, to the Foundation, and also to the physicians who treated the boy. Cedars-Sinai is an outstanding medical center—one of the finest in the United States—and has a reputation of having an outstanding medical staff.
What “genetic reaction” could have occurred during the anesthetic? No details have been released in the press, and readers are left to puzzle over what went wrong. As a practicing pediatric anesthesiologist, I’m interested in what happened. I have no access to medical records, nor any inside information on the case, but based on my education and experience my impressions follow below.
Regarding “a rare and unexpected genetic reaction to anesthesia,” the phrase used in the press release to describe the event, I see these possibilities:
Malignant Hyperthermia. Malignant Hyperthermia (MH) is a disease in which a severe reaction occurs during general anesthesia, only among patients who are genetically susceptible. Symptoms include hypermetabolism, muscle rigidity, high fever, acidosis, sudden high blood potassium levels, and a risk of cardiac arrest. MH can only occur in patients who have the genetic predisposition to the disease, and who are then exposed to a potent anesthetic gas (e.g. sevoflurane, desflurane, or isoflurane), or the intravenous muscle relaxant succinylcholine. The treatment for MH involves emergency intravenous injection of the antidote dantrolene, immediate cooling of the patient, and immediate treatment for acidosis and elevated potassium concentration. The treatment for MH is usually effective if the diagnosis is made promptly. The quoted mortality rate for MH is now less than 5%. A potent anesthetic gas such as sevoflurane is commonly used in most pediatric anesthetics, and could have been used in Matidi’s case. Succinylcholine carries a Black Box Warning from the U.S. Food and Drug Administration regarding its use in pediatric patients, and it was unlikely to be used in this Matidi’s anesthetic. Even if Matidi had a previous surgery for his cleft palate, it is not unheard of for a patient to fail to develop MH on their first exposure to potent inhaled anesthetics, and yet develop MH on a later exposure.
An occult muscular dystrophy. A patient who has an undiagnosed genetic muscular dystrophy can develop a sudden cardiac arrest after the administration of the muscle relaxant succinylcholine. Administration of succinylcholine to a patient with an occult muscular dystrophy can cause sudden cardiac arrhythmias, and for this reason succinylcholine carries a Black Box Warning from the U.S. Food and Drug Administration, restricting its use in pediatric patients to emergencies. Because of the Black Box Warning against using succinylcholine in pediatric anesthesia, it is unlikely succinylcholine was used in this patient’s anesthetic.
The mass effect of the tumor in this patient’s face. If one can assume Matidi was born with this tumor, then the existence of this congenital mass lesion next to his airway and breathing passages is a genetic issue. From the photograph of Matidi, the tumor dominated his face. The tumor pushed his mouth to the right, and likely encroached on breathing anatomy. Once general anesthesia is induced, large tumors like this can compress the airway further. Every general anesthetic requires safe management of A-B-C, or Airway-Breathing-Cardiac, in that order. A child such as Matidi with markedly abnormal facial anatomy brings the risk of the loss of control of the airway at any point during the anesthesia or surgery. Loss of airway means there is no clear path for oxygen to traverse from the anesthesia machine through the head and neck to the lungs. Lack of oxygen to the lungs can lead to lack of oxygen to the brain and heart. Five minutes of oxygen depletion to the brain can cause anoxic brain damage. Oxygen depletion to the heart can cause cardiac arrest. Airway problems related to congenital diseases are discussed in the article Specific Genetic Diseases at Risk for Sedation/Anesthesia Complications, in the journal Anesthesia & Analgesia.
After scouring the world’s anesthesia literature and textbooks, I can find no other plausible “genetic reaction to anesthesia” to explain this patient’s death.
This patient’s care will be discussed in peer review and quality assurance committees at the hospital where the event occurred. There is always an autopsy on any unexpected death in an operating room, and more information may come from that. But whenever there is an adverse patient outcome, for medical-legal reasons, do not expect the healthcare professionals to reveal the specifics of what happened to the outside world.
As a practicing physician, I find it to be a fascinating paper, and I recommend you click on the link and read it. The authors begin with a discussion of the art and value of BS detection. They mention that Ernest Hemingway was once asked, “Is there one quality needed to be a good writer, above all others?”
Hemingway replied, “Yes, a built-in, shock-proof, crap detector.”
The authors write, “While flat-out dishonesty for short term financial gains is an obvious answer, a more common explanation is the need to say something positive when there is nothing positive to say. . . . The incentives to generate BS are not likely to diminish—if anything, rising spending and stagnant health outcomes strengthen them—so it is all the more important to have an accurate and fast way to detect and deter BS in health care.”
The authors list their Top 10 Forms of BS in Health Care. The first four forms of BS weave a common theme:
Top-down solutions: High-level executives and top management in the health care industry are supposed to engineer alternative payment models, but nothing has worked to date.
One-size-fits-all, off-the-shelf: Leadership of industry and government assume one solution will work for multiple organizations, without customization.
Silver-bullet prescriptions: A “silver bullet” is described as something that will cure all ills, and must be implemented because it been “decided that it is good for you,” Electronic health records (EHRs) are a prime example of a silver-bullet prescription. The federal government pushed the use of EHRs, claiming the systems would reduce costs and improve quality—but Burns and Pauly argue EHRs “eventually raised costs and only mildly touched a few quality dimensions.”
Follow the guru: We must follow a visionary guru with a mystical revelation about what needs to be done. The authors describe how, in health care, Harvard professor Michael Porter and former CMS (Center of Medicare and Medicaid) administrator Don Berwick launched theories based on population health, and per-capita cost, to little success.
The current U.S. healthcare market is dominated by large corporations, led by businessmen who outline a yellow brick road for physicians to lead patients along. There is minimal effective policy-making from physicians. Healthcare stocks consistently grow in value, with little relationship to an improvement in clinical care, value, or cost. The government is involved as well, as in their mandate for Electronic Health Records (EHRs), a technology change that cost a lot of money, while forging a barrier between clinicians and the patients we are trying to interview, examine, and care for.
Where will the current trends take us? Will businessmen and/or the government prescribe health care? Will more and more computers and machines dominate health care?
Self-driving cars, Siri, Alexa, automated checkouts at Safeway, and IBM’s Watson are technologic realities. Will we someday see a self-driving physician with the voice of Siri and the brains of Watson?
Call that device “Doctor Vita.”
The saga of Doctor Vita arrives in 2019 from All Things That Matter Press.
Is sublingual sufentanil dangerous? The United States Food and Drug Administration (FDA) voted to approve the narcotic sufentanil for sublingual use in November of 2018. Sublingual sufentanil is 5-10 times more potent than fentanyl, and dissolves under the tongue in seconds.
In an era of opioid overdose crisis, we now have a new, even more potent pill form of opiate.
Sublingual sufentanil is approved for use only in medical settings, for the treatment of moderate to severe acute pain. But it is also possible that sublingual sufentanil will become the most dangerous street opiate ever known. This column reviews the arrival of sublingual sufentanil, from the viewpoint of a practicing anesthesiology attending.
Raeford Brown, Jr., MD, chair of the Anesthetic and Analgesic Drug Products Advisory Committee, and professor of anesthesiology and pediatrics at the University of Kentucky, disagreed with the FDA approval for sublingual sufentanil, citing the drug’s risk for “diversion, abuse, and death.” He cited the possible harms of such a “dangerous” drug — estimated to be 500-600 times more potent than morphine — coming to market in a tablet form. He warned of the risks of diversion of sufentanil by anesthesiologists and other medical personnel. He was quoted, “Sufentanil is a very potent opioid that is in a preparation that will be easily divertible. In the IV formulation, it has been a drug of abuse for health care providers.”
I agree with Dr. Brown. Sublingual sufentanil raises dangerous concerns. Sublingual sufentanil has the potential become the hydrogen bomb of all opiates—the mother of all lethal street drugs.
I have extensive experience administering intravenous sufentanil to patients. Intravenous sufentanil was FDA-approved in 1984. Its original primary use was as an anesthetic for cardiac surgery. I practiced cardiac anesthesia from 1985 until 2000. In the 1980s, cardiac anesthesia was achieved by high dose narcotic techniques, specifically with high dose fentanyl (100 micrograms/kg) techniques. For a 70-kilogram patient, this required injecting 7000 micrograms of fentanyl, or 140 ml of fentanyl (nearly two and an half sixty-milliliter syringes full of fentanyl) at the time of anesthetic induction. When intravenous sufentanil was approved at the same 50 mcg/ml concentration as fentanyl, but with a potency of 10 X of fentanyl, the narcotic induction only required 14 ml of sufentanil total. I can still remember my wide-eyed professors saying, “With sufentanil, the entire cardiac anesthetic is here in one syringe.” The use of sufentanil for cardiac anesthesia faded as anesthesiologists began using lower doses of narcotic as part of early-extubation techniques in the late 1990s.
We also used intravenous sufentanil to supplement anesthesia for non-cardiac surgeries. The most common method was to dilute the sufentanil 10:1 with saline, to a concentration of 5 mcg/ml. At this concentration, sufentanil was indistinguishable from fentanyl at 50 mcg/ml. After several years it became apparent that there was no advantage of using sufentanil IV over fentanyl IV in non-cardiac anesthesia, and the administration of IV sufentanil dwindled. The intravenous sufentanil form of the drug was also approved for epidural anesthesia. Over time, the use of sufentanil for epidural anesthesia also decreased, also supplanted by fentanyl.
Just when it looked like sufentanil was a drug nobody really neededà enter AcelRx Pharmaceuticals, a San Francisco Bay Area company which manufactured and tested a sublingual sufentanil product designed to melt under a patient’s tongue. Pamela Palmer, the founder and Chief Medical Officer of AcelRx, received her MD and PhD at Stanford, and is an acquaintance of mine. Dr. Palmer is an anesthesiologist who is brilliant and well informed regarding the pharmacology of sufentanil and the use of sufentanil in anesthetic practice.
Because sufentanil is highly lipid (fat) soluble, it is quickly absorbed into the bloodstream through the mucosal lining of the mouth. AcelRx will market the drug under the name Dsuvia, in a sublingual sufentanil tablet system (SSTS) which consists of a single-dose applicator prefilled with a single 3-mm-diameter 30-mcg tablet, administered by a healthcare professional no more frequently than hourly.
A radio frequency identification (RFID) cartridge, requiring the patient’s thumbprint, helps reduce unauthorized dosing. The device is tethered to the patient’s bed to reduce risk of product loss. Each tablet is pre-loaded into a single-dose applicator within a pouch so it is suitable for field/trauma use. Both the fixed drug and dose and lockout time interval eliminate the end-user programming error risk associated with Patient Controlled Analgesia (PCA) intravenous narcotic pumps.
Dsuvia will be marketed as “postoperative, sublingual, patient controlled analgesia.” Once administered under the tongue, the sufentanil tablets typically dissolve within 5 minutes. The FDA approved the drug to be used in hospital settings only, for the treatment of moderate-to-severe acute pain, where a narcotic is needed and rapid onset is desired, but the route of administration does not require intravenous access. Typical settings would be the surgical wards after major orthopedic or general surgery procedures. The chief competition for Dsuvia will likely be Patient Controlled Analgesia (PCA) intravenous narcotic pumps, a commonly used analgesic method in which patients push a bedside button and self-administer intravenous narcotic (e.g. morphine, fentanyl, or Dilaudid) on demand through their IV line.
The most significant risk involving sublingual sufentanil is its potency, specifically its extreme potency as a respiratory depressant. The product description by AcelRx states that sufentanil has a “high therapeutic index” of 26,716. The Therapeutic Index is the ratio that compares the blood concentration at which a drug becomes toxic and the concentration at which the drug is effective. The larger the therapeutic index (TI), the safer the drug is. The TI affirms that sufentanil toxicity starts at a concentration of 26716 times its therapeutic concentration, but this ignores the risk of respiratory depression at much, much lower doses. A patient treated with an overdose of sufentanil will stop breathing at a dose only slightly greater, i.e. in the ballpark of only 2 – 4 times greater, than its therapeutic concentration. Like all opiates, sufentanil has side effects of respiratory depression, sedation, nausea and constipation. Respiratory depression is the reason why opiate overdose patients die. Opiate overdoses do not cause death because of an inherent “toxicity” of the drug concentration in the blood, but rather because of respiratory depression. People simply stop breathing.
Regarding sufentanil, the National Institute of Health website states: WARNINGS: Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Sufentanil Citrate injection should be administered only by persons specifically trained in the use of anesthetic drugs and the management of the respiratory effects of potent opioids, including respiration and cardiac resuscitation of patients in the age group being treated. Such training must include the establishment and maintenance of a patent airway and assisted ventilation. Adequate facilities should be available for postoperative monitoring and ventilation of patients administered anesthetic doses of Sufentanil Citrate Injection. It is essential that these facilities be fully equipped to handle all degrees of respiratory depression. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status.
There is also hope that sublingual sufentanil will have battlefield applications. A statement from FDA Commissioner Scott Gottlieg, MD on November 2, 2018 read: “(Sublingual sufentanil) has some unique features in that the drug is delivered in a stable form that makes it ideally suited for certain special circumstances where patients may not be able to swallow oral medication, and where access to intravenous pain relief is not possible. This includes potential uses on the battlefield. For this reason, the Department of Defense (DoD) worked closely with the sponsor on the development of this new medicine. This opioid formulation, along with Dsuvia’s unique delivery device, was a priority medical product for the Pentagon because it fills a specific and important, but limited, unmet medical need in treating our nation’s soldiers on the battlefield. The involvement and needs of the DoD in treating soldiers on the battlefield were discussed by the advisory committee . . . The FDA has made it a high priority to make sure our soldiers have access to treatments that meet the unique needs of the battlefield, including when intravenous administration is not possible for the treatment of acute pain related to battlefield wounds.”
In conclusion, will sublingual sufentanil be dangerous or not?
My assessment of sublingual sufentanil, based on the information above, is as follows:
Sublingual sufentanil (SS) can be useful in hospitalized post-operative patients following major, painful surgeries such as orthopedic total joint replacements or intra-abdominal surgeries. SS could replace PCA intravenous morphine or fentanyl.
The market share, or prevalence of SS use will largely depend on its cost versus intravenous PCA units. AcelRx will market the drug beginning in early 2019, at a wholesale price of $50 to $60 per dose. https://www.washingtonpost.com/national/health-science/fda-approves-a-powerful-new-opioid/2018/11/02/88cd27e6-deaf-11e8-85df-7a6b4d25cfbb_story.html?utm_term=.f4efacea46ad
SS will not be frequently used in Post Anesthesia Care Units, Intensive Care Units, or the Emergency Department, because patients in these settings all have intravenous lines in place, and can receive traditional IV narcotics as needed. There is no need or demand for a sublingual narcotic product in these settings.
If SS tablets are diverted or stolen and are taken outside of medical settings, they can cause death. Overdoses as low as two to four times a therapeutic dose could cause respiratory depression and death. If hospital personnel divert the drug for recreational use, these personnel will be at high risk for mortality.
If SS ever reaches the streets as a recreational drug or heroin substitute, users will achieve opiate overdose and death at a very high rate. If anyone naively believes the drug will not reach the streets, consider that manufactured forms of all the other pill forms of opiates, i.e. Percocet, Vicodin, and Oxycodone, eventually reached the streets. What will prevent this new drug from doing the same?
Efforts to educate street users regarding the dangers of this new drug will likely fail. There can be no safe use of SS outside a medical setting. People will likely overdose and die.
Regarding battlefield use: In military settings where IVs are not common, the capacity to administer potent sublingual narcotic may become standard. But misuse and abuse in the military and on the battlefield are also possible. Tales of rampant drug abuse by soldiers in the Vietnam War are part of the lore of that conflict. Access to sublingual sufentanil in the military would need to be strictly confined and monitored.
An added note: An intentional overdose with SS is probably an outstanding drug for physician-aided suicide.
I have no crystal ball, but the bottom line is this:
If sublingual sufentanil use is confined to acute care hospital settings, it will be useful and not dangerous. But if sublingual sufentanil reaches the streets as a drug of abuse, it will be lethal.