#NewYork budget excluded provision that would have undermined physician-led anesthesia care, opposed by @ASALifeline & @NYSSApga. #THANKYOU to New York lawmakers for protecting patient safety. #SafeAnesthesia4NY https://t.co/3M5wQm0TK8
I was shocked to see that the NHS could ban surgery for the obese and smokers. That’s socialized medicine. You take a conglomerate group of people (the UK) on a limited budget for healthcare… and basically find the cheapest most cost-effective way to deliver healthcare. But in a way, it’s empowering patients to take responsibility for their own health. Smoking, for sure — I agree 100% that surgery should be banned for this population. Obesity is a bit trickier — there’s genetics and environmental factors at play in this one. I don’t think anyone chooses to be obese. But, people do have the power to change their eating and exercise habits. Despite these efforts, there are some people who are still obese…. and these people should not be faulted.
Why single out the obese and smokers?
Smokers and the obese have elevated surgical risk and mortality, which means more cost to treat and hospitalize and provide ongoing care.
I think the NHS is on to something here. They’re opening doors to moving the liability and responsibility away from physicians and towards patients. This is a plus. Outsiders may see it as separatism and elitist to only provide care for people who are healthy. But look at the facts and the data…. obesity has a lot of co-morbidities associated. Smoking has a lot of co-morbidities associated as well. Why should physicians be penalized for re-admissions, poor wound healing, longer hospitalizations when the underlying conditions themselves are already challenging enough? In fact, I would urge insurance companies to provide incentives to patients/the insured with discounted rates for good and maintained health and wellness. With all the technologies, medications, and information out there, it’s time patients take responsibility for their own health. I take responsibility for mine — watching my diet, exercising, working on getting enough rest, maintaining activities to keep my mind and body engaged, meditating for rest and relaxation. It’s not easy, but my health is 100% my responsibility. I refuse to pass the buck to my husband, my family, my physician, etc. I do what I can to optimize my health and future — and if that doesn’t work… I call for backup.
Patients need to change their mindset re: health. It is not your spouse’s responsibility to track your meds. It is your responsibility to know your medical conditions and surgical history. The single most important (and thoughtful) thing a patient can do is keep an up-to-date list of medications, past/current medical history, surgical history, and allergies to bring to every doctor’s appointment and surgery. This helps streamline and bring to the forefront your conditions and how these will interplay with your medical and surgical plan and postoperative care. Please do not forget recreational drugs, smoking habit, and drinking habit in this list. It is very important to know all of these things. Also, your emotional history is very important. Depression, anxiety, failure to cope, etc. This all helps tie in your current living situation with stressors and your medical history.
Links for educating yourself in taking responsibility for your health:
It seems like in today’s day and age, emergencies are occurring everywhere. From hurricanes to shooters to earthquakes and fires… I think it’s always important to know what to do. Here are some fabulous checklists I’ve found for getting through those emergencies. These are not substitutions for knowledge and training. Clinical judgement warranted.
A couple of weeks ago, I took care of a patient who desperately needed to get better from acute CHF. At that time, we placed the patient on an impella… but the next day, it was deemed that he needed ECMO to reperfuse his organs. After a week on ECMO with continued impella support, ECMO was titrated down and off while maintaining 3.9L/min flow from the impella. During the wean off ECMO, the patient had been extubated and was mentating clearly and interacting appropriately.
Fast forward a couple days after getting extubated, the patient was ripe for an LVAD. But which one? (We ended up placing the patient on HeartWare LVAD).
ENDURANCE trial: Randomized patients eligible for DT 2:1 to the HeartWare centrifugal flow LVAD versus the HeartMate II axial flow LVAD. The trial did reach its primary noninferiority endpoint of stroke free survival at 2 years (55.0% in the HeartWare patients versus 57.4% in the HeartMate II patients). Of note, a change in the design of the HeartWare device during the trial (sintering of the inflow cannula) appeared to decrease the incidence of pump thrombosis. Overall, the stroke rate was higher in the HeartWare arm whereas device malfunctions requiring exchange or urgent transplantation were more common in the HeartMate II arm. Data analysis suggested that better blood pressure control in the HeartWare arm may decrease the stroke rate and a second cohort of patients is being enrolled with more attention being paid to blood pressures management.
ROADMAP study: (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Heart Failure Patients) was an observational study of the Thoratec HeartMate II LVAD compared to optimal medical management in patients with advanced heart failure. Thirty day mortality was the same in both groups (1%) while one year survival was 80% in the LVAD group compared to 64% in the medical group (on an as treated basis). Functional status and quality of life improved significantly more in the LVAD group (analyzed by 6 minute walk, health related quality of life, and NYHA class). Unfortunately, adverse events in the LVAD group remained similar to what was previously reported in the DT trial, with bleeding being the most frequent adverse event.
“There’s an emergent case coming for impella placement.”
Impella? I’ve read about these devices and I’m familiar with managing patients on LVADs as well as providing anesthesia for LVAD placement. But, I’ve never done an Impella on a critically unstable patient.
They say that anesthesiology is 95% comfy and relaxed and the other 5% is “oh shit”! It’s a great career choice — pretty flexible hours, great patient contact, broad spectrum medicine, crisis management, leadership role, etc.
There happened to be an interesting case in the OR — awake tracheostomy for a patient coming in from home.
Our patient had two prior tracheotomies all with successful decannulation. His most recent trach was about 2.5 months ago (which a fiberoptic intubation was used with a 6.0 ETT). He had a neck cancer with a rapidly growing tongue base tumor that seems to be less responsive to chemo than his shrinking neck tumor. Because of the enlarging size of the tongue base tumor, he is starting to notice worsening stridor without his trach. The ENT surgeon evaluated his airway just days before and deemed it unintubateable. Therefore, my plan was to have a pedi FO scope with 5.0 cuffed ETT (smallest available in our OR), glidescope, emergency cric supplies (14g angio cath, 3cc syringe with plunger removed and 7.0 ETT adapter hooked into the end of the syringe), jet ventilator and tubes, and ENT surgeon.
Monitors were placed in the OR and we used a face mask running 10 L/min O2 with ETCO2 monitoring. Every now and then he would obstruct while lying supine, therefore, we placed a nasal trumpet to aid the obstruction. The surgeon localized the surgical area. See video for procedure.
The patient coughed once the trachea was perforated, but it was short lived as the surgeons were able to place the trach and hookup to our anesthesia circuit. After confirming ETCO2, we pushed propofol IV and the remainder of the case was performed under general anesthesia (direct laryngoscopy and biopsy by surgeon).
Key take home points
Effective communication with the patient pre-op: expectations, sedation, potential complications.
Arm yourself! Do this like you would a difficult airway! Fiberoptic intubation supplies, glidescope, emergency cricothyroidotomy supplies, backup LMA, extra hands on deck (grab your anesthesia colleagues, anesthesia techs, extra help!), ENT… it never hurts to be over prepared!
Deliberate, effective communication with the ENT colleague across the drape.
Document any intubation performed, tools used, trachs placed so your anesthesia colleagues will know what worked in the past to secure an airway.
Breathe a sigh of relief bc these kind of cases are extremely uncommon! Pat yourself on the back for a job well-done!