A Day in the Life of an Anesthesiologist
Check out @ASAGrassroots’s Tweet: https://twitter.com/ASAGrassroots/status/981951115062337536?s=09
#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.
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.
Responsibility for health: personal, social, and environmental
Trends are evolving in decreasing intraoperative and postoperative opioid use. Therefore, anesthesiologists are constantly learning new regional techniques to help with postoperative pain. For shoulder surgeries, I’ve moved away from interscalene blocks toward supraclavicular blocks. I think the interscalene block provides a better block of a total shoulder surgery, however, certain patient comorbidities often make the supraclavicular block a better choice.
Nice paper from Anesthesiology, Dec 2017: Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology 12 2017, Vol.127, 998-1013.
Nowadays, it seems that suprascapular blocks are gaining in popularity (I’d probably use it to supplement the supraclavicular block.
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.
Emergency Manual from Stanford — Printable PDF
Ariadne Labs OR Crisis Checklist
Ariadne Labs Safe Surgery Checklist Template
Ariadne Labs Ambulatory Safe Surgery Checklist Template
Newton-Wellesley’s L&D Checklists
Checklist for Trauma Anesthesia
ASRA checklist for Local Anesthetic Systemic Toxicity
Johns Hopkins Central Line Checklist
STS Adult Cardiac Surgery Checklist
Ariadne Labs Cardiac Surgery Checklist
STS General Thoracic Surgery Checklist
STS Congenital Heart Surgery Checklist
University of Kansas Daily ICU Quality Checklist
Transthoracic echo: a beginner’s guide #tte #cardiac #echo #meded
Knowing how to do a quick focused echo exam can be instrumental in diagnosis as well as treatment. This has helped me determine how severe cardiac tamponade has been in an emergent case prior to induction when there was no prior echo. There are so many more useful answers that a bedside echo can provide. Time to get acquainted.
Helpful links:
Helpful articles:
It seems to me that the CRNA-led debate is financial… once you tease through all the fluff.
So here’s some literature I found:
As an anesthesiologist, I work in an MD-only anesthesia group. This is by choice: I prefer doing my own cases and being responsible for my own liabilities. The times I have required an anesthetic, I have requested a physician anesthesiologist. As a resident, I had very good insurance coverage, so I wanted a physician for my surgery. At that time, I was ok with having a resident anesthesiologist paired with an attending anesthesiologist for my case. My second surgery was done at my current hospital, and we only have MD anesthesiologists. Perhaps I’m biased? I know and I understand the path/journey/training it takes to get to become a physician anesthesiologist. I want someone who is well-trained, independently thinks, vigilant, and knowledgeable.
I’m sure there are great CRNAs out there… but when I was a resident… we used to supervise CRNAs in our final training year…. and it was scary some of things they would do. Who extubates from a trach R&R on 30% FiO2? Yeah, that particular CRNA told me they had 30 years experience. 30 years experience of doing something wrong doesn’t equate to 30 years of knowledgeable experience. And let’s not forget that CRNAs need a 15 minute morning break, 30 minute lunch break, and 15 minute afternoon break and they go home when their “shift” ends (even if it’s in the middle of a complex case). I take a break when I can… I eat lunch and take a bathroom break when I can…. and I choose to stay and finish complex cases for better continuity of care.
Would you want a nurse practitioner or physician assistant solely performing your surgery without a surgeon? I know I would NOT. I think there’s plenty of room for teamwork in healthcare. This is how to improve hospital efficiency and patient care. My fear is if CRNAs gain independence for purely financial reasons. But then, they will have to carry their own liability, cover their own breaks, take night call and discover that they had it so good in a healthcare team.
Opinions from other physician anesthesiologists:
Bottom line in my opinion:
Enhanced recovery after surgery #ERAS #anesthesia #pain #recovery
Summary of Enhanced Recovery after Surgery Guideline Recommendations. Canada.
Regional Anesthesia for surgery and other comparative studies. Sweden.
ERAS: Role of Anesthesiologist. UTSW.
Stanford Anesthesia ERAS pathway website
The Role of Regional Anesthesia in ERAS pathways. Sept 2015. UCSF.
Anesthesia Practice and ERAS. Cooper University Hospital. 2017.
ERAS: Anesthesia Tutorial of the Week. Number 204. Nov 2010.
ERAS and Anesthesia. Anesthesia Business Consultants. May 2015.
I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.
