The Independence debate in Anesthesia

The independence debate in anesthesia. #anesthesiologist #physician @nmsahq @asahq Physician-led anesthesia care team provides patient safety, which is the #1 priority in patient care. #va #patientsafety #healthcare

The physician vs. crna debate has reared its ugly head…. yet again.  There have been multiple bills presented to suggest crna independence WITHOUT physician anesthesiologist oversight.  In 2017, proposals were made to the Veteran’s Affairs to replace physicians with crnas.  Here’s what they found when they looked at the VA databases to conclude that nurses will continue with physician oversight in anesthesia:

Current laws in 45 states and the District of Columbia all require physician involvement for anesthesia care and the VA in 2017 decided to maintain its physician-led, team-based model of care. The VA’s Quality Enhancement Research Initiative (QUERI) could not discern “whether more complex surgeries can be safely managed by CRNAs, particularly in small or isolated VA hospitals where preoperative and postoperative health system factors may be less than optimal.”

Here’s my evidence and reasons why I believe the care of the patient is best when it is physician-led.  After all, would you want a nurse or assistant doing your actual surgery?  The ultimate goal is patient safety.

Physician anesthesiologists have up to 14 years of post-graduate medical education and residency training, which includes 12,000-16,000 hours of clinical training, nearly seven times more training than nurse anesthetists.

From 2010:

From 2011:

From 2017:

 

Yet, here’s another debate that shows there’s no difference in an anesthesia care team setting with an anesthesia assistant and a crna:

Bottom line in my opinion:

  • Physicians endure years of grueling medical education that starts with the why, how, and treatment of disease. This is followed with years of residency training in anesthesia. There’s also further training in the form of a fellowship for specialized fields.
  • Getting into medical school is an extremely competitive process. You take the top 1% of college graduates and high MCAT scores to get into medical school.  The board certification for becoming certified in anesthesiology is quite complex and difficult in both the written and oral board exams.
  • I will continue to be FOR team-based physician-led anesthesia care.
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What it’s like to be a female anesthesiologist…

To promote the series #asawoman started by @nataliecrawfordmd (from Instagram)
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Throughout medical school, residency, fellowship, even now in private practice… patients have often judged a book by its cover. They’ve thought I was their nurse, volunteer, high school student or college student shadowing, almost everything but the person who will lead their anesthetic care. While this can seem deflating given all the extra work and studies one puts in to become a physician, I’ve changed my mindset re: my patients’ initial thoughts on me.
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First of all, thank goodness they think I’m super young! I have my mom’s genes and beautiful skin to thank!! At this rate, I hope I start to look 30 when I hit 50. When patients ask my age, I happily oblige them with a bold 39. Then I see a look of relief over their faces. I, of course, ask them how old they think I am….and I get the range of: just graduated college to mid-20s. Awesome!! I use it as a bonding moment and icebreaker with my patients. Sometimes with the right patient, I joke with them that it’s my first day… it usually entertains a good laugh. Then, I go into an overly technical schpeel on risks/benefits of anesthesia, expectations, PACU recovery. This typically solidifies to the patient that it’s not my first day on the job. Additionally, many patients tell me in the PACU that they feel better than their prior experience or better than their expectation and are quite grateful for my care.
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There are a lot of men in my anesthesia group. Sometimes, after I introduce myself to the patient, they’re shocked that a woman anesthesiologist would be delivering their care. In this day and age, I’m shocked that a lot of patients still assume that a male physician will oversee their care. When caring for female patients with this mentality, I purposefully address a gentle and vigilant anesthetic plan. With my male patients with this mentality, often times they’re happy to talk about the “happy juice” cocktail they’ll get and some much deserved relaxation knowing that I will carry a watchful eye over their surgery and anesthetic.
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Lastly, since becoming pregnant with my first and currently pregnant with my second… I feel I have a better understanding of the worried/concerned parents who are at the bedside to be with their child about to enter surgery.  Oftentimes, the parents think I’m young and want to know where I trained and when I graduated.  I offer them this info, and continue speaking to the patient (their child) about their concerns or questions.  I make sure the parents know everything that will go on re: anesthetic plan, how the patient will feel in recovery and risks/benefits of anesthesia options.  I TAKE MY TIME with the parents and the patient.  While my age and gender often work against me (even though it shouldn’t!), I make sure the controllable worries by the parents are addressed.  I speak to the parents after the surgery.  They go into the recovery room and see their child (older than 13 at our hospital) comfortable and recovering.  While I can’t change my appearance (nor would I want to…), I can change perceptions of women physicians.  We are every bit as capable of everything our male colleagues can do.  In addition, we tackle pregnancy, motherhood, businesses, and everything in between.  #asawoman As A Woman, I feel more empowered now than ever before.

Women in Anesthesiology

American Medical Women’s Association

American College of Physicians: Women in Medicine

Bias, Bravery, and Burnout: The Journey of Women in Medicine

IABP

There’s always a good reason to review the physiology and reasons for placement of an Intra Aortic Balloon Pump (IABP).  We come across these a couple of times a month in our cardiac patients.  They’re a great temporary measure to stabilizing and treating the patient.

Contemporary Clinical Niche for Intra-Aortic Balloon Counterpulsation in Perioperative Cardiovascular Practice: An Evidence-Based Review for the Cardiovascular Anesthesiologist. JCVA, February 2017. Volume 31, Issue 1, Pages 309–320.

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From JCVA, Feb 2017.

One of the best explanations that I have ever seen for the IABP is from Dr. Rishi Kumar.  He’s a board certified anesthesiologist and is ICU fellowship trained and is pursuing a cardiac anesthesia fellowship as well.  This lovely human is no joke.  I’ve read his blog and his instagram posts, and he’s a wonderful teacher and mentor to those he reaches.  Please click his link for an entry regarding IABPs on his blog.

RKMD.com: Intra-Aortic Balloon Pump, Arterial Line, and EKG Waveforms. April 2018.

iabp-inflate-deflate-600x570

iabp-ekg-arterial-line-waveforms-aligned-600x559

 

TEE for placement of IABP

Anesthesia & Analgesia, July 2011. Vol 113, No. 1.

  • Want the tip 1-2 cm from left subclavian artery (LSCA)
  • X-plane aortic arch down to descending aorta to see the left subclavian artery
  • Visible during systole when the IABP balloon is deflated

Good visualization of the LSCA

A Novel Technique for Intra-aortic Balloon Positioning in the Intensive Care Unit.  J Extra Corpor Technol. 2012 Sep; 44(3): 160–162.

 

Cardiac Arrest in the OR

Cardiac Arrest in the Operating Room:  Resuscitation and Management for the Anesthesiologist Part 1

Moitra, Vivek K.; Einav, Sharon; Thies, Karl-Christian; Nunnally, Mark E.; Gabrielli, Andrea; Maccioli, Gerald A.; Weinberg, Guy; Banerjee, Arna; Ruetzler, Kurt; Dobson, Gregory; McEvoy, Matthew D.; O’Connor, Michael F.

Anesthesia & Analgesia126(3):876-888, March 2018.


Cardiac anesthesiologists and LVAD patients: Pro vs Cons

There’s been a big debate re: who should care for LVAD patients… a general anesthesiologist or a cardiac anesthesiologist?  See below for pros and cons of each.  Ultimately, I think all anesthesiologists should be comfortable caring for these patients as we’ll see more and more LVAD patients undergoing procedures.

Troubleshooting the Left Ventricular Assist Device.  Emergency Medicine. 2016 February;48(2):58-63.

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From Emergency Medicine, Feb 2016.
LVAD Parameter Abnormalities:
  • High power, low-pulsatility index and fluctuating pump speed: Consider pump thrombosis or hypotension, vasodilation, initial response to exercise.
  • High power with high pulsatility index: Consider fluid overload, normal physiological response to increased demand; myocardial recovery.
  • Low power, low pulsatility index, and unchanging speed: Consider hypertension or inflow/outflow obstruction, LV failure, dysrhythmia.
  • Low power with normal or high pulsatility index: Consider suction event.

Pro: Cardiothoracic Anesthesiologists Should Provide Anesthetic Care for Patients With Ventricular Assist Devices Undergoing Noncardiac Surgery. JCVA, February 2017. Volume 31, Issue 1, Pages 378–381

Con: Cardiothoracic Anesthesiologists Are Not Necessary for the Management of Patients With Ventricular Assist Devices Undergoing Noncardiac Surgery. JCVA, February 2017. Volume 31, Issue 1, Pages 382–387.


VAD-2
From LifeInTheFastLane.com

Ventricular assist devices and non-cardiac surgery.  BMC Anesthesiology201515:185

  • Goals of care for LVAD patients undergoing non-cardiac surgery should be directed at maintaining forward flow and adequate perfusion. Three main factors that affect LVAD flow are preload, RV function, and afterload.
  • The right ventricle is the primary means of LVAD filling; therefore, maintaining RV function is imperative.
  • Marked increases in systemic vascular resistance should be avoided.
  • Generally, decreases in pump flow should first be treated with a fluid challenge. Hypovolemia should be avoided and intraoperative losses should be replaced aggressively. Second line treatment should include inotropic support for the right ventricle.
  • Low-dose vasopressin (<2.4 U/h) may be the vasopressor of choice due to its minimal effect on pulmonary vascular resistance.
  • Standard Advanced Cardiovascular Life Support Guidelines should be followed; however, external chest compressions should be avoided during cardiac arrest.
  • Steep Trendelenburg may increase venous return, risking RV strain. Peritoneal insufflation for laparoscopic surgery also increases afterload and has detrimental effects on preload.  Insufflation should utilize minimum pressures and be increased in a gradual, step-wise fashion.
  • TEE can be extremely valuable in diagnosing the cause of obstruction.

Perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery. Annals of cardiac anaesthesia 2016. Vol 19, Issue 4: 676-686.

LVAD: What Should I report? Feb 2017 ASE conference. **ECHO**

  • Higher the RPMs (pump speed)
    • More LV compression, smaller LV size
    • Less functional MR
    • More AI, less AV opening
    • Less LVED diameter
  • De Novo Aortic Regurgitation Post LVAD
    • Proposed mechanisms
      • Aortic valve remains closed during systole
      • Commissural fusion of the aortic valve from disuse
      • Subsequent degeneration of valve
      • Turbulent blood backflow from small outflow cannula onto a closed valve
      • Persistent elevation of aortic root pressure –> aortic root dilation and valve incompetence
    • Treatment
      • Lower LVAD speed (but that may worsen mitral regurgitation)
      • Aortic valve surgery or percutaneous intervention
      • Heart transplant
  • RV Fractional Area Change (RV FAC)
    • RVFAC is a rough measure of RV systolic function (4 chamber view)
    • RVFAC = (RVEDA – RVESA) / RVEDA
    • Normal RVFAC = 35 – 63%

Ventricular Assist Device (VAD). LifeInTheFastLane.com. .

Care of the LVAD patient PPT. Summit 2014.

  • Pulsatility Index:
    • —normally decrease as pump speed is increased

LVAD: Understanding equipment and Alarms. Duke Heart Center PPT.

LVAD Management in the ICU. Crit Care Med 2014; 42:158–168. 

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From Left Ventricular Assist Device Management in the ICU Pratt, Alexandra K. MD1; Shah, Nimesh S. MD1; Boyce, Steven W. MD2 Critical Care Medicine: January 2014 – Volume 42 – Issue 1 – p 158–168 doi: 10.1097/01.ccm.0000435675.91305.76 Concise Definitive Review
Screen Shot 2018-11-26 at 11.20.47 AM
Left Ventricular Assist Device Management in the ICU Pratt, Alexandra K. MD1; Shah, Nimesh S. MD1; Boyce, Steven W. MD2 Critical Care Medicine: January 2014 – Volume 42 – Issue 1 – p 158–168 doi: 10.1097/01.ccm.0000435675.91305.76 Concise Definitive Review

 

Anesthesia for Left Ventricular Assist Device Insertion: A Case Series and Review. Ochsner J. 2011 Spring; 11(1): 70–77.

Medical Management of Patients With Continuous-Flow Left Ventricular Assist Devices. Curr Treat Options Cardiovasc Med. 2014 Feb; 16(2): 283.

 


My blog posts:

HeartWare vs. HeartMate LVAD

Ventricular Assist Devices: Impella

Anesthesia and Breastfeeding

I get a lot of questions from my friends about receiving anesthesia while breastfeeding.  As more moms are breastfeeding, I think it’s an important question to tackle for the baby’s safety.  I’ve included references and summarized key points below.  If you have any questions, please do not hesitate to ask your anesthesiologist or physician who will be taking care of you.

 

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From Anesthesiology, October 2017.

Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk.  Transl Perioper Pain Med. 2015; 1(2): 1–7.

ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017.  BREASTFEEDING MEDICINE Volume 12, Number 9, 2017.

KellyMom: breastfeeding and surgery resources

Key Points:

  • Intrathecal and epidural anesthesia and opioids are ok for breastfeeding mothers.
  • Acetaminophen, ibuprofen, and ketorolac are ok because they have relatively short half-lives.
  • Celecoxib: ok.
  • Naproxen: ok.
  • Propofol is ok.  Proceed with breastfeeding when mom is awake after anesthesia.
  • Midazolam (sedation dose) is ok.  Proceed with breastfeeding when mom is awake after anesthesia.
  • Fentanyl is short-acting enough.  Proceed with breastfeeding when mom is awake after anesthesia.
  • Avoid meperidine in the post-operative unit – its metabolites have long half-lives.
  • Hydromorphone has a long half-life (10hours).  Best to avoid this medication or pump and dump.
  • Morphine: low dose is ok.  Caution if using morphine PCA.
  • Hydrocodone: dosage should be <30mg/day in breastfeeding moms.
  • Oxycodone: dosage should be <30mg/day in breastfeeding moms or not used at all.
  • Tramadol: ok. But FDA not recommend for breastfeeding moms (USA).

Things to Consider

  • Try to have your case booked as early in the morning to decrease the amount of time for fasting.
  • Pump a stash of breast milk ahead of surgery for 1 day of feeds just in case.  You can always use this expressed milk later.
  • Breastfeed or express milk just before the start of the procedure.
  • Have an adult supervise you post-operatively as well as the baby in case there are signs of medication transferred to the baby.
  • Consider anesthetic techniques (local anesthesia, regional anesthesia, non-narcotics, etc.) to minimize opioid consumption.

 

 

Interested in Medical School? Start Early.

A friend of mine’s son is just about to graduate from high school.  He’s interested in medical school, and his mom asked me what advice I would give to help him pick a college knowing that he has an interest in medicine.

Keep in mind: I am not a counselor or an advisor.  I am a physician, and this is what worked for me.

My advice:

  1. If you’re interested in medicine…. start early.
    • The college and medical school application process are getting more competitive.  Students are bright, prepared, and eager.  Let’s start with the basics.  Are you sure you’re interested in medicine?  Like really interested?  Sure, the media portrays some glamour lifestyles for physicians… but it’s not all glitz and glam.  You’ll put in at least a decade of extra work vs. your peers who get a job right out of college.  While they’re building their nest egg, you are not.   
    • Luckily, I stumbled upon my interest in medicine at an early age when my family practice physician encouraged me to pursue it.  He proved to be a great mentor as I was able to shadow him and really get a feel of his day and what he does.
  2. Once you’ve decided medicine in your passion… solidify that decision.
    • Volunteer at the hospital.  Observe your physician.  Volunteer to help people.  If this excites you, you’re on the right track.  Put yourself in situations where you can get involved in medicine.  Read and research what medical school is like.  Reach out to a medical school and see if you can get more information: chat with a medical student, find out if anyone needs help with a research project.
  3. Do well in school.
    • This is a must.  Applicants are incredibly competitive and intelligent with tons of extracurriculars on their resumes.  Get good grades.  Do well on your SAT/ACT and then do well on the MCAT.  Your grades and your test scores are the most basic comparison tool for schools to compare applicants.  Doing well gets you noticed.
  4. Get involved and signup for extracurricular activities.
    • Once you’ve put in the work for good grades and test scores… get involved.  This could be anything: sports, clubs, arts/music, babysitting/caring for loved ones, volunteering, job in a lab, travel/cultural growth.  The key is to show that you’re well-rounded and multifaceted all while achieving the good grades.  Once the colleges and med schools have seen your test scores, they’ll next use your extracurricular activities to help separate out the different applicants.  The key is maintaining good grades while all these other activities are happening.  AAMC fact sheet for medical schools.

If you’re in high school and interested in medicine:

  • Get good grades and do well on SAT/ACT (consider college prep courses to help)
  • If you’re able to take honors classes or AP classes and do well, definitely sign up for these.  It’s another way to separate yourself from other applicants.
  • Volunteer at your local hospital and/or doctor’s office
  • Get a job at a research lab or hospital
  • Get involved in extracurricular activities
  • Talk to your high school counselor about career paths
  • Attend career fairs (my school offered a career night in medicine where we got to go into the operating room) and college fairs on getting into medical school
  • Ask a college pre-med what they’re taking and how to do well in college
  • If you’re torn between two schools on your college list, consider taking a good look at the college that may also be linked to a medical school.  There’s a good chance that some of the medical school professors will be teaching some of the upper level physiology or anatomy college courses.  Some of the professors may also sit on the admissions committee to medical school.  Lastly, it may be easier to get involved in clinical research or scientific studies that the medical school professors are working on… and that would be a great way to introduce yourself to medical school staff as well as get a stellar recommendation letter to show off your work ethic and dependability.

If you’re in college and interested in medicine:

  • Get good grades and do well on the MCAT (consider prep course to help)
  • Get a major in something you’re interested in (you do NOT have to be a pre-med major… you just have to take the pre-med prerequisites to take the MCAT and apply for medical school).  Even though I majored in biomedical science (a pre-med major at Texas A&M), I would have done biomedical engineering if I had a do-over.  Science and math have always been my interests…the engineering major would have given me a nice background beyond my pre-med major.
  • Talk to your college counselor/advisor early (freshman year)
  • If you get into an honors program in college (usually based on your SAT/ACT scores), go for it.  Typically the honors classes are smaller and are a fantastic way to build report with your professor as well as get deeper into the subject matter.  Plus, being in the honors program will further help you standout on your application to medical school.
  • Volunteer at the local hospital.  Although you may start out as a volunteer, see if you can get into the OR (operating room) as well as outpatient clinics.  This will expose you to a wide variety of practices: surgery, anesthesiology, pathology, internal medicine, family practice, OB/GYN, specialties, etc.
  • Get involved in extracurricular activities in college.  There are a ton of clubs and interest groups in college.  If you don’t find one you like, start your own!
  • Need a job in college?  Consider getting one in the research lab or at a medical school or in a hospital.
  • Consider doing summer school to get some credits out of the way.  When I was in college, 12 credits was a full-time student.  I always took 15 credits because I thought I could handle it.  (Now I cannot recommend the following…) My junior year in college, I signed up for 21 credits to see if I could handle a medical school work load.  It was a tough semester, but I did it and got a 4.0.  I wouldn’t recommend that route because you need to focus on grades… but it worked for me.
  • Apply to a lot of medical schools (in-state and out-of-state).  I grew up in Texas and at the time they had a Texas match with 7 medical schools.  I only applied to the Texas (in-state) medical schools because I knew that was all I could afford.  Keep in mind your debt burden: a $9,000/yr education vs a $30,000/yr is a big difference.  I chose an option that made the most sense to me — I didn’t want to be in debt forever.  In fact, I highly recommend reading this book: The White Coat Investor: A Doctor’s Guide To Personal Finance And Investing.  If I had that available to me, I would’ve read that in high school… re-read it in college… read it again in medical school… and read it again throughout life.  Yes, I’m constantly revisiting this book because it is that good.
  • Interviews: honestly, I can’t remember if I interviewed for medical school or not (geez that makes me sound old!).  If you do have interviews… put your best foot forward and practice interviews with your friends/parents/professors/etc.  Be positive, engaging, and professional.  Interviewers DO judge a book by its cover.
  • Once you’ve applied to medical school, sit back and wait for your results to roll in.  Honestly rank the schools you would like to go that caters to your learning style/goals/etc.  My medical school (UTMB) was one of the first in the country to incorporate systems-based learning and problem-based learning.
    • Systems-based = learn subject material based on the different organ systems vs. separate anatomy, physiology, pharmacology, pathology, etc.  (I learned based on the cardiovascular/gastrointestinal/genitourinal/neurological system, which included the anatomy, physiology, pharmacology, pathology, etc related to that system.  I thought it was a more intuitive way to learn medicine) .
    • Problem-based learning involved small groups where we would discuss medical cases, labs, clinical problems, etc.  It was a nice environment to express yourself as well as work together in a team.  This is how the real-world works where you talk to your colleagues to work through various medical issues.  It supports professionalism and engages a teamwork mentality.
  • Lastly, thank the people who helped you get here.  It’s easy to overlook your mentors, friends, professors, and family.  As you enter the medical school/medicine world, your family will learn along the way that you made a commitment to a profession that will take priority over them.  You will miss weekends, evenings, date nights, holidays, anniversaries, etc.  Not only will you sacrifice a lot to get to medical school… you’ll continue making sacrifices once you’re out practicing medicine in the real world.

AAMC fact sheet for medical schools

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