putting you to sleep

Monday, July 21, 2014

Pitcher CC Sabathia could not sleep at night, worried that he might need significant knee surgery that might end his career. After seeing the team orthopedic surgeon and discussing options, microfracture surgery which might cause him to miss two seasons, was not needed. Masahiro Tanaka, another Yankees pitcher with elbow troubles, sought opinions from three different orthopedic doctors before deciding not to have Tommy John surgery to repair an ulnar collateral ligament injury. Every day, thousands of people seek second opinions to be reassured that a planned surgery is appropriate. Every day, people forget that the surgeon is only one part of the operating team.

Most people will not know the name of the anesthesiologist assigned to put them to sleep and perhaps more importantly, to wake them up. On the assigned day of an operation, the patient and family show up to the hospital or surgical center and begin the pre-op process, where nurses assess and prepare the patient for their procedure. Eventually, an anesthesiologist or nurse anesthetist shows up at the bedside, introduces themselves and begins their evaluation. Odds are, they are randomly assigned that day to the surgeon but hopefully, they have reviewed the medical record the day before. For patients who are hospitalized, that visit may take place the evening before. But few people consider who that anesthesiologist might be.

Anesthesia is not what it used to be. Depending upon the surgery, the patient may have options to choose different types of anesthesia, whether it be local, regional or general. Most people have had a local anesthetic where medication is injected into a small area of the body. From laceration repair to a dental filling, the purpose is to block pain fibers but touch, pressure, vibration and movement sensat8ons are all intact. For that reason, most people feel stuff under local; the goal is to have little or no pain.

Regional anesthesia blocks whole sections of the body. The anesthesiologist can inject medications into the spinal canal area like an epidural used during labor or C -section, or inject medication into a vein to anesthetize a single limb. It’s easy to talk about, but there is technical skill needed to get the anesthetic into the right place, in the right amount and to monitor the patient to make certain complications don’t occur and the anesthetic wears off at the proper time.

General anesthetic is the one often seen in television dramas where the patient is sedated and sometimes paralyzed so that an operation can occur. Not all operations require a patient to be paralyzed but should that be the case, the skill of the anesthesiologist is even more important. The paralyzed patient needs somebody to breathe for them and to monitor and support their vital signs. This is where the critical part of this critical care specialty comes to bear and why the pre-op visit is so important.

Not every patient is young and healthy and the patient with heart disease, lung disease, diabetes or on dialysis, all pose a challenge to the anesthesiologist. Pick a disease or illness and it can cause an anesthetic complication. Every patient has a unique set of circumstances that will affect the choice of anesthetic and the type and amount of medications used. Not everybody qualifies for anesthesia; patients can be too sick or too complicated so that the risk of dying during the operation or postop course is greater than the benefit that surgery might offer.

History and physical are the important tools for that pre-op evaluation. Past medical history is obvious, but not so with family history where a relative who had a bad anesthetic outcome might be the clue that it could be hereditary. Medication history is more than prescriptions meds but also needs to include over the counter medications and herbal remedies that might interact with the anesthetic. Physical exam might uncover an issue that would increase the risk. Showing up the day of an operation with a cold or other infection might be enough to have the procedure postponed. For the anesthesiologist, it’s all about controlling risk and minimizing disaster. Heart attack, stroke, pneumonia, vocal cord damage from being intubated, temporary and not so temporary confusion are some of the anesthetic risks independent of what the surgeon is doing.

The anesthesiologist is one of the invisible doctors in medicine, where their work is invaluable to their colleagues and their patients but most people don’t know their names or qualifications…nor do they seem to care. Radiologists who look at x-rays rarely touch patients but their opinions drive diagnosis and treatment decisions. Pathologists look at tissue samples and cells to make a variety of diagnoses including cancer/not cancer. Their world is set apart from touching patients, yet their skill is invaluable.

So back to Mr. Sabathia and Mr. Tanaka. Surgeons sought by elite athletes often have their own team, from anesthesia, to scrub nurses to physical therapists. Regular patients often search the country for the surgeon but leave picking the rest of the team to chance. Credentialing and peer review committees hold doctors, including anesthesiologists, accountable to maintain their knowledge and skills. It’s a stressful time when the doctor shows up at the bedside before surgery. Still, it might be nice to remember their name…they may hold your life in their hands.

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