Tag Archives: anesthesiology

We Still Have an Opioid Epidemic

COVID-19 has changed every aspect of our personal and professional lives.

In the midst of this pandemic, we still have an opioid epidemic. It is not one thing unfortunately, and the Centers for Disease Control and Prevention (CDC) describe three distinct waves of opioid-related overdose deaths.

Centers for Disease Control and Prevention

Given the complexity of the opioid epidemic, we have to keep working within our spheres of influence. For those of us in anesthesiology, that means focusing on surgical patients: improving their outcomes and providing effective perioperative pain management along with opioid stewardship.

Dr. Chad Brummett and his colleagues at Michigan OPEN have been leading the way in procedure-specific opioid prescribing recommendations. Their process, which takes into account data from the Collaborative Quality Initiative (CQI), published studies, and expert input, specifically focuses on the perioperative care of patients who are not taking any opioids prior to surgery.

Through multimodal analgesia, we prevent and treat pain in a variety of ways without depending solely on opioids. At our institution, we offer patients regional anesthesia and have been able to decrease the amount of opioid pills that patients are given when they leave the hospital by basing the prescription on how much they use the prior day. Patients participate in this process, and we give them clear instructions on how to safety taper their opioids at home.

As a representative of the American Society of Anesthesiologists (ASA), I have been able to collaborate with surgical societies such as the American Society of Breast Surgeons and the American Academy of Orthopaedic Surgeons to develop pain management recommendations and toolkits that emphasize multimodal analgesia, use of regional anesthesia techniques for targeted non-opioid pain management when it is available, and opioid safety in the hospital and at home.

ASA-AAOS Pain Alleviation Toolkit

I also represent ASA as a member of the National Academy of Medicine (NAM) Action Collaborative Countering the U.S. Opioid Epidemic. The first discussion paper from the NAM pain management workgroup was released on Aug 10: Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings. This paper highlights best practices in opioid tapering and identifies evidence gaps to drive future research.

Despite the massive amount of resources, human effort, and time dedicated to the fight against COVID-19, we have still managed to make progress in decreasing opioid-related risk in the perioperative period. However, there is still a lot of work left to do, and our patients are depending on us.

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A Year Ends and a New One Begins

This academic year was truly like no other.

At the end of July, we graduated three new physician experts in regional anesthesiology and acute pain medicine (RAAPM), and I could not be more proud of them! From our welcome party in the summer of 2019 to a year’s worth of teaching sessions, socials, and medical missions to the opening of the new Stanford hospital, the #COVID19 pandemic and #BlackLivesMatter movement – what a year for our amazing grads! Check out this fantastic graduation video from Dr. Jody Leng:

Our graduating fellows surprised me with the honor of being their Teacher of the Year along with Dr. Ryan Derby! It is such a privilege to be part of our fellows’ training every year and see them grow into physician consultants with RAAPM expertise.

Our new fellows are off to a strong start and are now officially part of our Stanford RAAPM family! If you are interested in learning more about our fellowship program, please visit our fellowship website and contact me with any questions.

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Congratulations to Our Newest Anesthesiologists

2020 is a unique graduation year for all of our anesthesiology residents and fellows due to COVID-19, but never before has the role of anesthesiologists been more relevant. The American Society of Anesthesiologists (ASA) has prepared this special graduation message so programs can incorporate it into their virtual ceremonies, and it features a very special commencement speaker: Dr. Jerome Adams, the Surgeon General of the United States!

Link to graduation video: https://bit.ly/3eMg5ET

Nearly all of these physicians who are just starting their careers specializing in anesthesiology have completed 4 years of college, 4 years of medical school, and 4 years of internship and residency plus 1 or more years of fellowship training for many. Hopefully this message will help our newest graduates, their families and friends, and their teachers and mentors recognize and commemorate this important milestone in their lives.

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Beyond COVID-19: Stand Up for Veterans Having Surgery

Our Veterans have made tremendous sacrifices to defend our freedoms. Now it is our time to defend them.

Many people, even those who work in the operating room every day, take safe anesthesia care for granted. There has been growing pressure during this pandemic to remove physician supervision of nurse anesthetists with the latest threat coming from within Veterans Affairs (VA) healthcare. For our Veterans, our heroes and arguably some of the most medically complex patients, having a physician in charge of anesthesia care at hospitals where anesthesiologists and nurse anesthetists work together as a team makes the most sense.

Having a team with members who train differently and have different perspectives can only benefit the patient; anesthesiologists are physicians who draw on their medical training while nurse anesthetists bring valuable nursing experience. If you were a patient having surgery, wouldn’t you want an anesthesiologist directly involved in your care? If the answer is yes, please sign the Safe VA Care petition and let your elected officials know by filling out this contact form.

Continue reading Beyond COVID-19: Stand Up for Veterans Having Surgery

Providing anesthesia is often compared to flying a passenger airplane, and the anesthesia care team model is like having both a pilot and a co-pilot. Who thinks flying has become so safe that we no longer need the pilot? Seconds count in flight, and they count just as much in the operating room when a patient’s life is on the line. 

In 2016, the VA rejected independent practice for nurse anesthetists after careful consideration, but this decision was recently overturned by a memo citing the COVID-19 pandemic. This memo abolishes the anesthesia care team model without giving Veterans a choice. Veterans having surgery may now only get a nurse anesthetist without the option of having an anesthesiologist involved. If they were given the choice, however, I think our Veterans would choose an anesthesiologist or an anesthesia care team instead of a nurse anesthetist alone. We all should. With the COVID-19 pandemic, elective surgeries at the VA have been stopped so there is no shortage of anesthesiologists. Anesthesiologists all over the world have been fighting COVID-19 and have shown what they can do with their specialized medical training in a crisis. Although commonly referred to as “going to sleep,” general anesthesia is more like a complex drug-induced coma that can carry serious risk. If or when a crisis happens during surgery, every patient should have access to an anesthesiologist.

Modern anesthesiologists are physicians but also scientists, educators, and patient safety advocates. Anesthesiologists specialize in relieving anxiety, preventing and treating pain, preventing and managing complications related to surgery, critical care, and improving patient outcomes. The average anesthesiologist spends nearly a decade in postgraduate education after college including medical school and logs 16,000 hours of clinical training to learn to apply the best available evidence in clinical practice. Academic physicians and scientists focused on anesthesiology are responsible for the discovery of newer and safer anesthetics, pain therapies, and technologies that are advancing healthcare throughout the world.

Anesthesia administration by non-physicians such as nurse anesthetists and certified anesthesiologist assistants is supported by the American Society of Anesthesiologists within the physician-led anesthesia care team model. To uphold safe, high-quality physician-led anesthesia care for our nation’s Veterans, please speak up by signing the petition and reaching out to legislators using this contact form. It only takes a minute to stand up for safety, but the consequences of not saying something may be serious and long-lasting.

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Conference Cancelled Due to COVID-19? Go Virtual!

Due to the COVID-19 pandemic, the usual spring meeting season for medical societies never got started. In San Francisco, all events hosting more than 1000 people were prohibited. As a result, the 2020 annual ASRA regional anesthesiology and acute pain medicine meeting was cancelled.

However, there were nearly 400 scientific abstract posters submitted to the meeting and posted online. For so many registered attendees, the ASRA meeting was an opportunity to share their latest research and medically challenging cases with their colleagues and solicit feedback.

Continue reading Conference Cancelled Due to COVID-19? Go Virtual!

There was no way to preserve the complex structure of an ASRA meeting (e.g., workshops, plenary lectures, problem-based learning discussion, networking sessions), but a moderated poster session was feasible using common videoconferencing applications. The Chair of the 2019 ASRA spring meeting, Dr. Raj Gupta, took it to the next level by using StreamYard to simultaneously broadcast the video feed to multiple social media platforms (e.g., Twitter/Periscope, Facebook, YouTube). In addition to accessing the livestream for free, participants could make comments and pose questions to the speakers and moderator through their social media applications.

Dr. Gupta hosted 6 sessions, and these were archived on YouTube for later viewing. As an example, here is one session focused on regional anesthesia abstracts in which I participated:

Although it was disappointing to not have an ASRA spring meeting this year, something good came out of it. The livestreamed poster discussions were an innovative way to showcase the science and educational cases as well as leverage social media to attract a global audience. Since medical conferences may never completely return to pre-COVID normal, embracing technology and incorporating online sessions should be considered by continuing medical education planners going forward.

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PPE Considerations for COVID-19 Airway Management Personnel

Personal protective equipment (PPE) for personnel involved in advanced airway management in cases of known positive or suspected COVID-19 should not replace recommendations by the Centers for Disease Control and Prevention (CDC).

However, the additional risk of exposure to healthcare personnel involved in advanced airway management for a disease with airborne transmission must be taken into consideration. Past experiences with variations in PPE during other major respiratory diseases in recent history have been published along with recommendations for the current COVID-19 pandemic. Experts have recommended a higher level of PPE for personnel involved in advanced airway management due to limitations of standard PPE, particularly neck and wrist exposure.

Continue reading PPE Considerations for COVID-19 Airway Management Personnel

Use of an air filtration system, preferably an N95 mask, is recommended by CDC and anesthesia societies and is a minimum requirement for airway management personnel. Proper air filtration is a basic need for healthcare professionals caring for patients with airborne diseases and participating in aerosol-generating procedures (AGPs). N95 fit testing should be prioritized for these healthcare professionals. For airway management personnel who do not successfully fit test or cannot wear an N95 for other reasons, ideally a hooded Powered Air Purifying Respirator (PAPR) should serve as the alternative.

Basic features of PPE for airway management personnel are IN ADDITION to CDC recommendations for PPE and airborne, droplet, and contact precautions which may include:

  • Second layer of eye/face protection
  • Neck coverage
  • Second layer of long gloves

This level of PPE is not universally recommended by societies and other organizations. Advanced skills in airway management are a limited resource, and those with these skills require adequate protection. In addition, anesthesiologists are critical medical specialists who can provide perioperative and critical care as well as pain management during a surge in addition to performing endotracheal intubation when needed.

Implementation of these features will vary given the variability of available PPE between institutions and supply shortages worldwide. It is essential to train airway management staff as soon as possible to develop a local PPE protocol that takes into account CDC and special precautions for high-risk procedures like intubation as described above.  Each facility will likely develop its own unique PPE protocol.

The following videos are being shared for educational purposes only. They represent only one example of applying additional precautions to PPE for airway management personnel, and there will be many others. Creating local videos can help expand training at a facility without depleting available PPE supplies. Remember that each institution or practice will develop its own version of PPE for airway management personnel, and many variations can achieve the same goal.

VIDEO: Enhanced Airway PPE Donning (1:52)

VIDEO: Outer Layer Doffing (1:28)

VIDEO: Inner Layer Doffing (2:21)

VIDEO: COVID-19 Airway Management Simulation (1:44)

For other helpful resources, visit
https://www.edmariano.com/resources/ppe.

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Being Essential in the Post-Normal Era

Traffic is non-existent. Schools are closed. Restaurants are only offering take-out and delivery. Parking lots at strip malls are empty on weekends. Only a limited number of people at a time are allowed inside the grocery store. 

Welcome to the post-normal era since the COVID-19 pandemic hit the scene in Northern California. 

One day we will look back at this time and realize how much it changed everything. Simple things like a handshake or sitting together with a colleague during a lunch break will hopefully never be taken for granted again 

Continue reading Being Essential in the Post-Normal Era

The California Governor has issued a statewide order to shelter in place. It’s only natural that the husband and father parts of me consider staying home like everyone else. 

But I’m not like everyone else, and none of us in healthcare are. We are considered “essential,” which is why we continue to go to work day-and-night while the rest of our society shelters in place in a monumental effort to “flatten the curve” of COVID-19. 

I have always liked this blog by Dr. Kathy Hughes about working at hospitals around the holidays and being essential. Hospitals at that time of the year are actually festive places. It’s different now. There are no holiday potlucks in the ward lounges to bring people together. There is no celebrating. Yet, we all understand that we are needed and share the burden of being essential together. 

Our work as anesthesiologists has changed. We no longer perform elective surgeries in our operating rooms. The weight of our role as specialized physicians has shifted from perioperative and pain medicine to emergency response, critical care, and crisis management. We are at particularly high risk since COVID-19 is a respiratory disease. Every time we are called to perform tracheal intubation in an infected or suspected patient who is coughing and having trouble breathing, we are staring down the barrel of a gun. 

Protecting ourselves is a priority because our expertise is a limited resource. If we get sick, we can’t help others, and we risk spreading COVID-19 to our families. Personal protective equipment or PPE is a necessity, and multiple layers are required by anesthesiologists and other airway management personnel given the high risk procedures we do in these patients. It takes time to put on PPE, but there can be no shortcuts when it comes to safety. SLOW IS SAFE, and we need to remember that there are no more emergency intubations in this post-normal era.

Being essential in the hospital is not limited to just the healthcare professionals of course. The engineers, the technicians, the housekeepers, the cafeteria and food service workers–they are the unsung heroes of the hospital during this pandemic. Without them, our facilities and our healthcare workers would cease to function. Whenever I see them, I thank them for the work they are doing to support us on the front lines of patient care. We share stories of how things used to be and give each other some encouraging words. 

It is surreal to get up, get ready for work, have a cup of coffee as part of my normal morning routine, drive through deserted streets, and walk into the hospital not knowing what the day will bring. We have a job to do, and that calling to help humanity drives us to keep coming to work. We chose medicine, but medicine chose us too.

This blog has also been featured on KevinMD.

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My Trip to Washington: Speaking Out Against Drug Shortages

UPDATE: The MEDS Act was incoporated into the Coronavirus Aid, Relief, and Economic Security (CARES) Act and passed into law on March 27, 2020.

On November 5, 2019, I had the opportunity to participate in a Congressional briefing related to drug shortages at the Capitol in Washington, DC. Senator Susan Collins (R-ME) opened the session and co-sponsored the Mitigating Emergency Drug Shortages (MEDS) Act with Senator Tina Smith (D-MN). I was one of only two physicians on the panel and tried to represent the voice of clinicians involved in perioperative care and the patients we care for (video). Below are the notes from my presentation.

As a physician specializing in anesthesiology, this ongoing crisis of drug shortages in the United States is frankly terrifying.

Continue reading My Trip to Washington: Speaking Out Against Drug Shortages

Anesthesiology is a unique specialty within medicine. Our patients are the most vulnerable in the hospital. Patients under general anesthesia cannot advocate for themselves and trust us with their lives.

We do not know what the next drug shortage will be or how long it will last. This week it is prefilled syringes of lidocaine, a life-saving emergency medication we give in case of a dangerous heart rhythm. Two weeks ago it was phenylephrine, a routine medication we use to increase blood pressure when it goes down after inducing anesthesia.

Last year, we had complete shortages of common injectable opioids and local anesthetics used for numbing injections. This directly affected surgical patients in terms of anesthesia and pain management. For 3 months in 2018, we did not have the local anesthetic indicated for spinal anesthesia. We know this is the safest anesthetic for patients having certain surgeries. During this shortage, we used an alternative anesthetic in order to continue providing spinal anesthesia, but our patients experienced more side effects. The reasons for this shortage were complex and involved a limited number of manufacturers and quality issues.

Thankfully, the shortage of spinal local anesthetic ended. We do not know when or if the rest of our current drug shortages will end. All we know for sure is that there will be another one.

The predictably unpredictable cycle of drug shortages puts physicians in an impossible position. Medicine is a calling, and we physicians have sworn an oath to support the well-being of our community and humanity in general.

Not having access to the right drugs at the right time for every patient and being forced to use less acceptable alternatives, if any exist at all, represents a form of moral injury. Moral injury “is being unable to provide high-quality care and healing in the context of health care” and is now recognized as a contributor to the epidemic of physician burnout.

Listen to my interview with Paul Costello on SoundCloud.

From left to right: Daniel Teich (Fairview Pharmacy Services), Dr. Peter Adamson (Children’s Hospital of Philadelphia), Senator Susan Collins, me, and Brian Marden (MaineHealth Pharmacy)

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Regional Anesthesia Education and Social Media

At the 2018 annual meeting of the European Society of Regional Anaesthesia and Pain Therapy (ESRA), I was invited to give a talk on regional anesthesia education and social media.  In case you missed it, I have posted my slides on SlideShare.

After my session, I was asked by ESRA to highlight some of the key points of my lecture:

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My Reasons to Visit San Francisco for #ANES18

This year’s American Society of Anesthesiologists meeting (#ANES18) happens to be in my “neck of the woods”—one of the greatest cities in the world—San Francisco, California. Here are a few things you may or may not have known about San Francisco.

San Francisco is the biggest little city. At just under 47 square miles and with more than 800,000 inhabitants, San Francisco is second only to New York City in terms of population density. Despite its relatively small size, “the City” (as we suburbanites refer to it) consists of many small neighborhoods, each with its own charm and character: Union Square, the Financial District, Pacific Heights, the Marina, Haight-Ashbury, Chinatown, Little Italy, Nob Hill, Russian Hill, SoMa (South of Market), the Fillmore, Japantown, Mission District, Noe Valley, Twin Peaks, Castro, Sunset, Tenderloin, and others. This is probably why die-hard New Yorkers love it so much.

In the summer especially, San Francisco weather is somewhat unpredictable even when going from one side of the city to the other (part of the unique experience of visiting the city). “The coldest winter I ever spent was a summer in San Francisco,” a quote often mistakenly attributed to Mark Twain (no one really knows who actually said it), is nevertheless often true. Here in the San Francisco Bay Area, our local meteorologists provide daily forecasts for each of the region’s microclimates. The western side of the City along California’s coast is regularly plagued with fog while the eastern side of the City tends to be sunny most days of the year. It’s always a good idea to check the microclimate forecast before heading over to see the Golden Gate Bridge just in case it happens to be shrouded in fog. Average July temperatures in the City range in the 50s-60s Fahrenheit (no different than average November temperatures), so summer tourists often contribute to the local economy by buying “SF” logo sweatshirts for their walk across the City’s most famous bridge. Fortunately, #ANES18 is in the fall, and the weather near Moscone Center and the popular shopping area Union Square tends to stay reliably nice most of the year.

San Francisco is very family-friendly. If you’re debating whether or not to make a family trip out of #ANES18, my advice is to do it. Right around the convention center there are a number of attractions and events worth checking out. I highly recommend visiting the farmers market at the Ferry Building. While there, you can also take a ferry ride to a number of other destinations in the Bay Area (try Sausalito, a short trip that takes you past Alcatraz). For kids, there are parks within walking distance as well as the Children’s Creativity Museum, the San Francisco Railway Museum, Exploratorium, and the cable car turnabout at Powell and Market Street. Trips to Fisherman’s Wharf, Ghiradelli Square, or the aquarium are a short taxi or cable car ride away. In addition, runners will love running up and down the Embarcadero which gives you a view of the Bay Bridge and takes you past the City’s many piers. Shoppers will be in heaven, and foodies will have to make the impossible decision of choosing where to eat for every meal.

But don’t take my word for it—come to #ANES18 and see for yourself!

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