The Most Important Question To Ask Before Surgery

Today's issue of the Wall Street Journal has a nice little article advising patients how they should discuss their anesthetic care with their anesthesiologist. Since it's in the WSJ, you know every anesthesiologist in the country has already read it this morning. So we're well prepared for the onslaught of questions by the well to do patients and readership of the paper. It goes into the some statistics about the safety of today's anesthesia: 3 deaths per 10,000 procedures and a 4.8% anesthesia complication rate according to one study.Those numbers seem high to me but that's the conclusion they reached.

Naturally they have to bring up the death of Joan Rivers. What they failed to mention, but which I already have, is that no anesthesiologist was involved in her care immediately before she went into respiratory and cardiac arrest. The article's best suggestion may have been this blurb, "Find out who will monitor you during the procedure—the surgeon, a nurse or an anesthesiologist. Only a medical professional specifically trained to administer anesthesia and monitor patients should care for you throughout a procedure." Presumably the surgeon has not been formally trained in administering anesthesia. So unless he is double boarded in surgery and anesthesiology and he tells you he will give instructions to the nurse on what drugs to push for sedation, get ready to run the hell out the door. I wonder how the morbidity and mortality figures from that study would have changed if only anesthesiologist provided care was used to calculate its results?

We anesthesiologists don't presume to understand how other doctors do their jobs. We don't want to know how to perform an endoscopy or a cardiac cath. Yet these non anesthesia trained doctors are so arrogant as to assume they know how to provide dangerous anesthetic drugs while performing their procedures at the same time. So Dr. Murray, Dr. Cohen, and all you other procedurists out there who are putting your patients to sleep out of expeditiousness and greed without any anesthesia training, I hope you start getting a lot of hard questions about why you're not using an anesthesiologist for this most risky portion of a case.

What The Deaths Of Michael Jackson And Joan Rivers Have In Common

Following the unexpected death of Joan Rivers, I am once again inundated daily with questions from concerned patients about the safety of anesthesia. Everybody comes in with wide eyed fears while family members produce a list of questions about how likely their loved one will die during a routine outpatient procedure.

This hysteria is similar to the events five years ago when Michael Jackson was found dead in his rented mansion after being sedated by an inattentive cardiologist. At that time patient anxiety was actually far more intense because of Mr. Jackson's notoriety and the widespread news of propofol's involvement.

However, my answer to questions about both Mr. Jackson's and Ms. Rivers's deaths are quite similar--in both cases an anesthesiologist was not present to give the sedation. We know for a fact that MJ was overseen by Dr. Murray in a private bedroom with absolutely no evidence of any anesthesia resuscitation equipment available, not even oxygen. Ms. Rivers's case is still under investigation so we only have gossip and heresay to tell her story. However all evidence point to Dr. Cohen, her gastroenterologist, as the primary procedurist in the room. He has strongly voiced his opinion that the use of propofol by a non-anesthesiologist is just as safe as when an anesthesiologist is giving the sedation. With such a strong advocate of DIY anesthesia as Dr. Cohen, it is unlikely that he let any anesthesiologist sedate his patients, especially for a procedure as "benign" as an EGD.

As you can see, in both tragic cases there was no anesthesiologist in the room when a crucial airway emergency occurred. When patients ask about these sensational events, they must be firmly told that an anesthesiologist would most likely have prevented the untimely deaths of these two celebrities. No amount of PR material from the ASA about physician anesthesiologists (how I hate that term) can compare to a face to face bedside education that an anesthesiologist can give to his patient about the safety of our craft. This is another golden opportunity to inform our patients about the frequently misunderstood practice of anesthesiology. Out of tragedy anesthesiologists can really shine and demonstrate to the public the indispensable skills we possess to safely guide a patient through his most vulnerable period.

Propofol Doesn't Kill People...

I read about an anesthesiologist who was facing a dilemma.  Patients, when told they will receive propofol for their anesthetic, will express trepidation and fear.  They always point to the unfortunate death of Michael Jackson as the source of their anxiety.  The doctor tried to explain to the patient all the scientific studies and minimal risks associated with propofol.  This scientific babble usually didn't help much.  I have a better idea; use the analogy that has worked for the National Rifle Association for decades.

A patient asked me about the safety of propofol.  Will what happened to Michael Jackson happen to her?  I told her there is nothing wrong with propofol, just the doctor who gave it to Michael.  Propofol in the proper hands is very safe.  It's like a gun.  A gun in the right hands is very useful in society.  When a crime is committed with a gun, it's not the gun's fault.  Guns don't kill people; people kill people.  Right away patients get the analogy and are much more relaxed and at ease.  The tension is released and everybody's happy. 

Regulate doctors, not propofol

Today we hear the DEA is considering making propofol a controlled substance, with the same level of scrutiny of distribution as narcs and benzos. Though Michael Jackson's toxicology reports have not been made public, everybody is concentrating on propofol as the culprit. I have a better idea. Why don't we regulate and punish these unethical doctors that led to this tragedy in the first place.

Propofol is a wondrous drug, revolutionizing the practice of surgery and anesthesia with its ease of administration, predictable efficacy, and rapid emergence. Many outpatient surgical procedures would not be possible, or would be more difficult, if it were not for propofol being widely available. Patients wake up quickly after propofol anesthesia, with very little side effects. This property of propofol allows the patients to recover quickly, letting them go home sooner. This lets surgery centers operate more efficiently and lower their costs. They can schedule more cases each day instead of waiting around for a recovery room full of patients to wake up.

If propofol becomes a controlled substance, the process of acquiring and using it becomes more cumbersome, slowing efficiency. Sure we would still have access to propofol, just like we can use morphine and versed now. But having to account for every drop of propofol that is used on a patient, like we do for morphine and versed, will inevitably slow down the operating room. When a vial of narcotics is not accounted for, the whole operating room practically shuts down until it is found. Yes propofol can have addictive properties. But deaths from propofol addiction are very rare. Alcohol kills thousands more people each year than propofol. Alcohol is also a mind altering substance but you don't see the government locking up all the beer in this country.

Instead we should be concentrating on getting rid of these doctors that are giving medicine a bad name. Where do celebrities find these "physicians"? MJ's personal doctor reportedly isn't even board certified in Internal Medicine or Cardiology. Was he the one who brought the propofol into the house? Who was the anesthesiologist that was reportedly travelling with MJ in the 1990's on his concert tour? MJ was supposedly getting propofol every night to help him sleep.Who referred Anna Nicole Smith to her doctors. What about Heath Ledger, or Elvis? Celebrities or their handlers always seem to be able to find these doctors that have no ethical fiber in their being. These so called doctors, if found to have contributed to the deaths of their patients by overprescribing or abusing medications, should be prosecuted to the maximum extent of the law. As a board certified anesthesiologist, I hate to say medicine needs more regulations. But we need to put the fear of God, or the DA's office, into all physicians to help prevent any more wasted lives.