Life, Cancer, Etc.
Life, Cancer, Etc.
Talking about Anesthesia with Dr. Debbie Egbert
Dr. Debbie Egbert is an anesthesiologist in practice in Oregon. Debbie is a wealth of information and has an obvious passion for serving her patients. Side note: she's also a fabulous gardener and cook! In this episode, we talk about what anesthesia is and how it works.
NOTE: I am not a medical professional. Everyone on the "Life, Cancer, Etc." podcast is sharing their own experiences, not giving medical advice.
Photo © 2021 Dr. Debbie Egbert
Keywords: questions about anesthesia, types of anesthesia, anesthesiologist
You can also find some episodes on our YouTube channel: https://www.youtube.com/c/LifeCancerEtc
I'm Heidi Bragg and this is Life, Cancer, Etc. My goal with this podcast is to connect you with stories and resources that help you feel happier, more resilient, and less stressed, especially when you're going through hard times. So my guest today is Dr. Debbie Egbert. She's an anesthesiologist in practice in Oregon and a friend and just an all-around good human being. Hey, Debbie. Hey, Heidi. How are you? I'm good. I'm good. I was really glad you were willing to do this because I think For example, when you get cancer and you need a surgery and things need to happen kind of fast, anesthesiology is obvious. Getting anesthesia is obviously a critical part of that process, but it's not something you necessarily know the ins and outs of. You just know it needs to be done and you do it. Well, it goes beyond that. No one knows who their anesthesiologist is. No one has a clue what anesthesiologists even do. So sometimes it's only those that have medical people in their family or have had a bad experience or have had a baby and had an epidural. And of course, then they know what we do. But yeah, it's a big black box of mystery to most people. Okay. I think that's a really good way to sum it up. So if you don't mind, give us a little background on you and why you chose medicine and why you chose anesthesiology. Okay, well, I'm the oldest of three children. And at the age of 12, when I went to my pediatrician, I thought he had the coolest office and it was so cool that he always knew what was wrong with us. And it was actually kind of a happy place. I hated shots, but I was very intrigued. And I'd say that at the age of 12, I decided I wanted to be a doctor. Of course, I had no clue what that meant, but that was when I first had the idea. Time went on through high school and college. I really did love and appreciate was pretty good at the math and sciences. And I found that my linear, more black and white thinking really fit with that model of science and math than the more, really for me, painful three-dimensional liberal arts, connecting dots. That was history. All that was a lot harder for me. My brain didn't work that way. So it was a good fit that I decided being a doctor would be fun. And it's Turned out that math, science, chemistry, biology were my favorite subjects in high school. So, and I also had a dad who was an attorney and he was a self-made man, three kids at a very young age. And I remember as a child, him saying, if I had to do it over again, Debbie, David, Terry, I'd be a doctor. So I took, I was my daughter, my dad's kind of apple of his eye. I was the quote, son, first son. Yeah. I think there– I don't know to what degree, but there was definitely an element of having my dad be kind of my hero, and I sort of followed through with– His dream, which by the way, he would have made a horrible doctor because I don't think he would have liked it even though he says he would do it again. And yeah, so I think he went to my medical school graduation and was the proud papa. So there was an element of that. After I finished my undergrad in zoology, I went to Georgetown Medical School. Oh, nice. And then I was married at the time and really struggled to actually– pin down anesthesia, that was a journey in and of itself because I thought I'd be a pediatrician when I first started. I can tell that later. If you want to, you may not want to spend a lot of time. But once I hit upon anesthesia near the end of my fourth year of medical school, I knew that it's exactly, I knew it was a good fit. And then I did four years of residency at Walter Reed Army Medical Center. And I did that because I joined the Army to pay for my medical school. And they give you rank so they can pay you to do that. And I ended up finishing my four-year residency at Walter Reed Army Medical Center. And Washington, D.C. is a great place to do training because of all the great specialty hospitals. And then after that, I had a three-year payback, which was at Tripler Army Medical School in Hawaii. A little hardship tour of duty. And I actually learned a lot and loved doing the military route because I had no exposure to that before. It was really a great experience all the way around. And before I left Hawaii, I told my director when they were trying to see if they could get me to stay, I said, well, you could make me an offer. I couldn't refuse. If you make me non-deployable and keep me in Hawaii, I'll stay. But I guess the Army doesn't do that.
SPEAKER_01:So
SPEAKER_00:I did get out of the Army and then came to Eugene, Oregon and joined at, at the time, 18-member MD group at Riverbend in Eugene. And I was the first female in the group. Wow. and the only female for five years. So that was kind of a little bit of a pioneer pathway here, but I stayed 29 years and it was a great professional experience, raising a family and working here. And it's not as rosy as I just made it sound, but it was a great career. Well, and it sounds like you were in a place where the things you wanted in your life were possible, not that they weren't easy. Not that they were easy, but that it made the things you wanted to do possible. Yep. It was all a good fit. Yeah. And you still practice. You just aren't full-time anymore, correct? Correct. I'm actually semi-retired. I was going to completely retire. However... They really had a great need at the hospital. And since I was just shy of 60 years old and I still love what I do, but it was the 14 and 15 hour days that I, I mean, I stopped doing call, which is the all night call about five years before I retired. And our group is structured so that you could do that when you're balancing lifestyle and professional work. you know, issues. And so I have gone back to work and they actually want me to work two weeks a month next year. So I'm still trying. I mean, I really enjoy the freedom of being able to visit kids and grandkids and do the other things I've been waiting to do. But I also still like it's, it's not my identity, but it's a big part of who I am. And it brings me a lot of satisfaction, enjoyment. So I have not given it up, even though I thought I was retiring. I'm glad you're not. I'm glad you've got that other facet to what you do. I don't think I'm the kind of person that's ever going to retire, retire. I enjoy the interactions. I enjoy learning. I enjoy all that. Yes. And it's just more time and season because I'm busier now. semi-retired than I was working. Because before I just worked and then came home and kind of collapsed. Or then I would fit in my things. And now I just have so much more energy to put more of myself into all my other interests and family members. So it's really great. Well, and Debbie does a lot of volunteer work too. So how... Can you give us kind of a basic understanding of how anesthesia works, both how it works in the body and then what's happening when you go in and you get, whether you have conscious sedation or general anesthesia, how those things work? Well, anesthesia is basically making the body insensitive to pain, the mind unconsciousness to awareness. And you're doing those things and balancing those things, taking into account the patient's age, risk, comorbidities, underlying medical conditions, and how all the interchanges go with that. What I've always thought about it, what appealed to me, it's pharmacology and physiology in action, meaning so many times you hear doctors and lawyers and perhaps other professionals say, oh, you spend eight years in school and then real life has nothing to do with what you learn about. Anesthesia, that is not the case. You are dealing with physiology, whether it be respiratory physiology, cardiovascular physiology, the blood pressure, the heart rate, whether you're oxygenating, the lungs. I mean, all that comes to life every single day in the actual real life thing. Now, no one's aware of that. I don't want to go into medical speak, which probably sounds confusing and interesting, but it's really where the lights up my brain. I mean, I could talk about it. And if someone one-on-one, sometimes I have to kind of reel back because it is so amazing how it all works together. So with anesthesia, I mentioned you have different elements. There's unconsciousness. There's analgesia, which is pain. There's also muscle movement. You don't want a surgeon, even if a patient's asleep in their, you know, in a sleep state in their EEG or or they're not having pain based on their neurologic nocioception, they can still move. People probably don't know that. So you have muscle relaxation as another element. Now, of course, I'm referring to general anesthesia, those elements, but you're basically rendering the patient with as least amount of bad side effects as possible to give a good surgical environment, which is no pain, No bad memories, no movement. So the surgeon can do what he's doing, and then you can reverse all those things, and they can start gaining consciousness. They can start feeling enough pain to breathe, because if you have no pain, you don't breathe. I didn't know that. Yep. Yeah, that's one of the reasons why people that overdose on narcotics, that's why they die. They have respiratory arrest. They stop breathing. It changes the pH in the brain that stimulates us to breathe better. And again, more than you want to know, but... No, I find all this stuff fascinating. Yeah. People stop breathing when they have too much morphine, Dilaudid, or fentanyl. So that's why. The cardiac arrest is secondary to the hypoxemia. I didn't know that. Yeah. So anyway, so I'm kind of all over the map. So there's general anesthesia, which is, I think, what you're talking about with certainly cancer surgery. We also have a big part of our... armamentarium, which is regional anesthesia. And that consists of spinal blocks, epidurals, things that make you not feel any pain, disconnect what the brain is perceiving and what the body's feeling, which is a really great form of anesthesia for people that are really sick, have bad heart disease, because then you can have a hip surgery, a knee joint surgery. You can have hernia surgeries, lower extremity surgery, and you don't have to undergo anesthesia. general anesthesia. And for someone that's 80 years old, and sometimes people that are older are more susceptible to sometimes the neuro neurologic effects of maybe their memories aren't the same or going on cardiopulmonary bypass. There's some studies that have shown, you know, I mean, it's kind of nice to have regional anesthesia as an option to avoid a general anesthesia. And then the most recent thing, which is one of the been the most exciting things for me in the past 10 years has learning, um, how to do ultrasound guided pain blocks. And that has changed anesthesia as far as people going home earlier, physical therapy earlier, better, um, less nausea, vomiting, less readmission for nausea, vomiting, and pain, because you have pain blocks. These could be interscaling blocks for upper extremity surgery. They could be adductor canal or femoral, um, femoral nerve blocks for knee surgery. I mean, it used to be something that was never done and then became introduced, and now it's standard of care. And if you don't have a shoulder replacement and you don't have an interscaling catheter that gives you 48 hours of pain relief afterwards... I would want to go to another place because it takes a certain level of expertise and follow-up, but it's so worth it. So the post-op pain management with blocks has become a big part of anesthesia. And everyone that's trained... now has a high skill set in that area. Fortunately, I'm in a group that was a multi-specialty group, had a high level. And so I was able to learn those things after I finished my training from colleagues that we hired. And we would train each ourselves and always have observers. That's a whole different subject. But that's, again, why it's been a dynamic changing field that's really satisfying. So can I ask something about those blocks? Okay. So when I, for example, when I go and get the procedure where they... I get a cystoscopy, a retrograde wash. They go up into my ureter to check to see if there's tumor regrowth. So I'm under general anesthesia. I'm intubated. They give me some kind of a paralytic. So I'm not, you know, there's going to be no movement because we don't want to tear my ureter or anything. When I do that, so tell me the things... As an anesthesiologist, when you're sitting there being watched or a nurse anesthetist in this case, who's overseen by an anesthesiologist, what are the things you're looking for? You're looking for blood pressure and heart rate. You're looking for your respiratory rate. What other things do you watch? What other vitals? So monitoring is what we are there and paid for and being paid for. So it's all monitoring. So we have a huge thing and it's very sophisticated of monitoring. And we are in charge of monitoring basically all your physical functions. So you've already mentioned some of them. There's, um, airway, um, So when you take a patient back into the operating room after you've met them, done a pre-check, you put an IV so you've got vascular access so you can give medications and drugs. Then you put on monitors that include EKG to monitor the heart. You're monitoring for arrhythmias. You're monitoring for heart rate so that you can diagnose, treat those if necessary. And if the heart rate's too fast, that's bad. If it's too slow, that's bad. And I can get into why that is. It's very important because the heart rate is just one indicator of of your cardiac output. Your blood pressure. Your blood pressure. Why does that matter? That's your organs perfusing. If the blood pressure is too low, you are not going to get good perfusion to anything in your body. And perfusion means the blood flow to that area, correct? Right. Meaning sending oxygen so that your bowel and gut have blood and oxygen so they don't have ischemia and death. So you're perfusing your entire body, all your end organs, and that is blood pressure is probably the best indicator of that. It's not the only indicator because to be quite honest, you can give drugs that increase the blood pressure. So you feel like, Oh, we're good. But the perfusion actually goes down because you're vasoconstricting because you've treated low blood pressure. So it's like, Oh, I feel better, but we're not doing better. And that's again, the art of medicine, not just treating the number. Um, so you are, so then you put, after you put the patient asleep with medications through the IV, you Then you, to protect the airway, put a breathing tube in, intubation. The reason that is is when you are asleep, you don't have the airway protection you normally would have that would keep things in the stomach and not coming up and going into the lungs to give an aspiration pneumonia. So a breathing tube protects against aspirating. So you have the airway. You're making sure that you're taking the right amount of oxygenation and ventilation. Oxygenation is vital. is exactly what it is, how much oxygen is going in. And you don't want to do 100% oxygenation. That's not good for the lungs either. And there's other things that happen. So you want to make sure they've got enough oxygen, which is determined by if you breathe, how many times you breathe, what tidal volume, meaning how much you breathe, and then how much oxygen is in the air that's being delivered. And you're making all those adjustments with flow rates and pressure and positive airway pressure and making adjustments for people that have COPD or restrictive lung disease. You have to take all that into account. So you've got the breathing, oxygenation, ventilation. Ventilation is the CO2 coming out. Of course, anyone that has emphysema knows that the CO2 has a hard time coming out. It takes a lot longer coming out. You build up the CO2. That means you have... what's called a respiratory acidosis again, beyond this point. But so those are the things you're just kind of quietly, you don't see anything on the outside, but you see the end tidal CO2 curve with a breath. You see the EKG, which is the indicated in the heart rate and arrhythmia. So how the heart's doing. Um, you also have the pulse oximeter, which is a tracing from a thing on your finger, which gives a lot of information, most sensitive for, um, Are you getting oxygen at the tissue? Because you can be getting enough oxygen in the lungs, but you want to make sure it's getting to work. Yeah. So you're monitoring the oxygenation there. You're monitoring temperature. Temperature is really important. People don't think about it. It's a freezing cold room. You don't have the normal protective things that keep your temperature since we are... warm blooded and we need to use energy to keep ourselves at a certain temperature unlike reptiles and so in an operating room when you're uncovered and prepped and draped and it's freezing there because the surgeons like to not be uncomfortable with their non-breathing things and so we monitor that and work to counteract all the temperature losses because once you lose it it's hard to get back and things don't work well in the body you get below 33 degrees centigrade and your heart starts fibrillating so there's a lot of reasons to keep patients warm. So respiratory, blood pressure, heart rate, end tidal CO2, temperature. Those are the things that we're constantly monitoring for like the number and the quantitative. And now we have electronic medical records, so it keeps track of that. And then we just keep track of the drugs you give and the reasons why you give them. And then it should follow along with the vital signs you're seeing. So we monitor the vital signs, which are indicative of what's going on physiologically. And then you've got the record to help reflect. Repair against, yeah. Reflect, yeah. Was that too much? No, I thought that was great. I thought that was great because you go through it and you know me, I ask a lot of questions. So I like to ask a lot of questions and like to know what's going on and be aware of what's going to be happening, but you don't have time with the person who's coming in, the provider who's coming in, to get all that nuance. They're always like, do you have any questions? I'm like, no, I've never had any problems with anesthesia, blah, blah, blah. Well, let me also add one more thing. As we are trying to take care of the whole person and keep everything healthy and keep a good surgical environment, and especially we don't want them to have memory or recall, And we also don't want bad things to happen. That's all the whole monitoring thing. And we also want to have a good surgical environment. And you don't want to have anything go poorly. You don't want to have a heart attack. You don't want to have a PE, pulmonary embolism. You want to avoid those catastrophic things. The anesthesia has been compared to an airplane pilot anesthesia. flying an airplane, the most critical times, critical meaning the most likely for things to go wrong or poorly or not be as smooth are takeoff and landing. And it's very similar with anesthesia because you're taking someone from an awake, alert, conscious state or taking them to go, go to sleep. And it's a critical time. And then the landing is when you're waking them up. So you're pulling back all these things, but you want to make sure they've got enough pain so they don't get tachycardia, so they don't have cardiac ischemia because their heart rate needs to go slow because that's what determines, you know, myocardial oxygen requirement. I mean, that's when you are thinking and preparing, thinking and preparing. So much of anesthesia isn't doing, it's preventing proactively ahead of time bad things from happening. Yeah, it sounds like it's mitigation and monitoring. You know what I mean? And it's this balance. Like you're constantly making sure things stay in balance. Yeah, it's trying to be predictive versus reactive. Once you start getting reactive, it's like, oh my gosh, the blood pressure is just gone away. You know you have three minutes before you have cerebral ischemia that matters. So that's when you are calmer and you are treating what's the underlying problem, even though I'm going to make sure we get our cerebral perfusion right. why is this happening? I mean, just like when you're at a code, you can do all these things to get people, get oxygen in the lungs and the heart going. But unless you, if someone's bleeding to death, unless you stop the bleeding and give them blood, all the CPR in the world is not going to do anything. So you have to be thinking in a three-dimensional way with diet. I like that. It's like three-dimensional chess, chess. Excuse me. So what do people need to know about what are normal side effects and normal recovery you'll have after a procedure where you've had general anesthesia. Okay. When we do our pre-op anesthesia interview, we talk about complications, post-op complications. Probably the most common is post-op nausea and vomiting. That is something that while generally self-limiting is common, common and causes a lot of distress and sometimes causes people to be admitted to the hospital. Because if you have abdominal procedure and you are... Oh, gosh. Vomiting, it is miserable. Are you going to die from it? Is it like a heart attack? No. But even though it's self-limiting, it is very unpleasant. It increases the cost of medical care, increases. And the things that affect the patient really matter a lot, especially with their experience. And so a lot of attention to energy and research has gone into post-op nausea vomiting. So that's the most common. The way where we are now, we've gotten rid of halothane, which caused everyone to get nauseous. And ether, same thing. I was not doing medicine when ether was around, but that was before my time. And even nitrous has been associated with some increased nausea, vomiting in some studies. So we tell everyone with a general anesthetic, post-op nausea, vomiting is likely. The things that increase the risk are being a non-smoking female, Older people do not have as high incidence of post-op nausea vomiting. Who knows why? Non-smoking female, breast surgery, laparoscopic surgery, and a history of nausea vomiting, seasickness, air sickness, or they've gotten sick with anesthesia before. All those increase your risk, and we let people know that. The story we frequently get is, oh my gosh, I've had it really bad before, but the last two anesthetics, they gave me this, this, and this, and I had none. So that's always really good to know because, because we are always trying hard to avoid it. We, uh, proactively treat it. Um, even if, you know, we don't wait until they wake up from anesthesia in the recovery room and start feeling nauseated. We treat it ahead of time. The way we treat it most of the, with most patients is by, um, Limiting the amount of narcotics to just as much as you need, not too much, because narcotics are the number one offender for causing nausea, vomiting. So that's a balance. We also pre-treat usually with a small dose of steroid at the beginning, usually Decadron. We also will give Zofran or Odansetron at the end of the surgery. And then we leave rescue drugs in the recovery room, PACU, because there are other things like Benadryl, Compazine, even Anapsine, which is droperidol is another name for that. We used to use droperidol a lot, but it caused side effects that were... They made people a little bit too tired. Sometimes you can get dysphoria. So we actually don't use that routinely anymore, but we still have it. So we routinely give everyone antiemetics prophylactically. Decadron and Zofran. And then we have some rescue drugs to help in the recovery room. There are a very small subset of patients that will still have problems. And then we will do other things like give a second dose of Zofran. The incidence of post-apnosia vomiting has probably gone from 80% down to 30%. That's great. But the 30% are usually those people that have had gastric surgery, plastic surgery, and laparoscopic surgery. So they're already predisposed. Yes. So we can't bring that incidence down to zero, but we have brought it down a lot. So common side effects, post-op nausea, vomiting, that's how we tackle it. Another way we tackle it is by doing regional anesthesia. Someone that says, I just get the worst nausea vomiting and I don't stop for a week. Well, it's probably not still the anesthesia, but for whatever on that, it's like 48 hours. That's not an uncommon history in someone who is really susceptible and has had a history of it. So then I would say, gee, let's do your total knee under a spinal. I won't give you any narcotics and we avoid it altogether. So regional anesthesia is another way to decrease the amount. Also, Pain blocks, it means you give a lot less narcotic, loss less general anesthesia because you have no pain. That's another way to diminish the most likely vomiting. Other things that are bothersome, grogginess, a lot of people don't like that out of control grogginess. Again, with propofol and light general anesthetics, that has been improved a lot. And so, uh, then it's just patient populations that are super susceptible that might have that unpleasant grogginess and that goes away. Um, is for me has been wonderful because I go out quickly. I come back, I go down quickly. I come back out quickly. I don't end up with that residual nastiness that just feeling gross and nauseated and
SPEAKER_01:And
SPEAKER_00:I've had the same procedure every three months for the last year and a half. And it's been great. It's awesome. Propofol is the best drug that's been introduced into anesthesia in a long time. It's wonderful. It's amazing what you can get away with with Propofol. You can really do for conscious sedation, Propofol, a little narcotic, a little benzodiazepine. When I say, oh, amni... Intraoperative recall. Let me just... finish the first question. Everyone's always worried about, I don't want to wake up during my surgery, which that nomenclature isn't actually accurate, but we'll leave that aside. People don't want to remember or have memories or hear people talking if they're expecting to be asleep. So frequently what will be added to the mix when going to sleep is a small dose of benzodiazepine or midazolam. In the olden days, it was Valium or Ativan. Those are really long acting drugs, hardly ever get used except maybe heart surgery. More often than not, a little midazolam, it's just like amnestic from that point on, which has really been nice to significantly decrease the intraoperative recall or the remembering what was said or waking up because even though that doesn't cause any long-term problems, Physically, emotionally, and mentally, it has caused significant problems, especially when you read the horror stories or the Stephen King books that talk about someone being paralyzed but not being able to talk. I mean... Could that happen? Yes. Does that happen now? I would like to say 100% no, but I've never heard of it in my practice or my patients having that happen. The closest thing with intraoperative recall, which I'm not going to say the incidence is zero, it's more of a, I vaguely remember something, and it's usually if someone's having an emergency C-section and you really hold off on giving lots of drugs until baby's out and And so there may be a little bit there, but usually this, I don't want this to sound flippant, but no memories are better than no memories. If someone's bleeding to death, any anesthetic is going to cause a blood pressure to drop, a cardiac output to drop, and you're trying to save a life in that situation. So intraoperative recall is almost always. is most commonly with life-threatening emergencies that are life and death. And that includes a C-section that's an emergency for a baby that is not doing well, that you want to get the baby out, and then you take care of adding in all the amnesty. The other stuff, okay. The anesthetics. So again, this is more information that you need. But having no recall is a part of the anesthetic goal. Well, yeah. I mean, I, when I had open heart surgery, I don't, I mean, it was, it was my cardiothoracic surgeon described as we spent a very long day together, you know, and I, and I was on bypass for a long time and they were doing a lot of repairs, right? Let's say again, it flew for you. It's like, yeah, I don't remember anything. No. And it was great. I fell asleep in the cardiac cath lab because they wanted to check every, all my veins and everything first. And, um, and then woke up briefly when they transferred me from ICU to the cardiac care step-down unit. And then again, about a day later. So they kept me really, really nicely out of it, which I was very grateful for. One thing I have sometimes is I get facial flushing. Can that be a side effect of some of the drugs used or just that you've had a surgery? Well, yeah. you kind of say yes to everything. It could be related because it could be capillary vasodilation. There are a few drugs that do cause some different side effects that we don't use routinely, but use in certain instances. For example, atropine is a drug that is used when you want to, when the heart rate is going very, very low, sinus bradycardia, or maybe even worse, and you need to quickly get the heart rate up and atropine can be given. And it does a great job. It's a resuscitation drug. If your heart rate's 20, you're not going to be able to maintain a cardiac output or a blood pressure for very long. And atropine is the drug of choice. It's the ACLS drug of choice. But the problem is atropine, as an anticholinergic, it crosses the blood-brain barrier. So some of the other side effects you get is... Wait, what does what anticholinergic mean? That's the class that atropine is in. Robenol and atropine are anticholinergics. It means it blocks the cholinergic... You kind of get into the sympathetic and parasympathetic nervous system, but... but you're blocking that nerve that's slowing down the heart so the heart can speed up. But it also can cause very dry mouth. I mean, just cotton dry mouth. It can cause facial flushing. So your face is just like red. You know, you say red is a, red is a what? Red is a beet, hot, hot is a something, mad is a hatter. Kind of make you feel crazy. So, I mean, these are, we have different acronyms that I can't even remember them on the spot. So you know if you get an anticholinergic that crosses a blood-brain barrier, you say, oh, you're going to have a really dry mouth, you're going to feel hot and flushed, and that's all going to go away. So there are side effects to different drugs. Ketamine is another drug. It's really great. as a pain reliever, and it can be a complete anesthetic. I think it's used a lot in veterinary medicine. And it's kind of had a renaissance. It's coming back in other ways. But if you don't give ketamine with an anticholinergic like Robanol, you're going to have bubbly frothing at the mouth because then you have this release because of the ketamine of all the salivary glands. And also, ketamine can be associated. It's like a hallucinogenic. You can have like bad dreams, like traumatic bad dreams. So we always give it with, with a midazolam. So you don't have the bad dreams. So there are certain set of side effects as different drugs, and we kind of know what they are and try to avoid those side effects. So I don't know if that's what caused your facial flushing, but that's one thing that came to mind. Maybe if your heart rate got a little too low, maybe someone gave you atropine and you could have woken up with a facial flushing. I need to ask them about that. And then that, what is it? Midazolam? Is that also a benzodiazepine or not? That's Versed. You know, every drug has two names. Right, right. Midazolam versus ed, same thing. And it's awesome. And with conscious sedation between midazolam and then propofol, you can keep someone snoozing the whole entire time while you're doing something that isn't too painful because you can only do that if you're doing... I mean, you could... Colonoscopies and stuff like that. Yeah, we do it all the time. Okay, awesome.
UNKNOWN:Yeah.
SPEAKER_00:What are some things you wish patients knew ahead of time if there's stuff you haven't covered already? One thing I forgot to mention is the sore throat from the breathing tube. Oh, yeah. Almost everyone has one. I always let them know about the sore throat because that way when you kind of know what's going to happen, it's a lot easier to handle instead of, being angry. Like no one told me this. So we really do try to go over the more common things, post-op nausea, vomiting, sore throat, grogginess. Um, and, uh, sometimes people that are going to have a full, uh, Foley catheter, they almost all feel like, oh, I have to pee. I have to pee. And it's like, well, go ahead. But they, it's the irritation, um, in the detrusor muscle that just causes that uncomfortable feeling. So again, you let them know you're going to feel like you have to pee. Don't worry. There's a catheter. Your bladder will drain. You're going to have a sore throat. Sometimes you might have itchy, scratchy eyes. Sometimes you can get corneal abrasions. That's also something we mentioned, which... I mean, we always tape the eyes shut to avoid anything, you know, because we've got their face going to sleep, putting in a breathing tube. There's a lot going on. Just as protection for... Right. Corneal abrasion is not uncommon. For people that have difficult airways, either that have TMJ, they can't open their mouth, they have, you know, loose or cracked teeth, we always talk about possibly having dental damage or injury, which is... More common with people that have bad teeth, but it could be just they have limited mouth opening, small mouth, a difficult airway because of the congenitally difficult airway, meaning hard to get the breathing tube in, requiring other techniques, which could put them at risk for having a tooth chipped or something like that. So we're pretty good about mentioning that to everyone. So that's another thing. Well, and I find it's... It's important to honestly answer the questions that are asked because they always ask, have you ever had problems with anesthesia? Have you ever been told you have a difficult airway? Do you have any crowns, bridges, et cetera, et cetera? They ask those questions for a reason and it's for our safety. So it's not something that you want to gloss over with somebody just to get into the procedure. Let me, while you just met, you just reminded me of one. We ask everyone if they or any family members had complications to anesthesia or We are specifically asking not only for drug allergies, because of course anaphylaxis, which is the severest form of a drug allergy, is something that's life-threatening and we want to know about, and not only not give those drugs, but be prepared to treat an allergic reaction. Anaphylaxis is the worst form of it. For anesthesia, we are always thinking MH, which stands for malignant hyperthermia, which is a very rare and uncommon disease. but it is deadly and it's a higher risk of it in muscular dystrophy, children with different musculoskeletal abnormalities, latex allergies. And even though I can't off the top of my head, give you the incidents, if you've ever had one, you will remember it forever. And that's why it requires a muscle, sampling that you make the diagnosis for malignant hyperthermia. And because it's so rare, but can be so deadly and treatable. There's a malignant hyperthermia hotline that every, when any anesthesia providing location has one, you also have dantrolene and there's a newer dantrolene that's not so hard because you have to mix it with vials of sterile water. And it's, you need to call people in the room and have people, it's like running a code to treat it because what happens is their body goes into a hypermetabolic state, massive muscle release of potassium and from the muscles. You can go into kidney failure because of the rhabdomyolysis, which is caused by the malignant hyperthermia. What's rhabdomyolysis? Breakdown of muscle tissue. And then you have those products that go into the kidneys and cause kidney failure because the body isn't intended to do that. And it's marked by high entitled CO2 you start producing. If you think of hypermetabolic, you're producing CO2. You can't get rid of it quick enough. The CO2 goes up. You get a severe acidosis. Acidosis things in the body start not working very well. And then you've got the cardiac effects of the high potassium. You can go into a cardiac arrest with that. So if anyone has a history of MH, we basically do what's called a non-triggering anesthetic. And the thing that triggers MH or malignant hyperthermia is succinylcholine, which is a depolarizing muscle relaxant. So you never use succinylcholine. And matter of fact, we've gotten away from succinylcholine I mean, it's the best drug in that it works in a minute. You can't intubate and you can ventilate. Ventilate meaning you can handbag ventilate. But if you can't intubate, sex can save the life of a baby who you can't get the breathing tube in because you just get immediate paralysis. But at the price you pay, it's a depolarizing, meaning it causes every muscle to contract and then it can't uncontract forever. a short period of time, and that's how you get the total body muscle relaxation. So it's succinylcholine will trigger malignant hyperthermia and the inhalation anesthetics. So we do anesthetics safely now all the time, all the time meaning a patient that's been diagnosed or has a family history, and we treat someone with a family history because it's genetically linked, the same as if they had the diagnosis. So that's been ruled out. And you just do propofol, Anything IV medication only, it's called TEVA, total intravenous anesthesia. So it's propofol, narcotics, and benzodiazepines, and muscle relaxant. We've done people that had major hardware back surgery all under TEVA. They take the anesthesia. Okay, so can you talk, sorry, we cut out there for a second. Can you talk about TEVA again? TEVA is total intravenous anesthesia, meaning no inhalation agents. Inhalation agents are a key component to almost all anesthetics, unless you're having a regional, and then you just put propofol with a regional. So Teva helps you avoid using, you don't use sex, no choline. You can use other muscle relaxation at the other muscle relaxants, the non-depolarizing muscle relaxants, meaning they block the motor in plate. They don't trigger like sex, no choline depolarizing meaning the the muscles contract and you get the outlay of potassium, non-depolarizing means it blocks the sites. So the muscles don't work that way. And it's not- And you don't get that potassium dump. Right, exactly. So succinylcholine and inhalation agents, the ones that are most common now are desflurane. We used to use isoflurane, don't use anymore. Used to use halothane, don't use that anymore. But it's sevoflurane and desflurane. And all the inhalation agents- that I just mentioned all contribute to malignant, triggering malignant hyperthermia. So you clean the machine out with a high flow. You take it out of the room. You take the sex out of the cart, sex, no choline, and you just use total intravenous anesthesia. That's neat to know that there's a way to handle that though. Now. Oh yeah. Works for people that without, because without propofol, we, I mean, It's really become standard. Sometimes we have patients ask for Teva, not because they're at risk, but because if you have severe nausea, vomiting, even despite using all those things I mentioned earlier, that is the very... Teva's trickier. So it's not something that I'm anxious to go do on everyone. I mean, it's a lot trickier to have patients moving the right level and using a ton of propofol because... I mean, so, I mean, it's very doable. It's a great anesthetic. You wake up a wake alert and it's awesome. So, but some people ask for Teva to, because they have intractable nausea vomiting. So that's also used for those patients. Okay. But it's on a specialized basis as needed, not. Yes. Not commonly. Okay. Let's see. So what has, I love just looking, You're just like this fountain of knowledge. And I'm just sitting here listening, spinning and thinking about all this stuff. Well, you're interested in it. I always feel sometimes people's eyes glaze over because I kind of give more than people want to know. Well, but I've been through a lot of procedures and surgeries over the last eight years. And so it's just interesting because then when somebody asks me a question, I can answer and I can ask better questions back about what it is. They're saying, I just, I don't know. I like, no, some people like to go into things kind of blind, like, yeah, my physician knows what's going on, whatever. That's just not me. Like, I want to know. I have had, you do get a feel in the pre-op interview when you're going over risks and complications and, and you want to do an informed consent. Some people don't want an informed consent. It increases their anxiety level. And so, um, So what do you do with that? Sometimes what I will do is I say, well, is there a chance I'll die, that I'm going to die? And I'll say, there's always a chance and there's always risks. I usually, you want to give them what they want, but you feel compelled. I feel compelled to let them know the most likely things that they probably will deal with that I've already mentioned. Sometimes I will say, you know, the chance of you dying being a young, healthy person is is remote and the chance of you dying in a car accident on your way to the hospital today, which is about one in 250,000, is greater than you dying under anesthesia. And that usually puts people's anxieties to rest. Well, and it gives them a perspective and a recent event to tie it to. Yes. Okay. And then we stop. I don't really insist on force feeding every possible thing that can go wrong. And there are... different things depending on what they're having done and depending on their baseline medical condition. A diabetic is going to be the increased risk for a lot of different things. Someone who is morbidly obese has an increased risk for almost everything, every complication. And I could give the reasons why, because that is not a loaded statement. It is scientific and factual. Well, and there's already a lot of stress on In both of those conditions, there's already a lot of stress on certain body systems as it is before you went into surgery. Yeah, I remember. Smokers. Smokers. Oh, yeah. I mean, really increased risk. And then, so diabetics, smokers, people that are on anticoagulants for heart things, for DVTs. You know, usually that's been resolved. The systems have gotten pretty good at resolving that as far as knowing how long they need to be off those things and bridging with heparin. So that's less of an issue unless you don't have the right information, like when they last took limidin. which is really, really important. And that's why, like I did my pre-anesthesia call this week for the procedure I have to have in a couple of weeks. And I was like, what supplements are you on? What are you doing this? And we always talk about what can I take? What can't I take? When am I NPO? Which things do I need to stop a week before? Which things do I need to stop three days before? Et cetera, et cetera, et cetera. You're very informed and dialed in. A lot of people have no clue why they can't take all their supplements, why some supplements cause an increased bleeding. For some surgeries, it's not a big deal. For other surgeries, it is a big deal. Well, like ginger and valerian, I'm not going to be taking those things. I guess what I'm trying to say is it's really important to have an open, honest relationship and an open and honest conversation with the medical care providers you're going to have. Because your outcomes will improve dramatically if you'll just be opening up front about things, whether it's them calling ahead of time to ask what kind of things you're taking. They always ask, do you take illicit drugs? I don't. But some people do. And you need to know that they're on those things before you start giving them narcotics and other drugs. It's just, I don't know. I just think that's crucially important. It's part of being an informed partner in your own health care. Yep. And it's also really helpful to know which blood pressure meds you take. Some of them are essential to take to protect your heart. Other ones put you at higher risk because once you go to sleep, you'll have such a big drop on your blood pressure with ACE inhibitors or R blockers that we're giving you something to increase your blood pressure the whole entire case, which is not risk-free either. So you definitely want to, that's one of the really important things in the pre-anesthesia visit is which drugs to stop, continue. And there's good reasons for both. Yeah. And make sure they know the dose and how often you really take it. And like you said, they'll always say, did you take your propranolol this morning? Yes, I did. But I talked to them ahead of time and make sure I can take my propranolol the morning of the surgery. You have to take responsibility for your own health. You can't just walk in there and expect somebody to take care of everything for you. And I think that's when people have the worst experience, outcome, whatever, is when, not always, that's not universally the case, but in most cases, if you have a good relationship with your provider, you're open and honest, you do your due diligence, you will have a good outcome. And I have to also sidebar here, you are an educated medical consumer, right? I mean, I don't think it's necessarily easy, all those things with communication, with elder people, with people that have care, care providers, with families. I think because of the time constraint and pressure in the medical system for efficiency and speed, and you don't have a lot of time and there's miscommunications and you're being referred from consultants from another city, I think there are so many areas and room for miscommunication, misunderstanding. I mean... It's, uh, it's fraught with potential pitfalls and increased risks due to no one's fault, but just our medical system. And I've had to slow people down sometimes and say, I would say, excuse me, could you explain that again? Or could you like, what does that word mean? Okay. What do you ask? And, and, you know, some people don't want to feel dumb and I just kind of don't care at this point, but I want, I want to make sure I understand what I'm agreeing to. And, and that's why if you go, um, I don't know, I think if you're going as a patient or you're going as a caregiver for a patient, just please, please, please ask good questions. Please make sure you understand what you're getting into as much as you possibly can. And like you said, that's not always possible, but as much as you can. Okay, what has this line of work taught you about yourself? You know, I think it has... I think it's just made me, it's brought me humility and gratitude. Humility in that sometimes it's easy to get going in the fast pace of all the different things you're juggling and doing, but because I get to take care of one patient at one time, focus and clue in to alleviating their anxiety, taking care of them and dropping them off, And then having been a patient myself, I feel like it's really a privilege to be able to be kind of the point person and saying, I'm going to take care of you. Everything's going to be okay. When they're the most vulnerable, the most frightened, they've got doctors coming and going, and it's just kind of a dizzying, overwhelming experience. And they've lost total control of their life and their body. limited period of time, and they may never remember my name because if I'm doing my job, they don't remember anything. So you don't go in there as an egocentric, I'm going to be, I'm so awesome, I'm going to save the world kind of thing. That's more of a surgeon's mentality, and I don't mean that in a disrespectful way, but they are definitely, you have pain, they cut it out, and that's a different personality type. Not a different personality type, but a different person that goes into that field, a very... Anyway, I won't go there, but I'm just feel like it's, you know, you're kind of the behind the scenes. No one knows what you do, so it's okay, but you know what you do and you get to, I think, make a difference in a really scary experience being hopefully a little less scary and knowing someone's going to get you through it. Yeah. I'm always really grateful to have a great whether it's an anesthesiologist, nurse, anesthetist, whatever, that just puts a connection there. And you know, they're the one that's there with you as you're wheeled in. They're going to be there as you go to sleep. That's it. You've got to kind of let go of the fear, let go of the what ifs, let go of the worry and think, okay, I'm going to let go of that. I'm going to let you take care of me. So, and that's, you know, some people have a harder or easier time with that. It's amazing. Some people just like, they just kind of trust you from the And I love that faith and trust, but as medical professionals and people that tend to have a lot of control in their life, it's very hard to let go of that when I'm on the other end as being a patient. And what have I learned about me? So that's one of the benefits of it. I think that... There's so much anxiety and fear and pressure, time compression with the whole medical training and finding a career and raising a family. And then as a woman, you have guilt. Am I doing the right thing? What toll is it taking? I think over the years, I've really embraced and felt great that I was able to find a specialty that suited me. suited me and I see my personality. I see the way I approach things in the other aspects of my life. And there's a lot of carryover. I do try not to be a control freak in, I mean, I'm controlling everything in the OR environment. I have insight into that and realize, okay, I'm not supposed to have all these other elements. So I feel like being at work, it's in my wheelhouse. And then as with everyone in their life, you compartmentalize. But I think that I'm okay feeling that this was a good match for me with my brain, with my abilities. And I don't feel apologetic about that. So I guess it makes me feel really good about myself and I can embrace that instead of, I don't think it's in a cocky, I'm not better or higher than anyone else. But matter of fact, I'm, there's so many things I don't know anything about. I'm a big seeker of information from everyone else that has an opinion as I try to figure out life. But, um, it is like you're at peace with your choices and that's beautiful. Yeah. Yeah. And it, and it has not always been that way. No, I think that's great. That's a great place to be. Um, let's see. I think we covered all the tips and tricks you had for patients. Is there anything else you wanted to say just for as patients come in? And if you don't have anything, that's okay too. The best thing patients can do is give us information, not only about the clinical health stuff, but their fears and concerns. And that just helps us to not, I don't know, I just feel like that can be the best thing separate from the drugs, separate from the anesthetic technique is just to feel free and open, safe about what you're really afraid about, as well as what you're on and what your medical conditions are and your past experiences. And I think that's probably the best way to have the person who's just maybe met you 10 minutes before actually be able to help calm the anxiety that's always associated with having a procedure or surgery.
UNKNOWN:Yeah.
SPEAKER_00:I've had them a million times, but there's still that moment of like, okay, all right, here we go. You know, there's always that moment. What are some of your personal bucket list items? Well, I like to travel and I've done more since I've been semi-retired. I would like to trek Nepal up to base camp someday. Oh, wow. Yeah. I would like to go to Greece and visit the islands. I want to get more of the Mediterranean. I just like water and beauty and being outside and having experiences I haven't had. I actually just want to travel more of the United States to go to places I haven't been to. So I think that is one of my bucket list things. One of the things I wanted to do when I retired was to start taking piano lessons again. I quit in sixth grade and kind of regretted that. And I'm a musical and artistic wannabe. I feel like I don't have those in my skill set, but I value them highly. I started taking piano again and I have, I took a break during COVID and I want to get started, but I would love to play beautiful songs that my children played. They both, they're Two of my sons took piano. And so I love hearing piano in the house. So I want to do that. And I've kind of been learning how to garden and plant flowers and vegetables and fruit. And I've been doing canning and I just finished gardening. taking our grapes and juicing them. And I've been roasting our garden tomatoes and freezing them. So those are things that were sort of on my bucket list that now aren't on my bucket list because I do it now. No, it's awesome. It's been fun to expand my repertoire. And someday I want to take a cooking school. Like Cordon Bleu?
UNKNOWN:Yeah.
SPEAKER_00:Yeah, I've never, yeah, I don't, I think I'd want to go do something cool like learn how to do bread in France or Italy. I mean, just do something that combines the travel and the cooking element. If I was a wine drinker, I would love to learn about wines, but I'm not, so it'd be kind of wasted. No, I like the bread idea, like bread school. I love Italy. Anyway, long story, we'll have to talk about that later. And your tomatoes, I forgot, I was going to tell you, I gave them to our son because he makes this roast tomato soup and he brought me some this morning and I sauteed some shrimp with that. And it was so, those tomatoes were so ripe and so good that it was almost sweet. It was so good. I just made some last night and I'm going to have that when we're done talking. It was really good. What are, well, we've already talked about some of this, but any other favorite places to be by the water and outside? I heard that. Yeah. I'm a Southern California girl, so the beach is always my fave, even more than the mountains. I love the beach. Places to be. I'm just going to say with my family, I've got seven grandchildren. Some of them live in Europe right now. I'm leaving October 18th to spend two weeks. We're going to be in Sicily for 10 of those days, but I haven't seen the one-year-old in... Well, he's one and a half and I haven't seen him in a year because they went back. So I'm going to say being with my kids and my grandkids. That's awesome. Well, first of all, thanks for the time. I appreciate it. And thanks for explaining things that we don't usually have a whole lot of time to absorb. So it's nice to have it done outside the pre-op setting and get more information on it. I really appreciate it. Well, you're welcome, Heidi. I'm pretty hyperverbal. So I hope It worked for you and whoever else might be listening. It was great. Thank you. Okay. Take care. Debbie has a passion for her work and for helping people, most especially her patients. And that comes through so clearly. I'm thankful that we have good people like her in the medical field who do so much for so many of us. This week as you go around the world, please do something nice for somebody else in whatever way you can. Count your blessings and make it a great week. Thanks for listening.