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Sick Hearts, Simple Surgeries with Cory France · Style Points

0:00
Hello anesthesia enthusiasts and welcome to this month's episode of Style Points.
0:15
If you work in a NOAR, try to remember the last time you were in a crisis scenario.
0:20
Who would you want there with you?
0:22
For a lot of us here at the University of Cincinnati, it's Dr. Corey France who's
0:26
joining us to talk about patients with sick hearts who are having non-cardiac surgery.
0:31
Before that, I'll turn it over to Nate Moore who will introduce this month's RSI.
0:37
Thanks John.
0:38
I'm excited to introduce Dr. Krista Selinger, the star of our RSI today.
0:41
She is taking a quick break from her perioperative care rotation to teach us about IV anesthetics.
0:46
Let's hear it from Krista.
0:48
Now I know you're all busy juggling OR schedules, pre-op assessments, and the occasional 2 a.m.
0:54
a case, but for the next 5 minutes we are going to break down IV anesthetics in a way
0:58
that's quick, digestible, and useful for your everyday practice.
1:02
So let's get started.
1:03
What are we really talking about when we say IV anesthetics?
1:08
These are medications delivered intravenously that induce or maintain anesthesia.
1:13
They work by depressing the central nervous system and we use them for everything from
1:17
induction of general anesthesia to sedation in the ICU.
1:21
Let's focus on the big 4 IV anesthetics you'll see in the OR.
1:25
Propofol, ketamine, atomidate, and benzodiazepines.
1:30
We'll also briefly touch on opioids and dexmedetomidine.
1:34
First up, propofol.
1:36
This one's the workhorse of induction agents.
1:39
Quick onset, short duration, and most patients wake up pretty smoothly afterward.
1:43
Mechanism, it enhances GABA activity leading to CNS depression.
1:48
Clinically, you'll notice it drops blood pressure.
1:52
This is due to vasodilation and a bit of myocardial depression.
1:56
So if you've got a hemodynamically fragile patient, maybe a septic ICU transfer for example,
2:01
think twice before pushing a big bolus of propofol.
2:06
Dosing is typically 1 to 2 milligrams per kilogram for induction in adults, but you'll
2:10
tweak it based on patient factors.
2:12
And remember, propofol burns on injection.
2:15
A little lidocaine or using a larger vein can help with that.
2:20
Next up, ketamine.
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This drug is like the Swiss army knife of anesthetics.
2:25
It works as an NMDA receptor antagonist and has some unique properties.
2:29
It's both an anesthetic and an analgesic.
2:32
It also maintains a patient's spontaneous ventilation while most other induction agents
2:37
cause apnea, making it a great option in situations such as patients with cardiac tamponade or
2:42
those predicted to be difficult to intubate and ventilate.
2:46
Here's the kicker.
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Ketamine increases sympathetic tone by causing a systemic release of catecholamines.
2:52
So while most anesthetics drop blood pressure, ketamine can actually support it.
2:56
This makes it a great choice for trauma patients or anyone who is hypovolemic.
3:00
However, ketamine also has direct negative inotropic effects on the heart.
3:05
Normally, the indirect catecholamine release overpowers this, but the negative inotropic
3:10
effect can be unmasked in a catecholamine-deplete patient.
3:14
So ketamine may not be the best option in patients with decompensated heart failure
3:18
or sepsis.
3:20
Don't forget that ketamine is hallucinogenic at the right dose.
3:23
Watch for emergent delirium, that funky dissociative state where patients may hallucinate or get
3:28
agitated.
3:30
To mitigate this, consider co-administering a benzodiazepine like menazolam.
3:36
Administering for ketamine is typically 1 to 2 milligrams per kilogram for induction.
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Bonus use for ketamine.
3:41
It can be safely given intramuscularly, which makes it a great option for patients who won't
3:45
tolerate an IV placement.
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IM induction dose is 4 to 5 milligrams per kilogram, which is a pretty whopping dose
3:52
that can take a long time to recover from.
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So it may be wiser to give a small enough dose so that your patient will tolerate an
3:58
IV and then complete induction with a different agent.
4:02
Now let's talk automidate.
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This is your go-to for induction in the patient with a weak heart or hemodynamic instability.
4:10
It's also a GABA agonist, but with minimal cardiovascular effects.
4:14
Sounds perfect, right?
4:16
Well, not quite.
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Automidate has two main drawbacks.
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First, it suppresses adrenal function by inhibiting 11 beta hydroxylase.
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After a single dose, this isn't necessarily a huge deal, but prolonged infusions can lead
4:29
to adrenal insufficiency.
4:31
Second, myoclonus is pretty common, those little jerky movements during induction.
4:37
Don't worry, it's not a seizure, but it can be a nerving if you're not expecting it.
4:42
The typical dosing is around 0.2 to 0.3 milligrams per kilogram for induction.
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And finally, midazolam.
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It's a benzodiazepine and its primary role is sedation and anxiolysis.
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Mechanism?
4:56
Once again, it's all about GABA enhancement.
4:59
Benzodiazepine has a slower onset than propofol or automidate, so you don't use it much on
5:03
its own for induction in adults, but it's a great premedication or light sedation drug.
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Be cautious with elderly patients or those with respiratory issues.
5:13
Benzos can cause significant respiratory depression, especially when combined with opioids.
5:17
However, midazolam generally does maintain hemodynamic stability.
5:22
Quick shout out to dexmedetomidine, which is an alpha-2 agonist.
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It's an awesome sedative, particularly in the ICU, as it doesn't cause significant respiratory
5:31
depression.
5:32
And there's EEG evidence that its effects mimic natural sleep patterns.
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However, you'll see bradycardia and hypotension pretty frequently with dexmedetomidine.
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These side effects limit its use as an induction agent, since a bolus dose of dexmedetomidine
5:46
would cause significant hemodynamic changes.
5:49
And then there are opioids, fentanyl, sufentanil, and remifentanil.
5:54
They're crucial adjuncts for pain control, but aren't traditionally used as a sole agent
5:58
for induction outside of the classical cardiac induction, in which high doses of opioids
6:04
are slowly titrated to effect.
6:06
But we'll save those for another episode.
6:08
All right, let's summarize.
6:11
First up, propofol.
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It's fast, reliable, but watch out for hypotension.
6:16
Ketamine, hemodynamic stability plus analgesia.
6:21
Just keep emergence in mind.
6:23
Atomidate, perfect for fragile hearts, but beware of adrenal suppression and myoclonus.
6:29
Medazolam, great for sedation, less so for induction in most cases.
6:34
Remember, every drug has its pros and cons, so it's all about picking the right tool
6:39
for the right patient.
6:49
Corey France is an assistant professor of anesthesiology at the University of Cincinnati,
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who did a fellowship in cardiac anesthesiology.
6:56
Whenever a case is particularly complicated or when disaster strikes, most of the people
7:00
that I know would pick Corey to be there.
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He brings a calm demeanor and significant expertise to almost any situation he's involved
7:07
with.
7:08
Corey, thanks for joining us.
7:10
John, thanks for having me.
7:11
I appreciate it.
7:12
Absolutely.
7:13
So first off, why do you think people see you this way?
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How have you developed this reputation in the time that you've been here to where everybody
7:21
seems to want you there when bad things are happening?
7:25
I think part of it is I'm a giant black cloud.
7:28
I'm turning gray, but I was and have been for a long time a black cloud.
7:32
And so just having these terrible experiences, I wouldn't say terrible, but difficult experiences
7:37
early on in my training, every time I'm on call, seeing it over and over, kind of get
7:42
used to it to some degree.
7:45
And then I also am my pathologies fit well within our specialty.
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So me being a paranoid, pessimistic person, I'm always thinking, what's the worst thing
7:55
that can happen?
7:56
What am I going to do if that thing happens?
7:58
So you combine that with the fact that I always just seem to turn the corner right when something's
8:03
happening.
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And I think that would probably be why.
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Do you think that you're more of a black cloud?
8:08
Or are you more of a storm chaser?
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Because it seems like you you find yourself in those situations more often than a lot
8:14
of people.
8:15
I mean, early on, I was definitely a storm chaser, especially end of residency, early
8:20
fellowship.
8:21
I definitely don't seek these things out anymore.
8:23
I'm not going looking for them.
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I do not wander the halls just waiting for stuff to happen.
8:29
Fair enough.
8:30
That was me probably five, six years ago, though, for sure.
8:32
I remember when you started, my first year as an attending was your first year as a fellow.
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I think we graduated at the same time.
8:40
And I remember we were always in different cases because you were doing all the cardiac
8:44
analysis, but people always spoke very highly of you, even though I never really got to
8:49
work with you.
8:50
Yeah, I appreciate you saying that.
8:53
Yeah, glad I could be seen that way.
8:56
So when we were discussing topics for this podcast, I asked you if there was anything
9:01
that you were particularly interested or passionate about.
9:04
You're known as the cardiac guy that everybody comes to.
9:07
But I wanted to know if you had any particular subsets of cardiac anesthesia that you wanted
9:12
to talk about on the podcast.
9:14
But you answered very quickly.
9:16
You said you wanted to talk about non-cardiac surgery on cardiac patients.
9:21
Yes.
9:22
Why?
9:23
Part of it is a frustration on my end because I see people, we have a lot of residents who
9:29
graduate and stay on as faculty here.
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So I see these residents, I watch them grow throughout their years here during training.
9:38
They get through residency, they're very good at what they do.
9:41
And they start as an attending and they're willing to take on these difficult cases,
9:45
challenging patients.
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And then slowly a year or two in, they're kind of shying away from them.
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And it's not because they've lost their skill set.
9:53
I don't really know why they do it.
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But I think when you finish training, you are prepared to take care of the sickest patients.
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You know, especially if you finish residency here, our residents are ready to take care
10:05
of almost anyone that's going to come through the door.
10:08
So you need to foster that and continue that, not shy away from it as you kind of go on.
10:12
You might not be doing the cardiac cases, the valves, the cabbages, that kind of stuff.
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But you know how to take care of these sick cardiac patients.
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Don't shy away from it.
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Use the skill set that you've trained yourself to have and gained from your residency program
10:25
and continue to care for these sick patients.
10:28
And also it's not going to go away.
10:30
I mean, if you look at our population, our surgeons are no longer declining someone just
10:33
because of their age or their frailty or their baseline mental status, dementia status.
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So you're going to have to take care of these patients, whether you're working in a surgery
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center somewhere sometimes, at an academic center, at a private practice group in the
10:46
suburbs, they're going to come your way.
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And so just I would love if people continue to stay comfortable caring for some of these
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people, because you can't have cardiac anesthesia care for every person that has a bad heart.
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It's just not feasibly possible.
11:00
Yeah, that makes a lot of sense.
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I've handled plenty of those scary cardiac patients myself over time, and I do my best
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not to shy away from them.
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I would be lying though, if I said that I asked for patients like that.
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Yeah, there's still going to be wrong there days where I would love to not interact with
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any of those patients.
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But like I said, you're just not going to be able to hide from that, I don't think,
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especially as our field goes into the future.
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As these people continue to want a palliative hip replacement, right when they're in hospice,
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that kind of thing.
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It's just something we're going to have to do in our field.
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I definitely think it's good to have some of these sick patients.
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I'm sure I have several every week where they have decreased EF or a valve that's bad, or
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there's some terrible vascular path, something like that.
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It's definitely good to be in an academic center where I can keep up my skill set despite
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not having done a cardiac fellowship.
11:57
So let's back up for a second and ask one of my favorite get to know you questions,
12:02
of course, the who has you asked a dinner question.
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So you can invite anyone in the world over to dinner.
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I've had a lot of really interesting responses to this so far.
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You could invite somebody from the past from fiction, who are you going to have over and
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why?
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Yeah, you gave me a heads up about this question.
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And I thought I would struggle with it.
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And I sat down to think about it.
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I was actually thinking about it.
12:23
I live, if you know the traffic situation in Cincinnati right now, we're a little off topic
12:26
for a sec.
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I live in rural Kentucky and my bridge is broke.
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So I have a long time to think on car rides home.
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And when I get stuck in bumper to bumper traffic, I don't want music on.
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I don't want to listen to NPR.
12:37
I just turn everything off.
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And I zone out and I just fall the car in front of me.
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And so I had time to think about this.
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It took me all about 10 seconds.
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I would be my paternal grandmother Joan.
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She's no longer here.
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And I thought I would really struggle to find someone of historical interest or something
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that fit with some of my passions outside of medicine.
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But no, it would be her.
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It would be her for sure.
12:58
What would you talk to her about?
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Just life.
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She was someone who helped raise me growing up and she is probably the most incredible
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woman I've ever met.
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And so just getting to talk to her, just interact with her, hear her, some of her anecdotes,
13:15
some of her advice for stuff I'm dealing with.
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Now in the last few years, having her interact and know that I have a kid now.
13:23
So another great grandchild, she had a few before she passed, but just spending more
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time with her.
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I think that's great.
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And I've asked this question to many people.
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I ask it on the interview trail.
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And I get a mixture where a lot of people will talk about historical figures or somebody
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like that.
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But there are a lot of people who really wish that they had more time with somebody that
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they love.
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And I think that that's a good way to tell what people are thinking and where their values
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are.
13:53
I appreciate you sharing that.
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What we're here to talk about.
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Yes.
13:59
Cardiac anesthesia.
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Can you tell me a little bit about your background in cardiac anesthesia and what sort of made
14:04
you decide to do the fellowship?
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Yeah.
14:07
I tell our trainees this all the time.
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There's only a few reasons to do a fellowship in anesthesia.
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And for me, the biggest reason to do a fellowship is if at the end of the day, you cannot imagine
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practicing anesthesia without that specific type of anesthesia for the rest of your career,
14:22
whether that's a 15, 20, 30 year career, then you should do that fellowship.
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And so there are a lot of things I liked about anesthesia.
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A lot of some of the subspecialties I did enjoy my time on.
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But the only time I found myself sitting at home going, man, I really hope I'm doing X
14:39
tomorrow or Y tomorrow was I really hope I get put in a cardiac case.
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And then when I wasn't doing it, I wanted to do it.
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When I didn't get to do it, I got upset.
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Like, why didn't they pick me to do that case instead of someone else?
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And that was the reason I did the fellowship.
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That's what drew me to it.
14:56
Well, that definitely makes sense.
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That's not how I felt about cardiac.
15:02
And there's like specific things about it for sure.
15:05
The fact that it is a very, there are very specific steps to the dance in that operating
15:09
room.
15:10
Right.
15:11
The communication is very open, it's very fluid, and everyone is part of that team.
15:16
That's not a I'm doing my thing on my side of the drapes, ignoring what you're doing.
15:21
You know, everyone that's in that room knows what the surgeon is doing at that time, what
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I'm doing at that time.
15:26
And just some of the challenge and again, my pathologies kind of drove me there too.
15:30
So I don't have to sit there and just do nothing for an hour and a half while someone's dissecting
15:36
down to a nerve or something.
15:38
I am always doing something.
15:39
So I'm always busy using my hands, using my brain, working through something because I
15:44
don't do well with boredom.
15:45
I can't focus and just sit there and watch a monitor for an hour and a half.
15:49
So that room is a good place for me to be.
15:52
Yeah, I think that's fair.
15:54
There's definitely a lot to be said for the team dynamic and the relationship that you
16:00
build up with the surgeons over time.
16:01
That's something that I enjoy with some of the cases that I do, whether it's doing an
16:05
awake cranny with neurosurgery or OB or doing something with interventional pulmonology
16:12
with Rachenko or somebody like that.
16:15
It's really nice when you feel like you're in the flow and working on the same team as
16:19
the surgeon.
16:20
So that makes a lot of sense.
16:22
So we're here to talk about patients with cardiac conditions who are not having cardiac
16:29
surgery.
16:30
Can you give me an example of a patient archetype that you are wanting to talk about?
16:34
Yeah, I mean, we're a trauma center.
16:36
We get a lot of ortho trauma.
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So I'll deal with what I know.
16:40
You get someone who comes in, falls on the ice from the snowstorm, recently broke their
16:44
hip.
16:45
They're 80 years old.
16:46
They know that they needed some kind of intervention on their heart, whether it's their aortic valve
16:50
replaced, or they needed a bypass surgery, but they didn't really want to do it because
16:55
they don't really do much.
16:56
They're not active, so they don't really get chest pain that often.
16:59
Or they know they've needed an ICD because their EF is 25%, never recovered after they
17:04
got their cabbage five, six years ago.
17:07
But now they're here, no fault of their own, and they need a procedure done and they want
17:10
it done and the surgeon wants to do it.
17:13
So let's say that a patient like this who has fallen and broken a bone is coming to
17:20
the pre-op clinic.
17:21
Let's say we have the luxury of they're not inpatient yet, and we're able to see them
17:25
in pre-op clinic.
17:27
Given time for optimization, what kinds of things are we doing in a pre-op clinic?
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What would you be interested in knowing?
17:36
What would you be interested in ordering?
17:38
What would be your process there?
17:39
I kind of go back to electronic health records, a lot of these people are not new to us.
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So even though we're seeing them maybe for the first time in our department, they are
17:50
well known to a health care system somewhere.
17:53
So I always start with, was this person ever in the hospital and sent home when they were
17:59
at their best state, their best self?
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So if I can go back and say, okay, they were admitted for heart failure, exacerbation,
18:06
they got diareased, they got put on goal-directed medical therapy.
18:11
What did they look like when they left the hospital when those teams felt like they were
18:14
at their best self?
18:15
What was their dry weight?
18:17
What was their functional status?
18:19
Did they have orthopnea?
18:20
What symptoms did they have?
18:21
And then I compare, if I can find that, I compare their best self to how they're presenting
18:25
today.
18:26
And then I see, is there any major discrepancy between those two?
18:30
And that's where I start.
18:31
That gives me a picture, is this person where they should be better than where they were
18:35
before maybe?
18:36
Maybe they've even recovered some more with the medical therapy.
18:38
Or are they worse than when they were, quote, at their best?
18:43
And then after that, I start with functional status and symptoms.
18:48
One thing I've put more and more stock in is I've seen more patients go through health
18:52
care systems is their functional status.
18:54
I've seen people with very scary conditions, very severe valvulopathies, really depressed
19:00
LVRB functions, and the ones that are functional and can do things.
19:07
And if you read data, it's going to be four METs is right around your cutoff.
19:10
But if they can do a lot of their ADLs, their grocery shopping, they're caring for themselves,
19:15
they can walk, do an exercise bike maybe for short periods of time.
19:18
That puts my mind at ease compared to someone who has absolutely no functional status.
19:23
For some of our listeners who might not know about METs, can you tell me a little bit about
19:27
that?
19:28
Metabolic equivalence.
19:29
I'm from Kentucky, I like to keep things simple.
19:32
So if you look at the and I brought them with me today, we're not going to look through
19:35
them at all.
19:36
But I have them here just so I could remember all the societies that are in on them.
19:39
But the core has a stack of papers here that is that an inch high.
19:46
The 2024 AHA, ACC, ACS, many, many more guidelines on perioperative cardiovascular testing and
19:54
management for non cardiac surgery.
19:56
Put out again, 2024 just recently.
19:59
But if you look at that, they break it down into metabolic equivalence.
20:02
And these are all based on historical studies done, you know, right around the time of my
20:07
birth really.
20:09
But four metabolic equivalence of activity, and I liken that to one simple thing, two
20:15
flights of stairs without stopping, three to four blocks on flat level ground.
20:20
And that is a that'll get you to a metabolic equivalent that is enough activity that should
20:24
be raising your heart rate, requiring you to augment your cardiac output and index to
20:28
keep up with the metabolic demand of your body and your muscles doing that amount of
20:31
work.
20:32
It doesn't seem like a lot.
20:35
But that has good data behind it that if you can achieve that amount of metabolic activity
20:40
without symptoms, that's important thing.
20:42
Like if you go up two flights of stairs and you get chest pain, crushing chest pain at
20:45
the top, that's not good.
20:46
But if you can do those things without symptoms, that your risk in the perioperative period
20:51
is lower.
20:52
So four meds, two flights of stairs.
20:55
That's kind of where I start when I'm talking about functional status and activity.
20:58
I'd be remiss if I didn't mention my favorite unit when I'm talking about metabolic equivalence,
21:03
which is the lap around Walmart.
21:05
Yes, I usually am asking all of my patients, can you walk a couple of laps around Walmart
21:10
without getting chest pain or short breath?
21:11
What if you were pushing a cart?
21:13
Could you do it?
21:14
Right.
21:15
So that's a good point, because you have to you have to liken it to things that they might
21:17
do every day.
21:18
Right.
21:19
And a lot of people have no stairs at their houses, right?
21:22
Or they live on the sixth floor of an apartment building and they take the elevator because
21:26
they're definitely not going to walk up six flights of stairs four times a day, you know.
21:30
Another one of mine is like our parking garage is downhill from our hospital.
21:35
So when patients come into our hospital, even if they're taking elevators in the parking
21:39
garage to get into the hospital, they have to walk up what is basically over a ramped
21:44
period, it's not in a vertical stairs, but over a flight of stairs.
21:49
So that's another one I'll use as kind of a surrogate.
21:51
Hey, did you walk in today?
21:53
Right.
21:54
And if you're like, I tried, but I had to stop halfway off that ramp to get a wheelchair.
21:56
All right.
21:57
I know where I'm at right away.
21:58
Right.
21:59
I guess if you made it to preop clinic, you're cleared for surgery.
22:01
No, that's all joke, right?
22:02
If you put the preop clinic on the third floor and have no elevator, if they make it there,
22:06
they're good.
22:07
OK, so we have seen them.
22:09
So we know a little bit about them.
22:12
We know what their metabolic equivalents are.
22:14
What are some things that we can do preoperatively to optimize these patients?
22:18
I mean, we know what their valve looks like.
22:20
We know what their dry weight is.
22:22
What can we do?
22:24
I think a lot of it, unfortunately, there aren't a lot of medical therapies or interventions
22:29
for sure that you can do, especially with valves.
22:33
Obviously, the first thing to ask yourself in this situation is do I have time to do
22:36
anything?
22:37
Sure.
22:38
Right.
22:39
Our preop clinic here, it's gotten better, but you still might be seeing someone who's
22:41
48, 72 hours out from their procedure that is time sensitive.
22:46
We're not even talking about the logistics of this surgeon is going on vacation in a
22:49
week, doesn't have any block time, you know, any time else.
22:52
But do I have time to do anything?
22:54
Right.
22:55
And if the answer is yes, you have time.
22:56
OK, in my system, how long does it take me to get this patient in to see a cardiologist
23:02
who can start them on goal directed medical therapy, get them on a beta blocker in a mineralococorticoid
23:08
receptor antagonist, an Acer and R, can get them on an SGLT2 inhibitor, all those things,
23:13
because we don't usually prescribe them to start a therapy that's going to continue in
23:17
the preop clinic ourselves.
23:18
Right.
23:19
Our nurse practitioners and us will do some drugs, but that's not our role per se.
23:24
And if I have time to do that, then it is that referral and it is let's get you on the
23:28
right medicines.
23:29
Maybe your heart's going to recover some.
23:31
Do we have time to start them assess for tolerability, side effects?
23:36
But then you're talking months, right?
23:37
This isn't something that's going to take a day or two.
23:39
So that's in an ideal situation.
23:41
We don't often have that amount of time.
23:44
So some of these patients, like you said, really can't wait, but some of them are really
23:49
sick too.
23:50
So philosophically, what does that look like for you?
23:55
What sorts of things are you considering when you're deciding whether the surgery is urgent
24:00
and needs to go forward despite the risk or maybe we need a couple of weeks?
24:05
What's that decision process like for you?
24:08
If I think they are near their baseline optimized state, then it's a question of making sure
24:14
the patient and the surgeon truly understand their risk and making sure there isn't an
24:18
alternative therapy or intervention that might be less invasive or risky for the patient
24:23
to treat that same condition.
24:26
So that leads us to kind of the risk calculators that you see.
24:30
And that's kind of where I'll start.
24:31
And I present that data to the patient and a lot of them I'll do with them in the room
24:35
on the computer.
24:36
I've done the computer a lot in the clinic, but that's where I'll pull it up, do their
24:39
risk calculation using an RCRI or the GUPTA or the ACS when they're both based on the
24:45
NISQIP data.
24:47
And when patients see that and they get to see that percentage chance of stroke, heart
24:51
attack, major adverse cardiac event, then suddenly they're kind of realizing how serious
24:56
this is.
24:57
We're not just talking about, yeah, yeah, this might happen and kind of brushing it
25:00
aside.
25:02
And so making sure they understand that and then just having a discussion with the surgeon.
25:06
Look, this is what their risk is if you look at how they fit into these risk calculators.
25:12
And then it's a question of is everyone willing to assume that risk?
25:18
And if everyone is, then it's a question of is there anything that I can do short term
25:21
to mitigate that risk?
25:23
And we talk about short term, it's morning of throughout the procedure immediately post
25:28
up at this point, right?
25:29
Because we've already decided they might not have time to go see a cardiologist and get
25:32
started on therapy and wait three months for recovery, that kind of thing.
25:36
So there are lots of different types of anesthesia that you can do more than one way to skin
25:41
a cat.
25:43
What kind of anesthesia techniques are you looking at when you're dealing with patients
25:49
who are maybe exquisitely high risk?
25:52
What do you sort of think about?
25:54
What do you jump to?
25:56
Yeah.
25:57
I like to put this one in a situation for a patient.
26:03
So say we have a patient with severe aortic stenosis, LVEF is 30-35% with that RV functions
26:09
mild to moderately reduced and they need a knee replacement.
26:16
So we have options there in terms of our anesthetic technique.
26:19
This goes back to me being paranoid and pessimistic.
26:22
I'm always thinking, okay, this patient, what is going to, if they're going to die on the
26:26
day of surgery, hear me out on this, no one should die.
26:29
I don't want anyone to die.
26:30
But if they're going to die, again, me being paranoid and pessimistic, what is going to
26:34
be the etiology of their demise?
26:38
In this patient, I'm thinking, okay, it's going to be their aortic stenosis that's going
26:43
to cause them to have a backup of blood and pressure in their LV because they can't get
26:46
it across that valve that's going to dilate the heart even farther and then their LV is
26:50
going to not be able to actually generate enough pressure.
26:53
So that downward spiral of aortic stenosis that you see, because you're already part
26:57
of the way on it with that reduced EFN function.
27:00
And it's how do I prevent that from happening?
27:02
So how do I prevent that downward spiral that starts with building up blood and pressure
27:07
in the LV because they can't get it across that valve?
27:10
And is there an anesthetic technique that I could do that could minimize that?
27:14
And to apply it more broadly to any patient I see, it's how can I minimize the amount
27:20
of drugs and impact I have on my patient?
27:22
Is there a way that we could do this procedure without me involved?
27:26
Could the surgeon use just local?
27:28
Is there a way that we could do it with a nerve block instead of a neuraxial or a neuraxial
27:33
instead of general?
27:35
That's my personal philosophy on seeing it.
27:37
I like to minimize my involvement in a patient if at all possible.
27:43
The data doesn't support that, to be honest.
27:45
If you look at a lot of the studies on anesthetic choice and outcomes after surgery and even
27:50
in the guidelines, this giant stack of paper I have over here on my right, they even say
27:54
there is no real evidence to suggest you do one type of anesthesia, whether that's volatile
27:59
or TIVA or regional over another for these patients who have cardiac disease or non-cardiac
28:05
surgery.
28:07
But to me, keeping it simple, minimizing my impact on them on the day of, that's where
28:12
I start.
28:13
So knee replacement.
28:15
Can I do this under regional?
28:18
Spinal alone, probably not.
28:21
Could I do it under a neuraxial?
28:24
Yes.
28:25
Could I do that neuraxial as a single shot spinal or a CSE or a spinal catheter or just
28:30
an epidural?
28:31
You could do it under any of those, but then you start to worry about if I do a single
28:35
shot spinal, what level do I need to get up to?
28:38
Do I trust me doing that spinal and managing the spread of the drug to not knock out their
28:44
cardiac accelerator fibers, to not get them so vasodilated that we suddenly drop their
28:48
preload, they can't fill that LV, they can't get blood across that aortic valve?
28:53
And I just think through it like that.
28:55
If I do this type of anesthesia, will it keep the patient safe and comfortable?
28:58
Will it allow the surgeon to do what they need to do?
29:01
And how will it impact that patient's pathology?
29:03
But at the end of the day, again, I do believe that the type of anesthesia you do does not
29:08
matter as much as you meeting your hemodynamic endpoints and parameters and goals for that
29:13
patient.
29:16
The paranoid and pessimistic traits that you referred to, this is something that I actually
29:21
talked a little bit about to Jesse in the last podcast.
29:26
We were talking about it in terms of being husbands, fathers, that sort of thing.
29:32
How do you approach having those traits in your real life?
29:37
How do you make sure that that isn't too dramatically affecting your life at home?
29:43
It's stopping you from going anywhere and doing anything.
29:45
I like to think that it doesn't to some degree that I'm one of the few people that in this
29:50
part of the reason why I'm in anesthesia, I'm at work, I'm at work, I'm not at work,
29:54
I'm not at work.
29:55
I don't want to take my patients home with me.
29:56
I don't want to have to worry about long term follow up.
29:59
That's one of the reasons I went into this field.
30:01
And I do have that ability to kind of switch between me at work and me at home to some
30:06
degree.
30:07
I know my wife will disagree.
30:08
And if she ever listens to this, she's going to remind me of our trip that we did with
30:11
her nephew and our little kid this summer to Europe.
30:13
Oh, I want to hear about this.
30:14
Right.
30:15
I'm always thinking, okay, we're gonna lose our passports.
30:17
Where's everyone's passport?
30:18
We're gonna forget to catch this train because we got to do we got to go from this platform
30:22
to that platform and downtown Berlin at this time.
30:25
So we got to make sure that we're hustling from here to here and that kind of thing.
30:29
And so I do carry some of that with me.
30:30
And it does impact it.
30:32
And I'd like to say that we didn't miss any of our transport.
30:36
No one ever got lost.
30:37
We didn't lose any major documents.
30:39
Nothing bad happened.
30:40
But I know that it does drive her nuts sometimes.
30:42
And that does creep in to my personal life.
30:44
And it does, right, to some degree.
30:46
But usually it's only in those kind of stressful situations, my day in day out activities.
30:51
I do a fairly good job of separating work and life.
30:56
I think when things get stressful, we probably just default to our anesthesia mode, maybe.
31:03
Right.
31:04
So that's that's how we get through our day to day jobs when things get stressful.
31:07
I guess when it's at home, we sort of do the same thing.
31:10
Yeah.
31:11
And the majority of my time at home is not stressful.
31:13
A lot of not all my time, but a lot of my time at work is a little more stressful.
31:16
Sure.
31:17
And so, yeah, it's when that stress level picks up at home that those characteristics
31:21
in me start to come out.
31:23
So let's go back to our patient.
31:26
What kind of lines, monitors, pulmonary artery catheters, arterial lines?
31:31
What are we thinking about putting in and why in some of these patients?
31:35
Does every cardiac patient need a PA catheter?
31:39
Yeah, I don't see it recommended as much anymore.
31:43
And I'm kind of glad for that because I truly believe PA catheters are largely overused
31:49
in cardiac surgery, even in general.
31:52
The really only indication for one that I think is a strong indication is undifferentiated
31:56
shock.
31:57
Right.
31:58
So the number of times you encounter that truly undifferentiated, I have no idea why
32:03
this patient is so unstable, are few and far between.
32:07
We put them in for liver transplants here.
32:09
Well, I know the form of shock in there.
32:10
It's vasodilatory from the liver disease and then it's turned into hemorrhagic from
32:14
the surgery itself.
32:15
Sure.
32:16
I know how to fix those.
32:17
There is no question of if it's another form of shock.
32:20
And then in the cardiac surgery, it's almost always cardiogenic shock, maybe a little bit
32:24
of vasodilatory sometimes.
32:26
So I don't usually routinely want a PA catheter put in.
32:29
Again, in cardiac surgery for some valve replacements, valve repairs for some high risk patients,
32:39
putting in an LVAD, doing a heart transplant.
32:40
Sure.
32:41
But outside of that, I don't really see much of a role for using a PA catheter.
32:46
Other monitors, arterial lines, I used to use them all the time.
32:52
I would put them in on people.
32:54
I only did this once or twice, so I don't want people going spreading rumors about me
32:57
when they listen to this, but I've done it in endo a couple of times for endoscopy procedures.
33:02
But the real role I think for arterial lines is do I need to have such tight control over
33:08
hemodynamics that I do not have two and a half to three minutes to wait to get another
33:13
reading to intervene?
33:16
Or do I really truly think I'm going to need to be getting labs and objective data from
33:18
someone on what their base excess is, what their lactate is, what their hemoglobin is
33:24
so often that I need some point of access to get blood quickly without having to stick
33:28
them or pause an infusion, draw off a line, that kind of thing.
33:34
In terms of people with really bad hearts getting lower risk procedures, patients with
33:39
EFs 15, 20%, severe pulmonary hypertension, severe valvulopathies in endo, I'm not putting
33:45
our lines in those patients anymore.
33:48
In EP lab, I'm not really doing it for the a-fib ablations in those patients much anymore.
33:52
And a lot of that is knowing what my backup monitors and modalities are.
33:58
If the proceduralist already has an arterial sheath in and I can quickly access it, then
34:02
I'm definitely not going to put an R line in for a low risk procedure.
34:06
If the proceduralist is using intracardiac echo in the EP lab, then they can pause what
34:11
they're doing, flip over, look at the LVRV for me, and I can get an idea of how things
34:15
are when they can scan a valve even less likely to put an invasive monitor.
34:20
But the patients that arms are tucked, that I do need to manage hemodynamics on a more
34:26
acute basis than every three to five minutes, those are the patients I'm probably putting
34:30
an arterial line in.
34:32
I have heard anecdotally that if you really don't like going to endo, then you should
34:37
just put arterial lines in a lot of your patients and you quickly won't be invited back there.
34:41
Yeah, and I think that goes true for any of our roles or rotations that we go on.
34:46
You don't want to go to IR, just be really inefficient and slow and you won't be in IR
34:49
anymore, right?
34:50
This is not any, we're not making any recommendations.
34:54
No, this is not advice for people in the future.
34:57
You decide that you don't want to ever do ECTs.
34:59
Don't just become really bad at them just so you don't have to do them.
35:01
That's not the right way to do it.
35:03
That being said, when's the last time you've been in endo, Corey?
35:07
Every time I'm on call on the weekend, I'm there and that's about it.
35:11
This fits great because it's always this patient got transferred from Mercy or sorry, this patient
35:16
got transferred from an outside hospital.
35:17
Cut that out.
35:19
Yeah, they didn't feel comfortable doing their ERCP there because their EF is 20% and they
35:24
got pulmonary hypertension and they're kind of decompensating so we'd like to do them.
35:28
Well, they're in the room now so.
35:31
But yeah, no, I get sent over there twice a year.
35:35
Otherwise it's only on call.
35:37
So how are we managing the hemodynamics in these patients?
35:41
You've mentioned you might need the arterial line if you're managed again on a hyperacute
35:46
basis.
35:47
How are you managing their blood pressure, heart rate and maintaining cardiac output?
35:51
What does that look like in some of these really sick patients?
35:54
This is where I think we do so much preparation and planning in our field that it is a huge
36:00
pet peeve of mine, drives me nuts when we identify someone as high risk.
36:05
We say this person with their aortic stenosis and their low LVEF, they're going to have
36:09
surgery and then we don't do anything different in terms of our anesthetic technique and management.
36:14
So we give them the normal induction dose of propofol, we chase it maybe with some fluids
36:19
and phenylephrine and then we're like, oh geez, that didn't work.
36:23
We tailor your approach to your patient, know their pathology, know what your drugs are
36:27
going to do to them and then I like to be preemptive.
36:31
An ounce of prevention is worth a pound of cure.
36:33
So if I know my patient has a low LVEF, I know I'm going to put them on a volatile that's
36:37
going to depress their myocardium a little bit more, I'm empirically starting a low dose
36:42
of an onotrip.
36:44
If I know that what we're going to do is just vasodilate them out the wazoo and that's
36:48
bad for them because they need all that preload because they have a severe tricuspid regurgitation
36:53
or mitral regurgitation, then I'm going to vasoconstrict them from the start.
36:58
And if they have a depressed RV or LVE, I'm not going to use a drug that is going to add
37:03
pure afterload to both of those chambers.
37:04
I'm going to use a drug that will add afterload but also maybe help those chambers squeeze.
37:11
And that's kind of how I look at it.
37:13
I started doing that during my fellowship and I continue to do it today.
37:18
This is just a sidebar for people that are listening.
37:20
I'm a huge believer that you can safely give low to moderate doses of vasopressors and
37:26
onotropes through a peripheral IV and I do it all the time.
37:29
Like all the sirenes that work with me over an EP, they know I'll start debutedamine at
37:33
two and a half with a little bit of vaso when the pressures come up and the heart rate comes
37:37
up then we induce.
37:38
And then you're kind of preemptively bringing them up knowing that you're going to drop
37:42
their pressure back down and you settle out at their baseline state instead of starting
37:48
out at their baseline state, dropping their pressure really low and then scrambling to
37:52
recover them.
37:53
Yeah, that's something that I tend to emphasize to trainees and people who are taking care
38:01
of very sick patients as well as it's usually better to have a little bit of hypertension
38:06
than a little bit of hypotension.
38:07
So hypertension, that's something that most people experience on a day to day basis.
38:13
If somebody comes up behind them and shouts boo then they're going to be hypertensive
38:18
and their body's used to it.
38:19
But there's not a lot of things that we do in life that cause acute hypotension that
38:24
might be a little bit trickier to recover from.
38:26
Exactly.
38:27
Yep.
38:28
So what are some pearls for fluid management for these folks?
38:33
We've talked about optimizing preload, afterload, all that sort of stuff.
38:39
What are we doing beforehand to try to get these patients to their goal weight, things
38:44
like that?
38:45
Yeah.
38:46
This is going back to if they're coming in our pre-op clinic, we have the time.
38:49
It is what is your weight now on a standing scale, right?
38:52
With not your purse on and your giant winter coat and your hat and all this stuff and your
38:57
three cell phones and pager in your pocket.
39:00
Having an accurate weight on them, comparing that to their dry weight, right?
39:03
And then working with whoever is managing their conditions to potentially change their
39:08
diuretic therapy around to get them to that dry weight state.
39:13
If we don't have that time and I'm seeing them for the first time, again I like to keep
39:16
things simple, cardiologists during my intern year showed me a trick.
39:19
If you have someone laying supine in bed and you have their hand, if you can see veins
39:25
in their hand, you have them laying supine in bed and their hand is resting on their
39:28
body, if you lift that hand up, the farther it is above the level of the heart, if those
39:33
veins stay plump and full on their hand, then they are probably hypervolemic.
39:37
If you take that hand and they've rested on their body laying supine and they're flat
39:41
there, they're probably hypovolemic, right?
39:43
If their veins look slightly full, normal veins when they're laying flat, hand at the
39:46
level of their heart, they're probably uvolemic.
39:49
That's really interesting.
39:50
I'd never heard anything like that before.
39:51
And again, it only works when you can see veins in people, which is not all of our patients.
39:57
We definitely have some patients that come to us with seemingly zero veins.
40:01
Right.
40:02
But that is one thing I like to use just to get a quick idea.
40:05
And it's not the most accurate thing in the world.
40:07
But yeah, if you take someone and you raise their hand above the level of their head when
40:11
they're supine and all their veins are plump and full, chances are they're fairly voluminous.
40:15
Like if you look at mine right now and I have it, you can't see me, but my hand is above
40:19
the level of my head.
40:20
I don't see any veins in my hand.
40:21
Right?
40:22
I bring it down onto my lap and you can start to see some fill up.
40:25
Yeah.
40:26
I think that makes sense.
40:28
Yeah.
40:29
I guess I can see it on your other hand.
40:30
It's been down a little bit longer.
40:32
There you go.
40:33
So there are all these devices that are attached to people's hearts these days, complicated
40:39
devices, LVADs, RVADs, ICDs, pacemakers.
40:44
What are some of the considerations that you have for these patients who come in for surgery
40:49
with some of these devices?
40:50
What's your approach to that?
40:52
And maybe the patient doesn't even know what kind of device they have.
40:55
Yeah.
40:56
So first and foremost, you need to know what that device does.
41:00
Why is it there?
41:01
Why did it get put in and what can it do?
41:04
What is it doing?
41:05
I'm going to separate it out into two categories here because if you look at pacemakers and
41:12
ICDs, they are very different than some of these mechanical support devices that we see.
41:16
Sure.
41:17
I think most people know when they have an LVAD.
41:19
Right.
41:20
Yep.
41:21
I agree.
41:22
So pacemakers and ICDs.
41:23
Okay.
41:24
Why was it put in?
41:25
What can it do?
41:26
And then are they dependent on it?
41:28
Right.
41:29
So if someone has a pacer and they're dependent on it, I need to potentially treat them differently
41:34
than if they are paced 10% of the time at home.
41:38
So it's again, looking for those interrogation reports, reaching out to the rep, knowing
41:42
what your surgeon's doing.
41:44
Right.
41:45
Because most of the guidelines, they've simplified it to say you don't really need to do much
41:48
for ICDs and pacers if everything is below the belly button on the belichis.
41:53
But if your surgeon is working on a knee and you can't put the bovie pad anywhere because
41:58
they have replaced other knee, replaced tips, all this other stuff.
42:01
And so they potentially put in a bovie pad, you know, up near the umbilicus somewhere.
42:07
You might have to intervene on that device because you have EMI even though they're working
42:12
below it.
42:13
Right.
42:14
So know where your surgeon's going to be working, what they're doing.
42:16
And then am I going to need to do anything with the device?
42:19
And pacers and ICDs are fairly simple.
42:20
If they're pacer dependent and there's a risk for EMI because they're working above the
42:24
umbilicus, you need to put it in asynchronous mode.
42:27
Right.
42:28
Because they will not pace if that device thinks that your bovie is their intrinsic
42:32
cardiac activity.
42:33
And if they're dependent on it, they will not have a native ejection from electrical
42:36
activity.
42:38
Most ICDs, they can pace and a lot of them, and this is a good point to discuss, they're
42:45
by the ICDs.
42:46
Right.
42:47
So someone has put one in for cardiac resynchronization therapy, long-term.
42:51
Someone who has an EF less than 40%, who has a prolonged QRS interval and they want to
42:56
resynchronize their ventricles so that the RV and LV beat in sync to maximize their cardiac
43:01
output and index.
43:02
If they're beating in sync, the RV can generate more blood flow to the LV side and the LV
43:07
has more blood flow to generate out to the body.
43:10
That has been a long-term guideline from cardiology for people with heart failure, low EFs and
43:15
wide QRSs.
43:16
They're going to be paced like 99.9% of the time, right?
43:21
But they are not necessarily pacer dependent.
43:23
That just means that if you don't pace them and they're not being by the paced for synchronization
43:30
reasons, they will have a native QRS that does lead to mechanical ejection of blood
43:36
from the cardiac chambers, but they just might not be in sync with each other in terms of
43:41
the RV and the LV and they might have a little bit of a decline in function.
43:45
That is usually long-term, not short-term.
43:48
So if you take someone's bivy ICD and you suspend or they don't get bivy paced because
43:54
of EMI, they're not going to suddenly go from an EF of 50% to 20%.
44:01
That's one little thing I've seen and actually caught me a couple of times in the clinic
44:04
when I was first starting to work there.
44:05
I'm like, well, we got to put it in asynchronous and all this.
44:07
I call the rep and the rep is like, no, we don't.
44:09
You're crazy.
44:10
And they explain that to you.
44:12
The reps know a lot about their products.
44:16
And then the ICD is that you just don't want your patient to be shocked inappropriately.
44:18
So again, above the embolicus, I'm putting a magnet on an ICD, which is usually going
44:22
to suspend its anti-tachyrythmias function, the shock.
44:25
Although most of the new ones, and you've probably seen some of these, they have auto-sense
44:30
EMI function.
44:31
They don't do anything to a magnet.
44:33
And the companies firmly believe, and they have FDA approval for this, that their device
44:37
is smart enough to know the difference between bovey, radio frequency ablation, lithotripsy,
44:43
that kind of stuff, and an actual conduction from the heart.
44:48
Do you believe that?
44:52
I've only been in a situation where that could potentially be a problem about four or five
44:57
times and it's worked as it should every time.
45:00
Do I completely trust it?
45:01
No.
45:02
But again, I'm a pessimistic person who's very paranoid.
45:05
Yeah, that makes sense.
45:06
Yeah, but the reps will refuse to turn those off.
45:09
Like if you call them and you want the anti-tachythmias function turned off, they just were like,
45:13
you don't need to do that.
45:14
We're not doing that.
45:15
Interesting.
45:16
So let's say that we've made it through the case.
45:20
We have kept them alive through the operation.
45:23
We've maintained a smooth anesthesia.
45:25
But now we have to turn that off and send them to an ICU.
45:29
How are we going to keep them stable going from an anesthetized state where they're not
45:34
feeling anything to a non-anesthetized state when they're awake, maybe their heart rate
45:39
and blood pressure are going up as a pain response.
45:42
They're sort of coming back to reality and experiencing some of the anxiety that comes
45:47
with waking up from anesthesia.
45:49
How are we going to manage the patients who are going through that transition?
45:55
We didn't talk about LVADs or RVADs and I don't think we necessarily should for this
45:59
particular talk because that's a whole big in-depth discussion about other cardiac devices.
46:03
I was going to ask you a follow-up about LVADs in a second.
46:08
That could be a potential topic for a future podcast.
46:12
So you're undoing what you did at the beginning at the end of the case.
46:19
Keep it simple.
46:20
So at the beginning, they went from their baseline normal walking, talking self to fully
46:24
anesthetized.
46:26
I know what my drugs did.
46:27
I know what I did to counteract that.
46:29
If it was something that I had to counteract because of their pathology.
46:31
Now we have to undo that and ideally we do that smoothly and not abruptly over the course
46:38
of five or ten minutes.
46:41
So before I start that undoing process, because if you're just undoing something, I started
46:47
2.5 adbutamine and 0.03 units per minute of vasopressin while I was inducing and maintaining
46:54
anesthesia and now I'm stopping those drugs because I'm turning my anesthesia off.
46:58
That's a fairly simple thing to do.
47:00
You can just stop them, you can wean it every five minutes or so, half the adbutamine, wait
47:04
three minutes and then turn it off again as your volatile gets lower and lower and lower.
47:09
But the bigger question is did I or did the proceduralist do something that I need to
47:15
keep in mind when I am thinking about undoing the things that I did?
47:20
An example of this is in the EP lab, maybe they did an ablation and they end up giving
47:24
three liters of crystaloid through their catheters during ablation and someone within you have
47:29
to do it.
47:30
Well in that patient, I can undo what I did but that doesn't get rid of the fact that
47:34
they might be grossly volume overloaded now because of what the proceduralist had to do
47:39
during their procedure.
47:41
Or in the knee replacement in someone with really bad aortic stenosis and a low LVF,
47:45
well I can undo what I did if I started a vasopressor before I induced them to maintain
47:50
their afterload so that they didn't get ischemic and have trouble ejecting across that stenotic
47:54
valve.
47:56
But if I do that and the surgeon lost two liters of blood during the knee replacement
48:00
and they don't have that preload anymore, it doesn't matter if I decrease that afterload,
48:05
my volatile comes off, they're not going to be able to generate it because they don't
48:07
have the volume to anyway.
48:08
They don't have enough to fill the LV to generate a pressure to overcome that.
48:12
So if your proceduralist has done something that doesn't allow you to undo what you did,
48:16
you don't undo it.
48:17
And I think that's a very important thing.
48:19
You might come in with the best intentions and plans.
48:22
This patient was coming for an aphid ablation, they're supposed to go home at the end of
48:25
the day.
48:26
Well they might need to stay and they might need to be potentially ICU status.
48:31
And it's assessing the patient for that at the end.
48:33
And so a lot of times it's an easy thing to do.
48:36
Again if your proceduralist has ice or if you're comfortable putting a probe on their
48:40
chest real quick and looking at their heart, is their LV dilated out?
48:43
Does it look pretty close to baseline?
48:47
Did the surgeon lose a lot of blood and did we account for it?
48:51
And if so then you can give it a shot of weaning your drugs as you wean your anesthetic, your
48:58
vasoactive drugs as you wean your anesthetic and try to get them to a state where they
49:01
are back at their baseline.
49:04
And I think that's an important thing too.
49:06
When people come in, if they come in walking and talking, that blood pressure, that heart
49:12
rate, that loading condition is probably compatible with life.
49:17
So if you can get them to that same spot at the end then they'll probably be okay.
49:22
But you have to know what the proceduralist did and sometimes you can't get them to that
49:27
state quickly and easily.
49:28
And you have to change your plan from a simple outpatient procedure to maybe an ICU admission.
49:34
If someone's borderline, I keep it simple.
49:36
I try to undo what I did and if they get worse I redo what I did.
49:41
And then I say okay I tried.
49:43
This is what happened.
49:44
We might need to escalate their care.
49:45
We might need to change the path that they were on in terms of where they go after the
49:48
procedure.
49:50
So let's go back to your storm chaser days for a second.
49:53
You walk into a room.
49:56
You don't really know much about the patient except somebody has said they have a bad heart
50:01
and the patient is crashing.
50:03
What is your approach in your mind to these sort of crisis situations that you seem to
50:08
find yourself in quite a bit?
50:11
It is preparing.
50:12
So if someone like you say you're peri-arrest, a lot of times you can get someone back if
50:18
they do arrest pretty quickly but you have to have the right tools there.
50:21
So if someone is crashing and we don't have more help in the room, we haven't brought
50:24
the crash cart in, we don't have pads on the patient, we don't have the drugs that we need
50:28
if they do code in the room, it's getting those supplies, getting those things ready
50:31
so that when it happens you're ready to treat it off the bat.
50:34
And then after that it is well what has happened so far?
50:39
You come in, the heart rate is 180, the patient's map is 40, what has happened?
50:46
What did someone do?
50:47
Well they just insufflated the abdomen but they're not sure about their trocar.
50:52
Before that you assumed they were fine, they haven't been this unstable from the start
50:55
of the case.
50:56
Usually there's an event, something that happened acutely that has caused this change in patient
51:00
condition and then if you know what that last thing was, what that event was, then you can
51:05
start building a differential of things that it could be that have caused it.
51:08
Maybe that trocar went into a vein and they injected a bunch of CO2 into a vein or maybe
51:13
they built up a bunch of pressure in the abdomen and the patient didn't tolerate that from
51:17
peritoneal stretch and decrease in preload from that pressure.
51:21
So that's my kind of first thing, get the supplies in, again pessimistic, I assume they're
51:25
going to code, get the supplies in the room and then what was the last thing that happened,
51:29
how were they before that and what changed so I can build a differential and start treating.
51:34
So let's say that you're a resident or a medical student that's listening to this and they
51:41
really think that what you're saying makes a lot of sense to them, maybe they're really
51:45
pessimistic as well and paranoid.
51:49
What would you recommend that they do in order to walk in your shoes?
51:54
What kind of resources do you recommend?
51:57
How would you advise residents and medical students that are interested in pursuing the
52:02
kind of work that you do?
52:04
I think a lot of, med students probably don't mind hearing this but a lot of residents probably
52:09
don't like hearing this, it's work more, do more cases, just get more reps and so I moonlit
52:14
a ton as a resident and that just means you're seeing more.
52:18
You have an opportunity to see a condition, a pathology, you have an opportunity to see
52:22
some kind of procedural complication that you may not see otherwise and you seek out
52:28
those difficult patients, those difficult cases, you don't shy away from them and say you know
52:33
what I'd really just like to do AV fistulas all day today.
52:38
You always push yourself to kind of get exposure, get experience, the more experience you have
52:44
the more you're going to be like I've seen this before, I've seen something like this
52:47
before or I encountered this particular complication, I know this pathology as it relates to the
52:54
surgery.
52:55
That would be thing number one and I didn't moonlight because that was not why I moonlit
53:01
at the time, because moonlit can get you paid.
53:05
But that is a positive thing that came from it and if you look at my class there was a
53:09
group of us that all graduated together and there was three or four of us that moonlit
53:13
a ton and there was a noticeable difference towards the end of our CA3 year in terms of
53:19
what some of us were more comfortable with and it was just because we'd seen more, we'd
53:22
done more.
53:24
If you do 600 more cases than someone else throughout the course of four years you're
53:29
going to have more exposure.
53:30
And that's why in residency, I tell them all the time, you're going to learn more your
53:35
first two years out of residency than you probably did during the majority of your residency
53:40
just because your exposure gets doubled or tripled if not quadrupled of what you see.
53:48
What kind of style points or points of personal preference have brought you success in your
53:52
career both in and out of the operating room?
53:55
I think if you look organized, you look like you know what you're doing and you kind of
54:03
have a plan and a backup plan, right, because you're a little paranoid, then people are
54:09
going to have more confidence and faith in you even if they should or shouldn't.
54:12
So little things like being on time, keeping your work area clear, being like, well, I
54:20
thought about this and so I was thinking if they insufflate and the patient doesn't tolerate
54:24
it, I'm going to ask them to go down with insufflation right away.
54:27
Just having thought through those situations.
54:29
That's how I started my day as a resident.
54:31
When I'm setting up my room in the morning, I was thinking what things could go wrong
54:35
with this case and how I would respond to that.
54:39
What can I do to avoid it?
54:41
And again, I'm keeping things clean.
54:42
I'm knowing my patient.
54:43
I'm knowing what their labs were, their last test.
54:46
That way you're kind of mentally prepared and you're walking through that.
54:50
And similar to what some athletes and professionals do is they kind of visualize things.
54:56
If you talk to or you look at interviews, I don't talk to athletes or professionals
54:59
at all, but if you read interviews with some of these people, they're like, I just would
55:03
visualize myself finishing the last 10 miles of this ultra marathon uphill in the mountains
55:10
or I would visualize myself going downhill on the slaloms and this is what I would be
55:15
doing.
55:16
If you do that for simple things like you're lap happy on someone and you kind of walk
55:22
through mentally all the steps of that case, induction, maintenance, emergence, all those
55:26
things, you're kind of mentally prepared for stuff.
55:30
You're not so surprised when things happen.
55:33
And so I think that is something that also, again, even if it's not justified, people
55:38
when they see that and they see that you have this plan or you responded quickly because
55:43
you'd already thought about this, everything's not a cluttered mess.
55:48
They just, it calms everyone else down.
55:52
That kind of reminds me of one of the things that I like to ask residents at times, which
55:58
is what do you think would be the thing that would kill the patient the fastest right
56:03
now?
56:04
Yes.
56:05
Corey, thank you so much for joining us.
56:08
Yeah, thanks for having me, John.
56:12
Thanks for joining us for this month's episode of Style Points.
56:16
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56:19
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56:22
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56:27
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56:32
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56:36
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56:41
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