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Primate Anesthesia with Brian Vaughan · Style Points

0:00
Hello anesthesia enthusiasts and welcome to another episode of Style Points. If you're
0:14
just joining us for the first time, I'll tell you a little bit about the podcast. We'll
0:18
start with an RSI, which of course stands for Resident Selected Information. This is
0:24
a short segment at the beginning of the podcast featuring our anesthesiology residents at
0:28
the University of Cincinnati, where they will present a quick five-minute anesthesia topic.
0:32
Next, I'll talk to my colleague, Dr. Brian Vaughn, about his experience working at the
0:37
Cincinnati Zoo. I'll let my co-host, Chief Resident Nate Moore, introduce our RSI.
0:43
Thanks John. I'm happy to introduce Dr. Morgan Moorhead, one of the interns in our program.
0:48
In addition to being the founding member of our department book club, she is a brilliant
0:51
resident and here to talk to us about whole blood transfusion. Take it away, Morgan.
0:57
Thanks Nate. Today I wanted to discuss the topic of whole blood use during massive transfusion.
1:03
I was recently on a blood bank rotation that got me interested in the use of whole blood
1:08
because it's a topic I was personally not very familiar with. Starting broad, what is
1:14
a massive transfusion? Specific massive transfusion definitions tend to vary slightly at different
1:20
institutions, but generally a massive transfusion involves a patient requiring more than 10
1:27
rates of red blood cells within 24 hours or replacement of more than half of their total
1:34
blood volume in four hours. Let's set the stage for massive transfusion, but maybe not
1:40
too graphic. It's 2 a.m. and you get paged to the ED for a trauma. Upon arrival, you
1:47
see a patient exsanguinating blood from a traumatic MVC. On exam, the patient is tachycardic
1:54
and hypotensive with delayed capillary refill. They have hemorrhagic shock and they have
2:00
lost a significant amount of blood. They require resuscitation. Now you as a provider have
2:06
a choice to make when it comes to their resuscitation. You can do a balanced transfusion or a whole
2:13
blood transfusion. So let's look further into what a balanced transfusion involves. Let's
2:19
take a step back first and remember that when patients are bleeding, they aren't losing
2:25
just their red blood cells. They're also losing their coagulation factors and their platelets.
2:29
Most of the time we do a balanced transfusion. This involves replacement of fresh rosin plasma
2:37
or FFP platelets and red blood cells in a one to one to one or one to one to two fashion.
2:46
Note that the order of the components here is different than how we usually talk about
2:51
blood products, meaning that in the group of one to one to two, for every one unit of
2:58
plasma given, one unit of platelets and two units of red blood cells will also be given.
3:05
In the proper study from 2015, there was found to be a significant decrease in the number
3:10
of patients who died due to exsanguination in the one to one to one group, along with
3:16
an increase in the number of patients who achieved hemostasis when using this one to
3:21
one to one protocol. Thus, most practitioners today recommend the use of the one to one
3:28
to one ratio for massive transfusion. Now, what is a whole blood transfusion? Whole blood
3:35
transfusions are about as simple as they sound. It's a blood product taken directly from one
3:40
donor containing red blood cells, platelets, FFP, and cryoprecipitate with a preservative
3:46
that is added. These products are often group O Rh positive blood with low titers of antibodies
3:54
to groups A and B. The relatively small pool of potential donors with O negative blood
4:01
makes it difficult to obtain enough O negative blood for exclusive use in massive transfusion.
4:07
Instead, most centers use protocols that preferentially give O negative blood in the setting of specific
4:14
patient demographics, such as women of childbearing age, or they will just exclusively use O positive
4:21
blood. What are the advantages and disadvantages of whole blood transfusion? One of the advantages
4:28
of whole blood is the simplification of transfusions. It only takes one bag of whole blood compared
4:35
to three separate bags of components. Likely, these three separate bags of components are
4:42
from three different donors when used in the balanced transfusion. Using one bag of whole
4:47
blood reduces the chance of clerical errors, ABO incompatibility, and a patient's exposure
4:53
to multiple donors. Whole blood overall is more concentrated in terms of platelets and
4:59
coagulation factors. Because all the components are together in whole blood, less preservatives
5:05
are used overall, and this adds up to being less volume than total that has to be transfused.
5:12
Interestingly, platelets in whole blood can be stored cold and actually have better hemostatic
5:17
function and a longer shelf life than individual room temperature stored platelets. Because
5:24
the platelets are cold stored, it also decreases the risk of bacterial contamination. What
5:29
are some of the disadvantages? Some of the disadvantages or concerns with whole blood
5:34
include the risk for hemolytic transfusion reactions because type O positive whole blood
5:40
contains the antibodies to A and B. Generally, this risk is reduced as blood with low titers
5:48
for these antibodies are preferentially used. Along similar lines, because the blood is
5:53
Rh positive, you also risk allot immunization. Consider this when choosing between balanced
6:00
transfusion and whole blood transfusion for women of childbearing age. Other things to
6:05
consider with whole blood are more logistics that you wouldn't be thinking of in the moment,
6:11
including cost of initiating a whole blood program at a blood bank, having enough donors
6:17
in the already limited type O donor pool, and possible wasting of blood products as
6:22
whole blood can only be kept for 14 to 21 days. Last, I'd like to talk about the settings
6:28
you could see whole blood use. Whole blood has often been used in military settings and
6:34
it is more often being used in traumas. Other places you may see it used is in the pre-hospital
6:41
setting with paramedic administration, in OB for postpartum hemorrhage, and possibly
6:47
in surgeries associated with high blood loss such as liver transplants or cardiac surgeries.
6:55
And that is the whole story on whole blood. Thanks again, Morgan. Today, I have the acute
7:00
pleasure of welcoming Dr. Brian Vaughn. Brian is an associate professor of anesthesiology
7:05
here at the University of Cincinnati, and he serves as the director of acute pain and
7:10
regional anesthesia for the UC Westchester Medical Campus. In addition to his passion
7:15
for coaching and following soccer, he has also formed a special connection with the
7:19
Cincinnati Zoo and their veterinary team. Brian, thanks for joining us. Thanks for having
7:25
me. Brian, I'd like to get to know you just a little bit better, so let me ask you one
7:29
of my favorite interview questions. If you could have dinner with anyone, including somebody
7:34
from the past or even from fiction, who would you invite over for dinner and why? Well,
7:39
for those that know me and know my passion for soccer, I'm sure they'd be sorely disappointed
7:43
if I didn't mention someone from soccer. So I'll have to answer that in two parts. First
7:48
would be Sir Alex Ferguson. He was the amazing manager for Manchester United for over two
7:53
decades. Just an amazing soccer mind, how he managed the team, how he managed personalities,
8:00
and really was able to take all sorts of different working parts and make an amazing team. But
8:05
I think my real answer would really be Albert Schweitzer. He was the reason I went into
8:10
medicine. He was just an amazing Renaissance man, one of the most intriguing figures of
8:16
the 20th century. Before he was 30, he was sort of world renowned in the fields of philosophy,
8:23
theology, and music. When he turned 30, he went off to med school, got his degree in
8:29
medicine and then went for the next 50 years off to West Africa to be a missionary. He
8:34
really was an outstanding example of a Christian life and everything he did, including his
8:40
philosophy of reverence for life, really pointed to that. For all of his service, he was awarded
8:46
the Nobel Peace Prize, he was awarded the British Order of Merit, the French Legion
8:50
of Honor, really as a sign of respect for all that he did. It would be really intriguing
8:55
to have conversations on a wide range of topics with him.
8:59
What would you ask him if you had the chance?
9:02
Would be interested to see how he came to his philosophy of reverence for life and some
9:07
of his perspective on Jesus and his life and how he melded those two things together. Obviously,
9:12
we both have a common interest in medicine, but really it was a passion for helping other
9:16
people and following in the command to love thy neighbor, Jesus, that I'd really find
9:24
fascinating.
9:25
Well, I appreciate that. Speaking of our neighbors, can you tell us a little bit about your connection
9:30
with the Cincinnati Zoo and how that came about?
9:33
Right. I sort of got lucky a little bit in that I've always been interested in the outdoors
9:39
and nature. I'm an Eagle Scout, my son's an Eagle Scout, my wife has degrees in forestry
9:44
and applied ecology. She's been involved in endangered species management and habitat
9:48
restoration. It's really a passion of our families to be in the outdoors, love of nature
9:54
and things like that. It just so happened that one of my former partners at Christ Hospital
10:01
used to do the anesthesia for the zoo. When he retired from anesthesia and moved to Florida,
10:06
there was a void there and he asked me if I'd be interested in doing it. Certainly,
10:10
he was not going to say no to that. It's been a real fun journey to be helping the zoo for
10:15
the last few years with that.
10:17
What kind of animals have you worked with at the zoo?
10:20
It's pretty much exclusively the primates. Basically, the vets are very skilled at doing
10:26
a lot of things. They're actually quite amazing. I have a hard enough time keeping track of
10:30
just one species where they're taking care of not just primates, but just a whole range
10:37
of species, mammals, reptiles, amphibians, and a whole gamut of animals. It's amazing
10:46
that they can keep track of it all, but they like us to come there to help them with the
10:50
primates because they're very human-like. Typically, the primates have a little bit
10:54
more human anesthetic than maybe a typical veterinary anesthetic. Our expertise allows
11:00
us to help them with those and also allows them to concentrate more on the care of the
11:06
animal during the anesthetic if we're able to be there during the anesthetic.
11:09
I would assume that the primates that you're working on aren't having a lot of elective
11:14
procedures such as cosmetic facelifts and such. I wonder if you could tell me a little
11:19
bit more about what types of procedures that these primates are actually having.
11:24
Well, it's pretty much, for the most part, routine medical exams and preventative medicine.
11:32
You're not going to generally have one of these animals submit to, let's say, a chest
11:40
x-ray and stand in the right position and not interact with the animal training staff
11:46
or the veterinarians or other wild animals. They could be unpredictable. You have to anesthetize
11:51
them to do what we would consider routine tests for humans. Whether that's looking at
11:56
the hearts with echocardiography, whether that's doing dental cleanings or other routine
12:02
preventative maintenance. Again, we recently had the gorilla at the zoo break their arm,
12:08
so they had to be anesthetized to check the x-rays to see if the arm was in fact broken
12:13
and then come back a second time to fix the arm.
12:18
How does working with these primates compare to working with human patients? What do you
12:23
see as some of the differences and challenges that are associated with that?
12:28
It's really quite similar. I mean, that's why we're involved in terms of a human versus
12:32
a primate. I think the biggest difference is the communication and the ability for the
12:39
patient to really understand what we're doing. Obviously, the zoo has a wonderful animal
12:47
care staff that has a rapport with these animals and does a few things to help us, but they
12:54
really can't truly understand what we're doing, no matter how much you talk to them or try
12:58
and explain what you're doing. That really actually was an interesting conversation I
13:02
had with head veterinarian there when it came to the arm fracture for Gladys. I was like,
13:06
what are we going to do for the post-op pain?
13:09
On a previous trip to the zoo, they were doing some ultrasound exams. I said, well, let me
13:14
borrow the ultrasound and just check. Can I see the brachial plexus if we ever needed
13:19
to do a nerve block in the future? Can I see the femoral and sciatic nerves in the leg
13:23
if we ever needed to do something in the future to help an animal? We could see it, but then
13:28
when we got to talking in this specific case, I was sort of like, well, what's a gorilla
13:33
going to think if they can't feel their arm? I mean, in one sense, you think, oh, that's
13:39
great. We're going to preserve the animal from having pain. But on the other hand, pain
13:45
is an evolutionary adaptation. It prevents us from doing things that hurt ourselves.
13:52
If you can't communicate with an animal to tell them, well, hey, for the next 18, 24
13:58
hours, you're not going to feel your arm, what is the animal going to do in response
14:03
to that? Is it going to start banging its newly fixed arm against the wall trying to
14:07
feel it? Is it going to start picking at its fingers or biting its fingers or perhaps harm
14:11
itself because it can't feel it? Would you not be able to, if the arm was swollen underneath
14:18
the cast, it was causing complications from blood flow, the animal wouldn't be able to
14:21
feel it. So you almost need a little bit of a monitor. So we elected not to do that. But
14:27
again, that understanding or being able to explain to a patient or get feedback is a
14:33
lot different. And I think that's where it makes it more challenging.
14:37
That's really interesting. I hadn't thought about it from that perspective. That sort
14:41
of reminds me of how patients who get dental anesthesia can chew on their tongues. Later,
14:45
of course, they tend to regret doing that.
14:48
Yeah, pain is really interesting scientific topic. I mean, that's partly why I got into
14:55
acute pain. But when I was at Georgetown and I started my career as an orthopedic resident
15:00
at Georgetown in med school, we had two of the very rare cases of the syndrome called
15:04
congenital insensitivity to pain. So these two twin boys literally could not feel pain
15:12
and they were a wreck because they sit there and wrestle with each other and they dislocate
15:16
their shoulder and they wouldn't realize it. They'd run around and they break their ankle
15:20
and just keep running around on it. And so they would continuously come back to us at
15:24
Georgetown for all of these procedures because they couldn't feel pain. And it wasn't anything
15:31
malicious that we're doing to each other. But the feedback signal of like, that's a
15:35
bad idea, it wasn't there. So again, that same concept of like trying to do a nerve
15:40
block would in theory be helpful. But trying to think through all the consequences of your
15:45
actions is a little tougher with these animals because you don't have that ability either
15:48
before or after to console, to explain, to give feedback.
15:53
Yeah, that certainly is a challenge. So you're called into the zoo for an arm fracture, you
15:59
go in on one of your days off. What does your day look like? What time do you get there?
16:04
What sort of steps are you taking? When do you first see the gorilla or primate that
16:07
you're working with?
16:09
Yeah, for the most part, these are scheduled well in advance. I mean, even with the fracture
16:15
arm, there was communication a number of days in advance trying to piece together the team,
16:21
for example, the orthopedic surgeons from Children's Hospital, the anesthesia team from
16:24
the University of Cincinnati to get everyone's schedule coordinated, but then also to sort
16:30
of plan and make sure everything was in place. Because this really is sort of like a human
16:35
anesthetic. So for example, we would call our patients beforehand and say, and give
16:39
them instructions, say, don't eat or drink after this sort of time. So, you know, there's
16:43
an email that goes out to everyone involved saying, hey, please hold food and water, you
16:47
know, at this time, we're planning to do the initial injection at this time, the induction
16:53
at this time, we're planning on, you know, transporting from the enclosure to the veterinary
16:59
hospital at this time, and sort of sort of an itinerary to make sure that all the various
17:03
pieces are in place and coordinated. So that includes the animal care team, who's with
17:11
the animals daily and controls their food, water and training schedule, traffic control
17:16
within the zoo, as we have to transport from the enclosure to the veterinary hospital and
17:20
back and forth, make sure there's not people in our way, all the different pieces to that.
17:26
So the case really starts a couple of days in advance. Depending on what's going on,
17:30
we usually start somewhere between seven or eight in the morning with the initial injection
17:36
of the animal. So obviously, they're not going to just sort of walk over to the vet hospital
17:42
for you and lay down nice on the table while you put in an IV like maybe a human patient
17:46
would. So typically, the animal care team has gotten them trained to accept a hand injection.
17:52
So we do a little bit of basically sedative medication to get them calmed down before
17:57
they do like a full intramuscular injection. So they don't get startled and hurt themselves
18:03
from that. And then once they're sedated, then we take them over. So typically try and
18:07
start fairly early in the morning so we can get them back to the enclosure in reasonable
18:11
time.
18:12
So have you spoken to the vets about how they train these gorillas to get injections?
18:19
A little bit. I mean, it seems from the outside, I probably won't use the correct term, but
18:25
very Pavlovian. I mean, it's a reward system. So you ask an animal or try and get an animal
18:31
to do a certain behavior. And you reward that approximation of them. And every time they
18:37
get closer, you do serial reward. So some of the animals will actually let you do a
18:43
few things. Obviously, the animals inside the enclosure, the people doing the procedure
18:48
or doing things outside. But they can safely get them, for example, to extend their hand
18:52
out through the enclosure to take a brief injection or even do some of the animals,
19:00
depending on what's going on. Maybe you can listen to their heart and lungs a little bit.
19:03
You can do very quick looks at the teeth or things like that to get kind of trained to
19:07
do that. But it's always a very careful dance, so to speak.
19:12
So as an anesthesiologist, the thing that I think of that I might use in this type of
19:16
situation is ketamine. Is that the drug that they're using? What kinds of drugs are they
19:21
using in the veterinary setting for these animals?
19:25
Yeah. So a lot of the drugs are very similar. I mean, we're using things like propofol.
19:29
We're using things like ketamine. We use things like epinephrine. Some of them, because
19:33
of species differentiation between how metabolic pathways work, for example, you can't give
19:39
ibuprofen to a dog because the way it gets metabolized, it's toxic to the dog. But other
19:45
NSAIDs are fine for dogs. So typically, the main medicine that I've worked with with them
19:53
that's different is something called telazole. So basically, it's a combination of teletamine,
19:59
which is sort of an analog of ketamine, and zolazepam, which is very similar to a benzodiazepine.
20:05
And so it's like a combination injection that you can give. And that really sedates the
20:10
animal to the point where you can safely work with them in close proximity. But it's not
20:15
a respiratory depression. It actually supports respiration. So it's safe to use to sedate
20:20
them when you don't have a controlled airway. And then once we do that, then we sort of
20:25
get them moved. And then it becomes more of a human anesthetic at that point.
20:30
So how do vets know or test when it's safe to go into the enclosure?
20:36
Well, this is sort of a graded process. So again, it's just you start with observation.
20:42
If they're moving around and looking at you, they're not sedated enough for you to be working
20:47
with them. So gradually, they kind of go off to sleep. But then you use some stimulation
20:53
from a safe distance, typically maybe a long piece of material. Though you can kind of
21:03
tap the animal from outside the enclosure to make sure there's not a reaction. And you
21:09
make sure that they're not reacting to that. And then there's some safety doors to get
21:14
into these enclosures rather than the main door. So we'll have some of the staff go in
21:19
one of the safety doors ready to quickly get out if, for example, the animal responds to
21:24
the human presence rather than just sort of a poke, for lack of a better word.
21:29
Safety strikes me as one of the critically important concerns here, not just for the
21:33
patient, so to speak, but for everyone involved. I think most people listening are probably
21:38
aware of the relative strength of a gorilla being just wildly out of proportion as compared
21:43
to what one might expect from a human. So what sort of safety precautions do you take
21:48
into consideration, whether it's during transport or anything else?
21:52
Yeah, a lot of it's communication and redundancy. So for example, there's multiple locks on
22:00
the doors. There's multiple doors that separate enclosures from, let's say, the animal side
22:06
to the human side or the exterior. So when we're interacting with the animal, there's
22:13
multiple levels there. I think the most important team is the wonderful animal care team and
22:19
staff at the zoo that really form a rapport with these animals. And I mean, they're amazingly
22:27
dedicated. They're wonderful people. They spend an enormous amount of time working with
22:30
these creatures. And really, they're like their family. And just, I think, their ability
22:38
to whether it's their soothing voice, because obviously they don't understand words necessarily,
22:43
but just a soothing voice, their presence, their calming reassurance when we're either
22:49
starting the process to get an animal sedated or emerging them out of an anesthetic that
22:54
really provides a level of safety, both for the animal, but also for us that they're not
23:01
getting excited. They're not feeling threatened. And I think that's probably the biggest safety
23:06
piece. There always is what they call the dart team at the zoo, the dangerous animals
23:12
response team that is always available on call if an animal interaction would go awry
23:21
or if, for example, an animal was able to get out of an enclosure. I mean, that's basically
23:26
back in around 2016, what happened with Harambe and the unfortunate outcome there with the
23:32
child.
23:33
The Harambe event was, of course, very tragic for everyone involved. Let's talk a little
23:39
bit about some of the techniques and equipment that might be different. At what point are
23:43
we putting in a breathing tube? At what point are we putting in an IV? How does that whole
23:48
process look?
23:49
Well, I guess I'll just kind of start at the beginning and work our way through. And a
23:53
lot of it's very similar. I mean, I think that kind of your biggest difference is you're
23:57
not going to put in an awake IV to do a traditional IV induction. You don't really get to sit
24:02
there and have pre-oxygenation, for example. And then the emergence piece as well, like
24:08
you've got to safely get out the breathing tube. You've got to make sure the airway is
24:11
safe to remove that tube. But you also don't really want to be in the enclosure to remove
24:16
the tube once they're too awake. So it's a little bit of a dance there. So I think the
24:21
sort of the induction emergence is the biggest challenge and difference that you're going
24:27
to have to do that differently than humans.
24:29
The other piece is the movement. Like we typically don't put a person to sleep in one place and
24:37
then put them in some sort of a transport vehicle and move them to another place to
24:42
do the surgery and then put them back in a transport vehicle to go to the recovery room.
24:48
So that's a bit of a challenge. You want them sedated enough. Obviously, you don't want
24:54
too much. But then you've got to, with a team, pick them up on a stretcher and get them into
24:59
the back of a van that has a mobile anesthesia machine in it. Basically, an open circuit
25:04
anesthesia machine to continue to start the process of getting them gassed, keep them
25:09
asleep. We always have ketamine on backup to do some IM injections. Get them to the
25:15
veterinary hospital, pick them up again, get them into the facility. And then that's where
25:21
you sort of what most people would say is, oh, there's a human anesthesia machine there.
25:26
And it looks like a mostly human anesthesia machine. There's some differences in terms
25:31
of the pressures that can generate, the volumes that can generate just because of the size
25:35
of these animals. The bag, actually the reservoir bag is significantly larger because especially
25:41
for example, the orangutans have enormous lungs. So it's actually like a wide piece
25:45
and two big breathing bags on there. But yeah, so getting them in there, but then it becomes
25:52
very human. The patients are dated, we put it in an IV, we give them a little extra propofol
25:58
perhaps to get them more deeply anesthetized to do a regular direct laryngoscopy to get
26:03
an endotracheal tube, but the tube's obviously bigger. The laryngoscope is bigger.
26:07
Do you recall what size breathing tube you were using?
26:10
Yeah, a lot of times it's like a 10 or 11. Whereas an adult human male might be an eight.
26:15
So it's significantly different. Obviously they have much bigger tubes for things like
26:19
giraffes for example, which are interesting to see. But yeah, that's kind of where the
26:25
difference is, induction, emergence, and then the transport. But again, the anesthesia machine
26:29
is very similar. The vital signs are very similar. The medications for the most part
26:34
are very similar that you're going to use. So sort of the middle of the anesthetic is very similar.
26:41
So if I have this right, you're transporting the gorilla. Is it you with the vet on the back of the van?
26:47
Right. There's kind of a team that goes over. So it's one of those large, you could probably have
26:52
four or five, would be able to have like four or five rows of seats in it, sort of a van.
26:57
So there's always three or four people in the van that are helping with transport,
27:01
just physically lifting some of these animals that can be three, 400 pounds.
27:06
But then behind that seat for the back half of the van, there's a mobile, open-circuiting
27:13
anesthesia machine bolted to the floor. And then usually myself and then one of the other vets are
27:17
in the back or one of the other UC physicians, anesthesiologists are in the back monitoring
27:23
the primate to make sure they're staying asleep and make sure they're breathing and not obstructing.
27:28
How does it feel being in the back of a van with a say 200, 300 pound gorilla? It's an experience.
27:34
Very few people in the world must have had. What's going on in your mind when the gorilla
27:40
coughs or moves? Luckily, most of the time they don't. We do a lot of testing to make sure they're
27:46
properly sedated. But again, we do have intramuscular catamine to give them additional
27:50
sedation if we need to. But certainly, yeah, every once in a while they do move a little bit,
27:54
they cough, they hiccup. It does give you a little bit of moment of pause there, sort of,
27:58
you know, not to date myself, but back to the Tom and Jerry cartoons. You know, sometimes you see
28:04
them get into a fight inside of a sort of a closed space, whether that was like a tent or a vehicle
28:09
or whatever. And you can see the vehicle being dented with images of Tom or Jerry from the
28:15
inside, you know, as it gets tossed around. So that kind of goes through your head sort of
28:19
humorously. But you know you're safe. The vets do a wonderful job. They know what they're doing.
28:24
They're very professional and wonderful to work with. So I'm not really concerned that they're
28:27
going to wake up, but it does run through your mind. That definitely seems like an intense
28:32
situation to be in. Yeah, you certainly have to pay attention. I wonder if you can share with us
28:36
some of your most memorable experiences working with the primates at the zoo. Well, certainly,
28:41
I think the most memorable will always be the first one, you know, when you first have an
28:46
opportunity to come close to one of these amazing primates. So the first one I did was in Doume,
28:52
he was the he's the silverback at the zoo. So obviously a very large gorilla. And it just,
28:58
you know, you see them from a distance and you appreciate the beauty and the majesty of the
29:04
large primates. But when you see them up close and see really how human like they are, like
29:08
especially the eyes, the hands, and things like that, you really gain a really deep appreciation
29:15
for their beauty. And it was just amazing. And I think each time you take care of, let's say,
29:21
a different species. So the first time I did an orangutan, the first time I did a bonobo,
29:25
just seeing the differences between them. But also, again, especially the bonobos, which is
29:31
genetically our most closely related primate and more physically sized like a human, you know,
29:40
you're like, wow, this is sort of like a close relative, you know, and things.
29:46
I bet that's really fascinating. You know, it strikes me that you might not be able to use normal
29:51
EKG stickers on primates. Do the EKG stickers work? They can use some tricks to get them
29:58
work. They can shave a little area of the skin to get them to work. They also have some modified
30:02
EKG electrodes to use to be able to get the EKG. But again, if you look at the monitor that we're
30:08
using, it looks very much like one of the monitors we've had on top of our anesthesia machine. And
30:13
the pulse ox looks very similar, for example. The blood pressure cuff is identical. So there's
30:18
there's not a lot of difference there. So really, we're using the same monitors?
30:23
Essentially, yes. Yeah, we monitor end-tidal CO2. We monitor frequent blood pressure,
30:30
frequent heart rate, as we always do. You also mentioned that they do cardiac exams.
30:36
Is that something that translates over in the same sort of way?
30:39
Yeah, certainly. And that's one of the things that I think when you ask about challenges,
30:42
the differences, is learning some of the differences in anatomy, physiology,
30:49
and disease processes for some of these different species. For example, like the large primates
30:57
typically have a problem getting accelerated cardiac disease, and not necessarily coronary
31:02
artery disease. But they typically are at higher risk for getting valvular disease and also
31:08
lethal dysrhythmias. So one of the things that they do is they do frequent echocardiograms
31:14
to monitor their heart function, their valv status. Interestingly enough, they bring an
31:20
echo tech from one of the local hospitals over, and they bring their TE machine, and
31:25
it looks exactly like pretty much like a human heart. But they do that. But they also, for example,
31:31
in one of these sort of multi-zoo collaborations, are actually doing a study on these dysrhythmias.
31:36
So we've actually, as part of that study to improve the ability of these animals to live
31:43
and survive, they've actually implanted loop monitors, basically human cardiac monitoring
31:52
loop recorders, into these animals to study the incidence of dysrhythmias or what's happening,
31:58
and why they're at risk for these lethal dysrhythmias. So it's interesting.
32:03
Yeah, I don't suppose a Holter monitor would be of much use in the gorilla pen.
32:08
It would probably not stay on very long. I mean, going back to Gladys, the gorilla with the broken
32:13
arm, they sort of had to do a more robust fixation than maybe would be typically done for a human.
32:21
But also, there was some involvement with GE and local aviation to use some different materials
32:28
with the brace and cast the gorilla that would be a little more sturdy for her recovery.
32:35
Yeah, I imagine so. So you've gone through the anesthetic, it's time for emergence.
32:40
What's different about the emergence process? I know you described it as a bit of a dance.
32:44
Tell me more. Right. So in a typical human, we would just,
32:50
for the majority of cases, turn off the gas at the appropriate time, wait for the patient to
32:54
exhale enough gas that the level of gas within their brain drops to the point where they become
32:59
conscious again, they get conscious enough to protect their airway and be awake enough
33:04
to not hurt themselves. And we take out the breathing tube and transfer them to the recovery
33:09
room. Obviously, you don't want a primate to be fully awake before a transport or being in the
33:17
room with them. So basically, we're modifying their level of anesthesia to give us time to transport
33:26
the animal. So we'll pretty much leave the gas at their maintenance level so that we know that we
33:34
have time to transport the animal. And then again, we leave the IV in during transport so that we
33:42
could give some additional medication, whether it was your propofol or ketamine to keep them sedated.
33:46
If the gas doesn't last as long as we think it might. Obviously, just like humans, the longer your
33:51
inner procedure, the longer it takes to get rid of the gas. So if we have some shorter procedures,
33:55
sometimes we need to supplement it because the gas comes off quicker. If there are longer procedures,
33:58
then oftentimes we can just rely on the gas. So that's basically it. But then the emergence
34:05
portion of it, we don't want these animals to hurt themselves either accidentally because they're
34:12
not aware of what they're doing or they're startled. And so we take them back to their enclosure in a
34:17
very padded environment that the care team has gotten set up for us. So we give them a nice soft
34:23
place to emerge from. And then we monitor them carefully. When they're awake enough to get the
34:31
tube out and protect their airway, we take it out. But then we still monitor them from outside the
34:35
enclosure to make sure that they're breathing properly, not obstructing. They're waking up in
34:40
a safe fashion. They might be a little clumsy, a little awkward, just like anyone would be
34:46
when they're waking up. If you've ever seen your dog at the vet come out from being sedated,
34:50
you see they're a little clumsy. So you see that. I mean, they're not just going to sit nicely on a
34:55
stretcher or a bed like people do. Well, not all people do. Well, this is true. We try to keep them
35:01
in the bed as best we can. But that's the challenge is to get them awake and let them wake up in a
35:08
fashion that they don't feel startled or threatened. And again, that animal care team that's there is a
35:14
huge benefit because those animals trust those people and they're reassured by them. So they do
35:19
a great job. So when we're dealing with human patients, there's a whole set of ethics we're
35:25
used to thinking about and using. As anesthesiologists, we're used to treading these
35:29
waters. Are there different ethical considerations for these primates versus our human patients?
35:34
Obviously, they're not people. But I think we still follow the same ethical rules that we do with
35:41
people. I mean, we treat them with respect. We don't joke around. We give them the best care
35:46
possible. We're not taking frivolous pictures to post on social media. And the other piece of it
35:55
is, I mean, we're basically doing these for routine exams. We're doing these anesthetics
36:03
for preventative health maintenance, occasionally for an injury, an illness,
36:10
some sort of infection where the animal needs help. So we're not doing anything controversial.
36:19
You know, we're just maintaining the health of these animals. So there's not really much in the
36:24
way of ethical considerations here. I think it gets a lot more complicated when you get into the
36:30
host of issues that humans choose to do or not do certain procedures or use certain technologies
36:38
in health care. But I think it's a little more straightforward, actually.
36:42
Let's say that you met with a young anesthesiologist who was really interested
36:46
in pursuing this sort of exotic type of anesthesia. Do you have any advice for how
36:51
they might go about partnering with their local zoo? Like I said before, it wasn't something I
36:56
planned. So I don't have this great pathway that I took to say these are the three steps that you
37:01
should take. I would just offer that the vets at these zoos are incredibly dedicated, professional
37:08
people. And I'm sure they would be happy for additional help or expertise. So my advice would
37:17
only be to reach out to your local zoo and talk to the vets and see if there's anything you could do
37:23
to help. Can't hurt them. Worst they can do is say no, but they might very well be very happy to
37:28
have your help. How do you feel about the teamwork with the vets that you experience at the Cincinnati
37:33
Zoo? It's a great team. I mean, you see how much they care for these animals, the interactions
37:39
between the vets and the animal care team, but even the people like the animal safety officers
37:47
or even the people who are maintaining traffic flow at the zoo, they really do care for these
37:52
animals and they're really looking to do the best for them. I think that's the value that we add.
37:58
They could do these anesthetics without us. I think they feel more comfortable with us there
38:03
because of our expertise since they're sort of like humans. But more importantly, when we're there,
38:09
we are focused on the safety of these animals during their anesthetic, which allows the vets
38:15
who have the expertise to take care of these animals to focus on that and not have to worry
38:22
about the anesthetic as well and either divide their attention or divide the work taking care
38:27
of the animal, which means then the animals under anesthesia longer, which as with humans,
38:33
the longer you're under anesthesia, although anesthesia is very safe, there's more risk to the
38:39
longer procedures. And some of these animals have some issues. Some of the primates have heart
38:44
failure. Some of them have valve disease. And so the anesthetic for them is challenging.
38:50
And the quicker you get done with those exams or treatments, the better it is for the animal. So
38:57
that's where I think the teamwork comes together and they appreciate us being there and it's great
39:02
to be part of that team. So since the vet's attention isn't divided, they don't have to do
39:07
all the things at once. They're able to more efficiently do the things that they need to do
39:10
and therefore minimize the time under anesthesia and minimize the risk of these primates.
39:15
Exactly. I really appreciate you sharing your experience working with the Cincinnati Zoo and
39:21
some of the unique challenges that you face in that environment. Before I let you go though,
39:25
I'd like to ask you about your own personal style points. What style points or points of personal
39:31
preference have brought you success both in and out of the operating room? I think for me,
39:37
it's really important to be personable, to be kind, not take myself too seriously, have a good
39:45
sense of humor. As an anesthesiologist, I think a lot of people from the outside think we go into
39:50
anesthesia because we don't want to talk to patients or we can't talk to patients. However,
39:56
these patients are at one of the most vulnerable points of their lives. They literally have to
40:02
trust us with their life and we get a very small window of opportunity to be able to talk to these
40:10
people, meet them before we accept that responsibility. So I think it's really
40:15
important to be able to make that connection, whether that's with a kind word, a little bit of
40:21
a story, one of my famous dad jokes that just puts them at ease but allows them to feel cared for
40:28
and trusting, to be able to kind of put them at ease more importantly than using medication to do
40:35
that, for example. I think that's true with our coworkers at our hospital as well. I mean, the
40:39
hospital is by definition a very stressful place to work at. So if you can make people feel valued
40:46
for their work, a kind word, not making them feel pressured, the whole system is going to work
40:52
better. And that's the same, I feel like as a coach and as a parent, it's amazing how we
40:58
can make people feel better. It's amazing how well someone can work or play or live
41:06
with the confidence or ease that they are put at by treating them well, being kind to them,
41:15
giving them that empathetic kind word or even just a laugh.
41:20
Okay, so now I have to ask, hit me with your best dad joke.
41:23
I'll go with the one that I used at the zoo and I sort of try and put my fellow anesthesiologist
41:29
first time they come. And they're always talking, they see people taking maybe some pictures of the
41:36
experience so that they can kind of educate other people on things. And there's always a question
41:41
about privacy and different things. And I always tell people that luckily, because we're at the zoo,
41:47
we're not governed by federal privacy acts. But we do, even though we don't take care of them,
41:52
they're very careful with Fiona and her family and their privacy, because we wouldn't want to
41:56
commit an accidental HIPPO violation. Excellent, HIPPO violation. I will remember that.
42:02
Well, Brian, thank you again for joining us and sharing your insights.
42:07
I really appreciate your point of view. Appreciate you having me.
42:10
Well, that about wraps it up for this episode of Style Points. If you liked what you heard,
42:14
there's more to come. While our previous episodes have focused on some difficult anesthetic cases,
42:19
such as liver transplant, pheochromocytoma, and obstetric cardiac anesthesia, or Dr. Aribal's
42:26
excellent rundown of GLP-1 agonists, we have more in the works, including anesthesia for ECMO and
42:32
a mock oral board scenario given by a real board examiner. Search your favorite podcast app on
42:38
your phone for Style Points, and it should come up under my name, John Crowe. Once again, thanks for
42:44
joining us. Take a deep breath, open your eyes, we're all done.