Your Anesthesia Questions - Continued

Question: Do anesthesiologists carry malpractice insurance?
Anesthesiologists (MDAs – medical doctors of anesthesia) are doctors who specialize in anesthesia. CRNAs are nurses who specialize in anesthesia. This is confusing to patients, and I should do a whole post on it. Here’s the mini version: I’m a nurse with a masters degree, not a doctor with a specialty. I work in a hospital that has a “team model.” My attending anesthesiologist does the pre-op assessment (usually while I’m in the previous case), and he’s present for the induction (where we put the patient to sleep and secure the airway) in case I need an extra set of hands or a second opinion. On a normal day, he just stands there and looks pretty. Then he’s gone for the rest of the case. He only comes back if I call him because I want advice or because I need to go to the bathroom (and sometimes not even then!). The MDA’s also do their own cases some days; they don’t always supervise. In addition, many hospitals have only CRNAs or only MDAs. There are many different practice models.
Nurse anesthetists have been around in some form since the American Civil War. My granddaddy was a nurse anesthetist. A number of studies have been conducted on quality of care. They all indicate that you get equal quality care whether you’re anesthetized by a CRNA or an MDA. We get the same training in anesthesia. However, medical doctors are qualified to do things like mange home mediations for pain, high blood pressure, and other co-morbidities. CRNAs don’t do that. We are perioperative specialists.
Sorry for the tangent. You asked whether MDAs carry malpractice. I’m sure they do, but I don’t know how it’s set up, because I am not an MDA. I am insured through the anesthesia group that employs me. If I took a 1099 job, I’d have to buy my own malpractice insurance. One way or the other, you’ve gotta have it. Anesthesia is a high law-suite area. It comes with the territory.
Question: Have you ever used your knowledge of anesthesia in writing fiction? (I suspect so, looking at poisons in Panamindorah)
Sure. Most often, I use basic medical knowledge to make injuries or medical events realistic. I could do a whole blog on silly medical scenes in fiction. :) My only story that directly related to anesthesia was “Blood of the Dawn,” and I’ve hidden that story because it’s got such huge spoilers for Walk Upon High. Sometimes, my medical background probably gets in the way. My characters are too right too often. They should probably believe more nonsense about health and injury.
Question: Know this sounds odd, but any truth to redheads being more resistant to certain anesthetics?
Not a silly question at all. There have been multiple studies on this. As far as I know, it’s inconclusive. Some anesthetists believe that redheads need more drug, and some do not. I have no strong opinion about it.
Question: Why do they give you that horrendous anti-nausea shooter before anesthesia when it just makes you sick to your stomach?
I had to quiz the questioner about this, since our antiemetics are generally given after the patient is asleep through the IV. I guessed that her surgery was a c-section, and I was right. C-sections are considered a full stomach, they are more likely to vomit, even if you do everything right. Consequently, they routinely get bicitra before the case. It’s 30 ml of nasty-tasting liquid that decreases the acidity of your stomach contents. It does not prevent nausea. However, if the patient does vomit and aspirate, they are less likely to get pneumonia, because there will be less damage to their lungs because the vomit is less acidic. Make sense?
Question: Do people really say weird stuff/ reveal secrets as they go under?
Not usually. They usually behave as they normally would; they just don’t remember it later. Often, they say the same things over and over because they forget what they just said. On the other hand, propofol is a mild aphrodisiac, and some people get aggressively flirtatious during a sedation. When that happens, you just deepen them, and they start snoring.
Question: I don't know anything about anesthesia except that the anesthesiologist on Greys Anatomy did crossword puzzles. Do you do puzzles?
During long cases, you sometimes have a period where you’re just monitoring the patient, charting, and nothing else is happening. During that time, many of us read something. Studies indicate that  you’re actually more alert for problems when you’re switching your attention between a book and the monitor, as opposed to just staring for hours at the monitor. Light reading keeps you awake. I typically read either my Kindle or articles from Google FeedReader on my Phone. iPhones have become the overwhelming source of reading during anesthesia cases in the hospital where I work. People hardly ever carry magazines or newspapers anymore.
Question: How do perfusionists fit into the whole surgery/anesthesia thing?
Perfusionists run the heart/lung bypass machine. This is used for coronary artery surgery, heart transplant, and lung transplant. In very specific situations, you can also crash on bypass to save someone’s life in an emergency/trauma situation. The bypass machine is a delicate instrument with rules all it’s own. A perfusionist is trained to run that machine. CRNAs and MDAs don’t do that. During a cardiac case, the dangerous time (for us) is going on bypass and coming off bypass. When the patient is actually on bypass, there isn’t a lot for us to do.
Question: Why did I see the spirit of Odin when I went under anesthetics for my operation? Or was it Loki?
That was actually the spirit of Silveo. He is annoyed that you didn’t recognize him.
Question: I am curious about training for anesthetists. In vet med, we get a DVM then do a residency to be an anesthesia specialist. But as general practitioners we anesthetize patients and our techs are often doing a lot of monitoring.
To become a CRNA, you need a 4 year nursing degree with a few extra sciences/maths. Then you need to work for 1-5 years in the ICU. Then you need to get into an anesthesia program. These programs are competitive, and you need high grades. They take only the cream of the ICU nurses. Once you get into a program, you will spend 2.5-3 years getting a masters in anesthesia. This may involve living all over the country at different clinical sites. You say good bye to your family before you start. That’s what everyone needs to become a CRNA.
In addition, I personally have a pre-medical background. My first degree was biology. I was pre-vet. I ended up with a biology degree, a chemistry minor, a minor’s worth of other classes (physics, calculus, statistics), and I was 9 hours short of a English degree. I got into Purdue veterinary school and spent a semester there. I left (for reasons beyond the scope of this question), cast about for a while, got half a literature masters, did some teaching. Then I went into nursing. So, I have more than the minimal requirements. For the difference between MDAs (anesthesiologists) and CRNAs (nurse anesthetists), see my answer to the first question in this post.

Your Anesthesia Questions

I’m a certified registered nurse anesthetist (CRNA). Read my bio for a quick run-down of my day job. One of my goals with this blog is to de-mystify anesthesia. For most people, it’s a mysterious process. The average person has surgery a handful of times in his or her life. I find that most people don’t truly understand what happened to them during their surgery. This is not because doctors and nurses try to be obtuse. It’s because these things are complicated. In addition, unless you already have some idea of what you’re looking for, it’s hard to find thorough, accurate information about anesthesia for free online. You need the education and experience of the profession to sift what you see. Most good anesthesia articles are written in the language of the profession. They’re difficult to understand if you don’t already know what they’re talking about.
So earlier this week I asked my twitter and facebook followers for questions about anesthesia. Here are the questions and my answers.
Disclaimer: I am not a doctor. Nothing I say constitutes medical advice.
Question: What are the the various kinds/types of anesthesia?
  • General Anesthesia - usually involves gas and an airway - either an endotracheal tube (ETT) or a laryngeal mask airway (LMA) 
  • MAC – monitored anesthesia care, AKA sedation – typically only involves drugs given through the IV, no gas
  • Local anesthesia /blocks – numbing medicine injected near or on a nerve. This does not affect the brain or make you sleepy, but it does make you numb. Epidurals and spinals (central neuraxial blocks) fall into this category, as do femoral nerve blocks, sciatic blocks, interscalene blocks, etc. for joint surgery. The optic nerve is sometimes blocked for eye surgery. You can do hand or finger blocks. Sometimes the surgeon does this, and sometimes the anesthesia provider does it. Dentists use local anesthetic without an anesthesia provider present.
  • TIVA – total intravenous anesthesia – a rarely used hybrid of general and MAC, in which you introduce an airway, but do not use gas, keeping the patient asleep with IV medications instead. There are only a few situations where you would want to do this, usually because you need a controlled airway, but the patient has a severe reaction to gas.
Question: What chemicals do you use? Do you know how those chemicals are manufactured?
I personally prefer a nice cup of coffee to anything in my anesthesia cart. :D Just play’in. By “chemicals,” I’ll assume you mean medications that we give the patients. This question is really too broad, but I’ll try to answer. The goals of general anesthesia are:
anesthesia (sleep)
amnesia (no memories)
akinesia (no movement)
analgesia (no pain)
To this end, we give halogenated anesthetic gases (sevoflurane, desflurane, isoflurane) and IV propofol or etomidate for sleep, versed and ketamine for amnesia, paralytics (succinylcholine, rocuronium, vecuronium, cisatracurium ) for akinesia, and opioids (fentanyl, morphine, remifentanyl, sufenta) and other medications (toradol, tylenol) for pain. We also give antiemetics (zofran, decadron), since anesthetic gases cause nausea. We give medications to control blood pressure, as anesthesia can make BP dangerously low, and surgical stimulus can make it dangerously high. We give agents to reverse our paralytics and other drugs to counteract the negative side-effects of that reversal. And there are plenty of options I haven’t listed. Providing a good anesthetic is like cooking. No two cooks are alike. It’s a cocktail with two customers – the patient and surgeon. The patient has to be comfortable and alive, and the surgeon has to be able to do his or her job. We facilitate this with a formidable arsenal of “chemicals.”
How these chemicals are manufactured is a question outside the scope of my practice (and, frankly, outside the scope of practice of everyone I work with). You’d need to ask an organic chemist. I could probably follow their explanation, but that’s about it.
Question: How is being anaesthetized different than being asleep?
The short is that when you’re asleep and someone cuts your belly open, you wake up. ;) There are 4 Stages of Anesthesia. Adults typically sink down through stages 1 and 2 so fast that you don’t notice. Children, on the other hand, have a noticeable excitement phase (Stage 2). Surgical anesthesia is Stage 3. The 4th stage is essentially brain death or something close to it. You always keep the patient hovering above the abyss.
Question: Do people really hear what med staff says while under?
During stage 3 anesthesia: no. During stages 1 and 2: sometimes. True surgical awareness is very rare and usually happens when the patient’s blood pressure is so low that the anesthetist had to decrease their level of anesthesia in order to save the patient’s life. This happens most frequently in a trauma situation, such as a car accident victim, where the patient is bleeding out. Emergency c-section is also a high risk for awareness. This happens because medical staff are trying to save the life of the baby and mother. Sometimes very fragile patients simply cannot tolerate enough anesthesia to keep them unaware. However, this is extremely unusual. We have excellent amnesic drugs these days, such as versed, which can erase memories retroactively if given within a few moments of the event.
On the other hand, “general anesthesia” should not confused with a “MAC” (monitored anesthesia care) AKA “sedation.” If you’ve ever had a colonoscopy or endoscopy, it was probably done with a MAC. People can remember things from a sedation; no guarantee can be provided that they will not. In fact, some level of awareness is often desired, as the patient may need to follow instructions. However, I can tell you that, in practice, people hardly ever remember anything from a MAC, either.
Question: What is more dangerous, being under anesthesia, or having the actual surgery?

That depends on how sick the patient is and what kind of surgery he or she is having. Also most surgery is impossible without anesthesia. Aside from the fact that the patient would be a moving target (writhing in pain), abdominal muscles would make abdominal surgery difficult or impossible without paralysis, which is part of the anesthesia. In addition, it would be difficult for the surgeon to hear his iPod over the screaming, and surgeons get really cranky without their music. ;)

Seriously, anesthesia is a component of the “actual surgery.” You can’t tweeze them apart. However, if you’re asking who has more opportunities to kill you (the surgeon or the anesthetist), that’s easy. The anesthetist.
I think that's enough for one evening. If I haven't mispelled any of these drugs, it'll be a small miracle. I'll answer some more questions tomorrow.