Episode 305: Master Clinician Part 7: Eric Busch
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Hello and welcome back to ACRAC. I'm Jed Wolpaw and I'm thrilled to be back with another Master Clinician episode. I have with me today Dr. Eric Bush, who was recommended very broadly and widely by folks at Ochsner in New Orleans, where he has worked for a long time. People described him in a lot of really incredible ways, which I will share a couple of those with you in a second.

Just as a little background, Eric attended Case Western for medical school. So Cleveland, near and dear to my heart as someone who grew up in Cleveland, then did his residency at Ochsner. He went back to Cleveland for a chronic pain medicine fellowship, then came back to Ochsner and interestingly led the cardiac anesthesia team there from 2008 to 2014. Now does a lot of interesting stuff, I think, including a lot of interventional cardiology procedures.

And he is somebody who folks there just really look up to and love working with. Let me read you a couple of things that the trainees sent to me. So one person said, in addition to a wealth of knowledge from the past 35 years of practice, I think the most fascinating thing about Eric and what makes him so good is his perpetual curiosity.

He has seen many things, but if he hasn't, you can best believe he will deep dive until it makes sense to both you and him. And on top of that, he's just a great guy to be around. Lots of fun and never a bad day when working with him. Another wrote, Dr. Bush is a mentor to so many in our program.

Our residents highly look up to him and always relish the opportunity to work with him in the OR. His experience from his career is something I personally try to absorb any chance that I can. So, Eric, I'm thrilled to have you here on the show so you can share some of this with the wider audience. Thanks for coming. You're welcome. Happy to be here.

So I captured, I think, a little bit of your background, but let me just ask you to start by just saying a little bit, maybe more fill in the gaps a little bit. How well did I do? Talk a little bit about kind of your path and how you got where you are now. And then maybe since I just said a very little bit, talk a little about what your day-to-day looks like now. I did go to CWRU med school, went to Ochsner for my anesthesia residency. After residency, I

For my CA3 year, essentially, because I was in a transition year, as you know, Jed, there was a time when you just had two clinical years of anesthesia. Somehow, my fellowship was my CA3 year. I don't know how that worked out. And that was at Mayo in Rochester. Okay. And so I had to do a third year. There was a third year you had to do. And I said, some people just did a third year of clinical years.

at our main site, but I decided to go to Mayo and just because I thought, well, this will be interesting. And I did a chronic pain with a guy called Tim Lamer, who is still doing it. Back then, pain was not necessarily a full-time thing. You know, in the early, I guess, really in the early 2000s, that's when people who did chronic pain, that's all they did.

But when I got into it, it was a couple days a week. And when it became apparent that you were going to have to run a clinic and do it all the time, I was done with it. And around that time, right after that, it was maybe 2004, Alan Santos was our chairman. And Alan identified that he wanted to subspecialize the department.

And that meant cardiac subspecialization. And that was like the writing on the wall. You were going to have to become PTE certified. And at that point, I said, well, you're either going to be in or out, right? And so I decided I wanted to be in. And me and a number of other people just really started to bear down on learning how to do transesophageal echo.

At that point, you could actually become certified without doing a fellowship. That changed. So we all learned how to do TEE. We took the exam and we formed our cardiac anesthesia team, which became necessary because the surgeons that started to come out at that point, the cardiac surgeons, they

In particular, a guy named Gene Perino came from Cleveland Clinic and was specializing in, he really loved valve surgery. He needed T.E. and it couldn't be casual. You had to know how to do T.E. So that, I really got into that and we formed the team. David Broussard was on that, you know, was first people on the team as well. And then I did that for about 10 years and

And then said, well, you know, I mean, to me, cardiac anesthesia is kind of like a young man's game. A little bit amount of energy, doing transplants at night, things like that. So then I got off the team and as a call taking member. And, you know, then that was almost almost 10 years ago and then started doing a lot of.

I guess you would say like non-pump cardiac anesthesia, people with low EF, people with ovular disorders. And then we started to develop a much busier EP service. And now our EP service is really busy. We run, you know, I don't know if it's busy compared to who, but we run four rooms a day and TEE and the practice is really developed. And so that, you know, became something or is something that I do regularly.

a lot more now. So yeah, that's sort of how it worked out or for me, like the, I guess you call it a career arc. That was my career arc. And fortunately, now at this point,

you know, it's all days, you know, so my average day, we have an unusual schedule we won't get into, but, you know, I don't have to work nights and I don't work weekends. I work during the day doing anesthesia, you know, clinical anesthesia. A lot of it is like Nora anesthesia, you know, EP, endoscopy. I do Nora more, not Nora anesthesia, more than I do operative anesthesia.

which has been the trend, right? So yeah, I guess that's my intro for you, if that helps. Yeah, that's great. And what I love about that, I think that's such a great demonstration of one of the wonderful things, certainly about anesthesia, maybe it applies to other areas of medicine, which is how fluid your career can be over time. I mean, you started off in chronic pain, or at least part-time chronic pain or anesthesia, then you became, you know,

really very invested in pump cardiac anesthesia. And then you transitioned into more Nora anesthesia, including some, you know, non-pump cardiac and some other. And I'm sure at some point you were taking a ton of call and now you're not taking call. I mean, but the flexibility is, I think, a really nice thing about our specialty. Oh, I agree. Yeah, you can change your direction. I guess it depends where you are.

and what sort of practice you're in, but you can change your focus and your interest. And yeah, that's a great thing about the specialty. I was far into it too. When I started, I'd already been doing clinical anesthesia or like was already 15 years into my career when the cardiac thing came along. But I've seen plenty of people like

All of a sudden, they start learning a lot of regional, you know, and applying to that practice, their practice. So, yeah, you can you can move your focus of interest within the specialty. You're not stuck just doing the same thing. Yeah. Yeah, I love that. Well, let's talk about the difference between procedural and operative anesthesia. Tell me what that means to you and how it applies to what you think of in terms of our specialty. OK, here's something that irritates me.

The term MAC. Okay, so let's start. We're going to do a MAC. Okay. Well, you're down into some description of procedural anesthesia, monitored anesthesia care. I'm going to do a MAC. What does that mean? It's like, I want a burger. Well, what do you want on it? You know, it means nothing. And if you don't define your nomenclature properly, you don't think about it properly.

Okay. So we'll talk about procedural anesthesia. First of all, never use the term MAC. Modern anesthesia care was a billing term, right? Early on, you had general anesthesia and you had MAC, and I think they were paid differently. And so people started associating the term MAC with sedation. But so you're working with someone, I want a MAC. Okay. What do you want?

You know, so you start with the concept of operative anesthesia. You're going to do major harm to the body, right? You need analgesia. And, you know, like it is very, very basic way. The patient needs to be unconscious and they need to have analgesia. Well, when you're doing procedural anesthesia, you know, let's say colonoscopy, there's people who lie there, they get nothing for it.

So the physiologic insult for procedural anesthesia is minimal. Let's say for the most part, minimal. Although with some things like an EP, you can do some physiologic insult if you keep inducing VT or something like that. Like you can make problems. So when you start thinking about it that way,

You start designing your anesthetics differently, and then you have to have the concept that the airway management is separate from the anesthetic. So, for example, a good example of that, Jed, is robotic bronch. You know, some people say, we're doing general anesthesia for robotic bronch. Okay, you're running propofol and you're intubating, right? Because the proceduralist doesn't want to, you know, breathe properly.

SIBO all day as they go in and out with their robotic brunt. So that is not operative anesthesia. That is a propofol infusion with an endotracheal tube to facilitate the procedure, right? And muscle relaxation. So it's a different way of thinking about what you need to do

For the case, you know, let's say you have someone who comes in and you say, well, we're going to do a colonoscopy. This colonoscopy, for some bizarre reason, is going to take five hours. You're probably going to intubate that patient. Now, in that case, you might decide you want to run a gas case. You may not. But the amount of gas it's going to take is going to be different. So, you know, I think it's very important to...

I guess the way I think about it, Jed, is that when the terminology general anesthesia was starting to be talked about, the options were so much more limited than they are now. You know, general anesthesia was a gas. It was like curare, pentothal, sucks, a tube, a gas. You know, it was halothane, n-flurane, like these ancient agents. And, uh,

But now the options are so, have expanded so much, you have to have better terminology to describe what you're doing. A GETA doesn't get it. You know, there's a lot of different ways to put that together. So that's, you know, why I just think that for me, the terminology of procedural anesthesia versus operative anesthesia is,

is a useful way to think about it and get yourself on the right track. Yeah, I like that, especially because I think, and I try to correct our residents when they initially come in with this idea, but people think,

If there's an endotracheal tube, that's general anesthesia. And if there's not, then that's MAC, right? Or maybe if there's an endotracheal tube or an LMA, that's general anesthesia. And if there's not, that's MAC, which of course is not right, right? You can absolutely have general anesthesia without an endotracheal tube or an LMA. If you're doing, you know, a colonoscopy with deep sedation and the patient is completely unresponsive, which is usually how we're doing it, right? That's not MAC, right?

And to the extent that MAC is even a useful term, right? But by definition, general anesthesia is a patient who is unresponsive even to painful stimuli. It is not defined as a patient who has an endotracheal tube in place. And the way I would term that is that's deep sedation. I don't term that generally. I think that's deep sedation with the natural airway. Okay. Right? So if you say, what are we doing here? We're doing deep sedation with the natural airway. Or here's where you end up a lot of times.

You're going to do a pacemaker and you go in and you're infusing propofol. Everything's fine. Now the patient starts obstructing a lot. You put in an LMA and you put them on PSV Pro. What is it? It's deep sedation with airway support. You know, just for the, let's say their body mechanics are poor. They can't take a big, big breath or whatever. So,

To me, even general anesthesia is no good anymore. It's operative anesthesia. Okay, interesting. So you're getting rid of the general – because I was going to say, what is general anesthesia? But you want to get rid of that term. So what we have is – Operative anesthesia, well, let's say you're doing a Teva spine, propofol and Remy and some ketamine. That Remy is the intense analgesic component, right? So it's operative anesthesia, but how you –

The term, like I said, when Max started out, there wasn't deep sedation. There was like little bits of Valium and there was a gas case and there was nothing in between. But now, you know, we have operative anesthesia. And so even if you, for example, do an endovascular AAA, that becomes operative anesthesia. It's a big, or let's say a TAVR.

Right. The physiology, the physiologic insult gets to be pretty great. Yeah. You know, it has to be more than just maybe it's Haver's a poor example. I think it probably is. But so, yeah, I like procedural anesthesia. And then just expand on the idea, deep sedation, moderate sedation, light sedation. Right. If you can talk to them and they're responding well.

It's light sedation, right? If they're responsive, everything else. And then if they're completely unconscious, you can't wake them up. It's deep. And there's probably something in between, but it's pretty much deep sedation or light sedation. Yep. Yep. Absolutely. You know, it's like, it's like grading a lot of things. You have light, you've got the small sedation,

medium and large. Well, it's just, you have large and small and whatever's left over. Yeah. Yeah. So you have light sedation. We know what that is. We know what deep sedation is. Medium is moderate. Sedation to me is a really confusing concept. So like it's just deep sedation. Yeah. Okay. I love that. Now, how are you doing your, your sedation for colonoscopies? Just propofol? Do you, do you, are you using a little fentanyl? Are you using anything else? Yeah.

If they are in the outpatient setting, they're usually just propofol, you know, like the freestanding. And then when they get, you know, and then they have like the exclusions, you can't go into the outpatient place, you need to go to the inpatient unit, those people get adjuncts.

But they're still mainly propofol cases. Any thoughts on how best to reduce the pain from the propofol going into the IV? Do you have a technique for that? No, nothing special. I think it's probably where it is and then –

It's patient-dependent. Some patients freak out and go completely crazy occasionally. But, yeah, I don't have any tricks for that. Yeah. I think that's one of the perpetual –

you know, things we deal with, right, is that, and you're right, it's very patient dependent. I agree with you. I think the more distal the IV, the more at risk for that pain. But I've always found everyone's got their own technique, you know, how they give, if they're going to give lidocaine, you know, as an attempt to deal with this, how they do it, you know, do they mix it with a propofol? Do they flush it in first? Do they, you know, push it and hold it and then give it, do they give it slow? Do they give it fast? And I don't know that there's really any way to know what's the best or if it really matters much at all.

Right. I think if you tell the patient this is going to burn, then it's probably enough for most people. I mean, you do what you can do and just say, hey, this is going to burn for a second. Yeah. I think if this surprises them, then it's worse. Yeah. They're going to have a great experience. Right. Well, it's very interesting. Some people think, I agree with you. I would rather someone say to me, this is going to hurt. Be ready. It will last only a second, then you'll be asleep. As opposed to, you know, you do hear from some people that it's better to say something like you

You may feel a little sunshine in your eyes or something, you know, because you don't want to set them up to think there's going to be pain. I don't know. Maybe it's just me. I would much rather be ready for what is to come and not be surprised. I don't know. Maybe sunshine works for some people to each their own. All right. So...

I know that you are a fan of LMAs. I feel like LMAs in some ways are a lost art. At least when I was a resident, we had some attendings who were probably, you know, started around when you did, who were real experts. I mean, they were, I thought of them as just LMA, you know, masters. And I feel like we don't have that as much anymore. But tell me a little bit about intubating through an LMA. How do you do that? And kind of other ways in which you like to use and teach about LMAs.

Right. The LMA is one of the greatest things ever in anesthesia, right? So we'll just start there that before LMAs, you had a lot of situations that were very difficult to deal with. So they've solved a lot of problems. The one technique that I think people or some people don't know is intubating through an LMA and how to do that.

Which, you know, the scenario is you're in a room, you're having trouble. For whatever reason, you shove in an LMA and now you've established an airway. And you may have looked, you can't see. But you've decided that you want to intubate through the LMA. That's like the safest thing.

you need an Aintree catheter, right? Which is the catheter that fits over, you know, it's like how to get the tube through the cords. It's a catheter that fits over a fibroscope, fibroscope. And then you put that through. Usually you're looking right at the cords, right? And then you can slip that off. Then you have to take everything out and use that as a stylet to put your tube in. And that's something that, yeah,

It's very useful to know. I mean, honestly, with video laryngoscopy, the incidence of difficult intubations is gone. It's almost nil, right? Unless it's an identified anatomic problem. But it does come up, you know, or you have a patient in whom

You need to keep them breathing spontaneously, like one of these weird airways where when you paralyze them and put positive pressure on them, it all bunches up. And the only way you can keep the airway open is or have gas exchanges for have someone to take a breath. And when they're breathing, their cords and that whole area that, you know, that's all this bunched up tissue will open up. So there may be someone like that that you can

put them to sleep, you're having all kinds of trouble ventilating. They come back breathing and you have an LMA. Something like that. Or someone, let's say, for example, who's got a huge tumor. Things are displaced. You just don't want to get a blade in there. But it's a really useful thing to know how to do when you get in a bind. But like I said, I mean, video laryngoscopy has...

made intubating for the most part pretty easy, right? And even all those anterior larynxes that you couldn't see before, there they are. And so the only thing that comes up with that would be sort of the people where you're going to be able to see the cords, but you can't get the tube to go because of the extreme angle of

And then sometimes that's where you would use a fibroscope. And maybe sometimes using something like an AIM tree that's stiff will help, you know, get through there. But the other place where the LMA is really useful is with LMA wake up, you know, which I think people don't think of. It's like if someone you put to sleep, they're hard to mask or they're big. And then someone will think, well, they're big, they're hard to mask. We're going to have to, you know, wake them all the way up.

Well, you may not want to wake them up. You know, for example, if you're doing an AP case and you don't want them coughing and bucking because of the, you know, these venous sheets that were in there, you want to pull the tube before they do that, but they're hard to mask. Then you do an LMA wake up, which just doesn't, I don't think occurs. Some people maybe think, well, it's expensive or something, but no.

So when you do that, you obviously pull the tube deep, put the LMA in. Now you can ventilate through the LMA. And then do you just wait until they're fully awake and then pull it out? Do you take them? I mean, you know, when I was a resident, we actually sometimes would take patients to the PACU with the LMA still in. And then basically the PACU nurses would let either the patient would pull it out when they were ready for it to come out or the PACU nurse would pull it when they were clearly waking up. But, you know, what's your how do you deal with the LMA when you do an LMA wake up?

Just let them tongue out. They'll just stick their tongue out a few times and it comes out. But I think for me the rule of thumb is if I pull the tube and if for whatever reason I think I'm going to have to manage that airway for more than a couple of minutes, I want to put an LMA in. I don't want my hands tied up, right? Yeah, yeah. So even if it was somebody that isn't a problematic airway,

If I extubated them and it just seems like, God, this is taking a long time, I don't want to stand there all this time. It's just not – you have other things you could do. So get an LMA in and free up your hands, and you'll have better –

then, you know, better gas exchange anyway. Yeah. Now, do you worry at all about laryngospasm? Obviously, the tube comes out and now you've got an LMA in and so you don't, you're not protected against laryngospasm. Obviously, if it happens, then you'd have to deal with it. But is that something you see much or no? It seems to go fine with the LMA in. Well, I mean, first of all, you know, I'll tell people laryngospasm is just a fact of life in anesthesia. And partial laryngospasm is almost universal.

You know, when you pull a tube on someone, the cords are there for a lot of reasons, but they're there to protect. They're there to make noises, but they're there to protect the lungs, right? And they do it very well. When you pull a tube out, unless the patient, if someone's breathing and has good tidal volume, then you're not in a deep plane of surgical anesthesia anymore.

And when you pull the tube out, something's going to happen. And usually it's partial, right? So, you know, you have airway resistance. You have to work your way through it. So that's almost all the time. But you're better off doing that with an LMA. You can provide more positive pressure. That happens, Jed, like immediately upon pulling the tube. Yeah. And then you work your way through it, and it's not going to probably come back again.

Yeah. And so it seems to me like one of the things you're saying is that if you're going to have some partial or, you know, significant laryngospasm, one of the ways we deal with that is positive pressure. And you're going to be able to apply more and better positive pressure through an LMA than you are through a mask. Yeah, presumably. Yeah, you can for sure. Yeah. Yeah. That makes sense. Or there can be people like it's just you're struggling. Let's say you pull the tube. You're struggling just to have a mask seal.

Okay, so now you're still going to have a mass seal and put on top of that the fact that you want to do some serious positive pressure for 30 seconds. It's going to be too difficult to do. Yeah. Now, how do you place your LMAs? Do you deflate them completely and then put it in? Do you partially deflate it? Do you not deflate it at all? I see all these different approaches. What do you like to do? The ones that the original LMAs that came out that were made of latex,

were deflated. The LMAs that come now all are partially inflated, right? I just put them in how they come out of the bag, you know, however they come out of the packaging. That's how you put them in. Anything special to kind of do you use a tongue depressor, your finger, any, any way to make sure it doesn't, you know, get, get pushed aside by the tongue or the tongue get bunched up or you just troubleshoot when it happens? Well, the original description was the thing where you, you have your fingers, uh,

You know, tongue depressor wasn't in the original. Was this guy's name Archie Brain? Yeah, Dr. Brain. Yeah. It was just you put your fingers in there and then you just shove it back. And so I don't want to put my – I see people, they put their fingers in the mouth and all this stuff. Basically, with an LMA, it's not a gentle thing. You shove it in, right? And the people that I saw early doing it best, they just shove it in. It's not – there's nothing subtle.

Yeah. You know, how to shove it in, shove in the LMA. Great. So I know you're not a big fan of the term deep extubation. But as we just talked about, the kind of unconscious wake up is the default for you, whether that's, you know, pulling the tube and putting an LMA in or what. But talk to me a little about that. What what why don't you like the term deep extubation? And what what is your approach to the unconscious wake up? Well, deep extubation, that term implies deep.

that they are quote deep and that you know where they are. And you don't, once a patient is unconscious, you're not doing any EEG, you're not using BIS, you don't know where they are. You don't know how close they are to being awake. So there, and presumably you actually don't want them very quote deep. Deep would mean surgical plane of anesthesia. Well, why would you want to extubate them there and wait what, 15 minutes for them to wake up?

right, while they blow off the gas. So the patient is emerging. You want to pull the tube, in my opinion, before they start actively emerging or reacting to the tube. And that's all you know. They're not swallowing. Are they deep? Aren't they deep? What is deep? It goes back to the thing with the language, you know. So they're not awake. They're meeting your criteria, which is like good tidal volume. They're reversed.

and no contraindication to, like they didn't go to sleep with a bunch of stomach contents. You know, you're not, they weren't like an extraordinarily difficult intubation or some strange masking problem. Then you pull the tube and then you actively manage the airway. That's why I said earlier, you're going to, for the most part, have some increased airway resistance if you look for it. So if you put air,

The mask on the patient and you see what they're doing the moment you pull it out, like, and you don't mess around, right? The tube is out. The mask is on. The oral airway is in just that fast. Most people will have increased tone across the airway, meaning instead of the cords being, you know, let's imagine them at 45 degrees. They're 30, you know, just for a little while.

So, and the reason this is important is, you know, you finish the case, you want to leave the room, right? If you say, this is why I think extubating before the patient is awake is important, because if you want them to be doing all these things, like, you know, Jed, open your eyes, Jed, squeeze my fingers, all these things, you're putting a lot of

pressure on yourself to get that patient right there, right when you want them to. So I'm actually, I'm shifting it to you and saying, okay, like now Jed is in control of when he's going to get extubated. When Jed is ready, he'll let me know. Well, when I start the case, I don't ask you if you're ready to be induced, do I? Jed, are you good to go? No, I want to finish the case, pull the tube and

manage the airway. And then at some point between the time that you extubate the patient and the bed comes in and you move the patient, they will have an independent management of their airway, you know, or at least you don't have to support them and you can leave the room, which is really one of the, you know, no one's going to want to work with you if you can't do that repeatedly. Like the case is over. Right. Bring in the bed and let's move the patient over and let's get her to PACU.

No one wants to watch you for 20 minutes. Jed, wake up. Right, right. So if you require that, you know, so that's why I think what most people will call a deep extubation is more practical. But you have to know how to manage that airway. And you have to buy into the fact that occasionally you will have real laryngospasm.

Yep. And you might have to give suctional calling. Yep. So it sounds like you often will put an oral airway in when you take the tube out. Is that right? Yeah. Okay. And then sometimes, is it when the oral airway doesn't seem sufficient, that's when you'll go to the LMA? Stay with us. We'll be right back.

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Plan your visit today to experience Tutankhamen, his tomb and his treasures, and Biltmore in full bloom. All right, and we're back talking about LMAs. Yeah, if you're struggling. You know, most people are going to need an oral airway when you pull the tube. But sometimes, you know, you get lucky.

And, you know, they'll rise up and they're very close to being conscious, but they're not reacting to the tube and you pull it. And then, you know, they start moving their tongue around and they have their reflexes. Right, right. And some people are just slow to come around and you don't want to, and they're hard to mask, you know, for whatever reason. Hard to get a mask seal, no teeth. Their cheeks are falling in, stuff like that. Yep. Okay. So pulling the tube before...

So not doing the whole, you know, squeeze my hand, stick out your tongue, just they're breathing. They weren't a particular high risk. They're not a full stomach. Okay, so you're ready. You're going to pull the tube out knowing you have to pretty actively manage this or at least be ready to. Oral airway, if that works, great. If not, LMA. And then sometimes you're going to have the inability to move air in the setting of true laryngospasm. And in that setting, you have to be ready to give sucks and either re-intubate or mask until you kind of get them through it.

Yeah, the key skill, Jed, is assistance ventilation. You pull the tube, they're breathing. You have to have the ability to assist them, right? And be able to get onto their rhythm and assist them through this transition process. And that takes practice. It seems so simple, but it's...

It takes good masking skills and, you know, coordination to be able to assist people to get through that. That's why when you first start a resident at the beginning, they can't do that. They can't assist someone. That's why they're there. You couldn't tell them you, but you could say when the patient is opening their eyes, if you couldn't come to the room, when they open their eyes and all that, you can take the tube out. That will be safe. It's only safe to extubate people first.

who aren't awake. That's why in the ICU, they wean them and they pull them when they're awake because they're not prepared to actively manage their airway. Right.

And we are. Yep. That makes a lot of sense. All right. Let's talk about patients with low ejection fraction. This is something you said up front, you know, you, since you stopped doing pump cases, but you still take a lot of care of a lot of these patients. And I think these patients are scary for a lot of practitioners. They come in, they've got a known EF of you name it, you know, anything 20, 25%, 30%, but something not normal. And that's scary. It feels like things could

could go terribly wrong at any time. What do you do in terms of your dosing? How do you handle these patients? So you do this a lot. What advice do you give people about how to do an anesthetic for these patients in the safest possible way? So let's say we have someone who has an EF of 15%, 15% to 20% preserved right-sided function. So we'll just make it the LV doesn't work well, and they're coming in, and let's say they need –

Now, something that doesn't have a lot of, okay, a hip pinning. How about that? So it's not like going to be, you know, your average hip pinning is pretty quick. It's not going to be real bloody. My mindset on that is baby steps, okay? So you bring the patient in. You got to get to know them. They got to get to know. You have to get to know them, and they have to adjust to you. So the first thing, let's say you put an A-line in.

Okay, so we can, if we're going to actively manage their hemodynamics, let's get them in there, give them a little bit of sedation, get your ultrasound, put your A-line in. Then your induction, the answer is not a time of date, okay? The answer is to kind of very slowly get to know how they're going to react.

Okay. Some people with EF 15, 20, 30%, whatever it is, they do great. They don't need a lot. Some people need a lot. So now you're realigning. Let's assume you have good IV access. Give them 20 milligrams of propofol. See what happens, right? Let's say you give them 20 milligrams of propofol. And usually people like low EF, people like that are going to have a low systolic pressure to start with. So let's say they started 105 and you gave them 20 and they went down to 70.

All right. Okay. Now they've told me that they need something. So now you're going to think, okay, well, what am I going to do? Do I want to start low-dose epinephrine? Do I want to start low-dose norepinephrine? I'm going to make my adjustment. Usually that's not going to happen. You give them 20, not much happens. You give another 20, not much happens.

And you just, instead of your induction, Jed, being something that lasts 90 seconds, 60 seconds, your induction may take 10 minutes, right? And you're getting to know them. You're getting to see what they need. Maybe all they need is a little efetrin. Maybe they need calcium, something like that. And you're making your adjustments and you're making your adjustments

Your moves, their baby steps, your little moves give you time. Make your adjustment. Right. That's why I don't like a Tom and Dave because you give a Tom and Dave. OK, you've done what you believe is a neutral induction, but it doesn't give you information. It doesn't let you know what's going to happen later. So, yeah, you just do that. And so for the most part, you'll have time to decide what to do and see, you know, what works.

and construct it that way, right? What if they come in and you give them 30 milligrams of propofol and they almost code? Okay, time out, right? We really need to regroup before this gets worse, you know? So I think that's sort of, you know, without getting too specific about, everybody's going to have a different way to solve a hemodynamic problem. You know, they have like things they like, you know, and that's fine. But the key is your tempo, right?

of how much time you take to do these things, right? And that gives you time to tweak it and to keep it kind of a smooth anesthetic. Yeah. So it makes a lot of sense. I think it's something we don't do very often is to take that much time, but it makes a ton of sense to do it. A few things you pointed out that I think were really key. One is the awake A-line, right? So we don't do those a lot, but I had an attending when I was a resident who used to say,

if you need an A-line, it should be an awake A-line, right? In other words, the induction is the most hemodynamically unstable portion. And so you need it for that. So that's what you said. And I think that makes a lot of sense. And then just taking your time. Now, do you ever start, like, let's say the patient's got an EF of 10, 15%. Do you ever say, listen, before I even do the 20 of propofol, I'm going to preemptively start, you know, a low-dose norepi or a low-dose epidrip. Do you ever do it preemptively or you always want to see what happens first?

first with a little bit. Yeah, sure. Sure. You can do that. The other thing is, Jed, is that the worse the patient, the worse their physiology, the more solid everything has to be. So for example, in that case, you can't have a small IV, right? You need an IV that works. You need an infusion pump that works. Like you don't, you have to really make sure that your technique is very solid and there's, there's no weak points.

Right. So that's the other thing. You don't have room in a patient like that, let's say, with a very low EF. You don't have room to make any mistakes. You can't have like an IV that infiltrates. You know, you give the propofol and now you can't give a presser. You don't want to put yourself in that sort of bind. But yeah, I think having it infusing or at a minimum, you have your, we use a laryngospump. So your laryngospump is up, it's primed, you make sure it works and it's in line.

You know, and yeah, you could start that. You don't necessarily know that's what's going to work though. So, but yeah, nothing wrong with that. I mean, think about when you go to sleep, when you go to sleep on a pump case, you have everything there and, you know, you, you're doing the VAD. You've got everything in line and going. So how is this different? Right. You know? Yeah, that makes a lot of sense. All right.

You mentioned mask inductions in adults. And I have to say, I...

was talking to somebody probably, you know, similar to you, been practicing 30, 35 years, a year or so ago, who mentioned this to me, that he likes to do mask inductions in adults. And I think he called them like a single breath mask induction or something like that, because he likes to teach his residents, you know, that it's a possibility. And I had never heard of it. So tell me about this. What do you mean when you say mask induction in adults? And how do you do it?

The reason I bring it up is it's more for the difficult IV patient. Okay. Or patients who are very frightened. So you go to your pre-op area and they've stuck the patient twice. And the patient's just like, I have poor veins. That's where you're much better off going to the first, don't waste any time, take them to the OR, let them breathe gas. They're very nervous. And then start figuring out how to start your IV. Okay.

And it may develop into entire mask induction. For the most part, it doesn't. But what you're really doing, I guess, is mask anxiolysis, analgesia, you know, and using that instead of turning into like this stubborn desire to have an IV before you do anything.

Right. Like before we do anything, we have to have an IV. Even if it takes 45 minutes, we're going to bring the ultrasound into the room and the families in there and all this kind of stuff. And it just it turns that into like the focus of the entire visit or the experience instead of like, oh, look, they've tried a couple of times. Let's bring you to the room. Let you breathe some anesthesia gas. Everything's going to be fine. So really, the mass conduction therapy.

It's more mask, anxiolysis, and analgesia. You know, it usually doesn't go that far. They're not going to be – they may even be unconscious, but they're still breathing. Yeah, and it's just ceboflurane that you're having them breathe? Yeah, and it just – it makes the whole thing – it decompresses the whole situation, right? Yeah.

That that's really more. It's not like, okay, you have an IV and we're going to do a mask induction. That doesn't, that's not how I'm intending it. Okay. Have you ever done a single breath mask induction? No. Yeah. I haven't either. I've never heard of it. I I'll have to look more into it. Um, yeah, never, not something I've done or, or even had heard of before, before about a year ago. So, uh, we'll see. Well, I'll, I'll look into it and see if it's a real thing. Okay. Um, all right. Um,

So central lines, often these days we rarely do them. How do you feel about that? Do you think we should be doing more central lines? Or now that we have ultrasounds and can very easily do ultrasound-guided IVs, do we need central lines less often? And let's say outside of cardiac. I think probably everyone is still doing central lines for cardiac pump cases. But, you know, outside of that, what do you think? We certainly do a lot less than we used to. Yeah, it's – I mean the central line is now vilified, right? Right.

You know, it's if there's a central line infection, it's, you know, someone is going to take the blame and it won't be the patient, right? So in that setting, central lines are just kind of a hassle now, right? And ultrasound guided IV placement or, you know, is for the most part pretty effective. You know, you do find patients who don't have

much in the way of reasonable targets. Like we use these micropuncture kits. So for a lot of cases where we used to use central lines, now we can find something. Yeah. So it's, it's and I think it's a good thing that we don't do them a lot, but sometimes maybe we make compromises like, you know, you're doing a case, maybe you really should have really fantastic IV access, but you know, surgical practice has changed so much.

that cases that entail a lot of blood loss aren't frequent, right? And so you don't need the central line. We need central lines for, let's say you're doing a hepatectomy or partial hepatectomy. Yeah, that needed a central line. That was going to be a case that got transfused. Now, no, don't need it, right? So really modern surgical practice is, you know, with the exception of a

Some of the cardiac and some of the, you know, liver transplant or things like that or trauma, they don't need large bore IV access, which was the advantage of a big central line. And then if you were saying, hey, this person's going to be in the hospital for X number of days, you know, and we'll have a central line to be able to draw lab and just, well, they want to get it out as soon as possible anyway. Right. Right.

So, yeah, it's really changed, you know. And central lines now take a lot more time than they used to because, you know, you have to – all the prepping and, well, of course, you prep, but you have the full body drape and no one else can do anything else.

So it takes a lot more time out of a case than it did before all the bundle and everything was introduced. Right. And you probably initially, did you initially start learning central lines without ultrasound, I would imagine, right? Oh, yeah. Yeah. So that saved time too when you were doing it just blind and weren't kind of draping the ultrasound with a sterile drape. That's right. Ultrasound, I mean, ultimately ultrasound saves you a lot of time.

You know, that's the same thing like if you look at A-lines. I could do an A-line faster perhaps on one case without an ultrasound width. But if I do 100, I'll be faster width. Yeah, that's a good point. So the one-off, you can be very fast with an A-line without an ultrasound until you're not, you know, getting it right away. Yeah. But, yeah, there are so many anomalies there.

of the vessels that were previously unknown to us. You know why you're struggling, right? And those are eliminated by the use of ultrasound, even if you decide not to use it. But, you know, there was like a transition period, Jed, where now the ultrasound there, you're going to use it in real time. There was a period where we would just scan the neck and

And say, okay, everything looks how it should be. The carotid's where it should be. The IJ's where it should be. Things are the right size. Boom, put it over there. And then, you know, you go back to like a fine renewal technique. But then that, it's now gone. Look, it's there. You're going to use it in real time. Unless for some bizarre reason it's not available. And then it's not available and you have to put a line in. Right. Yeah, but...

Yeah, that's my thought. Okay, great. So you've said informed consent is not really possible. Tell me about that. Why not? And what do you do in terms of your consents? Well, you know, the informed consent documents that we have, there are many, many pages. You know, they're not written in transparent language.

They're just like confusing. And the information is not presented to the patient in advance, right? So really the only way for informed consent to probably work would be like, okay, Jed, I'm going to push this consent out to you four or five days before the procedure, study it. And when you come in, we can talk about it and then I'll get you to sign it. Well, I don't think that's the process. I don't think...

For whatever reason, at least where I am or medical places, they don't want to push the consents out through a portal. So now you have a consent that even if someone sat and read it, they don't have time to digest it. Because let's say you were really going to read it. Well, you say, okay, I don't understand this word. I'm going to look it up. I don't understand this word. I'm going to look it up. Right? None of that occurs.

And let's add to that the idea that you're kind of not in your right mind. You're there. You're fasted. You're ready to go. Everybody's ready for you to get your operation. Are you really going to say no, right? So what are you consenting to? You're consenting to all these risks, but you're really not. Where's the part that's, okay, you've got confusing language. You're nervous. There's no time to read it. Maybe it's on an iPad where you have to scroll. So you can't even go, you know, how is any of this –

A true agreement. How are you informed? Right? So, yeah, that's, now, perhaps there are exceptions to that where, for example, let's say you come in and, so, yeah, the normal informed consent process is, I don't know, it's. Lacking. It's lacking. I mean, to me, what I tell patients is this is an anesthesia consent. What this means is I came in, I met with you, and I talked to you.

That's what it means. It means I was here in front of you. I asked you if you had questions. Then you signed this semi-absurd document. But it proves that we were both here. That's what it proves. Now, if you want to inform someone, you might say, like, for example, let's say you're a professional singer. And we talk about changes, you know, like, look, Jed, I'm going to intubate you.

I don't think this can affect your voice and your ability to sing high notes, but I'm not sure. Well, then I'm picking that out and I'm really talking to you about it. And I may note that. And, you know, are you okay with that, Jed? Like, look, I'm going to do everything I can to preserve your voice. But if it, but, you know, let's both understand the voice is pretty strange, anatomic or physiologic process, right?

And we don't know what's going to happen with it. Then you really, you know, you've really given you a little time and we put things in a very simple way. We've talked about it, you know, we've talked about it. And it's also like a bite-sized quantity. We're talking about your voice, right? It's one thing, a particular concern that you may have.

Yeah, no, that makes a lot of sense. So other than kind of saying to the patient, you know, this is really saying that I was here, I asked you some questions and we kind of, you know, briefly talked about the anesthesia.

There's not a whole lot to do about this, right, that you're doing. I mean, you're not trying to send this out to people beforehand or, you know, I mean, this is clearly I agree with you. And even having had anesthesia myself, you know, I don't read the thing. You don't have time. They give it to you and they want you to sign it, right? So you'd really have to redesign the whole thing. And as far as I know, nobody's really doing that now. But I think you make a good point that maybe we should be thinking about this.

Well, I think the other thing you could do, and we don't do it, but you could design, for example, you're going to have an operation, right? Well, now you're directed to a discussion. Here's some videos about anesthesia. You go in again, if it's in a portal, which most health systems have, it's optional.

But it's out there for you. So, hey, you go in here. Do you want to look at some things? Nope. That'll be most of the people. But some people will. And then you'll look at these videos where they discuss your, you know, maybe it's like, okay, you're having a total hit. This is how we do it. This is, you know, how we typically do it.

And then, you know, there will be some discussion of risks in there, I guess. And then you would be, would you like, there's going to be an informed consent process. Obviously, we would need to redesign it so it is readable. But you say, would you like to see the informed consent that you're going to be asked to sign? Yes. Okay. Now you can look at it. Of course, maybe they don't, whatever who they is.

And then you can read it in advance. And then when you're coming, you're ready to ask questions. Yeah. That would be maybe how the process would work. Yes. Sounds like a much better process. I'm with you. What if you have to delay or cancel a case? Is there a better way to do that and a worse way to do it? What do you recommend if your junior faculty come to you and say, you know, I just don't think we should do this case? How do you tell them to handle that? Well...

I think you go from the perspective of, well, canceling a case involves canceling someone's case. Okay. So like, let's say you're the surgeon and this is Jed's case. I want you to reach the conclusion with me that this case shouldn't go. Right. We're going to come to that decision together. Unless I come to you, Jed, your case is off.

Okay, that's just confrontational. That's an argument. It's going to be like, um, Jay, I want to tell you about this. I have a concern. Can we talk about it? Yeah. What is it? Okay, this guy's K. You know, he, you got preoperative lab, he's preoperative lab. His potassium is 6.1. Let's, let's, you know. And then you start talking about it, right? Okay, what are we going to do? How urgent is the surgery? But,

Is there any way we can lower it? Is it a risk? What type of case is it, right? How can we get to the – and then you may go, look, 6.1, man, I just don't want to do this. You may immediately come along, but if you're insistent, okay, look, this needs to go. Okay, let's get an EKG, right? Are the T waves peaked?

You know, let's do, let's, you just want to work with the person to get to that point together. I mean, the other concept is we're always trying to move the patient forward. We're moving you forward on your journey. What else? Let's say, you know, you have lung cancer and you come in and something's wrong with your NPO guidelines and you didn't follow them. We're trying to move you forward. We're trying to get you better. Okay, if we cancel you,

Now what? You didn't, you know, you didn't fast properly, whatever it is. Are we moving you forward? Or are we just like, okay, we're going to have to reschedule you. That's going to be six weeks from now. You're always trying to move the patient forward. So if you're creating such a risky diversion that you're moving the patient away, you know, someone comes in for a procedure and then they're in what you feel they're in heart failure. This comes up a lot. You know, they're overloaded.

Can we do the case? If we do the case, we're going to try a diuresis and we're not going to be able to extubate you because you already have pulmonary edema. Okay, I hear it. And so by doing the case, we're going to put you in the ICU on a ventilator to be weaned. We're probably moving you away from getting better from whatever we're trying to accomplish. You know, we're trying to give you a bivy pacer. This comes up all the time with patients who need bivy pacers for low EF.

So how do we move you towards getting better? Okay, we're going to need to diurese you. Is that in the hospital? Is that outpatient? But always, we want you to move forward. And if it's not moving you forward, it's, you know, then you're moving backwards, I guess. So those are a couple of ways I think about it. But I never want to tell somebody their case is canceled. Yeah, you want to work with them on it. That's right. Hey, let's figure out how to do this. Let's figure out what's, you know...

Another good example of that is the patients with really high blood pressure. They come in and their pressure is like, you know, 220 over 130. Okay, so case canceled. So, all right, well, now what? Maybe their PCP has been trying to reduce their pressure for years and they just can't. They're one of these people that's super resistant. You know, what are we going to do to get you there? So, yeah, that's a case where sometimes these high blood pressure things, you're not helping them by sending them home.

You know, you're going to come back again. They're going to be just as hot. Right. And then in the interim, maybe something bad is going to happen to them. Right. So, yeah, those are a couple of thoughts on cases and sort of delaying them. Yeah. And but then if you work with people that way, then if you get something that you feel strongly about and you have a lot of credibility, then they're like, yeah, you know what? Let's do it your way. You know? Yeah.

Yeah, I couldn't agree more. I think the communication is so important. The way you do it can build relationships or hurt them if you do it poorly. Yeah, that's right. I know you think anesthesia is a fabulous specialty. Why do you think that? Leave us with some thoughts on why you've loved this specialty over the decades you've been doing it. Well, imagine you're a psychiatrist, okay? And every day you're dealing with people who are like,

have anxiety and mental illness and depression. It's like, where's the fun? Where's the fun in your day? You know, there's this like, you know, very little fun, like, or you're in an internal medicine office with geriatric patients, you know, where's the humor, right? Like it's just a serious environment all the time. And I think in anesthesia, there's a lot of, I mean, there's just a lot of funny things happen, right?

You know, people are funny and it's so social. There's so many people around. There's action. You know, there's a lot of teamwork. So it's not a lonely specialty like a psychiatry. How lonely if you're just talking to one person and other people. So you interact with so many people. I think that makes it interesting. And I think you learn a lot about so many different areas of medicine, right? And that's...

That's good too. And yeah, I don't know. It's versatile. You can change your scope. I think there's a lot of smart people who go into anesthesia. So you can be around a lot of pretty bright people, you know, so that's cool. Yeah. Well, I couldn't agree more. Couldn't agree more. Well, let's turn to the portion of our show where we make random recommendations. Eric, anything you'd recommend the audience check out for fun?

I really have been enjoying the series Landman with Billy Bob Thornton. Okay. So, uh, that think it's on Paramount plus, um,

Good stuff. Check it out. I have not heard of it, but I'm always looking for good shows to add to the list. So thank you. I am about to almost done with the second book in the Empyrean series. This is a fantasy series. People know it as the fourth wing series because the first book was called Fourth Wing. I was hearing about this.

People kept talking about it. We'd have interviewees come in and say that they had loved this book, and I kind of didn't know anything about it. And then one of my recent grads mentioned it to me as a great series he had read, and so I now am finishing up the second book and loving it. It is definitely not really high-end. It's more – I think of it almost as like a beach –

read fantasy series, very quick read, but it's very well done in kind of a fun way. So I would recommend if you like fantasy fiction, check out the Empyrean or Empyrean series. It's spelled E-M-P-Y-R-E-A-N. And the first book is called Fourth Wing. The third book in, it sounds like what is going to be a five book series is coming out in any minute now, just in the next probably week.

So there will be three, but then two more to come, which I never love starting series before they're done. I didn't realize that there was going to be more than three books, but it's still a lot of fun to read. So I would recommend checking it out. All right, Eric, thank you so much for coming on the show. This has been a lot of fun.

Well, good. Well, thank you for having me and I hope people get something out of it. All right. Hopefully you got as much out of that as I did. That was really fantastic. Let us know what you thought. Go to the website, akrak.com, where you can leave a comment. Others can learn from what you have to say.

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