Getting Over Getting Under by Dr. Barry Friedberg


Five reasons why Dr. Barry Friedberg, a 36-year private practice, Board certified anesthesiologist and the founder and president of the 501c3, non-profit Goldilocks Anesthesia Foundation wrote Getting Over Going Under, 5 things you MUST know before anesthesia

Let no one ever kid you, being an advocate for change, especially in anesthesia, is about the most difficult task one could ever attempt to shoulder.

Hercules

     Hercules should have had it so easy.

 

 

In 1992-3, after seeing my first 50 cases of propofol ketamine (PK) sedation emerge without PONV or need for postoperative opioids, I felt much like Archimedes, “Eureka. I’ve found it.” PK numerical reproducibility was established with the addition of BIS/EMG monitoring in 1998.

I have published 5 peer reviewed papers, 15 letters to the editor in Outpatient Surgeon Magazine, more letters to the editor in Anesthesia & Analgesia, British Journal of Anaesthesia, Anesthesia Patient Safety Foundation, Plastic & Reconstructive Surgery, & Aesthetic Plastic Surgery, a landmark textbook ‘Anesthesia In Cosmetic Surgery,’ and 51 lectures in the US, Canada, Mexico, Dominican Republic, Israel, Malaysia & Singapore.

Many people publish papers. However, half of all published papers are never subsequently referenced. My papers have been subsequently referenced in 144 papers and in 50 textbooks.

Despite my Herculean effort to change the minds of my fellow dedicated anesthesia providers (DAPs), the subjects of postoperative pain management and PONV continue to appear in the literature as if the solution had yet to be discovered (or worse if my efforts had never occurred.)

As Aspect’s Dr. Paul Manberg often opined, ‘Change is glacial.’ When presented with my thoughts about getting better patient outcomes, most of my colleagues attitudes were essentially, ‘We’re not killing anyone, why should we change?’ Somewhere Semmelweis’ corpse is turning over in his grave.

Actually, as Li reported in 2009 Anesthesiology (110, 759-765), we are killing one American patient every day from anesthesia over medication, the natural result of not directly measuring anesthetic effect on the cerebral cortex. Even more saddening was that the editors of Anesthesiology did not deem this mortality study worthy of being an article of special interest.

Part of the human condition is that all people regardless of their profession resist change. Physicians as a sub-set are notoriously resistant to change. DAPs as a sub-set of physicians are virtually impossible to change. Unless presented with this simple paradigm in training, most DAPs will not even consider the notion of a differing paradigm.

The DAP syllogism goes like, ‘All surgery is painful. Opioids (narcotics) are painkillers. Therefore, all surgery requires the judicious use of some opioids.’ Having successfully practiced for the past 16 years without intra- or postoperative opioids, I would beg to differ.

Postoperative pain is a function of intra-operative pain.

Only by midbrain NMDA saturation prior to incision (or injection) does one avoid entrance of pain signals to the brain. NMDA saturation is accomplished in 98-99% of patients with a 50 mg dose of intravenous ketamine 3 minutes prior to stimulation. Hallucination free use of ketamine is accomplished by incrementally titrating propofol to BIS <75 with baseline EMG; i.e. tinyurl.com/n98x86k

Instead of being frustrated with my apparent inability to produce change in my fellow DAPs’ intra-operative conduct, I considered using the same paradigm for change that got fathers in the delivery rooms for the births of their children; i.e. public knowledge leading to public demand.

What are the 5 reasons I wrote ‘Getting Over Going Under, 5 things you MUST know before anesthesia?’

Reason #1: How can a pre-surgery patient know to ask for the best available technology, a brain monitor, if they do not even know that such as thing exists?

Reason #2: Why would they ask for one without the knowledge that over medication can lead to delirium, dementia and even death, especially in those over 50?

Reason #3: Why would the general public not assume they would receive the best available technology for their anesthesia care, especially if it might improve their chance of waking up without brain fog?

Reason #4: Why does PONV still exist and is there is an established way to avoid it?

Reason #5: Why does postoperative pain still exist and is there an established way to avoid it?

The answers to these reasons are easily digested in his 2010 book for which a free Kindle giveaway this summer was very successful and another is planned for this fall.

All proceeds from the sale of this book support the education message of Dr. Friedberg’s non-profit Goldilocks Anesthesia Foundation, “No major surgery under anesthesia without a brain monitor.”

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For further information, contact Dr. Friedberg @drfriedberg@drfriedberg.com

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