So I'm from Massachusetts General Hospital.
That's where I practice. Here is the, you can see the, let me see this, we have a highlighter? We don't but that's the old hospital right there. We're famous for the Ether Dome which you can see pictured in the bottom left.
And it's important, or it's importance of that is that was the first public demonstration of anesthesia, of Ether, by H.E. Moore. And you can see in the bottom left the picture right there, of the excision of a mass on this patient.
That changed the entire world of surgery. So it was novel. You know I've been workin' in IR full time for the past two years. And one thing that stands out is this lie, the cultural differences.
You now you have the same hand gesture but it means different things in different cultures. And it's kind of like the same for anesthesia in IR. When I first got there it seemed like we were different cultures. We were always in different silos.
You know and you never, and I think we have to make more of, and we've made more of an effort of knowing the local culture and knowledge. And we've actually have done something very special.
And in terms of talking about understanding our culture, our knowledge,
I just wanna give you a reminder of what anesthesiologists actually do. And give you a brief description. An anesthesiologist is a perioperative acute care physician. We evaluate patients. Give recommendations on how to optimize them.
We provide advanced life support during procedures. We formulate perioperative anesthetic plans of care. So we administer general anesthesia, you know when a patient has a breathing device, a breathing tube, they don't have any recollection, they're still.
We can also do a neuraxial anesthesia for a laboring patient where we do a spinal, epidural, and we get rid of the pain, and you know we have a safe delivery. We also can do peripheral nerve blocks. We've kinda heard about nerve blocks,
'cause that's one of our specially for shoulder surgeries. You know we do general anesthesia, and we combine these sometimes. We also offer various levels of sedation. Anywheres from really deep sedation to conscious sedation.
And you know, people who practice here and give sedation, they know that there's different levels and that's where our specialty is. In addition we also manage post surgical pain. And also complications, and support the patient.
IR in the modern era. It's busy. You know, this media you can see all the innovations, all difference of specialties. It's a very complex operation that's underestimated. And I think it's underestimated by the surgical people.
Because everybody's world revolves around their own world. So our world for anesthesiologists is the operating room. Anything off site of that is foreign. It's almost, you know we're almost dismissive of that. But vice versa, you know for the radiologist,
or you know, corresponding clinicians, their world revolves around their specialty. So IR, you know everything revolves around them and they don't really know much about us. And that is just cultural differences that I think we're gonna see less and less.
And for us, for anesthesiologists when we practice outside of anesthesia we call that non-OR anesthesia. It's NORA for short. And for us that's the final frontier. So you know I'm a big Trekkie,
and I always picture myself, you know, like being in the you know, Enterprise. And I'm havin' my little journal, Star Date 2019, 2018, you know, I'm goin' down to IR world, and we're gonna see the different life forms.
And they have really advanced techniques. We're not really familiar, but we're gonna you know, get ourselves, or equipment and see what's goin' on. These people can be hostile. (laughter) We're not sure.
You know, so you can see that. And that's what I felt like. That's why I put this in. So that's our final frontier for us. Again non-OR anesthesia is anesthesia that's practiced outside of the operating room,
our comfort walls. So NORA sites for us is IR, EP, endoscopy, cath lab.
And this is interesting that since 2000, this paper, there's came out is Anesthesia Practice and Clinical Trends in Interventional Radiology. Even in 2000 they were saying there's a rapid growth of IR.
And we kept on sayin' that, and sayin' that, and sayin' that, but it's finally here. You know the procedures are so complex. And me bein' down in IR, and I say down in IR because see, this is me talkin' about we're up in the clouds,
and IR for us in the basement. But it's not, it's really not. It's actually on the second floor. And we're on the forth, third floor. That's all the difference. But it seems like another different world.
But the things that we're able to do, that the radiologist's are able to do, the IR team's able to do with very sick patients is amazing. I mean you know, treating cancer percutaneously. You know, pain issues.
The services that are rendered are very, very impressive. I'm very amazed and I'm happy actually to be involved. So we can see the procedures are more complex, more time consuming. The patient populations keeps on getting sicker and sicker.
And from the previous presentations we've seen that a lot of the slides start with a patient, non surgical candidate. Patient non surgical candidate. So you know they're very sick. And then the next question is like,
okay so what kind of support do they get? Can they lay flat? How's their heart? Is it barely beating? you know, they have a tomato for a heart. Or not.
But these is a study of the amount of off site anesthesia cases that are bein' done. And you can see since 2010 to 2014 the trend is increasing. So now we're up to like 40%. And that's nationally.
For us anesthesiologists the NORA challenges
are the ergonomics, or unfamiliarity with the landscape, limited help, we're consultants to consultants. And this is like, you know you read, you turn the book and you read, everything is the same story you know. And I find these excuses,
because I don't think we've, we hide under these challenges. And I think a lot of people refuse to accept that we're here, and we're here to stay. And you know, you're gonna love us. You're gonna love us, and we're gonna
love you no matter what, so these challenges are just the misconceptions I think. Traditional misconceptions that I hope that I can, for you, invite you, and tell you that, you know, these are just misconceptions.
so our story starts out at MGH, the IR, you know in grade two, where we do it. We have six rooms where we do anesthesia. Every room is actually outfitted with anesthesia equipment. So room four's our CT. Room six we do our anesthesia cases.
Room two we do our complex cases, CERTs, pre CERTs. Room one, neuro IR. So it's typical IR program I think. But I think a lot of special things happen. And although it doesn't seem like that at some point. But I believe that we're at the leading edge
of the contemporary trend that's coming. So IR at MGH our case growth has increased by 20% over the past year. From 2016 to 2017 we went from 1200 cases to 1400 cases with, this is IR anesthesia only. We're growin' pretty rapidly.
It's 20% growth. And I believe that we're gonna grow more this year just because, I'm not sure what's goin' on, put the patients just keep on getting sicker and sicker. And our services keep on getting more and more wanted, I suppose.
The top three cases that we do are G-tubes, tunneled line catheters, our fistulagrams. Our CT microwaves as well. So those are the top three, top four cases that you can see where general anesthesia is utilized. We do about 50-50% of inpatients and outpatients.
At MGH I believe we're special because we have, given this explosion we actually have had anesthesia full time in IR. So we reside there. We have a dedicated IR team. So there's no,
you know we kinda heard before, there's a stranger comin' in, and now you don't know, hey, anesthesia, you're on your cell phone. Now we actually attach names to people. We already know.
So actually that's one of the big cultural barriers I think, and misconceptions that we've kinda broken in. And you know I think a lot of people know each other by first names now. We run two to three rooms per day four times a week.
And again like I stated previously all rooms are outfitted with anesthesia. And the IR suite at MGH is the new IR anesthesia. This is the future. So it's no longer, you know, you go down, and before being assigned to IR,
as anesthesiologist it was a punishment. Oh my goodness I'm gonna have some sort of, you know, patient who's on death's end, and nobody knows a clue, and now I'll have to sedate 'em, or do general anesthesia.
I have no idea what's goin' on. That's no longer, you know, I'm just gonna give versed, fentanyl, or nothing, just hold hands. We're gonna use propofol, use a little sedation. That's long gone. I think my colleagues are kind of upset
that we've already broken the mold. That I'm gonna show you what we're doing at MGH, and this is coming to you, to your regional practices very soon.
So a couple of things. So we got this state back,
and it was important in IR suite, it's patient satisfaction. You know CG CAHPS, HCAHPS, that's very important for patients how they felt during a procedure, right. The other thing that's very important in IR right now is the opioid epidemic right, pain.
Prescription of opioids. And actually one of these, these two things anesthesiologists are good at.
In looking back, one thing that actually popped into my head is, we came, we saw, and instead of we conquered,
I actually thought it was we helped actually. We can help. And we didn't do anything novel at MGH. I wish we did. But what we're doing right there, is with that full time team,
we're making everything, we're mainstreaming all these nice studies that have shown anesthesia to benefit in patient care. So right now we're, there's these, just a couple studies that I pulled up. Five, and two on the left are just using
this very cool Jet ventilation, an advanced ventilation technique that was traditionally used in the operating room. And in was invented in 1960s, 1970s. And you see these papers are from 2011, and the other one I think is from 2012,
about using this ventilation modality for ablations. We're also doing paravertebral nerve blocks. And we talked about pain blocks for chronic pain. But these actually for acute pain for biliary drains we can actually use these paravertebral blocks that's been written about.
And was written about in 2011. So actually relatively, just, it's new. But nobody kind of got written up and kinda forgotten about. But now since we're there, we actually are bringin' these things back.
The newest paper that came out is using a block for, a brachial plexus block for fistulogram to enhance patient comfort. And actually that's what we're doin'. We are doin', peripheral nerve blocks for fistulagrams. Especially of the forearm.
We've noticed that those are actually very, very painful. So we actually go in and do a nerve block that lasts for four hours, something very, very short. And the patient's get still, they still need sedation.
But the pain is gone, and we find out that they actually, they don't need as much versed, or fentanyl, that they're much better satisfied. And this is where we're still doin' this. And we're still formulating this. We're also doing advanced,
right now we're doin' a Swan-Ganz catheter to measure cardiac output for percutaneous banding of these fistulas, where several patients have had issues with blood pressure, cardiac outputs increase with a fistula.
So the question is, if you actually band it, and you stop the blood flow, or decrease the blood flow, can it improve the cardiac performance. And we don't know that but we are able to place these lines, measure cardiac outputs.
We can actually compress, and you'll see actually right there in the bottom picture, over there I should say, where there's a tourniquet, and they're compressing the fistula, and we're actually shooting cardiac outputs
to see the decreased blood flow actually makes a difference. If it does make a difference in terms of decreasing cardiac output, the cardiac performance, they proceed with banding. And I think what we're gonna do next, in the future is, you know, in the anesthesia world,
we actually have this device that measures cardiac output non invasively, without a PA line. So I think we're gonna continue doing that to kinda guide our management. And this is anesthesia and IR working hand in hand, you know, applying novel ideas,
where existing, merging of actually two different technologies which exist down there, we just don't talk to each other. The other thing that's coming to light as well
is the effect of cancer recurrence and anesthesia. So the effect of anesthetics and cancer recurrence.
Do the anesthetics actually, can that impact cancer recurrence for these surgeries. You know can general anesthesia, do they you know, do they impair the immune system. And when you ablate, you know, if you impair the immune system
do you render the patient more susceptible for recurrence. If you start giving a lot of opioids, and there's evidence that opioids can actually cause or contribute to cancer recurrence. Is that an issue. So should we concentrate on decreasing opioids,
maybe avoiding general anesthesia, or certain anesthetics that are linked to cancer recurrence. Well that is a new thing that we're actually bringing, discussing. So we came up with, at MGH,
is enhanced recovery after procedure. And is short term for ERAP for microwave ablations and our TACE procedures. So what we do there is we give, in the pre procedure area we give medications. Analgesics, Tylenol, Celebrex.
We do paravertebral blocks, or certain blocks for the patients who are in the procedure. And after the procedure we actually do, we use adjuncts to decrease the opioid consumption, increase patient satisfaction. And we've heard it before,
the previous speakers talking about how peripheral nerve blocks help. They do help. So they do enhance, patient's love it. And this is what we're doin' and it's actually very unique.
I think we're one of the first to do this, roll this out, is enhanced recovery. And this is what's been taken, we've been doin' in the operating room. So we went to the operating room. And I said okay why don't,
if we're already doing enhanced recovery after surgery, why don't we do it after a procedure. They're the same patients. They bleed, they have blood, they still have pain. And it's been getting a lot of traction. And this is just us doing a peripheral nerve block
in the IR suite, and you can see actually the IR tech and the nurses are in the background actually helping me do the nerve block. We have a little regional nerve, anesthesia regional nerve block that we've put downstairs, our offsite block.
Which is pretty neat.
The other thing I mentioned earlier that we're going at Mass General is jet ventilation. And the jet ventilation is a very cool concept that's been around since the 1970s, but hasn't been employed in IR in mass.
So there's been studies that I showed you. But that creates a static field, so you get these little short bursts of 15 mls at 100 times per minute. And that creates actually a static field in the internal organs, the lungs.
And imagine a radiologist, if he knew about the static field, no patient moving, no apnea, he just goes in there and does the procedure. That actually increases the procedure accuracy, decreases radiation exposure.
Actually lesions that were thought to not be amenable to you know, some cryoablation, are now amenable to cryoablation. So if there's a lesion at the base of the lung, you traditionally couldn't get it. But now with this jet ventilation,
we brought it downstairs, we actually treat that lesion, treat that patient and offer, other treatment benefits, or modalities that the patient wouldn't otherwise be a candidate for. And you can see the jet ventilations over there. In one of the screens, the middle screen
you can see us putting the jet catheter, and then the jet ventilator's right there. But this has been, this technology has been in existence since 1970. It's old to us, but it's novel now in IR. And I think it's gonna gain traction.
But the most important thing is that out of all the important, you know, all these new techniques that we're using, we're utilizing, it wouldn't be possible if we didn't have a close IR collaboration. You can see Dr. Ronnie, one of our premier
interventionists, he's lecturing the CRNAs, and our MD anesthesiologists on the procedures that they're doing with our banding for fistulas. Explaining the concepts between cardiac output. So we had this little conference just to increase understanding of what's goin' on.
and there's no hey, you know anesthesia's comin' in, they're interrupting us, you know, actually we know what they're doin'. And paramount to this is communication. And you know, it's the old cliche, communication, communication.
You know a lot of break down in communication leads to patient mortality or bad outcomes. But we've been really, really pushin' it. And enhancing this. So the nice thing about our program is that the phone call nurses,
you know when they screen their patients ahead of time, if they have any questions they reach out to us, to me personally. Contact us either with questions, or you know, manage, they ask about consults in terms of what patients
are appropriate for conscious sedation versus anesthesia. We also are pushing a daily IR schedule so people actually know who's who. So we actually highlight the anesthesia floor walker. We have the IR physician. They're the IR lead who we call to make changes.
We have all the rooms with all the fellows names with the anesthetist, their names, and also the nurses, their names, in case there's any questions. You know it's a big deal. It's just small, but it's big when somebody knows your name.
You know you can attach a name to a face. It just makes everything so much better. We also have a operations meeting that happens biweekly right now. So we talk about issues that happen with scheduling, that have to do with anesthesia,
and in particular, you know, what goes right, what goes wrong. and this continues, it's a lot of work actually. And for every, it seems sometimes, for every two steps forward, we take three steps back. But we're always movin' ahead.
And it's not easy but I believe that this is what makes us special. And what this is kinda, I think this is the model for what we need to achieve in other institutions. Now with all the innovations that we've
brought down at MGH, we could not do it without the IR nurses. And I thought before that oh, I'm just gonna go ahead and do a block, and it's gonna be fine. And then I'm like oh my, just wait a minute. You know actually, there's actually more
to taking care of a patient with a block, like how do you take care of 'em. How do you assess 'em, and you know, yeah the IR nurse, had to collaborate with the IR nurses. And Alexandra's here and you know, she's, it was up. Brought it to my attention, like yeah,
when you're utilizing all these, when you bring in other technologies you at least have the people that live there, you got to educate them, because they'll be taking care of it. They have to understand what you're doin'.
You know it's not a one way street. This is a practice change you know. So we had our nurses train in regional safety. You know have some share point slides for knowledge of how to take care of a block. The recovery protocols which is another thing.
You know it's like everybody comes here, and says, oh yeah, do a block. And you're like okay so how do we take care of it. Who's right, who's wrong. Where are the discharge instructions. Who takes care of that?
And it's the nurses actually. You know so there's a beginning, a middle, and a conclusion to a procedure. And it seems like, you know I'm guilty of this. We just concentrate on the procedure, but we never actually concentrate on the followup.
But anyway, we've been good with the nurses in terms of educating them. Our nurses, what I've noticed is that number one, patient advocate, you know, they're always getting pushed to do more and more. You know nights we don't have anesthesia
or this patient doesn't need anesthesia. Or you know proverbial like, mismatch. And you know they're always there fighting. And I encourage you to continue doing that because you know you are the patient's advocate. No I'm not saying that as an anesthesiologist,
but just you know, if I, you know as a third party, you know our nurses at MGH, consider they're truly truly a patient advocate. They just care about the patient. Their comfort. And doing the procedure, they just don't sit back,
they have to also pay attention and help us out. If we have a patient here who's from cardiac ICU who's on you know, eight drips, and we're not a one person machine you know. This patient needs a lot of care you know. It's good that we have the nurses.
And I don't wanna forget the IR technologists who are also key and vital in patient safety. And what we've been doin' is administering. I administered a survey to identify gaps in knowledge. Like I just wanted to see how much do the techs actually know about anesthesia
because they're the first ones to come in when we have complications. you know or if the table is turned, and we're doing you know a MAC anesthesia, and now the patient starts aspirating. You know the tech actually has to know to turn the bed.
Right, recognize that. When we have a difficult airway, before when we are anticipating one we have to know, we have to be able to rely on the tech to say hey, you know, I notice that you talked about a difficult airway,
do you want me to tilt the bed? I can tilt the bed. I was like oh, I didn't know that this table, that it was capable of doing that. Or we have a pneumothorax, you know, like hey why don't we shoot a quick xray.
You know, so and so can you shoot an xray. Stuff like that. So what we've done is administer a survey and asked questions about techs have speaking up. So we are actually actively working on this. So you know, how important are the techs
recognizing the anesthesiologist is struggling. When the anesthesiologist is struggling can you speak up, and see how. You know we kinda have a wishy washy world where people are not really comfortable to approach the anesthesiologist.
Is that appropriate, is it not. Do we appreciate it, do we not? So I am actually very excited that we can actually intervene. And we're gonna give another survey afterward. And well, we're gonna provide education.
And you know, educate the techs on hey, you know, you can always speak up. You know it's okay if you know, nobody's gonna get offended if you say, hey do you need help or anything. Also being familiar with our equipment,
anesthesia equipment. The second survey on the bottom, you can see it asks about a glidescope, do the IR techs know what a glidescope is? It's our video laryngoscope that's used for difficult airways.
So you see the top right patient, the top right the patient has a huge neck mass. And it was gonna be cryoablated. We've learned about cryoablation, it's great. Yeah. And patient is, can't really breathe.
So we have to do an intubation. So a patient like this, and the cryoablation is not gonna be straightforward. It's gonna take hours. We know that. So we need anesthesia.
But this patient was very, very challenging. And we needed the nurse, the IR nurse, and the IR tech to help us with securing the airway. Not an emergent situation, but they need to know the equipment that we use. Again is being vital.
And last but not least, in anesthesia we have these emergency manuals, cognitive aids. That when people know here when we actually have a crisis your cognitive, your attention span, right, decreases. We kind of learned that before.
So what do we do? We have these emergency manuals. And this is in our culture, in the operating room culture we have these emergency manuals ready, available. We put one in in every single IR room.
But we haven't actually educated the providers how to use it. We also haven't really had much work in terms of a crisis situation, of going over drills. And this is what we're doin', because again if the patient starts vomiting,
we need to be able to, everybody needs to know their roles. What does the nurse do? Who do they call for help? What's the tech do? What's their role?
Move the bed. Can they help us with mask ventilation? What's the IR fellow, or the IR attending, what's their role? Can they help us out as well? Because we are removed.
We don't have many hands on deck. But you guys are our first hand, you know first responders. And you should be able to know what we do to help the patient, because every second does count.
So I wanna just finish out by saying that, you know, the world is your oyster, and this is just a talk to motivate you, and tell you that you know, the future is here. That you need to collaborate with your anesthesia colleagues in terms of you know,
coming up with ideas of how to increase patient safety. You know don't be ashamed to ask them, hey, you know, what are you doin'? What's goin' on, how can I help you? And in your institutions, I say go back and maybe look at your practices
with anesthesia cases and you know, it's not just two different people comin' in. You're gonna see more and more of this. And I strongly believe that. And you know I hope by attending this talk you could be more cognizant of that.
And then maybe be a little bit more proactive in terms of you know, what's goin' on, and maybe preparing yourself. Thank you. (applause)
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