THE NEW YEAR IS COMING.


This is the time for resolutions. It is almost the new year. Have you met your goals this year? If you have not, there is nothing to be worried about. There is still time. If you have run out of time you are not alone. Most of us are too busy living life to focus on our resolutions. I would suggest that we all use this time to look back over our year and be thankful for all that we have accomplished. We all have come a long way and are on the brink of a new year. Let us be happy.

The new year will bring new challenges that will give us more opportunities to grow. Let us take hold of our challenges and continue to succeed in spite of the opposition. All our challenges should be viewed as a means to success. It is only by confronting and overcoming that we can advance. Wipe clean the slate, start anew and conquer. The only person standing in our path is ourselves. Set that goal, make a plan, hold yourself accountable and make it so.

Have a wonderful and successful 2015.

BEACH


The cab was waiting as I ran back into the house for the third time. I had forgotten our passports. I ran upstairs to our bedroom and the passports were on the bed. It was in the same spot I had left them earlier. It was supposed to be the start of a long-planned trip. It was more than three years in the making and I was running late for the easiest part of it. I was usually the early bird, but not today. I was too nervous. Mike was shouting from the cab and I was ignoring him. I was nearly down the stairs when I tripped over one of Amy’s toys and fell flat on my face. As soon as I hit the hardwood floor I could hear the crunch of my nose and the wetness of blood soon followed. Mike was there in a flash and helped me to my feet. He got a wet towel and cleaned my nose. The cabbie was not as patient, he started to hunk.

Mike, not easily intimidated, shouted back at the cabbie. I had not heard Mike curse in a long time, but the expletives came thick and fast. I squeezed his hand to let him know I was fine. The cabbie was shouting back and unloaded our bags and drove off. It was all going badly so fast, it seemed our long-planned Tanzanian vacation was going to be over before it started. I was already disappointed.

Mike collected our things as I cleaned up. I called another cab. The cab arrived before Mike could get all our luggage back into the house. He was annoyed that I had called a cab, but he was happy that I was still up for the trip. I had assessed that my nose was not as bad as it seemed and I was not going to lose thousands of dollars for a bloody nose. The cabbie was efficient and we were packed and on the move quickly. Fortunately for us we always left early for the airport in spite of living within 15 minutes. Traffic was light and we made it to the airport in 14 minutes. We made it through security easily and got to our gate with time to spare. As I took a seat I remembered that I had not taken any allergy medication. It was too late. I would have to get something once we arrived in Tanzania. I did not tell Mike that I had left the allergy medication. I was too embarrassed since I had misplaced so many things already today.

Mike had just gotten comfortable when the boarding announcement was made. We had first class seats and were in our seats with drinks in our hands long before most of the passengers had boarded. The service was wonderful and all I could think of was finding a beach on the Indian Ocean. The rumbling of the aircraft engines made it real. We were going to be in Tanzania soon. We both were looking forward to the beach and the mountain. Kilimanjaro was the goal. We both had always wanted to climb Kilimanjaro and meet because we had mutual friends that knew of our interest in Kilimanjaro. We were starting our dream vacation.

As the plane rolled down the runway I closed my eyes as I always did on takeoff. The rumble of the engines were ever-present and my headphones were not a real barrier. I had my takeoff routine and Mike had his. His was to squeeze my hand. I could feel the acceleration and Mike’s grip became tighter and tighter. As we started the accent there was a loud bang and the plane fell rapidly. It felt as if I was being pulled from my seat. The seat belt held me tightly and then there was a second bang as we crashed into the water. Mike got his seat belt off and was urging me to do the same, but I was in a dream. We had gotten to the beach a lot sooner than I had hoped.

POSTOPERATIVE DELIRIUM


Life expectancy in the USA as of the most recent data is 78.61 years. Along with longer life span we have a every increasing number of surgery. With out-patient surgery rapidly growing year over year. The population over 65 years are living a more active life still and are requiring more surgical intervention. Our peri operative technologies have improved to allow us to provide safer care to those at the extremes expectancy range. WIth this improvement and comes many additional questions. The question of post op delirium continues to be a problem and will increase as the populations ages and more surgical procedures are available.

How the older patient is cared for in the peri operative time frame is and will continue to be of special concern to themselves, families and increasingly to payors. The process of getting from diagnosis to the surgical suite is basically divide in 2 routes, either via he emergency room or the physician office. The peri operative preparation is as import as the intra operative care and involves many, however as an Anesthesiologist i will present the process from my vantage point.
The care of any patient starts with the basics, taking a good history. For all patients under the care of an anesthesia provider taking a focused and directed history is vital to the safe delivery of appropriate care. For the older patient extra attentions should be placed on history of delirium in the post operative period which i would suggest should be considered to include the first 24 hours post PACU discharge. Other vital components to evaluate include vision impairment and hearing loss. For the visually impair consider how soon after arrival in PACU to return glasses. For the hearing impaired do they use hearing aids, can they be left in for the procedure. Does the patient lip read. Even for those that do on lip read, looking directly at them, speaking clearly with proper enunciation without shouting works very well to transmitted data.

Carefully look over medications for hints to treatment for early dementia. Ask about early dementia. What happened after last surgery. Who will be present in the post operative period?

There is no clear evidence that anesthesia specifically is the cause of post operative delirium. The choice of anesthesia should be based on what intervention will provide for the safest working conditions and facilitate a rapid low pain recovery.  For those with dementia the suggestion that regional alone maybe advantageous is not as clear to me as it maybe to others. From my experience regional as the sole anesthetic in a demented even for very minor procedures will be a challenge because of the lack of circumstantial awareness from the patient. The lack of awareness can and often leads to lost of cooperation and increased risk of morbidity to the patient. The primary anesthetic must provide the appropriate working conditions firstly. The demented patient like all patient must first be in optimal surgical condition. General anesthesia is often the most optimal choice. General anesthesia is not one thing but many varied combination of drugs and this is where the judgement of the anesthesia provider can be very helpful. From my vantage point the goal is to provide the most advantageous conditions using the lowest dose of the fewest drugs required. A monitor that was dependable in the judgement of anesthetic depth would be of great utility in the older patient. The BIS monitor is claimed by some to be such a monitor, but many others find it inconsistent and unreliable. I have not seen any evidence that convinces me that it provides and advantage. It may provide some advantage but that advantage is not clear to me. The traditional monitoring of anesthetic depth includes observation of changes in vitals and direct observation of the patient may be insufficient to guarantee adequate depth but is still the best we have. A vigilant provider is still the best monitor. I hope that one day soon we will have an even better monitor. Without that monitor the provider needs to be conscious to balance depth with risks of post operative delirium. The drugs that we use to maintain anesthesia are important potential risk point and one area that is especially concerning are the anticholinesterases. These drugs are used as apart of the cocktail for reversal of paralysis and can cause delirium and should be used with caution. The optimal situation would be to not need them, meaning if necessary we should avoid paralysis. However, if paralysis is needed full reversal should be used because incomplete reversal could make the post operative situation worse. Additionally making sure all our anesthetic if below therapeutic levels before going to the PACU is beneficial.

Once the optimal condition for surgery have been meet and the anesthetic is optimized to decrease the risk of post operative delirium the patient needs to be cared for in a PACU that continues to  optimize recovery. The environment needs to the at an appropriate temperature with appropriate lighting and quiet. Use the minimum required monitors to get the job done. The nurse in the PACU is a vital partner, she needs to orient the patient to date time and location. Orient, orient and orient again. Assurance of adequate hydration, pain control, empty bladder, treatment of nausea if present, prevent hypoxia are all vital. If delirium occurs, low dose benzodiazepine and family at bedside should be considered. The use of regional anesthesia is a great tool to assist the post operative period. I find the most utility of regional in the patient with dementia or at risk of delirium is in its ability to provide significant long-lasting pain control that decreases the amount of opioids needed in the recovery period.
Special attention to the needs of the older patient at risk for post operative delirium is a worthy goal. However, we must not be lead from first principles. We must provide a safe environment for the procedure. With careful planning and attention to detail we may be able to decrease the risks, but we should not lose site of the facts. Fundamentally, there is no good evidence that the type of anesthetic correlates with risk of post operative delirium. The only consistent fact is that the patient has had surgery. Teasing out the specific component of the peri operative environment that increases risk is still some way off. What anesthesia providers need to provide safe conditions that decrease risks based on the evidence we have.

WHERE IS THE CHECKLIST?


I have loved health care for as long as I can remember. I cannot imagine doing anything but providing care . What I have learned in the trenches is that the love of providing care is not enough. Over time i have realized that a fundamental problem with health care is not in the expensive of it but in the nature of the people in it. We want to provide care, but we bring into the system our biases. Those biases allow for less attention to be paid to some patients because of their language or skin color. We may say that we provide the same care to all patients, but as a black physician I see otherwise. My experience of the system at institutions where I am not known by members of staff is vastly different. The consequence of this uneven care is a system where those that can afford care and are the correction completion receive care that is more compassionate and timely.

How do we overcome the inherent bias in the system? The answer is not more training nor necessarily more diversity. The answer will be in the wide-spread use of evidence based payment structures. Our medical systems are complicated and expensive but are systems in name only. We have a complex string of components. All the parts are mostly well-trained and competent. However the results we obtain are not commensurate with the level of training nor the level of expense. The incongruity of expense and quality of results continues because those attempting to improve the system have not acknowledged or do not recognize the biases of the system. The gap in quality of outcome is most obvious in communities of color. The often given excuses are truly just that. Recognizing that there is a problem is the first step to a solution.

Paying for quality work is the only avenue to improved results. The question as to how we get better care for all patients is simple and complicated, but we have a great example in the aviation sector. My brother is an airline pilot and his training is extremity rigorous, but he starts his day with a checklist. He does not feel that his autonomy is being challenged, but that he is making sure that he does not kill himself. We in health care do not have any real skin in the game. Until the decision makers have some skin in the game we will not embrace what is necessary to make our constellation of components into a functioning system. Let us start delivering quality care by implementing checklists. Checklists are reminders of the quality in our options. The checklist is not for you it is for your parents and friends. That checklist is not for you, it is for that provider that is on her sixth surgery of the day. It is a nudge because she is tired. A checklist is for every one of us. It helps us by removing silly mistakes from our systems. For me the checklist is my hope that I will be treated like a patient deserving of care on the off-chance that I am a patient in a strange place where all that can be seen is the color of my skin.