Q&A Session 2

Speaker 1The, um, Georgias is just, uh, dealing with some internet issues, but I wanted to ask, uh, Doctor Bullock the questions about anesthesia. So I think that it's interesting cause, I mean, as surgeons, honestly, once the drapes go up, we really don't think about the, the physiology issues. But I wonder if you could speak about some of the physiology issues associated with spinal versus general.

Speaker 2Yeah, uh, absolutely. First off, um, the catheters, uh, are great. The nimbus pumps are great, um, uh, and, and when those can be used, it's, it's, it's effective, efficient. I've had catheters myself. Uh, I'm also a big proponent of Xperel, so I think both of them are tools that, that are good to be used, um, that, uh, are really beneficial. The intermittent bolus technique, I just want to touch on that for a second, is, um, really, uh, really beneficial for any sort of fascial plane block.

Speaker 2Because what you're doing is reopening the fascial plane and getting the local anesthetic to spread where you need it to, as opposed to a continuous infusion where you're just essentially dripping in medication that may or may not be going where we're intending it to go. So, when we do quadratus lumbarum blocks, tap blocks, ESP blocks, if we were to put in uh with an intermittent bolus protocol, you re-expand that space and you get the local anesthetic where it needs to be, and you're seeing the good results with it.

Speaker 2Uh, the catheters that we use come from B Bron, uh, or from Payunk. Those are the two companies that, that we use. Um, I think 11 of the questions was which catheter do you use? Um, and so those are the two that we use. Uh, the BBron is catheter through needle, the Punk is, um, catheter over needle. Both of them have advantages, um, both of them have, uh, you know, challenges as well. So, um, so that, that's kind of, uh, just a little add-on to, um, to the previous question.

Speaker 2In terms of the physiology for the anesthesia, um, you know, uh, going back to Ernest's talk, um, general anesthesia is safe, but there are a lot of issues that come along with it. One of the ones that you brought up that was interesting is, uh, the epidural veins that continue to bleed with a positive pressure ventilation. So, imagine you're expanding your thoracic cavity and you're decreasing your preload. Where, where's all the blood going? Well, it's going back into the venous system, so if you do have, uh, any sort of issues with, you know, preload dependent, um,

Speaker 2Um, pathologies, then you're gonna have issues, uh, cardiopulmonary wise. Um, likewise with the bleeding with the epidural veins, that blood just gets pushed back. So, the physiology of having somebody spontaneously breathe without having positive pressure ventilation decreasing that preload, uh, is, is obviously important.

Speaker 2Um, one of the papers that you showed for postoperative cognitive dysfunction as well comes from Duke. Uh, it's, uh, Doctor Berger, Miles Berger, who's looking at this, uh, postoperative cognitive dysfunction, looking at, um, a variety of different parameters, and finding that older folks are, uh, a little bit more susceptible to postoperative cognitive decline with, uh, with general anesthesia.

Speaker 2Um, and like I said earlier in my talk, I, I like to give less anesthetic as possible, and the reason is because the more anesthetic you give, the more side effects you can have, and the more physiologic, uh, derangement you're going to have, and you have synergistic effects effects with medications. So, physiologically speaking, a general anesthetic is going to get a patient to where we need them for Surgery, but it may not be the most appropriate for the patient.

Speaker 2Uh, and it may not be because of their comorbidities, um, cardiac wise, we definitely want to have somebody, uh, more awake, uh, than we would if they don't have cardiac morbidities, um, pulmonary wise, same thing.

Speaker 2Spinals have been shown to increase.

Speaker 2Or to have better outcomes with uh pulmonary outcomes postoperatively, and that's across the board. Um, cardiac-wise, similar benefits, uh, and except for uh perioperative, uh, MI which uh tends to be the same across the board. Um, there's less infection rates, there are, um, less issues with, uh, DVTs and PEs with spinals. All of these things are really important. Now, all this data is coming from, uh, total knees and total hips, but I think it can be applied to the Spine as well.

Speaker 2Um, so, physiologically speaking, the spinals keep people in more of a homeostatic, um, kind of condition than a general anesthetic would.

Speaker 1That that's, I mean, I, I think that's the really.

Speaker 1Interesting point.

Speaker 1I'm a little jealous because Mohammed really coined the term surgical footprint, but I think it's so valid in this whole situation that we don't think about the surgical footprint that we have. It's, we all, we all understand the carbon footprint inherently. And so I think that we don't think about the, the surgical footprint. Um, I think the Other interesting point is the point about keeping them in homestasis is the point that Ernest brings up, which is not something we think about a lot, which is the humanism aspect of it. Uh, we had, um,

Speaker 1In my previous practice, a surgeon who was taking his Spanish proficiency test while doing a vascular procedure.

Speaker 1So his, uh, I think his assistant had him on the phone and he was doing his Spanish proficiency test while that, and then that blew up.

Speaker 1Badly, in the press. It didn't, it didn't, I think he had to stop practicing, ultimately. I think Ernest, it would be interesting. I don't know if the mic is working for you, but if you can speak a little bit, I want to sort of understand what your thinking is around that, how you got that evolution.

Speaker 3Oh, I, my mic's out, but I'll, I'll, um, I guess the folks that, uh, the folks won't do it here as well.

Speaker 4So, I mean, it's um

Speaker 4I, I think there are just, there's a tendency when the patient is asleep that that, that are under a general anesthetic that you can just do or say whatever you wanna, wanna do that may or may not be appropriate. Um, we had a very famous case in Denver, Colorado. I'm not gonna mention the surgeon's name, but he figured out a way to um get the monitors to play 40 year old virgin, so he could watch.

Speaker 4The movie, and it's not, it's a funny movie, but I mean, it's not appropriate to to watch a movie during Surgery. It's one thing to have music on, but actually, you know, if you're doing something that requires your visual attention to have a movie playing on, it's just inappropriate, obviously.

Speaker 4Patient found out about it and it, it didn't go well for him. He ended up having to, to leave that, that, that job. And I find as a very busy surgeon that's running my own practice, that I kinda get, I can kinda get sucked into that too. Like, I started walking in and I was on a conference call, board meeting, and I was coming to the patient, and the patient, and I was like, hey,

Speaker 4Hey, I, I need to stop this call. I, I need to focus more on this patient. And, and for me, it's a time to really bond with my patient. I may not be able to give them as much time as, as, um, they would like in the clinic. I probably spent about 15 minutes with a patient, indicating them, um, going over films. I have a whole team that's, that's kind of really screened all the patients out for me. But like in the operating room is when I really get to know, get, get to know people. So I'll say, you know, so what do you do for a living, you know, um.

Speaker 4How did you come to Vail or, or what, you know, and we just talk. We have, you know, we have a nice conversation. Some patients don't, would prefer not to talk. Some patients are really into it. Some people just like to watch the procedure. And I think all these things makes it a more humanistic experience. And, and sometimes we forget, you know, uh, I think we can lose that a little bit with all the sterile drapes. You make it, you make it less human. And then, um, and that's not, that's not the reason I started doing Awake Surgery as really for the Other benefits, but I found that that's, that's something that patients appreciate.

Speaker 1I think to your point, you had mentioned before about how we both got Business degrees and um in Business school, we learned about the experience economy and I have a paper out there online about um the experience economy and how it relates to something called the net promoter score. But ultimately, like what I'm saying is that um as we continue to evolve,

Speaker 1Patient experience is not about whether or not the food is good or the wallpaper looks good, or if the nurse answers the call bell, but the experience part is really tying in some of the emotional aspect of what you do. And if the more you could do that, the more likely you are to sell iPhones, sell Starbucks coffee, and uh get people to watch videos on Netflix. You can only, you can really do that ultimately when the patient's awake during Surgery.

Speaker 1And so to uh Ernest's point over there that you really can tap into the net promoter score or experience part of things with Awake Surgery.