There has been a marked increase in mass casualty events in our society. Targets have included schools, malls, houses of worship, and yes, hospitals. Our staffing crisis unfortunately has negatively affected even our most robust trauma system and emergency rooms; there has also been the closure of many hospitals in rural areas, which has created healthcare deserts. The inability of many towns and small cities to care for “terror event” patients’ issues, of course, will affect how we deliver trauma care.

As such, it’s critical that anesthesia providers in small hospitals and ambulatory surgery centers receive training in Advanced Trauma Life Support to augment the local response. Additionally, communities need to develop a response plan that includes all of the local medical resources, such as ambulatory centers and urgent care facilities, in the event of an attack.

Finally, we should advocate for the public at large to participate in the American Red Cross’s STOP THE BLEED program to increase the pool of first responders who are able to treat severe bleeding. We should stockpile bandages and tourniquets in all potential target areas. Working together, we may be more able to respond to these horrific events in a more effective way, and ultimately save more lives.  

The American healthcare system is experiencing a growing crisis: How do we adequately staff our operating rooms, hospitals, clinics and offices with healthcare professionals? The lack of staff crosses all professional lines, from physicians to nurses to lab technologists—all levels of staff are in short supply. To deal with this challenge, health administrators have resorted to using temporary contract workers known as locums. These temporary, stop-gap employees are usually paid multiple times more than permanent staff. This practice not only undervalues full-time employees, but also exacerbates the crisis because it robs staff from other facilities to staff another. Finally, the increase in locums, and its associated costs, has undeniably harmed the bottom line with many services and facilities closing down, further decreasing access to healthcare for the public.

We as health professionals need to address this crisis. To do so, the causes must be analyzed and solutions developed. Some issues, such as salary lines and child care, can easily be addressed. Others, such as professional burnout due to electronic medical record systems, which have taken professionals away from patient care—essentially making them data entry clerks—should be addressed, and jointly with technology companies. The bottom line is that all of us must focus on this crisis or it will lead to a marked decline of the American healthcare delivery system.

At the 2023 spring meeting of the American Society of Regional Anesthesia and Pain Medicine, Rajnish Gupta, MD, a professor of anesthesiology at Vanderbilt University Medical Center, in Nashville, Tenn., discusses how podcasting can be a way for anesthesiologists to highlight their academic work and communicate with other like-minded professionals in the specialty.

“The beauty of podcasting is that it allows the speaker to talk on a specific topic to a narrow audience. That way you can expand on a topic that may not be appropriate for a large population of people, but in that small niche, there is a lot of enthusiasm.” 

Barbara Orlando, MD, PhD, an associate professor of anesthesiology and the division chief of obstetric anesthesiology at McGovern Medical School at the University of Texas Health Science Center, in Houston, discusses several ways to reduce morbidity and mortality in pregnant patients. She also addresses high-risk pregnant patients with various comorbidities, such as obesity and those with a lack of prenatal care.

“This podcast is about my personal journey as an anesthesiologist in gaining understanding and being more involved with societies and committees in charge of maternal mortality and morbidity. My interest was sparked by my passion for obstetric anesthesia, and my new role as a division chief of OB anesthesia at UT Houston. Reviewing bad outcomes and thinking of ways of reducing such events was very eye-opening to me, and I hope to inspire others as well.”

Obstructive sleep apnea (OSA) affects 20% of U.S. adults, of whom about 90% are undiagnosed. The major risk factors for OSA include obesity, male sex and a family history of OSA. There is a large body of literature showing that OSA is an independent risk factor for hypertension, heart disease, type 2 diabetes and stroke.  This case illustrates how a patient presented for elective admission for surgery and suffered a stroke.  

A 55-year-old man with obesity presented for elective surgery for a chronic nonhealing ankle fracture. The patient reported a long history of loud snoring and type 2 diabetes. He was administered a general anesthetic and had no issues during the case. The patient recovered and was admitted to the hospital overnight, and it was noted that he had marked bouts of hypertension overnight while sleeping; the patient had no past history of hypertension. The staff also noted evidence of sleep apnea patterns of sleep and snoring. The patient was then discharged home. Three weeks later, the patient presented with a large embolic stroke and was admitted to the neuro-ICU. He was discharged to a rehabilitation facility with marked cognitive issues.  

This case illustrates how important it is for anesthesia providers to screen patients for OSA and educate patients about the major risks of OSA. There were also some key incidents during this admission that support the need for staff education. The episodes of hypertension during sleep and not while awake are a key sign of the cyclic sympathetic outflow that occurs during OSA. This also supports cyclic release of mediators that occurs during severe OSA that can affect the endothelium and cause activation of coagulation cascade. The snoring can also cause direct vibratory trauma to the carotid blood vessels, and also cause endothelium damage on the interior of those vessels that can generate a clot.  

We as anesthesia providers should be at the forefront of identification of OSA and have a protocol to educate patients and refer them to sleep specialists for testing and proper treatment. This can be a major public health contribution of our specialty.  

Cancer is a major global public health concern that affects all citizens and communities around the world. Globally, the incidence of cancer is predicted to increase by 50% by the year 2030; and during the same period, cancer-related mortality is projected to increase by 60% to 13.1 million deaths worldwide. This increasing trend in cancer-related mortality exists despite a slow but steady decline in cancer-related death rates since the early 1990s in the United States and the Western world.

Citizens 65 years of age or older have a cancer incidence rate that is 10 times higher than among younger people, while the mortality rate among older cancer patients is 16 times greater than among younger patients. However, cancer is no longer considered a terminal disease. With the implementation of effective cancer prevention education programs, widely available screening programs leading to early diagnosis, and the advent of effective biologic and immunotherapeutic modalities, the profile of cancer is changing to a chronic medical condition.

There are more than 20 million cancer survivors currently living in the United States alone. Of the nearly 20 million new cancer cases worldwide in 2021, more than 80% of cases will need surgery, some several times as curative resection is essential for global cancer control, particularly for patients with solid tumors. It is estimated that by 2030, over 45 million surgical procedures will be needed globally for cancer control. Furthermore, both patients with cancer and cancer survivors will continue to need the services of our specialty in the perioperative setting well beyond their primary cancer care.  

As most of the diagnostic and interventional procedural care for patients with cancer is provided in the community setting around the world, this textbook, “Perioperative Care of the Cancer Patient,” will serve the educational needs of anesthesia providers in all settings globally. Each of the chapters is authored by international experts in the field and discusses the current understanding and practices, current controversies and unanswered questions, and the direction for future studies.  

I believe this is an exciting time for anesthesiology and perioperative medicine as we continue to partner with oncology and other specialties to break down silos and work together to improve postoperative outcomes and increase disease-free survival.  

Neil Ratner, MD, has played remarkably divergent roles in his life, initially as a rock-and-roll drummer and staging entrepreneur, working with the likes of Edgar Winter and Emerson, Lake & Palmer. But he always had an interest in medicine, so eventually he ditched his successful rock career and went to medical school, later becoming an anesthesiologist who embraced the then-novel concept of delivering non-OR anesthesia, which he helped pioneer.  

It was through his work as an anesthesiologist for a plastic surgeon that he ended up meeting Michael Jackson, of all people, who immediately liked Dr. Ratner and his rock-and-roll roots.  

His rock music and medicine careers enjoyed some precipitous highs but also significant lows, all of which he candidly details in his book “Rock Doc.”

Perhaps surprisingly, however, our interview with Dr. Ratner is mostly not about his rock-and-roll past or his work doing non-OR anesthesiology, but instead about what he is up to today: serving as a kind of public health announcer for a radio station in, fittingly, Woodstock, N.Y. His work interpreting medical news—particularly as it relates to COVID-19—for the station (WDST; 100.1 MHz) has made a difference in the public’s understanding of the complicated issues brought about by the pandemic.

The Drug Enforcement Administration Washington Division is warning local residents of a dangerous new drug emerging in the D.C. area that is as deadly as fentanyl. We as neurocritical care practitioners may therefore soon find ourselves caring for patients that have overdosed on this drug and may be suffering from severe hypoxic injury and coma.

In the fall of 2019, a new synthetic opioid named isotonitazene made its debut in the U.S. and Canada. The drug, which is not a derivative of fentanyl but is equally as potent, is legal to export from China and was not initially banned in North America or Europe despite not being an approved pharmaceutical product anywhere in the world. However, the DEA has now issued an emergency temporary order placing isotonitazene as a Schedule I drug.

Isotonitazene is a derivative of benzimidazole, an opioid analgesic. It is 500 times more potent than morphine and has slightly more potency than fentanyl with respect to causing relaxation, euphoria and respiratory depression. In March 2020, isotonitazene was found in counterfeit hydromorphone tablets sold on the streets of the United States and Canada. There are also reports that this is being mixed with other street drugs such as cocaine. Isotonitazene is a growing public health risk and a real danger to those who misuse drugs, especially users of heroin and cocaine. Street names of this drug including nitazene or ISO may be volunteered by patients and other involved parties.

Another major issue for us in the ER and neuro ICU may be that normal toxicology screens do not identify this drug. Luckily, however, the drug is responsive to naloxone. It may be important for us to collect blood samples from patients responsive to naloxone but who tested negative for narcotics in our facilities and send it for analysis to help government agencies track the distribution of this drug. I also suggest that blood samples be sent for patients who present with hypoxic brain injury with unclear causes, especially individuals at risk.

Over the past two years, Saddleback Hospital, in Laguna Hills, Calif., has implemented a robust ERAC (early recovery after cesarean) protocol that includes a transversus abdominis plane block with liposomal bupivacaine for post-op cesarean delivery pain. Results have shown that the protocol has reduced the use of narcotics for the post-op period by 80%, and has improved the overall satisfaction with the post-op period considerably by reducing nausea and vomiting, itching, and constipation. In addition, hospital length of stay has been reduced by one day.

According to Steve Garber, MD, a practicing obstetric anesthesiologist for more than 30 years, moms are eating earlier, up and around quicker, and ready and willing to go home earlier. The patient in this case study, who had a myomectomy 20 months earlier, essentially had a very similar surgery to a cesarean delivery. The incision was the same, the uterus was operated upon and the patient remained in the hospital. Her post-op course, as related to Garber and her husband, was vastly different in regard to her narcotic usage and how she felt. She was “out of it” for two to three days, and these were days she was home already. She felt dizzy, wasn’t able to concentrate and was in moderate pain, which is to be expected for the extent of her procedure.

So now, we get to compare the experience for the same patient, having essentially a very similar surgery, with a different post-op pain protocol: the ERAC protocol. Of note is the extent of the hemorrhage that occurred, the overnight stay in the ICU, Bakri balloon intervention and the patient didn’t require any narcotics for pain throughout her stay. The patient was amazed how well she felt post-op day 1, back in her private room with her newborn.

“Cesarean delivery is the most commonly performed major surgery in the world, with 1.3 million performed in 2019,” Garber said. “Unfortunately, every year 26,000 women become persistent opioid users after cesarean delivery. With a robust ERAC protocol, the reduction of opioid use is quite significant.

“If you look at our patient, if no ERAC protocol was used, she would have felt the same, or probably worse, than after her first surgery. Lethargic, out of it, dizzy, and would have been expected to bond with and take care of a newborn. The first hours and days with a newborn are so precious, and I believe all the moms should have the ability and opportunity to experience it with little to no narcotic use.”

In the previous chapters of “Anesthesiology News Presents The Etherist,” we defined just what physician well-being is, when it came to light and why the concept needs to be addressed at institutional and systemwide levels. We also explored managing the cognitive workload during residency, the stress of working during the COVID-19 pandemic, and the unexpected toll that burnout can leave behind.

And now, for the final episode of the series, various experts share their thoughts on how to best recognize and manage burnout, as well as how to strive for an optimal work‒life balance. These aren’t instant fixes, but rather takeaways for anyone, regardless of whether they are struggling or not. There has been no shortage of thought-provoking quotes throughout this investigative series, but the one that has most resonated with us is one that we hope you also hold onto: “When I think about wellness, the first thing that comes to mind is the old cliché of being on the airplane and being told, ‘Put on your own oxygen mask before you help those around you.’ So certainly, in the long run, one cannot be an effective doctor, caring for one's patients, if one does not also care for oneself. However, it’s equally as important that physicians work in environments that support their ability to do that.” Translation: Management can't simply prescribe yoga when the reason for burnout is staffing shortages.

Researchers recently found that 62.8% of physicians had at least one manifestation of burnout in 2021; and while the pandemic's peak is over, supply chain issues and staffing shortages still continue. Substance use disorder does affect anesthesiologists, as we know. This might be due to the ease of access to intravenous opioids, propofol and other anesthetic drugs. More sobering is the fact that every year in the U.S., roughly 300 to 400 physicians die by suicide. The ASA has a comprehensive webpage highlighting various help resources, including suicide and physician support lines, well-being apps, a burnout calculator and guides for doctors facing adverse outcomes and malpractice litigation. However, the most important thing to know is that you are not alone. Despite what you may think, many of your colleagues have previously gone through or are even currently experiencing many of the same feelings of burnout. So create a buddy system and know that there's nothing wrong with confiding in a peer, friend or even a trained professional.

While your focus is predominantly and perpetually on taking care of patients, it's okay to think about yourself for a change. Because as a former AMA president once said, "The most important patient we really have to take care of is the one in the mirror."