Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and I'd like to welcome you to my podcast and videocast station. Today I have the chance to interview Dr. Sandy Zalstein, who's an anaesthetist and a colleague and I'm delighted to welcome you today, Sandy. How are you? I'm really good. Thank you, Warrick. Sandy, look, so many people go through surgery and so often they're talking about what they're having done and the operation, but none of that can happen. unless there's an anaesthetist there. Just in the most simple and practical terms, how do you define anaesthetics for the patients who you're looking after through those procedures? Thanks, Warrick. Yeah, there's no doubt. There's no modern surgery without modern anaesthesia, and it's sometimes being described as one of the greatest gifts to mankind, obviously after cardiology. Look, usually there's different, in simple terms, it's a couple of different things that anaesthetists do. Number one is we make people to varying degrees, if you like, unaware of their environment. Number two is we make them comfortable. We address their pain needs. Number three is we have varying degrees of sleepiness. That's a very traditional approach, and I guess increasingly now a more sophisticated view of what anesthetists do is we look after you, we protect you, we keep you safe, we look after your vital bodily functions, and increasingly the modern sort of view of anesthesia as it's evolved over the last little while is we address your... if you like, your chronic health conditions before, during and after your surgery. So if you like, if you move from the traditional sleepiness, lack of awareness and pain relief, and then now increasingly there's more and more things that anaesthetists are responsible for, as well as some technical things. You know, anaesthetists aren't just limited to providing care in theatre. When did anaesthesia really start? Has it been something that's been with us since the onset of surgery? I mean, we see cartoons of people biting on a tight cloth and the surgeon operating out in the battlefield. But when did anaesthesia really, and what started anaesthesia? Was it that ether, the sort of stuff over the face? So I'm not an expert historian, but I'll have a crack and I have some idea about it. And I'm pleased to say for the Tasmanians listening or watching in, there's a really strong Tasmanian connection. So if you went back to the dark ages, they were dark ages, and any sort of surgical procedure, whether it was a bloodletting or the resetting of a bone, was pretty grim and pretty uncomfortable, and patients were moving around in the dark ages. You know, in various cultures and civilisations, there were varying levels of, if you like, basically doping people up with some sort of concoction to make them, if you like, not wriggle so much and not complain so much. But it was not a pleasant thing. Around the time of the mid-1800s, some... developments, basically technology and some science came to the pass and it came about a gas called nitrous oxide, which came and laughing gas is what most people, and that was, people worked out that that was a good thing that made people, took away a lot of pain and made people tolerate, like, for example, dental procedures and things like that. That was really a big development. And to be fair, nitrous is still in use today. And then there were some really big developments in, you know, there was a series of developments. The big ones obviously were whether or not you were using ether or chloroform. Chloroform became, they both became two of the options for anesthesia in the United Kingdom and America. And around... not similar times about the mid-1800s. And, in fact, there was a very early adoption. I can't remember how many days after the first use in the states of ether. It was used in Launceston, actually, very early on. I think it's in Vincent's from memory. So they were the two anaesthetic gases. Now, chloroform has fallen by the wayside. It's pretty unpleasant. bit toxic. And then over the sort of, I don't know, 160 plus, 170 odd years since then, what's happened is a series of evolutions and developments to improve the quality of the anaesthesia, both from the point of view of the patient experience, as well as from the surgeon or proceduralist experience, and maybe the anaesthetist experience too, to be honest. And to address every step of the way, there's... All these agents, as we've refined and improved them, there's been some sort of problem or limitation with them that, if you like, a new development has sought to address and improve on. So from the ethers, we went to some newer compounds, and we still use, if you like, the grandchildren of the original ether, we still use their halogenated ethers. We use them in practice today, and that makes sense. Yeah, that makes for a better, safer and more pleasant anaesthetic. Look, we might come back to some of the specific agents because I'm sure some of them are going to be interesting. But one of the things that people going into surgery often ask about is in regard to whether they have a local or a general. And a lot of people get attached to having one or the other. Maybe just define what a local anaesthetic is versus a general anaesthetic. And just a couple of situations where you might use one or the other and guide a patient to the best selection there? Well, I think the best way for me to answer that one, Warrick, is you asked me, I think, once, you know, what's more important, the surgeon or proceduralist or the anaesthetist? And I could say quite comfortably I can look at you and say, well, it's the patient. And by addressing, and so basically we've sort of ticked off now the three things that you've got to consider when you're developing an anaesthetic approach. In simple terms, there are patient factors, there are surgeon or surgery factors, and there are anaesthetic factors. And so the anaesthetic plan, the technique of choice starts with a qualified anaesthetist. who makes a thorough assessment of all of those factors and comes up with a plan depending on where you need to go, what your perioperative journey is going to be. And, you know, obviously at one end of a spectrum, small peripheral procedure. that lends itself to having an injection with a local anaesthetic, which is a medicine that's injected adjacent to a nerve or under the skin where the nerves run, and that makes basically the area being supplied by those nerves numb, and it makes them numb for a period of time, usually an hour or a couple of hours. And then there's a range of, if you like, increasing complexities of it. of local anesthetics. You know, a lot of maybe your listeners, maybe some have had cesarean sections and that's local anesthetic. That's often done by a, sorry, that's done by a spinal procedure, which is a small injection. And actually we put the local anesthetic in the fluid that surrounds the spinal cord and that provides really good. from, if you like, the chest down, that these pregnant women are able to have an operation to take their babies out and be aware at the same time. So, you know, there's some really good examples of when you can, that's really what we call a regional technique where we use the local anaesthetic not just to numb a little patch of skin, for example, but we use it to, if you like, anaesthetise or numb a... a whole part of the body in fact in those situations half the body if you like and then there are other procedures which really require if you like that going back to what we were talking about before being asleep being unaware and being pain free and that they're not areas of the body that can be um uh you can put to sleep with an injection either of a under the skin or if you like near the spinal cord um Yeah. Would it be fair to say that surgeries that require you to control the airway would require people to be asleep? So where you're breathing for people, if they're having surgery on the chest or the abdomen, those people need to be... Absolutely. I'd say even further, you know, you could say, you know, neurosurgery and big operations, you know, where you require control, alluded to controlled mechanical ventilation, operations that require, if you like, a degree of muscle paralysis. They're the sorts of things that we, and ones that usually involve the, as you said, the big body cavities, the chest and abdominal pelvis, but not exclusively. And what's really important to know is sometimes we, in fact, increasingly, and it's often. view favourably is to do a bit of both. Oftentimes, for example, I'm thinking of the surgical colleagues I work with. It's pretty common for us to use a local anaesthetic or regional technique combined with a general anaesthetic to improve their anaesthetic before, during and after surgery, in particular to give them some pain relief. And, of course, I really don't want to miss out on the point that, you know, One important category is sometimes anaesthetists are just not doing either of those. Sometimes we're just providing expert sedation, and that's with some monitored anaesthetic care, and that's an important part too. So, you know, anaesthetists, what we do is we assess, you know, we assess those patient surgical and anaesthetic factors and come up with a plan that involves varying levels of those things. One of the things that patients... raise with me is the difference between a local and a general and often they think that a local is safer perhaps and my understanding as a cardiologist is given the same procedure in general terms the risks are pretty similar between a local and a general and um and there's not a huge deal of difference would that be a fair comment in a very general sense I'm going to push back and say that there are definitely some patients who we can safely give some local anaesthetic to for small peripheral procedures. And whereas, if you like, general anaesthesia would expose them to a variety of stresses and risks that might be able to be avoided. Because you're right, general anaesthesia usually will involve some degree of... Airway management will involve some degree of control of breathing. And so there are some patient groups where we actively look to just give them a local, use local anaesthetic if that's acceptable, if that will get you the right result because... For them, it is safer. There's no doubt about it. And it makes sense that, you know, if you could just put an injection under the skin and, you know, if you've just got a little lesion or something, for example, in your skin and just put some local in and it gets, when the surgeon can take that out, well, great. I mean, general anesthesia for well patients is incredibly safe in the modern era. It really is. But, you know, with... Increasingly now, the modern problem for your, if you like, your audience, increasingly is we're dealing, anesthetists now are dealing with, generally we have older patients, which is one issue, and we all know that as one ages, your body systems. aren't as robust as they were when they were younger, and that affects anaesthesia. You're more likely to have acquired illnesses through your life, and they require medications, and so that adds a degree of complexity and risk. And, you know, the optimisation of those is a really important thing, and that's where anaesthetists like to talk to cardiologists. That's pretty important to us. We increasingly are having to deal with those sorts of issues. For some patients, if you like, at extremes of physiology, age or pharmacology, sometimes for them a local anaesthetic with some sedation might be, depending on the procedure, might be a really, really good approach. But there are also too some patients, as you rightly pointed out, that local anaesthesia with or without sedation is not an option, and then you've got to have a safe, well-executed anaesthetic. to get you through. So I get the sense, just in very general terms, that there's a lot hinges on the individual patient together with the requirement of the surgeon or the procedures for whatever needs to be done in combination with the skill set of the anaesthetist. And that sort of makes perfect sense, evaluating each person with their own merits. But with an eye to the time, Sandy, what I'd really like to do is just tease you out a little bit. on how you ended up in anesthesia. But the preamble to that is that we often think of medicine as having such a broad range of specialties that anyone with any personality disorder can find something that suits them. So we might say that surgeons and cardiologists are a little bit type A. We might say that people who do pathology or radiology are very detailed and meticulous. Where would our... Where would we see anaesthetists and how did you do that? I've told you a million times not to exaggerate, Warren. It's all about, and, yes, that is Percy in the background there. Look, there are, and I'll go back a step, medicine is a great vocation and there is something for everyone. And as you rightly point out, we all bring our own. individual character to how we choose, you know. It would be great. I'm sure there's been books written about how, you know, do we choose the vocation or does it choose us? I'm really not sure. If there was a stereotype of an anaesthetist, I'm wondering you might have anaesthetists who listen to this and I'd hate to. get any of them upset because I might be thinking of some of them now, including they might be thinking of me. But, you know, what makes, what do I, I guess the easiest thing is I could say what I enjoy about anaesthesia and that might apply to some of our anaesthetic colleagues. You know, number one, anaesthesia is a, it's a hands-on technical specialty. So, you know, you have to enjoy that part of it. It's quite, There's quite an intellectual component that involves knowledge and understanding of things like physiology, how the body works, and pharmacology, how drugs work. And there's some science to it. You have to understand when you're dealing with... Everything from gases to temperature to fluids to pressure and volume, you do need a bit of a science-y sort of background and have an interest in the physical world. So they're the sorts of things that attract us. And, you know, an exodus may be unfairly, I would suggest, get a reputation as people who don't like talking to patients. You know, we seem to want to put them to sleep. do whatever we do in theatre at that time. I'd say, again, in the modern era, I think you'd find that anaesthetists are very involved in talking to their patients before and after the surgery. And all those sorts of good assessments about safety and quality are really important parts of an anaesthetic. Anaesthetists spend a lot of time talking to their surgeons. We talk to our... Our other physician colleagues who know their patients really well, you know, after a long period of time. So anaesthetists are pretty comfortable with that. So, yeah. So I think, yeah, they're the sorts of things anaesthetists probably get anaesthesia looks for in potential anaesthetists. Well, I'm going to let you off the hook for now. I reckon we've come to the end of our time. I'd love the opportunity to speak with you again because there's still plenty of stuff I'd love to cover, things like tricky patients and your advice for people coming up for surgery and what are the fears and the concerns that you talk people through. So I would love the opportunity to speak with you again, and I'm sure the people listening would love to hear that. For now, though, thanks so much for sharing. Some of the historical stuff is I'm so glad that we're now in the 21st century and not back in the ether and chloroform days. Sandy, thanks so much for joining me. Absolute pleasure. For those listening, thank you for joining me as well. Appreciate your attention. Stay tuned. If you have any queries or questions, of course, drop us a note. Please sign up for the podcast so that you get regular alerts. And of course, as always, please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
