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've got the opportunity to follow up for a second interview with Dr. Sandy Zalstein, who's an anaesthetist and colleague. Hi, Sandy. How are you? Hello, Warrick. Hello, audience. Look, thanks so much for joining me again. We really ran out of time last time, Sandy, and we covered a bit. We covered what an anaesthetic was. We talked about locals and generals. even covered some of the history. And really, there's so much more to cover. And this, I hope, will be an opportunity for us to just tick off on some of those issues that people will possibly have questions about as they come up for surgery. But look, one of the things I was meaning to ask you is how long have you been in the game of anaesthetics? That's a really, it's a good question, Warrick. I guess it depends if you want to count from when I started or when I finished my training and so on and so forth. But given that, I'll, yeah, I'll divulge a few personal truths here. So I went to, I went to, I went to. Sorry, I'll just mention there for those who are listening. Sandy is on call as I'm on call and we're squeezing this in between patients. So that person, as soon as we finish this podcast, sorry, Sandy. Yeah, absolutely. So I was a, I went to Melbourne Uni. I started there in 1988 and I finished there in 93. And a few years after that, I went and got into an anaesthetic training program. I did a couple of years through that and then I diverted off and actually back then I went into an intensive care medicine training program and I went through and I finished that and became an intensive care specialist. And I worked at some intensive care units in regional Australia, as well as in some big metro hospitals, which was great. And by then I actually had really wanted to go back and give some more anaesthetics. And so I went back and actually I finished off some anaesthetic training here in Hobart, where I live now with my wife and kids. So, yeah, it's been a long journey. I've done a few things along the way. I'm proof that you can have a long and interesting career and it still works out okay in the end. So, yeah, these days I've sort of retired from a lot of other things that I've done previously, whether they were hyperbaric medicine at one stage or some retrieval and certainly the intensive care. I'm just happy these days just to. give some good anesthetics and look after my patients, look after the surgeons. So all of us in medicine know that there's a distribution curve, a bell distribution or natural distribution curve where there's average, there's less than average and there's more than average. I think people listening can imagine that. And most of our patients obviously fall in a normal spectrum, but we are constantly confronted. sometimes by some very easy and straightforward things, but I want to focus on the other end, the tricky end. The people who are maybe two standard deviations from the mean, they're harder, maybe they've got bad lungs, maybe they've got bad hearts, maybe they're very much overweight. We would call those bariatric patients. Maybe they have psychiatric issues. And this wouldn't be day to day, but in recent experience, what are some of the biggest challenges you've had, Sandy? Well, biggest challenges ranges. You know, one of the first things that I think anaesthetists look at when we meet a patient, when we have a patient referred to us by a surgeon or proceduralist for their anaesthetic and perioperative care. One of the things we try and assess in the first instance is things like risk. We look at risk. We look at optimization. We look at what we need to provide for, what plan is. There's a big difference between having, say, a bunion operation versus having brain surgery. The journey is very different for those patients. And then we always like to anticipate and avoid any specific pitfalls. In fact, some of the trainees, that's actually how I used to frame it up for when they went for their fellowship exams, used to do our risk optimisation, the plan and the anticipating of pitfalls. So at each one of those levels, we can really sort of, when an anaesthetist does an assessment, they're the sort of things, that we're looking for and trying to address. And, you know, I can think of many cases where I've, through the assessment, and, you know, certainly ones that our colleagues and I, when we reflect on interesting or difficult cases we've been involved with, we've caught out, you know, it's always those issues of have we found a risk? Have we... Have we seen a problem with their optimisation? Was there something unique or special that we needed to provide for? And was there a pitfall that maybe tried to catch us out? So which one of those do you want me to go for first? Well, I'll tell you a quick story which came up for me just the other day. I was called around to the... for a patient who was being prepped in the day of surgery unit. And this patient was going for an orthopaedic procedure. I think it was a hip or a knee. And this particular patient was an older lady who knew, I'm pretty sure, that she had heart-related problems. And the anesthetist had asked me to look in on her because what I want people to understand as they listen to this is that The anaesthetist is constantly looking to make sure people get through the surgery as safely as possible so they're good on the other side. Otherwise, it just doesn't make sense. And so one of your colleagues was good enough to give me a call for this lady. He said, look, this woman looks a bit puffy and she's a bit short of breath and her legs are swollen. And I think she's had an echo. And there being the ultrasound on her heart, I went and checked that up. This lady had valves that were leaking left, right and centre. Her heart was pumping at like 50% or less of what it should have been. I went and saw her. She was short of breath laying in bed with puffy legs up to the knees. And, of course, without the due preparation and opportunity to get her as well as possible, if you like, buffed up before the procedure, I advised her that I was going to cancel her. Now, she was spitting mad at me, actually, and she was adamant she wanted to have a surgery. I said, look, I'm genuinely sorry, but I would just have to say to the anaesthetist, the risk is too great right here, right now, and I don't think we can be held responsible for killing you just because you want to proceed with your surgery today. So it sounds to me like the... I'm going to jump in there. It sounds to me like the issue there is one of optimisation. And when I think of how well patients are optimised, we always do it in the context of, what's the word, how urgent the surgery is. All right, the procedure is. We call planned procedures that happen at a time of your choosing, call them elective. And elective procedures, you know, with those, you're obliged to look for the lowest perioperative risk. You know, you want everything right. You want everything in your favour. You don't want anything, you know, you want the lowest risk profile for that patient. And, you know, there's no reason not to. And they should be – those patients should be beautifully optimised. There should be – that doesn't mean they may not have health issues, but those health issues have been assessed and addressed by the right experts to the right degree. And, you know, we can talk about what that means for your cardiac patients, for example, in general terms. So anaesthetism really – your patients come to see me or one of my colleagues for their anaesthetic assessment, what we want to do is, like I was saying before, is one of those things is we're looking at the degree of optimisation. Now, how does an anaesthetist get involved in optimisation? Well, number one is the surgery may not be elective. It may be emergency. They may be, for example, a trauma patient or, you know, and the sort of optimisation those patients get we call resuscitation. It happens really quickly. It happens then and there, and that might involve giving them blood, giving them fluid, giving them medications, putting in appropriate intravenous access. The sort of optimisation we do there is also too involved in making sure they're getting to theatre at the right time. the right way for the right care by the right person with the right equipment and so on and so forth. And anaesthetists play a big part in facilitating that. We facilitate that care. And that's really hyper-acute sort of optimisation. And I think anaesthetists are vital, are critical in that. In fact, many times we're the ones driving that process, together with the surgeons, obviously, and our emergency colleagues and all the nurses and supporters. There's another sort of optimization, which is the one where, you know, a patient might come for me for an elective operation and I say, you know what, you're not the best in this and that. Why don't we go? And I'm just thinking of a case just this last week. I really want to, I want to speak to your cardiologist. I want to speak to your respiratory physician. I'm not happy. You're not happy. Maybe you should go and see them again. Maybe we just need that clarification, that certainty, right? Or there's a new problem of you've been getting increasingly short of breath and no one's ever looked at it. It's time to have a look at it, all right? And we have time. The surgery, for example, it may not be particularly time critical. So we have time to get this sorted out and identified. And that might be as simple as, for example, a patient, for example, with what you suspect might be uncontrolled, assessed and unmanaged sleep apnea, obstructive sleep apnea. And why don't you go see a respiratory physician, get your sleep study, have a talk to your GP and the other doctors about your weight and your other health issues related to the things that are driving your sleep apnea or as a consequence of it, go and see, get that sorted out and we'll get you back and we'll get you as well as you can be. And when you're established on the right sort of medications or treatment, we'll proceed safely to your surgery. And then there's an intermediate group, which are the patients in whom, if you like, they're maybe, for example, they're in hospital and we only have a little bit of time. But we do have a little bit of time and we've got to, you know, and the anaesthetist might want to come and sort out those acute issues together with all the doctors looking after you. And that might be simple things like stopping your blood thinners, getting your, you know, there's a whole range of things there that. anaesthetists need to be involved, like I said, to make sure, together with all the other doctors and clinicians looking after you, that allowing for the urgency of your surgery, that you are in the best shape for the best outcome. Look, from a practical perspective, there's not a lot of time in that acute situation where it's life and death and you're literally resuscitating someone to get them to surgery. a life-saving procedure. There's little wriggle room and obviously you guys just have to grab the ball and run with it as best as you possibly can. I'm going to touch on the other end because I think not only the optimisation opportunity in elective surgery is important, but in my own experience, what I think is incredibly important and often not considered with the weight it deserves is a very clear discussion around the risk benefit of the procedure for the individual. And one of the things that I really try and make a point of these days as part of that optimization, for example, to get someone as well as possible for a procedure that you'll be guiding them through with their surgeon is to let that person know about the risks and benefits inherent. Because you and I both know we don't live in a zero risk world anymore. And unless we're educating patients around that and letting them know we're giving them the best opportunity and really engaging with them in that, I don't think they're emotionally prepared and nor are their families if things go wrong. And fortunately, uncommon for things to go wrong these days. But I think that that communication and that understanding is. is critical in what we do, actually. Well, I completely agree. I think, you know, the surgeons are really good at consenting their patients. And I, you know, in my practice, I quite enjoy or I find it very valuable when the patients come to see me they've already been planned. And I'll often spend a moment saying so just to go through, you know, to reiterate and reflect on. what they understood, what they took away from the surgical consultation, the consent process with them from their point of view. And then that's a nice segue for me to talk about the specific anaesthetic side of things. And so that is very important. I mean, and it's really nice, you know, they do, the patients that are... The surgeons I work with are very good at educating their patients about what the expectations are, the benefits, the risks, the alternatives, the option of not having the procedure, for example. They're really good at that. And the surgeons come in well-informed to their satisfaction and they understand those factors. And then it's over to me to tell them from an anaesthetic-specific point of view exactly that, what I'm going to do. and what I'm going to do and what I expect the outcomes of those to be and what the downsides are and where the options are. They talk a lot about what's called shared decision-making. And I'm a believer in it. You want the patients to be involved as much as they can be in acting on their behalf. You know, I think there are some things that are maybe not negotiable. You know, if I'm going to put you to sleep, I have to manage a rare one. There's not a lot of wiggle room there. But, you know, they have to understand that going to sleep, you know, it's a bundle and maybe sometimes it's not a lot of – it's not a menu sometimes, you know. But in terms of that entry point is do they – don't they have things done? You know, I never – I don't force people to have stuff. You know, we want the patients to understand what we're doing, why it's in their best interest or to their benefit and how it fits in with their overall care and their goals, both short-term, long-term. I think that's really important, you know, and it makes me feel good when I see that reflected in the patients. And I think at the very least, not only is it, you know, not only is it a professional obligation on my part, but I think it's really, you know, it's not, you know, we want the care for the patients. treated like our family, our loved ones. You know, we want them to give them that same standard of care. And part of that is giving them knowledge, giving them autonomy wherever possible, you know, giving them options, giving them control, and reducing their anxiety about it, you know. Even, Sandy, giving them education like this. So I really hope that people who maybe come out for surgery get, to listen to a podcast like this and realise that guys like you and I and our colleagues take this stuff incredibly seriously. We really do. We're on their side, actually, very much. And, you know, I think you asked, you know, I think we've previously talked about why do people become anaesthetists and why do they become cardiologists? We actually like looking after people, you know. That's a big part of it, I think. We actually like looking after people. I genuinely want to see people live as well as possible for as long as possible and everything forms around that premise. Look, unfortunately, the time has just disappeared again. I am going to wind it up, but I get the sense there's still lots of stuff to cover. I was very interested in talking about some of the cardiac issues around anesthetics. And if you can find the time to share with me about that, I'm sure some of the people listening would be interested. But for now, Sandy, thank you so much for joining me. Absolute pleasure. For those listening, I really hope you got something out of that. The differentiation between acute, elective and subacute optimisation of patient care, which is really getting people as fit as possible to get them through their procedures as safely as possible. Honestly, you wouldn't believe the team that... behind your surgeon wanting you to have the best outcome. I'm going to wish you all the very best. If you have any queries or questions, there is a line, drop us a line. I'm going to encourage you to sign up for the podcast so you don't miss out on any. And of course, till next time, 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.
