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 welcome to my podcast and videocastation. And today I have the chance for interview number three with Dr. Sandy Zelstein, who is an anaesthetist and a colleague. Welcome, Sandy. How are you? Hello, Warrick. Look, for anyone who may have missed the first two episodes, I really encourage you to go back and have a listen. In the first one, we not only talked about some of the history of anaesthesia, but we also talked about local versus general anaesthetics. In the next episode or the second interview, we covered the difference between elective cases and urgent cases and those in between. And today I'd really like to talk about what patients can do in their lead up to surgery and also cover some of the issues around heart-related matters. Now, I guess one of the questions I had, Sandy, is what would your advice be to an individual patient in terms of... who's coming up to surgery, would you encourage them to seek out an anaesthetist and find someone who seeks them? Or what would be your comments or thoughts or guidance around that? So I guess I can make it easy for your patients and say that, look, almost all the time it's always sorted out for you in many respects, and there's good reasons for that. If you go to the public hospital, obviously, you're not picking. Any of the doctors looking after you when you turn up and there's an anaesthetist on duty and, you know, trainees at various levels, which is great, and, you know, they'll take really good care of you, you know, as part of a big team. In the private sector, which is where I work and these days work exclusively after sort of 25 years or so of public medicine, The way that most patients will meet their anaesthetist is because that's the anaesthetist their surgeon or proceduralist uses. And there are usually good reasons for that because, you know, basically the surgeons and proceduralists put together a team around them. That team includes their scrub team and where they work, which hospitals they choose, and, you know, and it also includes an anaesthetist often they've got long professional relationships with, and the anaesthetists understand the surgeon, they understand the cases, and they understand the patient groups. And so the surgeons have their, if you like, their anaesthetist who's allocated to that list or that session, and the anaesthetist will... provide the patients with care there are some exceptions to that obviously in in the private sector but uh by far and away you know to be honest you're always going to get the best result when uh when you go to your selected surgeon for your procedures for your procedure um you know you're gonna he's got a team and the anesthetist is one of the people on that team and that's usually how you'll meet would uh so this is just a um a nosy question as much as anything, but do the anaesthetists and surgeons who work together, do they tend to have friendships outside of work? Are they close often as friends or is it generally business related or is it a bit of a mix? It can be both. It generally works best if they've got good rapport and a good relationship because communication is really important between them. Communication... when things are going well. And sometimes, you know, patients get into trouble and we have to help them out. And it's important to, you know, good communication helps the surgeon and anaesthetist combination, if you like, keep out of trouble, but also to address any problems that come up from time to time. So good relationships go without saying. Sometimes those relationships, you know, some surgeons, I'm really good mates with them. You know, we don't see each other away from work, but I've also got some surgeons that I've been really lucky to have worked with for years. And, you know, we are good friends and our families catch up and, you know, there's a lot of really... good interpersonal stuff that goes on. And that makes for a lot of trust. You know, that really helps us, I think, get a lot of work done. It's a commitment. In fact, it's a relationship. My wife might despair, but it's a relationship in many respects, not dissimilar to a marriage, you know. And, you know, it lets us look after people best. I can certainly imagine that. the importance of that relationship because the pair of you are caring for that individual patient. They're big stakes. Something goes wrong. They're big stakes. Well, you know, it's like it's almost a, dare I say, and I don't want to get too misty-eyed about it, but there is a sort of sense of family about it, you know, and I think for surgeons too. You know, it's a really big deal for them, you know. And these are patients who come to them looking for their care. And the surgeons are, you know, quite rightly, I think, have some say about who they have, you know, providing the care at the other end of the table. And it's, you know, we've both got, it's very much a shared responsibility. So, you know, I think, you know, the takeaway message, I think. for your audience is that there is a lot of thought and there are good reasons why these guys or these people are working together and, you know, and they're really fortunate to have, you know, these people, these doctors working together. They'll get good results as a consequence. Yeah, good teams, good results. Yeah. One of the things that I wanted to cover was how an individual patient might make the most of their pre-surgical time and that evaluation with you. We've talked about this in the past, and one of my soapboxes is... Yeah, I'm going to jump in here, Warrick. I'm going to say I reckon those patients should turn up with an accurate list of their medications. So that must be a big soapbox I've got because clearly there's room for you to stand on it as well. Yeah, well, I'll just stand at the back, but I'm right there with you, frankly. You know, there's nothing, it's hard. You know, you want to do your best for patients and, you know, someone will come up and, you know, he's, you know. What tablets do you take? Sorry, there's another wrong call coming through. What tablets do you take? I take the little red one. Yeah, exactly. If you know the blue one, I take a half. Do you take it in the morning? Oh, you know, yeah. Do you take it? I can't help someone when they're in that zone. Just for those listening, Sandy, just to fill in the gaps, some of these medications are critical for us to talk about. Some of these tablets thin the blood. Some of these tablets alter blood pressure. Some of these tablets... treat cardiac failure. And you can imagine if we don't know exactly what you're on, the consequence could be disastrous. There's a lot of potential mischief. And one of the things, whenever patients come and see me in my rooms for big operations and so forth, is one of the first things we'll do is we'll sit down and they're actually obliged to bring in our current list of their medications, all their medications with them, so we can make a list. Because also, too, it's a source of great errors. You know, I have to chart their medications when they get admitted. You know, we can't just be making it up. You know, yourself or other colleagues have gone to a lot of trouble over a long period of time to get these patients well stabilised. You know, we don't want that to come adrift during the, you know, particularly important times. So I'm going to emphasise and summarise this. Whatever you do, keep an up-to-date, clear list of exactly what you're taking. on your person at all times. At all times. I had some people say, oh, well, I've got the list on my fridge at home. And I said, well, it's the fridge in your home and I'm in your back pocket. And it isn't. So please, particularly if you've got one of those Webster packs or one of those devices that are issued by the chemist, which allow you documentation of your medication, tear that off and put it in your wallet or your purse. It could save your life. Oh, totally. And just to add to that, Warrick, if I may, you know, if you slip on the wet floor at the supermarket and you get taken into hospital, you may not be in any condition to describe. You may not even be able to tell us it was a blue pill. So having a list of those medicines on you in case of emergency too, really helpful because not all procedures, not all presentations do we have the time to, if you like, ring up someone and find out what was on the fridge at home. Yeah, exactly. So someone who's equally passionate as me about you being responsible for your own medications. Look, so you're going to take your list of medications there. But once you're there, what are the sort of things you'll say to patients to help them get ready for their surgery? Are there any sort of hints or tips? Because often these elective surgeries, they're not too far away. So you can't tell them to lose 10 kilos. You can't tell them to run because they might have an orthopedic procedure. But is there anything? in particular you guide them through with? So I think maybe we'll put it in the category of the red flags, all right, the sort of things that make me go, hang on, hang on, there might be a reason to, you know, stop the relentless progression towards the operation. And what are the red flags? Well, anaesthetic complications, you know, that's an easy one. You know, have you had or been told you had, any major anaesthetic problems. That's a good one to know. Or any difficulties. You know, sometimes patients come to me and one of the first things they do is they've been told, they've been given a letter by a previous anaesthetist and the anaesthetist on it is a colleague who's looked after them before, might eloquently describe some anaesthetic problem. It might be a reaction to the drugs. It might be a difficult airway. It might be... a referral they made to an allergist to have a look at the, you know, like I said, an allergy to one of the anaesthetic agents or a reaction. There's some very specific anaesthetic stuff that we really want to know. You know, at the other end too, there are quality and safety issues, you know, then it may devolve to. Nothing life-threatening but, you know, intractable nausea and vomiting. These are the sort of things anaesthetists are really concerned about because if we don't know about it, we can't steer you away from those issues. So that's a really big red flag. Conversely, if you've had nothing but safe, comfortable, effective anaesthetics in the past, that's a really good starting point and it's really good to know. Other red flags, you know, I think the highest order of things, I think, The patients that I see, and this won't apply to everyone, obviously, diabetes. Are you on medicines that, you know, change, that manage your blood sugars? And that's important. I'll come back to that in a sec. So maybe diabetes are important things. If you've got implanted electrical devices like pacemakers, defibrillators or spinal cord stimulators, these are the sort of things you need to just really want to know about. And medications that thin your blood. That's really important. Usually surgeons pick up on this stuff pretty quickly and they've already addressed all of that. I'll jump in very quickly, Sandy. The reason why diabetes is important is your sugars may drop while you're under anaesthetic. And if no one knows, you have low sugar and that could really cause all sorts of havoc. If you've got devices like pacemakers in the body, then the concern with that is if we're using the electrical diathermy, which are the sort of cutting and coagulating. the little devices are used to stop bleeding while surgery is occurring, they release an electrical impulse and that can confuse your pacemaker and that can cause a mischief. What was the last thing you said? Blood thinners. So if you're on blood thinners and the surgeon hasn't been informed, you can imagine if he's cutting things, you'll bleed. So these are so obvious and practical, but incredibly important. Absolutely. Thank you. Also, too, with that diabetes issue, you know, I'm going to push, you know, we're talking about soapboxes here. I'm going to push a soapbox and a couple of soapboxes of mine alongside yours. You know, there are, let's, I'll just put a personal perspective on it. Patients usually have in their lifetimes a number of procedures and operations. It's not uncommon. So it does make it of interest to me. This is my own personal view. But, you know, I think when patients get started on stuff or have stuff implanted in them, I think it's pretty reasonable to say, and when you come up for surgery in the future, you need to be aware because the surgical process usually involves not just bleeding risk, not just blood pressure, things like fasting. There are some new diabetes medicines which can cause real mischief. In general, diabetes medicines need to be changed when you're fasting. But the fasting process usually means you need to modify or stop some of those diabetes medicines to keep you healthy well and keep your blood sugars and other body chemistry in the safe range. Passion's got to know about that. And I think it's reasonable. you know, I think it's reasonable for patients to have a plan in the event they need to fast. And sometimes the patients need to say, hey, you need to know I'm on these tablets for this condition, right? Because sometimes, like I say, if they come in with an urgent problem, they haven't had time to stop the medicines and things like that. So it's really important to know about that sort of stuff. Blood thinners, as you say, are also in that category. Because sometimes, like I say, there's normally a safe period where if we stop a blood thinner, we know it's going to be out of people's system by the time they come to the surgery. But if they come in for an emergency, that may not be the issue and there may be antidotes or other therapies that they need. So I think there are really important things. You know, the lifetime incidents in the modern era, we do a lot of operating, a lot of procedures. Patients are invariably fasting for them. You know, you've got to be ready for those challenges, and these are good things to talk about with your doctors when you're starting new treatments. You know, it's good to get the full briefing. Look, I'm going to jump in, and again, I'm keeping an eye to the time because, again, the time has flown past. But one of the other things you would look at, particularly for patients over a certain age, and I think your cut-off's maybe 50 or 55, is you get an ECG. And I can remember a... It was a couple of years ago, but a very well-kept man in his, I think it was mid-70s or thereabouts, coming up for an orthopaedic procedure. He'd been wanting this for some time, but when he had his ECG done, it was flagged as abnormal. His heart was racing. It was running at about 150 beats a minute in a chaotic, sorry, in a regular. rapid rhythm that we call atrial flutter. The consequence was that his heart had been driven very quickly for a long period of time. And if you run the heart for too long with a funny rhythm for an extended period, the heart can stop working properly. Well, this guy actually felt not too bad. He didn't describe any symptoms, possibly because his bad hip or knee was stopping him walking. But his heart, instead of contracting and squeezing 60% of its volume with each beat, was squeezing about 20%. Terrible. His heart was barely moving. Yep. As part of an elective surgical assessment, I saw him and obviously cancelled his procedure. We didn't believe how rotten he was on me because he felt fine. Yeah. The consequence was we fixed up his heart, we fixed the rhythm, and six weeks later when we re-imaged his heart, it had gone back to completely normal. That's lovely. Completely normal because we fixed the rate and the rhythm. I've had a very similar thing just recently. Oh, let me finish. So he ended up having his surgery. All went very well. He saw me some months later. Happy? No, still cross at me for cancelling him. I've got a happy patient who turned up for her procedure. and she was in one of those irregular rhythms called atrial fibrillation and she didn't know. And I was able, because it's a fairly benign rhythm and she was tolerating it, and in her situation, given the nature of the surgery, she actually needed to crack on and I was able to do some things to control her heart rate a bit. But I had a big talk to her back then, you know, that pre-op ECG was really helpful. And it was really good. You know, I was able to start some treatment on a very early in conjunction with the cardiologist who I had seen. And I had to talk to her and I said, you know, you've got to understand, you know, if these patients, as you well know, but the audience may not, you know, they may not notice the slow, gentle, steady decrease in their function. And I said, number one, you know, if we get your heart beating better, you might just feel better and enjoy life better. And that might be really good. And then, you know, there were the related issues and I said to her, you know, it's a benign rhythm, but I said, you know, there's a significant stroke risk with this. And so she was very, very grateful, very, very grateful that we picked it and we started some treatment and got her under control and referred her to a very nice cardiologist who was going to sort out the rest of her heart and check it out and actually get her on some treatment to avoid, like I said, to make her feel better and avoid her having a stroke in the future. It's a good idea in my books. She was happy. So, look, we've pretty well run out of time again, Sandy, and that's just a testament to how much fun it is and how quickly the time has flown. I'm going to thank you one more time for joining me today. Thank you. Any time. Always a pleasure, Warrick. I'm going to use the joke that I've been saving up till the last of our... which is it's been an absolute gas sharing with you. Absolute gas for those listening is an anaesthetic joke. I'm going to thank those who've been listening. Thank you for your attention. I really hope you got something out of this series of interviews with Dr. Sandy Zellstein as I did. Sandy, it really has been my privilege to have you share. Thank you so much again. Pleasure. All the best to you and your patients. Thank you. For those who are listening, please sign up to the podcast so we can let you know on a regular basis when these are produced and released. If you have any queries or questions, drop us a note as always. And 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.
