If you are interested in or have questions about anesthesia, whether you are a patient, the loved one of a patient, or a medical professional, you will find Dr. Friedberg’s insights interesting and useful.

We welcome your questions and invite you to submit them on the Contact Us Page.

Steven Shafer on Conrad Murray & propofol… today in court

While Dr. Steven Shafer attempted to explain to the jury what the terms ‘pharmaco-mechanics,’ & ‘pharmaco-kinetics’ meant, I could not help thinking what utter nonsense these areas are relative to what really matters to you, the patient, in general and Michael Jackson, the victim, in particular.

Direct brain measurement devices, like the bispectral (BIS) index, have been FDA approved for 15 years & validated in over 3500 published scientific studies.

Anesthesia is medicine given to your brain.

Unlike TEE (transesophageal echocardiography), BIS monitoring does not earn the anesthesiologist in the OR any extra money on a case by case basis.

The hospital views the use of the $20 disposable BIS sensor as a non-recoverable loss because there is no billing code for it.

There is no billing code for the sensor because universal brain monitoring would result in a 30% loss of drug sales to the companies who also supply the American Society of Anesthesiologists (ASA) with millions of dollars in various forms of support.

Expecting the ASA endorse universal brain monitoring would be asking them to threaten their financial viability.

Only you, the patient, are left to deal with the long term effects of your short term anesthesia care.

Those long term effects include delirium or postoperative cognitive dysfunction (POCD) that can last up to a year, dementia that never goes away and one patient anesthesia over-medication death DAILY.

The model for change is the same one that ultimately got fathers in the delivery rooms. Public awareness leading to public demand!

Having surgery under anesthesia without a brain monitor is like playing Russian roulette with your mind.

Download 3 free letters to save your mind & your life @ www.drbarryfriedberg.com


RE: Perhaps you are getting a better picture of just how hard it is to get my message out to the public.

Hi Barry,

Thank you for keeping me posted in your quest to inform the public of the dangers inherent in “going under.”

I watched with interest your interview; it made complete sense. The interviewer found it interesting and insightful as well. I believe you did more good than you will ever know. You have certainly opened my eyes.

As for the L.A. Times article about HLN that essentially belittles your effort to awaken the public to the dangers of anesthesia by referring to you as “a white robed man describing himself as an anesthesiologist dragging a rolling IV bag around campaigning for better sedation monitoring” I don’t think it understands the disservice it did.

I admire your courage and encourage you to keep up the good and necessary endeavor. Now, whenever I speak with anyone about to have surgery I tell them to Google your name and learn of the dangers in the anesthesia itself, as well as the surgery they are about to undergo.

Thanks,
Robert


Just in from ‘The Telegraph’ of London

The querulous parties are temporarily silenced by the arrival of a white-haired man in his hospital scrubs, a heart monitor under his arm. Dr Barry Friedberg, a renowned anaesthetist, hands out leaflets to the perplexed onlookers, and proceeds to explain the reason for his visit.

“It’s not the Propofol that killed Michael Jackson, it’s the unsafe Dr Murray,” he said. “There’s no lethal dose of Propofol, there’s a lethal failure to intervene when breathing is inadequate.” A self-professed “Propofol expert” who champions the use of a brain monitor with anaesthesia for optimum safety, Dr Friedberg insists Jackson’s alleged drug dependencies are irrelevant in the case against Dr Murray.


Pain: an ounce of prevention is worth a ton of cure

re: Tara Parker-Pope ‘Giving Chronic Pain Medical Platform of its Own’

http://community.nytimes.com/comments/well.blogs.nytimes.com/2011/07/18/giving-chronic-pain-a-medical-platform-of-its-own/

As a 34 year practicing, board certified anesthesiologist, I found the ‘ounce of prevention’ for postoperative pain in the fall of 1992.

Since I work exclusively in the world of elective cosmetic surgery, my anesthesia colleagues have been quick to dismiss my ‘nifty fifty’ paradigm shift as only being applicable to this type of surgery.

The ‘nifty fifty’ is 50 milligrams of ketamine 3 minutes prior to surgical stimulation.

In 1997, I added the BIS monitor to my propofol ketamine regimen, thereby creating a numerically reproducible level of propofol to effect to reliably prevent ketamine hallucinations.

Since that time, none of my several thousand patients have taken opioids for postoperative pain.

Disclaimer: Neither I nor my non-profit Goldilocks Anesthesia Foundation receive financial support from the makers of the BIS or other brain monitors.

Despite years of encouragement, I have not found a single academic university department of anesthesia willing to formally study this extremely simple paradigm. Shame on them.

Not until I personally received the benefit of the ‘nifty fifty’ preemptive analgesia for my total hip replacement have I been able to refute my fellow anesthesiologists’ assumption that it is only useful for cosmetic surgery.

see comment #20 to Tara Parker-Pope ‘When Pain Goes Beyond Words’

http://well.blogs.nytimes.com/2009/09/22/when-pain-goes-beyond-words/

Goldilocks anesthesia is BIS monitored propofol ketamine. Since your brain dictates the anesthesia dosage, you cannot get too much or too little, but only just the right amount.

Over the $20 sensor, don’t let anyone play Russian roulette with your brain when having surgery.

75% of US hospitals have the BIS monitor, yet it is only used 25% of the time.

Avoid routine anesthesia over medication by insisting on a brain monitor.

Download 3 free letters from www.drbarryfriedberg.com to help you get Goldilocks Anesthesia for any surgery.


The anesthesia dementia link

Denverpost.com 07/13/2011

Q: My 77-year-old mother recently had knee-replacement surgery and now is suffering from some form of dementia. She asks the same questions over and over. She had small memory problems before, but nothing like this. Did her surgery cause something to happen to her brain? — Denise, via e-mail

Re: Patient with aggravated dementia after anesthesia

Anesthesia is given without using a brain monitor guarantees the dose of anesthesia must be greater than that thought necessary for fear of under medication.

A brain monitor like BIS directly measures the anesthetic effect on the brain. 75% of US hospitals have this equipment yet it is only being used 25% of the time.

Goldilocks anesthesia is never too much or too little but always just the right amount because it is your direct brain response dictating to the anesthesiologist exactly how much anesthesia you need not to hear, feel or remember your surgery.

No one, especially those over 50, should ever have anesthesia for surgery without a brain monitor.

Download 3 free letters @ www.drbarryfriedberg.com to make sure you get Goldilocks anesthesia & that your anesthesiologist does not play Russian roulette with your brain while you are having surgery.


Thirty-four years ago today…

July 5, 1977, at Mt. Diablo Hospital in Concord, California, I stood ready to give my first anesthetic in private practice.

Several years earlier, on the very first day of his residency, on his first case, one of the Stanford residents had a child die from malignant hyperthermia (MH). (The antidote, Dantrolene, was not introduced until many years later.)

This unlucky resident’s liability insurance carrier even tried (but failed) to rate his private practice policy based on this hugely unfortunate experience.

My good fortune was to have started and finished my Stanford residency without ever seeing an MH case. However, I was hoping to get through my first private practice case without any such bad luck, too.

There I stood awaiting the arrival of plastic surgeon, Hale Tolleth, M.D. He was an hour late…

He introduced himself to me then explained the facial surgery case would take the whole day, but he did not want me to intubate the patient, ‘just’ sedate her.

There I was, prepared to anesthetize any cardiac case including a transplant but was being asked to provide a service about which I knew nothing.

During my residency, I had given intravenous sedation for cases as long as 45 minutes, typically with diazepam and meperidine.

I had never heard, read about, or had presented a ‘game plan’ of sedation for an 8 hour case.

Welcome to private practice, Dr. Friedberg, I thought.

After giving the problem some consideration, I guessed at what might provide the conditions for which my surgeon asked.

I took a 500cc bottle of saline, injected 500 mg thiopental and 100 mg meperidine, spiked the bottle with a 60 drop per cc set, gave some nasal oxygen & proceeded to titrate the patient.

She was in a semi-sitting position. The surgeon must have been very good with local anesthesia because I have no recollection of the patient moving or him re-injecting.

Another unique moment happened about half way through the case. Tolleth looked over to me and asked what I would like for lunch. I thought surely he must be teasing me. Having lunch was never a consideration during my 2-year residency.

I thought I would return the tease saying ‘lox and bagel would be just fine.’ To my astonishment, the surgeon told the nurse to fill my request and bring him his ‘usual.’

About 30 minutes later, in came the nurse with both lunch orders. My surgeon removed his gloves and we sat down and ate our lunch.

Never in the ensuing 34 years have I had such an experience.

Never lost the airway through the entire facelift, etc. case.

Needless to say, though, the patient was so hung over at the case’s end, she spent the night in the hospital. In 1977, no one thought it was an odd outcome after an 8-hour surgery.

However, I thought it would be really wonderful to have a drug that would go away after a case like that. Propofol was not introduced until 1989. We had no pulse oximeter until 1984.

As I think back over the triumphs and disasters through which I have persevered, I would have surely been incredulous if anyone would have told me I would author not one, but two books, receive a US Congressional award as recognition for contributing to the anesthesia safety of wounded troops in the forward units and create a non-profit foundation to promote patient awareness of the critical need for brain monitoring during anesthesia.

As the song goes, “What a long strange trip it’s been.”

Thank you for sharing this moment in history with me.


facebook posting

http://www.facebook.com/pages/Cosmetic-Surgical-Arts-Center/15199267983?sk=wall

Cosmetic Surgical Arts Center

Dr. Friedberg demonstrated his anesthesia technique with the BIS monitor today in our clinic. A breast reduction with augmentation and an arm lift was performed without narcotics or general anesthesia – a first in our clinic. She was awake and asking questions before the drapes were down.

We were thoroughly impressed with Dr. Friedberg’s commitment to patient safety and welcome him back in the future.

About Dr. Barry L. Friedberg, MD | Dr. Barry Friedberg – Cosmetic Surgery Anesthesia1

drfriedberg.com


21st century anesthesia standard of care comes to Newport Beach, CA

Just heard from my pal who’s brother is being operated upon this April 2011 at Hoag Hospital in Newport Beach.

When the nurse came from the OR to talk to my pal, she told him all the anesthesiologists are using the BIS monitor on every case!

HALLELUJAH!!! Finally, the 21st century standard of care is being employed.

Maybe my efforts have finally paid off or maybe it was this tidbit:

In the April 11, 2011 issue of “Current Opinion in Anesthesiology,” they conclude: “Given the trivial cost of the BIS (brain monitor) and the proven benefits demonstrated in prospective randomized studies, we consider its use justified in every general anesthetic.”

As the Orange County anesthesiologist who first routinely used the BIS in December 1997, I am pleased for all patients, especially me should I be so unfortunate to be taken in for emergency surgery.

I would imagine their recovery room activities, along with the hospital’s bottom line, have been improved.

Now if they would only give the nifty fifty – 50 mg ketamine 3 minutes prior to incision, they could also dramatically improve postop analgesia.

Friedberg’s Triad

I. Measure the brain…no BIS lower than 45 with General Anesthesia

Hint #1: trend EMG as secondary trace

Hint #2: respond to EMG spikes as if they were heart rate or blood pressure changes

II. Preempt the pain…the ‘nifty 50’ – adult patients rx 50 mg ketamine 3 min prior to stimulation

Hint #3: Number of adult NMDA receptors independent of body wt

III. Emetic drugs abstain…no narcotics (opioids) or stinky gases (iso-, des- or sevo-flurane)

Hint #4: stinky gases are also oxidizing agents

Hint #5: BIS/EMG monitored propofol ketamine not just for cosmetic surgery

Here is orthopedic anesthesia specialist, Dr. Parson’s one-take, unrehearsed testimonial:

http://www.youtube.com/user/narkose3535?feature=mhum#p/a/u/1/r6O-stIHlgo


19 years and counting…

Today is the 19th anniversary of my first propofol ketamine anesthetic that was given at a Newport Beach plastic surgeon’s office!

Propofol ketamine is the ‘lemonade’ I made from Martha’s ‘lemon’ or avoidable demise.

Had it not been for this plastic surgeon’s refusing to allow me to use narcotics or smelly gases, I would have never been motivated to find an alternative anesthetic paradigm.

Little did I know, 19 years ago, how dramatically for the better that motivation would change the lives of my patients as well as my professional life.

Louis Pasteur said, ‘Luck favors only the prepared mind.’

So when I heard Charles Vinnik talk about Valium-ketamine anesthesia @ the Hyatt Newporter in December 1991, I was ‘prepared’ to seek an alternative.

My first insight was finding that sleep doses of propofol blocked ketamine hallucinations every bit as well as Vinnik’s Valium.

Later, once I saw that giving 50 mg ketamine (aka the ‘nifty fifty’) before injecting the patient would prevent surgeons from inflicting pain on their unconscious, helpless patients, it became a matter of conscience to no longer give narcotics or smelly gases for cosmetic surgery.

Incorporating the brain monitor in December 1997 allowed others to reproducibly create my paradigm as well as giving every patient a custom tailored experience as opposed to ‘one size fits most’ anesthesia.

However, it was not until I experienced the absence of pain for 4 days after my own total hip replacement in May 2008 that I realized the ‘nifty fifty’ was applicable to any time the skin is breached for surgery.

While writing ‘Getting Over Going Under’ to help the general public deal with anesthesia fears, Michael Jackson died from unsafe propofol administration. I knew that I needed to add comment about his avoidable death to my book.

Brain monitoring would have enabled Conrad Murray to tell the difference between the benzodiazepine and propofol effect in Michael Jackson’s body. Jackson would still be alive today had this monitoring been used on him.

Brain monitoring is the 21st century standard for anesthesia care & propofol ketamine is the safest anesthetic.