Goldilocks Anesthesia Foundation

The National Health Federation
http://www.thenhf.com/articles/articles_1120/articles_1120.htm

Anesthesiologist Warns of Fatal Dangers Of Going Under
What EVERY Patient Should Know Before Surgery

By Dr. Barry Friedberg
April 22, 2010

“A lot of people wake up from surgery not quite the same person they were before they went under because of the overuse of anesthetic drugs,” said Dr. Friedberg, a board certified anesthesiologist who has been quoted in numerous medical journals and anesthesia textbooks . He has formed a not-for-profit foundation, called the Goldilocks Anesthesia Foundation, (www.goldilocksanesthesiafoundation.org) specifically to ask patients to request their anesthesiologists use a brain monitor during surgery. “When we watch a TV show like House or walk through a hospital, we just see a bunch of equipment and monitors, so most people figure that something as logical as a brain monitor would be in use when doctors use general anesthesia. But they aren’t in widespread use at all, and many patients don’t realize they can ask their anesthesiologist to use one. And they should if they want to stay alive and healthy.”

According to the U.S. Department of Health and Human Services, an estimated 53.3 million surgical and nonsurgical procedures are performed during 34.7 million ambulatory surgery visits each year.

“That’s a lot of surgery, and a lot of people being put under general anesthesia without knowing all the risks,” Dr. Friedberg said. “Without a brain monitor, anesthesiology is not an exact science. So most doctors figure it is better to give the patient more than they need in order to make sure they don’t wake up during the operation. Of course, no one in the healthcare food chain is opposed to using more drugs, as that is a large part of the revenue stream. With a brain monitor, each patient becomes an open book test instead of a mystery to be solved. Doctors would be able to use a more exact dosage, use less drugs and be safer. Instead of using too little or too much, they’d use a dosage that is just right, hence my reference to Goldilocks with my foundation.”

The risks of being over-anesthetized are many, including long term dementia, memory loss and even death, according to Dr. Friedberg. He added that not enough research has truly been done on anesthesia overdosing, because without widespread use of brain monitors during surgery, there is no way to really pinpoint whether anesthesia is statistically a culprit. That’s why Dr. Friedberg urges all patients to ask if their anesthesiologist uses a brain monitor at the time the surgery is scheduled, and to ask for a different anesthesiologist if the one assigned to them doesn’t use one.

Dr. Friedberg‘s message seems simple and prudent enough, but it has not been adopted by his profession, nor by the healthcare industry, because the major players don’t make much money from its use.

“Some hospitals don’t even have billing codes for the use of a brain monitor, and the pharmaceutical companies sponsoring all the junkets for doctors aren’t fond of them, because they invariably result in the use of lower dosages of the drugs they sell,” Dr. Friedberg added. “I don’t make any money from trying to spread this message. I don’t have a secret deal with the monitor manufacturers and I don’t have an axe to grind with the drug companies. In fact, my crusade has cost me professional relationships as well as money out of my own pocket to promote it. I am just tired of the primary task of my profession being not to kill patients. Instead, we should focus on caring for the patients, and understanding the long term risks of overmedicating patients while in surgery. We should be using every tool available to keep them healthy and reduce unnecessary risks through the entire treatment process.”

About Dr. Barry Friedberg

A native of southeastern Pennsylvania, Barry L. Friedberg, MD, came to Palo Alto, California in 1975 to complete his formal education with an anesthesia residency at Stanford University with department chief C. Philip Larson, Jr, MD. Following the successful completion of his residency and the requirements of the American Board of Anesthesiology, Dr. Friedberg became a Board Certified (or Diplomate) Anesthesiologist in April 1980. He has also lectured on safer, simpler, cost-effective and better patient outcomes to anesthesiologists and surgeons in the United States, Canada, Mexico, the Dominican Republic, Israel and Venezuela.

The ‘Establishment’ Strikes Back at Goldilocks anesthesia

Two years following publication of the groundbreaking textbook, Anesthesia in Cosmetic Surgery, ‘the establishment’ countered with Patient Safety in Plastic Surgery.

‘The establishment’ refers to the organized societies for plastic surgery and anesthesia – the American Society for Aesthetic Plastic Surgery (ASAPS), the American Society for Plastic Surgery (ASPS), and the American Society of Anesthesiologists (ASA).

Patient Safety in Plastic Surgery was recently reviewed in April 2010 Anesthesia & Analgesia. Edited by a plastic surgeon and an anesthesiologist, the book compiles 582 pages without a single reference to any of the numerous, earlier brain monitored propofol ketamine (PK) or Goldilocks anesthesia publications.

Particularly disappointing was the chapter ‘Managing Postoperative Nausea and Vomiting (PONV).’ Neither chapter author in Patient Safety in Plastic Surgery has previously published their PONV work in the prestigious New England Journal of Medicine (NEJM).

While citing Christian Apfel’s landmark PONV risk NEJM paper in the Patient Safety in Plastic Surgery PONV chapter, the authors managed to successfully avoid Apfel’s recommendations for solving the problem:

i.e. don’t give emetogenic anesthetics (stinky gases or iv narcotics) and do give PK for the optimal PONV outcomes, citing

Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five-year review of 1,264 cases. Aesthetic Plastic Surgery 23:70-74, 1999.

In the current edition of anesthesiology’s number one textbook, Miller’s Anesthesia, Apfel also asserts if emetogenic agents are used that the use of anti-emetics is of limited utility.

The Patient Safety in Plastic Surgery PONV chapter authors assert the “overall rate of PONV to be at 20-30%,” successfully ignoring the above mentioned 1999 paper with lowest published PONV rate in the anesthesia literature at 0.6% in a high PONV risk patient group without the use of anti-emetics.

Not surprisingly, the chapter authors’ conclusion states: “PONV is a major problem for patients undergoing plastic surgery.”

Can there be any doubt about the political strategy that motivated the writing of this chapter? How do intellectually honest authors ignore a decade of Goldilocks anesthesia having solved the PONV problem?

The answer may also be painfully honest.

The PONV information contained in Patient Safety in Plastic Surgery is a ‘regurgitation’ of the standard university teaching that ignores the accomplishments of the real world anesthesiologists and plastic surgeons that have followed the previously published Goldilocks anesthesia paradigm and solved the PONV problem without the need for anti-emetics.

There is also a complete absence of any reference to brain monitoring in Patient Safety in Plastic Surgery. Brain monitoring is a critical component of Goldilocks anesthesia.

Brain monitoring creates a numerically reproducible basis upon which PK anesthesia can deliver a 0.6% PONV rate while essentially eliminating postoperative pain requiring narcotic therapy.

Brain monitoring also eliminates the nefarious anesthesia practice of routinely over medicating patients for fear of under medicating them.

Perhaps the authors felt that further study of brain monitors was needed. However, more than 3,000 scientific papers have already been published validating the use of brain monitors to provide information not obtainable from vital signs and body weight indices of anesthetic response.

If PONV issue weren’t bad enough, the authors manage to write Patient Safety in Plastic Surgery while ignoring recent general anesthesia related deaths like that of Donde West and Stephanie Kuleba and simultaneously also ignoring the stellar safety record of Goldilocks anesthesia; i.e. no deaths, pulmonary emboli, hospital admissions for PONV or pain management, or airway disasters like aspiration and wrong site intubation.

The chapter about pulmonary embolism prevention also ignores the 2004 advice of a major medical liability carrier; namely

“The use of general anesthesia for long plastic procedures is a subject of current debate. While some authors laud its advantages, others caution that the immobility associated with general anesthesia is a significant risk factor for thromboembolism. Newer techniques for intravenous sedation that include the use of propofol drips, often in combination with other drugs, have made it possible to perform lengthy or extensive surgeries without general anesthesia and without the loss of the patient’s airway protective reflexes.11”

Reference 11 is also the same 1999 paper Apfel references in Miller’s Anesthesia – Friedberg’s 1999 PK paper.

The editors of Patient Safety in Plastic Surgery did not appear interested in providing a dispassionate, objective assessment of patient safety in plastic surgery. Instead, the interest is clearly is providing the anesthesia and plastic surgery establishments a ‘book level’ rebuttal to the cutting edge safety of Goldilocks anesthesia presented in Anesthesia in Cosmetic Surgery.

Let the unsuspecting reader of Patient Safety in Plastic Surgery be advised.

Yesterday, I had a few email exchanges with Dr. Harvey Rosenbaum, director of anesthesia resident education @ UCLA. I told him I was planning to attend Anesthesia Grand Rounds this coming Wednesday because the topic, Delirium: risk factors, potential mechanisms, prevention and treatment, was of great interest to me.

Without any admonition from Dr. Rosenbaum (or anyone else in his department), at 09:40 April 5, 2010, I received the following communication from the Director of Security Services @ UCLA:

Dr. Friedberg

Hello sir

I wanted to reach out to you about your upcoming unauthorized visit to UCLA Ronald Reagan Medical Center on April 7th, 2010. I have seen in the communications that you are not invited to speak or attend. I understand that wish to present some information, but the administration of the hospital is advising you not to attend. Please, do not attend the meeting. If you do so, you will be in violation of California Penal Code 602 (Trespassing). I will have you arrested and removed from the facility.

If you have any questions, please feel free to contact me.

Daniel Schmidt
Administrative and Operations Manager, Security Services
UCLA Health System
310-267-7106 Office
310-597-1640 Cell
757 Westwood Blvd., #B641
Los Angeles, CA 90095

To which I responded:

Dear Mr. Schmidt,

Re: Anesthesia Grand Rounds

Are UCLA Anesthesia Grand Rounds by invitation only?

If so, what are the criteria for such an invitation?

Will attendees have been issued such an invitation?

Are any and all board certified anesthesiologists not welcome?

Is UCLA not a public educational institution supported by California taxpayers, among whom I am one?

Is it the official policy of the UCLA is that I, as a board certified anesthesiologist interested in pursuing my continuing medical education as required by the State of California, will be denied access to attending Anesthesia Grand Rounds otherwise open to members of the physician community?

I would appreciate an immediate response to my questions.

Barry L. Friedberg, M.D.

Diplomate, American Board of Anesthesiology

CA. Medical License # G-29706

1-949-233-8845

cc: Steve Silvertstein, attorney at law

Russ Stanton, editor, Los Angeles Times

Board of Regents

So far, no response from the halls of academic freedom. Is academic freedom only for academics?

Google search for ‘American Society of Anesthesiologists’ yields 595,000 sites

Google search for ‘Barry Friedberg MD’ yields 798,000 sites

Google search for ‘Cosmetic Surgery Anesthesia’ yields 2,200,000 sites

www.drfriedberg.com is the #1 unsponsored site

Google search for PK Anesthesia yields 1,500,000 sites

www.drfriedberg.com is the #1 unsponsored site

What does this mean?

Maybe only that Semmelweis did not have the Internet but I do.

While most of the country is freezing, my new bride and I made a return to the North Shore of Oahu for honeymoon 1.2 in balmy 80 degree weather.

We were here last month, but as luck would have it, Shelley was sick with that nasty coughing virus that’s been going around. She is feeling better this trip but still recovering.

While we were here in December for honeymoon 1.1, at the invitation of chairman Dr. Don Parsa, I gave a talk to the plastic surgeons at Queens Medical Center. He was so pleased by the content (& delivery) of the talk, ‘What killed Michael Jackson & how to make office anesthesia as safe as possible,’ that he invited me back this month to speak to the Biennial meeting of the Pan Pacific Surgery society on Tuesday, Jan. 12th.

I was also interviewed for Dr. Denise Davis’ radio show in Cincinnati for an hour long show this morning while watching the fabulous surf roll in at Turtle Bay Resort.

Instead of continuing to ‘bang my head against the wall’ of a largely indifferent anesthesia establishment, I am finding greater pleasure going where people are at least open to the idea of patient-centered ‘Goldilocks’ anesthesia – that which is not too much, not too little but always just right because it is driven by the individual patient’s brain response.

I am confident that ‘Goldilocks’ is no fairy tale.

The forces of reactionaryism can only prevail for so long in the face of a cost-effective, simpler, safer anesthetic that yields demonstrably better outcomes.

Measure the brain

Preempt the pain

Emetic drugs abstain

Aloha!

Recent submission to Anesthesia & Analgesia:

PONV – Peter Obviously Not Victorious

Apfel’s Advice Unheeded

Peter Glass’ upcoming editorial (1) appears to ignore sage advice from Apfel. (2) Avoid emetogenic agents; i.e. inhalational anestehtics and opioids and embrace propofol ketamine paradigm. (3)

References:

1. Glass’ PSA: Postoperative nausea and vomiting. We don’t know everything yet. Anesth Analg 2010;2, 110.

2. Apfel CC: Postoperative Nausea and Vomiting chapter in Miller’s Anesthesia, 7th ed. Philadelphia, PA Elsevier 2010; p.2743.

3. Friedberg BL: Propofol ketamine technique, dissociative anesthesia for office-based surgery: a five-year review of 1,264 cases. Aessth Plast Surg 1999;23: 70-74.

received the following response:

Dec 30, 2009, at 09:11 AM, A&A Editorial Office wrote:

Dear Dr. Friedberg:

As explained in Dr. Shafer’s letter of February 2009, Anesthesia & Analgesia will not consider your submissions.

Editorial Office

Anesthesia & Analgesia

I responded with the following:

Great men discuss ideas

Average men discuss events

Small men discuss other men

Open minds? Let my readers decide for themselves.

PONV – Peter Obviously Not Victorious, Apfel’s Advice Unheeded

Glass’ upcoming editorial (1) appears to ignore sage advice from Apfel. (2) Avoid emetogenic anesthetics, i.e. inhalational anesthetics and opioids and embrace propofol ketamine paradigm. (3).

References

1. Glass PSA: Postoperative nausea and vomiting: We don’t know everything yet. (editorial) Anes Analg 2010;2: 110.

2. Apfel CC: Postoperative Nausea and Vomiting chapter in Miller’s Anesthesia, 7th ed. Philadelphia, PA, Elsevier 2010; p 2743.

3. Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five-year review of 1,264 cases. Aesth Plast Surg 1999;23: 70-74.

It’s obvious to all, if one wants to keep one’s horses, close the barn door before they depart, not afterwards. It should be equally obvious for the issue of control of postoperative pain. Far better to prevent it from occurring than to treat it after it happens.

Why should anyone care about the 50 mg ketamine I received for my THR in addition to my SAB with BIS monitored IV propofol sedation?

Every anesthesiologist with whom I shared my story asked the same question of me:

What could the ketamine possibly add to that anesthetic?

I purposely went to a Southern California hospital (St. John’s in Santa Monica) to have an internationally reknowned surgeon perform my surgery to be confident there was a large volume of previous THRs (5,000) with which to compare my care.

As many of you already know, for the past 17 years (& 5,000 patients), I have been giving 50 mg ketamine 3 minutes PRIOR to the stimulation of the injection of local anesthetic to the surgical field for elective cosmetic surgery AND reporting minimal postop pain with unprecedented PONV rates (0.6%) WITHOUT anti-emetics in high risk patient population (i.e. non-smoking females with high incidences of previous PONV +/or motion sickness having emetogenic cosmetic surgery – 4 out of 4 Apfel risk factors).

Understandably, many of you may have been skeptical that cosmetic surgery might have little relevance to the ‘real’ surgical cases most of you do involving substantial postoperative pain. Sometimes I’ve wondered that myself. After all, cosmetic surgey ‘only’ involves moving skin and fat.

When I was ‘looking down the barrel’ of facing my unavoidable need for a THR, I was given the opportunity to validate if it was indeed ‘nifty to give fifty’ for ‘real’ surgery.

I doubt many of you reading this blog would care to dispute that ‘whacking off’ a femoral head and reaming out the acetabulum doesn’t constitute a significant surgical stimulus with a fair bit of postoperative pain.

Add to the surgery itself the fact that I am by ‘religion’ a ‘devout coward’ which is partly why I became an anesthesiologist. I truly do not like pain and would much prefer to not have pain than to endure it and ‘tough it out.’ In short, not the best surgical candidate, a genuine ‘wus.’

So anxious about my surgery was I that I wrote a 3 page letter to the anesthesia service detailing my concerns about my care. I spoke to the person who assigned the cases to be sure to get a younger doc who routinely monitored propofol with a BIS.

When I met my anesthesiologist on the morning of surgery, May 6, 2008, I was able to convince him to run my propofol between 60-75 and give my 50 mg ketamine 3 minutes before my incision.

My surgeon, John Moreland, typically performs 5 THRs every Tuesday & Thurday. That 50 mg ketamine 3 minutes PRIOR to stimulation was the only difference between my anesthetic experience and the thousands of THRs before mine. The floor nurses were ‘blinded’ to my little experiment.

After my 2 mg midazolam premedication wore off in PACU, I was transferred to the floor. I spent another 48 hours on the floor before being discharged home.

During my stay, I required nothing for pain. Subsequently, I required nothing for PONV secondary to the opioids that are frequently used for postoperartive pain management.

Some may be willing to attribute the pain free postop course to the preop & postop local anesthetic wound infiltration and the 100 ug Duramorph in the SAB, but the floor nurses told me they still had to medicate the THRs for pain.

The most interesting aspect of my stay was the spontaneous and unrehearsed comment from each and every floor nurse that came to check on me:

“Dr. Friedberg, are you sure you had your surgery? We’ve NEVER seen a THR look like you. You don’t LOOK like you’ve had surgery.”

My response, in explanation, was, because of the pre-stimulation ketamine, no one ‘hurt’ me on the OR table.

Sure enough, I actually had more discomfort on week #2 than my first postoperative week as my brain ‘caught up’ to what had happened to my body.’

Yes, I understand my experience was an ‘N’ of one and was not ‘statisitically significant.’ BFD.

Personally, I did not suffer having my THR &…

professionally, my experience validated my clinical experience of 17 years and 5,000 patients!

What is your ‘take home’ message?’

If you never try saturating ALL of the NMDA receptors PRIOR to stimulation, you are still closing the ‘barn doors’ after ‘the horses’ have left.

It IS nifty to give fifty!

Ask yourself, is the brain weight of a 250 pound adult male 2.5X that of a 100 pound adult female? The number of NMDA receptors does not substantially vary with body weight in adults.

As long as BIS is below 75 (which for any general anesthetic it most assueredly is), you have nothing to lose and everything to gain for postoperative management.

Bonus – if you can convince the surgeon to inject some lidocaine before the incision & drop some bupivicaine in the incision prior to closing – all the better for the patient.

For all who note it, a good and sweet new year. For the rest, good tidings as well.

Barry

These questions were generated by one of my list’s recipients, Alan Cohen, a friend and thoughtful anesthesiologist colleague, who may have expressed a sentiment that many others, who either read my blog or receive my list, also had.

Consider, for a moment, what’s the largest organ in the body? The skin.

So, what organ also has the largest cortical representation of the homunculus? The skin.

What surgical ‘specialty’ performs most of its procedures on the skin? Plastic surgeons, ENT cosmetic surgeons, dermatologic surgeons, etc.

For whom have I been giving anesthesia exclusively these past 17 years and providing only PK MAC? Plastic surgeons, cosmetic surgeons, dermatologic surgeons, etc.

Are you beginning to suspect the next question might be, what organ has the most sensory nerves invested in it? You would be right again: the skin.

If I have had no contract (and I have not), what has secured my economic viability? The quality of the outcomes of my PK MAC.

IF the primary stimulus for the cascade of negative neuropeptides and G-d-knows-what-else happens within the brain chemistry is the ‘violation’ of the outer membrane (the skin) of the body (my belief),

and the blockade of the NMDA receptors for that stimulus only occurs by saturating them with 50 mg ketamine 3 minutes prior to stimulation @ BIS <75 (my belief validated by 17 years clinical experience with 5,000 patients and my personal surgical experience), then, it may matter little what happens within the body's envelope during the surgery relative to the actual duration of the NMDA blockade of the 50 mg ketamine. The bonus, of course, is the postoperative continuation of the blockade of the skin sensory nerves by pre-closure wound instillation of bupivicaine. FWIW, the duration of the dissociative period of the 50 mg ketamine for injection of local anesthesia varies between 10-20 minutes. Clearly, that duration is insufficient to explain the postoperative course of either my THR or my 5,000 patients' experiences. Bottom line: Only by clinical trial with your own patients can you decide 'Is it nifty to give fifty?' You have virtually nothing to lose* (under GA, all of your patients will be BIS <60 and most will likely be <45 anyway) and everything to gain for your patients by trying. *Friedberg BL: Hypnotic doses of propofol block ketamine induced hallucinations. Plast Reconstr Surg 91:196, 1993. In my answer, I hope you understand that I make no claim of 'science,' only that which I have clinically observed professionally and personally over the past 17 years, as well as that which I have published in peer-reviewed journals and in my Cambridge University Press published anesthesia textbook, 'Anesthesia in Cosmetic Surgery.' As Christian Apfel said about the 0.6% PONV outcomes reported in my 1999 5 year review of PK MAC* in his PONV chapter in the 2010 Millers 'Anesthesia:' "However, the lack of a control group in this study* necessitates a cautious interpretation. Nevertheless, this result is in accordance with small scale, high quality randomized controlled trials, such as the comparison of anesthetic techniques by White and colleagues." Any time PK MAC gets favorably compared by Dr. Apfel to the legendary Paul White's work, and my non-emetogenic technique's (NO anti-emetics) PONV rate is 10X better than White's 'multi-modal' anti-emetic PONV protocol on the pages of Miller's 'Anesthesia, I can only say, 'PK MAC doesn't really need any greater validation.'

No sooner than I sent an excited e-mail to my long time friend and colleague in Florida, Anthony ‘Tony’ Kirkpatrick,MD, PhD, about me appearing on pg. 54 of the August 10th, 2009 issue of People magazine then he replied with, that’s amazing, I am in the SAME issue, on page 70.

I was cited as an anesthesia expert about propofol and brain monitoring adding to the safety of propofol administration as it related to the Michael Jackson story.

Tony was cited for his good works with ketamine comas for ‘re-booting’ the patient’s brains with RSD or reflex sympathetic dystrophy and giving them their lives back to live without intolerable pain.

I congratulate my friend on BOTH his accomplishments of healing those desparately painfully sick RSD patients and getting some long deserved public recognition for his efforts!

Truly an amazing coincidence of timing!