The problem for most of my anesthesia colleagues (& their patients) is a failure of vision…
If you fail to measure the organ we medicate (i.e. the cerebral cortex), you are already doomed to over-medicate your patients.
If you fail to trend the electrical activity of the frontalis muscle or EMG as a secondary trace to the bispectral (BIS) index, you fail to have a useful, real time monitor.
If you fail to respond to EMG spikes as if they were heart rate or blood pressure changes, you fail to optimize the use of the BIS.
If you fail to prevent the signal of initial breach of the integument (i.e. skin incision or local anesthetic injection), all your anesthetic is doing is enabling your surgeon to inflict pain upon an unconscious patient whom you have rendered incapable of responding.
Over the past 15 years & >3,000 BIS/EMG propofol ketamine patients, none has required postop opioid (narcotic) treatment while posting the lowest postoperative nausea & vomiting (PONV) rate in a high risk group WITHOUT anti-emetic pretreatment.
If you insist on giving opioids +/or stinky gases, you continue to dare the patient to have PONV.
Most tragically, our colleagues have too often relegated my work to cosmetic surgery, not ‘real’ surgery.
Please consider listening to board certified, orthopedic anesthesiologist, Dr. Parson’s comments… http://www.youtube.com/watch?v=r6O-stIHlgo&list=TL8XOq1r9QY4Y
ALL surgery involves breaching the barrier between the world of danger & the protected world of self, aside from natural body orifice procedures.
Friedberg’s Triad: Measure the brain… preempt the pain… emetic drugs abstain.
Numerically reproducible outcomes for those professionals who choose to open their minds.