Sunday, February 12, 2012

help me help you

Off the top of my head: five tips for people who might need to undergo anesthesia.

1.) Know what medications you're taking, and know what you're taking them for.

I guess this must seem easier for us, because by and large if you're reading this you are on the younger end of the spectrum, statistically more likely to be healthier and on fewer medications, and demographically at least somewhat medically inclined, but--you'd be surprised how many people have no idea what medications they're taking or for what condition they were prescribed.

Patients--please know what medications you're taking! It really makes a difference, and can affect how your body might respond to anesthesia or the various insults of surgery. And it's often not quite enough information to tell me that you take "a blood pressure medication," because there are many different types and they all work through different means. Is it a beta-blocker? An ACE inhibitor? A diuretic? An alpha-2 agonist? And guess what--even if you don't know half of what I just said, it doesn't matter. Just know the names of meds you're on, tell me, and I'll figure it out, because it's my job. If it's hard for you to remember, write your med list down or have a family member help you. Carry the list with you in your wallet if necessary.

2.) Know your own medical history.

Equally important, see above. Do you have a scar over your sternum? Do you have a device implanted under your left pectoral muscle? Sure as hell I'm going to ask you about it. I'm not being nosy, I need to know these things to make sure I can take care of you in the safest way possible. If you can't remember, or have a hard time because you have a long medical history, write it all down (list of diagnoses, surgeries, doctors with contact info) and carry it with you, maybe along with your med list. Better yet, keep it as a file on your computer, so you can update and print it out as necessary.

I know it's annoying to have to answer the same questions again and again, but it's a matter of safety as well. So bring your information. And don't just trust that, "it's in the chart," because sometimes it's not. Anyway, a good medical practitioner doesn't just trust someone else's History and Physical, they do their own.

3.) Do yourself a favor and think long and hard about your allergy list.

As an anesthesiologist (or even as a doctor in general), when I ask you about drug allergies, what I'm really asking you is, "will the benefit of me giving your a certain medication as indicated be outweighed by an adverse reaction of giving you that medication, and do I have good alternatives?" Putting lots and lots and lots of drugs on your allergy list to which you're not actually allergic does nothing but tie my hands to treat you in the safest and most efficacious way possible. Feel free to tell me if you tolerate some meds worse or better than others--if Flagyl makes you queasy or that historically you respond better to morphine than Dilaudid. I do want to know these things, so yes, tell me. But when you tell someone that you're allergic to every antibiotic on the planet because sometimes antibiotics give you the runs, it can really hamper our ability to treat you in a safe, effective, evidence-based way, because the word "allergy" means something very specific in medicine, and we take that word very seriously.

(Also: no one is allergic to epinephrine. Your adrenal glands make epinephrine. If you were allergic to epinephrine we wouldn't be standing here having this conversation right now. Sorry, pet peeve. I don't blame patients for saying it, by the way--I blame the boneheads who, knowing better, write it down anyway and thus immortalize it in the medical record.)

4.) Don't eat or drink after midnight the day of surgery, but it's OK to take most medications.

The surgical team may ask you to hold certain medications prior to surgery, and most of these medications make sense to stop. Since you're not going to be eating for a good couple of hours the day of surgery, it makes sense, for example not to take medications that will further lower your blood sugar (meaning oral medications for diabetes, or your full dose of injected insulin--brittle diabetics, consult your endocrinologist for specific instructions). Also, as surgeons try to keep bleeding to a minimum when they're cutting on you, so with some exceptions in specific cases (like if you've recently had a stent placed in your heart for example, of if you risk for clotting outweighs your risk for bleeding), it's usually advisable to stop taking any blood thinners or certain anti-inflammatory medications for a period of time prior to the surgery date.

But for the most part, other medications are fine to take the morning of surgery, if that's when you usually take them. In fact, I prefer it if you take most of those morning medications, particularly including any medications for your heart, your blood pressure, any breathing issues you might have, or medications for chronic pain. When you think about it, it makes sense: you want to be medically optimized for surgery, not with your blood pressure through the roof, wheezing, and with your pain out of control even before incision.

 Have questions about taking or stopping a specific medication before you get to the OR? Ask to speak to an anesthesiologist prior to your surgery date. Don't just call the surgeon's office and ask--often the person fielding the call (not always a medical professional) will not have the first clue, and will instead say, just because he or she thinks it's the safest answer, "don't take any medications the day of surgery." I had a myasthenic patient come in for an afternoon surgery having skipped several doses of Mestinon because the secretary she talked to told her not to take her meds. Like I said, if you have medical questions about day of surgery medications, ask to talk to an anesthesiologist beforehand. Again: it's our job.

5.) If you have any specific fears or concerns about the anesthesia itself, let us know beforehand.

Help us help you! Are you claustrophobic and hate the idea of having a mask over your face? Do you have a needle phobia? Did you have a family member with a very bad reaction to anesthesia, or have you yourself have a traumatic anesthetic experience in the past? Do you have questions about "The Michael Jackson Drug" and want to know exactly how the same fate will not befall you? Let us know! We can help you! There are things we can do to make things easier! Better! Smoother! Less scary! We have all sorts of tricks in our bag, is all I'm saying. We just need to know when and for whom to pull them out.

Medical professionals in this or other fields: another other tips?

* * *

For people of a certain age, Whitney Houston runs throughout the soundtrack of our childhood and adolescence. So if you want to pretend that you've never been alone in the bathroom hoping that the tile acoustics would help you better belt out the chorus of "One Moment in Time," I'd think I'd have to call you a damn liar.

Thank you, Whitney. You were transcendent.


  1. LauraM9:09 PM

    Agree, agree, agree. I wish people understood that there is no "national medical record" and no, it is not permanently downloaded in my head.

    They have forms on-line for children with chronic medical conditions that are enormously helpful. (You can click through drop-down menus and select things such as "where I catheterize" for kids who have undergone urinary tract reconstruction and such for our spina bifida kids.) Plus, it folds up to a wallet-size. This would be a great idea for adults now that the world is largely internet-connected.

  2. Gretchen9:09 PM

    Amen on the allergies! My personal favorite is 'I'm allergic to erythromycin, it gives me diarrhea.' All that tells me is 'My GI tract works like everyone else's.'

  3. Richard9:09 PM

    Whitney was my childhood. At least her beautiful music will live on.

  4. I used to wonder why I was asked what my reaction is to the antibiotics I'm allergic to, now I get it.

    I feel for anyone who has to put me under, I have asthma and sleep apnea. Last time I apparently had an asthma attack on the table (that I don't remember) and woke up in ICU a day later. My ortho surgeon said his part of things went fine, which was nice, but yeah, even with using my inhaler before going to the OR things still went south. :-/

    Oh, yeah, there's nothing like being claustrophobic and waking up on a ventilator with my hands restrained. As I've had reactions over the years I always make a point to tell the anesthesiologist what reactions I've had in the past, but I always seem to find new and interesting ways to be challenging.

  5. Anonymous10:05 PM

    Yes to all of the above and thank you from the other medical professionals in the audience. The only modification I would make is to say that if you are a type 1 diabetic, PLEASE DO take your insulin, though probably not your regular dose - discuss with your PCP or endocrinologist PRIOR to the surgery what dose you should take. There is nothing like some bad (ahem, preventable) DKA to complicate someone's hospital course.

  6. Anonymous10:26 PM

    I hadn't thought much about Whitney Houston over the last several years. But today, when hearing some of her music, I remembered just how much of her music was a part of growing up for me. The first cassette tape that I got when I got my own 'boom box' was a Whitney Houston tape. And the first CD I got when I got a CD player was a Whitney Houston CD. Her voice was something to behold. You're right, she was transcendent.

  7. Great tips!

    Also, I can totally relate to the belting-out-Whitney-Houston-in-the-bathroom-hoping-the-tile-acoustics-will-make-me-sound-an-ounce-closer-to-her thing...

  8. Anonymous12:30 AM

    My favorite was the patient who had "hot water" listed as an allergy... because her dermatologist had told her not to take too-hot baths as it could dry out her skin. I took it off the allergy list but someone kept re-adding it :P

    One addition to the list (as someone going into trauma surgery this comes up a lot): We are here to treat you, not judge you. If you drink, smoke, do meth \ cocaine \ speed \ LSD \ oxycontin \ whatever please TELL us, don't hide it. I'm not going to report you to the police. I just want to understand what you're withdrawing from, or why your pain isn't controlled with normal amounts of narcotics.

    1. Yes, but afterwards the nurses get all pissy and don't treat the patient well. They especially withhold pain meds. I saw it happen to my brother many times.

    2. Anonymous4:34 PM

      "Nurses being pissy" is an unfortunate cost that your brother will have to bear as a chronic pain patient. If the anesthesiologist is unaware of his drug use/abuse history, your brother will risk waking up in excruciating pain, which is easily preventable by changing the anesthetic.

      Anesthesiologists ask questions not to be judgmental (although I'm sure there are judgmental anesthesiologists out there), but to tailor the anesthesia methodology to the individual.

  9. Seconding knowing what medications you take! So many patients tell me that they take "a little blue pill" which is "maybe for my blood pressure" and have no idea why I don't know what drug it is. I can't fathom not knowing what I'm putting into my body on a daily basis! Also seconding telling the truth about your drug/alcohol use. We use a lot of narcotics on the unit I work on, and we can figure out how to treat your pain much better if we have an idea of your baseline substance use.

    I would add to talk about your medical wishes with your family and have them written down somewhere, no matter what your age or health status is. You never know when something traumatic might happen, and when it's time to intubate is not the time to be discussing if that's in the realm of what you want.

  10. Heather7:59 AM

    As a patient, it's your right and responsibility to know what's being done to you when you're in the hospital, so ask about procedures, medications, etc. Every time my mom is in the hospital, she asks about every pill, IV drug, cord, cable, whatever that she's being given - what it's called, what it's for, who ordered it. Some nurses get annoyed, sure, but she'll be in a great position to help prevent an error if and when it comes up.

    Also, mention health care proxies and living wills before they actually become necessary - it's nice to know ahead of time if that's something you've thought about, have strong feelings about, or if you have non-obvious preferences about who to discuss information with.

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  12. I didn't know I had such unpleasant reactions (or, I guess the better term would be non-reactions) to pain medication until I had major surgery last summer. I mean, I knew I had thrown up three times during a c-section, but they were able to manage the pain, whereas with this surgery I was literally begging them to put me back out because they wouldn't give me more pain meds. I found out later it was because my O2 sats kept dropping into the 70s, but they didn't tell me that at the time.

    So I talked to an anesthesiologist the next day, and she gave me pointers for if I ever have to have major surgery again (it's a possibility with my GI tract issues). Always good to have people who try their best to make it better!

    And even though I'm 38, and only take 2 PRESCRIPTION drugs (and one of those is BC), I keep a list in my wallet of all the drugs/supplements I take - definitely makes it easier when they ask AFTER putting in the morphine drip!

  13. What a great list! Truly a personal pet peeve of mine is hearing people say, "It's all in my chart" and EMRs tend to be sooo accurate, argh!

    Thanks for the Whitney moment...a friend & I were recalling her songs last night after the Grammys, and just because, I really did try to hit the high note... :)

  14. It's the WORST when I go to the ER to see a consult and the patient says "Well, I already told the ER doctor... it should be in the chart." Don't be fooled! Nobody EVER asks about a surgical history besides the surgery resident!!!

  15. Anonymous7:32 PM

    I would add, when taking your sick child to the pediatrician, go ahead and GIVE them the tylenol/motrin/ asthma meds. We do not need to "see how sick she looks when her fever is high" or "know that she is really wheezing". We trust you. And controlling your child's pain and symptoms will help us take care of them.

  16. Anonymous2:28 AM

    Current EMT and soon-to-be MS1 here: regarding the "allergic to epinephrine", I've been taught that while people can't be allergic to the epinephrine itself, they can very well be allergic to the packaging chemicals in epi-pens that are injected alongside the epi into a person. In which case, in the field we have to get paramedics to give IV epi/benadryl instead of using an auto-injector which is significantly safer and issued to EMT-Basics who can't start IVs. Obviously not a concern in the OR, but it may be a legitimate allergy.

  17. Anonymous @ 11:28p: Good point! Also true for some people who say they have allergies to local anesthetics (lidocaine, etcetera)--that often it is the preservative rather than the lido itself that they are allergic to.

  18. Allergies to oxygen & epinephrine are truly my favorite.

    Side note: I've worked as an ER nurse in several facilities where we're told we have to write down every word that comes out of the patient's mouth when asked about allergies....because apparently one can't be trusted to determine between allergies, sensitivities, normal med reactions & side effects, and "my mom is, so I must be, too. I think." Apologies on behalf of nurses everywhere; it's not us, it's the Medical Industrial Complex Policy and Procedure. ;)

  19. we often have patient's labelled as "allergic to unknown drug/antibiotic", and also "unknown reaction... really annoys me when I have limited antibiotics that I can prescribe to my patients (almost all pregnant)

  20. and we have so many new immigrants or non-entitled visitors who had skin prick tests in their country and was told to have "penicillin allergy" and allergies to all sorts of medications, we never know which one is real.... sigh

  21. Thanks for the list. Almost makes me look like the perfect patient...except under allergies on my list I have two medications that I'm not technically allergic too, but I have such bad reactions too, I should never take them. One throws my electrolytes in the toilet and the other slows my heart rate into the 20's. I guess I should list them as severe reactions instead of allergies. Oh, and the epi thing, in the past when I tell the doctor that I should not take epi because of my arrhythmia they just blow it off. Oh well, keep the AED close by.

  22. Have one pharmacy where you fill every prescription and buy every herbal/dietary supplement (and from the pharmacy itself if your pharmacy is in the grocery store/Costco). That way if you see many doctors, someone can catch duplications.

    Know your pharmacist by name and ask questions every time you get a new prescription or decide to start a medication or hear something on Dr. Phil and make a change in what you take/where you store meds/whatever. Can't think of what to ask? Ask, "What can I expect when I take this [with my other meds[?" It's pharmacists' favorite question to answer.

    Also keep a paper record of all your immunizations in your wallet, and if you see an error in your EMR, bug someone to correct it until they actually get it fixed.

  23. Anonymous6:06 AM

    On the morning of surgery, "oh yea, I don't know if it's important, but I think there is a history of malignant hyperthermia in my family."

  24. wanda6:48 AM

    I am allergic to ambien, it makes me sleepy.

  25. Anonymous12:59 AM

    When you take your child to the ER/Hospital, know the pediatrician's name and practice and have some clue as to their immunization status.

    If your child is medically complex, carry a written list of PMH, meds and doctors who follow the child. I cannot safely admit your child in the middle of the night without some clue as to what his/her home meds are and why they are on them.

  26. Anonymous4:39 AM

    Nothing makes me smile more than a patient (or family member) handing me a list of medicatins, allergies, PMH, etc. Even if you know them by heart keep a list in your wallet or purse, most medics (or the cops, I'd prefer not to dig) will find it if you're unable to tell us due to your condition. Of course, nothing makes me sadder than a patient handing me a beautiful list and then saying "but it's old, I'm not on that stuff anymore." It's a whole lot easier then dragging that Walmart bag of half empty, duplicate and expired pill bags to the hospital.

  27. Anonymous4:42 AM

    We use to have this crazy lady that'd call all the time for breathing difficulty. Said (in complete sentences) that she was allergic to epi and albuterol. Whatever. Anyway, one day we went up there for the 98th time and she could only talk in 2 word sentences. I asked her if she was allergic to anything. She shook her head no. The drugs she was allergic to worked like a charm. The 99th time we picked her up she was allergic again. I just smiled.

  28. I was born with a cleft lip and have had several reconstructive surgeries, with most of them between the ages of 14 and 21. While my mother always struggled to remember my medications, at any time I could give both the brand and generic names, doses and how often I took them.

    General anesthesia ALWAYS causes nausea and vomiting for me. Obviously, I am not educated in anesthesia and I don't know the different drugs that can be used or their side effects. I finally began to ask for IV Phenergan. The first time, I didn't ask until the resident came to see me at about 5:00 the next morning and he said "Oh, I can give you something much better!" He didn't give a name, but the mystery drug did not work for me in the least. After another few hours and nurse called and asked for a new order, I got the phenergan and it was like magic. The next surgery I had was in another state, and the I asked the anesthesiologist for IV phenergan before I woke up (N/V after craniofacial surgery is not reccomended by me.)

    All of that story just to say that patients should be informed and know what works for them, if they can. If something doesn't work for you, tell your doctor! YOU are going to be the one suffering through the surgery and recovery, so don't make it any harder on yourself than it has to be. As a BSN student I would like to know that my patients would be able to tell me what drug or treatment they've had the best results with in the past so that I can give them the best care possible. Sometimes people just don't know what works for them, and that's fine too. Your treatment team will do their best to give you the best possible outcome.