Chapter 5: Breast Anesthesia

“In God we trust, all others must have data”

-Dr. Bernard Fisher


Breast cancer was first considered a curable surgical disease. In 1882 William Halsted, the Surgeon-in-Chief at the newly founded Johns Hopkins Hospital, performed the first radical mastectomy. In this operation the surgeon removed the breast tissue, axillary lymph nodes, and underlying muscle tissue. In subsequent decades other surgeons removed additional anatomical structures like ribs, the clavicle, part of the sternum, internal mammary lymph nodes, and the latissimus dorsi muscle. The word radical means “root” in Latin. Halsted thought by taking more tissue he was treating the “root” of the disease. He believed in the Centrifugal Theory of Cancer: cancer spreads locally like a pinwheel from its origin, therefore resecting more tissue means more cures. However, data showed more extreme surgeries did not cure more breast cancer, but they did horribly disfigure women, leaving them with permanent disability and painful complications

The Radical Mastectomy

In 1924 Dr. Geoffrey Keynes, a young physician in London, took a different approach. He was consulted for a ulcerating malignant lump in breast of a 47 year old thin, frail woman. He was concerned she would not survive the radical mastectomy. Instead he tried a more conservative approach: he buried 50mg of radium in her breast. Over the subsequent months the mass became smaller, softer, and less fixed to the underlying breast tissue. Keynes thought this smaller tumor could be resected without taking the breast or underlying tissue. Over the next 3 years he showed his cancer recurrence rates were at least comparable to the radical mastectomy. When he presented his data, Halstedian surgeons mockingly called his smaller surgical procedure a “lumpectomy”.

Dr. Keynes was largely forgotten until 1953 when Dr. George Crile of the Cleveland Clinic learned about him while on sabbatical in London. He reproduced Keynes’ results over 6 years in the United States. Surgeons began to seriously question Halsted’s Centrifugal Theory of Cancer. By the late 1960s the culture of medicine was also changing- society now demanded accountability for physician decision-making. In 1967 Dr. Bernard Fisher became chair of the National Surgical Adjuvant Breast and Bowel Project, a consortium of universities working together to design large scale clinical trials for breast cancer. Their first study’s results were made public in 1981: it showed breast cancer recurrence over 10 years was identical for radiation + lumpectomy and radical mastectomy. Turns our Dr. Geoffrey Keynes was correct.

The next 40 years of breast cancer research focused on treating breast cancer without harming women. In 1991 Dr. Armando Giuliano showed sentinel lymph node biopsy was just as effective as axillary dissection. That means women could have a single lymph node removed in a smaller surgery instead of a surgical exploration. This resulted in fewer complications, less pain, and reduced risk lymphatic arm swelling. I had the honor and privilege of working with him in the operating room several times in my residency. His kindness, engagement, and enthusiasm betray his age. Myself and my colleagues agree he is the only surgeon with the charisma to convince women a sentinel lymph node biopsy was just as good as an axillary dissection.

Breast Biopsy and axillary dissection

Today breast cancer treatment is a multidisciplinary discussion between the patient,medical oncologists, surgical oncologists, radiation oncologists, and laboratory scientists. Biological research into the cellular basis of cancer has transformed breast cancer treatment. Now we can individualize chemoradiation regimens and immunotherapy to precisely target breast cancer subtypes. The American Cancer Society recently reported breast cancer mortality has decreased 39% between 1989 and 2015.1

Anesthesiology also plays a role in breast cancer treatment. Anesthesia for breast surgery focuses on treating pain and preventing nausea.

As more breast cancer patients survive they will require medical care. Chronic pain is a significant problem in this patient population, affecting up to 80% of survivors. Risk factors for chronic pain after breast cancer surgery are obesity, young age, previous radiation, preoperative anxiety/depression, high pre and post-operative pain scores, and axillary dissection. Controlling perioperative pain may play a significant role in the quality of life of these patients after they survive cancer.

Young women are very susceptible to post-operative nausea and vomiting (PONV) from opioids and anesthetic gas. I find preemptive pain management utilizing a multimodal analgesic technique allows me to use less, if not no, opioids. I give an extra anti-emetic medication before surgery, then choose anesthetics that decrease PONV. During surgery I utilize ketamine for analgesia. Ketamine, given prior to incision in spine surgery, may decrease the incidence of chronic pain up to a year after spine surgery. Emerging evidence suggests it can prevent the transition from acute pain to chronic pain by inhibiting specialized neurons in the spinal cord and/or brain. Research is ongoing to fully understand who is most likely to benefit from its unique pharmacology.

After surgery is over I extubate patients deep in stage III of anesthesia then allow them to slowly emerge without choking on their breathing tube. Furthermore the use of regional anesthesia, which is using numbing medication like lidocaine to numb nerves, may further decrease the chronic pain experienced by breast cancer survivors.3 In the future anesthesiologists will likely play a significant role in prevention of chronic pain in breast cancer survivors.


Footnotes:

  1. My brief history of breast cancer is derived from pages 193-226 of Siddhartha Mukherjee’s book “The Emperor of All Maladies: A Biography of Cancer” published in 2010. I also summarized the advancements in breast cancer articulated by Drs. Stefano Zurrida and Umberto Veronesi in their 2014 article: “Milestones in Breast Cancer Treatment”. The American Cancer Society statistic was retrieved on July 4, 2020. It can be found here: https://www.cancer.org/latest-news/report-breast-cancer-death-rates-down-39-percent-since-1989.html
  2. I synthesized knowledge from my colleagues and my own literature search. My risk factors were derived from “Predictors of Persistent Pain After Breast Cancer Surgery: A Systematic Review and Meta-Analysis of Observational Studies” By Li Wang, MD; Et al. One article I found relating to breast surgery was: “Chronic Pain Following Cosmetic Breast Surgery: A Comprehensive Review” By: Ivan Urits, Md; Et al. Although breast cancer surgery is different from cosmetic breast surgery techniques might transfer between the two fields.
  3. Paravertebral blocks may become more prominent in the future of breast surgery. One article I found was “Thoracic Paravertebral Block Reduced the Incidence of Chronic Postoperative Pain for More than 1 Year After Breast Cancer Surgery” By: Hiroki Shimizu, MD; Et al

Chapter 4: Monitors

Pulse oximetry is based on optical physics principles developed in the 18th and 19th centuries. Many high school students may recognize these principles as the Beer-Lambert Law. In 1860 German scientists used these ideas to develop analytical spectroscopy, the use of light to measure the chemical composition of solids, liquids, and gases. In the 1930s George Stokes applied analytical spectroscopy to the different wavelengths of light (color) reflected by hemoglobin in its oxygenated and deoxygenated states. For the first time in history the oxygen saturation of hemoglobin could be quantitatively measured, but the device had several practical limitations. Over the next 40 years those practical limitations were solved by the US military and physiologists. Then in 1972 a young Japanese bioengineer named Takuo Aoyagi figured out how to use arterial pulsations to better calibrate the device.

Modern pulse oximetry was born- although Aoyagi’s employer, Nihon Kohden Corporation, did not see the potential in his innovation other people did. In 1979 Biox Technology was founded in Denver, CO, USA and in 1981 Nellcor Company in Hayward, CA, USA. Nellcor had an anesthesiologist Dr. Mark Yelderman, who introduced the pulse oximetry device at the 1983 ASA annual conference. By 1986 the American Society of Anesthesiologists endorsed pulse oximetry as a standard monitor. Interestingly there are no clinical trials showing pulse oximetry decreases mortality during surgery. Keep in mind there are also no clinical trials showing parachutes decrease death during skydiving!

The first time I understood the important of a pulse oximeter was during My 4th year of medical school during my pediatric anesthesiology rotation. I was with a PGY-3 resident for the day. He extubated an adorable 3 year old girl after a hernia operation. No one was in the operating room besides him, the patient, and myself. Suddenly her oxygen saturation dropped to the 60s, dangerous low. The resident immediately instructed me to hold an ambu-bag to her face with both hands. He quickly moved to the anesthesia machine turned a few dials then squeezed a green bag. I remember thinking: “I really hope this guy knows what he is doing, because I have no idea what is happening!!” After about 15 seconds she turned blue, then suddenly her color returned and she was breathing normally. She woke up 10 minutes later without further complications. I was speechless.

That resident expertly managed a laryngospasm, a complication most commonly seen in pediatric patients when the vocal cords become irritated then spontaneously close without warning. Without the pulse oximeter we might have intervened too late. Our first sign of a problem would have been the child turning blue. No one even knew this resident saved this girl’s life; not her, not her parents, not the surgeon, and not the nurse. Anesthesiology is a solitary act of defiance against Nature. You must perform at the highest level to even have the chance of success.

End-tidal carbon dioxide (EtCO2) is the other monitor that changed the landscape of anesthesiology. The measurement of CO2 from human breath was first reported by John Tyndall in 1865. Multiple practical advances led to the first volumetric capnogram in 1928 by American physicist John Aitken and English physician Archibald Clark-Kennedy. After wartime applications the technology entered clinical application in 1955 when the first capnographic profiles of human respiration appeared in anesthesiology literature followed by the 1970s when EtCO2 changes were linked to clinical changes in patients. In 1978 clinical capnography was introduced in the United States at the World Congress of Critical Care medicine. Initially it was thought to be “of little value”. Then a Canadian malpractice insurer granted massive discounts to anesthesiologists who used capnography during their cases because it decreased malpractice premiums paid out for esophageal intubation claims. The technology became widespread in the 1990s. It eliminated mortality associated with esophageal intubation and greatly improved the safety of sedation especially in endoscopy procedures.

I have accidentally intubated the esophagus twice in my residency. Both times the mistake was immediately recognized due to capnography. I re-intubated both patients safety and both cases proceeded without further complications or patient harm. If I practiced in the 1970s those two patients might have suffered brain damage or death. Today, I confirm my endotracheal tube placement with direct or indirect visualization, bilateral breath sounds, pulse oximetry, and capnography.

Our five senses are also important for detecting complications early. As a resident I had the privilege of training with Dr. Anahat Dhillon. Her kind demeanor betrays her depth of expertise and high expectations for herself and her residents. One day I was working with her during a robotic pancreatic resection. She asked me close my eyes then guess the heart rate and oxygen saturation. Because the tone of the heart rate changes based on the oxygen saturation, an anesthesiologist can know both values just be listening. After about 30 minutes of trying I could be within 5 beats per minute of the true value for the heart rate and within 2% of the oxygen saturation.

Since that day with Dr. Dhillon I learned my ears can give me information about the entire operating room. I learned to listen to the surgeon’s voice, the electrocautery, the suction, the circulating nurse, and my own monitors in order to grasp all activity around me. This is like sitting in silence in the middle of the forest. At first you will hear nothing. Eventually you will become aware of a symphony of activity around you: the sounds of the leaves rustling, animals walking, water running, and birds calling. I learned to isolate and interpret the individual sounds in real time. Now looking over the curtain seemed like cheating.

A year after my case with Dr. Dhillon I did a liver transplant with Dr. Avner Gereboff. Initially the case went well: the failing liver was removed, new liver inserted in its place then the supra-hepatic vena cava (1), infra-hepatic inferior vena cava (2), portal vein (3), and hepatic artery (3) were anastomosed to the patient’s native vasculature. Before working on the common bile duct (5) they repaired the femoral vein after decannulation from veno-veno bypass.

As the surgeons were suturing the femoral vein I noticed their yankauer suction catheters near the liver were making a characteristic sound. I asked them to explore the liver bed for an arterial bleed. At first they resisted then when they looked to humor me, immediately as they lifted the liver, multiple bright red jets of arterial blood appeared. My junior resident demanded I tell her how I knew about the arterial bleed! I smiled then said: “close your eyes and tell me what the heart rate is”.

Chapter 3: New Year’s Eve Intubation

I remember the first time I felt like a doctor. It was January 1st, 2018 at 0630, halfway through my intern year.

I was an intern on 24 hour trauma surgery call for New Years Eve 2017. The hospital was pandemonium. My pager went off so often I couldn’t delete the pages fast enough. I went to more than 20 traumas over 24 hours. On average we admitted 1 patient every hour to an ICU bed. In the emergency room young patients, mostly intoxicated, overflowed into the hallway. The hospital ward beds were at capacity. I sat down 3 times over 24 hours. Finally at 5:30AM the following day I signed out my fellow intern and turned off my pager. All I had to do was round on my 12 colorectal patients, write notes, and go home. After reviewing the morning labs and vitals for my colorectal patients I received a call from the general surgery chief resident. He requested my assistance in the trauma bay. 4 critically ill patients involved in a horrific car accident would arrive in the emergency department within minutes. I dropped my list of colorectal patients and ran to the ED.

The 4 patients required every available physician and nurse. My senior resident managed the first two traumas himself, intubated both, and managed their triage- one to the operating room and one to the CT scanner. The junior surgical resident managed the third trauma, intubated him, and took him to the second available CT scanner. I was alone to manage the 4th trauma- luckily Dr. Amar Shah, an excellent emergency medicine physician, was available to support me. After a several minutes both of us noticed our patient’s decline in mental status- in a trauma patient this is concerning because it might mean they will not be able to breath on their own or become unable to “protect their airway”, meaning oral secretions can travel into his lungs causing aspiration pneumonia. We both agreed the patient should have a breathing tube inserted to prevent both complications.

Suddenly a nurse appeared with two drugs, etomidate and rocuronium, and a respiratory tech appeared with an intubation tray. Before I realized what was happening, we performed a time out to confirm the correct procedure and both drugs were injected. The respiratory tech handed me the laryngoscope.

There are two kinds of laryngoscopy (looking at the vocal cords): direct and indirect. In direct laryngoscopy the physician must tactfully move all anatomic structures out of the way in order to obtain a “direct view” of the vocal cords. In indirect (aka video laryngoscopy) a lens is placed at the end of the laryngoscope blade, giving the operator a much clearer view of the vocal cords. Video laryngoscopy is easier to learn especially for non-anesthesiologists.  

Unfortunately for me both of the video laryngoscopes were used by the surgical residents. As I felt the patient’s jaw relax and his breathing stop I slid the direct laryngoscope past the right side of the tongue into the vallecula, the space immediately behind the epiglottis. Just as I achieved a Grade I view of the vocal cords someone I heard a loud sound- for a split second I looked to see what it was. I looked back at the patient- now I had a grade 4 view.

Successful direct laryngoscope relies on millimeter-precision movements of the elbow and shoulder. Useless. At that moment the patient’s oxygens saturation started to drop- first to 95, then to 94. I knew I had to get this tube in before his oxygen saturation dropped to zero. My heart rate skyrocketed.

I was physically and mentally exhausted. I hadn’t slept in over 24 hours. I had no cortisol left in my body. Then something happened. I slid the MAC4 past the tongue and into the vallecula, achieved a grade I view, then smoothly passed the endotracheal tube past the vocal cords. As I ventilated my patient with a purple ambu-bag his saturation continued to drop. Then it bottomed out at 68%.

As I ventilated him his oxygen saturation returned to 100%. It felt like the slowest intubation of my life- but it must have occurred in less than 15 seconds per the patient’s starting and ending oxygen saturation. I felt like my sympathetic nervous system and fight-or-flight response were turned off. I checked my heart rate: it was exactly 60. One beat per second.

After that moment everything seemed the same but somehow completely different. I was still tired, hungry, and had to work long hours for minimal pay; but I wasn’t the same person anymore. My perception was fundamentally different.

Chapter 2: Rounding with Lucas and Ledgerwood

“THIS PATIENT NEEDS A DOCTOR!”

-Dr. Anna Ledgerwood


I grew up and completed my undergraduate work in Michigan. My state is synonymous with mittens, Faygo, the Great Lakes, the city of Detroit, and a strange card game called Euchre. We do a few things differently: our carbonated sugary beverages are called “pop” no soda, our ginger ale is called “Vernors” and we say “ope” instead of excuse me. Our ideal getaway is “going up north”, which means packing your family and screaming kids into a cramped car, driving 3 hours north to a wifi-less cabin near a lake, then refereeing family arguments for a fun-filled weekend. When we are not fighting with each other we also grill, water ski, swim, explore nature, fish, and spend quality time with each other.

Michigan has a ritualized culture based off of the changing of seasons: Summer means enjoying the sunshine, going up north, and boating, Fall means apple orchards, the changing of the leaves, and pumpkin spiced lattes; Winter means Christmas, ice skating, and snowball fights; Spring means the end of the school year and commiserating with other Michiganders about the unpredictable weather. Now that I live in Los Angeles I enjoy the warm weather but I miss the seasons; they always gave me something to look forward to.

When I applied to medical school in 2012 there were three major medical schools in Michigan: Wayne State in Detroit, University of Michigan in Ann Arbor, and Michigan State in Lansing. After I started my medical education at Wayne State a popular anecdote was told about my school’s philosophy towards medical education. It goes something like this:

“3 medical students arrive at the bedside of a dying patient. All three medical students read the chart and examine the patient. Their attending physicians asks them what they think of the situation. The first medical from Michigan State knows the patient’s life story but has no idea what to do, the second student from University of Michigan knows exactly what is wrong with the patient but has no idea how to treat it, and the third medical student from Wayne State has no idea what is wrong with the patient but knows exactly how to treat it”

The story is not meant to put down the University of Michigan or Michigan State- I consider them valuable colleagues, have worked with them, they are excellent physicians- the point of the story is emphasizing Wayne State’s philosophy of medical education. Wayne State emphasizes experiential learning as the foundation of education.1 Looking back I think the three medical students from the story represent the three factors required for true expertise: knowledge (Univ of Michigan), metacognition (Michigan State), and experience (Wayne State).

Chapter 2 of my book is about why doctors are considered experts. For the purpose of this book an expert is “a person who, over the course of many years, accumulates knowledge, metacognition, and experience that enables him or her to make consistent accurate predictions in uncertain real-life situations”. The chapter answers the question: in a world of people who seem to know what they’re talking about, whom should I trust?

Let’s begin at my 3rd year medical school trauma surgery rotation. Let’s meet Drs. Anna Ledgerwood and Charles Lucas, the two most infamous surgeons at the Wayne State University School of Medicine.

Anna Ledgerwood has a magnetic personality. She trained in an era where there were no women in surgery; it was a classic Boy’s Club. She had to be the most intense person in the room just to survive. Despite her innocent-looking tuft of white hair her tongue has sharpened with age. She expects her residents and medical students to perform at her level whether they like it or not. She speaks with a Midwest accent and larger-than-life personality. Her green eyes can read your thoughts before you speak. She is like the person in gym class who you hope is on your team because you know you will lose if she isn’t. Her kindness is as boundless as her anger. She can hug her patient one minute and erupt at her residents the next.

Charles Lucas has a different style: he can communicate complex thoughts with a single look. He is the kind of person who doesn’t speak many words but when he does everyone listens. He is tall and thin with pale blue-grey eyes. He walks slowly with his hands comfortably folded on his lower back. Dr. Lucas has a different effect on his trainees: even though you might meet him only a few times in your training, he feels like your most trusted mentor. With Ledgerwood you fear her wrath, with Lucas you fear his disappointment. He is the father-figure you never knew you had. I remember him examining a patient before going into the operating room. When she shuddered at his touch he moved his right hand to his chest, produced a rare smile,  then said: “cold hands, warm heart”.

Rounds with “the Ls” were quite different from other rotations. Medical students were expected to be encyclopedias of their patients. My first time rounding with Ledgerwood she was appalled I didn’t know where my patient went to high school. From that day forward I knew I had to know literally everything. Literally.

My schedule was as follows: read the night before about my patients’ pathologies, arrive at the hospital at 5am, prepare my oral presentations, get “pimped” on rounds (asked aggressive questions to see if I know things). If I didn’t know the answer within 3 seconds I was in trouble…because then Ledgerwood would ask the exhausted residents detailed questions about pathophysiology. The best medical students knew all the pimp questions so their residents could relax in the background. If your whole team didn’t know the answer Ledgerwood would yell “THIS PATIENT NEED A DOCTOR! ARE YOU THAT DOCTOR? ARE YOU THAT DOCTOR? (as she asked each one of us individually) BECAUSE RIGHT NOW I DON’T SEE ANY DOCTORS!” When she felt especially offended she would walk away in disgust.

Rounding with Ledgerwood was intense-intense, whereas rounds with Lucas were calm-intense. When I didn’t know the answers to Lucas’ questions he would sigh, look down at his feet, and shake his head. The sense of disappointment was overwhelming. Then he wouldn’t let you finish your presentation! He would ask the chief resident to summarize the rest and move on to the next patient. In the world of Lucas and Ledgerwood there was no such thing as “I don’t know”. Doctors have ultimate responsibility for their patients; something “the L’s” took very seriously. Looking back I don’t know which I preferred: Ledgerwood’s wrath or Lucas’ disappointment.

I didn’t realize at the time but my experience with Lucas and Ledgerwood profoundly influenced my philosophy of learning. They introduced me to the work ethic, academic rigor, and professional qualities required to practice medicine at its highest level.

Footnotes

  1. The specific experiences I mentioned are representative of growing up in the Metro Detroit suburbs. The story is paraphrased from a story I heard and told 1st year medical students and applicants about the philosophy of WSU-SOM.

Chapter 1: Complications

“Medieval man was a cog in a wheel he did not understand; modern man is a cog in a complicated system he thinks he understands”

-Nassim Taleb, The Bed of Procrustees: Philosophical and Practical Aphorisms


The sickest patient I ever saw was in the cardiac surgery intensive care unit (CSICU) during my 3rd year of residency.

After a 28 hour liver transplant two attending anesthesiologists transferred a patient to the CSICU. Considering liver transplant patients usually go to the surgical ICU (SICU) I knew this was a strange case. He had a fresh liver transplant, continuous dialysis for renal failure (CRRT), an open abdomen with an Ab-thera device preventing his organs from falling out, and an open chest with two large plastic tubes connected to an extracorporeal membrane oxygenation (ECMO) machine.

My patient with central line, ventilator, ECMO (heart lung machine), and CRRT (continuous dialysis)

During the surgery the patient developed a blood clot which traveled to the right side of his heart, causing heart failure. Cardiothoracic surgeons were called and an emergent sternotomy was performed. He was connected to an ECMO machine, which takes deoxygenated blood from your right atrium, oxygenates it, then pumps it to your aorta to the organs of your body. After ECMO, the liver transplant was completed. His chest and abdomen were bleeding too much for safe closure so they were left open. His heart, lungs, liver, and kidneys failed yet he was still technically alive.

Unfortunately his brain was without oxygen for too long. He was pronounced brain dead in the CSICU 36 hours later. Considering thousands of livers are successfully transplanted every year why did this guy have this horrible complication? Early that morning at 0400 I explained the situation to his family. How do you tell them we did everything right and it didn’t matter?

Sometimes in medicine poor outcomes occur for no discernable reason; even when doctors do everything correctly. My first year practicing medicine I was the intern on the general/trauma surgery service. We had a healthy 44 year old gentleman who developed a perforated colon from diverticulitis, a pathologic weakening of the colon wall. I helped operate on him in the middle of the night, removing his diseased section of colon and creating a colostomy. He recovered uneventfully until post-operative day 5 when he developed worsening abdominal pain. My senior resident examined his colostomy. It was black and dead.

We took him back to the operating room, resected 15cm of dead colon and made a new colostomy. He recovered and left the hospital one week later without further complications. Later that month my senior resident presented his case to the entire surgery department to see if his complication could have been avoided. After reviewing the operative technique and post-operative management everyone agreed the patient had received the best care possible. The most senior colorectal surgeon said he has seen this complication once during his fellowship 30 years ago. He has created and managed more colostomies than anyone in the hospital (and probably the country). His eyes softened then he said “it just happens sometimes, don’t take it personally”.

I could tell our patient didn’t fully trust our surgery team after his complication. My attending surgeon felt awful. He did everything right and still had a poor outcome. Worse still we couldn’t tell the patient why it happened. I will never forget the way the patient looked at my attending. For a doctor there is no greater shame than to be distrusted by your patient. Surgeons and anesthesiologists care deeply about their patients. They understand surgery is very dangerous and they must perform at the highest level for favorable outcomes. But this was different. What do you do when you perform at the highest level and you still fail? How do you not take it personally?

Book Introduction

I will never forget my first day in the pediatric intensive care unit (PICU). My first patient was a five year old boy named John, who was admitted the previous night after nearly drowning in a bathtub. At first glance, John was lying on his back, eyes closed, and his hospital gown had elephants on it. I felt like I was peeking into the bedroom of a sleeping child. By the bedside his mother held his hand and silently sobbed. As I looked around the PICU, I noticed other rooms similar to John’s: 24 glass boxes neatly arranged in a U-shape around the nurse’s station. Doctors recorded and interpreted patient data, looking for patterns of improvement or deterioration. The various monitor tones, ventilator breaths, computer keystrokes, and quiet conversations merged into an emotionless symphony.

When it was time for rounds, the discussion was unexpected. Our team focused on the hypothetical possibilities of every patient more than what was actually happening to them. The ICU physicians– who are supposed to be the best trained doctors in the hospital– seemed to be obsessed with what they didn’t know. They talked about arterial blood gases, acute respiratory distress syndrome, then played with the ventilator like a new video game. As a result, I spent most of my nights in the library learning how to interpret the endless data, wondering why we were collecting all these useless numbers if we weren’t going to act on them. Remember John? Over the next 3 days, his lungs improved and his breathing tube was removed. Even still, the ICU doctors obsessed over dangerous uncommon events that never happened. Could they not see John was improving? Their vigilance seemed out of proportion to the clinical situation.

On my 5th day, our team gathered in front of John’s room for our morning rounds. Just as I did on my first day, I peeked into his room. But this time, he woke up, rose to his feet, and walked energetically back and forth in his crib! When he came to the side of the crib facing the doorway, he looked at me with the silly, innocent smile of a happy, well-adjusted 5-year-old. Suddenly– in the midst of the countless vital signs and machinery that can make hospitals seem so grim– my eyebrows unfurled, my shoulders relaxed, and my pursed lips transformed into the kind of smile that makes the corners of your eyes wrinkle, then we began to laugh together! Years later, I finally understood why the ICU physicians’ embrace of uncertainty was the key to John’s survival.

            After 4 years of undergraduate biochemistry, 4 years of medical school, and 4 years of anesthesiology residency I will complete a critical care fellowship at the Texas Heart Institute in Houston, TX. Anesthesiologists make excellent intensivists because we excel at managing multiple organ systems in real time, finding creative solutions in uncertain situations, and remaining calm during emergencies. In fact the intensive care unit was invented by an anesthesiologist! In Copenhagen, Denmark, 1952, Danish anesthesiologist Bjorn Ibsen applied operating room ventilation strategies to a ward of paralyzed polio patients. He decreased the death rate of bulbar polio –(which paralyzes the diaphragm)- from 90% to 25%.1

Several features make anesthesiology unique from other medical specialties. Our patient is always minutes away from death, with no time to consult other doctors when complications occur; we must tolerate long periods of uncertainty interrupted by short bursts of dangerous intensity; and events happen faster in the OR than any other place in medicine. Because of the speed and limited information available, anesthesiologists learned how to make smart decisions about unknown events that cause life-threatening conditions like bradycardia, hypoxia, and hypotension, among others. We specialize in the management of rapidly evolving, high-uncertainty, high-risk situations without a known solution. In other words, we figured out how to manage difficult situations we don’t understand.

We figured out how to save lives by abandoning a simple cause-and-effect view of reality, instead adopting a systems-based approach. Because we manage every organ system in the body– in real time– as they adapt to their internal changes and the changing surgical environment we view the operating room as a complex system. A complex system is an organic structure of components that communicate with one another and respond to changes in real time. Complex systems are all around us. Common examples include the human body, stock market, a class of 4th graders, or infamous Los Angeles traffic.

Conversely, simple systems –such as a math equation– are unchanging patterns describing part of a complex system. Simple systems are different from complex systems because they cannot react to predictions, they produce predictable results, and they follow the same rules regardless of size. The simple systems that form a complex system can describe individual parts of the complex system, but, the sum of the simple systems cannot predict the outcome of the complex system. This is because complex systems exhibit synergy; when interactions of individual components produce an effect greater than the sum of their separate effects. In other words, in a simple system 1+1=2, but in a complex system 1+1=3.

Complex systems exhibit synergy for three reasons: first, the components of a complex system can react to forecasts of its future (ex. Los Angeles drivers use apps to find the best way around traffic); second, the components can behave in unforeseen ways (ex. humans are free to choose their preferred driving route); third, the number of possible outcomes becomes unmanageably large as complex systems grow (ex. rush hour traffic). When complex systems have too much synergy they become random. Los Angeles traffic is so complex drivers experience seemingly random traffic jams at all hours of the day and night. Ask me how I know!

Think of a large complex system (ex. Los Angeles traffic) as a random event generator that produces events at a speed and intensity proportional to its complexity. A few events will cause positive changes (ex. parking spot becomes available at the exact moment you need it), most will cause no change (ex. rolling through a stop sign alone at night), and eventually one event will derail the entire system (ex. car accident on the I-405 freeway). Large complex systems are responsible for our political, economic, financial, and cultural institutions; however, the same complexity that makes them valuable also make them vulnerable to sudden, catastrophic, unpredictable events called Black Swans.

Black Swans are unpredictable, cataclysmic events retrospectively “obvious” due to psychological biases.2 They are named for the ancient metaphor, “rara avis”, which means “rare bird”, in Latin. The metaphor was originally used as a compliment, meaning “one-of-a-kind”. In Ancient Greece the expression evolved into “Black Swan” because, at that time, all known swans were white. Black swan meant “someone so exceptional they have never been seen before.” In 1697 black swans were discovered in Australia by Dutch explorer Willem de Vlamingh. The modern expression- popularized by Nassim Taleb in 2007- means “a major event that is unpredictable because it was beyond the scope of human knowledge when the event occurred”.3

Current examples of these events include the 9/11 terrorist attacks, the Sandy Hook Elementary shooting, and the COVID-19 outbreak. Historical examples include the stock market crash of 1929, World War II, and the sinking of the Titanic. Black Swan categories can be known ahead of time (ex. war, car accident, gun violence), but the event itself is unpredictable. They are unpredictable because over time, the synergy of a complex system grows in unexpected ways, and then evolves into an unforeseen event that crashes the system. Residents of Los Angeles cringe when we hear about a car accident on “the 405”. The only thing worse than one accident on the 405 is two accidents on the 405.

As the world’s financial, political, and economic systems grow in complexity, Black Swans will become more intense, and occur more often, because more complexity means more synergy, and synergistic interactions create Black Swans. For example, pandemics, like COVID-19, are a greater problem now than 150 years ago because our movement patterns are exponentially more complex. Like traffic, communicable diseases thrive on the number and variety of interactions between people for their evolution and propagation. In other words, as the complexity of human movement increases, the intensity and speed of pandemics will also increase. Our society is a car accelerating toward the edge of a cliff. So, what does this have to do with anesthesiology? Anesthesiologists already have a solution.

Foonotes

  1. The full story can be found in many places ranging from Wikipedia to academic journals. Two excellent summaries I found were “The physiologic challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology”, By Dr. John West and “The Doctor Who had to Innovate or Else”, By: Conor Friedersdorf.
  2. I highly recommend Nassim Taleb’s Incerto, a series of four books about luck, uncertainty, probability, opacity, human error, risk, disorder, and decision making. My  “complex system” is synergy from his original research into the epistemological and mathematical origins of random events. My definition of a Black Swan is based on Part I of his book, “The Black Swan: The Impact of the Highly Improbable”. For the purpose of the introduction I include Taleb’s “grey swan” in my Black Swan definition. Chapter 1 will articulate the differences between them.
  3. I found a summary of Black Swan etymology at en.antiquitatem.com. The specific page is titled “The white blackbird and the black swan are a rare avis (rara avis)”, and the author is Antonio Marco Martinez, a retired professor of Latin. English explorers also brought black swans back to England from Australia, however, de Vlamingh is generally credited with their initial sighting. A summary of his discovery can be found at lifeonperth.com, a website about the history of Perth, Australia.
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