Transcript
Gianluca Bini: All right, tonight we have with us Mika Hamilton, which is an assistant professor at the University of Toronto and a staff and anesthesiologist and intensivist at University Health Network.
Gianluca Bini: Thank you again for coming back. We didn't scare you away, so that's great. So i think tonight you have some questions for us. i have a bunch of questions for you.
Gianluca Bini: Tasha has some for you as well.
Ryan Bailey: And I'm just along for the ride.
Mika Hamilton: Yay.
Gianluca Bini: yes
Mika Hamilton: Yeah.
Annatasha: You're just here, hot dog guy.
Mika Hamilton: yeah and
Gianluca Bini: So, fan fact, i I spoke with one of our clients and figured out that her best hot dog was in the stand in Reykjavik.
Gianluca Bini: And I was like, this is endless.
Mika Hamilton: Yep.
Gianluca Bini: I was like, this is now the third person in three months.
Mika Hamilton: Yeah.
Gianluca Bini: but
Ryan Bailey: I'm going to need to to fly one more.
Annatasha: We should get this this hot dog stand to sponsor us. yeah i
Ryan Bailey: What's that Iceland airline that goes to Europe that like you always have to stop over in Reykjavik and then go on to, that's why I just need to, there you go.
Annatasha: Iceland Air is Iceland Air.
Mika Hamilton: Yeah.
Ryan Bailey: I just need to make sure to book my next trip on Iceland air just so I can stop in and get this hot dog.
Mika Hamilton: Yeah. I think they actively encourage it, to be honest.
Ryan Bailey: mean,
Mika Hamilton: yes
Gianluca Bini: Yeah, we should. I mean, at this point.
Annatasha: No, it's a free stopover.
Ryan Bailey: i mean
Annatasha: Like you go to the lagoons and then you go to for the hot dogs and you're out of there.
Mika Hamilton: I'm
Gianluca Bini: There you go.
Ryan Bailey: Or just a lot of hot dogs.
Annatasha: yeah
Mika Hamilton: sure it's been done.
Gianluca Bini: Yeah, she was showing my picture and she was like, yeah, this amazing. I was like, wow, okay. So that's real.
Mika Hamilton: So the when when I was there, we went on like a walk-in tour and the tour guide actually said, right now I'm going to take you to just to look at one of the the best restaurants that we have in Rikshavik.
Gianluca Bini: That's awesome.
Mika Hamilton: And he walked us over to this building and there was a restaurant in there and it's, I think it's in the Michelin Guide and it's super fancy. And he stood at the door and then he said, I want you all to turn around.
Mika Hamilton: And we all turned around and the hot dog stand was there and he was like, that's it. That's the best restaurant there.
Ryan Bailey: Oh my God. would have just dropped dead. I would just drop dead on the spot and just like,
Mika Hamilton: Yeah, bravo. I think he drums up a lot business. I don't even know if he needs to drum up business. I think I'm sure they get enough business.
Ryan Bailey: it feels like the Reykjavik tourism office is just doing a lot of work for this one hot dog stand. It seems like everyone's really just trying to divert all the business in Iceland to this hot dog stand, which, you know, awesome.
Mika Hamilton: Yeah.
Ryan Bailey: Awesome.
Mika Hamilton: yeah
Gianluca Bini: amazing. All right, Tasha, I think you had a lot of questions for dr Hamilton. I don't know if you want to start.
Annatasha: Oh, well, yeah, we we actually, in between our sessions, Dr. Hamilton, we recorded one on ventilation, which led to a question amongst the three of us about how often when we have pulmonary compromised patients, you know, or or how much do we perceive that inhalant versus total intravenous anesthesia is appropriate,
Mika Hamilton: Mm-hmm.
Annatasha: And then I gave one of my examples was that when I did my human anesthesia rotations, I participated for a few days on the burn unit in Manhattan.
Annatasha: And, you know, a lot of those, you know, actually 100% of those patients received Teva. regardless of whether or not, because one of the thought processes was, I would understand if you, for example, had smoke inhalation, but even the ones that was like localized burn were receiving Teva. And I was wondering, like, if are you, i don't know how much burn work that you've done per se. Are you familiar with it?
Annatasha: Do you agree that in the cases of either smoke inhalation or pulmonary compromise, that Teva is the way to go? How much do you worry about hypoxic pulmonary basal constriction associated with inhalants?
Annatasha: That's really our thought process.
Mika Hamilton: So I don't do burns, you know, currently, I think the last time I did burn anesthesia was actually when I was a trainee i'm back in the UK.
Annatasha: Mm-hmm.
Mika Hamilton: But from what I understand, I don't know that Burns in particular are a really strong indication for TEVA with regards to the hypoxic pulmonary basal constriction.
Annatasha: her
Mika Hamilton: I think it's more like there's like theoretically and physiologically, it makes sense, but likely in actual practice, it's probably equivocal.
Mika Hamilton: And it again, i think this goes back a bit to what we talked about last time is I think it can be very just center dependent, anesthesiologist specific.
Annatasha: Okay.
Mika Hamilton: So i Yeah, I think that would be my my understanding of it. i mean, we have like lots of UCs for TEBA, but I'm not aware that like burns anesthesia is a really, really strong indication. I'm sure you could argue for and against, and I'm sure you can argue for and against volatile anesthesia because, you know, I always say if you ask 10 different anesthesiologists, you'll get 10 different answers, you know?
Mika Hamilton: So...
Annatasha: We like to ask a hundred.
Ryan Bailey: Yeah.
Mika Hamilton: Yeah.
Annatasha: We always say ask a hundred.
Mika Hamilton: Yeah.
Annatasha: Yeah. So, okay. So your answer is classic anesthesia, which is totally wishy-washy, which is exactly how we feel.
Mika Hamilton: yeah
Annatasha: yeah.
Mika Hamilton: yeah
Annatasha: Yeah. There's, we rarely find like there, you know, there's hard and fast rules or one thing is right and one thing is wrong.
Mika Hamilton: yeah
Annatasha: And I get very upregulated about when someone says something is safer per se when, I mean, what does the term safer even mean? But yeah. Okay. Interesting.
Mika Hamilton: I think safer also depends on what you're familiar with using, you know. So maybe like your technique is a technique that someone else may argue is not the optimal technique. But if that was what you're more familiar with and what you use more in practice, that may actually be, you know, a safer technique for you and that patient rather to then try something new just because someone else told you you should, you know.
Mika Hamilton: so I think it's all very context specific.
Gianluca Bini: Yeah.
Annatasha: Okay. Yep.
Gianluca Bini: I think a lot of the times, like, you know, especially, and and i'm I'm sure that this happens to you guys too, like, you know, when we go speak at conferences and whatnot, the attendees come up to you after, and the typical question is like, what's your favorite protocol?
Annatasha: yeah
Ryan Bailey: Yeah.
Gianluca Bini: What's your, what's the safest protocol?
Mika Hamilton: Yeah.
Gianluca Bini: I'm like, 99% of patients, it doesn't matter.
Ryan Bailey: yeah
Gianluca Bini: 99% of patients, like as long as you stay within the dose range, whether you pick propofol ketamine or propofol medazolam, medazolam ketamine.
Mika Hamilton: Mm-hmm.
Mika Hamilton: Mm-hmm.
Gianluca Bini: i mean I guess you guys don't have alfaxolone. We do. Fortunately, it's a neurosteroid induction agent. Ooh.
Annatasha: Yika, are you a familiar at all with alfaxalone?
Mika Hamilton: I am in my head thinking, what is alfaxilum?
Gianluca Bini: Yeah.
Mika Hamilton: Mm-hmm. Mm-hmm.
Gianluca Bini: who we opened one Yeah.
Annatasha: Oh, yeah, no, it's a monster drug in veterinary anesthesia.
Ryan Bailey: Monster drug.
Annatasha: It is. I mean, it's our it's probably the primary induction agent outwits propofol. So,
Ryan Bailey: Yeah.
Annatasha: Yeah.
Gianluca Bini: yeah So it was developed in the seventies and it was released in both humans and veterinary medicine in humans was, so it was a combination of alfaxone and alfadolone.
Mika Hamilton: and
Gianluca Bini: And it was sold under the name Altesin in humans and Safan, I think, in veterinary medicine or vice versa, don't remember.
Mika Hamilton: Yeah.
Gianluca Bini: But anyway, yeah.
Annatasha: No, you're right. You're right.
Gianluca Bini: yeah
Gianluca Bini: But, you know, at that time, they they picked as a media
Annatasha: Camper oil.
Gianluca Bini: they
Annatasha: Camper oil.
Mika Hamilton: Camphor.
Annatasha: It was in Kemfer.
Gianluca Bini: there was a crap load of anaphylactic reactions. And so i think it lasted on the market a few months, and then they withdrew it. And then in the 2000s, an Australian company, Jurox, came out with alfaxirone alone in beta-cyclodextrin.
Gianluca Bini: Now, in humans, I think they are in phase three clinical trials in Australia with a different kind of cyclodextrin because I think 90% of humans are allergic to beta cyclodextrin specifically.
Gianluca Bini: And so but I don't know if they, yeah I don't think they made it to the market in Australia either, but they are definitely in clinical trials of it.
Mika Hamilton: Okay, I'll look out for it.
Annatasha: Yeah, it's a neuroactive steroid, Mika, and it, like everything else, works with GABA-sub-A receptors.
Mika Hamilton: Okay.
Annatasha: So the one major differentiation, for example, but between alfaxlon and propofol, I'm almost afraid to say anything about alfaxlon and propofol, but alfaxlon, you can either administer IV or IM.
Annatasha: So that has a really nice usage for us because when things are really going
Mika Hamilton: have and
Annatasha: Fractiously, we'll call it. You know, it's easier to slow something down for an IV catheter if you poke them IM, obviously. So commonly used, you know, in and dogs and cats for that reason. Can be volume limiting, though, just because of the concentration. So, for example, works really nicely in pigs, but you'd have to give like 50 mils.
Mika Hamilton: here
Annatasha: which IM is never going to happen unless you really feel like being run into a wall by a pig. So, but anyway, yeah, no, I was just curious whether or not it's, it's very veterinary specific, but I didn't know it if it had actually trickled over and like you guys, you know, had an like analog and development, like John Lucas said, or whether or not you'd ever heard of it, but.
Mika Hamilton: I mean i'm sure I'm sure some people have heard of it, or maybe some people have used the original formulation in and the 70s, but that was a little before my time. so
Gianluca Bini: I think it's before everybody's time on this.
Mika Hamilton: Yeah, I think so.
Annatasha: Well, I mean, think we're all from the aren't we? We're all from the 1900s, but I was definitely not at the university level in the Okay.
Annatasha: whoo
Gianluca Bini: No.
Ryan Bailey: Thank you.
Annatasha: okay
Gianluca Bini: But yeah, so, I mean, besides that, do you feel like You know, we were talking also on the last ventilation episode about pulmonary hypertension, right?
Gianluca Bini: So you you guys obviously have better tools to fight it than we do.
Annatasha: o
Gianluca Bini: Like, you know, you have nitric oxide blenders, all that, which we don't really have access to in veterinary medicine. Is there anything you would...
Gianluca Bini: If you didn't have an nitric oxide blender, is there anything you would... you know What would you do in these cases? what's
Mika Hamilton: Well, it's it's always beware of the right ventricle, so because it can turn in an instant.
Ryan Bailey: Thank you.
Mika Hamilton: So I think with these, key I mean, we have also like you know, peripheral hospitals here that also don't have access to nitric oxide, prostacycline.
Mika Hamilton: So i think it's about going kind back to basic principles, like what are you trying to avoid in pulmonary hypertension? You know, you've got likely a right ventricle that's already quite precarious and very dependent on its circulation. And then you've got pulmonary vascular resistance that you do not want to go up at all. And unfortunately, a lot of the things we do with induction of anesthesia and perioperatively makes that happen.
Ryan Bailey: Thank you.
Mika Hamilton: So for like in my practice, when I've anesthetized pulmonary hypertension patients, it's a case of thinking about, you know, perfusion to the right ventricle, maintaining normoxia, not letting the patient get hypercapnic or acidotic, you know, temperature control you have to think about as well, but generally unlikely to happen at your induction point too. And then thinking about, well, what happens when I intubate the patient and then what happens when I start ventilating them?
Gianluca Bini: Thank you.
Mika Hamilton: So, you know, you want to do a nice, smooth, cardio stable intubation that doesn't drop your systemic pressure, but also you don't want to do it in a half paralyzed patient where then you get coughing and bucking and that's going to, you know, kick up your pulmonary vascular resistance as well and caused by hemodynamic shifts.
Mika Hamilton: And, you know, these patients, people get nervous about these patients as well. And there's, I sometimes see a tendency, you know, when the patient's intubated and things are going well so far as people are like, yes, and they start ventilating the patient.
Ryan Bailey: Thank you.
Mika Hamilton: And they're like huge tidal volumes. And that's just going to, you know, increase your alveolar pressure and also increase your pulmonary vascular resistance as well.
Annatasha: Bye.
Mika Hamilton: So it's I think smooth is the is the term and it's about just going of back gone back to basic kind of physiologic like principles. But I was also quite lucky when I was doing those cases. Like I worked in a centre where we had, you know, like pulmonary artery catheter.
Mika Hamilton: So for those patients who were particularly, you know, precarious or with this severe pulmonary hypertension, we could actually look at the pulmonary artery pressures as we were doing what we were doing and Essentially, it was, you know, these patients would make sure they had a big IV in before we started. We generally have norepinephrine running prior to induction. And, you you know, you can argue which is the best vasopressor and which is the best inotrope in these patients. They all have their pros and cons.
Mika Hamilton: But in practice, and again, this goes back to what's most used in your center because the whole vasopressor inotrope argument always
Ryan Bailey: Sure.
Mika Hamilton: It can be just very center specific. as about what are you used to using? Should you use a new drug that you're not that familiar with just because someone else said it was better? So we would generally use norepi just to try and maintain the systemic vascular resistance and have that running with the induction of anesthesia and with the luxury of seeing your systemic pressure, pulmonary artery pressure, and your you know your your ventilation pressures, your peak pressures, et cetera.
Mika Hamilton: so
Gianluca Bini: That must be nice.
Ryan Bailey: yeah
Mika Hamilton: it's yeah but that is the benefit of working in a big you know a big hospital and i recognize that not everybody has that so
Gianluca Bini: Must be nice.
Ryan Bailey: I feel like we should also preface though a little bit about pulmonary hypertension in our patients.
Gianluca Bini: good
Ryan Bailey: It's like a real, we get very anxious about it because when they do bad, they do exceptionally bad. and But like the vast majority of dogs with pulmonary hypertension that we see doing like we anesthetize them for whatever dental, whatever, whatever it needs.
Mika Hamilton: Mm-hmm.
Ryan Bailey: It's not like it's, you know, whatever. And they're just like these giant nothing burgers that we do. Nothing special, like fairly standard anesthetic plan, whatever preferences you have kind of end up falling into place and,
Ryan Bailey: Sometimes they need ventilation, sometimes they don't. And like, it's it's this weird thing that our literature is so sparse. And so we always grab from the human side to be like, how do they manage these pH patients?
Mika Hamilton: but
Ryan Bailey: Because when we've had them, they're really scarring for all of us. But there's so many, like we probably anesthetized 95% of them. And it's like... The only reason we knew they had pH is because they had an echo coming in, but nothing during the case would have said this dog has anything wrong with it.
Mika Hamilton: Right.
Ryan Bailey: It's like, it's this very weird world for us of like, it's something we perseverate over and then snooze fast.
Mika Hamilton: one
Mika Hamilton: So do you change your management for those patients then or do you just do your so your standards safe technique?
Ryan Bailey: depends on how severe it is, I guess. Like if they're in the more severely affected patients who are like collapsing at home, because oftentimes the presenting complaint for these dogs is they're collapsing at home during exercise.
Ryan Bailey: They usually come in for us. If If they come in with the diagnosis, they're usually coming in on sildenafil. So we make sure they get that. I think as far as technique goes, it would depend on the procedure. I think most of us are probably going to reach for some sort of MAC reduction agent if it's a dog. So it's probably going to be either like opioid or Teva specific.
Ryan Bailey: Having ventilation available at the bat and making sure their CO2 stay relatively normal. Pressors, I think, I don't know if we have a consensus within the group on like, at at least within the three of us, I don't know.
Ryan Bailey: i would imagine all of us are probably going to start Norepi, but like where I trained as a resident, we all started like dopamine was our preferred pressor agent. So we started dopamine
Annatasha: I was trained on phenylephrine
Ryan Bailey: for pH cases.
Annatasha: for almost everything.
Ryan Bailey: Oh, oh, right, right, right. That's so weird. I forgot about that.
Annatasha: Cornell.
Gianluca Bini: Oh, yeah. Yeah.
Annatasha: yeah Cornell has a phenylephrine thing.
Ryan Bailey: Yeah, it's so weird. Yeah. So yeah, that would be my standard, but like there's lots of dogs who are going under anesthesia with pH and like probably no one's the wiser because they're not collapsing at home.
Mika Hamilton: Hmm.
Ryan Bailey: And it's it tends it tends towards like the little white fluffy dogs, I think.
Mika Hamilton: Right.
Ryan Bailey: I feel like they're overrepresented.
Annatasha: Or the bulldogs.
Gianluca Bini: oh yeah
Ryan Bailey: wal dogs?
Annatasha: Yeah, I seem to, maybe it's a Canadian bulldog thing. I don't know.
Ryan Bailey: Yeah.
Annatasha: But pH,
Ryan Bailey: I see them as pulmonic stenosis, but...
Annatasha: that as well. But yeah, no, if I'm going to see like pulmonary hypertension and something that's really decompensated, it's in like an obstructive bulldog patient for the most part.
Ryan Bailey: yeah
Ryan Bailey: Makes sense. Yeah.
Annatasha: Yeah. And those ones turn blue at the best of times. Okay.
Mika Hamilton: and that Is that purely because of their anatomy, like the way that they're bred, which has kind of resulted in I guess, one of many defects now?
Annatasha: Yeah.
Mika Hamilton: Yeah.
Annatasha: Yeah. So basically they're bred for the, for the maxilla to be recessed, but not the man mandible.
Gianluca Bini: yeah
Mika Hamilton: yeah
Annatasha: And then the issue is, is that the soft tissue, like the oropharyngeal soft tissue has not like allometrically scaled down with this failure of the maxilla. Like, and and along with that, like you also get, you know, aside from the fact that they have this truncated face, like they have stenotic neuras or, or, or nasal passages,
Annatasha: Their saccules tend to revert. They may have, you know, the biggest issue is that their soft palate constantly obstructs. And that can also lead to like other really horrible complications like you can get, you know,
Annatasha: laryngeal collapse or laryngeal dysfunction or even like myomalacia, like of the cartilaginous structures there.
Gianluca Bini: Thank you.
Annatasha: So it really depends on how severe they are. But bulldogs, obviously, classic. Persian cat, classic.
Ryan Bailey: Yep. Yep.
Annatasha: Shih Tzus, Laja Apsos, pugs.
Ryan Bailey: yeah
Annatasha: I specifically have a general dislike for anesthetizing pugs. So they're harder to intubate. They might have a hypoplastic trachea. So like you could have like a 40 kilo English Bulldog and put like a size five tube in it, which would be, you know, very disproportionate compared to the other breeds.
Annatasha: But yeah, and like, and then on top of that, they also are prone to various cardiac insufficiencies. And then on top of that, they're also prone to various GI insufficiencies or GI dysfunction. So they're just these obstructive, regurgitating, diseased skin that you can't get a catheter through, cardiac failure, back problem, joint problem, but skin problem, just Bulldogs are definitely the poster child in veterinary anesthesia of high risk.
Annatasha: That's the worst everybody.
Ryan Bailey: Yeah.
Annatasha: worst for everybody
Mika Hamilton: yeah So you have like a bulldog scale rating of anaesthetic risk?
Gianluca Bini: There is that.
Annatasha: Yeah, we we score like how bad their brachycephalism is, right? So like mild, moderate, severe. And then, yeah, sometimes like we'll look and we'll be like, we get really excited because they're like, look, he kind of has a nose.
Annatasha: Like it's not, it could, like it could be worse. Or like maybe they only snore, for example, when they're asleep. But some of them like French bulldogs or whatever, like as they walk by you you can actually hear them like obstructing, you know, like that. Yeah.
Annatasha: is like the classic, like excited bulldog noise.
Mika Hamilton: yeah
Annatasha: And you're like, here we go. And you just follow them around with a laryngoscope and an endotracheal tube like all day long. So yeah. I think like, don't you guys think though that brachycephalic dogs do a lot better than cats?
Annatasha: No, sorry, do a lot worse than cats. Like I don't have that many. Yeah. Like, I mean, a Persian, fine, that doesn't have a face, but I don't see them like try to acutely die the way that the brachycephalic dogs do.
Gianluca Bini: Yeah, no, no.
Annatasha: Like they're
Ryan Bailey: no not at all gets The cats do fine for whatever. They and just behave like regular annoying cats, but...
Gianluca Bini: Yeah.
Ryan Bailey: so
Gianluca Bini: Yeah.
Ryan Bailey: They don't obstruct their airways, you know, like, I don't know.
Gianluca Bini: And also they don't tend to regurgitate. you know
Ryan Bailey: That's true.
Gianluca Bini: You know, that's that's a big...
Mika Hamilton: Okay.
Annatasha: True.
Ryan Bailey: Yeah.
Gianluca Bini: you know and And unfortunately, you know i don't know if you have any... you know, miracle protocol slash drug, but, you know, we don't, there is no drug that at least in veterinary medicine has been having proven to improve regurgitation. Like, you know, we have plenty of drugs that treat nausea, they treat emesis, but they don't specifically treat regurgitation. And so do you have any miracle solution in humans or any treatment?
Mika Hamilton: I'm trying to, I mean, I'm thinking of all of our pro-motility drugs, you know, things like Domperidone, but that is just not really something we use in the perioperative setting. I remember when i was doing obstetric anesthesia, we would give the patients like sodium citrate to drink if they were coming in for an emergency C-section because of the higher risk of regurgitation.
Mika Hamilton: And that wasn't to stop it. That was just to make it hopefully less acidic, you know?
Annatasha: We used to, that's another weird Cornell thing is that all of the Cornell patients had to receive sodium citrate orally, which is a little harder in dogs because you can't tell them to drink this cup.
Mika Hamilton: Yeah.
Annatasha: Like you actually have to syringe it into their mouth and then you get sticky grape everywhere.
Mika Hamilton: Yeah.
Gianluca Bini: Yeah.
Annatasha: But yeah, we used to do sodium citrate all the time.
Gianluca Bini: yeah
Mika Hamilton: one of the One of the things we are dealing with right now is that more and more patients are taking the drugs like Ozempic, which you know really does increase your your regurgitation risk. so And again, and it's interesting because the guidelines about it have been kind of going back and forward over the last year. So initially we were telling patients to to stop taking it for three weeks.
Mika Hamilton: Now we're telling patients to take it as normal, but for the 24 hours before your surgery, the the fasting is different. So it would be essentially 24 hours of clear fluids pre-op as opposed to, you know, for two to four hours, depending on where you work pre-op, we would do the whole 24 hours.
Gianluca Bini: Gotcha.
Mika Hamilton: And some some places are also, I don't know if if this is something that you do in your practice, but... some places including where I work are employing the use of gastric ultrasound more to actually see if someone's stomach is full or empty to make an estimation of risk so if say someone had come in and they'd had specific fasting instructions and they're on you know one of the exemplary like drugs but you know they get a lot of information before the surgery so sometimes you know
Gianluca Bini: but
Mika Hamilton: it gets missed, then we would use gastric ultrasound in the morning to be like, okay, is your stomach empty or full? If it's full, how full is it? And then make a decision around, okay, should we be canceling this patient and bringing them back? Should we, and also depends on what surgery they're coming in for as well, because you know, it's benefits and risks should we be proceeding, but using like a rapid sequence technique to try and you know, reduce aspiration, did we push them to the end of the day to allow more time?
Mika Hamilton: So that's that's something that's really presenting a lot over the last couple of years. so But again, no that would be amazing to have a drug that flushes it.
Gianluca Bini: It would. Yeah, right.
Annatasha: Let me tell you, catch a case of Giardia, it'll really shoot things right through for you.
Gianluca Bini: Yeah, I
Mika Hamilton: Well, you know, I was just thinking, that's maybe some food poisoning, but...
Gianluca Bini: think one of us has some experience with that.
Mika Hamilton: not ideal yeah
Gianluca Bini: Right?
Annatasha: Oh, that's really interesting.
Gianluca Bini: right
Annatasha: Yes, because the that class of drugs has not percolated down yet. And i don't I don't think necessarily will per se. I mean, maybe in the cases of like diabetic management, but nothing in veterinary medicine that's really hit the mainstream.
Annatasha: Mika, do you have any questions that you're storing up? Because I know last time we didn't get through your list. we should We should give you a turn.
Mika Hamilton: Okay, so I'm gonna put the glasses on again.
Annatasha: Glasses on.
Ryan Bailey: it feels so official.
Annatasha: I love how Mika looks so like professional and the three of us are just like in t-shirts, just like talking about hot dogs and like being hot messes and like, okay, fine.
Gianluca Bini: Uh,
Ryan Bailey: I'm representing struggle bag.
Mika Hamilton: you should have seen me an hour ago, so this I don't always look like this. Okay. Oh, okay. so So one of my colleagues asked, what is your essential monitor in the operating room? Like if you had one monitor,
Annatasha: Oh my God.
Mika Hamilton: and
Annatasha: Don't ask, don't ask Ryan.
Mika Hamilton: what what could you not live without? And are there any animals where specific monitoring is difficult, like say, you know, pulse oximeter?
Gianluca Bini: who
Mika Hamilton: But what's the favourite thing first?
Annatasha: I'm not,
Ryan Bailey: Bullsecks is shit in our field. Like, it's just straight up dog shit.
Annatasha: I think, Mika, I think like it just, one of the important considerations is what like family of animals you're coming from.
Annatasha: So are you a fish or reptile, a bird or a mammal or an amphibian?
Mika Hamilton: Okay.
Annatasha: I mean, I think you guys will agree that anything really small, and I mean like 35 grams small, so like sugar gliders, budgies, mice, things like that, we don't actually have...
Annatasha: any devices that are calibrated or are scaled to to monitor that size patient appropriately because we're just pinching from human medicine. So for example, like when you have a sugar glider, I just secure like the Doppler probe over the entire heart.
Annatasha: And so all I'm doing is I'm listening for the heart rate of like 280, which is 100%.
Ryan Bailey: Yep.
Annatasha: which is And I can't put a cuff around anything cause it would kill them. Right? So I'm not using the Doppler for actual blood pressure. I'm just listening it for like proof of general life, but the pulse oximeter would like clamp the whole arm and make it, it would just become like a vascular.
Mika Hamilton: Thank you.
Annatasha: So, an ECG, for example, like, In reptiles, like trying to go through scales, you know, and or or, you know, amphibians, which have an incredibly delicate to kind of really delicate skin and they actually respire through their skin, you have to be cognizant. So, for example, in those cases, instead of like clamping alligator clips or putting pads on, I might actually just put like a small gauge needle through the skin. to minimize the damage and then clamp to the needle.
Gianluca Bini: Thank you.
Annatasha: Let's see what else, like you, we we don't even
Ryan Bailey: reptiles have the whole, like, their hearts can beat well after they're dead. So, like... If you're using like a Doppler, like I a worked at a zoo for a while doing anesthesia there and like they would ask me how the reptile was doing and my joke was always, well, the heart's beating, but I can't tell you anything more than that.
Annatasha: Who knows?
Ryan Bailey: Maybe dead, may not be, who knows? And so yeah, they, it was like a whole nother set of problems.
Annatasha: might
Annatasha: I always find that reptiles go a really weird brown-purple shade when they die. And other than that, I just assume proof of life. But, yeah, so we can actually use a lot of the monitoring equipment.
Ryan Bailey: Mm-hmm.
Annatasha: Like, like...
Gianluca Bini: Yeah. I mean, even in dogs and cats, we are using a lot of things that are derived from human medicine, right? Like our, you know, your pole socks, clips, a lot of the times they're, you know, even in cats, you know, they're, they're, they're messing up with your circulation on the tongue. We usually use the tongue a lot for pole socks rather than, you know,
Annatasha: And if they're digitally shaped for people, like it's, you can't use them for anything in vet med. So...
Ryan Bailey: Although like the newer monitors are much better at that. Like the older, the a lot of the monitors that we all grew up kind of using in our residencies were some of the older, you know, probably from the eighties and nineties.
Gianluca Bini: Yes. Yep.
Ryan Bailey: They're just not, they're just not as sensitive, but the new like, you know, like for us, the new like Mossimo rainbows do have a much better ability to pick up even, even in our like teeny tiny little patients, or we have like just this little bit of tongue or we like can get, you know, can somehow miraculously get it around like a pink cat toe bean or whatever.
Ryan Bailey: You know, we actually get information where like the old stuff is like, you were lucky to get anything out of it. and most of the time was just a crap shoot. And then like the other thing.
Gianluca Bini: Yeah.
Annatasha: A horse tongue is like that thick and a pulse ox only opens like that much.
Ryan Bailey: That's
Annatasha: Right.
Ryan Bailey: Yeah.
Annatasha: Okay.
Ryan Bailey: The other thing is all the clips, the like the reflectance clips are so big, like the Massimo, like reflectance clip is massive.
Gianluca Bini: The one you're, he's referring to your forehead head sensor. So you know that's what that's what they use it in humans for.
Ryan Bailey: Oh, yeah.
Ryan Bailey: Yeah.
Gianluca Bini: What we do is we, and this is my favorite kind of Pulzok's probe. So you shave below the paw pad and basically you just place it against it and then you wrap it.
Ryan Bailey: or in the mouth.
Mika Hamilton: Yeah.
Gianluca Bini: But you guys use it as a forehead sensor.
Mika Hamilton: Yeah. So we'll usually, first line is usually the finger or the toe, but you know, if the patient's kind of peripherally
Ryan Bailey: That's
Mika Hamilton: shut down or super cold, you might not get a read in there. So then we we've got we've got little earlobe clips and those clips can actually go, yeah, and they can go in the nose as well.
Ryan Bailey: a question.
Mika Hamilton: I've seen sometimes people put them like in the kind buckle area here too.
Gianluca Bini: Thank you.
Mika Hamilton: And then we have the, I would say maybe more on ICU, I've seen these used as the foreheads, the forehead forehead monitor as well.
Annatasha: You should take back to your team that sometimes we use like the the prep use.
Mika Hamilton: So yeah.
Annatasha: So we'll use a prepucial skin fold.
Mika Hamilton: Okay. Okay.
Annatasha: so You know, if we have very hairy patients or, you know, really like stubby little toes or like, you know, the someone's working on the head and so we can't access the tongue, I often use like the inguinal, like that pre-curl skin fold right there in front of the leg or you put it on the vulva or the prep use.
Annatasha: So just, you know, food for thought for humans.
Mika Hamilton: oh
Annatasha: You'll be like, you'll never believe where those vets put the pulse off.
Annatasha: Yeah.
Mika Hamilton: like I might get pulled into my chief's office if I did that.
Annatasha: yeah
Gianluca Bini: But I would try to bring...
Annatasha: So Dr.
Gianluca Bini: right
Annatasha: Beanie, what's your favorite modality of your desert island? We're not asking not asking Dr.
Gianluca Bini: I was...
Annatasha: Bailey that question because his answer is...
Gianluca Bini: I was going back to that. Exactly. So my... We asked ourselves that question a few episodes ago and I went with Paul Tux and I got a lot of shit for it.
Gianluca Bini: And
Annatasha: Not as much shit as Ryan.
Ryan Bailey: well
Gianluca Bini: Natasha went with Capnograph, which i think is totally fair.
Ryan Bailey: That's true.
Annatasha: I went with entitled CO2, like, capnography.
Mika Hamilton: uh
Gianluca Bini: But Ryan went with a Doppler.
Annatasha: Smart.
Ryan Bailey: I didn't.
Annatasha: Because he's from the nineteen hundred
Gianluca Bini: Yeah, when you talk about heavy
Mika Hamilton: oh
Annatasha: yeah
Ryan Bailey: I worked with Staffan back in the day.
Gianluca Bini: When you talk about monitors from the 70s and 80s, Ryan, talk about your monitors. At the end of the state, we had brand new monitors all the time.
Annatasha: I didn't grow up on some weird backhanded monitors like during residency. Like we had nice chairman monitors. Yeah. Yeah. Whoa.
Ryan Bailey: Hey, you can put a Doppler on like almost any animal that we anesthetize. So, you know, for a desert island.
Mika Hamilton: are you using it? Is it like continuous? Are you checking in every few minutes? where like And where are you putting it?
Ryan Bailey: So for dogs and cats, we usually put it on the... No, not, yeah, I guess it's like, it's a dorsal palmar artery, right?
Mika Hamilton: Yeah.
Ryan Bailey: In the dog. so like under their forearm, like right near the paw pad and then put your blood pressure cuff above it and then. I like it. i think it's a great mantra for your really super critical ones because you at least get you know, they're small and it's annoying, you can at least put that on, at least hear the heart beating so you can feel some level of confidence if they're too small or perfectly vasoconstricted and you couldn't get the art line in and it's been 15 minutes and you're starting to sweat and
Gianluca Bini: Thank you.
Annatasha: Thank you.
Ryan Bailey: things are going poorly and you want to get, it's like, do you, how long do you keep the case asleep while trying to instrument it versus like, just get the thing over with.
Mika Hamilton: Mm-hmm. Mm-hmm.
Ryan Bailey: and like, it works in like everything. Like you can put a Doppler on everything. like, I can't think of an animal.
Gianluca Bini: Yeah, that that is true.
Annatasha: Sure, I could put a Doppler on the sofa, Bailey. That's not going to help, is it?
Ryan Bailey: I can't think of an animal.
Annatasha: listen
Ryan Bailey: I haven't been able to put a Doppler on at all. on Honestly, you can at least put it on.
Annatasha: Can't you just use end-tidal CO2 like a grown-up?
Ryan Bailey: yeah Sure. i was As BD was asking the question, I was like, you know what?
Annatasha: right
Ryan Bailey: I probably would capnography because you get CO2, you get gas analysis, you know you got it all.
Annatasha: Cardiac output. o
Ryan Bailey: Sure.
Annatasha: Mika, how about you? Like, because you have to also remember, we don't put art lines in all of our cases, like I wouldn't necessarily put an arterial catheter and like a dog neuter.
Mika Hamilton: Yeah.
Annatasha: But you know, why does that not surprise me?
Ryan Bailey: I did, though.
Annatasha: But yeah, what's your preferred then?
Mika Hamilton: i'm I'm in the CO2 club. So the way the way I see it is your CO2, it shows that you've got a patent airway in place, which is obviously very important. It shows that you've got metabolism, you're actually making CO2, so you must be delivering and enough oxygen to make CO2.
Mika Hamilton: So that would be my gold standard. And it's, you know, like we have to use it in the operating room We're using it on the ICU now as well in all of our intubated patients.
Ryan Bailey: Oh, yeah.
Gianluca Bini: Right.
Mika Hamilton: Because you know when your CO2 disappears, you very quickly know that there's a problem. There's either a plug problem with your tube, with your circuit, or with your patient. you know
Gianluca Bini: yeah
Mika Hamilton: Saturations are like, you know, SAS probe is obviously super useful as well. It doesn't just show that you've got oxygenated blood. It shows that you've got enough pressure to make a waveform, gives you your heart rate as well if for some reason your ECG is not working so you can at least tell if the patient's bratty or tachycardic but then there is always that lull, you know, it's the kind of 45, 60 seconds back, you know, it's not real time monitoring and sometimes like last week I had a patient where we had to intubate the patient
Gianluca Bini: Yeah.
Gianluca Bini: and
Mika Hamilton: who was, you know, sick and the ET tube didn't go in immediately. but it went in and we got our CO2. So we knew it was in the right spot, knew oxygen was being delivered. But the sats then had dropped to 83 and they weren't coming up immediately.
Mika Hamilton: and so someone else who was watching this was like, your sats are 83%. And like we knew they were going to come up, but it's just that lag, you know? So it just,
Mika Hamilton: at least with your co2 you know you're in the right spot you haven't put the tube in the esophagus
Annatasha: and And it doesn't make any noise and you don't have to constantly fiddle with it for positional.
Mika Hamilton: yeah yeah
Annatasha: and like, I have a real thing about like white noise in the OR because, well, you, I'm sure you're aware that many of us lose our hearing over the years.
Mika Hamilton: ye
Annatasha: And because you've got suction and you've got people talking and you've got this. And like, in our case, we have things barking and how so I'm like, if I could not have that, like wow of the Doppler, then I'm more than thrilled to have that turned off. So.
Mika Hamilton: Yeah, I i usually have to, I don't know if it's because I'm getting older and I'm less tolerant to noise, but I usually turn the saturation tone down so that I can still hear it, but it's not super high pitched because I feel the same.
Mika Hamilton: There's so much noise in the operating room that it can be, you know, it's just a lot of input.
Mika Hamilton: It can be quite overwhelming. And I think when I last read about it, it's in human anesthesiologists for sure. I think it's like, was it 30, 40 percent have some degree of hearing loss at the end of their careers?
Ryan Bailey: go out.
Annatasha: and And it's vets right across the board mostly because of all of like the yelling and the barking and like all that kind of stuff.
Mika Hamilton: Yeah.
Annatasha: But like being in the OR definitely doesn't help.
Mika Hamilton: Yeah.
Mika Hamilton: Yeah.
Annatasha: And I agree, the older you get, the more noise intolerant you become, actually.
Mika Hamilton: thank you
Annatasha: Phil, our mutual friend, told me one day that I was going deaf and I needed to get my hearing checked because I wasn't, like, everything he said, I was like, what, what, what? Anyway, and I went to the audiologist and they're like, oh, your hearing is perfect.
Annatasha: she You know, she was like, this happens a lot to people in their 40s. They come in and think they're going deaf, but most of the time they just don't care. Yeah.
Mika Hamilton: Thank you.
Ryan Bailey: that
Ryan Bailey: Oh
Annatasha: And I was like, oh okay, yeah, that makes much more sense. But yeah. who
Gianluca Bini: That sounds...
Mika Hamilton: Yeah, it can be a very noisy place. Monitors, instruments, music, depending on your surgeon.
Gianluca Bini: yeah
Mika Hamilton: and Yeah.
Ryan Bailey: yeah.
Mika Hamilton: I don't know if you guys play music in the operating room at all.
Ryan Bailey: oh yeah
Gianluca Bini: Yeah.
Mika Hamilton: Oh, yeah.
Gianluca Bini: So do you always let your surgeons pick?
Mika Hamilton: the
Gianluca Bini: Is that how works?
Mika Hamilton: Usually, yeah. Yeah.
Annatasha: So I have this thing where if the surgeon is faffing around and I want them to finish the case, and you know how some surgeons, when they talk, they take their hands out of and they can't actually close and and talk.
Annatasha: And so I have two strategies, two musical strategies that I engage because I have master control in the o which is one, no offense, Dr.
Gianluca Bini: Thank you.
Mika Hamilton: Thank you.
Annatasha: Hamilton, but I'll blast bagpipe music. That's right. Strategy one. And strategy two, as a half Austrian, I will blast yodeling competitions. And I find it really takes the chit chat down and drives like completion of procedure.
Ryan Bailey: like
Annatasha: Because I'll be like, the longer you take, the more I'm going to play this.
Mika Hamilton: okay
Annatasha: So yeah, I have musical strategy to completion. yeah.
Mika Hamilton: Yeah, for us, it's usually the surgeons that that pick the music. And I've got like some surgeons, you know, love like the rock music. And I've got there's one surgeon I work with who loves classical music. It's super relaxing.
Ryan Bailey: this
Mika Hamilton: And you walk into the operating room and it's like, you know, there's this lovely piano playing. and But then some of our surgeons don't want any music played.
Annatasha: Do you have any surgeons who are really into like the greatest hits of Walt Disney?
Gianluca Bini: Mm-hmm.
Annatasha: Because I've known many Disney fanatics in my time and like, I'll pretend that there's some sort of patient crisis just so we can turn it off.
Mika Hamilton: Yeah.
Ryan Bailey: We
Annatasha: Right? Like I, I don't know.
Ryan Bailey: we get it?
Annatasha: I have to fix the blood pressure. Everyone turn off the Disney. Cause I'm like, can't I can't in the OR, I can't listen to The Little Mermaid. I just, no.
Mika Hamilton: I haven't heard it in the OR, but I remember, think it was like 15 years ago, I was in Australia and a friend was having a house party and it got to like 4am and nobody was leaving.
Ryan Bailey: Thank you.
Mika Hamilton: and And he was at that stage where he was like, I just need to go to bed. So he got like a Walt Disney soundtrack and just started blasting it, like turned off the pop music, put on Walt Disney, full blast. And ever everyone just so stopped and looked around and then just started slowly like trickling out the door.
Mika Hamilton: worked. Okay.
Annatasha: Try the yodeling. I really, that's my tip top. That's my tip top tip is the yodeling really, really encourages people to shut the hell up and get the hell out.
Mika Hamilton: Okay.
Annatasha: So. Yeah.
Mika Hamilton: I'll try it next, we can report back.
Ryan Bailey: I'll say the the Disney's definitely not going to work.
Gianluca Bini: Yeah.
Ryan Bailey: The surgeon I work with is a dad and he's got four children. And so he's well-versed in all the Disney songs. So there have been a couple of times where I walk in the OR and it's like Disney's greatest hits on Spotify or Pandora or whatever. And it's like, all right, cool.
Ryan Bailey: I'm going to just go ahead and see myself out real quick.
Annatasha: This is happening.
Ryan Bailey: This case looks very stable though.
Annatasha: Is everything going well? Stable patients alive? Yeah. Okay. I'm getting a coffee.
Ryan Bailey: I'll be watching through the glass window.
Gianluca Bini: That's awesome.
Annatasha: hi
Gianluca Bini: You can bless some baby shark, right?
Ryan Bailey: That would be a lot.
Annatasha: Oh yeah.
Mika Hamilton: Oh, no.
Ryan Bailey: That would be a lot.
Annatasha: Yeah.
Mika Hamilton: Yeah.
Annatasha: Yeah. Oh, your glasses are off.
Gianluca Bini: right, what else did we have?
Annatasha: Is that the end of the questions?
Mika Hamilton: No, no, no. Okay. Okay.
Ryan Bailey: What else do you got?
Annatasha: You took your glasses off.
Annatasha: I was like us that wasn't I think, okay, go ahead, Bailey.
Mika Hamilton: but So one of my colleagues asked, what do you think, maybe this podcast is a good example, but what do you think human and vet anesthesiologists can learn from each other?
Ryan Bailey: who
Gianluca Bini: Oh.
Ryan Bailey: Well, okay. I got one.
Annatasha: Go ahead.
Ryan Bailey: i This is this a really easy one, I feel, because this is like a real...
Annatasha: Is it alfaxilon? If you say alfaxilon, going to punch you.
Ryan Bailey: No, no. It's not. Uh... This is a thing I think we can learn from the human side LNSC is the recent, there was a recent paper about TIVA use in veterinary medicine.
Mika Hamilton: Mm-hmm.
Ryan Bailey: It was a survey amongst trainees and board certified anesthesiologists. And overall, the comfort level was exceedingly low.
Ryan Bailey: And The main reason being that we were only exposed, so many of us were only exposed in just going back to the conversation about Tiva at the beginning and comfort level was were only exposed to very specific cases and it hadn't trickled over into like general population. So I feel like that is a area that we could definitely learn from the human side because it's still like a...
Ryan Bailey: in even in like academic circles, it's still a, like, not, not forbidden, but like, it's still like, Ooh, this is still like the cutting edge.
Gianluca Bini: Yeah.
Ryan Bailey: And like,
Annatasha: You have to excuse Ryan. He also went to university that's stuck in 1984. So that's why he loves the Doppler.
Ryan Bailey: Hey, the paper, friend you paper, paper, I used him all the time, but the paper interviewed lots of other people though.
Annatasha: He doesn't even use TIVA but. Sad.
Ryan Bailey: And overall, the comfort level was pretty low. Yeah.
Annatasha: Sad.
Ryan Bailey: I don't just,
Ryan Bailey: and
Mika Hamilton: use it for like certain indications.
Ryan Bailey: Yeah.
Mika Hamilton: on so you know like patient who's had severe post-op nausea and vomiting before the you know surgery specific indications like the spine surgeries where volatiles interfere with your kind neurophysiological monitoring you know patients with you know history of malignant hyperthermia I actually don't know if that's a thing in animals yeah okay okay yeah yeah okay
Gianluca Bini: It is.
Ryan Bailey: It is.
Gianluca Bini: It is.
Ryan Bailey: Of course, it's
Gianluca Bini: Pigs for sure. It's a lot.
Annatasha: Dogs, but usually it's halothane related. So, and I mean, Bailey probably uses halothane because he's from of the 1900s, but a yeah, it's pigs and halothane are probably our biggest indicators, but you can, you can technically see it in any species.
Mika Hamilton: right mm-hmm
Ryan Bailey: No. Oh my God. Come
Ryan Bailey: on.
Annatasha: I think that in dogs, the subpopulation is Bernese mountain dogs, but like I said, yeah, but yeah.
Mika Hamilton: yeah
Ryan Bailey: and don't think it's been reported in cats or not reported reliably in cats. I don't believe.
Annatasha: Cats just get opioid induced self-limiting hyperthermia, but yeah, no.
Ryan Bailey: Not actual MH though.
Gianluca Bini: Yeah.
Mika Hamilton: I think with Ativa as well and and completely repeating myself but again it's it's just very specific to like where you trained and how you were trained and you know what your center uses a lot what kind of surgeries you do and what's your comfort level as well you know yeah
Annatasha: That's the one thing, Amika, just from having done human anesthesia rotation and then we used to at Cornell, we used to have... I guess the R3s from Weill Center in Manhattan come and rotate through us.
Annatasha: And I think one of the reasons why they sent their residents to us and why they like to have us and then oftentimes we would give talks while we were present was because we we are allowed to engage, I think, in a lot more like free thinking.
Annatasha: So we have less standardized protocols.
Mika Hamilton: Yeah.
Annatasha: And also because we do such a variety species, species I guess like our our lateral like problem solving or our aptitude for that is probably quite different.
Annatasha: So classic example is, you know, one of my mentors from Cornell was was anesthetizing rhinos in Namibia. And they were studying which position is best to avoid hypoxia for when they move them between countries because of poaching.
Annatasha: And they basically built like a a rebreathing circuit for the rhino from like PVC piping that they found locally because there's certain, it's like it's not manufactured and they couldn't transport it so they built it in Namibia.
Annatasha: But the issue that they were having was with what to what to make the unidirectional valves in the circle, what they wanted to make out of it.
Mika Hamilton: Thank you.
Annatasha: One, it has to be something that obviously has like good movement, but two, it couldn't get highly contaminated with sand because they were in the field in Namibia. What they ended up doing was actually cutting out pieces of like the Land Rovers like seat leather.
Annatasha: because the leather actually moved well and didn't trap sand and you could also take it out and wash it. And so they cut their car up with a bunch of PVC piping to make like a research level anesthesia circuit.
Annatasha: So yeah, I think, yeah, we just, we MacGyver or we jerry-rig a whole bunch more stuff than I think would be standard of care for you could probably get sued if you were this guy.
Mika Hamilton: yeah
Annatasha: Don't put it on the prep use. but yeah
Mika Hamilton: Yeah. Yeah.
Annatasha: But yeah, so like we we have a lot more like creativity out of necessity, not necessarily because we're inherently more creative.
Mika Hamilton: yeah
Annatasha: I don't i don't mean to undermine human anesthesiologist. But yeah, I think that's one thing you guys could learn from us. And I mean, we hold a lot of physiological variables in our head.
Annatasha: Just, you know, who has a two-chambered heart, a three-chambered heart, who has, you know, paired lung sacs, who oxygenates on expiration, who has hypoxic respiratory drive, you know, like who goes into a diving reflex.
Annatasha: And so we're usually like anesthesiologists and vet med are pretty hardcore physiologists for the most part.
Ryan Bailey: Yes.
Annatasha: so I don't know.
Gianluca Bini: Yeah. Yeah.
Annatasha: I think that's probably one of the things that when people like come shadow with us, yeah you know, yeah and we, for example, in my hospital too, like I'll switch between small and equine just by walking down the hall. And like a lot of times they're like mind blown, you know, cause you know, horses are obviously very different from cats and dogs and what have you.
Annatasha: So it's my two cents.
Gianluca Bini: yeah
Mika Hamilton: that Well, I mean, when I was thinking about that question, that's actually what i came up with was I don't know if adaptability is the right word, but that skill of just dealing with, you know, like hundreds of different species and different monitors don't work for different animals and having to like pull things together and being in different places and just kind of getting on with it, if that's okay to say, like you just have to.
Annatasha: resiliency yeah like we're a little yeah we're more like Ryan loves to build peep valves from bucket of water and like sometimes like most of us can probably build like a breathing circuit and and basic anesthesia machine just from like was like one of those games like a party game like here's a bunch of parts like build an anesthesia machine like you know we could probably most of us get away with that and I'm not sure that humans could because you're you know you guys all like beautiful like top of the line state of the art and everything is very like
Mika Hamilton: yeah, yeah.
Mika Hamilton: Yeah.
Annatasha: you know, protocolized and what have you. Whereas we're like a lot, sometimes when you're doing a case, you're like, someone's like, oh, have you done a lot of lemurs? And you're like, God, no, this is the first lemur I've ever done.
Mika Hamilton: yeah
Ryan Bailey: Yeah.
Annatasha: And they'll be like, well, how's it doing? And I'm like, I have So I feel like we roll with like the unexpected with a higher resiliency. But then again, your patients talk, which makes me feel nauseous.
Annatasha: So... Anytime the humans talk like on the table, like during like C-sections and things, I'm like.
Mika Hamilton: yeah
Mika Hamilton: no sometimes they have like some great conversations and you meet some really interesting people so it's quite nice but I'm thinking as well though like I mean you were talking last time about you know trained veterinary anesthesiologists and I'm just thinking about you know Obviously, I work in Toronto and we have amazing resources and machines and equipment and safety monitors. But there are like many countries in the world where, again, there's not enough trained anesthesiologists to look after the population.
Annatasha: only, you know, four or five drugs are legal to practice with, right? Because like a lot of countries have significantly more stringent, you know, drug related limitations, lot to do with like cultural beliefs and also like human dependency or the human addiction factor. But I mean, can be really challenging to get opioids and ketamine in Southeast Asia countries, right?
Annatasha: So yeah, I think that behooves us well. And I've definitely been in cases before where like people have called for advice and I'm like, okay, like i actually have to engage my brain to answer the question because their resources are so channeled into such a fine line that you would basically have to make magic happen with like maybe three things.
Annatasha: as opposed to like the entire toolkit to your, but and I sometimes have to remind diplomates, like you can be quite critical about things. I'll be like, you know, if we're sharing like an educational platform or we're presenting at a symposium or whatever, and they'll be like, well, this is very basic or this is da, da, da. And I'm like,
Annatasha: not everybody practices is it in like EU and North America, right? And if we're trying you know, address global standards, you have to have that whole spectrum available to people who may only have like limited resources or limited access to specialists.
Annatasha: So, yeah.
Gianluca Bini: Yeah, I wish we learned from human medicine, I wish we learned you know how important like
Gianluca Bini: you know having some of the monitoring, right? CaptionGraph only made it to being a basic anesthesia monitoring equipment in the 2025 anesthesia monitoring guidelines.
Gianluca Bini: You know what I mean?
Ryan Bailey: Yeah.
Gianluca Bini: like And people... Yeah, and people were having these like discussions on some Facebook group about, like, I read a post at some point where somebody was like, you know, so what do we do if we...
Gianluca Bini: And if we don't have one, and i'm like, fucking buy one. You know what I mean? Like there's people out there that spend like $30,000 on like, you know, digital x-rays and then they don't spend, you know, 5K on a monitor or they don't spend $2,000 to buy, you know, the Caprograph module for that monitor.
Annatasha: Thank you.
Gianluca Bini: I'm like, one of them is going to kill your patient. The other one definitely doesn't. You know what i mean? Like, so... i don't know, like, I wish we, you know, people a lot of people in that matter think they take anesthesia as like,
Gianluca Bini: you know, something.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah, it's something like they don't, they accept the fact that some of the patients die, right?
Ryan Bailey: yeah
Gianluca Bini: They just accept it and they're like, oh, it's okay. theyre Some of them are going to die. I'm like, that's not fucking okay.
Ryan Bailey: Our mortality rate is like, what, 10 times the human weight?
Gianluca Bini: In dogs, it's one in 600, and the last reporting humans is one in 400,000, which is, it puts it, like, probably close to, like, you know, 100.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: Yeah.
Ryan Bailey: And in rabbits, it's one in 10.
Gianluca Bini: Yeah. yeah
Annatasha: Because rabbits suck.
Ryan Bailey: As someone who did research in rabbits for anesthesia, I, oh, I remember.
