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Special Ep3 - From People to Poodles: Cross-Species Anesthesia Adventures
228 Plays3 months ago
Ever wondered how putting a person under stacks up against anesthetizing a poodle? In this special episode, our trio of veterinary anesthesiologists welcomes human anesthesiologist Dr. Mika Hamilton to the show! Together we compare the worlds of human and veterinary anesthesia—where they overlap, where they diverge, and the funny surprises in between. From monitoring gadgets to patient cooperation (or lack thereof), this conversation proves that while anesthesia may look different across species, the passion for keeping patients safe is universal.
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Transcript
Intro
Introduction and Guest Introduction
00:00:39
Gianluca Bini
So tonight we are joined by Dr. Mika Hamilton, which is an assistant professor at the University of Toronto and a staff anesthesiologist and intensivist at UHN.
00:00:53
Gianluca Bini
Thank you so much for being here with us on the Random Anesthesia Topic podcast. So I have a lot of questions for human anesthesiologist.
00:01:06
Mika Hamilton
Yeah.
00:01:07
Ryan Bailey
and
00:01:07
Gianluca Bini
hi I once attended a course that's usually done for human anesthesiologists at the Royal College of Anesthesia thing in London.
00:01:20
Mika Hamilton
yeah
00:01:20
Gianluca Bini
And they all looked at me super weird when I was like, am I actually a vet?
00:01:27
Mika Hamilton
Yeah.
00:01:31
Annatasha
surprised they didn't quarantine you in the tropical disease unit.
00:01:31
Gianluca Bini
And the
00:01:34
Mika Hamilton
Yeah.
00:01:34
Gianluca Bini
they they were about to. But...
00:01:36
Annatasha
Yeah.
Methadone in Human vs. Veterinary Medicine
00:01:37
Gianluca Bini
But got even where there looks when at lunch somebody asked me, like, you know, what what do you normally give to dogs for pain management and opioid-wise?
00:01:53
Gianluca Bini
and i And my answer was Medellin. It's one of my favorite, you know, opioids.
00:01:57
Mika Hamilton
yeah yeah
00:01:59
Gianluca Bini
And they were like, on which planet do you even live? Yeah.
00:02:06
Gianluca Bini
So I assume that that's not an opioid that you guys normally use. So, know, of course you guys have way more access to fancy toys than we normally do, but just for a matter of cost.
00:02:22
Gianluca Bini
But, you know, i i was one i always wondered, right? Like, so does methadone has even a place in human pain management at all?
00:02:33
Mika Hamilton
I would say we use it very rarely. Obviously, if a patient comes in already established on methadone from home, then, you know, we do our absolute utmost to continue it.
00:02:36
Gianluca Bini
Okay.
00:02:45
Mika Hamilton
it may have more of a role in our chronic pain patients. But from a sort of perioperative anesthesia perspective, I can't say that I've actually ever used it unless i've ordered it to make sure the patient gets the regular methadone when you know when they go back to the ward so
00:03:03
Gianluca Bini
So what do you normally use?
Opioid Use in the UK and Canada
00:03:04
Gianluca Bini
Is just fentanyl or morphine or what what do you...
00:03:04
Mika Hamilton
and
00:03:07
Mika Hamilton
Yeah, so, well, when I worked in the UK, it would be fentanyl and morphine, usually fentanyl for induction and then, you know, for acute pain postoperatively and morphine for, you know, more long acting.
00:03:21
Mika Hamilton
Then when I moved over to Canada and, you know, maybe this is just the centre where I work, but we tend to use hydromorphone instead of morphine. I do not know why we use one over the other.
00:03:33
Mika Hamilton
We have both available. I think and think a lot of the time your practice is a little dictated by kind of where you work and what's sort of established, be quite honest.
00:03:35
Ryan Bailey
Yeah.
00:03:43
Mika Hamilton
So in my practice, we use we use fentanyl for induction, fentanyl for pain relief. We can use fentanyl for PCAs, more ah more often we would use hydromorphone for post-op pain, IV and oral.
00:03:58
Mika Hamilton
We also use a fair bit of remifentanil as well, know which but which is super short-acted.
00:04:04
Gianluca Bini
My favorite.
00:04:05
Mika Hamilton
not the yeah
00:04:05
Gianluca Bini
My favorite.
00:04:07
Mika Hamilton
so So definitely just a sort of perioperative medication that we would
Steroid Use in Anesthesia
00:04:11
Mika Hamilton
use. So, yeah.
00:04:13
Gianluca Bini
I want to point out Tasha's face because I love Remy Fanden Heel. But...
00:04:18
Mika Hamilton
Yeah.
00:04:19
Annatasha
I don't hate remifentanil. Like it's just a weird favorite, to like it's it's just, you're just annoying.
00:04:24
Ryan Bailey
Awesome.
00:04:26
Annatasha
Like it's just a weird thing to be like, oh, I love drugs that disappear in four minutes. it's Like, no. but
00:04:34
Gianluca Bini
Why not?
00:04:35
Mika Hamilton
It's so reliable, though.
00:04:36
Gianluca Bini
It's amazing.
00:04:38
Annatasha
It's amazing, I guess, in the right circumstances. But like if I had a shattered femur, I wouldn't want to be recovered on an acute like remifentanil CRI that someone stopped.
00:04:47
Mika Hamilton
No, for sure.
00:04:48
Annatasha
because I'm a big believer, like, oh, I'll kick you. I'm a terrible patient.
00:04:53
Ryan Bailey
You probably have move your leg though.
00:04:55
Annatasha
Other leg. I've got two for now.
00:04:56
Mika Hamilton
The other one.
00:04:57
Ryan Bailey
yeah
00:04:58
Mika Hamilton
Okay.
00:04:59
Annatasha
All right. And can I ask, actually, Mika,
Surgeons vs. Anesthesiologists Dynamics
00:05:01
Annatasha
why? I know that methadone is very much used in, like, the human medical realm, particularly, like, what when I've seen it used, when I've gone on human anesthesia rotations, it's often used for people who, you know, like, it was most commonly used for
00:05:06
Mika Hamilton
Yeah.
00:05:15
Gianluca Bini
Thank you.
00:05:16
Annatasha
heart valve replacement in patients who had like a history of chronic IV drug use. And so they'd actually been transitioned over to methadone and and the anesthesiologists were, you know, giving or in first the anesthesiologist, then the perfusionist, then back to the anesthesiologist, were giving methadone just so the patient didn't go into acute withdrawal.
00:05:34
Mika Hamilton
yeah
00:05:34
Annatasha
But is there any like thought at all about why methadone, for example, because I mean, i mean we like make it rain with methadone in veterinary anesthesia.
00:05:42
Mika Hamilton
Thank you.
00:05:43
Annatasha
even though for example like I was trained back in vet school mostly on morphine then we all went to hydromorphone and now we've all
Veterinary Anesthesia Access Challenges
00:05:50
Annatasha
shifted a little bit more to methadone because in our patient populations we find that methadone tends to be you know like less ametogenic and it doesn't quite cause the same level of tachypnea but on the other hand it's not that great of a sedative like why don't people use methadone is it convention or is there a different pathway or what's happening here
00:06:08
Gianluca Bini
Thank
00:06:10
Mika Hamilton
I am going to say it's probably convention. I think methadone in human use is probably just more associated with like other other functions rather than sort of you know perioperative analgesia.
00:06:25
Mika Hamilton
So let's say you know the patients who have had you know like an opioid dependence disorder or
00:06:25
Annatasha
Yep.
00:06:30
Mika Hamilton
ah ah patients who have a chronic pain and they're on you know sort of a multi-modal regime it tends to be fairly well i would say it in my local practice fairly isolated to those indications it might get brought out for example if you've got the you know the patient who's post-op and you know they're on the ward and they're being seen by the acute pain team and you just cannot get on top of their pain
00:06:34
Annatasha
yeah
00:06:54
Annatasha
ye
00:06:54
Mika Hamilton
it may be something that's considered as an as an adjunct. But yeah, it's just really, yeah, it's just, i've I've really not seen it used very much in humans at all the perioperative phase, but.
00:06:57
Annatasha
Yeah.
00:06:59
Gianluca Bini
That's weird.
00:07:04
Gianluca Bini
Yeah.
00:07:04
Annatasha
Yeah. Because we'll use it and we'll use it in primates, right?
00:07:06
Mika Hamilton
yeah
00:07:08
Annatasha
Which, you know chicken you know, couldn't get any closer.
00:07:08
Mika Hamilton
Right. Yeah.
00:07:09
Ryan Bailey
Yeah, for sure.
00:07:11
Gianluca Bini
Yeah.
00:07:13
Annatasha
But yeah, we will use it in primates.
00:07:14
Ryan Bailey
Yeah.
00:07:17
Annatasha
Basically the same, just we're we're just naked.
00:07:17
Gianluca Bini
Yeah. Yeah.
00:07:19
Mika Hamilton
Yeah.
00:07:19
Ryan Bailey
yeah
00:07:20
Mika Hamilton
So what do you,
00:07:20
Annatasha
hairless Hairless apes, right?
00:07:22
Annatasha
But no, that's interesting because I mean, particularly like you know methadone, like I've used it in goats and horses and dogs and cats and rabbits, like the whole spectrum of these guys.
00:07:23
Mika Hamilton
Yeah. Yeah.
00:07:30
Gianluca Bini
yeah
00:07:31
Mika Hamilton
know Yeah.
00:07:32
Annatasha
But yeah, it's very, I just, you know, usually went the same thing with Gianluca, like you say that to a human anesthesiologist, they're like, what? But like I said, it's probably these days, it used to be hydromorphal, but these days it is very, you know, methadone centric practice.
00:07:47
Annatasha
So.
00:07:48
Ryan Bailey
Yeah.
00:07:49
Mika Hamilton
And what are the main reasons for that in veterinary practice then that methadone is now the analgesic of choice?
00:07:49
Gianluca Bini
yeah
00:07:58
Gianluca Bini
Well, I think part of it is that we see a lot of emesis with... So the way we... The way veterinary anesthesia normally in 99% of places work is that usually you administer your pre-meds IM,
00:08:15
Gianluca Bini
because you can oftentimes you can't have a patient stay still enough to place an IV catheter right?
00:08:19
Mika Hamilton
Mm-hmm. Mm-hmm. Mm-hmm.
00:08:22
Gianluca Bini
So in order to place an IV calder, we usually want to have a combination, upper medication IM that sedates your patient enough to then place an IV calder.
00:08:32
Gianluca Bini
So our usual combination for IM pre-med is alpha-2 agonist, usually dexmeletomidine, and then
00:08:32
Mika Hamilton
right
00:08:43
Gianluca Bini
If they're going to surgery, usually a pure muopioid like methadone. If we do give
Personal Anesthesia Practice Preferences
00:08:50
Gianluca Bini
morphine or hydromorphone, our patients do tend to vomit.
00:08:55
Mika Hamilton
Right. Hmm.
00:08:55
Gianluca Bini
And so then we you either give them antiemetic or soon enough in the morning before you give the premed to try and minimize the the risk of vomiting, or your patient is going to puke.
00:09:14
Gianluca Bini
So like we metadone, we don't see that as much or actually almost never really did never vomit. And so it's a, it's a pure me opioid.
00:09:25
Gianluca Bini
It has a little bit of NMDA antagonism as well, which is kind of unique amongst the opioids.
00:09:28
Mika Hamilton
Oh. Mm-hmm.
00:09:32
Gianluca Bini
And then it doesn't have the vomiting side effect. has a It causes a little bit less tachypnea, compared to like hydro and morphine.
00:09:41
Annatasha
You don' see like that idiopathic hyperthermia that cats get that you will see, for example, like oxymorphine, like methadone doesn't really give, we we do see idiopathic hyperthermia related to opioid use in cats, which tends to be self-limiting and will resolve once you stop dosing them.
00:09:48
Ryan Bailey
I think
00:09:54
Mika Hamilton
know
00:09:57
Annatasha
But you don't see that when you use methadone nearly as much as you would, for example, some of the other PMUs.
Species-Specific Anesthesia Challenges
00:10:04
Annatasha
But cats are really, cats are really an entity unto themselves.
00:10:05
Ryan Bailey
i think
00:10:06
Annatasha
And if, you know, yeah.
00:10:09
Mika Hamilton
And always.
00:10:09
Ryan Bailey
And even even if we do give it hydro IV compared to methadone, you still see a lot more, maybe not vomiting, but you see a lot more like signs of nausea.
00:10:10
Mika Hamilton
Mm-hmm.
00:10:20
Ryan Bailey
If you think that exists in dogs and cats, like you see a lot more of the like hyper salivation. I would speculate they tend to regurg a little bit more relative to methadone.
00:10:31
Ryan Bailey
I don't know.
00:10:31
Annatasha
wait When you said that nausea, whether it exists in dogs and cats, are you...
00:10:32
Ryan Bailey
Yeah.
00:10:35
Ryan Bailey
one There are people out there who are like, no, it doesn't exist because it's like the perception of the idea that you're going to vomit or something. It's like, because animals don't have conscious perception.
00:10:47
Ryan Bailey
i'm not I'm not here to talk about it. It's just...
00:10:49
Annatasha
I'm gonna disregard all of those stupid remarks, yeah.
00:10:51
Ryan Bailey
There's people who say hey these things because like there's some really good stuff on nausea in dogs and cats and like, or mostly in dogs. And so we were like, well, you know, does nausea actually occur?
00:11:02
Ryan Bailey
It's like, how do you tell it? Like we're putting these symptoms into a class. Like we're saying the dog's like hyper-salvary.
00:11:07
Annatasha
So we're being accused of anthropomorphizing as usual, right?
00:11:11
Ryan Bailey
Yeah, exactly. exactly Yeah. I'm not here like, you know.
00:11:15
Annatasha
I just wanted to make sure that you were on the side of believing quote in nausea and, and.
00:11:18
Ryan Bailey
Yeah. For sure. When the dog's drooling everywhere and like keeps licking their lips, like they're gonna fucking vomit.
00:11:22
Annatasha
She thinks.
00:11:25
Ryan Bailey
Like, yeah, that dog's nauseous. I don't know what to say. Like, that's the word I'm gonna use. I guess some smarter person can tell me why it's wrong. Whatever.
00:11:35
Mika Hamilton
So one of my dogs ate an entire pack of nut brittle last year.
00:11:35
Annatasha
Fine.
00:11:41
Mika Hamilton
He definitely looked nauseous all night.
00:11:43
Ryan Bailey
Yeah.
00:11:44
Mika Hamilton
Yeah.
00:11:45
Gianluca Bini
Yeah, of course.
00:11:46
Mika Hamilton
Fair guy.
00:11:46
Annatasha
And it's a schnauzer. So 100%, 100% the pancreas was like,
00:11:49
Ryan Bailey
Okay.
00:11:53
Mika Hamilton
Oh yeah.
00:11:54
Annatasha
yeah
00:11:55
Mika Hamilton
Luckily he was okay, but he was not.
00:11:56
Annatasha
yeah, those guys are basically the bread and butter of the internal medicine service.
00:11:57
Mika Hamilton
He was not.
00:12:01
Annatasha
Like, yeah.
00:12:01
Mika Hamilton
right
00:12:03
Mika Hamilton
guess I guess the thing with us in in humans is when we use these sorts of opiates,
00:12:03
Gianluca Bini
yeah
00:12:03
Annatasha
Yeah.
00:12:08
Mika Hamilton
I guess we're always
Adapting Human Anesthesia Equipment for Animals
00:12:10
Mika Hamilton
well, maybe me, I'm always, I always want to prevent nausea. So I will always give it with an anti emetic. So, you know, our favourites is on Dan's at wrong and dexamethasone.
00:12:22
Annatasha
Ours too.
00:12:23
Mika Hamilton
So
00:12:24
Annatasha
We don't use steroid as an antiemetic.
00:12:26
Ryan Bailey
hello
00:12:26
Annatasha
Wild.
00:12:26
Ryan Bailey
That is a great point. Like the steroid use in human anesthesia is so...
00:12:32
Annatasha
Wild.
00:12:33
Ryan Bailey
So vastly different. it's It's fascinating to me. Like the fact that like I've heard that before in that like, oh yeah, we use dexamethasone as like a anti-emetic drug or like there's something and I'm i'm not gonna remember this because it's like just a passing thing I learned many moons ago.
00:12:44
Mika Hamilton
Okay.
00:12:51
Ryan Bailey
something about like mucoceles and giving dexamethasone to like patients like post-operative mucoceles. I'm just like, whoa, if you brought that to the clinic, they would like be like, who's who brought the witch into the clinic?
00:13:07
Ryan Bailey
Thank you.
00:13:07
Annatasha
The shaman.
00:13:07
Gianluca Bini
Thank you.
00:13:09
Ryan Bailey
like, oh, what are we doing? Yeah.
00:13:12
Annatasha
Yeah, no, we we don't bandy steroids around a lot, especially because we we don't really see any difference in terms of like nausea levels with our patient populations.
00:13:15
Mika Hamilton
Right.
00:13:22
Annatasha
But because we really can't mix non-steroidals and steroids in most veterinary patients without causing severe GI upset, if not perforation.
00:13:31
Mika Hamilton
right
00:13:32
Ryan Bailey
Yeah. my
00:13:32
Annatasha
Like it's a big drama-rama if you have to give an NSAID a steroid.
00:13:36
Annatasha
And, you know, c steroids are reserved for very specific indications, you know, like adrenalectomy, for example, or Addisonian, or you know if a patient has, for example, IMHA or IBD, like all that kind of stuff.
00:13:49
Annatasha
So anesthesia anesthesiologists and vet med generally don't just, yeah, we don't sprinkle the steroids around, I don't think, at the same level that it seems to happen in human medicine, which is very interesting to us comparatively.
00:13:49
Gianluca Bini
Yeah. Yeah.
00:14:01
Mika Hamilton
yeah
00:14:02
Annatasha
So...
00:14:03
Mika Hamilton
Yeah, we use it quite a lot, for sure.
00:14:05
Annatasha
Yeah.
00:14:06
Gianluca Bini
yeah
00:14:06
Annatasha
And do humans get the same sort of like issues associated with like, ah like like if you had a steroid on board and then you took an Advil, like, is that a major consideration?
00:14:06
Mika Hamilton
Yeah. Yeah.
00:14:13
Annatasha
Because like this would send our critical care team like off the end of the earth if we did that.
00:14:14
Mika Hamilton
and
00:14:17
Ryan Bailey
I don't
00:14:20
Mika Hamilton
Yeah, so not really. We usually just give the one dose, you know, in surgery and it's usually, we'll usually give it near the start of the surgery so it's got kind of time to kick in when the patients are waking up.
00:14:25
Annatasha
Yep.
00:14:32
Mika Hamilton
So we generally don't have much concern around adding in the non-steroid dose.
00:14:37
Annatasha
So it's so weird because the other species that's like that is a horse, right?
00:14:38
Mika Hamilton
Yeah. Yeah. o
00:14:41
Annatasha
Like they jack up horses all the, sometimes they double the inset and give a steroid and you're just like, going pretend I didn't hear that.
00:14:45
Mika Hamilton
i
00:14:47
Annatasha
But, and horses generally seem to do okay.
00:14:47
Mika Hamilton
mr
00:14:48
Ryan Bailey
Yeah.
00:14:49
Annatasha
But if you did that to a dog or a cat, they'd either go into renal failure or perforate like within 48 hours.
00:14:54
Mika Hamilton
Wow okay good to know
00:14:55
Annatasha
So yeah.
00:14:57
Gianluca Bini
Yeah.
00:14:57
Annatasha
Now I have, can I ask a question?
00:14:57
Gianluca Bini
You
00:14:58
Annatasha
I have a really important question.
00:15:01
Gianluca Bini
can go over Yeah.
00:15:02
Annatasha
Okay. So Dr. Hamilton, as a general rule in veterinary medicine, anesthesiologists, veterinary anesthesiologists do not care for veterinary surgeons. And I'm just wondering whether or not this sentiment is also true of human anesthesiology.
00:15:22
Mika Hamilton
So,
00:15:24
Annatasha
I'm just going
00:15:26
Mika Hamilton
so I'm going to say that you're probably going be like, yeah, yeah, yeah. But the center that I work in, I actually work with a really great group of surgeons. Um, we have, you know, pretty collegial,
00:15:39
Mika Hamilton
atmosphere. that goes to like the whole ah ah OR team actually as well, our nursing staff and our attendants. So i'm quite I'm quite lucky because you know obviously I have heard that maybe relationships are not so great in other places.
00:15:56
Mika Hamilton
But I'm quite happy where I am. And I think one of the big things is the familiarity, is you you're working with the same person routinely.
00:16:08
Mika Hamilton
So you know what they like, what their quirks are.
00:16:08
Gianluca Bini
Yes.
00:16:12
Mika Hamilton
They know yours. can have you you know ah you know a respectful discussion, respectful relationship.
00:16:13
Ryan Bailey
Yeah.
00:16:20
Annatasha
We don't know any of this, what's that like?
00:16:24
Mika Hamilton
But it's really important.
00:16:24
Annatasha
And honestly, we can edit this out, but now you can tell us how you really feel.
00:16:27
Mika Hamilton
Yeah. And cut. yeah know ah ah And it's really important, actually, because like the data actually shows that good relationship and you know familiarity of the surgeon anesthesiologist dyad actually improves outcomes in patient safety.
00:16:36
Annatasha
Yes.
00:16:37
Gianluca Bini
Thank
00:16:44
Annatasha
Patient outcome, yeah. There's a big movement right now in VetMed where we're picking up on this OR cordiality is being related to not just like, you know, emotional health for the team and like professional wellbeing, but also we're now looking at our own patient outcomes based on that.
00:16:46
Mika Hamilton
hmm.
00:16:59
Mika Hamilton
Yeah, yeah
00:16:59
Annatasha
And next year we have a symposium that's actually looking at mitigating risk. And one of our topics is that is discussing, you know, this, the surgeon anesthesiologist dynamic and how it impacts the team and the patient. So.
00:17:11
Mika Hamilton
for sure.
00:17:11
Gianluca Bini
Yeah.
00:17:11
Mika Hamilton
I remember when I was in the UK, I think it was when I was in the yeah UK, there was actually like a, there was a campaign in healthcare and it was called Cut It Out. And it was all about sort of the, the,
00:17:25
Mika Hamilton
you know, the atmosphere in the operating room and sort of being collegial and civil and it, you know, actually improves things for everybody, like well-being and your healthcare workers and reducing nutrition and, you know, improved outcomes for your patients.
00:17:38
Mika Hamilton
So it's also very...
00:17:40
Gianluca Bini
Yeah.
00:17:40
Annatasha
I mean, I want to be clear that we're not the source of the issue.
00:17:41
Mika Hamilton
Yeah.
00:17:43
Annatasha
It's definitely the surge.
00:17:43
Mika Hamilton
Yeah.
00:17:45
Ryan Bailey
Yes. We're not the problem.
00:17:46
Gianluca Bini
know but No, but I think
00:17:47
Annatasha
Yeah. Mm-hmm.
00:17:49
Ryan Bailey
Idiosyncrasies here at all. Not in this team. Not for any of us. No idiosyncrasies at all. We're easy going. Go with the flow. Palm tree in the hurricane.
00:17:58
Mika Hamilton
Yeah.
00:18:00
Annatasha
Yeah.
00:18:01
Gianluca Bini
Well, part of the issue, I think that the difference
Comparing Human and Veterinary Anesthesia Practices
00:18:05
Gianluca Bini
between the difference between veterinary medicine and human medicine is that, you know, and and I don't know if you are surprised to hear this, but most 99% of pets do not go under anesthesia with an anesthesiologist.
00:18:20
Gianluca Bini
Like, you know, in the U.S.,
00:18:20
Mika Hamilton
yes
00:18:21
Ryan Bailey
So.
00:18:24
Gianluca Bini
that is active at the moment, there is about 240, 250 board certified anesthesiologists, period.
00:18:30
Mika Hamilton
Mm-hmm.
00:18:31
Gianluca Bini
And so like, yeah you know, and and most of us are, you know, in either academic institutions or very highly specialized referral centers, right? So, you know, big universities have 12 of us, nine of us, you know, and so like, I'm not saying they're hoarding us, but they kind of are.
00:18:53
Gianluca Bini
And so like, you know, a lot of surgeons are not used to have one of us around, right?
00:18:57
Ryan Bailey
Mm-hmm.
00:18:59
Gianluca Bini
They're not trained with one of us around. and or And so like, which which is interesting, right? Like it's, I would never want to go under anesthesia without an anesthesiologist.
00:19:13
Gianluca Bini
think the issue is that a lot of owners don't even know that that's the case.
00:19:17
Mika Hamilton
Mm-hmm. Mm-hmm.
00:19:17
Gianluca Bini
Like, you know, we have friends that
00:19:17
Mika Hamilton
Mm-hmm.
00:19:20
Gianluca Bini
I was at dinner with friends and they were like, you know, oh, yeah, we took our cat in for a spay. And the anesthesiologist, I was like, and there is no anesthesiologist.
00:19:29
Gianluca Bini
Two of us in the whole state of Oklahoma and it's me and the other one is, definitely not at the clinic.
00:19:30
Ryan Bailey
Yeah.
00:19:38
Gianluca Bini
So she was like, what do you mean? i was like, yeah, that your cat did not go under with an anesthesiologist. I'm so sorry. But, and you know, and and I think that that's part of the issue there, right?
00:19:50
Gianluca Bini
Like we don't have, there isn't enough of us. A lot of pets don't have access to one of us and surgeons don't have access to one of us either.
00:19:57
Mika Hamilton
Thank
00:19:59
Gianluca Bini
And so then they, when one of us comes in, don't have to of us. A lot of the times it actually creates issues, right? Like in in big referral centers, when they try to hire an anesthesiologist and start an anesthesia service, a lot of anesthesiologists face problems because the surgeons get paid, they get they paid you know a percentage of of what they make from the surgery, which includes anesthesia.
00:20:28
Gianluca Bini
Now, once they bring in an anesthesiologist,
00:20:28
Mika Hamilton
Mm-hmm. Mm-hmm. Mm-hmm.
00:20:31
Gianluca Bini
that percentage decreases because the anesthesia part goes to the anesthesiologist, right, or it should least. And so a lot of surgeons have that issue there with where, you know, their money actually decreases and they're not happy with it.
00:20:46
Gianluca Bini
And so some...
00:20:46
Ryan Bailey
Or everything's more expensive for the client. Like there's charges to factor in now the increased level of care that's being provided. So the ah ah sp the attending doesn't see a reduced charge.
00:20:57
Ryan Bailey
They subsidize the anesthesia costs by like adding in, you know, small fees to every case to add in like the additional care that's being provided is another another model.
00:21:02
Mika Hamilton
All right.
00:21:08
Ryan Bailey
But yeah, for sure.
00:21:10
Gianluca Bini
Some corporations didn't even want to hire
00:21:10
Annatasha
Also, some of them are just jerks. So yeah, it takes it's a lot of work to break a surgeon in, I find. I try to yeah, if they've never worked with an anesthesiologist before, it's a very big uphill battle.
00:21:22
Ryan Bailey
Yeah.
00:21:23
Annatasha
Now,
00:21:23
Ryan Bailey
They're also used to a whole level of like care that like they're having they're having to do two sides of the coin. Right. Like just not not to like take the surgeon's side, Bartel, calm down.
00:21:34
Ryan Bailey
But like. when they're training, they're having to learn how to manage anesthesia while also slicing and dicing in there, whatever they do, whatever it is that they do with the blade, I don't know. But, you know, they're having to also then manage when the tech says, oh, this is, this parameter is off. And they're like, they have to decide, do I focus on the surgery? Do I focus on the patient? How do I divide that attention? So there's, there is a level of control that they're being asked to give up. And I think that I can understand as,
00:22:03
Ryan Bailey
someone who has some control issues, how that could be incredibly challenging.
00:22:08
Mika Hamilton
and As a human anesthesiologist, that's given me palpitations to think about someone having to decide between the focus on the surgical procedure or the focus on there the airway, the hemodynamics, the oxygenation.
00:22:09
Ryan Bailey
Just to play devil's advocate a little bit.
00:22:20
Annatasha
Oh, yeah. no There's a lot of wild stuff that goes on in our profession. And like, I mean, we've got sometimes we've got patients on the table, for example, that might be you know, like race horses can be worth millions and millions of dollars.
00:22:31
Ryan Bailey
Okay.
00:22:32
Annatasha
a breeding cow that, you know, like really produces great calves for either meat or milk can be worth hundreds and hundreds of thousands of millions of dollars.
00:22:37
Mika Hamilton
Mm-hmm. Mm-hmm. Mm-hmm.
00:22:39
Ryan Bailey
Yeah.
00:22:39
Annatasha
Even fancy Japanese koi goldfish, like a breeding male can be worth like $50,000, right? And, you know, these patients go to the table and they don't have an anesthesiologist,
Regional Blocks in Veterinary Medicine
00:22:51
Annatasha
right? And they have, you know, and I think that's always crazy. Like when you have like a $20 million dollars race horse go to the table with a fractured leg,
00:22:58
Annatasha
And I mean, standing up a horse is a big drama-rama in terms of anesthesia risk. and And then they don't have an anesthesiologist on board. They have like the first year out of vet school intern trying to stand these horses up. Bailey's like pulling his hair out clumps.
00:23:10
Annatasha
But yes, no, it should give you heart palpitations and it gives us heart palp heart palpitations.
00:23:11
Ryan Bailey
I'm
00:23:13
Mika Hamilton
Yeah.
00:23:15
Annatasha
But There's a lot of people who don't, it doesn't seem to bother. And that includes the people who own these very expensive animals, which if it were my race horse, I would be like, I want six anesthesiologists standing this horse up, so.
00:23:21
Gianluca Bini
But they don't know. I think a lot of people don't know.
00:23:27
Mika Hamilton
hello
00:23:28
Gianluca Bini
I don't think they know.
00:23:29
Ryan Bailey
going to ask the stupidest question today, Mika, and I totally apologize, but you're like
00:23:30
Gianluca Bini
I don't they know.
00:23:38
Ryan Bailey
Like you're like one-to-one with a patient.
00:23:40
Mika Hamilton
yeah
00:23:41
Ryan Bailey
Like you are, like if I'm coming in to like have a rhinoplasty, that's whatever.
00:23:42
Mika Hamilton
but
00:23:47
Mika Hamilton
Yeah.
00:23:47
Ryan Bailey
You're going to be the person to like anesthetize me, monitor me, and subsequently wake me up.
00:23:50
Mika Hamilton
Yeah. yeah Absolutely.
00:23:54
Ryan Bailey
Okay, and then I'm going to jump into something that maybe you will want to cut it, whatever. But like, what is the role then of the CRNA?
00:24:00
Annatasha
Maybe you should debate a blogger.
00:24:07
Mika Hamilton
Oh, so we, CRNA, I think is more of a US style model. of
00:24:13
Ryan Bailey
Okay.
00:24:14
Mika Hamilton
We don't really know.
00:24:14
Ryan Bailey
Okay. I also wondered that too, because I was like, I don't know if that's a ah ah role that you have up in Canada.
00:24:16
Mika Hamilton
Yeah.
00:24:19
Ryan Bailey
Like that may just be an American. Because I do know there's some tension there.
00:24:21
Mika Hamilton
i
00:24:24
Mika Hamilton
It's an ongoing discussion, I believe.
00:24:26
Ryan Bailey
Yeah.
00:24:26
Mika Hamilton
We do have anesthesia assistants who are able to you know undertake sedation for patients, say, for example, well cataract surgery or, I don't know, upper limb surgery that's been done under regional block and the patient just needs some sedation in the operating room.
00:24:27
Gianluca Bini
you.
00:24:36
Ryan Bailey
Okay.
00:24:39
Ryan Bailey
What?
00:24:48
Mika Hamilton
So the anesthesia assistants can monitor those patients, but there will always be an anesthesiologist who's supervising them. they
00:24:58
Mika Hamilton
is I think and one it's one to two my my institution.
00:24:59
Ryan Bailey
Or there's probably, I'm sure there's some number ratio that you're allowed to do. and Okay. So yeah.
00:25:07
Mika Hamilton
for any induction of general anesthesia and extubation, an anesthesiologist has to be there.
Anesthesiologist Roles and Challenges
00:25:13
Gianluca Bini
I'm laughing.
00:25:13
Ryan Bailey
I mean,
00:25:14
Annatasha
We're sniggering, Mika, because sometimes we have done, like if especially when we've been at university hospitals, like you could have 29 things under.
00:25:16
Mika Hamilton
Thank
00:25:22
Ryan Bailey
yeah, for sure.
00:25:22
Mika Hamilton
Wow.
00:25:23
Annatasha
and And you're by yourself.
00:25:23
Gianluca Bini
And there is the one of you.
00:25:23
Mika Hamilton
Yeah.
00:25:25
Annatasha
And you act like there's usually a nurse or a student on every case, but you're literally like, ah you up the no, you know, 20 to 30 cases in your head, go to, and you just circle all the way around all the time.
00:25:30
Mika Hamilton
Yeah.
00:25:33
Mika Hamilton
Mm-hmm.
00:25:35
Annatasha
And if something goes potty in one place, then it may fall apart in another.
00:25:37
Mika Hamilton
Mm-hmm.
00:25:38
Annatasha
And, and I mean, I, I remember as a resident one night, I had splenectomy bleeding out, a ventral cervical disc, decompression case where they hit, uh, the artery and it was bleeding out.
00:25:39
Ryan Bailey
yeah.
00:25:44
Mika Hamilton
Mm-hmm.
00:25:50
Annatasha
And at the same time I was supposed to drop a horse for a colic surgery. by myself.
00:25:55
Ryan Bailey
yeah
00:25:57
Annatasha
So that does not happen in human medicine. Nice.
00:25:59
Mika Hamilton
and Yeah.
00:25:59
Annatasha
I knew I should have been a doctor.
00:26:00
Ryan Bailey
Yeah.
00:26:00
Mika Hamilton
So, sorry.
00:26:01
Ryan Bailey
i think I think the thing that blew my mind is the sedated cataract surgery.
00:26:01
Mika Hamilton
Oh. Mm-hmm.
00:26:05
Ryan Bailey
Like cataract surgery in a dog or a cat. can't think i've done one on a horse. It's like full anesthesia with paralytics, which for us is a big deal. Like, I mean, we can do paralytics. We're good at it, I think.
00:26:20
Ryan Bailey
But like paralysis is...
00:26:21
Annatasha
I was paralyzed to sun bear.
00:26:25
Ryan Bailey
That's cool.
00:26:26
Mika Hamilton
Yeah, for us, it's strong local anesthetic and then really just like conscious sedation.
00:26:28
Ryan Bailey
Good on
00:26:32
Ryan Bailey
So wild.
00:26:32
Mika Hamilton
so yeah. Obviously, you have a patient that can't lie still or maybe is claustrophobic you know, is not able to say so.
00:26:34
Ryan Bailey
It's wild. it
00:26:40
Annatasha
Yeah, because you can tell most people, like, you know, what to do, whereas we, you know, like, lemurs, for example, don't tend to sit still when you tell them to do that for x-rays.
00:26:41
Mika Hamilton
Yeah. Yeah. Yeah.
00:26:49
Mika Hamilton
I assume so.
00:26:50
Annatasha
So everything, most of our stuff goes under either very heavy sedation or general because it's just, just you know, these guinea pigs are just not as cooperative as you'd like them to be, so
00:26:50
Mika Hamilton
Yeah.
00:26:54
Mika Hamilton
Yeah.
00:27:01
Annatasha
Now I have another question too. so and Mika, what is your favorite type of anesthesia? Like, for example, like are you sub-specialized in neonatal or cardiothoracic what is your preferred preferred genre to anesthesia?
00:27:16
Mika Hamilton
So I'm a little bit different in that I actually spend half my time on the ICU. So then the other half of my clinical practice is in anesthesia. And I i do a little bit of everything at the at the place where I work. So a bit neuro, a bit of spine, general surgery, ortho.
00:27:36
Mika Hamilton
Neuro-radiology.
00:27:38
Gianluca Bini
If you had to pick one.
00:27:38
Mika Hamilton
So, yeah, okay. So I was actually thinking about, I've actually got a couple, i was thinking about like what's my kind favorite thing to do. Actually, one of my favorite cases to anesthetize for is bariatric surgery.
00:27:53
Mika Hamilton
and
00:27:53
Annatasha
Ooh, cool.
00:27:54
Mika Hamilton
yeah so And one of the reasons is is that the patients are usually, they're so happy. Like they're so excited. They've been waiting a long time for their surgery. They've gone through the whole process you know sticking to the diet losing a certain amount of weight going through the whole bariatric pre-assessment and you know obviously some some of them are nervous when they turn up which is completely understandable but so many of them are like okay time to go So, they're and they're really like, they walk into the OR and they're like, yes, you know, and and it makes a huge impact to their lives.
00:28:32
Mika Hamilton
So I really like doing those. And then my other kind of actually favorite case to do is, which is what I was doing today is anesthetizing for neuroradiology cases.
00:28:45
Mika Hamilton
So we will do things like embolizations of like cerebral aneurysms or AVMs. it's up in the neuroradiology suite, so it's not actually in the main operating room. And with anesthetizing these patients, you know, obviously there's a bit of stuff to do at the start, you know, like intubation, lines, art line, you know, infusions, making sure you maintain very, very stable blood pressure with the aneurysms.
00:29:01
Gianluca Bini
Thank you.
00:29:13
Mika Hamilton
But once you're settled and the radiologists are doing their thing, you can sit in a dark room quietly. you know There's no drama. There's no clanging of instruments.
00:29:27
Mika Hamilton
Sometimes there's great music on. Like today, the radiology team had lo-fi beats on, which was super relaxing.
00:29:32
Annatasha
but
00:29:35
Mika Hamilton
And it could be a two-hour procedure. it could be four-hour procedure. You just never know. And you just sit and make sure everything's as still and stable as possible.
00:29:46
Ryan Bailey
sounds like my ideal case, which is why my favorite animal to anesthetize is like an adult cow, like adult like ruminant, is because
00:29:48
Mika Hamilton
yeah
00:29:59
Annatasha
I think I did not know this about you, but anyway, continue.
00:30:02
Ryan Bailey
You don't have to do nothing.
00:30:02
Mika Hamilton
Mm-hmm. Mm-hmm.
00:30:03
Ryan Bailey
You dont have to do nothing. they They breathe great. They keep stable blood pressures. Heart rate stays fine. Like, a different situation.
00:30:10
Annatasha
Oh, it's mad hard to kill a cow, right? Like there's certain animals that just drop dead. Like if you look at them, cows are robust.
00:30:18
Ryan Bailey
But under anesthesia, they are just a flat line all the way across, and you don't have to do it single – you don't have to lift a finger. You just get to make your dots, and you're just, like, relaxing.
00:30:31
Ryan Bailey
It's great.
00:30:31
Annatasha
You love that.
00:30:31
Ryan Bailey
It's awesome.
00:30:32
Annatasha
You love going into that weird anesthesia Zen zone and like the quiet OR and you just sit and like overanalyze your ECG.
00:30:36
Mika Hamilton
Mm-hmm. Mm-hmm.
00:30:37
Ryan Bailey
Oh, my God, the quiet OR is like, oh,
00:30:39
Annatasha
I know you love that.
00:30:40
Mika Hamilton
yeah
00:30:43
Annatasha
No, no, no. I like the, I like the, like, you know, my hands pumping the heart, like, you know, actually pumping the heart and like we're pouring in like auto transfusions and Xeno transfusions and like there's shit everywhere.
00:30:48
Ryan Bailey
oh my God. Yeah.
00:30:54
Annatasha
Like I like the high, adrenaline, high stakes stuff, but yeah, Ryan.
00:30:57
Mika Hamilton
the
00:30:59
Annatasha
Yeah. You like to go into your Zen zone. zone
00:31:03
Mika Hamilton
I like that, intermitently because I have enough of that on the ICU.
00:31:03
Ryan Bailey
yeah
00:31:07
Mika Hamilton
So when I'm in my anesthesia, I would prefer that not to happen. But obviously, even in the most stable case, that's just the anesthesia is all of a sudden.
00:31:16
Ryan Bailey
Oh, yeah.
00:31:20
Mika Hamilton
you know, everyone's life is flashing before your eyes, and that's why we're trained to do.
00:31:23
Gianluca Bini
Oh, yeah.
00:31:24
Annatasha
I mean, it is nice sometimes just to have a nice case where you kind of go in the OR and you and the surgeon, like they're in their zone, you're in their zone, you know, you're kind of working together, but non-verbally and like you can just tune out and it's quiet and nobody asks you any questions and the that can be enjoyable.
00:31:25
Mika Hamilton
Yeah. yeah
00:31:40
Annatasha
Conversely, what's your least favorite type of anesthesia?
00:31:45
Mika Hamilton
so i wouldn't say least favorite but i think the type that stressed me out the most in which i don't really do anymore was obstetric anesthesia the emergency cesarean sections
00:31:58
Ryan Bailey
for you.
00:32:03
Mika Hamilton
Lots of panic, lots of stress. Patient's been rushed into the operating room and you're trying to talk to them and take a history and tell them what you're going to do as you're walking down the corridor. You're not doing things fast enough, you know so and and you know. And this was mostly when I was a trainee. So again, there's that added level of of of stress. So it can be a bit of a chaotic environment.
00:32:25
Mika Hamilton
Some of my you know anesthesia friends and colleagues love that.
00:32:26
Gianluca Bini
Thank you.
00:32:29
Annatasha
Love it.
00:32:30
Mika Hamilton
And they are obstetric anesthetists, you know, and that's why they are obstetric anesthetists. But yeah, that would and that would probably be the the type that would stress me out the most, I would say.
00:32:43
Mika Hamilton
Yeah.
00:32:44
Ryan Bailey
That is one thing we don't have to deal with. Like our patients are stressed for a variety of reasons, but we don't entirely have to deal with like taking a history and a person who is worried they're going to die or their baby's going to die. Like I can't.
00:32:59
Mika Hamilton
it's multiple layers of stress. but
00:33:01
Ryan Bailey
Yeah. I can't imagine what that's.
00:33:03
Mika Hamilton
And for people that like things to be controlled, can sometimes be not the most controlled environment, you know, lots of people.
00:33:09
Ryan Bailey
Yes.
00:33:12
Gianluca Bini
see some guitars. Do you play guitar?
00:33:15
Mika Hamilton
So I do not play guitar. Those are my partner's guitars. He was in a band before he went into medicine. So he has guitars and various...
00:33:22
Gianluca Bini
Oh wow.
00:33:24
Annatasha
Is he also an anesthesiologist?
00:33:24
Mika Hamilton
music No, he is... So he trains in emergency medicine and now he is a specializes in trauma.
00:33:29
Annatasha
Okay.
00:33:33
Mika Hamilton
So major traumas. But he also does critical care as well. so
00:33:37
Annatasha
Yeah, most vets you find it's like magnets.
00:33:37
Mika Hamilton
and sir yeah
00:33:40
Annatasha
We repel each other. So yeah, I wouldn't date yeah a vet for a billion dollars, but anyway.
00:33:41
Mika Hamilton
yeah
00:33:48
Annatasha
anyway
00:33:48
Mika Hamilton
We don't discuss medicine that much, actually, I have to say. Usually it's we'll come home, it's a five minute debrief and then, all right, Netflix time or, you know, yeah, try not to, yeah, try not to talk shop too much, so
00:34:01
Gianluca Bini
That's a very healthy way of doing it.
00:34:06
Gianluca Bini
That's fair.
00:34:06
Mika Hamilton
yeah So I don't play the guitar.
00:34:07
Gianluca Bini
So,
00:34:08
Mika Hamilton
I'm learning to play the violin. After 30-something years of not playing the violin, I decided life can't be all about medicine.
00:34:10
Ryan Bailey
Oh.
00:34:11
Gianluca Bini
wow.
00:34:19
Mika Hamilton
So I wanted to pick up that skill again. So,
00:34:22
Gianluca Bini
Fair.
Anesthesia Techniques and Experience
00:34:23
Mika Hamilton
yeah.
00:34:23
Gianluca Bini
Do you guys play an instrument like Ryan Tashley?
00:34:28
Ryan Bailey
I have no musical filming.
00:34:28
Annatasha
I have grade 10 flute under my belt.
00:34:32
Gianluca Bini
You have what?
00:34:33
Annatasha
Grade 10 flute under my belt. I also went to school in music scholarship.
00:34:38
Mika Hamilton
wow
00:34:38
Annatasha
And I, the only reason I didn't do a music degree is because my dad was like, I didn't pay all this money for you to serve tables. So I was like, oh, okay, dad. so yeah, he was not keen on me doing a music degree.
00:34:47
Ryan Bailey
a
00:34:50
Annatasha
So I didn't do my music degree. I did biology and here we are.
00:34:55
Gianluca Bini
Wow.
00:34:57
Annatasha
Yeah.
00:34:57
Ryan Bailey
I have no... I played an instrument as a kid, but never, never really.
00:34:57
Gianluca Bini
Wow.
00:35:01
Annatasha
Like a recorder. Yeah.
00:35:02
Ryan Bailey
No, I like did clarinet and then bass guitar, but I just never... I don't have a musical bone in my body. Like, I can't pick up a difference in a note. Like, I love listening to music, but I like...
00:35:14
Ryan Bailey
Couldn't tell you the difference between a B and a C or like a C flat or whatever the hell all the notes are called.
00:35:18
Mika Hamilton
Mm-hmm. Mm-hmm.
00:35:20
Gianluca Bini
Yeah.
00:35:21
Ryan Bailey
Yeah, I was it's not my i have learned I've taught myself to cook pretty well, though. So I think that's a pretty, pretty solid skill that I've got. I can really knock it out of the park.
00:35:32
Annatasha
Yeah, you can. yeah Both of you actually are excellent cooks. Now, Mika, do you, was just wondering, because we've asked you a lot of questions, and I usually find that human anesthesiologists have lots of questions for us about some of the weird and wonderful things we do.
00:35:36
Mika Hamilton
will
00:35:39
Mika Hamilton
oh like
00:35:47
Mika Hamilton
Yeah, so I actually, I have a WhatsApp group of my colleagues and I just sent a text saying, if you could ask, you know, veterinary anesthesiologist a question, what would you ask?
00:36:01
Mika Hamilton
And it was like, bing, bing, bing, bing.
00:36:04
Gianluca Bini
Oh yeah.
00:36:06
Mika Hamilton
So,
00:36:06
Annatasha
I knew that. Yeah. That's why i was like, we should let Mika have a chance to, cause I was like, I bet you there's a lot. Yeah.
00:36:11
Mika Hamilton
i there's a lot, so I'm not going to ask you all.
00:36:11
Gianluca Bini
yeah
00:36:13
Annatasha
She got glasses on.
00:36:14
Mika Hamilton
I know, I can't read it.
00:36:15
Ryan Bailey
my time to shine, everyone. Watch out.
00:36:17
Mika Hamilton
So some of the questions they had were, how do you monitor the depth of anesthesia in your patients?
00:36:17
Annatasha
Yeah. Be professional, Tasha.
00:36:25
Ryan Bailey
Oh, God.
00:36:26
Mika Hamilton
And is MAC a thing in vet anesthesia?
00:36:30
Annatasha
Yeah.
00:36:30
Ryan Bailey
Hell yeah.
00:36:31
Mika Hamilton
Yes, okay.
00:36:32
Annatasha
So it's totally species based. So both of those things, right?
00:36:34
Mika Hamilton
Right.
00:36:34
Ryan Bailey
Okay.
00:36:34
Mika Hamilton
Okay.
00:36:36
Annatasha
So Mac obviously varies with species. um um And the other thing is that monitoring depth of anesthesia varies very much between species, even within the own subclasses, right? So within mammals, fish, amphibians, reptiles, and avian, right?
00:36:50
Annatasha
Like, for example, you will find that in horses, like they could be very unpredictable in terms of how sympathetic tone relates to depth of anesthesia. But once they start to have things like palpebral and nystagmus, like you better be bolus and ketamine, otherwise that horse is going to walk off the table.
00:37:06
Ryan Bailey
Mm-hmm.
00:37:06
Annatasha
On the other hand, for example, like camelids, they only blink one of their two eyelids. So you have to look at the difference between like the dorsal and the ventral eyelid and and determine.
00:37:10
Mika Hamilton
Mm-hmm. Mm-hmm.
00:37:16
Annatasha
know, fish and snakes, for example, it's a writing reflex. So once they go on their back and they don't try to flip themselves, you would, they're at an appropriate depth, if not too deep.
00:37:24
Gianluca Bini
Okay.
00:37:24
Annatasha
So I mean, we still do the normal things. So we look at, you know, heart rate, blood pressure, ventilation, all that kind of stuff. but, but for example, when we're looking at the cranial nerves or the physical reflexes, cause you know, it can be very, very challenging if you have a horse on the table, who's actually having ocular procedure and you can't actually monitor the eye.
00:37:44
Annatasha
because like I said, a horse will go from zero to hero. Like it will literally like heart, it will go like this. And all of a sudden the horse will kick its leg. so it's totally species dependent.
00:37:52
Gianluca Bini
Thank you.
00:37:52
Mika Hamilton
Yeah.
00:37:53
Annatasha
And that's a big challenge is to you know, if you are doing a broad spectrum of species, you have to memorize all that. So So
00:38:00
Ryan Bailey
Okay.
00:38:01
Annatasha
Yeah, MAC is definitely a thing. We do use different inhalants. Like we've all used, I i don't know if you guys have used halothane. I'm the oldest here, but halothane, ISO, SIBO, and even desflurane.
00:38:12
Mika Hamilton
okay
00:38:13
Annatasha
It just depends on also where you practice to, like you said earlier. So it can be country dependent. It can also be conventional based on whatever institution you're in Brian Bailey and and I did some pretty interesting horse anesthetic protocols at UC Davis involving desflurane and propofol in a sling.
00:38:31
Ryan Bailey
First law.
00:38:31
Annatasha
But like don't ask, don't ask John Luca.
00:38:32
Ryan Bailey
First
00:38:35
Annatasha
But anyway, so it's species dependent and you have to you have to and essentially memorize it.
00:38:38
Mika Hamilton
Mm-hmm. Mm-hmm.
00:38:40
Annatasha
then, you know, the smaller the things get, i find, I prefer doing like megafauna or macrofauna to like teeny itty bitty things because in that case, like, I don't know what's going on. Like,
00:38:50
Annatasha
All of our equipment is human based, very little of it. It's been sized or calibrated for small species. And, you know, for example, you you think about a rabbit whose resting heart rate can be 260. two six see And the rule is, is if you can actually count the heart rate out, it's bradycardic.
00:39:06
Ryan Bailey
Mm-hmm.
00:39:06
Annatasha
and you And rabbits, of course, they metabolize atropine in their plasma, so they don't respond to atropines.
00:39:12
Annatasha
You have to use glycopyrrolate and da-da-da-da-da. And so, yeah, every little species has its own nuance.
00:39:19
Ryan Bailey
and
00:39:20
Annatasha
Yep. And, you know, we just... I mean, there's over 3000 tracheal variations within the animal kingdom as well. So that's super exciting on who bifurcates high, who bifurcates low, who has a diaphragm, who doesn't, who has a high right bronchial stem, who has a low right bronchial stem, who only has one right lung snakes.
00:39:27
Mika Hamilton
Thank
00:39:37
Annatasha
so yeah, so yeah, it's a lot.
00:39:38
Mika Hamilton
you.
00:39:40
Annatasha
It's a lot. There's a lot of crying overboard exams. Yeah.
00:39:43
Ryan Bailey
yeah
00:39:44
Gianluca Bini
I love i love how you went through all the species possible. You omitted cats and dogs.
00:39:51
Annatasha
Oh, that's boring.
00:39:51
Ryan Bailey
True.
00:39:53
Mika Hamilton
yeah
00:39:53
Annatasha
It's boring, I mean.
00:39:55
Ryan Bailey
At acceptable planes of anesthesia, goats eyes turn into bricks.
00:39:57
Mika Hamilton
Okay.
00:39:59
Annatasha
Yeah.
00:39:59
Mika Hamilton
and
00:39:59
Ryan Bailey
Like, yeah like, that's a classic, like, oh, it's a goat. Well, you're gonna look for when his pupil changes to the diameter of a brick.
00:40:06
Annatasha
know There you go. So, so we do have Mac. do practice max bearing techniques. I mean, we do a lot of local regional. I mean, all of us do ultrasound guided local
00:40:14
Mika Hamilton
okay
00:40:17
Annatasha
And I mean, I've done femoral sciatic on a beaver, know, like ultrasound guided.
00:40:21
Ryan Bailey
course you have.
00:40:21
Annatasha
Yeah, yeah, I know. So we do do it. So we do practice max bearing techniques. And like I said, yeah, our, our depth of anesthesia changes with the species. So.
00:40:31
Mika Hamilton
So that actually led my other questions, which was from one of my regional colleagues, was asking, what is the role of regional anesthesia in your practice and like what are some of your favorite blocks to do?
00:40:31
Ryan Bailey
We also have a lot
00:40:43
Ryan Bailey
Not what it should be is the answer.
00:40:44
Ryan Bailey
Like we are way...
00:40:47
Ryan Bailey
Yeah, way behind and it's super institution specific. Like where I trained, it was... it was just starting to become a thing, even though where Tasha trained, it was like their whole thing.
00:41:01
Ryan Bailey
Um, there are still places out there where they're just not, the, the trainees are not getting the exposure to local regionals. So they're coming out with like skills that are perpetuating a whole, it's a, it's a bit of a problem, but, we do it. We are probably like, i don't know, 10 years behind. I think Diego is catching up a little bit, but like,
00:41:21
Annatasha
Diego's catching up.
00:41:21
Gianluca Bini
Thank you.
00:41:22
Annatasha
But I mean, when I went to Davis, I actually taught your faculty how to do the blocks because I came from Cornell, right, where everyone did the ultrasound guided.
00:41:25
Ryan Bailey
Yeah. yeah
00:41:28
Annatasha
But what are my favorite blocks? I like ultrasound guided interscalene for forelimp amputation. That one's really technically challenging and something that's quadruped, right, like quadruped as opposed to an upright biped.
00:41:35
Mika Hamilton
Yeah. Mm-hmm.
00:41:41
Annatasha
I really like, know, for hip replacements or femoral head, ostectomies or pelvic fractures, I tend to do perilsacral sciatic and a psoas compartment block in lieu of an epidural so that I still have unilateral function so they can ambulate postoperatively.
00:41:59
Annatasha
Because getting our pets out and up and going to the to toilet outside, which is also very different from human medicine, a really big part of getting them home soon rather than later to limit, you know, post-operative nosocomial infection.
00:42:00
Mika Hamilton
yeah
00:42:02
Ryan Bailey
Yes.
00:42:11
Annatasha
So, yeah, those are my favorite blocks.
00:42:12
Mika Hamilton
Mm-hmm.
00:42:14
Annatasha
Beanie?
00:42:16
Gianluca Bini
think like ESP blocks are probably my erector spinae blocks. I love those.
00:42:22
Annatasha
you're doing that mostly for like hemilaminectomies and, yeah.
00:42:25
Gianluca Bini
Laminectomies, yeah. Yeah. But yeah, we're so behind. Like, for example, like epidurals, they were a thing in the past, but now like it's fizzing out a lot in vet med.
00:42:40
Gianluca Bini
Yeah. I don't know, like we're we're so behind humans. We're so behind. A lot of it is that we can't do sedation and a local, right?
00:42:50
Mika Hamilton
good
00:42:51
Gianluca Bini
You still need to do GA and a local because you can't tell the dog, hey, stay still. i i do a femoral sciatic for, you know, your knee surgery, right?
00:42:58
Ryan Bailey
Yeah.
00:43:01
Gianluca Bini
Like we can't do that. So, you know, unfortunately we're we're really behind. Right.
00:43:09
Ryan Bailey
But then the big advantage is the dog is now three-legged, you know, they can walk on three legs pretty well and we can send home the 70 kilo cane Corso to, you know, the 60 year old grandma who can't pick up her dog.
00:43:13
Gianluca Bini
Thank
00:43:21
Ryan Bailey
Like that dog can at least walk out and get into the car himself and get out of the car himself where the epidural that dog's immobilized and probably requires extra day of hospitalization all that.
00:43:32
Ryan Bailey
So.
00:43:33
Annatasha
And you have to pick your species too, right? Like you gotta be a little bit careful, for example, and that I tend not to block limbs out really heavily, for example, especially forelimbs and horses.
00:43:41
Ryan Bailey
Yeah.
00:43:41
Annatasha
because they actually get up by going onto their forelimbs first. And if they can't feel their leg, tend to panic because they're flight animals. So like, you know, it's very interesting. Like if a Labrador can't feel its leg, it doesn't care because it's still going to eat dinner.
00:43:54
Annatasha
a horse will thrash itself to death and probably break more limbs. So that's also bit species dependent.
00:43:57
Mika Hamilton
who
00:43:59
Annatasha
But I would say that I would block, I probably have a local regional block on board with nearly 100% of my cases.
00:44:06
Mika Hamilton
And is it all ultrasound guided?
00:44:08
Annatasha
It is for me.
00:44:09
Mika Hamilton
Yeah. Okay.
00:44:10
Ryan Bailey
Yeah, for the for most of us newer anesthesiologists, that's all ultrasound guided, before was all peripheral nerve stimulator.
00:44:17
Mika Hamilton
Yeah.
00:44:19
Mika Hamilton
Yeah. Same in human anaesthesia. I trained with peripheral nerve stimulators then ultrasound guidance was just coming in as I was finishing off my training and now it's, now it's how everyone's learning.
00:44:28
Annatasha
Yeah.
00:44:31
Mika Hamilton
and So yeah.
00:44:32
Gianluca Bini
Yeah.
00:44:32
Annatasha
Yeah. I think we're on this similar timeline trajectory for that anyway. But yeah, because I can do all my blocks with the both the nerve stimulator because sometimes, you know, if we locum in, like I might locum in a different practice or I might go teach and they might not have ultrasound access.
00:44:46
Annatasha
So I always feel that I need to be proficient in both techniques.
00:44:46
Ryan Bailey
No.
00:44:47
Mika Hamilton
Yeah.
00:44:50
Annatasha
There are still some wackadoos out there who are doing them all blind, which I do not canoe.
00:44:55
Mika Hamilton
he
00:44:55
Annatasha
But I don't do know it goes on.
00:44:58
Mika Hamilton
And on the subject of sort you know, using more and technologically advanced equipment, do you use um like video laryngoscopes for intubations in some of your animals or is it all direct laryngoscopy?
00:45:11
Gianluca Bini
So yeah, we we have it.
00:45:13
Annatasha
Not frequently.
00:45:14
Mika Hamilton
Yeah.
00:45:15
Ryan Bailey
no
00:45:16
Gianluca Bini
Like we have, we're not the ones with the camera on the blade.
00:45:16
Mika Hamilton
Mm
00:45:22
Mika Hamilton
hmm.
00:45:22
Gianluca Bini
We have like, you know, Ambu makes these little scopes that you can put into your endotracheal tube. And like we use it as a stylet.
00:45:33
Gianluca Bini
So it's not technically a video laryngoscope, although they try to sell it as such.
00:45:33
Mika Hamilton
Right. Yeah. Mm-hmm. Mm-hmm. Mm-hmm.
00:45:38
Mika Hamilton
yeah
00:45:39
Gianluca Bini
But sometimes it's...
00:45:39
Annatasha
You should appreciate though, Mika, sorry to interrupt Beanie, but like dogs and for dogs, particularly like dogs are dead easy to intubate. It's not quite as challenging as human beings.
00:45:50
Annatasha
Like you could literally like, if there was a Labrador over there that's Jaloban, like I could like arrow endotracheal tube in, right? Like, but then there are other species, for example, like pigs. which are nightmare or rabbits or camelids.
00:46:02
Annatasha
They just, they can't open their jaws.
00:46:04
Mika Hamilton
Right.
00:46:04
Annatasha
They have these humpy tongues that get in the way. They have terrible dentition with their little rabbit teeth.
00:46:09
Gianluca Bini
Yeah.
00:46:10
Annatasha
you know like They're prone to laryngospasm. Their larynx is like down the around the corner. So there's also species. So it it depends on on which case you're doing, but for the most part, we don't have those cool blades where it's embedded and that you guys actually dispose of or what have you.
00:46:19
Ryan Bailey
The horses do it today blind. Just things.
00:46:25
Annatasha
like We don't do that as much, no.
00:46:26
Mika Hamilton
right
00:46:27
Gianluca Bini
yeah
00:46:27
Annatasha
What did you say, Bailey?
00:46:29
Ryan Bailey
like Well, horses just do a blind. Just like...
00:46:31
Annatasha
Horses are done blind and cows are actually done by palpation, right?
00:46:32
Ryan Bailey
Your accident.
00:46:34
Annatasha
Like you actually put a gag in a cow's mouth, crank it open, and then one hand goes in and actually opens the arytenoids and then you use the tube and you actually feed it while your hand is actually on the larynx and that way you make sure that placement is appropriate.
00:46:37
Mika Hamilton
Mm-hmm. Mm-hmm.
00:46:46
Gianluca Bini
Yeah.
00:46:47
Annatasha
So we intubate very differently. Like I said, giraffes are the same.
00:46:50
Ryan Bailey
Giraffes are the same.
00:46:53
Annatasha
Elephants are blind. Yeah.
00:46:55
Ryan Bailey
Yeah.
00:46:56
Annatasha
Yeah.
00:46:56
Ryan Bailey
I will say, though, I was at the university, and their exotic service intubates rabbits with a scope.
00:47:03
Annatasha
Yeah.
00:47:05
Ryan Bailey
30 seconds.
00:47:06
Annatasha
I used to do it with the scope at Cornell if when it was available because rabbits make me want to.
00:47:06
Ryan Bailey
Like, more like with with a video scope.
00:47:11
Gianluca Bini
yeah
00:47:12
Annatasha
Yeah, yeah. I would do as a video scope to do rabbits.
00:47:14
Ryan Bailey
Yeah.
00:47:14
Annatasha
And even then it was.
00:47:14
Ryan Bailey
Oh my God. It was like 30 seconds. I was like, why don't we just get these everywhere? This is insane.
00:47:19
Annatasha
I don't know. I tend to use like my little rabbit adopted LMA for them because yeah i find superglottic is easier for rabbits.
00:47:24
Ryan Bailey
Yeah.
00:47:27
Annatasha
So I tend to do that.
00:47:28
Ryan Bailey
Yeah. Yeah, it's fair.
00:47:29
Mika Hamilton
i was I was actually going ask, do you use laryngeal masks much in the anesthesia? So.
00:47:34
Gianluca Bini
No.
00:47:34
Annatasha
Not much, much, but they're around.
00:47:35
Mika Hamilton
like
00:47:35
Ryan Bailey
Rabbits.
00:47:35
Annatasha
Yep.
00:47:36
Mika Hamilton
They're right, OK.
00:47:36
Ryan Bailey
Yeah.
00:47:37
Gianluca Bini
Mostly like cats. I think the the ones that we have that are most commonly used is rabbits. and There is some for cats, but I don't think that anybody actually uses them.
00:47:49
Mika Hamilton
know
00:47:51
Gianluca Bini
It's very rare. But for rabbits, we do because they're very hard to indubit.
00:47:56
Ryan Bailey
Yeah.
00:47:56
Mika Hamilton
Oh,
00:47:57
Annatasha
Yeah, they'll make you want to lie down and drink for a day. Like it is just, I mean, I've seen rabbit into visions take like four hours before, like it's just horror show.
00:48:00
Mika Hamilton
OK.
00:48:03
Mika Hamilton
And why is it hard?
00:48:04
Ryan Bailey
And the rabbit is intimately like profoundly cyanotic, like turns blue like.
00:48:06
Gianluca Bini
Thank you.
00:48:07
Mika Hamilton
Oh.
00:48:09
Annatasha
And they do not, they not into surviving. They're not a robust species.
00:48:13
Mika Hamilton
Yeah.
00:48:14
Annatasha
Like, yeah.
00:48:15
Mika Hamilton
Mm-hmm.
00:48:15
Ryan Bailey
Yeah. Rabbits at MAC anesthesia are hypotensive for sure.
00:48:18
Mika Hamilton
Mm-hmm.
00:48:19
Ryan Bailey
Map of 40 easily, easily. easily
00:48:23
Annatasha
Yeah, I usually weasel my way out of rabbits when I can.
00:48:24
Mika Hamilton
Is it just... Yeah.
00:48:27
Ryan Bailey
Me too. And I did my research at Rabbits.
00:48:31
Annatasha
I know. oh
00:48:31
Mika Hamilton
What is it anatomically that makes it so difficult to intubate a rabbit?
00:48:34
Annatasha
Well, this is a good exam question.
00:48:36
Mika Hamilton
Yeah.
00:48:36
Annatasha
This is a classic exam essay question, but yeah.
00:48:37
Ryan Bailey
I don't like this.
00:48:38
Mika Hamilton
Okay.
00:48:41
Annatasha
you can't open their jaw very wide.
00:48:42
Gianluca Bini
Okay.
00:48:43
Annatasha
They have that like rodent-esque dentition, right?
00:48:44
Mika Hamilton
okay
00:48:46
Annatasha
So they've got those super pronounced incisors that overlap. have these terrible dental arcades. They have ah ah a lingus torsus, which is basically a hump at the back.
00:48:56
Annatasha
And if you occlude those cotolingual
00:48:58
Ryan Bailey
Yep. Yep. Yep.
00:48:59
Annatasha
vessels, like they just become cyanotic, they swell and they obstruct.
00:49:03
Ryan Bailey
ye
00:49:03
Annatasha
You can't visualize it because it's so like, it's very caudal and distal. They're prone to laryngospasm and they're herbivores, which means they like to have cheeks full of crapola and they don't like ruminate or regurgitate, but yeah, their throat is usually goopy and
00:49:09
Ryan Bailey
yep
00:49:17
Ryan Bailey
yep
00:49:24
Annatasha
they just usually when a rabbit comes to you for something that's anesthetic related, it's usually like a late stage illness type thing in most cases, in which case they're already on like the cusp of deep like totally like being and non-compromised situation and they just die and you're like, Oh God.
00:49:40
Ryan Bailey
Thank
00:49:40
Annatasha
Yeah.
00:49:41
Mika Hamilton
here
00:49:42
Annatasha
Yeah.
00:49:43
Mika Hamilton
None of that is fun.
00:49:43
Gianluca Bini
So, I...
00:49:46
Annatasha
but
00:49:46
Gianluca Bini
So, now...
00:49:46
Annatasha
No, we should send you a picture sometime.
00:49:47
Gianluca Bini
okay
00:49:48
Annatasha
The other one that's a thrill is a Guinea pig.
00:49:49
Mika Hamilton
Yeah.
00:49:50
Annatasha
We actually use otoscopes to intubate Guinea pigs. So,
00:49:53
Mika Hamilton
Oh, okay, okay.
00:49:54
Annatasha
Yeah.
00:49:55
Gianluca Bini
so now
00:49:55
Annatasha
Really you know reptiles, right? Like snake, like the tracheal opening is like really forward and under their tongue and you, and they're, and they don't have a glottis. So you actually just pass a cold tube right through and it just seeds right there.
00:50:07
Annatasha
So.
00:50:08
Gianluca Bini
So I have a question for you now that I'm sorry to interrupt your streak of questions ri but real fast.
00:50:14
Mika Hamilton
yeah There's so many.
00:50:15
Gianluca Bini
but like But so but Ryan mentioned blood pressure, right? So what's your target for MAP? Like I'm assuming that you, I mean, of course, like we,
00:50:28
Gianluca Bini
at least in VetMed. We do use MAP as a surrogate for perfusion. We do make the assumption that if we're above a certain target, perfusion is good.
00:50:40
Gianluca Bini
We do not, at least in VetMed, have a good device that tells us you know whether perfusion is good or not. know that there are some devices that are coming out on the market, probably more in in humans that they're looking at perfusion, I guess.
00:50:55
Gianluca Bini
do you Do you have a target for map to stay above of and what that is?
00:51:04
Mika Hamilton
So it can be a little obviously patient dependent and procedure dependent.
00:51:04
Annatasha
speech.
00:51:09
Mika Hamilton
I would say if we were going to take a number, 65 millimeters of mercury is usually what we aim for for MAP.
00:51:17
Ryan Bailey
yeah
00:51:17
Gianluca Bini
Okay.
00:51:18
Mika Hamilton
Give take, depends on the patient. If it's a young, healthy patient who's got, you know you know, no cardiac issues or cerebrovascular disease, they can probably tolerate a lower MAP for a period of time.
00:51:31
Mika Hamilton
you've got the patient that's chronic hypertensive and has cerebrovascular disease and there is stroke risk, you probably want to run them with a higher map. So figure out what's normal for them. Some of our procedures, for example, some of our spinal cord surgeries, you know, there's various...
00:51:49
Gianluca Bini
Okay.
00:51:50
Mika Hamilton
or I should say variable evidence on this, but in those types of surgeries where we're doing, for example, say decompression infusion in the spine the surgeries are operating around the spinal cord, there may some evidence for pushing a much higher MAP target. And in those cases, we would aim for about 85, 80 to 85.
00:52:10
Mika Hamilton
So we would supplement that with, you know, usually with a vasoconstrictors. Saying that, the evidence is a little variable on that number and you know so it's very hard to get the exact number, but you need a number to work with for a start.
00:52:26
Gianluca Bini
right
00:52:26
Mika Hamilton
And then you just kind of vary it based on your patient. What are the comorbidities? What's their normal blood pressure? procedure are they having done? What position are they in? Because some of our surgeries are done in a sitting position.
00:52:39
Mika Hamilton
So the blood pressure here is not necessarily...
00:52:39
Annatasha
Mm-hmm.
00:52:43
Gianluca Bini
right
00:52:43
Mika Hamilton
sure that you're getting up here so we may want to push it higher sometimes that increases bleeding and makes the surgery a little bit harder particularly if it's you know like a shoulder arthroscopy or something like that so then you may have a little bit of uh i wouldn't say conflict but you'd have to balance balance out you know so but the magic number i would say would be around 65 for sure for sure
00:53:09
Gianluca Bini
Do you put an arterial line in most of your patients or?
00:53:09
Annatasha
Interesting.
00:53:14
Mika Hamilton
No, I put arterial lines in for patients where want to keep like a much closer eye on the blood pressure. So for example, those big spine cases, neurosurgical procedures where we want to know what the map is so we can, you know, try and figure out where, you know, if we've got high ICP, we want to make sure we've got so good cerebral perfusion pressure.
00:53:38
Gianluca Bini
Okay.
00:53:39
Mika Hamilton
So we need the map to, you know, do our maths and make sure we're perfusing the brain during neurosurgical procedures. In procedures, for example, like my neuroradiology patient who's you know got an aneurysm and we don't want it to rupture on induction of anesthesia, we want a very nice stable blood pressure during induction of anesthesia, we'd put arterial lines in for those.
00:53:56
Gianluca Bini
Right.
00:54:01
Mika Hamilton
I would say the big cardiac and thoracic cases, yeah, ART line for sure. And then if you've got the patient who perhaps, you know, their surgical procedure is not that extensive, but they have significant comorbidities where, you know, you want to keep a good eye on their their oxygenation, their CO2 levels, they're and their, you know, their mean arterial pressure, or and or you want to be taking frequent blood work to keep an eye on electrolytes, acid base, you know, even, you know,
00:54:31
Gianluca Bini
Done.
00:54:36
Mika Hamilton
The hemoglobin, but again, particularly, well, I guess you're in a lot of our major cases, you want to keep an eye on the hemoglobin. But then in some specific cases, there's you know hemoglobin targets, for example, again, in big spinal cases.
00:54:50
Mika Hamilton
So it's very, ah so I think the short answer is no. Where I practice, I wouldn't put arterial lines in most of my patients. But if I was a cardiac anesthesiologist, I'd probably would have art lines in all of my patients, you know.
00:55:07
Mika Hamilton
So yeah, again, center specific, specialty specific, procedure specific, but then also patient dependent as well.
00:55:07
Gianluca Bini
but Fair.
00:55:17
Annatasha
And what's generally speaking, like what's your first line for if going use a sympathomimetic for blood pressure intervention? Like what do you reach for as like your bog standard one?
00:55:26
Mika Hamilton
So for, well, when I was in the UK, it was metaramino. which is a good vasoconstrictor, but we don't have that here.
00:55:31
Annatasha
okay.
00:55:34
Mika Hamilton
So phenylephrine is what we tend to use as our first choice, you know, vasoconstrictor in the OR.
00:55:36
Annatasha
Yeah.
00:55:39
Annatasha
Okay.
00:55:42
Mika Hamilton
If there is bradycardia or a risk of bradycardia, like say the heart rate is low normal and you don't want it to drop any further when you get the vasoconstrictor, then we would use ephedrine with alpha-based activity.
00:55:54
Annatasha
Yep. Okay.
00:55:56
Mika Hamilton
So those are definitely our two main ones that we would use and they're the ones that we would generally have drawn up for most cases just in case.
00:56:06
Annatasha
okay
00:56:07
Mika Hamilton
If... we are doing, say, for example, again, I keep going back to this case, is what I see quite frequently, but the big spinal case, we and we want to maintain that higher map than usual, map of 85 to 90, sometimes the surgeons actually request a specific map, then you might get to the point where
00:56:15
Gianluca Bini
Thank you.
00:56:29
Mika Hamilton
We're running a phenylephrine infusion and we're running it at 0.3, 0.4 and it's just after that point, it's just not working anymore. So actually norepinephrine in these patients is is much more effective.
00:56:41
Annatasha
Okay.
00:56:41
Ryan Bailey
Yeah.
00:56:41
Mika Hamilton
And it doesn't necessarily have to be run through a central line.
00:56:45
Mika Hamilton
It can be run through a peripheral IV as long as you know it's a reasonable size IV, it's flushing and you can check it regularly to make sure it's not tissueed.
00:56:56
Mika Hamilton
So yeah.
00:56:56
Annatasha
Yeah, for sure.
00:56:58
Mika Hamilton
So yeah, but definitely the estrogen are the main ones.
00:56:58
Annatasha
Interesting.
00:56:59
Gianluca Bini
I think we reached for Norebi way earlier than you do.
00:57:07
Ryan Bailey
Okay, so I've always said this, and and can i I want to ask and see if this is true. I've always said that we in veterinary anesthesia tend to reach for, like, inotropes and less likely for vasopressors because we don't have the same coronary arterial disease where the human patients are at higher risk for having some degree of coronary arterial disease. So vasoconstrictors are generally preferred because of, like,
00:57:30
Gianluca Bini
Thank you.
00:57:31
Ryan Bailey
the risk of tachycardias and positive vina tropis together. But I don't know that's like, yeah, like, is that an accurate statement? Or is that even close? Or is it just like, nah, whatever, we don't worry as much about it, unless they have existing evidence that they coronary T.O. disease.
00:57:47
Mika Hamilton
Yeah, we don't, I wouldn't say we worry too much about that. I would say that our adult patients are less likely to get bradycardic.
00:57:50
Ryan Bailey
Okay.
00:57:56
Ryan Bailey
Hmm.
00:57:56
Mika Hamilton
I'm going to take a guess that maybe in vet anesthesia, do do you see bradycardias fairly regularly?
00:58:04
Ryan Bailey
Hell yeah.
00:58:04
Mika Hamilton
Yeah, so.
00:58:05
Gianluca Bini
Yeah, especially because we're met with a bunch of Dexmed.
00:58:08
Mika Hamilton
okay
00:58:10
Ryan Bailey
Not
00:58:10
Mika Hamilton
Yeah, so bradycardia is definitely more an issue in pediatric anesthesia, for sure. Not so much in our in our adult population. Obviously it can happen. And then there's certain procedures that actually bradycardia is a big risk, you know, like if you're doing laparoscopic surgery with the pneumoperitoneum, then bradycardia is going to be a risk. We also, it sounds like maybe we don't use dexmedetomidine as much as you do. I use it a lot on the ICU actually for sedation, but perioperatively we don't.
00:58:42
Mika Hamilton
And again, i don't want to say, don't want to say this is how everybody does it because again, it's all very center specific and specialty specific but don't use it a ton where I work but what we do use it for actually is a neurosurgery and particularly for awake craniotomies it's a really nice sedative agent quick on quick off you know apart from the bradycardia risk obviously it's hemodynamically pretty stable patients can be very
00:58:59
Gianluca Bini
Mm-hmm.
00:59:18
Mika Hamilton
you know, relaxed with it, but can still, you know, follow some commands, which is what we want patients to be doing when they're having awake craniotomies, because we want to see what's happening up here is, you know, can they lift, lift, yeah.
00:59:30
Annatasha
See, this is the thing that freaks me out the most about human anesthesia is that your patients start talking in the middle of stuff.
00:59:34
Gianluca Bini
Yeah.
00:59:34
Mika Hamilton
Yeah.
00:59:36
Annatasha
Like I had to spend a day, like i when I did my human anesthesia rotations, we did OBGYN and, you know, we kept going to cesareans and, you know, they were talking.
00:59:37
Ryan Bailey
Okay.
00:59:49
Annatasha
And I was like, I'm going to pass out, right? Because I was like, I'm not used to things being like awake and sentient and verbalizing and being, oh, I feel nauseous or, oh, I feel pressure.
00:59:55
Mika Hamilton
Right.
00:59:57
Annatasha
I was like, oh, like I was like, that freaked me out big time. So I was like, the the verbal component of human anesthesia is definitely weird from our point of view, I think. So
01:00:07
Ryan Bailey
Yeah.
01:00:08
Annatasha
Yeah.
01:00:08
Mika Hamilton
yeah
01:00:09
Annatasha
Did you want to ask another question before we, I think we're probably close to wrapping up, aren't we? So we should end with, you got the glasses back
01:00:13
Mika Hamilton
Let me see.
01:00:14
Gianluca Bini
Sort of, yeah.
01:00:15
Mika Hamilton
yes
01:00:18
Gianluca Bini
love I love that. I love that.
01:00:19
Mika Hamilton
so So I think we actually can answer most of them in our in our discussions. but And you you were talking about this before with regards to you know anesthesiologists and veterinary practice. But what is your threshold for when should i an anesthesiologist be doing the anesthesia as opposed to you know the anesthesia that a pet might get, for example, in their local practice?
01:00:45
Ryan Bailey
Just depends on how much you love your cat and dog.
01:00:46
Annatasha
what This question is fire
01:00:50
Mika Hamilton
Sorry.
01:00:51
Gianluca Bini
give you my answer. so Unfortunately, it comes down to, for the longest time,
01:00:59
Gianluca Bini
it came down to money, right? So like the owners has the money to spend, they can have an in-person anesthesiologist at their vet clinic come in.
01:01:11
Gianluca Bini
Now, an in-person, the going rate in the US for and an anesthesiologist is usually 250 an hour with a minimum of $2,000 a day for the practice, okay?
01:01:22
Mika Hamilton
Mm-hmm.
01:01:24
Gianluca Bini
Very little owners can afford that. The top 1%, probably not even, okay? And that's to a regular vet. Now, some referrals do have an anesthesiologist, very few, very, very very few, rare.
01:01:39
Annatasha
Thank you.
01:01:41
Gianluca Bini
Now, I mean, there are some options to increase access to care. and like And so, you know, we we do that with our, I have like a teleconsulting company that does that.
01:01:53
Gianluca Bini
So we have some anesthesiologists that do video call remotely with veterinarians to to increase access to care and make it affordable and doable.
01:01:59
Mika Hamilton
Mm-hmm. Mm-hmm.
01:02:04
Gianluca Bini
But you know for the longest time, people did not have access to one of one of us. it's it It was insanely expensive,
01:02:12
Ryan Bailey
once
01:02:13
Gianluca Bini
which is sad, really sad.
01:02:17
Annatasha
Yeah, and I think to actually Bailey, go ahead.
01:02:17
Ryan Bailey
i think was gonna say i think once you know what the world of veterinary medicine is like and the equipment that we're using and the people who are using that equipment
01:02:20
Annatasha
Go ahead. Go ahead.
01:02:24
Gianluca Bini
then
01:02:33
Ryan Bailey
my threshold is really low. Like my own cat who is healthy, does not have kidney disease somehow at like 16 years old or no, I guess this was probably three or four years ago. She had to, she had to get a dental.
01:02:47
Mika Hamilton
Mm-hmm.
01:02:47
Ryan Bailey
And I was like, well, she has to go somewhere with an anesthesiologist because I know what's out there and I know how scary it can be. If you know everything that the four of us know about anesthesia.
01:03:03
Ryan Bailey
And so I found a dentist who would let me run the case. i was going to take her to the university. that was my other option. Cause I know, I know the anesthesia team there and I know they would provide good care, but like, yeah, my threshold is really, really low. Like there is, and and I work in America and i work in Illinois, who has, like, it's it's so state dependent here.
01:03:27
Gianluca Bini
And
01:03:30
Ryan Bailey
Like in Illinois, you can't be a licensed CVT unless you've gone to school and passed the exam. In California, you could become like a CVT or RVT or like, there were two different licensure things you could get.
01:03:43
Ryan Bailey
But one was you went to school, passed the exam. The other was you practiced for X number of years and passed the exam.
01:03:47
Mika Hamilton
Mm-hmm. Mm-hmm. Mm-hmm.
01:03:48
Ryan Bailey
So like, yeah.
01:03:48
Gianluca Bini
and I think we need to specify. So CVT is Certified Veterinary Technician. RVT is Registered Veterinary Technician, which is sort of the equivalent of a registered nurse.
01:04:02
Gianluca Bini
It's just that, you know, I think for some sort of trademark issues in the U.S., they can't use the term nurse for veterinary nurses, which I think is stupid.
01:04:15
Annatasha
You can't in Ontario, or you can't use veterinary nurse.
01:04:15
Gianluca Bini
Yeah.
01:04:18
Annatasha
The nurses union will come right after us. We use veterinary technician, but ye yeah.
01:04:21
Ryan Bailey
Yeah.
01:04:22
Gianluca Bini
Which I think is true.
01:04:22
Ryan Bailey
And the equipment's all like, it's the equipment's so old. It's like shit that was like probably using human anesthesia in the sixties. Like the safety features are so few and far between and we're not, you know, required to.
01:04:36
Annatasha
Let's not forget Some practices build their own circuits and machines too. So sometimes you'll go to a practice and you've been called in as a locum where they want to do some continuing education.
01:04:40
Ryan Bailey
Holy shit. No, yeah.
01:04:46
Annatasha
And I can't i can barely figure out the machine because it was like hand built by Dr. Ron in 1979 and it's never been upgraded.
01:04:53
Mika Hamilton
Thank you.
01:04:54
Annatasha
And you're like, anyone I don't know what's going on here. But yeah, I agree with Bailey. My threshold's pretty low. And I actually think if you look at the literature, because every 10 to 15 years, they produce these big multicenter international studies looking at anesthesia-related mortality.
01:04:59
Ryan Bailey
and
01:05:10
Annatasha
And specifically, we look at it in horses and we do like the common small animals. So in in other words, dogs and cats. In our mortality, you would, you and the overall mortality, especially compared to example between like an academic institution or a high level referral versus general practice, you would find, i think, the mortality levels, especially in the general practices, unacceptable.
01:05:27
Mika Hamilton
Mm-hmm.
01:05:34
Ryan Bailey
Yeah, for sure.
01:05:35
Gianluca Bini
But the owners don't know. The problem is that the public, the general public totally ignores all of this.
01:05:37
Ryan Bailey
Yeah.
01:05:43
Gianluca Bini
like
01:05:43
Ryan Bailey
They just, they don't know. They don't ignore it. They just don't, there's no way for them to know that information, unfortunately. You know, it's, it's, it's heartbreaking.
01:05:50
Gianluca Bini
yeah
01:05:52
Ryan Bailey
It's heartbreaking. Okay.
01:05:53
Gianluca Bini
There is no transparency.
01:05:54
Annatasha
And there are places too that I've actually seen and like long before i was an anesthesiologist and I did my own GP, like I work for somebody and the way it works is that while the the technician's assistant, who is non-certified, non-licensed, is basically just, you know, trained off the street in the hospital, would both be cleaning the teeth, monitoring and recording the anesthesia all at the same time.
01:05:58
Mika Hamilton
Mm-hmm. Mm-hmm.
01:06:17
Annatasha
So would I take my cat there? Absolutely not. My cat only goes to tertiary referral.
01:06:22
Mika Hamilton
who
01:06:22
Annatasha
and like if it were my if i was Even if it was a spay or a neuter or something even more straightforward, I'm straight to tertiary referral.
01:06:22
Ryan Bailey
Right.
01:06:23
Gianluca Bini
right.
01:06:28
Annatasha
And I think that's what it is. It's one of those things, like the more you know, the more terrified you become.
01:06:32
Ryan Bailey
Yep. Oh yeah.
01:06:33
Mika Hamilton
Nice.
01:06:33
Annatasha
But unfortunately, like Gian luca said earlier, I mean, over 98% of the anesthesia that goes on in vetment in the world does not involve an anesthesiologist. And actually actually, at the end of the day, you will find that they mostly do live.
01:06:45
Annatasha
But when you actually look at the papers and look at our mortality and our morbidity compared to human centers, you would be horrified.
01:06:51
Mika Hamilton
man happen
01:06:53
Ryan Bailey
Oh, yeah.
01:06:54
Gianluca Bini
Yeah. A hundred times more.
01:06:56
Ryan Bailey
Yeah.
01:06:57
Mika Hamilton
right
01:06:57
Gianluca Bini
it's It's crazy. It's crazy. But like, you know, bringing a pet to a tertiary referral involves paying probably 10 times more.
01:07:07
Mika Hamilton
Yeah. yeah
01:07:07
Annatasha
Yeah.
01:07:07
Ryan Bailey
Yeah.
01:07:07
Gianluca Bini
The same dental cleaning that you can do in a practice for 800 to $900, US dollars in a tertiary referral is three grand. Right?
01:07:18
Ryan Bailey
And then you have to find it.
01:07:18
Gianluca Bini
Yeah.
Veterinary Care Challenges in Ontario
01:07:20
Annatasha
And also too, like there aren't, I mean, my referral hospital is the northernmost referral hospital in the province of Ontario. Basically the next closest referral hospital north of me have to go over the other side of the world in Norway. So, I mean, people aren't gonna drive 11 hours in Canada in the middle of winter to have their cat neutered because there's an anesthesiologist, it's just not going to happen.
01:07:39
Mika Hamilton
Mm-hmm. Mm-hmm. Mm-hmm.
01:07:41
Annatasha
and So we also have some pragmatic constraints too. It's just, there aren't enough referral centers. They're not affordable. And unlike the UK, there's not enough of us.
01:07:50
Ryan Bailey
enough for us.
01:07:52
Mika Hamilton
who
01:07:52
Annatasha
And unlike the UK where over 85% of domestic pets are insured, right?
01:07:52
Mika Hamilton
yeah
01:07:58
Annatasha
Our capture is less than 20% North America. which I never understand because I find pet insurance incredibly affordable. but at the same time, and like you all like guaranteed in the life of your pet, as you very well know, you will always run into an incident, like either trauma, like, I mean, dogs eat stupid things like corn cobs and underpants, or they run into sticks or your cat has, you know, cats love to go into renal failure because they're desert species.
01:08:11
Gianluca Bini
Thank you.
01:08:12
Mika Hamilton
Yeah.
01:08:25
Annatasha
And anyway, and, and it,
01:08:27
Ryan Bailey
so
01:08:28
Annatasha
In your pet's lifetime, like you're going to hit a vet bill that will pay you back cent for cent for whatever you have invested in your pet insurance. And like that message just doesn't percolate in North America for whatever reason.
01:08:35
Mika Hamilton
yeah
01:08:40
Annatasha
Whereas in the UK and the EU, it's incredibly widespread. So people like, you know, people like very straightforward, ordinary people will walk in. They won't even bat an eyelash at a $40,000 estimate for their dog because the insurance captures, and you know, 95% or more.
01:08:55
Annatasha
yeah Like their copay is $500.
01:08:57
Mika Hamilton
Yeah.
01:08:57
Annatasha
Here, though, like people will second mortgage their house, right? Or they'll just put it to sleep.
01:09:01
Ryan Bailey
Yep.
01:09:02
Annatasha
So it's a very different culture. And unfortunately, it's detrimental to the animals, is why we get very frustrated.
01:09:10
Gianluca Bini
Yeah.
01:09:10
Mika Hamilton
Yeah, you see a lot of GoFundMe's as well for,
01:09:12
Annatasha
ye
01:09:13
Ryan Bailey
yeah
01:09:13
Annatasha
And a lot of stuff in the media about how we're just money-grubbing pieces of shit, know, because all we want to do is, you know, veterinary care should just be free and there's apparently no overhead and our training doesn't mean anything.
01:09:13
Mika Hamilton
yep
01:09:24
Annatasha
So it's not always the happiest profession. Yeah.
01:09:27
Mika Hamilton
No, yeah.
01:09:28
Gianluca Bini
yeah
01:09:29
Mika Hamilton
I understand it's very stressful profession.
01:09:30
Gianluca Bini
Yeah.
01:09:33
Gianluca Bini
It is.
01:09:33
Mika Hamilton
Yeah.
01:09:34
Gianluca Bini
is.
Missed Topics and Future Episode Teaser
01:09:37
Gianluca Bini
Well, on that very sad note,
01:09:40
Annatasha
Not how I was hoping to end that podcast.
01:09:40
Mika Hamilton
yeah
01:09:44
Gianluca Bini
well, I guess we'll have to have you another time as well because like I think we have a long list of questions and we haven't gone through...
01:09:52
Ryan Bailey
We didn't even get to ventilation.
01:09:54
Mika Hamilton
Or the hot dogs.
01:09:54
Gianluca Bini
We didn't get to any of it.
01:09:55
Annatasha
Count your blessings, Dr.
01:09:55
Gianluca Bini
We've
01:09:55
Mika Hamilton
What about the hot
01:09:56
Ryan Bailey
Yeah.
01:09:57
Annatasha
Hamilton. Bailey didn't get to you about cat sympathetic tone and ventilation.
01:10:00
Ryan Bailey
Oh, my God. Oh, my God.
01:10:01
Annatasha
Oh my God. Is this the first podcast we haven't talked about hot dogs?
01:10:06
Gianluca Bini
Holy cow, we could have the hot okay
01:10:06
Ryan Bailey
I mean, you can't think it.
01:10:08
Annatasha
We didn't even talk about hot dogs. Oh my God.
01:10:10
Mika Hamilton
I was worried about hot dogs.
01:10:10
Annatasha
This is wild.
01:10:14
Gianluca Bini
Okay. Okay. Okay. So.
01:10:14
Annatasha
Dr.
Hot Dogs and Cultural Cuisine
01:10:15
Annatasha
Bailey is going to kill himself with coronary artery disease based on the number of hot dogs he ingests.
01:10:17
Mika Hamilton
Mm-hmm.
01:10:20
Annatasha
See? So.
01:10:21
Mika Hamilton
yeah
01:10:21
Gianluca Bini
yeah ryan Ryan is a hot dog connoisseur.
01:10:21
Ryan Bailey
I have a hot dog shirt on today. I'm ready. And
01:10:28
Gianluca Bini
So he goes around and tests all sorts of different hot dogs.
01:10:28
Annatasha
Legit. Yeah. yeah
01:10:33
Ryan Bailey
and various sausages or meats that might be like a sausage.
01:10:37
Annatasha
Any tubular meat, really.
01:10:39
Ryan Bailey
Yeah.
01:10:40
Annatasha
oh
01:10:40
Mika Hamilton
That's so appetizing.
01:10:41
Ryan Bailey
I'm pretty loose with my definition.
01:10:44
Annatasha
yeah As we set tell this to Dr.
01:10:46
Annatasha
Hamilton, who's a vegetarian.
01:10:48
Ryan Bailey
Yes. So what is your, so do you, a do you like vegetarian hot dogs? do you have a go-to brand? Or is there like a hot dog you, like a vegetarian hot dog you had one time and you're like, wow, they really knocked it out of the park?
01:11:02
Mika Hamilton
So no. But there...
01:11:03
Ryan Bailey
Right.
01:11:05
Mika Hamilton
So what are we one what I would say is that I'm mostly vegetarian.
01:11:08
Annatasha
No.
01:11:12
Mika Hamilton
were you know We don't buy meat. We don't cook it.
01:11:15
Ryan Bailey
right
01:11:15
Mika Hamilton
But if I was to go to someone's house and that's what they'd made for me, then I'll eat it. So I'm one of those. You can't really even call vegetarian.
01:11:23
Annatasha
You're a moral relativist. No, no, no, that's totally cool.
01:11:25
Mika Hamilton
Yeah. Yeah.
01:11:26
Annatasha
So are we.
01:11:27
Mika Hamilton
So, but but that's prefacing my answer about hot dogs.
01:11:27
Ryan Bailey
Yeah.
01:11:31
Mika Hamilton
So when I did eat more meat, we went to um Iceland and there's a very famous hot dog stand in Iceland in Reykjavík.
01:11:37
Annatasha
oh
01:11:41
Gianluca Bini
Holy shit.
01:11:42
Annatasha
Dr.
01:11:42
Gianluca Bini
Are you serious?
01:11:42
Annatasha
Hamilton, this was on our last podcast, this exact famous Iceland hot dog thing. This our second podcast where this has come up.
01:11:47
Mika Hamilton
and
01:11:47
Gianluca Bini
a
01:11:48
Annatasha
Yeah.
01:11:49
Mika Hamilton
There's a very unflattering photo of me with the hot dog in my mouth
01:11:52
Gianluca Bini
question.
01:11:55
Mika Hamilton
which we have on, know, we have one of those little screens that rotates photos digitally. And so every now and again, this photo pops up of me looking awful eating this world famous hot dog.
01:12:10
Ryan Bailey
should have to like bought my flight to Europe on Iceland Air so I could like stop in, get a hot dog, and then...
01:12:16
Mika Hamilton
Yeah.
01:12:16
Annatasha
free stopover because the behaviorists
01:12:20
Mika Hamilton
Do the stopover, have the hot dog, go to the Blue Lagoon, and then get your flight the next day.
01:12:27
Ryan Bailey
Okay.
01:12:27
Mika Hamilton
Yeah.
01:12:28
Gianluca Bini
I'm really low.
01:12:28
Annatasha
Mika, if you, cause you're Scottish. So I'm just going to test the waters here a little bit.
01:12:30
Gianluca Bini
so letnna
01:12:30
Mika Hamilton
Yes. Yeah.
01:12:32
Annatasha
So let's say you were having a night out in Scotland.
01:12:36
Mika Hamilton
In Scotland.
01:12:37
Ryan Bailey
Oh, God. Okay.
01:12:38
Annatasha
Specifically, are you going for a late night, like kebab or like buddy or, okay.
01:12:39
Mika Hamilton
Yeah.
01:12:42
Mika Hamilton
Yes.
01:12:44
Annatasha
Yeah. So you're going to eat meat when you've been on the town, like in Glasgow or what have you.
01:12:44
Mika Hamilton
Yeah. oh Oh, so i would prop I would probably not get a kebab. I would probably go for chips.
01:12:53
Annatasha
Okay.
01:12:57
Mika Hamilton
And when I say chips, I don't mean the crunchy ones.
01:12:59
Annatasha
No, you mean, we know, we know.
01:13:00
Gianluca Bini
Okay.
01:13:00
Mika Hamilton
I mean like...
01:13:01
Annatasha
Yeah, yeah.
01:13:01
Mika Hamilton
Proper fries.
01:13:01
Annatasha
Yeah.
01:13:02
Ryan Bailey
Yeah.
01:13:03
Gianluca Bini
perfect
01:13:03
Mika Hamilton
So chips and cheese was a favourite.
01:13:04
Gianluca Bini
that
01:13:09
Mika Hamilton
And actually when I was a you know at university in Dundee, there was a 24-hour bakery, it was called, which is where everybody would go after a night out. It was a bakery, it also made chips and cheese and curry sauce and baked beans and hamburgers and
01:13:27
Annatasha
Did it do like the, because I know so also Scottish people will deep fry anything. It's not just the Mars bars. It's deep fried slices of pizza.
01:13:34
Mika Hamilton
Yeah.
01:13:36
Annatasha
They'll deep fry the entire cheeseburger.
01:13:38
Ryan Bailey
We'll deep fry a whole sausage.
01:13:38
Mika Hamilton
Yeah.
01:13:40
Annatasha
Yeah.
01:13:40
Mika Hamilton
Yeah. Sausage supper. but
01:13:42
Ryan Bailey
I had that. it was so good.
01:13:44
Mika Hamilton
It took me, it took me until I was in my twenties before I realized that the pizza from the fish and chip shops was deep fried.
01:13:45
Annatasha
Oh, no.
01:13:53
Mika Hamilton
i just thought I honestly thought that was just what pizza was.
01:13:57
Gianluca Bini
Holy cow.
01:13:58
Mika Hamilton
And I didn't realize until I was in my 20s that it was was deep fried this whole time.
01:14:02
Annatasha
Oh, the Italian is clenching every sphincter in his body.
01:14:02
Mika Hamilton
I'm so sorry.
01:14:05
Annatasha
Like, now this is another famous podcast topic of ours is how other people ruin pizza.
01:14:06
Mika Hamilton
I'm so sorry.
01:14:11
Annatasha
And he specifically focuses on Americans, but now I think he switched his allegiance of hatred to the Scottish.
01:14:12
Ryan Bailey
Oh, yeah.
01:14:14
Mika Hamilton
I'm sorry.
01:14:19
Gianluca Bini
after
01:14:20
Mika Hamilton
does taste very good, though. So.
01:14:22
Gianluca Bini
No, that's okay. That's okay. i'm not
01:14:25
Mika Hamilton
yeah yeah
01:14:25
Ryan Bailey
i
01:14:27
Annatasha
yeah
01:14:28
Gianluca Bini
I'm not going to go into pizza.
01:14:28
Annatasha
no Yeah.
01:14:28
Mika Hamilton
But yeah.
01:14:29
Annatasha
Yeah.
Conclusion and Future Episode Teaser
01:14:30
Gianluca Bini
but But yeah, definitely we need to have you again for another episode because we have so many more questions and an hour just flew by.
01:14:39
Mika Hamilton
I know.
01:14:40
Ryan Bailey
Oh, yeah.
01:14:42
Gianluca Bini
Thank you so much for being here with us. Thank you, everyone. i think the next episode is going to be Ryan again, right?
01:14:50
Ryan Bailey
We're going back to ventilation, part two.
01:14:53
Gianluca Bini
OMG. OMG. All right. Thanks, everybody.
01:14:59
Annatasha
Thanks guys.