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Special Ep3 - From People to Poodles: Cross-Species Anesthesia Adventures
481 Plays8 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
Podcast Introduction
00:00:06
Speaker
Welcome everybody to the Random Anesthesia Topic Podcast. In this episode, we have Dr. tora Natasha Bartel from King's Animal Hospital in Ontario, Dr. Ryan Bailey from Premier Veterinary Group in Chicago, and I'm Dr. Gianluca Beeney, owner and founder of Safe Pet Anesthesia, a training and teleconsulting company, and I'm an assistant professor of anesthesia and analgesia at Oklahoma State University.
00:00:35
Speaker
Let's get started.
Methadone in Anesthesia: Human vs Veterinary
00:00:39
Speaker
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
Speaker
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.
00:01:07
Speaker
I... I once attended a course that's usually done for human anesthesiologists at the Royal College of Anesthesia, I think in London.
00:01:20
Speaker
And they all looked at me super weird when I was like, am I actually a vet? Yeah.
00:01:30
Speaker
I'm surprised they didn't quarantine you in the tropical disease unit. They they were about to. But I got even weirder looks when at lunch, somebody asked me, like, you know, what what do you normally give to dogs?
00:01:50
Speaker
for pain management and opioid wise? and i And my answer was Medan. It's one of my favorite you know opioids. yeah And they were like, in on which planet do you even live? on So I assume that that's not an opioid that you guys normally use.
00:02:11
Speaker
So, you 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
Speaker
But, you know, i i was want I always wondered, right? like So does methadone have even a place in human pain management at all? e 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.
00:02:45
Speaker
And 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
Opioids in Human Anesthesia
00:03:01
Speaker
go back to the ward. So...
00:03:03
Speaker
So what do you normally use? Is it just fentanyl or morphine or what what do you... 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
Speaker
Then when I moved over to Canada and, you know, maybe this is just the centre where I work, but it we tend to use hydromorphone instead of morphine. I do not know why we use one over the other. We have both available. i think I think a lot of the time your practice is a little dictated by kind of where you work and what's sort of established, to be quite honest. So we in my practice, we use um we use fentanyl for induction, fentanyl for pain relief. We can use fentanyl for PCAs, but more more often we would use hydromorphone for post-op pain, IV and oral.
00:03:58
Speaker
We also use a fair bit of remifentanil as well, you know which but which is super short-acted. My favorite. were my family so So definitely just a sort of perioperative medication we use.
00:04:13
Speaker
I want to point out Tasha's face because I love remifentanil. yeah I don't hate Remy Fenton. Like, it's just a weird favorite. Like, it's it's just, you're just annoying. Like, it's just a weird thing to be like, Oh, I love drugs that disappear in four minutes. Like, no.
00:04:34
Speaker
Why not? It's so reliable. It's amazing. It's sort of 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 remy fentanyl CRI that someone stopped. No, for sure. Because I'm a big believer. Like, oh, I'll kick you.
00:04:53
Speaker
Terrible patient. Other leg. I've got two for now.
Veterinary Anesthesia Practices and Challenges
00:04:59
Speaker
All right. And ah can I ask actually, Mika, why, I know that methadone is very much used in like the human medical realm, particularly like what when I've seen it used, um when I've gone on human anesthesia rotations, it's often used for people who, you know, like it was most commonly used for like 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 the first anesthesiologist, then the perfusionist and then back to the anesthesiologist were giving methadone just so the patient didn't go into acute withdrawal.
00:05:34
Speaker
um But is is there any like thoughts at all about why methadone, for example, because I mean, i mean, we like make it rain with methadone in veterinary anesthesia, 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 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 or is it is it convention or is there a different pathway or what's happening here i am gonna say it's probably convention i think i think methadone
00:06:16
Speaker
in human use is probably just more associated with like other other functions rather than perioperative analgesia. So let's say you know the patients who have had you know like an opioid dependence disorder or the patients who have a chronic pain and they're on you know sort of a multimodal regime.
00:06:35
Speaker
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. 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. Cause we'll use it in, we'll use it in primates, right. Which, right. You know, yeah, for sure.
00:07:11
Speaker
Check it, you know, just sort couldn't get any closer, but yeah, we will use it. Basically the same, we're just, we're we're just naked. so Hairless, it's hairless apes. Right. But no, that's interesting. Cause 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. But yeah, it's very, I just, you know, usually went the same thing with Gianluca. Like you say that to a human anesthesiologist and they're like, wow.
00:07:39
Speaker
yeah um 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. practice so And what are the main reasons for that in veterinary practice then?
00:07:54
Speaker
The methadone is now the analgesic of choice. um 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 IEMs.
00:08:15
Speaker
Because you can oftentimes you can't have a patient stay still enough to place an IV calder, right? 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. So our usual combination for IM pre-med an alpha-2 agonist, right?
00:08:40
Speaker
usually dexmedetomidine. And then if they're going to surgery, usually a pure muopioid like methadone. If we do give morphine or hydromorphone, our patients do tend to vomit.
00:08:55
Speaker
And so then we you either give them ah antiemetic soon enough in the morning before you give the premed to try and minimize the um the risk of vomiting, or your patient is going to puke. So like with methadone, we don't see that as much, or actually almost never, really. They never vomit. And so it's ah it's a pure mu opioid.
00:09:25
Speaker
it has a little bit of NMDA antagonism as well, which is kind of unique amongst the opioids. And then it doesn't have the vomiting side effect.
00:09:36
Speaker
it has a little It causes a little bit less tachypnea, converts to like hydro and morphine. You don't see like that idiopathic hypothermia that cats get that you will see, for example, with like oxymorphine. like Methadone doesn't really give, we we do see idiopathic hypothermia related to opioid use in cats, which tends to be self-limiting and will resolve once you stop dosing them. But you don't see that when you use methadone.
00:09:59
Speaker
nearly as much as you would, for example, some of the other PMUs.
Comparing Human and Veterinary Medical Practices
00:10:04
Speaker
But cats are really cats are really an entity unto themselves. and and all 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. If you think that exists in dogs and cats, like you see a lot more of the like hyper salivation. would speculate they tend to regurg a little bit more relative to methadone.
00:10:31
Speaker
wait when When you said that nausea, whether it exists in dogs and cats, are you? 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
Speaker
i'm not I'm not here to talk about it. i'm going to disregard all of those stupid remarks. Yeah. There's people who say hey these things because there's some really good stuff on nausea in dogs and cats, or mostly in dogs. And um so we were like, well, does nausea actually occur? It's like, how do you tell it? like We're putting these...
00:11:05
Speaker
symptoms into a class like we're saying the dog we're being accused of anthropomorphizing as usual right yeah exactly exactly yeah i'm not i'm not here like you know i just wanted to make sure that you were on the side of believing quote in nausea and and when the dog's drooling everywhere and like keeps licking their lips like they're gonna fucking vomit like yeah that dog's nauseous i don't 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 So one of my dogs ate an entire pack of nut brittle last year.
00:11:41
Speaker
He definitely looked nauseous all night. Yeah. Yeah. yeah Yeah, of course. yeah And it's a schnauzer. So 100%, 100% the pancreas was like, ooh. Oh,
00:11:55
Speaker
Luckily, he was okay. But he was more. Those guys are basically the bread and butter of the internal medicine service. Like, yeah. I guess the thing with us in in humans is when we use these sorts of opiates, I guess we're always, well, maybe me, i'm always I always want to prevent nausea. So I will always give it with an antiemetic. So,
00:12:18
Speaker
You know, our favorites is ondansetron and dexamethasone. Ours too. So. We don't use steroid as an anti-emetic. That is a great point. Like the steroid use in human anesthesia is so.
00:12:33
Speaker
Wild. So vastly different. It's, it's fascinating to me.
Anesthesiologists and Surgeons: Dynamics and Collaboration
00:12:37
Speaker
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, but something about like mucoceles and giving dexamethasone to mucus 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
Speaker
The shaman. Yeah, oh what are we doing 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. But because we really can't mix non-steroidals and steroids in most veterinary patients without causing severe GI upset, if not perforation.
00:13:32
Speaker
I'm like, it's a big drama-rama if you have to give an NSAID with a steroid. and you know, steroids are reserved for very specific indications, you know, like adrenolectomy, for example, or Addisonian, you know, if a patient has, for example, IMHA or IBD, like all that kind of stuff. So anesthesia anesthesiologists in 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.
00:14:01
Speaker
and comparatively so yeah we use it quite a lot for sure and do humans get the same sort of like issues associated with like like if you had a steroid on a board and then you took an advil like is that a major consideration because like this would send our critical care team like off the end of the earth if we did that yeah so not really we usually just give the one dose you know in the 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 for when the patients are waking up. So we generally don't have much concern around adding in the non-steroidals. So that's so weird because the other species that's like that is a horse, right? Like they jack up horses, sometimes they double the inset and give a steroid and you're just like, going pretend I didn't hear that. But, and horses generally seem to do okay. But if you did that to a dog or a cat, they'd either go into renal failure or perforate like within 48 hours. So, okay yeah. Now, i can I ask a question? I have a really important question.
00:15:02
Speaker
Okay. So Dr. Hamilton, as a general rule 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. I'm going to say that
00:15:26
Speaker
so i'm going to say that you're probably going to be like, yeah, yeah, yeah. But the centre that I work in, I actually work with a really great group of surgeons. We have, you know, pretty a collegial atmosphere. And that goes to like the whole ah OR team actually as well, you know, like our nursing staff and our attendants.
00:15:47
Speaker
So I'm quite blu quite lucky because, you know, obviously I have heard that maybe relationships are not so great in other places, but I'm, 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
Speaker
So you know what they like, what their quirks are They know yours. You can you have a you know a respectful discussion, respectful relationship.
00:16:20
Speaker
We don't know any of this. What's that like? But it's really important. We can edit this out, but now you can tell us how you really feel. yeah and cut you know uh and it's really important actually because like the data actually shows that yes good relationship and you know familiarity of the surgeon anesthesiologist dyad actually improves ocean outcome yeah patient safety there's a big movement right now in vet med where we're picking up on this or cordiality is being related to not just like you
Challenges in Veterinary Anesthesia
00:16:52
Speaker
know
00:16:52
Speaker
emotional health for the team and like professional well-being but also we're now looking at our own patient outcomes based on that yeah 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 yeah for sure I remember when I was in the UK I think it was when I was in the UK there was actually like a there was a campaign health care and it was called cut it out And it was all about sort of the, the you know, the atmosphere in the operating room and sort of being collegial and civil and how 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. I mean, I want to be clear that we're not the source of the issue. It's definitely the surgery. We're not the problem.
00:17:47
Speaker
Yeah. No, but I think he's 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 the tree in the hurricane.
00:18:01
Speaker
Well, part of the issue, I think that the difference 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. Like, you know, in the U.S.,
00:18:23
Speaker
that is active at the moment, there is about 240, 250 board certified anesthesiologists, period. 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,
00:18:44
Speaker
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. And so like, you know, a lot of surgeons are not used to have one of us around, right? 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
Speaker
I think the issue is that a lot of owners don't even know that that's the case. Like, you know, we have friends that... 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. Two of us in the whole state of Oklahoma and one it's me and the other one is definitely not at the clinic. So she was like, what do you mean? I was like, yeah, your cat did not go on there with an anesthesiologist. I'm so sorry. Yeah.
00:19:45
Speaker
But, um you know, and and I think that that's part of the issue, right? i did We don't have, um 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. And so then they, when one of us comes in, don't have to one of 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 paid, you know, a percentage of of what they make from the surgery, which includes anesthesia. Now, once they bring in an anesthesiologist,
00:20:31
Speaker
that percentage decreases because the anesthesia part goes to the anesthesiologist, right, or assured at 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. And so some- 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 sp The attending doesn't see a reduced charge. They ah subsidize the anesthesia costs by like adding in, you know, small fees to every case to add in the the additional care that's being provided is another, another model. But yeah, for sure.
00:21:10
Speaker
Some corporations don't even want to hire. 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
Speaker
Yeah. They're 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 side, Bartell, calm down, 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
Speaker
someone who has some control issues, how that could be incredibly challenging. And as a human anesthesiologist, that's given me palpitations to think about someone having to decide between to focus on the surgical procedure or to focus on the the airway. 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. 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.
00:22:39
Speaker
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, right? And they've, 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
Speaker
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. because Bailey's like pulling his hair out clumps. But yes, no, it should give you heart palpitations and it gives us heartp heart palpitations. 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. did a job apart horse on I would be like, I want six anesthesiologists standing this horse up. So...
00:23:28
Speaker
I don't think they know. yeah this no I'm going to ask the stupidest question today, Mika, and I totally apologize, but you're like, like you're like one-to-one with like a patient. Like you are like, if I'm coming in to like have a rhinoplasty, that's whatever. You're going to be the person to like anesthetize me, yeah monitor me and subsequently wake me up.
00:23:53
Speaker
Absolutely. Absolutely. 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... should be a beta blocker.
Dr. Hamilton's Anesthesia Preferences
00:24:03
Speaker
What is the role then of the CRNA?
00:24:07
Speaker
Oh, so we... CRNA, I think, is more of a US style model. Okay, okay. also wondered that too, because I was like, I don't know if that's a role that you have up in Canada. Like, that may just be an American. Because I do know there's some...
00:24:24
Speaker
It's an ongoing discussion, I believe. um We do have anesthesia assistants um who are able to you know undertake sedation for patients, say, for example, 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. So the anesthesia assistants can monitor those patients, but there will always be an anesthesiologist who's supervising them.
00:24:56
Speaker
And they'd be like one to four, one to five, maybe. i for there's one I'm sure there's some number ratio that you're allowed to do. and It's one to two in my institution. And for any induction of general anesthesia and extubation, an anesthesiologist has to be there.
00:25:13
Speaker
I mean, I'm not seeing it. 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. Yeah, for sure. And you're by yourself.
00:25:25
Speaker
but And you like there's usually a nurse or a student on every case, but you're literally like, you have to know 20 to 30 cases in your head, go to and you just circle all the way around all the time. And if something goes potty in one place, then it may fall apart in another. Yeah. 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 the artery and it was bleeding out. And at the same time, I was supposed to drop a horse for a colic surgery by myself.
00:25:56
Speaker
ah So that does not happen in human medicine. Nice. she knew i sure wouldn and I think the thing that blew my mind is the sedated cataract surgery, like cataract surgery in a dog or a cat.
00:26:09
Speaker
I think I've done one on a horse is 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. But like paralysis paralyzed a sun bear. That's cool. Yeah, for us, it's strong local anesthetic and then really just like conscious sedation.
00:26:33
Speaker
yeah. Obviously, you have a patient that can't lie still or maybe is claustrophobic or, know, not able to still. 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 exercise. So everything, most of our stuff goes under either very heavy sedation or general because it's just...
00:26:56
Speaker
just, you know, these guinea pigs are just not as cooperative as you'd like them to be. So 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 or, or what is your preferred, preferred genre to anesthesia?
00:27:16
Speaker
So i'm 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 of neuro, bit of spine, general surgery, ortho, neuroradiology. If you had to pick one.
00:27:39
Speaker
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 and cool 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 so i really like doing those and then
00:28:37
Speaker
My other kind of actually favorite case to do is, which is what i was doing today, is anesthetizing for neuroradiology cases. So we will do things like embolizations of like cerebral aneurysms or AVMs.
00:28:52
Speaker
And it's up in the neuroradiology suite. 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 lines.
00:29:06
Speaker
you know, infusions, making sure you maintain very, very stable blood pressure with the aneurysms. But once you're settled and the radiologists are doing their thing, you can sit in a dark room quietly.
00:29:23
Speaker
You know, there's no drama. There's no clanging of instruments. Sometimes there's great music on. Like today, the radiology team had lo-fi beats on which was super relaxing. 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
Speaker
Sounds like my ideal case which is why my favorite animal to anesthetize is like an adult cow. like adult, like ruminant is because.
00:29:59
Speaker
think I did not know this about you, but anyway, continue. You don't have to do nothing. don't have to do nothing. They, they breathe great. They keep stable blood pressures. Heart rate stays fine.
00:30:10
Speaker
like 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. It's a different situation. But under anesthesia, they are just a flat line all the way across and you don't have to do a single, you don't have to lift a finger.
00:30:27
Speaker
you just get to make your dots and you're just like, relax and it's great. but You love going into that weird anesthesia Zen zone and like the quiet OR and you just sit and like overanalyze your ECG. I know you love that. oh my God. The quiet OR is like, no, no, no. I like the, I like the, like, you know, my hands pumping the heart, like,
00:30:48
Speaker
you know like pumping the heart and like we're pouring in like auto transfusions and xeno transfusions and like there's shit everywhere like I like the high high adrenaline high stakes stuff but yeah Ryan yeah you like to go into your zen zone I like that and recently because I have enough of that on the ICU so but 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 anesthesia is all of a sudden, you know, everyone's life is flashing before your eyes. And that's why we're trained. 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 that's, that can be enjoyable. Conversely, what's your least favorite type of anesthesia?
00:31:45
Speaker
So I wouldn't say least favorite, but I think the type that stressed me out the most and which I don't really do anymore was obstetric anesthesia, clean the emergency cesarean sections.
00:32:03
Speaker
Lots of panic, lots of stress. Patients being 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.
00:32:14
Speaker
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. Some of my, you know, anesthesia, our friends and colleagues love that.
00:32:29
Speaker
Love it. And they are obstetric anesthetists, you know, and that's why there 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
Speaker
Yeah. 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
Speaker
It's multiple layers of stress. Yeah. I can't imagine what. And for people that like things to be controlled, it can sometimes be not the most controlled environment.
00:33:10
Speaker
You know, lots of people. I see some guitars. do you play
Balancing Work and Hobbies
00:33:14
Speaker
guitar? So I do not play guitar. Those are my partner's guitars. He was in a band before he went into medicine.
00:33:21
Speaker
So he has ah guitars. Is he also an anesthesiologist? No, he is. um So he trains in emergency medicine. Now he is a specializes in trauma.
00:33:32
Speaker
So major trauma. ah But he also does critical care as well. So... Yeah, most vets you find, it's like magnets. We repel each other. so Yeah, I wouldn't date yeah a vet for a billion dollars. but but We don't discuss medicine that much, actually, I have to say. Usually it's a, we'll come home, it's a five-minute debrief, and then, all right.
00:33:58
Speaker
Netflix time or, you know, yeah. Try not to. That's very healthy way of doing it. Yeah. Try not to talk shop too much. So. That's fair. So I don't play the guitar. I'm learning to play the violin.
00:34:11
Speaker
After 30 something years of not playing the violin, I decided life can't be all about medicine. So I wanted to pick up that skill again. So.
00:34:22
Speaker
Fair. Yeah. Do you guys play an instrument like Ryan Tasche?
Dr. Hamilton's Colleagues' Questions on Vet Anesthesia
00:34:28
Speaker
I have no music. have grade 10 flute under my belt. You have what? Grade 10 flute under my belt. I also went to school on music scholarship.
00:34:38
Speaker
Wow. 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, so I didn't do my music degree. I did biology, and here we are. Yeah.
00:34:57
Speaker
I have no... I played an instrument as a kid, but never. Like you were a corker? No, I 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 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.
00:35:21
Speaker
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. Yeah, you can.
00:35:33
Speaker
yeah Both of you actually are excellent cooks. Now Mika, do you I was just wondering, cause we've asked you a lot of questions. um And I usually find that human anesthesiologists have lots of questions for us about some of the weird and wonderful things we do. yeah So I actually, I have a,
00:35:52
Speaker
WhatsApp group of my colleagues and I I sent a text saying, if you could ask, you know, veterinary anesthesiologist a ah question, what would you ask? And it was like, bing, bing, bing, bing. I
00:36:06
Speaker
so i knew that. Yeah. That's why i was like, we should let Mika have a chance to, because I was like, I bet you there's a lot. Yeah. There's a lot. not going to ask you all. She's got glasses on. know. Time to shine, everyone. Watch out. Okay. So professional, Tasha. Some of the questions they had were, how do you monitor the depth of anesthesia in your patients? And Oh, gosh. Is MAC a thing in vet anesthesia?
Monitoring Anesthesia Depth in Animals
00:36:30
Speaker
Hell yeah. Yes, okay. So it's totally species-based. So both of those things, right? So MAC obviously varies with species. 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?
00:36:51
Speaker
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. 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.
00:37:16
Speaker
You 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. So, yeah, I mean, we still do the normal things. So we look at, you know, heart rate, blood pressure, ventilation, all that kind of stuff.
00:37:32
Speaker
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
Speaker
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. 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 yeah.
00:38:01
Speaker
Yeah, MAC is definitely a thing. We do use different inhalants. Like we've all used, i've used I don't know if you guys have used halothane. I'm the oldest here, but halothane, ISO, SIVO, and even desflurane.
00:38:13
Speaker
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
Speaker
what like Don't ask, don't ask John Luca. But anyway, yeah so so it's it's species dependent and you have to you have to end essentially memorize it. And 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 All of our equipment is human based, very little that 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.
00:39:00
Speaker
two sixty And the rule is, is if you can actually count the heart rate out, it's bradycardic. um and And rabbits, of course, they metabolize atropine in their plasma, so they don't respond to atropines. You have to use glycopyrrolate and da, da, da, da. And so, yeah, every little species has its own nuance.
00:39:20
Speaker
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. So yeah, so yeah, it's a lot.
00:39:41
Speaker
It's a lot. There's a lot of crying overboard exams. Yeah. i love I love how you went through all the species possible. You omitted cats and dogs.
00:39:51
Speaker
True. That's boring. At acceptable planes of anesthesia, goats' eyes turn into bricks. Yeah. like Like, that's a classic. Like, oh, it's a goat. Well, you're going to look for when his pupil changes to the diameter of a brick.
00:40:06
Speaker
Yeah. There you go. So. So we do have MAC, we do practice MAC sparing techniques. I mean, we do a lot of local regional, I mean, um all of us do ultrasound guided local. And I mean, I've done femor sciatic on a beaver, you know, like or got it yeah, yeah, I know. So we do do it. So we do practice max bearing techniques.
00:40:26
Speaker
And like I said, yeah, our our depth of anesthesia changes with the species. so 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?
00:40:43
Speaker
Not what it should be is the answer. Like we are way, yeah way behind and it's super institution specific. Like where I trained, it was amazing. It was just starting to become a thing, even though where Tasha trained, it was like their whole thing.
00:41:01
Speaker
And 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 ah it's a bit of a problem, but ah 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
Speaker
Diego's catching up. 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. 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. And I really like, you know, for hip replacements or femoral head, um, 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
Speaker
Because getting our pets out and up and going to the to toilet outside, which is also very different from human medicine, is a really big part of getting them home sooner rather than later to limit post-operative nosocomial infection. So yeah, those are my favorite blocks. Beanie?
00:42:15
Speaker
I think ESP blocks are probably my erector spinae blocks. I love those. You're doing that mostly for hemilaminectomies? Hemilaminectomies, yeah.
00:42:27
Speaker
Yeah. um 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. 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? 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? Like we can't do that. So, you know, unfortunately we're, we're really behind.
00:43:09
Speaker
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, 70 kilo cane Corso to, you know, the 60 year old grandma who can't pick up her dog. 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. So.
00:43:33
Speaker
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. because they actually get up by going onto their forelimbs first. And if they can't feel their leg, they 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. Whereas a horse will thrash itself to death and probably break more limbs. So that's also a bit species dependent. But I would say that I would block. I probably have a local regional block on board with nearly 100% cases.
00:44:06
Speaker
and is it all ultrasound guided it is for me yeah yeah for the for most of us newer anesthesiologists it's all ultrasound guided before was all peripheral nerve stimulator yeah same in human anesthesia i trained with peripheral nerve stimulators and 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 so 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. So I always feel that I need to be proficient in both techniques.
Intubation Techniques in Veterinary Medicine
00:44:50
Speaker
There are still some wackadoos out there who are doing them all blind, which I do not canoe. But I don't do know what goes on.
00:44:58
Speaker
And on the subject of sort of you know, using more um technologically advanced equipment, do you use like video laryngoscopes for intubations in some of your animals or is it all direct laryngoscopes? Not frequently. yeah Yeah, we we have it. Like we have, we're not the, not the ones with the camera on the blade.
00:45:22
Speaker
we 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
Speaker
So it's not technically a video laryngoscope, although they try to sell it as such. Yeah. But sometimes it- You should appreciate though, Mika, sorry to inter 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. Like you could literally like, if there was a Labrador over there that's jaw open, 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. You know, they just, they can't open their jaws. They have these humpy tongues that get in the way. They they have terrible dentition with their little rabbit teeth, you know, like they're prone to laryngosposm, 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- Horses do it today blind.
00:46:20
Speaker
We don't have those cool blades where it's embedded and then you guys actually dispose of or what have you. Like we don't do that as much normally. Yeah. What did you say, Bailey? like Well, horses just do a blind. Horses are done blind and cows are actually done by palpation, right? 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 in while your hand is actually on the larynx. And that way you make sure that placement is appropriate. So we intubate very differently.
00:46:50
Speaker
<unk> sort of thing Giraffes are the same. Elephants are blind. um I will say though, I was at the university and their exotic service intubates rabbits with a scope.
00:47:03
Speaker
Yeah. 30 seconds. I used to do it with the scope at Cornell if when it was a video. With the video scope. Yeah, yeah. I would do it a video scope to do rabbits. And even then it was- Oh my God, like 30 seconds. I was like, why don't we just get these everywhere? this is I don't know. I tend to use like my little rabbit adapted LMA for them because yeah I find supraglottic is easier for rabbits. So I tend do that.
00:47:29
Speaker
Yeah, that's fair. I was actually going to ask, do you use laryngeal masks much in the anesthesia? Yeah. Not much, much, but they're around. They're right. yeah Mostly like cats. I think the the ones that we have that are most commonly used is rabbits.
00:47:46
Speaker
There is some for cats, but I don't think that anybody actually used them. It's very rare. But for rabbits, we do because they're not very hard to intubate. Yeah. Okay.
00:47:57
Speaker
Yeah, they'll make you want to lie down and drink for a day. Like it is just, I mean, I've seen rabbit intubations take like four hours before. And think it's just why the rabbit is intimately like profoundly cyanotic.
00:48:07
Speaker
Like turns blue. They do not, they're not into surviving. They're not a robust species. like Rabbits at MAC anesthesia are hypotensive for sure. Map of 40, easily.
00:48:21
Speaker
Easily. Yeah. I usually weasel my way out of rabbits when I can. Me too. And I did my research in rabbits. I know. What is it anatomically that makes it so difficult to intubate?
00:48:34
Speaker
A rabbit? well This is a good exam question. yeah This is like this a classic exam essay question. But yeah. Well, you can't open their jaw very wide. They have that like a rodent-esque dentition, right? So they've got those super pronounced incisors that overlap.
00:48:51
Speaker
They have these terrible dental arcades. They have ah a lingus torsus, which is basically a hump at the back. And if you occlude those codlingual vessels, like they just become cyanotic. They swell and they obstruct.
00:49:03
Speaker
You can't visualize it because it's so like, it's it's very caudal and distal. um 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...
00:49:23
Speaker
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 de like totally like being on non-compromised situation and they just die and you're like, Oh God. Yeah.
00:49:41
Speaker
he Yeah. Yeah.
00:49:46
Speaker
No, we should send you a picture sometime. The other one that's a thrill is a guinea pig. We actually use otoscopes to intubate guinea pigs. Oh, okay, okay. Yeah. so Really, they're reptiles, right? Like snakes, like the tracheal opening is like really forward and under their tongue and you and they and they don't have a glottis. So you actually just pass a cold tube right through and it just seeds right there. so So I have a question for you now that I'm sorry to interrupt your streak of questions, Riella. Yeah, there's so many.
00:50:17
Speaker
So but Ryan mentioned blood pressure, right?
Blood Pressure Management in Anesthesia
00:50:21
Speaker
So what's your target for MAP? Like I'm assuming that you, I mean, of course, like we...
00:50:28
Speaker
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
Speaker
We do not, at least in VetMed, have a good device that tells us you know whether perfusion is good or not. I 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.
00:50:56
Speaker
Do you... Do you have a target for MAP to stay above of and what that is? So it can be a little, obviously, patient dependent and procedure dependent. But I would say if we we're going to take a number, 65 millimeters of mercury is usually what we aim for for MAP.
00:51:17
Speaker
Give or take. Depends on the patient. If it's a young, healthy patient who's got, you know, no cardiac as issues or cerebrovascular disease, they can probably tolerate a lower MAP for a period of time. if you've got the patient that's chronic hypertensive and has cerebrovascular disease and they're a stroke risk, you probably want to run them with a higher MAP. So figure out what's normal for them.
00:51:41
Speaker
Some of our procedures, for example, some of our spinal cord surgeries, you know, there's various... 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 and 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
Speaker
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, it's very hard to get the exact number, but you need a number to work with for a start.
00:52:26
Speaker
And then you just kind of vary it based on your patient. What are the comorbidities? What's their normal blood pressure? What procedure are they having done? What position are they in? Because some of our surgeries are done in a sitting position. So the blood pressure here is not necessarily correct. 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 ah you'd have to balance balance it out you know so but the magic number I would say would be around 65 for sure
00:53:08
Speaker
for sure Do you put an arterial line in most of your patients or? No, I put arterial lines in for patients where want 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.
00:53:33
Speaker
where, you know, if we've got high ICP, we want to make sure we've got so good cerebral perfusion pressure. So we need the map to, you know, do our maths and make sure we're perfusing the brain during neurosurgical procedures. um 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. right We want a very nice stable blood pressure during induction of anesthesia. We put arterial lines in for those. I would say the big Cardiac and thoracic cases, yeah, Artline for sure.
00:54:08
Speaker
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, 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 uh the hemoglobin again particular 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 and like big spinal cases so it's very so i think the short answer is no um where i
00:54:56
Speaker
practice, I wouldn't put arterial lines in most of my patients. But if I was a cardiac anesthesiologist, I probably would have art lines in all of my patients, you know?
00:55:07
Speaker
so So again, center specific, special specialty specific, procedure specific, but then also patient dependent as
Use of Vasoconstrictors in Anesthesia
00:55:16
Speaker
well. so And what's generally speaking, like what's your first line for if you're going to use a sympathomimetic for blood pressure intervention? Like what do you reach for as like your bog standard one?
00:55:26
Speaker
So for, well, when I was in the UK, it was metaraminol, which is a good vasoconstrictor, but um we don't have that here. So phenylephrine is what we tend to use as our first choice, you know, vasoconstrictor in the OR.
00:55:42
Speaker
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, you know, alpha- let So those are two definitely our two main ones that we would use and they're the ones that we would generally have drawn up in most cases just in case.
00:56:06
Speaker
Okay. 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 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
Speaker
and And it doesn't necessarily have to be run through a central line. 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 not tissueed so yeah for sure yeah interesting yeah but definitely we reach jenner the main ones so i think we reached for norebi way earlier than you do 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,
00:57:31
Speaker
the risk of tachycardia is in positive vina tropes together. But I don't know if 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 have coronary RTO disease. 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.
00:57:56
Speaker
I'm going to take a guess that maybe in vet anesthesia, do do you see bradycardias fairly regularly? Yeah. Yeah. Especially because we're met with a bunch of dexmed. Okay.
00:58:09
Speaker
it 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 um if you're doing laparoscopic surgery with the pneumoperitoneum, then bradycardia is going to be a risk.
00:58:31
Speaker
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
Speaker
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 we 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 um it's a really nice sedative agent quick on quick off um you know apart from the bradycardia risk obviously it's hemodynamically pretty stable.
00:59:15
Speaker
Patients can be very, 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 a weight craniotomies because we want to see what's happening up here is, you know, and they see, this is the thing that freaks me out the most about human anesthesia is that your patients are talking in the middle of stuff. 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, the, they were talking and I was like, I'm going pass out. Right. Cause I was like, I'm not used to things being like awake and sentient and verbalizing and being really feel nauseous or, oh, I feel pressure. I was like, like, I was like, that freaked me out big time. So I was like the verbal component of human anesthesia is definitely weird from our point of view, I think. So yeah. Did you want to ask another question before we, I think we're probably close to wrapping up, aren't we? So let me see. sure'll Yeah.
01:00:14
Speaker
alex just got the glos yeah but but hello yeah I love that. so So I think we actually can answer most of them in our in our discussions.
Pet Insurance and Cultural Differences in Healthcare
01:00:23
Speaker
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 a an anesthesiologist be doing the anesthesia as opposed to you know the anesthesia that a pet might get, for example, in their local practice? Right.
01:00:45
Speaker
It depends on how much you love cat and dog. This question is fire. I'll give you my answer. So unfortunately, it comes down to, for the longest time,
01:00:59
Speaker
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
Speaker
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? Very little owners can afford that.
01:01:26
Speaker
The top 1%, probably not even, okay? And that's to a regular vet. Now, some referrals do have an anesthesiologist. Very few.
01:01:36
Speaker
Very, very many few. Rare.
01:01:41
Speaker
Now, I mean, there are some options to increase access to care. and like um And so, you know, we we do that with our... I have a teleconsulting company that does that.
01:01:53
Speaker
So we have some anesthesiologists that do video call remotely with veterinarians to to increase access to care and make it affordable and doable.
01:02:04
Speaker
But, you know, for the longest time, people did not have access to one of one of us. it's it's It was insanely expensive. once Which is sad. Really sad.
01:02:17
Speaker
Yeah, and I think to... ah Actually, Bailey, go ahead. Go ahead. Go ahead. as I 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, 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 it done to all. Um,
01:02:47
Speaker
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
Speaker
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,
01:03:16
Speaker
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. Like in Illinois, you can't be a licensed CVT unless you've gone to school and pass the exam. In California, you could become like a CVT or RVT or like there were two different licensure things you could get. But one was you went to school, pass the exam. The other was you practice for X number of years and pass the exam.
01:03:48
Speaker
So like, I think we need to specify. So CVT, it's Certified Veterinary Technician. RVT is Registered Veterinary Technician, which is sort of the equivalent of a registered nurse. It's just that, you know I think for some sort of trademark issues in the US, they can't use the term nurse for veterinary nurses, which I think is You can't in Ontario either. You can't use veterinary nurse. The nurses' union will come right after us. so We use veterinary technician. The equipment's so old. It's like shit that was like probably used in human anesthesia in the 60s. The safety features are so few and far between, and we're not required to... Some practices build their own circuits and machines, too. So sometimes you'll have a practice... yeah and you've been called in as a locum or they want to do some continuing education. 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. And you're like, i 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 multi-center international studies looking at anesthesia-related mortality. um And specifically, we look at it in horses and we do um like the common small animals. So in in other words, dogs and cats.
01:05:18
Speaker
In our mortality, you would... you would 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.
01:05:34
Speaker
Yeah, for sure. But the owners don't know. The problem is that the public, the general public totally ignores all of this, right? 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,
01:05:51
Speaker
It's heartbreaking. It's heartbreaking. There is no chance. 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 technician's assistant, who's 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.
01:06:16
Speaker
So would I take my cat there? Absolutely not. My cat only goes to tertiary referral. um oh 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. And I think that's what it is. It's one of those things, like the more, you know, the more terrified you become. Like John Lucas said earlier, I mean, over 98% of the anesthesia that goes on in Vet Med in the world does not involve an anesthesiologist. And actually, at the end of the day, you will find that they mostly do live. But when you actually look at the papers and look at our mortality and our morbidity compared to human centers, you would be horrified.
01:06:53
Speaker
Oh, yeah. Yeah. A hundred times more. it's It's crazy. It's crazy. 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 you have to go over the other side of the world in Norway. So, I mean, people aren't going to 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. 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. And unlike the UK where over 85% of domestic pets are insured, right?
01:07:38
Speaker
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. And anyway, and, and it,
01:08:07
Speaker
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, 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 $40,000 for their dog. Because the insurance captures 95% or
Public Perceptions of Veterinary Care Costs
01:08:34
Speaker
more. like Their co-pay is $500. Here, though, like people will second mortgage their house, right? Or they'll just put it to sleep. So it's a very different culture. And unfortunately, it's detrimental to the animals, which is why we get very frustrated.
01:08:49
Speaker
Yeah. You see a lot of GoFundMe's as well for. Yeah. And a lot of stuff in the media about how we're just money grabbing pieces of shit, you know, cause 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. So it's not always the happiest profession. No. Yeah. drop and Yeah. Very stressful.
01:09:11
Speaker
It is. it is. Yeah.
01:09:15
Speaker
Yeah. Well, on that very sad note. That's not how I was hoping to end that podcast. Well, i guess 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. We didn't even get to ventilation.
01:09:33
Speaker
We didn't get to any of your're blessings Dr. Hamilton, Bailey didn't get to you about cat sympathetic tone and ventilation. Oh my God. Oh my God. Is this the first podcast we haven't talked about hot dogs? Yes.
01:09:45
Speaker
Holy cow, we talked about hot dogs. We didn't even talk about hot dogs. Oh my God, this is why. Okay, okay. He's going to kill himself coronary artery disease based on the number of hot dogs he ingests. See, so. yeah I have a hot dog shirt on today.
Cultural Differences: Food Preferences
01:10:02
Speaker
I'm ready.
01:10:03
Speaker
ryan Ryan is a hot dog connoisseur. So he goes around and tests yeah all sorts of different hot dogs. And various sausages or meats that might be like a sausage. Any tubular meat, really.
01:10:18
Speaker
Yeah. I'm losing my definition. yeah we As we set tell this to Dr. Hamilton, who's a vegetarian. right 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?
01:10:41
Speaker
So no. but there So what are we one what do I say is that I'm mostly vegetarian. We're, you know, we don't, buy meat we don't cook it 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 moral relativist no no no that's cool so are we so yeah but but that's prefacing my answer about hot dogs so when I did eat more meat we went to Iceland and And there's a very famous hot dog stand in Iceland. Holy shit. In record, Hamilton, this was on our last podcast, this exact famous Iceland hot dog thing. Our second podcast where this has come up. There's a very unflattering photo of me
01:11:32
Speaker
With the hot dog in my mouth, which we have on, know, have one of those little screens that rotates photos digitally. And so every now and again, this photo pops up of me looking in awful eating this world famous hot dog.
01:11:49
Speaker
I should have to like bought my flight to Europe on Iceland Air so I could like stop in, get a hot dog. Yeah, stop over. Because the behavior is... do the stopover, have the hot dog, go to the Blue Lagoon and then get your flight the next day.
01:12:06
Speaker
yeah Mika, if you, because you're Scottish, so I'm just going to test the waters here a little bit. So let's say you were having a night out in Scotland. In Scotland. specifically Are you going for a late night like kebab or like buddy or, okay, yeah. So you're going to eat meat when you've been on the town, like in Glasgow or what have you. i would prop I would probably not get a kebab.
01:12:32
Speaker
I would probably go for chips. And when I say chips, I don't mean crunchy ones. mean proper fries.
01:12:44
Speaker
chips and cheese was a favorite. And actually when I was ah you at university in Dundee, there was a 24-hour bakery, it was called, which is where everybody would go after a night out.
01:12:58
Speaker
It was a bakery, but it also made chips and cheese and curry sauce
Podcast Conclusion
01:13:04
Speaker
and baked beans and did it do 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 they'll deep fry the entire cheeseburger deep fry a whole sausage yes sausage supper i had that was so good it took me it took me until i was in my 20s before i realized that
01:13:28
Speaker
the pizza from the fish and chip shops was deep fried. i I honestly thought that was just what pizza was. Holy cow. And I didn't realize until I was in my 20s that it was it was deep fried this whole time.
01:13:42
Speaker
The Italian is clenching every spinger in his body. This is another famous podcast topic of ours is how other people ruin pizza. And he specifically focuses on Americans, but now I think he's switched his allegiance of hatred to the Scottish. I'm sorry.
01:13:58
Speaker
It just tastes very good, though. so No, that's okay. That's okay. I'm not going to go into pizza.
01:14:09
Speaker
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. I know. I know.
01:14:21
Speaker
Thank you so much for being here with us. Thank you, everyone. i think the next episode is going to be Ryan again, right? Next ventilation part two.
01:14:33
Speaker
OMG. OMG. All right. Thanks, everybody. Thanks, guys.