From Amy Benedikt MD of SPA’s wellness committee
From Nicole McCoy MD
I am a peds anesthesiologist at Medical University of South Carolina in Charleston, SC. (I am also a board certified pediatrician!) I read your PAAD on screening pediatric patients for suicidality and I have to admit, I should be asking more about cigarette, vaping and drug use especially with my background (and previous practice of asking every teen every time) but I am not savvy at how to have this discussion on the day of surgery. In a general peds office you would traditionally ask the parents to step out to have a private conversation with the teen but that doesn’t seem as organic on the day of surgery (or even in a preop clinic). I would have similar angst over suicide screening.
One of my main concerns is … what do we do when we have a positive screen (for suicide- illegal drug use- abuse…or for example, uncover that a child is cutting themselves once we undress them in the OR while the surgeon is prepping… who takes responsibility to report to the parent, DSS, hospital social services, a mental health professional and who follows this up since we are not the primary or consistent providers… lots of things to think about).
Additionally, in places that don’t have a preop clinic or only see a very small subset for a preop evaluation- what happens when screening these patients on DOS (similar to the questions/concerns you alluded to at the end). I think this is a fantastic project and would be honored to be included.
From Elliot J. Krane MD
I’m very glad to read this PAAD because it touches on one of the fundamentals I have tried to teach trainees over the years. How many times have we seen anesthesiologists across the experience spectrum stuck in the mindset that everything is all right and misinterpreting data through those rose colored lenses? We see our colleagues and trainees futzing with the pulse oximeter probe when it reads zero rather than starting with the assumption that the saturation is zero, or changing blood pressure cuffs when the Dinamap reads triple zeroes rather than opening up the fluids.
This also occurs in residency evaluation committees. I think it’s possible to train a high school student to deliver an anesthetic, and 9 out of 10 times they’ll get away with it. Unfortunately the tenth patient will die. The corollary of this is that 9 out of 10 evaluations of a bad resident will be okay, and one will say “this guy is a danger.” IOW it is the “anomalous” evaluation that should carry the weight. But my colleagues in an evaluation committee so often brush the anomalous one aside, saying “Yes, but, nine of the evaluations say he’s doing fine.”
I’m reminded of a great Gary Larson cartoon of 2 pilots in the cockpit of a jetliner approaching a mountainside with a mountain goat on a rocky ledge, with one saying “Say, what is that goat doing up here at 36,000 feet?”d
From Amanda Brown
I am searching for information regarding perioperative management in the setting of maintenance naltrexone and related therapies. I am seeing this more often than I'd like not as a substance abuse therapy but for behavioral modification. I can't find any topical literature for adolescents. I would presume receptor upregulation in chronic therapy. I hesitate to say holding therapy for an interval prior to surgery predicts a reliable mu response. I'd be happy to write this as a community question if needed. Send responses to amkabr@hotmail.com