July is the beginning of the yearly migration from residencies and fellowships to attendinghood. Before you start reading today’s Reader response PAAD, I’d like to ask all of you to pass the PAAD along to your new faculty and students and encourage them to join. MY
From Alan Jay Schwartz, MD, MSEd, Henry Rosenberg, MD on MH
The past 50 plus years has witnessed enormous evidence-based strides in understanding and treatment of MH. The April 24,2024 PAAD, A New Era in Malignant Hyperthermia (https://open.substack.com/pub/ronlitman/p/a-new-era-in-malignant-hyperthermia?utm_campaign=post&utm_medium=web) highlighted advances in our understanding of MH.
Rare as MH is, it still occurs! To expand anesthesiologist’s appreciation of this life-threatening malady, read “Two Lives” a poem published in “Flowers from the Farm” (https://mybook.to/flowersfromthefarm) (https://acrobat.adobe.com/id/urn:aaid:sc:us:c61bca0b-a15a-4d84-9e02-2df307b20902), 2024 by Melissa Domiati and listen to her podcast,https://www.flyingdoctor.org.au/news/82-melissas-muscles-melted-and-she-was-unable-walk-talk-or-move/, both expressing her experience as an MH patient! As clinicians and researchers, we know about MH as a secondary experience to us. There is no substitute for a rarely available yet poignant first-hand account in the words of a patient. The poem and podcast speak loud and clear for themselves.
From Dr. Bob Brustowicz, Boston Children’s Hospital on mandatory pregnancy testing
The discussion of the article misses one on the reasons for pregnancy testing of children. It affords an opportunity to identify the sexually abused or exploited child. I do not know the prevalence nationally and am only aware of one case from my personal practice. The child was coming for some routine procedure and tested positive on the screening test. The surgery was delayed and the results confirmed. At Children’s we have a team to handle the counseling that followed. The long and the short of it was that the family, were recent immigrants to this country and totally unaware of the situation at home. Both Mom and Dad had jobs that required that they be gone for most of the day and the uncle was left in charge to care for their young daughter. This child never would have been rescued from this abusive situation had it not been for the pregnancy test.
What I tell parents who question the need for pregnancy testing is that we test everyone not because we are necessarily interested in identifying the promiscuous adolescent but rather to identify a child who might be sexually exploited. To be selective in testing could lead to accusations of profiling, so we try to test everyone.
From Dr. David Polaner
I have a vaporizer that I use as a bookend. Several of these were in a pile to be thrown out when Denver Children's (now Children's Hospital Colorado) made the move from the old 5 Points campus to the Anshutz Campus in Aurora. As someone who "grew up" at the end of the halothane era of pediatric anesthesia I couldn't let this go into the trash. As you can see in the picture, although it is a temperature compensated model this is a particularly old one- it is a stand alone vaporizer from before pin indexing. It was designed to just be connected into the breathing circuit at the fresh gas outlet, thereby bypassing any possible safety mechanisms in the anesthesia machine. Of particular note is that the vaporizer just sat on the anesthesia machine, and if tipped over, liquid halothane would spill into the inspiratory limb of the circuit. This actually happened to a new anesthesia resident during my residency (I am not sure why one of these was in use), and resulted in cardiac arrest and, I believe, the death of the patient.
From Raylene Dias DM MD, Assistant Professor and In Charge, Department of Pediatric Anesthesia, Seth GS Medical College and King Edward Memorial hospital, Mumbai, India.
I was delighted to read your PAAD “Halothane , Yes Halothane!”. Coming from a teaching Institute in India, I must say that we are fortunate enough to get the best of both worlds. Practice here is based mainly on whether you have an Instiutional/Corporate affiliation or you are a free lance anesthesiologist. So even in a busy and developed city like Mumbai, there are big corporate Hospitals and Teaching Hospitals that are well equipped and then you have the smaller nursing homes which may not be that advanced in their anesthesia armementarium. If you practice in a teaching Hospital and even more so if it belongs to the Municipal Corporation, you can ask for whatever you need and in due course of time one usually gets it. So when I started my training in Pediatric Anesthesia in Seth GS Medical College & King Edward Memorial Hospital in Mumbai which is affiliated to the Municipal Corporation of Greater Mumbai, I did work with Halothane albeit for a brief period. And I loved the agent. I loved what it did to our children and how smoothly they went under and came out of anesthesia- no emergence, no coughing, no crying. They would not move on IV cannulation and I still recall my mentor Dr Nandini Dave teaching me why. She would ask us to go back and read Cote for the answer to this question and this enlightened me about the vaporiser settings and the safety margin we have with Sevoflurane. I recall seeing a lot of benign arrythmias during laparoscopies with halothane and eventually, our very well equipped hospital was loaded with sevoflurane and desflurane and we never had to worry about cost cutting so we lavishly switched over to the latter insoluble agents.
I too miss using Halothane just like you although we switched over only 12 years ago. We do have a vaporizer in our department. In fact we have 2. The only purpose it serves now is in the Examination cupboard for the Viva Voce of our Pediatric Anesthesia DM residents and fellows and in the anesthesia museum. I wouldn’t trade it for anything in the world. In fact I’m going to steal your idea of converting it into a table lamp. How innovative!!
On the other hand, free lance anesthesiologists practicing in smaller nursing homes still use it on a daily basis. In fact if you register for Doctors without borders or Smile Train initiatives in South East Asia, they ensure that you are familiar with halothane and the delivery systems since most rural and low resource settings still have this agent due to cost restrictions.
Lastly it was a treat reading your article and discussing it with my residents yesterday as a part of our journal review in the department. And just as I was taught by my teachers, I enjoyed breaking the secret to my residents to that one Question---- Why do children still move on IV cannulation under sevoflurane… and again this time I told them just like I was told 12 years ago--- Go back home and read the chapter in Cote. It has the answer!!!