Category Archives: News

Anesthesiology, California Society of Anesthesiologists, Healthcare, Leadership, News

My First Report as CSA President

September 3, 2022 ermariano

At the first in-person House of Delegates (HOD) session since 2019, I became President of the California Society of Anesthesiologists (CSA), the first Filipino-American to do so. This could have only happened because of the incredible mentors and sponsors that I have been fortunate enough to have in my life.

Over the course of the HOD weekend in June, we held a fundraising luncheon for the CSA Foundation, listened to project presentations from the first cohort of our CSA-UC Irvine Leadership in Healthcare Management Program launched by Drs. Phillip Richardson and Ron Pearl, were treated to a special guest lecture by Sasha Strauss on how to communicate as leaders and demonstrate value, and I provided an educational session on using social media for advocacy. We hosted Dr. Robert Wailes, President of the California Medical Association (CMA), for an update on the Medical Injury Compensation Reform Act (MICRA) since passage of AB 35 (MICRA Modernization). For more information, see Dr. Wailes’ summary.

During the HOD session, I outlined my leadership priorities for this year: expanding public-facing and internal member communications; continuing leadership development; planning the CSA’s 75^th anniversary (diamond jubilee); and promoting wellbeing and professional fulfillment within the CSA membership. I discussed the challenges facing anesthesiology and the importance of recruiting and retaining members. I summarized the value proposition as “Community, Solidarity, and Advocacy,” which also happen to have the acronym “C-S-A.”

Receiving the gavel from Dr. Ron Pearl, Immediate Past President of CSA and my biggest mentor and sponsor

We followed HOD with our first Board of Directors (BOD) meeting of the governance year. We welcomed new Directors, appointed the CSA delegations to the American Society of Anesthesiologists (ASA) and CMA, and approved committee appointments for this governance year including an expanded Committee on Professional and Public Communication (CPPC). This new CPPC chaired by Dr. Emily Methangkool and staffed by Kate Peyser, and in partnership with Alison MacLeod and Lisa Yarbrough at KP Public Affairs, will be interfacing will all major committees, divisions, and task forces as well as the CSA Foundation to actively promote the great work by CSA members and advance the recognition, social standing, and influence of anesthesiologists.

Over the summer, I was Visiting Professor at the University of Michigan, hosted by Dr. Chad Brummett, and then had the privilege of participating in the American Medical Association (AMA) annual meeting as an ASA delegate to the AMA HOD. In this role, I was able to cast my vote for Dr. Jesse Ehrenfeld and witness him become the first anesthesiologist President-Elect of the AMA!

With Drs. Chad Brummett and Mark Bicket at the University of Michigan stadium

My family and I visited Greece for the first time as I participated as a guest speaker at the European Society of Regional Anaesthesia and Pain Therapy (ESRA) congress in Thessaloniki, and I also welcomed attendees to my first CSA educational event as President: the 2022 CSA Summer Anesthesia Conference. This meeting was chaired by Dr. Brendan Carvalho and featured a superstar all-women expert panel of dynamic speakers: Drs. Dalia Banks , Sapna Kudchadkar, Alana Flexman, BobbieJean Sweitzer, Romy Yun, and Elizabeth Ozery. All week, attendees and speakers engaged in conversations related to the practice of anesthesiology, caught up with old friends, and made new connections within the meeting room and around the resort. It was an amazing week of learning and family time and reinforced the value of CSA and its educational events in fostering community.

With friends and fellow ESRA invited speakers (Drs. Amit Pawa, Steve Coppens, Lloyd Turbitt, and Clara Lobo)

Before leaving Hawaii, I participated in a face-to-face meeting of the Hawaii Safer Care initiative, part of the Improving Surgical Care and Recovery collaborative supported by the Agency for Healthcare Quality and Research, and led by Dr. Della Lin, Senior Fellow in Patient Safety Leadership with the Estes Park Institute and is an inaugural National Patient Safety Foundation/Health Forums Patient Safety Leadership Fellow. Dr. Lin invited me to participate as a virtual coach during the pandemic last year and work with improvement teams focused on implementing multimodal pain management for surgical patients, so this was my first time meeting the group in person. For this meeting, teams from three statewide health systems within Hawaii reported out the results of their projects. The leadership and collaboration among the multidisciplinary teams to implement change despite the challenges of variable resource availability, staffing, and inter-island coordination could serve as a model to inspire our statewide efforts within CSA.

What do we have on deck for CSA?

At the time of this report, we are receiving applications for the next CSA-UC Irvine Leadership in Healthcare Management Program cohort. Anyone interested can sign up here. We have appointed the task forces to work on revamping the CSA website and planning activities for the 75^th anniversary, including a family-friendly reception at the Annual Meeting in San Diego (April 27-30, 2023) that will be chaired by Dr. Christina Menor. Stay up to date with CSA events through our online calendar. Then in October, our CSA delegation heads to New Orleans for the ASA annual meeting, and CSA members will actively participate in educational programming, committee deliberations, and governance activities. CSA will host a member reception during the conference, and our delegates will stand proudly when CSA’s very own Dr. Michael Champeau takes over as President of the ASA at the conclusion of the Wednesday ASA HOD session!

Anesthesiology, California Society of Anesthesiologists, Healthcare, Leadership, Medical Education, News, Patient Safety, Research

You Are Not “Asleep” Under Anesthesia

September 23, 2021 ermariano

“You will be asleep for your surgery,” anesthesiologists often reassure their patients. Just before the start of anesthesia, a patient may hear the operating room nurse saying, “Think of a nice dream as you go off to sleep.”

While these statements are intended to soothe patients during a stressful time, they gloss over this critical fact: Anesthesia is not like normal sleep at all.

That’s why you need medical doctors – anesthesiologists – to take care of you under anesthesia, and why you don’t need us when you’re sleeping comfortably in your own bed.

Differences between natural sleep and general anesthesia

Natural sleep represents an active though resting brain state. Every 90 minutes, the brain cycles between rapid eye movement or “REM” sleep and non-REM sleep. During each of these REM cycles, the brain is active, and dreams can take place. The rest and rejuvenation that result from getting a good night’s sleep are essential for overall health and wellbeing.

On the other hand, general anesthesia produces a brain wave pattern known as “burst-suppression,” where brief clusters of fast waves alternate with periods of minimal activity. In a recent article published in Frontiers in Psychology, Drs. Akshay Shanker and Emery Brown explain brain wave patterns found in patients under general anesthesia. They are similar to those of critically ill patients who fall into a coma, have a dangerously low body temperature, or suffer from other serious diseases. Under general anesthesia, patients do not dream.

Confusing general anesthesia and natural sleep seems innocent but can be dangerous. A person who falls into natural sleep doesn’t require constant monitoring or observation. A patient under anesthesia, like an intensive care unit patient in a coma, may appear peaceful and relaxed, but anesthetic drugs don’t produce natural sleep and may cause breathing to stop or have other serious side effects. Some may recall that Michael Jackson died at home while receiving the anesthetic drug propofol in his veins without an anesthesiologist nearby to protect him.

For patients with chronic health problems, having surgery and anesthesia can put significant stress on the body. Anesthesia gases and medications can temporarily decrease the heart’s pumping ability and affect blood flow to the liver and kidneys. Patients under general anesthesia often need a breathing tube and a ventilator to breathe for them and support their lungs with oxygen.

Respect anesthesia, but don’t fear it

While having anesthesia and surgery should never be taken lightly, anesthesia care today is very safe as long as it is directed by a physician specializing in anesthesiology: an anesthesiologist. Anesthesiology is a medical specialty just like cardiology, surgery, or pediatrics. Research by anesthesiologists has led to the development of better monitors, better training using simulation methods inspired by the aviation industry, and new medications and techniques to give safer pain relief.

As a medical specialty, anesthesiology focuses on improving patient safety, outcomes and experiences. Anesthesiologists work with surgeons and other healthcare professionals to get you or your family member ready for surgery, designing an anesthesia care and pain management plan specific to the type of operation you need. The anesthesia plan will guide your care during your procedure and throughout your recovery. While general anesthesia is far different from natural sleep, the job of the anesthesiologist is to make sure that you wake up just the same.

This post has also been featured on KevinMD.com.

Anesthesiology, California Society of Anesthesiologists, COVID-19, Healthcare, News, Patient Safety

Beyond COVID-19: Stand Up for Veterans Having Surgery

May 11, 2020 ermariano

Our Veterans have made tremendous sacrifices to defend our freedoms. Now it is our time to defend them.

Many people, even those who work in the operating room every day, take safe anesthesia care for granted. There has been growing pressure during this pandemic to remove physician supervision of nurse anesthetists with the latest threat coming from within Veterans Affairs (VA) healthcare. For our Veterans, our heroes and arguably some of the most medically complex patients, having a physician in charge of anesthesia care at hospitals where anesthesiologists and nurse anesthetists work together as a team makes the most sense.

Having a team with members who train differently and have different perspectives can only benefit the patient; anesthesiologists are physicians who draw on their medical training while nurse anesthetists bring valuable nursing experience. If you were a patient having surgery, wouldn’t you want an anesthesiologist directly involved in your care and leading the anesthesia team? If the answer is yes, please send your comments to Safe VA Care and let your elected officials know by contacting them.

Continue reading →

Providing anesthesia is often compared to flying a passenger airplane, and the anesthesia care team model is like having both a pilot and a co-pilot.

Who thinks flying has become so safe that we no longer need the pilot? Seconds count in flight, and they count just as much in the operating room when a patient’s life is on the line.

In 2016, the VA rejected independent practice for nurse anesthetists after careful consideration, but this decision was recently overturned by a memo citing the COVID-19 pandemic. This memo abolishes the anesthesia care team model without giving Veterans a choice. Veterans having surgery may only get a nurse anesthetist without the option of having an anesthesiologist involved. If they were given the choice, however, I think our Veterans would choose an anesthesiologist or an anesthesia care team led by an anesthesiologist instead of a nurse anesthetist alone. We all should. In areas affected by surges of COVID-19, elective surgeries at the VA are stopped so there is no shortage of anesthesiologists.

Anesthesiologists all over the world have been fighting COVID-19 and have shown what they can do with their specialized medical training in a crisis. Although commonly referred to as “going to sleep,” general anesthesia is more like a complex drug-induced coma that can carry serious risk. If or when a crisis happens during surgery, every patient should have access to an anesthesiologist.

Modern anesthesiologists are physicians first but also scientists, educators, and patient safety advocates. Anesthesiologists specialize in relieving anxiety, preventing and treating pain, preventing and managing complications related to surgery, critical care, and improving patient outcomes. The average anesthesiologist spends nearly a decade in postgraduate education after college including medical school and logs 16,000 hours of clinical training to learn to apply the best available evidence in clinical practice. Academic physicians and scientists focused on anesthesiology are responsible for the discovery of newer and safer anesthetics, pain therapies, and technologies that are advancing healthcare throughout the world.

Anesthesia administration by non-physicians such as nurse anesthetists and certified anesthesiologist assistants is supported by the American Society of Anesthesiologists within the physician-led anesthesia care team model. To uphold the highest quality physician-led anesthesia care for our nation’s Veterans, please speak up by supporting Safe VA Care and reaching out to legislators.

It only takes a minute to stand up for safety, but the consequences of not saying something may be serious and long-lasting.

Anesthesiology, COVID-19, Healthcare, News

Being Essential in the Post-Normal Era

March 27, 2020 ermariano

Traffic is non-existent. Schools are closed. Restaurants are only offering take-out and delivery. Parking lots at strip malls are empty on weekends. Only a limited number of people at a time are allowed inside the grocery store.

Welcome to the post-normal era since the COVID-19 pandemic hit the scene in Northern California.

One day we will look back at this time and realize how much it changed everything. Simple things like a handshake or sitting together with a colleague during a lunch break will hopefully never be taken for granted again

Continue reading →

The California Governor has issued a statewide order to shelter in place. It’s only natural that the husband and father parts of me consider staying home like everyone else.

But I’m not like everyone else, and none of us in healthcare are. We are considered “essential,” which is why we continue to go to work day-and-night while the rest of our society shelters in place in a monumental effort to “flatten the curve” of COVID-19.

I have always liked this blog by Dr. Kathy Hughes about working at hospitals around the holidays and being essential. Hospitals at that time of the year are actually festive places. It’s different now. There are no holiday potlucks in the ward lounges to bring people together. There is no celebrating. Yet, we all understand that we are needed and share the burden of being essential together.

Our work as anesthesiologists has changed. We no longer perform elective surgeries in our operating rooms. The weight of our role as specialized physicians has shifted from perioperative and pain medicine to emergency response, critical care, and crisis management. We are at particularly high risk since COVID-19 is a respiratory disease. Every time we are called to perform tracheal intubation in an infected or suspected patient who is coughing and having trouble breathing, we are staring down the barrel of a gun.

Protecting ourselves is a priority because our expertise is a limited resource. If we get sick, we can’t help others, and we risk spreading COVID-19 to our families. Personal protective equipment or PPE is a necessity, and multiple layers are required by anesthesiologists and other airway management personnel given the high risk procedures we do in these patients. It takes time to put on PPE, but there can be no shortcuts when it comes to safety. SLOW IS SAFE, and we need to remember that there are no more emergency intubations in this post-normal era.

To all airway management personnel:

❗This is the post-normal era. There are NO MORE emergency intubations.

❗Proper donning of PPE takes time. SLOW = SAFE.

❗You are a precious resource. Do not risk getting exposed.

❗Start training your backups.#COVID19 #GetUsPPE
— Ed Mariano, MD (@EMARIANOMD) March 25, 2020

Being essential in the hospital is not limited to just the healthcare professionals of course. The engineers, the technicians, the housekeepers, the cafeteria and food service workers–they are the unsung heroes of the hospital during this pandemic. Without them, our facilities and our healthcare workers would cease to function. Whenever I see them, I thank them for the work they are doing to support us on the front lines of patient care. We share stories of how things used to be and give each other some encouraging words.

It is surreal to get up, get ready for work, have a cup of coffee as part of my normal morning routine, drive through deserted streets, and walk into the hospital not knowing what the day will bring. We have a job to do, and that calling to help humanity drives us to keep coming to work. We chose medicine, but medicine chose us too.

This blog has also been featured on KevinMD.

Anesthesiology, Healthcare, Leadership, News, Pain Medicine, Patient Safety, Regional Anesthesiology

My Trip to Washington: Speaking Out Against Drug Shortages

November 13, 2019 ermariano

UPDATE: The MEDS Act was incorporated into the Coronavirus Aid, Relief, and Economic Security (CARES) Act and passed into law on March 27, 2020. I commented on the COVID-19 pandemic’s exacerbation of ongoing drug shortages in this interview with CBS news.

On November 5, 2019, I had the opportunity to participate in a Congressional briefing related to drug shortages at the Capitol in Washington, DC. Senator Susan Collins (R-ME) opened the session and co-sponsored the Mitigating Emergency Drug Shortages (MEDS) Act with Senator Tina Smith (D-MN). I was one of only two physicians on the panel and tried to represent the voice of clinicians involved in perioperative care and the patients we care for (video). Below are the notes from my presentation.

As a physician specializing in anesthesiology, this ongoing crisis of drug shortages in the United States is frankly terrifying.

Continue reading →

Anesthesiology is a unique specialty within medicine. Our patients are the most vulnerable in the hospital. Patients under general anesthesia cannot advocate for themselves and trust us with their lives.

We do not know what the next drug shortage will be or how long it will last. This week it is prefilled syringes of lidocaine, a life-saving emergency medication we give in case of a dangerous heart rhythm. Two weeks ago it was phenylephrine, a routine medication we use to increase blood pressure when it goes down after inducing anesthesia.

Last year, we had complete shortages of common injectable opioids and local anesthetics used for numbing injections. This directly affected surgical patients in terms of anesthesia and pain management. For 3 months in 2018, we did not have the local anesthetic indicated for spinal anesthesia. We know this is the safest anesthetic for patients having certain surgeries. During this shortage, we used an alternative anesthetic in order to continue providing spinal anesthesia, but our patients experienced more side effects. The reasons for this shortage were complex and involved a limited number of manufacturers and quality issues.

Thankfully, the shortage of spinal local anesthetic ended. We do not know when or if the rest of our current drug shortages will end. All we know for sure is that there will be another one.

The predictably unpredictable cycle of drug shortages puts physicians in an impossible position. Medicine is a calling, and we physicians have sworn an oath to support the well-being of our community and humanity in general.

Not having access to the right drugs at the right time for every patient and being forced to use less acceptable alternatives, if any exist at all, represents a form of moral injury. Moral injury “is being unable to provide high-quality care and healing in the context of health care” and is now recognized as a contributor to the epidemic of physician burnout.

Listen to my interview with Paul Costello on SoundCloud.

From left to right: Daniel Teich (Fairview Pharmacy Services), Dr. Peter Adamson (Children’s Hospital of Philadelphia), Senator Susan Collins, me, and Brian Marden (MaineHealth Pharmacy)

Anesthesiology, News

New VA Palo Alto Anesthesiology Website

April 17, 2011 ermariano

We recently launched the first website for the Anesthesiology and Perioperative Care Service at the VA Palo Alto Health Care System. As our patient population gets more connected with instant access to information via the internet, it is more important than ever for us to reach out to them. We know that going through the surgical process is a stressful experience for patients and families. Through this website, we hope that our Veteran patients will be able to learn more about the cutting-edge anesthesia and pain management services we have to offer them. We also want our prospective staff, trainees, and colleagues to see the great things we’re doing at the VA Palo Alto these days. Please visit us at online!

News

Welcome

December 8, 2008 admin

va_flags Welcome to EdMariano.com!

I am an anesthesiologist at the VA Palo Alto Health Care System (VAPAHCS) in Palo Alto, California. My specialty is regional anesthesia which involves performing a variety of specific nerve block techniques to numb areas of the body for pain control. Our research has shown that nerve blocks provide patients with the best possible form of pain management after surgery. At the VAPAHCS, we even use nerve blocks as the primary anesthetic for outpatient surgeries so patients can wake up faster, pain-free, and without the nausea and other side effects associated with general anesthesia.