Do I have your attention? Being triple – specialized in Anesthesiology, Acute Pain, and Intensive Care, I sometimes find myself thinking about patient problems in unique ways.
For example, in October 2019 when a young patient in his 20s presented to the Neuro-Intensive Care Unit at UVA with Guillain Barre Syndrome, paralyzed and intubated on mechanical ventilation, in severe pain with autonomic dysfunction, my mind went to whether I could use peripheral nerve stimulation (PNS) as an alternative, non-pharmacologic, analgesic modality to get him through his acute illness and minimize his pain and suffering.
The rest of the ICU team at the time thought I was kidding because this modality of therapy had never before been tried in this patient population. As the ICU team increased his opioid and gabapentin dose, I went back to the literature and found a case of GBS in the 1970s where they had tried transcutaneous electrical stimulation with some relief in a GBS patient who presented to the pain clinic years after their initial presentation with chronic pain. This was reassuring that electrical stimulation may be useful in GBS.
The idea for PNS in GBS came to me through my work on a pilot study with a wonderful team of researchers at McGuire VA, implanting PNS in amputee patients with acute pain in the perioperative period. I had witnessed the dramatic reductions in pain scores in these patients which occurred immediately upon placing and activating the device. I saw first-hand how PNS was working to control amputee’s phantom (neuropathic) limb pain.
The patient I encountered in the Neuro ICU did not seem so different – he was also experiencing severe neuropathic pain. Unlike the amputee patients, the pain was in every limb! He described it as a sharp burning pain that made his entire body feel like it was on fire. No wonder this young man’s heart rate was in the 160s and blood pressure was in the 180s/100s – the neurologists called it “Autonomic Dysreflexia”, but to me, this was due to severe excruciating pain! After all, he felt like he was on fire!
Rather than watch him become more and more sedated on intravenous pain meds, all of which are well known to have detrimental long term side effects, I advocated to place peripheral nerve stimulation therapy. I spoke with experts around the country who utilized PNS in their practice, none of whom had done so for GBS patients, but all of whom thought it was “worth a shot”.
After obtaining full informed consent from the patient and his family, explaining that this had never before been tried for GBS, they agreed to allow me to place six leads, two around his brachial plexus, two around his femoral, and two around his sciatic nerves. The results were immediately evident – he had a dramatic decrease in his pain scores, level of satisfaction, and psychometric scale scores – for the first time in weeks he slept eight hours straight!
Over the next few days, his IV pain meds and adjuncts were weaned, his vital signs improved, and most importantly, now that he was feeling better, he was able to smile and wanted visitors to come and visit, evidence that his psyche had also improved (this was of course prior to covid).
The point of this story, and this issue on “Controversies in Anesthesia”, is that we, in medicine, are still learning. This quarter’s newsletter issue is dedicated to the themes and topics that many of us question, but either don’t have the answers, or don’t dare discuss for fear of being judged, uncomfortable, or on the wrong side of the issue.
In medicine, there is only one thing we clearly know, and that is, we do not have all the answers. There is still plenty we haven’t figured out. I hope this issue gives pause, opens your eyes to new and diverse perspectives, and allows you to consider alternative solutions – after all, medicine is just as much an art as it is a science.
When the VSA newsletter staff and I came up with the idea for this theme, we were uncertain whether we’d garner any interest from authors. Fortunately to my surprise, this theme has become one of our most popular to date!
This issue covers a well-rounded variety of controversial topics, ranging from scope of practice, reintegration into Anesthesiology after addiction, use of medical marijuana, to the banning of inhaled anesthetic gases. Trust me, you don’t want to miss reading this!
I’m thrilled the VSA Update is able to offer a platform for advocates standing up for thoughtful, well researched, relevant issues to anesthesiologists of Virginia, for an opportunity to affect change in our community.
Thank you to all the brave advocates willing to “Be the change that you wish to see in the world.” ― Mahatma Gandhi
Enjoy this issue!