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SNI Digital, Innovations and Learning,
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a new 3D Live video journal interactive with discussion.
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Now offering this program and others as podcasts on Apple, Amazon, and Spotify podcasts,
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look for SNI Digital,
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in association with SNI, Surgical Neurology International, a 2D Internet Journal,
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is pleased to present
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another talk by Ransis Colli, a
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neurosurgeon and clinical practice who is board certified in neurosurgery, anesthesia, critical care, and pain management.
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His topic is neuro anesthesia and neurocritical care for the neurosurgeon. How to manage all of this in the corporate era.
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Extra Ghali is Clinical Professor of Neurosurgery Anesthesia Neuro critical care and pain management
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and he is the founder of Golly Neurosurgical Associates in nineteen ninety five he can reach erased by the email above and by the phone List today we we are where we're talking with Rams and scaly
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rams as a as as boards and neurosurgery critical care anesthesiology at a practice is all three specialties and as for yours I want to I dunno if anybody else had Anesthesia as those those have
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qualifications to you know actually there is no no one else shall wind in America and international in the world that has this photo boards which is fully and continue to practice the neurosurgery,
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the anesthesia slash neuro anesthesia, pain management, and neurocritical care. Yeah, that's so, this is a unique opportunity to talk to Ramses. Ramses is in Chicago, Illinois. He's been in
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practice and academia for, I'm not gonna say how long, but for years. And still looks as young as he did when I first known And so today Ramses, you wanted to talk about what neurosurgeons really
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need to know about neuro anesthesia and some of the controversies in that field. Yeah, this
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is really a good discussion and elevate the awareness for the neurosurgeons because as you taught us and as we know that surgery is not everything to control the outcome
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And what is good when the neurosurgeon does a great job and something happened during surgery from the anesthesia and aesthesiologist or post-operative or even pre-operative that affects the overall
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outcome. And this is usually the issues. And back then, we used to be, we used really to be Dr. Asman much more involved with the patients
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And at that time, I remember you're teaching and sometimes we used to admit the patient night before. You taught us and it was a beautiful lesson that you have to know about the patients, what's
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the AKG showed, what is just six-ray, what is his labs, how is his heart, what is his ejection fracture, how is his kidney function? And then gradually as the corporates have done, as well as
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the payment system have done, told the surgeon that. Whatever you take care of the patient, we're not going to pay you, we're only going to pay you for the procedures. And as the physicians or
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the surgeon starts to get employed by, by corporate, corporate starts to make sure that the surgeon does activities that get paid for it, not the things that didn't get paid for it. So what they
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have to solve this is very interesting because it's no longer the same like the past and it's the same for other physicians also including the anesthesiologist. So now here is what the current thing
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that will surprise you and will surprise many. The anesthesiologist will not see the patient is not allowed to see the patient night before or to know anything about the patient except the day off
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and many of my patients they'll know something about the patient five minutes before the surgery. So where do you get this information that the husband decided to hire PA and qualified nurses and
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they interviewed these and all this data goes into the Epic system as a nodes. And you wanted to know about your patient, read the nodes. Now, you can read as much nodes as you can, but the nodes
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cannot replace surgeons position to see the patient. Plus, what kind of nodes you're gonna read, if everything is cut and paste, and it's fragmented, and what questions you're gonna ask the
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patient. So now if you look at the current system, the Anesthesiologist doesn't see the patient, the Anesthesiologist used to see the patient before, doesn't accept the day off. You have no
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control of who's the Anesthesiologist that is gonna do the case. It can be the CR name, it can be a general Anesthesiologist. And
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now let's talk about the neurosurgeon. His last surgeon, he's not allowed to see the patient, usually the BAC, the patient. The neurosurgeon usually will only look at the films and say, this is
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a human scheduling for surgery. because you can the surgeon can sign the note of the BA. So there is a lot of places that the neurosurgeon doesn't see the patient either. But when did you see the
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last time a neurosurgeon when he would listen to the lungs? Is equal zero percent? I will attest to you if you ever can see a neurosurgeon backup the Cisco. In fact, you're probably not gonna see
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a neurosurgeon and have a turning fork or
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the vibrations or bend break like the times that you thought us. You're probably not gonna see that. They basically look at the films and they look at the patients and say, yeah, you need surgery,
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this human needs to be out. And who does the exam then? It's usually the nurse outside. And when the patient comes in the reception, the aid will take the vitals, then the nurse will interview
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the patient or write all the notes And that note, by the time it goes to the irisurgent, I'll just say. I looked at your notes and all of this stuff and I think your surgery. Or if it doesn't see
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pathology saying I can't help you, go to a pain clinical test. So you can see now the point that I feel that this topic is so essential because ultimately who's gonna be the price for this
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fragmented medicine. Until the AI will get hold in this and they think that the AI is gonna do this job that one of us used to do it many years ago The AI is supposed to put all these nodes together
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and tell the surgeon, Here, what are you gonna do? And go do it. This is what the healthcare is going to, by the way. So now here is you have the neurosurgeon. Doesn't know much about the
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medical condition except you would like to have a note from the medicine guy say he's cleaved for surgery. But those people also are smarter now and they write moderate risk, high risk I don't know
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what it means to the surgeon. You know, you have an aneurysm to clip what it means, moderate risk, high risk, or low risk. So there is no continuity of care or somebody that has the same
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comprehensive look as a neurosurgeon back then. So what I ask then and what people have told me, except you and Dr. Aldere that you're doing great that you're an anesthesiologist. In fact, one of
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the things that you said, oh my God, I never had a resident that was an anesthesiologist and we need to incorporate this mind into the neuroprotection during surgery and anesthesia. Nobody cares
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about these things now. But then I looked at the times and said, oh my God, God send me Dr. Osman and Dr. Aldere and all of those wonderful people. And I'm glad that I have these four boards
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'cause you know what I do now? I'm the primary physician. I clear my patient, I tell the patient, any distance and distance. I decided for division what is the right thing to do because I found
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people around me they're not helpful and then what they do is is according to our statistics this vision doesn't need an ejection and that doesn't need an echo cardiac echo insurers will not approve
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doesn't need this kidney function or he does the other thing you'll need to do is send any co eggs innovation because the insurance will not approve and when things happen communication Heaven is only
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the surgeon that is going to be pointed to why because he's the one that has a knife and did the surgery number one number two medicine and other people will say you didn't fight hard enough you
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didn't tell me that you need for regulation profile and then we going say will you just leave the basin said well I think his blood pressure dropped during surgery and that is why he and AM I or AM I
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OH My God maybe you had any AM I because the coroners were bad to start with This is where we are nowadays. So what is the conclusion? The neurosurgeon are by himself taking the risk of having a
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patient that he doesn't have a good information about that. So what can we do now in this? One, the neurosurgeon should know a lot about neuro anesthesia. The neurosurgeon should stand strong and
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say, I need an anesthesiologist that is highly qualified and knows what neurosurgeon is all about. I cannot do an aneurysm surgery with an anesthesiologist that is doing general anesthesia for bowel
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obstruction or for vasectomy or for hysterectomy. There is a big difference between the brain, the heart and the other organs. So I think is a worthwhile fight I have published an article and you
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rightly so.
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in a surgical neurology, and this should be our reference for discussion today. This was in 2013, and the article is about do neurosurgeon need neuroanesthesiologists. This is back in 2013, and
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you kindly publish that article. It's a huge article is used as a reference for so many specialists. And at that time, I asked neuroanesthesia to have a wonderful specialty that can do in a neuro
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monitoring, can also do all the advanced monitoring under anesthesia for
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neuro. However, neuroanesthesiology as a society did not fight hard enough. So we lost the neurocritical care to the neurology. And now the neurologist that they do a lot of neurologists studying,
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they becoming the neurocritical care. So believe it or not, the neurologist that we used to consult them to tell us what do you do you do for neurologic diseases. Now they're doing the
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neurocritical care and they're telling the neurosurgeon what to do. Which one needs surgery? Which one needs clipping and how you treat the ICB? And now the neurosurgeon said, you know what, I
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had it. Here's my patients, I did the surgery. I am not gonna put an ICB monitor and you deal with it. You tell them why you don't beat an ICB monitor? They say because people in the unit,
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they're not as qualified and they're just gonna keep bugging me with the ICB that is high So you actually lift the patient out of control of a neurosurgeon. So where is the neuro anesthesiologist and
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the neurosurgeon that actually taking care of the patient in the operating room and in the ICU? I'm afraid is limited places and usually the high referring centers for neurosurgery cases. But
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nowadays we don't practice neurosurgery only at university. is in many places. So
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go ahead. You do anesthesia also when you're in your anesthesia outfit, you're doing anesthesia for people who are doing spine surgery and other kinds of neurosurgery. So you're a neurosurgeon
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on the side of the traips of
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the neuroanesthesiologist See the neurosurgeon doing this. What do you see? Oh, it's him. So as a neuroanesthesiologist, here is the sad bar. I see, and God forgive me, I see that
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neurosurgeons has no interest in knowing the vitals, in even doing monitors, Dr. Asman. They don't want to do monitors. And then they just finish the case, and they dumped, they lit the case B
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in the recovery handle by nurses, and then in the surgical ICU, handling by a general trauma surgeon. or trauma ICU. This is what you see. And the neurosurgeons are okay with that because now
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they're employed. Employed means I just need to get paid for the surgery, have it somebody else deal with it. Now remember, this is now is the principle of the new healthcare. When you have a
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chiropract, then that patient in charge of that patient now is gonna be another person that is employed Another nurse that is employed. So it's no longer the neurosurgeon by himself. It's a team of
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people and when a legal case
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comes, the entire hospital system will defend that case with as one voice. This is the new system that they try to implement. So there is no neurosurgeon that I have met currently in practices
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where I am that they actually put his nose and manage the patients in the ICU, or be aware of what is going on with the neurosurf within the operating group. You would be lucky to have a
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neurosurgeon say, Hey, I need to make sure that this blood pressureis like this or this or this or that. And this is really the issue. So let's get an examples of that. Example of that is a
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patient with cervical fracture, or a patient with cervical cord compression or something So the anesthesiologist will look at the surgeon saying, Do you want to wait fiber optic? Is it okay to put
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the patient to sleep? So he puts the, he turns the responsibility now to the anesthesiologist, to the surgeon. This is what they do now. You want to do a wait fiber optic? Okay, so you do a
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wait fiber optic and the patient struggles, fights and cough. And he actually torture the patient and he cannot do fiber optic a slick neuro-eciciologist. So what is a neurosurgeon will do? He
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can't complain, otherwise he's gonna be written up. He can't yell and scream because he's not gonna be written up. He just have to swallow it. So, and this is what you see. So how can the
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neurosurgeon will know to do a weak fiber optical death? If the neurosurgeon is smart, he can say, you know, I would like you to do what is good for your hand or whatever your judgment is But now
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you lift it up to the judgment. So let's say that the complication happens. What are you going to point the finger to who? You're going to point the finger. It's still ultimately the patient. So
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what you see is I have a patient that if you wake up with the hand numbness, the hand is numb. The positioning, the IV was infiltrated. So this is an anesthesia issues. Everybody agree with that,
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right? After the surgery, I have to be the one to answer to the patient, because the anesthesiology will not follow the patient. So what I'm trying to say is everything is, what is the surgeon?
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What is the surgeon? What is the surgeon? So I see totally different neurosurgeons. I see currently a neurosurgeon just focused toward the surgery part and accept what kind of anesthesiology is
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gonna do the case, and that's it. If you talk to the anesthesia people, there is no fellowship. I had not worked in a place that a nurse, that the husband has a neuro anesthesia fellowship, or
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the anesthesiologist has neuro fellowship. The only ones that you see in few universities. And this is why I started my article back in 2013. They refused to make a board certification for a neuro
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anesthesiologist They refuse to make extra payments. for neuro monitoring or neurocritical care for the neuro anesthesiologist. So the neuro anesthesiologist fellowship was not attractive to the
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anesthesiologist to do fellowship. And this is what I started that article back in 2013. I said neuro anesthesia and neurocritical care we should get an ownership of it. Only neuro
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anesthesiologists and neurosurgeons are the one that can improve the critical care management of the brain and the spinal cord and the spine surgery. And it never, because neuro anesthesia, it
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dropped and it made it not attractive to the anesthesiologists because there is no poor certification, there is no extra payment. And then how many cases that the neuro anesthesiologists will see in
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private practice? Not a lot. In the meantime, the anesthesiologist and
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the neuroanesthesiologists were able to publish articles and from the Europe experience to say that a Syrian nurse anesthetist is as good as a general anesthesiologist. And a general anesthesiologist
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is as good as neuro anesthesiologist. Therefore, you don't need neuro anesthesiologist. Well, it's gonna get worse now. The people that say that, like Michael Todd for innocent, he was a chief
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editor in the anesthesia journal, all of these people, Dr. Asman, you would be surprised. This is the people that
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they did all their academic, and they got the academic scholarships from being assistant professor to full professor by proving that intra-acranial pressure monitor is so important and do all kind of
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monitor to protect the brain and to have neuro anesthesiologist This is the people that 25 years later.
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turn back and say hypothermia is not important. Doing aneurysm surgery by an adrenal anesthesiologist is okay. And ICP monitor is not important because we overdo and we over that. So we became from
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a highly monitored, technologically advanced care a lot about neuro monitoring and the critical status of the brain and the strive to make monitors during anesthesia for the brain and the spinal cord
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to say evidence-based practice indicates it doesn't make any difference. And this is what you see. And now we are allowing this to promote itself because we're no longer doing creative research and
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we don't have the creative neural minded physicians that take us to the next level and the next level and the next level into the intra-operative. improvement of the patients. So this is what I see
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during surgery. We become passive, rather than we should, who's post the director in the OR? Who is the leader in the OR? We, you always told us that the neurosurgeon is. I have to make sure
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that the floor is clean. I have to make sure there is a piece of paper hanged and communicated with the anesthesiologist. This is the steps of the surgery, and I expect you to follow up with this.
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How can the anesthesiologist that is doing bowel surgery will know the steps of the spinal surgery? They don't even know where the screws goes to. So if you don't know where the screws goes to, how
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do you know that the screws can go to the aorton, can go hemorrhage and you better be ready? So now they don't put a lines. They put one IV because most time the case will fly okay, They don't
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know why the navigation system we needed and what is the value of that. In the old days, if you go back to 1960s, the nurse used to know the neuroanatomy much better than the medical students. So
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the nurses used to know a lot more about the patients. And the time, your time, and years ago time, when his wife was the nurse that's taking care of the OR for him, now you don't even have the
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kids, the surgery kids. You have to share it with the 15 surgeons. The nurses doesn't know the steps. You have to tell her HSEP. And don't you dare tell her you should know or whatever it is.
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You have to be very patient. I need this type of person. What this type of person is not here. So you don't have the nurse that does this all the time. And you don't have control in this because
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it comes from the chief of the OR. So this is number one. You don't have the anesthesiologist that worked for you all the time because every case I do is a different anesthesiologist. You don't
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have the neurocritical care that you have the
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neuro anesthesiologist in it. You have a neurocritical care board certified but this is by the neurology, it's not a surgeon. And the neurosurgeon is what he's doing. It's just doing surgeries.
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And the nurse tells him what to do tomorrow So where's this going? No, it's going, but we show money for it. Yeah, where is this from what you're describing? It's obviously, it's not a team
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approach. It's an individual, individual group of people are acting as individuals and not integrated. Is that correct? Or, yeah, or you can summarize and say, It's a coribut lid.
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And the corporate looks at the finance of that. And what's the cost effective of this? Right, I can see that. And
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so each person gets paid to do what they're doing specifically and they don't are not paying attention to other people, they don't get paid for it, they're not interested in it. So you have a
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integrated, you have a team of people working who are not integrated and paid differently for their services, which essentially makes them isolated. Is that right? Yes, or you can say politically
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correct, mind my own business. No, I understand that. That's what it is, yeah. So take us 10 years down the line, where is this gonna be? Oh, I already know what is gonna happen and I bought
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it in my books and I wrote 23 books already and I'm writing my two-second book. It's going to be in a long mask. The government is going to be in a long mask artificial AI. This is all going to be
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artificial AI. This is going to be all this data. It's going to enter to the AI center system. And the center system will make all the management. The surgeon will be still at the end who will do
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the surgery. But a lot of these things is going to be monitored. Here is a blood pressure. Here is this. So the NHS shows will come and intubate until they find the robot to do it And the surgeon
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is going to do the - unfortunately, the surgeon is still going to do the surgery. Still going to come in the middle of the night. Because I don't think the robot can do it in the near future. And
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that's it. So we will be passive in it. And this is what they want you to be.
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You want to surrender. They want you to surrender. And they want you to be quiet. They want you to be - they call it professional. You cannot raise your voice You can not add a cue. This is the
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anesthesiology need and all. So how can we deal with this? You know what I mean? As a society, you wish that the neurosurgery societies will make a point that we should have neuroanesthesiologists
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when I say
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it down the line. They should have fought the same like in your vision. They should have fought and say, neurocritical care is essential part for the neurosurgeon and it should run by neurosurgeon,
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like at University of Illinois or other places, because this is the bottom line. So the bottom line, if you look at it now, balmondry intensivus is a neurocritical care. The balmondry intensivus
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would ask you
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the surgeon, where you want the AVD, where you want the blood pressure, and that's it. So the
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neurosurgeon doesn't really get it, that you're in it legally, Not just to look at the MRI and say. My job is to take the tumor out and no brain hemorrhage. So if I look at the MRI, the tumor
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mostly out and no hemorrhage, this is my job. I don't care about how the patient is doing or what happened during surgery. But there is a lot of things happened during surgery. So what I will
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encourage the neurosurgeons to do. So first, it depends on the case. You have to know essential things that you already know. Is the intracranial pressure is high? Is there is a mass effect?
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It's okay to ask the anesthesia, to ask a night before and say, I want someone that is neuro anesthesiologist. Well, you don't have. Well, I need somebody at least that know about neuro
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anesthesia and know about the steps. It would be wonderful if it be like you, Dr. Osman, you write a piece of paper and say, here is the steps and you have a quality time with that
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anesthesiologist. Here is the steps of the surgery And let's discuss what you're going to do. This is will be an advice to the neurosurgeons. Let's say that the patient has a brain tumor. And this
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is what you did. This is what you sit down with a neuro anesthesiologist or the anesthesiologist saying, how are you going to intubate the patient? What are you going to get before the intubation?
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I want you to give Lasix. I want you to consider Manetol. I want you to give Decadron to these patients. I want the patient not to cough and not to sneeze because the ICB is going to go up. If the
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patient has an EVD, Dr. Osman, I would be saddened to tell you that none of the anesthesiologists know how to monitor ICB. We have to get an ICU nurse to show them. And none of them know that
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this ICB needs to be monitored during the surgery, and this is how you drain fluid. Now, back in the days of Mitch Felder, if you remember him from Mayo Clinic, and the giants of neuro
28:41
anesthesiologists, they even published a book. and say the hypothermic brain. And the panjapok can say, you know, you better have this and that for the ICB, monitor the ICB during induction.
28:54
During induction is the highest to elevate the intracranial pressure. So the patient can herniate. So maybe it's a good idea to measure, to examine the pupil before induction. After the
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anesthesiology to integrate the patient, see if the pupils are still reactive Also, make sure the central line, don't put the head all the way down during central line. You have to make sure that
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the very briefly, but keep the head elevated. All of these things, it will be very important. And this is, you're gonna get a bit surprised. When I tell you now, you ready to be surprised?
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Here is it. Here is the dose I'm gonna surprise you. The neurosurgeon is in the coffee shop. Drinking coffee while the anesthesiologists are putting the lines in a debating the basis. This is the
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current practice. This is really the sad practice. It's not like you talking to the nurse and the surgeon. This is what it is. We accepted this behavior because we think that we are here to do the
29:57
surgery and that's it. Now it's very different than you care. Who knows about this patient better? You or the anesthesiologist, I can bet you that the new researcher knows much more. Why?
30:11
Because you had to see the patient in the clinic. If you are a real good new researcher, you have seen the patient several times, you know the family, you know, hopefully you read the chart, you
30:23
read the medical note from the medical doctor, how is the heart, how is the lungs, how this is, you know much more than the anesthesiologist that five minutes before the surgery. So you know
30:35
better, even allergic reaction, you have it in a computer patient allergic
30:43
the anesthesiologist give answer because they didn't, the left hand didn't know the right hand. The checklist, I developed the checklist and you rightly so published in New York Journal about
30:56
anesthesia checklist. And this is what I do now and I encourage the audience to look at this article. I developed a neuro anesthesia checklist that published by surgical neurology and it has
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everything in it Before induction, what does the anesthesiologist do? During induction, after induction and during surgery. Everything, the best I can do, I wrote it there. So I will urge you
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the audience, neurosurgeon, to make a copy of this, laminate it and read it and go with the anesthesiology and say, Let's discuss
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that this is what we wanted to do. So this is what you have to do Two questions, one, would you send me the reference? the article you're saying, so I can put it at the end of this. Oh, 100.
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Yeah, send it to me. It's in surgical neurology international or? Yeah, yeah, surgical SNI. But all of all of these things is in surgical neurology. The galley, the novel galley checklist,
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and it has the neuro in it. Is it is an SNI
32:06
or? SNI. It's not surgical neurology, which was before 2009, right? Or 2009? No, no, after 2009. Yeah, okay. So, okay.
32:18
Send it to me, the reference, that's critical. Now, I got a couple of other questions. I'm listening to this. I'm a neurosurgeon on the talk. I'm either on my podcast listening to this. I'm
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getting more into press as I can. I almost fell over a rock just a minute ago. And what the heck can I do about all this? I'm saying. Well, what Dr. Colli is saying is absolutely right. What
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can I do about this as a neurosurgeon?
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Take ownership. This is exactly what you taught us. Take ownership. No, this is your basic. If I take ownership, they're gonna give me a lot of arguments and so forth and you remember our
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colleague Eric Nussbaum said as he was leaving the University of Minnesota, he found out why the former head was leaving and the dean told them we're not interested in stars anymore, we're
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interested in team players. Which basically means we're not interested in excellence, we're interested in mediocrity. So here you are, here's the followers, who is listening to the podcast or
33:28
watching this video and he's trying to figure out what the heck do I do about it, that's exactly what I see every day And I'm frustrated about it and it depressed. It makes me want to quit medicine.
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What do I do about it and you said you got to take charge but they're going to give me heat for taking charge yes yes but that but it but it is it is the things that I use in my practice because in my
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Practice I don't have new anesthesiologist every time I have a different anesthesiologist this is what I have so what do I have to do I for one very important is increase your knowledge know about the
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minimum accepted risks that you need to take when you take a patient revert to the scientist surgery one principle we learn is a neurosurgeons that decision making and and the candidacy of the patient
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is so important so think about it you're going to do multi level T one two s one fusion in a patient with a can do my Apathy or with a patient with ejection fracture of 30 are you nuts? So put your
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nose into this. Do not be blinded by how much payment you can get out of the surgery case, even if you had a dead patient. So, and this is what I mean by taking ownership. Be professional, but
35:00
you are in charge of this patient. This is your patient. Whether you like it or not, in the chart, everything written, this is Dr. Gallipatient. From the minute the patient enters, the epic
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system, to the end of the patient until discharge or dies, Gallipatient, Gallipatient, regardless. So, take an ownership. So, spend quality time with the patient. Know about the kidney
35:28
function. You think the creatinine, and instead of being 12, is three. This guy, a little high boot tension during surgery by an aesthetic is going to end by arena failure. Are you really gonna
35:41
do multi-level fusions? So this is really then, are you waiting for a medical doctor to say vision is clear for surgeon? And the for surgery, and this is what we waiting for. This is what the
35:54
preoperative, they call them, pre-procedure, a check or nursing, or this is. So start to incorporate medical with the surgery. How can you do this? Maybe you need to take a class for very
36:09
operative medicine Maybe you need to take a class about what is it, since the new graduates don't know a lot about these things. And the working 70 to 80 hours is not like you and me my time. I
36:21
remember in the time that we trained with you. We'll get the nephrologist and you'll ask, you don't even call the nephrologist and say, what is the nephrologist say? You ask us to learn from the
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nephrologist and to tell you what we know, because it's ultimately our vision. And this is what we need to know. called the nephrologist, called the cardiologist. You know what I mean? Here is
36:43
another thing that is currently no solution for it. There is a patient in comatine because the patient has atrial fibrillation. Until today, Dr. Asman, this is how we are so fragmented. When do
36:55
we start the comatine? When? They'll tell you, talk to the new research. But how the new research will know when? But this is what it is. I'm struggling every day about this. And then the new
37:10
research will like to say, burn the hematologist. But you know what? They started. I saw a patient. A patient had the same problem. They listened to the doctor. They started the calculation.
37:24
The patient had massive hemorrhage. And the patient is paralyzed now. So whose responsibility is this? But you need to have the neurosurgeon that you told us. You need to ask, what is the risk
37:36
factors for this guide to be of anticoagulation. does he have a bad heart or just that the irregularity will if he has an atrial fibrillation originality two to three weeks is not a big deal but
37:48
having a guy with a bull heart or those of metal valve or he had a immobile heart like the wall motion is this is he's a high risk for thrombus formation so maybe you need to do cardiac echo or de to
38:02
try to find out if this is a high risk so this is the first the first educate the Neurosurgeon taken ownership of your patient do not leave the camp blindly to everybody else like what I see now so
38:17
this is the first you have to believe that there is evidence based practice I agree but a good attorney will tell you that there is no text book for each patient you are going to have to use your head
38:30
and your brain to make the good judgment don't wait for an AI or some notes to tell you that divisions cleared what else you need from me And this is the behavior now. So take the ownership, improve
38:43
your knowledge. And the third, read Gali Neurochic List or anything else, and go with the anesthesiologist. And tell him, let's talk about this. This is my concerns. This patient has a high ICB.
38:56
This patient can herniated this. I want this spine is unstable. I want to examine the patient after intubation. I want the patient to be awake to make sure it's okay. Things like this The other
39:09
thing is I want the blood pressure to be between this and this, but don't just turn your head the other side. If you hear a monitor that is peeping, ask the anesthesiologist, what is peeping? Or
39:21
intermittently, look at the vitamins. What is the blood pressure now? A good people like anesthesiologist or this will not disagree with you and say it's 96. Are you okay with that? Open
39:34
communication during the surgery is so important.
39:39
neurosurgeon during surgery. When I see them, they don't talk. They don't talk. And you know what they talk about to the nurse about what they did yesterday
39:52
or what they have eaten. This is really the people you graduate. If you do the surgery now, you're never going to come back. But the problem we're graduating surgeon that this is what they like
40:04
because it's called according to this CEO of the husband, their team player. Why team player? Because they taught me this lecture. You have to be team layers. You have to have the people, people
40:17
write me up. I said, why? You need a room to be called and you don't want any people to talk and you don't want loud music and you are. What do you think this is? This is what, this is what the
40:31
people tell me, they criticize me. You need to start to to talk to people, you need to have music and all of the stuff. This is the real story with all of this so yes you are you Gonna bite to
40:43
this it this is what you want or you going to be mediocre like the rest of them be it but we talking about quality surgeons we talking about quality why because neurosurgery is not like taking a
40:56
bendix out is not like an M and B they think a foot you're actually work with the brain and every little cell counts so if you have a hyperthermia if you have the blood pressure low during the case
41:10
and you're not watching this patient may have cognitive dysfunction when he awakens and then they going to say your surgery screw him up but maybe there's something you could have prevented by being
41:22
more diligent so having this is for now is great nothing would replace to go back to the to the Institution and Say I preferred to have a neuro anesthesiologist I want my team to be a team that is
41:39
actually had done these cases before. And now becomes your discussion, Dr. Osman is, do I really need to do these big critical cases in a facility that is not like
41:54
a, it doesn't have a neurocritical care, neurosurgery, residence, day and night, things like that. Should we just restrict them to just subdural hematoma or two-level fusion or something like
42:09
this? At least you should know this is a decision the neurosurgeon should make that is good for his patients. The hospital will push him to do something big in his place but if he doesn't have the
42:27
setup, he shouldn't be attracted for the money or for the different it is He can tell the husband until then I can do the case. but this is the issue that we deal with this is exactly the issue we
42:42
deal with this is some of the points that I would suggest that those are excellent points I think a lot of people who are listening to this will resonate with it it's frustrating to think about it
42:56
because I look into the future
43:00
I see several things I think people are depending upon artificial intelligence which is what it says it is it's artificial it isn't real intelligence if but the people just like I'm sure when they are
43:16
they I introduce to try to think of an analogy from earlier on everybody thought there might have been solved all the problems the problem with artificial intelligence is it can only deal with the
43:31
data that is put in myth it can't create It can only give you the data and analyze the data. It can't create an answer because sometimes the answers that you come to are a combination of concepts
43:50
that you have and training, which you can't quantitate. And if you can't quantitate it, they can't put it in AI, which means it doesn't enter into the judgment of the patient. So AI, to me, has
44:03
its limitations. That's number one Number two, medicine is becoming complex. It is,
44:13
if you just look back even over a period of time, it's far more complicated than it was before. We know more and so forth. I foresee that, and a lot of people aren't gonna like this, but I
44:29
foresee that we're gonna be seeing More and more group practices. We're going to see a change in the compensation systems because what happens now is what we just talked about everybody gets their
44:46
own compensation and it's the same
44:50
well that doesn't make a lot of sense I think of it's a very complicated case and the neurosurgeons are very involved in doing this it's one thing if the Anesthesia has a very complex set of problems
45:05
that's different than if it's a routine case so I think that I could see people sitting in a room before surgery discussing these points rather than reading a chart which becomes overwhelming to read
45:18
to get this information and yes that means you may have to have medicine people in in the your team you may have to research people in your team so I think that things are going to involve that you're
45:30
going to have team approaches to it What a you would be integrated and rewarded for their total results and each person obviously is going to they're either going to pay a dow total down payment or
45:43
payment for what the procedure is I or you come together with a combined price and people get paid on that basis I don't see the answer to this and continued banned a practice of socialized medicine
45:60
that's what you're talking about and it's obviously not working so I think that to me as I look at it now I see that's where things are going I think you've given up a very practical summary of what
46:15
is happening to the Neurosurgeon today in the operating room what is the inner anesthesiologists doing what is a medical consultant doing that you send would you clear the patient for surgery we used
46:30
to do that but it would if there were questions and all the rest we would as the things that you're talking about and and and they need to understand what the risks are you need to talk with the
46:43
family and understand what the family circumstances are the computer come on tell you that and if you're only spending a minute or a day and won't matter I I think I mentioned this before we are is
46:57
operating on a woman in in Los Angeles who who is opposed to a pituitary tumor removed was scheduled for surgery I walked into the residence attain the patients or walked into the patient's room and
47:16
the room was filled with family members
47:21
I was it was obvious I was operating on the matriarch in a Spanish family it changed it changed my entire approach to the case What it meant to me is if you understand the Spanish culture this woman's
47:37
ahead of this entire family all twenty five people depend upon the wisdom of this person I'm not going to do some aggressive surgery that's Gonna have her coming out of the hospital I impaired it
47:51
would be a tragedy for the family so I you have to take those that that calculates into your risks so that part that AI duck can't compute for you and you can't decide that and looking at an x ray and
48:11
scheduling a patient for surgery you Gotta know more about what's going on that may sound like it's old fashioned and I don't get paid for that but you'll pay for it in a malpractice or in the in the
48:24
in the complications you get in a will be satisfy and so you'll say This isn't really what I wanted to go into medicine for so you're going to pay for it so anyway do you have any thoughts about that
48:38
easy no no no as well good points there is a case and this is a plastic surgeon and it's in the news now and that liposuction in thirty five years old and then numb he think he did a good job somehow
48:57
he did not see the patient follow up which i already told you that to see patient back and recovery is almost unheard of to examine to examine the patient was to operate then say moves the arms and
49:10
the legs it's it's it's it's it's now the surgeons already in the clinic or somewhere so anyway so the blood pressure dropped of this patient and continued to drop so abundantly according to this case
49:24
they tried to reach him but he cannot be reached but it's okay don't you think the blood pressure is low It should be more doctors in the recovery in the end this is whatever it is anyway everybody
49:36
dropped it and the patient died what was it what was the original reason for surgery Liposuction Liposuction Yeah Holy Cow Okay so so now you have a liposuction and the certain way but it can be
49:54
anything it can be likened the day the beard and then a it's not a habit any more that you examine the patient recovery and you wait until because to wake up the patient you need to have two hours
50:07
because this is nothing neural anesthesiologist then he's giving medication to the patient you never know what the medication is I have I have recovery nurses tell me that this patient had a stroke
50:18
after the surgery and the patient actually under the influence of drugs who knows if this is a stroke or my medication Anesthesia you need you don't need an AI right so they bring We bring the tellem
50:31
Euro this is the other thing we didn't talk about a lot of this neuro critical care is done by a tele and urologist sitting somewhere in Arkansas so the they give him and say what is this what is this
50:43
yeah let's go and get a tiki a so you taking the patient just surgery is still under recovery you think come all the way to the basement to do sep eight so that you can have a seat the aid that says
50:56
okay and if you wait for half an hour good judgment maybe the medications going to be released maybe you know that this is anesthetic effect so everyone drop the corrupted corrupted Inhibition die
51:09
what do you think are the results of the asthma the chord no no in the court what's happened in the court who to blame
51:19
who blamed in that case that the patient died who you think my room the Neurosurgeon I guess at the plastic surgeon Yeah and and and that why why because he didn't answer his page he didn't see the
51:37
patient after this is his complication how much the kids get the the the the the the money settlement set and how much it went to the court sixty six million dollar again is that Surgeon Oh my this is
51:56
in Chicago and this isn't comes to your point are you going to outsmart the anesthesiologist is going to tell you everything on video game during surgery are you going to outsmart the recovery say
52:08
when we called you are you going to outsmart the Gothic I can say We've done everything right it's your surgery that this is so Yeah if you want to have a good outcome if you wanted to go the Bible
52:23
always tell you if you fall look when did you Fall Do used to love me now you don't love me anymore you better start from why you're not loving me anymore rather than go to these rituals that doesn't
52:37
make any sense if you don't have love so if you ended in neurosurgery you'll get an oath that you're going to take care of the patient if we are I agree with you Dr osman that that they need a team
52:51
player but the problem is Eric is one person but if the organization of CNS or doubling as get altogether we only two thousand neurosurgeon in America God's sake we can all get together and say when
53:07
will we need this and we need this and it's going to happen but we get your absolutely ruined pisses absolutely ruled in in the meantime but in the meantime teach your anesthesiologist if you have to
53:22
put up with anesthesiologist that that a new out in the situation that you cannot change at least for now the EA talk to teach them he does extensive surgery teach me about what you're Gonna do is
53:36
start to know what drugs is only two things in Anesthesia or three things that you want to know about what the drugs to use which you already know because a lot of them will use it in Neuro critical
53:47
care US propofol for induction you try to avoid get them mean or how to finish as the drugs you wanted to make sure the bishop only hyperventilate before the range of subdued up but not throughout the
53:59
case you want to maintain that CBP the monitors try to use neural monitoring so you wanted to be aware of the steps of Anesthesia the drugs the monitors that you're going to but if you get knowledge
54:13
of this in during surgery it's too great pay attention to monitors before the surgery talk to the doctors and know what is really the risk cause that they're afraid to write or to talk to and after
54:27
the surgery an ownership. What I do in my practice, my patients have my cell phone. The patients, I tell them, I call it patient empowered care. I tell the patient, never enough nurses in the
54:41
room, never enough of this. You wanted to sit in the room, sit in the room. Here's what you need to watch for. And this is why the husband say, hit me. The pulse oximeter should be more than 90.
54:52
The blood pressure should be like this. So I get patients and call me and say, you know what, Dr. Kelly, we're concerned. This isn't this. I call the nurse. I know I'm a bad guy, but I tell
55:01
the nurse, would you please make sure that the blood pressure is okay? It's okay. And this is what you do. Be instrumental in opposed to opportunity. Don't be passive, because having a
55:13
complication, you're only going to be in it. And ethically, you have to deal with your heart and your outcome You're absolutely right. well the doctors or the Doctor or the Neurosurgeon is always
55:30
responsible for his case the doctors responsible for his case when you go I always used to say when you go to when the case goes to court you're in court the other people aren't know and and go and
55:42
and and ask yourself are you and outsmart them useful genius yet you're going to outsmart them i remember I had a member as a citizen was doing the surgery and one of my Anesthesia way man as he's a
55:54
classmate I the patient was doing thoracic fusion and at that time there were using the instruments and all of this and the anesthesiologist swear that the that day that day that one of the
56:06
instruments slipped and and this is what he thinks that the patient wake up completely but advice for the rest of his life twenty years old so everybody starts to point the fingers the surgeon said I
56:18
think to be honest it sounds just drop the blood pressure the as it's the opposite I think the spinal cord was injured at the time and this is what happened and you know who's happy the lawyer let me
56:29
sue more people
56:32
one more paper but ultimately well who's lost the citizen has got to be blamed and the patients that suffer are you trying to outsmart the system do you really digging a patient to surgery and you
56:44
don't care about the outcome is it OK to have a patient completely out of life whoever made this mistake is still your patient that you actually sit with him in the clinic and you promise him you
56:56
going to do your best and this is really the ethics of this AI doesn't know the ethics of this and by the Way I love when I Practice Anesthesia and surgery people tell me to to Kelly how did you know
57:11
that this is that you went to this approach you know according to the evidence based practice you're supposed to do this and as I said you know what there's something called Galley evidence based
57:21
practice I've been in practice for thirty five years whatever I Know I cannot write, express everything. There is things that you develop by practice, by hands on. And this is to come to your
57:34
point. Well, very well said. I think we covered a lot of ground this morning and I think you made some really good points. I wanna thank you, thank you for the people that are watching because I
57:46
think they learned a lot, okay? Yeah, and give them my websites and I'm very happy to answer any questions for them And there is a common say, if we group together and we fight for the best care
57:59
as a neurosurgeons, we will go somewhere. Send me with you. When you send me that reference, send me your website and send me your phone number that
58:13
they could call you, okay? Yeah, 100. And unfortunately, my articles is one of the few articles stood against the media and this is that. Do we need new Anesthesia for neurosurgery I said
58:27
absolutely i need the Neurosurgeon the neural anesthesiologists and neurosurgeon to handle the patient from top to bottom to do the very operative to be in charge of the bitty operative we call it
58:39
betty operative rather than having the anesthesiologist be in charge of it so I don't have to prolong its just a minute but I can see the young people or residents and I was always involved with him
58:55
but they will grow grew up in an environment where they were learned to be quiet and to tend to not object or to to stay with their preferences that would be one with the dean was saying I don't want
59:08
a star I want a team player so I think that that's where the patient loses okay So Err what wind while a heavier here Dr Osman and the Am while I have you here The the article of the Galley the Galley
59:27
Chiklis was in its and I and was in two thousand and twenty one okay good and then and then and then the other one due due in Europe and the Seizure I was very sad to know that the neural
59:41
anesthesiologist did not support what they say needed the neurosurgery and I had to write an article a newer and you will you you actually have have publish it for us and sooner to reference Yeah and
59:59
this one was in essence an eye Doctor Usman and he was in in two thousand and fourteen this exactly the time that noodle and seizure saying we're not going to be in charge of Neuro critical care and
1:00:12
they give it to neurons challenges do you believe that they give it to the to the neurologists and to the moneris to take care of this and this is the time that I said Noodle Anaesthesia should know
1:00:23
everything about neurosurgery. There is anesthesia for an IR, neuroradiology. There is anesthesia for functional. There is anesthesia for this. You guys should be able to capitalize in all these
1:00:36
patients and know the steps of surgery. Let me ask you one. And this is why you started that. Yeah, let me ask you one other question. Is this same principle occurring in cardiac surgery? No,
1:00:49
oh my God This is a fantastic question, this is a fantastic. Okay, I love that question because all my books, I wrote it in volume one in 2007. So you read my answer and I'm ready for it because
1:01:03
it's so beautiful. Back in the Coughton Code Civilized Egyptian Farrows, this is really a beautiful story. In Egyptian Farrows, what they used to do with the mummies, what they used to do with
1:01:17
the mummies, They use to put their finger in the nose and get the brain out. So they didn't know what is the function of the brain. They used to get rid of the brain. But the only thing they
1:01:29
glorify is the heart. Why? Because the heart beats, the heart is big, and there is blood running. So everybody glorified the heart. So in the Biblical times, in the Old Testament, in the New
1:01:44
Testament, they always say the heart, the heart of people, the heart of this. And people were stupid enough to think that the heart is this heart. But we said they were ignorant because they
1:01:58
didn't know anatomy. So now we know anatomy. We know the heart is a bunch of muscles, no mind in the heart, but we're still doing the same stupid thing. We think that the heart is everything. So
1:02:10
how this happened, this influence, the hospitals, the media, the people, put all their money to ask men in cardiac surgery, Cardiac centers. In fact, I got kicked out of the freaking hospital
1:02:25
because they said that we don't need neuro-ICU or neuro-intensity. We need cardiac and institute. Because if you have a heart attack, oh my God, you're gonna go to the fast track, from the fast
1:02:36
track to the cardiac cat, from the cardiac cat to the cardiac surgery. There is a cardiac anesthesiologist or call. There is a cardiac surgeon on call and glory to the heart and the cardiac team.
1:02:48
In neuro, oh, excuse me. Who cares about the brain? You have a stroke? Let him sit in the
1:02:56
AR. Now, only now that we're trying to, when I start to publish the paper about stroke is brain and the husband said they're not going to get paid unless they have a stroke track. They do it now
1:03:10
with this, but still there is no team. So I tell in my book, we're not any better than the Egyptian people. We still think that the heart is in the brain in the, in the chest. But everything
1:03:23
biblical when they say the heart, the heart, the heart, the heart actually meant the heart of the brain. And there is heart in the brain. This is where our knowledge and conscious and all of this.
1:03:34
And I say the one that knows it first is King David. When he got this giant guy, Gilead, and he was a huge, his heart was so big. But he got it with a stone to the heart because he knows the
1:03:47
stone through the brain in the forehand and that's how he killed the guy because he knew by God that the brain is so important. So I say, if we know that the brain is so important, why we don't
1:04:00
have a neural team? Why the cardiac is because of this? People still think the heart is everything. In fact, the insurance will approve. If you say a chest pain, oh my God, you can do anything
1:04:12
to the patient insurance approved But you say an MRI for the brain, no, no, no, no, no, no, no, no, only CAT scan. And why CAT scan? You say Anita Carotidaplar? No, there's no criteria.
1:04:24
You need an MRA, oh my God, got it. You need a spectra scan or the diamoxic spectra scan? No, we cannot approve it. So you actually ask, it's so smart to question, why the media is still
1:04:38
worshiped hard, but they're not worshiping the brain.
1:04:43
Why? If this is part of us, a fault, absolutely. Neurosurgery, neurology did not do their job to educate the whole world That is why my book, my first book, is titled Christianity and the Brain.
1:04:56
And I tried to redirect. I even tried to give lectures in the church and to say how treasure is creating the brain and we need to start to teach the public that this human brain that is 1500 gram
1:05:11
have everything that nobody can ever duplicate. And then I proved it. I know how I proved it very easy I said, I can get the heart of Osman. and God forbid for Dr Osman has a heart that that is
1:05:24
Bad I can transplant a heart of my mother patients to Doctor Osman and Doctor Osmond would remain the same so the heart doesn't have one but you cannot change that brain this brain is the treasure did
1:05:40
you ever think about this doctor Dr Osman we cannot regenerate the brain but I can live with a big kidney now according to the studies I can I can have an a a metal heart and can do all of this stuff
1:05:53
but why that carried the egg Anesthesia and the cardiac surgery is so advance much more than the brain because we the public and the media put all the research and all the resources to improve the
1:06:10
harm now they're doing much better than US and the neural we started in Europe nineteen seventies because we still were ignorant we didn't know that the brain is an important organ that we really need
1:06:22
to take care of. So you ask the right question. And this tells you, we as a scientist, we did not do a good job to extend our to there. We're only 2, 000 neurosurgeons in the country. We can
1:06:35
stop one day and say, this is what we need. And instead of saying, you need to do this aneurysm in downtown Chicago, and this is the only place you do, you want to do the fusion by this is, why
1:06:48
don't you group together and just put your demands for a better patient care. This is would be the best we do. Outstanding answer, outstanding answer. Well, thank you very much, we appreciate it.
1:07:02
And we'll be back to you about critical care and pain medicine. So thank you very much. I'm going to stop the recording.
1:07:17
Take the references follow, it would be best to take screenshots and save this information for your records and for reference information.
1:07:31
In the talk, Dr. Galli referred to a paper published in
1:07:38
2014, Do neurosurgeons need neuroanesthesiologists and
1:07:42
should every neurosurgical case be done by a neuroanesthesiologist. And a
1:07:49
second reference on a novel checklist for anesthesia in neurosurgical cases, written for neurosurgeons, and the checklist is listed in the following slides for your reference from this paper in 2021.
1:08:12
This is the first slide on the checklist. of Dr. Golly for general and neuro anesthesia, take a screenshot
1:08:23
for your records.
1:08:29
Continuing on with this checklist, take a screenshot
1:08:39
further additions to his check checklist take a screenshot
1:08:46
of a final list of references are here
1:08:52
and the abbreviations used in his list and table of of steps and ER and Er Anesthesia Anesthesia
1:09:04
are written here
1:09:08
after Ghali also his other videos on ESPN or digital go to the home page and Insert Collie and the search term
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and those videos will come up another one of interest should be how do you manage patients with drug addiction in your neurosurgical practice
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