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SNI Digital, Innovations in Learning, a new 3D live video journal, which is Interactive with Discussion, an association with SNI, Surgical Neurology International, a 2D internet journal, are
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both pleased to present SNI Digital interviews with clinical neuroscience leaders, another in the series,
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a speaker in this series is Ramsus Gali, who is board certified in neurosurgery, anesthesia, critical care, and pain management medicine.
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You will talk to us about his experience and practice dealing with what neurosurgeon should know about the increase in patients on addictive drugs like ketamine, opioids, and cannabinoids in their
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clinical practices.
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He's also a clinical professor of neurosurgery, anesthesiology, neurocritical care and pain management at a number of hospitals. He can be reached at the web address shown on this slide.
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There's some background information is valuable to UHEC for you to know about substance abuse and addiction.
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Substance abuse in the United States is one of the leading health conditions which impacts millions of lives. 165 million people in the United States, it's own 62 or 60 of the people. Ages 12 and
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older currently abuse drugs, including alcohol and tobacco. 700, 000 overdose deaths are recorded each year and it's increasing at a rate of 4 per year. Like other chronic diseases of diabetes and
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cancer,
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the cost of this addiction. is almost equal to the others. It includes health care expenses, loss journeys, and income costs of drug related crimes, overdoses, and more.
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These are the common addictive drugs.
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Marijuana, Hashis, and other cannabis related substances. Some that are inhaled, inhaled K2 spice bath salts. Barbiturates and benzodiazepines, hypnotics, can be ingested or injected.
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Methamphetamine, cocaine, and other stimulates. Gamma-hydroxybutyric acid, GHB, or hallucinogens, LSD, and sphencyclidine.
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Other substances which can be used as inhalants, glue, pain thinners, correction fluid, felt tip marker fluid, gasoline,
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and opioid painkillers. which are most familiar to physicians heroin, morphine, coding, methadone, fentanyl, and oxycodone.
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A very brief summary of the anatomy and physiology of this disease. These toxic substances become molecules and
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the bloodstream going to the brain. They stimulate nerve cells in the midbrain which are connected to the nucleus and combins, which is in the third ventricle, and from there those impulses are
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related to the memory circuits in the amygdala, on each side of the brain, to the hippocampus which involves the emotional circuits, goes to the frontal areas and from there spreads to the frontal
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lows for executive function. In a normal and a normal, non-addictive person, these pathways can be very pleasurable. However, in an addicted person, the pleasure that they get from the drugs is
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short lived
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So more of the drugs are ingested or are inhaled. And this increases by plasticity, the pathways along which these impulses are transmitted and make it larger. In addition, there are changes in
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the biochemistry of each cell. And those are affected in more of the condition behavior
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So we see in the end genetic, biochemical, metabolic changes, neuroplastic changes, all involved in addiction. And here are two references we will show you later which you can copy your
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screenshot and save for your records.
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Ramsis Galley. Ramsis is a neurosurgeon, a board-side certified neurosurgeon. He also happens to be a board-certified critical care specialist, and he is also board certified at anesthesia.
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Thank you for this opportunity. But also,
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you accepted the first letter to the editors that predicted back then in 2005 about the abuse of fentanyl and opioids. And I wrote a beautiful letter to the editor to warn again is the liberal use of
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fentanyl and opioids. And 10 years later, or even 15 years later, they start to discover this. So these drugs affects our patient as neurosurgeons. So we can start with talking what the most
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recent about ketamine.
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And ketamine is a good anesthetic drug that introduced back in 1960s and has a very strong analgesic and logistic means.
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is good for pain. So me as an anesthesiologist, if there is a burn patients and you wanted to change dressing and the burn patients usually like a lot of skin pain, you give them ketamine. So
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ketamine, when you monitor the patient, is very attractive and aesthetic and analgesic drug. Problem comes when you take that drug from the hands of the provider to the outside, the hostel, and
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they start to liberally use it. And this is what has been happening. And I see it happening now in ketamine, as it did happen in opioids. If you look at morphine and fentanyl for innocence back in
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1980s,
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late 1980s in surgery, anesthesiologist used it frequently to provide anesthesia and to provide deep analgesia tubation. In fact,
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I was told that morphine by itself and fentanyl by itself is a good anesthetic and you don't need anything else. And the problem is started with opioids when we convert from the hands in the
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operating room with the trained providers to make it available for the public. And this is something really I see it all the time. And as it happens in opioids and it did 15 years to be harmful and
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to water regulation, I see it now happening to ketamine. Why ketamine started? Because the government went after the opioids, the fentanyl and the opioids. So now the physicians and the public
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wanted to see something alternative. So now defining the alternative is ketamine. The same like for narcotic and instead of writing narco or oxycodone, you can write tramadol for innocence. So
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they're trying to find something that the government doesn't have regulation yet. And this is the problem. These drugs have one criteria, all of them, the susceptible for misuse and abuse by
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regular and imagine regular adults, now imagine now the kids. For instance, the marijuana and the ketamine, they've been using it now in nightclubs and in an age more than 12 years, 12 years old
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has started to use it and it goes up to some statistics show 24 million people and it's not just in America, it's worldwide including the United Kingdom. So imagine now the immature kids that
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started to use these drugs. Now, is these drugs harmful to them? Absolutely, it's harmful It alters the mood, it makes the mood swings, it makes them and susceptible to pain. If you take them
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to surgery now, we used to say in surgery marijuana, not a big deal, just take them to surgery. And we used to do surgery as an anesthesiologist to that, and it turned out that they have serious
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side effects. So now they start to form guidelines to stop that. What is the side effects for innocence from marijuana or
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ketamine or this is heart attack, stroke, swings in the blood pressure? You're talking to a patient that you don't know if he understands this or not. The pain threshold is low, they require more
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pain medication, the blood pressure drops or the blood pressure is high. So this is our all side effects. And what they found in their studies with the narcotic that we as physician responsible,
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and this is what they try to say. And why? Because they link it to the first surgeon that wrote the narcotic to this patient's life. Norco or Oxycodone, they decided that the first prescription,
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the likelihood for them to use it and abuse it in the future is high. So now we are at fault. So now we as a neurosurgeons, that we having a patient with a spine pain. Let's take a that's a common
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daily practice case that all the neurosurgeon faces. So this patient has a
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severe sciatica, has a disc herniation, has severe sciatica pain. What are you gonna do? The patient doesn't want surgery. As a give, they don't like surgery. They've been afraid of surgery.
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They're afraid of anesthesia. Then it becomes a be on narcotic. From be on narcotic, epiduralistroids. From epiduralistroids, what we found out that some of them now, very easy. Just let me get
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a CBD oil. Let me get some marijuana from outside. I have patient come to my office like this. You examine them, they're always high. Their mode is changing And you don't know if you're talking
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to the patient. you're talking to somebody else. But now what you see now is an open gate for misuse and abuse. And then I have to tell them who say that these drugs are not outside effects. And
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I'm literally you think that this is only for young people. I have been seven years old. She was high in these drugs. And finally the kids convinced her 10 months later, she said, I'm sick of
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these drugs. I am taking my drugs off. And now I have a lot of pain and I want you to help me. And gradually when you take them, you don't want to jump to surgery to these people because now they
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have alterations in the cognitive function, into their memory, into the pain perceptions and all of that. So you try to go step by step with them. And then when you do the surgery and you correct
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the problem, then they come back normal and say, I don't know. which state I was in it. So this is now what we're facing. It used to be narcotics and opioids in the operating room. It went to
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the intensive care unit. Now it's in the clinic. And now the pain clinic and other surgery centers and
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all of that, now they start to open the door to say, you know what, if you have depression, 10 minutes will give you an injection, depression is gonna go away, come back every week So now it's
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becoming as very available in the clinics to use. So this is what you have. Remember the stories that when I was a resident under you for instance, I had a patient that had seizures. And somebody
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told them, take more alcohol to drink more alcohol procedures. So he keeps drinking alcohol, alcohol, alcohol. Until it turned out that the
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seizures is caused by the brain tumor that is now coming out of the skull. And this is what we're doing now we have an axis to evaluate the pain. and to cover up the real diagnosis. And now we're
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closing the access to what is the real treatment that if we think as a scientific people and as a clinician is the best for these patients. I'm standing, I'm standing a summary with real, real life
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experience.
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Obviously they get the drugs on the marketplace somewhere. So, 100 Yeah,
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and then the question is, what's the likelihood that you can break them of this? Get them off their drugs. Yeah, very, very difficult. Once you get them to the use and the abuse, this is what's,
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it's very difficult to take them out. We know that human life is full of stress. There is no, in fact, when you talk about burnout physicians and burnout and nurses or burnout and any. and buoys,
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so this tells you we're in a lot of stress. And I don't know, I think this is part of our modern civilization now, we're not then simple people that grandfathers were, and we're able to buffer our
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stress by natural things and physical, take a walk or a hike or things. Now we just swallow pills, we just swallow drugs. Some drugs to help us sleep, some drugs to help us eat us. I have
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patients now in Xanax and have patients in sampalta So all these medications together. So now the easiest access, Dr. Osman to a treatment, to any stress or any of this is to give them a bell.
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Now imagine now that you're gonna take them off it. Okay, take an off it for a day, for a do, for a week. Another crisis comes and it comes back into the real studies when patients start to die
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from opioid overdose. They did a massive study in the whole world and they found out much of them starts by a prescription, just one prescription, and this is really what you're gonna see. If I
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taste ketamine today, I have no problem to get ketamine again. Where do you get all of these drugs? Oh my God, you get it very easy now. In fact, in my church and in other churches, even the
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most religious people, I have, they have pain, they go to the doctor, now the doctor is afraid to prescribe Norco or this control because there is a lot of regulation. So what happened now with
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them, you do something like this, now the patient has pain, doesn't want to go to the doctor to know what's wrong with him. He think it's just a little arthritis, then he goes to the street. So
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one of them went to the street, he got that bell for Norco, it turned out that there is fentanyl in it and the patient died That patient never used any drugs. So now we're running, we encourage,
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in my opinion, the public to use this system as a run away, as a getaway to an order to decrease the stress or to be the first line of treatment. In my time when you taught me under your residency,
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the first line of treatment is to make a diagnosis. How are you gonna make a diagnosis? Insurance doesn't, many don't have insurance The insurance is very expensive. They don't approve MRIs. If
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you see the hell that I go through to approve a surgery, just a microdesk and how much paperwork I'm gonna go through and how much you're threatening the patient that insurance will not, I'd rather
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go to the next door neighbor and get a drug that helps the pain because my pain is bad. Then you're gonna say, when did you go to the ER? Most of the ER, now you wait for 12, 15 hours order to
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get something and then you'll be lucky. if you get a CAT scan or an MRI. So now the, and then you get the bell at home for 30 to40, 000. So you tell me, if I'm a regular person, a labor have a
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lot of pain. What is my options? And this is really the issue. The drugs becomes very easy. And if it is easy, I'm gonna get used to it, abuse it and misuse it, and I have it in my cabinet.
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And this is the scary one. Outstanding explanation Why don't we go to, can we skip to, we can come back to the skip to
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math and to THC, you can explain that to the audience, 'cause these are some others. And tell us a little bit about where they come from, what they are and what their effects are. Okay, so this
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is a plant that actually, literature supports that we discovered in China 2, 800 years ago. And it's by, and it's called cannabis. And one of the substance in it is the titra hydrocabinoids, is
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a plant equal to another plant called the stevac, and the other one is called jinnison. And
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this marijuana,
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which forms this plant, it has a male and a female, and it has substances in it or ingredients in it. Some of them makes you high. And this is really the catch of this marijuana drug. It makes
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people high. And it found out there's a lot of receptors that works with this, which is in the memory, in the brain, in the pain receptors.
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So let me interrupt you a second. You said it makes you high for our friends
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watching this in another country. What does high mean into it? It's a state of mind that is euphoric. It's an euphoric. You feel elated. You feel very happy. You feel out of space. Some people
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think for any sense in these substance, you feel near this experience. It takes you somewhere else. And it covers your drama, your miseries. If you have a lot of stress in your life, it takes
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you away. So it's a high state. And that euphoric state is what makes it the addiction, addiction, and the use in abuse. I wanted to feel high. I wanted to go to get some of this. And you can
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smoke it in the streets. This is what is high means. And this is also, you see it in opioids, like fentanyl and all of that. The word high is coming in all the abuse of drugs cocaine for the
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innocence. And it's interesting that once you take one, you mix it with one another. So ketamine goes with cocaine, it goes with alcohol, and it becomes a vicious cycle, you try all of this.
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And they found that this is what we see now, and we see it at the age of 12 years old. In fact, there is a night club, so they call the ketamine for innocence, vitamin K. And imagine now, if
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you wanted to rape people, you can actually get the mixtures of this They become elated in a different mode, different stage, and you can rape them. And this is where all these issues are
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happening. People are trying to continue to find places that take them from reality and from the streets where they are, and we make it easy for them. Wow, just if you're on fentanyl,
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on fentanyl. or if you're on ketamine, do you still get a high with that? Of course, and the most dangerous is
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fentanyl is the most potent because you innocently stop breathing and you die. And in anesthesia, we have seen it repeatedly now and it's becoming a dangerous, dangerous observation. We lost
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residence to this because you have an access to these drugs as an anesthesiologist. And in fact, they found out if a resident using this a 40 chance, even if you take him for a year or two to all
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these programs, rehabilitation program, they come back into this addiction with a high mortality. So this is really the issue. The side effects of these drugs that is becoming a serious. If you
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take the mean for an instance or marijuana. Um, you have a high, you use a sip, you, you see, you, you expose yourself to heart attack, to high blood pressure, to a stroke. And this is what
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we tell the patients. In fact, some of the new guidelines that we try to pursue, which I do. In my practice, even in the office here, even in people that they look to you, like you think you
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don't use it, I just tell them, do you use ketamine, do you use street drugs to use marijuana, and all of this, and you'll be surprised, many of them, Lydia, are using drugs. I have, I have
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a patients that, like, really patients that will educate it, they use marijuana every day, and they, for 25 years, what are you going to do with them? You can't, you have to think three times
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before you do surgery, if you find the discrimination in them, because you're going to end up by major problems. Anesthetic-wise complications as well as being management. Well, let's go into
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that for a minute because you see this, you're unique because not only you see it as a neurosurgeon who's taking care of a person who is an organic disease, a
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desk or something that's causing pain. You see it in the intensive care unit because some of these people come in there acutely ill, I'm sure, and they want to call you to consultant You see it in
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anesthesia because you have to deal with it on the other side of the drapes. Yes. How does this make surgery more complicated? Extremely complicated, extremely. Because first, you have to see if
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they actually can subject themselves to the risk of anesthesia. But one of the important things that we discover, they require so much anesthetics, so much drugs during anesthesia, analgesic-wise.
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and recovery, they usually scream of pain. A normal person after this surgery does not scream of pain, the scream of pain. So what usually happens to ask men is you give them more narcotic and
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they get arrested from breathing.
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And everyone is trying very hard to put the joint commission and the government as it has nothing to do with the abuse of opioids for instance, but it's actually, to me, I witness it. When you,
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when you, they say pain is a another vital that you must take. So if you go to the hospitals in 2005 and afterward, you ask it a pain and what is the pain score? If you write that the pain score
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is 10 and that's what the Europatient's gonna tell you. The same that the patient walk in your office and you know that they exaggerating and you have to, they have red flags. you tell them what's
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your pen score 10. Now, if you're in the clinic and you have pain in 10 and you look at the MRI and you say, there is no large disc herniation. This is in itself for its flag. Now you need to
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think what is causing all of this, whether there is drugs in it. And why is that? Because you're obligated to go why this person is different. If you end by doing surgery just because of the pain,
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then you end by a very bad prognosis, because what happened in these patients, and you saw it and I saw it, once you marry these patients and you do surgery, you're gonna have to start to write
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the drugs to this patient. Why? We have seen it a lot. Because that patient will come and threaten you. Until you know you mismanaged me this, he gives the help to your staff, and you're afraid
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that he's gonna sue you and all of this. So you marry a patient like this is a nightmare recovery when they wake up from surgery first. you have to ask, do they really need this extensive surgery?
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Is this is really a good indication to subject a patient like this with surgery? And then you say, okay, so we did it. And the surgeon nowadays, as you know, they don't see the patients often.
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They let other people see the patients for them. So he does the surgery and you get stuck with this in recovery. So now what we do for them, we cannot give them a lot of narcotics. So we try as a
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hostel to get some sort of protocol Most of the time it ends by giving him something else other than opioids to try not to suppress their breathing. So they start to develop, you have to put them in
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Title CO2, you have to put them in a teleband, you have to increase the observation and the supervision in these patients. And many times we end up by putting them in the ICU under ketamine
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infusion. And then for the next three, four days, you need to start doing this medication off. And then
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you replace it with a stronger, longer acting opioids. So if you do cases like this, it's none when, when. Yeah, that's incredible. Is the, it looks like from what you're telling me, is that
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the final common pathway is respiratory, a respiratory death. Is that, is that, am I right or am I wrong? Yeah, so it's several things For the
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opioids, 100, 100 respiratory arrest.
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And a lot of them, they don't realize it. This is the sad and the scary part. You take fentanyl, you think you're high, you think you're with it, but you don't breathe. So they don't perceive
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that they actually cannot breathe. They don't breathe, they don't want to breathe. So they become hypoxic So if you watch the narcotic, when you give narcotic, we breathe about 20 per minute.
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they will breathe seven per minute, and if you give them more, they start not breathe. And the next thing you know, it's in desaturation, hypoxemia, a heart of stops, the brain stops, and now
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you have a cardiac arrest. And the sad bar to Dr. Aldrich, Dr. Roseman, you will see it in most of the cases. And here is the comment scenario that I see it The nurse gives 02 milligram dilated,
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or 03, or sometimes one, because this is what the protocol said. Turn her back and leave. Next thing is a cold blue. This is how fast because you give it intravenous. And I have developed in my
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practice so many guards to prevent this. And I teach the patient. I said, It's okay to have pain That is, you have the right to say, I don't want you to inject me with intravenous medication.
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or I commonly use now ice packs. So we call it multi-modern to prevent this. So this is one cause of death, which is common for opioids, for fentanyl, and this is number one reason why the entire
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world get mad and the government get mad for narcotic abuse. Okay, so this is one. From ketamine and other drugs is something else. It's no protection It's the patient is not him anymore, it's
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not himself. Like very Matthew, for instance, he didn't know that he's in a bathroom for innocent. So you sink, you drown, you don't have good judgment. Your cognitive function is not with it.
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Your self or protective measures is not with it. So you can do things to change and you don't have to go far. I don't know the name, but just recently a month ago, the famous singer in Argentina
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found in the hotel. dead and mutilated, traumatized. This has just happened now. And why? Because they found out that he was on high drugs, the same drugs, and then he jumped, and he hurt
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himself, and he didn't know. So the important part about the cause of death here, you're not protecting yourself. You're not yourself anymore. And if this is the message that I wanted to give to
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all the new resurgence and all of it, be very careful, you must ask what drugs they use. Do not operate in patients and drugs. You have to clear them from this, because they're not who they are.
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And ultimately, you can obey the price because you're the physicians of that patient. Imagine now that you have a patient that takes morphine as a baseline. You do spine fusion. How long are you
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gonna give them this high dose of narcotics at home? And who's gonna monitor him at home? And then if you say, you know what, I cannot give you more, then he's gonna be mad from you. So this is
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a dangerous time where we live in. And guess what? From opioids, now we're opening ketamine. And ketamine, they got another drug called esketamine. Imagine now, what
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is the next drug? You're gonna give it because we're humans. We're gonna develop more, and we have an industry that is hungry for money. And this was gonna happen How much money this is drugs is?
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50, 000 plus a month, when one person used to get ketamine. You know what I mean? Imagine marijuana, imagine mix it up with other drugs, and you don't know what they mix it with.
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Amazing. So,
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it almost seems like a point of no return. I can see that the patient comes in, he comes back, he's got tremendous pain.
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You operate on them, you're done operating on them. How do you deal with that? And some doctors are, they don't have a lot of colleagues or other people in their community to refer them to. I'm
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sure one thing is, because I saw this in practice of doctors and there are some specialties that do that, just stop seeing the patient after surgery and refer him to an internist or something that
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he settled with the problem Yeah, and actually the primary physician doesn't take care of them anymore because they're afraid of the federal government. So now they send it to Ben Clinic and you and
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me know the Ben Clinic and here's what the Ben Clinic will do 'cause I also certified in pain as well. So what they do, they'll start to justify injections. So now you did a spine fusion. Now
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they're getting medication. They're gonna get also all kinds of injections and all kinds of exoplanation of their pain that you are the surgeon. have no control in. So now from having a patient
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that you enjoy good outcome and you're under your control and you manage him. Now you have a different people controlling him, managing him. And unfortunately I hate to say it, feed into his
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complaint. Wow, you know what I mean? So it's really, really, really tough. It's a very tough problem And what you always told us is the patient is a whole. You have to know everything about
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the patient, the care about the patient. Nobody else is gonna take care of this patient better than you. So you sit and you direct. We as neurosurgeons and as physicians, we are physicians before
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neurosurgeons and we have the opportunity. And this is what I do in my practice all the time I tell them, I will listen to you. And this is what I do, and it's been working great. Based on your
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complaint of paying 10 out of 10, of legs that is paralyzed, of all of this, I'm gonna get an MRI. A patient that complained like this, I must see something in the MRI in order for me to help.
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And in order for me to match both of them. If I don't see it, then we're talking about something else. I could list about the insurance, about the insurance pay the money I do now, Dr. Osman, I
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do MRI,
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the first thing. And you know what? I found facilities, the MRI is400. I tell liberation, you know, I'm not gonna wait for the insurance to pay for you. It's the plumber when it comes to your
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home. It comes for400. So might as well just do MRI. You'll have a piece of mind what you have. And I found this helpful. If he has a desk and there is a problem, I'm okay. Then I go take him
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to the routes We're gonna do an end point, this is the end point. Iceman, this is, and I try to minimize the pain medication. If I don't see that, then the patient himself starts to feel sorry
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for himself because I tell him, I don't know where this pain is, because you made me order this MRI for you. I try to find the problem, there is no. So this is called functional problem. So this
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is how it helps me. But I will not, I'm one of the surgeon. I will not do surgery unless I get to the bottom of this drug history, and then make sure that the patient is not addicted, is not
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abusing, and is not misusing. Well, that's just a terrific quick overview of this, just a horrendous, difficult problem, really difficult, and it's worldwide. Yes, in your time when you were
35:43
a surgeon and you taught us, we don't mess with this. If you have a problem and it can fix, I'll fix it The patient will love you. and say thank you, Doc, I want you to fix me. Now, it's
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really different. You know, I tell him the difference between America and the remote area in Africa, big difference. In America, I am here to help you fix the problem you don't want. In the
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remote area in Africa, they don't have me. And so they don't do the surgery. So America now, in the world civilized countries now, is becoming like the remote country in Africa that we think were
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better than them. And actually, we're not. Because they're no longer looking at fixing a problem. My standard patients, Dr. Osman, I see now, is a patient that's been in hell of pain and
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suffering for 15 to 20 years, swallowing tramadol and drugs. And this is what they do. And the minute I see them, I say, you're here? What the drugs have done to you? meet you a different
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person. you're not even feeling any improvement because you need to swallow more medication. And we do, you go to the job, your brain is not with you as sharp as you should be. And now let's
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prevent this. So I start to wind them off. And you need to find support people, support medical providers that believe in this because you have medical providers that they have liberal use of this
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medication So you have to be careful in your practice.
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I'll show you that. The husband's now Dr. Osman without interrupting you. They seeing the uprise of this. So they start to develop something called enhanced recovery. This is you, a rest.
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You're gonna see that everything is a rest. I'm serious, a rest in particular tumor. I review an article, a rest in particular tumor. I said, well, the arrest that you wrote a regular
37:48
neurosurgeon should do, but you just put the word arrest. So now they trying to find arrest for people coming with a spine surgeon that does surgery in addictive drugs. How are we gonna handle them
38:01
in the hospital for five, six days and get them in and subjecting the liability to the hospital instead? So you said, I was trying to understand what you said, you said a risk or a arrest?
38:14
No, the risk
38:17
of having this patient in the hospital. So everybody categorizes and
38:23
says, these people are now a different risk, is that what you're saying? 100, 100. The
38:29
risk of dying from sleep from this is, there is abuse and hostility to the staff, they can jump and it becomes a fall and it becomes a report and
38:45
the joint commission, all of that.
38:48
liability to the hospitals and to the individual. How can they write a good patient satisfaction that the measures of the hospital, if you're not going to give them the drugs they want? So it all
39:01
boils down to once it starts out with a patient's problem, it winds up being the hospital and the doctor's problem from possible suit and malpractice. Yes. Oh, 100. We have seen it, not just me,
39:15
many that we become a hostage with such a patient. If I ever regret, I probably would regret about two or three patients in early of my career that I felt am marrying them for the next two years
39:32
because they've been threatening, threatening and threatening. And it's a hostage. It's a hostage.
39:39
I just call it you marry them. You do surgery, you marry them And actually, we know, and if you want to marry somebody. you need to marry somebody that is not going to put you in trouble. Well,
39:54
terrifically practical, terrifically practical explanation, Ramses, it's just wonderful. You got a background in neurosurgery and pain and critical care and anesthesia. And
40:10
you have, you have to take a lot of credit. Dr. Asman, you're the, the chairman that supported me with all of that I still remember I used to do when I did anesthesia. I was doing anesthesia
40:20
attending in one of husband. I was in the neuro ICU. I start to implement some of the drugs, like the proper fall and things like that. So it becomes complimentary. And, and then I wrote it in
40:32
some of my box, though, because at that time, many people said, you're crazy. You're crazy. Now I'm a person with a good Christian faith. So I just, I just love what I do. only years later,
40:46
Dr. Osman, which is now that I found, now I found why God allow me to this and how God allow you to be in my, in my path because now it's everything is fragmented. So I'm gonna give you an
41:01
example. When a patient comes with a desk, herniation, sometimes if I don't see a large desk or I see some neurologic deficit, I do an injection for an incident During the injection, I'm testing
41:15
them. I'm also evaluating them. If this patient overly acting when I put a needle or it's fainting, I need to think more about this patient for us before I jump to surgery. So you start to get
41:28
this. And if you wait for anesthesia to clear the patient for you, you know what is happening now in the hospitals? The anesthesiologist see the patient five minutes before the surgery So what is
41:40
the analysis challenges in my time and your time? See the patients beforehand. night before. Now they don't. Only the nurse practitioner and you look through the epic system or the retina, the
41:51
records to see what they have. So imagine now, for me, I bring up the patients, I work the patient up. I make sure they can fit surgery because who's going to do this otherwise? Now you're going
42:05
to talk to a primary physician. You know what they do now, Dr. Osmond? I don't know if you're aware. Now they don't clear the patient in my time. They clear, but they found that they're legally
42:16
problem. So they say optimization. This is a word, but then the second thing you say, I'm going to clear the patient for you, but it's a high risk. Oh my god. What is this to mean to a
42:27
neurosurgeon? What do you mean by high risk? You know what I mean? So it's not like the old days and now I work them up. I wanted to know the rejection fraction. I wanted to know either kidney
42:37
function. I know now what patients I can take them to surgery now I regularly learn new assertions now. is minimally invasive, it stays in the OR, and that's it. I feel bad for them, but for my
42:51
patients, I'm pain, I'm an anesthesiologist, I'm a neurosurgeon because nowadays everything is very fragmented. So I feel I add more to that. Well, good, this has been a terrific session. So
43:07
we're gonna have you back in the future talking about what neurosurgeons need to know about anesthesia for their patients, right? Yeah, perfect. And then the practical things they need to know
43:19
about critical care because obviously it differs across the world. Some people don't have critical care, some have minimal and some have very extensive, some have critical care run by other people.
43:32
So those are some things we're gonna talk about. Is there something else that we left out? know, either I just wanted to, to, to, to, to, to tell it. to tell the audience in particular, it's
43:46
very important to be like Dr. Osman and the professors, our fathers. You have to know about your patients from beginning to the end. It's your patient. Once you advocate or you commit yourself to
44:03
cut this patient to do the surgery, it's your patient. You must know what the anesthesiologist do, what is the drugs available So this is a very important plus we, as neurosurgeons, we have the
44:15
trust of patients. So we are in the situation at all that we can make a big difference. And it changed the lives. And it's very complicated now because things are so sub-specialized or
44:26
super-specialized that the anesthesiologist do what you say. They see them, everybody else. And the doctor is further and further away from the patient. Yeah One of the things that I, you can ask,
44:41
you can just ask, in the journal as a question, how many neurosurgeons wait in the operating room for neuro-assessment, for the patients to wake up from surgery and assist them before they leave
44:57
the operating room? I am so surprised when I see my colleagues as just they don't, they don't, they say, Oh, he's still under anesthesia. And no exam for these patients There's a lot of
45:11
principles that we have changed. And this has come to the point when we discuss next time how important for the surgeon to know the anesthetic used and how important to do neuro-assessment before you
45:23
leave the operating room. And ultimately, many hospitals will let the neurosurgeon take care of that patient post-operative. So ultimately you're responsible. Well, Ramsey, I wanna thank you. I
45:37
think you did a superb job It was just a great explanation. And -
45:43
It's a huge problem and you even made it bigger because it's almost impossible for the doctor to manage this with all the forces he has to deal with, but you gave some tips along the way, that's
45:60
good Okay, thank you very much and
46:06
these are the references
46:11
for Dr. Galley's talk. Take screenshots of each page and save them for your records
46:16
This is the first set of four
46:21
resources you can use. The web addresses for each one of them are given. They're associated with foundations in San Francisco, at National Institute of Drug Abuse, pain medicine and anesthesiology
46:35
sites. If you look at those, you can find a lot of information on what he discussed.
46:45
There are several references here which would be also of value, and Dr. Kelly recommends if you're interested in ketamine, there are two references on ketamine, and there is a third reference on
46:57
marijuana, which can be available from a government source. If you go to the web address there, you will find that you can get that and download that
47:11
Another subject Dr. Galli discusses is enhanced recovery after surgery known as ERES. And this study, Dr. Portion, associates on spine surgery patients shows that you can enhance the recovery
47:27
after surgery and return their physiologic function in patients who appear to be frail or undergoing surgery with early ambulation and early enhanced recovery after surgery. Very good reference to
47:45
read. Conclusions are, to his paper, enhanced recovery after surgery or early ambulation strategies significantly improve, return a physiologic function, length of stay in patients, even if
48:00
they're frail and that is compared to those patients who are not frail.
48:08
And this is the slide I told you I would show you on the genetic biochemical metabolic and neuroplastic changes involved in addictions. There are two references here.
48:21
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