The Evolution of Anesthesiology
By Tyler Greer
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Tony Jones, M.D., chair of UAB’s Department of Anesthesiology, discusses postoperative pain.
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Shooting. Throbbing. Sharp. Dull. Pounding. Tingling. Hot. Pain may be a universal experience, but for each person it’s also a unique experience—one that’s tough to measure, with an endless list of possible causes and physical locations.
Therein lies the challenge of pain management. Pain is the main reason people consult a physician, but how do doctors treat something that is so hard to quantify and describe?
For the UAB Department of Anesthesiology, the solution is to redefine that treatment with a two-pronged approach. While teams of specialists focus on specific types of pain, new programs take a look at the big picture, integrating multiple fields of medicine to manage pain’s physical, psychological, and even social aspects.
If you need directions at UAB, ask an anesthesiologist. They know the campus well; after all, they work in UAB Hospital and UAB Highlands, The Kirklin Clinic, Callahan Eye Foundation Hospital, and the Veterans Affairs Medical Center—basically anywhere there are operating and procedure rooms.
Keith “Tony” Jones, M.D., faces the challenge of coordinating this sprawling service. As chair of UAB’s Department of Anesthesiology, he is responsible for a team that performs more than 45,000 anesthetic procedures each year—and on any given day, those could include treatment during specialized medical procedures or preliminary medical evaluations; comprehensive management of acute, chronic, and cancer pain; and full-time critical-care treatment in three intensive-care units. The patients, who could be pediatric, adult, inpatient, or outpatient, are treated by anesthesia care teams that involve physicians, nurse anesthetists, laboratory technicians and anesthesia assistants, respiratory therapists, recovery room nurses, and trainees including residents, fellows, and student nurse anesthetists.
With so many variables to consider, Jones says the key to blanketing UAB with high-quality anesthesia care is to cultivate the clinical skills and interests of his anesthesiologists. “What makes people good at what they do is when they love what they’re doing,” he says—and a new fellowship training program endeavors to do just that, enabling anesthesiologists to acquire an extraordinary level of proficiency in one subspecialty and a very high level of proficiency in another.
“By promoting this subspecialty focus in two areas, it broadens their interest, and they become more engaged,” Jones says. “That results in better outcomes for our patients and a sense of fulfillment for our clinicians.”
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Department chair Tony Jones is spearheading a program to train UAB anesthesiologists in multiple subspecialties, including critical care, neurosurgical, and cardiothoracic anesthesia.
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Not only that, but the program also creates “redundancy” in the anesthesia practice, allowing faculty to back each other up, particularly in certain areas. Anesthesiologists who work in the pain clinic, for example, may also practice in the operating room, spending 60 percent of their time in the pain clinic and 40 percent in the operating room. Physicians who do their critical care medicine fellowship could also subspecialize in neurosurgical or cardiothoracic anesthesia. Jones adds that the additional training strengthens the camaraderie between anesthesiologists and surgeons, leading to close working relationships that raise the quality of patient care.
For UAB anesthesiologists, expanding their areas of expertise helps them treat myriad complex medical conditions now—and could also benefit future pain sufferers. The fellowship programs “will continue to evolve in the next four to five years,” Jones says. “One reason we’re doing this is so that at some point down the road, we develop a comprehensive perioperative cardiac program with physicians trained in critical care medicine with high degrees of proficiency in adult cardiac or neurosurgical anesthesia. We would be able to administer the anesthesia intraoperatively and help take care of the patients postoperatively in the critical-care units,” Jones says.
Jones, who earned his medical degree from the School of Medicine at UAB in 1986, saw a similar program in action at the Mayo Clinic, where he rose to the rank of professor and program director of the Smooth Muscle Physiology Laboratory. When he returned to UAB in 2006, he inherited a pioneering anesthesiology department—founded 50 years ago as one of the first academic units of its kind in the nation—ready to take its next big steps.
Developing a well-rounded skill set lays the foundation for future advances, suggests Jones. “Because of the way the UAB Health System’s surgical enterprise is structured, it would be almost impossible to create isolated obstetric, cardiac, critical care, pain, and neuroanesthesia divisions and sections,” he says. “There’s no way to provide every subspecialty service 24 hours a day, seven days a week, in a silo fashion. It could triple the size of the department.
“The best way to do it is to create two areas of interest instead of one and have them ‘cross-fertilize’ one another.”
Growing Pains
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Thomas Vetter directs the new chronic pain medicine clinic at Children’s Hospital, which focuses on pain related to diseases such as cancer and sickle cell along with headache, musculoskeletal pain, and sports-related injuries.
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One of the fruits of that cross-fertilization is the establishment this spring of the new chronic pain medicine clinic at Children’s Hospital, the first of its kind in the southeastern United States. While many physicians at Children’s Hospital have treated chronic pain for years, the new clinic provides a cohesive unit that will enable them to integrate their resources to help optimize patient outcomes.
Thomas Vetter, M.D., the clinic’s director and an associate professor of anesthesiology, says the collaboration “presents a great opportunity for Children’s Hospital and UAB to raise the bar in pain management for children and adolescents and to meet an area need.” Vetter knows the impact this type of clinic can have; he helped build similar clinics at children’s hospitals in Indiana and Ohio.
Published data, including some of Vetter’s own research, indicate that children and adolescents most commonly seek pain treatment for headache, chronic musculoskeletal pain, chronic abdominal pain, and a variety of disorders including cancer-related pain, sickle cell disease, and rheumatologic disorders. Other common problems for young patients include sports-related injuries and chronic sports-related pain as well as back pain brought on by obesity.
“Unfortunately many children suffer from chronic pain disorders, just like adults,” Vetter says, adding that the clinic can assist specialists who are comfortable managing these disorders as well as those who might need more support. “What’s exciting is that this clinic is a multidisciplinary effort,” he says. “Everyone wants to come together to improve clinical care for children and adolescents in this city, state, and region. These initiatives are going to be good for the patients, and we also have an opportunity to make a name for ourselves on a regional and national level with this clinic.”
Biopsychosocial Solutions
The same ideas behind the Children’s Hospital chronic pain medicine clinic also form the foundation of what Vetter calls the UAB integrative pain medicine center, which is targeting a 2010 opening. A variety of specialties—anesthesiology, palliative care medicine, physical medicine and rehabilitation, neurology, psychiatry, and psychology—will come together to provide comprehensive care for adults, Vetter says.
It’s all part of a biopsychosocial approach to treating chronic pain—the best approach, according to Vetter. “You address not only the biomedical aspects but also the psychological and social aspects of pain,” Vetter says. “If you develop a chronic pain condition and are unable to perform your job, it will have a significant adverse impact, both in terms of your pain symptoms and how it affects your ability to be the breadwinner for your family, a partner to your loved one, and a parent to your children.”
Vetter says that developing an interdisciplinary, biopsychosocial strategy to treat chronic pain will result in better care for patients. Physicians will be more satisfied as well, Vetter adds, because they are more likely to see successful outcomes.
“I think any physician, including those of us in pain medicine, can take inventory of their practice and say, ‘I’ve got some patients with chronic pain who just aren’t doing as well as I’d like, and it’s because I don’t have all the skills and resources that I need,’” Vetter says. “What we need to do as an institution is to bring all of those various skills and resources together, using an integrated approach, for the patients’ well-being.”
As an example, he describes a hypothetical patient with back pain who isn’t a candidate for surgery. Anesthesiologists can administer nerve blocks and epidural steroid injections. But if those don’t help, Vetter says, alternative methods need to be explored to relieve the pain.
“Maybe then we need to apply a physical medicine and rehabilitation model,” Vetter says. “We also have to start dealing with psychosocial issues that could be contributing to the problem.” Rather than one physician focusing on one treatment, integrative pain medicine explores “what we as a collaborative team can do.”
Another area of interest for the clinic is the management of chronic opioids, often prescribed for patients battling cancer but also used in treating other pain issues. Vetter points to several recent journal articles that recommend a structured, goal-directed approach to chronic opioid treatment; the protocol calls for selecting and monitoring patients carefully and weaning them from therapy if treatment goals are not reached. “The current consensus is that chronic opioids are not as effective or as free from addiction risk as was once thought,” Vetter explains. “Knowing this, many ethical dilemmas arise, especially in relation to patients’ right to treatment competing with physicians’ need to offer the treatment selectively. In the future, we must learn how to select patients for this therapy who are likely to achieve improvement in pain, function, and quality of life without interference from addiction.”
Vetter says that many patients, including those who do not have cancer, do well when placed on a chronic narcotic. The risks for the patient and doctor, however, are high. That’s especially true for those patients without a life-threatening type of cancer.
“The problem is that as a society and as a collective group of physicians, we’re often uncomfortable prescribing narcotics for patients who don’t have cancer,” Vetter says. “If you’ve got cancer, that’s another story. That’s often a life-threatening illness.
“But let’s say you have chronic low-back pain, and you’re not a candidate for surgery, or you’ve had surgery and it’s not been successful in treating your pain; you might very well need to be on chronic opioids to get back to a relatively normal and functional life,” Vetter continues. “That’s no different than someone who has high blood pressure, diabetes, thyroid dysfunction, or high cholesterol. We don’t have any hesitation to put patients on medication to treat those conditions. But when people start talking about narcotics, everybody gets a little uneasy, which is understandable. There are medical legal issues—your license can be at risk, and the Drug Enforcement Agency is watching—so doctors practice defensive medicine.”
Integrative pain medicine offers the answer, Vetter says. Anesthesiologists, physiatrists, surgeons, internists, family practitioners, and psychiatrists can come together to determine the best course of treatment for each person. “One of the things we’re going to tackle through this interdisciplinary program is how to address the large population of patients in our system who have been started on chronic opioids and whose caregivers feel uncomfortable in continuing to prescribe those narcotics. Just like other groups at UAB, the Department of Anesthesiology and the Division of Pain Treatment are not in a position to do that by ourselves.”
Sound Moves
Along with new clinics and programs, innovative techniques and technologies are reshaping anesthesiology at UAB—particularly the Regional Anesthesia Pain Service, which began just two years ago.
Regional anesthesia relies on nerve blocks, or injections of local anesthetic, to numb specific areas of the body where an operation will take place. And according to Jim Sparrow, M.D., medical director of the Regional Anesthesia Pain Service, the number of blocks performed each month has increased from 45 in 2007 to more than 200 now. Today’s blocks are more precise as well, following a shift to an advanced ultrasound-guided technique from the traditional nerve-stimulation format.
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Anesthesiology professor Mali Mathru, M.D. (center), trains residents David Miller, M.D. (left), and Richard Gist, M.D. (right), to be part of a multidisciplinary team with experience in all aspects of anesthesiology clinical care.
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Previously, anesthesiologists would administer a block using anatomic landmarks and specialized stimulating needles. Once they were near the nerve bundle to be blocked, the corresponding muscle would twitch to let them know where to deposit the local anesthetic. “That’s not going completely blind because you’re near the nerve,” Sparrow says. “The problem is that you don’t know if you’re in the nerve.”
The new ultrasound-guided regional anesthesia enables doctors to visualize the nerve and needle on a monitor. As a result, they can ensure that the needle avoids hitting the nerve and see exactly where the injected anesthetic is going.
“Sometimes when you use the nerve-stimulation technique, you get great twitches, but the local anesthetic would track back in a different way—not get around the nerve—and we wouldn’t get a good block,” Sparrow says. “Since we received our two ultrasound machines, we’ve gone from 100-percent nerve-stimulation blocks to about 70-percent ultrasound-guided blocks. That’s a pretty significant shift in our practice, and it’s really enabled anesthesia to have a little bit of a renaissance.”
In addition, Sparrow says, approximately 80 percent of the blocks are performed preoperatively, which benefits patients in two key ways: They can be comfortable when they wake up from surgery, and they require a lesser amount of opioids during the procedure than patients who don’t receive preoperative blocks.
“The sheer amount of narcotics we no longer have to give is enormous, even in the recovery room, because when the patients are asleep, they don’t feel the area where the operation took place,” Sparrow says. “And when they wake up, they’re still comfortable. To see patients at ease and experiencing no pain in the recovery room provides a great sense of pride that we’re really helping people.”