By TERRI STALEY/Journal News Editor
The first patient couldn't wake up.
The second patient woke up too soon, while still in surgery.
The third patient slept only while the operation continued and woke up easily in recovery with no side effects. In other words - just right.
Hence, the Goldilocks Anesthesia Foundation founded by Dr. Barry Friedberg to educate and advocate concerning overmedication by anesthesiologists.
Self-described as one who embraces technology, Friedberg, whose residency in anesthesiology was at Stanford University and who is a Diplomate of the American Board of Anesthesiology, was an early user of automated blood pressure devices in 1977 and a pulse oximeter in 1984, was in 1997 the first in Orange County, Calif., to routinely use a brain monitor to gauge anesthetic levels during surgery.
As all anesthesiologists, he had been taught that monitoring heart rate and blood pressure also provided awareness of what is going on in the brain under anesthesia. He no longer holds to that teaching but believes a patient needs separate anesthesia approaches for the heart and body versus the brain.
"In the 20th century we got really good at monitoring the heart and blood pressure," he said, but a brain anesthetized without a monitor forces the anesthesiologist to give more medication than necessary so as not to be giving too little. It is the 21st century, and "you want to make sure you get the best care and everything modern medicine can offer," he said.
The first mortality study regarding anesthesia came out last year, Friedberg said, reporting that one patient every day dies from anesthesia overmedication. While in comparison to the number of surgeries performed daily that may seem small, "If it's your family or you" who dies or is left with lifelong impairments it is unacceptable, he said, especially when it all is avoidable with the use of a $20 sensor - a situation he termed "outrageous."
It was his own surgery two years ago "that crystallized for me" the need to advocate for use of brain monitors by anesthesiologists.
Most people face surgery fearing the outcome concerning the body part which is the focus of the surgery when in fact they should be more worried about protecting their most valuable asset - their brain, he said.
Being over-anesthetized can cause long-term dementia, memory loss and death.
Using what he admits is a "hokey" analogy, Friedberg said if your brain is represented by marbles, you want to make sure you wake up with as many marbles as you had when you were put to sleep. With a career of 31 years in the field behind him, that was Freidberg's concern for himself. He asked for a younger anesthesiologist who was comfortable with brain monitor use.
Six companies manufacture brain monitors and usually are willing to provide them to hospitals at no charge in exchange for the opportunity to sell the disposable sensors at $20.
Just $20 - a small price to pay to protect brain function. Small enough that many patients would be willing to pay it out of pocket.
But, alas, in the complex American medical system they cannot.
Many hospitals have no billing code for the item and contractual obligations prevent them from such a straightforward approach, Friedberg said. Also, there is no money to be made. Use of the sensors results in less medication being used which means less profit for pharmaceutical companies, and hospitals make no money on their use.
Sixty percent of hospitals have the technology on site but it is used only 20 percent of the time, Friedberg said. He said he will not quit advocating for monitor use until it is at 90 percent.
The answer will not come from the medical community, he said, based on his preaching there the past 12 years.
Surgeons are enthusiastic, he said, but the anesthesia community remains in a fog of tradition and is slow to change.
The answer will come from the public, Friedberg believes.
Surgery candidates should do their homework, find out who is giving the anesthesia and ask if they will be using a brain monitor. If not, he said the response should be "Thank you, but I will be having my surgery at _____" where they use monitors.
Just as couples who wanted the father in the delivery room would not take no for an answer and found facilities that would honor that preference until now it is commonplace, so too will hospitals respond to a loss of business, Friedberg believes.
He recommends a follow-up letter to the hospital administrator stating why the surgery was scheduled at another facility. Soon that $20 cost will become trivial as memos go out to the chief of anesthesiology asking if the hospital has that capability and why it is not being utilized.
For patients who do such homework, surgery becomes like an open-book test for the anesthesiologist who knows clearly from the brain monitor what is going on as opposed to the mystery of guessing the right dosages without it.
For instance, Friedberg said, dosing a 200-pound man based on body weight alone can result in overmedication if he is a teetotaler and fragile.
One one-tenth of 1 percent of surgery patients have anesthesia awareness (meaning they are more awake than they should be during surgery). Most of those feel no pain and few suffer post-traumatic stress, Friedberg said. And sometimes no change in heart rate or blood pressure occurs - meaning the anesthesiologist may not be aware unless the brain monitor is being used.
In addition, use of the monitor is cost-effective with less waste of drugs, he said.
The nonprofit Goldilocks Foundation, founded last spring, is Friedberg's attempt to get the message out there in terms the general public can understand. To that end he also has written a book, "Getting Over Going Under: 5 Things You Need to Know Before Anesthesia," due out this summer.
While he continues to speak at medical seminars such as this week's 6th annual conference of facial and cosmetic surgeons in Las Vegas and seminars for Frontiers in Knowledge in far-flung places such as Khalapar, Singapore and Dubai, Friedberg's message is to the general public that "The ball is in your court, folks" and that "You must live with the long-term consequences of short-term care."
He urges people to speak up for themselves.
"The general public has no idea what goes on when they go to sleep," Friedberg said.
He is giving them a wake-up call.