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April 4, 2013

Books, Journals & More

A closer look: Steven Orebaugh

orebaughMedical school faculty member Steven L. Orebaugh’s book, “Understanding Anesthesia,” might be the literary equivalent of cod liver oil — perhaps not palatable to ponder, but ultimately a benefit to health. “It’s probably not a really entertaining book,” admits Orebaugh, who teaches in the Department of Anesthesiology and practices at UPMC East and UPMC Mercy South Side Outpatient Center.

“It’s not a light read for the beach, but it’s something that if you know you have upcoming surgery and you want to know more about what they’re going to do to you … I think this book would be a nice contribution as far as patient education goes,” he said.

Written for a general audience, the book outlines the differences between anesthesia and sedation and describes various types of regional (numbing) and general (sleeping) anesthesia.

In simple terms, the book addresses both advantages and potential risks to each type of anesthesia, with sections on concerns pertaining to special groups such as children, people with apnea and women in labor.

Chances are, virtually everyone will need a surgical procedure at some point in life. According to estimates by the American Society of Anesthesiologists some 40 million anesthetics are administered each year in the United States.

“We’re all going to face this,” he said.

Given that especially in outpatient settings patients typically meet their anesthesiologist just prior to surgery, they may feel as though they have little opportunity for discussion or choice.

And, while patients’ “Just put me out, Doc,” attitude is common, Orebaugh said, “It’s nice to be informed and to be able to ask some reasonable questions. ‘What would work for me?’ ‘What are my options here and do I have options here?’… I think that kind of education really empowers patients if they can take the time to pick up a book like this and read it.”

Certainly patients have the option of deciding not to know more about their anesthesia choices beyond what’s required for them to give informed consent.

“But what I like people to know is, we can put you out but we can do a little bit more, so that when you wake up — because you’ve got to wake up to this potentially painful situation — would you rather wake up to significant pain or would you rather wake up reasonably comfortably, not needing a lot of pain medication and able to get up and on your way sooner and get out of here quicker?” he said.

Orebaugh, who completed his undergraduate work at Pitt and returned for an anesthesiology residency in 1996 after completing medical school at Temple, a residency in emergency medicine at Wright State in Dayton, Ohio, and three years as Navy emergency physician, developed an appreciation for regional anesthesia techniques when sports orthopaedic surgeons from UPMC Montefiore were moved to the South Side outpatient facility a little more than a decade ago.

Until then, the surgery cases had included general operations such as gall bladder, appendix and bowel surgery, urological and gynecological surgery, back surgery, some orthopaedic surgery and some plastic surgery, typically with general anesthesia. “We didn’t do a lot of nerve blocks,” he said. “We’d done it as residents, but not had a lot of follow-up with that or ongoing training.”

That all changed when the orthopaedic surgeons, who brought with them mostly outpatient surgical cases, arrived. Given the painful nature of the types of procedures they performed — setting bones or realigning ligaments, for example — “They had a regional anesthesia culture” including spinal anesthesia and peripheral nerve blocks in the arms and legs, Orebaugh said.

With some training from anesthesiologists who accompanied the orthopaedists, regional anesthesia procedures became the bulk of Orebaugh’s practice as well.

“I don’t think I anticipated how well it would work and how much we needed it,” he said, adding, “I think we’d have a hard time doing a lot of the cases we do and allowing people to go home on the same day if we didn’t do these nerve blocks.”

He added: “What I found was the patients that came to us weren’t very well versed. They didn’t understand the distinctions between regional anesthesia and general anesthesia or how the two could be combined in effective ways to wake up with less pain and improve outcomes.

The opportunity to write the book came when Orebaugh, a Navy reservist, was called up in 2004 to serve at a naval hospital in Virginia. While stationed on an aircraft carrier for several weeks, he had time to develop the framework for the book, finishing the basics over the course of the following year, before connecting with the publisher, Johns Hopkins University Press.

“I felt there was a real need for some public education for the patient about understanding how the different components of anesthesia could be aligned to give people their best outcome.”

A common misconception is that general and regional anesthesia are either-or options, Orebaugh said.

“People tend to think of them as mutually exclusive: regional anesthesia and awake, or asleep with some sort of breathing device. But you can combine the two very effectively and also make people have a greater degree of comfort when they wake up and satisfy what their real requirements and needs are,” he said.

“Waking up with less pain allows people to overall get less anesthesia, usually to wake up more alert and appropriate as far as their medication goes. Of course the pain is less, because that’s the point of the nerve block. Then they don’t need a whole bunch of extra morphine and so forth in the recovery room that acts almost like a second anesthetic and keeps them drowsy for many more hours” preventing some patients from going home.

“It really reduces the need to stay in the hospital and, in this move in the past 20 years from inpatient medicine into outpatient medicine, really facilitates letting people go home early.”

understanding anesthesiaFor instance, Orebaugh said, patients who had shoulder surgery without nerve blocks typically woke up with a lot of pain and consequently were given a lot of morphine. “Probably one-third of them, or maybe even half of them, couldn’t go home because they were just so drowsy and nauseated from the morphine,” he said.

“Morphine works and is effective but it has a lot of potential side effects that can make people feel really lousy. If you can spare them that by giving them a head start with their pain control for 12 or 24 hours and then they can start taking pain medicine as that block is wearing off, I think that they’re ahead of the game and they just feel better,” he said.

In another option, seen in some knee repair surgeries for example, patients can go home with a nerve block that continues to infuse for several days. “I think that really reduces the amount of pain medication they need to take; it usually then makes them less nauseous, less constipated, less itchy, less drowsy. They can have a more active and appropriate role in their rehabilitation for the next few days instead of just being kind of a zombie, and avoid inpatient admission which used to be much more common.”

The majority of patients who have had nerve blocks do well, he said, adding, “The vast majority of people I see who have had them before are in favor of having one again.”

Regional anesthesia does more than merely control pain, serving to help tame the body’s sympathetic nervous system response, which can raise a patient’s heart rate, respiratory rate and blood pressure as a result of the stimulus even if the patient isn’t feeling pain.   That stress response can raise risks in the perioperative period for older patients, especially those with heart disease or other vascular disease. “Adding regional to general anesthesia can be very helpful in that kind of a population,” he said. “Uncontrolled pain can contribute to things like heart attacks and strokes or perioperative death. Because of those types of mechanisms, controlling pain becomes more than just making people comfortable. It can be a real health issue,” Orebaugh said.

Pre-surgical fears have shifted as anesthesia has become much safer. Rather than worry about not waking up, as might have been a common fear 50 years ago, patients today are more concerned about nausea or pain, the most common aftereffects.

“Our job is to get people safely, successfully and as comfortably as possible through surgery. The surgeons tend to be in the limelight because they’re providing the actual care, the change in health that the patient needs.  So, we don’t mind being in the background. If we’re keeping people safe and no one ever talks about us, we’re happy as can be,” Orebaugh said.

“It’s always unfortunate when something comes out in the popular culture that’s derogatory about anesthesia,” he said, citing as an example the 2007 film, “Awake,” which dramatized anesthesia awareness — a theoretically possible, but extremely rare situation in which a patient appears to be anesthetized but remains conscious — and the implication of a common anesthetic in the death of pop star Michael Jackson.

“No one knew what propofol was” before Michael Jackson. “Now most people know,” Orebaugh said.

“A lot of people were very concerned. ‘You’re using that drug in me; it killed Michael Jackson.’ The point is you can’t take drugs like that home. Somebody’s got to be watching you, watching your vital signs, which is the very essence of anesthesia. Don’t take an anesthetic without an anesthesiologist or an anesthetist there with you to make sure that you’re going to be safe and breathe and have a normal blood pressure. Or else you’re taking a huge risk.”

Arming patients with information is important. “We really enjoy patients asking questions: How long will this affect me? Are there any potential side effects? Is this what the average patient does? Is there anything about me that would make this more or less risky?” Orebaugh said.

“Anybody who’s well-informed and has taken time to read a book like this or view a web site, we really appreciate that because that lets us expand a little bit more — we know that they’re not intimidated by our explanations but they welcome them.”

—Kimberly K. Barlow

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