Is Anesthesia Dangerous? We Asked Our Plastic Surgery Anesthesiologist

Speaker 1 (00:07):
You're listening to The La Jolla Cosmetic Podcast.

Monique Ramsey (00:14):
Welcome everyone to The La Jolla Cosmetic Podcast. And I'm your hostess, Monique Ramsey. Today, I have a very special guest, Dr. Steve Saltz. And you all might not know unless you've been in our OR that he's one of our anesthesiologists. So people do a lot of research to trust that their plastic surgeon is capable and competent, but plastic surgery takes a team. And one of the most important people on that team, who you may never really think about and who you don't see because you're asleep, is the person delivering your anesthesia. So I'd like to introduce you to Steve Saltz. Welcome.

Dr. Steve Saltz (00:55):
Good morning Monique.

Monique Ramsey (00:58):
He's a board certified anesthesiologist, and you've been at the Centre for how many years?

Dr. Steve Saltz (01:04):
I started with La Jolla Cosmetic Surgery Center back in '92 or '93. And we've had several locations, but I've been there the whole time.

Monique Ramsey (01:16):
That's awesome. You've probably done thousands of cases. I don't know if you count them. Do you have a little chart where you make a tick mark of how many cases you've done or could you approximate for the audience?

Dr. Steve Saltz (01:29):
I would imagine in a normal busy anesthesia practice, you're probably doing several thousand cases every year. And the same is probably true at La Jolla. I would imagine at 50 weeks, you could do 15, 20 cases. So maybe that would be about 1,000 cases for one year since 1992. So you begin... Yeah, you accumulate a lot of experience.

Monique Ramsey (01:58):
So, Dr. Saltz, tell us about your background.

Dr. Steve Saltz (02:01):
So unique I think is probably a good descriptor of that. So I came the long route to anesthesiology. I started medical school back in 1977 and after medical school, I first trained in internal medicine and I did a residency in that. Then I decided to specialize in pulmonary and critical care medicine and I did a fellowship in that, but in between internal medicine and pulmonary, I worked full-time in an emergency room for a while. After finishing my training in pulmonary, I started my private practice in pulmonary and critical care medicine in the San Diego area up in Oceanside. That was in 1985.

Dr. Steve Saltz (02:47):
But after five years, I made the decision to switch to anesthesiology. And so I went back and did an anesthesiology residency on top of everything else from '90 to '92. And then in 1992, I finally decided what I wanted to be when I grew up. I started my anesthesiology practice in 1992 and I've been doing that since then. And so that's still-

Monique Ramsey (03:14):
Amazing.

Dr. Steve Saltz (03:15):
Despite that long background, it's been 30 years since I've finished my training and I've been working as an anesthesiologist since.

Monique Ramsey (03:23):
Let's get into our patients' mindset a little bit. What are the most common fears that people have with anesthesia?

Dr. Steve Saltz (03:33):
Well, it's pretty consistent. Patients are mostly concerned with being safe and it's especially intense in the young mothers with small children at home. It's something that we gently prod about because often they don't offer it up, but they're very afraid because they have small children at home. They want to make sure that everything's going to go well. That's actually quite sweet. But then they're worried about the possibility of awareness during surgery. Postoperative nausea and vomiting is a big concern and then pain after the procedure and pain also even from something as what we consider minor as putting in their intravenous catheter. People are even very, very aware of that. There's a big needle phobia that's present. People just don't like needles. They don't like the IVs. They don't want to even think about it. Let's go through the day of surgery and then we can address those four concerns as we go.

Dr. Steve Saltz (04:33):
So the process on the day of surgery starts way before the day of surgery. The nurses and the surgeons, they take their history. We get all the information about past medical problems, current lab, maybe even prior consultations from other physicians who might have been involved in their care. And the nurses there who do the preoperative preparation, they're very good about being aware of when there might be a potential problem or something that we need to know ahead of time. And then if we have any concerns, then we can at that time request, well, the patient needs to see a cardiologist or their own doctor. These issues need to be addressed and make sure that everything is stable and as well treated as it can be. Or we may request more labs or an additional EKG or something like that.

Monique Ramsey (05:25):
So you clear the patient way before they get to meet you, but the morning of surgery or the afternoon, whenever they're having their surgery, describe that process a little bit.

Dr. Steve Saltz (05:35):
Sure. So after the patient's checked in the day of surgery and they're in their gown and they're waiting in the preoperative room, we go in, introduce ourselves, and we go over their history. If there's any points that need clarification, we ask for more information. We like to make sure that there's been no change since the time the information was obtained and the day of surgery, and especially we want to make sure that someone hasn't been sick in the interval. Even something minor as a cold could have implications for their surgery in terms of their airway could be more reactive, more sensitive.

Dr. Steve Saltz (06:13):
So it's important to know all that information. And we confirm all the information with the patient and double-check what medications they're on to make sure that they haven't had anything to eat or drink that day, double-check their allergies. And then we do a physical examination. We like to evaluate the airway, their heart and their lungs, and any other things that might be pertinent to that day. And then we have time to sit down with the patient and describe the process to them and alleviate their fears. And that's when we get into their concerns about safety, pain, and postoperative nausea and vomiting. And so we find that having just a few minutes to talk really goes a long way towards alleviating their concerns. It's been described as a full dose reassurance.

Monique Ramsey (07:04):
Yeah. Oh, that's nice.

Dr. Steve Saltz (07:06):
Yeah. And it's been shown that that's probably as effective as a preoperative sedative or medication that calms somebody down.

Monique Ramsey (07:14):
Really?

Dr. Steve Saltz (07:15):
Yeah, yeah, that's clearly been shown. Now, it's nice to actually have both. We make sure that the patient's questions are answered, that they have all the information they need to proceed for that day, and then we go into the operating room and we get them comfortable on the operating room table, which is as comfortable as you can be. The operating room is very clinical. It can be an intimidating environment. And there's a lot of lights, a lot of equipment, it's bright. And all that can be stressful for the patient, but we're all very aware of that. The nurses are very good at that. They usually talk to the patient as I'm doing what I have to do and reassuring them and just getting them comfortable and a little bit distracted of what's going on.

Dr. Steve Saltz (08:05):
So things start to happen simultaneously at that point. I'll start to do the IV, but the nurse also starts to put on all the monitors that we use in the operating room at the same time. So to talk about the fear of needles and the pain of starting an IV, we're very successful at minimizing any discomfort because we use local anesthetic before we start the IV. And it really goes a long way towards alleviating any pain the patient may have. We use the tiniest needle that's available to put in a little bit of lidocaine into the skin where we're going to insert the IV. And I would say the majority of times, we can actually get the lidocaine in and the patient doesn't even notice it or minimal awareness.

Monique Ramsey (08:50):
Really?

Dr. Steve Saltz (08:50):
Yeah.

Monique Ramsey (08:50):
Wow.

Dr. Steve Saltz (08:51):
It's very effective. And the key is just giving it slowly. And then once the skin is numb, you can usually insert the IV without any further discomfort. And that comes as a great relief and a surprise to most of the patients that the IV is in. And then we can proceed. So once the IV is in, we immediately give a little bit of sedation into the IV. And that goes a long way towards getting the patient nice and relaxed. They have a warming blanket on them at that time, all the monitors are on. We check their vital signs, make sure that we're starting out with a patient that's stable, that their vital signs are within a normal range for them, and we can begin the anesthetic.

Dr. Steve Saltz (09:34):
So the most important medication I have in the operating room is oxygen. People don't think of it in those terms, but that is absolutely the number one most important drug that I use. So we start by having the patient breathe oxygen through a mask for a minute or two before I put them to sleep because once we put someone to sleep, I take over their physiology. I take over their airway and their ability to breathe and oxygenate themselves. So oxygen is extremely important. So it's very easy. They breathe the oxygen through a mask, maybe have them also take a few deep breaths, and then with a shot in the IV, they go to sleep. And now they're under an anesthetic.

Dr. Steve Saltz (10:16):
Now, the shot alone by itself would only last several minutes, right? We call it the induction dose just to get things started. After the induction of anesthetic has been achieved, we place an airway. Sometimes it's a breathing tube, sometimes it's just what we call an LMA, a laryngeal mask airway. And it's much easier to place than an endotracheal tube. It's really been one of the revolutionary discoveries in anesthesiology and certainly for outpatient anesthesiology. It's less of a stress for the patient, and we use it I would say probably at least 75% of the time in our practice.

Monique Ramsey (11:01):
And what is the indication that you could use the LMA or when you have to do it too? Is it the length of the surgery or what is your determining factor?

Dr. Steve Saltz (11:12):
Good question. Yeah, it's several things. Length is one. For the longer operations, we prefer to have an endotracheal tube. I don't know that anyone knows what the limit is. I think it's arbitrary, it's what everybody feels comfortable with. Then after that, do we need to secure the airway in terms of protecting it from any possibility of a patient giving a history of reflux where something might come up from their stomach up the esophagus and contaminate the airway if it's not secured? Now, normally, that's not an issue. Reflux is very common, but by the time patients come to the OR, they've been on treatment for that, and if they're asymptomatic, it really isn't worrisome. So we can use an LMA in someone who's had a past history of reflux but who's well-controlled now. And for the patient, it doesn't make a difference to them. They won't know the difference.

Monique Ramsey (12:09):
Right. Because you're asleep and-

Dr. Steve Saltz (12:10):
They're asleep. Yeah, both go in when you're totally asleep. You're totally unaware of it. Both the LMA and the tracheal tube can cause a sore throat. So we do advise them of that. Just as long as they're aware of it ahead of time, patients do very well with that. So now we move on to the maintenance part of the anesthetic. The surgeon is ready to start. He likes to be sure the patient's ready and the surgery begins. And so now the anesthesiologist and the OR nurse were there just to monitor the patient, make sure that everything is going properly and that the patient is safe. And we do that in a number of ways. The anesthesiologist is present in the entire case. It's interesting that some people have the idea that we leave after the anesthetic has started. Totally untrue. We are there the entire time.

Dr. Steve Saltz (13:06):
We monitor the patient very carefully, all the aspects of their physiology that you can monitor in terms of their airway, their breathing, how they're oxygenating, their blood pressure, their pulse, their heart rate, their temperature, all that we are constantly monitoring. We have to decide how much fluid to give them, how much pain medicine to give them, what kinds of medicine we're going to use to prevent postoperative nausea and vomiting. And all that occurs during the maintenance part.

Dr. Steve Saltz (13:38):
The whole field of anesthesiology has been changed by the ability to use a lot more non-narcotic pain relief than we have in the past and it's quite effective. We've been very lucky. I would say that I'm definitely using less narcotics for pain relief than I have in the past. It isn't zero and it depends on the operation, but there are non-narcotic pain relievers. There are long-acting local anesthetics that can be injected into the operative sites that are very effective towards relieving postoperative pain. And we hope to deliver the patient to the recovery room pain-free, with no nausea and vomiting, hopefully with no sore throat and comfortable. I mean, feeling safe and secure.

Monique Ramsey (14:30):
So when you're talking about monitors, where are the monitors and what are they?

Dr. Steve Saltz (14:37):
All right. Well, the standard monitors would be a blood pressure cuff. So that goes on one arm. The IV goes into the arm, usually opposite the side from the blood pressure cuff, but there are exceptions to that. There is a pulse oximeter which monitors the oxygen content of their blood, and that goes on the finger to snug over the finger. So it's not uncomfortable at all. And then we monitor the EKG continuously throughout the case. So those are the monitors that we place that the patient's aware of. But then also once the airway is established, then that's hooked up to the anesthesia machine and there's additional monitors there. We can monitor the oxygen content of the gas that's going in, the oxygen content of the gas that the patient is expiring. We monitor their carbon dioxide content of the gas that they breathe out, and that is critical and just absolutely can't be stressed how important a development that was for anesthesiology. That with the ability to monitor their oxygen level revolutionized the safety of anesthesiology.

Monique Ramsey (15:50):
And why is that? Why is the carbon dioxide…. ?

Dr. Steve Saltz (15:55):
So being able to monitor the carbon dioxide and the patient's breath tells us that we have an airway that is well-established and that it is open, that there's no interference with their breathing, and that we can use that to monitor very various aspects of the respiration. And it shows us that the most important vital sign, their breathing and their oxygenation are being constantly monitored. So in the past before that was available, someone's breathing could be inadequate for their needs or they could stop breathing altogether and it may not be quickly recognized by the anesthesiologist or the operating room team. In its infancy, anesthesiology was much more dangerous mainly because of those two factors, being unable to adequately monitor their breathing and their oxygenation. So with those two things in place, the safety of anesthesiology has just vastly improved.

Monique Ramsey (16:55):
And then the other thing I was wondering as you talked about the narcotic, how you can use a lot less narcotics, is the narcotic element the part that makes you feel nauseous?

Dr. Steve Saltz (17:07):
So there are a lot of culprits for postoperative nausea and vomiting. Narcotics are one, but also unfortunately, the main anesthetic gas that we use, all the anesthetic gasses can also contribute towards nausea and vomiting. So nitrous oxide, laughing gas, I think the trend in anesthesiology has been to use less of it over time. However, if you're using it only for 45 minutes to an hour, it's probably been. It's not a factor and it can't be used. And if we do use it, we'll use it in smaller amounts. We won't give as high a concentration as we used to when I was in training. We use less of it.

Dr. Steve Saltz (17:45):
So the anesthetic gasses, the narcotics, and then the patient's own anxiety can contribute. So addressing their anxiety is also helpful. And so the other factors, interestingly enough, is women have a higher incidence of nausea and vomiting than men. For some reason, being a non-smoker is actually a risk factor also for postoperative nausea and vomiting, right?

Monique Ramsey (18:11):
Really?

Dr. Steve Saltz (18:12):
Yeah. Now, we don't encourage people to start smoking to address that issue, but it is something to be aware of. So when we evaluate patients preoperatively, what we're looking at is like, well, is this person a non-smoker? Is she female? Does he or she have a history of postoperative nausea and vomiting? Right? That's a factor. If they've had a history in the past, the odds are that if you don't treat it aggressively, you're going to have a problem again. And then is a patient going to require postoperative narcotics for their pain controls? So those are the four main factors.

Dr. Steve Saltz (18:45):
And so the more risk factors you have out of those four, the higher the incidence of postoperative nausea and vomiting. But usually, when somebody says, "Well, they gave me something and it worked," generally, you know that's one of two drugs. They've either had Decadron, which is steroid, and/or they've had Zofran, Ondansetron, which are both very, very effective for relief of postoperative nausea and vomiting. And I'll always have the nurse in the recovery room give the patient a list of what we used, what was successful or what might have not have been successful. And I tell them, "Keep that with you. It'll be very helpful for the next anesthesiologist to know exactly what worked and what didn't work."

Dr. Steve Saltz (19:32):
There's different types of, call it, postoperative nausea and vomiting because it used to be all lumped together. Everybody assumed that it started immediately in the recovery room and we found that sometimes it doesn't and there's immediate postoperative nausea and vomiting. Sometimes people do great in the operating room, in the recovery room and they don't have nausea until you try to move them. They don't know it until they get up to go to the car. So that's why sometimes they'll sit them up in the recovery room just to make sure they're ready for that. Sometimes patients do well. People get motion sickness. Sometimes people are doing well in the recovery room, they do well being transported to the car, but they get into trouble on the drive home. And then sometimes even the drive home things go well and they get home and they have nausea when they're home. So it's good to know when that occurs. That's why taking the time to take a history is important because it doesn't always, but often will help you to figure out, well, what happened? When did it happen? What were the possible causes?

Monique Ramsey (20:41):
And let's talk about who's in the room. So let's say I'm the patient and I've got you there, Dr. Saltz. You're the anesthesiologist. Who else? And then there's obviously your surgeon, your plastic surgeon, but there's a few more people in the OR.

Dr. Steve Saltz (20:55):
Yeah, absolutely. So you'll have someone assisting the surgeon. We have excellent OR technicians, scrub technicians who set up the surgeon's instruments and the table in a manner that's useful for them. The scrub techs get used to doing in a certain way, so they know where everything is. And so they can hand off the instruments in a timely manner. And their experience makes a huge difference. It's fun to watch an experienced scrub technician work with a surgeon when they've been working a while together. It's like watching Fred Astaire and Ginger Rogers do this little dance. And the scrub tech gets to know the surgeon and can anticipate their needs. And that's a big factor towards making things run smoothly.

Dr. Steve Saltz (21:41):
And then we also have the OR nurse, okay? So this is a registered nurse who's in the operating room who's there to obtain any supplies that the surgeon or the scrub technician might need, assist in caring for the patient the whole time that they're in there, she's there to assist me. And we have wonderful OR nurses from a variety of backgrounds, which I find invaluable. They have experience in OR, ICU, emergency room, and some of those additional areas of expertise really bring a lot of added value to what we do in the operating room because they sometimes know things that I haven't seen. I know we had one case where we had a patient who needed a Foley catheter, a tube inserted into their bladder to drain the urine out, and she showed us a trick or two on how to make sure that it was properly placed. And I've been in practice since I left training in 1980 originally and that's something I'd never before, right?

Monique Ramsey (22:50):
Interesting. Oh, wow.

Dr. Steve Saltz (22:51):
Yeah. So they do a wonderful job and they're there to make sure that the patient is safe.

Monique Ramsey (22:56):
And they're dedicated to that room. And I think that's something that I learned when I started in this industry, that some places have the person who's in recovery sort of check in on the people in the OR and go back and forth. And we have dedicated recovery room nurses and dedicated OR nurses. And I think that's important, don't you?

Dr. Steve Saltz (23:19):
Absolutely. And I think that it gets to the question of how is it that we keep patients safe? Number one concern, as we mentioned, was safety. So how do we achieve that safety? So the important thing is that at La Jolla Cosmetic Surgery Center, we have the same standards, same personnel, same equipment, same monitors that you have in a hospital setting. We follow all the recommendations from the American Society of Anesthesiology, all the recommendations and guidelines from the American Patient Safety Foundation in terms of how to conduct safe anesthesiology in an outpatient or an office setting. The surgeons at La Jolla, they have privileges for doing their surgery at a hospital. Nothing gets done at La Jolla that if it had to be, it could also be done at a hospital. You don't want to have a situation where someone's doing it in an office because they can't get permission to do it somewhere else. That's not the case.

Monique Ramsey (24:26):
Our surgery facility is also accredited by, we call it quad A because there's four As and then SF. So AAAASF, which stands for the American Association for Accreditation of Ambulatory Surgery Facilities. And that is a body that we follow their standards, their guidelines, and they come and do inspections. Is that right?

Dr. Steve Saltz (24:52):
Correct. And in addition, I belong to a medical group, ASMG, Anesthesia Services Medical Group, and in order for one of their anesthesiologists to practice in an outpatient setting, ASMG insists that on a regular basis, a representative comes and inspects the facility and makes sure that it meets all their standards. And in that way, between quad A, ASMG doing the inspections and following all the available guidelines, we meet the highest level of safety that you can achieve. And we're very proud of that. And it's reassuring to me as an anesthesiologist not only do I have to reassure the patient that the patients are going to be safe, but it's reassuring to me to know that I've done everything that I can do to make sure that the standards are high and that the patients are going to be well-cared for.

Dr. Steve Saltz (25:53):
The other thing I wanted to mention is I touched on the recovery room, but that's such an integral part of what goes on there. It's worthwhile to spend a few extra minutes on that. People ask, well, how are you going to keep me safe in surgery? And it's important to realize, well, it's after surgery too. That sometimes is even a more critical part. In the operating room, things are almost under better control. There you have an airway that's secured. You have all your monitors on and you can control things better. Once the patient is awake and the airway is out, now the patient's in the recovery room and we have to be sure that everything is safe before I turn them over to the recovery room nurse for them to take over their care in the recovery room.

Dr. Steve Saltz (26:46):
So once the anesthetic is completed, the surgery is completed, the patients actually wake up for the most part by turning off the anesthetic gas and then they wake themselves up. The patient wakes up by eliminating the anesthetic gas. And the way they do that is just by breathing. So it's a matter of timing. We monitor the surgery, check in with the surgeon, "Doc, how long do you think it's going to be before you're finished?" And so we know that we want to start lightning the anesthetic at a point so when they're finished, the patient is several minutes away from waking up. And they do that by breathing. They expel the gas. So the gas that has entered their body is keeping them asleep will reenter the bloodstream and from the bloodstream will go to the lungs. From the lungs will be breathed out. When the anesthetic gas falls to a certain level, then the patient will be awake.

Dr. Steve Saltz (27:48):
We make sure that they're safe and we transport them. Both the anesthesiologist and the operating room nurse take the patient to the recovery room and we give a report to the nurse in the recovery room so the nurse can have some idea of what might be some issues in the recovery room. And then we make sure that the patient is stable and that the recovery room nurse is satisfied before we leave. And even if we leave, the operating room and the recovery room are 10 feet away. We leave, but we don't leave. And that's one of the nice things about the office setting. The preoperative area, the operating room area, and the recovery room are all within 10 feet of each other.

Monique Ramsey (28:37):
Right. Yeah, you're not going very far.

Dr. Steve Saltz (28:38):
No. Even when we're not there, we're right there. So if we start another case and we're in the operating room and the recovery room has a question, she walks 10 feet, pops her head in the door and says, "Dr. Saltz, what about..." We can have a discussion. And then we can address the issues of pain control and postoperative nausea and vomiting. So at this point, usually there's been local anesthetic injected into the wounds where it can be. We've given the non-narcotic pain relievers. If the patient needs an additional dose for pain medication, it'll be ordered for them in the recovery room. And what we do is we get into the recovery room and then they can fine tune it because they'll be awake and they can say I'm having pain. And if they are and they want it treated if it's still a level where it needs to be treated, then they'll be small doses of medications and the recovery room nurses then will titrate it in and watch them, watch the vital signs, see how they're doing, give them a small dose of pain medication and monitor it and see how it works.

Dr. Steve Saltz (29:39):
And they're very experienced at that. And the important thing is with everything we do around the time of surgery is give a little bit, see how it works. I'll joke with the patients. I tell them, I'm like a barber. I never want to do too much. I just do a little bit of... I can always do more. I can't take it back. So I'll give them a little bit and we'll see how they respond to it and then that gives us right away even when we start. When we first have the IV in and we give them some sedation, some patients, you give them a small dose and they're looking at you like, well, well, when are you going to give me the medication? Other patients, it's almost the start of a general anesthetic. They're totally asleep.

Dr. Steve Saltz (30:23):
And life is a bell-shaped curve. All right? So those are the extremes. Most people are in the middle. You give them that dose and they're comfortable, but they're still interacting and talking with you and they'll need more medicine to go to sleep, but it gives you an idea of what they need. And so that's what we constantly do. We give them medication, we judge the response to us. It gives us an idea of where they are. And so that helps me decide how much and what kind of pain medication I'm going to give them and then we'll fine tune it. The nurses watch them, they're happy, they're comfortable, they wake up quickly and they can take some fluids and the IV comes out and they're on their way. So I would say most patients in the recovery room spend about 45 minutes there.

Monique Ramsey (31:08):
Oh, really? That's all?

Dr. Steve Saltz (31:10):
That's all. Everything that we use in modern day anesthesia, not just unique to us at La Jolla, but modern anesthetics are quick acting, they're pretty clean in terms of very often minimal side effects. And so properly conducted, we like to have the patients really waking up as they get to the recovery room. And they'll be ready to go in about 45 minutes. Now, there's always exceptions. Some people wake up so fast that it's almost startling. They wake up immediately and they run to get out and you almost have to-

Monique Ramsey (31:46):
Pump the breaks.

Dr. Steve Saltz (31:49):
You do. You have to convince them to stay for a safe period of time. It's really kind of funny. And they do very well. And sometimes people give you that history. They'll tell you, "Oh, it takes me a long time to wake up." And we don't consider that a problem. That's what the recovery room is for. I never ignore that information. We review in our head what medications we're going to use and how much. We'll take that into account, but we're not going to skimp on an anesthetic for fear that they might have to stay an extra 15, 30 minutes in the recovery room. They stay until we know that it's safe, till they meet the criterion for a safe discharge and then they'll be on their way.

Monique Ramsey (32:27):
So since we're talking about waking up, one of the four things that you talked about people are afraid of is being aware during surgery or somehow. So talk about that.

Dr. Steve Saltz (32:39):
Yeah, that's just what I was thinking. You made me think so good. Let's double back to that. So intraoperative awareness. That sounds horrible, doesn't it? It is so scary. And unfortunately, it's juicy enough to where news, TV, the media likes to make a big deal out of it. We take it very seriously, but it is extremely rare. We're not cavalier about it. We don't discuss it in a joking manner, but people can scare themselves to death by watching YouTube videos just prior to their surgery.

Monique Ramsey (33:12):
Step away from the YouTube.

Dr. Steve Saltz (33:14):
Yeah. It's good to get information. It can be very, very useful, but you can scare yourself half to death by watching this stuff. Now, a lot of times, awareness can occur in a setting where you can't give a full anesthetic. Well, that's never the case of La Jolla. What am I talking about? If you're in a car accident and you lose a lot of blood, you can't go to the operating room to, say they have to intervene in the operating room. You need an operation now. You need an emergency surgery and you've lost a lot of blood. You can't get a standard anesthetic. At that point, the human body is very resilient, but a standard anesthetic in a setting where you're unstable because you've lost a lot of blood or you're in septic shock from an infection and your blood pressure is always low, a standard anesthetic would be dangerous. It might even be fatal.

Dr. Steve Saltz (34:06):
And so when I was in training, we had a big trauma unit at the university. And we often had to take patients after bad trauma to the operating room and we'd warn them. We'd say, "Look, in order to be safe, in order to keep you alive, we'll have to give you a minimum anesthetic. You may be aware, you might hear something. You might be aware of something, but as soon as you're stable and the bleeding is controlled and I know that it's safe to do, we'll deepen the anesthetic." And I can't say they were all relieved by that, but I think most people understood and accepted it. It was a safety issue.

Dr. Steve Saltz (34:43):
La Jolla, this is totally different. So these people are healthy. They're in the prime of their life. They can take a full anesthetic. We use multiple overlapping drugs that all will guarantee to keep the patient asleep and unaware of what's going on. It's because we've had people come to us with previous cases where they said, "I was aware during the case." We always listen to that with the utmost respect and sincerity because it's something that we want the patient to know that we're going to take steps to make sure that it doesn't occur.

Monique Ramsey (35:18):
So, one thing that patients might wonder is after surgery, how long will they feel the effects of anesthesia?

Dr. Steve Saltz (35:26):
Good question. So, like I mentioned, the anesthetics are very short acting and what we tell people, again, the fact that you're going to be going home in 45 minutes tells you a lot of what you need to know. That people are street-ready, that they're recovered from an anesthetic to the point that they can go home in 45 minutes, but that means having a nurse take you out in a wheelchair, put you in a car and then you go right home. And they're going to probably feel tired. They'll feel like taking a nap. Some of that might just be the stress of going through surgery and the anesthetic and the whole process. So they haven't fully recovered by any means. They just got out of the OR basically an hour or two ago. So we encourage people to go home and take a nap.

Dr. Steve Saltz (36:16):
But sometimes you have to go over and over that they're not allowed to do anything else that day. They're not supposed to make important decisions. They're not to be going anywhere else. They're not to be driving a car because they feel good enough to do so. Wait until the next morning before you resume normal activities because you never know. Again, life is a bell-shaped curve. You don't know who is going to have a residual effect. That's why we tell people, you got to have someone come with you and drop you off, pick you up, take you home, stay with you-

Monique Ramsey (36:49):
Stay with you.

Dr. Steve Saltz (36:49):
Stay with you overnight. Yeah. You don't want to cut corners with that because you don't want to be the exception, the bad exception to where you do have an effect and there's nobody around to help you.

Monique Ramsey (36:59):
Right. And I think just having that person help you with your medicine dosing. There's sometimes an antibiotic and you take that every six hours and then you have your pain, and keeping track of that as a patient in that first 24 hours, I think it's a little bit too much.

Dr. Steve Saltz (37:14):
And that's why it's important to have somebody with you because giving postoperative instructions to the patient, they won't remember. So you have to have another person. Aside from putting it in writing, you tell the other person, they're going to be remembering. They know what to do, what medications to give, what instructions need to be followed. The poor patient at that point, it's better for the patient just to surrender and let somebody else take care of them and do what needs to be done for a while until they're ready to take over on their own.

Monique Ramsey (37:43):
Now, what is it about working in plastic surgery that you like versus let's say just the traditional OR in the hospital?

Dr. Steve Saltz (37:54):
Yeah. Well, there's two issues. The difference between the hospital and the difference between plastic surgery and non-plastic surgery. All of it is very rewarding. You're taking somebody and you're helping them through a time of when they're not feeling well, or if it's a stable condition, it's not that they're not feeling well, but they're having a problem. You're getting them through time of intense stress in terms of physiology stress to go through a surgery under an anesthetic.

Dr. Steve Saltz (38:23):
The difference with plastic surgery I would say is although it's rewarding and people are very grateful otherwise, in plastic surgery, there's a level of joy that you don't quite see. Nobody is crying with joy because they had their gallbladder out. For anybody who has cried with joy, I don't mean to offend you, but you see people who are really literally crying with joy. Maybe some young girl who's had an issue her whole life with her appearance. She's been dying to get it fixed for 20 years or whatever it's been, and comes in, and she gets it addressed and they're so happy afterwards. There's just no way that isn't extremely rewarding. And I think it's very, very unique to plastic surgery. It's a privilege to be part of that.

Monique Ramsey (39:16):
Now, for all of you who might have caught the fact that Dr. Saltz's name is Dr. Saltz, Dr. Steve Saltz, your wife works in this surgery center, Dr. Lori Saltz. So we have-

Dr. Steve Saltz (39:32):
She does.

Monique Ramsey (39:33):
Boy Saltz and girl Saltz. And so tell us about are you guys in the same OR a lot of the time and how do you like that?

Dr. Steve Saltz (39:42):
Yeah. Yeah. When I first started anesthesia practice and I was at the hospital and doing hearts and a very, very busy practice and she was very busy at the time, working in the OR is the only time we'd see each other sometimes.

Monique Ramsey (39:56):
Hey honey, how've you been?

Dr. Steve Saltz (39:58):
Yeah. Yeah. And that's where we would touch bases and make plans. And it was kind of funny, but it's fun for me to watch her because she is so meticulous and so obsessive about what she does. It's just fun to watch her interact with her scrub techs because they appreciate Lori and how meticulous she is. And so it's fun to watch that. It's fun to watch her interact with her nurse, Ruth, because Ruth and Lori, they're like introvert and extrovert. So then I call them the odd couple of plastic surgery. It's just hilarious to watch them interact together. And they do a great job between the two of them.

Dr. Steve Saltz (40:36):
And so it's really a lot of fun. It's never an issue. It's just all good. It's all fun. I'll tease her a little bit. I tease the patients. They say, "What's it like working with your wife?" And I go, "Oh, it's great. That way she can... Not only does she get to tell me what to do all the time at home, but she can tell me what to do in the operating room too." So it's perfect. It's a very uniform approach.

Monique Ramsey (41:01):
Well, this has been so informative. And if you had one piece of advice to a prospective patient who might think they're scared or be scared of anesthesia, what would it be?

Dr. Steve Saltz (41:11):
I'll say what I tell them. I go, anesthesia is extremely safe, all right? You can say that. And there's a lot of qualifiers to it, of course, but I said anesthesia for the people that we see because they're young and they're healthy is safer than driving to the surgery center the morning of surgery. You hop in your car, you don't even think about... There's risks to driving a car? You realize what the risks are, but we don't even think about it because we're used to it. Something we do every day. So it's not really in our minds. Surgery in an anesthetic stands out because we do it so infrequently. So you're going to focus on that.

Dr. Steve Saltz (41:54):
I emphasize what we've talked about that there's no other time in your life when you're going to have so many people just taking care of you. When do you have two doctors taking care of you at one time? That's very, very unusual. And I emphasize to the person, my training, that I'm going to be there with them the entire time, and I'm shameless. I have no problem with trotting out. If the patient seems to need a little extra reassurance, I will trot off the fact that I'm board certified in medicine and pulmonary and I did critical care and I did cardiac anesthesiology. And I don't do it for my benefit. I do find that for a lot of people, that's very reassuring and that's all they needed to hear. They just want to know that they got somebody who's there for them. And we take our responsibility extremely seriously. We fully realize that what we're doing, again, has to be approached with the utmost humblest... Is that a word? You have to be humble.

Monique Ramsey (42:56):
Yes.

Dr. Steve Saltz (42:58):
And you have to be honest and you have to be attentive. And that's what we strive for.

Monique Ramsey (43:03):
Well, I know you're all those things. I've known you the whole time I've been at La Jolla Cosmetic. And that was, I came in 1991. So it's an honor to have worked with your wife and with you for all these years and see your kids grow up and it's so fun. And have you take care of me over the years. And so it's really a pleasure and I thank you for coming on the podcast.

Dr. Steve Saltz (43:29):
Oh, it was my pleasure. Yeah.

Monique Ramsey (43:30):
Yeah, this was really fun. And for anybody who's listening, if you're a subscriber to the podcast, take a picture, show us, and we'll give you $25 off of $50 or more. And please write a review of the podcast if you like it. And we would love to hear from you. So thanks all for joining us and we'll see you next time.

Speaker 1 (43:54):
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code "PODCAST" to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I-5 San Diego Freeway in the Ximed building on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com or follow the team on Instagram at @ljcsc. The La Jolla Cosmetic Podcast is a production of The Axis, theaxis.io.