Anesthesia, with special guest Dr. Jon Bauman

Paul: [00:00:00] Hey, Howard. We're we're we're back again. And this time we have a guest, right?

Howard: [00:00:04] We have a really special  guest we have a doc I've known for a long time now.

Jon: [00:00:10] My name is John Bauman. I'm an anesthesiologist in, Westchester, New York.

Paul: [00:00:15] Having a surgeon and an anesthesiologist on the same podcast discussion was a little like that scene in Max Max, Thunderdome, where two men enter, one man leaves, kind of thing. It doesn't, as I recall, it didn't turn out badly for someone. I just don't remember who it was.

Almost all non trivial forms of surgery, maybe with the exception of hangnail removal and a few other things are done with some form of anesthesia, right?

Jon: [00:00:39] That's right. Most procedures will have some form of anesthesia involved. Be it, you know, local, topical regional they're there various forums that you can employ to keep a patient comfortable during, during procedures.

Paul: [00:00:54] That's a relatively recent development, right?

Jon: [00:00:57] I think that's fair to say, even in, you know, the period of time that I've been practicing, which is approaching about 20 years. we've seen the increase in our anesthetizing locations and for cases that when I first started, we didn't really give anesthesia for, you know, one of the, one of the biggest areas where.

We've seen that as with, you know, GI physicians, endoscopy's colonoscopies and upper endoscopy. When I first started and anesthesiologists would be involved. Once in a while. but now, especially in this area, we're involved in almost every, GI procedure, you know, colonoscopy or upper endoscopy. And it adds a level of, of not only comfort to the patient, but I think a level of safety and it increases the efficiency.

Paul: [00:01:48] It's become safer, right? That way you feel more comfortable and there's more modes of anesthesia we can deliver.  Rather than putting someone under general or nothing, there's lots of different tools in the toolkit.

Jon: [00:02:01] There definitely are.  if you look back, the real reason that anesthesia has become so much safer over the years is because the training of anesthesiologists has become much more rigorous. so the people who are practicing, you know, are, are. Well trained and able to utilize the new technology to make sure that patients are safe in all different settings. You know, it used to just be a few, if you're going to get anesthesia is in a hospital. we, we deliver anesthesia and, you know, in offices and in GI suites and ambulatory surgery centers and all safely,

Paul: [00:02:35] One of my favorite books, and I babble about it all the time, but is the butchering art, Lindsey, FizHarris's book about the early days of surgery. We had no anesthesia speed was at a premium and otherwise people tended to have this bad habit of dying of shock before you were finished with them. And so you had to just, you have to whack off that limb in 30 seconds. And it just, it was someone who could stand there and help you do whatever you were doing to keep the patient from running away.

Jon: [00:02:58] Right. They basically would pour, you know, ether on a rag and the surgeon would say, hold this over the patient's face.

Paul: [00:03:03] Out of the early, what we would've called, anesthetic agents had any of those survived. I was thinking about your nitrous oxide, maybe as an example of an early one that we still use. Are there any others?

Jon: [00:03:13] Yeah. You know, nitrous is a very good example. No, Mo most of the others we don't use anymore. I, when I was training, we still used halothane.  a lot of the original agents have been replaced by, newer medications that, that often have a better safety profile and a much better side effect profile.

Paul: [00:03:33] let's get to the thing I've been dodging, which is what is is anesthesia anyways? And, in the case of general, am I actually asleep? People we use these words loosely, and maybe they aren't so well-defined.

Jon: [00:03:45] so anesthesia,  if you break the word down into its root, it's from a Greek root and, you know, a or, or an is without, and, fusion is a sensation or pain. So it's basically without, without sensation, . Is the way to think about anesthetics or anesthesia, what anesthesia is.

And, you know, anesthesia is a very broad term because you can, you can achieve a lack of sensation or pain through Many different means. You can have a local anesthetic. You can, you can have a general anesthetic, you can have a neuraxial anesthetics. So there are all these different types of, or, or ways to provide, anesthesia. I'm trying to keep it very simple is to induce a state. of unconsciousness so that you don't respond to a surgical stimulus . And a lot of people think if you're going to go under a general anesthetic, you have to be put on a ventilator and you need to, you know, inhale gas and you need a breathing tube, but in actuality, you don't.

Howard: [00:04:48] It's not sleep per se. Right. If we do an EEG clinically asleep, where are you? Where's your brain?

Jon: [00:04:58] so right. We don't, we don't actually know. It's, it's very funny, especially with the inhaled Asians. we don't know how those drugs actually work are theories behind them and it has to do with the lipid membranes and, So we don't, we don't actually know where you are, but you're right.  It's not sleep, it's not restorative. These drugs, you don't, you don't wake up from a general anesthetic or a propofol infusion, and your body has kind of undergone the restorative functions of sleep. So we say you're asleep, but you know, if you were asleep and I took a scalpel and cut your knee to, you know, do a total joint, you would wake up from that, from that sleep. So this is much different.

Paul: [00:05:37] So we've mentioned it now a couple of times, but we talk about general anesthesia as if it's monolithic, but it's not right. There's induction agents. There's things that get you into this state. That's keep you there. So why don't you talk a little bit about the, the various elements of it

Jon: [00:05:52] Yeah. So, so we don't have, there's not one drug that will give us, all of the properties that we need for a, for a general anesthetic. So you want, you know, before somebody goes into the operating room, you want them to be relaxed.

You don't want them to remember the experience. so to achieve that, we typically use a class of drugs called benzodiazepines, which are the most common one we use is a drug called Modafinil and the trade name is verses and the properties that they, it relaxes you and causes amnesia. So those are two good properties.

We also during surgery, we don't want you to have pain. So some of our there in there are a lot of you, I guess you're kind of getting the sense that this is more of a, a cocktail of medications that we give to get all the, all the properties. We want to have a general anesthetic. So for pain, we often use narcotics.

you want to induce the general anesthetic and, you know, nowadays the, the typical, and there are many induction agents, but yeah, the one we use probably 90% of the times the medication called propofol. Propofol is probably one of the biggest, if not the biggest breakthroughs in anesthesia in the last it was developed in 1989. that medication, is very nice. It's, it's a very quick onset. it induces a general anesthetic.

So, and that'll, that'll get us into the, you know, next phase of a general anesthetic, which is muscle relaxation. So we have, medication that will do that. The problem with that medication is you can't give that alone because it does nothing to, to affect your mental capacity. If I were to give a drug, let's say called rock uranium, which is a common paralytic or muscle relaxant that we use., and not give you any other medication, you would be wide awake. You'd be completely aware of everything that was going on around you.

Paul: [00:07:48] No, that's bad.

Jon: [00:07:50] Right. So, so, and typically to maintain the general anesthetic so that during, you know, two, four hour operation, we'll use one of the inhaled. Agents, and that's, that's delivered through the breathing tube, into your lungs, and that will maintain, anesthesia for, for basically as long as, as you keep that medication on. and then when you want the general anesthetic to, to turn off, you let the patient, breathe typically 100% oxygen and they blow off that inhaled agent. And that's how they wake up.

Paul: [00:08:24] And then maybe the most important question: what the hell do anesthesiologists do while I'm out? This is the pressing question I have.

Jon: [00:08:31] basically what we do, while the surgery is going on, it's really a dance with the surgeon, to be honest with you. If you're really, you know, practicing, anesthesia correctly, it's, you're having a, conversation whether or not it's spoken, but you're having kind of a, a dance with the surgeon. So you're paying attention to what the surgeons doing, throughout the surgery. Not only are you monitoring the patient's vital signs, which is constant.

but you're looking, you know, you may have a, an operation where all of a sudden, The surgeon hits a vessel and there's a lot of blood loss very quickly. Well, if you're not paying attention to what that surgeon is doing, what's going on with the patient's vital signs. you can have a very bad outcome from that.

Paul: [00:09:12] let's say the alarms start going off in the O R and it's something to do with the, with vital signs. What typically, what does the surgeons just say? Yeah, not my table. I mean, this is an anesthesiologist issue that dude, you should be watching those vital signs closer.

Jon: [00:09:26] typically what happens is when the alarm start ringing and something's going on, the first thing you'll see is the surgeon cower in the corner.

No. So, so

a lot of times that's when, that's, that's when the conversation, you know, really heats up. Right. So you want to figure out very quickly. Why, why that'll alarm go off? Or why did the patient's blood pressure suddenly drop? Why did the heart rate suddenly increase? and there you're, you're now you're troubleshooting.

Right. you'll, you'll ask the surgeon. Hey, Howard. You know, did you just get into bleeding? you know, maybe, maybe it's a case where. there's an additional stimulus that you weren't ready for. Maybe the surgeon just injected a local anesthetic with epinephrine in it. there are a lot of different things that can, that can cause a change in vital signs.

it can either be due to your anesthetic. It could be due to something that's happening with the patient or can be due to something that, that, is going on surgically. so that's when. Yeah. So that's when you know, you'll see it and Anissa, we're all a little bit different. Some of us get quiet, some of us get very outspoken, but really what's going on when you see those changes is we're troubleshooting and we're looking, you know, we're kind of going down a list in our head of most common things that can cause that and things that are reversible so that we can treat the patient.

Howard: [00:10:52] from my perspective, you know, if, if it's worth anything, I, I, I don't cower in a corner. I attended the head of the table and help, but it's also a very, yes, it's also a very individual response on anesthesiologist's part, as well as the surgeons. You know, you really don't know how. Your anesthesiologist. Well, until you see them in one of those moments and those moments are don't happen frequently. some may run out the door and yell for help. Some are gonna to just quietly manage it, you know, and communicate with you. just like every other workforce member. Right. There's good. And there's bad. And the same thing with surgeons, some will cower, some will run, some will get angry, and some will step up and help.

Paul: [00:11:41] I was looking at the numbers in terms of general anesthetic. It's safer than most things we do probably get safer than getting on freeways, something like seven and a million general anesthetic cases worldwide, die, which is a remarkably low number.

Jon: [00:11:53] patients come to the holding area to the operating room and that they're all very anxious and the majority of them are anxious because anesthesia is this great unknown. And they have a relationship with their surgeon. They've talked about the surgery. They, they know what to expect on that front, but they've never met me before. They've only heard horror stories. and they're, they're worried. So one of the things I use is, is exactly what you just said, you know, say to them, you know, look, you had more risk coming to the hospital than you do for me. And, you know, putting you under a general anesthetic and you didn't think twice about getting in your car and coming here. this is actually safer than you driving to the hospital. and I think that that often puts people at ease. you know, it's, it's meant to, and it's, and it's true.

one of the challenges with anesthesia is we, we only have, you know, five or 10 minutes to make a patient, you know, comfortable, with us. Caring for them and taking their lives in our hands. again, versus a, you know, the surgeon who's had time to sit down in the office, explain things where, where just, you know, some random person saying, Hey, guess what I'm gonna do, you know, I'm gonna basically put you in a coma for two hours and then wake you up and send you home. Part of the, I guess art of anesthesia is to make that person comfortable and understand in a very short period of time, what it is you're going to do.

Paul: [00:13:16] why is that important? Why should I care? What impact does that have? On surgical outcomes, the depth of, of, of incentivization that I'm in, in general, what, is there any sort of measurable difference it makes in the case?

Jon: [00:13:31] No. So I don't, I know 'em years ago and I wish I could quote you the study. But yeah, they haven't been able to show a correlation between, you know, you know, comfort level going into a surgery and outcome,

Paul: [00:13:42] Like I saw, I w I remember when my kids had their wisdom, teeth removed, one of them was really nervous and upset going in. And when he came out, the other end of the, of the, of the process out of the general anesthetic, he was, he cried for about 20 minutes, which was  baffling to me. And then the surgeon said to me, and I have no idea if this is true, but he said, often people who are feeling really emotional, going into a procedure that is mirrored on the other side as they come out .

Jon: [00:14:09] We, you know, we see that, but again, there's nothing, there's no data to support that it's anecdotal. but I absolutely see that. And especially in kids often will say, you know, a kid is kinda, we expect them to wake up the same way they went to sleep.

Howard: [00:14:20] so you folks do, sometimes in the morning cancel some of our cases.

Jon: [00:14:26] So the way you, in a risk stratify, a surgical procedure and the anesthetic, has to do with the type of procedure that the patient is going to have and the, medical conditions that that patient has. for example, if you're coming in for a very low risk operation, so, so you're going to have cataract surgery, which is a very low risk operation. but you are a high risk patient. You have cardiac disease and you had stents placed and you had, you know, you have, emphysema, whatever it is because that, that surgery is so low risk.

the only way you're really going to cancel that operation is if the patient is an active disease on the day of that operation. Right? So if they come in and they say, Hey, you know what? I woke up this morning, I'm really having a hard time breathing, or I have substernal chest pressure or something like that,

take that now, if you take kinda you flip it and you take a very high risk operation, like a, you know, an open, aortic aneurysm repair. And you have a patient who's otherwise relatively healthy. I'm coming in for this, this, you know, very little age or high risk operation. And they, you know, say that, that they've had a history of hypertension and in the past have had, you know, that's pressure with walking upstairs, but that kind of got better and they don't think it's a big deal.

And they haven't seen their cardiologist before the operation. You're probably going to cancel that operation and say, you know what, you need to have that pressure in your chest checked out. It may be nothing, but before this operation, you need to go do it. So we're not gonna, you know, you need to see your cardiologist or we're not going to, we're not going to go forward with the operation today.

Howard: [00:16:20] No, that's what I was driving at. there are a lot of comorbidities that we, as surgeons need to look out for, and look into before we send the patient to the operating room. And if we don't, then an anesthesiologist is going to speak up and say, we really shouldn't go forward. But that, that relationship can go arise sometimes, since some surgeons may not take that very well.

Jon: [00:16:48] there was a kind of an old school of thought, and I'm generalizing. but that the role of an anesthesiologist was to cancel a case. So if you didn't have all of the labs ordered and an EKG and a chest X Ray, and, you know, the slew of testing, the anesthesiologist was going to cancel the case.

So you better check off all the boxes and make sure even, you know, you're, you're your healthy 25 year old who runs marathons and is coming in for a knee arthroscopy, you know, has gone through. Through, you know, chest X, rays EKG is, you know, that's been seen by a cardiologist because you're worried that that one of us will cancel the case.

That's changing a lot now. but there is still a little bit in, and a lot depends on where you practice, but there is still a little bit of, of, Head budding, I guess, between surgeons and anesthesiologists. I think it's probably less than it used to be

Paul: [00:17:39] is there a liability factor there that anesthesiologists are concerned about or is that even part of the picture?

Jon: [00:17:47] Yeah. So, it. Yes, we think about that. because when you're in the operating room and there's a, there's a negative outcome, there are really only two physicians who are to blame for that, the surgeon and the anesthesiologist.

We're looking to make sure that the patient is going to have the safest. Experienced in the operating room that we can offer. And in order to do that, it's not that the patient can't have hypertension or can't be diabetic or can't have emphysema. We just want to know that those, those medical issues are all optimized, that they're on the correct medications and they're in the best shape that they're going to be in before coming to the operating room. We we'd never want to see a patient get hurt because of something we did.

Paul: [00:18:29] on the topic of canceling surgeries and comorbidities, and what have you has, COVID changed that at all for you.

Jon: [00:18:38] Oh, sure.  we saw firsthand the outcomes of, of patients who are critically ill because of COVID and what happens when you put them on, on ventilators. and they, they don't do well. So I think it's heightened our, our, kind of, sense of risk in the operating room of, of putting somebody who we think may be COVID positive or exposed, or have any symptoms from it on a, on a ventilator, in the operating room, we're doing a procedure where we may have to ventilate them or sedate them or affect their breathing because I think we all know that, that they can do very poorly, very quickly.

Paul: [00:19:17] Does that also factor in, in terms of aerosol production with an intubation?

Jon: [00:19:21] So basically every patient who comes to the operating room nowadays has to have a negative COVID test unless it's a, it's an emergent or, or very urgent operation. The problem is, as we all know, these, these tests are not a hundred percent. and. Being, you know, anesthesiologists and we are in direct contact with patients airways. So you know, their, their mouth and their nose and their breathing, and where sometimes inches away our, I guess, threshold for right. The risk has changed. Because there's an increased risk to a patient, but there's also increased risk to the people, everybody in the room, including, and probably, you know, especially the anesthesiologist who was at the head of the bed, managing that patient's airway.

Paul: [00:20:09] Yeah. You're facing a deadly orifice. .

Jon: [00:20:11] Exactly. That's it. That's a great way to put it.

Paul: [00:20:16] I've always gotten the sense that surgeons like to feel like they're leading the parade hour. Plug your ears here, and that they want to see. And this has been true since the beginnings, I think of anesthesiology that they want to see themselves as see themselves in charge and everybody else is doing their thing and jumps when they say jump and what have you. I, and I'm sure with the best surgeons, that's not an issue, but my sense is it's, it can be a very complicated dynamic between surgeons and anesthesiologists in general. Is that a fair characterization?

Jon: [00:20:46] Yes. but I do think, I think that the setting. In which you practice, kind of dictates that relationship a little bit. And what I mean by that is, you know, I came, I trained at a, at a big academic institution and there are a ton of residents and there are a ton of fellows.

and you, you don't ever really form that relationship, as an anesthesiologist with the surgeon that you do in a small community hospital, in a private practice. so. So, so there is some of that kind of, I don't even know if you want to call it a hierarchy in the, in the, or, but you do see that dynamic every once in a while.

My experience in private practice is it's, it's seen less in that environment because you end up spending, you know, I know, I know most of the surgeons better than I know. The people in my department, because I spent so much time in a room with them

Paul: [00:21:42] okay.

Jon: [00:21:43] and the, the, you know, dynamic typically, look, if you want to. Again, I think in the operating room, the way I see the relationship between the surgeon and the anesthesiologist is it's a partnership. You have the same goals in mind.

 I try to get along with every surgeon that I work with. Because again, you need an open, open line of communication for that time, when something goes wrong. If you don't get along, speak to that surgeon, if there's going to be, you know, chest beating, and I know what I'm doing, and you don't know then that patient's going to get harmed, but if you have a relationship and Howard, I'll use us as an example where if there's any question or there's a concern, either one of us can look over that blue screen and ask the other is everything okay?

Howard: [00:22:26] and if we're not communicating well, then that technique may not be optimized for the patient.

Paul: [00:22:35] What are some of the most common questions you get, you know, I think of the ones that I, you hear, you know, what if I don't wake up? What if I don't fall asleep? What if I wake up in the middle?

Well, my, my question, same to Howard earlier. My question was, I'm convinced that anesthesiologists have lied to me for years because when he would get wheeled into the O R and I'm on the gurney. And Howard is going to laugh at me here. Cause I told him this story already, convinced because it always is the same drill, you know, the bright lights, the music's coming on, someone's talking about Spotify or whatever. And then, you've got a line in your arm and something coming down, he said, this is just a bit of saline, and then whammo I'm out. I've always been convinced that they lied to me about what's actually in the line, the IV line, because I'm trying to put me at ease and it actually is the drug. They just didn't want to tell me.

Jon: [00:23:20] It's possible that they are doing it. I try not to lie to my patients, but I'm sure there are anesthesiologists that, that, that do that.

Paul: [00:23:28] that's all the ones I had in terms of FAQ. But what about real people and not crazy ones like me? What are some of the questions you get in terms of the most common ? That the, what if I don't wake up? What if I do wake up and I'm, I'm frozen in a paralytic and can't tell you how horrible this is? Are these the kinds of stuff you get asked?

Jon: [00:23:45] yeah, the biggest one is, you know, what, if I wake up in the middle where I don't want to wake up in the middle or make sure I don't wake up in the middle, you know, that that's probably the most common one. .

Paul: [00:23:57] As an actual

Jon: [00:23:58] Oh, my God, it it's, it's incredibly uncommon, to have happened, but one of the things, and this is why I think it's so important for the anesthesiologist to communicate to the patient well beforehand is we do a lot of operations now. under what, you know, we will call sedation. And during that sedation. So if, if you're gonna, you know, do what would people think of as a general anesthetic? So you put them on a ventilator and the breathing tube, you can basically guarantee that that, that patient is not going to remember anything.

Throughout the surgery, when you're doing cases where the going to inject some local anesthesia, and you're just going to, you know, sedate the patient by whatever means, you know, the anesthesiologist, whatever drugs they decide to use for that. During that sedation, there is a chance that the patient is going to have some recall or recollection of what's going on in the, or. So we know that they're comfortable in the operating room. But there are times throughout that procedure where the patient may have some awareness or may kind of open their eyes.

And if you let the patient know beforehand that that's a possibility that yes, you may, you may, at times in the, or have some, some memory you may join in on the conversation. You may, you may talk to us, but you'll, you'll always be safe. You'll never have pain.

And if something bothers you, you'll be able to tell us I've never had a patient complain about that or, or, or have concern about that. So I think the communication's incredibly important.

Paul: [00:25:30] so the waking up one is the, in the middle of the procedure and just like a horror movie staring there. Blank-eyed: can't do anything.

Jon: [00:25:37] And, and as long as you put them at ease and say that that is not going to happen to you, they're, you know, they understand that they're in good hands. I hope. But yeah, that's what their fear is, is that, you know, they see in that horror movie, they're paralyzed and the surgeon is, you know, removing their gallbladder and they can't do anything about it.

And then, and then, you know, a lot of people have a fear that they won't wake up.

Paul: [00:25:57] which is, should low on their list of concerns, obviously, because once you put them on oxygen, they don't have too much choice in the matter.

Jon: [00:26:04] that's right. That's exactly right.

Paul: [00:26:06] Craziest question you get asked by people. 

Jon: [00:26:08] I very often get asked, how long I've been doing this for.

Paul: [00:26:12] Oh,

Jon: [00:26:13] So that, that's a very, very common question. yeah, and, and it's always the same response, you know, this is my second day. I just can't help myself,

Paul: [00:26:25] so let's, let's jump to futures then. if you imagine yourself, 10 years from now, and you're looking back, all the things we do today, if you had to look, what would you then think was barbaric or I can't believe we were still doing that or that's changed so radically since then. What sorts of things would you imagine 10 years from now have changed really radically or if any.

Jon: [00:26:47] Yeah. So, when they first started to try to automate anesthesia, I think we all got a little bit nervous. but realize at least now the technology isn't there to, to achieve that. so that that's kind of fallen off the radar a little bit of most anesthesiologists for there to be an automated system that can actually work.

because I think there's, there's too much of the human interaction that you need. You know, especially with, with any automated system, God forbid the, the system is wrong and maybe gives a little bit too much in it.  I'm sure there are going to be some automated systems that, you know, make us a little bit more hands free. I can definitely see that, that happening, but to completely, you know, replace or replace, you know, 90% of what we do, I'm not sure about,

there's one thing that I've never been able to prove there have been studies to suggest it we've over the, over the course of my career.

We've started to utilize regional anesthesia much more. So nerve blocks were very similar, you know, principle to when you go to the dentist and they give you an injection in the back of your mouth and your whole mouth gets numb. You know, I can give, I can give you an injection in the nerves, in your neck that go down to your arm and I can make your entire arm numb.

we, we use those a lot now and we avoid, general anesthetics by using these, these nerve blocks. one of the things at one point everybody was trying to show was that regional anesthesia was going to have benefits for certain types of cancer surgeries. the, the data wasn't there to really show that it reduced either metastasis or recurrence or anything like that, even though in the back of our minds, we think it may. so I'd be, yeah. I'm curious to see if some of our techniques, you know, in 10 years are shown to, to decrease risk of, of metastasis or recurrence or even improve wound healing or recovery.

Paul: [00:28:49] if you see someone going around now, a resident on a surgical rotation, has your advice to them changed over the last 10 years?  what's the advice you're giving to someone now on an a rotation who ends up in this thinking about anesthesiology?

Jon: [00:29:01] So, The, the practice of anesthesia. So to me, it's something, if you, if you really enjoy, critical care, if you enjoy being in the operating room, if you like, doing procedures, but you, you don't necessarily want to have your own patient population. and, I guess to take that a step further, one of the things that, especially new grads, who are looking at anesthesia, like is that you can have a little bit more of kind of a shift work mentality.

So if, if you have other priorities in life, you have your evenings and you have your weekends. you can also join a practice where you have more of a hospital based where you're going to take call. You're going to do bigger cases. so one of the nice things with anesthesia is you have a variety of, of options when it comes to, you know, work environment, but you also have a variety of options when it comes to patient population.

and if you, if you're somebody who really likes the practice of medicine, but doesn't want to have an office and prescribe medications and, you know, treat hypertension over over six months or years, you can, you can treat all of those illnesses in the operating room and get the results you want in a matter of minutes.

I think it's a fantastic field. you know, it allows you to deal with a ton of different, types of cases and types of people and, and personalities. And you get to be in the, or, and you get to do procedures and you get to help patients. You know, you really get to help people.

Howard: [00:30:31] I, you know, I've seen, yeah. You know, I just want to echo that really briefly, you know, I've seen tremendous changes in my anesthesia colleagues across the decades. and they're, they're far more involved in the management of the patients in terms of managing their pain and their comorbidities, and they are responsible for a lot of the success that we have on the backend, in terms of the patient, getting home and being comfortable and not being nauseous and vomiting and being sick. It used to be a very big problem. and certainly working, you know, with John, my patients would compliment him more often than they would compliment me when I saw them in the office.

Paul: [00:31:15] Oh, that's very good.

Jon: [00:31:17] I'm talking about kind of the depth of breadth of, you know, what anesthesiologists do nowadays is, you know, I always think of anesthesia is  we're perioperative consultants. So we're the, we're the consultant for everything around the surgery, preoperatively, interoperatively, and postoperatively. And it's just kind of a nice way. I think when I'm describing what it is, we do: think of an anesthesiologist we're the, we're the perioperative consultants.

Paul: [00:31:44] Well, thanks again. I appreciate you doing

Jon: [00:31:46] Yeah.

Paul: [00:31:47] Thanks Howard. For organizing it.

Howard: [00:31:48] My pleasure.