Episode 84: Cutting-Edge Anesthesia Protocols to Improve Surgical Outcomes with Travis Osborne

Foreign Dr. Rob Whitfield, the board certified plastic surgeon specializing in explant surgery Breast implant illness is a topic that is not often talked enough about, especially in medical community, but is something that affects many women. In this podcast I'll be discussing the latest research, treatment options and personal stories of women who have undergone explant surgery in an effort to heal breast implant illness. In this podcast, we'll explore the symptoms of breast implant illness and delve into the latest surgical techniques for explantation and the recovery process. Whether you are currently experiencing breast implant illness or are considering explant surgery, this podcast is a valuable resource for anyone looking to take control of their health and wellness. So let's dive in. All right everybody, I have a special guest on the show today. Travis Osborne, msn, crna, is the co founder of Celebrity Anesthesia, an innovative anesthesia management group dedicated to elevating the standards of care in outpatient surgery settings. Operating across more than 40 locations across Texas, Michigan and Illinois, Celebrity Anesthesia partners with surgery centers and offices deliver a patient centered approach to anesthesia care. At Celebrity Anesthesia, the focus is not only providing expert anesthesia services, but also enhancing patient safety, experience and outcomes. The team places a strong emphasis on reducing post operative pain, nausea and anesthesia related complications, striving to ensure a smoother, more comfortable recovery for every patient. By developing and implementing enhanced recovery after surgery anesthesia protocols, celebratory anesthesia has helped set new benchmarks for minimizing postoperative discomfort and maximizing patient satisfaction in the outpatient surgery setting. Well, welcome to the show Travis. This has been a long time coming for everybody listening. Travis has really taken care of patients of mine since 2017 when I started my solo practice and he's done thousands of explant cases for our patients and does great care of the patients. So it's an extreme pleasure and honor to have Travis on today. And Travis, so what does it mean when we say we're going to provide the best eras or some kind of way to diminish postoperative pain in my extremely sensitive patient population? No pressure there on the answer.

First of all, Dr. Whitfield, thank you for having me on the podcast. This is awesome. We've talked a lot about this offline and this is a long time coming. So I'm excited to be on here and be able to share a little bit about our experiences, what we've seen in patients over the years, and just how we have both fine tuned our craft with both your patients and then my collective patients. You know, across all of our coverage locations. So what does it mean to, to deliver that highest level of care to, to your patients and minimize, you know, any as many of the complications and issues that can arise after surgery, from pain to nausea, all of those things. It really, our focus has shifted to this early recovery after surgery or ERAs protocol. And it's, it's work extremely well in your patient population. And one thing we've done as an anesthesia group is we've taken all of these providers from level one trauma centers, heart hospitals, doing big cases at the hospitals on very, very sick patients, and taking these very detail oriented approaches to solving very complex issues that arise in sick patient populations. And then we've brought those techniques into the outpatient surgery world and now we can use those with your patients. And those center around minimizing narcotics, decreasing postoperative nausea and vomiting, decreasing pain through multimodal pathways. And we can talk more about that here in just a few minutes. Basically meaning that we're using a bunch of different medications to stop and block pain at the site and systemically rather than just relying on a bunch of narcotic medications making you sleepy and not feel good and then sending you home afterwards. So we put a huge emphasis on hydration pre and post op. I, we've kind of done every, we've fine tuned every, you know, facet of the surgical experience and that the pre op and post op surgical experience we possibly could.

So I want everybody listening to understand what Travis is talking about. So Travis started out as a cardiac anesthesia provider. So there's nothing more risky or dangerous than doing cardiac anesthesia. And then my background is really in complicated oncology reconstructive cases that would take sometimes multiple different types of surgeons and definitely lengthy or times. So someone in Travis's position would have to keep that patient from an anesthetic viewpoint. You know, great blood pressure, great heart rate, completely sedated feeling, you know, and not having variations in those parameters so that we could perform this oncology reconstruction or when he started it was a heart surgery or a valve replacement or all these different things. So when he talks about complicated, I don't want y' all to like, you need to have a flavor for that. These are the most complicated things that are done and they have a very, very high risk reward, if you want to think of it that way. So all those techniques that we kind of, both Travis and I, we don't take for granted because that's our experience. But sometimes when you, you hear us talk, it seems like we don't talk about those things because that's. Travis is a very humble person and he's a very strong, compassionate, empathetic provider of care. So when I talk to him about something or I have a question, he's very curious about trying to expand that. So we provide the highest level of care. And I really appreciate his curiosity about helping us deliver a higher and higher level of care. So we've had early recovery after surgery protocols in my practice since I started practicing really in 2005. And then as things have progressed and we started focusing on explants and we'll. We'll go directly, you know, into that. It's a very specific type of surgery and it has a very specific patient population. And because of their not underlying medical problems all the time, but they're underlying chronic inflammation, it can be difficult to provide a level of care that he's describing. So now we look at genetics for drug metabolism. So people have problems with P450 or people have problems with different drug metabolites. That helps Travis and his group better deliver care. They already are excellent delivering care anyway. But this, we're always trying to push what we can do to personalize and individualize, you know, the way our patients get cared for. And Travis and I were talking before we started this show about our ERs and you know, how it's changed and evolved. And so, you know, for everybody listening, we use something to help with neuropathic pain, we use something to help with nausea and we use some anti inflammatory and those are started in my practice the night before to reach a certain blood level. And then Travis and his team, and I'm letting him talk about the, the morning of. And we'll kind of just walk you through. Okay. Because that's basically the best way to describe this. And we can do, you know, basic explant care. And you know, I would come in and mark the patient and then I will let Travis take it from there because at that point you're under his care and then in the O or I'm going to operate, but he's going to provide the, you know, color and background of what he does.

Yeah, no, I appreciate that and thank you for all of those things about our practice and about my practice. You know, I just want to elaborate on one thing you said earlier. It's, you know, in the outpatient setting when, when I kind of first started practicing and before we started our group, the emphasis in the outpatient setting wasn't on these advanced techniques that we're using now that was that was basically kept for the hospital. Right. And when we're talking about eras and all of these. So when I was referring to, you know, doing that stuff with heart surgery and you know, level one trauma cases, and when Dr. Whitfield's talking about these like high risk vascular repair cases and, and flaps that he was doing, that was when we were thinking about eras protocol. We have now really taken eras out of just being a hospital centric approach to now being the at the forefront of outpatient anesthesia care and outpatient surgical care. So I mean, huge tip of my hat to Dr. Whitfield. You have continued over, you know, the past seven, eight years, we've known each other to just advance your practice. You do the same thing that I do. And I think that's why you have a ton of success with, with your practice. And your, your result is that you're constantly iterating, you're constantly looking for ways to improve. And it just shows, you know, how much you care about your patients and how good of work you do. So, you know, over the past several years, we have con continued to fine tune this technique, getting these patients loaded on medications like pregabalin, Celebrex, you know, doing things to optimize hydration preoperatively. When they get their day of patients show up to the surgery center, they are seen by our pre op nurses or the pre op nurses at the facility. An IV is started, they're doing a couple of things, paperwork and all that good stuff. Dr. Whitfield shows up, he marks the patient, ask, you know, answers all last minute questions and everything, and then anesthesia steps in. So either me or one of our team members would enter the room, we'll ask you a series of questions. We've reviewed your chart, we reviewed your labs, we've reviewed everything ahead of time. We're asking kind of day of questions, making sure that everything lines up, asking general questions about your health history. Then we develop what we refer to as an anesthetic plan. So kind of in our head we come up with how we're going to navigate that anesthetic, kind of how we're going to tailor our approach to fit your specific needs. Between, you know, the allergies that you may have, your medical comorbidities, or, you know, medical problems that you have, medications that you take for those, and then any issues that you've had with anesthesia in the past, if you've had nausea in the past, you've had trouble controlling pain in the past with surgeries, we Take all of that information collectively, kind of synthesize that, and then we build an anesthetic plan. If we're talking about a. A pretty straightforward explant case, which Dr. Whitfield would argue, there's no straightforward explant case. Just like people would be like, oh, it's a straightforward anesthetic. I was like, there's actually no straightforward anesthetic. But in those explant cases, we will typically do one of two blocks. If we're doing an explant plus, you know, fat grafting in multiple areas of liposuction, we would probably do two types of nerve blocks. And I'll talk about those here in just a second. We've gathered your health history. I've told you about anesthesia. I've told you about general anesthesia, because that's what you'll have throughout the procedure. So general anesthesia, just as a kind of a refresher, means that you will be completely unconscious during the procedure. You will either have an endotracheal tube down into your airway to protect it and maintain your airway throughout the entire procedure, or an lma, which is a laryngeal airway mask that sits right above your vocal cords and keeps your airway open and protected during the procedure as well. You'll be breathing on your own throughout the case, but you will be completely asleep and completely unconscious. The nice thing about both of those is, you know, we're able to control your ventilation, control your airway, and know that it is patent or completely open throughout the procedure. That allows us kind of the highest level of control and over your physiology so that Dr. Whitfield can do what he needs to do, and we can make sure that you are safe and comfortable the entire time. Just, you know, because this question comes up quite a bit, I'm just going to attack it up front. Once you are. Once you roll back to the operating room with one of our either CRNAs or anesthesiologists, our anesthesia provider is with you from the second that you enter the room until the second that you wake up in the recovery room. We are by your side. We're monitoring you beat to beat, breath to breath. We do not leave, and you are fully monitored the entire time. It's not, you know, I always. Some patients ask, you know, well, when I go into the. And you put me to sleep, like, do you go out and you grab coffee? Like, what do you do? I was like, oh, man, I wish. I wish it was like that. It is. It is not like that we are there the entire time.

I'm in too, because there's one thing asked all the time is like, they're going to wake up.

They're not going to wake up during surgery.

No wake ups during surgery.

No wake ups during surgery. No, that doesn't happen. And unfortunately, you know, media, movies, everybody has glamorized this idea of awareness and I'm going to wake up during surgery. Awareness under anesthesia. That's what we call it in anesthesia and in, in health care. That's the, the actual term for it is awareness under anesthesia. That is only a real risk factor when you are too sick and your comorbidities are so high and you have all kinds of medical, underlying medical issues that would inhibit you from receiving the amount of anesthesia that you would need to be put to sleep. That really is only happening in patients that are in life or death situations when they are entering the hospital or entering care. So for people coming for elective surgery, that is not going to happen. I, I want, I want to make you, you know, you guys need to rest assured. Yeah, yeah. You are not that patient. You're. There are about 20 different stop checkpoints that would happen or notify us as the anesthesia provider that you were, that your anesthetic was starting to get light before that would ever, ever, ever take place. So, you know, I get that question all the time as well. My, my answer to that is typically, you are in very good hands. This is not going to happen. I understand that fear and that unknown, but that is very known to us. I can tell immediately what's going on while you're actually asleep.

It is those, like, super anxiety provoking. It is all, you know, issue around anesthesia. And for everybody listening, just so you know, like, I'm a surgeon, been operating forever, I don't know, 26 years. And I've had seven surgeries myself. So when people say like, or want to know like what it's like, I can tell you waking up too quickly, bad for you. So everybody's worried about waking up during surgery and then being under anesthesia for a longer period of time. All right, so we're going to attack this question too, because I get this all the time. Somehow in the whatever information or disinformation world, however we choose to describe this world, it's become concerning, you know, hour over hour over hour that you're under anesthesia, which to a degree I understand, but so I have very specific limits in my practice of what I will do. And Travis knows this. I won't operate over four to five hours outpatient surgery for a lot of reasons, but the main one is I don't feel like those cases that are requiring longer periods of time really should be done in an outpatient setting, having done cancer surgery for a long period of time, or complex reconstruction for a long period of time. Those patients who have very extended periods of surgery and, or blood loss and, or changes physiologically need to be monitored typically overnight or in a more hospital type setting, if you want to think of it like that. So there's a level of care that's different. I'm usually operating from, you know, two to four and a half hours. That's pretty much my average. Travis has known this for many, many years about me. And I'm efficient in the operating room. I don't, I don't take a long period of time. But for his team, and he can speak to this specifically, like if I'm a patient under anesthesia, I want the appropriate level of care during that, you know, one and a half to four and a half hour period because it actually makes it easier for the anesthesia provider to then wake me up when surgery is complete. Absolutely.

I'm trying to think of a good way to kind of describe this in, in layman's terms, but you know, typically longer surgeries that Dr. Whitfield was just referring to, when you're talking about lots of blood loss and an eight hour, nine hour surgery to put rods in somebody's spine, you were talking about much, much bigger systemic inflammatory response. You're talking about much greater bl. You're talking about a huge volume shift with fluid dynamics and that the, the physiology and the pathophysiology related to that get much, much more complex as you start to add layers of blood loss and, and how many things you're doing. What we're doing for your case is, you know, we really, really do not have a whole lot of blood loss at all on these, on these cases. I mean, it's very minimal. So we're not seeing that massive shift in blood volume, hemodilution or anything like that. So we're, we're worrying less about that in these cases. We're also not having that massive accumulation of drugs and narcotics and things that we're doing because a, we'll talk about regional anesthesia and some things that we're doing to reduce the amount of narcotics that you need. But as you start to get more and more medications over longer periods of cases, that just builds up in, inpatient system. Right. So that, that's referred to as a context sensitive halftime for, for medications. And when those medications are given by infusion or more and more of that medication is delivered, obviously that builds up in the patient's system and it takes longer for those to kind of wear off, if you will. So, you know, typically when we're under the six, seven hour range, case wise, we're, we're really not looking at, at those issues. Our group is 100% outpatient based. We do a lot of plastics in our practice. So our providers are very used to. And once you get working with surgeons like we are with Dr. Rob, I mean, we can basically operate without talking to each other. I can sense where you're at every step of the case. I become ingrained with where you're at in the procedure. I can anticipate and I can start to tailor my anesthetic to those needs in the case. And you know, anesthesia is very analogous to flying a plane, right?

Yeah.

You put somebody to sleep or you take off, you get to that cruising altitude, you're just kind of in that cruising altitude of that general layer of anesthesia. Once it's time to start landing the plane or waking the patient up, there's certain checks you have to do, there's certain things you have to think about. Deploy the landing gear, you start kind of dialing back the anesthetic and start landing that plant so you have a timely wake up that's done in a nice stepwise fashion. When you work with somebody long enough, it's like, I already know the flight plan, right? I already know where that plane's going. I already know when to start landing the plane. So that works very well. And it turns, it allows us to, to just operate very efficiently and produce a really good wake up and a really good go to sleep kind of technique for these patients.

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Yeah, absolutely. And just to backtrack for one second about that serratus anterior block, we do place that in, in pre op before we head back to the or. Again, that is another way can kind of preemptively treat pain. Right. So we want to, we want to block those pain pathways before that pain is sensed. We want to block that sensation at the brain, sensing that pain is is ever happening. We also want to block it at the actual site. So when we place that serratus anterior block, it's basically placed right in your axillary line, right underneath your armpit on your side. That's done with some sedation so that you don't feel the needle going in or the needle coming out. It feels actually much less. You'll feel much less than you did when you had your IV started. That block goes in. We place that local anesthetic solution in. It's like a. It's almost like a longer acting version of lidocaine, if you will. We'll put it in there. It bathes the nerves that kind of innervate the entire front part of your chest wall right here where your breast is, that is placed right underneath the serrat muscle. That plane gets covered. So all the nerves that are in there just get bathed in that local anesthetic. And that's how a local anesthetic works. And that'll shut down those nerves firing. So then any insult that happens, like an incision that's made or when Dr. Rob is underneath there and he is actually removing some of the capsule from the chest wall or from the ribbon that is not actually felt and that is not actually taken back to your brain and saying, oh my gosh, that hurts, we're stopping that, that nerve conduction or that impulse conduction. So that's one way that we get ahead of that pain even, even happening. That also helps to decrease what's called wind up phenomenon. When you don't do a pain block or a nerve block, those nerves experience pain. What that does is it can cause some ramp up of cytokines and inflammatory mediators in that kind of, in that ne space. So when those nerves are communicating and they're saying that they're having pain, it's just like an eruption of firing, well, blocking that decreases that eruption of firing of nerve impulses that that pain is happening. And there are good studies to show that decreasing that windup phenomenon actually helps with postoperative pain course and pain scores over the next several weeks to months after the procedure.

So as Travis describes, there's everything is being done before. So instead of reacting to a patient's pain score in the recovery area and the nurses are dealing with that, what we're trying to do from my team's perspective is start everything the night before. So that the neurologic response that he's describing, the inflammatory response he's describing, and what we call post op nausea, vomiting, you know, basically we're preempting all of that. And he and his team are doing this block, they're preempting it further. I'm adding to it in the operating room. So I'm looking at everything and I know where I've been because I'm looking right at it in the operating room and I'm blocking those areas. And then, so when you get to recovery and you, you know, if you're a recovery room nurse listening to this, you should want to work for us because it's a very easy job. Probably celebrity anesthesia, if you looked at them and benchmark them around the country against groups, they probably have this, you would see less narcotic used per group because they don't really, based on what we're describing, need to give people or advise the nurses to have to give patients additional short or long acting narcotic in a, in a way that is, I would say, traditional. And you know, that's, I want my patients to be up, ambulatory. You know, obviously this is an ambulatory surgery and outpatient surgery, but the point being I have people flying in from all over the United States and out of Europe and Asia now and they want to, you know, get up and their caregiver meet them and be able to leave. And I want them obviously coherent. Many times I'll have, I'll be there at the surgery center and I can have some time to speak with them. But to speak with someone after anesthesia, the joke has always been, you're never going to remember what I tell you. But actually in my patients, actually can remember pretty much everything you tell them because they're actually awake.

Yeah. And they're not blunted by this massive dose of narcotic medication because we've used other non opioid medications to accomplish a very similar outcome. Right. But without hopefully that laundry list of side effects like the brain fog, the constipation, that feeling of lethargy. You know, narcotics are not the, the cleanest drug profile from a side effect standpoint as, as other drugs that we have in, in our arsenal. And you know, when we're doing that ERAS protocol, we're hitting pain receptors in all different areas of the body outside of just relying on that typical opioid spectrum.

Right. And so in summary, I'll let you know, Travis have last word. I've chosen to work with him for this period of time because not only is he great at what he does, he's very, very interested in making the experience better. So if you can really level up someone's experience and decrease their anxiety, provide this really, you know, holistic environment for them to get cared for. And really, you know, it's a pretty difficult emotional setting that we take care of patients in each and every day. I find that his group is really performed above and beyond expectation, and that's why I continue to have him as my anesthesia care provider for both myself and family. So anybody listening, you can hit us in the comments, and I'll have Travis give his last words, and then we'll wrap it up.

Yeah, no, I. I really appreciate that. And again, hats off to you because you run your practice in the exact same way. It's. It's constant iteration. It's constant improvement. It's looking for how can we make this very stressful and difficult time as good as possible for our patients. And there's. There's an optimal experience, I think, that we all strive for. And, you know, I'll kind of leave it with this. My business partner's name is Alex. He lives up in Chicago, and he. He runs our day to day in the Midwest. I run everything down here in. In Texas. And, you know, we both have this philosophy that outpatient care should be run at the same level and under the same microscope as inpatient. Big hospital cases are running, and we kind of. Our litmus test across the board is if we would not do the same thing for our mothers, our family, our wives, our friends, then it has no place in our practice. So if there is an optimal anesthetic, and I would have. If my. If my wife had to have surgery tomorrow, and I would do it a certain way, I want that done for every one of our patients, because that is, in my mind, the optimal anesthetic. So, you know, everything we've talked about here today, everything that you and I have have done and worked on make things better for patients are just that. They're the exact same anesthetic that I would do for my wife, I would do for anyone that I've taken care of in your family. So it truly is about making that. That patient experience is absolutely good as possible.

All right, you heard it from Travis, and he does work extremely hard to deliver the best experience. I want to thank him for being on my show. But I want to make sure you all comment on this, because this is literally about the anesthesia is something I get asked about every day, multiple times a day, and obviously, I'm not the expert. That's why I had Travis on, because he is the expert, and I worked with him for many, many years on this issue and I feel like, you know, together we've continued to push each other to make things better. So please comment and if I cannot answer it, I will get ahold of Travis and he will answer it for us. So until next time, thank you, Travis.

That sounds great, man. Yeah. Thank you. Please ask and we'll answer.

Thanks for joining me today. I hope you found the information and stories shared on this podcast helpful and informative. Remember, taking control of your health and wellness is key to recovery from breast implant illness. If you're looking for additional resources and support, be sure to visit our online store, Dr. Rob's Solutions. At DrRobSolutions My Shopify, you'll find a wide range of wellness products and supplements to support your journey to recovery. From specially formulated detox supplements to personalized skincare products, we have everything you need to aid your recovery. Visit Dr. Rob's Solutions today at drobs solutions.myshopify.com thank you for listening and we'll be back with another episode soon. Remember, you're not alone in this journey and together we can overcome breast implant illness. Take care.