The Truth about Anesthesia

Welcome everybody. We're going to start here in a little bit. We're going to allow everybody to get in. We're live on Instagram, TikTok, Facebook, Substack, YouTube. We're live streaming in Dr. Rob's Circle. So we're going to let everybody come in. We're going to make sure everything's working in the circle. So anybody live in the circle, just hit, hit me on chat so I know that the circle is running. And let me see. We will start on time tonight. I have a special guest with us. All right, everybody. All right, everybody's hopping on. Make sure you get on. All right, we're sharing across our private group on Facebook as well. All right, awesome. All right. Let everybody filter in. Let everybody know that we're sounding good. You can hear us just fine. Hi Misty. Hi Jess. Hi Rima. And who do we have over here? Just have a couple people here. And a couple people here. All right, all right. TikTok's going well. Hi Sue. Hi Teresa. Who else do we have? Hi Natalia, Isabella. Michelle. Hi, Serena. Sorry, we can't co-host, uh, we already have a program rolling. We're going to get started here in a few minutes. We're letting everybody filter in. Just going to double-check and make sure everything's streaming properly on circle. So gonna check something really quickly, and then we'll get going with our talk. Now we're gonna dig deep. We have a great guest tonight, super fortunate. Gotta be respectful of his time, so we're going to start here in just a minute, let everybody filter in. And then I'm going to put this back up. Oops, there we go. All right. Ah, Lana made it. Perfect. Lana was having trouble earlier, but she's in the room. Perfect. All right. Almost. It's 7:01. Just a couple more minutes. We'll get everybody in the room. Get everybody online. We're going to set it up as a 10-minute talk. We'll start the Q&A out here with our special guest. And then we'll go in, uh, drrobcircle.com for live Q&A, ask us anything. And we'll carry that on as long as y'all have questions. I'm going to stay on and answer them and, um, go from there. All right, how many people do we got on here? Hi, Danielle. Hey Jen, I will say it is hard to see everything over here. Letty's on, on Facebook, Substack. I have one person who's this. Alright, let's get going with the talk and then we'll dig in. Tonight we're going to discuss the truth about anesthesia. It's not often discussed, but it's paramount to my success in the operating room. So let's talk about something that really nobody discusses before surgery, except if you, you're kind of dealing with us. And most patients are frankly terrified about it. They don't really understand it sometimes, but it's anesthesia. The, the thing that most people, when they think about anesthesia, they're, they're obviously concerned about going to sleep and waking up. And they've seen some of the documentaries and things that have highlighted people being awake during surgery. That's never happened to me in my 30 years of surgery. So it creates a real mental block for them. So tonight I want to pull back the curtain on how we actually think about anesthesia in our practice. Because it is fundamentally different from what you'll find almost anywhere else. Once you understand it, you'll understand why our patients wake up feeling so different from what they expected. And here's the reality: in most operating rooms, anesthesia can be really a one-size-fits-all. The anesthesia provider's primary job is, of course, very important, and it's to safely get you off to sleep and wake you up. What often doesn't get accounted for is this: not all patients respond to anesthesia the same way. Women dealing with breast implant illness have often been managing a dysregulated nervous system, heightened immune system activation, and systemic inflammation for years. Their bodies are already under extreme physiologic stress. Giving that patient the same protocol as a healthy 25-year-old with no underlying issues is not precise medicine. And the consequences are real. Patients wake up in more pain than expected, significant nausea, they may feel unwell for weeks. We decided we weren't going to do it that way. So we've adopted several principles in our practice that are different. It starts before you ever enter the operating room. We work extremely closely with our anesthesia team, and preoperatively everybody runs my SHARP method. So preoperatively we prepare our patients with this protocol to prime the body for the least, you know, anesthetic, if you want to think of it difficult experience as possible. We want to prepare you and optimize you ahead of time. So I guess the, the way to think about it, surgery is no different than, you know, running a marathon. You don't go run a marathon without preparation. So for the SHARP method, we want to identify each individual's opportunities really for sensitivities and prepare them for surgery. Some patients are really sensitive to anesthesia, So we try to use a different approach with them. We'll talk about that with our provider. And we want to identify, identify those issues before we go back to the operating room. And then one of the things we always do is an ERAS protocol. We do it a little bit differently in terms of when we start our ERAS. We start our ERAS the night before, and I've always felt compelled to do it a little bit earlier so that we prepare patients. We want to help them certainly control things like nerve pain, which can be very difficult after surgery to deal with. We don't want patients to have problems with nausea at all if we can avoid it, because that's one of the fears is throwing up or being sick to your stomach for even, even not just the recovery room, but throughout the first day after surgery and into the next. And then inflammation, obviously, you know, if you know me, I'm the biggest causer of cortisol in the world. So every day I operate on someone, I raise their cortisol levels, I cause stress in their system, and that increases their inflammatory response. And although that's appropriate for surgery, we want to control that to the best of our ability so that it doesn't overwhelm the patient from the outset. Things that we try to avoid in our protocols are long-acting narcotics. Narcotics delay recovery, cloud cognition, affect gut function, and do not support the healing state that we're trying to create. So we minimize them intentionally and certainly work diligently with our anesthesia providers to execute that. For patients who are really anesthesia sensitive, and many of our explant patients are, we don't rely on just general anesthesia alone. We incorporate regional anesthetic techniques. Our providers use ultrasound guided nerve blocks when appropriate, and they're great at them. It's precision work to them. Instead of flooding the entire system with larger and larger doses of anesthesia or narcotics, they can be very precise and specific with local anesthesia delivery. The result is it lowers the overall anesthetic requirement. It's less stress on an already stressed nervous system. And the patient's waking up, they feel better when they wake up. They're not in as sharp or difficult situations with pain control. And most of my explant patients really enjoy having had a nerve block. They wake up in an entirely different state from the time that they remember back when they had an augmentation, which probably was very difficult to them. So that day is very simple for our patients. You know, we want to provide the best possible experience for them. On the day of surgery, our goal is simple. Patients want to go home feeling comfortable and safe after this procedure. Everything for us is an outpatient procedure, and everything we describe is designed, you know, like I said, to make it safe and comfortable so they can go home. We want patients to be able to move around freely as soon as they're able to the day of surgery. I don't need anybody overdoing it or pushing through pain, but just, you don't need to go home and lie still for hours after surgery with us. The lymphatic system is no exception. We really leverage movement, and then we have special devices in the office, Flopessor from New Zealand. So the next day everybody comes to our office anyway for lymphatic massage, and we've designated this as a big part of our post-operative sequence, as well as use of the Human Regenerator, which lowers sympathetic activation. We use a hyperbaric chamber in our office. We feel like delivering, obviously, oxygen right after, uh, a wound from surgery is a great way to not only prevent infection, but enhance wound healing. We use NanoVie as well. And we have a big 6-foot-tall red light. So we have all the things in the office to really help enhance and speed the process along after surgery. And once again, everybody comes to the office the day after surgery, not the week after surgery or not 2 weeks after surgery. They are here the day after surgery. So those modalities, we feel, separate us further from other practices by enhancing recovery always. We're always trying to figure out ways to speed recovery for the patient because they want to return to their activities of daily living as soon as possible. So in closing, you know, the truth about anesthesia for us is that it doesn't have to be something that just happens to you. When done appropriately and carefully and precisely, it's really designed for you, designed for your specific physiology, your history, and what your healing needs will be. And that's why we've built the program we've built in conjunction with our providers. So we'll, we'll bring Travis Osborne on here in a moment and open it up to questions. So I'm going to pause this and bring Travis on, see if I can do this without losing the feed. All right, welcome Travis Osborne, the president of Celebrity Anesthesia, who's done my anesthesia case— anesthesia for my kids since 2018, I believe.

Yeah, it's, uh, it's been quite a while. We're here, we made it. You made the, uh, you made the switch over to, uh, to get me, me on the, on the feed without any problems.

That is. So we got to take some questions from the audiences that we have going. Let's see, let's take something from TikTok if I have something right away here to my left. If you guys could only see how many cameras I have running right now, I think I have 6 up. I'm trying to get a question. If there's questions anywhere, put them in the chat and we'll let Travis talk here.

Go ahead, man. Yeah, my wife always laughs when we go to a dinner party or any type of social function and people hear that I do anesthesia, like, oh my gosh, I've got it. I've got to know. I've got a question. 15, 20-minute TED Talk at every party or every event we go to.

So Travis is going to tell us, Travis, or is somebody going to wake up during anesthesia?

Um, at the end of the case, yes. So, uh, and I'm not making light of it, uh, you know, I, I know that there are several movies, uh, the one, you know, Awake, there have been all kinds of movies, documentaries, or writing things and pieces about awareness under anesthesia. People were saying, I am awake under anesthesia. This is a very, very, very rare mishap that happens in anesthesia. I'm talking infinitesimally small chance that this happens. And in this day and age, we have so many monitors and so many ways of knowing whether you are awake, feeling anything, becoming more conscious, less sedated during the procedure, we would know far beyond that actually happening. There are so many signs and triggers that would alert us that we could deepen the anesthetic before it was ever even close to an issue like that. So, Short answer and simple answer is, is no. If you are working with a competent, good provider, the times when that happens are typically trauma cases where people are, you know, bleeding out, heart surgeries where they can't support someone's blood pressure, life-saving events like that. And again, these, these are exceedingly, exceedingly rare.

Yeah, I was, you know, the, the whole like trauma situations were the, the most likely ones where you'd have somebody more aware, but that's, those are, you know, infinitesimally small. For 30 years doing cases, large cancer reconstructions that lasted, you know, sometimes all day, and then, uh, Yeah. And then all the outpatient cases, I've been really impressed with how the balance is. And I guess that's probably the best word is like, I feel the celebrity anesthesia providers understand the balance that's needed for my patients because my patients do have a lot of nervous system issues. They have a lot of inflammation. They typically have a lot of endocrine issues, many thyroid issues and and everything. And, and we'll do a PSA right now, like, we don't allow— and, and, or Travis and I don't allow anybody to go to the operating room who's got a thyroid problem that's not checked and not taken care of because it's not safe. He won't put anybody to sleep, and I won't operate on anybody, and the facility won't let it happen either. So we always want everybody to be medically, uh, taken care of. Yeah, absolutely. Thyroid's I, it just was top of mind because we had a discussion about that earlier in the week. It sounds like people are having a little trouble hopping on to this circle. So if you're having trouble logging on to drrobcircle.com, basically you have to open a private window on Safari or an incognito window on Chrome or wipe your search history because we updated the platform and your phone or your device is just replaying playing the old URL, if you want to think of it like that, like an old search. So now what you're watching us on now is a brand new platform. So, um, you know, I was always impressed. Um, so Travis knows I remain very curious and try to push to get, um, things better and better for patients in terms of experience. And I asked Travis to help us with Regional anesthesia, and he told us he could do these different regional nerve blocks for us. So I'm gonna let him explain like how he's really helped us with breast surgery in my practice.

Sure, yeah. You know, our experience, or my anesthesia group, me and my co-founder founded the group. We've been in practice now for a little over 5 years, and we cover in 3 different states and we're 100% outpatient-based. And what we did was we saw this big need in the market from an outpatient standpoint where we felt like patients should have a tailored, individualized approach to every anesthetic. And that is the lens that we view everything through for the entire business. And I've been working with Dr. Whitfield MD, like I said, since 2018 and every single patient that I've taken care of myself of his and our entire team that takes care of his patients. It is about optimizing for the type of surgery that Dr. Rob's doing and the patient's comorbidities, their history, everything they've got going on and coming up with a game plan together, both Dr. Whitfield and our team and then us and the patient as well. So, When we started looking at this, we saw that there was opportunities to optimize for decreasing pain the patients are experiencing with these procedures. There is obviously, you can just do a regular general anesthetic. You can give somebody a bunch of narcotics through their IV and try to control pain that way. Patients wake up, they feel groggy, they feel dysphoric, they, they can feel nauseous. Then later on, if you got to give a lot of long-lasting narcotics, sometimes it can lead to constipation and other issues. So we were looking for ways to enhance that early recovery after surgery, that part of that ERAS protocol. And we do that by leveraging targeted nerve blocks throughout the body. When those nerves leave your back or your spine, they come around and they wrap around through this area. And we can actually go in with an ultrasound and we do a couple of nerve blocks that are PEC blocks and then also serratus anterior nerve block that actually targets the nerves that innervate the entire front of the thoracic wall. So your entire breast area, we can pretty much target with local anesthetic. Now we're able to use— technology has advanced like crazy and we're able to use ultrasound and in real time see both the needle, the tip of our needle, the nerve bundle that we're trying to place that numbing medicine or that local anesthetic around. And then we're able to go in and in real time make sure that we are not touching the nerve or in the nerve and deposit that local anesthetic around the nerve bundle so it bathes those nerves. Once we bathe those nerves, it essentially turns the volume down on transmission signals from that area back to your brain. So your brain isn't experiencing that pain. You're not feeling that pain as much. That volume is turned down.

Yeah, I feel like everybody's got to think about the combination of things. The, the way we were trained was very different. I was trained to, you know, have a narcotic prescription and the really forward-thinking surgeons dropped it off beforehand. And most people just wrote it and left it on the chart. After the fact. And we are really programming it quite differently. So trying to get everybody up front in the best possible situation, you know, we look at genetics that gives us clues to methylation problems that lead to problems with anesthesia and different metabolic issues. Certainly looking at toxicity burden has helped because it highlights some of the things that people can deal with and why they may have other problems and their gut health and hormonal balance and such all contribute to that. But it's very hard sometimes for both Travis and I to gauge someone's individual state of inflammation. Some of it we can obviously understand through history and exam, but our patients definitely are different. There was a question I was going to bring up too, because this has happened more and more since the pandemic, which is mast cell activation syndrome, which, you know, we were taught about in school was a very rare problem, but it's certainly become a more common thing that we get asked about and see patients by history being told, you know, that they have that because it's not really a defining examination or I'm sorry, a biomarker for it, just like there isn't for breast implant illness. So maybe kind of your team has done this for me a lot of times and discussed muscle activation. So maybe just hit some high points for that. So that helps people understand. Yeah.

I think the main take-home point there is individualizing the anesthetic, the medications we give, delivery type, and what we're gonna do related to anything that the patient's presenting with. So whether it be mast cell activation, mild hyperthyroidism, mild hypothyroidism, well-controlled blood pressure issues, anything like that, we are adjusting our anesthetic in real time to the patient's needs specifically. And sometimes with that mast cell activation, that means a little bit more of one medication, a little bit less of another medication. And we're taking that all into account when we're developing that anesthetic plan and moving forward and getting that patient off to sleep safely and maintaining anesthesia throughout the case.

Yeah, I, you know, the— I've had several nurses with Masso Activation Center, oddly enough, and they've They get triggered different ways, obviously. So they're, they're very careful with their diets. And, you know, for the most part, we keep things pretty streamlined. So I don't feel like we've had any specific either. Certainly nothing intra-op, and I haven't had any post-op issues. With patients specifically, because everybody here, um, every— for everybody on, you know, the, the different streams, everybody stays in Austin about a week with us. So, um, the, the reason we do that is I think it's imperative to get people to take care of themselves, because once you get back to your daily lives, you're, you're typically not paying attention to your self-care, which this is a very important aspect of our program, which is taking care of yourself after surgery. You know, I, I harp on people a lot, Travis, about sleeping, uh, the quality of the air, the quality of the water, and the quality of the food they ingest, and the amount of protein they take in, and things like that. Because if you can't take care of those fundamentals, um, it's really not going to be very easy for either of us to do our jobs. So I think our jobs become infinitely easier when like the person is optimized. And those are the easiest things, like, you know, to sleep better, you need to not drink wine or fluids close to bedtime and try to stop eating about 3 hours before bed. And like I said, bring the fluid intake down a couple hours before bed. And it really can't be alcohol, especially if you have a lot of inflammation, because it's just going to make your HRV drop. And go ahead.

The one thing I would say specifically related to mast cell activation is just, you know, avoiding, avoiding potential triggering medication. So any, any medication that could lead to a histamine release, you know, we're making sure that we're not giving on those patients. We're really, you know, being careful and cognizant of that. That reality, right? We're also, you know, anything we can do to decrease the inflammatory response or kind of that wind-up phenomenon that happens during surgery. I think, you know, this is a great, another great example of how local anesthesia and nerve blocks help because when you don't feel that pain, your blood pressure and vitals stay rock solid throughout the case. You're just You know, you're just cruising. You're, you're essentially, we need less medications to keep you asleep and maintain that level of anesthesia because you're not even feeling most of it.

Right. I'm going to take this time to pause for just a second. So, I know there's been some trouble on the stream. People have said it's a little difficult to get into drrobscircle.com, but if you open a new window or clear your search and just type in drrobscircle.com, you'll get in and go ahead and join the, uh, the stream internally in Dr. Rob's Circle. And, um, I want to shift gears a little bit because I, I feel like, um, the, the other, I would say, thing that I found interesting that, uh, both Travis Dez and his team do for me is do a lot of IV cases for me where, um, you don't really need any of the volatile gas. You don't need any gas at all. It's just there for a purpose to have control of the airway, but they're not getting anesthetic gases. Maybe touch on that because sometimes that's a little confusing for patients.

Sure, yeah. And I want to make a couple of distinctions with this specifically so patients can kind of better understand the continuum that is anesthesia, right? So when we're talking about general anesthesia, that means that you are not reacting to surgical stimuli and it also means that you do not have airway reflexes. That's kind of a gross oversimplification suffocation, and it means that you are asleep or you're, you do not, you're not conscious, right? We can, we can create those, those conditions in, in a few different ways. One is by giving a volatile anesthetic or an anesthetic gas. We can induce with it, we can keep you asleep with it, and that can produce general anesthesia conditions. We can also do it all completely through an IV with IV medication. That medication can just be given at larger quantities and we can achieve general anesthesia with just an IV medication going through your IV. Sometimes we do a combined technique. Sometimes we have anesthesia gas going and then we're running a background medication in in your IV that's also helping to keep you asleep, but also reduce the amount of volatile gas that is going in to keep you asleep as well. So, you know, we really do, when we're able to reduce that volatile gas anesthetic and we're able to get either that background infusion of the medication that's IV that keeps you asleep, or we do it 100% through your IV, really does serve to help reduce nausea postoperatively, makes for a little bit smoother just wake up and experience in general for patients. And we do that for most of your, of your cases.

Yeah, somebody's asking about a ketamine protocol. So Travis and his group are very familiar with ketamine. There's reasons and very specific cases where they, they use, have used that in the past. A lot of times because we're running an ERAS, a lot of things overlap. So we try to be very careful with how many medications we're using because we're trying to do fundamentally some very specific things. We're trying to address through what his group is doing, you know, preoperatively taking care of local regional pain control before they ever go back to the operating room. We've already helped with our ERAS the night before so the pathways are fundamentally, you know, being addressed upfront. And, you know, I guess those are currently our kind of and have been our standards of care for quite a while now. And then intraoperatively, he's described ways that they go ahead and address and they tailor it specifically for all my patients. There is no like one way anything gets done for any of my patients. So for me to say it's all very cookie cutter would be very short-sighted. So they talk to all of our patients and speak to them about, for instance, I did a case today and the patient's very worried about post-op having nausea and vomiting because every time they've had anything done, that's always been the experience. So it's like a program loop in there, it's very hard that, you know, to imagine somebody who's had that experience every single time is this time not going to have that experience. But that doesn't really happen with my patients because Travis's team takes care of them so well.

Yeah. And, you know, I'll briefly touch on ketamine. You know, any drug used in in the wrong quantities can be a bad medication, right? And we've got to just understand that up front. And then this is also different from a ketamine infusion that would be done for either pain or, or psych purposes. Completely separate situation. Ketamine is a dissociative anesthetic. It can be given as a standalone anesthetic. It is never done that way anymore. Like back in the day when it was originally created. Now, at very low doses, it can actually help support a well-rounded multimodal anesthetic. It's got some pain-relieving properties, which again, if you have somebody like Dr. Rob's patient from today who said, hey, I really have a hard time with nausea post-op, sometimes we can give a very low dose of ketamine during the case, get a Avoids the, you know, kind of the dysphoria side effects that some people are worried about because we're giving it in very low doses. And then we also give other medications along with that. And again, it's a, it's a very well-rounded and balanced anesthetic. It's kind of like if you go to build a house, you can't just go build a house with a hammer and a nail, right? You need all the tools at your at your disposal to build something worthwhile. You're not going to get very far. You're going to have a very crude-looking house if you just have a hammer and a nail. So again, we put all the tool— all the tools into our tool belt, and we use what we need to for the patients just to get them the best possible experience that they can have.

Yeah, I think, you know, more and more that's That's become, you know, commonplace that somebody's got a lot of history of just nausea and vomiting. Some of it's very, I would say, location-based, where they had it done, what they were having done, and that goes without saying many times. Hospital-based strategies are very different than what we're talking about, which is helping patients be on the fastest track to recovery as possible. So, um, so everybody, we're gonna go into drrobscircle.com now. So I'm going to cut off these feeds, go into the bio, and hit the link that says drrobscircle.com. Any trouble logging in there, just clear your search history and type in the same search in a new window and log in new and you'll be able to log in. Okay, so we'll see you inside. I'm gonna shut these off now. I can do that. And