Hello, Reddit! My name is Alex Tripp. I'm a devoted gamer and anesthesiologist and am here to answer any questions you have regarding anything relating to mental or physical health. My goal is to make medical info easily accessible for everyone.

Frustrated with the lack of publicly-available immediate, reliable information during the pandemic, I started discussing medical current events and fielding questions live in February of 2021. Whether it's being on the front lines of the COVID pandemic, managing anxiety or depression, getting into or through medical education, life as a physician, upcoming surgeries, medical horror stories, or anything else you can come up with, I'm ready! AMA!


A little bit about me:

As mentioned, I'm an anesthesiologist, dopey dad, and long-time enthusiast of all types of gaming from video to tabletop. I trained at the University of Kansas, and I'm currently in private practice in the Kansas City area. Throughout my medical education and career, I've been a sounding board for medical questions from those around me. Gamers and medicine, it turns out, don't overlap much, and given that we're often not the healthiest of folk, the demand for info has always been high.

Since the pandemic started, it has become painfully obvious that people's functional access to reliable information sources to answer their medical questions is extremely limited. Health care centers are overcrowded, and face time with providers was scarce before COVID hit. Misinformation is far too prevalent for many people to differentiate fact from fiction. I have a long history of being an adviser for medical students and residents, and after fielding constant questions from friends and family, I wanted to spread that influence broader.

I decided to get more involved in social media, showing people that medicine can be really cool and that the answers they're looking for don't have to be shrouded in political rhetoric and/or difficult to find. Ultimately, over the past year, I started creating video content and doing interactive Q&A live streams on topics ranging from COVID to detailed descriptions of surgeries to interviewing for positions in healthcare, all while gaming my brains out. It has been extremely rewarding and lots of fun to provide information live and help everyone gain a better grasp on our rapidly-evolving healthcare system. A surprising amount of people simply don't know whom to trust or where to look for information, so I typically provide or go spelunking for high-quality supporting evidence as we talk.

Overall, my goal is to make medical information readily available and show that doctors are just dude(tte)s like everyone else. I love talking about some of the cooler parts of my job, but I also enjoy blasting some Space Marines in Warhammer 40k and mowing down monsters in Path of Exile. Whether you're interested in the gaming stuff or how we do heart surgery, I'm here to tell all. AMA!

Proof: https://imgur.com/ef2Z56R

YouTube: https://www.youtube.com/MilkmanAl

Twitch: https://www.twitch.tv/milkmanal1

edit at 1600 Central time: Thank you all so much for your contributions. What a response! I've been furiously typing for about 5 straight hours now, so I'm going to take my own advice and hop over to the gym for a little decompression. If I haven't answered your question, I'll do my best to get to it in a bit. Also, I'll be live on Twitch and YouTube this evening at 8 Central if anyone wants to join then. Thanks again for the interest!

edit 2 at 2000: Oh man, you guys are amazing! I didn't expect anything near this kind of turnout. I hope I've helped you out meaningfully. For those whose questions I didn't quite get to, I'll do my best to catch up tomorrow, but it's likely going to be a busy work day. In the mean time, I'm going to start my stream, so feel free to hop in and hang, if you like. We'll at least briefly be talking about stabbing hearts and eating placentas. Yes, really. Thanks so very much for all the excellent questions. I promise I'll get to all of you eventually.

Edit 12/31: Just for the record, I'm still working my way through everyone's questions. I probably won't be able to get to any today, but I'll make a final push tomorrow during the day. I'll also link some answers to questions that got asked multiple times since those are obviously hot topics. Thanks again for participating, and I hope I provided the answers you're looking for! If I miss you, feel free to DM me, or I'm live Wednesdays and Sundays starting at 8 PM Central.

Comments: 628 • Responses: 99  • Date: 

zortlord223 karma

What does anesthesiology have to do with mental health?

MilkmanAl336 karma

Awesome question! It seems like I'd mostly be hidden in the operating room with sleeping patients, right? It turns out that I manage anxiety and other mental health issues all day, every day. I frequently see people - both patients and patients' families - at their worst and most downtrodden. They are often scared, uncertain of how or when they'll recover. Many are desperate, trying to understand what is happening to them and why. When unexpected complications arise, I am typically present to break the news to the family. Sometimes people have simply had bad experiences with surgery in general or anesthesia in particular and are understandably apprehensive about undergoing that process again. It's common to have a fairly lengthy discussion with people about what to expect from their care, essentially managing expectations when bad outcomes are likely.

I rarely, if ever, have to deal with mental health longitudinally, but that's a challenge in its own right. I have to go earn someone's trust - usually in 15 minutes or less - and assure them that I'm staunchly on their side when they're mired in all of the above issues. When they've been through multiple surgeries and/or in and out of the hospital frequently, as a large percentage of the people I see have been, that's not always easy. Depression and anxiety are rampant in the chronically and severely ill, and making them feel better is part of the gig. My job is primarily safety with comfort as sort of a distant second, but if I'm looking to treat the whole person, mental health is a big part of physical recovery. Without hope or motivation, few people would make it out of the hospital and stay out.

Last but not least, I deal with a lot of chronic pain patients. Chronic pain, anxiety, and depression are generally densely interwoven, so there's not going to be much treating that pain without addressing the mental aspects of pain patients' issues as well. Certainly, I'm not the one to be doing deep-dive therapy sessions, but addressing their concerns and taking the time to validate their experiences is extremely important. If people feel heard and appreciated, they are much more likely to do the difficult things you ask them to do, which for pain patients often means doing some physical therapy that causes more discomfort in the short term for long term improvement or - this is the big one - weaning off narcotics they've been on for years. Addiction and dependence are a big part of the anesthesia game, and we're unfortunately usually the ones who have to be hardasses and develop and enforce plans to scale them back on their narcs.

Wow, that was really long-winded. Hopefully I answered your question!

socal_lowcal76 karma

You hit the nail on the head and I thank you so much for what you do.

I’ve never felt more scared or uncertain than going into surgery after surgery this summer but the anesthesiologists were always a comforting and ensuring presence and I am grateful.

MilkmanAl32 karma

Happy to help! Thanks for your question. :)

daveypageviews66 karma

As an anesthesiologist and gamer myself, I appreciate the post!

One thing I always say, is that we forget this is normal for us. We’re in the OR more than anywhere else, including our beds. This environment is not normal for anyone else.

MilkmanAl65 karma

Absolutely agree. I have to remind myself often that watching people get chopped up and put back together is not a normal day at the office for...just about anyone.

CySU26 karma

I had the same question going into this AMA, but now that you’ve explained your job, I’ve realized whenever I’ve had to go, or had to take someone into the hospital for a surgery, anesthesiologists are usually some of the most upbeat personalities in the room when it’s “go time”. I appreciate everything you all have to do. It can’t be an easy job.

MilkmanAl18 karma

That's really cool of you to say. Thanks for that! It's not an easy job, but I really enjoy it. The wins aren't common, but they are massive when you get them.

Laney2023 karma

Word of advice to the anesthesiologists out there - don't be like mine the one time I was put under general and discuss a recent patient death out in the hallway just before coming into my room to knock me out. That will NOT help me be calm and reduce my anxiety about the situation. I can only assume others would appreciate this courtesy, as well.

MilkmanAl16 karma


HumbertHum16 karma

Hi, I am a chronic pain patient. I cannot tell you how important it is to validate chronic pain. Many times I gaslight myself, and get angry that I didn’t get a lot done because I was in pain. I take opioids to manage my pain, but it took me so long for someone to take a “chance” on me and do the first prescription. I firmly believe I wouldn’t be alive today if I hadn’t been given opioids. Thank you for what you do.

Also, for others reading this, maintaining an opioid prescription over a long term is HARD. monthly in person visits and pee tests and 20-page questionairres. It’s expensive too (not the drugs, the visits and labs.) not to mention the side effects.

MilkmanAl12 karma

Thanks for the perspective on this issue. I definitely didn't mean to imply that nobody should be on narcotics, just for the record. They are excellent, useful drugs when used appropriately, and they are an utter godsend for many people. It's nice to hear they're doing you some good!

Chalifive8 karma

Last but not least, I deal with a lot of chronic pain patients.

So, I have a request that could potentially help your patients (and by extension, you since you do seem to genuinely care). Small preface: I'm 26m and have had chronic pain since childhood that was slowly getting worse until 2 years ago where I could no longer walk or do much of anything, and the pain was severe enough to make me mentally "checked out".

This was until I found muscle therapy known as trigger point therapy, and ever since my life has been dedicated to it and as a result im 200% better and actually have a quality of life again. Once I improve enough I intend on entering a related career to try and help others who have a similar issue as I did.

But anyways this isn't supposed to be about me - I don't know if you've heard of trigger points as its a growing field but the world tends to be slow to adapt. If you could research it a bit yourself and (provided you find that I'm not peddling some dumb product or something) potentially recommend it to patients then I think you could help a lot of people.

MilkmanAl8 karma

Trigger point injections are a really common thing for us to do, actually. The medical evidence in favor of it isn't great, but most of the people who get them seem really happy with the results. I'm glad you found something that works for you!

Attygalle206 karma

Hi Alex! What is your least favorite medical specialization to work with and why did you pick orthopedic surgery?

MilkmanAl212 karma

Definitely a bad question to ask after I was up all night doing orthopedic surgeries. LOLZ

ForProfitSurgeon59 karma

Anesthesia is a really important part of hospital operations. Do you feel valued?

MilkmanAl80 karma

Absolutely. I have a great working environment. There's a lot of talk about anesthesia vs. surgery vs. administration around, but I experience very little of that. Yes, there are clearly disagreements, but I've never felt like anyone has hindered our work or been anything but appreciative of our department, at the end of the day.

O_Punishment_O161 karma

Hi Alex! I've heard that it's harder to apply anesthesia to redheaded people. I am one of those people so how much of this is true? I never had to go through anesthesia but I've always wondered if that it's true or just internet crap. Thanks for your time!

MilkmanAl319 karma

The redhead thing is actually true! It does, indeed take a whole lot more anesthesia to keep someone with red hair down. Y'all have a mutation in your melanocortin-1 receptor that makes anesthesia less effective. I've seen estimates as high as 50% more anesthesia required. If you're looking for some really dry reading, here's a study that shows a 19% increase in "volatile anesthetic" (read: anesthesia gas) necessary to anesthetize people with red hair. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1362956/

dasbin107 karma

Is this something us gingers should mention/remind an anesthesiologist of before going under? Waking up during surgery is a terrifying thought to me, and now that I'm older my hair has faded to brown and gray so it's not obvious from appearances.

MilkmanAl222 karma

Yeah, I'd definitely mention it. I mean, it kind of becomes obvious that you need more juice during surgery when you're physiologically responding to whatever's going on - usually meaning a pain response like increased blood pressure and/or heart rate with faster breathing - but if they know ahead of time to expect you to facetank a bunch of meds, that's helpful for both sides.

GoblinGeorge44 karma

I'm a redhead with a pseudocholinesterase deficiency. I'm a lot of fun for anesthesiologists (I've had to have a number of surgeriea in the past couple of years).

MilkmanAl57 karma

Whoa, a strong genetic showing, to be sure! At least you get to know your anesthesiologist well before each procedure.

DulceEtDecorumEst11 karma

Quick side question.

Is your username a reference to propofol?

MilkmanAl5 karma

It wasn't originally, but it is now!

DulceEtDecorumEst2 karma

General surgeon: this case is going to be tough…. Fuck it…. Call in Milk Man Al

Born to be wild starts playing in the background

Milk man Al Sporting a pair of shades skids in to the hospital parking lot in his blue El Camino

This script is writing itself at this point

MilkmanAl2 karma

Do I get to wear a brightly-colored leisure suit?

ANGLVD3TH28 karma

Not a redhead, but my mother is. I once got 4 shots of novacain in my hand to help remove a very large splinter under my fingernail, all it did was give me pins and needles. Then supposedly when I had knee surgery they said it took a "triple dose" to put me under, though I assume they don't actually mean 300% of a normal dose.

MilkmanAl37 karma

An actual triple dose would be a crapload, but we see double doses fairly often, usually in young, healthy dudes who drink heavily.

RogueTanuki2 karma

I actually had a patient take like 700mg of propofol during a colonoscopy, but it was fractionated over 45 min to an hour.

Der_Latka7 karma

Going for my 2nd colonoscopy in January. Doc originally offered the (cologuard?) poop in a box, but after reading about the high (10-12% I think) rate of false positives and negatives, I thought about it (and had the cologuard) for a month or so and ended up emailing my doc and asking for a referral for the traditional procedure. I still remember feeling the night-night juice (Propofal I believe. It looked like a big syringe full of milk!). Err anyway - I remember as the anesthesiologist was administering it, I felt it “move” through my arm for just a couple of seconds before…I remember waking up. :) That stuff is good! I’m a big dude too - 6’6” and 300lbs. I’m surprised they don’t just shoot me with one of those elephant tranquilizer guns when I walk through the door!

I have tried to convince so many of my same-age friends to get their colonoscopies. I tell them the procedure is a breeze. You get knocked out, wake up, and you’re done! It’s the frickin’ prep for the thing that sucks!

I was told that the 1 gallon of the “stuff” I had to drink has been reduced or changed to a new thing? I remember trying to put Crystal Light or something like that into my multiple glasses of it. There’s just no way to make it taste good…and then when you finally board the “omg am I EVER going to stop pooping” train - lol you just don’t want to drink any more!

Now you’ve got me curious. I’m gonna have to ask my anesthesiologist how much it takes to knock me out! :)

Well that was a much longer and more rambly post than I thought it would be.

Guys, don’t be afraid. Colonoscopy = easy peasey procedure, and it could save your life!

MilkmanAl2 karma

For the record, there are small-volume bowel preps that you can drink these days that reportedly cause less nausea and cramping. I'm not colonoscopy age yet, but I'm definitely going to ask for one if they prescribe me the 55-gallon laxative drum. If the barrel-o-poop-juice is holding you up from getting scoped, that's an option you should explore.

rseccafi17 karma

How do you approach this in your practice? Do you automatically give redheads more anesthetic or do you ask them first if they've needed it in the past (would they even be aware that they've needed it in the past). How do you decide if a person with limited responses needs a bunch more anesthetic?

MilkmanAl42 karma

Yeah, you just assume they'll need more. Quite frankly, people typically tolerate anesthesia over a wide range of doses, so it's fairly easy to pour it on at the beginning and back off as necessary. It's way better to make sure someone is properly anesthetized at the onset. There are always mitigating factors, so if you think giving someone more anesthetic may be unsafe, that's when you just titrate to effect. Give a little at a time until you get the desired result.

When you say "no responses," I'm assuming you're talking about them being unable to like verbally respond. There's a continuum of depth general anesthesia ranging from EEG burst suppression, which basically means no brain activity, to normal consciousness. We generally want you somewhere in the middle where your reflexes (gag and cough, in particular) are ablated, recall is absent, and response to pain is blunted or nearly absent. That said, most people will respond to pain or discomfort while anesthetized with increased heart rate, blood pressure, and respiratory rate. If you start seeing those things, it's likely you need some more pain meds and/or anesthetic gas on board. That's still pretty far from awareness territory, though, fortunately.

TheWhiteRabbitY2K6 karma

Does this also apply to general anesthetic and carriers of red headed genes? My mother was a true redhead, but I have a weird mousy blonde, but my dentist has problems keeping me sedated during longer procedures.

MilkmanAl2 karma

Yep, it seems like if you carry the genes, you're set up for being an expensive date.

RufusBowland12 karma

Hi… does it also apply to those of us who are just a carrier of the ginger gene? I always get extra numbing at the dentist; partly due to being needle phobic and a nervous patient as a result and partly after being aware (but not in agony) one time despite the extra numbing. He was surprised, but as soon as I mentioned I’d read something about redheads needing extra numbing and that I’m genetically “half-ginger” he Ahhhh-ed knowingly and loaded me up with even more numbing. I’ve been since and he always says he’s giving me a double dose. Works a treat!

I had a general anaesthetic for the first time in October. Mentioned the “half-ginger” thing to the anaesthetist (I’m in the UK). No idea if he did anything differently, but whatever he did also worked a treat.

Also, and sorry to semi-hijack this question, I was absolutely wired for 30 hours afterwards and didn’t sleep. Pinged wide awake in theatre (i.e. the OR), didn’t need to go to recovery, ate relentlessly all evening and into the night, would have gone for a jog if my leg had been working properly, and made Dory from Finding Nemo look like an intellectual great for over a week. Do you see this often?

Many thanks for reading this and for your time!

MilkmanAl16 karma

I'm not sure if the gene that fiddles with the melanocortin receptor is dominant or not, but it sounds like if you've got a copy of it, it has at least SOME effect. The wiredness afterwards is probably from dexamethasone, a steroid commonly given prophylactically as an anti-emetic during surgery. I'm not certain how things go in the UK, but literally everyone here in the US gets that and zofran (ondansetron) prior to waking up, unless there's some medical reason not to do so. Both are really effective drugs with minimal side effects, outside of the eating ravenously for 30 hours thing.

Interesting fact about dexamethasone: if you push it in someone's IV really fast, it makes their butthole burn. Good times.

RufusBowland11 karma

Many thanks for the reply and the extra info. The ginger gene is recessive, although I’ve got plenty of red highlights in my (dark brown) hair when the sun shines on it. Have always wished I was a proper redhead; I think red hair is stunning.

I know the anaesthetist gave me something to stop sickness; he mentioned he’d already done it when I told him I didn’t like throwing up. That was whilst he was loading me with a tasty little selection of syringes. Don’t recall my arse being on fire though - haha!

I also warned him I don’t metabolise codeine at all (CYP2D6 gene variants proven) and my resting blood pressure is always ridiculously low (80s/40s-50s), which was appreciated.

I was loopy afterwards - repeatedly asked if I was dead (no), had I been abducted by aliens (no), and would he go and get me a Maccies (polite no). I had no pain because I’d also been given a local anaesthetic into my right thigh (excisional biopsy of an intramuscular myxoma). Felt so well and bursting with energy. The staff were bemused/amused by it all. Had a meal when I returned to the ward, stuffed myself with biscuits (cookies), then pleaded for extra toast and tea at 11pm (NHS toast and tea is food of the gods) and was found shovelling down a massive bar of chocolate and flicking around on my iPad when they came round for 2am rounds.

I also went down to theatre loopy. Due to the needle phobia they’d given me diazepam an hour before. Didn’t sedate me, didn’t erase my memory, just got rid of all the anxiety and any verbal filter I previously had. Begged them to sell me as many pills as the £12 I’d brought to hospital would buy, and when I saw the big syringe of propofol asked if that was what killed MJ. When he laughed and said yes I replied “Coooool… at least you know it works!” Then boom, it was 90 minutes later in what felt like two seconds.

I think you folk are amazing - keeping us safe, free from pain and then waking us up after we’ve been operated on. Many thanks!

(and to any NHS staff reading, you’re also amazing).

MilkmanAl2 karma

This was an awesome post. I LOL'd...inappropriately, of course, because that's the only way to LOL at the internet.

JJE37124 karma

I feel like many of us have spent a long time sitting these past two years. What's the laziest way to mitigate risk of blood clots? Aspirin, stockings, air wraps, or how long should you go before stretching your legs?

If you do suspect dvt, what's a good course of action/escalation?

MilkmanAl163 karma

Laziest way? Buy one of these: https://www.compressionmanagement.com/our-products/sequential-compression-devices/

Never move again, and be clot-free!

If you're looking for a serious answer, most recs I've seen are you should do some calf extensions and flexion for about a minute every half hour if you're sitting. If you're up and walking around intermittently, you're probably fine, assuming no weird clotting issues.

uselessnavy24 karma

What about people who have lay about for two years? Is lying down all the time worst than sitting down all the time?

crazycarl119 karma

Lying down is astronomically worse than sitting down. Even sitting engages some back/core muscles where as lying down does nothing. Sitting also has your head up, meaning gravity is still pulling on your lungs which helps keep them open

MilkmanAl28 karma

I don't know of any actual data on sitting vs. lying down for clots, but I'd assume it's worse if you're literally not moving *anything*. If you're truly bedbound, you start to lose muscle mass really fast, to the tune of a few percent per day over the first 10-14 days. It's not good for you at all, and I can't imagine the situation is any better where clotting is concerned.

neuritico16 karma

Despite everyone using them for legal fodder, hasn't it been shown that SCD's are insignificant in reducing the risk of VTE in hospitalized patients?

MilkmanAl15 karma

Yeah, I think it's one of those apocryphal things that sticks around because it's tradition and is in every written care standard everywhere. Anticoagulants and mobilization are where it's at.

hotsprings123493 karma

What's it like to pass gas for a living?

MilkmanAl80 karma


thespecific-ocean2 karma

Quality shitpost

MilkmanAl4 karma


fantumn71 karma

My mother and I (and my grandfather, from his anecdotes) both have an undiagnosed resistance to normal pain meds. I wake up during dental procedures before I should, local anesthetics wear off very quickly (sometimes they don't even take), etc. My mother has had multiple surgical procedures where she has tried to warn to anesthesiologist that she will wake up/be able to feel pain before they want her to, but it never seems to get through to them.

My question: how do we tell anesthesiologists that they need to monitor our status with greater care without coming across like opioid addicts looking for an extra kick? And gaming question: whats your favorite Skyrim build?

MilkmanAl98 karma

Unfortunately, it's pretty easy to come off like a drug-seeker these days. The opioid epidemic made sure of that. Thanks, Purdue Pharma! Anyway, the best you can do is plead your case. It sounds like you may be fast metabolizers of local anesthetics, which does definitely happen. If you mention the familial thing, that might trip some "this is real" sensors for your anesthesiologist, so I'd be sure to include that piece. Speaking personally, I do tend to take people who mention stuff like that seriously. During surgery, it's pretty easy to get a feel for how much pain meds you're going to require afterward, believe it or not, and there are plenty of options for a little extra pain control that have virtually no drawbacks.

one-hour-photo65 karma

why is it sometimes when I get out from under general, I feel like my depression is completely cured for a day or so, but other times I just feel "high" and woozy.. is it not the same chemicals every time?

And, if I feel like my depression is cured, is there something in the cocktail that I should take note of?

MilkmanAl112 karma

I can only guess at this one since I obviously don't have your anesthetic records handy, but here's my best shot:

Propofol, the drug we typically use to get you to sleep, has a known side effect of a "sense of well being" that lasts well after the primary effects of the drug are long gone.

Ketamine has some sketchy evidence of being useful for depression when administered in small doses, so you may have gotten some of that, too.

As for the second part of your question, it's not always the same meds, believe it or not. We're not very creative folks, but there are definitely a lot of ways to do a safe anesthetic. Most commonly, you'll get propofol to get you out, fentanyl for pain, maybe some versed beforehand for anxiety, and an anesthetic gas to keep you out since propofol only lasts like 10 minutes, tops. The gas is what hangs around and keeps you groggy, but you can totally do anesthesia without it. Many people just get a continuous infusion of propofol. That's a really effective strategy for people who has massive nausea after anesthesia since propofol is actually one of the strongest anti-nausea meds we have, while the gas will turn your stomach if you take a strong whiff of it sometimes.

Goat_66636 karma

Ketamine has some sketchy evidence of being useful for depression when administered in small doses

Is it really that sketchy? I've had the impression that in short-term treatments it's pretty safe and also effective. Though, I gotta admit, I haven't read any studies of it myself, but I trust the official guidelines in my country.

MilkmanAl22 karma

I guess I should be more specific. Ketamine has shown good results in trials over short periods (72 hours is the number I keep seeing). Most places offering ketamine infusions recommend multiple treatments over a few weeks. I have no idea if insurance here covers ketamine infusions for depression, but if not, it's potentially a very expensive treatment that many couldn't afford. That said, if it's available, the side effects of ketamine, especially at low doses, are very minimal. You might get congested or have a slightly racing heart or something. Psychotropic effects are possible but relatively unlikely. Might as well give it a go.

Im_The_One11 karma

Side question based on this that I would love an answer to if you find your way back to it. I'm currently in residency after completing dental school.

How do you feel about oral surgeons or dentists with extra training using moderate IV sedation on patients for certain procedures. No propofol, only versed and fentanyl with Max dosages of 10mg/100mcg respectfully.

In order to practice legally with an IV sedation license in my state, I need 25 cases under my belt which I think is a joke and not near enough to be comfortable. By the time I'm finished with residency I should have around 150 sedation cases.

Would love to hear your thoughts on these procedures from an expert POV. Thanks!

MilkmanAl19 karma

I think it's completely appropriate, given proper training. I'm only familiar with the oral surgery program here in town, but they get 6 months of anesthesia training during their rotations. That's plenty to administer the kind of deep in-office sedation that they most often use, in my opinion.

Not to split hairs, but I'm not sure about the 10mg of versed limit, to be honest. That seems like a rather whopping dose, while 100mcg of fentanyl isn't really all that much. However, both are very nice because they have reversal agents available, so you can dig out of an overdose situation easily. Also, consider ketamine. Ketamine doesn't ablate your respiratory drive, and when versed is given beforehand, patients are really unlikely to have ketamine's psychotropic effects. Chocolate and peanut butter, baby!

Im_The_One6 karma

Makes sense thanks! And yeah apologies I didn't mean 10 and 100 as a bolus. Typically we just start with 2mg versed and titrate up from there as needed but don't go past a maximum of 10mg regardless of the patients sedation level over the period of the appointment.

Jmh07292014 karma

This is such an interesting conversation! I’m an LVT and run anesthesia on cats and dogs. Because we have such massive weight ranges for our animals we dose all of our drugs out in mg/kg. I see here you say you give 2mg to every patient starting. Do you change your starting doses based on the size of the person? Do people typically do mg/kg dosing in human medicine? Always interesting to see how vet med and human med are so similar yet so different.

MilkmanAl9 karma

Yeah, we definitely change the dosing as appropriate for weight and age. I typically don't give anyone over 70 versed at all because it has a pretty high chance of making them delirious post-op. 2mg is just the standard because that's the dose the manufacturers supply, and it's typically pretty effective for stopping anxiety across most sizes and ages without undue side effects. Most anesthetics hit way harder in the elderly, so we scale back as appropriate, usually titrating small doses to effect. Pediatrics is where dose/weight is most common since kids are so variable. Those doses break down a bit for adults, though, due to metabolic differences. That is, if you stuck with the pediatric weight-based dosing, you'd often end up giving adults an unnecessarily gigantic dose.

one-hour-photo-3 karma

ahhh, makes sense now! weird that y'all have any type of freedom at all in what meds you use.

MilkmanAl18 karma

It's nice to have options! All of them are a little bit different and have strengths and weaknesses. Propofol, for example, is the most common because it's so easy to use and disappears in minutes if you somehow screw up, but it does tank your blood pressure. Consequently, it may not be the best choice for someone with a terrible heart or who is actively bleeding out and struggling with BP issues anyway.

KayDashO8 karma

If Propofol disappears within minutes, what happened with Michael Jackson exactly?

MilkmanAl20 karma

He was on a propofol infusion and wasn't being monitored. When he stopped breathing, there wasn't any way to know about it, so the propofol kept coming, and he kept not breathing. That was an exceptionally tragic way to lose a legend.

KayDashO5 karma

Thank you so much for the reply! I agree, it was absolutely tragic. Was a fan since the age of 6!

I didn’t realise he was on a constant infusion, that’s insane. I thought maybe he was just given some to get him to sleep in the hope that his own body took it from there. If I might ask one more thing: do we always lose total control of our own breathing when under general anaesthetic?

MilkmanAl9 karma

Not always. One of the biggest benefits of Ketamine, one of the alternative anesthetics I mentioned, is that it doesn't affect your breathing. That's super useful for people in whom it might be difficult to secure a breathing tube in. Anesthetic gases also do not stop your breathing. Propofol, opioids, and benzos can, though.

MrJoeMoose44 karma

If you were The Emperor of Mankind, how would you fix medical billing?

My wife had surgery last year. Neither the surgeon nor the anesthesiologist had any idea what their services would cost. It turns out that the surgeon didn't cost us much at all. But it took almost a year for the insurance company and anesthesiologist to decide what we owed. Of course both sides sent propaganda to try and enlist us (and other patients) in their contract war. In the end we owed a few hundred bucks which seems preposterous given the prices we were quoted in excess of $20k.

I'm going through the same thing now with a psychologist. 6 months of visits and no bill while they argue with insurance. I don't know if I owe them $500 or $3500. They don't know either. Putting aside inflated costs that make healthcare unattainable for some, it seems like the system is too broken to even charge us efficiently. I need the Carmax no-haggle price.

On another note, how do you get enough rest? Our anesthesiologist was clearly exhausted by long hours. What does it take to stay healthy in your line of work?

Edit: Last one I promise. What's your favorite tabletop game? Do you like RPGs, board games, or war games?

MilkmanAl47 karma

Billing? Dang man, it's probably beyond fixing. There's so much in that system that's just FUBAR. Oddly, what's probably the best thing going right now in that regard is the rise of concierge care, AKA "direct care," which is basically just a subscription service to a particular doc or group of docs with an additional fee for service on top of that. Right now, that's not super viable for extremely expensive medical care or things that require hospitalization, but it's a hint that we might be able to get away from reliance massive insurance companies for at least a decent chunk of our routine health care. Ugh.

To be honest, I have no idea what my services cost, most of the time. There are some really common things I have a good idea about, but the cost is also insurer-dependent since those rates are negotiated individually. As above, the whole system is a nightmare. I'm sorry you got caught up in that struggle.

My job is actually fairly forgiving in terms of rest and off-time, most of the time. I was on call last night and slept from 1130-6, which is fairly typical. I generally work 45-50 hour weeks, though it has been closer to 55 over the past 2 months, thanks to everyone trying to squeeze in surgeries before their deductibles reset Jan 1. I also have 10 weeks of vacation, which is totally awesome.

That said, all the downtime is necessary. We work HARD. My group in particular is at roughly 85th percentile nationally in terms of production per person. We run lean to maximize income, and that can really bite you in the ass if disaster strikes in terms of scheduling. We don't have much choice other than to suck it up. Like, if there was work to do last night, it'd be me. I'm the only anesthesia doc in the hospital, so I'd be hauling ass all over the place if necessary. That rarely happens, fortunately, but it's definitely tough when it does. Working 24 straight hours at that level of focus is very taxing, and performance suffers in the wee hours of the morning. That's a huge issue in residency where residents are routinely up and working hard through the night. I do not miss those times.

Scorch20029 karma

How is production per person defined in your group? Thanks for doing this btw!

MilkmanAl7 karma

I believe it's RVUs for the group averaged per person.

drop_panda2 karma

You mentioned elsewhere that you would feel uncomfortable being sedated by a nurse-level anesthesiologist. What about an overworked one clocking in on their 20th work hour? Should I as a patient feel safe with that? As a software developer, and code I wrote in that state would be littered with bugs.

MilkmanAl2 karma

Oh no, I meant being anesthetized by a tech. Looking back at the post, I guess that wasn't clear. Nurse anesthetists and anesthesiologist assistants are extremely highly-educated providers and are generally very capable. No issue there. I'll edit that for clarity.

Work hours are definitely a concern. Speaking from experience, care quality suffers toward the end a 24 hour shift during which you've worked the whole time. I think it's basically impossible to function on the level anesthesia requires for that long. If you're having something non-urgent done in the wee hours of the morning, consider putting it off a few hours for the day shift, or at least asking if they have dedicated night staff. If the latter is the case, you're probably okay.

kgcounselor37 karma

Hi Alex,

Thanks for doing this! As a mental health therapist, I appreciate your comments about the hyperactive response when coming out of anesthesia. I work with a lot of clients who have experienced trauma. Often, they have body "memories" or reactions to triggers that they are not (yet, at least) consciously aware of. I try to use the analogy of someone coming out of anesthesia who may be combative. I share with them their body is aware that something traumatic has occurred and is trying to protect itself, while the executive part of the brain is still "off-line." I'm not a medical doctor but I want to make sure I am giving my clients a good analogy that they can understand. Does this sound like a sufficient analogy to you or would you add/change anything? Thanks again!


MilkmanAl46 karma

It sounds pretty reasonable to me. I generally describe anesthesia emergence exactly like I did above: we turn your brain off, and when it reboots, the stimulatory parts come back first with no inhibitions. Consequently, people with previous emotional traumas are more likely to react severely. Put another way, PTSD is a big risk factor for combative or violent behavior immediately post-op.

Just for the record, nobody holds it against you if you're wild after anesthesia. Nobody wants to get hit or deal with a combative patient, obviously, but everyone in the OR and recovery area knows that's part of the game. We don't take it personally. Some people are really worried about that, so I figured I'd mention it.

Ungarlmek4 karma

I'm a big guy with a lot of fights in my history mixed with PTSD and I'm going to need surgery soon so I've been worrying about this quite a bit. Can they, I dunno, put on some restraints when they wake me up or something?

Undrende_fremdeles3 karma

I am a small woman, but I was put under for some surgery a while back and have a history of an abusive ex that among other things would try getting way with me while I slept. The surgery was for "downstairs issues" and combined with me being in a vulnerable state (just like when I was sleeping) - yet I had no problems at all.

There were people that talked with me before the procedure, that would also be there during. Nurses were compassionate, surgeon was effective but not unkind.

Came to, was shaking heavily until my partner was allowed in. He put his hand on my shoulder and my body instantly turned off the shaking. And after that I was fine.

By the time the nurse came back to see how I was doing and to ask if I was ready to try some bland yogurt (think they needed to see if I could eat or something) I'd already had cup noodles, apple juice, and other snacks we'd packed in preparation for hospital food being bland 😅

So my recommendation is to bring simple snacks that are not cup noodles since they don't allow as many people in hospitals etc these days, and my SO had to get access to boiling water for that.

I believe it helps to be aware of your past history, rather than have suppressed or unprocessed emotions, memories of danger and/or current helplessness in your life that you aren't/can't be honest about.

Not that it is a guarantee, but it just seems logical to not have a fighting instinct kick in unless your conscious self is all that holds that back on the regular to begin with.

I would probably let them know about your history though, because it would make me less nervous to know they know, if that makes sense.

MilkmanAl3 karma

I second this. Any sort of extra information regarding past psychological issues (or anything else, really) that may affect your care is good to have.

MilkmanAl2 karma

If you mention those things ahead of time, it's likely you'll get a sedative at the end of your surgery that'll carry you through that wake-up process in a fashion that isn't quite as abrupt as usual. Dexmedetomidine (precedex) is a great drug that really helps with "emergence delirium" (i.e., being a jerk on wake-up) without big side effects. Restraints might prevent someone from getting hit, but there's quite a lot of evidence that restraining a delirious person makes their delirium worse. We try not to do that unless it's for patient safety.

Fun_Inevitable_541229 karma

What do you think is the best way to relieve mental pain from depression/anxiety without conventional drugs? I’m thinking an activity that isn’t addictive. I’m easily addicted to a variety of things.

MilkmanAl77 karma

Anxiety is always a tough nut to crack. There are some general strategies that apply to *most* people, but the ultimate solution needs to be individualized. Despite my job, which basically involves slinging drugs in all directions all day long, I'm 100% in favor of doing everything you can to treat things with the minimum necessary medical intervention. It's just better for you. All medications are ultimately poisons - just poisons administered in very controlled, measured fashion.

Anyway, the anxiety relief method that has the most research supporting it is physical exercise. Get yourself on some sort of exercise regimen and scale it as appropriate. I'm not necessarily talking 2 hours in the gym pounding out reps, mind you. Go walk a mile. Do some mild aerobics in your living room. Most recommend 30 minutes of at least light exercise per day.

Meditation is another big one. Schedule some time per day to sit in a mostly stimulus-free environment and calm your mind. It seems easy, but meditating is actually quite difficult, in my opinion. YouTube has many how-to videos, so I suggest watching one of those.

Yoga is one of my favorite pastimes, as it basically combines both of the above and gives you a full-body workout.

Make sure you're getting good, regular sleep and getting enough of it. 6 hours per night is sort of a bare minimum. 8+ is ideal. Try to go to bed and wake up at the same times daily. Avoid highly stimulating things like watching TV or messing around on your phone for 30+ minutes prior to sleep. Keep your bedroom for sex and sleep only so that when you're there, it's time for bed (or getting laid!). Avoid stimulants or depressants (like booze) before bed.

Keep in mind that behavioral change is a difficult thing to do. Don't expect to just fall into these habits. Set yourself alarms and calendar reminders. Start small and grow to your goals.

In addition to behavioral changes, it is very important to seek professional help. I can't emphasize that enough. Counseling is often expensive, but if you have health insurance, you should be able to find someone somewhere around you who accepts your coverage. Maybe try online sources, too. It's a shame that mental health is stigmatized so harshly in the US when it should be as normal as seeing your doc for a checkup. Get the support you need so you can treat the PROBLEMS not just the SYMPTOMS. Mental health is *so* important, but way too many people feel weak or ashamed for speaking with a therapist. That's what they're there for. Don't fall into that trap.

arcticfawx21 karma

Re physical activity, I'd add that it's better to find an activity that you enjoy in it's own right, and happens to involve moving your body. Rather than force yourself to slog through exercise that you hate. So things like a beer league for a team sport, swimming, dance, climbing, biking (mountain or road) would be good to try. It's much easier to motivate yourself to do a fun thing than to do something that's good for you but not enjoyable.

MilkmanAl8 karma

Amen to all of that! Change is much easier to make if you enjoy doing it.

iron_knee_of_justice19 karma

Hey Alex, as a gamer and hopeful future anesthesiologist, I just wanted to say I love what you're doing! Do you have any tips on how to better maintain physical and mental health during medical school and residency? PS: Can you get me an interview at KUSM anesthesia?

MilkmanAl22 karma

Hey, I appreciate the props! Thanks!

Staying healthy in med school is just like staying healthy any other time. You have to carve time out for yourself. Exercise and other forms of active relaxation are really important to switch your brain out of constant study mode. Work hard at being efficient, because that will serve you extremely well throughout your training. Try to get through that practice test in 45 minutes instead of an hour. Read that chapter in 30 minutes instead of 45. Constantly push for improvement. Less time spent studying means better scores and more time for being human and down the line, better, more efficient patient care.

Burnout is a big deal in medical education, so do your best to be in tune with when you're starting to falter in that regard. If you're reading the same slide 5 times, and it isn't sinking in, take a break. Maybe take a day or even two off. You're human, and if you're at your breaking point, it's time to stop. You're only harming yourself by trying to push forward. Your work will be exceptionally inefficient, and you've squandered time that could've been used for recovery. Maintain your support structures as much as you can so you can go hang with people and blow off steam when you need. It's a tough balance, but you'll be there with dozens of classmates whom you can bounce your feelings off. They're in the shit, too, so they'll be able to easily relate when you need a boost.

Good luck to you! It's a long, hard road through medical education, but life is pretty sweet on the other side.

dicknipples14 karma

Do you know if there’s been any new research on the long term effects of anesthesia? I get put under anywhere from 1-3 times a year, and I know there were studies showing the possibility for memory issues and general cognitive decline, so I was wondering if anything new has come up in that field.

MilkmanAl17 karma

Yes, indeed. That's a frontier of the field, at the moment. As I mentioned in another comment, "post-operative cognitive decline" is being looked at fairly vigorously at the moment. It seems like there are lots of risk factors for it, including duration and frequency of anesthetic exposure, age, systemic inflammation, and type of surgery. Of course, the number one risk factor for everything in medicine is having had that thing before, so if you've had some cognition deficits after surgery, you're much more likely to experience that again. I don't think anything terribly definitive has cropped up just yet. We're mostly just aware that it exists and is rare. Details to come...in a few years...probably.

mbardeen13 karma

What's the latest news on malignant hyperthermia? Is it more recognized now than it was in the 1980's?

I went in to the ER for a broken femur in 1984. I woke up later in the ICU with a catheter (not the most pleasant experience for an 11yr old). Turns out I had an allergic reaction that was caught (thankfully) by the anesthesiologist.

MilkmanAl37 karma

Malignant hyperthermia is unique in that it's basically an anesthesia-only problem. As far as I'm aware, the only things that cause it are our various anesthesia gases and succinylcholine, a common paralytic. MH is a constant threat and pretty easily recognized these days. It is standard of care to have a "MH cart," much like a "code cart," available in all areas where anesthesia is provided. I can't speak for care standards outside the US, but MH is definitely a well-described issue that anesthesia providers are aware of.

For anyone curious about what MH is, it's basically a dysfunction in calcium channels in your muscles triggered by the above drugs that results in spastic muscle contraction with subsequent heat generation and muscle breakdown that floods your body with potassium. It's really dangerous, and the treatment is hydration, cooling, and a whole shitload of dantrolene, a paralytic to help stop muscles from destroying themselves.

fritzlbasement12 karma

Why are some people more prone to panic/anxiety after waking up from being put under? I had that happen with deep sedation a couple years ago. Is it a sensitivity to the meds used?

MilkmanAl12 karma

Hyperactivity is actually a really common reaction to anesthesia. There's a period of "emergence" from anesthesia - the part where you're waking up - when your brain is actually massively hyperexcitable. The easiest way to think about this period is picturing the activating portions of your brain coming back online before the inhibitory parts. Sometimes they take a little while to equilibrate which in practical terms means women cry a lot, men come out swinging, and kids freak the hell out. It happens. Usually it's a person-to-person thing, but it certainly can be different between experiences for the same person, too.

LotteLiterati11 karma

Were you inspired by other doctor/gamer/streamers like Dr. Alok Kanojia of HealthyGamerGG? Sounds like y'all should collaborate!

MilkmanAl28 karma

Dr. K is the man, no doubt about it. I ran across his content a few months ago after watching some videos by Devin Nash, his talent agent. I'd totally dig a collaboration with him, but I think he might be a little out of my league as far as digital presence goes! He is definitely an inspiration that there is demand for and interest in direct access to physicians on a casual, approachable level. He's got the mental health thing down, but while I feel I can contribute meaningfully in that arena, my strength is more in general medical and surgical questions. Dr. K and I would be like chocolate and peanut butter. Alok, if you're reading this, hit me up!

OkamiKhameleon10 karma

Your username. Lmao.

Uhm, but I do have a question!

So, is brain fog/memory issues after anesthesia a thing? I've had over 5 surgeries for an autoimmune disease, plus I go in for an exam where I'm sedated once a year, and I do find that I've had some brain fog issues afterwards. But it seems I do normally as well. I just wanna know if this is due to how often I've been put under, or if it's due to childhood head trauma, or both.


MilkmanAl9 karma

There's a phenomenon called "post-operative cognitive decline" that has gotten a fair amount of press in the research world recently. It sounds basically like what you're describing, but I've seen one case where the patient was essentially totally unable to function normally whereas he was functionally normal preoperatively. It seems like we're still trying to pin down what's going on, but duration and frequency of anesthetic exposure, age, inflammation, and type of surgery (cardiac being the worst offender) are all apparently risk factors. According to a Cochrane review of the available evidence, it looks like anesthesia gas is a little worse than IV anesthetic in regards to causing POCD.

In short, yes, long-lasting "brain fog" does happen. It's quite rare, fortunately, but it's something we're aware of and actively trying to figure out.

gamelover429 karma

I’ve been a software engineer for 25 years. What’s the best way to mitigate the cumulative harmful effects of sitting for long periods of time?

MilkmanAl10 karma

Generally speaking, physical therapy is the first-line answer for pretty much any chronic pain or stiffness issue. That means routine breaks for stretching, core exercises, and maximizing ergonomics (meaning keep all your joints and muscles as neutral as possible). Like, maybe take 10 minutes every hour or two do stretch your back and hamstrings, the things most compressed by a day of sitting. If you can, some active stretching like yoga will be great for you. If you're having pain, tylenol and ibuprofen as tolerated are your best friends. Those adjustable standing desks are pretty cool, but I don't know of any actual research stating that standing is better than sitting. If it helps, why not?

LordSalem3 karma

Also a software engineer. The real question is how do you actually do it? I think it's safe to say we all know we should stretch every hour and move around and look outside. I think the issue is managing to keep flow but not at the cost of health.

MilkmanAl4 karma

Yeah, that's definitely a challenge, and as with anything else, there's a balance to be struck. If a regular alert or alarm is too jarring, maybe just make a point to stretch when you think about it? Like, if you find yourself wiggling around, let that be a trigger for a break. Generally speaking, small breaks are good for production and mental clarity, even if you feel like you're "in the zone." Not to mention that the crick in your back or wrist doesn't really care how much work you're burning through. It's gonna be there until you deal with it somehow.

Speaking from personal experience, alarms have been extremely helpful for me when trying to instill new habits. It's really annoying and inconvenient at first to have something jar you out of focus. Change sucks. After a bit, though, the thing that alarm is supposed to be for becomes normal and part of the routine, and you hopefully won't need the irritating alarm any more.

sandaz132 karma

In the same world, a sit/ stand desk has made an amazing difference for me. Just make sure you get an anti fatigue mat to go with it

MilkmanAl2 karma

Second this times a bajillion. Standing in the OR for hours at a time, day after day really wrecked my feet. Make sure you've got something squishy to stand on.

stealthkat147 karma

I am also a physicia and a gamer, and i found many patients i encounter have little to no access to online accurate medical information or resources. Do you have any intentions to expand this idea of open and easy access to accurate medical information, and if so what are your future plans?

MilkmanAl7 karma

Great question! I don't have any plans for anything, currently. I've just been doing this as a hobby. This AMA is really my first true move at getting some exposure. We'll see what happens! Realistically, I'll probably just keep doing live streams, YouTube videos, and Discord chat to keep in touch for the time being. I've slowly grown a small community over the past year, and I'm hopeful that lots of people here will be interested in joining up to discuss medical topics. If you have any thoughts on expansion, I'm definitely all ears!

Mishkae7 karma

Ah, a great place for the question I’m terrified to look up. I’m having a procedure on Monday that will involve IV sedation. As someone who experiences somewhat frequent sleep paralysis, how likely is it that I could wake up during and be unable to notify anyone?

MilkmanAl12 karma

That is extremely unlikely, and even if it happens, you almost certainly won't remember it. You might mention that beforehand so whomever does your anesthesia errs on being a little heavy-handed, just in case.

Mishkae7 karma

Thank you so much. I’m really anxious and struggling right now. Your individual attention to my question means more than you know. ❤️

MilkmanAl5 karma

Very cool. That's exactly what I'm aiming for, and I'm really glad to have helped. If you have any other questions, obviously, I'm available.

decklund6 karma

How do you like it when a surgeon just calls you 'Anesthesia', instead of your name?

MilkmanAl21 karma

I have a name?

slimzimm6 karma

Hi Alex, thanks for doing this. I have a question on chlorophyll, does it really boost red blood cell production? Are supplements containing chlorophyll beneficial or is it snake oil?

MilkmanAl21 karma

Hey, cool question! For anyone curious about where this thought came from, chlorophyll is very similar to hemoglobin in terms of chemical structure, and there has historically been some talk about how to come up with some sort of synthetic hemoglobin from it. As above, many have indicated that simply ingesting chlorophyll might be a way to increase your hemoglobin concentration. I don't see any studies that indicate your red blood cell count will increase with chlorophyll supplementation, but here's one that says it may increase platelet production, for whatever that's worth: https://link.springer.com/article/10.1007/s11332-018-0477-7

Also, there are numerous studies showing that dietary chlorophyll can bind free heme groups from ingested red meat and prevent them from breaking down into toxic metabolites. That is to say, chlorophyll may have a role in preventing colon cancer if you're a red meat eater, but it doesn't look like anything definitive is out there.

Orcus_6 karma

How accurate is this really?

MilkmanAl7 karma

Actual footage from all of my interviews.

blutmilch5 karma

I don't think this will get answered, since I'm pretty late, but here's to hoping!

I have a phobia of being unconscious. Sometimes just trying to fall asleep gives me massive anxiety. (Thanks, trauma!)

I need to get some procedures done that require general anesthesia, and I keep putting them off because I'm absolutely terrified. I've explained to my doctors that I'm afraid of going under, and I never seem to be taken seriously.

Is this something you've ever seen in someone before? If so, how would this be managed to make the patient comfortable?

MilkmanAl2 karma

I'm not sure that I've had someone afraid of being unconscious in the general sense, but people who are afraid of being anesthetized specifically come in all the time. That's a really common - and not unfounded - fear. Sometimes it's loss of control driving the fear, sometimes it's fear of complications, sometimes it's fear of uncertain outcomes. I would imagine/hope you are taken seriously, but there's unfortunately not a whole lot to be done about your fear from a medical perspective. If this fear is affecting your life - and it sounds like it is since you can't get the procedures you require done and, more importantly, are having sleep disturbances - perhaps some therapy is in order?

If you were to come to me and tell me in the pre-op area what you've written here, I'd say the above plus this: Anesthesia is extremely safe. Like, really, really safe. Dangerous complications from anesthesia in particular are exceptionally rare. Chances are overwhelmingly good that you will have no complications of either anesthesia or your procedure and that you'll be better off for enduring the experience. If you're okay getting an IV placed, that's your gateway to anxiolytic medication, and there's a good chance you won't remember any of the experience after that. To be clear, I absolutely do not endorse substance abuse to calm anxiety, but in a controlled, one-off medical setting, that is an entirely appropriate course of action. It's unrealistic to expect someone to complete a successful course of therapy prior to having any sort of surgical intervention that they need, and again, it's a one-time thing administered by medical professionals in an acutely anxiety-triggering situation.

Basically, keep communication open with your providers. We can't help what we don't know about, and a few milligrams of versed is a really easy fix that will make your procedure(s?) much less harrowing.

TheMayorOfRightHere3 karma

What are your thoughts on online gaming for younger kids during this time that in-person friend contact is more infrequent? Good or bad for mental health?

MilkmanAl12 karma

I've actually looked into this topic a lot, as I have a 5 year old son and don't want him to fall into some massive screen time trap. Given that I'm a game junkie, he's at pretty high risk for that. It seems like there is quite a lot of evidence that the pandemic has at least sort of student little kids' social development but that it's an easily-reversible issue. That is, once they're back into society (school, playdates, etc.), they fall back into a normal age-appropriate progression pretty quickly. My hot take is that, like with anything else, moderation of screen time is best. It's fine to watch movies and play games and stuff as long as there's a little electronic-free time outside of that. It's really tough with everyone being quarantined all the time, right?

alyas19983 karma

Greetings! I would like some advice from you regarding my journey towards med school and anesthesiology. I graduated with a chemistry degree as an undergraduate. Currently I am completing my masters in Healthcare administration. My end goal is to go into your field because I find it very interesting and bewildering how you can control once consciousness as such. What are some tips in succeeding in your field?

Thank you again!

MilkmanAl8 karma

If you like chemistry, you'll be right at home in anesthesia. That and physiology are basically all we do. The MHA will be very useful to you. Docs are notoriously bad at business, so having someone around who can wrangle the admins when contract negotiations roll around will be massively helpful and will likely make you more employable.

As an anesthesiologist you'll have to adapt to weird situations on the fly pretty much all the time and be willing to work under suboptimal conditions (putting in IVs or other lines sideways under surgical drapes, surprise medical conditions that affect your plan, etc.), constantly push for improved efficiency, and be ready for disaster at a moment's notice. You'll also constantly be triaging your patients and prioritizing care. I manage 4 operating rooms at once, so sometimes the healthy 18 year old getting a hangnail removed gets ignored in favor of the multiple gunshot wound patient who's bleeding out. You have to learn to swallow your pride and ask for help when you're stumped or tilted because your ego shouldn't factor into your patient's care. It's a weird job full of occasional big highs and catastrophic lows, but I wouldn't choose anything else.

As for actually getting into an anesthesia program, it's fortunately pretty much in the middle of the road in terms of competitiveness. As long as you're clocking in 50th percentile in school and on standardized tests, you're set to get a residency SOMEWHERE. It might not be Harvard or UCLA, but you'll make it. Good luck!

mechmind3 karma

I heard recently heard that red heads require 20% more anesthesia than non redheads. Is this true?

MilkmanAl3 karma

Yep, sure is. Some sources say more than that - like 50% more. They have a receptor mutation that makes them less susceptible to several common anesthetic meds. Crazy, right?

Phonascus133 karma

Hey! My son just left the cath lab at your place of work. He's thinking of getting his CRNA at some point!

Also, if you haven't, do yourself a favor and watch Dr. Glaucomfleckon. His videos are hilarious! Here are the ones about Anesthesiology.

How to Ace Your Anesthesiology Residency Interview

Anesthesia On/Off Switch

Surgery vs Anesthesia: Add-Ons

The Anesthesiologist Goes to Therapy

Hanging out with the anesthesiologist

Surgery has an add-on

anesthesia vs ortho

MilkmanAl3 karma

Oh yeah, his videos are great. Entertainment guaranteed. My personal favorite is interviewing for neurosurgery residency because it's spot on.

Good luck to your son, BTW. I'm happy to chat with him if he has any questions.

Ltfocus3 karma

Is it true you get hour breaks every hour?

MilkmanAl2 karma

I'll get back to you when my break is done.

lxwolfhopexl2 karma

A few questions when you can get around to them (if you can).

I'm a pretty big gamer whose been looking at going into medicine. Growing up my passion was deadly infectious disease and BLS4 zones (Thanks Richard Preston), but I've really been looking at going into the medical field as an atypical student once I wrap up my masters in psych. I would end up starting around 32 so I know after residency I'd be a good deal into my 40's. How hard did you find school and residency? Setting aside my younger passion of infectious disease what are your feelings on psychiatry, pediatric oncology, and palliative care? Did you have rotations in those fields, how were they, and do you feel that there are skills you developed as a gamer that make you a stronger doctor?

MilkmanAl3 karma

Man, really awesome set of questions. Med school is quite challenging, and residency is obscene. Psych residency, generally speaking, is less strenuous than most, but it's still long hours with difficult patients. I had several people in my residency class older than you'll be, so I wouldn't sweat the age part of it too much. You'll still have a lengthy career ahead of you, so if that's what you want to do, go for it!

Psych is very different than most medical fields. You're much less focused on labs and hard data than basically every other field. It's more about the patient and figuring out clues they drop you. It takes a very particular type of person to want to do psych, and most med students and doctors don't fit that mold. It's a great profession, so if that's your thing, by all means, fire away.

Peds onc is absolutely heartbreaking, but it's one field where you can completely change someone's life. I spend a lot of time keeping people with little life expectancy alive. You'll be letting many kids live a full, happy, essentially normal life. The upside is gigantic. Seeing the bad outcomes would be tough.

Palliative care is one of my favorite services. It's another one that's pretty different from the rest of medicine, but being able to have difficult talks with patients and families is an exceptionally important part of healthcare. We as physicians are generally quite bad at breaking news to people, so having someone dedicated to that purpose is invaluable.

Notice that you're basically chosen the three most heart-wrenching specialties available. You, sir (madam?), are a saint. I rotated through all those fields and have a great appreciation for every one of them.

Gaming hasn't had a big influence on my abilities as a physician, I wouldn't say, but it is good for manual dexterity and hand-eye coordination. It's also where I first learned to grind through difficult, laborious tasks, so there's that. I might be able to think up some other pluses if I tried, but it's mostly just a hobby.

Hellcat7132 karma

Hello and thank you for this AMA.

What is the easiest (laziest) way to deal with neck pain?

MilkmanAl4 karma

Hey, thanks for participating!

As I've told others, conservative measures are best. Stretching and strength exercises routinely throughout the day are pretty easy to do for your neck. If you're actually having pain, tylenol and ibuprofen (simultaneously) are good options. The game changes if you're having neurological signs like numbness, tingling, or weakness anywhere, especially if those things change with neck position. In that case, it's worth bringing to your primary care doc for further evaluation, because you may have a surgical issue.

G1adiat0r2 karma

How come people paralyse there body after doing surgeries? I see these kind news in newspaper. They say mostly because of anesthesia? Can you explain y?

MilkmanAl3 karma

Well, for most surgeries, you get paralyzed because that makes it easier for us to place your breathing tube and easier for the surgeon to operate. Sometimes people can be sore from that afterward, but it's very rare to remain paralyzed (unintentionally) after your surgery is done. There is a condition called pseudocholinesterase deficiency that makes succinylcholine, one of our paralytics, last about 6 hours instead of 5-7 minutes. Historically, it was somewhat common for people to have a little bit of residual muscle weakness after surgery, but since the advent of sugammadex, a new drug that binds the paralytic in your system instead of just competing with it, that has mostly become a thing of the past.

jkdjeff2 karma

I had a colonoscopy a few years ago, propofol was used to sedate me.

When I woke up in recovery, I felt horrible. Worst sore throat I have ever had. Couldn’t even really swallow saliva, could barely speak. I was given a note with my discharge paperwork that mentioned a possible aspiration into my lungs while I was under (I was then rushed out while still half conscious).

Ever since then I have had chronic sore throats and laryngitis after even limited amounts of speaking. I’ve gotten differing opinions from ENTs that I have seen; one said it looked like I had been intubated, another said she just saw inflammation. The GI doctor insists that even aspiration didn’t happen, much less an intubation.

I don’t even care about legal liability, I just would like to know the truth. Any guesses based on your experience?

MilkmanAl5 karma

From that, it definitely sounds like you both aspirated and were intubated traumatically. I obviously don't know the details, so while that's an *extremely* soft call on my part, yours is not an entirely uncommon situation. It's possible that you're what we refer to as a "difficult airway," and they had to muck around a bit in your mouth to get the tube in place. If you did aspirate and require intubation, it's pretty unusual that you'd be discharged home immediately afterward, regardless of how you were doing on paper. I'd imagine they'd at least admit you for observation. It's good that there's no obvious structural damage to your airway, though. That can be a pretty big problem, potentially.

So yeah, my money's on aspiration with tube. Sorry you went through that. Aspiration sucks a lot.

albz54242 karma

This may be a dumb question.. but I’m curious - I (redhead, F18 at the time) went under once for an endoscopy. Right as the anesthesia was pushed, it felt as though fire was rushing through my veins. I may or may not have cried audibly (probably just in my head lol). Is this normal? Could this be a side effect of being a redhead?

MilkmanAl3 karma

Nope, that's just propofol. It burns like hellfire. We always tell people, It's okay, it'll go away reeeeeal soon." We leave out the "because you'll be unconscious" part.

EatTheBiscuitSam2 karma

Might be out of your wheelhouse.

Why do I have to take a pill and wait 45 minutes for pain to subside? Why can I hit a ibuprofen inhaler a time or two and then get back to functioning without a headache?

MilkmanAl2 karma

Oh yeah, excellent question! The short version of the story is that you have to wait for pills to digest. Ibuprofen takes a particularly long time because it has a coating that helps it not start dissolving in your stomach, where it'd be more prone to causing you ulcers directly. Consequently, you have to wait until it gets into your intestines to start working, for the most part. By contrast, ibuprofen in your lungs goes straight into your bloodstream to block COX like a pro.

twojs1b2 karma

Good afternoon, joint replacement frequent flyer here. Both hips with 2 revisions on left, total knee, hemi left shoulder and fused ankle. I opted for spinal for most of these and when advising my anesthesiologist of my choice they always reacted with a smile. Why is that? Also I had a catch phrase when I'd go under, "here come the bee's!

MilkmanAl7 karma

Not sure what the smile is about, but coming from a hospital where some of the orthopods can't finish a joint replacement before a typical spinal wears off (2.5ish hours), that might have had something to do with it. Generally speaking, spinals are the anesthetic of choice for joint replacements. Recovery is better and faster, and you can generally do PT immediately after your block dissipates, which, in turn, helps long-term recovery. Maybe they were smiling because you chose wisely?

Of note, I've definitely been guilty of an "Oh shit!" right after pushing propofol if I'm taking care of someone I know and want to mess with them.

g1zzy2 karma

What games do you play?

MilkmanAl6 karma

Right now, I'm mostly into Path of Exile, but Last Epoch and Darkest Dungeon have also taken up an unreasonable amount of my time. I try to diversify, but having grown up on Diablo 2, the ARPG genre is really tough to get away from.

yamaha2000us2 karma

Can you write me a prescription for laughing gas?

MilkmanAl6 karma

You don't need one, I don't think. Nitrous is commonly available, isn;t it?

Uresanme2 karma

How much can you bench?

MilkmanAl2 karma

I haven't maxed for like 15+ years, but last I tried, I lifted 225 almost 3 times. I was in much better shape then than now. Currently, I do 135 for 10 3-second reps. I hurt my pec/shoulder/bicep? about 2 years ago and have been focused on tendon and ligament strength since.

Jaharsta2 karma

How do you feel about ER nurses doing Moderate sedation?

MilkmanAl2 karma

Given that there's an ER physician present supervising the situation, that seems fine to me. They do all sorts of small procedures in the ER under sedation, which is great for everyone, including the patient. As far as I'm aware, ER docs get trained in sedation during residency, and most of them at least do a month or two in the OR with anesthesia to get some rapid-fire reps on that front. When all is said and done, they're frequently preventing patients from having to go to the OR for what will be billed as a full-on surgery with anesthesia. That takes more time, more money, and more resources for everyone, so if we can avoid it in a reasonable and safe fashion, why not?

junniper6102 karma

I know I'm a little late getting to this so I don't expect a response but I figure it doesn't hurt to ask.

I struggle with a lot of mental illness (depression, GAD, OCD, phobic anxiey, CPTSD) in addition to development disabilities (autism & adhd). I am terrified of anesthesia, though I suspect it's not for the standard reason. Those videos of people acting high or loopy after anesthesia. I am phobic of anything that would make me "not myself" or "high". I don't drink or use any kind of mind altering drugs for this reason.

I was anesthetized once for an endoscopy and had told them this beforehand and they told me there were multiple options for anesthesia and they couldn't guarantee anything but that they could use something that doesn't usually do that. Thankfully, they chose correctly and I was only a little nauseous when I woke up with no psychological side effects.

My question is two parts. 1 - Is it true that there are different options that have different chances of causing that effect and is there any way for me to know what they used that time?

2 - I worry that I won't be taken seriously enough when I tell a doctor or anesthesiologist of that need. I don't want to be blown off because it's "not that big of a deal" or because most people see it as funny. How can I most effectively communicate my need? When do I bring it up first? What words best describe that "loopiness" or high or whatever (clearly I don't know what to call it lol) in a way that is clear and concise and I won't be misunderstood about what im actually afraid of?

Thank you in advance for if you even take the time to read this. I'm sure you are very busy and have much better questions to answer. I hope I made myself clear enough, as mentioned earlier, I do have a communication- related disability :)

MilkmanAl2 karma

Generally speaking, anything that can smooth the transition from anesthetized to awake will help with what we call "emergence delirium," the time where you would potentially act without inhibition. It's uncommon for people to do things they wouldn't normally do, but if you were going to act out, that's when it would happen. That said, your mental health history does put you at higher risk for post-op delirium, so definitely make your anesthesia provider aware of those issues. Personally, my choice would be a dose of a drug called precedex before you wake up, but there are lots of effective ways to prevent that sort of delirium.

As for what to say, simply tell your anesthesia provider, like you've told me, that you have a significant mental health history and what that includes and that you're terrified you'll wake up confused and delirious. Then, ask if there's anything they can give you to lessen the risk of emergence delirium. That should be enough for them to understand that you've done some research on the subject and have a legitimate fear that needs to be addressed.

I am definitely very busy thanks to work and this thread absolutely EXPLODING, but your question is an excellent one that will likely help many people. Look around the thread. How many people do you see asking about waking up violently or being afraid of anesthesia? There are a ton who posted, so there are very likely a ton more who have the same question but didn't ask. Thanks for contributing!

unzercharlie1 karma

Should I be concerned about my heart rate when gaming? I'm 40, and my fitbit said I hit like 150 bpm the other day, took quite a while to go back down.

MilkmanAl2 karma

That's pretty fast but not unusual if you're really worked up while gaming. If you're not having any symptoms (like chest pain, sudden shortness of breath, feeling faint or passing out, etc.) and your heart rate decreases back to normal afterward, all is probably well.

Madmallard1 karma

What is the anesthesia risk to a patient with diastolic dysfunction stage 1, adrenal insufficiency, and mildly low cardiac output?

MilkmanAl2 karma

Mild diastolic dysfunction is generally a non-issue. For the other two, it depends on severity. Risk also depends on the type of surgery you're having. You'd likely be on the low end of an ASA class 3, as defined here. Specifically, the main risks that jump to mind would be hypotension due to adrenal crisis, so you'd probably get a "stress dose" of steroids before surgery, or due to cardiac issues. Depending on severity of those issues and tthe type of surgery you're having, you might require an arterial line - basically an IV that goes in the radial artery in your wrist - to monitor your blood pressure during the surgery.

Senray1 karma

How do I know that when someone wakes up from general anesthesia they still have the same consciousness they went under with? Is it possible that the original person "dies" and what remains is a new consciousness with the same memories?

MilkmanAl2 karma

Whoa, that's like, deep, man.

filbertsnuts1 karma

Have you ever thought of making your own game? Might I suggest Alex Tripp in Medical World?


MilkmanAl2 karma

Oh damn, it's gonna be a blockbuster!

YouveBeanReported1 karma

Two questions, one science one random,

Why does anesthesia apparently cause post-surgery depression? Do we know why? Is it the anesthesia or just the trauma and ow and being in a hospital woken up every hour for vitals?

Also what are your thoughts on VR, just in general. I've been debating if I can afford to get a headset.

MilkmanAl3 karma

Depression is a pretty common complication of surgery in general. Being in pain and in a hospital sucks, no matter how you slice it, and that takes its toll on many people. I'm honestly not sure what anesthesia's role in that situation is. Most anesthetics are fairly short-acting so typically have big mood effects for any longer than the recovery period There are certainly exceptions to that rule, though. Propofol can have you feeling pretty good for a day or two, and people with dementia are often notably more confused for a few days after anesthesia.

Here's an interesting paper on the interplay of anesthesia, surgery, and depression: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4736276/

As for VR, I think it's awesome. The games I've played are really smooth, and the graphics are coming along nicely. that said, it makes me motion sick after about 30 minutes, so long sessions are a no-go for me currently. I'm sure they'll improve that over time. If you haven't already, I'd definitely give it a go first to see if that's an issue for you, too. No sense in shelling out for an expensive piece of tech that just makes you barf.

gravy_trane1 karma

Dr. Tripp!

Whats your outlook on the current state of EMR's for anesthesiologists? Specifically preanesthetic assessments and perioperative records.

MilkmanAl2 karma

I really like both Epic and Cerner. I currently use iPro, which is an inefficient mess, in my opinion. It's absolutely awful for throughput, though ease of use is good. Part of the problem is likely that our hospital has gone the penny wise, pound foolish route of contracting multiple EMRs over the years, and they all have a bit of difficulty communicating with each other. We've had to make a lot of adjustments just to get the basic stuff into our records without a ton of hassle.

Overall, EMR is revolutionary for anesthesia. It's a little laborious on the front end sometimes, but during the case it allows for way better care and more attention to the patient with fewer distractions from constant documentation. When all the phases of the game communicate as they should, it's amazing!

ChiveNation_121 karma

I want to go to school for anesthesiologist.. how long is school ? And can you tell me more about it

MilkmanAl3 karma

As above, in the US, it's a total of 8 years after college - 4 of med school and 4 of residency. It's a long, difficult, and expensive path, but I really, really like my job.

AchilleanHighElf1 karma

How much do you make?

Asking as a current CA-1 and game enthusiast.

MilkmanAl6 karma

I'll answer indirectly. Here's a listing of available anesthesiologist jobs: https://gaswork.com/search/Anesthesiologist/Job

I will tell you, though, that working in a relatively undesirable location is good for your wallet. I make over the MGMA median.

Polyknikes1 karma

Who's more fun in the OR, surgery or interventional radiology?

MilkmanAl7 karma

Interventional radiology blows balls for anesthesia. The IR rooms usually aren't set up with anesthesia in mind at all, so we have to cram all our crap into really tiny spaces and often have to port over a bunch of meds and/or supplies. We also have to work around all the IR equipment, whether it's C-arms, CT scanners, or whatnot. The IR docs I've been around also tend to work on really haphazard schedules, so they just sort of expect us to be available whenever they decide they want to do their cases. Not my favorite, even though the cases are really cool.

jowww870 karma

How much do you make annually and how much do you have in loans?

MilkmanAl6 karma

Not enough and too much...said everyone ever. I'm definitely well-compensated for my efforts, and I came out of residency with over $500k in debt after those sweet 4 years of capitalized interest. It was awesome.

ReallyBillyGoat0 karma

Is it true that FUT champs has a more detrimental effect on your mental health than crack cocaine?

MilkmanAl1 karma

Clearly, but why not combine the two for better focus?

someonehadaquestion0 karma

I'm avoidant of medical treatment, not because I don't think treatment itself is helpful, but because oftentimes unless you have an emergent issue doctors seem like they're mostly guessing at your problem.

Example from my life, haven't had morning wood naturally since 17, am mid 30s. Went to doc, said lose weight, gave me cialis sampler. Lost 33% of my bodyweight and kept it off for ~18 months but problem persisted, doc shrugged, gave up and told me to see a therapist.

I've just continued buying cialis on the internet since it seems to work for my problem.

What would you say to someone like me, who finds going to the doctor pointless, even if there is some kind of issue?

MilkmanAl7 karma

First off, I'm sorry you've had a rough experience with the healthcare system. That's not how it's supposed to go.

That said, yours is a somewhat unusual issue, to be frank. Erectile dysfunction is most commonly psychogenic, in which case you can still get morning wood as normal but falter at "game time," or physiological, in which case you're never getting hard. Common causes of the latter are chronic high blood pressure, diabetes, or some sort of neurological issue or injury.

In any case, it's not going to hurt to talk with a therapist. that's something just about everyone can benefit from, anyway. I understand that seeing a doctor has been frustrating experience for you, but keeping communication open on that front is important. It's true that some people have problems that are kind of nebulous and/or don't have easy treatments. That can be really frustrating to deal with as a patient, for sure, since you're presumably seeking a physician's opinion for a definitive fix.

In your case, I'd do what the doc told you, get some therapy on board, keep up with the cialis as needed, and check back with your primary doc later. If you show that you've held up your end of the bargain, that goes a long way towards the doc feeling like you're working with him and not just demanding a fix. Not to say that's what you're doing, of course, but with the production pressure a lot of physicians are under, it's sometimes easy to just throw something at the wall to see what sticks instead of working through the problem with you.

someonehadaquestion3 karma

Wow, great answer, I appreciate it!

While my personal situation is one thing, its good to see some background/insider info on the thought processes of doctors.

Not that I mean to offend you or anything but I'm likely going to just continue on with the method I've adopted that works for me when interfacing with the healthcare system. That is, research the problem myself and try things out and only once those things fail, see a doctor.

Another example from my personal life is sleep issues, but I only made one attempt at a doctor for that problem before I decided to just start eating edibles every night.

It works, I feel good, I don't really see a need to address a problem that isn't a problem anymore. Also, like you said, something nebulous like that would likely take multiple appointments over a long span of time to actually get any kind of semi-solid medical opinion on.

Not to say I won't go to the ER or something if I break my leg, the medical system seems to be extremely good at that type of thing.

In any event, I appreciate your time and effort. Thanks again.

MilkmanAl3 karma

I 100% support educating yourself first. That's exactly what you should do. Unfortunately, most people don't actually know how to do that properly, which is why I started getting vocal on social media and making content in the first place. Johns Hopkins, Mayo, and the NIH are remarkably good places to look for common medical information. WebMD and other similar sites are kind of meh. They oversimplify things (sometimes a positive, to be fair) but also tell you about the big, nasty, scary, but extremely unlikely complications in a sort of nonchalant way. If you're looking for more technical, high-end research sort of stuff, searching Goggle Scholar is a great way to go, though a lot of what you find will be jargony nonsense if you don't have a science background.

Sleep is a tricky beast, but if edibles work for you, that's actually not a bad option. It may stop working at some point, though, in which case you'll probably have to fall back on old standards like regular bed and wake times, no TV or computer before bed, etc. If it ain't broke, don't fix it, though!

All the best to you, man. May your morning flag fly!

jordonmears-7 karma

What part of being an anesthesiologist makes you an expert enough to give advice on mental amd physical health? You just pump people full of drugs... literally. You're not a diagnostician or practitioner.

MilkmanAl3 karma

Hmmm...I think your understanding of what anesthesiologists do may be a little lacking, my man. Maybe read some of the other responses in this thread.