Administering Anesthesia
April 23, 2008
By Dr. Jon Miyagi
Dr. Jon Miyagi
Anesthesiologist
What’s your background and where did you receive your training?
I am from Pearl City and graduated from Iolani School in 1981. My medical school training was here at the John A. Burns School of Medicine, after which I did an internship year in obstetrics at Kapiolani Hospital. I spent three years in anesthesia training at the Oregon Health & Science University in Portland before returning home. I was in private practice for 10 years. I’ve been at Kaiser for more than three years now.
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Can you explain the differences between an anesthesiologist and an anesthetist?
An anesthesiologist is a medical doctor who goes to medical school. After getting a medical degree, an anesthesia residency is a four-year program. You do a year of internship in medicine or surgery or some combination of the two, and then you do an anesthesia residency for three years, after which you become an anesthesiologist. An anesthetist is actually a critical care nurse who spends at least two years in the critical care unit. The nurse has to apply for anesthesia school, which is a master’s type of program. They usually spend two years in the anesthesia school, where their training can be tied in with the anesthesia programs for M.D.s. Our anesthetists at Kaiser are very well-trained in patient care. The anesthesiologists and anesthetists work together as a team. We formulate a plan to carry out the anesthesia and work together to get the patient through the surgical procedure. In all procedures, we have someone monitoring the patient at all times.
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Can you discuss the different types of anesthesia?
There are three different types of anesthesia. There’s general anesthesia, where the patient goes off to sleep and stays asleep for the entire time. The most common way to perform a general anesthetic is to administer medicine through an IV to get the patient off to sleep. The patient will remain asleep with anesthetic gases, which are administered via a breathing tube. With a regional anesthetic, the patient receives an injection of anesthetic to block the nerves in a specific area. The medicine we inject for a regional anesthetic is similar to the numbing injection you receive with a dental procedure. We sometimes combine a general anesthetic with a regional so the patient can be totally asleep for a procedure and wake up more comfortable with the regional anesthetic in place. The other form of anesthesia is monitored anesthesia care, where we typically administer sedative medicines through an IV to help a patient get through a procedure.
What are the biggest differences in administering anesthesia to a child?
With children, we often will have them fall asleep using anesthesia gas and start the IV afterward. We have to be very vigilant with drug dosages because of their small size. Oftentimes, children don’t have as many cardiac problems or chronic diseases as adults, so we will really focus on their airway and breathing. They can often pose challenges with placing IVs because everything is much smaller, including the vessels.
Can you talk about different types of epidurals and what they are for?
For surgery, we sometimes use an epidural in addition to the general anesthetic for pain relief after the operation. This is an example of the combined general and regional anesthetic I mentioned before, and we often offer it to patients who will have a big abdominal incision. Typically we place the epidural before the surgical procedure and give medicines through the epidural during and after the surgery for pain relief. We also can use an epidural alone for a surgical procedure involving the lower extremities or lower abdomen. Another use for an epidural is for women in labor. To place the epidural, we insert a small tubing or catheter into the back through a needle. After taking the needle out, we tape the catheter in place and run medicine through it to ease the pain from labor.
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How do you determine the dosage of medication to give a patient?
We administer our drugs based on the weight of the patient and make adjustments as needed by the response of the patient to what has been given. If the patient is awake enough to communicate, we will administer more medicine as needed. If the patient is asleep, we monitor such things as heart rate and blood pressure to adjust the anesthesia.
Can you describe what an average day is like for you?
What’s unique about Kaiser is we have different assignments every day. So, for instance, today I was assigned to the preoperative evaluation and education clinic. There’s an anesthesiologist assigned to the clinic every day, and what we do is we see the patients prior to the day of surgery. We are able to create an anesthetic plan with the patients and answer their questions. Hopefully, this will make their surgery experience less fearful. At Kaiser, we are fortunate to have the opportunity to look up their chart and history on our computer system, because getting the person’s history is probably the most important thing about doing anything in medicine and anesthesia. We also have the opportunity to communicate with the primary care physician to see if we need to do further testing and whether the patient is optimized medically for surgery. We can do all these things beforehand so when the patient shows up on the day of surgery everything is ready to go. We also have duties in the operating room. On a normal day in the operating room, we prepare the patients, check the patient’s record, coordinate care with the anesthetists, and together we go ahead and get the cases on their way. Sometimes with sicker patients or patients who are undergoing a really complicated procedure, we will insert extra monitors, which involve placing special catheters through a needle into neck veins and arteries.
Are most of the patients you see scheduled or emergency situations?
I would say majority of the cases are scheduled. If there are emergency situations that arise throughout the day, we have to adjust the schedule. The good thing is we have a lot of staff, so we are able to delegate responsibilities.
Are there any health-related issues that do not allow a person to receive anesthesia?
In terms of having a scheduled case, we would watch for things that unexpectedly arise with a patient’s health. For instance, if the patient has an active cold with a fever or is coughing up things, then we would usually wait until those symptoms resolve before having the surgery. Anytime we feel that the patient is not medically optimal, we will wait.
Do you experience high-pressure or stressful situations?
High-pressure and stressful situations come about when surprises occur despite being as well-prepared as possible. For anesthesiologists, I would say problems with a person’s airway and the resultant inability to breathe would cause a lot of stress. With an airway problem, we have to react quickly and decisively because there’s not much time before the patient gets into problems from a lack of oxygen.