Neuraxial Anesthesia for Labor and Delivery: Epidurals

Background:

In obstetrics an epidural is usually placed for labor and delivery. It is placed for pain control. Typically the epidural is placed during active labor, however an epidural can be placed prior to active labor if the patient is committed to labor. In some cases an epidural may be placed not for labor and delivery but for use during a cesarean section (c/s). The reason is that an epidural can be used for a prolonged c/s.

An epidural differs from a spinal due to the anatomic placement and the resultant effects. An epidural needs a larger volume of local anesthetic to be as effective as a spinal anesthetic. An epidural is typically administered via a catheter which allows the anesthesiologist to titrate the anesthetic slowly, which isn't the case typically in a spinal anesthetic, and also allows for a continuous infusion of local anesthetics which is comforting during a labor. 

The diagram above will serve to conceptualize the anatomy of the epidural procedure. To the left on the illustration is the skin. To place an epidural a needle transverses the skin, next the interspinous ligament (between the spinous processes which are the knobby projections in the middle of your back), then the ligamentum flavum, and finally the epidural space. We do not want to enter the dura, because for an epidural we are using a much larger needle than what we typically use for a spinal procedure, so that means if you puncture the dura with an epidural needle the chances of a spinal headache after the procedure are very high.

The Procedure:

Above is a typical epidural kit. When you request an epidural you obstetrician will page for the anesthesiologist or nurse anesthetist. The anesthesiologist will interview you and do a history and physical. Basically we are ensuring you are an appropriate candidate to receive an epidural. Our main concerns are to rule out an bleeding abnormalities, neurological or cardiac issues. We also want to make sure the delivery is running smoothly, although the obstetrician will alert us prior to us seeing you if there are any issues. We will look to see if there is any pertinent blood work drawn and we will also ask about the pregnancy. Verifying that there are no issues during your pregnancy or with past pregnancies or with past epidurals. The main risks associated with epidural placement are causing a post epidural by inadvertently going through the dura as described above. We also inspect the back to ensure no skin infections in the area that we will be placing the epidural. We typically place the epidural in the lumbar area. Typically below the L2 area, although this isn't as stringent as with a spinal since we will not be going intrathecally (below the dura, and potentially injuring the spinal cord). Risks of dosing the epidurally are typically hypotension, or lowering of the blood pressure and causing fetal decelerations. I dose my epidurals slowly and make sure that my patients have received adequate fluid boluses. This has been highly effective for me. Other less common risks include seizure, paralysis, and death. These risks are a lot less common.

After we obtain consent, we prepare to place the epidural. We sterilize your back with a prep solution.  After doing this we wash our hands and don sterile gloves and draw up the local anesthetic. I find the spot that I will be placing the epidural and put local anesthetic in that area.

I allow the local time to take effect. In the picture above is a blue hubbed needle, this is the needle I use to infiltrate the skin with local anesthetic. Next I use the needle that is in the picture that has the silver and black demarcation. This is what is termed a Tuohy needle. This is the needle that will be used to place the epidural catheter. I slowly advance the Tuohy needle through the skin, the interspinous ligament, the ligamentum flavum (there is a characteristic popping sensation).

Once I am in the interspinous ligament area, I pull the plastic stylet that is in the middle of the Tuohy needle and place the syringe in the picture above onto the back of my Tuohy needle. This is my loss of resistance syringe, it is filled with sterile saline. The loss of resistance syringe allows me to judge when I am in the epidural space, once I pass through the ligamentum flavum, there is a potential space prior to reaching the dura. This potential space causes a loss of resistance, this is felt and the anesthesiologists thumb sits on the plunger of the loss of resistance syringe. Once the loss of resistance is reached, beyond the ligamentum flavum, the plunger gives way and the anesthesiologist injects the sterile saline into the epidural space. This injection of saline into the epidural space is itself useful as it decreases the likelihood of placing your epidural catheter into an epidural vein. This procedure is all done on feel and landmarks. So, final knowledge of correct placement of the epidural only occurs once the patient begins to feel appropriately comfortable.

In the picture above to the left is the sterile saline that is used for the loss of resistance syringe. The vial in the middle is the local anesthetic that is used at the beginning of the procedure. And the vial to the right is the test dose. I will get to that in a short while. Once I have loss of resistance, I next begin to thread the epidural catheter into the epidural space. The epidural catheter is a long flexible tube that is about the thickness of a strand of spaghetti. Once the catheter is in, you may experience a shooting pain down one or both of your legs, this is typically transitory. I next dose the catheter with the test dose, the reddish vial on the right. This test dose helps confirm the epidural catheter is not in an epidural vein or in the spinal space. The anesthesiologist will typically ask if you feel any funny taste to your mouth or ringing to your ears after the test dose, this would mean the catheter is in a vein, and would need to be repositioned.  The neurologic side effects are from the lidocaine in the test dose going into a vein. There is also epinephrine in the test dose and is a second signal that the catheter is malpositioned. If the patients heart rate goes up after the test dose, this means the catheter is in a vein. The lidocaine is a test to see if the catheter is in the spinal space, if after the test dose the patient becomes extremely comfortable or can't move their legs, then that means the catheter is probably intrathecal (in the spinal space).

Post epidural care:

Once the epidural is in and the test dose is done, the next thing I do is check the baseline blood pressure and start to slowly bolus the epidural catheter with Bupivacaine, a local anesthetic. I will be frequently monitoring the patient and the blood pressure to ensure each is stable. Hypotension can occur and if it does it will happen usually within the first half hour after dosing an epidural. Once I have bolused the catheter and ensured the patient is stable I begin a continuous infusion of bupivacaine and sufentanil into the epidural catheter from an external epidural pump.

Neuraxial Anesthesia for Labor and Delivery: Spinals

Background:

Neuraxial anesthesia comes in two forms, spinal and epidural (can also have a combined spinal/epidural).  For labor and delivery you will most likely only have a spinal anesthetic if you are going to have a cesarean section. Of course there are exceptions to every rule and there is an exception to this rule as well. Some anesthesiologists will place a low dose spinal if you ask for an epidural for labor. 

Some anesthesiologists perform spinals when they place an epidural for labor in order to deliver quick pain relief. The reason I choose to not do this is because I like to know my labor epidural is working.  If I place a spinal anesthetic and then I thread in an epidural catheter, I won't be able to know if my epidural catheter is working, here is why. The spinal that I placed prior to threading the epidural will make the patient comfortable. I rely on dosing my epidural and then having a comfortable patient 15 minutes later to verify that I have a working epidural, if the patient is already comfortable from a spinal I have placed, I cannot dose my epidural and have verification of correct placement because the patient is already comfortable.

You may be wondering, what is the difference between an epidural and a spinal, or is there any difference? The difference is based on anatomy and location. An epidural is above the dura. Eli- meaning on top of, and dura meaning tough ligament. So an epidural is a space on top of the ligament. A spinal, also know as intrathecal, is below the dura, or below the ligament. The dura is a tough ligament thats main function is to hold the cerebrospinal fluid; similar to a balloon that holds water. The cerebrospinal fluid in the dura is used to protect the brain and the spinal cord. So an epidural is above the dura and a spinal is below the dura.

The Procedure:

Start by obtaining the consent from the patient, letting them know the risks and the benefits. The benefits are obvious, pain relief. There is belief that decreasing the amount of pain will decrease the catecholamine response, which in turn will increase uteroplacental perfusion. Most spinals in obstetrics are done for cesarean sections. However, like I stated previously, some anesthesiologists will used a combined spinal/epidural technique for labor and delivery. Back to the main point, spinals are done for cesarean sections (c/s) because numerous studies have confirmed a spinal or an epidural technique is safer than a general anesthetic for c/s. An epidural would be used in a c/s if a mother is laboring and during the course of labor is administered an epidural and subsequently is taken to the operating room (o/r) for a c/s. An epidural is sometimes used in patients who have had numerous previous c/s or are morbidly obese. The reason being, an epidural allows the anesthetist to length the neuraxial anesthetic because a catheter is left in place when you do an epidural and commonly is not for a spinal anesthetic. The side effects are multiple. The main ones being hypotension. The hypotension has a cascade effect and can lead to nausea/vomiting and fetal decelerations if not treated quickly. The less common side effects are high spinal, when the anesthetic is too high, it may be hard for the mother to breath or she may not be able to breath at all, in which case the spinal is switched to a general anesthetic and we breath for the mom. Seizures and death being the other rare side effects of a spinal anesthetic. Another fairly rare side effect is a spinal headache. Spinal headaches have almost been entirely eliminated. Through research on the issue, we have been able to substantially decrease the occurrence of post spinal headaches. What we have learned is to use smaller needles and a needle with a pencil point tip.

We also will perform a history and a physical exam. The basis of the history is to ensure you are appropriate candidate for a spinal anesthetic, there are no bleeding disorders, neurologic disorders, or any cardiac valve abnormalities that may make us reconsider using a spinal as our anesthetic. Parturients typically have lab results, I will look at these results to ensure they are normal. We will also ask about the course of your pregnancy to ensure no serious issues are surrounding the course of your pregnancy, such as pregnancy induced hypertension, cardiomyopathy of pregnancy, placenta accreta, etc.

Next the anesthesiologist will prepare the spinal tray, seen in the picture above. Also we begin to prep the mothers back to sterilize the skin surface as much as possible. 

Once the prep is done, the time out is done, the anesthesiologist has wash their hands and they are set up, they will begin the spinal procedure.

We start by infiltrating your skin with 1% lidocaine, which is in the bottle on the left. This allows us to advance larger needles later on in the procedure without causing as much discomfort. We allow the lidocaine to take effect and then we go onto the next part of the procedure. For a spinal anesthetic we typically use the L3-L4 interspace to decrease the risk of injecting our solution into the spinal cord. A

To get to the spinal space, the anesthesiologist needs to put the spinal needle through multiple layers, the skin, adipose layer below the skin, interspinous ligament, ligamentum flavum, the epidural space, and then the dura, and then into the cerebrospinal fluid. Confirmation that one has reached the spinal space is the presence of cerebrospinal fluid (CSF) in the spinal needle hub.

The spinal needle is in the above picture. The spinal needle in the above picture is the blue hubbed longer needle. When you reach the spinal space you will see CSF in the hub of the blue spinal needle.  The hub is the blue portion of the needle. There is a stylet that goes into the center of the needle. The stylet is a thinner needle that delivers more strength and integrity to the spinal needle and also prevents tissue from clogging the spinal needle as the spinal needle is advanced through skin, fat, and ligament. If there were tissue in the core of the spinal needle then one would not be able to confirm proper placement of the spinal needle in the CSF as the tissue would prevent CSF from traveling into the core of the spinal needle and into the hub.

Once CSF is seen in the hub of the spinal needle the local anesthetic that will be used is injected in the spinal needle. I typically use 0.75% bupivacaine with dextrose mixed with fentanyl and morphine. There are a number of mixtures that anesthesiologists use, it is similar to a recipe, each has its own merits. I use bupivacaine, a local anesthetic, for the pain relief, the loss of motor (so you cannot move your legs while the operation is in progress), and its lack of painful aftereffects. I mix the local anesthetic with fentanyl for its quick action and synergistic action with bupivacaine. I add morphine because it lasts for 24 hours, offering you pain control once the operation is over. However, adding narcotics is not without deleterious effects. Nausea, vomiting, pruritus are all potential side effects of adding narcotics to the spinal mix.

Post spinal anesthetic:

Like I have stated previously, I never use a spinal anesthestic for laboring patients. So, I will briefly touch on the experience of a c/s from the anesthetic standpoint, after administering a spinal. 

After a spinal, unless contraindicated, I will typically administer a vasopressor, which will maintain the blood pressure. I have had good success with this approach in decreasing the number of hypotensive patients, thereby decreasing the number of patients retching after the spinal.

When the baby is being delivered, you will feel them pushing, as they will be pushing in the substernal area. This is uncomfortable. Throughout the procedure, mothers report sometimes feeling uncomfortable about not being able to move their legs, or may feel queasy when the obstetricians are pulling at different layers when they are operating. Mothers report feeling touch throughout, but you should very little pain. Most mothers also have shivering that lasts through the procedure. This is more a nuisance than anything else.

This Month in Anesthesia History: February

1723 February 25: Christopher Wren died in London. Around 1660 the English architect and astronomer began to experiment with the transfusion of blood between animals and intravenous injections into animals. An account of his work was published in the Philosophical Transactions of the Royal Society of London in 1665. [see Bergman NA. Early intravenous anesthesia: an eyewitness account. Anesthesiology 72:185-186, 1990] Recent biographies of Wren include Lisa Jardine's On a Grander Scale: The Outstanding Life of Christopher Wren and Adrian Tinniswood's His Invention So Fertile: A Life of Christopher Wren.

1804 February 6: Joseph Priestley died in Northumberland, Pennsylvania. Among many other achievements, this English Unitarian minister and scientist isolated nitrous oxide. In 1774 Priestley wrote about his research on gases, "I cannot help flattering myself that, in time, very great medicinal use will be made of the application of these different kinds of airs..." [Priestley J. Experiments and Observations on Different Kinds of Airs. 6 vols. 1:228, 1774] Priestley was born on March 24, 1733, near Leeds, England. For many years he was a member of the Lunar Society, a loose organization made up of scientists and industrialists such as James Watt and Josiah Wedgewood. Many of these men later supported the research by Dr. Thomas Beddoes and Humphry Davy on nitrous oxide and other gases. Priestley was a supporter of the American Revolution and considered by many a heretic; on July 14, 1791, his home in Birmingham was burned by a pro-Royalist mob. His laboratory, large library and unpublished manuscripts were destroyed. In April, 1794, Priestley and his wife sailed to America. You can learn more about him at http://www.historyguide.org/intellect/priestley.html

1807 February 27: American poet Henry Wadsworth Longfellow was born in Portland, Maine. On April 7, 1847, physician/dentist Nathan Cooley Keep administered the first obstetric anesthetic in theUnited States in Cambridge, Massachusetts. Dr. Keep was a prominent physician of the Boston area and the first Dean of Dentistry at Harvard. The patient was Frances Appleton Longfellow, second wife of Henry Wadsworth Longfellow. In his journal entry for April 1, the famed poet and scholar had noted, "Went to town the first time for several weeks and had a conversation with Dr. Keep about the sulphuric ether and its use." Under ether anesthesia, Fanny did not lose consciousness but felt no pain during the birth of her child. She later wrote about her experience, "I am very sorry you all thought me so rash and naughty in trying the ether. Henry's faith gave me courage...I feel proud to be the pioneer to lessen suffering for poor, weak womankind. This is certainly the greatest blessing of this age and I am glad to have lived at the time of its coming and in the country which gives it to the world..." [See Clark RB. Fanny Longfellow and Nathan Keep. ASA Newsletter 61(9), September 1997]

Henry Wadsworth Longfellow, his wife Frances Appleton Longfellow, with sons Charles and Ernest. Circa 1849. From the collection at the Longfellow National Historic Site, Cambridge, MA.
Copyright Easter National Park and Monument Association 

1814 February 7: Gardner Quincy Colton was born in Georgia, Vermont. Colton introduced nitrous oxide to Horace Wells, among other achievements.

1824 February 21: Englishman Henry Hill Hickman wrote a letter to T.A. Knight describing his experiments with painless surgery on animals using carbon dioxide as an anesthetic.

1829 February 15: Silas Weir Mitchell was born. This American surgeon, neurologist, novelist and poet explored the relationship between pain and the weather and eye strain to headaches. Mitchell died on January 4, 1914.

1836 February 25: A patent was granted to Samuel Colt for his revolving pistol. In the 1830s Colt, calling himself "Professor Coult" or "Doctor Coult" of "Calcutta, London and New York", toured the eastern United States giving demonstrations of nitrous oxide inhalation to raise money to put his revolver prototype into production. In 1836 he patented a revolving-breech pistol and founded the Patent Arms Company in Paterson, New Jersey. The company failed in 1842, but an order for 1,000 revolvers by the U.S. government five years later during the Mexican War allowed Colt to restart his business. Colt was born in Hartford, Connecticut, on July 10, 1814 and died on January 10, 1862. The text of an advertisement for Colt's nitrous oxide demonstration in Portland, Maine, on October 13, 1832, can be found in Smith, Under the Influence: A History of Nitrous Oxide and Oxygen Anaesthesia [pp 37-38].

1848 February 1: The Mexican-American War ended with the signing of the Treaty of Guadalupe Hidalgo. The first major battle of the U.S. war with Mexico was fought at Palo Alto, Texas, on May 8, 1846. Ether anesthesia was first used in a military conflict in this war, sometime in the spring of 1847 under the direction of American surgeons Edward H. Barton and John B. Porter. [See Aldrete JA, Marron GM, Wright AJ. The first administration of anesthesia in military surgery: on occasion of the Mexican-American War. Anesthesiology 61:585-588, 1984] The Library of Congress offers an excellent list of resources on this conflict at http://www.loc.gov/rr/program/bib/mexicanwar/

1873 February 1: First documented death from nitrous oxide inhalation in Great Britain was reported in this issue of Lancet.

1874 February 16: Pierre-Cyprien Ore [1828-1891] reported to the French Academy of Sciences a case in which he administered the first intravenous general anesthesia in humans. “Ore was very enthusiastic about intravenous anesthesia with chloral hydrate, and believed it to be superior to inhalation anesthesia with ether or chloroform.” [Keys, The History of Surgical Anesthesia, p. 57] Two years earlier he had published a preliminary report on the technique. In 1875 he published the first monograph on the technique, Etudes Cliniques sur L’Anesthesie Chirurgicale par La Methode des Injections de Chloral dans Les Veines. Acceptance of the method was delayed by slow recovery and high mortality.

1878 February 10: Claude Bernard, French physiologist, died. Bernard's classic work, Lectures on Anesthetics and on Asphyxia [1875], is available from the Wood Library-Museum of Anesthesiology in a fine translation by B. Raymond Fink, MD, published in 1989.

1884 February 26: Scottish physician Alexander Wood died. Wood introduced the hypodermic syringe for drug administration.

1908 February 22: A.D. Waller described his chloroform balance at a meeting of the Physiological Society in London. This apparatus was the first to give a continuous and almost instantaneous reading of the concentration of vapor received by the patient.

1909 February 20: Congress passed the first U.S. law prohibiting the manufacture and sale of opium. Opium had been used for centuries to relieve pain, but by 1900 an estimated 200,000 people in the U.S. were addicted to opium and its derivatives such as laudanum, paregoric and morphine.

1936 February 13: American Society of Anesthetists was founded. In a letter from Paul Wood to John Lundy, dated February 14, Wood noted, "I was reminded at the meeting last night which approved the change in title from New York to American Society of Anesthetists..." This letter is in the Collected Papers of John Lundy, Mayo Foundation Archive in Rochester, Minnesota. In a few years another name change would create the current name. The ASA can trace it’s history back to the Long Island Society of Anesthetists founded in the very early 20^th century. A history of the ASA isBacon DR, McGoldrick KE, Lema MJ, eds. The American Society of Anesthesiologists: A Century of Challenges and Progress [Wood Library-Museum, 2005].

1938 February: The American Board of Anesthesiology became affiliated with the American Board of Surgery.

1941 February 16: The American Board of Anesthesiology achieved independent status.

1943 February 13: Sir Robert Macintosh published as article in Lancet about the laryngoscope blade that now bears his name.[Mactintosh RR. A new laryngoscope. Lancet 1:205, February 13, 1943]

1969 February 2: British actor Boris Karloff died at age 81. Although perhaps best known for two roles, as "The Monster" in Frankenstein (1932) and the title character in The Mummy (1932), Karloff acted in dozens of films between his start in 1916 in silent films and his death. In one of the films made toward the end of his career, Corridors of Blood (1958), he plays Dr. Thomas Bolton, a physician in the early Victorian era who is determined to find a drug that will obliterate pain during surgery. As he tells the other hospital physicians who mock his efforts, "Operations without pain are possible, and I'll not rest until I prove it to you." Like some of the historical figures in early anesthesia history, Bolton experiments on himself as he searches for the right dosage and becomes addicted.

Don't go to the mall

Islamic Retribution for the Crusades

Obama warned us that being Christian we are deserving of terrorism from the unnamed terrorists. Don't blame the muslims because not all of them are bad, but you can blame all modern day Christians and non Christian Americans for the acts of Christians over 900 years ago. Never mind that Islam aggressively used the sword 900 years ago to convert and gain territory.

If you look at Muslim countries throughout our world, they are 99.9% muslim. This isn't obtained through peaceful adherence and peaceful belief in a religion. This is obtained through coercion that is both church and state based. Saudi Arabia, the Mecca of the muslim world, is also 99.9% muslim and is theocratic in its laws and government. To evangelize is an illegal act punishable by death. There are only a few recognized religions, the other religions, including atheism is not recognized and is punishable by death.
Saudi Arabia has long been criticized for its human rights record. Human rights issues that have attracted strong criticism include the extremely disadvantaged position of women, capital punishment for homosexuality, religious discrimination, the lack of religious freedom and the activities of the religious police.
In 2010, the U.S. State Department stated that in Saudi Arabia "freedom of religion is neither recognized nor protected under the law and is severely restricted in practice" and that "government policies continued to place severe restrictions on religious freedom". No faith other than Islam is permitted to be practiced, although there are nearly a million Christians—nearly all foreign workers—in Saudi Arabia. There are no churches or other non-Muslim houses of worship permitted in the country. Even private prayer services are forbidden in practice and the Saudi religious police reportedly regularly search the homes of Christians. Foreign workers have to observe Ramadan but are not allowed to celebrate Christmas or Easter. In 2007, Human Rights Watch requested that King Abdullah stop a campaign to round up and deport foreign followers of the Ahmadiyya faith.

Conversion by Muslims to another religion (apostasy) carries the death penalty, although there have been no confirmed reports of executions for apostasy in recent years. Proselytizing by non-Muslims is illegal, and the last Christian priest was expelled from Saudi Arabia in 1985. There are some Hindus and Buddhists in Saudi Arabia. Compensation in court cases discriminates against non-Muslims: once fault is determined, a Muslim receives all of the amount of compensation determined, a Jew or Christian half, and all others a sixteenth. Saudi Arabia has officially identified atheists as terrorists. The regulations place secular citizens who commit thought crimes in the same category as violent terrorist groups Proselytizing by non-Muslims, including the distribution of non-Muslim religious materials such as Bibles, is illegal. The country has just recently passed a law recommending the death penalty for anyone caught carrying or smuggling a bible into the country. Killing someone for handing out a bible isn't hostile? Demanding non muslims to celebrate Ramadan and not allowing them to celebrate Christmas, isn't hostile? Giving plaintiffs that are non muslim 1/16th of a recourse isn't hostile? Death penalty for atheists and homosexuals isn't hostile?

President Barack Obama is a fool

Krauthammer 'Stunned' By Obama's 'Banal & Offensive' Prayer Breakfast Remarks

Discussion regarding false moral equivalency of the presidents statements



How does the president reconcile the fact that he is making a straw man argument? In order for his argument to work, you first need to be a Christian, if you are a Jew, Hindu, Atheist, etc, his argument means nothing. Your ancestors weren't Christians that were involved in the Crusades, so how does that fact exonerate the fact that muslims are killing innocent people? It doesn't, his argument is flawed.
Weak part of argument number two. The Crusades happened nearly a millennia ago. There has been a number of occurrences in Western Civilization that have managed to alleviate the power that the Christian church has over society. In order for President Obamas argument to hold any sway, you would have to wipe out the Enlightenment, the introduction of movable type, the mass literacy of the populace, and the internet. Once people were able to read the bible themselves and the failings of the bible were brought to the open, the bible was no longer allowed to have the same fundamental innerancy that it once had. These events have not had the same hold on Islam as it has on most other parts of the world. Illiteracy in muslim countries is widespread. The introduction of freedom of religion and freedom from religion is not the norm in muslim countries.
Issue number three. The objective of the crusades was to prevent the islamization of the entire western world and to try to regain some territory that had been lost from the west to the muslims. This point was entirely missed in the presidents speech. Besides it wouldn't have been the fault of the muslims, as they gained all territory peacefully in his mind, I am sure.
The main issue that I have with President Obama is he understands the lack of knowledge of his core constituency. He owns the Walmart shopper. He doesn't own the Saks or Wall street type. The troubling part of the matter is that he also owns most academicians, simply because the Republicans are the home of the religious right. With the press and university in his corner, Obama is able to speak such dribble without any backlash. He is able to spread the blame for terrorism. He can make the argument that it isn't the fault of the terrorist, but the real fault is in each of us, each American.

Here are some of Obamas famous quotes, if you agree with these quotes, I would enjoy knowing why.

"If you've got a business- you didn't build that, someone else made that happen."

"I've got two daughters. 9 years old and 6 years old. I'm going to teach them first of all about values and morals. But if they make a mistake, I don't want them punished with a baby."

This quote is especially cringe worthy. Is this a utilitarian philosophy he is trying to espouse? That the best decision is what garners the greatest happiness? Is he espousing hedonism here? But is this truly the most happy of decisions? In his mind it must be. The baby is labeled as such..a baby, he doesn't say fetus or pregnancy, he says baby. To him, a baby is equal to a mistake. 

If you are at all interested in a what an intellectual has to say about the future and the truth of our current world crisis, then listen to an intellectual. Obama is clearly a populist president. He makes zero qualms about this. He enjoys debasing himself (or being himself) in order to relate to what he supposes is the mindset of his constituents. He paints a bleak portrait of the common man and woman. He thinks them so stupid as to believe or to view a baby as a mistake and to think that terrorists actions are exonerated due to the actions of a group from a thousand years ago.

Christopher Hitchens debating Islam

Hypnosis and its use in Anesthesia

Approaches to Hypnosis


This is an interesting adjunct to my anesthetic regimen.

A link to societies for hypnosis

American Society of Clinical Hypnosis

The American Board of Medical Hypnosis


I try to ensure I am giving positive suggestion and am always aware of my own ability to affect the patients experience through my words and actions. I try to make the experience one that is positive for the patient. I have always wanted to broaden my ability to make the patient more relaxed and in a suggestible state to have a better overall experience.

Use of hypnosis as a substitute premedication and adjunct to anesthesia

What is Guided Imagery?

Guided Imagery & Heart Surgery

The effect of preoperative suggestions on perioperative dreams and dream recalls after administration of different general anesthetic combinations: a randomized trial in maxillofacial surgery

Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures

Selected topics in perioperative multimodal pediatric pain management


Above are a few guided imagery studies and sites. I will look into hypnosis and non pharmacological means to assist a patient recover and get through positively the preoperative experience.

This video is a demonstration of hypnoanesthesia.


Hypnosis in the OR, ICU, and ER

Interesting Book on Medical Hypnosis: Clinical Hypnosis and Pain Therapy-Palliative

2014 in retrospective, Medical school and Affirmative Action

This has been a crazy year, to say the least.
Highlights of the year
1) Simon learning he loves ice skating, Jena skating, and Oliver playing basketball
2) play lots of basketball
3) join the Mount Holyoke gym with Oliver
4) post a ton of pics to pinterest
5) visit D.C.
6) visit the Cape
7) visit Bahamas

Might as well promote my pinterest page

https://www.pinterest.com/tnobabbott/

I am going in a new direction on my blog. I had in the past posted quite a few things on Facebook. I think in the future posting on my blog would be more beneficial. Fighting with people on Facebook is about as useful as a punch to the face.

One of the issues that I have argued about in the past consistently is affirmative action. I am vehemently against affirmative action, and this is why. I argue that affirmative action is racism. Racism is the belief that one race is superior to another race. Affirmative action was put into place originally as a system to break the barriers that were inherent in many corporations, universities, and societies. What was once used to allow people of differing races to enter into a job, profession or obtain an education, is now a system of white guilt appeasement. Affirmative action was used to allow people of differing colors with the skill sets necessary or the aptitude necessary to compete with whites of similar aptitude and skill set. That is no longer the case. The case now has been to put people of color with lesser skill or lesser aptitude in positions that they could not compete for without a system in place that gives them credit for being black. It is a racist system that judges a person competent based solely on the color of their skin and not on their skill set. This is racism.

In order to matriculate in a medical school an applicant needs to have the necessary credentials to do so. An applicant must have an overall GPA >3.8 and a science GPA>3.7, a MCAT score >32, and be a well rounded individual. What constitutes a well rounded individual? Community service, having a skill in a science or non science related field (being a concert pianist, having engineering experience, etc), would constitute what medical schools would be looking for to round out a well rounded individual that would separate them from the other stellar applicants. Does being black entitle one to the criteria of being well rounded? Does diversity mean you are well rounded?

The argument for diversity usually revolves around the future patient. Many believe that patients would like to be treated by someone of their own cultural and racial makeup. However when I posted some time ago on a medical forum that there were too many Asians and that I think that impairs my ability to be seen by a white physician, I was rightfully argued against that I was being racist and that this type of thinking is unacceptable in this day and age. If it is unacceptable for me to desire to be seen by someone of my cultural and racial makeup, then why is it acceptable and sought after to go after black applicants that have lesser aptitudes than other applicants? Would it be acceptable to fill an NBA team with white players in order to meet a quota? To accept players with lesser skill, simply due to race?

Here are the facts that clearly show a discrimination towards accepting blacks with lesser qualifications than whites and asians:

MCAT Scores and GPAs for Applicants and Matriculants to U.S. Medical Schools by Race/Ethnicity, 2014

There is a large statistical gap separating the MCAT and GPAs of white/asians from blacks. This is clear racism against white/asian applicants in order to benefit black applicants. Should we be judging based on the content of a persons skill set or on the basis of the applicants skin color? If the tilt was to the opposite direction, say whites with lower GPAs and MCAT scores in comparison to blacks with higher MCAT scores and GPAs the outcry I am sure would be widespread and immediate.

Mindy Kaling's brother exposes affirmative action