By Lewis S. Coleman, MD
I noted the correspondence of Aaron I. Cohn, MD, titled “Questioning ‘Is This Patient Truly Difficult to Intubate?’” and am delighted to see that this subject is getting some of the attention it sorely needs. Back in 2015, I authored “Routine Mask Induction and Intubation Without Paralysis Optimizes Safety,” in which I argued that routine mask induction and intubation without paralysis may be safer than the presently prevailing and unquestioned habit of intravenous induction with hypnotic agents followed by paralysis to facilitate elective intubation, both of which are inherently hazardous and have caused numerous deaths.1 I didn’t bother to submit the letter to “prominent” journals, such as Anesthesiology or Anesthesia & Analgesia, because I knew they wouldn’t entertain such a challenge to prevailing dogma.
There are numerous aspects of anesthesia practice that need to be scrutinized and reformed, including the following:
• the notion that opioids and carbon dioxide (CO2) are toxic and harmful, when in fact both have powerful therapeutic properties and are totally lacking in toxicity;
• the notion that elective paralysis is essential to prevent broken teeth and vocal cord damage during intubation;
• the notion that blood pressure is the “driving force” of cardiac output and tissue perfusion;
• the notion that hyperventilation confers benefits of any sort2-4;
• the assumption that inhalation anesthetic agents possess analgesic properties. They have no such properties. They abolish the ability of consciousness to perceive nociception as pain in a dose-related manner, but they do not prevent harmful surgical nociception that is conveyed via spinal cord pathways to sympathetic ganglia that inhibit organ perfusion and oxygenation during surgery unless anesthesia is supplemented with analgesia; and
• the assumption that all stressful nervous activity is mediated via the brain and can be prevented by general anesthesia. Instead, anesthesia indirectly exaggerates harmful sympathetic hyperactivity by abolishing the corticofugal (descending) nervous signals that inhibit spinal cord nociception pathways.5
Most of this destructive dogma originated with the campaign of Ralph Waters, MD, and Chauncey Leake, PhD, to destroy the reputation of the nurse anesthetists who dominated anesthesia service in the aftermath of World War I and replace them with MD anesthesiologists.6 The available evidence suggests that their endeavors were generously rewarded by powerful medical corporations.6,7 They devised specious animal experiments to confuse anesthesia with CO2 asphyxiation, which can mimic anesthesia under narrow circumstances. Waters then vilified CO2 as “toxic waste, like urine” that must be “rid from the body” using mechanical hyperventilation. He also published fictitious clinical reports claiming to demonstrate the toxicity of CO2. This mischief produced a deadly hoax that prevails to the present day, has killed and maimed countless patients, derailed the era of stress research, and literally reversed medical progress. Before such derailment, the success of the nurses nearly revolutionized medicine because physicians were beginning to accept the therapeutic benefits of narcotics and CO2—which work together like love and marriage—to treat heart attacks, strokes, carbon monoxide poisoning, smoke inhalation, drowning, inebriation, asthma, atelectasis, pneumonia, drug overdose, and newborn babies with breathing problems.8,9
There are numerous ways to do something, but there is only one best way. While working in dental clinics, I routinely performed elective mask inductions and nasotracheal intubations without the help of either paralysis or intravenous hypnotic agents—this is detailed in my book.10 Samples of my computerized anesthetic records are available to the public.11 Patients were often prepared for surgery within five minutes of the moment they set foot through the door of the OR. There were no patient complaints, broken teeth or damaged vocal cords.
The anesthesiology profession is now poised to realize priceless public prestige by reforming these shortcomings, promoting clinical studies to confirm the benefits of stress theory, re-revolutionize surgery and restore medical progress. Must this await the arrival of our great-great grandchildren? Why not us? Why not now?
Coleman is the chair of the Science and Education Board of The American Institute of Stress, in Weatherford, Texas. He reported no relevant financial disclosures.
References
1. J Anesth Surg. 2015;2:1-2.
2. Anesth Analg. 2006;102:1290-1291.
3. Intraoperative hyperventilation may contribute to postop opioid hypersensitivity. APSF Newsletter. 2009;24(4). https://www.apsf.org/article/intraoperative-hyperventilation-may-contribute-to-postop-opioid-hypersensitivity/
4. Can J Anaesth. 2011;58:473-475.
5. Science. 1965;150:971-979.
6. J Anesth Surg. 2015;3:1-17.
7. Oxygen transport and delivery. 2022. https://www.youtube.com/watch?v=efi9v86isSw&t=117s
8. Science. 1936;83:399-402.
9. Henderson Y. Cyclopedia of Medicine. Vol. 3. F.A. Davis; 1940.
10. 50 Years Lost in Medical Advance: The discovery of Hans Selye’s stress mechanism. The American Institute of Stress Press; 2021.
11. TcO2/TcCO2 Anesthesia records of Dr. Lewis S. Coleman 2019-2020. Discovery of the Mammalian Stress Mechanism. 2020.
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I think he’s a quack
Me too
Me three , I think he’s trying to make a name for himself based largely on largely BS .
What, Ho! What have we here? Could it be Huey, Dewie, and Lewie of Disney fame?? Or could it be Donald himself, hiding behind pseudonyms????
Gentlemen, have you ever listened to yourselves??? Real ducks love nothing better than to quack alike, and they aren’t noted for their brains. The true meaning of a professional “quack” is woefully misunderstood.
Consensus is not science, and science is not consensus. Extremism for patient safety is no vice, and compromise for professional consensus is no virtue.
Surely you can do better than this. You are welcome to offer some intelligent rebuttal. But thanks for the laugh.
Dr. Coleman,
I absolutely applaud your bravery in publishing and challenging more than one long held dogmas in the field of Anesthesiology. Had I met you sooner, and not left academic anesthesiology, I might have moved simply to work with you. As a young Asst. Professor,
I worked with Dr. Benjamin Rigor, Chair at the University of Louisville. He demanded of his students (I was a Professor, yet we learn from our peers), they have a good reason for paralyzing patients, and that was not for intubation. I once mask ventilated and induced a patient for tonsillectomy who weighed over 600lb., used a now obsolete device called a “Fast Track” (sp?). I used no muscle relaxant, and the patient was breathing spontaneously the entire time.
All that to say, I am not bragging, just that there have been many lawsuits for loss of airway. In fact, I was almost one of them-a patient induced & paralyzed with ankylosing spondylitis I could not intubate, rapid sequence, full stomach. I asked the general surgeon to trach him. He survived & thrived at 83.
I am retiring this year, but would love to keep in touch.
I ironically trained at the University of Pennsylvania.
Sometimes challenging the status quo can be difficult. I believe you are right on the money.
Sincerely,
Sandra L. Stolzy
sstolzymd@yahoo.com
Dear Sandra,
Thanks for your commentary,and by all means you are welcome to communicate with me any time at lewis_coleman@yahoo.com. You might enjoy my website www.stressmechanism.com, where you can download copies of my published papers.
VTY,
LSC
I am Board Certified (if that means anything), and have been retired from 35 years of private practice (33 years doing cases solo, last 2 years some nurse supervision) and due to the nurse supervision began to question some "dogmatic" ideas on induction of anesthesia. For example:
1) if ER docs can successfully use a "bougie" to blindly intubate patients with minimal trauma, why MUST we visualize the vocal cords to successfully intubate someone? Because I trained before pulse oximeters and ETCO2 monitors this was the only way we could make sure the ET tube was in the "right place", ths subjecting many patients to unnecessary trauma and sore throats from excessive force during laryngoscopy.
2) Does cricoid pressure REALLY protect? Tons of recent articles questioning this dogma.
3) Do we need to preoxygenate ALL patients? Before pulse oximeters and LMA's (for rescue use - few minimally traumatic option before this devise) we had little data on the speed at which hypoxia could ensue, so we pre oxygenated everyone to give more time to intubate DESPITE patient fear and complaints regarding a mask being held over their face. Why not induce, see if mask ventilation can be accomplished, then intubate if needed after conditions are optimized?
Nice to hear of other known, safe options to intubate. everyone needs to consider safety of these "other" techniques
some of the most difficult airways are unanticipated. I see no harm (pledged to patients) in preoxygenating and have benefited from this practice when tolerated. Of course within reason and patient's request. Some don't want blood. As a practioner, I have my limits also. We all hope the patient who refuses preoxygenation will not be the same patient that suffers from hypoxia. ER, is great, we often collaborate to rescue their hypoxic airways with full stomachs. Suggamadex has helped everyone. Nothing perfect out there. Goal: great outcomes and preventing poor ones.
Many thanks for your commentary. I too was trained during a time when capnography and pulse oximetry were not yet available. The older attendings still remembered the superior safety of mask induction and emphasized bag and mask induction and management as well as airway safety via elective intubation. The merits of both seem to be forgotten these days.
In private practice I adhered to the entrenched “Leake/Waters” technique for many years until I experienced a “close call” with a “can’t intubate, can’t ventilate” predicament that inspired me to consider alternatives. By that time Sevoflurane as well as capnography and pulse oximetry had become ubiquitous, and with a little practice I discovered that I could achieve elective intubation with reasonable speed, especially since it eliminated the need for pre-oxygenation.1 Then I discovered that fentanyl supplementation accelerated Sevoflurane mask induction and produced excellent vocal cord relaxation without the dangers and side effects of paralysis. I was often able to accomplish nasotracheal intubation and fully prepare patients for dental surgery within five minutes of the moment they entered the operating room. Furthermore, the fentanyl facilitated “pre-emptive analgesia” that reduced inhalation agent requirements in half, maintained beneficial hypercarbia, accelerated emergence, prevented postoperative pain, minimized PONV, and eliminated unexpected postoperative respiratory depression. Eventually I realized that I had re-discovered the forgotten anesthesia science that prevailed during the “golden era of ether.”2,3
Thanks also for drawing attention to the question of cricoid pressure (Sellick’s Maneuver). During my residency I was called to perform emergency anesthesia for an old lady who had parked her car on an incline but failed to set her brakes properly, so that after she exited the car it began to drift backwards down the hill. So, thinking quickly, she ran behind the car and attempted to halt its headway (rearway?) but the car won the contest and ran over her abdomen. Despite Sellick’s maneuver, she vomited during induction with the Leake/Waters technique, whereupon I discovered that vomit has better lubricating properties than the finest oil. The laryngoscope handle spun around in my hand no matter how firmly I grasped it. Thankfully, she didn’t aspirate anything, her innards were spared, and her outcome was uneventful.
Disaster stalks anesthesia practice, like a wolf. So, I do not recommend mask induction, as described above, for emergency situations. Sellick’s maneuver isn’t perfect, but it’s better than nothing.
1 Smith, T. E. & Elliott, W. G. Routine inhaled induction in adults: a safe practice? Anesth Analg102, 646-647; author reply 647 (2006). https://doi.org/102/2/646-a [pii]
10.1213/01.ANE.0000190741.87353.41
2 Coleman, L. S. Four Forgotten Giants of Anesthesia History. Journal of Anesthesia and Surgery 3, 1-17 (2015). <http://www.ommegaonline.org/article-details/Four-Forgotten-Giants-of-Anesthesia-History/468>.
3 Coleman, L. S. Routine Mask Induction and Intubation without Paralysis may be Safer. J Anesth Surg 2, 1-2 (2015).
Iv induction doesn’t have to always involve paralysis for a Quick Look to see if someone is truly difficult to intubate. Hopefully, that assessment has been made well before the pt goes back to the OR. As an anesthesiologist who has been a patient, I was appalled on more than one occasion by the lack of a good airway exam by both the anesthesiologist and the AA. They also didn’t bother to listen for any heart or lung sounds. Not sure I know how long it would take to mask induce an adult!!!!
Many thanks for your contribution to this discussion. Your point that careful pre-operative assessment is important is well-taken. It is always better to keep out of trouble than to get out of trouble. However, there are anatomical airway problems that can’t be detected by pre-operative examination, no matter how carefully and thoroughly it might be performed. My argument is that embracing a routine habit of mask induction for all cases provides additional safety, above and beyond careful pre-op examination. I have been surprised to discover that patients seem to prefer this approach to being stabbed with IV needles. At the very least, they appreciate being given the choice of mask induction. Mask induction enables safe abandonment of the induction in the event that unexpected problems are encountered. Also, it introduces inhalation agent toxicity gradually, as compared to bolus doses of Propofol, which can cause irreversible cardiac toxicity. For all these reasons, I believe that many lives could be saved, lawsuits avoided, and side effects minimized by embracing routine mask induction and intubation without paralysis.
I agree with much that is in your article, most of it, but not all.
I trained with Drs Ted Smith at Loyola and Lucien Morris in Ohio.
So much of what they taught me agrees with what you write. Not all, but most. I have tried to discuss CO2 lessons from those learned men with colleagues and you just don't find such training and insights taught anymore.
Try finding an anesthesiologist who can mask anesthetize a patient anymore.
I miss those days when we were colleagues, friends, and challenged each other on provision of anesthesia. When I started, we were allowed to practice new techniques and were not heavily, heavily persecuted if we did not follow "the protocol." Have you not noticed how anesthesia has become "protocolized" if you will?
Do you think ERAs protocols allow you room or if you don't follow ERAs are you questioned as to your competency?
Doc, try something different in the present day era of cookbook anesthesia and see how quickly you are shunned, mocked and quickly lose your "job."
It is why we need a powerful union which protects practitioners from the pharmacy department dictating best practices and medications allowed, million dollar baby CEOs extractingbthe last penny, private equity, people who do not know anything about anesthesia but control the patient physician relationship, and people with training and education along with commonsense back in, not out.
Both of us remember a different type of anesthesia delivery, and we delivered it well, but look at all the shameful crack pot comments above and they mirror today's poorly educated role fillers. Shame on their closed minds.
I never thought that I would ever read an editorial like this that says the things that I have always believed but am usually reluctant to share. To do so would sometimes get a response of eye rolling or no response at all. Thank you.