There is no such thing as “Twilight”

Despite what wikipedia says.    There is no such thing as “twilight anesthesia.”  Whoever says otherwise is an idiot and ignorant.  Using that term leads to a misunderstanding of how anesthesia works.

Many patients come into surgery asking me for twilight anesthesia which their surgeon told them about.  First off, each medical specialities should refrain in speaking on behalf of other medical specialities.  It creates doubts in the patient’s minds when there is a conflict of information.

These patients expect the following from twilight anesthesia-

memory loss of the experience

be completely unaware of the surgery

no pain during or sensation of pressure during the surgery

smooth wakeup

While all of these things might happen with twilight, if this is what is expected, the only way to accomplish this is with General Anesthesia.  General anesthesia is the only way to actually achieve the above mentioned items time and again.  There is no guarantee that it will occur with twilight.

Twilight anesthesia is actually conscious sedation.  It means that the person may come in and out during the procedure and may occasionally see, hear, and feel things.  Example, most colonoscopies are done under conscious sedation also known as Moderate Anesthesia Care.  Most patients have no recollection of their colonoscopy which is great, but it can never be guaranteed unless the procedure is done with general anesthesia.  And general anesthesia is generally not needed for a colonoscopy.

As a nation we need to stop being so fearful of medical procedures.  Conscious sedation is a great alternative to general anesthesia and leads to faster recovery from anesthesia with less side effects.  You just have to accept the fact that you may come in and out of the procedure.  Guess what….that is ok!   And as I mentioned before, most people don’t remember anything anyways!!!!

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Why I am A Dissappointment

Occasionally, I have patients come to the office and they start off the visit by saying the following.

“Oh my God.  I am so happy that I am finally here.  I have been waiting so long to finally get to meet with you. ”


These visits usually end with them saying something like this…


“thats it?”


So…what happened here?  

Expectation management was the problem.  If someone has been suffering with a pain issue for a while…. why would they believe that on one singe office visit their pain of let’s say 5 years will miraculously go away?

Medicine is not that advanced especially in chronic pain management.  For all of its benefits we are yet to cure the most common medical problems.  Medicine is nowhere near as evolved as say….an iphone.  Hell, we barely have a cohesive electronic medical records system as it currently stands.

I often tell my patients that I have never cured anyone of their chronic pain.  All this humble servant has been able to do is help patients manage their pain so that they can move forward with their lives.  Anyone who tells the patient that they can be cured of their chronic pain is a liar. Cures in chronic pain management are rare.

Pain control is multifactorial and one visit with any Pain Medicine Physician will not alter their course.  It takes teamwork and a lot of energy to turn debilitating pain into something manageable.  There are no quick and simple solutions especially when the pain has lasted for greater than 6 months.  When patients come in with high expectations for grand outcomes from their first visit with a pain management specialist they are inevitably disappointed.

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Oh Whitney!

So…. I decided not to post again about my feelings on the way prescription medications are doled out to people with money.

Just go to my past post on Michael Jackson and his medication use and see how I feel about this subject.  My feelings on this have not changed one bit.   Then again, I see there has been no change in prescription habits to the wealthy.  Three types of benzodiazepine prescriptions?   Really?   Why!

Take Care All

Yours Truly;

Edwin Perez

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Generic Drugs

So here is something that really bothers me…..

Its the subject of generic drugs.   No, it is not the generic drugs that offend me but the rampant hypocrisy in our society surrounding generic drugs.

People are talking about generic drugs everywhere.  People in many cases now ask for generic drugs.  Why?  There has been a long and hard campaign by the government and physicians that was created to convince patients that generics in many cases are as good as the brand name.  Combine this with the fact that people feel entitled to all possible health regimens. (meaning they expect to pay nothing at all for it) And what you get is exactly what has been starting to occur in larger and larger numbers.  People want generics and more of them.  We love getting a month’s supply of a generic for 4 dollars a month at Walmart.

People say….”hey we are smart.  We are reading the labels and literature and we love generic medications.”

Yet, how many of these same people have super expensive cosmetics in their bathroom?  Alot…..  Beauty companies hide behind a facade that is based on practically no science.  If you read the labels on expensive shampoos and cheap shampoos, you will often find the same ingredients.  Yet the public still believes that Armani shampoo is probably better than Suave.

Why are people willing to believe that medications that save lives are ok to substitute with generic versions but not beauty products?

Thankfully there was finally an article on generic beauty products…..the article which I think is connected to some blog site compared generic and branded hairspray.

If we are going to be rational about our medications it is certainly time to become rational about our beauty products.


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High Dose Opioids

Opioids such as morphine are commonly used in pain management to treat all sorts of pain.  For many patients, the Percocet they get from their dentist is instrumental in helping them get over the pain of say a tooth extraction.  The pain control from the Percocet allows them to stay active and connected with the world while the area worked on by the dentist heals.

There is a large body of evidence that shows that opioids given after an acute event that causes pain leads to decreased long-term residual pain and ensures a high quality of life for the patient.

So from this people made an assumption.  If opioids given in the short term for example after surgery while the patient heals….then if we give patients with chronic pain problems opioids they will do just as well.

This has certainly worked out in cancer pain.  However, cancer pain seems to be similar to post-surgical pain in that cancer pain is a dynamic process it is always changing sometimes for the better and sometimes for the worse.  Post-surgical or acute pain also is dynamic in that tends to improve with time as the body heals.

But chronic pain is not the same.  It is not dynamic….by definition it is there all the time! For years, the pain community tried using opioids for chronic pain and the results were well….not so great.  In addition it led to things like prescription opioid abuse…see the documentary Oxycontin Express. After all these years, we have practically no good data that shows that high-dose opioids work for chronic pain problems like low back pain or fibromyalgia.

Why not….because the nerves have undergone all types of peripheral and centrally based changes.  Meaning after 6 months the nerves or tissue causing the pain are very different from the way they were before whatever caused them to be damaged in the first place.  They express different genes, they behave differently in tissue culture, they connect differently to the brain, and even areas of the brain begin to change.

So you need the right tool for the right job.  Hence, it was actually not that surprising to learn that high dose opioids really don’t work in chronic pain.  That is why we need to look for things that work.  Antiepileptic medications and other developments such as spinal cord stimulators have paved the way in finding things that work for chronic pain.

Now…there are certainly going to be people who say well….opioids work for me.  That’s great and it is true that sometimes it works.  I prescribe quite a bit myself for patients with chronic pain.  However by in large they don’t.   Chronic pain needs to be addressed as what it is…..which is something different from acute pain.

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Voodoo Medicine

So I want to continue my rant from the previous post.

Lots of people believe that current medical practices and policies are based on scientific data.  That is not true.  There is plenty of voodoo in modern medicine. Infection control policies at most hospitals are ripe for mocking because they are notoriously not based on data and yet affect those of us who work in a hospital on a daily basis.

Example, I was once told by a nurse not to fling my surgical mask into the garbage can.  She states that the mask should be balled up and put in the trash without flinging.  She stated that my act of “flinging” would cause the microbacteria in the mask to be disseminated throughout the operating room.  Really?

This person took what little knowledge she had and used it to make a blanket policy. It is true that a little knowledge is a dangerous thing and that ,my friends,  is a proven fact.  Does she even know that the way microbacteria stick to things is so complicated there are full laboratories and scientific papers dedicated to it.  I mean here read about it yourself.  Her logic was flawed because she used her own ill-informed and uneducated logic to come up with that policy.

Scrub attire in the operating room is another ridiculous issue. So many rules and regulations about where and when you can wear various scrubs.  How they should or should not be washed.

Yet…there is no evidence that any of these rules and regulations used by hospital infection control departments helps do anything at all other than infuriate people.

This then leads people to break some of these rules because they are drastic in nature with NO benefit.  There are so many things that we know that do work to prevent infection why don’t we focus on those?  Yes….many of these protocols and regulations are unfounded!

What’s the harm you say. Here

1) It increases the cost of medicine to follow rules that have no basis.  Example…. having scrubs washed, maintained, and dispensed at the hospital costs alot of money with no proven benefit.  That money could be used to improve patient hospital experiences or improve patient care.

2) It promotes voodoo.  Creating rules from flawed and uneducated “common sense” as opposed to researched data. These rules become a runaway train for even more bad policy.

3)It promotes voodoo.

4) It promotes voodoo.

5) did I mention it promotes voodoo medicine

Why can’t we focus on things that are know to work like given antibiotics promptly before surgical incision?

Maybe we need less administrators and more worker bees.  You want to know why medicine is so expensive…..  Try adding up the cost of all these stupid rules.

Btw…can anyone tell me why I can’t wear my scrub cap out of the OR using actual data? Or is it all based on fairytales? At least admit that to me instead of pretending its based on something.

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How about Evidence-Based Public Policy?

Going through a list of people on twitter, I found #NoMorePain.

One of his tweets which I should have retweeted caught my attention.

It was the one titled Has Pain Managment been bungled by the government?  He then links to the following article by Dr. Jack D’Angelo of the Richmond County Medical Society.  The article can be found on this hyperlink.

What a phenomenal article.  I advise everyone to read it.

Now for my soapbox……..

In medicine, as physicians we keep being told that we need to practice evidence based medicine.. What is that you ask?  In other words doctors should only use things on their patients that are basically very well tested and proven to work on thousands of people.  Insurance companies are beginning to only reimburse doctors for procedures and medications that fall under this premise. There is no room for logic or experience.  Now…in an age of cost containment this is not a bad idea.  Government and Insurance Companies can keep costs down and cover more people if they only pay for things that are completely proven.   As for any other treatment such as say shark cartilage….the patient is always welcome to pay out of pocket for such things.

So why don’t we do the same with public policy.  It seems that people keep coming up with new rules and regulations that seem “logical.”  We keep adding more and more paperwork in every industry.  For example, hospitals now have to put bracelets on everyone being admitted that read…”fall risk.”   This added paperwork means extra cost and for what???  Can anyone go back and prove that any of policies enacted in the last five years at say a hospital has made any difference in patient care? If they can then keep the policy that led to the change, if they can’t then retract the policy.  Rarely do I ever see a policy get removed from the great book of policies and I am sure that not every policy written has improved the state of affairs.

So if doctors have to practice evidence based medicine then policy writers should have to practice evidence based public policy.

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