Thursday, January 12, 2023

Q&A with David D. Alfery




David D. Alfery, M.D., is the author of the new book Saving Grace: What Patients Teach Their Doctors About Life, Death, and the Balance in Between. He worked as a cardiothoracic anesthesiologist for 36 years, and was an adjunct associate professor of anesthesiology at Vanderbilt University Medical Center.


Q: Why did you decide to write Saving Grace?


A: My original intent was to memorialize some of the amazing things I witnessed during my 36-year career as a cardiothoracic anesthesiologist.


But before I began writing, I looked to see what other books had been written by anesthetists that described the secret world I worked in, and I found nothing at all in depth. I found that amazing, as the discovery of general anesthesia is considered by many to be the greatest advance in the history of medicine.  


So, I expanded my horizon to make it a book that would fully bring to life the hidden world that I inhabited and would include much of the “inside information” that is known only to those who work in the OR and ICU – how we think, how we talk, the secret language that we sometimes use, how we maintain our composure in a life-threatening emergency, how we handle death, and much more.  


As the book progressed, though, I found I was writing about far more than the world of anesthesia. In the stories that I tell, I was describing interactions that demonstrate the shared humanity that binds physicians to their patients.


Some of these were emotions, some characteristics, and still others principles by which we live. All were the critical components that make each of us human. And none of that could ever be experienced without patients entrusting their care to me. Thus, the subtitle, What Patients Teach Their Doctors About Life, Death, and the Balance in Between.


Q: In the book, you write, “With my anesthesia training, I learned to bring you closer to death than you will ever come to in this life – all in an attempt to forestall your death – and then bring you safely back. Can you say more about that?


A: That is a reference to the four “stages” of anesthesia – stage 1 is awake, stage 2 is termed “excitement,” where a patient is not sufficiently anesthetized to permit surgery being safely performed, stage 3 is the plane of surgical anesthesia where operations are done, and stage 4 is overdose, where too great an overdose leads to death.


So, anesthesiologists must walk a line between deep enough to operate on but not so deep that it could end your life. Further, anesthesiologists have been termed the “ICU doctors of the OR” because our work is often a form of critical care medicine, only done in the Operating Room.


In some emergency operations we are asked to take the most medically unstable patients imaginable, bring them to a depth of anesthesia where they can tolerate being operated upon and the insult that surgery entails on the body, and then bring them back. Standing back from it after all these years, it is a pretty remarkable thing that we do.

Q: How has the field of medicine changed since you began?


A: All aspects of anesthesiology have become much more sophisticated since I did my training. For example, when I was a resident, we monitored most patients with blook pressure, EKG, heart rate, and listening to breath sound (to ensure we did not have a disconnect from a ventilator).


Now, patients are routinely monitored with all that, but in addition have continuous pulse oximetry to measure oxygen saturation in the blood, continuous exhaled carbon dioxide as well as inspired and expired anesthetic gas concentrations, cerebral “depth” of anesthesia monitoring, quantitative analysis of muscle relaxation, and much more. We have a transesophageal echocardiogram when we wish to literally watch via ultrasound the heart beating as well as the function of its valves.


Similar advances have been made in the drugs we use and all other aspects of the specialty. As a result, we have evolved from a point where we used to have patients “too sick for anesthesia” to now, where we can bring just about any individual through surgery safely.


Q: What do you hope readers take away from the book?


A: On the surface, I want readers to know what the specialty of anesthesia entails, what it is that we do in our amazing hidden world each day. It is sometimes a heart stopping, dramatic, life-and-death environment where a single decision can mean the difference between a patient living or dying. That is why some have termed working in anesthesia 99 percent boredom and 1 percent sheer terror.


And interestingly, even most physicians have almost no significant understanding of anesthesia.


(Further, with all we have learned about how to administer anesthesia, we don’t actually know how it works! All we know is that it puts you to sleep, along with birds, mammals, reptiles, insects, and fish. Even the notorious insect-eating Venus fly trap is rendered insensible with our agents, and seed germination ceases. And yet, when our anesthetic vapors are withdrawn, all miraculously awaken!)


Beyond the wonders of the world of anesthesia, though, I hope readers appreciate more the human connection that binds physicians to their patients and how those relationships enrich the lives on both sides of that equation.


Q: What are you working on now?


A: With all the remarkable things that I describe and the amazing events the reader witnesses in Saving Grace, there are many more that I have tucked away after eight years of training and 36 years of practice. I guess I have more tales to tell, so round 2 is beginning to germinate.


I am also working on becoming a better guitar player, but that is pretty intimidating living in Nashville, where there seems to be a virtuoso guitar “slinger” on every corner!


Q: What else should we know?


A: Just about all the doctors I worked with during my career – and that means the doctors who take care of the readers of Saving Grace – understand that it is a privilege to take care of patients. We know that no greater honor can be given to us than to be entrusted with the life of a patient.


When we care for those who come to us, we have made the transition of believing – usually as medical students – that the patient is there for us, to knowing it is actually the other way around. Most doctors care deeply for their patients and put everything they can – their time, their energy, their emotions – into the betterment of their fellow human beings. In the end, we are all human, all made the same way.


--Interview with Deborah Kalb

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