Residents in a Room

Episode Number: 70

Episode Title: The History of Anesthesiology

Recorded: October 2024

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VOICE OVER:

This is Residents in a Room, an official podcast of the American Society of Anesthesiologists where we go behind the scenes to explore the world from the point of view of anesthesiology residents.

If you don't know history, your research might take a lot longer. Because what if you're repeating the same experiments?

Are there any military specific history points about anesthesiology? Did the military help advance our…

One of the novel anticoagulants that was discovered was actually in the secretions of leeches.

You can see this process of how things have come throughout history to get to where they are.

MR. DONALD KEATING:

Welcome to a Residence in a Room the podcast for residents by residents. I'm Donald Keating, a fourth year medical student at Kansas City University and today's guest host. I'm here with some fellow residents and our special guest today, Dr. Melissa Coleman. Dr. Coleman is a contributor to Classic Papers Revisited in Anesthesiology. And it's on the board of the Wood Library Museum of Anesthesiology. She's going to share her thoughts on the history of the specialty and why it matters. Let's start by meeting the residents with me today.

DR. ZACHARY MEADE:

Hi, I'm Zachary Meade, a Navy resident out of San Diego. I'm a CA2.

DR. LINDSAY MURPHY:

Good afternoon. My name is Dr. Lindsay Murphy. I am a CA2 anesthesiology resident at Walter Reed National Military Medical Center in Bethesda, Maryland.

MR. KEATING:

Great. So now it's time to meet Dr. Coleman. Dr. Coleman, can you tell our listeners a little bit about yourself and how you got involved in the history of anesthesia?

DR. MELISSA COLEMAN:

Sure. I'm a pediatric anesthesiologist at the University of Minnesota, and my history journey began when I was actually a resident. My resident research project was going to be on inventing a new type of endotracheal tube that had a bite block built into it. And I couldn't understand why we were using rolled up pieces of gauze when I was also using a laryngoscope with a video camera on the end of it to intubate patients, and it just seemed completely disconnected. And so I thought, well, before I invent this wonderful new thing, I'm going to research the history of it. And one of our senior members of our department said, well, you've heard of the Wood Library, right? And I said, no, I have no idea what you're talking about. And I was introduced to this amazing anesthesia history resource. I traveled to the suburbs of Chicago on my vacation, and my really lovely husband actually came along with me, and the and the two of us spent a week in the in the archives and the library and the museum collection looking at the history of bite blocks. And I wanted to know how did we get here? And the short answer of it was that the in the early days of anesthesia, we didn't use endotracheal tubes. It was all native airway. So in order to keep the mouth open and and part of the strategy of, of keeping a patient, um, unobstructed and breathing where they would sometimes put bite blocks in. And so over time, the surgical equipment evolved into something that the anesthesiologist used to keep the mouth open. And then eventually we used endotracheal tubes and some of that same equipment today is what we use to keep patients from biting down on bite blocks.

MR. KEATING:

Oh so interesting.

DR. COLEMAN: So I never actually invented that.

DR. MEADE:

You hinted to this in your response, but what are the benefits of clinicians understanding the history of their specialty?

DR. COLEMAN:

So I'm biased, but I think it's multifaceted because when you're thinking about tackling the clinical and the academic the research problems that we have today. It's all rooted in in what came before. And so if you think about efficiency of research, everyone knows the Churchill quote, if you don't know history, you're doomed to repeat it. And I think it applies more accurately in the world of research. If you don't know history, it's your research might take a lot longer. Because what if you're repeating the same, you know, the same experiments and you're trying to redo what already happened? And there's a lot of times that our research outstrips what we're able to monitor, what we're able to actually provide clinical care wise. And so some of the research falls by the wayside.

So I think an interesting example of that, it's kind of loosely touches on this point that we've known since the the 40s that on clinical exam even experts are really poor at detecting cyanosis in patients clinically. You know, when the patient's blue, their sats are probably in, like, the 70s. But so, you know, essentially we knew from research that clinical exam was not the most efficient way to tell if a patient was cyanotic. But we didn't have anything better. There wasn't any technology that could consistently and effectively monitor on oxygen saturation. And if you fast forward to the 1980s, Nellcor released the N100, which was the first consistently usable oxygen saturation monitor.

MR. KEATING:

So you're saying people had to do anesthesia without a pulse ox?

DR. COLEMAN:

Oh yes. Yeah. Ask a few of your ask a few of your attendings. I'm sure you'll get some good stories.

MR. KEATING:

Oh, I'm sure.

DR. COLEMAN:

It wasn't really that long ago. A 1986 Harvard standards did not include pulse oximetry. It wasn't until the later in the 80s. That that that was included. And it took really persistent advocacy on the side of some of the people that did the research that said, okay, we did a double blind study where we looked at patients who had the pulse oximeter and patients that didn't, and the anesthesiologist did not know what the SAT was. Um, it was blinded and that like, there was a set of anesthesiologists who had no monitor and they had to use physical exam, and they chose when to intervene when they thought the patient was cyanotic or hypoxic. And then there was a set that had the pulse oximeter. And so the research showed very clearly that when you had the pulse oximeter, you intervened a lot sooner. Um, sometimes the team that was using the physical exam, they thought patients who were in the high 70s of their oxygen saturation were were just fine. And it it was by no deficit of their own. You just can't know from from visual observation. It's just a really interesting example of: we knew that for 40 years. But if you didn't know the history of that research, you might have just continued to argue: It's fine.

MR. KEATING:

Yeah. That's interesting. And I think as a med student right now and, uh, going through my sub eyes and reading through, uh, the Baby Miller textbook, I know the first chapter is actually on the history of anesthesia. And I hope you would be proud of me, because I actually, I actually read some of that first chapter, and I was really tempted to be like, oh, history of anesthesia. Let me just switch to chapter two. Um, but I read some of it, and there is a lot of fascinating aspects to how we got to where we are today with the current way, uh, anesthesia is performed. But I also was thinking, wow, it's really nice as I'm preparing for a sub, I and I'm, I'm on a really easy rotation right now. I can sit here and read through this chapter on on the history of anesthesia. I can only imagine when I'm in my CA1 and two and three years when when life gets busier, what would you say to the current residents right now who are on really busy rotations? Why should they spend time learning about the history of anesthesia?

DR. COLEMAN:

I'm so glad that you asked, because I completely wouldn't blame you for wanting to skip over that chapter and to avoid history entirely. I think a lot of times people are scarred from prior encounters with history in their education. It's often reduced to names and dates and order of events happening. And really, history is stories. And humans really love stories. And I think that it can be a nice brain break to read anesthesia. But I also really think that learning the history of anesthesia adds a depth to your clinical knowledge, to understanding your professional identity that you can't get in any other way.

MR. KEATING:

I remember--and correct me if I'm wrong--I remember local anesthetics, they were discovered centuries ago and it was the the tip of it was like a poisonous plant or something or used as a.

DR. COLEMAN:

Um, so I, I think you're combining two different, two different histories, but.

MR. KEATING:

Clearly I should have read the chapter two, chapter more.

DR. COLEMAN:

No, the the nuances of anesthesia history and really any history are are great. And anesthesia is applied pharmacology. And a lot of our medications come from sources that were discovered de novo by accident. Curare is a muscle relaxant and that was brought back from South America. It was found on poisonous darts. Um, and I think that's what you're what you're referring to.

MR. KEATING:

I remembered the poisonous darts. I'm like, I know there's something about that with with. It was being discovered a while ago, but, um.

DR. MEADE:

So you're telling me the Indiana Jones with the sharks, that's legit.

DR. COLEMAN:

Uh, yeah, there's aspects of that that that are based, in fact.

MR. KEATING:

But it goes along with that in that. Okay. Knowing that doesn't necessarily change how that drug might be being used today. But you can see this this process of how things have come throughout history to get to where they are and then can also be used to then further the advancement of of practice today, knowing the history behind it.

DR. COLEMAN:

Absolutely. Learning the evolution of the different drugs that we use, why we've changed, why people were curious to move on to the next better thing, that all informs how we practice, how we consider our next research project is.

DR. MURPHY:

There’s another great example too. In the realm of anticoagulation, we've had the classic anticoagulants, the vitamin K antagonist, the antiplatelet agents, and the search was on to find something that was more easily managed than warfarin, because that medication has very varying blood levels based upon the patient's metabolism, what the patient ate or didn't eat that day. You know, INR can bounce all over the place, and one of the novel anticoagulants that was discovered was actually in the secretions of leeches. Yes. Yeah. So that's hirudin is purified leech saliva, which gave us bivalirudin, which we use today in the setting of anticoagulation for patients who cannot tolerate vitamin K antagonism or a doac, a direct oral anticoagulant.

DR. COLEMAN:

There are so many interesting stories, even just in the anticoagulants -- transhexamine acid also…

DR. MURPHY:

Also, another classic.

DR. COLEMAN:

… also has a fascinating history. Um was originally derived from research using horse serum.

DR. MURPHY:

So, Dr. Coleman, you mentioned the role that residents have played in the history of the specialty. Can you give us some examples of residents leaving a mark on our history?

DR. COLEMAN:

Absolutely. And it was interesting and ironic that we were just talking about curare, which came from poison on the end of darts in South, in South America, because, um, it was a resident, Dr. Enid Johnson, who worked with her mentor, Harold Griffith. Um, they did the initial clinical use of curare in an anesthesia patient. So they were practicing at the Homeopathic Hospital in Montreal, and Dr. Griffith had a friendship and professional relationship with Dr. Squibb, who was developing De Tubocurarine. So the Squibb Company had worked out a medical preparation of it. It had been used by some psychiatrists, and he passed this information along to Dr. Griffith. And there was a young man who was receiving an appendectomy, and he received the first use of muscle relaxant in anesthesia, and it was a resident who gave that case and did the next 50 or so cases which which were published.

MR. KEATING:

Wow. When was this happening?

DR. COLEMAN:

So this was around 1942. Okay. When this happened, and it was when they started using muscle relaxants that then the use of endotracheal tubes, which was already in existence, started to gain more popularity.

DR. KEATING:

Interesting.

DR. MURPHY:

One goes hand in hand with the other Because if you are paralyzing a patient, if you are giving them complete neuromuscular blockade, you have to ventilate them somehow. And holding a mask for a one, two, three hour surgery is an exercise in hyperventilation as well as profound hand fatigue.

MR. KEATING:

Oh sure, I can imagine.

DR. COLEMAN:

The one more really interesting innovation that came from a resident during residency--which I really love this story--is Doctor Lucien Morris developed the Copper Kettle, which is a vaporizer that is no longer in use. But it was revolutionary in its time. And the way it came about is that he was working in the lab and kind of complained, like, you know, anyone could create a vaporizer better than what I'm using right now. And his chair was like, okay, so go ahead. Dr. Ralph Waters, who was the founded the first anesthesia residency program. It was like, okay, I'm going to throw down the gauntlet pretty much. And I don't think Dr. Morris thought much more of it until a postcard came from Florida because the chair was on vacation and he said, oh, did Morris invent that vaporizer yet? And and, you know, lo and behold, he worked through several different, you know, iterations of it. But it was during his residency that he identified this issue and worked through it. I remember when I was a resident thinking that, well, you know, what do I have to contribute here? Everyone's been doing this for a really long time, right? And I think it's so vital to appreciate the fresh perspective that you bring to practice. You may be asking questions that other people just take for granted. And so start with your questions and and follow them. But start with history.

DR. MEADE:

So in theory, I'm not saying this happened because of course it didn't. But if I had skipped that first chapter of history, what are people getting wrong about anesthesiology history? What are the myths?

DR. COLEMAN:

I think, you know, there are there are big things and little things, I think. I think a fun place to start is that a lot of people think the Miller blade comes from Dr. Ronald Miller, the author of the famous textbook.

DR. MEADE:

That's what I always thought.

MR. KEATING:

Seems reasonable.

DR. COLEMAN:

It wasn't him, though. It was Dr. Robert Miller, and it was invented in 1941, and he was frustrated by the view that he was getting with the traditional laryngoscopes at the time. And he created the straighter blade. And, you know, the rest, as they say, is history. But two different, two different Arthur Millers.

DR. MEADE:

No kidding. Can I ask, are there any military specific, you know, history points about anesthesiology. Did the military help advance our field?

DR. COLEMAN:

Oh, there are so there are so many. And you could fill about five podcasts, actually, um, or more, um, with the contributions of military anesthesia. And I think to a resident audience, perhaps one of the most interesting stories is when we were sending troops to the front in in World War Two, we knew that we would need people to deliver anesthetics. The clinicians were in low supply, um, for various reasons. And so what the military did was they set up these 90 day training sites and in, in several different areas of the country, and these physicians became trained in anesthesia in 90 days, and they were called the 90 day wonders. And, and, uh.

DR. MURPHY:

And I'm sure they had some other nicknames, too.

DR. COLEMAN:

And prior to this, physician involvement in anesthesia was not as pronounced. And what happened was the surgeons worked with these physicians on the front in Europe, and they all learned new things. You know, necessity is the mother of invention. And when everyone came back home after World War Two, the surgeons started saying, well, I'd like to work with some physicians. And they realized how well they worked together. And that was really the change in terms of physicians becoming more interested in anesthesia. That was around the same time that we became aborted specialty, and we had more formalized training programs. So like I said, there's a lot of stories and I think probably a little bit more complex than I'm saying, but that really was one of the impetuses.

MR. KEATING:

I mean these are some, some fascinating historical tidbits. I would love to hear more about your role with the Wood Library Museum of anesthesiology. Can you tell us a little bit more about the museum? It sounds like it's in Chicago. And for people who might be interested in visiting or accessing those resources, what's available out there and what do you do with the museum?

DR. COLEMAN:

Sure. So the Wood Library Museum of Anesthesiology is a foundation of the ASA. And so we have a board of trustees and then several committees that help care for the collection, in addition to several wonderful staff members who are professional archivists and museum collection specialists. I have been on the board of trustees for several years. I'm the incoming president of the board, and I look forward to doing more outreach. Our goal as an organization is to advance anesthesiology by preserving and sharing its heritage and knowledge. And our website is robust. If you go to woodlibrarymuseum.org, you can see over 400 pieces of art museum collection, all with blurbs about what they are, where they came from. We have primary sources from our library, we have archives, and we have an extensive living history collection where we have giants in the field of anesthesiology, interviewing other giants. And so you have the opportunity to hear the history from the people who made it. And it's it's truly an amazing and amazing website.

We do encourage residents to join us on committees and on the board. We're developing a mentor process where if people are interested in doing some anesthesia research, we have mentors available. We also have a fellowship where it's an all expense paid trip to the suburbs of Chicago. And if your research question can use our resources, we help support you in that research project.

DR. MURPHY:

Oh, that sounds fascinating.

DR. KEATING:

That that is fascinating. It sounds like there's a lot of different opportunities that you provide in order for medical professionals of all levels to get involved in the history of anesthesia and those, like myself, who are finishing up medical school and just starting residency to really dive into some of those opportunities available.

DR. MURPHY:

So let me ask you this. For those of us with an interest in the history of anesthesiology who maybe haven't quite dipped our toe in, or asking for the friends in the room who might not have read the first chapter of Morgan and Mikhail--no residents were harmed in the making of this podcast--what resources would you recommend for the budding historian of anesthesiology? Are there any good blogs or podcasts or books? Or are there any social media handles that you would recommend we follow in addition to the Wood Library?

DR. COLEMAN:

So absolutely I would start actually with the journal Anesthesiology. There's a regular series, The Classic Papers Revisited, where the people who did groundbreaking research reflect on the process of that research. Additionally, every month there are a few reflections from the Wood Library Museum little vignettes that bring out some of the interesting stories from the Wood Library collection. The Wood Library, of course, has its own social media handles, and there are several other anesthesia history museums that have their own social media. So there's the Geoffrey Kaye Museum out of Melbourne, Australia. There's the Anesthesia Heritage Center and not a museum in his own right, but Dr. Merlin Larson has a very interesting X stream. And he is always throwing out like, fascinating tidbits from anesthesia history. That's really a not myth, in my opinion. In terms of podcasts, I don't know if there are any dedicated solely to anesthesia history, but there was a podcast by the ABCs of Anesthesia with Dr. Christine Ball. She is an incredibly talented historian, and she was doing a podcast about anesthesia history and specifically her book The Chloroform Kiss, which was very engaging and I would encourage people to listen to.

MR. KEATHING:

Interesting. The chloroformist? And who is that?

DR. COLEMAN:

By Doctor Christine Ball.

DR. KEATING:

Excellent, excellent.

DR. MURPHY:

So Dr. Coleman, you have a spectacular amount of knowledge about the history of anesthesia, a great deal of which is probably not known to the world at large. So I'd love to hear about something that maybe most of us don't know. Facts that might surprise or entertain, or serendipitous circumstances that illuminate something really unique about the history of anesthesiology. Anything in that realm?

DR. COLEMAN:

Absolutely. So as a pediatric anesthesiologist, the art of induction is something that is near and dear to my heart because children are generally, when they're younger, are a mask induction. And that's a different type of, of process. And one of the first artifacts that I fell in love with when I started working with the Wood Library Museum was this space helmet, and it's on our website and it's in the exhibit in the ASA headquarters. And I had to ask myself, well, what is the space helmet? And as it turned out, there was a TV show called Space Patrol in the early 1950s. And space toys, all of these astronaut toys, were all were all the rage. And pediatric anesthesiologists would have the kiddos put on these like toy space helmets. And they would make the, um, the inhalational agent in the space helmet and had them go off to sleep safely and calmly. There are also other, uh, techniques for these sneak attacks. They would have little, like, stuffed animals that maybe they would put the circuit in. It was a really creative, and I think compassionate way to have children who might otherwise be very scared go off to sleep safely. And and there's no end to the creative solutions that anesthesiologists, whether pediatric or not, have come up with. And I think this is just one tidbit of many that, sure, you know, that you can find just by exploring some interesting history.

And, you know, the the other thing is that you never know where a conversation is going to lead to some new historical discovery. So I was connecting with a high school classmate of mine. And I said, oh, I'm an anesthesiologist. And she said, oh, my grandfather was an anesthesiologist. And we got to talking. And it turned out that he actually worked on Project Mercury in the late 50s as, as part of the lead up to the Apollo mission. And so they had actually recruited an anesthesiologist to research the biopax that eventually would help the astronauts as they went to the moon. And he was part of the team that developed these bio packs for the monkeys, for the test flights. And so that story had never been told. So this conversation that I was having with a friend from high school led to a really interesting history project. And I think something that a lot of people might not appreciate about the the space missions.

MR. KEATING:

Well, it sounds like maybe there could even be a part two here in the future. I have learned a ton today. I don't know about the rest of you, I'm sure. And thank you everyone listening for joining us. Thanks to our guest here today, Dr. Coleman. Please join us again soon for more Residents in the Room, te podcast for residents by residents.

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