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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