what's up everybody my name is max feinstein and i'm an anesthesia resident at the mount
sinai hospital in new york city in this video i'm interviewing the chief of neuroanesthesia at mount
sinai hospital dr ben toure i just finished my month-long neuro anesthesia rotation and had the
privilege of spending many days in the operating room with dr toure it was a very interesting month
and i thought it would be a great opportunity to make a video about neuro anesthesia so dr toure
very graciously agreed to let me interview him if you find this video interesting or helpful i'd
really appreciate it if you liked it and subscribe to the channel let's dive in my name is ben toure
i am originally from guinea west africa and i went to college in philadelphia and then i came
to medical school in new york i've been in new york ever since medical school i trained here at
mount sinai and at SUNY downstate in brooklyn and i've had a strong interest in neuroanesthesia from
downstate that's basically what i've been doing since after residency training - neuroanesthesia
and that's how i got to know you as a first year anesthesia resident as a ca1
i was rotating through neuroanesthesia and we spent a lot of time together in the OR
right and it was very interesting rotation i learned a lot - i'm glad you did - you were
willing to sit for this interview so that rotation at least went
well enough that you were willing to spend a little bit more time with me
i hope so i mean i think it was a good rotation i'm kind of a little biased because i work here,
mainly here in neuro but i think it's a good rotation for the residents to see
and the medical students too
what's the position that you hold here on faculty at mount sinai specifically
so on faculty here specifically i'm in charge of neuro anesthesia chief
you know a lot of medical students aren't very familiar with anesthesia as a field
and i would say even fewer are familiar with neuroanesthesia i for one had no idea that that
was even a subspecialty until i came and did an away rotation so then i got introduced to
neuroanesthesia can you help me understand what is it that makes neuroanesthesia its own subspecialty
so it's its own speciality because the nuances within anesthesia that have to be specific to just
neuro for example if we're doing a patient that's having a spinal cord detethering procedure that
patient will require someone that has familiarity with somatosensory evoked potential monitoring and
motor evoked potential monitoring on top of the regular general anesthetic
techniques that are applied to other surgical procedures
what would you say are some of the unique anesthetic considerations of neurosurgery
in addition to being familiar as you said with some of the evoked potential monitoring
it depends on the kind of operation we're doing if we're doing operations in the brain,
sort of the unique sort of considerations -- ways to manage intracranial hypertension and manage
cerebral perfusion pressures -- those are quite specific to just neuroanesthesia you know for
example patients that are having aneurysm surgery because they have a subarachnoid
hemorrhage from an aneurysm rupture- the considerations, they are quite different from
for example a patient that's having a laparotomy done for a hemicholectomy we kind of have to
manage their blood pressures to their circle of Willis as opposed to just managing their blood
pressure to their aortic arch pressures that we do for a general non-neuro kind of operations
in practical terms what sort of changes does that necessitate for your anesthetic plan if
you're going to do say a craniotomy instead of a laparoscopic surgery
multiple things-- from a pharmacologic standpoint
we've pushed towards doing mainly total intravenous anesthesia for these operations
because we find that doing total intravenous anesthesia
helps and minimizes interference with the neural monitoring the monitoring of the
you know corticospinal tracts and the spinothalamic tracts, and sometimes even brainstem
auditory evoked potentials if we do just TIVA (total venous anesthesia) we tend to have less
interference and maybe even better monitoring so that's sort of the pharmacological consideration
now as far as how to protect the brain there's neuroprotective things that we can do with you
know hyperventilating the patient so that we'll have cerebral vasoconstriction that will lower the
patients intracranial pressure when we do neural monitoring we can actually use EEG monitoring to
you know how deep the patients are and titrate the anesthetic to the level of depth that we want
them to be during the resection you know they're some of the more rare operations- not rare but
not as common- which are the awake craniotomy operations and that's kind of its own special
sort of sub-specialty within neuro as well where we're putting the patients on the
general anesthesia but for very short time and then the patients are awake
throughout the procedure so that we can do the resection without without causing any sort of
injury to them and then towards the end of the operation the patients will either stay awake
or depending upon how much work needs to be done they'll go back under general anesthesia
you've mentioned neural monitoring several times and i've met some of our neural monitoring
specialist as i've been rotating with you
help me understand why we do neural monitoring and what is it
so neural monitoring is essentially another layer of safety or security
to maintain the patient's neural pathways or to minimize damage if damage does happen
i'll give you an example if a patient has a big spinal cord procedure, you know spinal cord
operation being done say for example for i don't know, the patient is having a laminectomy and
decompression for nerve injuries from disc compression for example, or even trauma, it
would be good to be able to maintain the patient's neurologic status the way it was and then improve
it without injuring them while you're trying to do this operation so having neural monitoring
is a safety mechanism for that to prevent such injury from happening. it's safe to
say it's specific to neurosurgery and orthopedic surgery, a little bit of vascular surgery that
directly involve the brain, in other words carotid endarterectomy sometimes have done with
neural monitoring which makes sense because that's perfusion to the brain
what does one have to do to become a neural monitor?
the people who do neural monitoring have to go to a specific school a training program for it,
i think it's about a two-year program and then once they do that they- obviously within
that training- they have to do clinical rotations as well and then there's usually
a neurologist or a neurosurgeon that oversees the technicians who are doing the
monitoring and interpreting what the EEG findings are
in this hospital that role is spread out between i think
two neurosurgeons and one neurologist who do the overall interpretation of the monitoring
but we have at least a dozen technicians there who are actually in the room and measuring it
we can do it too in anesthesia, and it's in fact tested quite a bit in anesthesia,
but because our focus is on so much of the patient itself with other things to do,
we've sort of delegated that need to a subspecialty, to neural monitoring people
what other type of equipment do you normally have in a neurosurgery operating room that you use that
wouldn't necessarily be found in other types of operating rooms?
other than the neural monitoring specific portion like we said SSEPs and EMGs and
motor evoked [potentials], other than that sometimes we're faced with
actually directly measuring the patient's intracranial pressure (ICP) so we'll
transduce a catheter to the patient's ventricle and we'll be monitoring the ICP
the other issue that we can sometimes monitor is actually sometimes the patients have
external ventricular drains and we'll be monitoring how much fluid is coming out of that
drain and communicating that with the surgeons and at times where we have to release small CSF fluid
or less, that's another role that we're trusted with doing, besides the normal
regular vital signs and sometimes even the BIS monitor if you want to do that route as well
what's it like working with neurosurgeons?
in general my perception is that they're very nice they're usually very very smart and also
very humble and listen to everyone's opinion before making up their mind
so if i was to give a general, in my opinion, they're a very nice bunch of people to work with
i take my bluetooth speaker into the operating room and i'll set it up and put on some music
so i haven't really gotten too much of a sense of what type of music my colleagues
on the other side of the drapes listen to but perhaps you have-- curious to know,
what kind of music do neurosurgeons listen to while they're working, if any?
it's a funny thing one of the neurosurgeons here doesn't want any music in the room at all
i sort of understand why he doesn't want any music because he's doing
the pretty complex vascular operations and he doesn't want any sort of a distraction so
no loud talking, no music, even our monitors we turn the volumes down a little bit,
but there are other surgeons who do pretty invasive operations too, they listen to
everything, they listen to reggae, they had a guy here who liked to listen to classical music
and then the others that, you know, whatever you feel like playing they leave it up to the other
staff in the room to decide and they're just happy to go with it, all depends on the personality
what do you like to play?
i like to play a lot of reggae but
lately i've been playing a lot of international world music, music from the sahara in africa
next time we're in an OR together we'll put on your spotify playlist
okay yeah yeah it'll be it'll be fun, i think you'll enjoy my list as well
i assume you also work in the general ORs doing
anesthesia for types of surgery beyond neurosurgery. can you talk about the
balance that you have between doing anesthesia for neurosurgery and then other types of cases?
i'm here doing neuroanesthesia maybe
four days a week, and then the other day i'm sometimes here or sometimes in the main OR
because i take call i have to cover, you know, all comers, from endoscopy to
general surgery, sometimes even the liver resections,
you know whatever comes we have to be able to sort of handle it comfortably as well
so i do other operations as well but i'm primarily here for i'll say at least 80% of the time
can you tell me about your work-life balance
and how much call you take, the length of your typical work day?
because we're doing neuroanesthesia our operations can be pretty long operations we do take call,
overnight call, so when we're on overnight call we come in later in the day and work
till the next day if you don't want to stay long in neuroanesthesia you can choose to do the most
specific one to two level spine operations and that would be interesting as well but
they're shorter operation. i'll say a short day would be a day that you work seven hours a day
and then you have mentioned longer surgeries. how long can these neurosurgeons go for?
it depends you know they have operations, some neurosurgeries
or procedures can go for 8, 9, 10, 12 hours
what kind of surgery would that be that takes so long?
for example a severe GBM that's in a really difficult location those patients can have
you know two sub-specialties doing the operation
you can have an ent surgeon usually a rhinologist that comes
and they can easily work for five or six hours to get the exposure and then a neurosurgeon will
come in and do their part of the operation that could easily add another three four hours there
you had mentioned that you frequently use TIVA- that we frequently use TIVA-
what agents do you most commonly incorporate as part of total IV anesthesia?
over the past maybe six seven years i've come to rely heavily on remifentanyl
but we do a lot of propofol and remifentanyl
i know people that do propofol and maybe some dexmedetomidine as well
and i know people can do propofol and fentanyl but because remifentanyl
essentially doesn't have a context sensitive half-life, it's plasma esterase metabolized,
i rely heavily on it because then i can turn it off quickly and get a neurological exam on
the patient if the patient needs to go downstairs for CT scan because there's a concern of a bleed
postop i'm fairly confident that the remifentanyl will be gone quickly and the propofol i titrate
so i'm fairly confident that the delayed awakening is not because of an anaesthetic issue per se
what would you say are some of the biggest challenges of doing neuroanesthesia?
the biggest challenges are you know the patients' conditions. these are very
difficult operations to do, sometimes the risk of a stroke as a complication is a significant
one. the risk of a neurologic deficit is a significant one after neuroanesthesia--
usually something that we talk to the patient about it and plan for it but they're not without
risk you know so i would say that's the most difficult part of being in neuroanesthesia but
you know we do help a lot of people and if these operations are not done
then people don't have a chance to cure their illnesses and the tumors or their malformations
that they have or even their seizures that they have so that's the hardest part to me
curious if you would like to speak at all to being a minority physician and what that has been like
in terms of your training, your practicem anything that that you'd like to share about that
you know it's an interesting thing i graduated- finished training in 2007. it's 2020 now,
you know in those 13 years of working
i actually haven't seen an increase in the number of underrepresented minority
residents or attendings for that matter but i'm told that there are, i just haven't personally
seen it so that's kind of surprising and maybe even shocking a little bit here at mount sinai i
feel that we don't have enough minority students but i'm hopeful that that will change within my
lifetime as far as my own personal self, being a minority in anesthesia or in neuroanesthesia
i actually haven't seen any basis for any sort of a concern or anything
i feel like i get treated the way i get treated outside of the hospital
some people are nice others are not, some people are polite others are not, i just kind of
do what i have to do and i try to be good at what i do and let the rest take care of itself
is there anything that i haven't asked you about that you think
would be interesting for a medical student or the general public who's watching this?
well i think for medical students considering different sub-specialties in anesthesia or in
medicine in general i highly recommend anesthesia and neuroanesthesia as biased as that sounds,
i think intellectually it's very very interesting and technically as well,
as far as the actual procedures that we would physically do with our hands
i think they're quite challenging but very interesting so i would encourage any student
that wants to come and do a rotation with us or read about anesthesia, neuroanesthesia,
to go ahead and do it. it's very rewarding in that way. i've had you know kids and their parents
basically crying in happiness at the end of the operation and were able to wake up
their kid and extubate them right away it's very fulfilling and rewarding in that sense
it's quite a sales pitch for neuroanesthesia as i think about
what sub-specialty, if any, i'd like to do. thank you very much for your time
most welcome feinstein thank you very much was fun
i really appreciate it
thank you