58. Preparing for Surgery with Linda Bluestein, MD

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00:00
Dr. Linda Bluestein
Actually, this is shocking, but 88% said that they had a problem with a local anesthetic injection not working adequately or properly. I mean, that's huge. That is huge. 

00:25
Jennifer Milner
Welcome back to the Bendy Bodies podcast, where we strive to improve well being, enhance performance, and optimize career longevity for every Bendy body. This is co host Jennifer Milner, here with the hypermobility MD linda Bluestein. 

00:39
Dr. Linda Bluestein
We are so glad you are here to learn tips for living your best Bendy life. This information is for educational purposes only and is not a substitute for medical advice. 

00:50
Jennifer Milner
Our guest today is our very own Dr. Linda Bluestein. Dr. Bluestein. Welcome to bendy bodies. 

00:57
Dr. Linda Bluestein
Hi, Jen. Thanks for having me. It's always great to chat with you. 

01:04
Jennifer Milner
I know it's always great to chat and we have something to talk about today that is absolutely one of your areas of expertise. But for the people out there who may not know exactly what you do in your background and just know you as one of the voices on Bendy Bodies, can you tell them a little bit about yourself? 

01:20
Dr. Linda Bluestein
Sure. So I am anesthesiologist, and what that means is that I went through regular medical school and then my residency was specific to anesthesia and I did that at the Mayo Clinic. And so I then practiced in the operating room for over 20 years before my own Eds. I like to say it kind of caught up with me. The signs were there for a very long time, but I started having more and more problems. So I had to come up with a plan C because Plan A was to be a professional ballerina that didn't work out. Plan B was to be anesthesiologist that worked out for quite a while. And then plan C is to be an Eds specialist, which was not really something that I originally planned to do, but so I've been able to take my training as anesthesiologist, which really includes a lot more things than I think people realize. 

02:10
Dr. Linda Bluestein
As anesthesiologist, we need to know basically two buckets of things, and the first bucket is the things in the body that affect the potential for complications in surgery. So that means how the kidneys are working, how the liver works, the cardiopulmonary system. We need to know a lot about the heart and arrhythmias, and we need to know a lot about the lungs. Of course we take over your breathing in certain circumstances. We need to know a lot about neurology. And pain management actually is part of anesthesia. So I did go through pain management training in my anesthesia residency as well. And then we need to know about the surgeries, of course, because they have specific I mean, I don't know how to do any of them, but I need to know how they impact the safety of the patient. And what type of anesthesia do you need for XYZ surgery? 

03:02
Dr. Linda Bluestein
And the potential complications that the patient might have that influence the type of anesthesia that you choose, what kind of positioning is the patient going to be in, and a lot of different surgical nuances. Oh, this type of surgery is very low risk, so even if somebody is really sick, it's usually going to be okay. Or this other type of surgery is really high risk. So if the person isn't really in their best shape going into the surgery, then maybe we need to have a conversation with the surgeon and the patient and maybe try to get them better optimized before we have the surgery. So it was really taking kind of my experience as anesthesiologist and then my own self study on Eds. There is no Eds fellowship, which is appropriate. We can't really have fellowships based on conditions. We need to have fellowships based on bigger buckets of things. 

03:57
Dr. Linda Bluestein
But I've basically taken kind of all of these different areas of knowledge and training and then I can put them together and I can specifically advise patients and clients if they're going to have surgery. This is a big thing that we often talk about because I have kind of a unique background in that regard. 

04:16
Jennifer Milner
Which we are all very grateful for because you share that knowledge with us. So for anybody listening who has not figured it out, we're talking about anesthesia today. And it's a conversation that's worth having and sort of broader than that. We're talking about preparing for surgery. So it's not just the anesthesia aspect of it. And we wanted to discuss this for two reasons. One, many bendy bodies may end up having a surgical procedure at some point, and we know it can be scary and it can be a bit of an unknown. And we know our bodies may need extra preparation. We may want to be really well prepared for whatever we're going in for. And second, bendy bodies can have unique reactions to anesthesia, sort of atypical, skin healing and so many more issues. So we thought this would be a valuable conversation to have that's broader than preparing for this type of surgery or that type of surgery. 

05:10
Jennifer Milner
So let's dig into it. First of all, let's talk about hypermobility and medication in general. As anesthesiologist and a hypermobility specialist, what have you seen with that? 

05:23
Dr. Linda Bluestein
So the challenging thing is that a lot of people with symptomatic joint hypermobility, they often end up on a lot of different medications and sometimes a lot of different supplements as well. So one of the things we need to be aware of are potential drug interactions. So drugs can interact with each other, but maybe the person isn't really aware of it. And it's kind of a low threshold type thing. But now you go in for surgery and anesthesia and a lot of people don't realize when you're getting anesthetic, especially a general anesthetic. Well, actually, I guess any type of anesthetic, but especially a general anesthetic, I should say, you are often getting 810 different drugs during the course of that procedure. So it's important to be aware of what these potential interactions are, especially with supplements. And we'll get into that a little bit more in a little bit. 

06:15
Dr. Linda Bluestein
But a lot of people that have symptomatic joint hypermobility, they do react more easily to supplements. They can be more sensitive to what we call excipients, which are the quote unquote inactive ingredients in medications. And they can often have a long they might call it an allergy list, but some of them are allergies and some of them are intolerances. And I definitely advise my patients and clients to really go through all of the medications and supplements that you may have a quote unquote allergy to and to really go through that list and describe next to each one what is the reaction that you've had, because some of those maybe can even be removed from the list. For example, I've seen people come in with lists 20 things long, and I will tell you, the operating room is a very fast paced environment. If you come in with a list of 20 things long, that's a lot harder for a person to pay attention to than if you come in with a list of three things. 

07:13
Dr. Linda Bluestein
So I always recommend that people clarify what are true allergies. Meaning that your throat swells up, you get hives, you get a rash. If you have anaphylactic or anaphylactoid type reaction, your blood pressure drops, you may have difficulty breathing, you may have wheezing, but you don't have to have that extreme of a reaction in order to have an allergic reaction. But then a lot of reactions are intolerances where a person maybe has some GI issues, they might have some abdominal pain or something like that. But a lot of what people often list are actually not allergies. They're not intolerances. They're just known side effects of the medication. For example, they'll say opioids make me nauseated. Personally, I would remove that from the list because that is a known side effect of opioids. You can say I get nauseated really easily from medications as part of your disclosing your medical history. 

08:08
Dr. Linda Bluestein
But I just think that for that list of medications and medication allergies, you want to keep that highly specific and things that are really relevant. So that's the first thing. The second thing is people that have symptomatic joint hypermobility often have a lot of variability from one day to another. So things that might not impact them negatively one day might impact them negatively a different day. So I think that's just another important thing to be aware of. And then lastly, it's so important to disclose to your surgeon when you're seeing them, before you're even discussing surgery, make sure you disclose all of your medications and all of your supplements, whether they're ones you take every day, ones that you take on an as needed basis. It's very common for people to forget mentioning supplements and I would even recommend taking all of your supplements with you to your pre op appointment so that they can see the bottle and they can see what's listed on there. 

09:05
Dr. Linda Bluestein
Now, of course, we also know that supplements aren't regulated like medications are, so supplements can have other things in them that are not necessarily on the ingredient list. That's a whole nother topic. But I think it's a good idea to bring all your medications and all your supplements in a bag to your pre op appointment so that the person who is doing your pre op assessment knows exactly what you're taking. 

09:27
Jennifer Milner
That's great advice. And even if you can't bring all of medications, maybe you could take pictures of the labels to be able to bring that or something along those lines just so that they have a clear idea. I know every time I fill out forms with my doctors, they're like list all medications and supplements and I'm like, oh my gosh, again. But it's important that they understand all the things and that they can see everything because as you said, how do those things interact? But even going bigger than that, are there any studies out that talk about how people with connective tissue disorders may process medication in general differently or may process anesthesia differently? Just my casual observance. I know I metabolize anesthesia super fast and always startle all of the doctors with how quickly it wears off and other sort of anecdotal incidents of people saying, well, this medication had the opposite effect on me and that just seems to be more common in hypermobility. 

10:26
Jennifer Milner
Is that just a thing that I'm seeing or is there some sort of common thread to that? 

10:31
Dr. Linda Bluestein
So the fascinating thing about that is, right, we have a lot more anecdotal evidence than we do have actual studies. I will tell you I wrote an article with my mentor, Dr. Pradeep Chopra, who is also anesthesiologist, but he has done pain management for he's a board certified pain management physiciand he's done pain management for most of his career. I don't know how much time he's spent in the operating room, but he is an expert at treating people with symptomatic joint hypermobility. He's really phenomenal. He and I wrote an article together on surgical and anesthesia considerations for people with Eds and we tried to get that published in a high level that I thought when were writing it, I was like, this is going to go in the New England Journal of Medicine, this is going to go in JAMA. I mean, I was like, we're shooting for the moon. 

11:24
Dr. Linda Bluestein
And I will tell you, this is so he because he was the first author, he submitted it to so many different journals and they all said no one's interested in I. We were both to they need to be interested in this and I trained, like I said, at the Mayo Clinic. And one of my faculty there who was head of the department for a while, he was actually president of the ASA at one point, which is our big international organization, the American Society of Anesthesiologists. And he's kind of an expert in positioning under anesthesia. And I tried to talk to him once and say, look, this is a huge important topic. People with Eds and getting positioned under is, I believe we can really cut down complications if anesthesiologists were more aware. There is a specific population of people that are at increased risk of having problems with positioning, but there was no interest. 

12:23
Dr. Linda Bluestein
So I think a study coming out on how people with these conditions react to general anesthesia or other type of anesthesia medications, I think that we're quite a long ways from having a study like that. But I will tell you that there are some fascinating genomic and pharmacogenomic studies. So you can have your DNA base pairs analyzed, which is different from looking doing the type of genetic testing that looks for a disease. This is genetic testing that looks more like at pathways and things like that. So if you have that kind of genetic testing done, it can tell you, oh, you are a fast metabolizer of XYZ, you are a slow metabolizer of ABC. That pharmacogenomic testing can give you information about anesthesia. And some of the anesthesia drugs like Propofol, that's the Michael Jackson drug that he was getting administered at home. It's a drug that we use all the it's very safe if you're doing it in a monitored setting. 

13:27
Dr. Linda Bluestein
It's not safe if you're doing it at home. So Propofol, yes, there's a specific genomic test that we can do that gives us information about how you metabolize Propofol. So yes and no. There's no big studies, but we do have some information about that. And in terms of bendy bodies and these genomic findings, there is some fascinating research that's coming out about MTHFR, which I don't know how many people in the audience are familiar with MTHFR, but that is one of those pharmacogenomic things that we can test for. And there's long been a suspicion that people with symptomatic joint hypermobility have a higher prevalence of MTHFR mutations, either homozygous or heterozygous. And Tulane actually published a paper in August about this and high serum Folate levels, but low intracellular Folate levels. And that being correlated with symptomatic joint hypermobility. So we definitely are on the cusp of, I think, a lot of information in this regard, but we don't have great huge studies yet. 

14:35
Jennifer Milner
But that's encouraging that these things are being looked at and we've got a lot of dots that have now been drawn and we're just in the process of connecting those dots, right? 

14:43
Dr. Linda Bluestein
Yes. 

14:43
Jennifer Milner
So the dots have been plotted and it's just sort of connecting it. So if someone is going to be going in for surgery for some reason. What are some important diagnosed or even suspected medical conditions a person should share with the anesthesia team? 

15:00
Dr. Linda Bluestein
So there are a bunch of different things that are very important to mention. And for my patients that they're working with me and they send me a message and they say, hey, I'm planning on this XYZ surgery. Can we meet to discuss that? Oftentimes one of the things that I will do is I will provide a customized letter because again, I know what the anesthesia team is going to want. I know what the surgeon is going to want. And I've written a lot of these letters now and I've gotten really great feedback from patients. I will write them for clients too. And I've gotten really great feedback that they showed it to the surgeon, they showed it to the anesthesia team and they seem to really read them carefully. And I used to have these cards that I created when I had my previous practice and I keep thinking, oh, I should redo those cards, but they're not as helpful because they're generic. 

15:47
Dr. Linda Bluestein
Whereas the letter is customized and it lists these are your specific complications that you've had under anesthesia before, for example. And I know how to describe those in terms that the person reading the letter will go, oh, she knows what she's talking about. So anyway, so that's one thing that I like to do. But in terms of things that people should disclose, and I agree if it's suspected or if it's formally diagnosed, these are things that people should talk about first, things that like the function of the gut. So if you have gastroparesis, which is slow motility through the gut, or if you have gastroesophageal reflux disease, we may want you to have an NPO or nothing per mouth, nothing per OS is the formal like Latin for that NPO duration. So we might want you to go a little bit on the longer end without eating or drinking. 

16:39
Dr. Linda Bluestein
The hard thing with the NPO guidelines is what we call them in anesthesia. So again, that's nil per OS is what the actual formal thing is. But it's how long do you have to go without eating or drinking. And we actually know from looking at gastric fluid that you really should be able to drink water and other truly clear liquids up until two to 4 hours before the surgery because those clear through the gut very quickly. And especially water. Because if you aspirate water, meaning it comes up and goes into the lungs, that's not going to cause as much damage as, like, black coffee, which is also a clear liquid. So clear liquids are generally things that you can see through, black coffee you can't see through, but like apple juice would also be considered a clear liquid. But if you have gastroparesis and or gerd gastroesophageal reflux disease, we may want to consider extending that NPO duration a little bit. 

17:31
Dr. Linda Bluestein
And usually solids and clear liquids are different the duration that we advise people that they need to conform to. But sometimes, for simplicity's sake, you will be told nothing to eat or drink after midnight, even if your surgery is not scheduled until three in the afternoon. And I will tell you why that is. Surgery time is, of course, very valuable. It is extremely expensive. Having in every or there's probably between like eight and more, sometimes 15 people that are assigned to that room, that case that are handling materials, whatever going to be in the room, we don't want those people sitting idle. That's very expensive. So you might be scheduled for 03:00 in the afternoon, but you're told to come in at noon because if they've had some cancellations or whatever, no shows, then you're going to get moved up. Or sometimes they have everybody show up first thing in the morning. 

18:27
Dr. Linda Bluestein
So we don't want to tell you that you can drink fluids or eat at two in the morning if we might be moving your surgery up quite considerably. So that's why usually people will just give a general thing of like, nothing to eat or drink since midnight. If you have dysautinomia, for example, or if you have other conditions where you are very sensitive to not eating or drinking and being dehydrated, I would strongly recommend discussing that specifically with your surgeon and or whoever's doing your pre op and ask specifically can I please have clear liquids up until a couple of hours before my surgery, or can we loosen that part of the guidelines? Not the solids. Solids take a lot longer to clear through your body, and we don't want you to aspirate solids, we don't want those to come up and go into your lungs. 

19:18
Dr. Linda Bluestein
But clear liquids are a different story. So the first thing is those things that can affect the NPO guidelines, the gerd and gastroparesis, and also dysautinomia can affect that kind of in the other direction. It's also important on dysautinomia to mention that because that can affect IV fluid management and medications that we may give you, or medications that we may ask you to keep taking up until the time of surgery or ask you to hold. So when a person, whenever I was working in the operating room and someone came in and they had a diagnosis of dysautenomia, or even if I suspected it, there were a couple of times where I suspected it. As I started to learn more about these things towards the end of my career in the operating room, I would put that IV in right away and I would just start running it wide open, especially if it was a young, healthy person, because I'm not going to fluid overload them. 

20:06
Dr. Linda Bluestein
So those are important things to mention, GI things, and also dysautonomia. It's also important to mention if you have any issues with either storing or if you've been diagnosed or have suspected sleep apnea, either obstructive sleep apnea or non obstructive, because that can affect airway management, that can affect your sensitivity to opioids and things like that. That can affect our considerations for alternatives to opioids in the perioperative period, things that won't suppress your breathing as much. So those are important things to mention. You also want to mention and we'll talk about this more later, if you've had atypical responses to any type of anesthesia, like you were mentioning about how you react to general anesthesia, or if you've had an atypical response to local anesthesia, definitely mention that to your surgeon because that may influence what they're going to do. You also want to mention if you've had any problems with joint instability, especially for certain particular joints, like if you've had cervical instability or maybe you've had instability of your temporal mandibular joint, which is your jaw, because we're going to be opening your jaw and putting in an airway device. 

21:11
Dr. Linda Bluestein
So it's really important if you have any instability of your jaw, to let us know about that. If you have clicking or if it's ever dislocated and things like that. It's important to mention if you have a diagnosed or suspected chiari malformation because that can affect your breathing, that can affect your hemodynamics, your coordination, a lot of different issues. You want to mention if you've had any issues with poor healing or easy bruising, because that can affect things like management of the surgical incision, the choice of procedure. You want to mention if you've had prior adverse reactions to medication, tape, suture, skin prep, things like that, because that can influence those choices and they'll actually put it on the schedule. If you've had an adverse reaction to one of the more common skin preps like Betadine, they'll actually put that right on the schedule so that everybody knows. 

22:03
Dr. Linda Bluestein
So that's an important thing to mention. And then if you have diagnosed or suspected mass cell activation syndrome, you definitely want to mention that because that may change the medication regimen that we use for the anesthesia and we may want to have different rescue medications on hand. 

22:17
Jennifer Milner
Those are all really helpful, and some of those are things I would think about, but some of them, like just mentioning different allergies like latex or Betadine or something, I just wouldn't have thought of. So that's really great. Thank you. You mentioned as you were talking through that list, sort of you might have a reaction to local you might have a reaction to general anesthesia. There's a lot of confusion around that, I think. So can you talk about the different types of anesthesia and why we should know about them? What do we need to know? 

22:47
Dr. Linda Bluestein
Sure. And they're really relevant because it influences potential risk for the surgery and the anesthesia. And there's different considerations that I think even as a patient we should have. So you can have something done under straight local anesthesia and what that means is you're not getting an IV. You're not usually not getting an IV placed. You're not getting anything, though, in the IV. You're not getting any medication at all. If you're getting straight local anesthesia, they might be putting just numbing medicine right in that specific area. So even if you're getting, like, a mole removed, that would be under local anesthesia, they're just injecting the numbing agent, and then they're removing whatever it is that they're removing. But there are other procedures as well that can be done under local anesthesia. And then there's something called peripheral anesthesia. And that's where we do, like, a type of block. 

23:41
Dr. Linda Bluestein
Like, you and I were talking before we started recording that if a person has shoulder surgery, we might do something called an interscaling block or a subclavicular block or a superclavicular block, which sounds like maybe that's what you had. But an interscaling block, the needle actually goes into the neck and will numb the entire upper extremity. So sometimes we do that type of anesthesia. And so it's really important for people to know what type of anesthesia is the surgeon planning to request that the anesthesia staff do if they're involved. So if you're having straight local, you probably don't have any anesthesia staff involved. If you're having a peripheral block, like an inner scaling block, the anesthesiologist is going to be placing that block so they will be involved. And usually they're giving you sedation on top of that. So I've had this happen so many times where someone has told me I had a general anesthesia. 

24:32
Dr. Linda Bluestein
I had a general anesthetic, and I look at the anesthesia record from their previous anesthetic, and they did not have a general anesthetic. They had a peripheral block, and then they had so much sedation that they didn't have any awareness. Exactly. You forget, and you just weren't aware during the procedure. And right. You could have been talking during the procedure, but you just don't know that you had that level of consciousness. And I think that it's helpful if you've had any issues with prior anesthetics, and if you have enough time, it would be very helpful to actually get that anesthesia record, especially if it was done at a different facility. So let's say you're going like I said, I trained at Mayo Clinic. Say you're going to Mayo Clinic and you have a surgery and you had some complication, and you're going back to Mayo Clinic and you're having another surgery. 

25:18
Dr. Linda Bluestein
They will have that record. But let's say you go to a different facility. You might want to get that record from Mayo Clinic so you can take it with you, so you can show it to the anesthesiologist and say, this is the problem that I had in it, because they're going to be able to look at that and read it and really glean some good information. So I think that would be a good thing for people to do if they have enough time beforehand. And then a neuroxial anesthetic is where you have either an epidural block or you have a spinal block. So you're numb basically from either the waist down or the chest down, depending on how much drug we administer. And that depends on how long the surgery is. So in that case, you're getting a needle put in your back and you're getting medication injected that will numb up. 

26:02
Dr. Linda Bluestein
Basically that half or more than half of your body. And then the other two types of anesthesia are monitored anesthesia care, which is mac, which is when you get sedation by the anesthesia team. And oftentimes you think you had a general anesthetic because sometimes the mac is so heavy that you think you had a general anesthetic. And then the last type of anesthesia, general anesthesia is where you are unresponsive. You're not going to respond to pain. You usually don't have like a cough reflex and that kind of thing. And usually with a general anesthetic, we're putting in some kind of airway device. So you might wake up with a sore throat. You might have a breathing tube that goes all the way through your vocal cords into your trachea, or you might have a type of airway device that just rests in the back of your throat, which is a little less invasive. 

26:56
Dr. Linda Bluestein
It depends on if the surgery requires paralysis or not. But the reason why I'm mentioning this is because a lot of people that have symptomatic joint hypermobility, a lot of us, have difficulties achieving certain positions. So for me, for example, if I have to have another surgery, I think I will ask them to please not put both of my arms all the way out at my side, standard on the cross position, because that is for most surgeries. Then we have access to both of your arms. If something happens and the IV suddenly gets infiltrated, meaning that now the fluid is leaking out, we can put an IV in the other arm. We like to have access to your arms for safety reasons, but for me, that would really hurt my shoulders to have my arms all the way out at my sides. So it's important to know because if you're having a local anesthetic, it doesn't matter. 

27:51
Dr. Linda Bluestein
You're never going to be unable to communicate, for example, you're never going to be able in a situation where you can't let them know, hey, that hurts. But if you're having a general anesthetic and sometimes you're going to be positioned under general anesthesia and that's when you're at risk of subluxation or dislocation, especially if we've paralyzed you, because if we've paralyzed you and completely relaxed all your muscles. Now, when we go to turn you, let's say you're having surgery on your lumbar spine and you're going to be prone, meaning you're laying on your belly. We put you to sleep. We have to put you to sleep on your back. Because we have to have access to your airway, we have to access to your mouth to put in the breathing tube. So we put you to sleep on your back. We put the breathing tube in and all of that, and then we roll you. 

28:32
Dr. Linda Bluestein
It's usually a bunch of people that are holding onto your body to roll you onto your belly. But if you have some unstable joints, especially if you have an unstable C spine, and if you have cranio cervical instability or any kind of instability in your cervical spine, it's very important for people to be aware, to be extremely careful. Not that we're not careful, but you just want people to be aware, oh, this wrist is very loose, and so please be careful when you're positioning me. I also often recommend if people are having a general anesthetic, especially if they're having a position change like that. And you can ask your surgeon if that's going to be the case because they'll definitely know if I was. Having a surgery nowadays, and I was going to be positioned on my belly. I would probably go in wearing a bunch of braces as a visual cue, and they may end up taking them off. 

29:23
Dr. Linda Bluestein
But I would either put on braces or tape on my wrists, on my elbows, on the joints on my body that are most problematic so that they see, oh, this person has enough problems with that joint that they actually have a brace that they wear periodically. I don't wear it all the time. I just wear it periodically. So I think those are things that are important for people to be aware of, because most people don't realize that after we put you to sleep, sometimes we move you around. And we do that because we have to. It's not that we want to, and we always do it, of course, as safely as we possibly can. But if you have specific particular issues with joint stability, that's a really important thing to let people know about. 

30:08
Jennifer Milner
And again, that's not something that I usually think about. I think about it during X rays. They're like, you need to hold this and do this. And I'm like, that's really uncomfortable. Can we figure out a different position? But as you said, I'm awake at the time able to talk about that. So just dwelling on the different types of anesthesia just a little bit longer, general anesthesia, you are completely out. And I think a large majority of people would be like, sign me up for that. That's what I want. I don't want to be awake at all. But it's not as if the other types of anesthesia epidurals, which are common during childbirth or like you said, a truly local anesthesia, like when you're getting oral dental work for Cavities and such, they're not going to do just a tiny amount and be like, this is going to hurt for a while, but just suck it up. 

30:56
Jennifer Milner
So if people are concerned about that, if the doctor says you're going to do a nerve block or we're going to do something along those lines, have a truthful conversation with the doctor and ask them questions, I would think, am I going to remember this? Will I be awake? Will I be able to tell you if I'm feeling pain? Because that can be a scary thing to think. I'm going into surgery. I'm not going to be technically unconscious. But you don't want to overdo the anesthesia. 

31:21
Dr. Linda Bluestein
Correct. 

31:21
Jennifer Milner
You don't want to do general anesthesia to have a mole removed. 

31:26
Dr. Linda Bluestein
Exactly. 

31:28
Jennifer Milner
Because anesthesia there's risks involved. 

31:30
Dr. Linda Bluestein
Right. 

31:31
Jennifer Milner
And they're highly managed, but there are risks involved. So for all of those people who are getting nervous out there as they listen to you describe all of the non general types, talk to your medical care providers because they really are not trying to keep you awake and torture you, right? 

31:45
Dr. Linda Bluestein
No, that's an excellent point. And I actually had a patient once who came for a hysterectomy, and she wanted it done under spinal, and it was the type that you could do under spinal, and she wanted no sedation. And I was like, none. None whatsoever. Are you sure? None for when I put the needle in your back? None for when they're working on you? No, I want none. Like, okay, fine by me. I mean, that's really true, to be honest. That's like the safest way. And in a lot of third world countries, what they will do is they will do lots and lots of procedures under spinal anesthesia, and the anesthesiologist will do spinal, spinal. But they won't stay there. I mean, they'll stay there for the first little while to make sure everything's okay, but then they have limited resources. So if you're not doing sedation on top of a spinal anesthetic, that's an excellent point that we always have to consider the risks and benefits of everything and definitely talk to your surgeon about what are my different choices? 

32:47
Dr. Linda Bluestein
Why might I consider different choices? And then talk to the anesthesia team also about the risks and benefits of the different options. And one of the things that I think is also just an important thing to mention because you were talking about, like, are you going to be aware or not aware? It's not always completely clear if a person is going to have recall or not. I remember so many times where oftentimes I would give a person some sedation before we would wheel them back to the operating room, because as you're getting that close, you start to get nervous. And there'd be times where somebody would seem still completely with it. They would look like they don't feel anything. And afterwards, I would talk to them, and they would say, I don't even remember saying goodbye to my family, for example. And then other times, people are like, I don't feel a thing, and they're slurring their words and they seem like they're really out of it, but they'll remember, like they'll say, oh, yeah, I remember when you wheeled me back and blah, blah. 

33:38
Dr. Linda Bluestein
So it's not like there's a perfect correlation for us to be able to know. So I usually say you probably won't remember anything because I feel like that's safer than saying you definitely won't remember anything, because then if they do remember something, they're going to say, you weren't truthful with me, which is totally fair. And that's a problem. I mean, we need people to know that they can trust us. 

34:00
Jennifer Milner
Yeah, well, that's a great point, and I just have to throw this as an aside. Anesthesiologists have given the world some really great funny home videos for us to watch. So just so glad that wasn't around when I got my wisdom teeth out. 

34:16
Dr. Linda Bluestein
That's so true. 

34:18
Jennifer Milner
We touched on this a little bit when were talking about drug interactions and hypermobility in general, but do you observe anything specific in people with joint hypermobility and how they do react with local anesthesia? 

34:31
Dr. Linda Bluestein
So it's really interesting because I worked in operating room for over 20 years, so I've cared for I don't know how many tens of thousands of patients, probably because there are days where you have lots and lots. If you're supervising nurse anesthetists especially, you'll have four rooms and every room has stacked. So I've taken care of a lot of people, but for most of my anesthesia career, I wasn't that tuned into symptomatic joint hypermobility. I wasn'tuned into it at all for the first decade plus. It was only in the very latter part I did have I remember one patient who had she was coming for a c section, and spinal anesthesia is by far the safest for a c section. Again, it depends on this type of surgery, the patient's conditions, et cetera. But a pregnant woman coming for a c section, that's the safest type of anesthesia in most every case. 

35:22
Dr. Linda Bluestein
So that's what I wanted to do. She said, my last three spinals all failed. And I'm like, what? Spinals never fail? Epidurals? Yes, epidurals definitely fail. But spinals, I'm like, really? And I'm looking at the notes, and it says they did get CSF because you need to see the fluid flowing before you inject the medication. They said they saw it. So I talked to her and I said, you know, I still would really like to try doing a spinal if you're okay with that. And if it doesn't work, then we'll do a general anesthetic and put you to sleep. And guess what? It didn't freaking work. And I had never had that happen in like again, I had done tons and tons of spinals. So now looking back on that particular young woman, I think she was completely resistant to local anesthesia because spinals, the failure rate for spinals is exceedingly low because of the way that they're done. 

36:14
Dr. Linda Bluestein
And we have a very good marker of that. We're in the right spot because of the fluid coming back. So in terms of my clinical practice, it's not like I've been able to make that much observation. But there is some fascinating research looking at people with the Ehlers Danlow syndromes and symptomatic joint hypermobility. And in fact, there was a survey done in November of 2018, or maybe it was published in November of 2018, and they looked at 933 Eds patients that completed the survey, 99% of whom had received local anesthetics. And actually, this is shocking, but 88% said that they had a problem with a local anesthetic injection not working adequately or properly. 88%, I mean, that's huge. That is huge. That is huge. Yeah. Now, interestingly, in the non Eds population, 54% reported a similar problem. So it could be that the way they asked the questions, that their threshold for a problem with local anesthesia was very low, if that makes sense, because they wanted to pick up on all of the people that had this problem. 

37:21
Dr. Linda Bluestein
But interestingly, there was a dental study that was done and they looked at people with Eds and non Eds. And in that study, interestingly, they found 88% recalled inadequate pain prevention, whereas 33% recalled inadequate pain prevention in non Eds respondents. 

37:41
Jennifer Milner
So the number of people with hypermobility was pretty constant between those two. 

37:47
Dr. Linda Bluestein
Exactly. 

37:48
Jennifer Milner
That's so interesting. 

37:50
Dr. Linda Bluestein
Isn't that fascinating? 

37:50
Jennifer Milner
88% is a pretty high number. 

37:53
Dr. Linda Bluestein
It's a huge number. Yeah. So right now there is a study that they're taking enrollment for this study to look at local anesthetic sensitivity in people with Eds. And I don't know if they're including HSD, I don't know the details of the study, but that study won't be completed until 2025. And I did want to do and I started to kind of formulate how I would do this, but I wanted to do in my office, like injecting several different types of anesthetics, because we also know that there are differences between the different types of anesthetic. So, like, Lidocaine is often more problematic than something like Mapivocaine. So Mapivocaine is something that something called mapivocaine and Bupivocaine tend to be more successful than something like Lidocaine. And there's things that we can do. There's additives that we can put in the local anesthetic. Like, we can put clonidine in there, we can put epinephrine in there. 

38:47
Dr. Linda Bluestein
There are things that we can put in that can help improve the success rate. But this is a very important thing. If you have had problems with getting numb in the dentist chair, I'm really glad you mentioned the dentist, because of course, that's a really important one when you're getting teeth worked on, that's a local anesthetic. So if you've had any problem with local anesthetics, definitely be sure to mention that to your surgeon because even if you're having a general anesthetic, oftentimes they will inject local anesthesia into the incision so that it's less painful when you first wake up. 

39:16
Jennifer Milner
That makes a lot of sense. I definitely have a sensitivity to local anesthesia. And my dentist finally, because I travel a lot with Dance, he wrote me a note on his prescription pad so that when I traveled, I could hand it to the other dentist that said she metabolizes anesthesia very quickly. She's not a junkie, you know, please believe her when she says you need to give her more than the usual amount. 

39:41
Dr. Linda Bluestein
Right. 

39:42
Jennifer Milner
So that's a lot about the local anesthesia. So important. And I know that you said the things that people would want to discuss, like medical conditions that people would want to discuss, whether they were documented or whether they were suspected. I know it can be really difficult to talk to surgeons if you are not one, if you are not a member of the medical profession. It can be a little intimidating. So at what point do people sit down and have these conversations with their surgeon? And how can they give them the information that they need in a way that's respectful and yet not overloading or challenging or anything like that? 

40:17
Dr. Linda Bluestein
Right. And I will tell you that's true whether you're a medical professional or not. Yeah. If I'm in an appointment and I'm talking to a surgeon who might be operating on me, I'm going to feel the exact same way. I will tell you I shouldn't say because I don't know how you're going to feel, but I'm going to also feel nervous. And it is hard to bring things up and ask questions, and definitely those can be challenging conversations. I would recommend that people bring things up as soon as possible. And I would really recommend that people try to have as much of a detailed conversation with the surgeon as possible to make sure that the surgery is really addressing the root cause of the problem. Because that's the other thing that I observe with people that have symptomatic joint hypermobility, is that we tend to have often less successful surgeries. 

41:04
Dr. Linda Bluestein
And I think it's because sometimes it's not really addressing what the root cause of the problem is. So if you have a bunch of loose joints and you have a surgery one of them, you're going to have to recover from that surgery, and then you may be more dependent on some of your other joints. So I had a procedure and I was on crutches for a while, and not only did the procedure not help my original problem, but being on crutches caused me all kinds of problems with both of my upper extremities, multiple joints in my upper extremities. Those crutches just totally did me in and the non weight bearing. So it's important first to find out what are the alternatives, because there are almost always alternatives. What are the risks and benefits of the surgery and then the other alternatives which they may or may not know as much about, because if they're a surgeon, remember, they have a scalpel they like to cut. 

41:59
Dr. Linda Bluestein
So I also, generally speaking, I advise my patients and my clients, it's good to have a surgeon who's a little more experienced because super young surgeons are super enthusiastic and maybe they just finished their training. So they have a lot of really great current knowledge. So that there's pluses and minuses to everything, of course, but they also might not have seen as many complications, and they might be more aggressive and they might not be as specific with their patient selection. So ask what those other things are. If you have a lot of medical problems, you may want to request that someone else do your surgical clearance. Sometimes the surgeon will do their own clearance for anesthesia, which is fine if you're relatively healthy. But if you have a lot of medical problems, you really should see your internist or whoever your general doctor is in order to get pre op clearance. 

42:53
Dr. Linda Bluestein
So, like an orthopedic surgeon, for example, that's fine if you're young and healthy and your orthopedic surgeon is going to, quote unquote, clear you for surgery. But they also have a conflict of interest, right. They're clearing you for the surgery that they're going to do. If you are older and or have medical problems, you should go see your internal medicine doctor or your family practice doctor and make sure you discuss your medical conditions with them and make sure that your medical conditions are optimized because I guarantee your orthopedic surgeon has no clue how to optimize your medical conditions. 

43:23
Jennifer Milner
That sounds intimidating, honestly, to think about saying to a surgeon, before I let you do this, I'm going to get someone else to clear me for it. 

43:33
Dr. Linda Bluestein
Well, that's an excellent point, Jen. You don't have to get their permission, though. I mean, what I would do if it were me and I've had this happen, my orthopedic surgeon is like, yeah, let's schedule this surgery for blah, blah date. I would then, on my own, contact my internal medicine doctor or my family practice doctor and say, hey, I'm planning on having this surgery on XYZ date. Can I come in beforehand and just make sure that you think I'm good to go? Yeah, no, that's an excellent point. You don't necessarily need to say that to them. Okay. 

44:08
Jennifer Milner
That makes a lot of sense. And that feels like you are keeping control of your and trying to stay on top of it with someone who has the big picture and not just focusing on your ankle or your hip or whatever exactly. 

44:19
Dr. Linda Bluestein
And knows you probably over a longer period of time. Yeah, that's great. 

44:25
Jennifer Milner
So let's say we've gotten the medical clearance and we are ready and we are confident in what kind of anesthesia we're getting. What, if anything, should people do about supplements before surgery? 

44:37
Dr. Linda Bluestein
So definitely discuss, as we mentioned, as I mentioned, bring all the supplements with you. Your surgeon, though, may or may not know which supplements you need to stop and which ones you can continue. And unfortunately, what often happens in that case is a lot of surgical practices, a lot of medical practices will have a very broad policy of stopping all supplements, like two weeks ahead of surgery. In fact, I came across one just the other day from an institution that I highly respect and they say their instructions are stop all supplements for two weeks before surgery. I will tell you I have a lot of patients I recommend supplements, a lot, ones that are tested and brands that are more reliable and things like that. But a lot of my patients, they have their mast cell activation disorder under better control because of the supplements that they take. 

45:29
Dr. Linda Bluestein
So these broad policies can be problematic because if you stop everything now, maybe you're going to run into a problem with your mass self. So that's where, again, if you can talk to your internal medicine doctor or talk to your family practice doctor or talk to someone like me who can actually tell, you can go item by item and say, stop, keep, stop, keep. But then what I tell them is take what I just gave you, circle back to your surgeon and let them know this is my revised plan. And I've never had anyone say that the surgeon wasn't okay with it. They just don't have the time, energy, knowledge, expertise to go through supplement by supplement. They don't know which is fair because they should know about joints and hammering and nails and all that they need to know about and how they're going to put all the bones back together and everything. 

46:19
Dr. Linda Bluestein
But per the ASA, which is, again, I mentioned earlier, what the ASA is, the American Society of Anesthesiologists. They have specific guidelines about what supplements you should stop. And it's a relatively short list. So there are the g's, garlic, ginkgo, ginseng and ginger. Those g's, garlic, ginseng, ginkgo and ginger can all increase bleeding. Want to stop all of those. You want to stop kava because that can potentiate anesthesia. You also want to stop St. John's wort because that can also prolong anesthesia, that and valerian root. And you also want to stop vitamin E because that can increase bleeding and cause problems with blood pressure. And ephedra is probably the most dangerous supplement, which also goes by Mahawang. That can cause dangerous changes in your blood pressure or your heart rate and can also interact with anesthesia medications. There's a few others that are more iffy and they're not on the ASA list. 

47:22
Dr. Linda Bluestein
But fever, few and sal palmetto can also increase bleeding. And then a couple other things that can influence blood pressure include golden seed, licorice and milk thistle. 

47:31
Jennifer Milner
Well, and hopefully whoever is clearing you for your surgery has that list. As we've discussed before it's so hard and you are like, I hate having to say everything I do, but it's important for them to know. St. John's Ward can interact with a lot of different medications, so it's important for someone to have all that information in one spot. So that's really great for people to sort of be reminded of anything else that a person can do to sort of help, know cutting out supplements, discussing all of the plans, all of that. Is there anything else they can do to help themselves either before surgery or in the recovery period to sort of help their body be ready and then be able to recover fast? 

48:11
Dr. Linda Bluestein
Sure. And when it comes to the supplements, make sure you read your labels carefully because oftentimes supplements have a lot of different things in them. So make sure you read the ingredient list and you know exactly what's in your supplements. So when it comes to recovering from surgery, if you can go into the surgery in the best physical shape. Now, obviously that's not always the case, depending on what's going on that's causing you to need the surgery. But if you can do some kind of prehab, which know, I mean, physical therapists now will work with you on a prehab protocol and work on strengthening other parts of your body, know, optimizing your physical functioning as best you can. Work on your know, if you can work with a registered dietitian nutritionist like Kristen KOSKIN and Bendy bodies, registered dietitian nutritionist, work with her or somebody else. 

48:58
Dr. Linda Bluestein
Work on your protein intake. Vitamin C is very important for wound healing. So is zinc. So it's important to have calcium and vitamin D for bone healing, you want to make sure you have fiber because constipation can be a big problem after surgery. And so you may need like a prokinetic type drug to help. Make sure that your bowels continue to move after surgery. A lot of the medications that we give you slow your bowels. So you want to make sure you take lots of fluid. You move as soon as possible because that will help your bowels wake up. People wonder, well, why are they making me get up and walk around right away? We used to have people lay in bed for days. Now we've realized that you have to get people up and moving in order to get their bowels to move. You want to sure that you really plan ahead before you have the surgery. 

49:38
Dr. Linda Bluestein
Have plenty of ice on hand, have anything that you need to apply the ice to the body part. If you're allowed to do that you have that, make sure you have foods that are convenient. Make sure you have props for elevating the body part. Make sure you have plenty of your medications so that you don't have to run out and get refills of any of the prescriptions that you were on from beforehand. And I think probably the biggest thing is to prepare for normal than longer recovery. I feel like even for connective tissue, typicals surgeons underestimate how long it's going to take to recover from the procedure. In a large percentage of cases, if they're telling you, like, I had a big elbow surgery and they told me it would take two years to recover, that was not an overestimate. That was actually, like, spot on, like, almost exactly right. 

50:25
Dr. Linda Bluestein
But I spent some time with a surgeon recently and going room to room and talking to the different people, and I was like, really? 

50:32
Jennifer Milner
You really think they're going to be. 

50:34
Dr. Linda Bluestein
Recovered in six weeks? And especially as we get older, it takes longer to recover. And the more things you have going on, that can cause limitations. So it's important to think of all of those things. You may also need some temporary accessible parking, so plan ahead. If you think you're going to need that, talk to your surgeon about it, and you can ask them to give you a temporary handicap placard for your car. Maybe you're going to need something like forearm crutches because you're like me, where you had loose upper extremities and you run into problems with standard crutches. Or maybe you even need a wheelchair. Maybe it's not a procedure where most people would need a wheelchair, but maybe you need a wheelchair. You obviously want to take care of all of those things ahead of time. 

51:19
Jennifer Milner
That makes sense. And so we're talking about things that might be happening afterwards. Right. But you want to prepare for it beforehand and before it happens. And I think it is really important what you said to prepare your mind for the fact that whatever they said is a really rough estimate and it may take you longer to heal. I always tell my clients, whatever the doctor has said, just double it. And then when it's sooner than that, you're like, Yay. Yes, totally. 

51:48
Dr. Linda Bluestein
That's perfect advice. 

51:50
Jennifer Milner
Especially with, as we know, people with connective tissue disorders, they can scar their skin, takes longer to heal. So even just that aspect of the surgery can take a lot longer, not much less the real issue that they were trying to address there. Right. 

52:06
Dr. Linda Bluestein
And we have a lot higher risk of reacting to the suture, which is something we kind of briefly skimmed on. But if you've had problems with suture in the past, try to get not the anesthesia record, try to get the op note, the operative note, because it will say in there exactly what kind of suture that they used. I've had suture spit up through so many incisions in my body, I reject suture like crazy. And so, again, if you're going to the same facility or the same surgeon, they have access to that note. But if you're going to a different person, try to get your operative note from your previous surgery so you can show them, hey, this is what I had last time and then describe exactly what happened. Like, for me, the suture was coming up through the incision in my wrist, through the incision in my belly button. 

52:47
Dr. Linda Bluestein
Yeah. So there's many different suture materials, and if you share that with them, then they can change what kind of suture they use, maybe how they make the incision. They need to know that information in advance, if possible. 

53:02
Jennifer Milner
So the best way to have a really efficient and healthy surgery is to have multiple ones before that so that you can learn what works and doesn't work for your body. Sorry. 

53:14
Dr. Linda Bluestein
Perfect. Yeah. That's funny. 

53:19
Jennifer Milner
Is there anything that we didn't talk about today that you want to make sure we covered? 

53:24
Dr. Linda Bluestein
Well, if I could wave a magic wand, you know, what I would do is take away all of those other previous surgeries and make it that we could predict if the surgery is going to be successful or not. Is the surgery actually going to take away your pain, improve your physical functioning? Because we know that oftentimes it does. It's phenomenal, but not always. So we would be able to have much more better predictive variables, like, okay, this person has ABC, therefore they're going to have a good outcome. This person has XYZ, they're not going to have a good outcome. So that would be phenomenal. If I could wave a magic wand, we would know in advance what kind of surgery was going to work, and also we would have anesthesia that had no risk or was super safe for everybody, even people like us. That might be more hemodynamically unstable. 

54:15
Dr. Linda Bluestein
Our blood pressure goes up and it goes down. I mean, everyone's blood pressure goes up and down, but ours tends to do that more. Our heart rate tends to go up and down more than connective tissue. Typicals. So I think I would waive those magic wands if I could. 

54:32
Jennifer Milner
I would let you. 

54:35
Dr. Linda Bluestein
You're going to give me the wand? 

54:36
Jennifer Milner
I'm going to give you the wand as soon as I find it. I know people talk medicine as a science, but it's still an art form as well. 

54:45
Dr. Linda Bluestein
Oh, totally. 

54:45
Jennifer Milner
You had said the surgeons who have been around longer start to have that instinct and that feel for it, which is what makes it that extra knowledge and those extra years so valuable for us. And they truly do. The vast majority of surgeons and anesthesialogists out there are really trying to do what they think is best, and they really are trying to help people. That's really why they're out there trying to do it. Communication skills might not quite be so great. They may have a lot of patience. They may be in a huge rush. But by doing just a little bit of preparation on your own and being ready with your talking notes, being ready with your conditions, and knowing what you need to tell them, knowing what is important to share with them. Is going to make the experience go a whole lot smoother and hopefully lower your risks for a lot of things to happen. 

55:44
Jennifer Milner
So a little preparation goes a long way. If people want to know more about it or if they want to work with you, where can they find you? 

55:53
Dr. Linda Bluestein
So the best place is to go to www.hypermobilitymd.com or bendybodies.org. I do see patients through hypermobilitymd and clients through bendy bodies. So if you live outside of the United States, you can become a client through bendy bodies. If you are unable to come in person in Wisconsin or Colorado, then you can also become a client. And the difference between clients and patients are patients can get prescription medication, they can get prescriptions for lab orders, they can get orders for imaging studies and things like that. I can actually treat them. But if you're a client, I do one one sessions and I give information that is specific to you. So it's not medical advice, it's information. But I make it detailed enough that you can take it to your own healthcare team and they can carry out my recommendations. So I might say patients with blah whatever you just shared with me, patients with blah often respond well to this medication and I'll even put like the dose and all of that in there so they can take that to their team. 

57:07
Dr. Linda Bluestein
And one parting thought I wanted to make was I also think that having a little bit older anesthesiologist is also helpful. Although you don't get to usually pick, but I know I became much you learn as you go and you're right, it's completely an art. Yeah, there's science, but I feel like it's almost more art than science sometimes. And so you learn as you take care of people. I mean, you're building your own it's not formal research, but you're building your own foundation of knowledge and you use that as you go into other things. So, yeah, the people who are young, they just finished their training and they got some great training and they know kind of some of those latest and greatest things. But I think if possible, someone kind of in the middle is nice. But again, not that you can pick your anesthesia team, but for your surgeon, yeah, if you can, I think that's helpful. 

58:05
Jennifer Milner
Well, and if it's someone younger, maybe they have been listening to our podcast and they can take the benefit of your expertise and carry that in there as well. We know so many doctors of internal medicine and surgeons and orthopedists who listen to the podcast and use it to kind of help deepen their own understanding of their patients. 

58:24
Dr. Linda Bluestein
Right. 

58:25
Jennifer Milner
So you are always welcome to recommend this podcast to your surgeon, probably not like the day before you go in, but it is an easy way for you to pass on a whole lot of information at a short time well. Dr. Bluesteme, we are so grateful for you sharing your expertise on this subject. Everybody knows you as the Hypermobility MD and all that you do for the hypermobile population, but to have a chance to kind of dive into your anesthesiology background has been hugely helpful. You have been listening to Bendy Bodies with the Hypermobility MD and our guest today was our very own Dr. Linda Bluestein, founder of Bendy Bodies. 

59:03
Dr. Linda Bluestein
It was great chatting with you Jen. Thanks so much. 

59:06
Jennifer Milner
Absolutely. And we will see you guys next time. 

59:10
Dr. Linda Bluestein
Bye. 

59:11
Jennifer Milner
If you love what you have learned, follow the Bendy Bodies podcast. To avoid missing future episodes. Screenshot this episode. Tagging us in your stories so we can connect. Our website is WW bendybodies.org and follow us on Instagram at bendy underscore bodies. Leaving a review. Following the Bendy Bodies podcast and sharing the podcast helps spread the word about hypermobility and associated conditions. This information is not intended to diagnose, treat, cure or prevent any disease. The information shared is for educational purposes only and is not a substitute for medical advice, diagnosis or treatment. Please refer to your local qualified health practitioner for all medical concerns. We will catch you next time on the Bendy Bodies podcast.