Challenging Conventions to Make a Difference in Patient Care: The 2017 Gaston Labat Award Lecture
First, some chronology. I am from New Zealand, and I am the second New Zealander to receive this award. Sir Robert Reynolds Macintosh was born in Oamaru, close to where I went to medical school in Otago. He was the second Labat awardee and recognized worldwide for developing the Macintosh laryngoscope blade. In regional anesthesia, he is recognized for developing the Macintosh balloon, a device to measure loss of resistance to aid in identification of the epidural space.1 His patron and supporter was Lord Nuffield, who funded a number of Nuffield chairs at Oxford and insisted on one for his friend Robert Macintosh. He became the first Nuffield professor of anesthesia in Oxford and in Great Britain.2 Like me, he developed his career overseas—in his case at Oxford, and in mine, Boston and New York.
I completed my medical school training in 1971, having done a year of research on exercise physiology and metabolism.3 After graduating, I came to the United States in December 1972 and completed a residency at Albert Einstein Hospital in the Bronx, then worked at Peter Bent Brigham Hospital in Boston for 2 years, Lenox Hill Hospital in New York City for 9 years, and have been at the HSS in New York City since 1986. Each location was formative in its own way.
I shall present 4 conventions I have challenged. First, that shoulder surgery should be performed under general anesthesia; second, that general anesthesia is the anesthetic of choice for total hip arthroplasty (THA) and total knee arthroplasty (TKA); third, that the best thromboprophylaxis for total joint is potent anticoagulants following surgery, and finally, I shall challenge the concept that hypotension is contraindicated in the elderly high-risk patients if hypotensive epidural anesthesia (HEA) is used.
The first convention: All shoulder surgeries must be performed under general anesthesia. Alon Winnie4 was the sixth recipient of the Gaston Labat Award in 1982, and he developed the concept of plexus anesthesia and described the interscalene block (ISB) in 1970. His classic article is worth reading. In it, he noted, “The interscalene technique is particularly useful in patients who are unable to cooperate due to inebriation, disorientation, or the extremes of age.”
In this context, I performed my first ISB in 1974 in the Bronx on a catatonic schizophrenic patient who had a forearm fracture. He did not budge with the skin puncture but moved as I advanced the needle. I considered this as a paresthesia and injected a healthy dose of local anesthetic, and the block worked fine. At the Peter Bent Brigham, I published my first article on regional anesthesia in 1976 entitled, “An Improved Technique for Locating the Interscalene Groove.”5 By the time I had left Lenox Hill Hospital in 1986, I had performed more than 1000 cases of ISBs, all using the paresthesia technique. I arrived at the HSS proficient at ISB.
In the 16 years since Winnie's original description of ISB, there were only a handful of publications of the technique for shoulder anesthesia—mainly manipulation of the shoulder. The convention was general anesthesia for shoulder surgery. In 1971, Balas6 described using ISB in combination with a T1–T2 paravertebral block for major shoulder surgery, which I had done, and this was the recommendation in 1986. This approach seemed impractical for general use and carried the risk of pneumothorax or total spinal anesthesia.