Episode 5: The Truth About Going Under!

Special Guest: Megan Parken

Dr. Franco: Welcome to “Plastic Surgery Untold” episode number five, The Truth about Going Under. I’m Dr. Johnny Franco, board certified plastic surgeon, also known as Austin Plastic Surgeon. I have the great privilege and punishment of being joined by my incredible cohost, celebrity anesthesia, Travis Osborne.

Travis: What’s up, what’s up.

Dr. Franco: Megan Parken, also known as Megan Worldwide.

Megan: Hey, guys.

Dr. Franco: And all of you know, Austin’s most eligible bachelor, Gilberto Saenz. Though, those you just listening, there’s an asterisk that we’ll get to it here, fact or fiction about this.

Gilberto: Yeah, I like that.

Dr. Franco: You’re gonna take no comment for now. Very good. Today’s gonna be all about anesthesia. This is one of the most common questions that we get, and Travis, as most of you know, is a certified registered nurse anesthetist and actually does anesthesia for a great majority of my surgical cases. But before we let him unleash his knowledge on all of you…

Travis: Get ready.

Dr. Franco: …we’re gonna do a little check in about New Year’s resolutions. And so maybe since you’re gonna be a killing today, can you lead us off on where you at with your resolution?

Travis: Yeah, not, not very good.

Dr. Franco: Can you remind people what your resolution was or for those two or three people in the world that didn’t listen to episode two?

Travis: Yeah, there can’t be many. So, yeah, me and Mary we’re gonna work on doing meditation three to four times a week, working out three to four times a week and also trying to eat at home three to four times a week. Those are not going well.

Dr. Franco: I mean, that’s part of the reason that we’re here on a Monday night is you guys haven’t been in town at all?

Travis: We haven’t. No. And we’re actually leaving to go out of town again on Wednesday.

Gilberto: That’s fair. I like it.

Dr. Franco: It’s a tough life that you live it. Megan, where’s your resolutions? What’s going on?

Megan: Okay, so I can’t remember if I specified if I have to wake up before 10:00 a.m. or…

Dr. Franco: Oh, you did. Oh, you did.

Travis: I think it was before.

Megan: Well, I’m about 50/50. I’ve been doing decent on that and yeah, I mean, I’m gonna keep going with it but…

Dr. Franco: That’s a tough goal for you to do. But, I mean, I’m glad…

Megan: I know.

Dr. Franco: …that we could accommodate your schedule. This is like lunchtime for you. So hopefully, if anybody wants to send lunch to the podcast studio…

Megan: This works much better.

Dr. Franco: …Megan’s up and running and rolling. Gilberto?

Gilberto: I’m doing okay.

Dr. Franco: What was your resolution?

Gilberto: So one of them was to start volunteering a little more. I’ve yet to get involved with that. The other is to…

Dr. Franco: There’s a lot of lost puppies that are still waiting for you, but that’s fine. Continue.

Gilberto: …the other was to spend a little more time with my family, with my brother, my sister-in-law, niece and nephew. They’ve been really, really busy and my brother’s been out of town so I haven’t really been able to see them. I still have Christmas gifts that I need to give them.

Dr. Franco: There may or may not be another factor that’s eating up your time. Then we’re gonna get to your fact or fiction.

Gilberto: The asterisk?

Dr. Franco: The asterisk.

Travis: I cannot wait.

Megan: Wait, Johnny, what about your resolution?

Dr. Franco: Mine’s been to work out and I’m holding down the fort because I have been working out. And just to show you how well this New Year’s resolution is going, I walked into surgery this morning, go to mark my patient, she’s like, “Dr. Franco, since I saw you three weeks, you’ve lost some weight.” And I was like, “Why, thank you. Why, thank you.” You’re welcome.

Gilberto: That’s all the motivation anyone needs. That’s all motivation.

Megan: That’s a nice part of Monday morning.

Travis: There you go.

Dr. Franco: Well, typically at this point, we’ll let Megan take over and do some relationship stuff. If you guys are okay with it, can we save it till fact or fiction? Because I feel like, G-Berto has a lot of fact or fiction to go through today.

Megan: All right. Good.

Travis: I cannot wait. This fact or fiction sounds juicy.

Megan: I’m good with that.

Dr. Franco: Do you wanna maybe kick us off with a little something, give us a little backyard about anesthesia? And then we’ve got a few common questions that we get all the time that, if you don’t mind, maybe you can walk us through a little bit.

Travis: Yeah, absolutely. So just to remind everybody at home, my name is Travis Osborne. I’m one of the nurse anesthetists here in Austin. I do anesthesia for Dr. Franco, a couple of other plastic surgeons around town. Yeah, so I was gonna cover anesthesia. We’re gonna talk a little bit about what it actually is, what happens, what the process is like. We go over some questions that patients hit both of us with a pretty often.
But, yeah, just a quick history of anesthesia. Back in the day, before the Civil War, they were using mostly nitrous. And then all of a sudden a dentist was like, “Oh my gosh, I can put ether on these patients.” So very famous place at Mass General Hospital, the Ether Dome, they did the very first surgery under ether drip anesthesia. Dr. Morton, I think was the guy’s name, the dentist that came up with it. They started using it. So he dripped ether and they were actually able to do the first surgical case inside the Ether Dome like 1846.

Megan: Wow.

Travis: Yeah, pretty neat.

Megan: I didn’t know that.

Gilberto: We don’t do any of that now. Just to [inaudible 00:04:41].

Travis: We don’t do any ether now. So that evolved quickly to other volatile, you know, gas, anesthetic agents, IV anesthetic agents, safety profile, everything has gone through the roof. It’s a much safer, much better now, obviously, than it was. And now we’re able to safely anesthetized patients all day, every day.

Dr. Franco: Can we maybe go through the process a little bit? And as we walk through the process, then you can jump in and kind of help people go through it because if we just kind of roll back all the way to where patients come in to see me, the first question I get about anesthesia is what type of anesthesia. Because there’s a couple of different spots in terms of…there’s one that’s completely under local, which is something where we just numb up or anesthetize a very small spot. The ones that typically include someone like yourself is either what someone call a sedation or a general anesthesia. And even when people say they’re gonna have it under “local,” and I say local in quotation marks, if they’re doing at surgery center, there’s typically a little bit more involved with it. And this is where I think it becomes confusing because people use these terms a little loosely.

Travis: Very [crosstalk 00:05:45]. Oh, yeah, absolutely. That’s one problem. If I could clean up anything in anesthesia, it would be how direct we are with patients and be more effective and clear in communicating what’s actually gonna happen back there. Really, there are four types of anesthesia. You can have general anesthesia. General anesthesia means completely asleep, completely unconscious with loss of airway reflexes. That will typically require either endotracheal intubation, meaning that you have a breathing tube for the entire procedure or you have a laryngeal mask airway or some kind of other advanced airway that’s helping to support the airway while you’re completely asleep and unconscious.

Dr. Franco: There’s this perception that general anesthesia is more dangerous than any other type of anesthesia. And I feel like you could talk for weeks about this. But I always tell people yes and no.

Travis: Yes and no. I think that’s a great answer. I think in the wrong hands, anything can be dangerous. Let me just go ahead and say that. You know, going somewhere and having something as benign as having blood drawn, that can be dangerous in the hands of someone that doesn’t know how to draw blood. So anesthesia is the exact same way. If you’re going to a place where you have either an anesthesiologist or a certified registered nurse anesthetist doing your anesthesia and it’s a general anesthetic, your risk profile is low, you’re not super sick, you’re not on all kinds of cardiac medications, things like that, your risk profile is super low for an adverse event happening while you were under general anesthesia.

Dr. Franco: I think sometimes people get confused because the one nice thing about general anesthesia is once you have a breathing tube or something else or an LMA in, you have complete control over this person.

Travis: Yeah, exactly. So that’s one other great thing about general anesthesia.

Dr. Franco: Great thing for them, great thing for me.

Travis: Great thing for them, great thing for me and great thing for the patient and great thing for you, right?

Dr. Franco: What about the surgeon?

Travis: That’s who we’re there for, to be honest. No, it’s great because it allows us the most flexibility. If you have a breathing tube in somebody, there’s really not a position that you can’t do a surgery in. You can turn the patient upside down. If we’re doing liposuction on the back or doing something on the back, for instance, the patient’s gotta be turned prone. In my professional opinion, the safest way to do that anesthetic is with a general anesthetic, with an endotracheal tube, meaning you have a tube down into your trachea, controlling your breathing, and no chance of losing that patient’s airway or not being able to intervene with that patient’s airway. When that patient is upside down with a breathing tube in place, I can mechanically ventilate them, I can give them more anesthetic, less anesthetic. I can do all that while they’re anesthetized.

Megan: So is it actually like normal sleep when you actually go under?

Travis: It is not like normal sleep. The EEG is completely different. It is actually just like a dull awake state, but you lose awareness and lose consciousness. We actually don’t know the exact mechanism of how the volatile anesthetics work, which is what we use primarily to do general anesthesia and to maintain general anesthesia, we don’t know exactly how they work. They are theorized that we actually turn off a part of the brain called the reticular activating system, which is what allows you to know whether you’re awake or not. Your idea of consciousness comes from that area in the brain.

Dr. Franco: But for the layperson, I mean, your eyes are closed.

Travis: Sorry. Sorry.

Dr. Franco: Your eyes are closed. You’re not aware of anything.

Travis: Usually, correct.

Dr. Franco: I mean, for me and Megan, this is no different than laying down. Lights get turned out. Boom. Alarm clock goes off.

Travis: Yes. Yes. Most people actually described this sensation in general anesthesia as, “I felt like I just went to sleep.” I’ll put somebody to sleep, we’ll do a six-hour procedure. I’ll wake them up, they’re like, “Are we really done? That was so fast.” They have no perception of time, which again alludes back to that why we think that we turn off the reticular activating system. You lose perception, time and consciousness, you don’t form memories. That’s part of the amnestic part of it as well.

Dr. Franco: And if we go to sedation just to…because I know we could spend all day on each topic talking about sedation or this kind of in-between. There’s plus and minuses of these two. And maybe you can give us a few of the bigger plus and the minuses and I can give you kind of the thoughts and questions I get from my patients.

Travis: Yeah, absolutely. So just real fast for everybody at home. General anesthesia is one form of anesthesia. MAC anesthesia means monitored anesthesia care. That can be either a simple as giving somebody some…

Dr. Franco: And this is where people get in trouble. They forget the, A part of the MAC. The anesthesia, and i.e., and I know it sounds funny, but there’s a lot of offices that aren’t partnered with either CRNA or anesthesiologists, I’m not interrupting, but I think there’s a super important…

Travis: Oh, I do too.

Dr. Franco: And who’s providing that anesthesia? So monitored anesthesia care because there’s…

Travis: It needs to be performed by either a CRNA, or a Certified Registered Nurse Anesthetist, or an anesthesiologist. In my mind, that should not ever be performed by a regular nurse, a tech in the room, some other provider or someone that is not…have a specialty in anesthesia.

Dr. Franco: And the nice thing is there’s split attention, right?

Travis: Oh, yeah.

Dr. Franco: Because when we’re working together, you are solely responsible for taking care of that patient in terms of the anesthesia, keeping them comfortable, protecting their airway, watching all the monitors while I’m doing whatever procedure. So I’m not looking at the monitors, I’m not worrying at these. But you’re doing that the entire time.

Travis: That is correct. And that’s a perception that most people do not have a right whenever they’re thinking…or that’s a common misconception in anesthesia. Patients think, “Well, when you go back there, I just go to sleep. What do you do the rest of the time?” “What do you mean what do I do the rest of the time?” I’m there with you the entire time. I’m making sure that you’re breathing, I’m making sure your blood circulating. I’m watching your heart rate and everything. I can control all that with the push of any medication. So it’s really a second-to-second, and minute-by-minute process, me watching that and vigilantly responding to the patient’s needs and also creating optimal surgical conditions for you so that we can do these cases.

Dr. Franco: And that’s where I’ve seen, a lot of people have heard in the news about, especially with liposuction, those types of things, and not to say that you can’t do them under local or sedation, but when somebody is completely asleep and you have them, they’re secure. The problem would come when people are under sedation, these things, is we’re still trying to keep them comfortable. We’re still trying to control them. And at some point, there’s the limits to how much lidocaine and those things to control people’s pain that we can give them. And we sometimes…sometimes people can get themselves in trouble.

Travis: So, and I think this segues perfectly into the other type of anesthesia that we were talking about, that MAC anesthesia, monitored anesthesia care. The idea of MAC is that you’re doing, you’re giving patients some sedation but you’re not taking away their airway reflexes or their drive to breathe. So what happens a lot of times is you end up in this limbo between, “I have a completely awake patient and I have a completely somnolent, completely asleep patient that is starting to lose their airway reflexes.”
And the idea of MAC is kind of staying somewhere in between, while maintaining the patient’s airway, while the patient maintain their airway on their own, and breathing on their own, but being comfortable. So that can be super difficult when…in cases, especially like a liposuction that you’re talking about, it’s not comfortable to have a huge rod jabbed in without being under general anesthesia. If you are doing it semi-awake or in this sedated or MAC area, you’ve gotta get a patient pretty, pretty sleepy and pretty comfortable to be able to tolerate that.

Dr. Franco: And I think this is where the plastic surgeon and anesthesia provider really have to be on the same page.

Travis: Absolutely.

Dr. Franco: And it sometimes works better for some procedures versus others. Gilbert, as some of you may or may not know, him and I have been talking about his calf implants that’s in the horizon. In the discussion I had with him is the, you know, the calf has a lot of muscle and that’s sometimes very hard to keep people comfortable and he’s got very small legs compared to the rest of his frame. And so there’s not a lot of place to put that implant. And so, I mean, for someone like Gilbert, what would you say to his reservation about doing this under a general anesthesia? Because he’ll be face down. We’ll be trying to keep him comfortable. He wants rather large calf implants in these small legs.

Gilberto: I thought we were doing a BBL.

Dr. Franco: Well, I mean, you’re such a fit guy. There’s no fats.

Travis: So I mean, my professional opinion, I have done calf implants on four patients in this semi-awake or, you know, MAC-sedation-type scenario. Is it more comfortable for them? No. It’s a lot tougher to get that patient to that plane of anesthesia that they really need to be, and to be comfortable and tolerate laying down for, you know, four or five hours to actually put those calf implants in. If you do a general anesthetic, sometimes it’s just easier to control as many variables as possible by having that patient asleep with a breathing tube and prone.

Dr. Franco: Megan, would you say that calf implants would move Gilbert up the most eligible bachelor or move him down?

Megan: I would have to say I don’t think I ever notice calfs on a guy.

Dr. Franco: So you say this would be kind of…

Megan: I don’t think it is a bad thing, but I just…

Dr. Franco: But you’re not saying it’s necessary either.

Megan: It’s a new thing that maybe I should start to look at, I guess.

Travis: There you go.

Gilberto: I might have to think this over a little bit more, thank God. I’m trying to have second thoughts about this calf implant stuff.
Dr Franco: Can we ask producer Donald if there’s maybe a way he can talk to Gilbert and see if we can have him do the next episode in shorts? And then we could do a poll and see whether this is necessary or not.

Gilberto: I mean, I can show you right now if you want.

Megan: Just pull off your pant leg.

Dr. Franco: I mean, I feel like we need to tease the audience a little bit. We can’t give them all the goods on day one.

Gilberto: Okay, all right.

Dr. Franco: Okay. A couple of other big things that I get from my patients and that has changed dramatically, and not to get your head too big already, but some of these changes came from you in terms of, because the biggest complaints, and when I had my own knee surgery done, nausea was a bigger problem for me than even pain. But there’s a few things that we’ve really changed in, and in my practice you were actually the instigator and we’ve worked together and still fine tuning that…

Travis: I’m always the instigator.

Dr. Franco: In good or bad for sure. But I think it’s made a big difference in my practice. Do you wanna talk a little bit about how we’ve decreased the narcotics but increased people’s comfort?

Travis: Yeah. So I actually did all my anesthesia stuff at Duke and I was there during the time where they were…

Dr. Franco: I was not a Duke grad.

Travis: I mean, it is what it is. But when I was there, they were trialing ERAS, which is early recovery after surgery. And that really, that push was to try to decrease narcotic consumption for patients or decrease opioid use in patients, get them up and moving as quick postoperatively as possible, to decrease post-op ileus, which is where your bowel doesn’t, you know, wake up quite as quickly after surgery, and that can be due to a large amount of narcotics, to produce a patient in recovery that was euvolemic or resuscitated appropriately from a volume standpoint or giving fluids in the operating room. So all these things put together kinda gave us a roadmap of what to do moving forward. And it was studied, you know, ad nauseum. Now, I’ve got pretty good research to show, you know, what we have kind of implemented.

Megan: And to kind of circle back around, I feel like this is a question people would have. Is cost a factor in the different types of anesthesia?

Dr. Franco: That’s a good question.

Megan: Is that something people would be interested in doing one versus another?

Travis: That’s a great question. I’m actually surprised anybody thinks that. Everybody thinks that, you know, cost is completely, it is no big deal. Like, well, let’s just, let’s do this versus this versus this. Everything has huge cost implications. Doing a total IV anesthetic is much more expensive than doing a just straightforward gas anesthetic where you put somebody to sleep with propofol, switch over to anesthetic agent, let them breathe that for a couple of hours. It is much more expensive to give them an infusion over that entire, you know, couple of hour surgery.

Megan: That’s interesting.

Travis: Yeah, a lot to think about…

Dr. Franco: Well, one of the things to that though, I think is even before they get to you in these [inaudible 00:17:54], I think people see a lot of differences when they come to the plastic surgeon’s office because before they even involve you, you see sometimes where people don’t involve an anesthesia provider because of the cost issue.
Megam: So they’re getting a quote. That’s a different, yeah.

Dr. Franco: That’s very different. And I think that’s sometimes a little confusing to people. I think. I mean, you tell me, you know, doing your research and so forth, but I mean, I think asking who’s gonna do my anesthesia is a super important question to at least get the conversation started.

Megan: To make sure they’re qualified and everything. And you’re in the best hands obviously is important.

Dr. Franco: Exactly. I feel like in a CRNA anesthesiologist is just like a life insurance. You don’t need it till you need it. And the hope is that you never need their expertise and skills in a real way. But if you do, you want somebody who does this every day, all the time.

Megan: Right. So as a patient coming in, is there anything like you have to do before having anesthesia or anything you shouldn’t do?

Travis: Yes. Another great question. First and foremost, come prepared. When you go to your plastic surgeon and you’re talking to them in the consult, find out from them, “What do I need to do before surgery?” If they’re a good plastic surgeon, they will tell you more than you need to know about what to do when you get to the surgery center or even the 24 hours before that. I know Dr. Franco goes over stuff, you know, all at length.

Megan: Because there is a protocol for it.

Travis: There is a protocol.

Dr. Franco: There is a protocol. Most people will get a certain set of labs. Depending on your age, you may get an EKG, depending on your other medical history, sometimes leads you down some other paths. No question. And then, Travis…

Megan: Are those done to ensure that when you do have it, you’re safe and everything?

Dr. Franco: Safe, and some of it has to do with anesthesia, some has to do with overall surgery safe, but no question, any surgery stresses you. So you wanna make sure the sure the heart’s good. You wanna make sure your blood levels are good. Surgery can affect your electrolytes so making sure those are good. I think there’s just a lot of stuff that’s done ahead of time to make sure. We have conversations all the time, whether you know there’s additional test or something else. Because if there’s ever a question, this is something that we discuss typically weeks, months before a surgery.

Travis: For sure. And if a plastic surgeon or Dr. Franco is requesting you to, “Hey, please go to this lab place, go get these labs done.” We’re not asking you to be mean or because it’s a protocol, or because we want more cost to be generated. We’re doing…

Megan: You’re doing for their safety.

Travis: That’s exactly right. And there are a lot of times, I mean, I can’t even count the times that we’ve found small things that wouldn’t, you know, the patient would think are insignificant, but to us that’s a huge red flag. Well, wait a second, like, why do you have this bleeding disorder? Where did this come from? Like how did we just find that your hemoglobin is way lower than it should be? Like you need extra testing or why is your EKG abnormal? Let’s send you out and have some other labs done. And it’s all about the safety of the patient. I think at the end of the day, everything that we do boils down to patient safety and getting good results.

Megan: Right. And for a patient also coming in, there is some piece of mind that you guys take all those necessary steps to ensure that they’re as safe as possible. And so obviously you should understand why they’re asking you to do certain tests in days before.

Dr. Franco: I think it’s always disappointing, and we work really, really hard to keep people from ever being canceled the day of surgery, but, you know, we don’t take it lightly. I mean, it’s not something we wanna do. That’s something we planned for as well. But I mean, you know, and that’s why I doing all those things too to your point, making sure your blood pressure is in a good check, make sure your glucose, those things are in a good spot for sure.

Travis: Absolutely. One of the things that, you know, we talked about a minute ago with patients and what can they do to be prepared. NPO guidelines. NPO means not eating after a certain time or not eating in a certain amount of time. So, you know, the ASA has put out good guidelines, the American Society of Anesthesiologists, about when you can’t eat, when you can eat your last meal before an anesthetic.

Megan: And I know they’re even specific about liquids too. They don’t let you drink a lot water or anything like that.

Travis: That’s exactly right. So we allow, in ASA standards at this point are two hours for clear liquid. That means water, broth, coffee with no milk or creamer.

Dr. Franco: Right. No creamer.

Travis: No creamer.

Dr. Franco: No milk, no half and half, like all that stuff.

Travis: Correct. Clear liquids. If you can see through it, it’s a clear liquid. I don’t know how to stress that enough. And then, really, now it’s six hours for a light meal, eight hours for a heavy meal.

Dr. Franco: But always check with your physician, with your anesthesia team, with your surgery center because everybody has some little different things depending on what they’re doing. There’s definitely some special procedures that those numbers are a little different.

Travis: And I really, I feel bad for patients not being able to eat morning of. I feel worse for patients when they decide that they’re going to eat and then we have to cancel the surgery. But that’s a huge thing and it puts everybody at risk, and first and foremost, it’s…

Megan: It’s for their safety. It’s not you guys trying to be hard on anyone.

Travis: That’s exactly right. We’re not trying to be, you know, hard on the rules or anything. But if, even consuming a small amount of anything increases your stomach acid production and could potentially put you in a space where you could aspirate, and that’s all we’re trying to do is decrease the risk of that.

Dr. Franco: And by that you mean stuff get into their lungs?

Travis: That’s exactly right.

Dr. Franco: Which sometimes becomes a big deal and people don’t realize that sometimes it’s not even recognized right at the time because that stuff gets in, cause some problems and even young people can have some issues.

Travis: That’s exactly right.

Dr. Franco: I’m gonna give you a chance to wrap up some stuff, but do you mind if I ask you just a few questions…

Travis: Yes, please.

Dr. Franco: …that I get all the time? And just bear with me.

Travis: Absolutely.

Dr. Franco: Number one question asked by our viewers, I feel like “Family Feud” right now, and the number one question by viewers, “Am I gonna wake up during surgery?”

Travis: I get asked this at least once a day. Short answer, no. I can’t say that with obviously 100% certainty. Just like I couldn’t say I am not going to get in a car accident with 100% certainty before I get here today. But if I drive safely and I do everything that I’m supposed to do as a driver to get here, I normally arrive without any problems.
What you referred to is what we call awareness under anesthesia. In the literature, it’s reported less than 0.1% of the time. The time that it’s actually reported is in high-risk patient populations, sick, sick cardiac patients that we cannot give enough anesthesia to or enough medication to cause them to be amnestic or to lose consciousness completely. Again, these are very, very, very infrequent times. I also get the, “Am I gonna wake up because my dad woke up during a colonoscopy?” Well, remember we just talked about MAC anesthesia or that twilight anesthesia. Some providers don’t explain that there are chances that you may kind of drift in and out of consciousness during that twilight or MAC anesthesia, that deep sedation, not general anesthesia. So that is a possibility during a colonoscopy or during a dental extraction because that’s normally not a general anesthetic.

Dr. Franco: And I don’t think most people realize how many different things you guys are monitoring to see people’s difference data. Everything from heart rate, to CO2, to gas flow to, I mean, I’m not even scratching the surface of how many different things you’re looking at. So it’s not like you’re just like, “Hey, let me pump some stuff and hope for the best.”

Travis: Exactly. And people always ask me, “You know, do you do it based on weight? Like, what drugs you’re gonna give me?” I mean, it took three years of training and thousands and thousands of anesthetics until I really got a knack for what I was doing and that feel where it is a science and an art combined to where I know how asleep someone is. And it’s using all of that data and synthesizing that data and then making changes appropriately.

Dr. Franco: Speaking of drugs, I’m going to be doing the service. We don’t talk about propofol and Michael Jackson. I get so many patients that don’t want it because they think that it’s a bad drug, and I wanna get your feelings, your thoughts on that. I’ve told Gilbert many a times it’s not good for him to go to sleep. I told him we can’t use this just for his calf implants, but I wanted to get your professional opinion before I make a decision.

Travis: So I actually think propofol is the best drug that is on the market anywhere.

Dr. Franco: You see, I’m looking out for you. I’m looking out for you.

Gilberto: Thank you. Thank you.

Travis: It’s my favorite drug. I think it acts as a rescue drug. I think it works for sedation. It’s a great drug.

Dr. Franco: It actually helps decrease nausea, if I’m correct.

Travis: It’s an excellent antiemetic. It has amazing properties. It’s a very…

Dr. Franco: It’s made for home use?

Travis: No, it’s not made for home use. It’s a very short half life so it acts very quickly and it wears off very quickly, which is the beauty of using it for quick cases like a colonoscopy or an EGD or a case like if we’re doing something under sedation, like if we’re doing eyelids or if we’re doing something quick and easy for getting a scar or doing a scar revision, sometimes we will do those under MAC anesthesia and I will give some propofol sedation for the patient. That wears off within two or three minutes and that patient is completely awake.
The problem with the Michael Jackson situation is he was being given an amount of propofol in a bag, dripped in on a dripper without a pump, wasn’t being monitored, no standard of care there. I mean, there’s really no excuse for what happened. I can say any drug in the wrong hands is a bad drug.

Dr. Franco: I agree. This is why doing stuff with a trained professional. And this is why even in my practice, all of our stuff is done with someone because you need someone that does this all the time.

Travis: Absolutely.

Dr. Franco: Anything else you want…a few last key points to leave with our peeps about anesthesia, stuff you want them, if they had to take home five things, what would you say?

Travis: I think know your provider. Know who’s doing your anesthesia. Ask questions. Say, “Where’d you go to school? Where’d you do your training? Are you board-certified?” Every anesthesia provider should be certified by some board. I’m certified. Any board-certified anesthesiologists…

Dr. Franco: And he went to Duke.

Travis: It is certified as well.

Dr. Franco: And it’s okay for them to ask the plastic surgeon. The plastic surgeon doesn’t know who or what group or who’s doing the anesthesia. That should be a flag. I mean, I may not know that it’s gonna be you in per se, but I know the other three people in your team. I know what team it’s gonna be, if they really had questions. And correct me if I’m wrong, but your team actually has a nurse that does some prescreening calls as well for patients.

Travis: Yep. And then if it’s anything over her head, she’ll point to me or one of my other partners and we will contact the patient directly prior to surgery. We’re talking a month or two months in front of surgery to say, “Hey, I received this. Is this real? Did you really…? You know, are you still on this medication? Did you have this heart condition that was listed in your history?” Sometimes that is just a typo or whatever and we get to the bottom of that.

Dr. Franco: Perfect. I think that’s pretty good to wrap this up. And then can we do a little fact or fiction?

Travis: Let’s do it. Yeah.

Dr. Franco: I usually go around and do everybody. Can we just start with G-Berto and then maybe you guys may have some followup fact or fiction for G-Berto?

Travis: Absolutely.

Megan: Sure.

Dr. Franco: G-Berto, fact or fiction, you are off the market.

Gilberto: I don’t know how to answer that.

Dr. Franco: I mean, would you steal Megan’s line from episode three where she said it’s complicated?

Gilberto: I wouldn’t say it’s complicated. I mean, I’ll just straight up explain the situation.

Travis: Oh, please.

Megan: Okay. Yeah, Let’s hear it.

Travis: We’re done.

Gilberto: So I recently reconnect…

Dr. Franco: Just so you know, this may break a lot of hearts in Austin right now and I don’t wanna start the week off on a sour note and have just like the streets flooded, you know, because of all the tears from the ladies in Austin, but continue if you wish.

Gilberto: I recently reconnected with an ex-girlfriend of mine about three or four weeks ago.

Dr. Franco: That sounds complicated.

Gilberto: It was complicated before because there was some separation and that she moved…

Dr. Franco: Separation anxiety?

Gilberto: She moved away to attend the same program that I went to, which is a physician assistant program.

Dr. Franco: Would you like to give us her handle so we can all look her up?

Megan: Were the holidays…

Travis: Cold-blooded.

Megan: I have a question. Were the holidays a factor in reconnecting? I feel like a lot of people reconnect over the holidays. Like you always get…

Dr. Franco: You think she was lonely.

Megan: Well no, but like you get messages from people you haven’t talked to in a while and like people reach out and just commonplace in the holidays. I mean it’s great time.

Dr. Franco: Yeah, that’s a great question. How did this rekindle happen?

Gilberto: So a mutual friend came in to see me and struck up a conversation about my ex-girlfriend, and she asked if I was seeing anyone at the time. And I said not anyone, you know, specific or anything. And so she’s like, well, you know, so-and-so asked about you and I thought…

Megan: So this was a planned thing on her part then. She was sent on a mission to get in there and figure out what’s going on. Yeah.

Gilberto: Is that girl code?

Megan: From a woman’s perspective, probably.

Dr. Franco: What do you think about rekindling with exes? For those of you that missed episodes one, two, three, and four, Megan is a relationship blogger.

Megan: No, yeah, I’ve talked about this a lot on my YouTube. I’ve only done it one time…

Dr. Franco: What’s your YouTube?

Megan: My YouTube channel, it’s just Megan Parken.

Dr. Franco: I forgot it. It’s just Megan…

Travis: She’s just Megan Parken.

Dr. Franco: Just Megan.

Megan: But I’ve been doing that for the last 10 years of my life. So I’ve shared like all of my relationships pretty much on there. But like my first big one in high school, we broke up for two years, got back together for a year, then it still wasn’t right. For me personally, I feel like unless people have fixed the issues, if there were issues. If it’s just like a logistics thing, then it can definitely work a second time around. And also if you had a connection with that person, there is probably a reason why you don’t have it with other people. Like there was something special there.

Gilberto: We have very strong connection, we’re together for a few years. And then we were apart for about three.

Megan: And I think when that happens, when you’re more mature too, it’s a different phase. And if you’re super young and you break up and it’s like a big volatile thing and, you know.

Dr. Franco: So what happens right now? Somebody, I mean a 11 out of 10 slides into your DM because they heard this podcast.

Megan: I do have to say also though that is, no, I’m not trying to rag on the women, but a lot of women also are attracted to men that are taken. Like once they hear that, they’re like, “Oh now I want him.” That’s a thing and I’ve seen it and I don’t agree with it.

Travis: That’s what you hear so you’re doing it.

Dr. Franco: I need to say I’m taken…

Gilberto: We need to get Dr. Franco set up.

Dr. Franco: Just for all the ladies out there…

Travis: Franco is taken.

Dr. Franco: For all the ladies out there, I am taken, don’t you slide into my DM.

Travis: If you’re an 11 out of 10…

Dr. Franco: Don’t you try.

Travis: Do not try slide into Franco’s DMs.

Megan: No, and I…

Gilberto: Twelve and over, please, only.

Dr. Franco: Because I am not available. Do not slide into DM @austinplasticsurgeon.

Megan: No. A big point, I remember when we discuss mine and I was saying it was complicated. That’s because in the past I’ve shared who I’m dating and then immediately girls go follow the guy and start DMing him and I’ll like be with him…

Travis: That’s dirty, that’s dirty.

Megan: I’ve looked through the messages and I’m sitting with him and they’re like, “Hey, wanna like whatever, whatever?” And it’s like, you know that he’s my boyfriend and you’re doing it because you know that. That is real.

Travis: That is cold-blooded.

Megan: And it’s not, it’s not good.

Travis: It’s catty.

Dr. Franco: So you’ve just…

Megan: I don’t think men do it, but women…

Dr. Franco: So he is just actually, if he wasn’t number one, he’s number one now. That is smart. You are smart G-Berto.

Gilberto: You know what? I just let the cards fall where they may.

Dr. Franco: Okay. Our next episode, we’re gonna want a little update to see where this is going. Any last comments before we get you behind the bouvie [SP]?

Gilberto: Don’t DM me.

Travis: But feel free to DM Dr. Franco @austinplastic…

Dr. Franco: So in honor of Anesthesia Day and it’s actually…

Travis: It’s actually…

Dr. Franco: …CRNA Week.

Travis: It is actually CRNA Week.

Gilberto: Oh, happy CRNA Week.

Travis: Thank you.

Dr. Franco: Yes, I do know.

Megan: It’s also MLK day as well.

Travis: It is.

Megan: Shout out Donald.

Dr. Franco: I wanna say that but he beat me to the punch here, so I was gonna do it out of principle. But can we, as the little behind the bovie, because people have lots of questions. Everybody thinks that you got to count backwards from a hundred before your anesthesia. Is this a thing or is this not?

Travis: I have never seen anyone actually do that, which is crazy. I do anesthesia and I’ve never… Have you ever heard me ask a patient to do the count?

Dr. Franco: I try to do it all the time just to annoy you guys.

Travis: I have never done it. And like some other people in the room will be like, “Count backwards.” I’m like, what are y’all doing, give them those…?

Dr. Franco: So counting backwards has nothing to actually do with anesthesia.

Travis: Absolutely not.

Dr. Franco: Okay. I just wanna it clarified.

Travis: Now, you know.

Dr. Franco: Can we do a little quote of the day?

Travis: Yeah, let’s do it.

Dr. Franco: Since you got to steal all the thunder today.

Travis: Since I talked the entire time?

Dr. Franco: I was gonna do a little quote and I was gonna do, and we’ve talked about this recently, “Rising tide raises all ships.”

Travis: I like that.

Dr. Franco: G-Berto, can you give me a little example of where “Rising tide raises all ships.” Thank you. And I’ll just give you an example of mine, would give you just a second to think. I was actually at a RealSelf board meeting this weekend. And it’s interesting because it’s…

Travis: Shout out RealSelf.

Dr. Franco: Shout out RealSelf. But it was interesting because I come there and they obviously want our opinion about how to make their site a little bit better and so forth like that. And hopefully, we’re gonna be doing some stuff at Modern Beauty in terms of trying to help patients figure out how to find the right provider for them. Because we have people listening in from all over the country. Very few people ever actually gonna come see us. If you do, you’re welcome. Appreciate it. But you know, we wanna help guide you to the right person. And so it’s just interesting because here’s this room of 13,14 very talented surgeons from all over the country. And I feel like every time I would leave that meeting, I walk away with more knowledge than I ever shared because here’s so many talented people that are just sharing all sorts of information.
I feel like the better it gets as a whole, we all improve. We all learn from each other. And I think sometimes people forget like, “Oh, well if I share my stuff with Travis, he’s, you know, he’s gonna beat me,” or, you know, don’t realize like me helping Travis do better is helping me, you know. And so the better we all do this podcast, the better all of us are, the better everybody does. And I think when people get out of this mindset that it just needs to be about me, everything gets better and stuff just works itself out.

Megan: I have another quote that actually kind of ties to that. It says, “A candle does not burn out by lighting another candle” and that’s kind of the same thing.

Dr. Franco: Damn.

Megan: You can lift someone else up.

Travis: That was double-quote of the day [vocalization].

Dr. Franco: I mean, the question is how many candles has Gilbert lit?

Gilberto: I’m feeling a little on the spot right now.

Travis: You are on the spot today.

Dr. Franco: I mean, I’m just saying this romance has had to light a few candles all night long.

Travis: I definitely agree with both of those. What’s wrong with collaboration and synergy? All it does anytime that I’ve been involved with anything big, which isn’t a lot, but anytime that I’ve been involved with something important or an organization, if everybody’s bringing their A game, everyone does better instead of this constant competition, if everybody’s supporting each other and building each other up, things just work out better.

Megan: It’s also if you surround yourself with really interesting inventive people, you’re gonna just rise to that occasion too.

Travis: Totally.

Dr. Franco: I think it pushes everybody to be better, no question. Well, producer Donald is giving us the wrap-up sign. So Travis, any last words about anesthesia?

Travis: Know your provider, you are safe if it is a trained good provider. And trust the person that’s putting you to sleep. They went to school for a long time. They studied to pass those boards. They know what they’re doing. Have faith in them and they’ll take good care of you.

Dr. Franco: I agree. I wanna give a shout out and plug to ourselves. Episode six is all about the breast lift, To Lift or Not To Lift. And so hopefully, people will tune in for that next week. And I wanna, of course, thank the producer Donald for getting us all together. It’s like herding cats and he seems to do it every week, so appreciate you, producer Donald. And that is it. Thanks for joining ”Plastic Surgery Untold.” We appreciate all of you guys. We appreciate you guys listening to the number one podcast in Austin rated by me. I appreciate it. Thank you. Boom.

About The Author

Dr. Johnny Franco
Episode 4: New Year, New Me!Episode 6: To Lift or Not To Lift


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