It’s 11:15 a.m. Monday at Paoli Surgery Center, and Dr. Don Mazur is about to sing. Topping 6 feet in scrubs and clogs, his voice muffled a bit by the surgical mask, the orthopedic surgeon is shaving away rough bone inside a patient’s left knee. He gives the nod to one of the nurses who make up the full-time staff at the center, and she presses a button on a boom box tucked away in a corner. The doctor and his nurses join together in song.
A long, long time ago,
I can still remember
How that music used to make me smile …
More voices chime in—one coming from behind the surgical drape. It’s the patient, a woman of a certain age who likely has more grown-up memories to go with the song than her surgeon does. She’s joining in as Mazur plumbs the innards of her primary leg joint. Then the chorus comes around, and her voice rises along with everyone else’s.
So bye-bye, Miss American Pie.
Drove my Chevy to the levee,
But the levee was dry …
Don McLean’s “American Pie” is something of a tradition for Mazur and the surgical crew during his last operation of the day. Granted, other surgeons play music in the OR and likely even sing along. But what’s different at Paoli Surgery Center is that the patient is awake to join in.
Looking on from the sidelines, Dr. Benjamin Jacobs takes pride in what he sees: a great surgeon at work on a patient who’s wide awake but completely free of pain—one who will walk out of the building under her own power just a few hours after the procedure is over. At Paoli Surgical Center, Jacobs and fellow anesthesiologist Dr. Philip Bilello—not the surgeons themselves—are the ones in charge. As such, their interactions with patients begin long before they set foot in the waiting room.
Prior to their arrival, Jacobs and Bilello have reviewed their case, taking note of any health issues that might affect the ability to provide a safe, pain-free surgery. Should something arise, they notify the patient and surgeon themselves to either recommend a delay in surgery or additional care.
Jacobs, who lives in Haverford, earned his undergraduate degree at Haverford College before studying medicine at Wake Forest University. A few years behind Jacobs, West Chester’s Bilello graduated from Brown University before heading to New York Medical College. Both met at Yale University while Bilello was beginning his residency and Jacobs was working as an assistant professor after completing his. The connection later led to Bilello joining the staff at Paoli Hospital after Jacobs was named the hospital’s chief of anesthesiology.
The two were integral in both the creation and design of Paoli Surgery Center prior to its opening in August 1994. Eventually, they formed the two-man practice that now controls the center’s day-to-day operations.
At 7:15 on this morning, the waiting room is already filling up, and nurses are preparing the OR for the first surgery of the day. At the same time, Bilello is visiting with the first wave of four patients, going over their charts and joking with them to ease their stress. By 7:30, he’s inserting a spinal anesthetic into the first patient, a 69-year-old woman awaiting an arthroscopic procedure on her knee.
When most people think of spinal anesthesia, which stops pain but allows a patient to remain awake, they think childbirth. The layperson might assume that a more complex operation would require a general anesthetic, in which a patient is completely unconscious.
But Jacobs and Bilello share a common philosophy that emphasizes regional, rather than general, anesthetics. This philosophy guides every step of what they do as part of their practice. They’ve found that, with ambulatory surgery—performed on an outpatient basis and after which a patient is expected to leave the same day—regional anesthetics increase recovery times for patients and improve the surgery center’s efficiency. They also result in less residual post-operative pain.
“She can be asleep if she wants to be, or the sedation we’re giving her right now will wear off in about 10 minutes. And if she wants to watch it on TV, she can,” says Jacobs about his first patient. “Then, at the end of the case, you just roll her onto her stretcher and she’s good. With a general anesthetic, it could take her 10 to 15 minutes to wake up.”
With general anesthesia, the time when a patient wakes up after surgery is carefully calculated, potentially contributing to a longer wait, slowing OR turnover and delaying other scheduled surgeries. The risk of complications also increases with a general anesthetic because it requires patients to be intubated (a long tube inserted down the windpipe to facilitate assisted breathing). The surgery’s risks aside, “tubing and venting” a patient presents its own specific dangers.
“If you look at a comprehensive review of all malpractice cases, the major disasters come from airway issues,” Jacobs says. “Doing a spinal anesthetic, you avoid that whole problem.”
Extra sedation is required so a patient can tolerate the breathing tube, and significant damage to the vocal chords can result. Studies show that inserting a breathing tube is more stressful on the body than the surgical incision.
By 8:32 a.m., the first patient of the day is out of surgery and resting comfortably in the recovery room. Here, patients are attended by a dedicated team of postoperative nurses who monitor their recovery until they are up, alert and on their feet. Three minutes later, Bilello is on to the next patient, performing another pre-op consultation before administering another anesthetic at 8:40.
Between waves of patients, either Jacobs or Bilello update the dry-erase schedule board listing each day’s surgeries. “Outside of the clinical [duties], this is like a mini-hospital. We’re responsible for a lot more than, say, a regular anesthesiologist,” Bilello says. “We’re responsible for ordering our drugs, so we have to be fiscally responsible to keep costs down. I order the materials we use, so we’re very hands-on.”
By 9:06, the woman recovering from knee surgery is wiggling her toes, a sign that her procedure went well and the anesthesia is wearing off. A half-hour later, she’ll be easing her way out the door. As the second wave of patients enters surgery, Bilello and Jacobs continue rounding through pre-op and the operating rooms.
Their organization and devotion to efficient and personable care permeates everything at the center. It’s why a growing roster of surgeons keeps returning to book their outpatient procedures with Jacobs and Bilello. For one regular, Dr. Vincent DiStefano, “time and efficiency” make the difference in dealing with Paoli Surgery Center.
“In order for this place to function the way it does, you need to have two good anesthesiologists,” says Mazur, who has operated on members of the Philadelphia Eagles, not to mention Jacobs himself. “Both Ben and Phil are experts at giving regional blocks, which is a lot safer than general anesthesia.”
Because of the center’s small size and self-contained nature, paperwork is reduced and turnaround time is shortened. Among the surgeons operating on this day, all estimate that turnaround at Paoli Surgery Center is about half of what they’d experience at another hospital. “They have a surgeon’s ‘get it done’ mentality—and that makes it work better for the surgeons,” Mazur says.
And while anesthesiologists are indeed the gatekeepers of the operating room, Jacobs and Bilello also know their positions will always be relegated to the background. Still, the motivation is there to make an unpleasant experience safer, more pleasant and as pain-free as possible.
“Ben always says, ‘Anesthesia is like wallpaper. No one notices the wallpaper until it becomes unglued,’” says Bilello. “We’re the unsung heroes of the operating room. You go into anesthesia, and it’s not the glamour job. I see Ben and I as the linemen. We’re in there pushing things around so the work can get done.”