Dr. Roberto Garcia sits down with David Armstrong, owner of Valentine Anesthesia, for a conversation that begins with David’s unlikely journey from working with tigers and other big cats to becoming a nurse anesthetist. They then break down the continuum of anesthesia—from local anesthesia and conscious sedation to monitored anesthesia care, TIVA and general anesthesia—along with the roles of CRNAs and anesthesiologist assistants. The conversation also covers airway management, postoperative nausea, common concerns about memory and cognitive fog after anesthesia, and the importance of individualized patient safety. The episode closes with Dr. Garcia reflecting on leadership, parenting and the example we set through our actions.
DR. ROBERTO GARCIA: You’re listening to The Confident Choice podcast with me, Dr. Roberto Garcia, a double board-certified facial plastic and reconstructive surgeon. Honest conversations and expert advice about the decisions that make you feel your best.
Welcome, everybody, to Season 2, Episode 3 of The Confident Choice. I’m your host, Roberto Garcia, and I am a board-certified facial plastic surgeon, as you guys probably already know. But very few times do I have the honor and distinction of being around one of the most interesting people I’ve ever met.
David, you are very interesting, man. In a minute, you’re going to tell us why you’re interesting. David owns a company called Valentine Anesthesia. How many years have you been doing anesthesia now?
DAVID ARMSTRONG: I finished school in 2014.
DR. ROBERTO GARCIA: Twelve years into it. Great practice. They’ve been doing our anesthesia, and you guys do a ton of practices around town.
DAVID: We do.
DR. ROBERTO GARCIA: It’s a big group. We’re going to get into, first of all, why you chose anesthesia. Then we’re going to start getting a little bit granular as to the different providers of anesthesia. Just today I was asked by two different patients about the memory issues that can happen with anesthesia, so we’ve got to touch on these subjects. These are things that people are really genuinely concerned about.
Tell us a little bit about yourself. You weren’t always an anesthesia provider.
DAVID: I wasn’t. No. I kind of had a convoluted start to it. I started out as a pre-vet major. I went to Rutgers University and graduated from there. I decided I didn’t want to go to veterinary school anymore, and I didn’t really know what I was going to do with myself.
During that program, I was able to help raise a couple of tiger cubs at a local wildlife sanctuary by Six Flags. That gave me this itch that I wanted to be around big animals, big wild animals. So I started searching for jobs training big cats, which is kind of silly. People are like, “Who does that?”
But I ended up getting a job out in Arizona. I worked at a wildlife park out there called Out of Africa, and I got to work hands-on and swim with lions and tigers and bears and leopards and jaguars and wolves.
DR. ROBERTO GARCIA: Swim with them? Like get in the water with them?
DAVID: Get in the water with them. At the beginning of our show, we would actually have them chase us like prey. We would dive into the water, and they would jump 10 feet in the air and land on me in the water.
DR. ROBERTO GARCIA: That’s a 400- or 500-pound cat, isn’t it?
DAVID: Absolutely. Then I came home to New Jersey, and I got lucky enough to continue doing it at that same Six Flags. I did that for six years. I was a supervisor there as a tiger trainer for six years. Basically, I worked with tigers. We did educational presentations called Temple of the Tiger, kind of SeaWorld-style, where you got to see the tigers running and jumping and swimming and really giving them the best life possible during that time.
DR. ROBERTO GARCIA: I read something somewhere that some of these tigers are close to being extinct, right?
DAVID: Yeah. In more recent years we’ve actually seen an increase in them. For a long time, the Bengal population was only in the 3,000s out in the wild. Now they’re starting to say 5,000 or 6,000 because of different things—curbing poaching and looking at them more as a protected species and bringing tourism in versus poaching for different medicines.
DR. ROBERTO GARCIA: That’s crazy. So then you were doing the show.
DAVID: Yes. I did the show for a while and got to the point where I loved what I was doing, but the rest of life kind of suffers. The animal industry is interesting in that it has to be a labor of love. It has to be something that you love doing because you’re not going to make a lot of money, and you’re not going to have that kind of outside life that you want to have.
So I looked into what I was going to do. One of the things I had during school was a functional human anatomy class where I spent time with a couple of cadavers, and I really enjoyed human medicine. I really enjoyed the human body. When I decided I didn’t want to go to medical school, I still decided I wanted to get into human medicine in some way.
I started looking into what was a good transition for me, having my pre-vet degree. I went into an accelerated nursing program and got my second bachelor’s degree in nursing. When I first started thinking about nursing, I was asking, “What am I going to do with this nursing degree? Where can I go specialty-wise?” I came across nurse anesthesia, and that was it. I knew right away that was what I wanted to do.
After working in the ER as a nurse and then working in the ICU for about three years, I went back to anesthesia school.
DR. ROBERTO GARCIA: This is now here in Florida?
DAVID: Yes. I moved here and worked at a couple of hospitals in the area as a nurse, then went to anesthesia school through Barry University. My campus was in Orlando, so I did most of my training in Orlando. I came back, moved here, and we’ve worked here since.
DR. ROBERTO GARCIA: I’m old enough to remember the days of—if you look at the history of anesthesia—it’s a nurse-driven profession. It was started by nurses, especially when antiseptic techniques started around the turn of the 20th century. Nurses were doing the anesthesia.
There was a professor here in Jacksonville who ran the nurse anesthesia program, and he said it to me perfectly. He said anesthesia is one of the few professions in medicine where you’re not actually treating disease. You’re maintaining a set level of vitals and parameters. You’re keeping them at status quo. You’re not medically treating a cancer or an infection.
DAVID: To be a nurse anesthetist, you have to work in the ICU, and some of your most critically ill patients are your patients in the ICU. Those nurses are maintaining that patient day in, day out, night in, night out—adjusting medications, titrating this, titrating that, making sure that person remains either on the upslope or at least on the straight path.
DR. ROBERTO GARCIA: You guys have mastered that. I’ve had the experience of working with anesthesiologists versus nurse anesthetists, and especially in my arena, where it’s not super complicated, I find that nurse anesthetists are so detailed and so on top of the patient. They’re watching them like a hawk.
DAVID: Most people don’t realize that a large percentage of the time they’ve gone in and had a procedure done, there was a nurse anesthetist at the end of the bed. They were there through each and every moment of that procedure.
Being a nurse, that’s what you do. You look at that patient. You’ve seen it even here in this facility. Our providers are there from the very beginning until the very end. They’re treating the whole patient. They’re there to make sure that patient gets home safely. That’s not just leaving the operating room.
DR. ROBERTO GARCIA: So what do you tell me about this specialty that’s gaining a lot of popularity—anesthesiologist assistants, or AAs?
DAVID: AAs are what we would say, politically, are a competitor of nurse anesthetists. Their predominant role is that they have to work with an anesthesiologist by law. They always have to work with an anesthesiologist.
They have similar education to us without the nursing background. They do a three-year program. It’s a master’s degree program. Nurse anesthesia programs now are doctorate level. In order to get into nurse anesthesia programs, you have to be a nurse in an ICU for at least two years. AAs don’t have to do that. They still have prerequisites and things they have to take in school, but they could come from a program where they’ve never touched a patient before.
DR. ROBERTO GARCIA: You talked about the doctorate program that’s now pretty much consumed all nurse anesthesia programs. What are the benefits of that at a patient-care level?
DAVID: The benefits are that it tends to be a little more research-based and education-based. At the patient-care level, I think it does have a benefit in that it is progressing the education and continued education of the nurse anesthetist, but they’re not adding a different clinical skill set.
DR. ROBERTO GARCIA: So if I go through a nurse anesthesia program today and end up with a doctorate, and I’m practicing, am I doing some kind of different maintenance of education or certification from a non-doctorate anesthetist?
DAVID: From anybody who’s master’s-prepared, it’s no different at that point.
DR. ROBERTO GARCIA: I remember when that transition happened from two years to three years. I thought that was a mistake in terms of making it mandatory. I think it’s good if somebody wants to do it, if they want to go into the academic world, but you guys are losing a year.
DAVID: It’s eight months. The program was 28 months for your master’s, and now it’s 36 months. I’m a master’s-prepared nurse anesthetist, and there are a lot of people you see in this operating room who have gone back to get their full doctorate. For me, like you said, it doesn’t change my clinical practice at all. If it changed my clinical practice, I absolutely would do it. I don’t have a real interest in being a teacher.
DR. ROBERTO GARCIA: Let’s talk about the different variations of anesthesia. Take us through from the very basic—getting a cavity filled—to having open-heart surgery. Where do we fall in?
DAVID: Anesthesia is kind of a continuum. You have to take different procedures and different patients into account for each anesthetic you do.
There could be a local anesthetic. It could be a block for your knee, a field block, or filling a cavity. That’s a local anesthetic where the patient is completely awake, but you’re blocking the sensation that causes pain.
Then you could have that in combination with things. You could have it with a little sedative. That sedative may be what we consider conscious sedation. “Conscious” means we’d be able to say to you, “Hey, turn your head. Open your mouth,” and you will, but you might not care too much that you did. It takes away some of the anxiety and makes you a little sleepy so you’re more comfortable for the uncomfortable parts of laying there.
DR. ROBERTO GARCIA: That sedation can be either oral or IV sedation?
DAVID: It could be. I don’t typically do oral. To me, IV is more controllable. It can be titrated more easily.
Conscious sedation starts that initial monitored anesthetic care. Now you have somebody monitoring you and making you less aware or less concerned about what’s going on. As you get deeper into sedation, you start asking: Are you maintaining your own airway? Are you able to react to painful stimulus? That’s where you get into monitored anesthesia care. You may add different medications that make you more sleepy.
As you get past that, you get into what we consider general anesthesia. General anesthesia doesn’t necessarily mean you had an airway device, an endotracheal tube, an LMA or some kind of assisted device. What it means is that there was probably a time during that procedure when you were not able to maintain your own airway or were not able to respond to painful stimulus. That’s where you get into what we consider a general anesthetic.
DR. ROBERTO GARCIA: So TIVA is technically a general anesthetic?
DAVID: It can be, yes. You can have what we consider a room-air general anesthetic, which means you have a nasal cannula in. We’re giving you sedation, and you’re breathing on your own, but at times you might not be able to maintain your airway completely and we may have to do a little chin lift.
DR. ROBERTO GARCIA: In case you guys don’t know what TIVA is, it’s total intravenous anesthesia. Generally speaking, medication is being given through your vein. There’s something in your nose, or maybe an oral airway, just to keep your tongue forward. But like David says, you’re probably not conscious at that point.
Would you consider the anesthesia given during a colonoscopy to be a TIVA?
DAVID: I would consider it a TIVA general anesthetic. If you’ve ever had a colonoscopy, you want to not know.
DR. ROBERTO GARCIA: Every patient I’ve spoken to says, “Oh yeah, I want that anesthetic.” We used to do it at our old center, and it was great anesthesia until the patient decided they wanted to wake up. Then they’re like a roller coaster. Then we moved into what we do now. Tell us about that.
DAVID: What we do generally for our bigger procedures—our facelifts or neck lifts, a bigger procedure where we’re sharing the head of the bed—it’s safest to intubate the patient and control the airway. That patient now has an airway that’s protected from blood and secretions, and the patient is completely asleep. We can control their breathing if we have to. We don’t have to all the time. Sometimes the patients are breathing on their own and they have a controlled airway, and they’re kept asleep at what could be the deepest level possible.
DR. ROBERTO GARCIA: We don’t really keep paralytics after the initial intubation. When would be a situation where you would continue those paralytics?
DAVID: It depends on the procedure. Sometimes you want the patient to be paralyzed because you need muscle relaxation. For us, you might continue paralytics if you were having hemodynamic issues and you couldn’t keep that patient deep enough. You could keep them paralyzed so that the anesthesia could be a little lower, because anesthesia does drop blood pressure. That’s the reality—it will drop your hemodynamics.
The typical patient we have is healthy enough to sustain that. But if somebody was having an issue, we might say, “Okay, we’re going to keep them paralyzed and run them a little lower.” They’re still not going to remember anything. They’re still not going to have any pain, and they’re going to be more hemodynamically stable.
DR. ROBERTO GARCIA: I remember ether, and those patients were sick afterwards. I remember on my anesthesia rotation in medical school, one of the test questions was about the incidence of nausea and vomiting post-op. It’s not that now.
DAVID: No.
DR. ROBERTO GARCIA: Our patients have a very, very low incidence. I think we have one or two patients a year, and we do about 360 anesthesia cases a year. Overall, it’s got to be less than 10 percent, right?
DAVID: It’s less than 10 percent. It’s because of all the medications that you can give them on the front end. We try to prevent it. For most of the procedures we do, we don’t use a lot of medications like narcotics that can trigger postoperative nausea. The gases are less irritating now.
If somebody comes to you and says they have a history of postoperative nausea, we plan ahead of time. We give medication during the procedure. We can run a propofol drip, which even at a light amount will help reduce it.
DR. ROBERTO GARCIA: One of the things that we do here—and I think you developed this protocol—is put a scopolamine patch on them.
DAVID: That’s very effective.
DR. ROBERTO GARCIA: Very effective. Anytime somebody tells me they get sick occasionally, I ask, “Do you get sick in the car? Do you get travel sickness?” If they tell me that, we put one on.
The last thing I want to talk about is something I hear more and more every day: concerns about an increased incidence of Alzheimer’s, memory loss, short- and long-term memory loss with anesthesia. Does that hold water?
DAVID: In my eyes, it doesn’t hold water in the sense that anesthesia doesn’t eat brain cells. It doesn’t do that to people. The reality is that it’s very hard to quantify.
You can’t put the patient who had a facelift in our office for a three-hour procedure together with a patient who came in with a huge trauma and has gone back for washouts over and over, every other day, having a full general anesthetic. You’d have to account for the fact that they’re also in an ICU and taking all kinds of medications.
The risk for someone coming in and having a short outpatient procedure, who we’ve optimized and who doesn’t have comorbidities or preexisting cognitive dysfunction, is extremely low.
DR. ROBERTO GARCIA: The research that I’ve done over the last three or four years points to patients who have had repetitive anesthetics in a fairly small window of time, patients who have had long anesthetics—over six hours—or patients who were already going down the path of cognitive impairment.
That’s what I tell patients. You don’t know if an older patient who has a little heart disease, diabetes or hypertension already has a disease process that may eventually lead to dementia, Lewy body disease or Alzheimer’s. That process may have been happening irrespective of a three-hour facelift they had at 72. It’s kind of the chicken-and-the-egg conversation. You don’t know which came first or if it was already happening.
DAVID: You can’t attribute that simply to anesthesia. There are many different factors in an anesthetic. You maintain the patient’s blood pressure and oxygenation and all these things to prevent problems. You’re not over-anesthetizing people.
DR. ROBERTO GARCIA: That’s the hardest issue I’ve had—trying to understand what particular medication we’re giving during an anesthetic that would cause that pathway. I don’t see it.
DAVID: It is common to come out of an anesthetic and feel sleepy or a little foggy for a day or two. That’s a common thing, but that should resolve. We’re not giving medications that are long-acting to cause those issues, especially in our arena.
DR. ROBERTO GARCIA: Our patients are wide awake that afternoon. I did two friends on Monday, and they actually stayed together. They told the sitter to call me so they could talk to me. Somebody who’s been cerebrally impacted with an anesthetic is not doing that four hours later.
DAVID: No.
DR. ROBERTO GARCIA: Maybe it’s you guys’ great anesthesia that you provide.
DAVID: I’ll pass it along to the crew.
DR. ROBERTO GARCIA: This has been really good. You opened up a lot of doors of discussion and, more importantly, you closed a lot of areas where patients sometimes don’t feel comfortable with the type of anesthesia.
I always close with a lesson my dad taught me. I remember my dad telling me, “Don’t do what I say, do what I do.” I always said, “What? But you don’t do that. Why would I do what you do?”
Then, when you become a parent, you realize that the best example you can serve to your children is not barking at them. It’s by just being the best version of yourself, because they are going to emulate and try to be that person. My daughters want to be my wife. My son wants to be me.
He would always tell us: Be the kind of individual—whether it’s with your kids, employees or friends—that everybody wants to gravitate to because they respect what you do, not what you say.
You have kids. Isn’t that your philosophy, too?
DAVID: One hundred percent. You’ve got to set a good example, for sure.
DR. ROBERTO GARCIA: That came to mind the other day. What’s crazy is, when they die, you hear them more and more. I hear my dad every day talking to me. It’s crazy, but it’s good. He reminds me of who I should be. He reminds me of being that good person.
This is going to conclude Season 2, Episode 3. Our next podcast is going to get a little bit granular with the consultation process because I want you guys to know everything about not only what happens during the consultation process here, but what should happen anywhere—what questions you should be asking and what information you should definitively have in your hand when you leave the consultation.
My sign-off is the same as it’s always been, and I get it right every single time: Good decisions come from good information.
Thank you very much, guys. Have a wonderful week.
Under the direction of visionary double board-certified facial plastic surgeon Dr. Roberto Garcia, Contoura Facial Plastic Surgery offers the latest surgical and non-surgical procedures in a relaxed and serene setting. Schedule a virtual or in-person consultation today to get the first glimpse of your future self.
230 A1A N, Ponte Vedra Beach, FL 32082