Anesthesiologist & Pain Specialist, Alopi Patel, M.D.

Hi, it's Doctor Robert Seikard with a new episode #10 of Doctor Podcasts. And I'm really pleased to be here today with our guest, Doctor Alopi Patel. Doctor Patel is an assistant professor of anesthesiology and pain medicine at the prestigious Mount Sinai Medical Center here in New York City. Thanks very much for coming today, Doctor Patel. We really appreciate it. And you're a board certified anaesthesiologist. Can you explain what you do as an anaesthesiologist in the hospital and then later we'll talk about your office patients that you see as well?

Sure. So an anaesthesiologist is a physician that sees patients before the surgery and we are essentially perioperative physicians in the sense that we ask a thorough history and do an examination, usually a respiratory cardiovascular sort of assessment before patients go into the operating room. In the operating room, we perform anaesthesia which comes in many different types, usually it's general anaesthesia, sedation or regional anaesthesia and off site such as on the labor and delivery floor.

We also performed neuraxial anaesthesia which is epidural anaesthesia or spinal anaesthesia. So those are all the different types of anaesthesia that we provide while also hemodynamically monitoring patients, making sure that they're safe and comfortable accounting for any emergencies if they arise, making sure that blood products are available, you know understanding CPR and how to resuscitate patients. And then we also take care of them in the post operative setting to make sure that they're pain free and their symptoms are controlled if they have any nausea or vomiting and other symptoms.

Right. My patients often ask me what's the difference between general anesthesia versus local anesthesia? Those are the two common terms. Can you explain that? Absolutely. So local anesthesia is usually local anesthetic, which is a medication which can be deposited into a certain area of the body. So in your instance, the eye or around the eye, or it can be in different parts of the body, such as the hand or the knee. But local anesthesia is exactly that. It's local, and it's also a medication that lasts for a shorter period of time.

And patients can also get some medication in an IV to make them calm and relaxed and happy during the surgery because they are awake. Yes, exactly. So if there's some level of sedation associated with that, we can also have an IV and give them short acting medication such as a benzodiazepine. Medazolam is the one that we frequently use. We can also use fentanyl or propofol for sedation. And then general anesthesia is when patients are completely asleep, usually with a breathing tube of some sort, which is either an endotracheal tube or a laryngeal mask airway called an LMA.

And that is essentially A protected airway where the patients will be relying on a machine to help them breathe for the procedure. But after the procedure is done, we usually take out the breathing tube all. Right. You mentioned fentanyl just briefly. It's fentanyl is known now as a very dangerous deadly drug but when used during surgery can you explain how you're monitoring patient and it's safe and. Absolutely. So fentanyl is a very potent opioid medication and when used without physician supervision, it can be very dangerous and it's otherwise illicit if it's used outside of the medical.

Setting. Exactly. But in the medical setting, when used with appropriate hemodynamic monitoring, respiratory monitoring and oxygen and whatnot, it's a very safe medication to use and actually quite necessary in the perioperative setting or that time around the surgery basically because of its really potent effects at pain control. So it's an important medication when needed. Right. And the important thing is it's monitored very carefully and used in tiny microscopic doses that you can monitor. Exactly.

Another drug patients asked me that which I actually used during eye surgery is propofol, which is a popular medication. Can you explain the the benefits of propofol? So propofol is a hypnotic medication and it essentially helps patients fall asleep and we call it the milk of amnesia, right as colloquially or jokingly we say that milk of amnesia. And it's a very safe medication, again when used under physician supervision in a monitored setting such as the operating room. So it's again a very good medication to help patients sleep and be comfortable during the procedure and we will watch the patient the entire time.

Right. And it wears off quickly, which is really nice too. So patients can resume their normal activities Now in addition to being an anesthesiologist and taking care of patients during surgery in a hospital, you're also a certified pain specialist, right? Can you tell us about that? So after four years of residency I I went to a fellowship which was interventional pain medicine. During that one year, we focus on learning more about the the the body from basically a different perspective now, which is how to manage pain.

We learned about medication management as well as interventions such as injections and other more interventional therapies to help with pain. So you you can deal with pain in different parts of the body and they're managed differently for different patients and depending what's causing the pain. Exactly. Now you also are an expert in Women's Health, right? Yes. Can you tell us about that and how you got interested in that and involved in that? Yes, absolutely. So when I was in pain fellowship, I I kind of got drawn to female patients and especially pelvic pain patients.

And it was something that I wanted to explore a bit more. And I went to additional courses, did a lot more reading and continue to learn and advocate for my for my female pelvic pain patients especially. And over time, I also kind of gathered male pelvic pain patients in my practice as well. But I kind of came about that because there aren't as many female pain physicians in the field, only 19% as of a few years ago, only 19% of physicians, pain physicians or women and especially for women centric sort of diagnosis such as fibromyalgia or migraines or pelvic pain or sexual dysfunction, whatever it may be, I think that having a woman physician can make a big difference to patients who are seeking seeking women physicians.

That's interesting. When I see patients in the office for eye things, I have them fill out a history form and it's interesting over the years how many people write down. They have pelvic pain, syndromes and and problems with that, which is difficult to manage. In the old days it was kind of a taboo subject, but now more and more people are discussing it and there's more pelvic pain specialists like you. Is that becoming more common? Absolutely. I think that social media probably has a role to play in that as well.

I think it was very stigmatized and many people, including male pelvic pain patients, didn't feel comfortable speaking up about it. With social media, there's more awareness and advocacy for pelvic pain patients, and more patients are now seeking care, which I'm very happy about because it's something that I think many people suffered silently for years. Right. And you mentioned men also have pelvic pain, which wasn't known. Men tend to kind of hide their symptoms more, but now it's they're opening up and so they need treatment as well.

So you do that also. Absolutely. So for female pelvic pain, depending on what studies you read, it can be up to like 20 to 30% of the population can have pelvic pain. And for male pelvic pain, that number is around 10%. Again, depending on which studies you're looking at, that's five to 10% of the population can experience some sort of pelvic pain, whether this is penile pain, post erection, post ejaculation pain, sexual dysfunction and whatnot. So there really are 10% of the United States population that are claiming some sort of pelvic.

That's like 30 million people. That's a lot of people with this problem. Exactly. Now in the old days, I used to think, and I think it was a common thought, that it's gynecologists and urologists that treat this mostly in women but occasionally in men urologists as well. How's your approach to pelvic pain different than a gynecologist or a urologist? That is a great question because I think that that the answer to that question has evolved a lot recently, which is how I am, where I am. So in general, when we used to treat pelvic pain, again women went to gynecologist, men went to urologist.

And just like that analogy of different people, kind of four blind men touching four different areas of the elephant, we only see what we know or we only know what we see. Sort of. Philosophy, right? Exactly. So I feel like for something like pelvic pain, there are so many different factors. There are muscles involved, nerves involved, tissue, which is usually like prostate, bladder, uterus or whatnot, and then sometimes bone. And those are four very different parts of the pelvic area that can be causing pain that no one person can essentially treat.

And having a comprehensive and collaborative approach, multidisciplinary approach is important. So I think often times when we didn't know what to do after, you know, certain physicians may have hit their area of expertise, the answer was sometimes opioids. We don't know what's going on. Let's try opioids as as a pain specialist, as an interventional pain physician, my job is to understand the body in different ways, right? So if it's a muscle involvement, what can I do about that? If there are nerves involved, what can I do about that?

And if it's tissue, it's often my colleagues. If it's something related to the uterus or the prostate, it's often outside of my hands. But if they've already assessed it, taking it out, whatever it may be, and they're still pain, I can still help understand where those nerves that are causing the pain are coming from and then kind of focus on that. So I think the way we're looking at pelvic pain has changed that. You know once we as one specialty have tried everything, that does not mean it's the end of the line.

There are other specialists that can help in certain ways, whether with medications or injections. Yeah, that's very interesting subject. So urologists and gynecologists understand those areas of the body very well, but they don't have a a deep an understanding of the innervation of those areas of the body and what causes pain and aren't trained and really dealing with with pain in those areas of the body. Whereas you have this pain background and knowledge that is helpful for patients who haven't gotten relief with their other doctors.

I think it's a different perspective in that sense and that depending on what type of pathology there is and if for example if it's prostatitis, right. So chronic bacterial or non bacterial prostatitis is treated in a certain way often with medications or antibiotics or whatever it may be. But if that fails and there's still pain, we could perhaps do some sort of some sort of like nerve plexus block. If somebody has, for example, like a motor vehicle accident and there's no really resection to do just like pain in the perineum, which is often times patients describe like a golf ball sitting in the middle of their pelvis.

And again, it could be we can do Emgs, we could do MRI, ultrasound, whatever it may be. But if there's nothing really urologically to do, like a resection or a cystoscopy or whatever it may be, or even medications, we can often try interventions like nerve blocks, I think. It's a different can you explain the different techniques, the medications, the injections, other things that you use to treat pelvic pain? Absolutely. So kind of going back to that philosophy of muscles, nerves, bone, tissue, I think the big part of me understanding my patients where they're coming from is understanding what type of pain they're having.

Because pain is not just muscle usually, or just nerve. It's often multifactorial, right? So if nerves are involved, almost automatically some sort of muscle will be involved, right? Because muscles tend to get aggravated if there's surrounding irritation somewhere, so especially in the pelvic floor which literally supports our pelvis, right. So muscles are almost always involved. So my approach, understanding that there are several factors that go into pelvic pain is to start with with the least invasive as I think most physicians usually do, right.

So the least invasive would be lifestyle modifications. So for example, if somebody has chronic rectal pain from straining for example, let's say like chronic straining related pain and now it's just hypertonic pelvic floor. So some lifestyle modifications that we can suggest would be, you know changing their posture for how they're defecating the angle basically of defecation, increasing fiber, increasing hydration, mind, body sort of exercises to help relax the pelvic floor. So those lifestyle modifications are the least invasive.

Then there would be some sort of medication, so medications. And again this would be kind of with my GI colleagues and I work with many different physicians. As you can see with pelvic pain, it can be GI, colorectal, urology, gynecology and whatnot. So if I'm speaking to my GI colleagues, and if they have suggestions for medications, whether that's a Suppository of some sort, laxative stool softeners, whatever it may be, we can try certain medications. What? What's contained in the suppositories that that works?

So for certain types of hypertonic pelvic floor, I will prescribe a muscle relaxant Suppository, so this is usually Baclofen or diazepam. So those can be taken as a Suppository. There's not as much systemic absorption as there would be for a medication that's taken orally. So you don't get the systemic or body side effects. It doesn't make you groggy or. Exactly. Exactly. So it doesn't make you you don't have as much of the systemic effects, so not as much as of the grogginess. But I do advise patients not to take it with alcohol like initially, just to make sure that they don't have any side effects.

But usually the suppositories are Baclofen or diazepam and sometimes together. So those are two medications that could be taken orally, but you're putting them very locally. So they just have an effect in the area where there's a problem. Essentially. Avoiding the systemic side effects you mentioned also injections. What kind of injections can you give for for pelvic pain? So for pelvic pain, kind of going back to that muscles, nerves and bone sort of philosophy. For pelvic pain in particular, one of the common injections ioffer are pelvic floor trigger points.

So just like we can offer trigger points in different parts of the body, so like the trapezius muscle, which is a frequently irritated muscle for many people and I would say for pelvic floor trigger points is essentially the same. I think a lot of people, men and women hold their tension in their pelvic floor and their pelvic floor muscles can become hypertonic and tense over time. And outside of the medications and the lifestyle modifications, if they're still having symptoms of a hypertonic pelvic floor, we can do pelvic floor trigger points.

And this is usually in conjunction with physical therapy. So I will say along that continuum, it's lifestyle modifications, physical therapy, medications and that injections would be the trigger points. What's in the injection? What medication are you injecting into the trigger points? So for the trigger points I use just numbing medication. So lidocaine usually sometimes we pivocaine. There are other physicians that will inject Botox, but again, that's kind of variable, but Botox can last longer than lidocaine or Bupivicane.

And the Botox relaxes. These muscles that you mentioned are hypertonic or stressed exactly constantly, right? I've heard of that use of Botox. Interesting how it has many uses. The lidocaine and bupivicaine are are numbing medications right? And they last for several hours just to get the patient off the acute phase. Exactly. So the lidocaine lasts a little bit less than the bupivacaine and it can be anywhere from like 8 to 12 hours. But really what the injections are doing in conjunction with the physical therapy, the breathing exercises and the medications is overtime helping the pelvic floor get a bit more relaxed.

So it's something that is a multi disciplinary comprehensive regimen and I tell patients that it's not going to be just the trigger points or necessarily just the the breathing exercises that are going to get them to a good pelvic floor tone. It's going to be many different things usually. Right. So again, what differentiates you from, I think the gynecologist, urologist is you know where those trigger points are for the nerves and exactly where to inject to, to get those trigger points, right? And a lot of my gynecologist colleagues and urology colleagues also do pelvic floor trigger points.

I think they have a bit more different specializations. So I think it's harder sometimes to find anybody that as pelvic floor trigger points even within the the pain physician world, it's very difficult to find people who do that. And even within urology and gynecology, there are few people that do them, but it's just not something that I think has been as popular as other types of therapies. And you also inject steroids right into those areas. What's? What's the purpose of that? Yeah. So if we're doing nerve injections or like bone injections, so that would be like the sacroiliac joint or something along the pelvic girdle.

But basically, if we're doing nerve or bone injections, then I usually inject local anesthetic and steroid. And nerve injections can be peripheral nerve, they can be part of the sympathetic nervous system or the epidural space. And for those, almost always I'll recommend steroid, unless we're doing a different sort of series, which I won't get into, but usually almost always steroid. So these steroids are the anti-inflammatory steroids, not the steroid, the bad steroids that you hear about on TV and the abuse steroids.

These are different categories. Steroid they they reduce the inflammation exactly and the steroid the purpose of the steroids. They last for a long time. Yeah. So the local anesthetic, like we said, lasts anywhere from like 8 to 12 hours. But the steroids can last anywhere from days to weeks and their effects can last for many months, which is why they're very beneficial for those nerve injections because it has that anti-inflammatory effect. Right. And you also treat pain in other parts of the body.

So if somebody has, let's say, a shoulder injury or a knee problem or a hip problem, you you treat those as well, right? Yep, absolutely so. How do you treat that? So for for different types of back pain, we'll do epidural, steroid injections, arthritis injections, which are called facet injections. There's some of the more common ones we do for back pain. I'll also offer joint injections such as knee joint, shoulder joint injections, injections for migraines. So we do, I do treat a lot of different parts of the body, but I think once I embraced Women's Health like wholeheartedly, I started seeing a lot of pelvic pain patients.

But I'll see patients for all types of pain. It's so you really know, have to know the nerve anatomy in all different parts of the body to know exactly how to treat that. Now you also treat transgender patients, right? And and increasingly, more of that. Yes. So I think that this is definitely a very evolving topic and being in New York City, we're very progressive and I've been seeing more patients in my practice over the last several years and I am, I am again, I I'd like to advocate for my patients and empower my patients to speak up and my transgender patients is one part of that population.

But I think often times patients who have pain, whether they're transgender or not, they may not know that there is a pain physician of some sort to go to, to help with pain such as pelvic pain, right. So not many people will do pelvic floor trigger point. So it's hard to know that that's even an option. Same thing with transgender patients. It's hard to know that physicians could treat some sort of pain that they. They just don't know there's a specialty for that. Yeah, exactly. So that that's that's very important.

You're also a lifestyle medicine doctor. That's another specialty you have. You have multiple specialties, all very important. Can you explain what lifestyle medicine is? Absolutely. So lifestyle medicine is a certification that I received a couple years ago now, but it's through the American Board of Lifestyle Medicine for any physician and actually even outside of physicians, they have certifications for other providers. But basically it focuses on reducing the burden of chronic disease, including chronic pain by addressing modifications that we can have control over.

So sleep, hygiene, exercise, positive psychology, nutrition, reducing toxic substances such as alcohol or tobacco and whatnot. So it's a very comprehensive way to address chronic disease. And as you can see, that goes very much hand in hand, especially with pelvic pain. But in pain in general, having good lifestyle practice in terms of sleep, exercise, nutrition, all of that can definitely help with pain. Right. So in addition to working in the hospital doing anesthesia for patients who are having surgery, you also have a separate office where you see patients for the pain issues as well as the lifestyle medicine, right?

Yes. And all this information is is on your website at alopipatelmd.com. Yes, in terms of what I treat, yes. Right. OK, that's good. So people need to know that if, if they're having these issues. You spoke about empowering patients and being an advocate for your patients. Can you explain more about that? Absolutely. So I think pelvic pain patients are stigmatized to a certain degree and being able to speak freely and talk about things that are quite intimate, often right, sexual dysfunction, pelvic pain, whatever it may be.

So I think in order to really encourage patients to talk about it, I created social media platform and a brand to be able to speak about it on A bigger forum and. That's also on your website, right, Those social media? Yes, exactly. So to be able to advocate for patients, I wanted to first let them know that there is help available. There are resources and it doesn't have to be a pain physician necessarily, can be a physical therapist or urologist or gynecologist, which I also promote on our social media platform as well.

But basically advocating for them to know that there are options out there to empower patients to to speak up when they feel unheard. And we had a whole episode on medical gaslighting for this very reason. A very popular episode about how to use different resources to advocate for yourself in a medical setting when you may feel that your voice is not being heard. Medical gaslighting. Can you tell us a little bit more about that? That sounds very interesting. Yes, absolutely. And I think I've encountered this often with my pelvic pain patients who are women, but you know having patients symptoms not taken seriously or dismissed or as attention seeking.

So actually this was in the news recently, but Bindi Irwin, Steve Irwin's daughter had endometriosis, has endometriosis, but it took her several years to be diagnosed for this very reason, right. So speaking up about pelvic pain or abdominal pain and doing some tests whatever it may be, but really not getting to a diagnosis and endometriosis is one of those diagnosis that can take several years to actually be diagnosed. The gold standard is surgery, right? Laparoscopy is the gold standard, but often times patients symptoms are dismissed and for especially for my endometriosis patients, I think they've encountered some degree of it's in your head, it's not that big of a deal, it's just associated with your period, but you know take some Tylenol allergy or whatever it may be.

So I think pelvic pain patients have had some issues with medical gaslighting about their symptoms not being taken seriously and having a long course to finally having treatment started. It's good you're bringing all this out to the public. What are your social media platforms? Can you just tell us the the names of them so people know? Yeah, absolutely. So it's called the female Pain docs. My friend and colleague Mira Kirpaker, and I created it during the pandemic a couple years, three years ago now.

Wow. So it's basically a platform to encourage patients to educate themselves about medical diagnosis, advocate for themselves and empower themselves to seek the treatment even when they think that there are no treatments available. And which social media platforms are those available on? So it's called the female pain docs. We are on Instagram as the female pain docs on twitterorx.com now as Female pain docs. And then we are on all major podcast streaming platforms and our podcasts are very popular, which I'm very excited about because that's exactly what we wanted.

And on most podcast podcast streaming platforms, it's called the Hurt by the Female Pain docs. It's. Good to know people can find it on your website or now they they've heard it and can look it up online. You mentioned about pain a lot. Obviously today, in recent years the subject have pain has been associated with opioid use and abuse and as we mentioned opioids do have a role in certain types of surgery and anesthesia. What about in your pain medicine practice? What role do opioids have there?

So I think the role of opioids is very important in the sense that there is a need for it for the right patient at the right time of their of their pain history. I think that opioids for surgery are vilified in the public eye and I think patients as well as physicians are often on the receiving end of that backlash. But at the same time, I think there's a time and a place for it. And I think for pelvic pain patients, I try to give them all of the options, all of the referrals, comprehensive sort of care necessary to avoid opioids.

But if there is a need for it at some point, I don't say that it's not necessary. You know, it will be something that we'll discuss when we need it, sort of thing. Often times patients will feel better without chronic opioids, but that doesn't mean that, you know, that's not an option necessarily. So it's sort of a last resort type of option and and you limited and keep careful track of it so patients don't develop the addiction problems and issues with it, right. Yes, exactly. AI, as you know, artificial intelligence has been in the news a lot lately, especially in healthcare and medicine.

Is there a role for AI and anesthesia and pain medicine and then the other things that you do? Definitely a hot topic and something that I just did a pub Med search on a few weeks ago. Ironically, but for pain management basically. And I think there's definitely a role for it in the future. How it's going to manifest, I'm not sure. But I had done a pub Med search for chronic pelvic pain and artificial intelligence and machine learning for this very reason because there are so many physicians that can treat pelvic pain, so many therapies for pelvic pain from invasive to non invasive surgical and whatnot.

And I was wondering, you know, if artificial intelligence might be a part of that solution in the future. If you have this sort of symptom for this long, you're more likely to have endometriosis versus this symptom for this long and you've had a baby before then perhaps it's more a peripheral nerve or something like that. Those algorithms are definitely a possibility in the world of pain, but especially for pelvic pain. In terms of anesthesiology, I'm sure there are. I've read about studies looking at machine learning for operating room efficiency, which I'm sure as anesthesiologists and a surgeons we're going to be very grateful for.

But you know, understanding how operating rooms can learn, can run more efficiently and utilize resources more efficiently with machine learning. I've read that there are anesthesia machines, right, That kind of work with or sometimes replace the anesthesiologist. Is that is that a possibility or is that science fiction? No, I think I did. I did read about this a couple years ago about a like a robot that essentially monitors the blood level of propofol and there's a certain target range of what amount of propofol should create a certain type of level of anesthesia.

And then having, you know, that constant monitoring, I don't think it's a near reality. Could it be in the future? Absolutely. I mean, we don't know what the future holds. I'm having surgery. I want you there. I would want me to, yeah. Get the robot out of the. Room, exactly. Put the robot. In exactly. Now, we mentioned that you're an anesthesiologist, that you also specialize in pain medicine and several other certifications, lifestyle medicine. How long did it take you to become certified and an expert in all these fields?

For the younger people in the audience who are interested in becoming pain specialists or anesthesiologists, it takes a lot of work. But tell us the details of that. So I after high school, you know, undergrad, I was a psychology major, which I am very proud of because I think I use a lot of my psychology background in my clinical setting. But outside of college, it's four years in medical school and then four years of anesthesiology residency, one year of pain fellowship. And then after that, the certifications were on my own time and I'm a lifelong learner.

So a lot of my certifications were while I was pregnant and postpartum and all of that so using my time to advance my medical knowledge. So it's it's at least nine years of of strict training and then of course we all have to constantly keep track of all the new things that are happening. That's a long time now. You also now teach and you have fellows in in pain and in anesthesia. Can you tell us about that? Absolutely. So I am at a teaching institution, which is very, very gratifying because I it's exciting to teach, you know, physicians who are going to be taking care of US in the future.

And same thing with the fellows. I am very excited to teach fellows who are very open minded to learning new therapies and it keeps me on my toes as well. Right. Because you have to be up to date and everything. And these fellows eventually go on to different parts of the country and learn from you how to treat patients with these various problems, Right, Exactly. And Stan, you were recently invited to other institutions to give lectures about your experience. Can you tell us about that? Yeah. And I think social media for for physicians who might be listening to this has been, has been a very great opportunity to expand my, my clinical and professional development.

And I have used social media to speak about issues such as pelvic pain, transgender medicine and whatnot. And one of the opportunities I've received is to to speak about perioperative management of the transgender patient, which I think is very important because I think, one, we're going to see more patients presenting in the perioperative period, whether this is when they are undergoing body contouring medication, hormone treatments basically or have had gender affirming surgery or had have had pelvic reconstruction surgery.

I think the transgender patient in the perioperative period can present in many different ways. And as perioperative physicians, it's very important to understand how to provide gender affirming, informed, sympathetic care. Right. So this is actually becoming a sub specialty of of pain medicine, right? Yeah, to a certain degree. There are some pain physicians who are starting to focus more on transgender patients and know that, you know, there are physicians who are going to be providing gender affirming care.

That's great. That's been very informative. I'd like to thank you very much for coming today to do this interview and doctor podcasts. I enjoyed it very much. Thanks for your time and we really appreciate it. My pleasure. Thank you. Thank you very much.

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