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deleted59964
its actually quite possible to lose an airway that is tenuous simply from topicalisation and loss of airway tone even without sedation.
and yeah know they "usually don't die" -- I'm talking a numbers game here
and yeah know they "usually don't die" -- I'm talking a numbers game here
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deleted59964
Periop cancer patient, American sedentary lifestyle, cardiac arrest when moving to/from OR table -> PE is way more likely than you'd think. The rest is between you and your conscience. Nobody's perfect.
Also, many deep venous thrombi are produced in the pelvic veins (what are the chances in ovarian cancer?), hence they never get detected before PE.
There is a differential between ante- and post-mortem clots. Believe the pathologist.
I would let you take care of my loved ones.
this - right here, is the crux of this thread
that's something I have yet to hear of happening
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deleted59964
reassuring isn't it?
I think so because you are probably getting into the range of 1/1,000,000 risk of something like that happening.
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deleted59964
i think you’re missing the point of the thread. there are lots of capable anaesthetists that have had patients die from lost airways - could be in any number of different circumstances.
point is - do high risk stuff enough, and despite making a reasonable plan and having reasonable skill - you can still end up contributing to someone’s death.
how do you come to peace with that inevitability?
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Lots of beer?
Count me in the group that had a patient code and die from a PE moving from table to stretcher. Was a kid who had just had an IVC filter placed. 2 other intra-op deaths, 1 other kid as an attending and one adult as a resident.
It's not easy. It actually seems like it gets harder with time, not easier, though some of that is mostly taking care of kids while being a parent now.
Talking it out with colleagues, debriefing with the team, exercise, they all help. Interestingly, I had vacation right after the last one, and I think it actually made things worse for awhile, as I had tons of free time to think about it and no colleagues to commiserate with. Getting back and doing cases where things went well also helped.
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Absolutely this
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deleted59964
I had a patient arrest on transferring to the table too -- in prone position. was a posterior fossa crani that had been attempted the day prior in beach chair and arrested intra op from air embolism - survived to ICU, back to theatre to treat the original pathology in the prone position this time. rolled prone and it all went bad, we transferred back onto the icu bed - resuscitated and went back to ICU on high dose inotropes ... patient died a few hours later. not a PE obviously - but similar pathophysiology.
When I ruminate on a case that hasn't gone as well as I'd like - one thing that really helps is the next case distracting me - so I get it about an immediate break not necessarily helping
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deleted59964
to you and consigliere ... when did you know it was time to get out of the high risk trenches.
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I actually find it funny the students that want to match into anesthesiology because they “want the adrenaline rush”. F that. I want “healthy” hearts (with a good surgeon) and LMA cases
Oh and someone to do my preops. I hate talking to patients in prestaging.
Oh and someone to do my preops. I hate talking to patients in prestaging.
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When I started going home with back aches for no apparent reason. High risk case are good for new attendings to get their feet wet with actually not having an attending micromanage you, but those cases get old after a few years and at the end of the day you just want straight forward cases with good surgeons. These cases can be hearts, vascular, peds, whatever but save the drama for someone else. This is especially so in private practice where some of use supervise. I really don’t need drama if I’m not in the room.
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I have to express sincere thanks for the candor many of you have shown in talking about the hard cases and appropriately managing the emotions that come with them.
I was recently rotating through the ICU, and we had a larger than usual amount of mortality, largely due to increasing quantity of sick patients (lots of VV ECMO for ARDS and VA ECMO for numerous reasons). When these patients died, I felt bad that they died, but very emotionally disconnected due to the grave nature of their cases from the start. I've been trying to process why these deaths aren't as emotionally draining and I think it's like those above have said; from the moment the interaction starts, you realize their chances are slim and you're doing your best to buy them time to heal, or at least have their family say goodbye.
This is in stark contrast to a 5yo girl who came in with a fatal injury that had been caused intentionally by a family member last fall. In the OR I managed to just focus and get things done (what's the alternative?) while everything inside of me wanted nothing more than to just RUN out of the OR. She had experienced an anoxic brain injury prior to arrival, so despite our resuscitation and intervention, her family withdrew care the following day. The whole thing had me wrecked for weeks. I could hardly sleep, I had nightmares pretty much every night (either reliving that experience or things happening to my kids). Broke into tears several time when alone in the car. Talking pretty openly to my wife, some co-residents, and a couple attendings about it was a big help.
My exposure to this sort of badness was very limited in medical school. At that time I rarely saw anything of high acuity. Residency has been filled with a lot of new experiences and emotions.
Thanks again for sharing everyone. You've put into words a lot of things I've been trying to process and come to terms with. It's sometimes nice to know you're not alone.
I was recently rotating through the ICU, and we had a larger than usual amount of mortality, largely due to increasing quantity of sick patients (lots of VV ECMO for ARDS and VA ECMO for numerous reasons). When these patients died, I felt bad that they died, but very emotionally disconnected due to the grave nature of their cases from the start. I've been trying to process why these deaths aren't as emotionally draining and I think it's like those above have said; from the moment the interaction starts, you realize their chances are slim and you're doing your best to buy them time to heal, or at least have their family say goodbye.
This is in stark contrast to a 5yo girl who came in with a fatal injury that had been caused intentionally by a family member last fall. In the OR I managed to just focus and get things done (what's the alternative?) while everything inside of me wanted nothing more than to just RUN out of the OR. She had experienced an anoxic brain injury prior to arrival, so despite our resuscitation and intervention, her family withdrew care the following day. The whole thing had me wrecked for weeks. I could hardly sleep, I had nightmares pretty much every night (either reliving that experience or things happening to my kids). Broke into tears several time when alone in the car. Talking pretty openly to my wife, some co-residents, and a couple attendings about it was a big help.
My exposure to this sort of badness was very limited in medical school. At that time I rarely saw anything of high acuity. Residency has been filled with a lot of new experiences and emotions.
Thanks again for sharing everyone. You've put into words a lot of things I've been trying to process and come to terms with. It's sometimes nice to know you're not alone.
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Ludwig's angina, angioedema, come to mind
Impending airway loss
I've personally had an awake patient code from airway
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It is mentally and physically draining to deal with poor outcomes on a regular basis. Anyone who tells you otherwise is a liar or a sociopath. Doesnt matter if you did everything right. Sometimes the circumstances suck
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Most of the surgeons I work with are also decent people.
But there are a handful that blame anesthesia for everything - especially all their surgical complications.
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Maybe I'm misunderstanding or just plain don't know, but I was under the impression the you put the patient into manual/spontaneous during a code and bag them yourself?
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I agree with both of you. There are some very decent minded surgeons out there while there are also those that believe “so long as I stop surgical bleeding, every other complication is anesthesia’s fault”. The later are the ones that make this more job difficult than it should be
I'm saying I've never heard of someone spraying local in the back of a throat and the patient instantly loses their airway. I'm well aware that impending loss of airway can be about to happen, but that's why you do the awake FOI. The awake FOI doesn't cause them to lose their airway, their disease process causes it.
I make a distinction in my mind between a patient's disease process causing them to die while I'm attempting to help versus my actions/inactions being a direct cause of their demise.
When you say "contributing to someone's death", that implies you made a medical error that directly lead to their death.
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Yeah I don't remember dying when I drink water and it goes down the wrong tube and end up having a coughing fit. If it was that dangerous loads of people would be dead before hitting the OR
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deleted162650
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We all will have multiple deaths under our belts before we are done. The vast majority will be on easily predicted patients undergoing long shot operations, but there will be times when it occurs unexpectedly. No matter the situation you will second guess and blame yourself, while trying to figure out what you “should” have done that would have saved them.
Sometimes you will find something, and it will eat at you for the rest of your life. You have to learn what you can medically from these situations and find a way to deal with the grief. Often just identifying it as grief will help. Swallowing pride and talking with colleagues will help. Professional help may be needed, despite the stigma associated.
I have worked with 2 anesthesiologists who blamed themselves for deaths that were 99% patient long-standing issues and poor timing. Both perseverated on these deaths, and rarely talked about them. Both committed suicide within a month of these instances.
Edit: wrong thread, but the one I was thinking of is in the private forum, and I’m going to leave this here.
Sometimes you will find something, and it will eat at you for the rest of your life. You have to learn what you can medically from these situations and find a way to deal with the grief. Often just identifying it as grief will help. Swallowing pride and talking with colleagues will help. Professional help may be needed, despite the stigma associated.
I have worked with 2 anesthesiologists who blamed themselves for deaths that were 99% patient long-standing issues and poor timing. Both perseverated on these deaths, and rarely talked about them. Both committed suicide within a month of these instances.
Edit: wrong thread, but the one I was thinking of is in the private forum, and I’m going to leave this here.
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36 hour weeks? No call? No weekends? No liability? 200k a year? You bet I want to be a CRNA.
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deleted162650
Pretty sure you can do better than that as an MD at the VA.
Hell, except for the liability part you can do better than that as a mommy tracker at my shop.
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Good. Some people don’t derive any sense of satisfaction, self-worth, or life’s purpose from a job. For them a job is a means to an end. If popping in LMAs for ASA 1s and 2s allows someone to achieve that means then all the better...whether that be an MD or a CRNA. In other words, it’s my diploma, I can do what I want with it.
If the OP is doing high risk cases and going home with a knot in his/her stomach then stop. Doing that just leads to depression, anxiety, cynicism, and bad habits. That’s not good for anyone. Find a job where you pop in LMAs for healthy knee scopes and figure out what makes you excited in life.
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Anyone in this line of work for any meaningful amount of time will say that the most formidable catastrophes they or colleagues have been a part of were completely unforeseen. Those are the ones that take a toll. Categorizing "high" or "low" risk in the context of an anesthesia job really just indicates labor intensity or lack of it. If the number of medical interventions during the conduct of an anesthetic becomes a psychological or emotional drain, some introspection might be called for.
It also misses the point. That a "high risk" patient does well in the OR is no indication what will happen 30 days out. So many CT type patients die in that time period without our even knowing about it. Even vascular surgeons I work with call reading the local obituaries on Sundays "doing rounds".
This job has enough drama without having to manufacture more of it. "High risk" in the context of the OP is a false category.
It also misses the point. That a "high risk" patient does well in the OR is no indication what will happen 30 days out. So many CT type patients die in that time period without our even knowing about it. Even vascular surgeons I work with call reading the local obituaries on Sundays "doing rounds".
This job has enough drama without having to manufacture more of it. "High risk" in the context of the OP is a false category.
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Morning breaks, lunch breaks, PM breaks, dinner breaks, post dinner breaks.
oh, don't forget bathroom breaks that last a little big longer than yours.
Firefighter available all the time.
3 12hours per week. The day finishes at 10hour mark. Want to leave.
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deleted59964
of course it's not instant, it sounds like you don't believe it happens at all - fine, it's not up to me to correct that.
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deleted59964
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deleted59964
I see it as 3 groups
1. patients that die and you can't reasonably prevent it
2. patients that die because you f'd up
but less clear, is group 3.
3. high risk patients with advanced serious medical / surgical problems, that die, and maybe if you'd chosen or implemented a different plan they may have survived -- even though your plan / actions are defensible .
1. patients that die and you can't reasonably prevent it
2. patients that die because you f'd up
but less clear, is group 3.
3. high risk patients with advanced serious medical / surgical problems, that die, and maybe if you'd chosen or implemented a different plan they may have survived -- even though your plan / actions are defensible .
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deleted59964
I agree there is nothing wrong with doing ASA 1 and 2 and LMAs if that's what you want.
As for me as the OP, I've been doing high risk cases repetitively for nearly 3 years, I've learnt a heap, and I love it. I do meaningful work and am well respected. The trade off, is that it is mentally exhausting, and increasingly I need to manage that.
This thread is about sharing similar experiences and how people deal with the toll they take.
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Everybody dies at some point. Vascular patients are just dying one piece at a time. A leg here, kidney there, and so on.....
I asked around my group with a roughly 500 years combined experience and nobody has either seen it happen or heard of it happening which is why I'm suggesting if it does happen it is extraordinarily rare. That's all.
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Shift work. High salary compared to my education. Union. The fact that they practically run one of the major AMCs (Shmorthstar)
I would never go to nursing school so I could never become a CRNA but I can still get my money as an anesthesiologists without dealing with ASA 4E everyday of my career and who are we fooling, we’re all in this for the money. If we wanted to be “doctors” we would’ve done IM or at least CCM
I've heard of it happening in laryngeal cancer cases. The proposed mechanism being loss of proprioception in people who are constantly struggling to keep their cords abducted.
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deleted59964
Really didn’t want this thread to turn into another airway thread, but yeah makes sense that you don’t see it if you do afoi for poor mouth opening or difficult upper airway anatomy - but do see it sometimes when the patient is breathing through some tiny aperture at / just above the glottis.
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Your group '3' is problematic when broadly applied because it imagines some sort of sway or preternatural ability to avoid the inevitable. We don't have that power anymore than the power to make people sick in the first place. So many variables that even the surgeon can't control...how can a technique tweak in the anesthetic change reality? At the end of the day one reasonable plan is as good as another and obsessing along those lines (not that you're obsessing, but I suspect some do) is not constructive or, really, rational.
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deleted59964
it’s all perspective- if you don’t think one reasonable plan is better than an alternative reasonable plan - why do you choose one?
are all of your choices the best?
is it possible that the choice makes a difference to the outcome?
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Why do I choose one plan over the other? Because it is easier, because it might be my only case and I have time, because I'm teaching that day...if it falls within reason, yep, it doesn't matter. No, all of them are not the best. But thinking I can know which is for a particular patient is magical thinking, given the fact that the surgeon holds so much of the outcome in his hands. As far as outcome goes...define outcome.
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deleted59964
umm no thanks - I can’t imagine that will achieve anything.
So you’re arguing that unless you f things up, you don’t have an impact on the patient’s outcome?
And really , it’s magical thinking to think that you can choose the best anaesthetic plan for a patient ?
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This thread has run its course
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With just a couple of possible exceptions, so long as the plan has keeping to some very basic principles part of it, no, the way it is done doesn't matter a whit. So in that sense, if you don't keep to those principles, you are f'ing things up.
I'm coming from the perspective of a cardiothoracic and vascular stand point and it's my opinion that thinking in the context of outcomes isn't really useful because that word means something different to everyone. What I do is optimize the patient for whatever recovery period they're going to get given what they've brought to the table and I can do that in a lot of different ways that in all likelihood don't have any benefit over the other.
