Pet Peeves

[kingcer0x]

Recovering patients in the PACU due to 'staffing issues' ...

Along those lines, lazy nurses/techs in academic hospitals who dump their work on residents.

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[deleted171991]

Along those lines, lazy nurses/techs in academic hospitals who dump their work on residents.

Nurses can do that only because the anesthesia attendings don't speak up, because "it's not their battle". They should not tolerate their residents being treated with even one iota less respect than what they would demand for themselves.

I still remember the attending who reprimanded a surgeon in the OR for disrespecting me. I also remember the one who got angry when the front-desk "nurse" called me by my last name, instead of "doctor lastname", as a CA-3; I wasn't his resident and he was just sitting next to me in the lounge. May both live long and happy! They were the exception, not the rule.

 

[Ronin2258]

Being given dirty looks by the nursing in the ICU for a direct admit of a cardiac patient from the OR, with the ICU attending complaining they have to recover the patient.

It's your job, you ignorant dolts.

I can certainly bring it up with one of the better (and more pleasant,) cardiothoracic surgeons I have had the honor to work with, who did the bypass. I just want to be behind him as he explodes in your faces like a claymore mine.

 

[excalibur]

Has anyone brought this up?

Two nostrils = "nares" (NER-eez)

I am pretty certain though that when referring to one nostril, it's...

"naris"

Not "nare" (NAIR)

Pretty sure that's right.

Not a pet peeve. Just something I have noticed.

 

[urge]

Dear gods. You got me started about an ICU case where I wouldn't trust the ICU as far as I could throw Mount Everest. Run by a bunch of ICU people who either really need to be put out to pasture permanently or shot.

Guy comes in for bowel resection for complete obstruction with active carcinoid. Too unstable to finish and closed night before, attending on that case ran through several sticks of vasopressin. Sent to ICU overnight. Comes down to me next day with no less than THREE liter bags of normal saline. Heard he got FIVE liters of the stuff overnight. NO BICARB correction bag.

Saline bags were on pumps, piggyback on piggyback to the Cordis the attending anesthesiologist put in the night before. Hypotensive/unstable. Where does the ICU put the pressors that weren't hitting him hard, and the octreotide?

In the bloody 18g PERIPHERAL IV >.<

Chloride was 117, BTW, as well as a pH lower than what I would like as a human. No wonder the pressors were doing squat.

Attending let me run the show. Stayed to sign him back into ICU because 1) we were short staffed for room help that day, and 2) I wanted to get this poor man optimized as I could. Reward: going home just after lunch the next day.

I switch all but one bag out for PlasmaLyte, hoping the acetate would buy me a stronger buffer system, switch lines to appropriately put the central line stuff central. Had to push bicarb to try to get the pressors to work. By the end and on arrival to the ICU, he was off pressors (used only a 2 units of vasopressin push throughout the case,) and was stable under GA, and a somewhat normalized physiology.

Attending, Attending surgeon, the senior surgical resident, and I all went to the ICU. All of us said to keep him on PlasmaLyte or LR if not available. No normal saline. Documented in post-op check notes by all of us.

Come in the next day? HALF NORMAL saline. By the closed (minded) ICU attendings orders. Surgical resident and I were infuriated. Documented our previous recommendations in notes.

I have never wanted to channel Alec Balwin from Malice while I was working in the hospital until that moment. I would love to have had immunity from punishment just to go off on those ancient SOBs and read 5 Big Blues worth of the Riot Act.

I don't understand how a case that sounds so ominous, turns around so easily because Plasmalyte was hung.

 

[Ronin2258]

I don't understand how a case that sounds so ominous, turns around so easily because Plasmalyte was hung.

Because correcting the iatrogenic acidosis was key in getting his heart contractility and response to beta-adrenergic agents better. Still pushed some bicarb to get it to happen, but I wasn't going to add to his problems by keeping him on poison, as someone said earlier.

http://ccforum.com/content/16/4/R153

I'm just glad I brought him back to the ICU in better condition than I got him.

Has anyone brought this up?

Two nostrils = "nares" (NER-eez)

I am pretty certain though that when referring to one nostril, it's...

"naris"

Not "nare" (NAIR)

Pretty sure that's right.

Not a pet peeve. Just something I have noticed.

Trust me, as someone who has actually taken Latin as a language, it is a bit maddening.
...
I've got to walk away from this before the Latin lessons come back to rant on.

 

[deleted547339]

This thread is very interesting as an outsider (emergency medicine). One thing I saw earlier in the thread was getting routine cbc, bmp, coags before routine surgery.

I know that coags don't help me a lick when I have an appy or acute chole come in, but I feel like I can't get a surgical patient admitted without coags. Same goes for cbc....no matter what I tell the surgeon on a consult I hear "what's the white count?" Obviously I'm admitting to the surgeons, not the anesthesiologist, but still.

 

[deleted171991]

CYA. Never more important than with emergent surgeries, where things can go bad by default.

- So doctor, why didn't you get coagulation studies before the surgery?
- The patient said he'd never had a coagulation problem and was not taking blood thinners. It was not indicated.
- What is warfarin, doctor?
- The blood thinner the patient was taking and forgot to tell me about.
- Was he in pain at the time of your interview?
- Yes.
- Do you think he was stressed by the idea of having emergent surgery?
- Probably.
- Then why do you expect him to not make mistakes? Isn't it reasonable to double check, given the risks of error? Isn't it the standard of care to trust what the patient says, but also verify?
- Err...

The hospital will not reward you for foregoing unnecessary testing, but the malpractice lawyers and juries will make you pay. It's not worth using common sense and skipping tests; you might find you have the one patient in 10,000 who is the exception from common sense and logic. A society which tolerates this malpractice system deserves the high healthcare costs that come with the defensive medicine of testing 9,999 unnecessarily.

 

[BuzzPhreed]

CYA. Never more important than with emergent surgeries, where things can go bad by default.

- So doctor, why didn't you get coagulation studies before the surgery?
- The patient said he'd never had a coagulation problem and was not taking blood thinners. It was not indicated.
- What is warfarin, doctor?
- The blood thinner the patient was taking and forgot to tell me about.
- Was he in pain at the time of your interview?
- Yes.
- Do you think he was stressed by the idea of having emergent surgery?
- Probably.
- Then why do you expect him to not make mistakes? Isn't it reasonable to double check, given the risks of error? Isn't it the standard of care to trust what the patient says, but also verify?
- Err...

The hospital will not reward you for foregoing unnecessary testing, but the malpractice lawyers and juries will make you pay. It's not worth using common sense and skipping tests; you might find you have the one patient in 10,000 who is the exception from common sense and logic. A society which tolerates this malpractice system deserves the high healthcare costs that come with the defensive medicine of testing 9,999 unnecessarily.

This is not a reason to order unnecessary tests. Get yourself acquainted with the ASA practice advisory on peri-operative testing.

 

[Mman]

This thread is very interesting as an outsider (emergency medicine). One thing I saw earlier in the thread was getting routine cbc, bmp, coags before routine surgery.

I know that coags don't help me a lick when I have an appy or acute chole come in, but I feel like I can't get a surgical patient admitted without coags. Same goes for cbc....no matter what I tell the surgeon on a consult I hear "what's the white count?" Obviously I'm admitting to the surgeons, not the anesthesiologist, but still.

Along those lines, here's a pet peeve. Why does a PTT nearly always get ordered with a PT/INR? I mean when people order "coags", they always get a PTT. What the hell are the odds of a randomly elevated PTT in a patient not on a heparin drip? I don't think I've ever seen it. I mean I've seen it elevated a handful of times and you repeat it and it's normal.

I cannot for the life of me think of a single indication for ordering that test as a routine preop evaluation. I mean if they are on a heparin drip or have some other known abnormality that would impact it, by all means. But to just order it along with a PT/INR for the sake of getting coags?

 

[BuzzPhreed]

If the PTT is prolonged and the cause is not anticoagulant therapy or heparin contamination, then a second PTT test is performed by mixing the patient's plasma with pooled normal plasma (a collection of plasma from a number of normal donors). If the PTT time returns to normal ("corrects"), it suggests a deficiency of one or more of the coagulation factors in the patient's plasma. If the time remains prolonged, then the problem may be due to the presence of an abnormal factor inhibitor (autoantibody). Further studies can then be performed to identify what factors may be deficient or determine if an inhibitor is present in the blood. Nonspecific inhibitors, such as lupus anticoagulant and anticardiolipin antibodies

The PTT may be prolonged in von Willebrand disease, the most common, inherited bleeding disorder, which affects platelet function due to decreased von Willebrand factor. Hemophilia A and Hemophilia B (Christmas disease) are two other inherited bleeding disorders resulting from a decrease in factors VIII and IX, respectively. Deficiencies of other coagulation factors are rare but may also adversely impact PTT results.

Prolonged PTT levels may also be seen with leukemia, excessive bleeding in pregnant women prior to or after giving birth, or recurrent miscarriages.

http://labtestsonline.org/understanding/analytes/aptt/tab/test/

I'm not saying it's valuable as a routine screening test in the general population, just other reasons why it's ordered - yes, in a somewhat 'knee-jerk' manner.

 

[Mman]

http://labtestsonline.org/understanding/analytes/aptt/tab/test/

I'm not saying it's valuable as a routine screening test in the general population, just other reasons why it's ordered - yes, in a somewhat 'knee-jerk' manner.

Oh I understand there are conditions that can impact it. But out of an estimated maybe 20,000 patients I've seen the combo PT and PTT ordered on as some sort of preop workup, I've never seen a single isolated elevated PTT that was unexpected. I mean it just doesn't happen. It's almost as if there is no way to order the tests separately unless it's a patient on Coumadin in which case they are only getting the PT for that specific reason.

 

[BuzzPhreed]

It's almost as if there is no way to order the tests separately unless it's a patient on Coumadin in which case they are only getting the PT for that specific reason.

We can order it separately at my institution.

I also "routinely" order PT/INR & PTT in patients with known liver disease, the "true" LFT for someone with any advanced form of hepatic pathology. But, again, this is a specific indication. And something that the pre-op testing guidelines proposed by the ASA supports.

 

[BuzzPhreed]

We'll talk after your first malpractice suit (hopefully never).

I've been named and subsequently removed already from one lawsuit. Details limited due to this being an "open" forum. But suffice it to say it was a surgeon f***-up into which they tried to entrain every deep pocket. I'm not talking about the sliminess of the neo-ambulance chaser. I'm talking about doing what's clinically right. You can always defend that. You won't be able to defend ordering a 1,000 tests on every patient going on some fishing expedition. It's a good way to shorten a promising career.

 

[deleted9493]

Having a defensible reason for NOT doing a test is the key. This is of as much importance--if not more--than what we actually do to evaluate patients. See the recent MH thread. Patient has an astronomically low likelihood of being MH-susceptible. You play it safe and order the tests. Now we're talking about false positives and the cost incurred from essentially putting your own self-preserving fear of litigation before the concern of the patient. You order the PTT unnecessarily and it comes back elevated with no apparent cause? Spurious? Lab error? Further workup needed? Why are you ordering a test without an indication to begin with!?

You're probably more likely to overlook positive work-up findings if testing is ubiquitous/mindless, than you are if testing is problem/symptom-directed. I'd bet that those in the former camp are more susceptible to litigation than those in the latter.

Do a Google search using keywords "litigation" and "anesthesiology". Most anesthesiologists go their whole careers without being significantly affected by a suit; a convincing majority of suits are unsuccessful.

 

[deleted171991]

hudsontc, I agree with you 100%, and that's how I try to practice medicine.

But after I read about many cases like the one in a million case of the Boston ED doc, I stopped being judgmental against physicians who practice defensive medicine. If the outcome is bad, having done the right thing for the patient and not getting sued are almost unrelated.

On the other hand, creating a strong paper trail showing that you did "everything" for the patient and not getting sued (because the malpractice lawyer thinks your fault would be tough/costly to prove): pretty related.

In case of a bad outcome, most families and juries want a scapegoat, so that they can at least feel better. It takes a good scientific education and an above-average IQ to understand that some things are beyond anybody's control and really nobody's fault (that's why malpractice premiums are sky high in certain states and counties). In a malpractice suit, we won't have a jury of our peers; we'll have a form of Chicago.

 

[Spinach Dip]

Do a Google search using keywords "litigation" and "anesthesiology". Most anesthesiologists go their whole careers without being significantly affected by a suit; a convincing majority of suits are unsuccessful.

This is a (relatively) big reason why I am considering a career as a professional intubator.

Now if you guys could just get together and limit the scope of practice of CRNAs....

 

[BuzzPhreed]

On the other hand, creating a strong paper trail showing that you did "everything" for the patient and not getting sued (because the malpractice lawyer thinks your fault would be tough/costly to prove): pretty related.

The fact is that it's still rare that doctors are successfully sued. That's not to say that it's not a complete pain in the ass to go through a lawsuit. But the bias in most jury boxes, although there shouldn't be any, is usually still in favor of the doctor. Unless you are in certain geographic areas. Fortunately laws limiting change of venue tactics by plaintiffs attorneys in some states has significantly impacted jury verdicts. Also laws in other states putting capitations on jury awards for "pain and suffering" has also helped. The result is a significant decrease in ambulance chasing and less overall interest by scumbag plaintiffs attorneys throwing spaghetti against the wall and hoping something sticks.

 

[gclax30]

Love the thread... so many good ones above!

Biggest for me: OR techs that LITERALLY throw around the metal instrument trays at the end of a case when I'm trying to extubate my patient like they're rummaging through a bin of $5 DVDs at Walmart. Now, I am a relatively reserved, patient guy in the OR. I play nice and try to get along with everybody...but this just sends my $hit into orbit. And of course they fire back that they're just trying to turn over the room quickly, blah blah blah. I call shenanigans because they are the same jokers who get pissed when I'm trying to bring a patient back early but they haven't counted their retractors 8 times with 3 different people yet.

Would it be bad practice to keep the N2O running and sit down until they're done throwing crap around, then explain my refusal to extubate the patient under such dangerous conditions? I really don't think so.

 

[sevoflurane]

Got one a couple weeks ago when doing a ruptured AAA.

Lab tech calls up to the OR and demands to talk to me as I'm actively ressucitating the patient.

Lab Tech: "Hi. Is this Dr. Sevo"
Sevo: "Yes. How can I help you?"
Lab Tech: "I have a critical value I need to verbally communicate to you"
Sevo: "Great. Wacha got"
Lab Tech: "We have a PAO2 of 265mmhg"

WUT....? Don't you know I'm busy....?

Fortunately, I think this person was new. It was a first for me, but still... annoying in the middle of a crisis situation.

 

[dhb]

Lab Tech: "Hi. Is this Dr. Sevo"
Sevo: "Yes. How can I help you?"
Lab Tech: "I have a critical value I need to verbally communicate to you"
Sevo: "Great. Wacha got"
Lab Tech: "We have a PAO2 of 265mmhg"

 

[BuzzPhreed]

That's a good one, Sevo.

 

[deleted171991]

Thank God stupidity does not hurt, or we would have to wear ear plugs in the hospital.

 

[Lurch]

This just happened to me...again. Biggest pet peeve.

As I roll patient to OR from holding, patient says that they have a brother/cousin/friend who is an attorney. What do they honestly think saying this will accomplish? Same goes for entitled VIPs that flaunt their VIPness at me. Puts me in a bad mood for the case.

 

[pgg]

This just happened to me...again. Biggest pet peeve.

As I roll patient to OR from holding, patient says that they have a brother/cousin/friend who is an attorney. What do they honestly think saying this will accomplish? Same goes for entitled VIPs that flaunt their VIPness at me. Puts me in a bad mood for the case.

Just tell them you have a cousin who runs a funeral home and you can hook up their estate with a good deal. Then say pleasant dreams and push the propofol.

 

[Lurch]

Just tell them you have a cousin who runs a funeral home and you can hook up their estate with a good deal. Then say pleasant dreams and push the propofol.

Nice. Before or after 6 of versed?

 

[IlDestriero]

Nice. Before or after 6 of versed?

Scop not versed. Lol.

 

[shibby1111]

Oh hell yes. This. If anyone says this to me, I fire back with "Today I got a cheeseburger for 99 sonts. And shoot, I got bit by a sontipede the other day."

haha wow i heard someone describing something the other day by saying sonameter - didn't know what he was talking about so i tuned out.

 

[Doctor4Life1769]

I first heard that as a med student on a surgical rotation. Honestly, does it ****ing matter?

 

[Vandalia]

Isn't heroin (diamorphine) available for clinical use some places in Europe? I'm sort of curious who uses it and for what.

I believe the British use it as their preferred choice for subcutaneous administration of pain medicine in palliative care patients. Well, at least they did a while back...

 

[fakin' the funk]

You roll into the ICU with a post-op patient, a couple lines are tangled
Nurses: "OMG look at all the spaghetti"
...
You go to pick up an ICU patient for a case, and LITERALLY THIRTY LINES are tangled
Nurses: "I'm catching up on my charting"

 

[G0S2]

You roll into the ICU with a post-op patient, a couple lines are tangled
Nurses: "OMG look at all the spaghetti"
...
You go to pick up an ICU patient for a case, and LITERALLY THIRTY LINES are tangled
Nurses: "I'm catching up on my charting"

Had a heart as resident. Drop pt off with perfect organization of lines. She was putting out more than you would like in chest tube. Go back to grab her for OR 2 hours later lines are tangled everywhere. I expressed my frustration and just received rolling eyes.

 

[sevoflurane]

Had a heart as resident. Drop pt off with perfect organization of lines. She was putting out more than you would like in chest tube. Go back to grab her for OR 2 hours later lines are tangled everywhere. I expressed my frustration and just received rolling eyes.

I'm not a big proponent of passive aggressiveness... but....

If you want to get back at them, don't place the OG tube at the end of your cardiac case. Let the ICU nurses do it once they get the patient... and right after you give the reversal agent...

 

[dhb]

Why do you need an OG tube for a heart?

 

[G-Man82]

Why do you need an OG tube for a heart?

Where I did residency, it was part of some "best practice guidelines." All patients going to ICU with ETT in place had to have an OG Tube placed, too. But it's so funny how it's the same everywhere. I had a nice system for lines when transporting a post-op to the ICU. The nurses promptly get rid of that system and then piggy-back lines on top of lines so that when you have to go back to the OR, it's an absolute mess of lines and tangles. I remember once that one line somehow made it under the patient and around again before I found it piggybacked on top of a peripheral on the opposite side.

 

[Random Anesthesiologist]

I'm very much over watching nurses in the OR in between cases throwing hissy fits for (fill in the blank) reason. Today I witnessed a full-on swear fest with throwing of equipment across the room. Apparently her hip hurt and she didn't like that she had to stay past 5. Usually it's passive aggressive bs from nurses, today it was flat out aggressive aggressive. Not impressed.

 

[IlDestriero]

I'm very much over watching nurses in the OR in between cases throwing hissy fits for (fill in the blank) reason. Today I witnessed a full-on swear fest with throwing of equipment across the room. Apparently her hip hurt and she didn't like that she had to stay past 5. Usually it's passive aggressive bs from nurses, today it was flat out aggressive aggressive. Not impressed.

You should write your equivalent of an event report for that kind of behavior. It will get you fired, and deservedly so. She can work at a 7-4 surgery center, though I suspect she will have the same problems there. "disability" is the answer...

 

[Spinach Dip]

This just happened to me...again. Biggest pet peeve.

As I roll patient to OR from holding, patient says that they have a brother/cousin/friend who is an attorney. What do they honestly think saying this will accomplish? Same goes for entitled VIPs that flaunt their VIPness at me. Puts me in a bad mood for the case.

This is most likely a show of insecurity/fear resultant from being in a foreign environment and scared.

 

[okayplayer]

ERCP positioning.

 

[joeDO2]

1. the vital sign o2 "stat"
2. trying to do a procedure, asking for anxiolysis, and getting an order for 0.5mg ativan PO
3. not getting paid for 4 years
4. interviewing a patient with chest pain/anaphylaxis/etc and having someone chime in and ask "do you feel safe at home?"

 

[Random Anesthesiologist]

You should write your equivalent of an event report for that kind of behavior. It will get you fired, and deservedly so. She can work at a 7-4 surgery center, though I suspect she will have the same problems there. "disability" is the answer...

I wish this could happen. In reality, I'm new to this program. Even though she was being a jerk, it would still probably reflect negatively on me, especially by other nurses, because it would be easy to see I was the one who reported it. Some nurses are really sweet. Even some CRNAs are really sweet. But there are some nurses and CRNAs that are just real a-holes with chips on their shoulders. IDK if this is location-specific, probably not. It would be different if I were established, I guess. I've also noted, as have other female residents, that we really serve no purpose for these people. They like the male residents and attendings, both anesthesia and surgery because there's the element of flirtation, but they can't get that from the female residents, so real personalities come through. It's a theory, anyway.

I really like my program, but they can't control the non anesthesia OR personalities I guess.

 

[IlDestriero]

You should talk to your residency director about this. That level of unprofessionalism is not acceptable anywhere.

 

[epidural man]

mine...

I work in the pain clinic. "Well doc, I have such a high pain tolerance...but this pain..." Oh brother.

People that don't like the same kind of music I do - especially when they play it in the OR
Douchebaggery
Anesthesiologist that won't use droperidol because of an FDA warning and back history they know NOTHING about
Unteachable residents
People that love Rocuronium and won't use cisatricurium
People that think Desflurane gives bad wake ups and think it is more expensive
People that think a BIS monitor is useless, just because it doesn't prevent intraoperative recall
Large intraoperative doses of opioids
Unwillingness to run lidocaine infusions intraoperatively (really? Don't believe in data? Afraid of a little lidocaine?)

 

[Random Anesthesiologist]

Surgeons that show up an hour late for the case, order labs when they get there, then complain because "anesthesia" is taking so long in preop (when we are really waiting for the type and cross/coags/lytes/CBC you couldn't be bothered to order in advance).

 

[BuzzPhreed]

When I was a resident there was a particular circulating nurse who was a complete PITA. She would always butt her nose in where it wasn't wanted etc.

During one vascular case she happened to look over at my monitor and said to me, "Hey, the patient's blood pressure is a little low, isn't it?"

I said, "Yeah."

She asked a little emphatically, "Well, aren't you going to do something about it?"

I said coldly and matter of factly, "If I need your help, I'll ask for it."

She made this incredible scoffing sound but didn't say anything. Stormed back over to her table and partially slammed her clipboard down. Then she picked up the phone.

At that point, the vascular surgeon (who was a pretty young dude and cool as hell) said, "Hey, Terry. We had a clamp on the vena cava. Relax. Buzz knows what he's doing."

I never had a problem with that circulator the rest of my residency. Of course she basically never talked to me again. No loss. Trust me.

 

[powermd]

This just happened to me...again. Biggest pet peeve.

As I roll patient to OR from holding, patient says that they have a brother/cousin/friend who is an attorney. What do they honestly think saying this will accomplish? Same goes for entitled VIPs that flaunt their VIPness at me. Puts me in a bad mood for the case.

Narcissists often conceal a desire for help with veiled (or direct) threats. It's their lovely way of saying "don't abandon me". A wiser way to handle these wonderful people is to appeal to their ego. "You deserve the best care possible, and I won't let you down." Magically disarming.

 

[Ignatius J]

Narcissists often conceal a desire for help with veiled (or direct) threats. It's their lovely way of saying "don't abandon me". A wiser way to handle these wonderful people is to appeal to their ego. "You deserve the best care possible, and I won't let you down." Magically disarming.

Along these lines, I hate colleagues (anesthesiologists, surgeons, even nurses) saying along the lines of "Your next patient is a friend of mine. Please treat them right".

Oh really? Because otherwise I wasn't planning on providing the best anesthetic care that I could before you said that.

 

[BobBarker]

Yes, that is annoying. I take care of many prisoners and they get the same level of care I would give my own mother.

 

[anes]

Along these lines, I hate colleagues (anesthesiologists, surgeons, even nurses) saying along the lines of "Your next patient is a friend of mine. Please treat them right".

Oh really? Because otherwise I wasn't planning on providing the best anesthetic care that I could before you said that.

What they really mean is "give them the real medicine, not the fake stuff".

 

[twoliter]

Along these lines, I hate colleagues (anesthesiologists, surgeons, even nurses) saying along the lines of "Your next patient is a friend of mine. Please treat them right".

Oh really? Because otherwise I wasn't planning on providing the best anesthetic care that I could before you said that.

I can't say I have a problem with that. I would do the same thing if it were my family member or friend. If you were providing anesthesia for a family member or friend (the ethical aspect of that aside), wouldn't you maybe do a little something different (e.g., double up on the anti-emetics, LTA if you don't routinely do that, etc.)? Even if not, it's just a reminder that that patient is someone's daughter/friend/mother/etc. I think it's ok to be reminded of that occasionally.