Small case for the new attendings

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XRanger said:
Inhalation induction with Sevo to keep pt spontaneously breathing and then gentle DL with cmac/glidecscope to see if you can visualize the cords. If you see the cords, sux then tube.


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The closet where they have you anesthetizing people does not have an anesthesia machine.

Ambu, suction, code cart nearby, and whatever airway equipment you call for ahead of time is all you have.

As a side question, how would you preoxygenate him? You have a nasal cannula, a regular O2 mask, and the Ambu bag in the room.Would you call for a non rebreather mask.
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urge said:
The closet where they have you anesthetizing people does not have an anesthesia machine.

Ambu, suction, code cart nearby, and whatever airway equipment you call for ahead of time is all you have.
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can we GET an anesthesia machine? if there is not one available, i would elect to have this moved to an OR suite where we can provide proper GETA, glidescope or C mac ready, and once patient is anesthetized attempt to place probe with DL. if probe sitll doesn't go, suggest imaging for lAA, TTE isn't going to tell you crap in this guy. but i also agree with the fact that we are going through a lot of rigamarole when we could simply rate control him
 
Since you all cannot see him, let's say he passes everyone's eyeball test for the airway, at least with videolaryngoscopy and maybe even DL for those who are very comfortable.
 
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confusingleaf said:
can we GET an anesthesia machine? if there is not one available, i would elect to have this moved to an OR suite where we can provide proper GETA, glidescope or C mac ready, and once patient is anesthetized attempt to place probe with DL. if probe sitll doesn't go, suggest imaging for lAA, TTE isn't going to tell you crap in this guy. but i also agree with the fact that we are going through a lot of rigamarole when we could simply rate control him
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Anesthesia machine does not fit in the room with the tee machine inside.

All rooms are busy.

Both the echo cardiologist and the ep cardiologist are getting impatient. They both have a full schedule ahead.
 
I don't want to drag for long. Let's say you induced, were able to ventilate with an oral airway and had a fairly good view with the Glidescope and had no problem intubating.

Multiple attempts at probe insertion are done by cardiology and yourself. No clot seen. Probe is pulled out but comes out pretty bloody. Cardioversion is done. You keep suctioning some blood from the mouth every few minutes. You can't tell where it is coming from.

What now?
 
urge said:
I don't want to drag for long. Let's say you induced, were able to ventilate with an oral airway and had a fairly good view with the Glidescope and had no problem intubating.

Multiple attempts at probe insertion are done by cardiology and yourself. No clot seen. Probe is pulled out but comes out pretty bloody. Cardioversion is done. You keep suctioning some blood from the mouth every few minutes. You can't tell where it is coming from.

What now?
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Keep patient intubated. Get a stat gastrografin esophagram/CT. Let thoracic surg know.
 
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FFP said:
Keep patient intubated. Get a stat gastrografin esophagram/CT. Let thoracic surg know.
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agree

probably also start investigating whether there is an ICU bed available
 
XRanger said:
Inhalation induction with Sevo to keep pt spontaneously breathing and then gentle DL with cmac/glidecscope to see if you can visualize the cords. If you see the cords, sux then tube


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What if you can't see the cords?

I think that an inhalational induction in an adult provides crappy intubating conditions.
 
Whatever happened to asking patients to swallow the probe?

The guy's 300+ pounds, he's swallowed cheeseburgers with greater diameter than that thing.

A little propofol and instruction are all you need.
 
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urge said:
Ok, let's continue.

Further attempts at passing the probe have been halted. Cardiology requests a 2nd anesthesia attending.

What now?
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Cards can request a 2nd echo attending to pass the probe.

Btw, I can't stand the way cards pass the probe. How the hell do you expect to have the probe go down the goose when you are standing by their side and pushing it up into their mouth?

I never topicalize for TEE. Straight propofol. Maybe ketamine. Local toxicity. Airway numbness also delay discharge. If I need precedex and awake FOI for every 300+er, I would still be at work. If you really need intubation for a TEE, tell them to come to the OR.
 
chfo said:
Whatever happened to asking patients to swallow the probe?

The guy's 300+ pounds, he's swallowed cheeseburgers with greater diameter than that thing.

A little propofol and instruction are all you need.
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I always picture a in-n-out double-double whenever I drop a probe in these guys.
 
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DrN2O said:
I always picture a in-n-out double-double whenever I drop a probe in these guys.
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I bet you could cover the probe in fried potato skins, and magically the probe will go down in 2 seconds easy.

Just make sure you have a bite block with such a delicious probe cover!
 
Agree with pgg. Tell patient and cardiologist that patient has strong chance of needing to be on vent post procedure. Intubate. TEE. Shock. Meet extubation criteria....great. My work is done here. If he doesn'...work on him a few hours in the PACU vented to see if you can get the tube out...if not...turf to icu. My work is done here.


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OK, let's continue.

After a talk to cardiology they find a bed for the patient in the CCU. They say they will take care of consulting the appropriate services.

You leave the patient intubated.

The next day when you go to post op him, you cannot find him in the CCU. He stopped bleeding, was extubated, and discharged home. No consultations or tests were done.
 
We had someone with an unrecognized esophageal perf during an ACDF go home. I think that person came back 4-5 days later. In bad shape.

Have a feeling urge's case isn't done yet. :)
 
urge said:
OK, let's continue.

After a talk to cardiology they find a bed for the patient in the CCU. They say they will take care of consulting the appropriate services.

You leave the patient intubated.

The next day when you go to post op him, you cannot find him in the CCU. He stopped bleeding, was extubated, and discharged home. No consultations or tests were done.
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Malpractice.
 
urge said:
Anesthesia machine does not fit in the room with the tee machine inside.

All rooms are busy.

Both the echo cardiologist and the ep cardiologist are getting impatient. They both have a full schedule ahead.
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really! really! the goddamn tee does not move? so the rolly things I see on a recular basis everygodamn place else in the world are just cemented into place there? sorry worst nonexcuse EVER!!!!!!!!
 
OK. It's been year and a half since you did this case. Just when you have forgotten about this case (thread).

As you are leaving your house for work you get served court papers. You, the cardiologist, and the hospital are getting sued.

Yada yada yada malpractice, loss of services to wife, loss of income, poor consent. Asking several million.

What now?
 
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urge said:
OK. It's been year and a half since you did this case. Just when you have forgotten about this case (thread).

As you are leaving your house for work you get served court papers. You, the cardiologist, and the hospital are getting sued.

Yadda yadda yadda malpractice, loss of services to wife, loss of income, poor consent. Asking several million.

What now?
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get a good lawyer
 
urge said:
OK. It's been year and a half since you did this case. Just when you have forgotten about this case (thread).

As you are leaving your house for work you get served court papers. You, the cardiologist, and the hospital are getting sued.

Yada yada yada malpractice, loss of services to wife, loss of income, poor consent. Asking several million.

What now?
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Why are they suing?
 
JobsFan said:
Why are they suing?
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I know you are not in the US.

Lawsuits here are generic and they cover all angles.

Basically, Dr So and So took care of Mr Smith and something bad happened leading to suffering, loss of income, unhappy wife, and in retrospect they would have not consented if you would have told them this was a possible outcome.

You don't even know what happened.
 
Thanks, occasionally we get sued here too, but we generally know it's coming.
...
Carry on
 
If this case is not purely hypothetical, I hope it's closed. If not, you should stop posting now.
 
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