Advice From One Anesthesiologist To Another

[leaverus]

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If you're someone who likes to give out unsolicited advice / "tips": DON'T

This happened yesterday:

Me, about to induce 300lb somewhat tall gentleman, certainly nowhere close to the hardest intubation i've ever had, nor even a suspected difficult airway.
Colleague who had walked in to help place monitors: "Mac 3? Why don't you use a mac-4?"
Me (thinking it but not saying it out loud to not be rude): "Why don't you shut the hell up and let me the use the blade i'm comfortable with and have been using exclusively for the past 10 years as an attending, unless i switch to a size 3 glidescope? I've never used a mac-4 in my life apart from residency (and the one time to intubate a 7' NBA player) and have never felt the need to. i'm not your crna"
btw, the guy above was a very easy intubation with the mac-3.

I've had other experiences too: recent eg, "hey, OB just paged and the lady in 137 needs a top-up, you're free so can you go do it? just give her like 8 - 10cc of 0.25% bupiv." what the hell? you think i don't know how to troubleshoot an epidural??

Don't ever do this to another attending (unless they ask for it), regardless they've been practicing for 10 years like me or they just graduated residency.

 

[GassYous]

I was just trying to help you out Michael, seemed like you needed it

 

[Precedex]

Too sensitive. A suggestion in good faith doesn't warrant this kind of wrath.

 

[Blockit]

Too sensitive. A suggestion in good faith doesn't warrant this kind of wrath.

I disagree. He’s not a new graduate. There’s any number of things that people do to undermine their colleagues in front of staff that are lower on the totem pole, and this thing is one of them.

 

[deleted1111114]

I disagree. He’s not a new graduate. There’s any number of things that people do to undermine their colleagues in front of staff that are lower on the totem pole, and this thing is one of them.

If it was while placing monitors it was in front of an awake patient…

 

[drmwvr]

If you're someone who likes to give out unsolicited advice / "tips": DON'T

That advice?

 

[pocafx]

Another troll post

 

[Mman]

Another troll post

a 17 year setup for it, that's the trolling long game

 

[patriot6]

MAC 4

 

[deleted875186]

I don’t think the MAC4 thing was a slight, then again it depends on the tone and personality of the person saying it.


The OB example is inappropriate.

 

[deleted875186]

Also, who gives 8-10 cc of 1/4%, yikes.

 

[patriot6]

Also, who gives 8-10 cc of 1/4%, yikes.

Wait, is that a lot or a little? 10 ccs of 0.25% bupi is my loading dose.

 

[Arch Guillotti]

Also, who gives 8-10 cc of 1/4%, yikes.

What's wrong with it?

 

[Test Boy]

What's wrong with it?

Absolutely nothing

 

[deleted875186]

What's wrong with it?

10 cc of 1/4% for a top up? Way more than I usually give, a 5 cc bolus is more than enough, why give so much, just asking for hypotension.

 

[deleted875186]

Perhaps because of people like me the other anesthesiooogist asked you to give 8-10 cc …..

 

[Test Boy]

10 cc of 1/4% for a top up? Way more than I usually give, a 5 cc bolus is more than enough, why give so much, just asking for hypotension.

No, that will almost never happen from a top off.

 

[GassYous]

I just give 5 of 0.25

 

[Planktonmd]

Sometimes this type of direct advice/instruction is caused by a background history that the OP might have had but is not sharing here. Also some anesthesiologists are just less than capable of projecting confidence around them which makes others think that they need to guide them.
In this business (and in every business) perception is reality and if you are perceived as being shaky or not confident people will always interpret this as being incompetent and feel they need to guide you.

 

[IlDestriero]

I don’t give any top ups. PCEA FTW. 💤
Any dumb advice would be immediately greeted by bitter sarcasm and snark.

 

[secretasianman]

Grab the mil 5 and stab him in the eye!

 

[dabears505]

This reminds me one time and old timer came in to give me a break and sarcastically commented how the or is super cold and he wonders what the temperature of the patient is since I didn't have a temp probe on. Now this case was a case where the asa did not mandate monitoring of temp. I exploded and yelled at him to keep his mouth shut and never offer unsolicited advice again. I later stabbed him in the parking lot.

 

[Mman]

10 cc of 1/4% for a top up? Way more than I usually give, a 5 cc bolus is more than enough, why give so much, just asking for hypotension.

I know people who give 8-10 mls of 0.5% for a top up. Not me personally, but they aren't having problems often.

 

[GravelRider]

Mac 4 is my favorite. It’s got a manly heft to it.

If someone is giving me very specific advice, I just assume they want to take over the task for me. I always say “sounds like you already have a plan, don’t let me get in your way.”

 

[coffeebythelake]

I only offer suggestions when someone is struggling. Gentle ones like, would you like a bougie or a glidescope? Do you want me to bag while you mask? I do think that in crisis situations people do get tunnel vision, perseverate and can lose the bigger picture

 

[BLADEMDA]

If you're someone who likes to give out unsolicited advice / "tips": DON'T

This happened yesterday:

Me, about to induce 300lb somewhat tall gentleman, certainly nowhere close to the hardest intubation i've ever had, nor even a suspected difficult airway.
Colleague who had walked in to help place monitors: "Mac 3? Why don't you use a mac-4?"
Me (thinking it but not saying it out loud to not be rude): "Why don't you shut the hell up and let me the use the blade i'm comfortable with and have been using exclusively for the past 10 years as an attending, unless i switch to a size 3 glidescope? I've never used a mac-4 in my life apart from residency (and the one time to intubate a 7' NBA player) and have never felt the need to. i'm not your crna"
btw, the guy above was a very easy intubation with the mac-3.

I've had other experiences too: recent eg, "hey, OB just paged and the lady in 137 needs a top-up, you're free so can you go do it? just give her like 8 - 10cc of 0.25% bupiv." what the hell? you think i don't know how to troubleshoot an epidural??

Don't ever do this to another attending (unless they ask for it), regardless they've been practicing for 10 years like me or they just graduated residency.

My comment to you would have been " I am pretty sure you can intubate him without a problem but would you like me to get you the McGrath or Glidescope just in case he is anterior?" Now, if you said the same thing to me after almost 30 yeas of practice I would respond with "sure, I will induce and attempt to intubate while you get the glidescope" or "no thanks, I will be fine." Either way, I wouldn't take your suggestion in a demeaning fashion.

As for the 0.25% Bup "top-off" I have been doing that for decades without any issues. If you prefer 1% lidocaine to test your epidural then that works too.
I just can't see why you are so sensitive to relatively minor issues. Typically, this indicates self-esteem issues or the fact you have had issues in the past with some pretty basic stuff.

Are you new to the practice? Sometimes older attendings are just trying to be helpful rather than demeaning as you seem to indicate in your posts.

 

[UscGhost]

Why not a Mac 4?

 

[BlueRug]

MAC 4 is the best.

 

[deleted87051]

MAC 4 is the best.

I was a big Mac4 fan until Glidescope 3. Now there is a new King!

 

[GassYous]

I had an attending who intubates everyone with a mac4 including kids

 

[drmwvr]

this attending of mine used to digitally intubate everyone...including kids...

 

[DrOwnage]

I understand why people like the MAC 3 better. The angle of the mac 3 is a little flatter with the pressure point in the middle of the blade which gives a better feel while lifting at a 45 degree angle.

 

[coffeebythelake]

I understand why people like the MAC 3 better. The angle of the mac 3 is a little flatter with the pressure point in the middle of the blade which gives a better feel while lifting at a 45 degree angle.

I usually use MAC3 for women and MAC4 for men. Plenty of times the resident will have a poor view with the 3 blade, "not enough reach" and it improves dramatically w the 4. The blade itself is longer but no different in thickness / girth

 

[deleted875186]

I understand why people like the MAC 3 better. The angle of the mac 3 is a little flatter with the pressure point in the middle of the blade which gives a better feel while lifting at a 45 degree angle.

I think for a biggish dude, the MAC4 gives you the little extra that helps me not touch any teeth or have to use excessive force.

 

[epidural man]

If you're someone who likes to give out unsolicited advice / "tips": DON'T

This happened yesterday:

Me, about to induce 300lb somewhat tall gentleman, certainly nowhere close to the hardest intubation i've ever had, nor even a suspected difficult airway.
Colleague who had walked in to help place monitors: "Mac 3? Why don't you use a mac-4?"
Me (thinking it but not saying it out loud to not be rude): "Why don't you shut the hell up and let me the use the blade i'm comfortable with and have been using exclusively for the past 10 years as an attending, unless i switch to a size 3 glidescope? I've never used a mac-4 in my life apart from residency (and the one time to intubate a 7' NBA player) and have never felt the need to. i'm not your crna"
btw, the guy above was a very easy intubation with the mac-3.

I've had other experiences too: recent eg, "hey, OB just paged and the lady in 137 needs a top-up, you're free so can you go do it? just give her like 8 - 10cc of 0.25% bupiv." what the hell? you think i don't know how to troubleshoot an epidural??

Don't ever do this to another attending (unless they ask for it), regardless they've been practicing for 10 years like me or they just graduated residency.

I think the lesson is a good one.

However, I think there is a lesson for you too.

EVERYONE thinks they do it the best - so when someone sees you doing it differently, they assume if they can get you to do it their way, you would be better off. That is a type of kindness. And some people just think out loud.

I think Blade is right, if you answer politely with an answer that says, “no, I don’t think I will take that advice right now” - hopefully the other person will get the message.

After you succeed you can turn it into a discussion. “I don’t like the MAC4. The curve is such that you have to displace a lot more tissue to see the same view so it really hurts more than it helps. I’m glad you have found a way to make it work though. You should consider trying a Mac3 on big folks though. I bet you would really like it and you would see what I mean. I have sat on a committee that reviews airway disasters and almost all of the failed attempts were with MAC4s. It is a horrible, horrible blade.”….something like that.

 

[ProwlerturnGas]

My partners are cool guys and gals and I know them well. If they offer up a suggestion I listen, it’s cool.

 

[vector2]

MAC 4 is the best.

Miller 2 FTW. MACs are the minivan of laryngoscope blades.




Softly curved and not built for performance.

 

[deleted126335]

Miller 2 FTW. MACs are the minivan of laryngoscope blades.




Softly curved and not built for performance.

Built for comfort.

 

[deleted875186]

I will agree with above, has to do with the relationship with the person “offering” their advice. If it’s someone I like and have a good rapport with, I would not feel slighted. The person in question must not have a good relationship with the OP I would think.

 

[Guillemot]

There is a distinct difference in how I receive advice depending on a few different factors:

1. Is the advice good or is it ****ty?
2. Is the advice given at an appropriate time or when I am busy with something else? Be respectful of people's time if you are giving advice.
3. Who is giving the advice? An idiot or someone that is intelligent?

It could be quite annoying if someone that is an (3) idiot gives, (1)****ty advice when one is (2)busy trying to concentrate on or do something else. This would fulfill all 3 criteria for being annoying.

If an intelligent person gives good advice at an appropriate time, then it is nice to get the advice.

 

[coffeebythelake]

Miller 2 FTW. MACs are the minivan of laryngoscope blades.




Softly curved and not built for performance.

If I remember, there was a study comparing sympathetic responses to larynogscopy with Miller vs MAC blade, and the latter had less pronounced BP and HR increase.

 

[deleted875186]

If I remember, there was a study comparing sympathetic responses to larynogscopy with Miller vs MAC blade, and the latter had less pronounced BP and HR increase.

Wonder how reliable this is, because ETT hitting the trachea is more stimulating than laryngoscopy, how could they tell a difference?

 

[Planktonmd]

When I was a young resident an old attending told me that Mac and Miller are like a Cadillac and a Jeep, (Cadillac being the mac), they both can get you where you want to go, but with the Cadillac your trip is actually pleasant.

 

[coffeebythelake]

Wonder how reliable this is, because ETT hitting the trachea is more stimulating than laryngoscopy, how could they tell a difference?

1st stage of intubation is laryngoscopy, getting that view of the cords
2nd stage of intubation is when the PVC passes cords (which is more stimulating)
the commonly used explanation being that RLN stimulation causes an intense sympathetic response, and when Miller blade is used to lift the epiglottis it stimulates the RLN on the posterior surface of the epiglottis. i imagine using a Mac blade to lift the epiglottis would cause a similar intensity response.

 

[secretasianman]

Miller is pc. No design language. Mac is Mac 🙂

 

[coffeebythelake]

Miller is pc. No design language. Mac is Mac 🙂

I mean, I agree that MAC blade is easier to use. I know when I get the most optimal view with the MAC, I don't need to fumble around with a Miller to try and get a better view. And If i get a poor CL view with my MAC blade, I'm not going to switch to a Miller. I would call for a video laryngoscope while busting out the bougie.

 

[abolt18]

When I was a young resident an old attending told me that Mac and Miller are like a Cadillac and a Jeep, (Cadillac being the mac), they both can get you where you want to go, but with the Cadillac your trip is actually pleasant.

I would agree. But every now and then you have to go off-roading and I choose a Jeep for those circumstances. More than once, I've put the Mac blade in, saw nothing despite numerous adjustments, switch to Miller blade and get Gr 1-2 view. It's rare but I think it's valuable to be skilled with both blades. I'll just get a 2 car garage so I can park both the Cadillac and the Jeep in it, take them both for a spin regularly but use the Cadillac as my everyday driver, while having the jeep available is clutch.

 

[vector2]

If I remember, there was a study comparing sympathetic responses to larynogscopy with Miller vs MAC blade, and the latter had less pronounced BP and HR increase.

Exactly. Lower BP and HR. Like when you drive a minivan.



But seriously, I'd argue that most people, when they're unfamiliar with the Miller, are putting as much pressure up and away against the epiglottis as they do then they're jamming a Mac into the vallecula to engage to hyoepiglottic ligament. This is incorrect.

. More than once, I've put the Mac blade in, saw nothing despite numerous adjustments, switch to Miller blade and get Gr 1-2 view.

This is the way.

 

[Mman]

I would agree. But every now and then you have to go off-roading and I choose a Jeep for those circumstances. More than once, I've put the Mac blade in, saw nothing despite numerous adjustments, switch to Miller blade and get Gr 1-2 view. It's rare but I think it's valuable to be skilled with both blades. I'll just get a 2 car garage so I can park both the Cadillac and the Jeep in it, take them both for a spin regularly but use the Cadillac as my everyday driver, while having the jeep available is clutch.

Just hand me a blade and I will put the tube in. If I can't see anything I will try something else.

 

[Nivens]

I’m the junior guy in my group- 3ish months out from training. I like to think I was well trained over six years, but still try and remain open to advice and guidance. I’ve also been really pleasantly surprised at the old-timers who are super interested to see and hear about new approaches to old problems.

Sounds hokey, but the longer you can keep the learner mindset, the better.