caligas

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Not that many details available but it sounds like a massive aspiration while a CRNA attempted to intubate.
The interesting part is that there is no anesthesiologist named which probably means solo CRNA?

Digging Deeper: Jury awards $10M verdict in medical malpractice case in Dubuque County
10 million for an 80 year old with cancer? Better have been some egregiously improper care to justify those kind of punitive damages.

I have gotten pretty conservative in regards to aspiration risk because of these legal risks.
 
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Noyac

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Who here routinely empties the stomach prior to induction and intubation?

If an NGtube is in place I will put it to suction until nothing is coming back and then pull it out while still on suction but I don't place one if it isn't already there. Unless of course it is a small bowel obstruction in which case it should already have one in place.

And another thing, I like that there is no crna bashing so far. This can happen to anyone. We don't have enough details to be bashing anyone.
 

AdmiralChz

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Sucky outcome, even more sucky legal decision. Expect most of that to be overturned on appeal, which never gets any news!

Who here routinely empties the stomach prior to induction and intubation?

If an NGtube is in place I will put it to suction until nothing is coming back and then pull it out while still on suction but I don't place one if it isn't already there. Unless of course it is a small bowel obstruction in which case it should already have one in place.

And another thing, I like that there is no crna bashing so far. This can happen to anyone. We don't have enough details to be bashing anyone.
Reminds me of newborn pyloromyotomies - routinely emptying the stomach with an NG tube if it’s not already there sounds like a great way to mega-piss patients off.

RSI gets a lot of talk on this board - prop, sux, tube. Have suction immediately available. Have help available (even if it’s the circulator to hand you stuff). Assess the situation before and have your video scope of choice around if you think you need it. Sometimes even the best-planned situations can go badly, though. Our job can sometimes be scary, important to keep this in mind and not get too cavalier.
 

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10 million for an 80 year old with cancer? Better have been some egregiously improper care to justify those kind of punitive damages.

I have gotten pretty conservative in regards to aspiration risk because of these legal risks.
Seriously. Maybe he died because he was an 80 year old with cancer having multiple operations. I understand that losing a family member is difficult but sometimes you have to figure out when it's time to let go. No one lives forever and the number of moribund patients I see in the hospital with unrealistic families is incredible. And people wonder why our healthcare costs so much with "poor outcomes".
 

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Taking too long to secure the airway... i mean if he vomited a ton during induction, i can see why itd take longer than usual to secure the airway .. got to suck out all the junk to see first, and even then we dont know if he had a challenging airway or not. i know not enough info has been released but so far the info released is ridiculous. they make it sound like theres no such thing as difficult airways and if there is one, it's the anesthesiologist/crna's fault. And even a self proclaimed NPO for 3 days can have stuff sitting in the stomach. should we NG tube everyone?

hope more details will be released to prove the above wrong, and show that it actually is an error
 

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Taking too long to secure the airway... i mean if he vomited a ton during induction, i can see why itd take longer than usual to secure the airway .. got to suck out all the junk to see first, and even then we dont know if he had a challenging airway or not. i know not enough info has been released but so far the info released is ridiculous. they make it sound like theres no such thing as difficult airways and if there is one, it's the anesthesiologist/crna's fault. And even a self proclaimed NPO for 3 days can have stuff sitting in the stomach. should we NG tube everyone?

hope more details will be released to prove the above wrong, and show that it actually is an error
That's where occasionally ventilating with a Supreme while suctioning on the gastric port can save the day. Followed by a therapeutic bronchoscopy to decrease particle load in the lungs. People get hurt more frequently by hypoxia than by aspiration pneumonia.

Another trick when doing RSI is to have two suctions set up (use the surgeon's suction), as you're supposed to do for bleeding tonsils. With the right type of suction, you can even thread a bougie down the suction catheter, followed by an ETT tube. Another trick is to plant the suction catheter (or ask for a helper to hold it) on the left side (instead of the right) while intubating.

Look up Suction Assisted Laryngoscopy and Airway Decontamination (SALAD). This is one more thing I have learned from our EM colleagues.

 
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leaverus

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Who here routinely empties the stomach prior to induction and intubation?
NPO for elective case? Never. Presumed full-stomach for urgent/emergency? Never (unless NG already in as you said).
Agree this can happen to any of us MD or CRNA; assuming the CRNA wasn't doing anything blatantly stupid, it may have just been bad luck.
 

caligas

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Would be good to know who the plaintiffs expert was and what they said.
That's where occasionally ventilating with a Supreme while suctioning on the gastric port can save the day. Followed by a therapeutic bronchoscopy to decrease particle load in the lungs. People get hurt more frequently by hypoxia than by aspiration pneumonia.

Another trick when doing RSI is to have two suctions set up (use the surgeon's suction), as you're supposed to do for bleeding tonsils. With the right type of suction, you can even thread a bougie down the suction catheter, followed by an ETT tube. Another trick is to plant the suction catheter (or ask for a helper to hold it) on the left side (instead of the right) while intubating.

Look up Suction Assisted Laryngoscopy and Airway Decontamination (SALAD). This is one more thing I have learnt from our EM colleagues.

Good demo, but just put the suction down the left side to begin with.
 
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Seriously. Maybe he died because he was an 80 year old with cancer having multiple operations. I understand that losing a family member is difficult but sometimes you have to figure out when it's time to let go. No one lives forever and the number of moribund patients I see in the hospital with unrealistic families is incredible. And people wonder why our healthcare costs so much with "poor outcomes".
Might easily have been the teams fault as well (not necessarily the anesthetist's though, imo). Not enough details in the article. Practicing in another country, I find it frustrating how people here just seem to randomly let go on patients that have any significant chance of doing poorly, especially on the elderly.
 
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We really don't have enough information here to predict how he should have done. He may have been an active, vigorous 80 y/o going for TURBT, or he could be a guy with advanced malignancy going for open cystectomy. We don't know his risk factors for aspiration, how his airway was initially approched (did they plan LMA then switched, did they do RSI and he still aspirated, was plan prop roc tube?) we really can't comment on this case further without more information...
 

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With a simple google search, found this brief online:

https://bloximages.newyork1.vip.townnews.com/telegraphherald.com/content/tncms/assets/v3/editorial/6/53/65314606-5967-5af2-a40b-d84cf0c4bb77/59c2cf1704e58.pdf.pdf

After reading through it, looks like this is only the plaintiff's brief (thus might have significant bias) but there are some big issues here consistent with the concerns others have raised.

Little bit more detail there but still not enough to say that the CRNA did anything definitely wrong. who knows what really transpired.
 

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facted

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Little bit more detail there but still not enough to say that the CRNA did anything definitely wrong. who knows what really transpired.
Well, the brief days the guy is distended, vomiting, and being operated on for sbo and it states the CRNA didn't preform a rapid sequence induction. If that's true, that's malpractice.
 

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Well, the brief days the guy is distended, vomiting, and being operated on for sbo and it states the CRNA didn't preform a rapid sequence induction. If that's true, that's malpractice.
yes, it SAYS that but it also says he waited too long for the sux to take effect. If he used sux then he necessarily must have done an RSI because i can't think of instance when even the stupidest of MD / CRNA would use succinylcholine in a full stomach situation and not push it immediately following the hypnotic. So again, doesn't make sense; unless you were there no way to tell exactly what happened given the info available.

btw, something similar happened to me once. NPO 40-something woman for elective ECT. i gave methohex+sux and immediately following the fasciculations and even before i began to ventilate her, the pt's oropharynx began to fill up with bilious liquid. it scared me because i was sure she aspirated but fortunately she did OK. RSI is the correct thing to do in full stomach situation but it certainly doesn't mean your pt won't regurgitate; that's why personally i think sitting the pt up at an angle is probably as important as RSI, at least gravity can help keep contents down.
 

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The times don't tally tho. Well some do some don't. He had a gen surg consult at 7.08 and then got some form of anesthetic induction at 7.30? How is that possible?

It takes 20 mins to even call a porter!

Also he did give sux just didn't give it fast enough! How they know that is beyond me


Also the op ended at 10.54 and he died in the ICU at 11am same day? I'm sorry but unless im reading the times wrong that is not aspiration pneumonia. The guys straight up was not fit for extubation for whatever reason. Probably opiates or reversal. Very unlikely aspiration pneumonia. Too early. Maybe ards but very early. He extubated a guy not fit for same.


It looks like they got the verdict very right but for the wrong reasons.

An ng tube cxr and bronch are all fine and nice but this guy needed the damn tube left in and a spin in the unit for a few days. Why the flip did he extubate him. His sats must have been crap
 

leaverus

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Also the op ended at 10.54 and he died in the ICU at 11am same day? I'm sorry but unless im reading the times wrong that is not aspiration pneumonia. The guys straight up was not fit for extubation for whatever reason. Probably opiates or reversal. Very unlikely aspiration pneumonia. Too early. Maybe ards but very early. He extubated a guy not fit for same.An ng tube cxr and bronch are all fine and nice but this guy needed the damn tube left in and a spin in the unit for a few days. Why the flip did he extubate him. His sats must have been crap
what makes you think he was extubated? i don't see that anywhere.
 

Newtwo

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You know I don't see that either.
He might not have been which makes it even harder to understand!
I've seen maybe 5 big aspirations and none died on table. It was always a long drawn out ICU process.
Do these times make sense to anyone? And the mode of death. Hypoxia and hypercarbia? I'd like to see the vent settings fio2 pressors fluids etc

Btw re salad post. Amazing link thank you
 

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You know I don't see that either.
He might not have been which makes it even harder to understand!
I've seen maybe 5 big aspirations and none died on table. It was always a long drawn out ICU process.
Do these times make sense to anyone? And the mode of death. Hypoxia and hypercarbia? I'd like to see the vent settings fio2 pressors fluids etc

Btw re salad post. Amazing link thank you
There was a large aspiration in an SBO pt at one of my former jobs (not my case luckily!!!). Pt did indeed die on the table. Couldn't oxygenate... Tough to ventilate. Bronch, etc... Died maybe 1 hr after the event.
 
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If the patient has evidence of obstruction or ileus then an NG tube should be at least attempted before induction. There might be circumstances where it might not be possible due to the patient not being cooperative or difficulty placing the tube but that would be the exception, not the norm.
Not doing a rapid sequence is also interesting, but what is more interesting is why this CRNA was not supervised by an anesthesiologist, and why the hospital was not found liable for hiring unsupervised CRNAs to provide anesthesia.
 
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AdmiralChz

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If the patient has evidence of obstruction or ileus then an NG tube should be at least attempted before induction. There might be circumstances where it might not be possible due to the patient not being cooperative or difficulty placing the tube but that would be the exception, not the norm.
Not doing a rapid sequence is also interesting, but what is more interesting is why this CRNA was not supervised by an anesthesiologist, and why the hospital was not found liable for hiring unsupervised CRNAs to provide anesthesia.
The brief also highlights the surgeon as responsible for lack of NG decompression. Surgeons put NGs in virtually everyone, how in the world did it not happen here?

Also the brief (likely biased) doesn’t mention any call for help or emergency steps taken by the CRNA. That’s like lesson one in residency - call for help if needed.
 

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Also the brief (likely biased) doesn’t mention any call for help or emergency steps taken by the CRNA. That’s like lesson one in residency - call for help if needed.
he may have called for help but for regurgitation and aspiration at the point you're calling for help it's probably already too late to avoid the sequelae. i'm not familiar with Dubuque at all but google maps shows this hospital smack in the middle of the city, so like plankton i'm surprised this guy was apparently practicing independently in a non-rural area. just to add a little speculation, it seems like this crna was an old dude and close to retirement so maybe he got complacent with the induction and didn't take the precautions he should have thinking it wouldn't happen to him.
 

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Also the brief (likely biased) doesn’t mention any call for help or emergency steps taken by the CRNA. That’s like lesson one in residency - call for help if needed.
Am I missing something? I read the brief a few days ago but as I remember it was the aspiration that the guy died from. Not a failed airway.
Calling for help would not have made any difference.
 

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. just to add a little speculation, it seems like this crna was an old dude and close to retirement so maybe he got complacent with the induction and didn't take the precautions he should have thinking it wouldn't happen to him.
Uncalled for and completely unnecessary.
We have little to no real information.
If this was an anesthesiologist, would you be so "speculative"?
 
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Noyac

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If the patient has evidence of obstruction or ileus then an NG tube should be at least attempted before induction. There might be circumstances where it might not be possible due to the patient not being cooperative or difficulty placing the tube but that would be the exception, not the norm.
Not doing a rapid sequence is also interesting, but what is more interesting is why this CRNA was not supervised by an anesthesiologist, and why the hospital was not found liable for hiring unsupervised CRNAs to provide anesthesia.
I agree with this, the crna should have been supervised.
 

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If the patient has evidence of obstruction or ileus then an NG tube should be at least attempted before induction. There might be circumstances where it might not be possible due to the patient not being cooperative or difficulty placing the tube but that would be the exception, not the norm.
Not doing a rapid sequence is also interesting, but what is more interesting is why this CRNA was not supervised by an anesthesiologist, and why the hospital was not found liable for hiring unsupervised CRNAs to provide anesthesia.
Shouldn't the NGT be placed before coming to the OR? It can be done in the ed, on the floor or in the icu at anytime. A surgeon or hospitalist isn't even required to place it, it can be done by a nurse.
 
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Not sure how they know he waited too long. Perhaps he gave another medication in addition to prop sux tube, thus the lawyers are saying it's not a true RSI. Or maybe he didn't document he applied cricoid pressure hahaha. There are many ways for lawyers to put the blame on the doctor
 

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Not sure how they know he waited too long. Perhaps he gave another medication in addition to prop sux tube, thus the lawyers are saying it's not a true RSI. Or maybe he didn't document he applied cricoid pressure hahaha. There are many ways for lawyers to put the blame on the doctor
Yeah. When i do RSI I always document prop, sux, cricoid pressure, tube. Nothing else. Why give ammunition to the lawyers. I never understood the "modified RSI" either. They are an aspiration risk, or they are not. If you do a modified RSI you are acknowledging the aspiration risk, and still not doing a by the book RSI. Lawyers will love this.
 
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Shouldn't the NGT be placed before coming to the OR? It can be done in the ed, on the floor or in the icu at anytime. A surgeon or hospitalist isn't even required to place it, it can be done by a nurse.
Doesn't matter. Aspiration occurs when the patient loses airway protective reflexes (in this case: the induction of GA) this is for the anesthesiologist to recognize and treat. FWIW I don't even think the surgeon should be named at all in this lawsuit. This is a pure anesthesia complication.
 

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Doesn't matter. Aspiration occurs when the patient loses airway protective reflexes (in this case: the induction of GA) this is for the anesthesiologist to recognize and treat. FWIW I don't even think the surgeon should be named at all in this lawsuit. This is a pure anesthesia complication.
NG tube placement is standard of care for small bowel obstruction. This should have been placed pre-operatively. Therefore, the surgeon should be the only one listed on this lawsuit. This is pure surgical malpractice.
 
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Yeah. When i do RSI I always document prop, sux, cricoid pressure, tube. Nothing else. Why give ammunition to the lawyers. I never understood the "modified RSI" either. They are an aspiration risk, or they are not. If you do a modified RSI you are acknowledging the aspiration risk, and still not doing a by the book RSI. Lawyers will love this.
I guess it’s different for you guys, being sued is less likely here, but pretty often I have a patient who is at increased risk of aspiration ... but I still don’t do an rsi because for some patients, you should prioritise cvs stability over aspiration risk.
 
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NG tube placement is standard of care for small bowel obstruction. This should have been placed pre-operatively. Therefore, the surgeon should be the only one listed on this lawsuit. This is pure surgical malpractice.
So when deposed as to why NGT was not placed prior to induction of GA your answer would be "well, surgery didn't do it"!!!?
This stomach needs to be drained/depressurized prior to induction of GA to minimize aspiration risk. If it wasn't done you need to do it. Pt died of aspiration not untreated SBO....
 

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I guess it’s different for you guys, being sued is less likely here, but pretty often I have a patient who is at increased risk of aspiration ... but I still don’t do an rsi because for some patients, you should prioritise cvs stability over aspiration risk.
Not in the American system. Airway comes before circulation, unless it's a code. If you think the patient has a serious cardiovascular problem and you need to do RSI, you are supposed to do an awake intubation. There is so much defensive medicine, I am surprised this country needs a military.
 
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NG tube placement is standard of care for small bowel obstruction. This should have been placed pre-operatively. Therefore, the surgeon should be the only one listed on this lawsuit. This is pure surgical malpractice.
Nope. It's anesthesia. While the surgeon should have placed an NGT to decompress the stomach, the patient did not aspirate while on the floor, but during the induction of anesthesia.

I had a similar case just last month (SBO). I insisted that we place an NGT while the patient was waiting in the holding area (the surgeon did). That put out 200 ml of bilious fluid. When we took the patient to the OR, dear CRNA wanted to do regular induction (because the stomach was "empty"). :bang:
 

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Nope. It's anesthesia. While the surgeon should have placed an NGT to decompress the stomach, the patient did not aspirate while on the floor, but during the induction of anesthesia.

I had a similar case just last month (SBO). I insisted that we place an NGT while the patient was waiting in the holding area (the surgeon did). That put out 200 ml of bilious fluid. When we took the patient to the OR, dear CRNA wanted to do regular induction (because the stomach was "empty"). :bang:
Yeah, a lot of the ones I work with, without clear direction, are really casual about RSIs: taping the eyes during induction, giving mask breaths....
 

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NG tube placement is standard of care for small bowel obstruction. This should have been placed pre-operatively. Therefore, the surgeon should be the only one listed on this lawsuit. This is pure surgical malpractice.
When a patient shows up in the holding area they belong to you too.
 

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We are doctors first, anesthesiologist second. Any MS4 could tell you this guy needs to be decompressed prior to induction.
 
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It's both surgical and anesthesia issue. Surgery prob should have decompressed stomach, may have prevented or at least decreased aspiration. Anes should have known to do real RSI.

It depends on how bad patient is obstructed. He seems to be an inpatient. Prob not food in a while, perhaps haven't had vomiting or much nausea. Not everyone would shove ng tube down . Ng tube has risks. Had a patient get a Ng tube down the lungs and had a to have wedge of lung removed by ct surgery. Not every obstruction is the same. Had plenty of obstructed patient w no Ng tube , and only put in if it doesn't improve or starts to vomit a lot.

Though I didn't read the case above so idk what happened here
 
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leaverus

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Yeah, a lot of the ones I work with, without clear direction, are really casual about RSIs: taping the eyes during induction, giving mask breaths....
I don't give mask breaths because modified RSI is BS but what's wrong with taping the eyes? I tape while waiting for the sux to take effect which is just the few seconds i need to protect the eyes; while it's nice to avoid aspiration, i'd like to avoid aspiration AND corneal abrasions when possible.
 
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I don't give mask breaths because modified RSI is BS but what's wrong with taping the eyes? I tape while waiting for the sux to take effect which is just the few seconds i need to protect the eyes; while it's nice to avoid aspiration, i'd like to avoid aspiration AND corneal abrasions when possible.
If you let go of the mask, you lose PEEP and derecruit. Ideally, you should have the pop-off valve at 5-10 or more during pre-oxygenation and induction, and the mask should be held tight on the face until it's time to intubate. Safety first, comfort second.

Respectfully, the corneal abrasions are pretty rare, easy to treat, and much less important than maximizing the FRC and potential apnea time.
 
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anbuitachi

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I don't give mask breaths because modified RSI is BS but what's wrong with taping the eyes? I tape while waiting for the sux to take effect which is just the few seconds i need to protect the eyes; while it's nice to avoid aspiration, i'd like to avoid aspiration AND corneal abrasions when possible.
airway before eyeballs.
 
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caligas

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I don't give mask breaths because modified RSI is BS but what's wrong with taping the eyes? I tape while waiting for the sux to take effect which is just the few seconds i need to protect the eyes; while it's nice to avoid aspiration, i'd like to avoid aspiration AND corneal abrasions when possible.
Not a big deal, just seems to be a weird thing to focus on during an RSI. also, usually the patient's eyes are closed when I'm intubating, tape or not.
 

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Not a big deal, just seems to be a weird thing to focus on during an RSI. also, usually the patient's eyes are closed when I'm intubating, tape or not.
Great video above regarding techniques for dealing with emesis during induction!

And I agree that it is the Anesthesiologists responsibility to empty the stomach prior to induction if it is indicated, even if it means having an argument with the surgeon, Nursing staff, or delaying the case. Or even, god forbid, picking up the NG and placing it ourselves. That is why we are here...
 

Newtwo

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Great video above regarding techniques for dealing with emesis during induction!

And I agree that it is the Anesthesiologists responsibility to empty the stomach prior to induction if it is indicated, even if it means having an argument with the surgeon, Nursing staff, or delaying the case. Or even, god forbid, picking up the NG and placing it ourselves. That is why we are here...
It might be our responsibility to place an Ng pre-op in sbo but it is negligent to the extreme that the surgeons didn't place the Ng first.

Anaesthesics could have done it but surgeons definitely should have done it. And that's probably part of why they're included in the legal case
 

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Please don't do that to me if I'm having surgery
1. Eyeballs taped
2. Mask securely on face with that awful black S&M strappy thing
3. Dexamethasone
4. Prop/sux/tube?
 
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