Another way to look at the problem with our “specialty”

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thegenius said:
At one of my ER's, the ED / ENT was numbing a guys throat to do a PTA or direct laryngoscopy or something. I can't remember the procedure. They gave nebulized 4% lidocaine and put lido directly on the tongue. Maybe they even numbed the back of the throat with a needle. I don't recall the specifics but I do recall the pt developing uncontrollable seizures, needing intubation and ICU admission.
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We do local injections in the throat/neck and put lido directly on the tongue all the time for awake fiberoptics. Maybe he didn't pull back to check for blood and hit the artery.
 
The only lidocaine toxicity case I've ever been (peripherally) aware of, was a kid that had a bunch of lacs. He also had a fracture, so it ended up that the ortho resident sewed him up. They used so much lidocaine across the multiple lacs that the kid seized. When they went back and calculated the amount, he did go over the limit.
 
Birdstrike said:
The only lidocaine toxicity case I've ever been (peripherally) aware of, was a kid that had a bunch of lacs. He also had a fracture, so it ended up that the ortho resident sewed him up. They used so much lidocaine across the multiple lacs that the kid seized. When they went back and calculated the amount, he did go over the limit.
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Yea I’ve only ever heard of it being an issue in kids. Toxic dose of lidocaine for a normal 70kg adult would be quite impressive.
 
I remember as an intern I was calculating the dose of lidocaine toxicity before using it -- and my attending asked me what the hell I was doing. I told him and he said, "you can give the whole damn thing."

That stuck with me. If you have to use more than one damn thing, then think about it.
 
Angry Birds said:
I remember as an intern I was calculating the dose of lidocaine toxicity before using it -- and my attending asked me what the hell I was doing. I told him and he said, "you can give the whole damn thing."

That stuck with me. If you have to use more than one damn thing, then think about it.
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I propose using "one damn thing" as a standardized unit of measurement.
 
I've used more than one vial of lidocaine before. It's pretty rare...one standard vial of 1% is 20 ml which is usually plenty...and once you do the math it's under 4 ml / kg or whatever it is. But sometimes some has like 2-3 feet of various lacerations on their arms or legs and I'm pumping it full of lidocaine.

Maybe in those cases it's just better to use ketamine and knock them out...but there is so much rigmarole in doing conscious sedation in the ED
 
thegenius said:
I've used more than one vial of lidocaine before. It's pretty rare...one standard vial of 1% is 20 ml which is usually plenty...and once you do the math it's under 4 ml / kg or whatever it is. But sometimes some has like 2-3 feet of various lacerations on their arms or legs and I'm pumping it full of lidocaine.

Maybe in those cases it's just better to use ketamine and knock them out...but there is so much rigmarole in doing conscious sedation in the ED
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Yeah at that point, it’s time for me to call surgery/trauma and let them take the patient to the OR. Never get any pushback for that.
 
zurned said:
That for 95% of our patients, there really is nothing a physician offers that a mid level can’t offer.
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What percentage of patients can be really dealt with by regular old Registered Nurses? You dont even need a mid-level? How about LPN?
 
thegenius said:
I've used more than one vial of lidocaine before. It's pretty rare...one standard vial of 1% is 20 ml which is usually plenty...and once you do the math it's under 4 ml / kg or whatever it is. But sometimes some has like 2-3 feet of various lacerations on their arms or legs and I'm pumping it full of lidocaine.

Maybe in those cases it's just better to use ketamine and knock them out...but there is so much rigmarole in doing conscious sedation in the ED
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bravotwozero said:
Yeah at that point, it’s time for me to call surgery/trauma and let them take the patient to the OR. Never get any pushback for that.
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So, this happened to me at like 3:47 AM one morning not that long ago.

Police bring in suspect after foot pursuit thru bushes, etc. The police K-9 took down the suspect, stopping the pursuit.
Cops bring in Homeboy McHomeyson. His extremities are full of lacerations from both brush and doggo.

I'm surveying these wounds, and I'm thinking: "Okay, this is going to take me quite the long time to suture up - and gen.surg is going to throw a pediatric tantrum if I call them to come clean up this guy only to release him to police custody. Guess I'll just suck it up and get it done."

At some point after leaving the room, my brain (jokingly, so as to not confuse those on here who will trip all over themselves on their way to being offended) came up with:

"I mean; could they not just have shot the guy? You know, like, in the leg? It would have been cleaner, easier, faster... all those things."

Lulz.

To be clear: in no way am I advocating for the police to just have opened fire on him. But it would have been easier to clean up and close one simple wound rather than eleventeen of them.
 
RustedFox said:
So, this happened to me at like 3:47 AM one morning not that long ago.

Police bring in suspect after foot pursuit thru bushes, etc. The police K-9 took down the suspect, stopping the pursuit.
Cops bring in Homeboy McHomeyson. His extremities are full of lacerations from both brush and doggo.

I'm surveying these wounds, and I'm thinking: "Okay, this is going to take me quite the long time to suture up - and gen.surg is going to throw a pediatric tantrum if I call them to come clean up this guy only to release him to police custody. Guess I'll just suck it up and get it done."

At some point after leaving the room, my brain (jokingly, so as to not confuse those on here who will trip all over themselves on their way to being offended) came up with:

"I mean; could they not just have shot the guy? You know, like, in the leg? It would have been cleaner, easier, faster... all those things."

Lulz.

To be clear: in no way am I advocating for the police to just have opened fire on him. But it would have been easier to clean up and close one simple wound rather than eleventeen of them.
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Depending on how many lacs there were, I'd just sedate the guy with ketamine. You could justify it in your chart by how you might hit lido toxicity if done normally. If you're looking at 11+ decent sized lacs, not having to numb each and every one is going to be way faster, even factoring in the time requirements of the sedation.
 
RustedFox said:
"I mean; could they not just have shot the guy? You know, like, in the leg? It would have been cleaner, easier, faster... all those things."
Click to expand...
I know it's just early morning musing, brother, but, the reality is that, if you shoot a perp, and he doesn't become inert (unconscious/dead), it's possible/likely he'll become more aggressive and violent, not pacified. The general public (less educated and intelligent as you) parrot that - "why didn't they shoot him in the leg?", without any idea of the reality of violent criminals.

It's now several years ago, but Dr.McNinja used the term "Mozambique Drill", like it was simple, common knowledge. MUCH more clearly, that is the "two to the chest, 1 to the head". You need to incapacitate the perp, not hobble him.
 
BoardingDoc said:
Depending on how many lacs there were, I'd just sedate the guy with ketamine. You could justify it in your chart by how you might hit lido toxicity if done normally. If you're looking at 11+ decent sized lacs, not having to numb each and every one is going to be way faster, even factoring in the time requirements of the sedation.
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Yup also running sutures or staples are a must in those situations. Sooo much faster.
 
Apollyon said:
I know it's just early morning musing, brother, but, the reality is that, if you shoot a perp, and he doesn't become inert (unconscious/dead), it's possible/likely he'll become more aggressive and violent, not pacified. The general public (less educated and intelligent as you) parrot that - "why didn't they shoot him in the leg?", without any idea of the reality of violent criminals.

It's now several years ago, but Dr.McNinja used the term "Mozambique Drill", like it was simple, common knowledge. MUCH more clearly, that is the "two to the chest, 1 to the head". You need to incapacitate the perp, not hobble him.
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Oh, I get it.
That was just the way my brain drew it up in the wee hours of the morning; like a part of script from say, an episode of "Arrested Development" or "Rick and Morty". I knew instantly: "That... that's not how that works, RustedFox... that's not how that works. Don't say that. Don'tsaythat."
 
RustedFox said:
So, this happened to me at like 3:47 AM one morning not that long ago.

Police bring in suspect after foot pursuit thru bushes, etc. The police K-9 took down the suspect, stopping the pursuit.
Cops bring in Homeboy McHomeyson. His extremities are full of lacerations from both brush and doggo.

I'm surveying these wounds, and I'm thinking: "Okay, this is going to take me quite the long time to suture up - and gen.surg is going to throw a pediatric tantrum if I call them to come clean up this guy only to release him to police custody. Guess I'll just suck it up and get it done."

At some point after leaving the room, my brain (jokingly, so as to not confuse those on here who will trip all over themselves on their way to being offended) came up with:

"I mean; could they not just have shot the guy? You know, like, in the leg? It would have been cleaner, easier, faster... all those things."

Lulz.

To be clear: in no way am I advocating for the police to just have opened fire on him. But it would have been easier to clean up and close one simple wound rather than eleventeen of them.
Click to expand...

Just steristrip him and send him on his way
 
GeneralVeers said:
Exactly. I don't worry about cosmetics closures on drunks and prisoners. Staple what I can, suture what I must, and leave open the small stuff.
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If it's a face, I'll suture it. If it's an extremity... well, have you seen the number of hip and knee replacements that they staple together these days?
 
southerndoc said:
If it's a face, I'll suture it. If it's an extremity... well, have you seen the number of hip and knee replacements that they staple together these days?
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Yep - it's not about the identity of the patient, it's about the nature and location of the laceration.

I'll do runnings or staples on a plastic surgeon's leg lac if it's appropriate - they can always get it revised as an outpatient.
 
Angry Birds said:
I remember as an intern I was calculating the dose of lidocaine toxicity before using it -- and my attending asked me what the hell I was doing. I told him and he said, "you can give the whole damn thing."

That stuck with me. If you have to use more than one damn thing, then think about it.
Click to expand...
Honestly for any normal sized adult this is my metric. If you need more than a whole bottle of lidocaine, maybe the patient is better served going to the OR or at least having the procedure done with sedation instead of a ****load of local.
 
I used two large staple guns on a little old lady who managed to deglove her whole calf (a big floppy L shaped lac) on a milk crate once. That's two damn things, I guess, but I was an attending by then so I just told the tech to get me another. It still took awhile. I don't remember how much lido; I might have just sedated her though. Little old ladies tend up be tough and it was the superficial fat that just sheared with the skin but one hell of a laceration.

Police-dog deglovings get surgery. Only been "privileged" to deal with one of those and that was back in residency. That's a whole other degree of nastiness that needs washing out.

But my favorite big honking abscess story? (To get us back on the first derailing...)
Little old guy comes in, tells me he went to sit on the pot that morning and SPLOOSH, all this goo came out of his chest where his pacemaker was.
Sure enough, there was at least another cupful of puss in the pacer pocket, and you could read the brand of the device by just looking at it. Yeah, that's a problem.
 
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