Concerned about inadequacy of my residency training

Discussion in 'Anesthesiology' started by Guillemot, Jun 19, 2016.

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  1. Guillemot

    Guillemot 5+ Year Member

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    I am a soon to be CA-3 and so far I have either little or no experience in the following areas:

    CVC (non IJ)
    A-lines (non radial)
    Regional Blocks (had a rotation, but did very few blocks)
    FOI
    Massive Transfusion (no transplant, rare trauma)
    Probably lacking in some other stuff I cant think of off the top of my head...

    I dont see it being likely that Im all of a sudden going to be able to accomplish these things during my CA-3 year. I dont really feel like the training I am getting will prepare me to practice independently. Is possible to transfer to another residency at this point, or am I destined to be a hack?
     
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  3. Machinery

    Machinery 2+ Year Member

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    I will definitely find a way to get up to speed with the lines. That is a skill you MUST have.
     
  4. confusingleaf

    confusingleaf ASA Member

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    i think some of these things a lot of people graduating now don't do a lot of, or any....i have done maybe 5-6 subclavian lines. i hate them, because i haven't done enough to feel comfortable. if it was an emergency and that was my access i would try, but in a non-emergency i would call someone more experienced. femoral lines.....not much different than an IJ. non-radial arterial lines, stick the ultrasound on it and put a catheter in. same technique....again not something i have a ton of experience with because we don't do it unless necessary. i did one brachial a line in my cardiac fellowship.

    have you considered doing fellowship to gain more expertise in one or more of these areas? cardiac fellowship will give you a lot of line training. regional will get you blocks. transplant/cardiac will give you massive transfusion/emergency experience. is your lack of comfort in these areas becuase you are at a community hospital with not a lot of exposure?

    having a weakness in 1-2 areas definitely doesn't make you a hack. but from the gestalt of your post it sounds like not only do you not have a lot of experience in more than one or two areas, but that you don't have a lot of confidence in your skills either. do what it takes (whatever that may be) to become confident in your skills.
     
  5. ryanjmy

    ryanjmy 7+ Year Member

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    The good news is you're going to make a great crna.

    Just kidding.

    You have to look for procedures during residency. If you're doing ij cvls ask the attending to let you practice with subclavians, argue less infection rate. Regional and non radial alines are basically ultrasound skills. Use us whenever you can. Practice finding the brachial plexus and popeteal nerves on your fellow residents. AFOI don't happen very often, I only do about 1 a year, but there's no reason you can't practice doing foi on an asleep pt.
     
  6. Guillemot

    Guillemot 5+ Year Member

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    Yeah, community hospital without much exposure to complex cases. I feel like Im getting great training to go work at an ASC though! Oh no actually regional here sucks too NVM. I think I ****ed up by not going to a university setting.
     
  7. Guillemot

    Guillemot 5+ Year Member

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    You might be kidding, but I would say the same thing about my training and not be kidding.
     
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  8. nolagas

    nolagas Member 10+ Year Member

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    It would be nice if you loved pain or critical care and had good training in thore areas. ?
     
  9. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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    Don't stress out... you will have the rest of your career to get better at the things you are not good at. You need to develop your confidence though and continue to challenge yourself, meaning if you are not good at something look for opportunities to do it more frequently and avoid doing only the things you are comfortable doing.
    For example if your FOI skills are lacking find opportunities to do FOI's on easy patients under anesthesia when you are in practice, you will fail initially but then you will start getting better.
    Don't worry nothing we do is rocket science!
     
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  10. Doctor4Life1769

    Doctor4Life1769 **tr0llin, ridin dirty** 7+ Year Member

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    That would actually require the anesthesia attending to know how to place a subclavian or to place a chest tube in the chance of a pneumothorax. I guess the surgeon could place a chest tube but I bet your ass he/she would hold it over y'all.
     
  11. aimedicine

    aimedicine 5+ Year Member

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    i'm shocked at this post...are residency training so weak these days we need fellowship to feel confident with our skills...?
    maybe you should have done a surgical internship, i logged well over 20 central lines this year and i can't even begin to count the number of alines that i did. Most of them in the surgical ICU, it was a closed unit ran by us residents....hated the 4 hour morning rounds tho.
     
  12. confusingleaf

    confusingleaf ASA Member

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    interesting that you did a number of a lines. at my institution the surgery residents essentially can't do them and will call anesthesia residents for help. and after first year they typically don't put in lines anymore, so by the end of our training we are much more facile at them. everyone has their strengths and each program different, i suppose.
     
  13. confusingleaf

    confusingleaf ASA Member

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    so, as my husband would say, that round is down range. you are where you are. focus on getting the most you can out of your CA-3 year. volunteer for each and every hard case or procedure. and, like the poster above me said, you just have to challenge yourself to do things, and doing that in a non-emergent setting makes it way easier when you are finally faced with the real deal.
     
  14. BLADEMDA

    BLADEMDA ASA Member 7+ Year Member

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    If you are highly motivated after Residency then the opportunity will be there to learn these skills. That said, you need a practice (like mine) where these skills are utilized hundreds of times per year. Also, you should be worried about signing up for a partnership track lacking these basic skills. Some groups may use this as a reason to deny you partnership. Perhaps, a fellowship wouldn't be a bad idea or 1-2 years at a busy AMC or Employed setting while you polish/learn those skills prior to finding a nice private practice gig.
     
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  15. signumvitalis

    signumvitalis 2+ Year Member

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    what about doing an 'away' month at a busier place to try to see if you can get to be around sicker, more acute patients more frequently?
     
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  16. FFP

    FFP Bored certified Gold Donor 7+ Year Member

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    S/He probably runs circles around you when about medical knowledge, which matters much more for an anesthesiologist. (Procedural skills can be easily improved by practice.)

    Surgeons tend to be about as good at internal medicine as midlevels, so don't be so excited about your internship. I regularly have surgical interns misjudge patients in the ICU. Surgeons, too.
     
    Last edited: Jun 19, 2016
  17. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    This is true. You won't make partner without these basic skills. Much less even be around in 2 yrs.
    I don't even consider community hospital grads for this very reason when hiring. They may be good but you just don't know. If rather take a chance with someone from a busy university system. Some place that does trauma and lots of it. This is the way to get good at all of this expect possibly regional.
    If I were you I would look to transferring to a trauma system. If you want to do cardiac then do a fellowship. If regional is still lacking then a regional Fellowship. But you will most definitely struggle in PP without these skills. And your pts will suffer.
    Now with all that said, it is entirely possible that you are not actually as far off as you think. Everyone goes through times where they feel they are not where they should be in residency. Possibly you are just right and in CA-3 year it will all come together. At least you are insightful enough to know this which is a huge positive. Now the easy part is fixing it.
    But I would definitely express these feelings to my attending a if I were you. They must address it. And ask your current CA-3's how they feel able their training. Some will be oblivious to their deficiencies. But you should be able to weed through the bullsh*ters and the informed.
    Personally, I'd try to switch to a university hospital with lots of trauma. Once you save a couple massive traumas you will feel much better about your skills
     
    Last edited: Jun 19, 2016
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  18. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    An away trauma rotation.
     
  19. urge

    urge 7+ Year Member

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    I wouldn't worry about it.

    I doubt many posters here do many non IJ CVC, non radial alines, FOI, or massive transfusions.

    You should probably work on the blocks, although my impression is that regional's popularity is fading to its normal level (zero) due to recent changes in reimbursement.
     
    Last edited: Jun 19, 2016
  20. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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    This reminds me of my old friend Militarymd who always thought that regional is stupid!
     
  21. urge

    urge 7+ Year Member

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  22. aimedicine

    aimedicine 5+ Year Member

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    YOU'RE WRONG, I'LL GO TO BAT ANY DAY AGAINST ANY MEDICINE INTERN when it comes to medicine knowledge especially in the areas of cards, pulm, g.i, and neuro...don't think because i did a surgery internship that all i was doing was surgery scutwork, i spent a good chunk of my time reading harrison internal med and marino ICU...got through marino ICU almost twice because i did 3 month in the ICU....all of this while studying for my step 3, which i am about to destroy by the way...med intern? haha i laugh at that...hahaha run circles around me, that's so cute.
     
  23. urge

    urge 7+ Year Member

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    I'll bet my money on the Medicine intern.

    It's not the same reading about it than living it.
     
  24. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    Regional is the bomb when necessary. You can take a complete disaster of a pt with a guaranteed ICU post op visit to the OR and send them to the floor instead like nothing ever happened. But at the same time you could do that with a well orchestrated GA as well. But it is my opinion that the best ANESTHESIOLOGISTS can achieve this either way. We are not a one horse ride.
     
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  25. urge

    urge 7+ Year Member

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    That doesn't compute. How does one send a patient to the ICU by doing GA for surgery on an extremity? Just put an LMA and have them spontaneously breathing.
     
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  26. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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    If a crappy CRNA is going to be watching the patient it's much safer to put a block in and tell them to do nothing but light sedation.
     
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  27. urge

    urge 7+ Year Member

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    You got me.
     
  28. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    I have done a TKA revision in a morbidly obese man with of EF 10-15% and severe COPD/PHTN under a combined femoral and sciatic nerve block and virtually no sedation needed. Maybe he would have done just as well with a straight GA in very skilled hands. But it's hard to agree with the outcome. And it's nice to be able to do it if necessary.
     
  29. urge

    urge 7+ Year Member

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    [​IMG]
     

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  30. aimedicine

    aimedicine 5+ Year Member

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    ya except i lived it...so there you go.... you are wrong!....and add on top that i did my surgical internship in one of the biggest hospital system in one of the poorest urban city in America, and you are really just wrong...saw way too many pathology in the ICU/Floor/Clinic, even the ones i thought were rare like VHL were not so rare...it's very seldom that i speak to medicine consult and they have anything to contribute that i didn't already think about...now those cardiology fellows are smart though, learned a lot from them.
     
  31. Robotic Wis-Hipple

    Robotic Wis-Hipple

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    I honestly can't imagine having gone to a residency where everyone is ASA 2 maybe 3 and all the disasters are shipped out. You only have 3 years to see everything and acquire the rockstar skills, go somewhere you're gonna get that exposure because learning that on your own license/malpractice is definitely not ideal.

    As for the OP, make it known that you want the biggest case and/or sickest patient on the board every day. Most of your CA-3 colleagues will be transitioning to coast mode, use that to let everyone at your place know that you want to do the hard ones.
     
  32. Robotic Wis-Hipple

    Robotic Wis-Hipple

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    Lol, you're well on your way to being a PGY2 surgery attending.
     
  33. aimedicine

    aimedicine 5+ Year Member

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    ya one that knows more medicine than gen med pgy 1...:hardy:
     
  34. FFP

    FFP Bored certified Gold Donor 7+ Year Member

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    Reminds me of what I usually say about midlevels: they don't know what they don't know. That's how patients get hurt. But you're still young, so you have an excuse.

    Seriously, there is a reason some people prefer to cut and sew all day long, while others prefer to think, and read, and learn. Let surgeons teach you surgery, but never let them teach you medicine. Real life is not Grey's Anatomy.
     
    Last edited: Jun 19, 2016
  35. urge

    urge 7+ Year Member

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    I reserve the right to some healthy skepticism.

    Best of luck with your endeavors.
     
  36. BLADEMDA

    BLADEMDA ASA Member 7+ Year Member

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    To the OP:

    In my neck of the woods most patients are ASA3 and 4. Regional anesthesia skills are necessary to the job as the surgeons expect it. Second, when doing arterial lines the radial artery can be difficult to cannulate about 5-10% of the time (my patient population) so a backup plan is necessary. I am choose the Axillary line over the femoral route these days most of the time.

    A good Anesthesiologist who covers traumas must be able to place a Subclavian line if needed and be able to handle massive blood loss with transfusion.

    FOI? You bet your arse. At 0100 the ER may call you to intubate the 380 pounder with angioedma of the tongue who is short of breath with hoarseness.

    Every one of these skills can be learned on the job (just as the CRNA can learn them) but a Board Certified Anesthesiologist really should have some proficiency with some, if not all, of them. Knowledge is great but in the real world where you are the ONE on the line solid skills are required to get the job done.

    I'm glad you are honest about needing to work on those skills and I encourage you to keep at it. Meanwhile, what's your plan post residency?

    I'm a long way out from Residency and I've never stopped learning new things or getting better at my job. I may be a half step slower than when I graduated residency but my skill level is far better. This is directly due to my job responsibility, patient acuity and types of surgeries I am involved with on a daily basis.

    Perhaps, you need to figure out what's your goal for a career and what type of Anesthesiologist you want to become. There are plenty of ASC jobs out there just as there are plenty of Level 1 high acuity ones.

    As long as your are honest about your short-comings and really work hard at over-coming them (especially post residency) then you should be able to learn all these skills over the first 12-24 months post residency. By being humble, honest, safe and most of all asking for help whenever you need it the odds are you will be successful.
     
    Last edited: Jun 19, 2016
  37. aimedicine

    aimedicine 5+ Year Member

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    Lets not lose sight of my point here, i'm not saying i know more medicine than a medicine attending...i'm disputing your statement that a pgy-1 medicine resident knows more medicine than me...you mentioned earlier in your post that surgery interns misjudge patients in the ICU....so med interns don't do the same???...anyway lets agree to disagree. goodluck to the OP though.
     
  38. Robotic Wis-Hipple

    Robotic Wis-Hipple

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    I think the consensus is you may be on the upper percentile range of the bell curve for surgery interns, but on average there's a reason medicine covers non surgical patients. And the bulletproof mentality mixed with a lack of humility is how bad things happen. Put your head down and continue to defer to those above you while keeping your head in a book. And eventually, you'll learn that cardiology notes are among the most worthless notes in medicine.....
     
  39. waterhammer

    waterhammer ASA Member 7+ Year Member

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    Do another month in the ICU, and practice your lines there.

    If your program has an affiliated surgicenter, ask to do a rotation there to get more blocks. Or you can hang out in the PACU and do some postop blocks.

    Ask your attendings to do FOI on routine cases. Most of them should be cool with asleep FOI.
     
  40. IlDestriero

    IlDestriero Ether Man 7+ Year Member

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    You have a year to practice. Just do it.
    Ultrasound a ton of lines.
    Ask to do blocks or to be in block rooms.
    Go to a difficult airway course and do a bunch of asleep fibers on healthy patients.
    Trauma isn't rocket science either. Read up on massive transfusion issues, review when to use what product, NovoSeven, etc.


    --
    Il Destriero
     
  41. FFP

    FFP Bored certified Gold Donor 7+ Year Member

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    Med interns see more medically sick patients than surgical interns. They are also taught a much deeper thought process, much more evidence-based (when about medical issues), for the simple reason that their attendings are better read and more up-to-date (as expected - it's their specialty). Their knowledge base might not be much better than a surgical intern's (since many surgical interns, especially those going into subspecialties, have good USMLE scores - before they get dumbed down by residency). But they see things you don't, and they are trained in an intellectual exercise you are not. So whenever a patient does not fit the knee-jerk pattern, which almost PGY-2 do you think has higher chances of figuring out what's going on? That applies in the ICU too, at attending level, by the way.

    People who like to feel clever become internists. People who like to play macho heroes become surgeons. Different talents, different skill set, different cultures, even different median personalities. Nothing bad about it, as long as one knows one's own limits. For anesthesia residency purposes, both internships have their advantages and disadvantages. Medical internship focuses on learning to think independently, while surgery emphasizes learning to follow the rules and get things done. Surgery will give one better manual skills, and comfort in the OR and around surgical pathology, while medicine will make one shine as the internist in the OR, but also possibly make one seem slower when compared to all the knee-jerk people around. Overall, I would still vote for a medical internship (especially if interested in CCM later) or, even better, one with surgical electives.
     
    Last edited: Jun 19, 2016
  42. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

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    In other words, you off your rocker by thinking you know more medicine than a medicine intern as a surgical intern.
    But the most medicine you would know as a surgeon would be as an intern. Don't confuse the two.
     
  43. FFP

    FFP Bored certified Gold Donor 7+ Year Member

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    Or just learn as much regional and airway as possible, then follow it with a year in a good CCM fellowship.
     
  44. FFP

    FFP Bored certified Gold Donor 7+ Year Member

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    Thank you for the tl;dr. :)
     
  45. pjl

    pjl ASA Member 10+ Year Member

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    First off, you are at the beginning of your CA3 year. You have 1/3 of your anesthesia portion of residency left. All of these deficits are recoverable, but other posters are right that you may feel the need to do a fellowship to beef up skills. That is a sad state of affairs for residency training, and those who are about to apply for residency should take note. Not all programs are equal.
    Specifics to get better:
    1. Sign up for more cardiac. If there is an away rotation available, this would be the one I would choose. When there, try to get sicker patients. Also, try to do things that are a little outside of your comfort zone. Do some lines WITHOUT ultrasound unless there is a stupid policy in place.
    If you are "lucky" you will get in on a really bad case where you have to transfuse them like crazy. Honestly, it is not that hard if you understand the theory, and get a few reps in. Figure out how to setup and use a Belmont.
    For alternate location arterial lines, figure out the locations that are acceptable, and the reasons to choose or not choose any. Then find your arteries in those spots by feel and with ultrasound. I personally feel that ultrasound is a crutch that you shouldnt need for the vast majority of art lines. however, reading guys on here it makes me feel like the guys who use nerve stim must have felt as ultrasound has become nearly universal for blocks.
    2. Do subclavian lines for EVERY line that is not in a cardiac or thoracic case until you feel comfortable.
    3. Find ANY attending with regional experience. Many attendings at a weak place may not want to teach you because they dont want to expose that they dont have experience doing this. Fortunately, regional is something you can pick up a lot of if you join a practice with helpful partners. I personally recommend axillary blocks as the best ultrasound training out there, since you are near parallel to the probe and get to hit a few targets.
    4. Do asleep fiberoptics. Once you get the basics down, see if you can spend time with the pulmonary guys doing bronchs. They may be excited to have someone topicalize the airway and get the exam started. You would be saving them some time potentially.


    Sent from my iPad using SDN mobile app
     
  46. rakotomazoto

    rakotomazoto ASA Member 7+ Year Member

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    This is a great thread. Although I am just finishing CA-1, there are certainly areas that I feel weaker in than others. The comments on here are a good reminder that I am responsible to actively seek out opportunities to increase my skills during residency. CA-1 year has been great, got to do some big cases, but I could certainly work harder to pick up even more.
     
  47. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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    I am not sure why many people (usually CRNAs) think that angioedema of the tongue is an indication for the use of fiberoptic scopes!!! Not every awake intubation has to be fiberoptic!
     
    cchoukal likes this.
  48. Robotic Wis-Hipple

    Robotic Wis-Hipple

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    So when you're teaching a resident about having an appropriate fear of the potentially rapidly progressive hypersensitive swelling of angioedema and how to secure the airway you'd argue for an awake glidescope? While I agree with your last sentence I think it's fairly accepted, at least in the oral boards kind of thinking, that angioedema is best managed with; transport to OR, non per os (no suction, Krause forceps, etc), maintenance of spontaneous respiration, and awake FOI in a patient with neck prepped and surgeon at bedside. Now of course there are different stages of progression of the situation and you may catch it early but I'd think avoiding mashing on oropharyngeal and submental tissues is still the best course.
     
  49. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor 10+ Year Member

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    FOB might not be your best option in a patient who is unable to swallow and a mouth full of secretions especially if you are not good at it!
    The best technique is the one you are best at which could be FOI or video-laryngoscopy or even DL, Just don't put the patient to sleep and lose the airway! The mistake that many people make is that although they rarely do FOI and they probably never learned it properly, when faced with a potential disaster like angioedema they want to attempt FOI, just because that's what they read or were told to say on the boards!!!
     
  50. Ignatius J

    Ignatius J 7+ Year Member

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    The only problem is with someone who thinks they are optimally trained out of residency. You will always feel like you can improve on certain things. What will be appreciated is knowing and recognizing your limitations. I see both surgeons and anesthesiologists do it all the time. where I have gone wrong is trying to "fake it". Don't fake. If you aren't comfortable with something, ask a partner and learn. We have all been there.
     
    Doctor4Life1769 and FFP like this.
  51. aimedicine

    aimedicine 5+ Year Member

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    A misconception most people have about surgery internship is that you are expose to very little medicine...which is not true, in my training programs most of this patient had multiple medical comorbidities and get admitted for things like abscess...the abscess is extremely easy to drain but very often you are managing their diabetes, afib, CKD, hyponatremia, sepsis, etc...we rarely ever called medicine consult in the ICU we just manage the patient medical issues on our own...while i might have been a surgery intern, i only spent 5 months in surgery...the rest of the time i was in the ICU and ED....So yes i saw a breadth of pathology and i doubt med interns are well equiped in medicine than me, i had a lot of interactions with them and no i was not impress...let stop beating a deadhorse.
     

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