Dear resident colleagues: Ask "why?"

[jetproppilot]

Fourteen years into this private practice gig, I've had an epiphany.

Anesthesia is like religion. You learn a buncha stuff thats questionable.

I encourage you, resident colleagues, when confronted with new material, a new case type, or when you are told "this is how you are supposed to do it,"

ask

WHY?

Lemme clarify myself.

I'm not suggesting you become an anti-social, angry, cynical hard core non-team player.

I'm not suggesting you call out an attending on his choice of anesthetic every time, just because you can.

I AM suggesting that a significant portion of your residency education is ACADEMIC DOGMA.

What I mean by that is you....the resident...is being apprenticed into our profession by the academic institution...the Pearly Gates, if you will...and a significant portion of your education is not supported to impact patient care.

in other words you are learning some stuff thats gonna waste YOUR time, the surgeons time, the patients time. You're learning stuff thats gonna make you needlessly delay and/or cancel cases. You're learning how to place invasive monitoring devices...which all have their place....but their indications are far less than what you've been lead to believe. You're learning the "danger" of putting a parturient to sleep over a neuraxial anesthetic...when that "danger" may impede you later to do the right/safe thing. Etc Etc Etc

Like religion, it is important for the individual to ponder

WHY AM I LEARNING THIS? IS IT RELEVANT TO ME LATER?

Anesthesia dogmas are legendary to those of us who have been earning our living practicing anesthesia; not spending half our careers writing books on anesthesia outside of the operating room.

I've been doing CASES every day of my private practice life. Day in and day out. Just like every other private practice anesthesiologist.

I am not in fear when I tell you

There is a HUGE difference between what you are learning in the academic setting...where there exists HUGE, LONG turnover times...which means there are fewer cases to learn from...than the more efficient private practice setting where cases are turned out in an efficient manner...day after day after day...

I want to instill in you to ask

WHY?

Maybe it just starts with asking yourself "why?"

Why am I placing this PA catheter?

Why is my attending cancelling this case because the sodium is 154?

Why is my attending delaying this C section 8 hours when the parturient had a cup of coffee if she's already considered a full stomach?

Is the 8 hour NPO rule some verse in the bible? At 8 hours does the stomach magically become void of gastric contents? If you go at 6 hours is there just a little in there? If you go at nine hours is there some vacuum effect?

Why is a patient fresh off dialysis being delayed because the phlebotomist is tied up and she can't draw a pre-op K+? Why do we need a pre-op K+? Was a KMart dialysis machine used or something?

Why am I starting this A line? Do I really need it?

Why am I starting a second IV, and delaying the surgery for said time? Do I really need it?

Why do I need to monitor CVP for this case, which means I have to place a central line? Do I really need it?

The potassium is 2.5 Is there any proof patient outcome will be altered by that lab value?

The glucose is 300. Do I need to cancel this case?

The HCT is 20. Do I automatically delay?

Theres no anesthesia consent. Its a nursing home patient who doesnt know what planet he's on, let alone what operation he's about to have. I've tried incessantly and can't get a family member. Its for a hip ORIF 48 hours post fracture. Do I stay or do I go?

Above are a couple laugh examples.

Some are an automatic go in my book.

Some are on the edge.

Thats getting off topic, though.

I want you, resident colleagues,

TO ASK: "WHY?"

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[notinkansas]

AMEN!

Too much of medicine is about "because we've always done it this way" or being taught a certain way just because that's attending X's personal preference.

I'd say this applies to all fields, not just anesthesiology.

Glad to see you back on this forum!

 

[IlDestriero]

AMEN!

Too much of medicine is about "because we've always done it this way" or being taught a certain way just because that's attending X's personal preference.

I'd say this applies to all fields, not just anesthesiology.

Glad to see you back on this forum!

There's nothing wrong with questioning anything at all, it's a great way to really learn. There's a great deal of dogma that is poorly supported. I feel that I can defend my position on all of the things that I delay/cancel, and most of my idiosyncrasies. However, for the residents in the crowd, don't forget that attending X is the one who will be sued if things go wrong, that is a powerful motivator in a highly litigious state. So, you will probably have to do it their way in the end.
I think that I probably do place more lines than I absolutely require. I would be comfortable with 2 reasonable IVs for many bigger cases. When there is any doubt, academic attendings often err on the side of adding a central line or an aline to maximize training opportunities. I think that is appropriate decision making at a teaching hospital. I practice somewhat differently now, in academics, than I did when I was on my own. There also may be departmental and/or hospital policies/guidelines in place to guide management. These can be complex agreements worked out between the surgeons and the anesthesiologists. Right or wrong, they are what they are. In PP you can, for the most part, just do whatever you want. "Violating" these guidelines in an academic practice may be harder than just saying "Go". Examples might include NPO guidelines for non emergent surgery, post dialysis lab guidelines (BTW, I've seen some really botched labs after the Kmart dialysis machine, so I check {trust no one}), preop HCG, timing of non emergent cases at night, etc.

 

[orangele]

I agree with the OP that alot of Anesthesiology and Medicine is really more dogma than science. After all, science cannot carry out studies which would be helpful in determining if dogma is fact because it would not be considered ethical.

Today I practice differently than I did when I first came out of residency. Medicolegally, it is perhaps harder to defend a practice that goes against common medical dogma, and I often ask myself how I would defend myself in court if the worst case scenario occurred. As a hedge, I sometimes will explain to a patient or family that there may be a particular risk to proceeding, and that we can wait if that is what they feel comfortable doing knowing the risks involved.

On a regular basis, things that were once considered standard of care are being revised or refuted. On the other hand, I would not do something where my own experience had demonstrated to me was very risky without making that clear to the patient and surgeon that I felt this way.

It is very uncommon for me to cancel a surgery. Much more commonly I simply inform the surgeon of a troubling lab result or EKG or history, and they do the rest.

 

[yasha83]

Although we may not quite grasp the scope of this discussion like a resident of PP attending does, this thread is still great food for thought for us incoming residents. I appreciate the perspectives on academia from you guys, Jet, ildestriero, orangele et.al.

 

[rsgillmd]

OK, this has been bugging me for a while, so I have to ask: Jet, where are you getting the idea that cases get canceled needlessly in academia? Is this just your experience in residency? Is it some study done at big name centers?

I can remember exactly 2 cases where I decided to cancel a case: a poorly controlled diabetic who belonged in the ICU for impending DKA, not in the OR for a relatively elective procedure, and a morbidly obese woman with language barrier and extensive cardiac history for elective hysteroscopy who had not been evaluated properly from the cardiac standpoint. The orthopedic surgeon initially made a fuss when we told him that if he felt this was that urgent we would do the case, but he should arrange for an ICU bed afterwards. He decided to cancel the case. Then GYN surgeon did not make a fuss at all.

There have been other cases, but they were canceled by the surgeons without us needing to say anything.

Granted Maimonides is pseudo-academic (private practice group with a residency program), but with your posts it makes seem like academics is nothing like real life. This is in disagreement to my experience. I'm in a community hospital affiliated with Univeristy of Tennesse (Memphis). We don't have a residency program, but are trying to get it back. In the main OR I end up covering CRNAs in 2-4 rooms (usually 3). Other than learning some of the local idiosyncrasies, I had no real problems adapting to working as an attending. In fact several of the OB/GYN surgeons have said to me that they like me because I tend not to slow them down.

I do not believe I am drastically different from my colleagues from residency. So please expand on this aspect of your post.

 

[urge]

rsgillmd,

Jet trained long time ago. They used to cancel cases if k wasn't 3.5-4.0. He must have been scarred pretty bad by the BS he saw. Times have changed. It would be nice if he went into academia now and gave us the flip side of the coin. I think residents would love to have him around.

What do the residents think? Are your attendings pansies?

 

[Jeff05]

not all academic places are super dogmatic and inefficient.
i agree with you that many things we do have NO rhyme or reason. but, and i think you know this, we do them for PURELY medico-legal reasons. we don't want to stand out of the pack WHEN (not if) we get sued.

so, yea, if you took a patient 6 hours s/p a meal for an elective OR case and there was aspiration (related or NOT related to the meal) you will go DOWN in flames. same with taking a K of 2.5, etc.

i agree with the spirit of this thread - always ask WHY (and then look it up).

 

[Pooh & Annie]

I've had the opposite experience. The vast majority of my attendings challenge me to defend my decision-making. We rotate at a private hospital too, where it seems like the attendings do a lot of things because "that's how our group does it". Also, most of my academic attendings are up-to-date on literature, and critically evaluate that literature with us, discussing how it should effect our practice. That's not to say I haven't learned important things from the private groups we work with.

 

[Idiopathic]

I typed a longer response, but Id just like to say that simply jets group does it a certain way and he calls out academics (all too frequently) doesnt mean what you learn in academic centers is wrong or inefficient. Personally, its insane to do a case on a patient with a HCT of 20 unless you know why its 20 (just like glucose, K, etc). Its not always black and white, and increased throughput does not always mean improved patient care. In my opinion, residency is about learning simple cases (3 months) complex cases (6 months) and complex issues within otherwise simple/complex cases (2+ years), which is why its sometimes the right thing to do to struggle with an arterial line or second IV that may not always be definitely needed, or to struggle with a FastTrack LMA even though direct laryngoscopy might be more efficient. Just because youll go out into the real world and settle for acceptable, doesnt mean you shouldnt strive for optimal.

 

[Gern Blansten]

OK, this has been bugging me for a while, so I have to ask: Jet, where are you getting the idea that cases get canceled needlessly in academia? Is this just your experience in residency? Is it some study done at big name centers?

I can remember exactly 2 cases where I decided to cancel a case: a poorly controlled diabetic who belonged in the ICU for impending DKA, not in the OR for a relatively elective procedure, and a morbidly obese woman with language barrier and extensive cardiac history for elective hysteroscopy who had not been evaluated properly from the cardiac standpoint. The orthopedic surgeon initially made a fuss when we told him that if he felt this was that urgent we would do the case, but he should arrange for an ICU bed afterwards. He decided to cancel the case. Then GYN surgeon did not make a fuss at all.

There have been other cases, but they were canceled by the surgeons without us needing to say anything.

Granted Maimonides is pseudo-academic (private practice group with a residency program), but with your posts it makes seem like academics is nothing like real life. This is in disagreement to my experience. I'm in a community hospital affiliated with Univeristy of Tennesse (Memphis). We don't have a residency program, but are trying to get it back. In the main OR I end up covering CRNAs in 2-4 rooms (usually 3). Other than learning some of the local idiosyncrasies, I had no real problems adapting to working as an attending. In fact several of the OB/GYN surgeons have said to me that they like me because I tend not to slow them down.

I do not believe I am drastically different from my colleagues from residency. So please expand on this aspect of your post.

This was my experience in residency and beyond. Where I did residency and where I am now, the dogmatic person is the outlier. Most are progressive and emphasize efficiency with excellent patient care and up to date knowledge of standard of care. As with others, it is rare for our group to cancel a case. We will, on occasion, help the surgeon come to the decision to cancel it himself/herself.

 

[jetproppilot]

rsgillmd,

Jet trained long time ago. They used to cancel cases if k wasn't 3.5-4.0. He must have been scarred pretty bad by the BS he saw. Times have changed. It would be nice if he went into academia now and gave us the flip side of the coin. I think residents would love to have him around.

What do the residents think? Are your attendings pansies?

Jet trained long ago? HAHAHAHAHAHAHAHAHA

You got me on that one, Dude.

I guess finishing residency in 1996 makes it in fact long ago.

Rsgill, the fact that you are practicing in a community hospital with (aspiring) academic ties in my mind tells me you are whats needed in residency education, i.e. a dude in private practice that wants to teach residents.

Successful patient outcome is the ultimate goal.

One can achieve that easily. Or arduously. And still have the same outcome.

Lemme give an example, of which I think residency teaching has missed the boat. I've lived it, and have seen it with emerging new partners fresh outta residency:

Academic attendings and residents,

Whats your opinion concerning the following?

You are the anesthesiologist for an urgent C section. Lets assume you are deft with a Tuohy or spinal needle.

Previously, you were able to accomplish an epidural steroid injection at the San Diego Zoo on a famous otter named Chloe who had achieved national notoriety as a role model for abused children, that had developed severe radiculopathy which required epidural steroids.

This isnt a crash section, but FHTs are questionable and your astute (lets assume astuteness in your colleague...not the dial-911! type) OB/GYN is concerned and wants to get the baby out now.

Despite your best efforts, you cant get the Tuohy where it needs to be. Nor a spinal needle.

For ten minutes.

What now?

 

[Jeff05]

Jet trained long ago? HAHAHAHAHAHAHAHAHA

You got me on that one, Dude.

I guess finishing residency in 1996 makes it in fact long ago.

Rsgill, the fact that you are practicing in a community hospital with (aspiring) academic ties in my mind tells me you are whats needed in residency education, i.e. a dude in private practice that wants to teach residents.

Successful patient outcome is the ultimate goal.

One can achieve that easily. Or arduously. And still have the same outcome.

Lemme give an example, of which I think residency teaching has missed the boat. I've lived it, and have seen it with emerging new partners fresh outta residency:

Academic attendings and residents,

Whats your opinion concerning the following?

You are the anesthesiologist for an urgent C section. Lets assume you are deft with a Tuohy or spinal needle.

Previously, you were able to accomplish an epidural steroid injection at the San Diego Zoo on a famous otter named Chloe who had achieved national notoriety as a role model for abused children, that had developed severe radiculopathy which required epidural steroids.

This isnt a crash section, but FHTs are questionable and your astute (lets assume astuteness in your colleague...not the dial-911! type) OB/GYN is concerned and wants to get the baby out now.

Despite your best efforts, you cant get the Tuohy where it needs to be. Nor a spinal needle.

For ten minutes.

What now?

1. 10 minutes is a LONG time to be messing around with a spinal.
2. it's either go time or it's not. if it's not really go time, pass on the needle to another pair of hands. if the OB wants baby out - i will provide them with the ability to cut in less than 60 seconds (once in OR with monitors on).
i have no problem doing GA for c/s.

 

[Idiopathic]

easy, you go to sleep - BUT its worth another try if you are letting your CA-1 resident try first

 

[Narcotized]

You are the anesthesiologist for an urgent C section. Lets assume you are deft with a Tuohy or spinal needle.

This isnt a crash section, but FHTs are questionable and your astute (lets assume astuteness in your colleague...not the dial-911! type) OB/GYN is concerned and wants to get the baby out now.

Despite your best efforts, you cant get the Tuohy where it needs to be. Nor a spinal needle.

For ten minutes.

What now?

You'll either tube them or keep trying. I suspect that will be more dependent on the attending than on the academic vs private hospital as well as dependent on further details (did she just swallow 3 cheeseburgers and has a MP 4 airway?)

 

[jetproppilot]

1. 10 minutes is a LONG time to be messing around with a spinal.
2. it's either go time or it's not. if it's not really go time, pass on the needle to another pair of hands. if the OB wants baby out - i will provide them with the ability to cut in less than 60 seconds (once in OR with monitors on).
i have no problem doing GA for c/s.

Thats the perfect answer.

We've all had to call a colleague for help in this situation.

My opinion, though, is that our residency education instills fear in residents concerning general anesthesia and the parturient.

So much so that it affects their performance in their first years in private practice.

 

[GasEmDee]

Thats the perfect answer.

We've all had to call a colleague for help in this situation.

My opinion, though, is that our residency education instills fear in residents concerning general anesthesia and the parturient.

So much so that it affects their performance in their first years in private practice.

My residency experience differs quite dramatically from yours. I am an academic attending at a major institution.

1) In reference to the specific example above, our OB anesthesia chief specifically emphasizes to resident not to fear GA in the parturient. Our L&D prides itself on evidence-based medicine, rather than dogma, and everything protocol in that unit can be grounded in a specific piece of literature.

My personal biggest issue against doing GA in a parturient is that it takes away the the ability of the mother to experience her child coming into the world. That is it. Otherwise, if she needs a GA, she is getting one. Aspiration is an exceedingly rare event. And with the airway management strategies we have these days, I have yet to run into a truly difficult airway, in the parturient, the morbidly obese patient, or otherwise.

2) With respect to canceling cases, I have postponed one case ever as an anesthesiologist (including my cases during residency). I do not postpone cases for numbers that are abnormal. I postpone cases if there are specific post-operative implications. I genuinely believe we can keep just about any patient alive during the procedure itself, but it is the post-operative course where they run into trouble. I did have a colleague who cancelled cases left and right for all these theoretical "academic" reasons, but she was let go.

I agree some anesthesiologists are dogmatic. However, I find them to exist in both academic and private practice environments. But then again, you know my viewpoint since we have sparred on this topic for quite some time. Glad to see you back on the forum.

 

[jetproppilot]

My residency experience differs quite dramatically from yours. I am an academic attending at a major institution.

1) In reference to the specific example above, our OB anesthesia chief specifically emphasizes to resident not to fear GA in the parturient. Our L&D prides itself on evidence-based medicine, rather than dogma, and everything protocol in that unit can be grounded in a specific piece of literature.

My personal biggest issue against doing GA in a parturient is that it takes away the the ability of the mother to experience her child coming into the world. That is it. Otherwise, if she needs a GA, she is getting one. Aspiration is an exceedingly rare event. And with the airway management strategies we have these days, I have yet to run into a truly difficult airway, in the parturient, the morbidly obese patient, or otherwise.

2) With respect to canceling cases, I have postponed one case ever as an anesthesiologist (including my cases during residency). I do not postpone cases for numbers that are abnormal. I postpone cases if there are specific post-operative implications. I genuinely believe we can keep just about any patient alive during the procedure itself, but it is the post-operative course where they run into trouble. I did have a colleague who cancelled cases left and right for all these theoretical "academic" reasons, but she was let go.

I agree some anesthesiologists are dogmatic. However, I find them to exist in both academic and private practice environments. But then again, you know my viewpoint since we have sparred on this topic for quite some time. Glad to see you back on the forum.

I'm glad to see such progressive thinking.

Please don't think I'm basing my opinion just on my personal residency training.

I maintain that programs like yours are the minority. Your program's philosophy should be, and hopefully at some point in the future will be,

the majority.

I maintain that most residents today are having fear instilled in them concerning general anesthesia and the parturient, and they should therefore diligently,albeit in vain, continue attempts at neuraxial anesthesia until the cows come home.

 

[IlDestriero]

I'm glad to see such progressive thinking.

Please don't think I'm basing my opinion just on my personal residency training.

I maintain that programs like yours are the minority. Your program's philosophy should be, and hopefully at some point in the future will be,

the majority.

I maintain that most residents today are having fear instilled in them concerning general anesthesia and the parturient, and they should therefore diligently,albeit in vain, continue attempts at neuraxial anesthesia until the cows come home.

I used to take home call for l&d, so a crash/emergent section was me in the bunny suit, all sweaty and out of breath pushing the prop sux & tube. Now, in my new career, I often provide anesthesia for EXIT procedures. All the moms get GA. I've never had an airway problem or aspiration. These concerns are real, but the fear is unfounded. There were times in residency where we gave a GA on the labor deck when we probably could have used the epidural. I think the times are a changin' with regard to this.

 

[urge]

I'm glad to see such progressive thinking.

Things have changed over 14 LONG years Jet.

 

[pgg]

OK, this has been bugging me for a while, so I have to ask: Jet, where are you getting the idea that cases get canceled needlessly in academia?

Maybe we need a "private practice dogma" thread where the academic guys can debunk all the PP-generated myths about needlessly cancelled cases and the alleged prevalence of weak-sauce amongst academic anesthesiologists.

My opinion, though, is that our residency education instills fear in residents concerning general anesthesia and the parturient.

This reminds me of how many times different attendings told me in residency, "Now, most people are extremely worried about general anesthesia for c-sections, but the truth is that the risk is probably way overblown. The risk is modestly higher, but GA for a section is usually no big deal." They all said that! All of them! I don't know where all these anesthesiologists who were "terrified" of GA in parturients were hiding, because I've never met one.

In fact, if jet wasn't trying so hard to convince us that people are afraid of GA for sections ... would it ever occur to people to think that most people are afraid of GA for sections? Who's spreading the dogma now?!?


I'm starting to wonder if "other people other places are afraid of GA for parturients" and "other people other places cancel cases all the time" aren't actually the biggest myths in all of anesthesiology.


Oh, and welcome back jet we missed you.

 

[Salt Creep]

Thats the perfect answer.

We've all had to call a colleague for help in this situation.

My opinion, though, is that our residency education instills fear in residents concerning general anesthesia and the parturient.

So much so that it affects their performance in their first years in private practice.

I'm a CA-1 and just finished my first OB month. I did 2 c-sections myself under general after failed attempts at neuraxial anesthesia, and I know of 2 others that happened during the month. And I don't mean urgent ones either - these were pretty much elective (repeat scheduled c/s type of case), so we had all the time in the world to be needle-jockeys.

The first one that comes to mind, we were doing a CSE (what we usually do, since our OB residents are the slowest creatures you've ever imagined), and I had a great LOR but couldn't get CSF. My attending tried with the same result, and again in another space. Then he tried a single-shot spinal without success. So he just said, "I don't trust an epidural I'd get here, let's just go to sleep." And we hadn't tried for 10 minutes either - more like 5 MAYBE. It was basically 3 good attempts.

The second was similar - great LOR (at an appropriate depth, something like 5cm on a neither skinny nor enormous pt) but no CSF. My attending thought I was just lateral & missing the thecal sac, so had me thread the catheter & just use the epidural. It must not have been epidural, because she got a level but never sufficient for surgery (ie - she clearly and intensely felt sharp pain), so off to sleep she went.

Long way of saying that I don't think our program instills that fear. One attending told me she'd done more GA than RA for c/s. I'm taught to respect the possibility of a difficult airway and to be prepared appropriately, but we don't have that fear. Even just a few sections in that one month ended up as general after failed regional, despite having all the time in the world for the regional.

And I agree - great to see you back.

 

[Salt Creep]

We do, however, get our share of dogma.

We have plenty of attendings that will call out dogma for being such too, though. In balance, I think most will say, "this is what we really should have here, but you can make an argument for an a-line; why don't you get the experience & go ahead and place one" Then if you struggle too much with it, just forget it & go without it.

 

[Planktonmd]

I have to say that I actually agree with Jet's observation.
All the new grads I have seen over the years had the following issues:
1- Fear of GA for a C section and lack of experience in how to do it
2- Fear of Succinylcholine
3- Tendency to place unnecessary invasive monitors
4- Tendency to ignore the political and financial factors in deciding which case should proceed and which case should not
5- Lack of understanding of the role of CRNA's and how to deal with them
6- Inability to effectively communicate with surgeons
7- Inability to diplomatically deal with other consultants
8- Tendency to make a big deal of things that don't need to be a big deal
These are some of the things I have seen and they tend to correct themselves with time and experience but they are important and they do indicate a lack of real world connection during residency training.
So, If things have changed recently and if things are different now this is really good news but I have not seen it yet.

 

[hoyden]

In fact, if jet wasn't trying so hard to convince us that people are afraid of GA for sections ... would it ever occur to people to think that most people are afraid of GA for sections?

Some are. I finished residency a year ago and our main OB anesthesia attending was plain crazy when GA came into picture - even if the patient insisted she wants a GA ( a patient was anesthesiology attending herself with a perfect easy airway, no other issues, young and healthy), not a neuraxial technique.

 

[seinfeld]

I have to say that I actually agree with Jet's observation.
All the new grads I have seen over the years had the following issues:
1- Fear of GA for a C section and lack of experience in how to do it
2- Fear of Succinylcholine
3- Tendency to place unnecessary invasive monitors
4- Tendency to ignore the political and financial factors in deciding which case should proceed and which case should not
5- Lack of understanding of the role of CRNA's and how to deal with them
6- Inability to effectively communicate with surgeons
7- Inability to diplomatically deal with other consultants
8- Tendency to make a big deal of things that don't need to be a big deal
These are some of the things I have seen and they tend to correct themselves with time and experience but they are important and they do indicate a lack of real world connection during residency training.
So, If things have changed recently and if things are different now this is really good news but I have not seen it yet.

As a grad in the past couple years i will agree with most of these observations. My group tends to fear Sux more than my training did.

Regarding the OB issue. My training taught me to fear GA for c-section. Since being in practice i have done plenty.

 

[ssmallz]

One attending told me she'd done more GA than RA
for c/s.

Ughhh, thats not very good either. That person must be really awful at RA or not do many c/s b/c I'd say we do more than 90% of our sections under regional. I understand what Jet's saying about not being afraid to do GA but lets not forget that RA is still the first option in most non STAT situations. My experience seems to mirror the rest of the responses, mostly RA but certainly done quite a few GAs, some for non emergent situations

 

[Idiopathic]

I won't lie, I'd rather not put a parturient to sleep. I think that residents at our program get somewhat nervous regarding GA in that situation and we may go a little overboard with our regional attempts but in the end, its the best for the patient and so i don't mind trying

 

[IlDestriero]

I won't lie, I'd rather not put a parturient to sleep. I think that residents at our program get somewhat nervous regarding GA in that situation and we may go a little overboard with our regional attempts but in the end, its the best for the patient and so i don't mind trying

Your risk of aspiration is far greater in the acute abdomens that you do every day without breaking a sweat. Unless she's as big as a house, with sleep apnea, micrognathia, etc or has severe edema from preeclampsia I don't think an experienced laryngoscopist has much to fear with her airway either. Bump her up, confirm optimum intubating position, cricoid pressure and go. Have a bougie and maybe glidescope backup. Think about that next time you're considering GA, and just do it. Tell your attending you NEED the experience a few times before you graduate. If he balks, tell him that it sounds like he/she needs the experience as well.

 

[EPADHA]

just trolling..
as an IM resident, I have been quite surprised by how conservative and cautious anesthesiologists are at at my institution. That's in stark contrast to several medicine specialities where I have to have evidence in my hand or else I might get chewed up on rounds. Having said that, I think we in Internal medicine overdo it.
But all said and done, given the acute situations and mess anesthesiologists deal with, in a way I am glad that they are so cautious and always trying to preempt things.
It shd never hurt to put one's thinking cap on.

 

[Idiopathic]

cricoid pressure

talk about dogma

And i didn't say i couldn't or wouldn't put a csection to sleep i just said id rather not.

 

[Gern Blansten]

It shd never hurt to put one's thinking cap on.

Welcome to the board.
Also, don't forget that if your head gets too big, your thinking cap won't fit anymore.

 

[IlDestriero]

talk about dogma

And i didn't say i couldn't or wouldn't put a csection to sleep i just said id rather not.

I don't think cricoid hurts, and if it is hampering your intubation you can have them release it. BTW, the MRI study a few years ago and again last year showed that it does occlude the esophagus in some people, AND DOES OCCLUDE the hypopharynx. If she aspirates and dies and you didn't try it, you will get sued. (and lose) Good luck trumping Jon Benumof and Andranik Ovassapian on the stand, you'll need it.
As cricoid pressure is extremely unlikely to hurt a patient, can be immediately removed if needed to facilitate intubation and, most importantly, MAY decrease the risk of a potentially avoidable life threatening complication in SOME patients, I see no reason to abandon it, and would urge you to reconsider your position. Aspiration can kill a healthy patient and your attitude seems quite cavalier. At least review the literature showing effective compression of the hypopharynx before you dismiss this routine practice as unsupported "dogma". (if you have not already)

Anesth Analg. 2009 Nov;109(5):1546-52.
Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant.

Rice MJ, Mancuso AA, Gibbs C, Morey TE, Gravenstein N, Deitte LA.
Departments of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida 32610-0254, USA. [email protected]
Comment in:

• Anesth Analg. 2009 Nov;109(5):1363-6.
• Anesth Analg. 2009 Nov;109(5):1360-2.

Abstract

BACKGROUND: Sellick described cricoid pressure (CP) as pinching the esophagus between the cricoid ring and the cervical spine. A recent report noted that with the application of CP, the esophagus moved laterally more than 90% of the time, questioning the efficacy of this maneuver. We designed this study to accurately define the anatomy of the Sellick maneuver and to investigate its efficacy. METHODS: Twenty-four nonsedated adult volunteers underwent neck magnetic resonance imaging with and without CP. Measurements were made of the postcricoid hypopharynx, airway compression, and lateral displacement of the cricoid ring during the application of CP. The relevant anatomy was reviewed. RESULTS: The hypopharynx, not the esophagus, is what lies behind the cricoid ring and is compressed by CP. The distal hypopharynx, the portion of the alimentary canal at the cricoid level, was fixed with respect to the cricoid ring and not mobile. With CP, the mean anterioposterior diameter of the hypopharynx was reduced by 35% and the lumen likely obliterated, and this compression was maintained even when the cricoid ring was lateral to the vertebral body. CONCLUSIONS: The location and movement of the esophagus is irrelevant to the efficiency of the Sellick's maneuver (CP) in regard to prevention of gastric regurgitation into the pharynx. The hypopharynx and cricoid ring move together as an anatomic unit. This relationship is essential to the efficacy and reliability of Sellick's maneuver. The magnetic resonance images show that compression of the alimentary tract occurs with midline and lateral displacement of the cricoid cartilage relative to the underlying vertebral body.


and

Anesth Analg. 2009 Nov;109(5):1360-2. Sellick's maneuver: to do or not do. Ovassapian A, Salem MR.

 

[Mman]

Why is a patient fresh off dialysis being delayed because the phlebotomist is tied up and she can't draw a pre-op K+? Why do we need a pre-op K+? Was a KMart dialysis machine used or something?


TO ASK: "WHY?"

I've had 3 patients in the last 6 months that have been dialyzed within the last 12 hours and presented with a K of > 6 in preop holding (each one verified with a repeat fresh draw). I have no idea how on earth they managed to get the patients K higher than it was before their last HD run, but they did.

 

[Planktonmd]

I've had 3 patients in the last 6 months that have been dialyzed within the last 12 hours and presented with a K of > 6 in preop holding (each one verified with a repeat fresh draw). I have no idea how on earth they managed to get the patients K higher than it was before their last HD run, but they did.

This is why I don't check potassium on patients who just had dialysis.

 

[Noyac]

I won't lie, I'd rather not put a parturient to sleep. I think that residents at our program get somewhat nervous regarding GA in that situation and we may go a little overboard with our regional attempts but in the end, its the best for the patient and so i don't mind trying

How is it the best for the pt?

 

[Noyac]

My residency was sort of mixed on this subject. I remember even doing a STAT c/s on a small asian girl under GA with a mask. Yes I masked her for the whole c/s with my attending right there. Neither one of us could intubate her but the mask ventilation was fine so we went with it.

On a side note, we vowed not to tell anyone bc of the backlash we would have received from the other attendings.

So it still depends on the individual as to how they feel about this topic.

Disclaimer: I am not endorsing mask ventilating a gravid pt if you have other good options. This may just be my own person DOGMA.

 

[Noyac]

The important point of this thread "ask WHY" is that we are trained by very intelligent people who have different practice experiences and have formed their practice style based on these experiences. When they tell you how to do something be respectful of their approach and give it try but don't be afraid to question it respectfully. Residency is a the time to learn. Part of learning is doing things in different ways and seeing for yourself which approach is your preferred method. I don't think any of us mean to belittle academia even though it may seem so at times.

Also, just be glad you are getting the training you are. Imagine training for 1 yr like a crna and coming out to the real world with hard and fast ways of doing everything. And thinking you are experienced on top of that.

 

[proman]

My residency was sort of mixed on this subject. I remember even doing a STAT c/s on a small asian girl under GA with a mask. Yes I masked her for the whole c/s with my attending right there. .

Isn't that what they do frequently in England, and also why they don't fear the gravid airway as much?

 

[Gern Blansten]

Also, just be glad you are getting the training you are. Imagine training for 1 yr like a crna and coming out to the real world with hard and fast ways of doing everything. And thinking you are experienced on top of that.

 

[Idiopathic]

How is it the best for the pt?

seriously? are you arguing that general for elective cs is somehow better than regional when given the choice?

 

[jetproppilot]

I've had 3 patients in the last 6 months that have been dialyzed within the last 12 hours and presented with a K of > 6 in preop holding (each one verified with a repeat fresh draw). I have no idea how on earth they managed to get the patients K higher than it was before their last HD run, but they did.

DUDE, SERIOUSLY. THINK ABOUT WHAT YOU'RE SAYING.

I mean, DUDE, REALLY?

Either the lab chick running the Ks is too busy fluffing an attending or the dialysis machine at your hospital doesnt work, since a post-dialysis K of six is more rare than Jesse James turning down a tattoed crakkwhore. Seriously. If thats occurring at your hospital, and the Ks are real and not a result of the chick running them fluffing an attending while shes running the labs, you're working at the equivalent of a Cambodian prison camp.

 

[Coastie]

DUDE, SERIOUSLY. THINK ABOUT WHAT YOU'RE SAYING.

I mean, DUDE, REALLY?

Either the lab chick running the Ks is too busy fluffing an attending or the dialysis machine at your hospital doesnt work, since a post-dialysis K of six is more rare than Jesse James turning down a tattoed crakkwhore. Seriously. If thats occurring at your hospital, and the Ks are real and not a result of the chick running them fluffing an attending while shes running the labs, you're working at the equivalent of a Cambodian prison camp.

 

[urge]

My residency was sort of mixed on this subject. I remember even doing a STAT c/s on a small asian girl under GA with a mask. Yes I masked her for the whole c/s with my attending right there. Neither one of us could intubate her but the mask ventilation was fine so we went with it.

I masked some parturient that had her baby stuck midway not too long ago. I thought at first I would take the edge off since she was going insane. I quickly realized 8% sevo was the way to go. Damn OB took like 45 min. Called for forceps... messed around for a while.... couldn't get the placenta out... It was painful to watch. The woman did ok.

 

[Noyac]

seriously? are you arguing that general for elective cs is somehow better than regional when given the choice?

I haven't given you my argument. I just want to know why you think it's "better" for the pt to go overboard with the regional?

And you can be assured that I have an opinion here.

 

[Idiopathic]

oh, okay...my argument is simply that regional for cs is preferrable over general, i dont advocate flogging patients unnecessarily, but im also not overly quick to go to general as fallback for failed regional. some of my colleagues are and thats their prerogative.

 

[Mman]

DUDE, SERIOUSLY. THINK ABOUT WHAT YOU'RE SAYING.

I mean, DUDE, REALLY?

Either the lab chick running the Ks is too busy fluffing an attending or the dialysis machine at your hospital doesnt work, since a post-dialysis K of six is more rare than Jesse James turning down a tattoed crakkwhore. Seriously. If thats occurring at your hospital, and the Ks are real and not a result of the chick running them fluffing an attending while shes running the labs, you're working at the equivalent of a Cambodian prison camp.

Trust me, I know. You wouldn't think it's a prison camp, though. Big shiny 900 bed hospital. Level 1 trauma center for 31 counties in our state. Hundreds of millions of dollars worth of new construction in the last 5 years and more to come.

I have to check the potassium because somehow I've seen them raise a patient's K post-dialysis. I don't know how. I'm assuming that there is a screwup in the dialysate bath. But I have to check because I'm not proceeding with an elective case when they screw up that bad.

I think in the last 6 months I've probably only had to cancel 4 or 5 cases and half of them are due to hyperkalemia on patients that were dialyzed recently. Needless to say I don't think too highly of the dialysis center here.

edit: should also point out that these are verified on multiple sticks from multiple sites and not hemolyzed specimens.

 

[IlDestriero]

Trust me, I know. You wouldn't think it's a prison camp, though. Big shiny 900 bed hospital. Level 1 trauma center for 31 counties in our state. Hundreds of millions of dollars worth of new construction in the last 5 years and more to come.

I have to check the potassium because somehow I've seen them raise a patient's K post-dialysis. I don't know how. I'm assuming that there is a screwup in the dialysate bath. But I have to check because I'm not proceeding with an elective case when they screw up that bad.

I think in the last 6 months I've probably only had to cancel 4 or 5 cases and half of them are due to hyperkalemia on patients that were dialyzed recently. Needless to say I don't think too highly of the dialysis center here.

edit: should also point out that these are verified on multiple sticks from multiple sites and not hemolyzed specimens.

I hope that you have filed safety reports to risk management, using the labs as clear proof. If this is true, their incompetence is going to kill someone.

 

[Mman]

I've tried getting an explanation from nephrologists when they wander through preop or PACU for a consult and I never can get a clear answer. All I know is that I now no longer trust them in our hospital.

 

[Arch Guillotti]

I can only think of a couple of cases in residency that were ever cancelled. Most of the attendings were pretty reasonable with things. Of course there were a couple out there that ran around like chicken little. I proceeded forward with many many cases when the patient clearly wasn't "optimized" (and not all were emergent cases). Some of the attendings I worked with were real cowboys that really pushed the boundaries sometimes. My experience after residenct is that cases are rarely cancelled, but I think that this is because the population I deal with isn't quite as sick and their surgeon really doesn't want any complications so the patients are usually more "tuned up".