Don't be afraid to change course

[jetproppilot]

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Residency programs appropriately spend alotta time indwelling into budding anesthesiologists the value of preoperative assessment of the patient and subsequent arrival at an anesthetic plan for the case.

In other words we see the patient before the operation, assess them physically and historically, and arrive at a plan.

I've written this very eloquently so I can deliver a point. This verbose style makes me uncomfortable so I'll translate what I really said for individuals like me who would rather see the above prose communicated as

Dudes, we see patients before an operation so we can size'em up, see what we're dealing with, and figure out what we're gonna do on

GAME DAY.

Regardless of which vernacular you're drawn to, both deliver the same message which is

current day anesthesiologists evaluate patients before a surgical intervention, then decide on an anesthetic

PLAN

which of course is carried out when the surgery occurs.

UNFORTUNATELY THE SCIENCE OF MEDICINE IS NOT PERFECT.

SOMETIMES IT IS NECESSARY TO CHANGE YOUR PLAN.

And that's ok, by the way. To change your plan. But we'll get back to that later.

I reflect on my residency training. I had many great attendings. A few though were, uhhhhhhhh,

not good.

I noticed a common trait among my

BOTTOM FEEDER STRUGGLING ATTENDINGS when I was a resident.

Namely, their

LACK OF ABILITY TO CHANGE COURSE.

We'd have an anesthetic plan. Me the resident working with

Bottom Feeder Attending. Here's an example.

Easy case, knee scope. Patient has moderate to severe asthma. Preoperative assessment done. Plan spinal. (I don't advocate this current day btw...just reflecting)

Beautiful.

I get to work, being my great resident self, look at the schedule. Ok I gotta spinal for a knee scope with asthma and I'm still living out all academic dogmas dictated by my attendings some of which should be Taco Bell managers but you know ******* it I'm rollin',

set up, blah blah blah,

attempt spinal.

I can't make it happen. I'm a CA-1 so a CA-2 comes in. Can't get it. So the attending steps in. Can't get it. So the attending calls ANOTHER attending. Can't get it.

Eventually we put the dude to sleep.

I WANT YOU TO LOOK WITH A CRITICAL EYE AT THE CASE ABOVE.

Yeah, it's a residency program so

a little leeway there but

this case points out a very important concept for budding anesthesiologists reading this.....which is....


DUDE...YOU HAD THIS PLAN. YOU INSTITUTED IT. IT DIDN'T WORK. IT'S OK TO


CHANGE


YOUR PLAN.


REALLY. YEARD ME??????


IT'S OK.

You're the attending watching a cuppla fumbling residents. No big deal. Ok, time for you to step in. You try, you can't get it. At this point you can prolong the misery or you can

CHANGE COURSE FROM THE INITIAL PLAN

and take care of business.

Many clinicians arrive at a plan and when said plan is unsuccessful they lack foresight which is revealing to them "uhhhhh dude you need to change course" but since they have a plan,

HELL OR HIGH WATER THEY'RE GONNA INSTITUTE

THE PLAN.

I'm here to tell you, budding clinical studs,

NO.

Not in this business.

IT'S OK...ACTUALLY SOMETIMES IT'S

BETTER

to change plans.

I'll give you a case from today.

46 y/o healthy dude for a shoulder scope.

We perform preoperative ultrasound guided interscalene blocks prior to surgery which dramatically reduces general anesthesia requirement and provides superior post operative pain relief to the point that NO opioids are required during the case or after the case.

We typically do these cases like...block done in pre-op. Bring'em back to the OR, monitors on, pre O2, push a stick of propofol, put an LMA in, crack some sevoflurane, use the BIS to guide volatile anesthetic administration. Case concluding, turn sevoflurane down commensurate to surgical stimulation and BIS reading, case finishes, pull out LMA, go to PACU,

patient going home in 30 minutes. Numb shoulder. Minimal general anesthesia insult. No opioids given/required.

Buh bye!

Another happy patient.

That's how we roll...

mosta the time. Unfortunately sometimes you have to change your plan.

The 46 year old dude I did today had a great interscalene block. We bring him back into the OR, monitors on, pre O2. Push a stick of propofol. LMA rolls in smoothly,

albeit initially.

Then, even under anesthesia, dude starts to do some weird s h it.

Sevo is on 5...he's breathing thru the LMA but his arms are still moving...no prob, its still early, sevo up to max, give a little opioid, actions taken in an attempt to achieve a comfortable anesthetic plane...keep in mind we just put him to sleep...we still haffta position...

Out of nowhere peak inspiratory pressures go up, I place my hand on the bag to assess respiration, cuppla squeezes, it's

TIGHT MAN.

READ:

I AM NOW IN THE OPERATING ROOM, STRUGGLING WITH MY PLAN FOR THIS CASE, AND THE %^CKING CASE HASN'T EVEN STARTED YET LOL

I've got 2 choices here.

I can

CONTINUE TO TRY AND MAKE "MY PLAN" WORK, which isn't working right now or i can

CHANGE COURSE, ADMIT TO MY SELF IN THE MOMENT MY PRE ANESTHETIC PLAN FAILED,

and move on.

I chose B.

Realizing that struggling with an LMA during induction and before surgery starts IS A BAD SIGN,

I

changed course, gave some more propofol followed by 140mg succinylcholine, and

INTUBATED THE DUDE.

This wasn't in my plan, yet within about a sixty second window I realized my plan...my coveted plan I had decided upon before we started and sounded GREAT

wasn't gonna work.

I chose to

CHANGE COURSE, RATHER THAN FORCE A PLAN THAT HASN'T WORKED BUT GOD DA M MIT THATS THE PLAN SO WE'RE GONNA MAKE IT WORK, as represented by my

Bottom Feeder Attendings

when I was a resident.

WHICH GROUP ARE YOU IN???

Are you gonna force your "PLAN", no matter what?

I HATE TO BE JUDGMENTAL BUT IN THIS CASE, DUDE, YA GOTTA MAKE THE CALL

or

GO INTO PSYCHIATRY.

It's ok to

CHANGE YOUR PLAN WHEN THE CHIPS ARE DOWN.

 

[Gern Blansten]

Agree. Couple of tries at initial plan. If it doesn't work, change the plan. If you're slick, you get it done before the surgeon even knew and there is no delay. I've seen people putz around for an hour trying to get a spinal. If it's not in in 10 minutes, time to move on.

 

[deleted126335]

Also agree.

When the facts change, I change my mind. What do you do sir?
-John Maynard Keynes

 

[btbam]

Good points Jet, but I don't think deciding to tube a guy cause an LMA won't seat is an earth-shattering decision. What's the alternative, mess around trying to seat it for 10 minutes?

 

[michigangirl]

Agree. The ability to ADJUST is one of the key components to the anesthesiologists I look up to and tried to emulate as a trainee-- and still do as an attending. In addition to the ability to adjust-- the ability to stay CALM during that adjustment is not to be taken lightly. There are too many attendings I've worked with that just can't seem to stay calm and keep their stuff together in the moment without making everyone else in the room nervous. So counterproductive, and not a good role model for trainees. Adjust, stay calm and poised-- even when you're scared out of your mind on the inside. Calm does not equal complacent. The calmest, most poised colleagues I know are the ones who get the most accomplished in the shortest period of time. Bumbling, nervous anesthesiologists are no fun when you're training.

 

[RxBoy]

I noticed a common trait among my

BOTTOM FEEDER STRUGGLING ATTENDINGS when I was a resident.

Namely, their

LACK OF ABILITY TO CHANGE COURSE.

Great advice. I work with these same type of attendings. Their also the same ones that blow their **** and start sweating under the lamp.

Couple months ago had a fem-pop bypass. Pt was sick, you know the usual PVD/CAD/ESRD/HTN/DM story. Pt needed a-line. Took pt back with plan to put radial aline once on OR table with mild sedation. I attempt left radial, no go. Try through and through, no go. Go more proximal, no go. He starts working on the other radial, no go.

20 minutes in putting track marks along this ladies radial arteries, I politely ask want to go different spot? He refuses. Calls overhead for u/s. Board runner rockstar cardiac trained attending comes in to see why the hold up. Walks in like he owns the place. Tells us to stand back, preps armpit and throws in an axillary a-line 2 minutes flat. he swaggered his way to the exit door. Thought to myself, I want to be just like him when I grow up.

 

[periopdoc]

Works for the boards too!

-pod

 

[jetproppilot]

.

 

[Idiopathic]

i must say i dont usually agree with jet. however, ive put women to sleep after failed spinal for cesarean section (heresy at my institution), put total knees to sleep following the same, aborted arterial lines, changed my mind about awake intubation literally as we were inserting the scope...its hard to justify sometimes, but there is a gut feeling that maybe it isnt the right thing.

its not easy. it is always much simpler for the attending to demand that the preset course is travelled, and any deviation from that course results in many-hour delays or worse, cancellations. weve all seen it. and we all know that the hardline approach in anesthesia is absolutely not always the best way to approach the situation at hand. the key is knowing when it is. recognizing the difference between the asthmatic and the true pulmonary cripple, understanding that its sometimes okay to put the run-of-the-mill gravid female to sleep, knowing that the dental abscess and the supraglottic mass will present fundamentally different airway challenges. these are the things that i learned as an attending that i did not necessarily learn as a resident.

btw, good post

 

[PMPMD]

Good points Jet, but I don't think deciding to tube a guy cause an LMA won't seat is an earth-shattering decision. What's the alternative, mess around trying to seat it for 10 minutes?

I've seen people do that, though. I believe JPP was saying don't be one of them.

 

[jwk]

Good points Jet, but I don't think deciding to tube a guy cause an LMA won't seat is an earth-shattering decision. What's the alternative, mess around trying to seat it for 10 minutes?

There are certainly people that would do that, especially if they already had the patient up in the damn beach chair and didn't want to take the time to do it right, just do what they could to get by. Dangerous choice. Much better to have it right before you start then have to manage an airway intra-op.

This is the same type of thinking that leads people to make several too many attempts at intubating an unanticipated difficult airway, totally traumatizing the airway into a bloody friggin mess and making FOB damn near impossible.

 

[nap$ter]

agree - be flexible.

was reading through this post looking for the jpp pearl... it isn't there (this time). change your plan if it isn't working? ummm, no kidding...

this post sucks. 😀

 

[cincincyreds]

Yup, things don't always go to plan. A lot of guys do total shoulders just with a block and a propofol infusion. I've had a few instances where I've had to go save the day as the block didn't work and they were on teh verge of losing the airway.

I would just come in with a glidescope and tube em. So with my shoulders, I do a block and a tube. Done.

Unanticipated difficult DL. I don't struggle. I just stick in an LMA temporarily until either the glidescope or fiberoptic comes in. It is not worth it to muck up the airway and have the case cancelled.

Epidural doesn't work for the total knee on incision? Just put them to sleep and do a femoral block as the patient is waking up.

Things happen, I just have a backup plan for everything and think through the scenarios before things happen.

IV infiltrates during a RSI, well the Sux is IM, so ask the nurse to call for help for another IV and in the meanwhile just put the tube in the trachea

 

[epidural man]

Plan spinal. (I don't advocate this current day btw...just reflecting)

Curious....why not?

 

[jetproppilot]

Curious....why not?

Doing a spinal for a knee scope works fine of course so what I should've said is I don't prefer to do it that way since with a GA I can have them outta recovery in 30-45 minutes..with a spinal they are in PACU too long waiting for the block to wear off...urinary retention...

Essentially any quick outpatient procedure gets general anesthesia from me.

 

[epidural man]

Doing a spinal for a knee scope works fine of course so what I should've said is I don't prefer to do it that way since with a GA I can have them outta recovery in 30-45 minutes..with a spinal they are in PACU too long waiting for the block to wear off...urinary retention...

Essentially any quick outpatient procedure gets general anesthesia from me.

Oh I hear that. And bupivicaine spinals are so very unpredictable - some last 4 hours, some 45 minutes.

Try a 2-cholorprocaine spinal. Very predicatable and lasts maybe 60-80 minutes. Uninary retention is not an issue (in my limited experience - not having done thousands)

 

[michigangirl]

I've had 2 knee scopes myself for partial meniscectomy-- Green mask GA with propofol, intraop phenergen and decadron with a little fentanyl worked in. I woke up both times feeling PHENOMENAL. And out of there within 45 minutes.

 

[cincincyreds]

For the knee scope, how about 1cc of Novicaine 10% diluted 1:1 with dextrose. Lasts about 20 minutes for those quick knee scopes, and works for cerclages nicely also.

 

[jetproppilot]

For the knee scope, how about 1cc of Novicaine 10% diluted 1:1 with dextrose. Lasts about 20 minutes for those quick knee scopes, and works for cerclages nicely also.

No reason to do that for a twenty minute case.

They'll still sit in the PACU much longer than a BIS guided general anesthetic.

 

[PMPMD]

No reason to do that for a twenty minute case.

They'll still sit in the PACU much longer than a BIS guided general anesthetic.

Gotta love PP.

We had a surgeon in residency who would take 2-4 hours for scopes or longer. We weren't even sure if tetracaine spinals would last.

 

[doctor712]

These last couple scenarios (with scopes taking much longer in academics then with jpps' setup), is it taboo to ask surgeons how long/what's the ETA on this surgery -- at START of case? I could imagine that if you have a nice relationship the surgeon would reply without much thought. However, you wouldn't need to ask in that scenario because you've been working together and know his/her style. So this is more for the resident/fellow/away rotation tryout situation. The point, in part, of this thread is to tailor a style and give it a shot, change as needed. If it were me, I'd like to know if the tetracaine will last and if it's going to be 4 hours, why worry about it, use something else for a spinal (i know it's more complicated than that, but for this question..) For example. I witnessed this observing. A 3 bypass CABG at the local Academic place nearby down here has taken +5 hours. Might have been a mitral valve repair in there, some yes. And some no. I saw a bunch, and can remember case starting at 730 and them closing around 1-2pm MANY times. and 2-3 other times.
At a friends place who is a CT anesthesiologist, PP, it was 2-3 hours. Sure, the surgeon will tell u when he's finishing sometimes and of course you can just look, but for these "first time with surgeon" experiences, if youre debating regional/spinal, or a certain local medicine, ask a fellow anesthesiologist if u can, or just ask surgeon ETA? There are a few surgeons that come to mind, don't think they'd take a question about ETA from a newbie at start of case too well...

D712

 

[PMPMD]

These last couple scenarios (with scopes taking much longer in academics then with jpps' setup), is it taboo to ask surgeons how long/what's the ETA on this surgery -- at START of case? I could imagine that if you have a nice relationship the surgeon would reply without much thought. However, you wouldn't need to ask in that scenario because you've been working together and know his/her style. So this is more for the resident/fellow/away rotation tryout situation. The point, in part, of this thread is to tailor a style and give it a shot, change as needed. If it were me, I'd like to know if the tetracaine will last and if it's going to be 4 hours, why worry about it, use something else for a spinal (i know it's more complicated than that, but for this question..) For example. I witnessed this observing. A 3 bypass CABG at the local Academic place nearby down here has taken +5 hours. Might have been a mitral valve repair in there, some yes. And some no. I saw a bunch, and can remember case starting at 730 and them closing around 1-2pm MANY times. and 2-3 other times.
At a friends place who is a CT anesthesiologist, PP, it was 2-3 hours. Sure, the surgeon will tell u when he's finishing sometimes and of course you can just look, but for these "first time with surgeon" experiences, if youre debating regional/spinal, or a certain local medicine, ask a fellow anesthesiologist if u can, or just ask surgeon ETA? There are a few surgeons that come to mind, don't think they'd take a question about ETA from a newbie at start of case too well...

D712

Unfortunately, not all the slow surgeons realize how slow they are, or have the ability to predict times. We tell the residents to top off the sevo.

 

[imfrankie]

Unfortunately, not all the slow surgeons realize how slow they are, or have the ability to predict times. We tell the residents to top off the sevo.

I don't miss slow especially with sick patients.