How early is too early?

[gunnershow]

When I get called to a floor code, I'm sure as s*** not wasting my time helping the RT properly bag. Just put the damn tube in and GTFO.

Also, a fair number of these codes are respiratory/hypoxemic arrests, of which the tube definitely helps with.. how often do you intubate and have frothy pulmonary edema come roaring back with compressions? Now that's if you're lucky... torrential aspirate if you're unlucky. Not uncommon that ROSC follows proper oxygenation/ventilation.

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[Beeftenderloin]

And how is the quality of mask ventilation at most floor codes?

If you walk in the room and see anyone who isn’t an anesthesiologist (and even some who are) bagging with a 1 hang mask seal, it’s all but guaranteed every breath is going in the stomach/room. We’re the only ones who learn properly in the OR with the feedback of a compliant bag, continuous ETCO2, monitors telling us exactly how much pressure it’s requiring to get the breath, that abrupt change in compliance when you put an OPA in or the paralytic set up and you know the breaths are going to the right place. And we do it 1000s of times in training.

Learning to bag with an AMBU is like learning to intubate on one of those rigid task trainer mannequins. I can’t tell you how many codes I’ve walked into to find some well meaning RT either smashing the patients face into the back of the bed with no OPA in, or with no discernible seal at all, just ventilating the room. Some have been great, doing 2 hang mask seal, pulling the mandible forward, with a buddy bagging. Way too much of the former, not nearly enough of the latter.

 

[T-burglar]

Oxygenation and ventilation is THE treatment for many unwitnessed arrests in the hospital, there’s a small number of disease processes where PPV may actually be so detrimental that you could argue to avoid it if at all possible, but those disease processes are usually the kind that make CPR pointless anyway once you have “mature” cardiac arrest.

The only plausible mechanism by which intubation worsens outcomes is pausing CPR for too long. For that just get a glidescope so you don’t have to pause.

 

[T-burglar]

And realistically - BMV isn’t adequate in many cases for a variety of reasons

 

[abolt18]

If you walk in the room and see anyone who isn’t an anesthesiologist (and even some who are) bagging with a 1 hang mask seal, it’s all but guaranteed every breath is going in the stomach/room. We’re the only ones who learn properly in the OR with the feedback of a compliant bag, continuous ETCO2, monitors telling us exactly how much pressure it’s requiring to get the breath, that abrupt change in compliance when you put an OPA in or the paralytic set up and you know the breaths are going to the right place. And we do it 1000s of times in training.

Learning to bag with an AMBU is like learning to intubate on one of those rigid task trainer mannequins. I can’t tell you how many codes I’ve walked into to find some well meaning RT either smashing the patients face into the back of the bed with no OPA in, or with no discernible seal at all, just ventilating the room. Some have been great, doing 2 hang mask seal, pulling the mandible forward, with a buddy bagging. Way too much of the former, not nearly enough of the latter.

I kept thinking this exact thing. Never seen an RT mask well with an ambu. Just smashing it on the face squeezing reeeeeel hard.

 

[Blockit]

My shop only cares about what time patients roll into the room. Even then the nurses will fudge it a bit to avoid the extra work of charting a delay.

This means I show up at 7:15 for a 7:30 start. For heart cases I’ll show up a little earlier.

So you can check your machine, stock everything that isn’t stocked, draw up all your drugs, and see the patient in 15 minutes? Or do you have extenders?

 

[thinkorswim]

So you can check your machine, stock everything that isn’t stocked, draw up all your drugs, and see the patient in 15 minutes? Or do you have extenders?

The 15 minutes is to change into scrubs, see the patient, and maybe grab a coffee. At most functional places you don’t even need to step foot in the OR until the patient is back there.

 

[abolt18]

So you can check your machine, stock everything that isn’t stocked, draw up all your drugs, and see the patient in 15 minutes? Or do you have extenders?

Our machine is checked overnight by the OR staff (I just check the screen to ensure that it passed its test today, crank on the suction, and make sure I've got an ambu bag). Everything is stocked by nurses throughout and at the end of each day. I draw up drugs while the nurses hook up monitors. They will text me when they're rolling to the room with the patient.

 

[pgg]

Our machine is checked overnight by the OR staff (I just check the screen to ensure that it passed its test today, crank on the suction, and make sure I've got an ambu bag). Everything is stocked by nurses throughout and at the end of each day. I draw up drugs while the nurses hook up monitors. They will text me when they're rolling to the room with the patient.

You chart review the night before or just walk in cold knowing nothing about the patient?

I have similar service and it's nice. But I still check equupment myself. They aren't perfect, and right after the patient's ass it's my ass.

Also, we sometimes have last minute schedule changes. Occasionally I come in expecting to be solo, but end up directing because someone called out or there was a surgical schedule change.

15 min prior to room time won't cut it here, unless you don't mind delaying cases and making the group look bad.

 

[thinkorswim]

You chart review the night before or just walk in cold knowing nothing about the patient?

I chart review on my phone in the morning while out walking the dog.

But for cardiac cases it’s a little more. I will actually look up the patient the night before and go in a little earlier to prepare the room.

 

[nimbus]

I chart review on my phone in the morning while out walking the dog.

But for cardiac cases it’s a little more. I will actually look up the patient the night before and go in a little earlier to prepare the room.

I chart review before I pick my lineup the evening before. If I end up with a BMI>60, EF<15%, or a terrible surgeon doing a case he has no business doing, it’ll be my own damn fault

 

[abolt18]

You chart review the night before or just walk in cold knowing nothing about the patient?

I have similar service and it's nice. But I still check equupment myself. They aren't perfect, and right after the patient's ass it's my ass.

Also, we sometimes have last minute schedule changes. Occasionally I come in expecting to be solo, but end up directing because someone called out or there was a surgical schedule change.

15 min prior to room time won't cut it here, unless you don't mind delaying cases and making the group look bad.

Not sure how my machine check is going to be different from theirs overnight. If the machine says it passed all its checks 3 hours ago, I'm not going to do it all over again. I do need to be better about checking my O2 tank on the back though.

Majority of the time I walk in cold knowing nothing.

OB, I check nothing except how many c-sections are scheduled and roll through the door at exactly 0630 when I go on shift.

Non-cardiac, I'll maybe review charts the night before 20-25% of the time, at least the first case, and see patients right before 7am (nurses will roll around 7:10-7:20).

If I'm directing our AAs, I'll pre chart everything the night before and start seeing patients at 0630.

Cardiac surgery, 75% look up the night before. Roll in 6:15-6:30 and get my syringes ready, tell the nurses if I want a swan or not (I don't), and see the patient before 6:45. Patient hits the room right around 7 for most of the surgeons.

 

[dabears505]

Man these days I'm waking up at 640 for a 730

 

[coffeebythelake]

I kept thinking this exact thing. Never seen an RT mask well with an ambu. Just smashing it on the face squeezing reeeeeel hard.

One of the RTs I've seen must be a pioneer in liquid ventilation. That's to say the patient had a mouth full of vomit, and this guy was just bagging it into the lungs. The patient ended up getting ROSC after intubation but not surprisingly ended up with severe ARDS and anoxic brain injury. Died not long after

 

[rowsdower88]

One of the RTs I've seen must be a pioneer in liquid ventilation. That's to say the patient had a mouth full of vomit, and this guy was just bagging it into the lungs. The patient ended up getting ROSC after intubation but not surprisingly ended up with severe ARDS and anoxic brain injury. Died not long after

I thought you were talking about that enteral ventilation idea for a second.

https://www.sciencedirect.com/science/article/pii/S2666634021001537

 

[Bryan O’Blivion]

I thought you were talking about that enteral ventilation idea for a second.

https://www.sciencedirect.com/science/article/pii/S2666634021001537

This is a pretty fascinating subject. Perfluorodecalin and perflubron breathing have interested me for years. Ever since I saw the video of the mouse immersed in Fluosol.

 

[abolt18]

This is a pretty fascinating subject. Perfluorodecalin and perflubron breathing have interested me for years. Ever since I saw the video of the mouse immersed in Fluosol.

The movie "the abyss" is awesome and they breathe some oxygenated liquid in that.

 

[Ronin786]

I'll add that to the reasons I'm glad I gave up call.

I can't give up call at my shop, but my workaround is that I don't ever switch my sleep schedule around when I'm on nights in the ICU. I figure a few nights of "bad sleep" where I lie down for a few hours is better for overall longevity than constantly switching my circadian cycle.

 

[pgg]

I thought you were talking about that enteral ventilation idea for a second.

https://www.sciencedirect.com/science/article/pii/S2666634021001537

My first thought was tracheal vomiting syndrome

 

[anbuitachi]

we do 730 starts here. so i get here at 630 to 645 depending on the type of case to consent, setup etc

 

[deleted1183938]

Not sure how my machine check is going to be different from theirs overnight. If the machine says it passed all its checks 3 hours ago, I'm not going to do it all over again. I do need to be better about checking my O2 tank on the back though.

Majority of the time I walk in cold knowing nothing.

OB, I check nothing except how many c-sections are scheduled and roll through the door at exactly 0630 when I go on shift.

Non-cardiac, I'll maybe review charts the night before 20-25% of the time, at least the first case, and see patients right before 7am (nurses will roll around 7:10-7:20).

If I'm directing our AAs, I'll pre chart everything the night before and start seeing patients at 0630.

Cardiac surgery, 75% look up the night before. Roll in 6:15-6:30 and get my syringes ready, tell the nurses if I want a swan or not (I don't), and see the patient before 6:45. Patient hits the room right around 7 for most of the surgeons.

So you induce your patient 75% of the time not having any clue about their health issues? Their heart, lungs, liver, kidneys nothing? Just prop roc tube let’s see what happens? Do you talk to them before hand or just meet them in the OR?

 

[abolt18]

So you induce your patient 75% of the time not having any clue about their health issues? Their heart, lungs, liver, kidneys nothing? Just prop roc tube let’s see what happens? Do you talk to them before hand or just meet them in the OR?

Lol no. I was saying I just don't look them up the night before. I usually pull up the chart right before I go see them and skim through labs, imaging, echo/Cath reports, and notes. I then do a comprehensive history with a limited physical exam (airway exam, regularly palpate pulses and check feet for edema while we talk, +/- on auscultation). I go to the OR very well informed.

 

[IlDestriero]

Our tracked time is wheels in, which is 730. I usually arrive at 7 to see the patient around 710, if I’m solo providing I come in 10 min earlier. Some folks come in much earlier and try to start by 715 or 720, but I’m not a morning person so that’s a non starter. I’ll just take a 9m snooze and start on time.

 

[T-burglar]

So you induce your patient 75% of the time not having any clue about their health issues? Their heart, lungs, liver, kidneys nothing? Just prop roc tube let’s see what happens? Do you talk to them before hand or just meet them in the OR?

More like 95% of the time, yes

 

[deleted1183938]

More like 95% of the time, yes

And this is something you are proud of?

 

[Beeftenderloin]

So you induce your patient 75% of the time not having any clue about their health issues? Their heart, lungs, liver, kidneys nothing? Just prop roc tube let’s see what happens? Do you talk to them before hand or just meet them in the OR?

I do a thorough chart biopsy before saying hello, briefly. But overwhelmingly, the most important factor in choosing my induction dose/strategy is the eyeball test.

 

[Robotic Wis-Hipple]

We have a few 6:30 starts on the general side and 6:15 starts for hearts. Everything else is 7 or later.

Early starts are stupid. If your cardiac surgeon wants to do 3 bread n butter hearts a day they need to be more efficient and have parallel room setups not ask entire OR teams to come in an hour earlier.

I hate that crap. So now your call doc is not only there later but also starting at 0545-0600? Or you have a staggered late start call “shift” which is also silly.

Edit: early starts are a cancer. Surgeons like to think starting 30min earlier will get them done earlier but instead they book another case (that is longer than the delta in early start timing). This practice is more rooted in surgeon narcissism and administrative desire to increase OR utilization that any concern for the actual “providers” it impacts.

 

[DazedWanderer]

I mean what percentage of people who code in the hospital survive? We shouldn’t be so quick to intubate until we get ROSC. To me it’s common sense. If you are ventilating properly during a code that’s all you need. An advanced airway is recommended. Not a must.

Depends on the etiology of the code. If they coded from respiratory failure and hypoxic arrest, it's pretty ludicrous and counterproductive to insist on waiting for ROSC to intubate.

 

[amyl]

More like 95% of the time, yes

ill say it depends on the place. my corn field hospital in indiana had an RN preop clinic that tracked down ekgs, echos, cath reports, verified meds and history, labs, etc. that chart was reviewed by me or one of my partners (4 other guys) the day before. I could roll in right before the case and have all the info i need plain to see.
at my current job when im covering plastics - same - theres one sheet with all the info i need. they are all ASA 1-2 for elective stuff. if there were any abnormalities in ekg, labs, etc. it would have been reviewed by a partner.
when im scheduled at the hospital (high acuity) I preop everyone the night before whether on care team or solo bc i like being organized and knowing what im dealing with.
it depends on case and patient population....

 

[deleted1183938]

Depends on the etiology of the code. If they coded from respiratory failure and hypoxic arrest, it's pretty ludicrous and counterproductive to insist on waiting for ROSC to intubate.

I know how to effectively bag a patient and you should as well. We are allowed to defer to our training, expertise and experiences.

 

[IlDestriero]

I secure the airway because I assume they have a full stomach and are a significant aspiration risk and/or they have been/will be poorly ventilated and will get a large amount of air in the stomach. A code isn’t like a mask induction in the OR, especially when the bag man isn’t one of us.
Being ‘Murica and all, I also assume I would be sued because they would say that not securing the airway or the aspiration or whatever was one of the reasons the code failed to resuscitate the patient. They can die with my tube secured in the trachea.

 

[sevo00]

If I’m getting called to a code I’m not going there to ****in bag mask wtf. Putting the tube in and I gtfo