how many mistakes?

[btbam]

Stands there smiling and goofing around while the kid starts to desat, at least just pop the LMA in quickly *******.

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[GassYous]

You can't put the lma in right away, the patient will fight you. Just let the medicine work and then you can pop it in without fighting the jaw muscles. The patient was in zero danger at any time, he is of normal habitus and healthy. He appears to be easily maskable and can tolerate pretty much anything. No need to panic for routine, healthy patients. The weak attendings are the ones who freak out about everything.

 

[coffeebythelake]

You can't put the lma in right away, the patient will fight you. Just let the medicine work and then you can pop it in without fighting the jaw muscles. The patient was in zero danger at any time, he is of normal habitus and healthy. He appears to be easily maskable and can tolerate pretty much anything. No need to panic for routine, healthy patients. The weak attendings are the ones who freak out about everything.

Self-assuredness aside, bad things can and do happen when you least expect it.
Doing things safely and by the book isn't weak. It is the standard of care.

 

[DocVapor]

This video is wild.

That said I have allowed the patient to push the propofol one time. Was during residency with a very chill attending. The patient was so terrified of the loss of control and just having that little bit extra control made her so much happier.

That said, she was also very healthy, had been Pre-O2ing for a few minutes with a mask, I gave her a syringe with only half the dose I was going to give her. I told her to go slow. She went limp before she even finished the syringe I gave her and I was able to slip in the LMA rapidly.

Turns out it was one of the smoothest inductions I had ever done up until that point. I learned a helluva lot about the dosing and pharmacokinetics of propofol with that case.

 

[abolt18]

This video is wild.

That said I have allowed the patient to push the propofol one time. Was during residency with a very chill attending. The patient was so terrified of the loss of control and just having that little bit extra control made her so much happier.

That said, she was also very healthy, had been Pre-O2ing for a few minutes with a mask, I gave her a syringe with only half the dose I was going to give her. I told her to go slow. She went limp before she even finished the syringe I gave her and I was able to slip in the LMA rapidly.

Turns out it was one of the smoothest inductions I had ever done up until that point. I learned a helluva lot about the dosing and pharmacokinetics of propofol with that case.

I think giving patients some semblance of control when they have a lot of anxiety can really help. Like having the claustrophobic patient who can't hardly tolerate the mask hold the mask themselves. It seems to change the whole dynamic for them.

 

[deleted162650]

I think giving patients some semblance of control when they have a lot of anxiety can really help. Like having the claustrophobic patient who can't hardly tolerate the mask hold the mask themselves. It seems to change the whole dynamic for them.

Yes, this. In fact, for the REALLY anxious ones I’ll have them hook up their own monitors, hold the mask, and push the prop. I’ll usually step out of the room too since it can be pretty unsettling having someone looking down at you from above like that.

 

[nimbus]

This video is wild.

That said I have allowed the patient to push the propofol one time. Was during residency with a very chill attending. The patient was so terrified of the loss of control and just having that little bit extra control made her so much happier.

That said, she was also very healthy, had been Pre-O2ing for a few minutes with a mask, I gave her a syringe with only half the dose I was going to give her. I told her to go slow. She went limp before she even finished the syringe I gave her and I was able to slip in the LMA rapidly.

Turns out it was one of the smoothest inductions I had ever done up until that point. I learned a helluva lot about the dosing and pharmacokinetics of propofol with that case.

The dude in the video is a very chill attending.

 

[Consigliere]

The dude in the video is a very chill attending.

Well he really isn't an "attending" now is he? I associate an "attending" as someone working in an academic medical center supervising residents not a slick private practice anesthesiologist working in a surgicenter. Most academic attendings are in academia for a reason - they suck, have a personality disorder, or other "issues."

 

[Hork Bajir]

Well he really isn't an "attending" now is he? I associate an "attending" as someone working in an academic medical center supervising residents not a slick private practice anesthesiologist working in a surgicenter. Most academic attendings are in academia for a reason - they suck, have a personality disorder, or other "issues."

Beg to differ. Some of us enjoy teaching, and academics offers a level of case complexity/acuity that is hard to match in most PP settings. I for one would be bored out of my f****** mind pushing prop on healthy ambulatory ASA 1s and 2s all day. Not to say there aren’t plenty of helpless dinosaurs in academics... Just like there are plenty of lazy and subpar docs in PP (PP doesn’t automatically equate to “slick ninja” despite what everyone on this board seems to think). Fortunately for all of us, there are shades of gray in the world

 

[coffeebythelake]

Well he really isn't an "attending" now is he? I associate an "attending" as someone working in an academic medical center supervising residents not a slick private practice anesthesiologist working in a surgicenter. Most academic attendings are in academia for a reason - they suck, have a personality disorder, or other "issues."

I work at an academic center as a young attending, and while I cannot confirm or deny having a personality disorder or other "issues", I think I can hold my own against any one of those "slick private practice anesthesiologists" out there

 

[Consigliere]

Beg to differ. Some of us enjoy teaching, and academics offers a level of case complexity/acuity that is hard to match in most PP settings. I for one would be bored out of my f****** mind pushing prop on healthy ambulatory ASA 1s and 2s all day. Not to say there aren’t plenty of helpless dinosaurs in academics... Just like there are plenty of lazy and subpar docs in PP (PP doesn’t automatically equate to “slick ninja” despite what everyone on this board seems to think). Fortunately for all of us, there are shades of gray in the world

We have obviously had different experiences. I stand by what I said.

 

[coffeebythelake]

We have obviously had different experiences. I stand by what I said.

Not sure what that means. It sounds like you hated where you did your residency training.

 

[Consigliere]

Nope. The quality of physicians I work with/have worked with in private practice far exceeds the majority of those I worked with in residency.

 

[coffeebythelake]

Nope. The quality of physicians I work with/have worked with in private practice far exceeds the majority of those I worked with in residency.

Cool story.

 

[Consigliere]

Cool story.

Thanks!

 

[OTCAwesome]

Nope. The quality of physicians I work with/have worked with in private practice far exceeds the majority of those I worked with in residency.

Same thing, absolutely goes for surgeons as well, life sooo much better +3 years after residency and fellowsh*t.

 

[teacher2md]

I just watched the video-- you can hear the patient desaturate, I think to the mid-80's. I can't make out the number but the hypoxemia alarm is blinking on the monitor, so he's clearly below 90.

How many of you would still say this was perfectly safe? I'm genuinely curious.

My reaction is that any margin for error has been taken away, so if any other fluke occurred (like troubleshooting the LMA seating, etc) you could get into trouble.

 

[coffeebythelake]

I just watched the video-- you can hear the patient desaturate, I think to the mid-80's. I can't make out the number but the hypoxemia alarm is blinking on the monitor, so he's clearly below 90.

How many of you would still say this was perfectly safe? I'm genuinely curious.

My reaction is that any margin for error has been taken away, so if any other fluke occurred (like troubleshooting the LMA seating, etc) you could get into trouble.

Notice how all the PP anesthesiologists here are like "oh, that's so slick" and then go on a diatribe about how this kind of slickness make them higher quality,

meanwhile the academic anesthesiologists are like "WTF is this joker doing", "obviously you've never taken care of a sick patient in PP"

 

[Arch Guillotti]

My reaction is that any margin for error has been taken away, so if any other fluke occurred (like troubleshooting the LMA seating, etc) you could get into trouble.

Disagree. Just mask the kid.

The while thing is idiotic as far as I am concerned.

 

[pgg]

I had a patient a couple days ago who saw this video and asked me if he could push his own propofol.

I said OK. We still put monitors on and preoxygenated him. He squeezed the syringe and went to sleep.

...

Spoiler: He lived. We did not record a video.



I preoxygenate everybody as best I can, no exceptions. For some patients it's harder to do than others but you've got to make the effort. Earlier this year our institution had an unexpected can't-intubate can't-ventilate scenario after induction that resulted in an emergency surgical airway. It happens. I did the internal QI review for it. At some point it will be presented it at M&M. I predict that the lack of preoxygenation in that case will be a topic of discussion and that there will be no attempt to defend that omission, just a mea culpa, so glad the patient survived without neurologic injury.

My career case count is probably an even split between academic, and private practice work. On the whole, speaking in general terms and anecdotally, I think most "avoidable bad things" happen in private practice because people are in a hurry and cut corners, while on the academic side they happen for skill- or experience-related reasons (slow surgeons, low case numbers, trainees getting first stab at everything). You guys who think the induction in that video was OK are nuts.

 

[dhb]

You guys who think the induction in that video was OK are nuts.

Didn't much like it either.
What would've been you thoughs if he had made him breath a little O2 before giving him the propofol.

 

[pgg]

Didn't much like it either.
What would've been you thoughs if he had made him breath a little O2 before giving him the propofol.

Perfectly fine, minus the camera, if a "little O2" means thorough preoxygenation.

 

[deleted697127]

You guys who think the induction in that video was OK are nuts.

No. I don’t think any of it is okay. I’ve lost friends to drug overdoses. Maybe there are warning signs in retrospect but you can’t always tell if someone’s using or drinking or whatever even if you’re close. Certainly can’t tell who is going to like it a little too much based on your 2 minute assessment in Preop. I think it’s irresponsible to normalize the act of injecting yourself with drugs.

 

[OneFellSwoop]

Notice how all the PP anesthesiologists here are like "oh, that's so slick" and then go on a diatribe about how this kind of slickness make them higher quality,

meanwhile the academic anesthesiologists are like "WTF is this joker doing", "obviously you've never taken care of a sick patient in PP"

That’s funny!

Private practice here with a busy ASC, and while ‘slick’ it’s just really dang sloppy, which negates any slickness for me. No points will be lost and tons of safety earned if he has the patient take 3-5VC breaths while you take 15-30s to finish placing monitors. Have him hold the mask instead of push drugs. He definitely wouldn’t have desaturated.

 

[coffeebythelake]

That’s funny!

Private practice here with a busy ASC, and while ‘slick’ it’s just really dang sloppy, which negates any slickness for me. No points will be lost and tons of safety earned if he has the patient take 3-5VC breaths while you take 15-30s to finish placing monitors. Have him hold the mask instead of push drugs. He definitely wouldn’t have desaturated.

good to know there are some PP anesthesiologists out there who take their work seriously, and unwilling to sacrifice safety for speed

 

[abolt18]

No. I don’t think any of it is okay. I’ve lost friends to drug overdoses. Maybe there are warning signs in retrospect but you can’t always tell if someone’s using or drinking or whatever even if you’re close. Certainly can’t tell who is going to like it a little too much based on your 2 minute assessment in Preop. I think it’s irresponsible to normalize the act of injecting yourself with drugs.

This was also a concern of mine. I was always taught to "avoid even the appearance of evil" and I've applied that in many ways in my life. In this case, I'd worry about it being too good of an experience for the person and triggering or facilitating some sort of desire to pursue drug use. Maybe a stretch, but I'll start very far away from that.