How often do you BS your surgeon when they ask for stupid things?

[pgg]

Not too long ago I did a distal fibula ORIF in our ASC. Popliteal block and an LMA, thigh tourniquet. Some time after the tourniquet's up, the surgeon says he needs "total muscle relaxation, for real, not that '1 twitch' half-ass relaxation you guys like" ...

I pointed out (in my typical respectful resident fashion) that not only did the guy have a surgical block to all the nerves below his knee, but he had a tourniquet on and the NMJ blocker wouldn't get past his hip, so there was no point in paralyzing him.

He insisted.

My choices were:

• Give the guy 30 of roc and put him on the vent. Cry myself to sleep later that night for being a wuss.
• Fight the good fight and refuse on principle. Invite being overruled by my attending, whose presence would surely be requested by the surgeon and obtained by the sycophantic tattletale OR nurse. Irritate an attending surgeon for no good reason.
• Make a big show of injecting saline from a syringe with a red sticker on it and putting on a twitch monitor with the current turned all the way down. "He's flat, sir."

I chose option #3. Then, of all people, the meddling scrub tech innocently asked why the patient was still breathing spontaneously if he was paralyzed. I lied and said he was on the vent. I would have bet that the scrub tech couldn't have picked an LMA out of a lineup containing an NG tube, plate of waffles, and a tire iron ... but she knew. She knew.

But the surgeon bought it.

Still, despite the victory (of sorts) it was depressing that the subterfuge was even necessary.

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[Bertelman]

I chose option #3. Then, of all people, the meddling scrub tech innocently asked why the patient was still breathing spontaneously if he was paralyzed. I lied and said he was on the vent. I would have bet that the scrub tech couldn't have picked an LMA out of a lineup containing an NG tube, plate of waffles, and a tire iron ... but she knew. She knew.


But the surgeon bought it.

Still, despite the victory (of sorts) it was depressing that the subterfuge was even necessary.

Thanks for the laugh.

 

[OB1🤙]

When I think it's something that doesn't make a real big difference in how I'm managing the case or in outcome, I'll often just do whatever it is they're making a fuss about.

In this case though, I'd have stuck hard to my principles. There's a frigging tourniquet there. Communication is your friend in this spot, and it's too easy to get caught BSing, as you luckily got away with.

 

[dhb]

We have one orthopod who likes full relaxation for his hip procedures (ant approach). When muscles contract due to direct stimulation by the cautery he pretends that the patient isn't fully relaxed. I'm just like i'll give him some more

 

[jwk]

My favorites are the OB's who ask us to give a muscle relaxant for closing in our epidural C/S patients.

Of course those are the same ones who struggled to get the baby out through that 3cm cosmetic incision. I'm waiting for DaVinci C-Sections next.

 

[proman]

Don't give the obstetrons any ideas! I am always happy to invoke my attendings. They back us up.

 

[Fastrach]

Then, of all people, the meddling scrub tech innocently asked why the patient was still breathing spontaneously if he was paralyzed. I lied and said he was on the vent. I would have bet that the scrub tech couldn't have picked an LMA out of a lineup containing an NG tube, plate of waffles, and a tire iron ... but she knew. She knew.

What a snivelling little snot... I would have told her to stuff a few more donuts down her maw when she took her 6th break of the morning.

 

[rsgillmd]

...I chose option #3. Then, of all people, the meddling scrub tech innocently asked why the patient was still breathing spontaneously if he was paralyzed. I lied and said he was on the vent. I would have bet that the scrub tech couldn't have picked an LMA out of a lineup containing an NG tube, plate of waffles, and a tire iron ... but she knew. She knew.


But the surgeon bought it.

Still, despite the victory (of sorts) it was depressing that the subterfuge was even necessary.

I've stopped being depressed by resorting to subterfuge. For every normal to good surgeon, there are two dodos (sp?) I would have done exactly what you did.

BTW, does this machine have bellows? If so, the tech may not be able to tell the difference between an LMA and an OG tube, but she can tell if the bellows aren't moving, the ventilator probably isn't on. I nearly got caught like this once by a surgeon -- I got away with it by saying I was hand ventilating the patient.

 

[SleepIsGood]

BTW, does this machine have bellows? If so, the tech may not be able to tell the difference between an LMA and an OG tube, but she can tell if the bellows aren't moving, the ventilator probably isn't on. I nearly got caught like this once by a surgeon -- I got away with it by saying I was hand ventilating the patient.[/QUOTE]

that's pure genius!!

lol..

this whole day of telling the surgeon that i'm 'giving more mx relaxant' is all good...up until the pt accidentally moves for whatever reason...then there is a problem.

 

[usnavdoc]

Subterfuge is always the prudent choice when dealing with most surgeons. Especially ortho. Those guys flush their IQ on match day.

Hey PGG did you find out where your next duty station is going to be? I need to track down a few people and see where they are headed.

 

[smq123]

What a snivelling little snot... I would have told her to stuff a few more donuts down her maw when she took her 6th break of the morning.

Please, don't exaggerate.

There's no way that she was ONLY on her 6th break of the morning. I kid, I kid. (Sort of.)

Of course those are the same ones who struggled to get the baby out through that 3cm cosmetic incision. I'm waiting for DaVinci C-Sections next.

Ugh, don't give patients any ideas.

If you elect to have a c-section, you have to live with the scar. Or else call a plastic surgeon once you're discharged from the post-partum unit. I'm sure they wouldn't mind the extra income that they'd get from doing your scar revision.

I hated those small c-section incisions as a 3rd year med student on OB - I was always getting yelled at for "not suctioning fast enough." It's like...that incision is barely big enough for the baby's head, not to mention the attending's hand. And now you want me to stick a Yankauer through that as well?!?

 

[pgg]

Hey PGG did you find out where your next duty station is going to be? I need to track down a few people and see where they are headed.

Lemoore NAS in California. Very small department - looks like it'll be me and 2 CRNAs (possibly a 3rd as I hear the hospital XO is a CRNA). Very very light caseload, sounds like basic ortho and GS cases, with OB making up the majority of call. Call is from home. The load is so light and acuity so low that I'll have to moonlight just to avoid brain rot ... not that I'll mind the extra income. There's the possibility of some periodic TAD trips to NMCSD to do bigger cases; not quite sure how I feel about that. Deployment risk appears low since I'll be the only MD. I just sent off the last bits of my CA license application (what a pain that was) and am starting to look for jobs.

Lemoore was #2 on my preference list (for family geographic reasons). I didn't think there was much chance of the Navy funding a cross-country move for me right out of residency, but I was happy to take it to get back home. Three year orders, but they claim it's treated as a semi-hardship tour, with the expectation being that we move to the duty station (or Navy approved fellowship) of my choice after two years.

Lemoore is the total polar opposite to my #1 choice, staying put at NMCP. There just wasn't room to keep residents at the mothership this year though, with the big wave of outservice people coming in. To tell the truth, I have some real concerns about two years at such a small command, but I think some aggressive moonlighting at a real hospital will hold off the brain rot. If I can get out as competent as I go in, I'll call it a win.

Please, don't exaggerate.

There's no way that she was ONLY on her 6th break of the morning. I kid, I kid. (Sort of.)

Ah, she was the scrub tech, not the room nurse. Some days those poor techs get fewer breaks than I do. I'll give her credit for paying closer attention than the surgeon at least, even if it did almost end in a Scooby Doo "woulda gotten away with it if not for that meddling scrub tech" moment.

 

[Gern Blansten]

...even if it did almost end in a Scooby Doo "woulda gotten away with it if not for that meddling scrub tech" moment.

Funny stuff.

 

[Laurel123]

What is with these orthos? I had a case like this recently. We were doing a simple washout of a small superficial abdominal wound. The only reason the ortho was doing it was because he had done a lumbar fusion on the patient with an anterior and posterior approach, and the general surgeon who did the anterior approach was out of town, so the ortho figured he could handle the little case. Patient was thin and healthy. She got an LMA and was breathing spontaneously.

Ortho grabs the knife and looks at the abdomen and proclaims 'the patient is awake and moving around' I humor him and look at my moniters, my ET Sevo of 2.7, stable vital signs, and a perfectly still patient tolerating an lma in her throat and assure him the patient is nice and asleep.

He says fine, and begins the surgery. He then starts complaining that the patient moving, and refuses to believe my explanation that the patient is BREATHING. And then asks 'if the patient is breathing, how can she be completely asleep?' I don't even know how to answer that since logic and reason obviously don't work with this guy. I don't even know why he needs a completely still surgical field to pop open some stitches, power wash and pack. Anyways, he won't suck it up and just do the surgery with a breathing abdomen, so I finally just gave her some propofol and put her on the vent for the 15 minute procedure.

 

[fakin' the funk]

For the veterans out there...

How do you explain to surgeons that there are more than 2 stages of hypnosis (awake and "asleep") and there are various degrees of spontaneous ventilation and there are various degrees of neuromuscular blockade? Do you even bother?

 

[huktonfonix]

Tell your surgeon, "Do you breathe when you sleep?" If he gives you some crap about pain and stimulus then ask "do your post op patients on pain meds breathe when they sleep?" If the light doesnt go on, then its a lost cause.

 

[aphistis]

Tell your surgeon, "Do you breathe when you sleep?" If he gives you some crap about pain and stimulus then ask "do your post op patients on pain meds breathe when they sleep?" If the light doesnt go on, then its a lost cause.

I thought this thread was pretty funny until my surgeon today asked me why we always talk about paralysis as a spectrum instead of "just a switch that's either on or off." She was refreshingly receptive to the explanation.

 

[leaverus]

Whenever i've gotten the request for more relaxation in a situation where the patient clearly does not need more, i usually just say ok and inject a drop of NMB. That way, i am giving "more" and everyone's happy...trying to reason with any surgeon, esp ortho, is just not worth the headache.

 

[ssmallz]

Doing a thyroidectomy last week. Surgeon tells me pt is gettin tight so I go to draw up more relaxant. While I'm still drawing it up surgeon comments on how much more relaxed the pt is now that I've given some roc and how the field is so much better now. Sometimes I wonder how much relaxant actually helps these guys

 

[aphistis]

What is with these orthos? I had a case like this recently. We were doing a simple washout of a small superficial abdominal wound. The only reason the ortho was doing it was because he had done a lumbar fusion on the patient with an anterior and posterior approach, and the general surgeon who did the anterior approach was out of town, so the ortho figured he could handle the little case. Patient was thin and healthy. She got an LMA and was breathing spontaneously.

Ortho grabs the knife and looks at the abdomen and proclaims 'the patient is awake and moving around' I humor him and look at my moniters, my ET Sevo of 2.7, stable vital signs, and a perfectly still patient tolerating an lma in her throat and assure him the patient is nice and asleep.

He says fine, and begins the surgery. He then starts complaining that the patient moving, and refuses to believe my explanation that the patient is BREATHING. And then asks 'if the patient is breathing, how can she be completely asleep?' I don't even know how to answer that since logic and reason obviously don't work with this guy. I don't even know why he needs a completely still surgical field to pop open some stitches, power wash and pack. Anyways, he won't suck it up and just do the surgery with a breathing abdomen, so I finally just gave her some propofol and put her on the vent for the 15 minute procedure.

Would have been a good time for a flat stare and a "Do I stand around at the gym criticizing your bench press technique?"-type response.

 

[MossPoh]

Would have been a good time for a flat stare and a "Do I stand around at the gym criticizing your bench press technique?"-type response.

Of course, I did lift a lot with an anesthesiologist that was a powerlifter. He loved to criticize bench press technique.

 

[panetrain]

I learned this one from my attendings. When the surgeon wants more relaxation (NDMR) for closing soft tissue and skin I inject a syringe of saline while they're looking.

 

[loveumms]

Once the surgeon can tell me the physiology behind muscle relaxation and twitch monitoring THEN, and only then, can they tell me when they need more.

I don't peek over the drapes and tell them to use a 2.0 vicryl instead of a 3.0 so unless they truly know what they are talking about, they can kiss it.

Furthermore, don't you find it amusing that they often ASK if the patient is relaxed. If they have to ask, then they have no true idea if the patient is actually relaxed or not. My answer is always, "yes ... why do you ask?"

My personal favorite - one of the notorius surgeons at our institution asked for more muscle relaxation. A senior resident, sick and tired of said surgeon dictating the anesthetic care, pushed a whole stick of panc. This was close to the end of the procedure. Patient didn't breath for another hour, surgeon got pissed and never asked that resident again for more muscle relaxation. Sometimes, you get what you ask for.

 

[proman]

The only ones I listen to are the thoracic surgeons when they complain about the diaphragm. Then I give more relaxant.

 

[Fastrach]

My personal favorite - one of the notorius surgeons at our institution asked for more muscle relaxation. A senior resident, sick and tired of said surgeon dictating the anesthetic care, pushed a whole stick of panc. This was close to the end of the procedure. Patient didn't breath for another hour, surgeon got pissed and never asked that resident again for more muscle relaxation. Sometimes, you get what you ask for.

Wow, that was a really, really bad idea on so many levels... I think I would have been kicked out for doing that as a CA3!

I remember early on in CA1 year, my first experience with surgeons asking about relaxation when closing, my attending told me just to reach over to the vaporizer and turn up the gas, as that will usually give them all the "relaxation" they need, and at least you're doing something very easily reversible. Still use that to this day.

 

[Jeff05]

we are there to facilitate the surgery. if the surgeon THINKs that more relaxation is needed - give it to him. there is more than 1 way to do this...

1. give a touch of succ - obviously before reversal given
2. give 50 of prop - this works wonders for 5 min of abdominal relaxation
3. 1-1.5/kg of lido
4. turn up the gas
5. bolus 0.5-1/kg of remi
etc...

if you can't relax a patient without paralytics, you need to hit baby miller...

i know that many surgeons are obnoxious, annoying, overbearing, etc...but, we are there as a consulting service. so if they want something done, unless it poses an inappropriate risk to the patient/us/them, we should comply.


the s-it with overdosing paralysis at the end to teach the surgeon a lesson, that borders on malpractice. sweet lesson that guy taught the surgeon - by directly punishing the patient. making the patient suffer with a tube for hours, on vent...f'd up.

 

[dhb]

making the patient suffer with a tube for hours, on vent...f'd up.

1. give a touch of succ - risk hours of paralysis if pseudoch deficient, MH, anaphylaxis
2. give 50 of prop: suffer from hypotension, ischemia, stroke...
3. 1-1.5/kg of lido: pro-arythmogenic
4. turn up the gas: see 2
5. bolus 0.5-1/kg of remi: suffer from hyperesthesia
etc...

everything you do can result in a bad outcome or at least a secondary effect, i don't see a little extra paralysis as being cruel.

 

[Arch Guillotti]

Under no circumstances in a stick of pancuronium a "little extra". Giving it in the manner that the resident in question did would earn a trip to the PD/chair or worse at my residency program.

1. give a touch of succ - risk hours of paralysis if pseudoch deficient, MH, anaphylaxis
2. give 50 of prop: suffer from hypotension, ischemia, stroke...
3. 1-1.5/kg of lido: pro-arythmogenic
4. turn up the gas: see 2
5. bolus 0.5-1/kg of remi: suffer from hyperesthesia
etc...

everything you do can result in a bad outcome or at least a secondary effect, i don't see a little extra paralysis as being cruel.

 

[aphistis]

i don't see a little extra paralysis as being cruel.

I'm still pretty green at this anesthesia thing; but like others have said, I don't think a full stick of panc, during closure, can be characterized as "a little extra paralysis."

Next time you want to make a point that way, you should call out to the patient's family to tell them about it. I bet they'll be proud to hear about their loved one's role in your moral victory.

 

[loveumms]

Let's get it clear that I did not do this. Rumor is that one of the senior residents that has long graduated, did it many years ago. It could be legend. Who knows.

I don't agree that we should do everything a surgeon asks. If this were the case then I would not be a consulting physician.

If all my monitoring states the patient is fully relaxed - no twiches, no signs of diaphram excursion on the ventilator, ect then why on earth should I give my patient more relaxant? Sometimes when the surgeon is having a difficult time and complaining that the patient isn't paralyzed it's because of other varialbes such as obesity, multiple previous surgeries or a handfull of other things that have NOTHING to do with muscle relaxation.

I totally disagree with the statement, "if the surgeon THINKs that more relaxation is needed - give it to him".

Yes, we should try and work with surgeons to make the operation go as smooth as possible but, discussion is key. Not one barking orders to the other. It's a two way street.

 

[huktonfonix]

Let's get it clear that I did not do this. Rumor is that one of the senior residents that has long graduated, did it many years ago. It could be legend. Who knows.

I don't agree that we should do everything a surgeon asks. If this were the case then I would not be a consulting physician.

If all my monitoring states the patient is fully relaxed - no twiches, no signs of diaphram excursion on the ventilator, ect then why on earth should I give my patient more relaxant? Sometimes when the surgeon is having a difficult time and complaining that the patient isn't paralyzed it's because of other varialbes such as obesity, multiple previous surgeries or a handfull of other things that have NOTHING to do with muscle relaxation.

I totally disagree with the statement, "if the surgeon THINKs that more relaxation is needed - give it to him".

Yes, we should try and work with surgeons to make the operation go as smooth as possible but, discussion is key. Not one barking orders to the other. It's a two way street.

True, but keep in mind the abdominal muscles and diaphragm will recover more quickly than the peripheral muscles (adductors and whatnot). Sometimes the surgeons are just whiny, but other times they actually have a point. You could always check a post tetanic count to see where youre at. If there no post tetanic, there is no way Im giving more relaxant. If there is, I'll consider it based on the surgery and patient.

 

[Jeff05]

worst comeback, ever.

when was the last time you saw ischemia or stroke from 50 of prop, umm and lido prevents ectopy, hyperesthesia from remi...make that all opioids. ok, lets not give those anymore.

now, when was the last time you saw a patient in the pacu, looking all miserable, gagging on the tube...

you've so masterfully demonstrated that everything we do is risk/benefit. i agree, but when the risks are extremely likely and clearly outweigh the benefits...

1. give a touch of succ - risk hours of paralysis if pseudoch deficient, MH, anaphylaxis
2. give 50 of prop: suffer from hypotension, ischemia, stroke...
3. 1-1.5/kg of lido: pro-arythmogenic
4. turn up the gas: see 2
5. bolus 0.5-1/kg of remi: suffer from hyperesthesia
etc...

everything you do can result in a bad outcome or at least a secondary effect, i don't see a little extra paralysis as being cruel.

 

[dhb]

I'm not saying i consider a full stick of panc an acceptable response to the situation. Actually i couldn't do it since it's not available here anymore.
Just pointing out that it happens that patients stay on the vent a little longer than what is stictly necessary for the surgery and it's not totally inhumane... (provided you keep them asleep).

 

[Arch Guillotti]

I'm not saying i consider a full stick of panc an acceptable response to the situation. Actually i couldn't do it since it's not available here anymore.
Just pointing out that it happens that patients stay on the vent a little longer than what is stictly necessary for the surgery and it's not totally inhumane... (provided you keep them asleep).

I am not sure I follow your logic here.

Are you saying that you would give paralysis when it is not clinically warranted but the surgeon is requesting it? An that by giving this extra paralysis you are willing to accept that the pt. is not extubated at the end of the procedure?

And that requiring a vent postoperatively (when it shouldn't be needed in the first place) isn't that big of a deal?

Please elaborate, thanks.

 

[bne_12mne]

The couple of surgeons I know of who seem to be constantly remarking about levels of relaxation and asking for more at times etc. are actually two of the better surgeons, and ironically two of the fastest which can make them difficult to deal with when starting out. One guy will make comments about the relaxation status and doesn't explicitly ask for NMB's. He often does it with junior residents as kind of a test to see what they are going to give. I think he secretly likes it when they say something like "I'm giving more Vec" so that he can come back with, "No, just give propofol, I'm closing" or whatever. So I'm pretty sure that these guys know what they are doing.

The point about the diaphragm and abdominal muscle recovery is spot on.

Of course many average surgeons also gripe about relaxation, so I think your response should should be appropriate for the situation.

There are many ways to skin a cat.

Under no circumstance that I can imagine, however, would I let the comments/requests of the surgeon persuade me to do something that I know is truly unnecessary or possibly deleterious to the patient. And I consider giving a "stick" of a long acting NMB during closure to fit that category. I know it's a rumor or whatever, but the counterargument "What's the harm, it's just an hour more on the vent...as long as he's asleep...etc" doesn't hold water in my opinion.

Don't do it.

BNE

 

[narcusprince]

This bud is for you PGG.
Today I had a GI case and staff as about to excise the tumor. When staff surgeon said I cannot work pt is moving. Pt was at 1 mac of sevo, had 2 twitches on twitch monitor. I respond will get to it. Pt was bordeline hypotensive MAP roughly 60 so I push 20mg of Roc. Surgeon proceeds to operate roughly 10 minutes later he repeats the same thing. So I paged staff approprietly the orders were to push NS in a 10cc syringe and tell surgeon you are working on it. Surgeon resumes but gives me **** all day about his pts jumping off table. I guess I am a member of the club.