I hate OB, but heres a great learning case

[jetproppilot]

I show up at my regular 0640 arrival, stride into the anesthesia office, glancing at my assigned penance.

The paper containing the physician's duties glares back at me this morning like Tiger's wife armed with a golf club:

OB, Pain, Lines.

I had a swagger in my step upon arrival. After reading my assignment, my swagger now feels like the pariah FSU kicker kicking wide right against The U.

"Ahhh, f u k it," I say to myself. Maybe it'll be a light day and I won't have to face the obstructionalistic, non-helping, "YOU'RE ON YOUR OWN, MUTHAF UKKA!" attitude that ensconces the labor and delivery unit at my hospital.

OB, Pain, and Lines, as an assignment in our group, means you cover labor and delivery, drop lines in the ICU like Nick Nolte drops tequila shots, and in your spare time laugh round on the twenty or so patients with post-op PCAs or epidurals.

I accept my penance and continue my routine.

Pour a cuppa bad coffee into one of those tiny styrofoam cups, breach the door to the men's place, hang up my WHITE COAT, change from my black clogs into my orange OR clogs, banter into the restroom, take a ......

you get the gig.

I have a morning routine.

After all the above occurs, my Droid's soothing text message alert sounds.

I know better, though. There ain't nothing soothing in this text.

THIS AIN'T GOOD.

Why? Because not too many people have my cell number. Uhhh, lets see: family members...I know my kids are OK since just twenty minutes ago I dropped them off to their mom.....my sister? Yeah, she's good. Friends? Of course there could be some rare emergent situation but I'm thinking thats not the case. Which leaves people at work. I've found it more efficient to communicate with our CRNAs via text rather than our paging system.

Which means it's probably the CRNA assigned to OB on this beautiful day, needing to establish contact with me.

Which means I'm gonna starve, since the six eggs over medium with those beautiful two pancakes, and the "can I have a cuppla extra syrups please, ma'am?"

IS GONNA REGRETFULLY HAFFTA WAIT.

I begrudgingly pull my Droid outta my scrub shirt and touch messages.

Its Brandy, our CRNA in OB today. Message says:

"Rolling back soon with C section. Nonreassuring HTs. Pt has HELP."

OK.

I've been at work for, like TEN MINUTES...I haven't even been able to take a sip of the sh itty coffee outta this ridiculously little styrofoam cup....

AND I'VE GOTTA DEAL WITH A C SECTION WITH A LADY WITH HELLP SYNDROME.

Fabulous.

Mind as well inform me that my prostate is enlarged and I'm gonna need a root canal next week.

I take my first sip of the questionable hospital coffee brew out of the stupid styrofoam cup. It sucks, as usual.

I text Brandy back:

"Coming."

THERE IT IS. A BEAUTIFUL MORNING IN LOUISIANA, RUINED BY A SINISTER TEXT FROM A CO WORKER.

Which I've gotta manage.

Within the next thirty minutes.

I call Brandy. She tells me about the patient. 29 y/o girl, G2, no coexisting morbidities. Healthy girl, other than this HELP s h it.

Platelets drawn a cuppla hours ago: 150.

She looks totally asymptomatic.

I'm speaking largely to our resident audience, cuz in private practice you will be faced with this, or something similar someday.

LEMME SUM THIS CASE UP FOR YA:

You....YOU...are gonna haffta anesthetize this chica somehow within the next THIRTY MINUTES.

Yeah, you could argue, you need more time, you're overwhelmed, whats her NPO status, the tennis net is too low, you've gotta pick up your kids, is the consent signed, do we have a potassium, is she really sane to sign the consent, her husband looks and smells like he recently imbibed on some smooth hydroponics so can he really sign the consent, etc etc etc

Dude. Ya gotta do the case.

Within thirty minutes. Assume the OB doc is credible and is truly concerned about the baby and wants to get the baby out YESTERDAY.

WHATCHA GONNA DO, DOCTOR?

---

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[DrDre']

So glad my favorite kracker is back.



unless she has platelets falling out of her body in front of me, or a back 15 inches thick...

SAB. Monitor her postop for possible hematoma which should be super super unlikely.

OR Prop, sux tube. be concerned about HCT and plts and deal if the CS goes awry

I am to be a fresh minted attending in 83 days.
I maintain a healthy respect for every airway but I agree with recent posts that we have become way too scared about parturient airways while as a group improving our airway management of the morbidly obese and developing new tools like the glide...

I show up at my regular 0640 arrival, stride into the anesthesia office, glancing at my assigned penance.

The paper containing the physician's duties glares back at me this morning like Tiger's wife armed with a golf club:

OB, Pain, Lines.

I had a swagger in my step upon arrival. After reading my assignment, my swagger now feels like the pariah FSU kicker kicking wide right against The U.

"Ahhh, f u k it," I say to myself. Maybe it'll be a light day and I won't have to face the obstructionalistic, non-helping, "YOU'RE ON YOUR OWN, MUTHAF UKKA!" attitude that ensconces the labor and delivery unit at my hospital.

OB, Pain, and Lines, as an assignment in our group, means you cover labor and delivery, drop lines in the ICU like Nick Nolte drops tequila shots, and in your spare time laugh round on the twenty or so patients with post-op PCAs or epidurals.

I accept my penance and continue my routine.

Pour a cuppa bad coffee into one of those tiny styrofoam cups, breach the door to the men's place, hang up my WHITE COAT, change from my black clogs into my orange OR clogs, banter into the restroom, take a ......

you get the gig.

I have a morning routine.

After all the above occurs, my Droid's soothing text message alert sounds.

I know better, though. There ain't nothing soothing in this text.

THIS AIN'T GOOD.

Why? Because not too many people have my cell number. Uhhh, lets see: family members...I know my kids are OK since just twenty minutes ago I dropped them off to their mom.....my sister? Yeah, she's good. Friends? Of course there could be some rare emergent situation but I'm thinking thats not the case. Which leaves people at work. I've found it more efficient to communicate with our CRNAs via text rather than our paging system.

Which means it's probably the CRNA assigned to OB on this beautiful day, needing to establish contact with me.

Which means I'm gonna starve, since the six eggs over medium with those beautiful two pancakes, and the "can I have a cuppla extra syrups please, ma'am?"

IS GONNA REGRETFULLY HAFFTA WAIT.

I begrudgingly pull my Droid outta my scrub shirt and touch messages.

Its Brandy, our CRNA in OB today. Message says:

"Rolling back soon with C section. Nonreassuring HTs. Pt has HELP."

OK.

I've been at work for, like TEN MINUTES...I haven't even been able to take a sip of the sh itty coffee outta this ridiculously little styrofoam cup....

AND I'VE GOTTA DEAL WITH A C SECTION WITH A LADY WITH HELLP SYNDROME.

Fabulous.

Mind as well inform me that my prostate is enlarged and I'm gonna need a root canal next week.

I take my first sip of the questionable hospital coffee brew out of the stupid styrofoam cup. It sucks, as usual.

I text Brandy back:

"Coming."

THERE IT IS. A BEAUTIFUL MORNING IN LOUISIANA, RUINED BY A SINISTER TEXT FROM A CO WORKER.

Which I've gotta manage.

Within the next thirty minutes.

I call Brandy. She tells me about the patient. 29 y/o girl, G2, no coexisting morbidities. Healthy girl, other than this HELP s h it.

Platelets drawn a cuppla hours ago: 150.

She looks totally asymptomatic.

I'm speaking largely to our resident audience, cuz in private practice you will be faced with this, or something similar someday.

LEMME SUM THIS CASE UP FOR YA:

You....YOU...are gonna haffta anesthetize this chica somehow within the next THIRTY MINUTES.

Yeah, you could argue, you need more time, you're overwhelmed, whats her NPO status, the tennis net is too low, you've gotta pick up your kids, is the consent signed, do we have a potassium, is she really sane to sign the consent, her husband looks and smells like he recently imbibed on some smooth hydroponics so can he really sign the consent, etc etc etc

Dude. Ya gotta do the case.

Within thirty minutes. Assume the OB doc is credible and is truly concerned about the baby and wants to get the baby out YESTERDAY.

WHATCHA GONNA DO, DOCTOR?

 

[sawthelight]

and for the creative writing. The "glaring back at me" line made me literally LOL. Thanks to all for their contributions...oh, but 9 more weeks until I get to start my CA-1 year!

 

[lfesiam]

and for the creative writing. The "glaring back at me" line made me literally LOL. Thanks to all for their contributions...oh, but 9 more weeks until I get to start my CA-1 year!

Great to see you back JET

 

[Consigliere]

Prop.Sux.Tube. Adequate IV access. Blood and blood products. Yaaaaaaawwwwwwwwnn!

 

[Substance]

I'm not an anesthesia resident(actually, I'm about as far away from gas as you can get) but in hindsight I think gas is pretty cool, so I'll chime in.

The platelet number means nothing without a trend. If she's dropping it quickly, I'd be more worried about her bleeding. Currently her numbers aren't in bleedy territory.

What's her liver looking like now? Do we have values?

How bad is her hemolysis? How's her kidneys holding up?

That being said, I would be loathe to epidural her, only to find out that her HELLP is causing a nice little spinal hemorrhage/hematoma. Screw that.

So, GA it is.

While I'm at it, I'd give her a good big line and order up some PRBC,cryo etc just in case.

I'd also be weary of her liver conking out and causing her to become acidotic, so I'd be prepared for that too.

I know this doesn't seem like a trainwreck yet, but it has the potential to become one. I'd rather be overprepared than underprepared.

 

[Noyac]

Well, since you say I've got 30 minutes b/4 incision I guess I'd go see some of those post-op pain pts, finish my coffee, take that sh** and wash my hands, then chat up the new hottie RN until time to push the Prop/roc/tube.

 

[DrDre']

Could do some lifting or cardio in there too!

I am excited to be visiting soon.

been cycling much?

Well, since you say I've got 30 minutes b/4 incision I guess I'd go see some of those post-op pain pts, finish my coffee, take that sh** and wash my hands, then chat up the new hottie RN until time to push the Prop/roc/tube.

 

[Noyac]

Could do some lifting or cardio in there too!

I am excited to be visiting soon.

been cycling much?

Not too much. the only trails that don't have snow are muddy. been on the motobike a few times though.

 

[jwk]

Well, since you say I've got 30 minutes b/4 incision I guess I'd go see some of those post-op pain pts, finish my coffee, take that sh** and wash my hands, then chat up the new hottie RN until time to push the Prop/roc/tube.

Now THAT'S the answer I was wating for.

 

[secretasianman]

i LOVE your posts. wb jpp .

I show up at my regular 0640 arrival, stride into the anesthesia office, glancing at my assigned penance.

The paper containing the physician's duties glares back at me this morning like Tiger's wife armed with a golf club:

OB, Pain, Lines.

I had a swagger in my step upon arrival. After reading my assignment, my swagger now feels like the pariah FSU kicker kicking wide right against The U.

"Ahhh, f u k it," I say to myself. Maybe it'll be a light day and I won't have to face the obstructionalistic, non-helping, "YOU'RE ON YOUR OWN, MUTHAF UKKA!" attitude that ensconces the labor and delivery unit at my hospital.

OB, Pain, and Lines, as an assignment in our group, means you cover labor and delivery, drop lines in the ICU like Nick Nolte drops tequila shots, and in your spare time laugh round on the twenty or so patients with post-op PCAs or epidurals.

I accept my penance and continue my routine.

Pour a cuppa bad coffee into one of those tiny styrofoam cups, breach the door to the men's place, hang up my WHITE COAT, change from my black clogs into my orange OR clogs, banter into the restroom, take a ......

you get the gig.

I have a morning routine.

After all the above occurs, my Droid's soothing text message alert sounds.

I know better, though. There ain't nothing soothing in this text.

THIS AIN'T GOOD.

Why? Because not too many people have my cell number. Uhhh, lets see: family members...I know my kids are OK since just twenty minutes ago I dropped them off to their mom.....my sister? Yeah, she's good. Friends? Of course there could be some rare emergent situation but I'm thinking thats not the case. Which leaves people at work. I've found it more efficient to communicate with our CRNAs via text rather than our paging system.

Which means it's probably the CRNA assigned to OB on this beautiful day, needing to establish contact with me.

Which means I'm gonna starve, since the six eggs over medium with those beautiful two pancakes, and the "can I have a cuppla extra syrups please, ma'am?"

IS GONNA REGRETFULLY HAFFTA WAIT.

I begrudgingly pull my Droid outta my scrub shirt and touch messages.

Its Brandy, our CRNA in OB today. Message says:

"Rolling back soon with C section. Nonreassuring HTs. Pt has HELP."

OK.

I've been at work for, like TEN MINUTES...I haven't even been able to take a sip of the sh itty coffee outta this ridiculously little styrofoam cup....

AND I'VE GOTTA DEAL WITH A C SECTION WITH A LADY WITH HELLP SYNDROME.

Fabulous.

Mind as well inform me that my prostate is enlarged and I'm gonna need a root canal next week.

I take my first sip of the questionable hospital coffee brew out of the stupid styrofoam cup. It sucks, as usual.

I text Brandy back:

"Coming."

THERE IT IS. A BEAUTIFUL MORNING IN LOUISIANA, RUINED BY A SINISTER TEXT FROM A CO WORKER.

Which I've gotta manage.

Within the next thirty minutes.

I call Brandy. She tells me about the patient. 29 y/o girl, G2, no coexisting morbidities. Healthy girl, other than this HELP s h it.

Platelets drawn a cuppla hours ago: 150.

She looks totally asymptomatic.

I'm speaking largely to our resident audience, cuz in private practice you will be faced with this, or something similar someday.

LEMME SUM THIS CASE UP FOR YA:

You....YOU...are gonna haffta anesthetize this chica somehow within the next THIRTY MINUTES.

Yeah, you could argue, you need more time, you're overwhelmed, whats her NPO status, the tennis net is too low, you've gotta pick up your kids, is the consent signed, do we have a potassium, is she really sane to sign the consent, her husband looks and smells like he recently imbibed on some smooth hydroponics so can he really sign the consent, etc etc etc

Dude. Ya gotta do the case.

Within thirty minutes. Assume the OB doc is credible and is truly concerned about the baby and wants to get the baby out YESTERDAY.

WHATCHA GONNA DO, DOCTOR?

 

[Gern Blansten]

Well, since you say I've got 30 minutes b/4 incision I guess I'd go see some of those post-op pain pts, finish my coffee, take that sh** and wash my hands, then chat up the new hottie RN until time to push the Prop/roc/tube.

I had this case on the oral boards and gave that exact answer!

 

[SammyDavisJrJr]

Lots of blood in the room, along with FFP and some platelets. We are fans of one-to-one (or as close as possible) where I am. Also, a trauma surgeon within yelling distance would be cool if OB gets in over his/her head. I'd transfuse early at the first signs of significant hemorrhage. Pt isn't bleeding crystalloid...

 

[SleepIsGood]

I had this case on the oral boards and gave that exact answer!

Did you get it the second time around too

 

[dhb]

spinal
why all the products? HELLP ain't a percreta

 

[Monty Python]

Great to see the JetMeister back !!!

Bringing back fond memories of the 10th floor at Charity Hospital.

 

[Monty Python]

12th?

The 12th floor at pre-Katrina Charity Hospital housed the OR and cysto suites.

OB was on the 10th floor, prior to moving to University Hospital (former Hotel Dieu) in the mid-1990s.

 

[Monty Python]

My bad. I spent 100+ hours a week on floor 12. That's when I was insane enough to consider a career in surgery. That hospital beat me to near death. Good times.

My father-in-law went to LSU med school in the late 1940s. He vividly remembers the grilling they would get at M+M in the Delgado amphitheater on the 12th floor. He and several classmates roomed together at a boarding house near Tulane's uptown campus, taking the streetcar to/from school. He still laughs when reminiscing about the effect of cadaver formaldehyde odors inside an un-airconditioned streetcar in the New Orleans September heat.

 

[Mman]

Recent platelet count of 150K is fine. Even if they are dropping, her platelets will still be 80-100K or more for at least some time. She gets a spinal with a 25 g needle. I'll make sure she has a type/screen with no major antibodies and I might start a 2nd IV. Otherwise, should be a pretty boring case in the OR. They are more likely to have problems over the next 24-48 hours with liver/coags.

 

[jetproppilot]

Forgot to tell you dudes what happened!

Of course if the chicks ate up w HELLP youre gonna

put her to sleep.

My patient lived in the vast majority.

Parturients with HELLP that don't appear sick.

SO...

HERE'S MY THOUGHT PROCESS.

Chicks got HELLP.

Great.

She looks asymptomatic.

Pretty recent platelet count OK.

MY POINT of this thread was to

DON'T FORGET THE LIVER!!!!

Chances are if mom is looking good its all good, but I ran an ISTAT pt/ptt/inr.

If her liver function was way out there it wouldda shown up on my istat.

Her ISTAT pt/ptt/inr was normal.

I elected spinal anesthesia.

She did fine.

Not every HELLP pt needs to be put to sleep.

Nor do I think I was stretching the boundary here.

Read our literature.

Here's what I came out of it with:

Chick looks normal? Neuraxial anesthesia OK as long as labs not out da box.

Chick looks sick?

Put her to sleep.

Compelling how, even in these OBAMA TIMES,

OUR PHYSICIAN EYES

are really important

when it comes to making

critical decisions.