isolated practices

[militarymd]

What would you do if you're in a practice where you're the ONLY anesthesia person and you develop a problem that requires going to the OR?

Let's say you develop severe RLQ pain with fevers/chills and a really high WBC.....and you are literally an ocean away from the nearest other hospital.

What would you do?

When I was in GITMO, I was literally an airplane ride away from the next hospital.

I always thought about what I would do if I developed an acute process that required surgical intervention.

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[Brian Fantana]

3rd world jungle vs. Bumf@ck Alabama with no General Surgeon in site?

Hmm... Acute Appendicitis Podunk USA- IVF + Abx and hope for the best while you have your best GS friend on your cell booking his next flight to said location.

Scenario 2 - Zaire jungle with no person to save your arse - Line up a 25G Spinal needle to a bamboo tree with 0.75% Bupiv, 25 mikes Fent, some mirrors to align your sites - pop that dude in - and then hope that (A.) you have sterile equipment and actually watched the otherside of the drapes once in a while. (B.) you don't give yourself a high spinal. Now why didn't they have this in "Tropic Thunder?"

 

[bostonblaz]

i would hope it would be something they could do with some local and ketamine. if not would you try to do a spinal on yourself?

 

[Brian Fantana]

Ah, I interpreted the question as being the only physician in site, not the only anesthesiologist, otherwise the answer is too easy as you alluded to.

 

[coprolalia]

I know a dude in rural Maine who fits that bill. He's on-call 24/7/365 (and rewarded accordingly). If he wants to take vacation, the hospital he works at (a small two-OR one) has to bring in a locums guy. Why they have a two-OR hospital, I'm not sure. Cuz they sure as hell can't run two rooms.

-copro

 

[militarymd]

When I was stationed at GITMO Naval hospital, we had one of each of the following:

general surgeon
orthopedic surgeon
OB/gyn
pediatrian
internal medicine
anesthesiologist
family practice
GMO - essentially a post pgy-1 md

I had a CRNA, but when he's on leave, I'm it, and I always wondered what I would do if I really needed surgery or got seriously ill.

Now in reality, we could call Cuban military command to get clearance over Cuban airspace to allow a learjet from Miami to come and get me...From a decision to medevac to arrival at Jackson Memorial is probably less than 10 hours.....but I had a TON of time on my hands, so I actually came up with a way for me to have surgery under GA...I had this written out.

- start IV
- self medicate with only fentanyl and glycopyrolate
- awake FO self intubation
- preset anesthesia ventilator to appropriate settings
- Isofluorane set at 2.0% (we had only iso and halothane)
- lie down on OR table
- have nurse administer 5 mg of versed 20 cc of fentanyl and 10 mg of pancuronium
- have nurse connect up the ventilator
- ICU style orders to nurse for vitals
- 5 cc of fentanyl per hour
- at conclusion of surgery...an additional 10 cc of fentanyl and glycopyrolate
- turn gas off and leave me alone to wake up

 

[nutmegs]

When I was stationed at GITMO Naval hospital, we had one of each of the following:

general surgeon
orthopedic surgeon
OB/gyn
pediatrian
internal medicine
anesthesiologist
family practice
GMO - essentially a post pgy-1 md

I had a CRNA, but when he's on leave, I'm it, and I always wondered what I would do if I really needed surgery or got seriously ill.

Now in reality, we could call Cuban military command to get clearance over Cuban airspace to allow a learjet from Miami to come and get me...From a decision to medevac to arrival at Jackson Memorial is probably less than 10 hours.....but I had a TON of time on my hands, so I actually came up with a way for me to have surgery under GA...I had this written out.

- start IV
- self medicate with only fentanyl and glycopyrolate
- awake FO self intubation
- preset anesthesia ventilator to appropriate settings
- Isofluorane set at 2.0% (we had only iso and halothane)
- lie down on OR table
- have nurse administer 5 mg of versed 20 cc of fentanyl and 10 mg of pancuronium
- have nurse connect up the ventilator
- ICU style orders to nurse for vitals
- 5 cc of fentanyl per hour
- at conclusion of surgery...an additional 10 cc of fentanyl and glycopyrolate
- turn gas off and leave me alone to wake up

did you have "treat" parameters for hypotension/hypertension and specific drugs to give?

 

[militarymd]

yes...just like in the ICU

 

[nutmegs]

I wonder how much of the abdominal wall you could get through with a lot of local? I read an article a few years back about a guy who had conducted orchiectomies on himself but wasn't satisfied and was trying to remove his adrenals in his dorm room. He got "sort of sick feeling" while retracting his liver and packed himself up and headed for the ED. No ****. So you might be able to give it a try.

 

[militarymd]

I wonder how much of the abdominal wall you could get through with a lot of local? I read an article a few years back about a guy who had conducted orchiectomies on himself but wasn't satisfied and was trying to remove his adrenals in his dorm room. He got "sort of sick feeling" while retracting his liver and packed himself up and headed for the ED. No ****. So you might be able to give it a try.

want to move south?

 

[radslooking]

When I was stationed at GITMO Naval hospital, we had one of each of the following:

general surgeon
orthopedic surgeon
OB/gyn
pediatrian
internal medicine
anesthesiologist
family practice
GMO - essentially a post pgy-1 md

I had a CRNA, but when he's on leave, I'm it, and I always wondered what I would do if I really needed surgery or got seriously ill.

Now in reality, we could call Cuban military command to get clearance over Cuban airspace to allow a learjet from Miami to come and get me...From a decision to medevac to arrival at Jackson Memorial is probably less than 10 hours.....but I had a TON of time on my hands, so I actually came up with a way for me to have surgery under GA...I had this written out.

- start IV
- self medicate with only fentanyl and glycopyrolate
- awake FO self intubation
- preset anesthesia ventilator to appropriate settings
- Isofluorane set at 2.0% (we had only iso and halothane)
- lie down on OR table
- have nurse administer 5 mg of versed 20 cc of fentanyl and 10 mg of pancuronium
- have nurse connect up the ventilator
- ICU style orders to nurse for vitals
- 5 cc of fentanyl per hour
- at conclusion of surgery...an additional 10 cc of fentanyl and glycopyrolate
- turn gas off and leave me alone to wake up

why are you self intubating? don't you think somebody else could do it for you?

 

[militarymd]

why are you self intubating? don't you think somebody else could do it for you?

Like who on that list would you trust to push stp and sux?

 

[coprolalia]

I wonder how much of the abdominal wall you could get through with a lot of local? I read an article a few years back about a guy who had conducted orchiectomies on himself but wasn't satisfied and was trying to remove his adrenals in his dorm room. He got "sort of sick feeling" while retracting his liver and packed himself up and headed for the ED. No ****. So you might be able to give it a try.

Ummm... ... WTF.... huh?

Was this dude trying to make himself into a chick? Or, did he just have something against testosterone? Or, classic schizophrenic break in a post-adolescent?

-copro

 

[coprolalia]

Let's say you develop severe RLQ pain with fevers/chills and a really high WBC.....and you are literally an ocean away from the nearest other hospital.

What would you do?

Military-style anesthetic (like they're doing in the Gulf) with an LMA (self-inserted). You just tell whomever is there to turn off the pump when they're done. No need to f*** with paralytics.

-copro

 

[nutmegs]

want to move south?

I can barely understand people here in NC.

 

[nutmegs]

Ummm... ... WTF.... huh?

Was this dude trying to make himself into a chick? Or, did he just have something against testosterone? Or, classic schizophrenic break in a post-adolescent?

-copro

He had serious sexual issues and was trying to control his "urges". He clearly had other psych diagnoses. I wish I could find a copy of the article.

 

[TheSandMan]

When I was stationed at GITMO Naval hospital, we had one of each of the following:

general surgeon
orthopedic surgeon
OB/gyn
pediatrian
internal medicine
anesthesiologist
family practice
GMO - essentially a post pgy-1 md

I had a CRNA, but when he's on leave, I'm it, and I always wondered what I would do if I really needed surgery or got seriously ill.

Now in reality, we could call Cuban military command to get clearance over Cuban airspace to allow a learjet from Miami to come and get me...From a decision to medevac to arrival at Jackson Memorial is probably less than 10 hours.....but I had a TON of time on my hands, so I actually came up with a way for me to have surgery under GA...I had this written out.

- start IV
- self medicate with only fentanyl and glycopyrolate
- awake FO self intubation
- preset anesthesia ventilator to appropriate settings
- Isofluorane set at 2.0% (we had only iso and halothane)
- lie down on OR table
- have nurse administer 5 mg of versed 20 cc of fentanyl and 10 mg of pancuronium
- have nurse connect up the ventilator
- ICU style orders to nurse for vitals
- 5 cc of fentanyl per hour
- at conclusion of surgery...an additional 10 cc of fentanyl and glycopyrolate
- turn gas off and leave me alone to wake up

You are a braver soul than me Mil. Based on the amount of stat icu intubations we get for patients that "coughed out their tube" (even patients that are completely snowed with sedation), don't like the idea of riding the peace pipe with no one around to put it back in if something goes wrong

 

[nutmegs]

found it!!
http://en.wikipedia.org/wiki/Self-surgery#Abdominal

 

[jetproppilot]

Ummm... ... WTF.... huh?

Was this dude trying to make himself into a chick? Or, did he just have something against testosterone? Or, classic schizophrenic break in a post-adolescent?

-copro

I moonlighted alot in a pretty busy ER when I was a resident....

one (rare) quiet Saturday morning I'm sittin'at the desk when an ambulance pulls in....paramedics wheel this dude in on a gurney...old guy, about 65...one of the paramedics is holding an open tin can with a Peaches label.

"Hey Doc."

"Hey guys. Whatcha got?"

"Well, uhhh, Mr Smith struggled all night with a voice in his head that kept telling him to cut off his....uhhhh.....balls."

"Whats in the peach can?" I said.

"His balls," the paramedic replied, shaking his head.

I got up and took a look.......sure enough this guy had hacked off his scrotum with a steak knife and placed his....uhhh....surgical masterpiece in the peach can.

Dude went to the OR for a washout of his area. Sans nutsack.

 

[jetproppilot]

When I was stationed at GITMO Naval hospital, we had one of each of the following:

general surgeon
orthopedic surgeon
OB/gyn
pediatrian
internal medicine
anesthesiologist
family practice
GMO - essentially a post pgy-1 md

I had a CRNA, but when he's on leave, I'm it, and I always wondered what I would do if I really needed surgery or got seriously ill.

Now in reality, we could call Cuban military command to get clearance over Cuban airspace to allow a learjet from Miami to come and get me...From a decision to medevac to arrival at Jackson Memorial is probably less than 10 hours.....but I had a TON of time on my hands, so I actually came up with a way for me to have surgery under GA...I had this written out.

- start IV
- self medicate with only fentanyl and glycopyrolate
- awake FO self intubation
- preset anesthesia ventilator to appropriate settings
- Isofluorane set at 2.0% (we had only iso and halothane)
- lie down on OR table
- have nurse administer 5 mg of versed 20 cc of fentanyl and 10 mg of pancuronium
- have nurse connect up the ventilator
- ICU style orders to nurse for vitals
- 5 cc of fentanyl per hour
- at conclusion of surgery...an additional 10 cc of fentanyl and glycopyrolate
- turn gas off and leave me alone to wake up

Geez Dude.

I think I'd send for the jet.

 

[radslooking]

I moonlighted alot in a pretty busy ER when I was a resident....

one (rare) quiet Saturday morning I'm sittin'at the desk when an ambulance pulls in....paramedics wheel this dude in on a gurney...old guy, about 65...one of the paramedics is holding an open tin can with a Peaches label.

"Hey Doc."

"Hey guys. Whatcha got?"

"Well, uhhh, Mr Smith struggled all night with a voice in his head that kept telling him to cut off his....uhhhh.....balls."

"Whats in the peach can?" I said.

"His balls," the paramedic replied, shaking his head.

I got up and took a look.......sure enough this guy had hacked off his scrotum with a steak knife and placed his....uhhh....surgical masterpiece in the peach can.

Dude went to the OR for a washout of his area. Sans nutsack.

wow, that brings added meaning to the phrase 'peaches'

 

[jetproppilot]

wow, that brings added meaning to the phrase 'peaches'

Yeah.

A peach can has always looked different to me from that day forward.

 

[core0]

When I was stationed at GITMO Naval hospital, we had one of each of the following:

general surgeon
orthopedic surgeon
OB/gyn
pediatrian
internal medicine
anesthesiologist
family practice
GMO - essentially a post pgy-1 md

I had a CRNA, but when he's on leave, I'm it, and I always wondered what I would do if I really needed surgery or got seriously ill.

Now in reality, we could call Cuban military command to get clearance over Cuban airspace to allow a learjet from Miami to come and get me...From a decision to medevac to arrival at Jackson Memorial is probably less than 10 hours.....but I had a TON of time on my hands, so I actually came up with a way for me to have surgery under GA...I had this written out.

- start IV
- self medicate with only fentanyl and glycopyrolate
- awake FO self intubation
- preset anesthesia ventilator to appropriate settings
- Isofluorane set at 2.0% (we had only iso and halothane)
- lie down on OR table
- have nurse administer 5 mg of versed 20 cc of fentanyl and 10 mg of pancuronium
- have nurse connect up the ventilator
- ICU style orders to nurse for vitals
- 5 cc of fentanyl per hour
- at conclusion of surgery...an additional 10 cc of fentanyl and glycopyrolate
- turn gas off and leave me alone to wake up

You have to look at all your resources. I'm betting you have some IDCs around that could do a pretty good job of intubating. When I was a medic I didn't have your understanding of anesthesia, but I could tube and bag. Now that I know a little more I can sedate tube and bag. We discussed this when we were in remote sites. The kind of places that in the event that the government would allow a US helicopter to evac someone you were still looking at 10 hours to get a chopper in there. There were generally three medics on the team. Two 18Ds and me a 91B (by way of EMT-P school). In the event of a bad thing happening (TM) assuming there were two functioning medics there was one to do the airway and one to do whatever meatball surgery was needed to get you out of there. If there was only one medic, most of the other 18 series have enough training to bag and push drugs as directed. The one understanding was that if you broke some teeth intubating that you would probably lose some when they woke up.

My thoughts in this area would be
Versed (most likely Valium)
Fent (or more likely morphine)
Sux
If the surgery took longer than the Sux took to wear off you are probably doing something wrong.

The 7th group BN surgeon did an emergency appy when I was there. If I remember correctly it was
10 mg Valium
5 mg Morphine
Sux (big dose) and tube.
Appy took about 10 minutes skin to skin. Put a drain in loosely close and done. All done with a minor surgery kit.

PT survived and did well (took two days to evac).

Given the amount of actual physicians that you had you are doing way better than most IDCs who don't have any help at all. The first reported surgery by an IDC was in 1942 recounted here:
http://www.history.navy.mil/faqs/faq87-3a.htm

David Carpenter, PA-C

 

[camkiss]

When I was an intern, I had a patient who not only cut off his balls, he proceeded to saute them in garlic and butter and eat them.
No joke. His voices told him to do it as well. I always wondered if they were female voices...

 

[badasshairday]

When I was an intern, I had a patient who not only cut off his balls, he proceeded to saute them in garlic and butter and eat them.
No joke. His voices told him to do it as well. I always wondered if they were female voices...

DAAAAAAMNN!!!!!!!

 

[dhb]

5cm laparotomy pure local.

 

[dhb]

pediatrian
internal medicine

one of these 2 dudes should be able to give you a spinal

 

[cfdavid]

I moonlighted alot in a pretty busy ER when I was a resident....

one (rare) quiet Saturday morning I'm sittin'at the desk when an ambulance pulls in....paramedics wheel this dude in on a gurney...old guy, about 65...one of the paramedics is holding an open tin can with a Peaches label.

"Hey Doc."

"Hey guys. Whatcha got?"

"Well, uhhh, Mr Smith struggled all night with a voice in his head that kept telling him to cut off his....uhhhh.....balls."

"Whats in the peach can?" I said.

"His balls," the paramedic replied, shaking his head.

I got up and took a look.......sure enough this guy had hacked off his scrotum with a steak knife and placed his....uhhh....surgical masterpiece in the peach can.

Dude went to the OR for a washout of his area. Sans nutsack.

Needless to say, this dude was forever known amongst his buddies as, well, Peaches!! LOL

This reminds me of a buddy of my own, whom, while at a bachelor party many years ago, sucked a peach slice out of a strippers vagina...... My buddy was never known for his intelligence, but was the horniest dude I knew at the time (since settled down a bit post-marriage).... So, for the next few years, we called him, ofcourse, Peaches! Wow.

Interestingly enough, it was a couple years outta high school. And the stripper was a chick we went to school with.....

True story, I'm almost ashamed to admit. But, felt compelled to share.....