It’s not MAC

[TheLoneWolf]

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During residency, rotated at hospital which exclusively treated cancer patients. Breast surgeons were very busy, high volume. 2 that I can recall were insistent that anything short of a mastectomy or reconstruction should be a ‘Mac case’. From us, it meant putting patients under proposal getting about 150-200 mcg/kg/min and face mask, that’s it. I didn’t like it because these cases could take two to three hours, and if patient obstructed and jaw thrust wasn’t effective then I would place an oral airway. Lots of obese patients with MP3-4 and shi**y neck extension. I figure that if they aren’t responding to surgical stimuli, then they likely have a wide open LES and abolished airway protective reflexes, not an ideal situation. Even an LMA could questionably serve to block some of what may be aspirated, definitely better than nothing.

If I brought it up, the surgeons would say they don’t want the patients nauseous and that the ‘Mac anesthesia prevented this’ as opposed to gas. The anesthesia attendings were all hospital employed, so If I told the surgeons that it’s still a general case at time out, I would get smirks from everyone in the room and corrected that my attendings call it MAC so it’s MAC. If they saw any airway device they assumed we were using gas and freaked.

Ideally, I feel the risks are minimized with use of a supraglottic device like the igel while using that level of propofol. But my attending would just mutter and walk off. ‘Don’t rock the boat’.

Also, I have noticed that for younger patients, it does not reliably prevent response to stimulation even with large initial bolus doses and it’s a fine plane between a good IV propofol anesthetic and apnea. Bad situation to tube the patient midway through a case.

 

[TheLoneWolf]

During residency, rotated at hospital which exclusively treated cancer patients. Breast surgeons were very busy, high volume. 2 that I can recall were insistent that anything short of a mastectomy or reconstruction should be a ‘Mac case’. From us, it meant putting patients under proposal getting about 150-200 mcg/kg/min and face mask, that’s it. I didn’t like it because these cases could take two to three hours, and if patient obstructed and jaw thrust wasn’t effective then I would place an oral airway. Lots of obese patients with MP3-4 and shi**y neck extension. I figure that if they aren’t responding to surgical stimuli, then they likely have a wide open LES and abolished airway protective reflexes, not an ideal situation. Even an LMA could questionably serve to block some of what may be aspirated, definitely better than nothing.

If I brought it up, the surgeons would say they don’t want the patients nauseous and that the ‘Mac anesthesia prevented this’ as opposed to gas. The anesthesia attendings were all hospital employed, so If I told the surgeons that it’s still a general case at time out, I would get smirks from everyone in the room and corrected that my attendings call it MAC so it’s MAC. If they saw any airway device they assumed we were using gas and freaked.

Ideally, I feel the risks are minimized with use of a supraglottic device like the igel while using that level of propofol. But my attending would just mutter and walk off. ‘Don’t rock the boat’.

Also, I have noticed that for younger patients, it does not reliably prevent response to stimulation even with large initial bolus doses and it’s a fine plane between a good IV propofol anesthetic and apnea. Bad situation to tube the patient midway through a case.

BTW Barrish states " Propofol in typical monitored anesthesia care doses (25 to 75 µg/kg/min) has minimal analgesic proper-
ties although propofol use during anesthesia has been associated with less postoperative pain and narcotic use when compared to
isolurane"

 

[CopaceticOne]

That’s a GA TIVA with an unprotected airway in the setting of arrogant surgeons and subservient anesthesiologists.

That’s about all I’ve got to add to this discussion.

 

[Onefellswoop87]

The MAC cases above were “minimal airway control”

 

[Guillemot]

Yeah.... people from all walks of life are able to be stupid. Surprised?

To help decrease sore throat dont over inflate your LMA. Once its in place I will usually let some air out. A lot of the time the pilot baloon will be pretty flaccid without any issue with leak and I can still do ppv if indicated.

 

[Arch Guillotti]

During residency, rotated at hospital which exclusively treated cancer patients. Breast surgeons were very busy, high volume. 2 that I can recall were insistent that anything short of a mastectomy or reconstruction should be a ‘Mac case’. From us, it meant putting patients under proposal getting about 150-200 mcg/kg/min and face mask, that’s it. I didn’t like it because these cases could take two to three hours, and if patient obstructed and jaw thrust wasn’t effective then I would place an oral airway. Lots of obese patients with MP3-4 and shi**y neck extension. I figure that if they aren’t responding to surgical stimuli, then they likely have a wide open LES and abolished airway protective reflexes, not an ideal situation. Even an LMA could questionably serve to block some of what may be aspirated, definitely better than nothing.

If I brought it up, the surgeons would say they don’t want the patients nauseous and that the ‘Mac anesthesia prevented this’ as opposed to gas. The anesthesia attendings were all hospital employed, so If I told the surgeons that it’s still a general case at time out, I would get smirks from everyone in the room and corrected that my attendings call it MAC so it’s MAC. If they saw any airway device they assumed we were using gas and freaked.

Ideally, I feel the risks are minimized with use of a supraglottic device like the igel while using that level of propofol. But my attending would just mutter and walk off. ‘Don’t rock the boat’.

Also, I have noticed that for younger patients, it does not reliably prevent response to stimulation even with large initial bolus doses and it’s a fine plane between a good IV propofol anesthetic and apnea. Bad situation to tube the patient midway through a case.

Your attendings were weak😕

 

[sethco]

Your attendings were weak😕

Weak was not the word I had in mind. I would of chose something more derogatory

 

[pgg]

Cases like this got me in trouble as a resident because I couldn't keep my mouth shut.

 

[Beeftenderloin]

If the surgeons primary concerns is PONV from using gas why not just do TIVA with prop at the doses you suggest and just intubate or pop in an LMA at the start of the case?

You can even still call it “MAC” if it makes the surgeons happy...

 

[MoMoGesiologist]

Maybe throw in some ketamine so you can reduce your propofol and get less apnea and add analgesia

 

[TheLoneWolf]

If the surgeons primary concerns is PONV from using gas why not just do TIVA with prop at the doses you suggest and just intubate or pop in an LMA at the start of the case?

You can even still call it “MAC” if it makes the surgeons happy...

Why risk sore throat, lip lacerations? they didnt want any airway insturmentation thinking that the white stuff was all that was needed in prior cases so why change it. Absence of harm is not absence of risk.

 

[deleted697535]

A 3 to 4 hour case with upwards of 200 mcg/k/m prop with a facemask? Obese?

You guys are all going to court there my friend.

I'm sorry you're stuck in sh1t bucket like that.

 

[narcusprince]

Sounds like a place I would not work. heavily institutionalized practice. Thin patient low risk factors no dm, no gerd, no gastropeesis, no morbid obesity, good surgeon lets do it. I have done these with prop alfenta infusions. I reserve the right to place the lma.

 

[TheLoneWolf]

Very reputable regional and national institution, big name. Heavily advertises, tv, radio, billboard, sports team sponsor.

Pays well but salaried, calls not too bad, no ED so few emergencies. Nice deal on paper but I have never seen attendings so stressed and insulted on a daily basis by their surgical "peers". When you see the department chair chewed out by a head and neck surgeon over tiny trivial items really puts the big stuff in perspective.

Surgeons interfering with how I perform an anesthetic is ridiculous. Its the same as if I pointed to random items on their standard trays and said they cant use it.

 

[T-burglar]

It’s hard for me to imagine working in a place where the anesthesia department has had their sack cut off

 

[narcusprince]

It’s hard for me to imagine working in a place where the anesthesia department has had their sack cut off

Try working in a place where you still have your sack but its pulled back and firmly tucked in your A$5

 

[Twiggidy]

Cases like this got me in trouble as a resident because I couldn't keep my mouth shut.

Ditto

 

[Twiggidy]

Anesthesiology.....damned if you do and damned if you don't.

If you're too conservative and er on the side of safety, you're the weak anesthesiologist who doesn't know what they're doing.

If you're too "cowboy" and give no fux, you're the loose cannon anesthesiologists who doesn't know what they're doing.

 

[nimbus]

During residency, rotated at hospital which exclusively treated cancer patients. Breast surgeons were very busy, high volume. 2 that I can recall were insistent that anything short of a mastectomy or reconstruction should be a ‘Mac case’. From us, it meant putting patients under proposal getting about 150-200 mcg/kg/min and face mask, that’s it. I didn’t like it because these cases could take two to three hours, and if patient obstructed and jaw thrust wasn’t effective then I would place an oral airway. Lots of obese patients with MP3-4 and shi**y neck extension.

What breast case that is not a mastectomy or reconstruction takes 2-3hrs? Lumpectomy? Breast biopsy?? Agree with above posters, not a place I would want to work. Life is too short to be chewed out by mediocre surgeons.

 

[nimbus]

Very reputable regional and national institution, big name. Heavily advertises, tv, radio, billboard, sports team sponsor.

As your post illustrates, this has zero correlation to actual quality. I’ve witnessed a lot of crappy care at such institutions. Morbidity that would never happen at an unknown community hospital. It is laughable.

 

[Psai]

Pecs blocks ftw

I think I know where you're talking about. We had a breast surgeon that trained at one of these world famous places; I've never seen such long surgeries or so many takebacks by plastic surgery.

 

[WholeLottaGame7]

In residency, just do whatever you have to do to get through the day. In real life, it's your patient, your anesthetic, do whatever you think is best for the patient. If the surgeons bitch about it, one of two things will happen. 1) You'll stop getting assigned those rooms, 2) you'll get a meeting with your "partners" where you can have a real discussion, that will result in one of three other possibilities. 1) You'll stop getting assigned those rooms, 2) you'll realize you don't want to work at that practice, 3) they'll actually back you up (low prob).

 

[24GaugeEJ]

As a new medical student who has worked in healthcare for a while, this thread frightens me. I realize it’s against the TOS to cross post, but I hope there are surgeons and other physicians who frequent this forum and are able to understand how sickening this is and how potentially dangerous for their patients this is.

 

[anbuitachi]

As a new medical student who has worked in healthcare for a while, this thread frightens me. I realize it’s against the TOS to cross post, but I hope there are surgeons and other physicians who frequent this forum and are able to understand how sickening this is and how potentially dangerous for their patients this is.

Too many surgeons don't give a crap.

 

[Psai]

As a new medical student who has worked in healthcare for a while, this thread frightens me. I realize it’s against the TOS to cross post, but I hope there are surgeons and other physicians who frequent this forum and are able to understand how sickening this is and how potentially dangerous for their patients this is.

If I'm being compensated for the risk it makes sense but to assume liability so that some suit can earn a buck is not ideal. It is definitely annoying to deal with a proceduralist who doesn't understand what we do but it's better for the patient that we're there for them. It's really the most ignorant people that are the most dangerous. There are too many misadventures that occur when other people try to replicate what we do without any resuscitation skills or even general knowledge of anesthetics.

 

[Man o War]

At the end of the day YOU are going down if you did something dangerous to appease someone else. That surgeon will throw you under the bus in a heartbeat.
Thankfully I’ve never worked in an environment where the anesthesiologists felt pressured to do things they felt were not safe. It’s one thing to have a discussion beforehand and adjust within reasonable limits if the surgeon has founded or reasonable concerns. It’s quite another to be expected to do something stupid at the request of someone who has little to no airway management training.

 

[TheLoneWolf]

Who knows? maybe the surgeons promise the patients this in the surgery clinic as slick marketing...on the surgical date you get a small IV, oxygen mask and you go off to sleep. In general, I have noticed most patients start becoming defensive or hostile when there is any change from what the surgeon had planned and discussed with them...strange when you are upholding their safety above the surgeons inconveninence and ignorance.

 

[BLADEMDA]

FWIW, I like LMA with propofol TIVA along with Pecs1/Pecs2 (or Serratus) for these cases. I'm sure a good discussion with the surgeons about TIVA vs MAC would clear things up a great deal. Adding a little Ketamine (30-50 mg) to the propofol would be nice as well. I've also used Precedex, Propofol with the LMA and chest wall blocks for a nice anesthetic.

The goal is a pain free, non nauseating anesthetic with fast discharge. I think a detailed conversation how you plan on accomplishing that will go a long way.

https://www.anesthesiologynews.com/...ONV-Following-Total-Mastectomy/36353/ses=ogst

“There’s a movement in anesthesia to improve patient care by implementing ERAS pathways,” said Monica Harbell, MD, assistant clinical professor of anesthesia and perioperative care at UCSF’s School of Medicine. “Nevertheless, there haven't been many enhanced recovery pathways in breast surgery. So we wanted to apply the principles of enhanced recovery in an effort to get our patients mobilized earlier, more active and involved in their care, and hopefully achieve better outcomes and greater patient satisfaction.”

The pathway calls for preoperative administration of 600 mg oral gabapentin and 1,000 mg oral acetaminophen in all patients, as well as placement of 1.5 mg transdermal scopolamine in patients aged less than 60 years with multiple risk factors for PONV. Intraoperatively, the pathway recommends total IV anesthesia, minimizes opioids, uses regional anesthesia (either Pec 1 and 2 or paravertebral blocks), and PONV prevention with 8 mg IV dexamethasone and 4 mg IV ondansetron. In the PACU, patients receive opioids, ondansetron and/or lorazepam as needed.

“And then we really encourage patients to mobilize as early as possible after surgery, to make sure we decrease risks that come with immobility, such as pneumonia and DVTs [deep venous thromboses],” Dr. Harbell said.

 

[Man o War]

FWIW, I like LMA with propofol TIVA along with Pecs1/Pecs2 (or Serratus) for these cases. I'm sure a good discussion with the surgeons about TIVA vs MAC would clear things up a great deal. Adding a little Ketamine (30-50 mg) to the propofol would be nice as well. I've also used Precedex, Propofol with the LMA and chest wall blocks for a nice anesthetic.

The goal is a pain free, non nauseating anesthetic with fast discharge. I think a detailed conversation how you plan on accomplishing that will go a long way.

https://www.anesthesiologynews.com/...ONV-Following-Total-Mastectomy/36353/ses=ogst

“There’s a movement in anesthesia to improve patient care by implementing ERAS pathways,” said Monica Harbell, MD, assistant clinical professor of anesthesia and perioperative care at UCSF’s School of Medicine. “Nevertheless, there haven't been many enhanced recovery pathways in breast surgery. So we wanted to apply the principles of enhanced recovery in an effort to get our patients mobilized earlier, more active and involved in their care, and hopefully achieve better outcomes and greater patient satisfaction.”

The pathway calls for preoperative administration of 600 mg oral gabapentin and 1,000 mg oral acetaminophen in all patients, as well as placement of 1.5 mg transdermal scopolamine in patients aged less than 60 years with multiple risk factors for PONV. Intraoperatively, the pathway recommends total IV anesthesia, minimizes opioids, uses regional anesthesia (either Pec 1 and 2 or paravertebral blocks), and PONV prevention with 8 mg IV dexamethasone and 4 mg IV ondansetron. In the PACU, patients receive opioids, ondansetron and/or lorazepam as needed.

“And then we really encourage patients to mobilize as early as possible after surgery, to make sure we decrease risks that come with immobility, such as pneumonia and DVTs [deep venous thromboses],” Dr. Harbell said.

This is a great point. I’m positive there are many anesthesiologists out there who stubbornly stick to their old ways of practicing, who are resistant to learning new and better techniques, and don’t want to get on board with ERAS. That is very frustrating for the surgeon I’m sure.
But again, patient selection is key. And so many surgeons just aren’t good at identifying good candidates for these types of anesthetics. Not everyone fits it into their nice box from our perspective.

 

[dhb]

FWIW, I like LMA with propofol TIVA along with Pecs1/Pecs2 (or Serratus) for these cases. I'm sure a good discussion with the surgeons about TIVA vs MAC would clear things up a great deal. Adding a little Ketamine (30-50 mg) to the propofol would be nice as well. I've also used Precedex, Propofol with the LMA and chest wall blocks for a nice anesthetic.

The goal is a pain free, non nauseating anesthetic with fast discharge. I think a detailed conversation how you plan on accomplishing that will go a long way.

https://www.anesthesiologynews.com/...ONV-Following-Total-Mastectomy/36353/ses=ogst

“There’s a movement in anesthesia to improve patient care by implementing ERAS pathways,” said Monica Harbell, MD, assistant clinical professor of anesthesia and perioperative care at UCSF’s School of Medicine. “Nevertheless, there haven't been many enhanced recovery pathways in breast surgery. So we wanted to apply the principles of enhanced recovery in an effort to get our patients mobilized earlier, more active and involved in their care, and hopefully achieve better outcomes and greater patient satisfaction.”

The pathway calls for preoperative administration of 600 mg oral gabapentin and 1,000 mg oral acetaminophen in all patients, as well as placement of 1.5 mg transdermal scopolamine in patients aged less than 60 years with multiple risk factors for PONV. Intraoperatively, the pathway recommends total IV anesthesia, minimizes opioids, uses regional anesthesia (either Pec 1 and 2 or paravertebral blocks), and PONV prevention with 8 mg IV dexamethasone and 4 mg IV ondansetron. In the PACU, patients receive opioids, ondansetron and/or lorazepam as needed.

“And then we really encourage patients to mobilize as early as possible after surgery, to make sure we decrease risks that come with immobility, such as pneumonia and DVTs [deep venous thromboses],” Dr. Harbell said.

Wow i didn't know ERAS was so complicated! Maybe i should do a fellowship 😉

 

[epidural man]

Nothing wrong with room air general. But do everyone a favor and gentle, humbly, and smartly - teach them the truth. Encourage them to use appropriate terms. You may want to look up the ASA definitions of the sedation scale and use that to explain what you are talking about. MAC is a broad term, but it part of the sedation scale and is NOT general anesthesia. If a supraglottic device, supplemental oxygen, or whatever is use - doesn't change the sedation scale and definition of general anesthesia.

 

[dannyboy1]

Nothing wrong with room air general. But do everyone a favor and gentle, humbly, and smartly - teach them the truth. Encourage them to use appropriate terms. You may want to look up the ASA definitions of the sedation scale and use that to explain what you are talking about. MAC is a broad term, but it part of the sedation scale and is NOT general anesthesia. If a supraglottic device, supplemental oxygen, or whatever is use - doesn't change the sedation scale and definition of general anesthesia.

Deep enough to tolerate an LMA = GA in my book

 

[caligas]

Well you could put an LMA in, run just propofol, and tell the surgeon it’s propofol MAC with an “airway.”

And while you’re at it, turn a little gas on.

 

[Ronin786]

FWIW, I like LMA with propofol TIVA along with Pecs1/Pecs2 (or Serratus) for these cases. I'm sure a good discussion with the surgeons about TIVA vs MAC would clear things up a great deal. Adding a little Ketamine (30-50 mg) to the propofol would be nice as well. I've also used Precedex, Propofol with the LMA and chest wall blocks for a nice anesthetic.

The goal is a pain free, non nauseating anesthetic with fast discharge. I think a detailed conversation how you plan on accomplishing that will go a long way.

https://www.anesthesiologynews.com/...ONV-Following-Total-Mastectomy/36353/ses=ogst

“There’s a movement in anesthesia to improve patient care by implementing ERAS pathways,” said Monica Harbell, MD, assistant clinical professor of anesthesia and perioperative care at UCSF’s School of Medicine. “Nevertheless, there haven't been many enhanced recovery pathways in breast surgery. So we wanted to apply the principles of enhanced recovery in an effort to get our patients mobilized earlier, more active and involved in their care, and hopefully achieve better outcomes and greater patient satisfaction.”

The pathway calls for preoperative administration of 600 mg oral gabapentin and 1,000 mg oral acetaminophen in all patients, as well as placement of 1.5 mg transdermal scopolamine in patients aged less than 60 years with multiple risk factors for PONV. Intraoperatively, the pathway recommends total IV anesthesia, minimizes opioids, uses regional anesthesia (either Pec 1 and 2 or paravertebral blocks), and PONV prevention with 8 mg IV dexamethasone and 4 mg IV ondansetron. In the PACU, patients receive opioids, ondansetron and/or lorazepam as needed.

“And then we really encourage patients to mobilize as early as possible after surgery, to make sure we decrease risks that come with immobility, such as pneumonia and DVTs [deep venous thromboses],” Dr. Harbell said.

ERAS is nice but the hype around it nowadays is terrible. It's basically putting together a lot of good practices into one, but as most other things in modern medicine, people will stick to it like the gospel.

 

[Twiggidy]

Isn’t the actual definition of MAC just quite literally monitoring the patient and very little sedation to the point where you can still converse with the patient?

I agree with what someone said above, anything that makes the patient sleep and not respond to stimuli is a general anesthetic in my book doesn’t matter if it’s simple mask, NO mask, LMA or whatever. The surgeons just need education that it doesn’t matter what drug is used but I can also understand not wanting to rock boats, especially in academics where it’s just not worth the headache.

 

[deleted162650]

Isn’t the actual definition of MAC just quite literally monitoring the patient and very little sedation to the point where you can still converse with the patient?

Technically “MAC” does not imply any particular level of sedation. It’s not part of the sedation scale. It’s actually a billing term you use anytime you are asked to be present and monitor during a procedure. Doesn’t matter if you give no drugs or propofol at 1000mcg/kg/min.

 

[MirrorTodd]

Technically “MAC” does not imply any particular level of sedation. It’s not part of the sedation scale. It’s actually a billing term you use anytime you are asked to be present and monitor during a procedure. Doesn’t matter if you give no drugs or propofol at 1000mcg/kg/min.

That's something we've been briefed on here at my program to avoid saying when we are presenting our plan to the attending. We are always reminded to present based on the sedation scale rather than stating that the overall plan is a "MAC anesthetic".

 

[anbuitachi]

Yea I keep seeing people equate MAC to mean not general anesthesia. MAC means monitored anesthesia care, with someone trained in anesthesia. It could be light sedation all the way to GA. ICU patients get sedation as well but it's not called MAC cause theres no anesthesiologist monitoring the patient

 

[sigrhoillusion]

Technically “MAC” does not imply any particular level of sedation. It’s not part of the sedation scale. It’s actually a billing term you use anytime you are asked to be present and monitor during a procedure. Doesn’t matter if you give no drugs or propofol at 1000mcg/kg/min.

THIS! Has NOTHING to with what type of anesthesia that is used. It just means that anesthesia is in the room, monitoring the patient, and there for when **** hits the fan...

For our pre-op notes (we use EPIC) the anesthesia plan options are MAC, General, regional , spinal, epidural, "other". So pretty much MAC just implies anything not LMA/ETT. But when you think about it General is a MAC as well since it has nothing to do with sedation scale, since GA is part of that scale. I think the term MAC is stupid and should be gotten rid of. The note should infer what level of anesthetic you plan on doing, conscious, light, moderate, deep, GA... and the way our billing works we can only click one button since you can only bill for one anesthetic. So for a hip we might do spinal with sedation, but if you click MAC and spinal, you get an e-mail to verify, so you pick the one you used "primarily" (whatever the heck that means...)

And although MAC is a billing term, I'm not even sure it affects billing rates. I thought most of the billing had to do with our presence, patient's ASA, type of procedure (base units), duration, modifying factors (but I'm not sure if MAC is a part of that...)

 

[deleted162650]

Anesthesia time is billed at the exact same rates regardless of the type of anesthesia used.

 

[sigrhoillusion]

Anesthesia time is billed at the exact same rates regardless of the type of anesthesia used.

I know that, but I'm not sure what all the "modifiers" were. I know things like emergencies, extreme age, hypothermia, controlled hypotension, field avoidance are included. I really should read up on billing stuff, especially if I ever switch to PP.

 

[deleted162650]

I know that, but I'm not sure what all the "modifiers" were. I know things like emergencies, extreme age, hypothermia, controlled hypotension, field avoidance are included. I really should read up on billing stuff, especially if I ever switch to PP.

No modifiers for anesthetic type, and you cannot bill separately for a block if that is your primary anesthetic. Invasive lines are the other add-on you missed.

 

[Twiggidy]

Anesthesia time is billed at the exact same rates regardless of the type of anesthesia used.

This. You can literally sit and twiddle your thumbs giving zero drugs or give a GA and get paid the same.

 

[Iso4ane]

Very reputable regional and national institution, big name. Heavily advertises, tv, radio, billboard, sports team sponsor.

Pays well but salaried, calls not too bad, no ED so few emergencies. Nice deal on paper but I have never seen attendings so stressed and insulted on a daily basis by their surgical "peers". When you see the department chair chewed out by a head and neck surgeon over tiny trivial items really puts the big stuff in perspective.

Surgeons interfering with how I perform an anesthetic is ridiculous. Its the same as if I pointed to random items on their standard trays and said they cant use it.

When they pick up a scalpel, you should say "If I can't tube them, then I wouldn't use that if I were you." When they invariably ask why. "Everytime you use that thing your patient wakes up in pain, why don't we try it with out that."

 

[AKMD_1984]

This is ridiculous.

I would decline to do these cases citing patient safety being compromised. More than welcome to get someone else to do it.

 

[Arch Guillotti]

This is ridiculous.

I would decline to do these cases citing patient safety being compromised. More than welcome to get someone else to do it.

Good luck with that as a resident.

 

[TheLoneWolf]

This is ridiculous.

I would decline to do these cases citing patient safety being compromised. More than welcome to get someone else to do it.

Like I said, it's a don't rock the boat mentality. I've seen my department chair get chewed out and yelled at over tiny stuff. They are all hospital employed. I have not found anesthesiologists so jittery or running around like dogs trying to appease the surgeons.

 

[narcusprince]

Like I said, it's a don't rock the boat mentality. I've seen my department chair get chewed out and yelled at over tiny stuff. They are all hospital employed. I have not found anesthesiologists so jittery or running around like dogs trying to appease the surgeons.

Their are jobs that are not like this. I have worked at a few protocolized practices and those are the most unpleasant. Play the game. Part of residency is figuring out what you would not tolerate.

 

[AKMD_1984]

Good luck with that as a resident.

Yeah you are right. Being a resident voids you from responsibility and logic...

Why stop at 200? You should run propofol at 500 mcg/kg/minute (or 1500), and cause cardiac arrest, do not resuscitate, and then blame the surgeon and your weak ass anesthesia attending instead because you don't want to intubate for PONV reasons.

Put their license on line. Document everything "as per surgeon" or "as per anesthesiology attending". Have fun with it - you are already putting the patient at extreme risk with hypoventilation and hypercarbia which is doing a number on their myocardium for > 1 hour, why not go the extra mile?

This is not science. I am sorry.

 

[coffeebythelake]

Like I said, it's a don't rock the boat mentality. I've seen my department chair get chewed out and yelled at over tiny stuff. They are all hospital employed. I have not found anesthesiologists so jittery or running around like dogs trying to appease the surgeons.

jeezus your department is weak as **** if they let stuff like this happen.
your department chair needs to nut up and stop acting like a mid level
if you can't even claim patient safety for changing practices there is no excuse