"Its very harmful to babies"

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TheLoneWolf

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On OB rotation, first case of the day for elective sections. Assigned with the most miserable attending probably in our whole program. Rips residents to shreds in front of all OR staff, swears at the top of her lungs, ridicules any resident at each turn she gets. Everyone dreaded working with her. Most senior partner in a large group covering multiple hospitals and has been practicing for over 40 years. Prefers to do her own cases.

Nobody can find the OBGYN. I go speak to the patient after room setup. 41 year old multip, obese but not terribly large, cHTN, uncomplicated pregnancy at 40 weeks. Had prior spinals for sections without complications. Labs and Vital signs normal. Going over the consent and informed her that GA is always kept as backup if difficult/impossible/ nonfunctional neuraxial. While explaining this, OB walks in with two senior OB residents and says to me " no, there will be no general anesthesia, it is very harmful to the baby. Are we clear"

She looks at the patient and said studies show it is very bad for the fetus and that we will not be using it. " you will get a shot in your back then you go numb, drapes go up, we test you to make sure you feel no pain then we will get the baby out"

Smiles, looks at me with an are we clear look then walks out.

I stood there for a few seconds thinking ' did she just say that, does she even know what she is talking about? That is very inappropriate.'

Looked at patient and told her that just in case, we will need to consent her for GA as backup. She was not happy to hear that but complied.

Now I have to go find the room nurse. Run into my attending, let her know what happened. She finds the OB and tells her " no more talk of this general anesthesia is harmful to babies, are we clear?" in a pressured voice. Both the OB residents are with their attending and they immediately turn bright right as soon as their attending attempted to deny it.

" oh no I would never say that, your resident must have misunderstood. That never happened."

I was right there and spoke up " yes you did and this is what you said to the patient verbatim. Let's go back and talk to the patient." Now the OB is bright red, keeps denying it then walks away, did not go back to see the patient.

Push patient to OR, prep back. Good musculature, no notable curvature, can feel the spinous processes with deep palpation.

Numb the patient, place the introducer, put the pencan spinal needle 25 gauge, no csf return. Reattempt with different angle and spinal needle bends with little applied pressure. I go up one level and reattempt, same thing , spinal needle starts to bend. My attending starts getting mad and starts berating me thinking this lady is easy; so before she exploded, I handed it to her and said go ahead. She attempts for 20 minutes and cant get it. I stand and smirk behind my mask, it's her comeuppance for her years of abusive, demeaning behavior, and arrogance.

She asks me to call the second most senior attending in the group. He's slick, very sharp, the one person you need in most emergencies and well respected, 30 years experience in anesthesia. He attempts for another 20 minutes. Lady's back looks like a pincushion. Good local so she didn't complain but is getting angry that it's taking so long with so many attempts.

They finally give up and told her " listen we have been at this for this many attempts and cannot with all our experience. I'm really sorry. Your going to have to go to sleep for this."

Patient who was stoic to this point starts balling her eyes out says " you are going to harm the baby. why cant you do the spinal? I didn't have problems before." Angry and difficult to console. Informed that this is it, not much else to offer. Angrily agrees, uneventful GETA.

So we look like incompetent **sholes. The damaging OB has a smug look on her and walks off scot free.

Granted, this lady had prior sections so an elective c section is indicated.

For elective primary c sections, I feel that the "scheduled" c section is harmful to both the mother and baby. M and M goes up for the mother. Poor stress response from lack of labor in the baby places them at risk of neonatal respiratory distress syndrome and NICU admissions (Elective Cesarean Section: It’s Impact on Neonatal Respiratory Outcome) . Also increases the risk of neonatal mortality within the first month of life (https://onlinelibrary.wiley.com/doi/full/10.1111/j.1523-536X.2006.00102.x)

If an anesthesiology resident says that to a patient they would probably get reported and given extra calls. If an academic or PP attending does that, they would likely get canned.

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I was right there and spoke up " yes you did and this is what you said to the patient verbatim. Let's go back and talk to the patient." Now the OB is bright red, keeps denying it then walks away, did not go back to see the patient.

This was indeed the climax of the story. i wish there was more. But at least the OB didn't start using castor oil to get the baby out....

She asks me to call the second most senior attending in the group. He's slick, very sharp, the one person you need in most emergencies and well respected, 30 years experience in anesthesia. He attempts for another 20 minutes. Lady's back looks like a pincushion. Good local so she didn't complain but is getting angry that it's taking so long with so many attempts.

Did she use the same needdle? any talk of stepping up to 22G needle?
What about ultrasound? or a CSE?
One of my rules i'm developing is that 3 attempts i'm going adjuncts and trying something else, no way my 4th attempt will be more successful than my first 3 attempts. But the ED resident that instrumented a dying pt's airway 6 times don't think that way so why should your attending? :D
 
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Horse sh1t.
Delighted you stood up to her. Well done.

Pity the spinal didn't work but sh1t happens occasionally...
It will happen again
Learn what lesson you can from it and move on.

Thanks for sharing! These instances are rare enough but do happen so it's good for us to have something prepared when an idiot pipes up with some rubbish
 
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This was indeed the climax of the story. i wish there was more. But at least the OB didn't start using castor oil to get the baby out....



Did she use the same needdle? any talk of stepping up to 22G needle?
What about ultrasound? or a CSE?
One of my rules i'm developing is that 3 attempts i'm going adjuncts and trying something else, no way my 4th attempt will be more successful than my first 3 attempts. But the ED resident that instrumented a dying pt's airway 6 times don't think that way so why should your attending? :D

My attending asked for another regular sized 22g pencan. The slick attending attempted with a standard size 22g pencan then switched to the 7 inch Quincke.

No ultrasound was used but I know we had one around the corner. Must have been too deep in the situation. Attendings and I didn’t think of it. To be fair, we almost never use ultrasound for neuraxial as most of the attendings are not very comfortable with it so it never became standard practice. The occasional academic will entertain it on a slow day and thin patient for the practice. No CSE.
 
My attending asked for another regular sized 22g pencan. The slick attending attempted with a standard size 22g pencan then switched to the 7 inch Quincke.

No ultrasound was used but I know we had one around the corner. Must have been too deep in the situation. Attendings and I didn’t think of it. To be fair, we almost never use ultrasound for neuraxial as most of the attendings are not very comfortable with it so it never became standard practice. The occasional academic will entertain it on a slow day and thin patient for the practice. No CSE.

wouldve definitely tried CSE. much better tactile feel to it. we as anesthesiologists do so many epidurals on morbidly obese patients without much issues. this couldve been another regular epidural on an obese patient
 
Honestly I still love it. Yes, **** hits the fan regularly but I feel I am there for the patient and can bring them through the local butcher shop safely. Also I become very bored outside of the OR. Will probably be doing at least half anesthesia if not full time
 
Your attending sounds terrible. Why demean your own team in front of other people? Are some people so used to disrespect from surgeons that the only outlet they have is their juniors?

The OB also sounds like a doofus. Who tells a patient they can only have neuraxial? Was the OB gonna place it if your team failed?

I'm glad you came out of it unscathed though. A lot of potential here for you as a resident to get effed
 
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I love a CSE when the spinal needle is too wimpy and the space is too deep in there. The tactile feedback from a touhy can't be beat.
 
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It's inappropriate for a doctor in a different field to opine on someone else's work. We don't tell them what kind of incision to make and they don't tell us what kind of anesthesia to use.
 
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Sorry if this was long winded. I write like Tolstoy not Hemingway.
Dang, I believe you presented another post about the surgery program where you trained. I think. Place sounds like a misery

I’ll echo a CSE + U/S. I do CSE for almost all of my C/S because the feel is just so much easy and you can “fish” in the bigger ladies. I don’t place a catheter just the spinal unless I feel I need the catheter
 
Dang, I believe you presented another post about the surgery program where you trained. I think. Place sounds like a misery

I’ll echo a CSE + U/S. I do CSE for almost all of my C/S because the feel is just so much easy and you can “fish” in the bigger ladies. I don’t place a catheter just the spinal unless I feel I need the catheter

Yeah that program sounds horrible top to bottom.

I would also have just used the Tuohy for guidance and then spinal through it, leave a catheter only if you thought it was necessary at the start.
 
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