Jetpearl Number 12

[jetproppilot]

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http://forums.studentdoctor.net/showthread.php?t=552365&highlight=Surgeon+dude

Resident collegues, what I'd like you to take away from this great learning case from a cuppla years ago is the importance of making small adjustments, even in an emergency. You can always give more. You can't give less once the syringe is hubbed.

 

[fastosprintini]

thank you for bringing back an awesome post !
have you considered publishing these things , maybe as a little handbook "anesthesia pearls for pp" ?
in residency i was told:" you can always give more but you can't take it back"
fasto

 

[BlitznFire]

Thanks for the all these pearls Jet ! They are giving me a great insight into the life of an anesthesiologist.

 

[sevoflurane]

Freak'n great post Jet. I think I was on sabbatical when it popped on SDN.
Dream: Good question man. I think it’s unpredictable. One of my old attendings at residency spoke of a 10 yr old kid that took a BB gun bullet. Speaking in the ER, didn’t look too bad for an acute temponade. Got ketamine on induction and the kid went into PEA almost immediately.

In general, once they are under 70 systolic my spider sense is going off. By the time they are 50 it’s off the charts. I’d consider Scop + Sux in this scenerio.

Ketamine is a direct myocardial depressant in someone that is catecholamine depleted.

Question: How do you know whether someone is catecholamine depleted and whether they will have a myocardial depressant reaction to ketamine?

 

[jetproppilot]

Freak'n great post Jet. I think I was on sabbatical when it popped on SDN.
Dream: Good question man. I think it's unpredictable. One of my old attendings at residency spoke of a 10 yr old kid that took a BB gun bullet. Speaking in the ER, didn't look too bad for an acute temponade. Got ketamine on induction and the kid went into PEA almost immediately.

In general, once they are under 70 systolic my spider sense is going off. By the time they are 50 it's off the charts. I'd consider Scop + Sux in this scenerio.

Nice post, Sev.

Dream: Good question. Like Sevo, don't have an answer for you. When you're in this type of dire emergency where hemodynamics are exceedingly critical, the induction agent needs to be something that won't contribute further to hemodynamic instability. I think when its this dire, as long as you use justa little, regardless of choice, the pt will be amnestic, which is the goal, and contribution to hemodynamic instability based on your chosen induction agent is insignificant.

I made my choice.

Maybe there was a better one, like Sevo suggested.

 

[jetproppilot]

thank you for bringing back an awesome post !
have you considered publishing these things , maybe as a little handbook "anesthesia pearls for pp" ?
in residency i was told:" you can always give more but you can't take it back"
fasto

I'm glad you like them.

Maybe I should speak with my agent 🙂D)

who btw is on this forum.

 

[jetproppilot]

Thanks for the all these pearls Jet ! They are giving me a great insight into the life of an anesthesiologist.

You're very welcome.

Glad you're here.👍

 

[hoyden]

I'm glad you like them.

Maybe I should speak with my agent 🙂D)

who btw is on this forum.

He is an interesting guy. Got in a lot of fights here, however )))

 

[jetproppilot]

He is an interesting guy. Got in a lot of fights here, however )))

Yep. Interesting. Also

Brilliant

Multi-talented..Dude's prose earns alotta bank. Yeah, I got that part. I couldda lived without the fact that he's a musician too. Dude sent me a clip on FB of him on drums during sound check of a major rock band....just...you know...RIPPIN IT UP.(huh?..THAT JUST HAPPENED.)

Down to earth. Most dudes in his cerebral-weight category wear kackies and sport BCGs, pants too short, and a pen holder with ten pens in their shirt pocket. Nope. Dude's got class too.

I'm feeling pretty diminutive right now. I'm a bodybuilding anesthesiologist. That and a dime will get me a cuppa coffee.

 

[hoyden]

Yep. Interesting. Also

Brilliant

Multi-talented..Dude's prose earns alotta bank. Yeah, I got that part. I couldda lived without the fact that he's a musician too. Dude sent me a clip on FB of him on drums during sound check of a major rock band....just...you know...RIPPIN IT UP.(huh?..THAT JUST HAPPENED.)

Down to earth. Most dudes in his cerebral-weight category wear kackies and sport BCGs, pants too short, and a pen holder with ten pens in their shirt pocket. Nope. Dude's got class too.

I'm feeling pretty diminutive right now. I'm a bodybuilding anesthesiologist. That and a dime will get me a cuppa coffee.

🙂

yet he still has dreams to come true - good for him, BTW 👍

 

[Planktonmd]

Thanks for the replies.

I don't know the answer. After getting *ss raped by orals, I'm not going to look up anything for another 6 months when I start studying again.

I'm freestyling this **** (as my homie Narcotized would say)...

You will have an a-line prior to induction with tamponade. What if you gave a test dose of ephedrine before induction? If no response, go with etomidate. If there is a response, go with ketamine. Thoughts?

I am going to revisit this again although we have given it a good beating in the thread Jet referred to:
It really does not matter what you use for induction, the most important factor here is TIME!
You need to allow the surgeon to enter the precardium as fast as possible.
An A line is great to have but it is not a priority.
Ketamine and maintain spont. ventilation is what I chose previously and I still think would be my approach.
The chatecolamine depletion and Ketamine induced myocardial depression is a sexy concept but honestly it would not on my mind dealing with acute tamponade.

 

[Planktonmd]

Your guy is a real artist, and I have told him that already.
He got in fights here because he could not tolerate stupidity and that made me admire him further.

Yep. Interesting. Also

Brilliant

Multi-talented..Dude's prose earns alotta bank. Yeah, I got that part. I couldda lived without the fact that he's a musician too. Dude sent me a clip on FB of him on drums during sound check of a major rock band....just...you know...RIPPIN IT UP.(huh?..THAT JUST HAPPENED.)

Down to earth. Most dudes in his cerebral-weight category wear kackies and sport BCGs, pants too short, and a pen holder with ten pens in their shirt pocket. Nope. Dude's got class too.

I'm feeling pretty diminutive right now. I'm a bodybuilding anesthesiologist. That and a dime will get me a cuppa coffee.

 

[doctor712]

You guys, led by my true great friend JET , are killin' me. 😀

Yes, I, D712, am Jet's literary agent, talent manager, all-things-Hollywood future Head Writer if all things go as planned for the next CUPPLA months, book publisher ad infinitum, ad nauseam, arboretum. I couldn't have found a better CLIENT. Or friend for that matter. I luck out with an AMAZING ANESTHESIA MENTOR to boot.

My COPRO and MMD days were not my proudest here, and I'm glad JET wasn't around for that blip in time to bear witness. 🙁 I see memories don't fade too easily here, I'll sleep in my bed. I made it. Lesson learned because in my future OR, I'm sure memories are even longer lasting. Somewhere along the lines of...FOREVER.

Nevertheless. Big writing job this summer that will pay for about 1/2 of MD school in one swoop, and that's the BIG PICTURE. And the goal. I've got my pubs pubbed, my research researched, MCATS in near future, Miller Vols. 1 & 2 on the shelf (GIFT) to keep eye on prize, I even get to visit the FRIGGIN' Ether Dome in about a week because of said GIG.

Thanks for all the words, Hoyden, Plankton, (who has ALWAYS BEEN IN MY CORNER). JPP..

Bottom line is, ever since I spent day ONE in the OR, at P&S, with Peds Anesthesia, and saw someone get paralyzed for the first time (AND WONDER WTF THAT was about!!!!) and saw someone INDUCED, o watched that Blonde haired blue-eyed 4 year old kid come in for Chemo to get a spinal so they could inject the drugs into his CSF, I never forgot the team of Docs I thought were the smartest, STUDLIEST, most amazingliest people providing the most IMPORTANT function in an OR, in the hospital.........YOU GUYS/GALS. And that's why I'm still here. And am not going ANYWHERE. And that was 9 years ago. I'm 36 now. I've battled through life and all sorts of BS, to get here. I'm stayin'. 🙂 If only to make sense of what all those DAMMED BRILLIANT JETPEARLS MEAN!!!!!!


D712

 

[doctor712]

He is an interesting guy. Got in a lot of fights here, however )))

Might I also note that those "fights" were an anomaly that occurred during Xmas 09 to Jan 10. I was fight free for a year prior to and ever since.

Hiccup.

Excuse me.

D712

 

[jetproppilot]

Big writing job this summer that will pay for about 1/2 of MD school in one swoop,

Feelings mutual, Dude. Thanks.

Btw....looking at your quote above, I have one retort:

HAHAHAHAHAHAHAHAHAHAHAHA

You've shared with me the benjamins your prose is bringing.

You are a very modest individual.👍

 

[doctor712]

HAHA.

I'm trying to keep my financial options open in case I want TUFTS or U COLORADO at $$$65K a year!!!!! 😀😱 (JPP: PLEASE STOP ME IF I EVER SAY THE WORDS: "I'm going to TUFTS or UC...) PLEEEEEEASE. Matter of fact, I'm giving you access to my AMCAS. Delete those schools if you see them listed.

No will power here.

D712

 

[rsgillmd]

Jet, one question for you. I read the argument for not doing a percardiocentesis, even under echo.

However, why not have the surgeon do this under local?

Prep, drape, shoot a bunch of local, cut. Once more hemodynamically stable, put to sleep.

I've done one window under local. Granted it was non-emergent. We barely gave the patient anything (I think 1 mg Versed, 50 mcg Fentanyl -- I can't remember now but it wasn't much). She tolerated the procedure very well.

 

[jetproppilot]

Jet, one question for you. I read the argument for not doing a percardiocentesis, even under echo.

However, why not have the surgeon do this under local?

Prep, drape, shoot a bunch of local, cut. Once more hemodynamically stable, put to sleep.

I've done one window under local. Granted it was non-emergent. We barely gave the patient anything (I think 1 mg Versed, 50 mcg Fentanyl -- I can't remember now but it wasn't much). She tolerated the procedure very well.

Your point is well taken.

Better yet, don't know why Dr R didnt consider inserting one of those long, scary-a s s needles sub xiphoid, in the ICU.

Great question.

I prosed it as it happened.

Doesnt mean there couldnt've been a better way.

 

[Hamhock]

Jet, one question for you. I read the argument for not doing a percardiocentesis, even under echo.

However, why not have the surgeon do this under local?

Prep, drape, shoot a bunch of local, cut. Once more hemodynamically stable, put to sleep.

I've done one window under local. Granted it was non-emergent. We barely gave the patient anything (I think 1 mg Versed, 50 mcg Fentanyl -- I can't remember now but it wasn't much). She tolerated the procedure very well.

Yeah, I guess something like that is my question too.

Not at my current hospital, but at my previous training grounds, the CT-ICU folks would have this guy tubed in the ICU and either re-opened the chest (most likely, depending on how far out from CABG the patient is) right there or, at the very least, stuck a needle sub-Xi. Most CT surgeons I know (which, I admit, is probably not more then ten), would re-open the chest in the ICU...most CCM docs would needle that pending disaster/death.

Why even transport to the OR? Emergent tamponade doesn't need an OR - it needs emergent relief.

HH

 

[sevoflurane]

I think it's dealers choice. I've seen a pericardiocentesis take out the LAD = bad luck. Really made things worse. Took him to the OR anyways.

The last temponade I did in residency, the patient expired as her aortic root dissected and then fell to pieces when trying to repair it. Was glad we were in the OR and did it open.

As Jet mentioned, the case took 20 min. from start to finish. If you are that good and have the right help I don't see a problem taking the patient to the OR especially if they are still talking to you. If they are so bad that they have hypoperfusion to their brain manifested by near unconsciousness I'd go for ICU pericardiocentesis. Dealears choice based on where you are on the spectrum of critical to almost dead. ICU to OR takes about 1.5 minutes at my hospital.

I woulda done things Jet style.