Noyac said:
Yeah we could do that but at least when we talk about it here, it gets read and not lost in all the esoteric BS they publish these days. Maybe thats a little harsh. I did read 2 studies in this months journal.
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I dont think its harsh.
We think the same. Early in my career I paged through the monthly
Anesthesiology periodical from cover to cover, in search of salient cutting-edge clinical info...after about 6 months in private practice one gets sick of reading articles on
Bovine Seminal Vescicle Wedge Pressure Reflects Bovine Right Atrial Pressure ....seriously...our periodicals are slim pikkins for useful stuff for the in-the-trenches clinician...
I think we're missing the boat here...lets think outside the box for a minute...how do we bridge the gap between academecians who publish the science of our specialty, who are usually not very clinically gifted, and not usually very clinically involved....and the "grunt" anesthesia physicians who are actually doing the cases, perfecting their trade through anecdotal observations and advice/suggestions from other busy clinicians?
Do these "powerful, published" academic anesthesiologists really have a grasp on our specialty? Are they concentrating on publishing literature that is significant to our trade? Or are most of our periodicals full of more "filler" studies than great studies?
I'm a "grunt" anesthesiologist. I do cases every day I'm at work. I take night call.
I'd like to pick up a periodical representing our trade and read well done, well controlled studies that address anecdotal observations that I and all the other grunts have made conclusions on over a ten year career. Studies that could REALLY make a difference in the day to day grind of taking care of patients. Namely:
1) REAL LIFE NPO guidelines...i.e. 20 year old for a knee scope ate a waffle at 7am...its now 11am...we've all learned this is a no-no...but in ASA 1's, is morbidity/mortality increased by inadvertently eating breakfast on your surgery day?
2) Does the Selleck maneuver really matter? If you don't do it, does morbidity/mortality increase in full-stomach patients?
3) Does giving pre-op Pepcid/Reglan really make any difference in outcome on patients with sub-optimal gastric emptying?
4) Is putting a C section to sleep really that much more dangerous than regional?
5) Regional vs general...yes, we know after 24 hours no difference in pain/morbidity/mortality is seen, but what about the first 24 hours? If your knee had just been replaced, wouldnt you care about the first 24 hours?
6) During a craniotomy your volatile anesthetic reaches 1.6 mac. Does this increase morbidity/mortality?
7) Is there any real advantage, patient-outcome wise, to using some of the "new" drugs (remifentanil) or can one do the case with similar efficacy using fentanyl?
8) Does ventilation on a "full stomach" emergency really show a statistically significant increase of aspiration, when said ventilation is done by someone who knows how to ventilate? How many times have you done an RSI, had trouble with an intubation (or have been watching a resident/SRNA having trouble), have had to pull out the blade, gently ventilated because of desaturation, re-visualized, intubated, with no sequelae?
9) How much preoperative lab stuff do we REALLY need for an operation, in order to influence perioperative morbidity/mortality?
10) Why do some clinicians insist on a post-dialysis K+ before they'll put someone to sleep? Does this really make a difference in morbidity/mortality?
11)OK, the SWAN studies are out. So why are we still using them intraoperatively? Yes, I know you have all the derived formulas memorized, and you are a PAC stud. But do your clinical decisions that are made based on the SWAN numbers make a difference in patient morbidity/mortality, verses making clinical decisions based only on BP, HR, SpO2, EKG, urine output, (and if the case is a CABG, how the RV looks visually?)?
12) Does a CVP number's guidance in clinical decision making make a difference in patient morbidity/mortality, compared to guidance based only on BP, HR, EKG, urine output?
13)Why do people have to take their clothes off and put on a gown for cataract surgery? Is infection rate affected?
14) Does Bicitra before a labor epidural affect parturient morbidity/mortality? Or are we making future new mothers unneedingly more nauseated for no reason?
15) If "full stomach" is such a risk in elective cases, why dont more trauma patients that ate at Burger King an hour before their catastrophic car wreck requiring helicopter transport and emergency surgery die of aspiration on anesthesia induction?
16) Why dont residencies teach their residents that all the "correct" doses of medicines they are learning are not actually correct, since midazolam 2mg/propofol 2mg/kg//rocuronium .6mg/kg//NTG .5ug/kg/min etc etc means so many different physiologic responses from so many different people?
17) So what is the real answer for diabetics? Is patient morbidity/mortality affected by which assigned-insulin-regime they follow: no insulin/half insulin dose on day of surger
18) Does drinking a cup of coffee 2 hours before your knee scope truly affect your expected perioperative morbidity/mortality?
19) Does cancelling a case because of an NPO guideline infraction really make a difference in patient outcome?
OK. Thats enough from me. Look, I learned all the "rules" just like you astute residents are learning now. What I've found over the years, IMHO, is that some of the stuff I learned was voodoo...didnt have an impact on morbidity/mortality and just wasted time.
I encourage you to ask
WHY during residency. Why am I doing this procedure? Why am I cancelling this case?
Many times we do things without science to back up our decisions. And most of these scenerios waste a buncha time: yours, the patient's, and the surgeon's.
Think outside the box you are being taught.
And add to this list.
Lets do things for a reason. And get rid of things we do in anesthesia for no reason.
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