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Jet's Clinical Posts Back Atcha

Discussion in 'Anesthesiology' started by jetproppilot, Apr 28, 2007.

  1. jetproppilot

    jetproppilot Turboprop Driver

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    WUSSUP DUDES & DUDETTES!

    Yeah, I've been dormant for a while. I'm sure I'll bore you with the details of my absence at some point in the future (read: post-Katrina personal woes).

    I feel the need (THE NEED FOR SPEED.....sorry...little Top Gun slip) to PUMP UP THE VOLUME ON THIS FORUM which seems to have taken a rating on the bore-meter lately.




    Hmmm......so whatcha think?

    A UFC fight between Mil & Volatile?

    Yet another thread on the CRNA threat? :)laugh: )

    How creatine has assisted my mini-muscles out of dormancy?

    Why on earth Copenhagen costs five bucks a can?

    A New York Mets scout watching my left-handed-batting four year old?




    I agree. All the above are relevant topics.

    But I'll lead out with a decision that is relevant to the every-day ins-and-outs of being a clinician at a busy private practice hospital.

    Boring, everyday scenerio?

    Yes.

    Does this happen at every busy hospital EVERY DAY?

    Yes.




    22 year old ASA 1, 120 lb girl with appendicitis.

    Not a perfed, septic appy, but appendicitis nonetheless.

    No appetite, but thirst overcame her 30 minutes ago and she downed a Coke Zero like you down a Hurricane at The Cat's Meow on Mardi Gras day.

    Now what?

    Do you tell the surgeon he's gotta wait? Or do you proceed?

    If you choose to wait, can you justify the wait?

    If you choose to go, can you justify going? And if you go, can you cite evidence on the stuff we've been taught to do (cricoid pressure, pepcid/reglan, NGT, etc)?
     
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  3. zippy2u

    zippy2u Senior Member

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    Buzz her with a little versed and fentanyl and slip a small bore NGT down her before anyone knows about it. Keep it to suction and pull out at end of case before she wakes up. Don't delay surgery. It's midnight dammit, she's medicaid and you be salaried. Regards, ---Zip
     
  4. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved

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    All my appy patients come to the OR with a stomach full of oral contrast.
    They go to sleep.
     
  5. rmh149

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    Jetprop,

    This case is an emergency. Proceed

    pre-treat with Bicitra, 10mg metoclopramide IV, Pepsid 20mg IV. RSI with cricoid pressure.

    After induction and intubation, place an OG tube to decompress the stomach.
     
  6. nimbus

    nimbus Member

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    As do mine.
     
  7. UTSouthwestern

    UTSouthwestern 1K Member
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    Have that suction in her mouth as soon as you induce. Had an appy the other day and I knew that with the pain she was in, all the morphine given in the ER, etc. her motility was squat. Induced, and here came the vomit train before I could even sux her. However, suction was right there and set on super suck.
     
  8. jetproppilot

    jetproppilot Turboprop Driver

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    Nice management.

    The patient drinks the Bicitra. About 75% of them throw up right after ingestion, as do the parturients we treat. Guess thats a good thing, since now theres less stuff in the stomach. Mind as well give ipecac.

    Any REAL evidence the reglan affects outcome? Any evidence the pepcid effects outcome? (I used both affect and effect since I can never remember which one is proper...:cool: )

    I think placing an OGT after induction is the most useful action.

    We all know that this girl is a full stomach...whether she's ate/drank anything or not.

    And in my humble opinion, a full stomach is a full stomach. Her disease process (appendicitis) says so. She's gonna get the same treatment, with the same outcome, whether or not shes eaten/drank within the NPO-guideline window.

    So heres Jet's question to practicing clinicians:

    Why delay the case, even if she ate a Whopper on the way to the OR?

    Her gastric emptying hasnt been functional for some time now.

    And waiting ain't gonna make it better. Da Whopper is still gonna be there 6 hours from now, albeit in a more ground-up fashion.

    Same goes for any insult that brings someone to surgery....fractures, complex lacerations, urgent C sections, etc.

    Surgery is what they need.

    So I agree.

    Pre-oxygenation. She's in her twenties. Paralyze her and her pulse-ox will read 100% for more-than-five minutes. And the rising CO2 wont hurt her.

    Propofol, sux as fast as you can push'em.

    Call your wife to pass the time. No ventilation needed. Do cricoid if your brother is a lawyer. If not, don't worry about it.

    Has a minute passed? Grab your Miller 2 and put the tube in.

    Tape her eyes and the tube. Crank on some sevo and turn on the vent.

    Pass an OGT and suck out Da Whopper. She'll have less post-op nausea.

    Give 20mg rocuronium.

    Sit back and update the chart. Think about your fishing trip tomorrow post-call.
     
  9. dhb

    dhb Member
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    :laugh: good to see some clinical relevant stuff on the forum again.

    No more Sellick for me: saw some nice mri pictures from this study

    "Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging.

    * Smith KJ,
    * Dobranowski J,
    * Yip G,
    * Dauphin A,
    * Choi PT.

    Department of Anesthesia, St. Joseph's Healthcare and McMaster University, Hamilton, Ontario, Canada. [email protected]

    BACKGROUND: Cricoid pressure (CP) is often used during general anesthesia induction to prevent passive regurgitation of gastric contents. The authors used magnetic resonance imaging to determine the anatomic relationship between the esophagus and the cricoid cartilage ("cricoid") with and without CP. METHODS: Magnetic resonance images of the necks of 22 healthy volunteers were reviewed with and without CP. Esophageal and airway dimensions, distance between the midline of the vertebral body and the midline of the esophagus, and distance between the lateral border of the cricoid or vertebral body and the lateral border of the esophagus were measured. RESULTS: The esophagus was displaced laterally relative to the cricoid in 52.6% of necks without CP and 90.5% with CP. CP shifted the esophagus relative to its initial position to the left in 68.4% of subjects and to the right in 21.1% of subjects. Unopposed esophagus was seen in 47.4% of necks without CP and 71.4% with CP. Lateral laryngeal displacement and airway compression were demonstrated in 66.7% and 81.0% of necks, respectively, as a result of CP. CONCLUSION: In the absence of CP, the esophagus was lateral to the cricoid in more than 50% of the sample. CP further displaced both the esophagus and the larynx laterally."
     
  10. BLADEMDA

    BLADEMDA ASA Member

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    It is my practice to use Reglan and H2 Blocker for Full Stomachs and Obese Patients (Pregnant Patients the exception).

    The 2006 ASA question/answer CME booklet (question 31) shows a good study in Anesthesiology 2005; 102:904-909 in which Regaln is compared to placebo. Although the study was underpowered (125 patients) there was a difference in Gastric Volume between Placebo and Reglan. Reglan works quickly (less than 5 minutes) and is effective. The study could only prove statistical difference in IDDM patients; however, I believe if the study was enlarged to 2,000 patients then statistical difference would have been proved in every type of patient. In summary, Reglan is very cheap, works quickly and is effective.


    While the data on H2 blockers is not as good I still use it because it is very cheap and may help. However, H2 Blockers take longer to work (about 45 minutes) than Reglan.

    Blade
     
  11. jetproppilot

    jetproppilot Turboprop Driver

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    Hence the danger of using surrogate endpoints for studies.

    Yes, Reglan reduces gastric volume.
    Has Reglan been shown to alter clinical outcome when used in the full-stomach arena?

    I think using surrogate endpoint studies to guide clinical practice, although it sounds good, may be a waste of time and money.
     
  12. BLADEMDA

    BLADEMDA ASA Member

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    No. But, if it has been PROVEN to reduce Gastric volume why not use it? It is CHEAP and although carries some side-effects (Dystonic reaction, etc.) it is worth using in my opinion. At least the data is better than cricoid pressure.

    Blade
     
  13. BLADEMDA

    BLADEMDA ASA Member

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    Total cost for H2 Blocker and Reglan less than two dollars. Add Decadron (4-8 mg), low dose droperidol (0.625 mg) and generic Zofran 4mg and the total package is $5.00!

    Blade
     
  14. militarymd

    militarymd SDN Angel

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    You beat me to it.
     
  15. cfdavid

    cfdavid Banned
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    Jet, tell me about the creatinine! I've heard it makes one retain water.

    Also, do you guys ever see anabolics or HGH used post-operatively?? It seems this would be useful in tissue healing, but somehow I suspect this is not employed very often at all. Too controversial?? I think deca-durabolin (nandrolone?) is still FDA approved for certain circumstances. Also, do you EVER see this stuff used in the ICU where wasting may be a serious concern??

    There's ample evidence that HGH has positive/trophic effects on collagen synthesis. I know that a major drawback is it's diabetogenicity. Any thoughts?
     
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  17. burntcrispy

    burntcrispy Member

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    Jet, if Cope is up to $5.00/can it may be time to change things up. When the prices got out of hand I switched to Grizzly which is about $1.75/can here in my state. You may go thorough some minor withdrawl for a while as it doesn't have that "kick" of nicotine that you get with Cope but you eventually get used to it. :)
     
  18. jetproppilot

    jetproppilot Turboprop Driver

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    Hmmmm.......Grizzly....thanks bro.


    Anyway, Blade,

    look, dude. This isnt an argument about cost. Its an argument about doing things a certain way based on surrogate endpoints. Its obvious you mind as well throw in the meds since they are inexpensive.....but then again, if it doesnt alter outcome, why are you doing it? How many cases have you pulled those meds for that don't alter outcome? How long does that take you? Multiply that time for a year worth of cases. What about the pharmacist restocking the meds that you've wasted time giving? How long does that take? Multiply that by a year worth of cases.

    More importantly, look at outcome. Isnt that where the c-notes lie?

    Do you use propofol for inducing a parturient for a C section when GA is required?

    I do.

    Uh oh.....propofol has been shown to lower fetal cord blood pH....holy s hit!!!! Thats bad, huh?

    Nah. Its all good.

    Outcome studies show no difference in fetal outcome.

    Can you think outside the box?

    What good are studies that use surrogate endpoints to sell their data if patient outcome is not changed??

    So, again, why are countless anesthesiologists using reglan and pepcid as an inferred safety-step when, in fact, there are no outcome studies to prove it?

    And why arent residency programs educating their residents about the difference between surrogate endpoint studies vs patient outcome studies, so at least the resident can make an informed clinical decision as opposed to giving-the-stuff-cuz-you're-supposed-to?

    How many residents may alter their thought process if they knew patient outcome was no different after said intervention?

    Hmmm...lets think of something big in clinical anesthesia.....that clinicians SWORE by for .....literally decades......something we performed on countless critically ill patients, thinking we were doing the right thing because surrogate endpoint studies said so.....

    then the outcome studies came out, and told us that....not only were we not helping the patients, but, in fact, we were killing quite a few of them with our "helpful" intervention....

    DA SWAN GANZ CATHETER.
     
  19. Noyac

    Noyac ASA Member
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    Hey Jet, can you dip that **** during cases? I had a resident a year behind me that could dip all day without spitting. Just the thought of it made me ill. Now thats an iron gut.

    About the case. I wouldn't pass the OGT awake personally b/c I probably wouldn't have even thought of it. I would go back and induce RSI style, prop, fent ,sux, tube. Then pass an OGT and pull it at the end. No pro-op meds. Thats my style.

    But how about a spinal? Would anyone do a spinal? Assuming a 13 yr old would go with it. Probably not. But how about in an older pt?
     
  20. jetproppilot

    jetproppilot Turboprop Driver

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    Thats how I'd do it too, Noy.

    Cant dip without spitting....but your boy Pisto....he'd splash in a big dippa Cop before a case when we were residents....probably still does!! :laugh:
     
  21. rmh149

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    A spinal maybe if this was an open Appendectomy. If it was laprascopic, no way.

    Question to you: If the case was open, and the girl and her parents were OK with spinal, would you pre-treat with pepcid, reglan, bicitra etc.?
     
  22. Noyac

    Noyac ASA Member
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    I think Pisto kicked that habit. I never saw him with a dip. Or I guess its possible that he got really good at hiding it.
     
  23. cfdavid

    cfdavid Banned
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    no takers???? lol
     
  24. rmh149

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    Way above my head....I'm just a nurse. :) LOL!

    Seriously though...I have no idea about any of that stuff you are talking about. I am interested to find out more though.
     
  25. BLADEMDA

    BLADEMDA ASA Member

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    Jet,

    You are all over the place with multiple topics.

    1. I use Pre-meds in my practice. I will continue to do so until there is good data showing it doesn't help. I believe that a few cheap meds that MAY help alter a bad clinical outcome are worth using. At my hospital the pharmacist and Nurse don't "bat an eye" at re-stocking or giving these meds. As long as they are cheap and easy to give everyone is happy.

    2. I won't be the one attacking your practice by NOT using these pre-meds as the data is weak at best. But, there is still some data and an aspiration like Mil's case is a horrible event. There may be an Academic dude willing to be a legal expert against you.

    3. You are aggressive and I am "moderate" in my practice. I use Propofol for C-sections and have done so for the past 5 years. No chage in clinical outcome except it is easier for me. I especially like propofol in small doses for C-sections under spinal. Patients LOVE this technique.

    4. There are OUTCOME studies on S-G Catheter. I do not routinely use them unless Surgeon requests it.

    Finally, we can agree to disagree on some things, right?

    Blade
     
  26. jetproppilot

    jetproppilot Turboprop Driver

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    Absolutely.
     
  27. fval28

    fval28 Junior Member

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    Thanks for saying it first Noyac- spinal is the preferred approach for me and the guys I work with- I have done them on 13 yo girls and convinced them (and their parents) that they will be VERY comfortable while I am doing the spinal and asleep through the surgery- versed and fentanyl with maybe a touch of propofol- they snooze the whole time.:sleep: Wake up an hour later and the spinal is wearing off, they have no pain, and go to their room ready to finish their whopper:hardy:
     
  28. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved

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    unfortunately we do 99% of our appy's laparoscopically so spinals are not that cool.
     
  29. cfdavid

    cfdavid Banned
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    Come on, someone's gotta have some input on this stuff.
     
  30. bigeyedfish

    bigeyedfish Member

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    Perry Mason: Dr. Jet, is it within the realm of possibility that you could have prevented this poor young girl from aspirating if you had given her GI meds preoperatively, as our expert witness Dr. Blade has testified?

    Dr. Jet: Its about as likely as my dog crapping 5$ cans of coppenhagen and pissing Don Julio. Meds would not have changed the outcome.

    Perry Mason: Aha! So it IS possible!

    What about the argument that if, by chance, she does aspirate it's better (from a legal standpoint) to have given the pepid, reglan etc? No matter what the date are, you never know what juries are going to believe.
     
  31. rmh149

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    I agree. Regardless if she has a spinal or a tube...you have to plan for a general anesthetic. Pre-med with a full stomach always...gotta show the jury you did everything that "might" help.
     
  32. jetproppilot

    jetproppilot Turboprop Driver

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    HAHAHAHHAHHAHAHAHHAHHAHAHAHHA

    I, of course, see your point.

    I have chosen to minimize practicing "legal friendly medicine" whenever possible. Doing things that you arent convinced is helping your patient, to please lawyers only, isnt for me. We all do it some, but I practice medicine as an advocate for the patient, not as a running-scared doctor covering my a ss every time I turn around from ambulance-chasing lawyers.

    I agree with Mil: thats why we have malpractice insurance.
     
  33. TIVA

    TIVA Member

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    Spinal block for appendicitis?

    I can see that, except where laparoscopies are involved as mentioned by Plankton.

    But then giving sedation in the form of versed, fentanyl, AND propofol??!! Thanks for obtunding airway reflexes in a full stomach. But not in my kid. One GA to go, please.

    Here's my recipe for nice sedation on a spinal anesthetic:

    PO Reglan, Pepcid, and Dramamine in the holding area with 30 cc's of water, preferably 30-45 minutes before trip to OR.

    Hang your liter bag of LR wide open until it's time to go to the OR or it runs low, whichever happens first, and then slow it down.

    2 minutes before leaving holding area, give IV Versed 1-2 mg plus 0.05 mg/kg morphine.

    In the OR, apply your monitors (pulse ox and BP cuff). Perform the spinal. Lay them back recumbent. Place EKG leads and keep eye on BP. Have phenylephrine ready.

    Once your satisfied with the height of the block, give the other 0.05 mg/kg morphine (for a total of 0.1 mg/kg morphine) and start a Brevital infusion (10 mg/cc) just like you would for propofol (25-50 mcg/kg/min).

    You will find that patients are very calm and comfortable, snoozing (or snoring) throughout, but easily rousable. It's a good drug, Brevital. It's easy to titrate. They go down smoothly, they wake up smoothly. They maintain their own airway patency and protect their own airway reflexes. But because it's a barbiturate, it stays in your system longer, so it's more appropriate for inpatients or same day admits than for outpatient surgery.

    Plus, when they're snoozing, all you have to do is call their name and they'll wake up, unlike a Propfol snooze, which means they're in stage 3.

    The problem with Propofol is that it's a general anesthetic. You might as well try titrating in Sevo to sedation. Either they're awake, or asleep, not a lot of room in between.

    And patients love this cocktail. They're nice and relaxed. Even the ones who have told me that no matter what, they don't want to hear anything or know anything, will say during and after the case that they feel good. I normally do this for knees, hips, major vascular revascularizations below the waist, and endovascular surgeries.
     
  34. Noyac

    Noyac ASA Member
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    Very interesting. I won't be trying it but interesting nonetheless.
     
  35. zippy2u

    zippy2u Senior Member

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    Damm TIVA, sounds like rocket science to me with all these drips and pumps and all... Last time used brevital was in the ECT neanderthal days when the shrinks liked to play "sparky" with patients' brains. Back in the med school days, I'd just play ping pong with these VA crazies, and it seem to do better than ECT or any drug therapy. Regards, ---Zip
     
  36. BLADEMDA

    BLADEMDA ASA Member

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    Zippy,

    I go old school on this case: Propofol, Sux and E.T. tube. Maybe, a pre-med or two for the kid. K.I.S.S.

    Blade
     
  37. BLADEMDA

    BLADEMDA ASA Member

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    Mil's and JPP's - both end in a catastrophic aspiration. Pt. dies.

    Jpp's expert claims "Reglan, H2 blockers, etc. are wortheless" no hard data.

    Plaintiiff's expert claims these drugs MAY have altered the severity of the aspiration or even prevented it. JPP and Mil are negligent.

    Case goes to Trial. Both sides have a truckload of experts, Anesthesia, GI, etc. The jury is flooded with medical jargon, studies and info.

    At summary, the plaintiff's attorney places a $5.00 bill in front of the jury and states " the reason we are here today is because of $5.00 and 30 minutes.
    The defendant was so callous, so cruel and so arrogant that he wouldn't give (the deceased) $5.00 extra dollars and 30 minutes." The attorney shows the $5.00 bill to the entire jury. "I need you tell the defendant loud and clear that we find that totally unacceptable."

    What does a jury of construction workers, plumbers, store clerks, etc. decide? I wouldn't bet my life savings on the verdict.

    Blade
     
  38. jetproppilot

    jetproppilot Turboprop Driver

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    Such a great story you've constructed, Blade. You should send your CV to Morris Bart.

    Yeah, I'm a Copenhagen-dippin'-lifted-truck-driving-redneck from Florida, but I've figured somethin' out.

    If I do something clinically EVERY DAY that turns out with satisfactory patient outcomes, chances are that my eleven years of busy private practice are guiding me in the right direction.

    My patient outcomes speak for themselves.

    I refuse to practice medicine dictated by hungry personal injury/plaintiff malpractice lawyers.

    You wanna practice tail-tucked-under-your-anus medicine dictated by a plaintiff lawyer?

    I respect your decision.

    I've chosen a different path.

    I've been doin' this gig in busy private practice for almost eleven years.

    I make daily clinical decisions based on my knowledge and experience.

    No pay-outs to the lawyers so far.

    Sounds like I know da' biz.

    Cocky?

    Yeah, maybe.

    Figured out, from my residency education-which-lead-to-board-certification, and eleven years of doing cases, when to toe-the-line, and when the line is a farce?

    Absolutely.

    Please see my D&C thread.
     
  39. rmh149

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    Interesting experience... I pre-oxygenated myself with 100% oxygen (with the anesthesia machine), hyperventilated till the ETCO2 reading was 17, kept my heart rate at around 54 (carotid massage) and didnt move a muscle. I then held my breath. It took 6.5 minutes of apnea for me to start feeling the effects of hypercapnia. Of course my chest hurt like hell...but there is a peak to the pain. For fear of losing consciousness and falling out of my chair I started breathing again. My O2 saturations never dropped below 98%. My ETCo2 with the first breath was 78.

    :laugh: I did this when I was teaching pulmonary physiology to some students....It always freaks them out to see someone hold their breath that long. More importantly, it demonstrated to them the benefit of pre-oxygenation. I am going to go for 7 minutes next time.
     
  40. jetproppilot

    jetproppilot Turboprop Driver

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    Nice post.

    The reason I knew that worked was from a residency experience.

    We're taught to bag, bag, bag all the way to the ICU after a case.

    I was with a senior resident when I was a CA-1 after doing a healthy twenty-something big-time AP spine case.

    "Whatcha thinks gonna happen if we don't bag him?" the senior resident asked me.

    The ICU was on the same floor at Tulane as the OR, but still a few minutes away.

    "Geez, I don't know about that Dave," I responded.

    Dave didnt squeeze the ambu all the way to the ICU, smirking to me all the way.

    SPO2 on arrival at the ICU, 100%.

    David Levitats taught me what FRC meant that day.
     
  41. BLADEMDA

    BLADEMDA ASA Member

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    I am not criticizing you; I am pointing out the other side of the argument and giving you a nice Law and Order type case.

    We both know the malpractice system is a joke based more on emtion and outcome than scientific facts. That said, I will keep pushing the Reglan my friend.

    Blade
     
  42. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved

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    Well, if we convince all the CRNA's to do this experiment on themselves, without the preoxygenation part, and tell them it's a sign of weakness if they take a breath too early, we might solve the CRNA problem.
    :laugh:
     
  43. jetproppilot

    jetproppilot Turboprop Driver

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    And I respect that.
     
  44. rmh149

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    LOL! Would a hypoxic brain injury really change the way we think? ;)
     
  45. Noyac

    Noyac ASA Member
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    :laugh:
     

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