Jet's most memorable, ridiculous anesthesia dogmas

Started by jetproppilot
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jetproppilot

jetproppilot

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1)CLEARED FOR SPINAL ANESTHESIA...sorry doctor, you've just proved your ignorance of perioperative anesthesia.

2)ALBUTEROL TREATMENT ON ADMISSION TO DAY SURGERY...I dunno who ordered this but bronchodilators aren't needed unless theres bronchospasm, even with asthmatics...YOU'RE NEEDLESSLY HOLDING UP MY CASE

3)SWAN NEEDED FOR OPERATION...first of all Mr Internal Medicine Dude, I dunno if you've reviewed the SWAN literature, but it seems that it might cause more harm than good...that being said, this is a thirty minute lap chole! Are you ****ing serious?

4)OH MY GOD I'M A TENURED ATTENDING IN OB ANESTHESIA...REGIONAL HAS FAILED SO I'M GONNA DO MY DAMNDEST TO AVOID GENERAL ANESTHESIA BECAUSE... dude...put her to sleep. Its all good.

5)I'M DELAYING THIS CASE BECAUSE THE POST DIALYSIS K+ IS NOT BACK. I wouldntve ordered a post op K in the first place so PUH LEASE, mister Academic Doctor, LET IT GO. Its gonna be ok. Trust me.

6)THE PATIENT IS REPORTING GERD SO I WON'T USE AN LMA. Dude, everyone where I live has GERD. EVERYONE. Does that mean you can't use an LMA? NO. When will I NOT use an LMA? When GERD is postural. If when they lay flat (rare) and the symptoms arise, no LMA. Avoiding LMA utilization because of reported GERD is ridiculous.

7)PRIOR DIFFICULT INTUBATION MEANS AUTOMATIC FIBEROPTIC. I learned to avoid that trap long ago. I put these people to sleep now and assuming ventilation is good, I paralyze. I've yet to be burned which leads me to the fact that most patients labeled as a difficult intubation REALLY MEANS yeah, I'm an anesthesiologist but I do not yield THE FORCE.

Thats seven of them.

Theres many more.
 
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jetproppilot said:
1)CLEARED FOR SPINAL ANESTHESIA...sorry flea, you've just proved your ignorance of perioperative anesthesia.

2)ALBUTEROL TREATMENT ON ADMISSION TO DAY SURGERY...I dunno who ordered this but bronchodilators aren't needed unless theres bronchospasm, even with asthmatics...YOU'RE NEEDLESSLY HOLDING UP MY CASE

3)SWAN NEEDED FOR OPERATION...first of all Mr Internal Medicine Dude, I dunno if you've reviewed the SWAN literature, but it seems that it might cause more harm than good...that being said, this is a thirty minute lap chole! Are you ****ing serious?

4)OH MY GOD I'M A TENURED ATTENDING IN OB ANESTHESIA...REGIONAL HAS FAILED SO I'M GONNA DO MY DAMNDEST TO AVOID GENERAL ANESTHESIA BECAUSE... dude...put her to sleep. Its all good.

5)I'M DELAYING THIS CASE BECAUSE THE POST DIALYSIS K+ IS NOT BACK. I wouldntve ordered a post op K in the first place so PUH LEASE, mister Academic Doctor, LET IT GO. Its gonna be ok. Trust me.

6)THE PATIENT IS REPORTING GERD SO I WON'T USE AN LMA. Dude, everyone where I live has GERD. EVERYONE. Does that mean you can't use an LMA? NO. When will I NOT use an LMA? When GERD is postural. If when they lay flat (rare) and the symptoms arise, no LMA. Avoiding LMA utilization because of reported GERD is ridiculous.

7)PRIOR DIFFICULT INTUBATION MEANS AUTOMATIC FIBEROPTIC. I learned to avoid that trap long ago. I put these people to sleep now and assuming ventilation is good, I paralyze. I've yet to be burned which leads me to the fact that most patients labeled as a difficult intubation REALLY MEANS yeah, I'm an anesthesiologist but I do not yield THE FORCE.

Thats seven of them.

Theres many more.
Click to expand...

Allow me to plug in #8: "I don't always drink beer, but when I do, I drink Dos XX." Stay thirsty my friends!
 
Thanks for coming back Jet. Your posts were part of what pushed me towards anesthesia. I'm also glad to see some bold posting, but what about the 72 point font that peppered your posts?
 
jetproppilot said:
7)PRIOR DIFFICULT INTUBATION MEANS AUTOMATIC FIBEROPTIC. I learned to avoid that trap long ago. I put these people to sleep now and assuming ventilation is good, I paralyze. I've yet to be burned which leads me to the fact that most patients labeled as a difficult intubation REALLY MEANS yeah, I'm an anesthesiologist but I do not yield THE FORCE
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This is an awful slippery slope. I may follow this routine with a few patients but I take the history of difficult intubation very seriously. We don't always have documentation/letter which doesn't make matters any easier.
 
Arch Guillotti said:
This is an awful slippery slope. I may follow this routine with a few patients but I take the history of difficult intubation very seriously. We don't always have documentation/letter which doesn't make matters any easier.
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The important point here is the ability to ventilate. If you can ventilate the patient there is no reason not to paralyse the patient to get the best exposure.
 
dhb said:
The important point here is the ability to ventilate. If you can ventilate the patient there is no reason not to paralyse the patient to get the best exposure.
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I agree. Tomorrow's VATS is a known difficult airway, but easy mask. I have no trouble inducing and paralyzing. But Arch is right, we do a terrible job communicating to others what actually happened. A solution is in the works though.
 
proman said:
I agree. Tomorrow's VATS is a known difficult airway, but easy mask. I have no trouble inducing and paralyzing. But Arch is right, we do a terrible job communicating to others what actually happened. A solution is in the works though.
Click to expand...

Reminds me of a funny story from residency. Pt. had some sort of abdominal surgery the day before. Now he is coming for another ex-lap, semi-emergently. The guy looked like he had should have a normal airway (to my CA1 eyes at the time). My senior says to me, "Yeah, I intubated him yesterday. There was something funny about his airway, but I don't remember what. However, I was able to get it." I did a DL with a Mac 3 and saw an infantile type epiglottis flopping down. I decided to use the Mac as a Miller and was able to get a decent view and tube the guy. I mentioned what I saw to my senior and his response was, "Oh yeah! I think that's what I saw also."

Point of the story: we worry about communicating years later but sometimes we forget what happened the day before. Of course the chart from the day before just reflected DLx1.
 
geogil said:
Thanks for coming back Jet. Your posts were part of what pushed me towards anesthesia. I'm also glad to see some bold posting, but what about the 72 point font that peppered your posts?
Click to expand...

Thanks for the kind words, geogil.

I gotta feel alotta passion to pump up the font that big.

Sit back, relax, hope you enjoy the posts....I'm sure a seventy two pointer is lurking out there somewhere. :laugh:
 
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proman said:
I agree. Tomorrow's VATS is a known difficult airway, but easy mask. I have no trouble inducing and paralyzing. But Arch is right, we do a terrible job communicating to others what actually happened. A solution is in the works though.
Click to expand...

Which is?

I would personally LOVE to hear some ideas that people have about increasing our specialty's communication with others. Our hospital just got full EMR and I can see all kinds of opportunities to document (and thereby communicate) what it is we do in the OR, ICU, codes, etc. I personally would be very much in favor of a "Brief Anesthesia Note" akin to the "Brief Op Note" the surgeons write.
 
rsgillmd said:
Point of the story: we worry about communicating years later but sometimes we forget what happened the day before. Of course the chart from the day before just reflected DLx1.
Click to expand...

I think widespread use of EMR's will create the opportunities to clearly document things like difficult airways and moment-to-moment management.

If you only have paper charting it is DAMN hard to do that (my hand hurts just writing the "routine monitors, preoxygenation, SIVI" etc at the start of the case)
 
fakin' the funk said:
I personally would be very much in favor of a "Brief Anesthesia Note" akin to the "Brief Op Note" the surgeons write.
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We do this in our EMR when we drop the patient in the PACU. It is useful for communicating the occasional difficult airway or other unexpected finding (or reason for leaving the patient intubated, etc.) For most bread and butter cases it's worthless, though, and my colleagues don't use it to communicate the important info uniformly enough to keep me from looking up old anesthetic records anyway.
 
fakin' the funk said:
I think widespread use of EMR's will create the opportunities to clearly document things like difficult airways and moment-to-moment management.
Click to expand...


I've got to say, the EMRs I have seen only make it MORE difficult to find relevant info. They turn a simple one page note into 2-3 pages, which utterly lack the formatting familiar to physicians. I find myself trudging through irrelevant info like a list of the 20 diagnoses they have accumulated throughout their life, even though most are no longer applicable. 90% of the page is worthless, and I find the pertinent info like Impression/Plan buried on the last page.
 
Bertelman said:
I've got to say, the EMRs I have seen only make it MORE difficult to find relevant info. They turn a simple one page note into 2-3 pages, which utterly lack the formatting familiar to physicians. I find myself trudging through irrelevant info like a list of the 20 diagnoses they have accumulated throughout their life, even though most are no longer applicable. 90% of the page is worthless, and I find the pertinent info like Impression/Plan buried on the last page.
Click to expand...

It all depends on who's writing the note and how its done. My impression has been that those who would have written a crappy paper note will do the same with an electronic one (autopopulate all the fields, etc... without leaving much by way of A/P). One of my ICU attendings had a hard and fast rule not to autopopulate fields and to try to limit the note to one page.

Re communicating known difficult airways, our EMR allows us to place this information in a banner bar that's prominently displayed at the top of a given patient's record. One downside is that any physician (IM, CCM, EM, etc...) can do this and so the information isn't always reliable. Still, it gives people a head's up as to a potential problem.
 
jetproppilot said:
1)[B

6)THE PATIENT IS REPORTING GERD SO I WON'T USE AN LMA. Dude, everyone where I live has GERD. EVERYONE. Does that mean you can't use an LMA? NO. When will I NOT use an LMA? When GERD is postural. If when they lay flat (rare) and the symptoms arise, no LMA. Avoiding LMA utilization because of reported GERD is ridiculous.


Theres many more.
Click to expand...

Agree with this 100% some of the guys I work with are a little crazy. The patient says "yeah I had some heartburn once when I drank too much beer and ate too much pizza in college" and they check reflux all over the chart and do RSI/tube/cricoid pressure for a 5 minute carpal tunnel. Me? I stick in the LMA every time unless they tell me about trouble laying flat or food coming back up. No problems. Keep it simple.
 
fakin' the funk said:
Which is?
Click to expand...

In the early 90s there was a project started by my mentor aimed at solving the lack of communication. The problem was that the information technology of the era wasn't well enough developed. That's all changed now, and we hope to relaunch the project. A benefit of doing it now is that many people initially involved in the project 20 years ago are now chairs and leaders of national organizations. Makes buy-in very easy. I'll be sure to post here more as it happens.
 
Bertelman said:
I've got to say, the EMRs I have seen only make it MORE difficult to find relevant info. They turn a simple one page note into 2-3 pages, which utterly lack the formatting familiar to physicians. I find myself trudging through irrelevant info like a list of the 20 diagnoses they have accumulated throughout their life, even though most are no longer applicable. 90% of the page is worthless, and I find the pertinent info like Impression/Plan buried on the last page.
Click to expand...

Yup, one of the affiliated hospitals here where I'm doing my medical internship recently switched to full EMR. All the notes are freakishly long and full of information that I just skim through or completely ignore. However, some Attendings have gotten the idea to place their Impression/Plan at the very TOP of the note, which is so much nicer especially when I'm asked to consult on a patient who has been in the hospital for 3 months already (I'm currently on the ID service - which is indescribably boring). Still, some attendings are so totally lazy (or just can't type) that in their plans, they just write "See Patient Orders." It's pretty ridiculous.
 
lushmd said:
It all depends on who's writing the note and how its done.
Click to expand...

Agree, but we'll never convince people who write poor paper notes to do any better with an EMR. What I'm talking about is poor formatting of the EMR, which comes down to the programmers and IT people servicing the software. That makes even good notes look bad.
 
Bertelman said:
Agree, but we'll never convince people who write poor paper notes to do any better with an EMR. What I'm talking about is poor formatting of the EMR, which comes down to the programmers and IT people servicing the software. That makes even good notes look bad.
Click to expand...

At least you'll be able to READ the note, though. Even if it still doesn't make sense....😀
 
Bertelman said:
Agree, but we'll never convince people who write poor paper notes to do any better with an EMR. What I'm talking about is poor formatting of the EMR, which comes down to the programmers and IT people servicing the software. That makes even good notes look bad.
Click to expand...

Agreed, problem #1 is that people who have never written a medical note, nor ever needed to read one, are the ones writing the software. They can't be expected to know that we don't care about a 2-year-old ER-visit for gastroenteritis and that it just clutters the screen.

Problem #2 is that a lot of older doctors can't type more than 3.2 words per minute, and they prefer and ask for the stupid clickety-X electronic forms, so the rest of us are stuck with pages of X'd negative findings.

And I guess problem #3 is that the EMR companies couldn't charge as much if their product was a glorified Microsoft Notepad free-text entry device, even though I'd prefer that.


cfdavid said:
At least you'll be able to READ the note, though. Even if it still doesn't make sense....
Click to expand...

One of my few passive-aggressive pleasures is paging or phoning other doctors I don't like to ask them to tell me what their illegible notes say.
 
proman said:
In the early 90s there was a project started by my mentor aimed at solving the lack of communication. The problem was that the information technology of the era wasn't well enough developed. That's all changed now, and we hope to relaunch the project. A benefit of doing it now is that many people initially involved in the project 20 years ago are now chairs and leaders of national organizations. Makes buy-in very easy. I'll be sure to post here more as it happens.
Click to expand...

Not to be all "Pro VA all the time," but the VA has been doing this for 20 years. Yes, I think EMRs follow the Peter Principle, and the amount of documentation expands to fill the space alloted, but there are up-sides. With regard to communicating life-threatening issues (previous difficult airway, anaphylaxis, etc), there's a separate tab for Clinical Warnings which pops up on everyone's chart (if such warnings have been entered) and is hard to miss or ignore. It follows patients wherever they go in the system.
 
cchoukal said:
Not to be all "Pro VA all the time," but the VA has been doing this for 20 years. Yes, I think EMRs follow the Peter Principle, and the amount of documentation expands to fill the space alloted, but there are up-sides. With regard to communicating life-threatening issues (previous difficult airway, anaphylaxis, etc), there's a separate tab for Clinical Warnings which pops up on everyone's chart (if such warnings have been entered) and is hard to miss or ignore. It follows patients wherever they go in the system.
Click to expand...

I agree the VA is a good system. Except when it reminded me to order a screening colonoscopy for my MICU patient bleeding to death from colon cancer. The problem with institution-based IT is that if you aren't a part of the institution, you have no access to the information. For example, if a known difficult airway happened at the Durham VA and is now at Duke for something, there's no way of knowing it. This project will eliminate those barriers.
 
pgg said:
Problem #2 is that a lot of older doctors can't type more than 3.2 words per minute, and they prefer and ask for the stupid clickety-X electronic forms, so the rest of us are stuck with pages of X'd negative findings.

And I guess problem #3 is that the EMR companies couldn't charge as much if their product was a glorified Microsoft Notepad free-text entry device, even though I'd prefer that.
Click to expand...

I used to think the same way until I realized that most of the worthless click-x crap that you find on these notes has nothing to do with documentation of patient care and everything to do with compliance.

No one gives a rats about my description of how I place a central line, no matter how elegant. They only want to see that all components of the infection control bundle were followed etc.

It doesn't matter if my review of systems is appropriately aimed at the problems of the patient, just that I have enough components included to be compliant in my billing, even if the included components are completely unrelated to the chief complaint. The billing and compliance folks won't/ don't want to/ can't read through a free text note to find the necessary components and just send my notes back. So now my free text notes technique has been modified to be a +/- list of these components just like the stupid click-x forms.

Of course all EMRs suffer from the same problem. They are designed for data entry, not data review and analysis. I still don't understand why I had to keep a manual log of cases as a resident and our EMR couldn't print a case-log appropriate summary of my cases at the end of the month, or better yet just automatically file my case-log with the ABA.

- pod
 
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periopdoc said:
I used to think the same way until I realized that most of the worthless click-x crap that you find on these notes has nothing to do with documentation of patient care and everything to do with compliance.
Click to expand...

No, no, no, it's all a bunch of ****. Feast your eyes upon this abomination:

It's about 1/5th of the pre-expanded volume of our pre-anesthetic evaluation form. I don't have the stomach to screenshot the entire thing and stitch the images together into one massive pic. I'd have to chug a carton of Bicitra to survive the attempt.

The blank "procedure entries at the top" ? Can't be edited, can't be removed. Clutter.

The allergies dropdown box I have open? WTF - were these preset entries conjured by meth-smoking Viagra-snorting ******ed monkeys too impaired to get poo-throwing jobs at zoos? "AnemiaBloodDisorder" is a common enough manifestation of an allergy to be one of six punctuation-free presets? What?!?

The ROS items that you leave blank because they're normal? Still shown on screen. More clutter.

crap.jpg



I've got some epidurals running right now - just tried to check a laboring woman's EMR to see what the OB's last progress note said. Under "L&D SuperNote" something like 2/3rds of the way down a similar craptacular form full of junk there's a series of notes the system puts in non-chronological order ... sometimes. I think if the OBs click the expander boxes in the right order (or something) they can get the notes in proper sequence.

Here's a snippet of her History & Physical ... you know, the document that's supposed to be full of pertinent positives and negatives. Thankfully there's a free text box at the top where the OB put the important information:

crap2.jpg

Seriously, what the hell is this garbage? A set of reminders to the OB for when to call peds for a delivery? None of these things were positives for the patient, but they're still there as open empty checkable boxes.

I'd go on and post more screenshots, but it's all the same. It's a bunch of ****.

Those wankers couldn't even be bothered to use TrueType fonts or antialiased Xs in their stupid checkboxes.


And at discharge, to compound the insanity ... they hit print, and 100s of pages of this magnified, pure, unadulterated bloated **** get put in binders down in records.


It makes me a little angry.


periopdoc said:
No one gives a rats about my description of how I place a central line, no matter how elegant. They only want to see that all components of the infection control bundle were followed etc.
Click to expand...

I see what you're saying, and if that's what our EMR did, in some neatly formatted reader-friendly manner, I'd be OK with it. Would love it, in fact.

The medical record exists to (1) document care, (2) permit billing, and (3) facilitate communication between members of the healthcare team.

When a loud and publicly stated objective of EMRs is to reduce medical errors, such an astonishing failure at #3 is simply unforgivable.


Maybe I'm just in the cursed minority and the rest of you don't have to use anything comparable to this craptacular EMR.


And the hell of it is ... this is the better of our two main EMRs. The outpatient one is a $multibillion spawn of a demon conspiracy that I imagine Satan himself probably feels bad about. I dare not speak its name too loudly ... AHLTA
 
I know we're getting a little side-tracked here, but as long as we're on the topic of tree-killing EMRs, I love it when I'm trying to admit an OSH transfer patient and I'm wading through piles of nursing notes, labs, and MARs, only to realize there are no H&Ps, discharge summaries, or transfer summaries.

Reminds me of this YouTube clip which I saw in medical school, which is about 800X funnier now that I'm almost done with intern year: [YOUTUBE]http://www.youtube.com/watch?v=xskFo75Wdhs[/YOUTUBE]
 
pgg said:
The medical record exists to (1) document care, (2) permit billing, and (3) facilitate communication between members of the healthcare team.

When a loud and publicly stated objective of EMRs is to reduce medical errors, such an astonishing failure at #3 is simply unforgivable.


Maybe I'm just in the cursed minority and the rest of you don't have to use anything comparable to this craptacular EMR.


And the hell of it is ... this is the better of our two main EMRs. The outpatient one is a $multibillion spawn of a demon conspiracy that I imagine Satan himself probably feels bad about. I dare not speak its name too loudly ... AHLTA
Click to expand...

Dear gods in heaven. That hurts even thinking of filling that out.

I challenge the people in records to see if they can get #3 right. Though as long as they get their billing right, I don't think they would care. "We billed correctly due to the right boxes being checked, but there is no space to document a bad airway/trouble intubating, as it isn't billable."

I want those extra text boxes. Then again, I have the advantage of taking a formal typing course when I was still in high school and can type at a reasonable pace. I would kill to type out the notes in my current job, as it would save me time and hand cramping from writing. >.<

But I would like to see more from Jet and his experience.
 
pgg said:
No, no, no, it's all a bunch of ****. Feast your eyes upon this abomination:
Click to expand...

I stand corrected. That thing isn't a dung heap, it is a dung beetle that feasts on dung heaps. How long does it take to fill out that form?

My five-yeaar-old could probably do better than that. I love the lack of spaces between the words in the pre-populated allergies drop down. the fonts, the non-editable procedures list... And I thought the VA EMR anesthesia preop was bad, this is an alpha product.

I love the inclusion of shoulder dystocia as an indication to have peds present at delivery. "Um hello yes, we are planning on a shoulder dystocia in room 5, could someone check the box and call peds?"


- pod
 
periopdoc said:
I stand corrected. That thing isn't a dung heap, it is a dung beetle that feasts on dung heaps. How long does it take to fill out that form?
Click to expand...

After a while you learn the forms and skip/ignore the ridiculous bits and can enter the data you want reasonably quickly. One of the worst things about it is the way certain fields on YOUR notes are autopopulated with data from notes other people put in ... whether irrelevancies like demographics or important stuff like vitals, meds, and allergies ... or annoying stuff like the non-editable "groin hurnia rpr" as the procedure entered by whoever checked the patient into outpatient surgery.

But worst case you can just free text stuff in. It's finding information in other peoples' notes that's where the system breaks down completely. S:N is just to low.

The system has a couple of bright spots. Order entry and order sets are pretty good. For the OB module, you can remotely monitor FHR/contraction tracings in real time from anywhere. Those modules just work.
 
doctor712 said:
.
Click to expand...

YOU GUYS SUCK BONE ROLLERCOASTERS!! YOU HIJACKED MY COOL DOGMA THREAD FOR SOME REE-DICK-U-LIS NERD BIRD CONVERSATION ABOUT DOCUMENTATION!!!! GEEZ, WHILE WE'RE AT IT LETS TALK ABOUT THE UPCOMING YAWNING FESTIVAL!! BETTER YET, WHAT ABOUT YOUR MOST RECENT DENTIST VISIT??


MAJOR HIJACK, DUDES....you suck:laugh:
 
jetproppilot said:
YOU GUYS SUCK BONE ROLLERCOASTERS!! YOU HIJACKED MY COOL DOGMA THREAD FOR SOME REE-DICK-U-LIS NERD BIRD CONVERSATION ABOUT DOCUMENTATION!!!! GEEZ, WHILE WE'RE AT IT LETS TALK ABOUT THE UPCOMING YAWNING FESTIVAL!! BETTER YET, WHAT ABOUT YOUR MOST RECENT DENTIST VISIT??


MAJOR HIJACK, DUDES....you suck:laugh:
Click to expand...

Now that's the JetFont we've been waiting for!!:laugh:
 
IN AN ATTEMPT TO RECAPTURE MY VERY COOL THREAD FROM TERRORIST INFILTRATION, I WILL CONTINUE:

1,231) Day Surgery Nurse Stupidvisor: "Dr Jet, there's no H&P on the chart. Yes, I spoke with the surgeon justa minute ago who is in the parking lot. He has it with him, but WE CAN'T ROLL TO THE ROOM UNTIL ITS ON THE CHART."

REALLY? This ortho dude brought in, I dunno...geez...lets round it off...FIVE MILLION CASH MONEY for this hospital last year....and you won't allow us to roll to the room with his patient in an effort to keep him on time because of some stupid piece of paper that means NOTHING????

HAHAHAHAHAHAHAHAHAHAHAHA

[
 
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jetproppilot said:
YOU GUYS SUCK BONE ROLLERCOASTERS!!
MAJOR HIJACK, DUDES....you suck:laugh:
Click to expand...


:laugh::laugh: That's what I'm talking 'bout dawg! :horns::horns:

How about this one....

Mrs. Nurse: Can't do a block until the surgeon marks the operative leg...

Sevo's Head is thinking: Ummm.... Doc is finishing his current case. I have the chart, I have the schedule and I HAVE THE PATIENT!! I wish not to poke my eye out with a pick out of pure frustration.

Sevo says: Marking pen please.... 😛 and on we go.
 
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Awake Fiberoptic
Immediately (and frequently) punting to awake fiberoptic intubation is certainly a part of "academic dogma", but occasionally they are needed. If you have a patient with no neck/severely abnormal anatomy that you question your ability to mask ventilate, awake fiberoptic is a prudent choice. For some of the more exotic neurosurgical cases, an awake fiberoptic is performed followed by awake positioning. The unintended consequence of really cool airway toys like the glidescope and mcgrath are that the residents being trained today aren't as facile with awake fiberoptics as were the residents of the past. Adequate sedation and topicalization are the key to a successful awake fiberoptic intubation - these techniques take practice.


LMA's with GERD
Aspiration is a rare, but potentially devastating anesthetic complication. The black or white patient histories are easy - the patient who only gets GERD after eating 12 tacos from Taco Bell with "fire" sauce can have an LMA, the person belching in front of you complaining of acid in the throat gets a tube. The "inbetween" scenarios are the toughies. What about someone who has GERD controlled with meds? What about someone who has GERD that is controlled with meds but who also has diabetes? What about someone who sometimes has GERD but is in a lot of pain and has been popping vicodin like crazy? Popping in an LMA in an "inbetween" case is a calculated bet. Most of the time you will win, but a very small part of the time you will lose. The problem with losing this bet is that the loss can be substantial - I'm talking about million dollar payouts. Jet is right that some people will intubate at the drop of the hat at the mere mention of any kind of GERD. But he also should acknowledge the pure agony of being wrong - it only takes one time in a career for this to happen.
 
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