Learning from the misfortune of others or yourself

[ucsfgaspain]

So I've found that some of the most memorable lessons I've learned have come from my own mistakes or those of others.

One that comes to mind:

During residency, one of the junior residents had decided to run a TIVA for a kidney transplant. They had propofol going in a pump, refilled it and then signed out the case to the senior resident who was coming in on the night shift to take over the case. Senior sits back and then 10 minutes later. Pt. sits bolt upright, pulls the tube out, and let's out a blood curdling scream!


After all the dust settled. It was found that the junior resident, when they went to refill the propofol syringe had forgotten to flip the stop cock back in line. The pump was pumping all the propofol to the syringe they had used to refill. Thus no pump alarm as warning.

Only blessing was that the junior had forgotten to give muscle relaxant as well.

So to this day, I always check my propofol lines after refills to not pull a doozie like this one.

So what are some other "stupid anesthesia moments?"

 

[jetproppilot]

I've posted this one before but its worth revisiting. Patient s/p CABG, in the ICU, bleeding. HCT low and headed lower.

Needs to go to the OR pronto.

We package the guy up and roll to the OR.

I was at the head of the bed...

On three! we moved the pt over to the OR table....

Uhhhhhhhhh.....only problem was that the A line and right IJ cordis stayed with the stretcher...

Dr. Teddy the heart surgeon, real laid back cat said

"Bill, that was f^&kin AWESOME!"

Oh well.

Replaced both lines likkity split.

Dude did fine.

I really helped with patient transfer, huh?

 

[drccw]

my first intubation as a CA-1 on the floor by myself in the middle of the night at the VA. I had just driven in from home and someone needed intubating for some reason. I was a little nervous, drew up the etomidate and rocuronium (for some reason that I dont remember that's what I thought to give).
Pre-oxy. Inject one syringe. Look down, see that the other syringe is etomidate. Inject that very quickly. Laryngoscopy, tube. The guy ended up dying two days later so it didnt really make a big difference but that is one way to really speed the onset of roc....

as a Ca-2 I take over a case from a senior resident. Neuro. Running TIVA. Propofol and remi. She signs out. Blah blah blah blah blah blah.... just refilled the propofol.. blah blah.. lots of pee to dump.. blah blah.. not too much longer... getting aquainted with the scene, make some chit chat. Look at the syringe- 2 full syringes. 40 minutes later.. I hear.. we're finished with all our monitoring and closing.... Decide to turn off the propofol and turn on a little gas (all day case) Turn my attention to the Baxter pump... hmmm not even on... oops... No real change in hemodynamics or anything, just a total REmifentanil anesthetic (plus whatever propofol he had in the other compartments). Guy was only Russian speaking so never did find out if he had any sort of awareness or anything...

I told this story to an attending and she related the best misfortune she had made during her residency...
1) Leaking AAA coming down. 2 18 G IVs in each AC. Move patient over to OR table one IV comes out... She's running around the table, steps on the IV tubing of the other IV, pulls it out....
2) Same attending, at the VA as a CA-1. Her attending tells her, go ahead and induce the patient. Gives Sux... and only sux....

 

[Planktonmd]

This happened at the end of my CA3:
I was the team chief that night and I get a stat call to a room where a CA1 was doing an appendectomy on a healthy 20 Y/O patient.
I get to the room before the attending and all I see is the surgeon doing chest compressions and basically a code in progress.
I ask what happened and the CA1 says that all was good until he gave the reversal at the end of the case, suddenly the patient's HR went down and he had a BP reading of 250/ 150 before he went flat.
So i asked what he gave for reversal and he said 5mg neostigmine + 1 mg Robinul.
we continued the CPR and we got a shockable rhythm after a few rounds of medications and eventually we got a SR with good pulse and BP that remained extremely high: SYS > 200, we thought it was the Epinephrine he got during the code but since the BP wasn't going down even 10 minutes later We started Nitroglycerine and the guy was taken to ICU.
After they left I went back to the OR and looked in the medication tray and I found that there was no Robinul missing instead there were 5 vials of Phenylephrine missing!
and sure enough there they were in the sharps container:
5 vials of 10mg Phenylephrine.
So the guy received 50 mg of phenylephrine mixed with neostigmine for reversal.
After a few days in ICU and recovering from stunned myocardium he walked out of the hospital.

 

[ucsfgaspain]

I've got another one. End of my last year in residency and bored to tears with cases. Get it in my mind to try to figure out the perfect ratio of neostigmine to glycopyrrolate so you absolutely get no change in heart rate.

Start my own dose response case series experiment. Start working down the dose of glyco in each subsequent case while keeping the neo at 5 mg. Reach nirvana on one patient. Think that I'm the SH+T. Give me the nobel for this...frame my picture up in the hall of fame..

Drop patient off in the PACU and in the middle of report. Pt. just has a massive code brown. I'm talking massive...You know the kind where it seems like niagara falls is pouring out. Shows you what unopposed parasympathetics can do.

PACU nurses are freaking out cuz guess who's got to clean this up? I quietly sneak away...never tried that experiment again.

 

[Gaseous Clay]

This happened at the end of my CA3:
I was the team chief that night and I get a stat call to a room where a CA1 was doing an appendectomy on a healthy 20 Y/O patient.
I get to the room before the attending and all I see is the surgeon doing chest compressions and basically a code in progress.
I ask what happened and the CA1 says that all was good until he gave the reversal at the end of the case, suddenly the patient's HR went down and he had a BP reading of 250/ 150 before he went flat.
So i asked what he gave for reversal and he said 5mg neostigmine + 1 mg Robinul.
we continued the CPR and we got a shockable rhythm after a few rounds of medications and eventually we got a SR with good pulse and BP that remained extremely high: SYS > 200, we thought it was the Epinephrine he got during the code but since the BP wasn't going down even 10 minutes later We started Nitroglycerine and the guy was taken to ICU.
After they left I went back to the OR and looked in the medication tray and I found that there was no Robinul missing instead there were 5 vials of Phenylephrine missing!
and sure enough there they were in the sharps container:
5 vials of 10mg Phenylephrine.
So the guy received 50 mg of phenylephrine mixed with neostigmine for reversal.
After a few days in ICU and recovering from stunned myocardium he walked out of the hospital.

Wow, that is quite an amazing story. Our current chief told me one time he gave a 10 ml syringe of neo (100 mcgs/ml) when he thought it was the reversal. We also had another former chief give 10 mg of neo, but 50 mg??? And to add to the fire, 5 of neostigmine ... just another example of how there should be a better way to label the vials, some of them look the same!

 

[fastosprintini]

i did all of the above or similar at some point in my career, however, my real mistakes were: trusting colleagues too much too early, buying a big house too early, believing in "gentlemen's agreements" that later on cannot be enforced, believing that becoming "partner" actually makes you a partner etc. etc. ...groan...
fasto

 

[Planktonmd]

believing in "gentlemen's agreements" that later on cannot be enforced, believing that becoming "partner" actually makes you a partner etc. etc. ...groan...
fasto

You must be in Florida

 

[urge]

This happened at the end of my CA3:
I was the team chief that night and I get a stat call to a room where a CA1 was doing an appendectomy on a healthy 20 Y/O patient.
I get to the room before the attending and all I see is the surgeon doing chest compressions and basically a code in progress.
I ask what happened and the CA1 says that all was good until he gave the reversal at the end of the case, suddenly the patient's HR went down and he had a BP reading of 250/ 150 before he went flat.
So i asked what he gave for reversal and he said 5mg neostigmine + 1 mg Robinul.
we continued the CPR and we got a shockable rhythm after a few rounds of medications and eventually we got a SR with good pulse and BP that remained extremely high: SYS > 200, we thought it was the Epinephrine he got during the code but since the BP wasn't going down even 10 minutes later We started Nitroglycerine and the guy was taken to ICU.
After they left I went back to the OR and looked in the medication tray and I found that there was no Robinul missing instead there were 5 vials of Phenylephrine missing!
and sure enough there they were in the sharps container:
5 vials of 10mg Phenylephrine.
So the guy received 50 mg of phenylephrine mixed with neostigmine for reversal.
After a few days in ICU and recovering from stunned myocardium he walked out of the hospital.

Was the drug error reported or was the code reported as a medical mystery?

I had a friend give 2 mg phenylephrine thinking he was giving 80mcg. I took the case over from him. Report was "he is really sensitive to neo" that's until I realized he was using a syringe prepared for the perfusionist (1mg/ml)

I once labeled a dobutamine drip as levophed. Pt was hypotensive coming off pump with "EXCELLENT" function but "unresponsive" to large amounts of levophed. Yeah right. That was until my attending drilled me a new hole after realizing the error.

I started a TIVA case with a lazy, blame everyone else but me, attending that was so lazy that she couldn't even hook up the propofol, remi and neo drips at once, so just plugged the "remi" drip and gave some iv propofol. Few min later I intubate and the BP goes thru the roof. She bolused the "remi" on the pump and stepped in a puddle of water on the floor. "What's that?" Traced back to the remi pump. All the remi was going to the floor. What she had hooked up was the neo. Of course it was MY fault for not labeling the end of the drips. I was so pissed. She cannot even hook up the right drip, is too lazy to hook all of them, and she blames me? What a f... ..unt! All I could say was "I'm so sorry"(that you are a lazy piece of sht that cannot even trace a line back to the pump) and look stupid. Same b..tch is trying to get an awake a-line some other day and asks me for lidocaine. I give it to her. She rams the needle into the patient and pushes the plunger as if you were pushing epi during a code. Pt screams in pain and she has the audacity to ask out loud, so that the pt and nurses in the room hear, "did you put bicarb into the lidocaine?"(with a tone converying my stupidity). Who the hell puts bicarb in the lido when you are infiltrating for an a-line or an iv?, I thought. I replied "no". "That why it hurt, if you put bicarb it decreases the acidity and it hurts less"(with a tone meaning "look how much I'm teaching you stupid"). I said "Oh, I didn't know. Learn something new every day", but was really thinking -yeah right you f......nt blame it on me while you can, your days are numbered. She thought she was the sht but in reality a lot of her pts croaked. She always managed to blame it on a "stupid" resident.

Alright, that was more venting than anything else. It felt good to get it out. I just saved a buck or too on psychotherapy.

 

[drccw]

I once labeled a dobutamine drip as levophed. Pt was hypotensive coming off pump with "EXCELLENT" function but "unresponsive" to large amounts of levophed. Yeah right. That was until my attending drilled me a new hole after realizing the error.

I started a TIVA case with a lazy, blame everyone else but me, attending that was so lazy

I had a friend who recieved a bag of antibiotic from the pharmacy... started it up and the patient got really hypertensive and tachycardiac... she deepened teh anesthetic, gave some fentanyl, but to no avail... looked at the bag of abx... mixed in dopamine.....

I always found that after the CA-1 year the attending got in the way and made life harder...

 

[maceo]

You must be in Florida

you mean,, he must be everywhere..

 

[fastosprintini]

no, but why do you say that? is florida that terrible to work? or is it just that there are many dishonest groups..? fasto

 

[powermd]

I was on team captain duty and got called to a CA-1 room for a patient that was having a minor abdominal case, and the HR and BP had drifted down a bit. I asked the resident to give 0.2 of glyco, and I'd be right down. When I got there, it seemed to be working. Heart rate was now in the mid 60's, and the BP was acceptable. As the BP drifted over 110/70, I thought that would be a good time to give some morphine. Gave it, then flushed it in with the syringe on the stopcock behind it. The heart rate shot up to 125 and stayed there. Oops. That was an unlabeled glyco syringe, so now the patient had received a full milligram. I tried some esmolol, knowing it probably wouldn't work, and it didn't. Thankfully the patient was reasonably healthy, and the case wasn't going to go much more than another 40 minutes. At that point I just gave neostigmine, titrating to a heart rate in the 60's.

Beware of unlabeled syringes that you didn't personally prepare...

I've heard of a few instances this past year where levophed was mistaken for dexamethasone (look alike vials), and neuro patients ended up getting a full dose of 4 mg levo. It wasn't pretty, but the patient's recovered. We no longer have norepi on our carts, which kinda sucks, cause when you need it, you need it. We still have epi though.

 

[Fooper]

This will show my age but back in the days of the precordial stethoscope & sodium pentothal...

As a young, naive CA-1 I was inducing a patient -- had my precordial in place with the molded earpiece in my ear, connected by a piece of IV extension tubing. Attending walks in, grabs the stick of NaPent, & shoots it in. Suddenly, an excrutiating wetness in my left ear then shooting out & down my shirt and spraying the patient and attending. Yep-injected it into the precordial tubing. I never got sleepy-guess you can't induce via the external auditory canal!

Another one...

Hanging out with another resident on OB duty....suddenly stat page for crash c-section. Buddy grabs handful of induction syringes he kept pre-loaded for just such an occasion, preparing to run to OR. Stuffs them NEEDLE END FIRST into his scrub shirt breast pocket, without noticing NEEDLE CAP HAS COME OFF one syringe! Gives himself a 50% pneumo, hits the deck, & buys a chest tube! Needless to say, I did the section by myself.

 

[urge]

This will show my age but back in the days of the precordial stethoscope & sodium pentothal...

As a young, naive CA-1 I was inducing a patient -- had my precordial in place with the molded earpiece in my ear, connected by a piece of IV extension tubing. Attending walks in, grabs the stick of NaPent, & shoots it in. Suddenly, an excrutiating wetness in my left ear then shooting out & down my shirt and spraying the patient and attending. Yep-injected it into the precordial tubing. I never got sleepy-guess you can't induce via the external auditory canal!

Another one...

Hanging out with another resident on OB duty....suddenly stat page for crash c-section. Buddy grabs handful of induction syringes he kept pre-loaded for just such an occasion, preparing to run to OR. Stuffs them NEEDLE END FIRST into his scrub shirt breast pocket, without noticing NEEDLE CAP HAS COME OFF one syringe! Gives himself a 50% pneumo, hits the deck, & buys a chest tube! Needless to say, I did the section by myself.

When I was a CA-1 we were "promised" a molded ear piece (which never came, btw) during the first week, but in the mean time my mentor made me one with an extension iv tubing and a small nasal airway which I had to shove down my ear. It was uncomfortable but it did work. Yeah, I felt like a circus clown when people would walk into the room to see me sporting it.


I stabbed myself the same way in the butt using the pant pocket. I don't do that anymore.

 

[jetproppilot]

Be careful with throwing a stitch on your a-lines.

I never sewed'em in before arriving at current gig, but everybody does it here, so whatever. I started stitching.

Started an A line on a CABG a cuppla weeks ago.

Threw in the stitch with a Keith needle, and as always, used the end of the needle to cut the stitch.

Only problem was my thumb got in the way......you haffta pull pretty hard to cut it so I hit my thumb with alotta force.

PHWAKKKK!!!!

Needle drives thru end of thumb. A slash, not a stab.

Blood (mine...) squirts outta my 8.0 Biogel.

Now I'm bummed.....CABG dude had tattoos on his knuckles.

Tested his blood and mine. Both of us came up negative for all the bad stuff, thank God.

Anyways, be careful with those straight needles if you use the end to cut a stitch.

 

[pd4emergence]

I was a senior resident, junior was in a room doing an amputation on some old guy with an aicd, aicd turned off pads placed, fem/sciatic block in. I leave the room. Come back a little later to see how things are going, junior had hooked up to the defibrillator (for no particular reason). Junior tells me, the guy just won't be still, he had given some versed/fent and was pulling out the propofol, I asked the guy who was still pretty with it what was up, guy said his leg was not hurting him, but that this "G D thing on my chest is shocking the sh i t out of me". Defibrillator was on and in pacing mode. The junior asked me to please not tell anybody about it and I told him not to worry. He never lived it down the rest of his time in residency. Even the surgery residents gave him hell. Turns out he was a very good resident but I still find this pretty funny.

 

[Fooper]

I was a senior resident, junior was in a room doing an amputation on some old guy with an aicd, aicd turned off pads placed, fem/sciatic block in. I leave the room. Come back a little later to see how things are going, junior had hooked up to the defibrillator (for no particular reason). Junior tells me, the guy just won't be still, he had given some versed/fent and was pulling out the propofol, I asked the guy who was still pretty with it what was up, guy said his leg was not hurting him, but that this "G D thing on my chest is shocking the sh i t out of me". Defibrillator was on and in pacing mode. The junior asked me to please not tell anybody about it and I told him not to worry. He never lived it down the rest of his time in residency. Even the surgery residents gave him hell. Turns out he was a very good resident but I still find this pretty funny.

This reminds me of another story, although I don't know if it's true or just an urban legend passed down through my program...

Two CA-1's killing time while on call goofing around with a defibrillator machine. One puts the paddles up to his head (what's wrong with this picture?? ) and wonders what would happen if they went off (guess he hadn't done any ECT's yet). Of course, somehow they're already charged & they do go off. Dude was knocked unconscious for about 15 min with bilat. ear burns. He ends up in the ICU overnight on seizure precautions

 

[seinfeld]

Cardiac surgeon was having issues with kidney stones, so my colleagues agreed to place an iv in Him to get him some fluid and toradol so he could complete the marathon case. Well, 6 hours goes by and one anesthesia resident gets changed out for lunch and one who has not done cardiac gives a break while they are on pump (attending is in the room mind you) Surgeons tells anesthesia resident " I think it time for another hit of that toradol" Resident draws up 30 mg and gives it into the cordis. 10 minutes goes by and surgeon asks " have you given toradol" resident "yup, i gave it in the cordis" as he looks up and sees the surgeons IV bag.

 

[ucsfgaspain]

One of my co residents confided in me this story. He as a Ca-1 intubated someone and knew that he had chipped their tooth. Not a bad one but noticeable that the front tooth was uneven.

He freaks out and thinks that he's going to get kicked out of the program. He takes the skinny pedi laryngoscope handle and uses the grip as a file and sands down the unevenness. No one ever noticed.

 

[VentdependenT]

Two words: Muscle Relaxants. Been burned a few times.

Now I only dose for intubation and reserve a redose for cases where the pt is seriously eating crap and I gotta go down on agent (and when we go on pump).

If surgeon yellen that pt isnt relaxed as they are closing fascia I just give PROPOFOL. Works every time.

 

[powermd]

Cardiac surgeon was having issues with kidney stones, so my colleagues agreed to place an iv in Him to get him some fluid and toradol so he could complete the marathon case. Well, 6 hours goes by and one anesthesia resident gets changed out for lunch and one who has not done cardiac gives a break while they are on pump (attending is in the room mind you) Surgeons tells anesthesia resident " I think it time for another hit of that toradol" Resident draws up 30 mg and gives it into the cordis. 10 minutes goes by and surgeon asks " have you given toradol" resident "yup, i gave it in the cordis" as he looks up and sees the surgeons IV bag.

This would be a better story if the resident gave 10 mg hit of vecuronium or 500 mcg fentanyl.

 

[Planktonmd]

no, but why do you say that? is florida that terrible to work? or is it just that there are many dishonest groups..? fasto

Florida is not terrible if you are ok with the fact that we have more lawyers than anywhere else on this planet.
The bad part is that most of the desirable locations are controlled by crooks who landed anesthesia contracts decades ago and know how to keep administrators happy but also know how to screw their colleagues.
The less desirable locations (and increasingly some of the desirable ones) are controlled by anesthesia management companies.
Other than these few issues Florida is great.

 

[epidural man]

thanks for the stories...... Very entertaining.
Best thread ive read in a while.

Reminds me of the book I read a while back called Complications. If u haven't read it, check it out.

 

[Bertelman]

thanks for the stories...... Very entertaining.
Best thread ive read in a while.

Reminds me of the book I read a while back called Complications. If u haven't read it, check it out.

Better is a good book, too. I should read Complications.

 

[Laurel123]

It is interesting to see the number of times phenylephrine has been drawn in place of glycopyrolate. And even more amazing are that the patients that do OK.

In residency, I heard about a similar incident. I was in the next room. It was an intracranial case and at the end of the case the patient was reversed. The head was closed and the neuro resident was doing some dressings and the attending was already gone. Well, suddenly the heart goes to 20 and the BP shoots through the roof! Stat page to the neurosurg attending and extra nurses and techs overhead, a big slew of people come rushing in, tear the head back open. Extra anesthesia people arrive and another resident goes to help clean up the cart and grabs three empty phenylephrine bottles, looks a it and comments 'wow, you went thru a lot of phenylephrine......'

Patient did OK.