- Joined
- Feb 20, 2008
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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?"
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?"