Little Victories

[OB1🤙]

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Did a rotator cuff repair recently, older grizzled vet type. Says after each and every anesthetic he's ever had, he barfs his guts out all day. "I'll see if I can help you with that today," I say. He rolls his eyes.

"I've heard that from a bunch of you before. Nothing works."
"Well, I can't promise anything, but let's see if I can help you."

U/s guided interscalene with decadron (thanks, sdn!), propofol, LMA, pure propofol TIVA. More decadron (probably not needed but why not, no DM), zofran. No narcotic.

Wakes up feeling like a million bucks, and thanks me as profusely as anybody has ever thanked me for anything. He felt great, his wife felt great, and I felt great.

The little victories in this business are awesome.

What are your stories?

 

[Gern Blansten]

Did a rotator cuff repair recently, older grizzled vet type. Says after each and every anesthetic he's ever had, he barfs his guts out all day. "I'll see if I can help you with that today," I say. He rolls his eyes.

"I've heard that from a bunch of you before. Nothing works."
"Well, I can't promise anything, but let's see if I can help you."

U/s guided interscalene with decadron (thanks, sdn!), propofol, LMA, pure propofol TIVA. More decadron (probably not needed but why not, no DM), zofran. No narcotic.

Wakes up feeling like a million bucks, and thanks me as profusely as anybody has ever thanked me for anything. He felt great, his wife felt great, and I felt great.

The little victories in this business are awesome.

What are your stories?

Cool story. One of my all time favorites was an elderly guy with pancreatic cancer. He was miserable and had to have high dose narcotics to keep the pain at bay. This resulted in severe drowsiness, constipation, and all of the other bad things that go along with high dose narcotics. I provided a neurolytic celiac plexus block which gave him 100% relief of his pain and he was able to taper off of his narcotics over the following week and a half. I received a note from the patient's wife 2 months later. He had died about 7 weeks after the celiac block. She wanted me to know that the last 7 weeks of his life was so rewarding because he was able to tie up all his loose ends, settle his affairs, and enjoy time with his loved ones before he passed. He was able to say all of his goodbyes, enjoy his favorite meals, and go out of the house to enjoy his last weeks. It was kind of her to let me know the impact that I had on their family by providing that block. As anesthesiologists, we often miss out on the follow up stories that can be rewarding.

 

[pgg]

What are your stories?

Labor epidurals. I'm a real life pain-destroying superhero. That poor OB slaves away with her for 6+ months' worth of clinic visits, NSTs, emotional breakdowns, birth plan drama, and worse ... and 10 minutes after I walk in the room all that's forgotten and she has a new favorite doctor.

 

[Yo GabbaPentin]

Did a rotator cuff repair recently, older grizzled vet type. Says after each and every anesthetic he's ever had, he barfs his guts out all day. "I'll see if I can help you with that today," I say. He rolls his eyes.

"I've heard that from a bunch of you before. Nothing works."
"Well, I can't promise anything, but let's see if I can help you."

U/s guided interscalene with decadron (thanks, sdn!), propofol, LMA, pure propofol TIVA. More decadron (probably not needed but why not, no DM), zofran. No narcotic.

Wakes up feeling like a million bucks, and thanks me as profusely as anybody has ever thanked me for anything. He felt great, his wife felt great, and I felt great.

The little victories in this business are awesome.

What are your stories?

My first case as an attending while moonlighting as a pain fellow last year was similar to yours. Only my patient was more so challenging us to control his pain with all off the opioids our pharmacy could supply. The case was a lap appy in a 50 y/o man located in a part of town where heroin and other opioid abuse was not uncommon. Lumbar epidural refused. At this hospital we supervised CRNAs while managing OB.

As a new attending, I assumed that a CRNA might call me for extubation. Well, I was called but when I walked into the room but the patient was extubated, sat 60s and looking like a smurf. After looking at the records, I find that the CRNA obliged the patients earlier request for infinite opioids. CRNA is half assed masking the patient when I walk into room. She says "oh he's just a little weak. Don't worry, I pushed more Neostigmine after I reversed."

Long story short, I fix the problem and as we bring him into the PACU, we witness one of the most amazing code browns in history from the CRNA giving the Neostigmine. Right in front of the head pacu nurse. The new guy might as well be wearing a cape, because he was quite the superhero... Oh wait, I mean super villain.

 

[Arch Guillotti]

As a new attending, I assumed that a CRNA might call me for extubation. Well, I was called but when I walked into the room but the patient was extubated, sat 60s and looking like a smurf. After looking at the records, I find that the CRNA obliged the patients earlier request for infinite opioids. CRNA is half assed masking the patient when I walk into room.

Welcome to private practice. I generally don't attend emergence and I think I may be glad because of the universal ugliness of the wakeups. Starting to emerge and coughing and moving around means extubation time to the nurses. It isn't uncommon for the nurses to half ass mask the patients for a while after the patient is extubated. As a resident if I ever masked a patient after a wakeup it normally meant the patient was getting reintubated (which was rare).

 

[alpha2agonist]

Ahh, only here can a thread about how good we feel about rendering a superb service to a patient turn into a rant against crna's.

 

[jwk]

Welcome to private practice. I generally don't attend emergence and I think I may be glad because of the universal ugliness of the wakeups. Starting to emerge and coughing and moving around means extubation time to the nurses. It isn't uncommon for the nurses to half ass mask the patients for a while after the patient is extubated. As a resident if I ever masked a patient after a wakeup it normally meant the patient was getting reintubated (which was rare).

If you're billing as "medical direction" then being present for emergence is required.

 

[Mman]

If you're billing as "medical direction" then being present for emergence is required.

True. But emergence and extubation aren't defined as the same thing.

 

[WholeLottaGame7]

My favorite so far was a 90yF with colorectal cancer scheduled for LAR and perineal flap. Surgeon tried to talk her into an end ostomy the morning of surgery but she and her family were insistent she wanted the full deal. Epidural, a-line with LiDCO for fluid management, large IVs. Ended up being an 8-hour case with prone in the middle. Extubated at the end, had 0/10 pain the next day.

Still totally blows my mind that you can do that big a surgery in that old a patient and not only get them through it, but have them awake and alert with 0 pain the following day. Crazy.

 

[Arch Guillotti]

If you're billing as "medical direction" then being present for emergence is required.

Depends on your definition of emergence. Is it when you dial down the volatile, the patient starts to wake up, extubation, immediately afterwards, on the way to the PACU or 30 minutes later when they are wide awake?

There is no logistical way possible for me to be able to attend extubation at every case. Running 4 rooms, pre-ops, blocks, labor epidurals, etc. preclude being present at the end of each case.

True. But emergence and extubation aren't defined as the same thing.

Agree. See above.