my case the other day

[ProRealDoc]

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13hr cases in general eat into any APR and RVU volume. That is why in surgery, they will commonly speak to a few trachs and a PEG being worth more then a whipple.

We don't cowboy our way forward into a 13hr elective case in the face of a cardiac event. That would look far worse on an APR. Also, trying to explain that to a jury (or pear review or license board) would look bad. Loosing such a potential case would not only look bad on the current hospital APR but would make it that much more difficult to obtain a future/alternate hospital position. Also, keep in mind that neurosurgeons generally do NOT manage their patients critical care issues beyond ICP. My experience with neurosurgery has been for them to ask general surgeons/trauma surgeons/critical care/anesthesia and/or cardiology if a patient was safe for proceeding. So, I would generally not rely on the neurosurgeon to determine safety in general in order to procede forward.

Finally, neurosurgery is so highly in demand, I don't see any neurosurgeon needing to cowboy through such a scenario for fear of an APR. They can only hurt themselves.

As far as RVUs, at some hospitals, the surgery attending is expected to run more than one room at a time. You have a group of residents/fellows, and you are expected to bounce between rooms, being present for the critical portion of the procedure. In this manner you are more productive.

I respect your deference to the other specialists to help you in patient management and that was my point in this case. Intraoperative medical issues are best left to the attending anesthesiologist to manage and make the ultimate call. This seems to work well for surgeons and that was my initial point.

As far as the potential repercussions for complications are concerned, some hospitals shield their medical staff from being personally named on any lawsuits and the institution becomes the responsible party.

It is also worthy to note that although surgeons are typically in high demand, we can't obviate the fact that there are many foreign surgeons who are itching for the chance to do your job for a fraction of your salary. Many academic hospitals have mastered this tactic and recruit skilled surgeons from india or elsewhere who are willing to work for peanuts.

They are excellent surgeons and do amazing work. I know two personally, both neurosurgeons. These guys come here, are made chief residents/fellows to allow time to get their paperwork in order, time to get acquainted with the way hospital runs and then voila! In a couple of years, they are your peers and are willing to do what you won't.

 

[nap$ter]

broken neck, brother. Seen a guy jump not insignificantly with barely a twitch on hand held nerve stimulator

this prone vs supine cardioversion debate is silly.

if the patient is unstable enough to justify electricity - you're not gonna wait to flip. i realize MEP's don't cause quite the jump that a cardioversion does, but we run motors all the time in prone pinned patients... but obviously one would try every pharmacologic intervention first.

the thing that doesn't quite compute for me about this case - at our hospital patients are pinned SUPINE, then flipped prone on a jackson frame. so if it was the pinning that caused the problem, why didn't your tachyarrhythmia occur before the flip?

or, did you guys give a bolus of remi or propofol for the pinning, and then by the time he was flipped it wore off and he got light?

0.6 mac of sevo and 0.1 of remi is way too light for pinning.

how much phenylephrine did you give? agree that ephedrine and epi are poor choices in this situation. if big doses of phenylephrine didn't work (ie 100-500ug), i would have gone to a unit or two of vasopressin before the epi. esmolol could be justified as well (although i know there will be some backlash re giving a beta blocker to a hypotensive pt, but i would try it in this case before i resorted to electricity).

if you can get him back into slow sinus and bring his blood pressure back up, there is no reason to cancel the case. i also agree that calling cardiology for a PHONE consultation is weak, but i can understand why it might be done in an academic setting. this is not a cardiac problem, this is an anesthetic problem. if you pin any healthy 64 year old with light anesthesia - you are guaranteed to generate arrhythmia, and if hypotension from that arrhythmia results, coronary hypoperfusion will follow even in the absence of CAD.

so, once he was back into sinus and BP recovered, deepen the anesthetic, keep the HR down, avoid hypoxia/hypercarbia blahblah, supracorrect calcium and make sure potassium's aright, keep up with that blood loss, and go for it.

 

[urge]

Has anyone considered how long it takes to get a cardiologist in the OR?

 

[Frank Rizzo]

Has anyone considered how long it takes to get a cardiologist in the OR?

Half of them probably don't even know where the OR is at where I work.

 

[dhb]

this prone vs supine cardioversion debate is silly.

if the patient is unstable enough to justify electricity - you're not gonna wait to flip.

Exactly, if he has just been pinned he is most likely paralyzed and shouldn't jump off the table.

 

[JackADeli]

As far as RVUs, at some hospitals, the surgery attending is expected to run more than one room at a time. You have a group of residents/fellows, and you are expected to bounce between rooms, being present for the critical portion of the procedure. In this manner you are more productive...

Yep, I'm aware of that. However, hard to answer the "question" by a jury if you are out of the room, VIP case, pre-incision cardiac event, procede to 13hr & 2+L blood loss case, etc....

...I respect your deference to the other specialists to help you in patient management and that was my point in this case. Intraoperative medical issues are best left to the attending anesthesiologist to manage and make the ultimate call. This seems to work well for surgeons and that was my initial point...

Not my "deference", just making a point as to what I have seen from neurosurgeons. As for myself or any other surgeon, we can be stopped from proceding with a case by anesthesia. However, we can not be pushed to proceed by anesthesia. Thus, we can not declare lack of responsibility in making a poor clinical decision and proceding forward with an elective case in the scenario you described.

...As far as the potential repercussions for complications are concerned, some hospitals shield their medical staff from being personally named on any lawsuits and the institution becomes the responsible party...

Not a chance and not a call the hospital can make. The medical records would be supoened and probably everyone in the room and even down the hall would be named. If the family particularly liked the surgeon, they may choose to not name them on the suit. But, the names of who was involved in this case would be a matter of public record once the case is filed. Further, the hospital would really have very little incentive to "shield" a surgeon or anesthesiologist that chose to move forward and generate such liability. The hospital would save money and save face by distancing themselves from this action. Hypothetically, a VIP physician dies and it appears to the lay person a blatantly stupid series of events leads to the death. The hospital looks unsafe. The hospital needs to show it does not use this "caliber" of physicians.

...It is also worthy to note that although surgeons are typically in high demand, we can't obviate the fact that there are many foreign surgeons who are itching for the chance to do your job for a fraction of your salary. Many academic hospitals have mastered this tactic and recruit skilled surgeons from india or elsewhere who are willing to work for peanuts...

As a surgeon, looking at the job market, etc.... I think you are fairly off base here. Academic centers do hire foreign folks. However, not so easily. There are a multitude of reasons why this is not as simple as you may think and why fresh neurosurgeons are commanding such high salaries and senior surgeons have been getting bonuses in excess of a million dollars in this field. And, they are not signing them to 1yr contracts for these bills. They are often hiring foreign neurosurgeons for lack of available domestic surgeons. It is often difficult to get the licensing issues and they are paying peanuts because they are still shopping for the US expensive neurosurgeon. Otherwise, they would just forego hiring expensive US trained neurosurgeons in the first place.

...These guys come here, are made chief residents/fellows to allow time to get their paperwork in order, time to get acquainted with the way hospital runs and then voila! In a couple of years, they are your peers and are willing to do what you won't.

Not in general..... and not so cut and dry or simple at any respectable academic center.

 

[jwk]

this prone vs supine cardioversion debate is silly.

if the patient is unstable enough to justify electricity - you're not gonna wait to flip. i realize MEP's don't cause quite the jump that a cardioversion does, but we run motors all the time in prone pinned patients.

Exactly, if he has just been pinned he is most likely paralyzed and shouldn't jump off the table.

I think that cardiovert/defib will trump your NMB any time. MEP's don't cause anywhere near the jolt that cardioversion does. Head locked in pins on top of that while the rest of the body jumps? I'll pass. A-Flutter, V-Fib, or otherwise - there's nothing that would cause me to shock a patient prone in a Mayfield, and certainly not the one discussed here.

HOWEVER - that being said, here's a case report of exactly this problem, and the patient was defibrillated while prone and in Mayfield pins.

http://bja.oxfordjournals.org/cgi/content/full/87/6/937

 

[JackADeli]

...there's nothing that would cause me to shock a patient prone in a Mayfield...

...here's a case report of exactly this problem, and the patient was defibrillated while prone and in Mayfield pins.

http://bja.oxfordjournals.org/cgi/content/full/87/6/937

Serious question, why? This maybe your primary life saving intervention. Is there a presumption of a predicted certain bad outcome if you intervene on v-fib under these circumstances or is there literature/data that supports a position that this would just be unsafe? You are presenting at least a case report suggesting it can be done safely. Is there more then this case report saying it would be unsafe?

 

[hoyden]

Serious question, why? This maybe your primary life saving intervention. Is there a presumption of a predicted certain bad outcome if you intervene on v-fib under these circumstances or is there literature/data that supports a position that this would just be unsafe? You are presenting at least a case report suggesting it can be done safely. Is there more then this case report saying it would be unsafe?

Because it takes literally few seconds to flip him back to supine position and the reason why the supine position is better in this situation was described above.

 

[JackADeli]

Because it takes literally few seconds to flip him back to supine position and the reason why the supine position is better in this situation was described above.

I understand in this specific (original post scenario) , uncut scenario, pt could be spun... but still in pins. However...

...there's nothing that would cause me to shock a patient prone in a Mayfield...

[URL]http://bja.oxfordjournals.org/cgi/content/full/87/6/937[/URL]

My "why" question is broader then this scenario as was the statement I was asking. The statement seems pretty absolute and I was again wondering why? Especially if it could be done safely? There could be lossed time, especially if the patient is cut open and/or spine now unstable.

 

[JackADeli]

... if hypotension from that arrhythmia results, coronary hypoperfusion will follow even in the absence of CAD...

agreed, hypotension will result in hypoperfusion.... If I read it correctly, the original scenario did not describe, hypotension with the tachy rhythm of "...all of the sudden...flutter w HR 150s and has ST depression diffusely...".

To get ischemia from tachy 150 in absence of hypotension with out vascular disease would be unusual in an acute setting. prolonged tachy maybe... But, isn't a stress test pretty much intended to elevate heart rate to detect ischemia under the stress. The scenario seems like a positive pseudo stress test.

 

[Arch Guillotti]

A lot happened quickly. first, tachy and then SVT w rates to 150s and ST depression and initially stable BP.

Was the patient in aflutter or SVT?

 

[hoyden]

I understand in this specific (original post scenario) , uncut scenario, pt could be spun... but still in pins. However...
My "why" question is broader then this scenario as was the statement I was asking. The statement seems pretty absolute and I was again wondering why? Especially if it could be done safely? There could be lossed time, especially if the patient is cut open and/or spine now unstable.

We are talking about this spcific case scenario, when the pt was not cut.

A case report might not be your best line of defense should the pt suffer some serious injury as a result of a cardioversion while in pins/prone but still not cut.
For this particular one - if I recall properly, his astrocytoma was extremely extensive - from occiput to his thorax. This would also be a reason why I would also prefer the pt to stay intubated after prolonged surgery( 13 hours) with big fluid shifts( ~ 3L blood loss and who knows how much replacement) even if his extubation criteria at the end of operation were acceptable.

 

[JackADeli]

We are talking about this spcific case scenario, when the pt was not cut...

I understand what you are talking to. however, as I noted, I was asking a broader question based on the statement that was clearly not limited to just this patient.

...there's nothing that would cause me to shock a patient prone in a Mayfield, and certainly not the one discussed here...

The case report is not my defense. I simply "quote-posted" it as it was provided by the individual who's statement I was asking about.... Still, even in the specific OP, is there data of injury, etc for defib pinned and prone? Is it a theoretical issue or data driven?

...a reason why I would also prefer the pt to stay intubated after prolonged surgery( 13 hours) with big fluid shifts( ~ 3L blood loss and who knows how much replacement) even if his extubation criteria at the end of operation were acceptable.

I am presuming that is directed at others... as I am not in any way asking about maintaining extubation on this pt.

 

[hoyden]

I understand what you are talking to. however, as I noted, I was asking a broader question based on the statement that was clearly not limited to just this patient.The case report is not my defense. I simply "quote-posted" the it as it was provided by the individual who's statement I was asking about.... Still, even in the specific OP, is there data of injury, etc for defib pinned and prone? Is it a theoretical issue or data driven?I am presuming that is directed at others... as I am not in any way asking about maintaining extubation on this pt.

I am sorry, I am not aiming it at you, obviously. I just have combined the answer, since it was me, who initially was surprised by amyl's will to extubate.

For a broader scenario - if the pt is cut open and the flip is to be prolonged, and he/she is unstable - you probably would do less harm by cardioverting prone.
Actually I would like to hear JWK elaborate a bit more on the issue - seems like he has some real experience in this situation not just speculations( as I do), therefore such a strong stance.

 

[pgg]

Exactly, if he has just been pinned he is most likely paralyzed and shouldn't jump off the table.

if the patient is unstable enough to justify electricity - you're not gonna wait to flip. i realize MEP's don't cause quite the jump that a cardioversion does, but we run motors all the time in prone pinned patients.

Neither paralysis from NMBDs nor the safe use of MEPs while in pins suggest that cardioversion or defibrillation while in pins is safe.

As we all know, NMBDs block at the NMJ - muscles will still contract if electricity is applied directly (eg, via bovie). MEPs work through the same pathway using very small currents. Defibrillating or cardioverting someone with 50-360J applied through pads on skin is NOT the same thing.

I would never ever shock someone immobilized in Mayfield pins. I might while they're still prone, after the apparatus was unbolted from the table so the head wasn't rigidly immobilized any more. Pins in the skull (but not bolted to the table) wouldn't stop me from cardioverting or defibrillating someone.

 

[ProRealDoc]

Yep, I'm aware of that. However, hard to answer the "question" by a jury if you are out of the room, VIP case, pre-incision cardiac event, procede to 13hr & 2+L blood loss case, etc....
Not my "deference", just making a point as to what I have seen from neurosurgeons. As for myself or any other surgeon, we can be stopped from proceding with a case by anesthesia. However, we can not be pushed to proceed by anesthesia. Thus, we can not declare lack of responsibility in making a poor clinical decision and proceding forward with an elective case in the scenario you described.
Not a chance and not a call the hospital can make. The medical records would be supoened and probably everyone in the room and even down the hall would be named. If the family particularly liked the surgeon, they may choose to not name them on the suit. But, the names of who was involved in this case would be a matter of public record once the case is filed. Further, the hospital would really have very little incentive to "shield" a surgeon or anesthesiologist that chose to move forward and generate such liability. The hospital would save money and save face by distancing themselves from this action. Hypothetically, a VIP physician dies and it appears to the lay person a blatantly stupid series of events leads to the death. The hospital looks unsafe. The hospital needs to show it does not use this "caliber" of physicians.As a surgeon, looking at the job market, etc.... I think you are fairly off base here. Academic centers do hire foreign folks. However, not so easily. There are a multitude of reasons why this is not as simple as you may think and why fresh neurosurgeons are commanding such high salaries and senior surgeons have been getting bonuses in excess of a million dollars in this field. And, they are not signing them to 1yr contracts for these bills. They are often hiring foreign neurosurgeons for lack of available domestic surgeons. It is often difficult to get the licensing issues and they are paying peanuts because they are still shopping for the US expensive neurosurgeon. Otherwise, they would just forego hiring expensive US trained neurosurgeons in the first place.Not in general..... and not so cut and dry or simple at any respectable academic center.

I will leave it at that because I do not wish to get into specifics in a public forum. Suffice it to say that despite what your experience may be, what I have described above does exist.

 

[nap$ter]

Neither paralysis from NMBDs nor the safe use of MEPs while in pins suggest that cardioversion or defibrillation while in pins is safe.

As we all know, NMBDs block at the NMJ - muscles will still contract if electricity is applied directly (eg, via bovie). MEPs work through the same pathway using very small currents. Defibrillating or cardioverting someone with 50-360J applied through pads on skin is NOT the same thing.

I would never ever shock someone immobilized in Mayfield pins. I might while they're still prone, after the apparatus was unbolted from the table so the head wasn't rigidly immobilized any more. Pins in the skull (but not bolted to the table) wouldn't stop me from cardioverting or defibrillating someone.

so you're going to have somebody flip the lever that keeps the assembly locked to the table, then have that same unlucky person hold the head/pin assembly, and cardiovert your patient and asistant at the same time?

or are you going to instruct them to insulate all their contacts with... towels? my point is that if the patient is in dire enough straits to justify a zap, you ain't gonna wait to discuss and flip - you better just apply electricity, or you will be flipping and unpinning for CPR..

if you have time, ie semi urgent situation, then sure, go ahead and flip. but good luck explaining taking the 1,2, or 3 minutes to flip before defibrillating vfib...

i have seen some MEP's make the patient jump quite a bit (when the tech can't find a signal, turns the stimulus all the way up, then replaces the needle that fell out, then stims with the system turned all the way up), but as i said before and agree with, MEP jump is a lot less than a cardioversion. but the neck is pretty dang flexible - you'd have to do a lot more than cardiovert to make the patient jump enough to damage any anatomy..

 

[pgg]

so you're going to have somebody flip the lever that keeps the assembly locked to the table, then have that same unlucky person hold the head/pin assembly, and cardiovert your patient and asistant at the same time?

Yeah, that's what med students are for. We could even bring in more from other rooms if multiple shocks were needed. 🙂


Flip lever, then either replace the head portion of the bed to support the head, or slide the whole patient down a few inches. Faster than flipping supine. And you could try pharmacologic cardioversion in the meantime.

I bet I could have the Mayfield arm released and the head supported before the crash cart was even in the room.

It's a lousy situation to be in for sure, maybe not quite as lousy as a crash c-section in an obese coagulopathic uncooperative intoxicated HIV+ non-english-speaking woman with known difficult airway, severe pre-E, and a percreta ... but still, priorities have to be made. I would delay defibrillation or cardioversion for the ~30 seconds to release and stabilize the head.

I'm not saying that shocking an unstable patient who's prone in pins is totally indefensible - just that I can't imagine a situation in which I would do it.

but good luck explaining taking the 1,2, or 3 minutes to flip before defibrillating vfib...

The only way it would take 3 minutes to release and support the head is if someone put Loctite on the Mayfield arm threads. 🙂 I wouldn't insist on a supine patient before shocking ... though if it's vfib you're treating compressions are probably in order and you'll be flipping anyway.

 

[Intensivist]

am l missing here something? Neurosurgeon should be perfectly capable of knowing wether this can be done from a Neuro point of view, and Anaesthesiologist from Anaesthesia point. Only rare cases demand further consultation.

 

[Planktonmd]

The situation where you actually have to cardiovert a patient in the prone position is extremely unlikely, not impossible but unlikely.
Things never happen as fast as you hope, it takes time to bring the defibrillator to the room and hook it to the patient, this time is more than enough to flip the patient and do proper CPR if needed while the defibrillator is prepared.
If the situation is dire enough for you to consider cardioversion prone then I am assuming the patient should be in cardiac arrest and you need to be prepared for chest compressions which is not a very elegant situation in the prone position.

 

[Arch Guillotti]

Anyone worked with a surgeon that puts local? Pts don't flinch. I don't know why people don't do it more often.

good point, I think local works very well also.

 

[Arch Guillotti]

I don't know where you work but where I work surgeons are expected to produce and generate enough billing units to justify their job. If you go around cancelling cases, your APR (annual performance review) will not be satisfactory and you will be shown the door at the end of your one-year contract.

That sounds like a toxic environment to me. We all understand production pressures and billing but good lord I really have a tough time imagining that it would be a problem in this situation.

All of us have proceeded with cases when the little voice in our heads is telling us not to or when things aren't optimally controlled (BP, blood sugar, renal fxn, etc) - partly due to production pressures.

Letting the beancounters dictate patient care is piss poor IMHO.

 

[Arch Guillotti]

As far as RVUs, at some hospitals, the surgery attending is expected to run more than one room at a time. You have a group of residents/fellows, and you are expected to bounce between rooms, being present for the critical portion of the procedure. In this manner you are more productive.

In theory.

My experience in residency was that there were only a few surgeons who could really effectively run 2 rooms. The rest just slowed things up.

 

[Arch Guillotti]

It is also worthy to note that although surgeons are typically in high demand, we can't obviate the fact that there are many foreign surgeons who are itching for the chance to do your job for a fraction of your salary. Many academic hospitals have mastered this tactic and recruit skilled surgeons from india or elsewhere who are willing to work for peanuts.

Sounds pretty unpleasant.

 

[amyl]

deleted

 

[urge]

initially the pt was not hypotensive, just tachycardic. looked like svt to me but cards thought some of it looked like flutter.

How long did you have to wait for cardiology?

How did you treat it in the meantime?

 

[dhb]

to consider cardioversion prone then I am assuming the patient should be in cardiac arrest and you need to be prepared for chest compressions which is not a very elegant situation in the prone position.

CPR in the prone position has been done successfully; i've looked this up in the past and there are a couple of case reports out there.

 

[ProRealDoc]

That sounds like a toxic environment to me. We all understand production pressures and billing but good lord I really have a tough time imagining that it would be a problem in this situation.

All of us have proceeded with cases when the little voice in our heads is telling us not to or when things aren't optimally controlled (BP, blood sugar, renal fxn, etc) - partly due to production pressures.

Letting the beancounters dictate patient care is piss poor IMHO.

I doubt anyone in medicine is exempt from the power the beancounters have over us.

 

[Planktonmd]

CPR in the prone position has been done successfully; i've looked this up in the past and there are a couple of case reports out there.

I didn't say it can't be done but do you really want to do it?
Almost anything can be done or has been done successfully by someone but the fact that something has been done by some one does not make it the best course of action.
The new guidelines for CPR emphasize high rate compressions as the main element in addition to effective compression force, can you imagine doing 100 compression/min on a prone patient?

 

[ProRealDoc]

Sounds pretty unpleasant.

Maybe, but it's no different than the anesthesiologist vs CRNA issue. It's always about $$.

 

[JackADeli]

That sounds like a toxic environment to me. We all understand production pressures and billing but good lord I really have a tough time imagining that it would be a problem in this situation...

...Letting the beancounters dictate patient care is piss poor IMHO.

Agreed. Especially with "VIP". In most VIP situations I have seen, the case load for the day is lowered....

...My experience in residency was that there were only a few surgeons who could really effectively run 2 rooms. The rest just slowed things up.

Agreed.

Sounds pretty unpleasant.

In reference to recruiting and hiring cut rate foreign surgeons i.e. "India", etc... First, unfortunately most universities are very poor at the production motive. Second, Universities with any kind of reputation are not going to start loading their boat with ~scab surgeons that will proceed to operate under high risk/poor clinical decision making, just for an APR. Any reputable university that operates that way will rapidly be disreputable. The community will start referencing the lack of domestic providers and the public list of complications. My experience at universities and community teaching facilities are that hiring foreign nationals is done as a ~"necessary evil" due to lack of available domestic talent. It was not done as a means of pressuring domestic surgeons to compromise in clinical practice. The hospitals & University medical centers strive to advertise there physicians credentials and emphasize board certification and "name brand" education/training.... right down to saying things like ~"Dr. X trained at USA university (in the boonies) under the third generation physician that is only three steps away from Halsted!". There is alot of mental gymnastics when you look at how they attempt to elevate the status of foreign nationals on their staff.... well beyond what they need to do for domestic trained. If foreign recruitment was such a winner, the I again say they would not be paying such lucrative salaries and bonuses to recruit neurosurgery.

Maybe, but it's no different than the anesthesiologist vs CRNA issue. It's is always about $$.

That is what the nurse anesth. would have you believe. There is probably more of a real impact threat on the domestic midlevel vs domestic physician war then there is on the domestic neurosurgeon vs foreign neurosurgeon war....

 

[Arch Guillotti]

initially the pt was not hypotensive, just tachycardic. looked like svt to me but cards thought some of it looked like flutter.

I realize you are at the whim of your attending.

If I thought it was SVT I wouldn't wait on cardiology, I would have given adenosine.

 

[Arch Guillotti]

I don't know where you work but where I work surgeons are expected to produce and generate enough billing units to justify their job. If you go around cancelling cases, your APR (annual performance review) will not be satisfactory and you will be shown the door at the end of your one-year contract.

I hear what you are saying but this is the CHAIRMAN of the neurosurgery department and this by no means is a soft cancellation.

 

[JackADeli]

...this is the CHAIRMAN of the neurosurgery department...

Yeh, I didn't even go to that point. But, chairmen at teaching institutions notoriously have less operative volume. I don't see the chairman being handed the door for decreased APR based on a cancellation of such a case. The argument does not apply to this scenario, IMHO/IMPO. I also do not see them replacing the chairman with a foreign neurosurgery grad that just finished some pseudo chief year domestically..... Again, too many empty chairs or interim chairs around the country to support such an argument.

 

[IlDestriero]

I didn't say it can't be done but do you really want to do it?
Almost anything can be done or has been done successfully by someone but the fact that something has been done by some one does not make it the best course of action.
The new guidelines for CPR emphasize high rate compressions as the main element in addition to effective compression force, can you imagine doing 100 compression/min on a prone patient?

It may not the best course of action, but it's worth remembering that you CAN do effective prone CPR as meds are pushed and the other bed, crash cart, etc are being brought into the room. Don't forget to support the chest.
All I can say about the case above is that I would have managed it differently. Why your attending, yourself or the neurosurgeon didn't get the juice when he was apparently unstable is anyone's guess.

 

[ProRealDoc]

Yeh, I didn't even go to that point. But, chairmen at teaching institutions notoriously have less operative volume. I don't see the chairman being handed the door for decreased APR based on a cancellation of such a case. The argument does not apply to this scenario, IMHO/IMPO. I also do not see them replacing the chairman with a foreign neurosurgery grad that just finished some pseudo chief year domestically..... Again, too many empty chairs or interim chairs around the country to support such an argument.

I think you are having difficulty accepting the fact that we are but mere spokes on a very large wheel. No one is special anymore (unless you're a chairman (but how many are?) Even then you can still be shown the door.

Your argument about foreign physicians being subpar is not consistent with the reality. I use the same argument about CRNAs. They maybe the workers behind the scenes that no one sees. May not be as good as Arch Guilloti. But yet, they are still there.

Why is it that Bill Gates does not pay top dollar for american software engineers? I am sure we have pretty talented people in this country who could do the job. Why does he prefer to go to the technical schools in India? Is it because they are cheaper? Couldn't he get the same quality of workers from MIT?

By the way, I am an american grad. Not dissing on my own kind but just trying to portray the fact that we all face stiff competition no matter how special we may think we are.

 

[Intensivist]

Just a med student question: Why would you call cards on this EKG/situation? I thought anaesthetists are perioperative docs, atleast when it comes to medical issues with patients. And this isn't some extraordinary situation, not seen before, with no existing plan in every book on Anaesthesia/ICU/Acute Medicine....

 

[JackADeli]

I think you are having difficulty accepting the fact that we are but mere spokes on a very large wheel. No one is special anymore (unless you're a chairman (but how many are?) Even then you can still be shown the door..

No difficulties here.... The scenario in question was apparently the chairman. Yes, spoke/cog in wheel and all that does not change some of the over all reality of business and practice. There are differing levels of individual importance and differing levels of what individuals can get away with and/or what production is required.

...there are many foreign surgeons who are itching for the chance to do your job for a fraction of your salary. Many academic hospitals ...recruit skilled surgeons from india or elsewhere who are willing to work for peanuts.

...These guys come here...In a couple of years, they are your peers and are willing to do what you won't.

Your argument about foreign physicians being subpar is not consistent with the reality. I use the same argument about CRNAs. They maybe the workers behind the scenes that no one sees. May not be as good as Arch Guilloti. But yet, they are still there...

I am not making an argument that foreign trained physicians are subpar. I know numerous that are in fact quite excellent and/or better then many of their domestic trained counterparts. I am making an observation as to what much of public perception is and what marketing efforts I have seen (or been asked to participate in...). However, if a foreign grad will come in and be willing to engage in possibly questionable clinical conduct to achieve some volume at the end of the year as was suggested early in this long line of discussion, I say that individual is "subpar" no matter if foreign or domestic trained.

...Why is it that Bill Gates does not pay top dollar for american software engineers? I am sure we have pretty talented people in this country who could do the job. Why does he prefer to go to the technical schools in India? Is it because they are cheaper? Couldn't he get the same quality of workers from MIT?...

I can't speak to what Bill Gates does. But, in general there have been plenty of survey studies in regards to engineering and technology.... Guess what? There is a stereotype in reference to these techys that is prevalent, that is, many perceive foreign scientists i.e. Japanses/Chinese/Indian as ~smarter in these fields. They may not want someone as such at the end of a "help line".... But the image is very commercialized in marketing tech companies as having the best and brightest. On the flip side, there is much concern about non-USA trained physicians. Yes, hospitals, in the field of neurosurgery, do pay top dollar for domestic trained neurosurgeons. They are by almost every survey study some of the highest paid grads in the country. i.e. http://www.cejkasearch.com/compensation/amga_physician_compensation_survey.htm

To keep arguing is pointless.... We have come full circle, now the caveat of a chairperson is being used (which was the original scenario) and we are comparing the vast computer science engineer/pragrammer field to the small community of neurosurgeons. Also, you look at some of the latest data.... MIT & Caltech are some of the highest paid college grads in the USA.

 

[IlDestriero]

Just a med student question: Why would you call cards on this EKG/situation? I thought anaesthetists are perioperative docs, atleast when it comes to medical issues with patients. And this isn't some extraordinary situation, not seen before, with no existing plan in every book on Anaesthesia/ICU/Acute Medicine....

Couldn't tell you. They would see him after I cancelled the case in the PACU. We've had the EP folks in the OR for some refractory arrhythmias. If they are free, they get there faster than you think. They recognize the gravity of the situation and that they may be able to offer life saving advice. A phone consult is almost worthless. In fact it probably is worthless as if you don't accurately report what you are seeing, they won't give proper advice. I've "phoned a friend" in the PICU for advice before. No shame in that. Their name would also never be found on the record. I wonder if the cards phone consult was documented? No need to spread the liability around. Something tells me "discussed with Dr cards who agreed that it was OK to proceed" is somewhere in there. Maybe not?

 

[Idiopathic]

I doubt this was a reentrant rhythm and there are one million causes for sinus tach. If you can slow him down prone in pins then you do it. Very difficult to appreciate significant st depression with v rate of 150 but still not an indication for urgent cardioversion if bp okay. 99 percent sure it's demand ischemia if anything and slowing the rate would help obv.

Arch - you would give adenosine prone in pins with a stable bp?

Not having seen it firsthand im a little skeptical but I think it's ok to rx as amyl did. Also any hypotension that is corrected with one cc of baby epi is hardly unstable, esp with that much beta blockade

 

[PL32]

So for the record, I'd just be interested to see what percentage of attendings would have felt comfortable continuing with the case once things got settled down (ie you assume it's demand ischemia, you treat and control the rate and assume all will be well for the next several hours).

 

[jetproppilot]

his BP dropped and didn't respond to anything but a whiff of epi.
staff called cards and they said go ahead but control the rate (no **** sherlock).
esmolol drip and a ton of IV push metoprolol eventually converted him and then all was right in the world. BP perfected w return of atrial kick, heart rate normalized. concerning that you guys said 700cc EBL though... i guess the surgeons were bad 'cause we ended up loosing 2L (and that was probably conservative).... and it took 13h.
he was breathing spontaneously at the end of the case... i wanted to pull the tube and see how it went but staff didn't even wanna try, oh well. cards recommened amiodarone if beta blockade didn't work. thoughts?

I've never heard of, nor experienced, a cervical laminectomy with two liters of blood loss and...

Uhhhhhh....

13 hours???

That must be a typo.

You and I could figure out that surgery in less than thirteen hours.

 

[Idiopathic]

So for the record, I'd just be interested to see what percentage of attendings would have felt comfortable continuing with the case once things got settled down (ie you assume it's demand ischemia, you treat and control the rate and assume all will be well for the next several hours).

its hard for me to say since i wasnt there but if you anticipate a 13 hour bloodletting then maybe that swings you towards cancelling and postponing. acute ischemia is high on the list of causes if it is truly fib/flutter and so if you really are convinced its one of those and not sinus tach then you should cancel IMHO.

 

[Idiopathic]

jet - it sounds like they did tumor resection/debulking as well, im sure it wasnt a straightforward laminectomy (although i could be wrong)

this also raises an interesting point about how much info we should be putting in these "my case yesterday" posts. anyone with 10 minutes and an internet connection could figure out who this patient is.

 

[sevoflurane]

initially the pt was not hypotensive, just tachycardic. looked like svt to me but cards thought some of it looked like flutter. pushed a ton of esmolol to control rate. then pt became hypotensive. pushed a bunch of phenylephrine. didn't work. pushed a little ephedrine w some phenylephrine. didn't work. pushed 10mcg of epi as a last resort.
you should all know that this was not following pinning. pt had been pinned and flipped for 10-15 minutes, surgeons were prepping and draping when it happened, no incision yet.
intially i thought we should cancel the case 'cause we couldn't fix him, ie couldn't control the rate -- he randomly converted w a ton of beta blockade. amiodarone was discussed. interestingly enough, staff i was working with never considered cardoversion. i wonder why? any ideas?
(and yes it was chair of neurosurg not anes)

Thanks for posting your experience, I would agree with idiopathic in trying to present the case in such a way that it remains anonymous. 👍

In the setting of ST depression which is likely demand mediated, I would have given 10mcgs of Norepi if phenylephrine did not work. I'm not convinced he had st depression however. Hard to tell with higher ventricular rates.

If he responded (which he likely would) and I still thought he needed to be cardioverted then I would flip him in less than 2 minutes assisting BP with norepi as needed. I can usually temporize BP long enough to flip someone supine. I don't ever want to go down the ACLS pathway in a prone patient. I don't think it would be as affective. My N=0.

Was he on an ACE inhibitor? If on ACE In. then maybe I'd give him some vasopressin, at .5-1 unit at a time.

If you are not sure if it's SVT vs. Flutter, you can still give Adenosine so you can look for the presence of Flutter waves vs. SVT once the rhythm slows down. Hypotension may be a relative contraindication, but if you know you can bring the BP up with Norepi or vaso then I would consider it.

Amiodarone is a good idea, but you can get hypotension with 150mg push. One thing to be cautious about in these scenerios is not to give a bunch of different meds. Cardizem + dig + beta-blockers = conduction block, hypotension and bad outcomes.


Did you send off troponins/chemistry once things settled down? If so what did you find? 🙄

 

[Arch Guillotti]

Arch - you would give adenosine prone in pins with a stable bp?

If I really thought it was SVT then I would give adenosine. I am not sure it matters if he is in pins or not. Obviously when I am going through any ACLS protocol I would rather not have the patient prone in pins.

Are you concerned about giving adenosine to someone with a stable BP?

 

[Idiopathic]

i wouldnt do it at this time in this scenario, my question is if you are giving it then shouldnt you be in position to go full force with resuscitation (i.e. cover the head, flip supine, pads on)?

if i was worried if probably arrange to expedite that and give it when i could do CPR shock etc.