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[BLADEMDA]

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Oh yea, some other things that bug me:
1) Anesthesiologists who don't know how to place peripheral nerve catheters under stimulation
2) Anesthesiologists who don't know how to place peripheral nerve catheters at all
3) Anesthesiologists who don't know how to do U/S guided blocks
4) Anesthesiologists who don't know how to do peripheral blocks for awake intubations and always rely on nebulizing instead
5) Anesthesiologists who do all of their awake intubations nasally rather than orally
6) Anesthesiologists who do their popliteal blocks posterior rather than lateral
7) Anesthesiologists who prefer a bronchial blocker to a double lumen tube
8) Anesthesiologists who try to do anything but a pure TIVA during SSEP and MEP monitoring cases
9) Anesthesiologists who use fentanyl in their thoracic epidural infusions rather than morphine or dilaudid
I could go on...but I will stop...Any residents reading this-If you "resemble" any of these statements, challenge your attendings...make them teach you these invaluable skills if they can...it will help in the future when you are in private practice...Otherwise, someone like me may think you are a hack.

Let us review your rant:

1. Stimulating catheters are more expensive and don't provide much of an improvement in success.

2. Placing a catheter is CRNA level work. A 10 minute internet review is all you need. Perhaps, they choose not to place one.

3. No proven benefit to U/S over nerve stimulation. Same success rate in experienced hands. Need expensive machine at all locations which is not cost effective. Again, a one hour review course is all you need plus a $30,000 U.S machine that gets better every year.


4. Nerve Blocks vs. Nebulizer- dealer choice. No proven advantage.

5. Awake intubations- Do what you are good at.

6. Popliteal- Lateral vs. Posterior. No need for U/S posterior so cheaper to do and works 99% of the time. Lateral- better with U/S

7. DLT works better but blockers are harder to place. It takes more skill to place a blocker successfully and fast.

8. Pure TIVA on a 4-7 hour case is expensive. A mixture anesthetic of less than half MAC Vapor plus propofol and ketamine combined with narcotic infusion like Sufenta. It works fine. It takes no additional brain cells to run more Prop/Ketamine and no vapor. Dealer choice.

9. Thoracic Infusions- At the Lumbar level Duramorph is superior to Fentanyl due to hydrophilic nature of MS04 and rostral spread.. At the thoracic level Fentanyl is just fine (no need for max. spread).

Your rant is baseless and without scientific merit. I would take a practitioner who can EXECUTE 1-9 with his/her preference over yours with a high success rate.

 

[xjohns1]

Wow!
I am assuming you are in the U.S.
May I ask where??

ucsf.

 

[HalO'Thane]

Most of the articles I've read dismissing N20, including the above post from Utah, studied the use of a 70% N20 mixture intraoperatively for very long cases (> 2 hours). It seems like the majority of practitioners on this forum that use it run a 50 - 70% mixture at the end of cases for skin closure (probably 15 minutes max). I have yet to see any articles showing any detrimental effects from this specific practice. Until I do, I will probably still continue to use it at the end of cases for that "smooth landing" everyone is talking about (assuming no contraindications such as a PTX).

 

[ncdoc1974]

Let us review your rant:

1. Stimulating catheters are more expensive and don't provide much of an improvement in success.

-But you've got to admit they are pretty sweet...

2. Placing a catheter is CRNA level work. A 10 minute internet review is all you need. Perhaps, they choose not to place one.

-I don't work with CRNA's-I am in an MD only practice...I don't like CRNA's

3. No proven benefit to U/S over nerve stimulation. Same success rate in experienced hands. Need expensive machine at all locations which is not cost effective. Again, a one hour review course is all you need plus a $30,000 U.S machine that gets better every year.

-We already have the machines everywhere I work and it is very helpful to do U/S guided blocks on fractured patients...no pain from movement during stimulation and higher patient satisfaction, which I personally believe is extremely important...


4. Nerve Blocks vs. Nebulizer- dealer choice. No proven advantage.

-nebulizing takes too long

5. Awake intubations- Do what you are good at.

-I hate bloody noses

6. Popliteal- Lateral vs. Posterior. No need for U/S posterior so cheaper to do and works 99% of the time. Lateral- better with U/S

-no need for U/S for lateral...it sucks to roll a patient with an ankle fracture prone if it is not necessary...be smooth...improve patient satisfaction and make your life easier

7. DLT works better but blockers are harder to place. It takes more skill to place a blocker successfully and fast.

-agreed, I use DLTs whenever possible...blockers suck, I'm glad we agree

8. Pure TIVA on a 4-7 hour case is expensive. A mixture anesthetic of less than half MAC Vapor plus propofol and ketamine combined with narcotic infusion like Sufenta. It works fine. It takes no additional brain cells to run more Prop/Ketamine and no vapor. Dealer choice.

-I don't care if it is expensive...It does not affect my pay...I will provide an optimal anesthetic regardless of cost...If I had access to Xenon, I would use it instead of Sevo for non-TIVA cases if I could...Xenon is sweet...

9. Thoracic Infusions- At the Lumbar level Duramorph is superior to Fentanyl due to hydrophilic nature of MS04 and rostral spread.. At the thoracic level Fentanyl is just fine (no need for max. spread).

-go back to school....

Your rant is baseless and without scientific merit. I would take a practitioner who can EXECUTE 1-9 with his/her preference over yours with a high success rate.

My rant is not baseless...I pride myself on being smooth, maximizing patient satisfaction, surgeon satisfaction, minimizing complications, and I think residents should learn all of these skills to be the best anesthesiologist they can be...As far as scientific merit....I guess I read more than you...

 

[BLADEMDA]

My rant is not baseless...I pride myself on being smooth, maximizing patient satisfaction, surgeon satisfaction, minimizing complications, and I think residents should learn all of these skills to be the best anesthesiologist they can be...As far as scientific merit....I guess I read more than you...

Comic Books don't count.