Novel approaches

[Carm]

There have been some interesting case threads lately. I would be interested in hearing of reasonable ways to 'spice up' bread and butter cases. I have started doing some of the cooler cases that involve double lumen tubes, lines, positioning issues eccetra, but the bulk of my CA-1 work load is still general surgery, gyn, ortho.

I would be interested in hearing of different methods to broaden our newbie skill set while still doing bread and butter cases.

Normal case for Carm:

+/- Versed
50-100mcg fentanyl
150mg Propofol
100mg lidocaine
140 Sux
Tube
Vec for paralytic
Neo/Glyco to reverse

Sevo
Anzemet
+/- Toradol

I am sure every program has a different "resident's favorite" routine. I am looking for ways to broaden my bag of tricks.

I'll start.

Treat the easy airway as a difficult. Discuss using light wand with attending for all intubations in general room. Does not alter the care of pt, but gives us practice at developing a difficult airway skill without the stress of actually dealing with a difficult airway.


We had a great thread a while back about all the different ways and recipes used to give an epidural or spinal. Hopefully we can get some tricks for the mickey mouse room as well.

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[seattledoc]

some ideas that have been used at our hosp.

1. difficult airway day as you said: bullard, shikani, light wand, fastrach, occas fiber optic.

2. no fentanyl days

3. no propofol days

4. 3 martini lunch days...maybe not

 

[johankriek]

+/- Versed
50-100mcg fentanyl
150mg Propofol
100mg lidocaine
140 Sux
Tube
Vec for paralytic
Neo/Glyco to reverse

Sevo
Anzemet
+/- Toradol
.

no such thing as a mickey mouse room


why would you use sevo and not des or iso on a routine case.. Do you know the metabolism of sevo is like 100 times the metabolism of des and iso? do you know also that the oil gas coefficient for sevo is larger than iso even though the blood gas coefficient rivals des'.

 

[seattledoc]

what's your point caller? He was asking for ideas on how to improve his skill set. I don't think critisizing his use of sevo and telling him to use desflurane really accomplishes that.

 

[Lizard1]

One day for fun everybody (well 2 cases - inpatient) got pentothal gtts. Another time I was bored like you so I tried ONLY Ketamine & Versed for a d&c --> that was fun !

 

[Carm]

One day for fun everybody (well 2 cases - inpatient) got pentothal gtts. Another time I was bored like you so I tried ONLY Ketamine & Versed for a d&c --> that was fun !

Ballsy

 

[VentdependenT]

There have been some interesting case threads lately. I would be interested in hearing of reasonable ways to 'spice up' bread and butter cases. I have started doing some of the cooler cases that involve double lumen tubes, lines, positioning issues eccetra, but the bulk of my CA-1 work load is still general surgery, gyn, ortho.

I would be interested in hearing of different methods to broaden our newbie skill set while still doing bread and butter cases.

Normal case for Carm:

+/- Versed
50-100mcg fentanyl
150mg Propofol
100mg lidocaine
140 Sux
Tube
Vec for paralytic
Neo/Glyco to reverse

Sevo
Anzemet
+/- Toradol

I am sure every program has a different "resident's favorite" routine. I am looking for ways to broaden my bag of tricks.

I'll start.

Treat the easy airway as a difficult. Discuss using light wand with attending for all intubations in general room. Does not alter the care of pt, but gives us practice at developing a difficult airway skill without the stress of actually dealing with a difficult airway.


We had a great thread a while back about all the different ways and recipes used to give an epidural or spinal. Hopefully we can get some tricks for the mickey mouse room as well.

If yer wanting to try some new poop:

Ditch yer potent inhalation agent and use a propofol drip and a remi drip for procedures which have minimal pain when finished. Yeah its expensive but youre in an academic center and you gotsta learn. Keep some nitrous running so that you have a decreased risk of recall. Or dribble in a bit of versed here n' there.

How about just doing an inhalation induction? Those can be cool. Keep your patient spontaneously ventilating. If its n' old fella you can keep a little neo dribblen in so that end tidal of 5% sevo doesn't bottem em out. Slip ye tube in!

 

[jetproppilot]

some ideas that have been used at our hosp.

1. difficult airway day as you said: bullard, shikani, light wand, fastrach, occas fiber optic.

2. no fentanyl days

3. no propofol days

4. 3 martini lunch days...maybe not

Cool teaching ideas!

 

[Gern Blansten]

no such thing as a mickey mouse room


why would you use sevo and not des or iso on a routine case.. Do you know the metabolism of sevo is like 100 times the metabolism of des and iso? do you know also that the oil gas coefficient for sevo is larger than iso even though the blood gas coefficient rivals des'.

First of all, there is such a thing as a Mickey Mouse room. I have seen it with my own 2 eyes. Many told me it did not exist, but I saw it. If only I had brought my camera. There it was, right next to the unicorn.

Second, do you know that patients wake up just as fast with sevo as thay do with des? Do you know that sevo does not form carbon monoxide when exposed to CO2 absorbers? Do you know that all inhaled anesthetics have certain characteristics that you can spout off to make them sound better than all others? If you don't believe me, listen to the speakers that are hired by Abbott and Baxter. If there was money to be made with Iso or halothane, you can bet we would be bombarded with all sorts of facts stating how much better they are than the others.
My point is, you are trying to make an argument somehow that Sevo is dangerous due to metabolism while iso and des are not. I don't think it holds water clinically and sevo is used quite a bit(~50% market share) so I think there are a lot of people that agree. I like des as well and, when used correctly, iso can give you quick(well-timed) wakeups as well. To each their own.
I am just curious if you are on the list of speakers for Baxter.

 

[VentdependenT]

First of all, there is such a thing as a Mickey Mouse room. I have seen it with my own 2 eyes. Many told me it did not exist, but I saw it. If only I had brought my camera. There it was, right next to the unicorn.

Second, do you know that patients wake up just as fast with sevo as thay do with des? Do you know that sevo does not form carbon monoxide when exposed to CO2 absorbers? Do you know that all inhaled anesthetics have certain characteristics that you can spout off to make them sound better than all others? If you don't believe me, listen to the speakers that are hired by Abbott and Baxter. If there was money to be made with Iso or halothane, you can bet we would be bombarded with all sorts of facts stating how much better they are than the others.
My point is, you are trying to make an argument somehow that Sevo is dangerous due to metabolism while iso and des are not. I don't think it holds water clinically and sevo is used quite a bit(~50% market share) so I think there are a lot of people that agree. I like des as well and, when used correctly, iso can give you quick(well-timed) wakeups as well. To each their own.
I am just curious if you are on the list of speakers for Baxter.

So friggen true.

In the big house downtown I use plenty of sevo. Its a great inh agent.

I'd use ISO on routine cases (juz like everyone had to some years back) if I had more experience with it. Just hard to justify when I have sevo and des hanging out next to it. Both of which I'm more familiar with.

But when the rep hands me out a bagle and cream cheese (I'm a cheap date these days) when Im starving in the am I always tell em that their poops the best.

 

[cchoukal]

We have an attending that will occasionally be like, "okay, today you can only use drugs that start with the letter..." Not ready for that yet, but sounds fun. Then he mentioned something about a lidocaine drip into one arm and thiopental drip into the other arm. Sounds olde-schoole.