one for the trainees

[caligas]

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5 pm on friday you finish your last EGD on a 33 yof with epigastric pain. Propofol wears off. She complains of pain and blurriness in her left eye. Nothing abnormal on gross exam. Everybody including yourself is anxious to go home. Plan?

 

[lobelsteve]

Send to urgent care, go home.

 

[Sublimazing]

Was this patient prophylaxed with monoclonal antibody valsava-maB?

 

[caligas]

Was this patient prophylaxed with monoclonal antibody valsava-maB?

As my board examiner kept asking me: why is that important to you?

 

[caligas]

Send to urgent care, go home.

Ok, Its 515 pm on a friday and you are moonlighting at an urgent care center. A 33 yof comes in complaing of left eye pain and bluriness......

 

[Planktonmd]

Well ... you need to look in the eye and see if there is intraocular hemorrhage.
I am sure at the ER there is someone who knows how to do a fundoscopy.

 

[lobelsteve]

Ok, Its 515 pm on a friday and you are moonlighting at an urgent care center. A 33 yof comes in complaing of left eye pain and bluriness......

Ask her if she had a recent EGD under Propofol.

 

[Random Anesthesiologist]

I would check for corneal abrasion or subscleral hemorrhage from maybe positioning issues. If none, monitor postop as usual. If yes, sent to ER for slit lamp. Provided there was nothing outstanding about the case. If she has a history when asked, postop and follow up with your PCP.

 

[Arch Guillotti]

Have the unit secretary consult optho with no furthur information and then go home.

 

[Laryngophed]

My first thought was corneal abrasion. That buys a looksee with the Woods lamp.

Is she having any trouble voiding or any other findings on PE?

 

[Random Anesthesiologist]

My first thought was corneal abrasion. That buys a looksee with the Woods lamp.

Is she having any trouble voiding or any other findings on PE?

Heh, our ER uses the slit lamp. Someone walked off with the woods lamp once so you have to guarantee your first born in order to use it now. At least the residents do.

 

[Planktonmd]

Whats concerning here is not the pain but the blurred vision... a corneal abrasion does not cause blurred vision

 

[Random Anesthesiologist]

Whats concerning here is not the pain but the blurred vision... a corneal abrasion does not cause blurred vision

Sure it can, depending on size and location

 

[Planktonmd]

Sure it can, depending on size and location

The corneal abrasions we see "as anesthesiologists" tend to be linear, small and do not cause blurry vision.
I am sure you can have a giant laceration of the cornea interfering with vision, but not in our practice my friend.

 

[Random Anesthesiologist]

The corneal abrasions we see "as anesthesiologists" tend to be linear, small and do not cause blurry vision.
I am sure you can have a giant laceration of the cornea interfering with vision, but not in our practice my friend.

I think anything is possible, even corneal abrasions that cause blurry vision. It's unlikely, but it's something to rule out, as are anything that might have been a red flag during the procedure like serious hypertension.

 

[BLADEMDA]

5 pm on friday you finish your last EGD on a 33 yof with epigastric pain. Propofol wears off. She complains of pain and blurriness in her left eye. Nothing abnormal on gross exam. Everybody including yourself is anxious to go home. Plan?

I call an optho guy on the phone for a quick consult. I ask whether this requires a trip to the ER or can wait until Monday.

I admit corneal abrasion is my first thought but the blurry vision would get me to make the cell phone call.

 

[BLADEMDA]

Symptoms of corneal abrasion include pain, photophobia, a foreign-body sensation, excessive squinting, and reflex production of tears. Signs include epithelial defects and edema, and often conjunctival injection (a tear in the surface of the cornea with possible intruding foreign matter), swollen eyelids, large pupils and a mild anterior-chamber reaction. The vision may be blurred, both from any swelling of the cornea and from excess tears. Crusty buildup from excess tears may also be present.

 

[deleted126335]

Have to ask, was she was wearing a contact lens when she went into the procedure that she doesn't have now?

 

[Sublimazing]

My thought was valsalva retinopathy 2/2 to the egd...which I think warrants a consult

Though at county; derm and ophtho are just pager numbers, i've never actually seen these ghosts unless theyre scrubbed in telling me how much versed is given for a MAC 😀

 

[Random Anesthesiologist]

I thought valsalva retinopathy was painless...?

 

[BLADEMDA]

I thought valsalva retinopathy was painless...?

Yes. Classic presentation includes no pain.

Individuals with a history of vascular disease, such as diabetes, hypertension,sickle cell disease, anemia, idiopathic thrombocytopenic purpura, or other blood dyscrasias, and those with a history of ocular venous occlusions are at increased risk for retinopathy to occur following a Valsalva maneuver.[8, 9, 10]

• Patients with Valsalva retinopathy initially present after recently performing a Valsalva maneuver. The severity of the Valsalva maneuver is not directly correlated with the severity of Valsalva retinopathy.
• Patients present with unilateral or bilateral manifestations, generally within 2 days after onset.
• Patients may complain of floating spots, cloudy or hazy vision, a reddish tinge over their vision, or a complete loss of vision.

 

[urge]

5 pm on friday you finish your last EGD on a 33 yof with epigastric pain. Propofol wears off. She complains of pain and blurriness in her left eye. Nothing abnormal on gross exam. Everybody including yourself is anxious to go home. Plan?

What other 500 drugs did you use for the case?
Any history of glaucoma?
Any history of migranes?
Can she describe the pain? Deep inside the eye or superficial?

Corneal abrasion is usually the culprit. I wouldn't go home before figuring it out.

 

[Spinach Dip]

Retrograde wire.



My work here is done.

 

[caligas]

What other 500 drugs did you use for the is nase?
Any history of glaucoma?
Any history of migranes?
Can she describe the pain? Deep inside the eye or superficial?

Corneal abrasion is usually the culprit. I wouldn't go home before figuring it out.

No other drugs. Just propofol and lido. No contacts. No migraines or glaucoma. Pain feels superficial, bluriness is more due to tear production than actual vision change.

 

[Random Anesthesiologist]

No other drugs. Just propofol and lido. No contacts. No migraines or glaucoma. Pain feels superficial, bluriness is more due to tear production than actual vision change.

Did she have her hands near her face at all?

Really does sound like corneal abrasion. Would send to ER to get a look under slit lamp to make sure it's not a keratitis, +/- ophtho consult depending on findings, home with ofloxacin or Toby drops, +/- analgesic drops, follow with PCP. And also make sure the pt doesn't have a background of sjogrens or other sicca like disease. (I wouldn't necessarily do all these things but anticipate the ER would do a lot of this)

 

[urge]

I'm fairly comfortable that it is a corneal abrasion. It would be nice to look with a woods lamp but I doubt many places have it. I would send home with erythro ointment and follow up the next day by phone.

 

[caligas]

I'm fairly comfortable that it is a corneal abrasion. It would be nice to look with a woods lamp but I doubt many places have it. I would send home with erythro ointment and follow up the next day by phone.

This was my approach. Symptoms resolved by the next day. Data says patching not needed. Data on abx is limited. Optho consult was offered friday night but pt declined.

 

[Random Anesthesiologist]

Thanks for the case!

 

[Dwindlin]

Question, as I get ready to start CA1 here soon (not soon enough), do some really send these to the ED for evaluation? I would think (assuming equipment is available) it would be our responsibility to evaluate and initiate basic treatment for a not infrequent complication.

 

[Planktonmd]

Question, as I get ready to start CA1 here soon (not soon enough), do some really send these to the ED for evaluation? I would think (assuming equipment is available) it would be our responsibility to evaluate and initiate basic treatment for a not infrequent complication.

Here is the deal:
As an anesthesiologist you are not an expert on ophthalmology... So if you say to yourself this is "just" a corneal abrasion, and I need to leave the surgicenter and go home... So I will send them home... If they come back later with a devastating infection or it turns out to be a hemorrhage inside the eye that you missed... you are screwed!
By the way... a corneal abrasion is NEVER a simple problem and it can turn into a terrible situation for both of you (you and the patient).

 

[urge]

Often times you hear on this site that anesthesiologists are better than crnas because they don't know medicine and it leads to more consultations and delays. Then you hear stuff like above.

Perhaps the learning point of the story is that people in amb surg centers should have an ophthalmoscope available.

 

[Laryngophed]

Often times you hear on this site that anesthesiologists are better than crnas because they don't know medicine and it leads to more consultations and delays. Then you hear stuff like above.

Perhaps the learning point of the story is that people in amb surg centers should have an ophthalmoscope available.

Isn't that just half of the problem? Fundoscopy still has to be performed.

 

[urge]

Isn't that just half of the problem? Fundoscopy still has to be performed.

You cannot look inside the eye with an ophthalmoscope?

 

[Laryngophed]

You cannot look inside the eye with an ophthalmoscope?

How many people did you graduate with that "can do" fundoscopy but can't reliably visualize the fundus or make decisions based on what they saw? I can visualize it, but obviously don't have the knowledge base and judgment to make those decisions as related to anesthesiology. But I can only visualize because I was terrible at it, and I was fortunate to have met a pediatrician who took it upon herself to teach me, and let me use her slow clinic days to practice whether the patient had an eye related concern or not.

 

[urge]

How many people did you graduate with that "can do" fundoscopy but can't reliably visualize the fundus or make decisions based on what they saw? I can visualize it, but obviously don't have the knowledge base and judgment to make those decisions as related to anesthesiology. But I can only visualize because I was terrible at it, and I was fortunate to have met a pediatrician who took it upon herself to teach me, and let me use her slow clinic days to practice whether the patient had an eye related concern or not.

Should we send you back to med school?

 

[Laryngophed]

Should we send you back to med school?

Why? I can perform fundoscopy? I don't know all of the potential anesthesia related diseases, so I wouldn't necessarily know all of the things I should be looking for. That's why I'm doing a residency.

But ask yourself, how many anesthesiology residents use an ophthalmoscope regularly? How many attending anesthesiologists do you think use one on the regular and are competent? That was my point. Merely having the scope doesn't mean they are going to use it, use it correctly to gather the necessary data, or know what to do with it.

 

[urge]

Do you know how mad I would be if I were your patient? First you scratch my cornea. Then you are incompetent to deal with it and send me to waste time and money in some ER where they are going to do what you could have done if you knew what you were doing.

 

[Orin]

But ask yourself, how many anesthesiology residents use an ophthalmoscope regularly?

Dude, I've been lugging this thing around for a while now. I'm dying to pull it out. It's right next to the retrograde wire kit and tuning forks.

 

[lobelsteve]

Do you know how mad I would be if I were your patient? First you scratch my cornea. Then you are incompetent to deal with it and send me to waste time and money in some ER where they are going to do what you could have done if you knew what you were doing.

If I were your patient and had this problem and you looked in my eye with your fancy tools. My lawyer is going to hold you to the same standard of care as the Ophtho that would have met me in the ER. Good luck explaining that in front of a jury.

 

[Laryngophed]

Dude, I've been lugging this thing around for a while now. I'm dying to pull it out. It's right next to the retrograde wire kit and tuning forks.

I bet you've got your reflex hammer and one of these bad boys in there too, amirite? You know, just in case.

 

[urge]

Well, don't come here and claim that you are better than crnas, because that's what a independent crna would do. Send them to the ER.

 

[Random Anesthesiologist]

If I could get fluorescin and a slit lamp or a woods lamp in a surgicenter then sure I'd do it myself. It's not rocket appliances. Besides, you'd have to know how to do those basic things if you moonlight in the ED. I mention the ED because maybe there are in hospital protocols and such.

Chances are they probably do have those at the surgicenter if they do eyes there anyway.

I also know how to do a fundoscopic exam. I'm a doctor after all.

 

[pgg]

Well, don't come here and claim that you are better than crnas, because that's what a independent crna would do. Send them to the ER.

In my experience, it's the rare militant shoulder-chippy I-can-do-anything CRNA who refuses to recognize the edges of his competence and does things he ought to refer or consult an expert on.

Is that reluctance to refer a patient really that far removed from the OB who thinks he's a general surgeon, or the dentist who thinks he's an anesthesiologist, or the anesthesiologist who thinks he's an ophthalmologist?

5 pm on friday you finish your last EGD on a 33 yof with epigastric pain. Propofol wears off. She complains of pain and blurriness in her left eye. Nothing abnormal on gross exam. Everybody including yourself is anxious to go home. Plan?

Horses before zebras. Someone was waving a scope around her face, probably while daydreaming about a new set of titanium golf clubs. Corneal abrasions cause pain and a foreign body sensation, which causes tears, which causes blurry vision. If I could get the patient to blink herself back to normal visual acuity, the pain went away with a drop of tetracaine, and a fluorescein exam showed an abrasion, by all means, I'd squirt some erythromycin goo in there, reassure her, send her home, and call her in the morning. If I think she needs a fundoscopic exam then it's going to be done by someone besides me.

 

[urge]

Horses before zebras. Someone was waving a scope around her face, probably while daydreaming about a new set of titanium golf clubs. Corneal abrasions cause pain and a foreign body sensation, which causes tears, which causes blurry vision. If I could get the patient to blink herself back to normal visual acuity, the pain went away with a drop of tetracaine, and a fluorescein exam showed an abrasion, by all means, I'd squirt some erythromycin goo in there, reassure her, send her home, and call her in the morning. If I think she needs a fundoscopic exam then it's going to be done by someone besides me.

That sounds more reasonable.

Question for residents: how are training programs teaching you to deal with this? Call ophtha? Deal with it? Do eye exam? I'm sure your dept has a policy.

In other words, am I a cowboy or are these guy a bunch of wusses?

 

[Random Anesthesiologist]

That sounds more reasonable.

Question for residents: how are training programs teaching you to deal with this? Call ophtha? Deal with it? Do eye exam? I'm sure your dept has a policy.

In other words, am I a cowboy or are these guy a bunch of wusses?

I can only comment from a surgical perspective at this point 🙁

 

[Dwindlin]

I can only comment from a surgical perspective at this point 🙁

Same here. Actually why I posed the question. It is surprising to me the comments about Wood's lamp isn't always available, I wouldn't think this is hard to find piece of equipment to keep around, its just a black light. Thankfully I had to use one relatively frequently on Trauma, since we evaluated eye complaints before contacting Optho.

 

[Random Anesthesiologist]

Same here. Actually why I posed the question. It is surprising to me the comments about Wood's lamp isn't always available, I wouldn't think this is hard to find piece of equipment to keep around, its just a black light. Thankfully I had to use one relatively frequently on Trauma, since we evaluated eye complaints before contacting Optho.

Personally, I would prefer the slit lamp since you can see more layers.

 

[Planktonmd]

Often times you hear on this site that anesthesiologists are better than crnas because they don't know medicine and it leads to more consultations and delays. Then you hear stuff like above.

Perhaps the learning point of the story is that people in amb surg centers should have an ophthalmoscope available.

Really?
How many surgicenters in your opinion have the equipment for an eye exam?
I actually think the problem in anesthesia is not only CRNAs but it's also people who have their heads in the sand and hiding in academia like yourself.

 

[chmd]

In my first month as an attending I examined a pacu patient w a woods lamp and dye. Then gave abx drops like we did as resident. My partners said they generally just ask optho to see patient if still causing problems next day.

Not sure what happens w outpts

 

[deleted171991]

I actually think the problem in anesthesia is not only CRNAs but it's also people who have their heads in the sand and hiding in academia like yourself.

Big mouth. 😀