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oral board answers that are relatively unrealistic?

TaoistDoc

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    So I've been studying for oral boards, going through stems in rapid review.

    It seems that every case of a relatively difficult airway which I think I can intubate easily with a glidescope, their answer is an awake fiberoptic.

    For every patient with CAD even if stable, their answer includes a preinduction a-line and a central line whereas in real life I usually would do it with just a large bore IV.

    I wonder what the real life oral board is like, whether I should be very conservative in my answers, as in the rapid review book, or if I should say what I would actually do and try to rationalize it to them.
     

    gasdoc77

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      Anesthesia 101. Tell em what they want to hear. First day of the rest of your professional life.
      Example
      "No twitches" -(meanwhile patient has an LMA in and is breathing spontaneously)

      So I've been studying for oral boards, going through stems in rapid review.

      It seems that every case of a relatively difficult airway which I think I can intubate easily with a glidescope, their answer is an awake fiberoptic.

      For every patient with CAD even if stable, their answer includes a preinduction a-line and a central line whereas in real life I usually would do it with just a large bore IV.

      I wonder what the real life oral board is like, whether I should be very conservative in my answers, as in the rapid review book, or if I should say what I would actually do and try to rationalize it to them.
       

      Urzuz

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        Anesthesia 101. Tell em what they want to hear. First day of the rest of your professional life.
        Example
        "No twitches" -(meanwhile patient has an LMA in and is breathing spontaneously)

        Can't quite tell if he's being serious...

        But anyway, I had the privilege of practicing with an actual oral boards senior examiner for around 2 months straight leading up to the exam. The biggest concepts to come to grips with, and the ones that took me a LONG time to get used to, were that: 1) there is not a single correct answer, and as long as what you're doing is safe and justifiable, then it's fine, and 2) you should NOT try to read the oral board examiners' mind. Say what you would ACTUALLY do. Do not go down the rabbit hole of trying to predict the right answer -- you will only confuse yourself, and it'll be apparent because your justifications will be weak, and it's easy to slip up when the examiner asks you something like, "Well, why are you doing an awake FOB when you have a video laryngoscope right next to you?"

        If they ask you how you would secure a moderately difficult airway, say something like: "though this patient's airway is concerning due to him being obese and a Mallampati class 3, his good mouth opening and neck range of motion make me confident in my ability to mask ventilate him. I will have oral airways, nasal airways, and an LMA readily available in the event mask ventilation is difficult. I plan to use a video laryngoscope during intubation, but will have a fiberoptic bronchoscope in the room in case it ends up being challenging." Sure, they may (and probably will) send you down the path of can't intubate/can't ventilate, but that just means you're on the right track.
         
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        fakin' the funk

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          So I've been studying for oral boards, going through stems in rapid review.

          It seems that every case of a relatively difficult airway which I think I can intubate easily with a glidescope, their answer is an awake fiberoptic.

          For every patient with CAD even if stable, their answer includes a preinduction a-line and a central line whereas in real life I usually would do it with just a large bore IV.

          I wonder what the real life oral board is like, whether I should be very conservative in my answers, as in the rapid review book, or if I should say what I would actually do and try to rationalize it to them.

          Assuming that you're not an insane person, which it sounds like you're not, the right answer is WHAT YOU WOULD ACTUALLY DO.

          HOWEVER, you must be prepared to defend why you chose that plan and not another -- either more or less conservative.

          Don't give the answers you think they want to hear, but be ready for them to question and critique your plan regardless. Because if you do say AFOI, they're gonna say "isn't that overkill/unnecessary for this patient?" And now you're stuck defending a plan you don't even like.

          This is a test to show that you have enough knowledge, good judgment, and ADAPTABILITY to be a reasonable anesthesiologist. That doesn't mean you line up everyone with a whiff of vascular disease and it doesn't mean you AFOI everyone with a beard, but as long as you are a reasonable person and can defend your decisions (and state why another plan is inferior in your opinion) you'll do fine.
           
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            You can say what your plan is with the background info as noted above. Lean conservative, but not necessarily ultra conservative. Have a justification as to why you would do what you suggest, why it is a safe plan, and what plan B and C are.
            And of course, no matter what you do, the case will take a turn for the worse and your answer is will turn out wrong, the patient will have an MI or a stroke, etc.
             

            Mman

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              as mentioned above, I believe the right answer to is to say what you would actually do. If they think you are being cavalier, they will ask what you will do if you can't get the intubation or the BP cuff isn't reading or whatever. They may take you down the rabbit hole to the point the patient is dead despite your best efforts and doing everything in a safe manner. That's OK. You just have to be able to explain your reasoning and show that you are practicing safely. Just giving the most conservative answer to every question they ask is not the correct approach.

              Just remember that the patient always dies in the board exam despite you doing everything right (well not always, but that's where they are headed until they lose interest and move on to the next stem). Don't panic when they make it turn out bad, just keep your calm poker face on and explain your plan of attack each step of the way. They will still make the patient die, but they will pass you because you handled it well.


              As an aside if your answer is always to do the awake FOI even in a slam dunk airway, they will make the patient not cooperate with it until you are inducing them anyway.
               

              Arch Guillotti

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                Anesthesia 101. Tell em what they want to hear. First day of the rest of your professional life.
                Example
                "No twitches" -(meanwhile patient has an LMA in and is breathing spontaneously)
                2v3na4l.jpg
                 
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                Arch Guillotti

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                  I think that both of these posts are excellent advice.

                  But anyway, I had the privilege of practicing with an actual oral boards senior examiner for around 2 months straight leading up to the exam. The biggest concepts to come to grips with, and the ones that took me a LONG time to get used to, were that: 1) there is not a single correct answer, and as long as what you're doing is safe and justifiable, then it's fine, and 2) you should NOT try to read the oral board examiners' mind. Say what you would ACTUALLY do. Do not go down the rabbit hole of trying to predict the right answer -- you will only confuse yourself, and it'll be apparent because your justifications will be weak, and it's easy to slip up when the examiner asks you something like, "Well, why are you doing an awake FOB when you have a video laryngoscope right next to you?"

                  If they ask you how you would secure a moderately difficult airway, say something like: "though this patient's airway is concerning due to him being obese and a Mallampati class 3, his good mouth opening and neck range of motion make me confident in my ability to mask ventilate him. I will have oral airways, nasal airways, and an LMA readily available in the event mask ventilation is difficult. I plan to use a video laryngoscope during intubation, but will have a fiberoptic bronchoscope in the room in case it ends up being challenging." Sure, they may (and probably will) send you down the path of can't intubate/can't ventilate, but that just means you're on the right track.

                  Assuming that you're not an insane person, which it sounds like you're not, the right answer is WHAT YOU WOULD ACTUALLY DO.

                  HOWEVER, you must be prepared to defend why you chose that plan and not another -- either more or less conservative.

                  Don't give the answers you think they want to hear, but be ready for them to question and critique your plan regardless. Because if you do say AFOI, they're gonna say "isn't that overkill/unnecessary for this patient?" And now you're stuck defending a plan you don't even like.

                  This is a test to show that you have enough knowledge, good judgment, and ADAPTABILITY to be a reasonable anesthesiologist. That doesn't mean you line up everyone with a whiff of vascular disease and it doesn't mean you AFOI everyone with a beard, but as long as you are a reasonable person and can defend your decisions (and state why another plan is inferior in your opinion) you'll do fine.
                   
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                  Arch Guillotti

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                    Just remember that the patient always dies in the board exam despite you doing everything right (well not always, but that's where they are headed until they lose interest and move on to the next stem). Don't panic when they make it turn out bad, just keep your calm poker face on and explain your plan of attack each step of the way. They will still make the patient die, but they will pass you because you handled it well.

                    I think the patient never dies in the oral board scenario unless you make a kill error.

                    I took a lot of practice tests and I gave a lot too. Nobody ever died.
                     

                    Mman

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                      I think the patient never dies in the oral board scenario unless you make a kill error.

                      I took a lot of practice tests and I gave a lot too. Nobody ever died.

                      Mine all got taken to the point of death and then after I gave my answer/explanation we moved on to the next stem. It was basically a bunch of scenarios, you make a decision and something bad happens, what now? Oh, you fixed that...how about this? Saved from that...what about this? One of my buddies that is an actual examiner almost always kills the patient just to see how the examinee responds as they go down that path. Make 'em sweat and see how they do under pressure.
                       

                      Colba55o

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                        Anesthesia 101. Tell em what they want to hear. First day of the rest of your professional life.
                        Example
                        "No twitches" -(meanwhile patient has an LMA in and is breathing spontaneously)

                        took me a minute to figure this out.
                        Surgeon: Patient is tight, is she still paralyzed?
                        You: Absolutely, she has "no twitches"

                        In residency one of my cohorts pulled this on an attending surgeon who then leaned over drapes, looked down and said "show me..."

                        In response to original poster I would take what people have said here with a grain of salt. Not sure how far you are out of residency, but if you've been in pp for awhile, not sure it's good advice to always say what you would do on the oral boards. This is an exam, not a casual conversation and they may try to make you feel like it is casual as a way to trip you up. Also they will likely ask you about cases that you don't do on a regular basis so you have to be able to think beyond your day to day routines.

                        Of course you will look like an idiot if you line up everyone and AFOI everyone. But just like a written exam, you have to anticipate what they will ask, and what they want to hear you say.
                         
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                        BLADEMDA

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                          So I've been studying for oral boards, going through stems in rapid review.

                          It seems that every case of a relatively difficult airway which I think I can intubate easily with a glidescope, their answer is an awake fiberoptic.

                          For every patient with CAD even if stable, their answer includes a preinduction a-line and a central line whereas in real life I usually would do it with just a large bore IV.

                          I wonder what the real life oral board is like, whether I should be very conservative in my answers, as in the rapid review book, or if I should say what I would actually do and try to rationalize it to them.


                          You are way off here. Let me go through a few cases where the Glidescope failed:

                          1. Tumor of Oropharynx- zero view with the glidescope and instrumentation of airway created a bloody mess. Patient ended up with emergency trach in the OR.

                          2. Glottic edema- Visualization of cords possible but unable to pass ETT. patient got a trach

                          3. Cervical Fusion- Unable to visualize cords, FOI utilized to secure the airway

                          4. Massive Angioedema of the tongue due to ACE inhibitors on a morbidly obese patient- FOI with Precedex, Ketamine, Midazolam

                          Glidescopes have a failure rate of about 5% and you need to keep that in mind when approaching any airway.
                           
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                          BLADEMDA

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                            So I've been studying for oral boards, going through stems in rapid review.

                            It seems that every case of a relatively difficult airway which I think I can intubate easily with a glidescope, their answer is an awake fiberoptic.

                            For every patient with CAD even if stable, their answer includes a preinduction a-line and a central line whereas in real life I usually would do it with just a large bore IV.

                            I wonder what the real life oral board is like, whether I should be very conservative in my answers, as in the rapid review book, or if I should say what I would actually do and try to rationalize it to them.


                            Arterial lines are very important for prompt recognition and treatment of hypotension in the OR. Hypotension kills patients. The advantage of the arterial line over the BP cuff is immediate recognition of hypotension with appropriate treatment as opposed to a ZERO reading on the cuff while the CRNA cycles it several times.

                            Central lines are for vasoactive drugs just as much as for volume.This shows the examiners you are planning ahead for when/if the case starts going badly and you need vasoactive medications.


                            Conclusion: Intraoperative hypotension, but not hypertension, is associated with increased 30-day operative mortality.
                            http://www.ncbi.nlm.nih.gov/pubmed/26083768
                             
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                            TaoistDoc

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                              You are way off here. Let me go through a few cases where the Glidescope failed:

                              1. Tumor of Oropharynx- zero view with the glidescope and instrumentation of airway created a bloody mess. Patient ended up with emergency trach in the OR.

                              2. Glottic edema- Visualization of cords possible but unable to pass ETT. patient got a trach

                              3. Cervical Fusion- Unable to visualize cords, FOI utilized to secure the airway

                              4. Massive Angioedema of the tongue due to ACE inhibitors on a morbidly obese patient- FOI with Precedex, Ketamine, Midazolam

                              Glidescopes have a failure rate of about 5% and you need to keep that in mind when approaching any airway.

                              With all due respect, I don't think I am way off. I understand that there are situations in which AFOI is warranted and situations in which A lines are waranted. I agree that most of the situations you described above warrants an AFOI. But I am talking about commonly encountered cases of relatively difficult airway, such as patient with MP3-4 or those with limited neck ROM but otherwise you are confident that you can intubate easily with a fiberoptic laryngoscope such as a glidescope. I encounter these cases almost everyday in practice and rarely use AFOI for them. Yeah, I'm a new atending. But I work with a bunch of seasoned anesthesiologist who practice the same way.

                              Also true about A line detecting hypotension quickly. But again, I encouter patients with moderate CAD everyday undergoing moderate surgical procedures and I don't put A line in all of them.

                              If what I'm doing is cowboyish, then I believe a large proportion of anesthesiologist out ther are cowboys too then. Just Saying
                               

                              Mman

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                                But I am talking about commonly encountered cases of relatively difficult airway, such as patient with MP3-4 or those with limited neck ROM but otherwise you are confident that you can intubate easily with a fiberoptic laryngoscope such as a glidescope. I encounter these cases almost everyday in practice and rarely use AFOI for them. Yeah, I'm a new atending. But I work with a bunch of seasoned anesthesiologist who practice the same way.

                                I estimate my personal incidence of glidescope failure when I think that's all we will need beyond a regular laryngoscope at well under 1%. Maybe 0.1-0.3%.

                                And no, oral board examiners won't fail you for telling them what you'd do with an airway so long as you can articulate your plan for how to proceed if you fail with your initial attempt. They just want to know that you can both proceed in the correct manner as well as explain it clearly and succinctly.
                                 

                                pjl

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                                  I didn't awake fiberoptic any of my board patients, and those words were never mentioned during my exam. In fact, they must have thought I looked really good at airways as I never struggled with one on my exam.

                                  I was, on the other hand, a lot more prone to placement of awake arterial lines for cases than I am in "real" life :)
                                   
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                                  BLADEMDA

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                                    With all due respect, I don't think I am way off. I understand that there are situations in which AFOI is warranted and situations in which A lines are waranted. I agree that most of the situations you described above warrants an AFOI. But I am talking about commonly encountered cases of relatively difficult airway, such as patient with MP3-4 or those with limited neck ROM but otherwise you are confident that you can intubate easily with a fiberoptic laryngoscope such as a glidescope. I encounter these cases almost everyday in practice and rarely use AFOI for them. Yeah, I'm a new atending. But I work with a bunch of seasoned anesthesiologist who practice the same way.

                                    Also true about A line detecting hypotension quickly. But again, I encouter patients with moderate CAD everyday undergoing moderate surgical procedures and I don't put A line in all of them.

                                    If what I'm doing is cowboyish, then I believe a large proportion of anesthesiologist out ther are cowboys too then. Just Saying


                                    Yes. Unfortunately, a lot of Anesthesiologists in PP are cowboys but they get away with it most of the time. The problem is that many Oral Board Examiners want to you elucidate a high standard of care in the cases they present and not do what many "get away with" on a routine basis.

                                    You haven't been around long enough to see what happens that 1-2% of the time when your "seasoned anesthesiologist's plan" goes to ****. The Oral Board exam is about making sure you are safe to deal with those 1-2% of cases encountered from time to time.

                                    If you want to pass the exam be "conservative" in your approach and show respect for the underlying physiology of your patient.

                                    FYI, I use the Glidescope about 3-4 per times each day and have been doing that since your Med School days (most likely earlier). Of course, the Glidescope is successful for MP3-MP4 airways most of the time but the Oral exam is about showing you are safe in all situations. Leave the 6 shooter at home when you take the Oral exam and be conservative in your approach like your mother's life depended on it.
                                     
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                                    BLADEMDA

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                                      I estimate my personal incidence of glidescope failure when I think that's all we will need beyond a regular laryngoscope at well under 1%. Maybe 0.1-0.3%.

                                      And no, oral board examiners won't fail you for telling them what you'd do with an airway so long as you can articulate your plan for how to proceed if you fail with your initial attempt. They just want to know that you can both proceed in the correct manner as well as explain it clearly and succinctly.


                                      Your failure rate is "low" because you are counting all-comers in your numbers. If you select for only difficult airways, abnormal anatomy, Tumor, etc the failure rate is much higher.
                                       

                                      BLADEMDA

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                                        http://felipeairway.sites.medinfo.ufl.edu/files/2009/06/Glidescope-2010.pdf

                                        The Failure rate of the Glidescope for those patients who could not be intubated via Direct laryngoscopy was 6% in this study. Note that MP score was not associated with success or failure for intubation with the Glidescope.

                                        The strongest predictor of Glidescope failure was altered neck anatomy with presence of a surgical scar, radiation changes, or mass.
                                         
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                                        Urzuz

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                                          Your failure rate is "low" because you are counting all-comers in your numbers. If you select for only difficult airways, abnormal anatomy, Tumor, etc the failure rate is much higher.

                                          Something I have been noticing is that the incidence of "difficult airways" requiring Glidescope intubation have spiked since Glidescopes became available. For instance, just last night I had an emergency case. The patient and her family had been told by the anesthesiologist two days ago that she was a difficult airway and needed "special tools" to secure her airway. Sure enough, I look in the chart and she was charted as having a grade IV view, but easy with the Glidescope. She needed an RSI for the case last night so I went with my trusty Miller 2...and guess what? Grade I. I don't consider myself by any stretch of the imagination to have extraordinary airway skills...in fact, I would say I am average. But how the hell can she be a grade four view for him, and a grade one for me? He even used a Miller blade as well.

                                          For better or for worse, Glidescopes have become mainstays in our practice. Some of my partners will use Glidescopes for every intubation regardless of how easy the patient's airway looks. And, for others that do happen to try direct laryngoscopy, they will call for the Glidescope at any sign that the airway will be less than a grade 1 view right off the bat. Tools and skills that are now antiquated in many peoples' practice include: bougies, repositioning the head, trying a different blade, and god forbid the asleep fiberoptic. In fact, I used a bougie a few months back and the scrub tech and circulator asked me what it was since they had never seen it before. Is this good or bad? I don't really know. On one side I wouldn't want my airway skills to atrophy since a Glidescope can't always save you (eg: patient is vomiting, Glidescope isn't going to do jack ****), but on the other side, as long as you get the tube in safely and the patient does well, who am I to judge?
                                           
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                                          BLADEMDA

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                                            Something I have been noticing is that the incidence of "difficult airways" requiring Glidescope intubation have spiked since Glidescopes became available. For instance, just last night I had an emergency case. The patient and her family had been told by the anesthesiologist two days ago that she was a difficult airway and needed "special tools" to secure her airway. Sure enough, I look in the chart and she was charted as having a grade IV view, but easy with the Glidescope. She needed an RSI for the case last night so I went with my trusty Miller 2...and guess what? Grade I. I don't consider myself by any stretch of the imagination to have extraordinary airway skills...in fact, I would say I am average. But how the hell can she be a grade four view for him, and a grade one for me? He even used a Miller blade as well.

                                            For better or for worse, Glidescopes have become mainstays in our practice. Some of my partners will use Glidescopes for every intubation regardless of how easy the patient's airway looks. And at any sign that the airway will be less than a grade 1 view right off the bat, they'll request the Glidescope be brought in. Tools and skills that are now antiquated in many peoples' practice include: bougies, repositioning the head, trying a different blade, and god forbid the asleep fiberoptic. In fact, I used a bougie a few months back and the scrub tech and circulator asked me what it was since they had never seen it before. Is this good or bad? I don't really know. On one side I wouldn't want my airway skills to atrophy since a Glidescope can't always save you (eg: patient is vomiting, Glidescope isn't going to do jack ****), but on the other side, as long as you get the tube in safely and the patient does well, who am I to judge?


                                            We agree on this. The problem with labeling someone a "difficult airway" is what do you do with that patient who prefers surgery at the local ASC? Many ASCs don't gave Glidescopes so that patient should not be permitted to undergo elective surgery at the ASC. I think many newer attendings (last 5-7 years) had the luxury of the Glidescope which the previous generations did not. We had to develop skills in difficult airway management like bougies, retrogrades, asleep FOI etc.

                                            Again, if the tube goes in safely who am I to judge? but, labeling a patient "difficult airway" does have consequences for that person.
                                             

                                            Mman

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                                              Your failure rate is "low" because you are counting all-comers in your numbers. If you select for only difficult airways, abnormal anatomy, Tumor, etc the failure rate is much higher.

                                              The failure rate is always dependent on how you define the denominator. If I define the failure rate as tracheal stenosis with a 10 cm mass on their carina, loud stridor, and a sat in the 80s and falling, the failure rate of any approach from above will be 100%.

                                              I'm defining it as a MP 3 or 4 airway that looks like it'd be at least moderately difficult with a blade for whatever reason (small mouth, mass in airway, hx of radiation, etc).
                                               

                                              Colba55o

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                                                With all due respect, I don't think I am way off. I understand that there are situations in which AFOI is warranted and situations in which A lines are waranted. I agree that most of the situations you described above warrants an AFOI. But I am talking about commonly encountered cases of relatively difficult airway, such as patient with MP3-4 or those with limited neck ROM but otherwise you are confident that you can intubate easily with a fiberoptic laryngoscope such as a glidescope. I encounter these cases almost everyday in practice and rarely use AFOI for them. Yeah, I'm a new atending. But I work with a bunch of seasoned anesthesiologist who practice the same way.

                                                Also true about A line detecting hypotension quickly. But again, I encouter patients with moderate CAD everyday undergoing moderate surgical procedures and I don't put A line in all of them.

                                                If what I'm doing is cowboyish, then I believe a large proportion of anesthesiologist out ther are cowboys too then. Just Saying

                                                jason I think you are being unnecessarily defensive...the oral boards really are not like real life. You don't encounter these drastically different complex cases in rapid succession on a day to day basis in real life. You are probably a safe rational practitioner but the boards are expensive and it sucks to fail them. Just play the game, bite the bullet and tell your examiner what you would do if you were being extra conservative.
                                                If they give you a patient with a lousy airway and limited ROM say you would do an AFOI. If the examiner feels that is overkill, they can easily tell you patient refuses, is altered, is a kid, etc then you can pick another backup plan, but chances are if they make a point of emphasizing the patients questionable airway, on their checklist they are looking for airway management proficiency and arent going to let you get away with a RSI with a Miller 2.
                                                 
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                                                pjl

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                                                  We agree on this. The problem with labeling someone a "difficult airway" is what do you do with that patient who prefers surgery at the local ASC? Many ASCs don't gave Glidescopes so that patient should not be permitted to undergo elective surgery at the ASC. I think many newer attendings (last 5-7 years) had the luxury of the Glidescope which the previous generations did not. We had to develop skills in difficult airway management like bougies, retrogrades, asleep FOI etc.

                                                  Again, if the tube goes in safely who am I to judge? but, labeling a patient "difficult airway" does have consequences for that person.

                                                  They are getting pretty cheap, I understand minimizing equipment at a ASC, but the benefits of having a video scope far outweigh the 2-3 grand (or less) to get one.
                                                   
                                                  Nov 24, 2007
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                                                  1. Attending Physician
                                                    We agree on this. The problem with labeling someone a "difficult airway" is what do you do with that patient who prefers surgery at the local ASC? Many ASCs don't gave Glidescopes so that patient should not be permitted to undergo elective surgery at the ASC. I think many newer attendings (last 5-7 years) had the luxury of the Glidescope which the previous generations did not. We had to develop skills in difficult airway management like bougies, retrogrades, asleep FOI etc.

                                                    Again, if the tube goes in safely who am I to judge? but, labeling a patient "difficult airway" does have consequences for that person.
                                                    This is one of the reasons I'm coming around to the Cmac video laryngoscopes. We have many kids with abnormal anatomy come in with the difficult airway label from an OSH that look like they can be intubated to me. If you use the cmac, you can use it like a regular blade and determine if they are difficult or not. Previously it was common to DL after the glidescope, but with the tube in place, it's not the same.
                                                     

                                                    BLADEMDA

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                                                    1. Attending Physician
                                                      They are getting pretty cheap, I understand minimizing equipment at a ASC, but the benefits of having a video scope far outweigh the 2-3 grand (or less) to get one.

                                                      I'm not sure that I would want a patient with a known difficult airway scheduled at the ASC unless I had the old records available for review. An ASC is not the place to find out that the Anesthesiologist needed the FIberoptic scope plus the Glidescope to intubate the patient.

                                                      Of course, if the anesthesia record is clear that the patient had a grade 1 or 2 view with the Glidescope and the ASC had one available I would do the case there.
                                                       
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