Patient dumped in the PACU

[EternalMD]

Now I am still a medical student so I don't know what would constitute the proper hand over of a patient in the PACU but the following case had me a little disturbed about the care provided for the patient. Preface: This is not a CRNA base as most of the ones i've encountered were pretty nice and seemed to know what they were doing. This particular one was the complete opposite

22 y/o obese (350lber) female having molar extraction in OR (i guess they had a hard time trying to do it in the clinic because she wasn't very compliant? i forget the exact reasoning but it was valid). Surgery went fine but the patient was either in distress or agitated when she awoke on the table taking off her BP cuff and complaining about pain/trouble breathing. They managed to move her over to the stretcher but she was in the prone position - the CRNA said she was fine because she can cough out the blood? anyways, the patient was then transported with minimal monitors, agitated, complaining of pain/breathing problems, and prone in the stretcher. It's the first time that I've ever seen a patient taken in this position but what do I know - it was only the 3rd week into my rotation.

CRNA wheels the patient in, starts doing her paperwork, gives a quick overview of what happened. The nurses ask for some meds to manage the patient - (patient still reporting pain and trouble breathing but O2 sats are 99%) where she replies, she got 150mcg fentanyl (1.5hrs ago) and 2mg versed (1/2hr ago). The nurses are struggling to put on the ekg leads, can't get the BP cuff on because shes moving all over the place. Eventually they get some leads on and the CRNA gets her info and just walks away. By this time, the patient is sitting on the edge of the bed with one leg caught in the side rail and im afraid that shes going to tip over. We try to get her to come back to the head of the bed but shes non-compliant. eventually i just tell her that she can still sit up at the head, we'll just move the head of the bed up. Still c/o of breathing problems with O2 sats 99%. I tell her we'll get her oxygen and see how her breathing is but she needs to move back. We eventually manage to get her back and she calms down a bit. The nurse looks for orders for pain meds and asks if she can get Tramadol. I remembered the surgical resident saying she could get it so i confirmed it for them. After that, i couldnt really do anything else so i said thanks and just left but i was pretty annoyed that it seemed as if the patient was dumped while complaining of pain/breathing problems. I didnt know what else i could do.

So any thoughts as to whether I'm just a naive medical student and the CRNA did the right thing or should she have stuck around and made sure the patient was okay?

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[Tenesma]

uhhh.... you are a medical student... shouldn't there be a physician supervising you? shouldn't that physician have played a bit of smack down w/ the CRNA while expertly fixing the patient's issues???

 

[Gas]

I never walk away from the patient in the PACU if they have breathing problems. That is kind of what we are there for. Even if it delays the next case in the OR by a few minutes, our surgeons appreciate the fact that we tuck the patient in PACU first. Or I will sign out the patient to a partner.

In this case, even though the sats were good, these obese patients sometimes become hypercarbic, which would be high on my differential given her agitiation/confusion. Of course this could just be post-op delirium, but you have to at least stick around and ensure the patient's vitals are stable. Sounds like they did not even have a BP confirmed. In this case, the CRNA should have stuck around, or called an anesthesiologist, not necessarily for help, but just to tell someone to keep an eye on this patient in the PACU. Something like "this patient didn't have the smoothest wake-up, probably nothing, but please just come take a look at her."

Regardless of whether it was a CRNA or MD that brought the patient to the PACU, they should stick around for at least vitals and assuring HD stability.

 

[dfk]

prone position recovery for a molar extraction?
wouldn't this create a worsening control of blood loss r/t gravity and the like?
and also a decreased FRC in this not-so-slim of a patient?
why not supine with HOB up to facilitate breathing?

 

[militarymd]

some patients are just like that.


you know...you can't shine sh it.

 

[militarymd]

If the patient wasn't compliant with a tooth extraction without mind altering drugs....

what makes you think they're going to be compliant after a GA?


in summary ...not enough info given despite a long post.

patient sounds fine to me.

 

[morpheus md]

If the patient wasn't compliant with a tooth extraction without mind altering drugs....

what makes you think they're going to be compliant after a GA?


in summary ...not enough info given despite a long post.

patient sounds fine to me.

Walking away from inadequate pain control and emergence delerium to the point of nearly falling off or tipping over the bed is OK? That wouldn't really fly in my PACU...if a resident pulled that crap of walking away without tending the patient in the immediate post-op period at my program they would be burned by their attending and rightfully so. Maybe a CRNA can get away with that if they are so inclined, I don't know.

 

[EternalMD]

The resident that started the procedure had to get going to lecture and I have no idea why the attending wasnt around. The CRNA took over the procedure half way through and usually both the CRNA and upper level residents take patients to recovery without direct supervision and handle all the post-op hoopla so I usually am not the primary individual responsible. In this situation, I noticed that both the surgical resident and CRNA left abruptly with the only responses being "she already got 2mg versed and 150mcg fentanyl 1.5hrs ago" so I decided to stick around and see if I could help the nurses with anything.

Also, the patient I suppose "sounds fine" but my post was more about taking a patient prone s/p molar extraction to recovery, leaving an obese patient at the edge of the bed agitated (with my fear of the bed toppling over), complaining of pain/breathing difficulty and/or agitation. The nurses themselves wanted to know if something could have been given to the patient but the CRNA just didn't feel it was necessary. It just didn't seem like the proper thing to do regardless of whether the patient was expected to be an agitated individual or not.

 

[militarymd]

Walking away from inadequate pain control and emergence delerium to the point of nearly falling off or tipping over the bed is OK? That wouldn't really fly in my PACU...if a resident pulled that crap of walking away without tending the patient in the immediate post-op period at my program they would be burned by their attending and rightfully so. Maybe a CRNA can get away with that if they are so inclined, I don't know.

You own a PACU?

Like I said...not enough info.

1) hemodynamically stable.
2) oxygenating fine


The other stuff...who knows...as for being prone...

Nothing wrong with prone positioning in a spontaneously ventilating patient. Actually a good position for patients with OSA and/or secretions.

And I don't involve myself in restraining and positioning patients...that's what attendants and nurses do.

I'm not going to hurt my back or other extremities over something someone else should do.

Do you know how much $$$ I would lose if I couldn't work because I herniate a disc muscling a patient around.....sorry not for me.

 

[militarymd]

Walking away from inadequate pain control and emergence delerium to the point of nearly falling off or tipping over the bed is OK? That wouldn't really fly in my PACU...if a resident pulled that crap of walking away without tending the patient in the immediate post-op period at my program they would be burned by their attending and rightfully so. Maybe a CRNA can get away with that if they are so inclined, I don't know.

how is your physical presence going to change any of that...other than allowing you to pat yourself on your back about how good a job you're doing???

Why do patients go to the PACU? so that they can have their pain treated before they go to phase 2 recovery or the ward.

How do you treat emergence delirium?

1) time
2) sedation
3) centrally acting cholinergics.

All of which does not require your physical presence...you write orders and walk away....and in PP...you give a verbal over the phone.

 

[Arch Guillotti]

And I don't involve myself in restraining and positioning patients...that's what attendants and nurses do.

So you have an ORCA who is sitting up on the side of the bed, delirious and about to tip the stretcher over possibly injuring herself and others, yet you just stand around and do nothing?

 

[militarymd]

So you have an ORCA who is sitting up on the side of the bed, delirious and about to tip the stretcher over possibly injuring herself and others, yet you just stand around and do nothing?

did I stutter?

 

[DwightKShrute]

did I stutter?

 

[jennyboo]

You didn't say if this was a MAC or a general anesthetic (I'm guessing MAC because the last dose of Versed came after the last dose of narcotic).

Either way, it's just a tooth extraction and I'm guessing the patient is probably going home, so she did not need any long-acting IV narcotic -- the fentanyl is gone if it was given 90 minutes ago. An oral agent (tramadol, Percocet, just plain acetaminophen or NSAID etc) would be appropriate now. I wouldn't have given any more IV narcotic.

Other issues to consider with more narcotics: She's a morbidly obese young female patient. You cause more respiratory depression in a person who might have sleep apnea and a questionable airway. You end up with more sedation, possibly increasing post-op nausea, and possibly increasing her PACU stay.

Transporting the patient prone to the PACU is, to my mind, unusual and a little weird. I'd have done it in lateral decubitus or sitting up. The disadvantage of supine position is that the airway tends to collapse in patients with obstructive sleep apnea and if they vomit it's the least favorable position. However, if patient is prone (which I've never seen intentionally done) you cannot access the airway without turning her over.

Most likely the patient has either delirium (after GA) or is baseline crazy and now disinhibited (after MAC). This always makes a PACU nurse mad but it's the patient, not the anesthetist's fault. Sometimes you can't get a delirious patient to take the position you want, or keep themselves covered for the trip to the PACU. The PACU RN will give you attitude for that, but screw that -- it's also not right for the PACU nurses to expect everyone to come in obtunded (which is often exactly what they want).

As for the shortness of breath -- I'd slap on the monitors when arriving in the PACU, and do a physical exam (i.e. watch the speed of respirations, look for accessory muscle use, listen with a stethoscope to elicit true respiratory compromise from a psychogenic complaint). I agree with Mil, it sounds like she was really OK.

 

[coprolalia]

Pulmonary embolism? Reactive airway/bronchospasm? Hypoxemia despite adequate SpO2 (#1 reason for agitation in the PACU)? Anyone? Did anyone there think of some differentials?

I would have, at the very least, listened to her chest and ordered a neb.

-copro

 

[Monty Python]

22 y/o obese (350lber) female having molar extraction in OR ... Surgery went fine but the patient was either in distress or agitated when she awoke on the table taking off her BP cuff and complaining about pain/trouble breathing.

1. I usually insert bilateral nasal trumpets in morbidly obese pts prior to waking them up. Seems to help ward off post-extubation breathing problems and if they have the strength to pull them out -- hey great.

2. Was she getting hypercarbic early?


They managed to move her over to the stretcher but she was in the prone position - the CRNA said she was fine because she can cough out the blood? anyways, the patient was then transported with minimal monitors, agitated, complaining of pain/breathing problems, and prone in the stretcher.

Questions to ponder: Was the socket actively bleeding? Could the CRNA manage a prone obtunded airway? Was the pt psychosomatic, or really suffering resp problems -- did you catch her resp rate?

CRNA wheels the patient in, starts doing her paperwork, gives a quick overview of what happened. The nurses ask for some meds to manage the patient - (patient still reporting pain and trouble breathing but O2 sats are 99%) was that room air sat or with supplemental oxygen? where she replies, she got 150mcg fentanyl (1.5hrs ago) and 2mg versed (1/2hr ago). The nurses are struggling to put on the ekg leads, can't get the BP cuff on because shes moving all over the place. Wonderful --- she's restless and they're off chasing vital signs which are tertiary in importance right then. Why not stabilize her resp and oxygenation status first, then check a 22 y/o's EKG and BP. Restlessness can be a symptom of hypoxia. Eventually they get some leads on and the CRNA gets her info and just walks away. By this time, the patient is sitting on the edge of the bed with one leg caught in the side rail and im afraid that shes going to tip over. We try to get her to come back to the head of the bed but shes non-compliant. eventually i just tell her that she can still sit up at the head, we'll just move the head of the bed up. Still c/o of breathing problems with O2 sats 99%. I tell her we'll get her oxygen and see how her breathing is but she needs to move back. We eventually manage to get her back and she calms down a bit. The nurse looks for orders for pain meds and asks if she can get Tramadol. I remembered the surgical resident saying she could get it so i confirmed it for them. After that, i couldnt really do anything else so i said thanks and just left but i was pretty annoyed that it seemed as if the patient was dumped while complaining of pain/breathing problems. I didnt know what else i could do.

So any thoughts as to whether I'm just a naive medical student and the CRNA did the right thing or should she have stuck around and made sure the patient was okay?

.

 

[Gern Blansten]

Sounds like a non compliant, uncooperative, obese patient that doesn't want to do anything that you want them to do. It happens and you just do the best you can. It is up to the provider to be able to tell when someone is really in trouble. It doesn't sound like she was. Perhaps the CRNA could have been a little more touchy feely, but what good would that have done? It would not make the patient suddenly cooperative. I agree with MMD on this one. Based on the info given, it is just an uncooperative patient. It happens. It doesn't always go as smooth as you would like it to, but you learn to deal with it.

If she needed restraining to keep her from hurting herself, I would assist until the situation was under control.

 

[EternalMD]

Just to answer a few questions:

- Procedure was GA (you are correct as to dosage of versed after last narcotic but it was not MAC)
- I don't recall whether she was hypercarbic or not
- no active bleeding, i doubt the anesthetist could have gotten to the airway if needed and I don't know how they could have rolled her over on the stretcher if required due to her size. I believe the symptoms could have been psychosomatic but with a patient c/o of breathing difficulty, at least it should have been checked out. Unfortunately, I did not get the RR
- 99% on RA which is why i just told her that we'd give her oxygen if she came back on the bed -- didn't appear to need it but wouldnt have hurt giving it if it calmed her down a little.
- The nurses were were trying to calm her down and simultaneously trying to get monitors on, no specific priority given to just monitors.


Most people seem to agree that its possible she was just a difficult patient however still would go the extra step to make sure she was okay in case she really was in respiratory distress or just delirious. I suppose thats all I wanted to make sure. I mean I've seen some odd ways of handing off patients. Last year I saw a senior attending at a PP hospital give a small touch of propofol to the patient prior to transporting her to the PACU because he said she was an @$$hole and didn't want to deal with her awake.

 

[Monty Python]

...... Last year I saw a senior attending at a PP hospital give a small touch of propofol to the patient prior to transporting her to the PACU because he said she was an @$$hole and didn't want to deal with her awake.

A PhD physiologist told me that the last cranial nerve to be affected by anesthesia was the auditory, and it was the first to recover from anesthesia.
Be VERY CAREFUL what you say in the OR, even if the pt's apparently completely under general anesthesia with a BIS reading in the single digits.

Appreciate your answers to the previous questions.

.

 

[EternalMD]

Thanks for the advice. I have not heard that before but definitely a point worth noting.

 

[leviathan]

Forgetting the fact that pulse oximetry is highly inaccurate, a good SpO2 reading does not mean your patient is oxygenating well, or ventilating well for that matter. (Ventilation and oxygenation are not the same process). Arterial oxygen content is determined by hemoglobin concentration, partial pressure of oxygen, and of course SpO2 (the only value you know). What was her respiratory rate, what was her Hb, pH, PaO2, PaCO2, blood pressure, how did her lungs sound, etc? Obviously you are not going to be drawing ABGs and invasive monitoring on an otherwise healthy 22 y/o at the blink of an eye because she cries that she can't breath, but remember to treat your patient and not a singular vital sign number. If a patient is telling you they can't breathe, the SpO2 reading only rules out a small fraction of the differential for dyspnea. The most important thing of all is what the patient looks like, and remember to treat the patient, not the number. (Cliche, I know ).

 

[militarymd]

Just to answer a few questions:

- Procedure was GA (you are correct as to dosage of versed after last narcotic but it was not MAC)
- I don't recall whether she was hypercarbic or not
- no active bleeding, i doubt the anesthetist could have gotten to the airway if needed and I don't know how they could have rolled her over on the stretcher if required due to her size. I believe the symptoms could have been psychosomatic but with a patient c/o of breathing difficulty, at least it should have been checked out. Unfortunately, I did not get the RR
- 99% on RA which is why i just told her that we'd give her oxygen if she came back on the bed -- didn't appear to need it but wouldnt have hurt giving it if it calmed her down a little.
- The nurses were were trying to calm her down and simultaneously trying to get monitors on, no specific priority given to just monitors.


Most people seem to agree that its possible she was just a difficult patient however still would go the extra step to make sure she was okay in case she really was in respiratory distress or just delirious. I suppose thats all I wanted to make sure. I mean I've seen some odd ways of handing off patients. Last year I saw a senior attending at a PP hospital give a small touch of propofol to the patient prior to transporting her to the PACU because he said she was an @$$hole and didn't want to deal with her awake.

Forgetting the fact that pulse oximetry is highly inaccurate, a good SpO2 reading does not mean your patient is oxygenating well, or ventilating well for that matter. (Ventilation and oxygenation are not the same process). Arterial oxygen content is determined by hemoglobin concentration, partial pressure of oxygen, and of course SpO2 (the only value you know). What was her respiratory rate, what was her Hb, pH, PaO2, PaCO2, blood pressure, how did her lungs sound, etc? Obviously you are not going to be drawing ABGs and invasive monitoring on an otherwise healthy 22 y/o at the blink of an eye because she cries that she can't breath, but remember to treat your patient and not a singular vital sign number. If a patient is telling you they can't breathe, the SpO2 reading only rules out a small fraction of the differential for dyspnea. The most important thing of all is what the patient looks like, and remember to treat the patient, not the number. (Cliche, I know ).

so did the patient survive?...did she go home?

Were the PACU nurses pissed?

Most of the staff involved probably are used to this...and KNEW that the patient was fine.

Monitors don't fix things...interventions do...and that's probably why there was no priority in getting the monitors on.

The PACU nurses who focus on getting the monitors on first drive me bonkers.

I want to see supplemental oxygen going on the patient FIRST (when feasible) before ANY monitors get onto the patient.

 

[coprolalia]

- 99% on RA which is why i just told her that we'd give her oxygen if she came back on the bed -- didn't appear to need it but wouldnt have hurt giving it if it calmed her down a little.

My experience with masks and/or nasal cannulas on uncooperative patients has not been stellar. Usually I find it just pisses them off more.

-copro

 

[Arch Guillotti]

did I stutter?

I am sure that your feeble attempt at an insult makes you feel good about yourself but the reality is that there are alot of us out here who aren't so self-serving that we stand around and do nothing while a patient struggles. Not all of us are scared to hurt our backs or extremities while helping a patient.

 

[militarymd]

I am sure that your feeble attempt at an insult makes you feel good about yourself but the reality is that there are alot of us out here who aren't so self-serving that we stand around and do nothing while a patient struggles. Not all of us are scared to hurt our backs or extremities while helping a patient.

Which disability policy do you have?

My 2 individual policies combined pays less than $14,000 a month , so yes I'm scared to hurt my back over some ORCA who should have known better than to develop biscuit poisoning.

Can I have the name of your disability insurance agent?

 

[bne_12mne]

So what would happen if the patient falls in front of you, gets hurt, and sues. Seems like that situation would involve a different insurance carrier.

Just curious, because that happened in my town at another institution within the last year. It was in the OR from a Jackson table, but still, I think the same concerns apply....

I too am concerned about my back, but it's probably not the first thought on my mind. I'd be helping, though certainly within my physical limits...

Oh, and I agree about the O2 before monitors...

BNE

 

[militarymd]

ahh choices....


1) patient gets hurt and sues you...IF....they win..your malpractice carrier pays up...life goes on.

2) YOU get hurt...and go on permanent disability....praying that your DI companies doesn't go belly up or deny your claim....in which case you're f uck ed.


You can pick option 2 if you choose....I pick option 1....I have good lawyers.

So what would happen if the patient falls in front of you, gets hurt, and sues. Seems like that situation would involve a different insurance carrier.

Just curious, because that happened in my town at another institution within the last year. It was in the OR from a Jackson table, but still, I think the same concerns apply....

I too am concerned about my back, but it's probably not the first thought on my mind. I'd be helping, though certainly within my physical limits...

Oh, and I agree about the O2 before monitors...

BNE

 

[dfk]

So what would happen if the patient falls in front of you, gets hurt, and sues. Seems like that situation would involve a different insurance carrier.

Just curious, because that happened in my town at another institution within the last year. It was in the OR from a Jackson table, but still, I think the same concerns apply....

I too am concerned about my back, but it's probably not the first thought on my mind. I'd be helping, though certainly within my physical limits...

Oh, and I agree about the O2 before monitors...

BNE

it's my understanding that with the jackson table issue, the entire OR room would be liable.
as for in the PACU, not sure.

 

[fakin' the funk]

Forgetting the fact that pulse oximetry is highly inaccurate, a good SpO2 reading does not mean your patient is oxygenating well, or ventilating well for that matter. (Ventilation and oxygenation are not the same process). Arterial oxygen content is determined by hemoglobin concentration, partial pressure of oxygen, and of course SpO2 (the only value you know). What was her respiratory rate, what was her Hb, pH, PaO2, PaCO2, blood pressure, how did her lungs sound, etc? Obviously you are not going to be drawing ABGs and invasive monitoring on an otherwise healthy 22 y/o at the blink of an eye because she cries that she can't breath, but remember to treat your patient and not a singular vital sign number. If a patient is telling you they can't breathe, the SpO2 reading only rules out a small fraction of the differential for dyspnea. The most important thing of all is what the patient looks like, and remember to treat the patient, not the number.

I realize the OP is a little green, but man, seems like you're well on your way to being a bow-tie wearing snob of a professor/attending.

 

[bne_12mne]

Yes, the whole OR was liable. The orthopods and the anesthesia resident in particular. I'll try to find the article...

Mil, good points, but I'm not quite as calculating "in the moment." So do you help move the ORCA's in the OR? As residents, we seem to have no choice when there isn't much lifting help around.

BNE.

 

[aphistis]

Why was the patient prone after routine oral surgery? Same as any other procedure, you don't just wheel the patient out the door actively bleeding. There should've been some gauze packs or something holding pressure over the sites and keeping her mouth open. If there's enough bleeding to be coughing blood out, the dentist/OMS needed to find and stop it before the case was properly finished.

That whole sequence seems a little strange at face value.

 

[dfk]

Why was the patient prone after routine oral surgery? Same as any other procedure, you don't just wheel the patient out the door actively bleeding. There should've been some gauze packs or something holding pressure over the sites and keeping her mouth open. If there's enough bleeding to be coughing blood out, the dentist/OMS needed to find and stop it before the case was properly finished.

That whole sequence seems a little strange at face value.

agree with bold.
however, i'm not sure you wanna pack the mouth in someone who is not only recovering from anesthesia, but also "having difficulty breathing"...
not my first choice.

 

[EternalMD]

Well the CRNA was managing the patient so far be it for me to question her management. The patient wasn't actively bleeding but she just said the position was good so she could cough out blood if needed - that was her reasoning. It just seemed like the anesthetist didnt want to deal with her anymore and just said "f it, lemme leave her prone".

 

[leviathan]

I realize the OP is a little green, but man, seems like you're well on your way to being a bow-tie wearing snob of a professor/attending.

What about my advice seemed snobby or condescending?

 

[dhb]

patient still reporting pain and trouble breathing but O2 sats are 99%) where she replies, she got 150mcg fentanyl (1.5hrs ago) and 2mg versed (1/2hr ago).

How hard can this be? 150mcg of fent isn't going to cut it after 1.5h. Please cut the hypoxia hypercarbia crap has anybody ever seen this? I haven't.. (watcha gonna do get an arterial sample on an agitated patient???)
Control pain done deal, and if you want to knock her out hit her with some K.

 

[DrRobert]

How do you treat emergence delirium?

1) time
2) sedation
3) centrally acting cholinergics.

So you give pilocarpine for emergence delirium?

 

[thegasman]

So you give pilocarpine for emergence delirium?

he probably means physostigmine (centrally acting cholinesterase inhibitor increases acetylcholine)

 

[thegasman]

This whole case sounds like a bunch of nonsense. Big fat uncooperative lady won't lay still. Give her some pain meds if she needs them and let the nurses hold her hand/reassure and do their job. If you really just can't get her to settle down a little bolus of dexmedetomidine might do the trick.

 

[dfk]

This whole case sounds like a bunch of nonsense. Big fat uncooperative lady won't lay still. Give her some pain meds if she needs them and let the nurses hold her hand/reassure and do their job. If you really just can't get her to settle down a little bolus of dexmedetomidine might do the trick.

that's quite an expensive "little bolus" there.
i don't know about your facility,
but our Rx won't let us walk around
with a multi-dose bag of dex. in our back pockets.
sure would be nice tho'!

 

[thegasman]

that's quite an expensive "little bolus" there.
i don't know about your facility,
but our Rx won't let us walk around
with a multi-dose bag of dex. in our back pockets.
sure would be nice tho'!

agree - we don't even have it available at my pp gig - but when I was in training I used it all the time. It is good stuff

 

[militarymd]

So you give pilocarpine for emergence delirium?

that is a Direct Acting Peripheral Cholinergic agent.

I was referring to InDirect Acting Central Cholinergic agent.

 

[sleepyone]

ahh choices....


1) patient gets hurt and sues you...IF....they win..your malpractice carrier pays up...life goes on.

2) YOU get hurt...and go on permanent disability....praying that your DI companies doesn't go belly up or deny your claim....in which case you're f uck ed.


You can pick option 2 if you choose....I pick option 1....I have good lawyers.

I am sorry but I would not want you as my doc. I want docs who care about me...not their pockets.

 

[leviathan]

I am sorry but I would not want you as my doc. I want docs who care about me...not their pockets.

I'm pretty sure he was more concerned about his back, and his CAREER, than his pocketbook. Back to the psychology forum you go, seems you need more practice with your psychoanalysis.

 

[militarymd]

I am sorry but I would not want you as my doc. I want docs who care about me...not their pockets.

ooohhhhhh....that REALLY hurt my feelings.....

thank god my pockets are full.

 

[sleepyone]

I'm pretty sure he was more concerned about his back, and his CAREER, than his pocketbook. Back to the psychology forum you go, seems you need more practice with your psychoanalysis.

ok lets look at another response he had earlier:

Which disability policy do you have?

My 2 individual policies combined pays less than $14,000 a month , so yes I'm scared to hurt my back over some ORCA who should have known better than to develop biscuit poisoning.

Can I have the name of your disability insurance agent?

hmmmmm....see the importance of the money there

 

[militarymd]

Do you work?

or are you going to vote for Obama so that people like me who work will have to support you?

ok lets look at another response he had earlier:



hmmmmm....see the importance of the money there

 

[sleepyone]

Do you work?

or are you going to vote for Obama so that people like me who work will have to support you?

I am a full time student, and work two part time jobs to support myself. This summer I worked full time, part time, and did school. and I totally HATE Obama.

So yes money is important to me, however YOU should care more about the patients whose LIVES are in your hands then you do about your precious paycheck

 

[militarymd]

I am a full time student, and work two part time jobs to support myself. This summer I worked full time, part time, and did school. and I totally HATE Obama.

So yes money is important to me, however YOU should care more about the patients whose LIVES are in your hands then you do about your precious paycheck

LIVES??? get a grip....

When you finish your residency, get a full time job, and actually have responsibilities to people who are dependent on your well being......then.....we can discuss what I should care about....

 

[Noyac]

A PhD physiologist told me that the last cranial nerve to be affected by anesthesia was the auditory, and it was the first to recover from anesthesia.
Be VERY CAREFUL what you say in the OR, even if the pt's apparently completely under general anesthesia with a BIS reading in the single digits.

Appreciate your answers to the previous questions.

.

Are you sure about that?

So the auditory n. works but does that mean that the pt will recall what they hear?

If you open their eyes, do they see? Will they remember what they are seeing?

I imagine these nerves are working/firing but its the consciousness that we are blocking. How come we can tell a pt to do something in the recovery room but them don't remember it later?

 

[Noyac]

THis whole case doesn't make sense. PT got fentanyl and maybe some versed then more versed an hour later but was under GA. Why give versed 30 minutes b/4 waking the pt up? Why is an adult having molars pulled in the OR? I suspect b/c of a psych issue of some sort. We are not getting the whole picture here which may be due to to the OP's greenness in the business (not taking a shot at you Eternal just stating my views that other things may be in play here that you are unaware of).

By the way, I don't let pts flail around on the stretcher risking a fall. I drop the stretcher down as low as possible so if they do fall its not so high. I don't drop pts off in the PACU uncomfortable. I do help restrain them until the nurses are comfortable with the situation which usually only takes about a minute or two.