Post your most memorable recent patient

[pd4emergence]

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So here's mine

18 yo with gallstones and ruq pain. Bmi is 23, she is currently asymptomatic, no nausea, no pain for a few days. I can almost see her glottis on airway exam. She also has both mom and dad there and they seem appropriately anxious. She does not smoke or drink, has no allergies and has had no anesthetic problems in the past.

Now you may ask why this one was memorable. She is healthy right? But thats my point. I don't see healthy. It's a good day when I have just one asa 1 pt. I could have posted the 55 yr old hip I did recently with critical aortic stenosis and a terrible ef who fell because they had syncope after a weekend long crack bender. But honestly the case above came to mind first. I am starting to remember my healthy patients more than the sick ones. So post yours, healthy or not.

 

[Monty Python]

So here's mine

18 yo with gallstones and ruq pain. Bmi is 23, she is currently asymptomatic, no nausea, no pain for a few days. I can almost see her glottis on airway exam. She also has both mom and dad there and they seem appropriately anxious. She does not smoke or drink, has no allergies and has had no anesthetic problems in the past.

Now you may ask why this one was memorable. She is healthy right? .

Hopefully she wasn't the one who brady'd from 83 to zero upon insufflation. She's in that profile.

 

[Monty Python]

Here's mine from a thread I started in 2005 (good God, where have the years gone?):

http://forums.studentdoctor.net/showthread.php?t=236895

 

[psychbender]

The other day, I assisted the fellow and attending with a small child with ectopia cordis and hypoplastic right heart. Don't see that everyday.

 

[proman]

Mine on Friday was a pothead 32 year old for mandibular hardware removal. Smokes pot every day, including day of surgery but did not appear intoxicated. Colleagues were 70-30 to cancel the case. I did the case.

 

[pd4emergence]

The other day, I assisted the fellow and attending with a small child with ectopia cordis and hypoplastic right heart. Don't see that everyday.

I'll be honest, I had to look up ectopia cords. Peds was a long time ago for me. Cool case.

 

[pd4emergence]

Here's mine from a thread I started in 2005 (good God, where have the years gone?):

http://forums.studentdoctor.net/showthread.php?t=236895

It's amazing how few ww2 vets are left. I've never seen the movies, but those guys seemed hard core.

 

[aneftp]

20 year old indignant African American For urgent c section at 4am.

I was with med student on call. That woman was annoying as hell. Complaining about everything. She wouldn't shut up for spinal I put in.

Well place spinal. About to start c section at 420am afyer verfiying T4 anesthesic level. Was talking to med student explaining anesthesia stuff. I told med student thank god the patient has shut up so I can explain things to him.

Than med student points out the pregnant woman looks blue. No wonder why she shut up....patient wasn't breathing!

We code her. Baby's out in 3 minutes. All hell breaks loose. Shock shock. All types of irregular rates. Finally after 20 minutes she get a pulse.

We bring her to icu intubated.

Next day she's extubated. Staff worried about neurological damage. She's a little slow. I go crap. These are the type of patients u worried about getting sued for. Pregnant healthy young woman who codes and has neurlogical damage.

Two days later her father shows up. Tell me....this was her baseline neuro conditions. He tells me she's "slow mentally" to began with.

I dodge a big one. She walks out the hospital 5 days later.

 

[Planktonmd]

Mine on Friday was a pothead 32 year old for mandibular hardware removal. Smokes pot every day, including day of surgery but did not appear intoxicated. Colleagues were 70-30 to cancel the case. I did the case.

Is smoking pot the day of surgery a contraindication to surgery?

 

[Arch Guillotti]

Than med student points out the pregnant woman looks blue. No wonder why she shut up....patient wasn't breathing!

The med stud was the one to figure this out............nice😀

Why did she go down the tubes?

 

[Arch Guillotti]

I would have done it too. Did your colleagues give a good reason for wanting to cancel other than the "what if something happens" routine?

Mine on Friday was a pothead 32 year old for mandibular hardware removal. Smokes pot every day, including day of surgery but did not appear intoxicated. Colleagues were 70-30 to cancel the case. I did the case.

 

[Bertelman]

20 year old indignant African American For urgent c section at 4am.

I was with med student on call. That woman was annoying as hell. Complaining about everything. She wouldn't shut up for spinal I put in.

Well place spinal. About to start c section at 420am afyer verfiying T4 anesthesic level. Was talking to med student explaining anesthesia stuff. I told med student thank god the patient has shut up so I can explain things to him.

Than med student points out the pregnant woman looks blue. No wonder why she shut up....patient wasn't breathing!

We code her. Baby's out in 3 minutes. All hell breaks loose. Shock shock. All types of irregular rates. Finally after 20 minutes she get a pulse.

We bring her to icu intubated.

Next day she's extubated. Staff worried about neurological damage. She's a little slow. I go crap. These are the type of patients u worried about getting sued for. Pregnant healthy young woman who codes and has neurlogical damage.

Two days later her father shows up. Tell me....this was her baseline neuro conditions. He tells me she's "slow mentally" to began with.

I dodge a big one. She walks out the hospital 5 days later.

I'm guessing you meant indigent, but sounds like she was indignant as well, right up through the time she rudely interrupted your lecture by arresting!

Also, is it just me, or was that a reference to cannabis?

 

[Arch Guillotti]

I'm guessing you meant indigent, but sounds like she was indignant as well, right up through the time she rudely interrupted your lecture by arresting!

Also, is it just me, or was that a reference to cannabis?

I though he meant that too until I read the thread😛

How dare she arrest.

 

[aneftp]

The med stud was the one to figure this out............nice😀

Why did she go down the tubes?

Oops. OP mentioned recent case.This happen a couple years ago.

Anyway they thought it was attributed to embolism. I didn't think it was a high spinal.

 

[sevoflurane]

Is smoking pot the day of surgery a contraindication to surgery?

In an o/w healthy 32 y/o who is not acutely intoxicated...

No. Not in my book anyways.... especially when I compare them to the methadone patients who smell like ashtrays despite the fact that they have a new gown on.

 

[aneftp]

I though he meant that too until I read the thread😛

How dare she arrest.

Sorry. U guys know what I meant. Stupid iPhone auto correct

 

[sevoflurane]

In an o/w healthy 32 y/o who is not acutely intoxicated...

No. Not in my book anyways.... especially when I compare them to the methadone patients who smell like ashtrays despite the fact that they have a new gown on.

and if she IS acutely high on the MJ, then bump her to the end of the day....

and put a good smelling hamburger and apple pie right outside of her room... with a fan blowing all of it's yummy smells right past her nose.

She must remain NPO.

Munchies or not.

 

[BobBarker]

Had LOR at 3.5 cm for a recent epidural. Usually have loss at 6cm with our patients.

 

[pgg]

Not my case, but happened Friday in the OR next door to me.


Healthy person coming in for excision of some dinky little mass on his wrist. They do a Bier Block with 0.5% lidocaine, tourniquet fails, patient seizes, then v-tach arrests. CPR, shocks, usual code stuff ...

Intralipid saves the day. Extubated neurologically intact a couple hours later. That stuff is magic.


Also, for some reason, they called the code blue overhead throughout the entire hospital. My next 3 patients, who were in the waiting room or preop area when "CODE BLUE OR 6" blared overhead were moderately freaked out.

 

[pd4emergence]

Not my case, but happened Friday in the OR next door to me.


Healthy person coming in for excision of some dinky little mass on his wrist. They do a Bier Block with 0.5% lidocaine, tourniquet fails, patient seizes, then v-tach arrests. CPR, shocks, usual code stuff ...

Intralipid saves the day. Extubated neurologically intact a couple hours later. That stuff is magic.


Also, for some reason, they called the code blue overhead throughout the entire hospital. My next 3 patients, who were in the waiting room or preop area when "CODE BLUE OR 6" blared overhead were moderately freaked out.

Wow, never used it. I hate bier blocks. Maybe it's just cause I haven't done that many but relying on a tourniquet to keep the above from happening (even if it's a double tourniquet) makes me uncomfortable.

 

[sevoflurane]

Not my case, but happened Friday in the OR next door to me.


Healthy person coming in for excision of some dinky little mass on his wrist. They do a Bier Block with 0.5% lidocaine, tourniquet fails, patient seizes, then v-tach arrests. CPR, shocks, usual code stuff ...

Intralipid saves the day. Extubated neurologically intact a couple hours later. That stuff is magic.


Also, for some reason, they called the code blue overhead throughout the entire hospital. My next 3 patients, who were in the waiting room or preop area when "CODE BLUE OR 6" blared overhead were moderately freaked out.

Whoa.

I bet that Vtach and arrest was short lived.

Did intralipid come in during the code or after? That's 250mg of lidocaine. 2.5x the intubating dose you'd give IV prior to intubation.

 

[sevoflurane]

Bier blocks give you no post op pain control.

 

[proman]

Is smoking pot the day of surgery a contraindication to surgery?

Acute intoxication certainly is.

I would have done it too. Did your colleagues give a good reason for wanting to cancel other than the "what if something happens" routine?

I didn't ask too hard. Seemed to be concerns about a patient too dumb to know not to do illicit drugs day of surgery. Who knows what else the tox screen would have showed. If we wouldn't have asked (standard question: smoking, drugs, alcohol) I wouldn't have had any idea he had smoked.

 

[drccw]

one of my most memorable patients the other day....

I get a call from our board runner... 5 PM on a Friday...

"can you head down to IR and sedate a patient?"

"sure, what are they doing..."

"I don't know... something dinky, like a biliary drain or something..."

I head down to IR, which is in the bowels of our hospital... deep down in the entrails...

See the nurse, Terri...

"Hey Terri, what are we doing..."

"I think it's a pulmonary embolization..."

Crap... head to the holding area... I can hear a lady spitting up.... doesn't sound good..

Pull the curtain back... 400 lb 35 yo female with a history of severe OSA and pulmonary HTN (PA ~80-90) and home O2 with a yankauer suctioning her mouth continuously....

Great...

drccw

 

[MRW]

Healthy 24yo having a diagnostic colonoscopy for some bleeding. He was a big lad with a number of tattoos who gave off a "I am going to take a lot to keep down" vibe. After a very healthy initial dose of propofol, he went off to sleep mid sentence (which was a mumble about the awesome drugs I just gave him). When the endoscopist went to insert the probe, he sat up and told him to f*ck off!

Uneventful clinically, but that was worth remembering!

 

[pgg]

Whoa.

I bet that Vtach and arrest was short lived.

Did intralipid come in during the code or after? That's 250mg of lidocaine. 2.5x the intubating dose you'd give IV prior to intubation.

It took a while to "find" the intralipid, which was right where it was supposed to be, but that's a different story.

Still, pretty amazing stuff - not a lot of lifesaving anesthesia gamechangers have been invented in the last 20 years, but that's got to be one of them.

Bier blocks give you no post op pain control.

I'm not a fan. I think they're a solution in search of a real problem.

A while back someone here suggested doing a forearm cuff Bier block - smaller volume, and you can let the cuff down sooner. I'm still waiting for an appropriate case to come up, where a better plan isn't simply local from the surgeon +/- light sedation +/- a hit of propofol while he injects.


Speaking of Bier Blocks, I accidentally did one with indigo carmine once. GYN case, gave the usual 5 cc of the dye at the end during their cystoscopy ... slowish IV so I flushed it in with 15 or 20 ccs of LR. Didn't realize the BP cuff was up. A few minutes later noticed that her arm had a bunch of blotchy blue patches. 😳

 

[pgg]

He was a big lad with a number of tattoos who gave off a "I am going to take a lot to keep down" vibe.

I did an amputation for a diabetic foot last night. Tattooed tough guy, said he had a very high tolerance and preferred Dilaudid because nothing else worked. I usually just light MAC these as the surgeon carves off the dead no-nerve-left tissue ... he wanted to be "totally out" ...

I gave him 2 of Versed and he was OUT. I popped a NP airway in him and ventilated him. Not what I was expecting.

I actually poked a stick in the sharps container to turn over the empty vial to confirm that I'd picked up a 2 mg in 2 mL vial and not one of the 10 mg in 2 mL vials.

 

[Endee]

one of my most memorable patients the other day....

I get a call from our board runner... 5 PM on a Friday...

"can you head down to IR and sedate a patient?"

"sure, what are they doing..."

"I don't know... something dinky, like a biliary drain or something..."

I head down to IR, which is in the bowels of our hospital... deep down in the entrails...

See the nurse, Terri...

"Hey Terri, what are we doing..."

"I think it's a pulmonary embolization..."

Crap... head to the holding area... I can hear a lady spitting up.... doesn't sound good..

Pull the curtain back... 400 lb 35 yo female with a history of severe OSA and pulmonary HTN (PA ~80-90) and home O2 with a yankauer suctioning her mouth continuously....

Great...

drccw

So what happened? Anything interesting?

 

[drccw]

So what happened? Anything interesting?

Pent Sux Tube....

Well not quite.. I grabbed one of our glidescopes, had a two suction setup and did a RSI...
She was actually a grade I with a Mac IV.

drccw

 

[MRW]

I did an amputation for a diabetic foot last night. Tattooed tough guy, said he had a very high tolerance and preferred Dilaudid because nothing else worked. I usually just light MAC these as the surgeon carves off the dead no-nerve-left tissue ... he wanted to be "totally out" ...

I gave him 2 of Versed and he was OUT. I popped a NP airway in him and ventilated him. Not what I was expecting.

I actually poked a stick in the sharps container to turn over the empty vial to confirm that I'd picked up a 2 mg in 2 mL vial and not one of the 10 mg in 2 mL vials.

I've had patients like that. They remember their tolerance from when they were abusing and forget that it goes away when they are clean for a while. Fast track to OD in some sad cases, but I digress... As for your patient, he might be just a guy who knows what to ask for but never really actually uses anything or maybe he just hasn't discovered benzos yet.