Procedure Ability

[DialAView]

Hi

I am really interested in Anesthesia but one thing that freaks me out(same goes for Surgery) is my ability to do 'things.' You don't get much exposure it seems in medical school, so how can you really know if you are good and have the ability to put in ABG lines, etc, etc? I guess it is my low self esteem(thanks to that girl who rejected me in 1st grade) questioning if I will have the ability to do things even though I don't have any hard proof either way.


Take Care
Paul

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[excalibur]

With practice and patience anyone can do any procedure.

 

[bubalus]

And even once you're comfortable with them, you may still have that occasional day where you can't seem to put in an A-line in less than 5 tries. As mentioned, with practice, you can learn to do it.

 

[militarymd]

With practice and patience anyone can do any procedure.

No...that's just NOT true.

I know surgeons who can do a Lap Chole in 15 minutes flat....from the time he touches the patient to the time he walks out of the OR.....while another surgeon will take 2 hours.

Both had the same training ...both have been practice for about the same time....

Why do some anesthesiologists take soooo long to do an epidural....while others walk into a L&D suite and walk out in 15 minutes with the lady smiling.

Anyone may be able to learn to do the procedure....but not everyone can learn to do them well....

and you're not going to know until you do it.

 

[Noyac]

No...that's just NOT true.

I know surgeons who can do a Lap Chole in 15 minutes flat....from the time he touches the patient to the time he walks out of the OR.....while another surgeon will take 2 hours.

Both had the same training ...both have been practice for about the same time....

Why do some anesthesiologists take soooo long to do an epidural....while others walk into a L&D suite and walk out in 15 minutes with the lady smiling.

Anyone may be able to learn to do the procedure....but not everyone can learn to do them well....

and you're not going to know until you do it.

I've seen the same thing with both surgeons and anesthesiologists. But I will tell you that it is my opinion that the vast majority of folks in this specialty can be average.

 

[The_Sensei]

I've seen the same thing with both surgeons and anesthesiologists. But I will tell you that it is my opinion that the vast majority of folks in this specialty can be average.

Thus far, not too many anesthesiologists I have encountered have deviated from this.

 

[bubalus]

I need to revise my previous statement to agree with Mil. He's right. His wisdom brought back memories of 2 hour lap choles and 6 hour IM nails. Some people have the hands, and others don't, and you don't know if you do until you're into your training. But I do think that most people, in general (enough qualifications?), can become functional--some achieve greatness, and others strive for the upper echelons of mediocrity. However, I don't think you should pursue psychiatry out of a concern that you won't be able to learn procedures.

 

[Planktonmd]

The key to "Having good hands" is in having self confidence.
It's all in the head!
And this is precisely why some people are better at procedures than others, and this is why some people can never improve, they are just too nervous, or too insecure.

 

[Bertelman]

I think the key to good hands is dexterity. Some people can step up with no confidence and still do rather amazing tasks with their hands. Confidence helps, but some folks just cannot be helped. I think when you see someone failing at a task w/o confidence, it is likely the failure that led to the lack of confidence. Unjustified confidence does not always lead to good outcomes.

My impression is that, by and large, many anesthesiologists succeed with only moderate skills in procedures. You won't be asked to anastomose an artery, or tighten up the stitch on the bypass graft with the heart beating. The closest you'll get to a laparsocopic procedure is a fiberoptic scope and a Magill. Just gain enough skills so that you don't embarass yourself, and you aren't a danger to the patient. You'll still manage to embarass yourself, but you won't be leading the next M&M.

I'm going into anesthesiology because I enjoy the procedures, not necessarily because I am great at doing them. I hope to be great one day, but only time will tell.

 

[UTSouthwestern]

Being able to adjust and having a wide variety of approaches to every procedure will make you better at doing procedures. In residency, there was always just one way to put in an IJ or A line and come hell or high water you were still doing it that way. In private practice, if your take more than 20 minutes to get you A line, TEE, CVP, and PAC into place, the surgeons ask if you are having trouble today.

 

[cchoukal]

When I was in med school I was dating this girl. When it came time for our "lab medicine course," we had to do blood draws on our lab partners, and she was mine. She got so nervous and flustered and shaky, she couldn't even draw blood off of me. She started crying and left the room. Now she's an ENT resident and loves cutting into peoples faces. I agree with the above posters that if you're into something and you practice it enough to be confident, you'll at least be competent, and that you shouldn't let early experiences as a med student drive you away from a procedural field. Good luck.

 

[tcw2u]

No...that's just NOT true.

Why do some anesthesiologists take soooo long to do an epidural....while others walk into a L&D suite and walk out in 15 minutes with the lady smiling.

Anyone may be able to learn to do the procedure....but not everyone can learn to do them well....

I am now a CA-2 and can do labor epidurals in about 5 minutes from the time I put on gloves to when test dose goes in... given that the patient is not morbid obese...

Here's my question, any masters out there want to give this grasshopper some pearls on doing epidurals on Morbidly obese patients?

I was faced with a 400lb lady last week, 5ft4, G7P?, had a 26wk premie in breech position, active labor, had cerclage removed... I was looking at her back and there were absolutely no landmarks... there must have been 20 fat folds. Push around with my hands and felt nothing but fat.

I made one pass with the long harpoon needle, got nothing but fat. I started to get nervous when I hubbed the needle and still no LOR@15cm. Of course patient was not cooperative and freaked out and told me to stop, so I did.

However one of my CA-3 colleagues was able to get a working epidural in her with the regular 10cm Touey needle after he took over the night shift. I asked him how he did it, he said "just pure luck".

This lady ended up having a SVD when I came back on shift the following day, baby was actually ok but the NICU team was nowhere to be found and I was asked to intubate the baby. I'm just glad mom didn't need a C-section with GA... I could already picture myself standing at the podium presenting her case at Q&A (Questions and answers, our program's complications conference)

I love CA-2 year! Anyway what are some hints on epidurals on fatties?

 

[DialAView]

thanks for all the advice.

 

[militarymd]

I am now a CA-2 and can do labor epidurals in about 5 minutes from the time I put on gloves to when test dose goes in... given that the patient is not morbid obese...

Here's my question, any masters out there want to give this grasshopper some pearls on doing epidurals on Morbidly obese patients?

I was faced with a 400lb lady last week, 5ft4, G7P?, had a 26wk premie in breech position, active labor, had cerclage removed... I was looking at her back and there were absolutely no landmarks... there must have been 20 fat folds. Push around with my hands and felt nothing but fat.

I made one pass with the long harpoon needle, got nothing but fat. I started to get nervous when I hubbed the needle and still no LOR@15cm. Of course patient was not cooperative and freaked out and told me to stop, so I did.

However one of my CA-3 colleagues was able to get a working epidural in her with the regular 10cm Touey needle after he took over the night shift. I asked him how he did it, he said "just pure luck".

This lady ended up having a SVD when I came back on shift the following day, baby was actually ok but the NICU team was nowhere to be found and I was asked to intubate the baby. I'm just glad mom didn't need a C-section with GA... I could already picture myself standing at the podium presenting her case at Q&A (Questions and answers, our program's complications conference)

I love CA-2 year! Anyway what are some hints on epidurals on fatties?

spinal catheter.....don't waste time on an epidural.

 

[tcw2u]

spinal catheter.....don't waste time on an epidural.

Ok then, what are some tips to doing a spinal catheter in these morbidly obese patients? Seriously I could not see or feel any landmarks no matter how hard I pushed on her back. I hated to stick a needle blindly into her.

At my program the attending anesthesiologist is stretched very thin when they are on-call, but probably so at most other places, he/she covers the main OR's, running between 3-4 rooms, being responsible for L&D, trauma, and the bag resident (one who responds to codes and floor/ICU intubations) if they have trouble...

I told him about this lady and my inability to get an epidural on her, and he said not to worry about it... he's an airway expert at our program, but the thought of intubating this 400 pound pregnant patient seriously was giving me the shivers... What if the attending was busy with a GSW in the OR and my patient's fetus started going into distress, then I'd be screwed.

So are there certain things you look/feel for in these patients, or you just stick the touey/spinal needle in and hope to feel something, either ligament or bone, and re-direct accordingly?

Ironically, I am watching this show called super obese on TLC right now. It's unfortunate that obesity is such a prevalent problem in our patient population these days.

 

[Carm]

Two quick tricks I have picked up on in the land of fatness here in texas

1. All of our patients wear external fetal monitors with two velcro straps that go around the patients back. This is going to sound crazy, but almost every time the place where the lower belt rides is the best spot to start the epidural.

2. Some concept, but different reference. Even looking at the fattest back if you take a step back and look at the space in between two huge rolls (essentially between the iliac crests and her back panus) there is a distinct band created between the two rolls of fat that relatively speaking has the least subcutaneous fat (can get most times with 10cm needle) and very close to L2-L3-L4. The initial stick is somewhat of a guess, but with some minor redirection you can usually find the space.

Not a perfect plan, but these principles have worked for me with the dreaded 3AM 300+ pound epidural.

 

[militarymd]

Ok then, what are some tips to doing a spinal catheter in these morbidly obese patients? Seriously I could not see or feel any landmarks no matter how hard I pushed on her back. I hated to stick a needle blindly into her.

At my program the attending anesthesiologist is stretched very thin when they are on-call, but probably so at most other places, he/she covers the main OR's, running between 3-4 rooms, being responsible for L&D, trauma, and the bag resident (one who responds to codes and floor/ICU intubations) if they have trouble...

I told him about this lady and my inability to get an epidural on her, and he said not to worry about it... he's an airway expert at our program, but the thought of intubating this 400 pound pregnant patient seriously was giving me the shivers... What if the attending was busy with a GSW in the OR and my patient's fetus started going into distress, then I'd be screwed.

So are there certain things you look/feel for in these patients, or you just stick the touey/spinal needle in and hope to feel something, either ligament or bone, and re-direct accordingly?

Ironically, I am watching this show called super obese on TLC right now. It's unfortunate that obesity is such a prevalent problem in our patient population these days.

that's what I do.

 

[cfdavid]

Ok then, what are some tips to doing a spinal catheter in these morbidly obese patients? Seriously I could not see or feel any landmarks no matter how hard I pushed on her back. I hated to stick a needle blindly into her.

At my program the attending anesthesiologist is stretched very thin when they are on-call, but probably so at most other places, he/she covers the main OR's, running between 3-4 rooms, being responsible for L&D, trauma, and the bag resident (one who responds to codes and floor/ICU intubations) if they have trouble...

I told him about this lady and my inability to get an epidural on her, and he said not to worry about it... he's an airway expert at our program, but the thought of intubating this 400 pound pregnant patient seriously was giving me the shivers... What if the attending was busy with a GSW in the OR and my patient's fetus started going into distress, then I'd be screwed.

So are there certain things you look/feel for in these patients, or you just stick the touey/spinal needle in and hope to feel something, either ligament or bone, and re-direct accordingly?

Ironically, I am watching this show called super obese on TLC right now. It's unfortunate that obesity is such a prevalent problem in our patient population these days.

Last night on Nightline, they showed this dude from Mexico City that was 1200lbs. The crazy thing is that they can't find anything "wrong" with him. No diabetes, normal heart function, and all that. The same old cast of characters kicked off the problem in the first place (eating too much, and not moving around), but they can't figure out why he doesn't show more "serious" symptoms. Perhaps it's still a matter of time.

What I find intriguing is how we don't have a serious handle on ways to modulate eating habits (chemically) and/or to safely speed up metabolism. But, I guess it just comes down to eating less and expending energy from exercise. However, that's not working for a LOT of people worldwide. So, it would be nice to have a medical solution (other than just surgical, but that's a start).

 

[tcw2u]

Thanks for all the tips guys on neuraxial blockade in obese patients.

Yeah on this show "Super Obese", there is this lady I think they said she is 500+lbs, but instead of getting a gastric bypass surgery she was getting "de-bulking" surgery by plastics, where they removed ~20lb of tissue from her lower extremities. There was so much fat dangling off her ankles that it was literally dragging on the ground as she walks.

I guess the debulking surgery helped her in terms allowing her to walk better and not kill her joints, but seems like a gastric bypass makes more sense.

 

[VentdependenT]

Or you could actually try and eat less calories than your body consumes each day....but thats a pain in the ass. Off the the land of quick desaturation and nightmarish airways.

 

[CambieMD]

Thanks for all the tips guys on neuraxial blockade in obese patients.

Yeah on this show "Super Obese", there is this lady I think they said she is 500+lbs, but instead of getting a gastric bypass surgery she was getting "de-bulking" surgery by plastics, where they removed ~20lb of tissue from her lower extremities. There was so much fat dangling off her ankles that it was literally dragging on the ground as she walks.

I guess the debulking surgery helped her in terms allowing her to walk better and not kill her joints, but seems like a gastric bypass makes more sense.

Putting down the fork and getting some exercise would make more sense.

Cambie
p.s.small world

 

[Intrathecal]

We almost never do spinal catheters at our program. I have heard of them done when residents get inadvertent wet taps but we never place them intentionally. What do you use, the same Touey needle and the same catheter in the epidural kit? Do you still have the problem of PDP headaches with them? How far do you thread the catheter into the intrathecal space?

 

[militarymd]

We almost never do spinal catheters at our program. I have heard of them done when residents get inadvertent wet taps but we never place them intentionally. What do you use, the same Touey needle and the same catheter in the epidural kit? Do you still have the problem of PDP headaches with them? How far do you thread the catheter into the intrathecal space?

yes

sometimes...but not as much as you would think.

4 cm

How does your program deal with morbidly obese patients,.

 

[Intrathecal]

We (the residents) usually get a few attempts at placing an epidural. If we don't get it the attending tries. If the attending doesn't get it, the patient gets only IV meds, and we pray that patient doesn't need a crash c-section.

I think the attendings get it in 95% of the time, even on the really big patients. So technically if you can reach the intrathecal space with the Touey needle, you should be able to find the epidural space too, but might just take longer and more patience, right?

 

[militarymd]

We (the residents) usually get a few attempts at placing an epidural. If we don't get it the attending tries. If the attending doesn't get it, the patient gets only IV meds, and we pray that patient doesn't need a crash c-section.

I think the attendings get it in 95% of the time, even on the really big patients. So technically if you can reach the intrathecal space with the Touey needle, you should be able to find the epidural space too, but might just take longer and more patience, right?

Getting into the epidural space is easy.......keeping the catheter in the epidural space...and having it continue to work is another.

 

[The_Sensei]

Getting into the epidural space is easy.......keeping the catheter in the epidural space...and having it continue to work is another.

So true!

 

[Intrathecal]

How do you achieve selective blockage with a spinal catheter? We are taught that pregnant ladies should still have sensory block and little to no motor block so that they are still able to push when the time comes. What do you dose the spinal catheter with? Sorry for so many questions but we are just not taught this at our institution.

 

[militarymd]

isobaric 0.25% marcaine.....1 cc bolus...prn

or

0.1 % marcaine + 2 mcg/ml fentanyl at 1 to 2 cc/hr infusion.

 

[Intrathecal]

Thanks so much. Next time we get an obese patient I will discuss doing a spinal catheter with my attending, I don't know how receptive they will be, but it would be a good learning experience.

 

[johankriek]

How do you achieve selective blockage with a spinal catheter? We are taught that pregnant ladies should still have sensory block and little to no motor block so that they are still able to push when the time comes. What do you dose the spinal catheter with? Sorry for so many questions but we are just not taught this at our institution.

I personally would advise you never to put a spinal catheter in..

Just dont do it.

 

[VolatileAgent]

I personally would advise you never to put a spinal catheter in..

Just dont do it.

agreed. the only spinal catheter's i've seen have been accidental ones.

in extremely overweight patients, use the tuohy to find the epidural space. then pass a spinal needle through it (as in a cse) and place the spinal. the tuohy is 18g and can much more easily and with better "feel" be directed than the small spinal needle with that little 3cm introducer, especially with a high level of posterior adiposity. needle and tuohy then come out as one unit.

have done this multiple times in bmi > 40 patients with good success. and, single sticks are always preferable (ie., not sitting there for 30 minutes trying to find the right spot with such a thin, hard to direct needle... oh, you can get it in there eventually doing it the standard way, but chances are you're going to spend more time trying... and usually time is of the essence... for everyone).

like someone once said, it's all about developing a high level of effeciency (meaning timely, safe, and effective therapy).