prone lma's... who does them?

[Surfer]

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Anybody out there doing lma's in the prone position?

 

[Arch Guillotti]

nope

 

[nimbus]

Yep. For quick hemorrhoids and condyloma cases, and an occasional back lipoma. Used to do deep sedation, but GA with LMA is much smoother and easier. No airway obstruction. We have the patient position themself prone with head turned to the side, induce and place LMA. Insertion is surprisingly easy with head turned to side, so much so that I now turn the patients head to the side even when placing LMAs supine.

 

[Surfer]

nope

if no, why not?


I've done it a few times for relatively short cases. It's pretty easy and painless.

 

[stonemd]

I would think some would be concerned if patient with LMA is prone and suddenly becomes difficult to ventilate due to laryngospasm or dislodgment of the LMA into a non-functioning position. If one cannot get the LMA to work again then prone mask ventilation or tracheal intubation is something I am not used to doing. In addition in the prone position sometimes the head is lowered and there is pressure on the abdomen perhaps increasing the risk of reflux -

If you use LMAs prone let us know how you would handle the potential problems. I tried it a couple times but was nervous because I myself didn't have all my rescues worked out! Btw I work at an asc, use LMAs all the time including for close to 1000 tonsillectomies a year, so I am not generally LMA-phobic.

 

[jwk]

Nope - never - ever - and don't ask me to do it.

We have a few in our department that do it, and I know it's very common in other places. I think if there is a problem, it's indefensible.

 

[excalibur]

if no, why not?


I've done it a few times for related short cases. It's pretty easy and painless.

...Until it isn't.

Very possible scenario...pt prone for hemorrhoidectomy and breathing spontaneously. Upon surgical incision, pt bucks maybe from light anesthesia. Laryngospasm ensues. ETCO2 waveform is flat. You struggle to ventilate and are not moving air effectively. Alarms are going off. What do you do?

 

[jetproppilot]

...Until it isn't.

Very possible scenario...pt prone for hemorrhoidectomy and breathing spontaneously. Upon surgical incision, pt bucks maybe from light anesthesia. Laryngospasm ensues. ETCO2 waveform is flat. You struggle to ventilate and are not moving air effectively. Alarms are going off. What do you do?

It's ubiquitous in the United Kingdom, Ex.

I still haven't done it.

But I'd like to for certain cases.

Like NIMBUS said.

We all do

PRONE MAC CASES

sometimes.

Why not

UP THE ANNIE

a little?

THE BRITS CAN'T BE THAT MUCH BETTER THAN US, HUH?🙄

 

[BobBarker]

Succ and flip the vent onto pressure control

 

[Bertelman]

We do it. When we do, the stretcher stays in the OR, period. Our next play is stopping the case, flipping and fixing it.

 

[jetproppilot]

We do it. When we do, the stretcher stays in the OR, period. Our next play is stopping the case, flipping and fixing it.

An LMA is a much less

INTRUSIVE

general anesthetic.

PUSH A STIKKA PROPOFOL, INSERT LMA,

CRACK THE SEVO,

THATS IT.

No muscle relaxants, no reversal agents, potentially no opioids or at least minimal opioids...

I'M TELLING YOU DUDES (and I'm telling MYSELF at the same time)

WE NEED TO EXPLORE THE POSSIBILITY OF USING LMAs

PRONE

in certain cases.

There are advantages to minimizing the pharmacologic milleau and intrusive intubation of a general anesthetic

TO THE PATIENT.

Bertel does it, albeit with an ESCAPE ROUTE.

NICELY DONE, BERTEL.👍

 

[excalibur]

If there were a serious airway disaster in an LMA prone case where a morbidity or mortality occurred, do you think that practice is defensible in court?

I am just asking. I don't know.

 

[excalibur]

Succ and flip the vent onto pressure control

Good.

Are you increasing the prone patient's aspiration risk now by administering PPV through an LMA? I don't know. I am just asking.

 

[jetproppilot]

If there were a serious airway disaster in an LMA prone case where a morbidity or mortality occurred, do you think that practice is defensible in court?

I am just asking. I don't know.

I've lived my professional career in a certain way, Ex.

I

DO NOT PRACTICE

DEFENSIVE MEDICINE.

I

PRACTICE MEDICINE LIKE I SEE FIT AS A

WELL TRAINED DOCTOR.

My intent on every case I do is

THE BEST OUTCOME FOR THE PATIENT,

not

how can I best defend myself from a lawyer.

Fu ck that sh it man. I refuse to let some cheesy group of plaintiff lawyers dictate how I practice medicine. I refuse to practice defensive medicine.

I'M A DOCTOR. I'M WELL TRAINED.

I'M GONNA DO THE CASE LIKE I WANNA DO IT

I'M GONNA ORDER LABS

OR NOT ORDER LABS

LIKE I SEE FIT

A PLAINTIFF LAWYER THREAT

DOESN'T DETER ME

FROM MY PLAN SINCE

MY PLAN AND MY INTENT IS TO DELIVER

THE ABSOLUTE BEST

FOR EVERY PATIENT.

I'm competent.

YOU are competent.

Don't

LIVE IN FEAR OF THE CHEESY PLAINTIFF LAWYERS.

Just do your thing man.

Your career and your gratification will be much higher if you learn to

DO YOUR THING.

It's

CATHARTIC

if you practice like that.

CLAIM BACK FOR YOURSELF THE MEANING OF BEING A

DOCTOR.

 

[soonerfrog]

I don't have qualms with others doing it, I've done it a handful of times in the properly selected pt/environment--but it'll never be a staple of mine. Even though it goes against Jet's mantra (sorry hombre-you're still Aces in my book), I just don't want to have to have the discussion on the stand---
"Dear Idiot, why did you use a prone LMA?"
Answer: "Because I was feeling: a) cowboy b) frisky c) threatened because m parter dared me to, or d) some combination of A-C"
Lawyers suck. I want as little to do with them as possible and if it means putting in a piece of PVC when I coulda prolly just slipped an LMA in.....so be it. I won't begrudge someone else for doing it but I won't ever go the way of those sausage and mash eating Brits either.

 

[imfrankie]

I do them in the right patient, for the right case. But I don't read in the operating room.

 

[jetproppilot]

Even though it goes against Jet's mantra (sorry hombre-you're still Aces in my book), I just don't want to have to have the discussion on the stand---
"Dear Idiot, why did you use a prone LMA?"
Answer: "Because I was feeling: a) cowboy b) frisky c) threatened because m parter dared me to, or d) some combination of A-C"

I hear and respect your thoughts and opinions.

As an aside, lemme ask you dudes out there something:

How many times have you looked at an airway and said to yourself

THANK GOD THIS IS AN LMA CASE BECAUSE THIS AIRWAY LOOKS

SCARY!!

This train of thought we have intuitively is hard to admit since our

"GUIDING FOREFATHERS" have taught us that

IF YOU SEE A DIFFICULT AIRWAY,

ATTACK IT AND INTUBATE IT UP FRONT.

We've been lead to believe this. We've been trained like this.

I ADAMANTLY DISAGREE WITH THIS PHILOSOPHY.

Of course there are cases that require an endotracheal tube that this philosophy hits...

CABGs, thoracic cases, ELAPs, etc

Turns out

ALOTTA CASES WE DO DO NOT NEED AN ENDOTRACHEAL TUBE AND

WE SOMETIMES CREATE ALOTTA PROBLEMS

TRYING TO PUT A TUBE IN WHEN WE COULDDA JUST USED AN

LMA AND INSTEAD WE CREATE PROBLEMS TRYING TO INTUBATE BECAUSE THATS WHAT OUR

GUIDING FATHERS SAY WE HAVE TO DO!! ATTACK A DIFFICULT AIRWAY UP FRONT!!!.

I call BULL SH I T on this point that's being taught to residents.

Let's say for conversation sake you are confronted with a patient for an elective hemorrhoidectomy that you say to yourself, looking at said patient in the holding area,

HOLY $%^%

THIS INTUBATION IS GONNA BE A PROBLEM

EVEN FOR ME THE

ROKKSTARR

Why not take the course that BERTELMAN takes

AND THROW IN AN LMA?

For the residents out there,

this is not a conversation you should have with your board examiner on your oral exam, btw.

We're talking

REAL LIFE

IN THE TRENCHES OF PRIVATE PRACTICE

ways of

SAFELY

taking care of patients.

I wanna point out that what you are required to

VOMIT OUT

on your boards doesn't always align with what's best for the patient in

REAL LIFE.

i.e.

"WHY YES, MR. BOARD EXAMINER,

SOMETIMES

IT IS IN THE BEST INTEREST OF THE PATIENT

to throw in an LMA and not try to intubate, if the case allows."

(don't say this during your Oral Boards. You're being examined by academic doctors who are incapable of thinking out of the box, so stick to dogmas.)

I realize

PRONE

throws in other concerns but

IT ALL COMES DOWN TO YOUR COMFORT ZONE AS A DOCTOR.

I'm from the audience that thinks we as anesthesiologists need to

become more comfortable with prone LMA cases since it's being used CURRENT DAY, albeit in another country.

Sometimes doing

LESS

is

MORE.

 

[ASA6]

this is not a conversation you should have with your board examiner on your oral exam, btw.

Ive never understood this. If its something thats done every day by most anesthesiologists how come that isnt the answer on the oral boards? I did a mock oral a few weeks ago, and the scenario involved a moderately difficult looking airway. Present a 100kg guy with a short thick neck, MP 3, no facial hair, some moderate surgery and ask how I would secure an airway. My answer: Optimize position, 'Id give some propofol see if I can ventilate him. If I can, paralize, insert ETT tube. Have fiberoptic as backup. So after the exam my examiner says: The way you described it is probably how 99% of us would do it, but consider saying awake fiberoptic on the exam. I dont get it. If my response is how 99% of people would do it....isnt that the right answer?

To get to the actual thread, ive never done a prone LMA, but if a prone deep mac is ok, a prone lma should be just as well, right?

 

[pgg]

Anybody out there doing lma's in the prone position?

I use fewer LMAs in supine patients now than I did 3 years ago. I don't often use them in sitting or lateral patients. I won't use the word "never" but I sort of doubt I'll ever feel either the idle motivation or the need to use an LMA in a prone patient.

I know lots of people in the world do so routinely and I'm throwing no stones here. But I just don't see the point of a prone LMA as a Plan A anesthetic.

 

[jwk]

If there were a serious airway disaster in an LMA prone case where a morbidity or mortality occurred, do you think that practice is defensible in court?

I am just asking. I don't know.

It's not, at least according to my former chairman, who is also a former ASA president, gives a lot of expert testimony nationwide, and sits on the claims committee of a large medical malpractice insurer.

I'm an old, yet experienced fart - it took me years to use LMA's routinely after more than 15 years of doing mask anesthetics before LMA's were available. They are not the cure all that many think they are. I don't/won't use them on prone cases, nor laparoscopies, nor tonsils, nor beach chair shoulder cases, and I don't care that the Brits think they're wonderful in their litigious-less society. I don't avoid it in these cases because I'm practicing defensive medicine - I avoid it because I think it's outright malpractice and just not the right thing to do for my patients.

 

[Surfer]

It's not, at least according to my former chairman, who is also a former ASA president, gives a lot of expert testimony nationwide, and sits on the claims committee of a large medical malpractice insurer.

I'm an old, yet experienced fart - it took me years to use LMA's routinely after more than 15 years of doing mask anesthetics before LMA's were available. They are not the cure all that many think they are. I don't/won't use them on prone cases, nor laparoscopies, nor tonsils, nor beach chair shoulder cases, and I don't care that the Brits think they're wonderful in their litigious-less society. I don't avoid it in these cases because I'm practicing defensive medicine - I avoid it because I think it's outright malpractice and just not the right thing to do for my patients.

So why is it malpractice?? What are you worried about in a beach chair shoulder? i use them routinely in beach chair or lateral cases and can't think of a single reason why not to do so. Patients are breathing spontaneously so even in the incredibly rare event of a lost tube (which, btw, can happen with an ETT), they're already breathing so they're not going to die. I could argue its actually safer.

 

[Idiopathic]

i just cant even participate knowing it takes jet about 100 times as long to write that post as it would take someone to read it...IF THEY COULD READ IT

 

[dhb]

So why is it malpractice?? What are you worried about in a beach chair shoulder? i use them routinely in beach chair or lateral cases and can't think of a single reason why not to do so. Patients are breathing spontaneously so even in the incredibly rare event of a lost tube (which, btw, can happen with an ETT), they're already breathing so they're not going to die. I could argue its actually safer.

good point

 

[Mman]

So why is it malpractice?? What are you worried about in a beach chair shoulder? i use them routinely in beach chair or lateral cases and can't think of a single reason why not to do so. Patients are breathing spontaneously so even in the incredibly rare event of a lost tube (which, btw, can happen with an ETT), they're already breathing so they're not going to die. I could argue its actually safer.

Ever have the arthroscopy fluid start tracking through the soft tissue into the patient's neck? I've seen it once or twice and heard a horror story from a colleague that did one with an LMA and learned to never do it again.

 

[Ipassgas]

About the shoulder fluid, for unimportant reasons I did an interscalene block post op and there was so much edema, it took awhile just to identify the anatomy. I'm sure it tracked to the airway, and probably happens every case. I was surprised about just how much there was.

 

[jwk]

So why is it malpractice?? What are you worried about in a beach chair shoulder? i use them routinely in beach chair or lateral cases and can't think of a single reason why not to do so. Patients are breathing spontaneously so even in the incredibly rare event of a lost tube (which, btw, can happen with an ETT), they're already breathing so they're not going to die. I could argue its actually safer.

Beach chair, with the table turned 90-180 away from me? Not a chance. If I don't have immediate access to the airway, they buy a tube.

I'm not sure how an LMA would be safer than an ETT in that type of case. I can have them breathe spontaneously with an ETT as well if that's your only concern.

 

[excalibur]

So why is it malpractice?? What are you worried about in a beach chair shoulder? i use them routinely in beach chair or lateral cases and can't think of a single reason why not to do so. Patients are breathing spontaneously so even in the incredibly rare event of a lost tube (which, btw, can happen with an ETT), they're already breathing so they're not going to die. I could argue its actually safer.

I think the bigger concern is if the pt began to obstruct with the LMA in those positions.

Have you ever dealt with trying to mask ventilate a pt with OSA or laryngospasm or a pt with LMA who obstructs from being light at incision or obstructs from a sudden new forceful stimulus? Can be challenging right? You sometimes struggle with mask ventilation and sometimes you intubate.

Imagine that scenario in prone position or beach chair.

If that were to happen, I think best thing is sux and PPV.

If you give sux and can't ventilate with PPV, you are in trouble

 

[nimbus]

I do all my shoulders....beach chair and lateral....including total shoulders with isb+light ga with lma. I get fewer problems, major and minor, and smoother intraoperative course and emergence with this technique than when I used to intubate. Just my experience.

 

[periopdoc]

The only lost airway in a "beach chaired" patient that I know of was in a patient with an ETT.

-pod

 

[IlDestriero]

(don't say this during your Oral Boards. You're being examined by academic doctors who are incapable of thinking out of the box, so stick to dogmas.)

You incessant bashing of academic anesthesiologists is tiresome.

 

[jetproppilot]

Beach chair, with the table turned 90-180 away from me? Not a chance. If I don't have immediate access to the airway, they buy a tube.

I'm not sure how an LMA would be safer than an ETT in that type of case. I can have them breathe spontaneously with an ETT as well if that's your only concern.

JWK,

THE 1970s ARE GONE MAN!!! GIVE IT UP!!!!

Just kidding with you. You know I have all the respect in the world for you.

You may be uncomfortable with it, but it works. You can't argue with numbers. An LMA general anesthetic with a good nerve block in place consists of

A STIKKA PROPOFOL AND A CRACK OF GAS.

If you decide to intubate a shoulder case with a good interscalene block in place

YOUR REQUIRED ANESTHETIC DEPTH IS FOR THE VERY STIMULATING ENDOTRACHEAL TUBE, NOT THE OPERATIVE SITE!!

With the ultrasound guided interscalene nerve blocks we do, there's no surgical stimulation. We do LMAs on nearly all shoulders. Beach chair, lateral, whatever. It's to the point where I think we could almost do MAC ANESTHESIA with these cases but an LMA is clearly safer and easier from a clinician standpoint IMHO.

Today I intubated a lateral shoulder for the first time in six months, only because the patient weighed 336 pounds.😱

JWK, I needed PRODDING to accept the whole ultrasound guided nerve block thing. I thought it was B.S. I WAS WRONG. Ultrasound guidance gives me better blocks with near ZERO failed blocks. I'm competent now and can perform them very quickly.

Guess what I'm trying to say JWK is

OPEN YOUR MIND, SENSAI.

You'll be surprised.

 

[KungPOWChicken]

The only lost airway in a "beach chaired" patient that I know of was in a patient with an ETT.

-pod

So how was the airway rescued? My guess is that it wasn't an ett.
When I was a resident we had a patient extubated in the prone position in a mayfield while the surgeon was performing a cervical fusion. To make things worse the surgeon hit the carotid and in the excitement got their foot in the co2 line which resulted in the extubation. Airway was secured easily with guess what??? (Hint: it wasn't an ett)

 

[jetproppilot]

Your incessant bashing of academic anesthesiologists is tiresome.

Don't take it personal.

IT'S TRUE, THOUGH,

AND YOU KNOW IT.

You're one of the few exceptions to the rule.

If you're honest with yourself, Dest, you'll agree.

ROKKSTARRS

ARE FEW AND FAR BETWEEN

IN ACADEMIA

 

[fakin' the funk]

When I was a resident we had a patient extubated in the prone position in a mayfield while the surgeon was performing a cervical fusion. To make things worse the surgeon hit the carotid and in the excitement got their foot in the co2 line which resulted in the extubation. Airway was secured easily with guess what??? (Hint: it wasn't an ett)

I don't see what your example of prone airway disaster rescue with an LMA has to do with this thread's topic, which is prone elective planned airway management with an LMA.

 

[fakin' the funk]

For those who are doing these beach-chair and prone LMAs, which LMA are you using?

Classic/reusable
Classic/disposable
Flexible (love the flexy shaft)
Proseal/reusable (gotta love the seal on these)
Proseal/disposable
Cook-Gas
Fastrach?

 

[nimbus]

For those who are doing these beach-chair and prone LMAs, which LMA are you using?

Classic/reusable
Classic/disposable
Flexible (love the flexy shaft)
Proseal/reusable (gotta love the seal on these)
Proseal/disposable
Cook-Gas
Fastrach?

Classic disposable

 

[jetproppilot]

Ive never understood this. If its something thats done every day by most anesthesiologists how come that isnt the answer on the oral boards?

Because academia and what is taught to residents and what is expected from you to regurgitate on oral boards

CONTAINS DOGMA

that, because of

THE GOOD OLE BOY SYNDROME THAT DOMINATES ORAL EXAMINERS...

POLITICS DOMINATE ACADEMIC MEDICINE, NOT

PATIENT CARE.

Yet

ACADEMIC PHYSICIANS ARE THE ONES PROCTORING THE ORAL BOARDS.

It is what it is man.

LEARN TO REGURGITATE WHAT THESE DINOSAURS THINK WHAT YOU NEED TO KNOW ABOUT OUR PROFESSION

then move on to a busy

PRIVATE PRACTICE

job where you'll

REALLY LEARN YOUR CRAFT.

IlDestrio is not too happy with me at the moment because I

NEGATIVELY CALLED OUT

ACADEMIC PHYSICIANS.

Current day,

THERE HAS BEEN NO MOMENTUM CHANGE.

GREAT DOCTORS GO INTO PRIVATE PRACTICE.

ACADEMIA IS A VACUUM FOR THE INEPT.

And THIS VACUUM IS WHO IS TEACHING OUR RESIDENTS.😱

There are exceptions to The Rule,

but it remains

A RULE:

ACADEMIC DOCS CAN'T TOUCH

PRIVATE PRACTICE

ROKKSTARRS

(I WISH RESIDENTS COULD LEARN FROM PRIVATE PRACTICE GUYS INSTEAD OF ACADEMIC GUYS. THEY'D BE MUCH BETTER OFF.)

 

[fakin' the funk]

Because academia and what is taught to residents and what is expected from you to regurgitate on oral boards

CONTAINS DOGMA

that, because of

THE GOOD OLE BOY SYNDROME THAT DOMINATES ORAL EXAMINERS...

POLITICS DOMINATE ACADEMIC MEDICINE, NOT

Can you please stop shouting.

 

[fakin' the funk]

(I WISH RESIDENTS COULD LEARN FROM PRIVATE PRACTICE GUYS INSTEAD OF ACADEMIC GUYS. THEY'D BE MUCH BETTER OFF.)

You know what, you're right.

The academic researchers and clinicians that have provided every advance in anesthesia care, knowledge, and safety in the modern history of the specialty, those guys are worthless.

Residents should be shielded -- nay, I say protected -- from these know-nothing, incompetent, non-"rokkstar" physicians. Throw the lot of them out.

They have in no way contributed to my education or yours.

And they sure as hell wouldn't be "slick" with LMA cases and blocks. 🙄

 

[Arch Guillotti]

You incessant bashing of academic anesthesiologists is tiresome.

Agree, it really is tiresome to hear. I think it is stupid to bash other anesthesiologists because of some outdated preconceived notions. Making sweeping generalizations gets old quickly.

Of course there are folks in academics because they couldn't "make it" in private practice. So what?

There are plenty of anesthesiologists in private practice that will dump a trainwreck on you so that they can get to their golf game. Or dump 4 rooms on you while they go do something else.

It goes both ways. There are duds all over and there are great anesthesiologists in private practice and academics.

I trained with a handful of oral board examiners. All were good folks and good anesthesiologists. They were all reasonable people. they were all lifetime academicians but none were dogmatic "ivory tower" types. My advice for oral boards would be to answer each question with exactly what you would do every day. You will get pushed around a bit and questioned but this is normal.

 

[IlDestriero]

Yeah, we suck at my shop. We're... stuperstars, not rokkheadstarz...
>30,000 cases/ year, dozens of papers, dozens of posters, lectures at every major meeting, simulations, leading advanced airway and block seminars, chapters in the leading texts in the field, authoring our own texts and developing smartphone aps.
Advancing innovation. I mean dogma.🙄
And that's just our little group at the children's hospital, this year.

I like the SDN ap BTW. All the text is the same size and color.😉

 

[periopdoc]

I had the pleasure of working with several current, prior and future oral board examiners.

Mostly good ones, believe it or not, but yes, some bad.

When I started, I would "play the game." AFOI every bad airway etc.

I quickly learned that they aren't so stuck in the old ways, and I was getting burned by them.

Just about every one of them told me to stop "playing the game."

"Tell us what you would really do and be ready to defend it."

It is an exam to see if you can think on your feet.

Not an exam to see if you can regurgitate dogma,

I followed their advice when I took the orals.

I did a few, um, non-traditional things.

So did most of my friends.

We all passed.

- pod

 

[imfrankie]

For those who are doing these beach-chair and prone LMAs, which LMA are you using?

Classic/reusable
Classic/disposable
Flexible (love the flexy shaft)
Proseal/reusable (gotta love the seal on these)
Proseal/disposable
Cook-Gas
Fastrach?

Whatever the purchasing agents are buying.

 

[imfrankie]

In defense of the academic endeavor, there is a general problem academicians have that private folks don't, and that is to try to bulletproof their anesthetic to some degree from sabotage by inexperienced trainees. While I am comfortable doing certain cases prone with xyz airway, I wouldn't be so comfortable entrusting a neophyte to the job. Do I think it's worth teaching, sure, but as a matter of course, the cases have to get done safely and quickly.

 

[ssmallz]

I had the pleasure of working with several current, prior and future oral board examiners.

Mostly good ones, believe it or not, but yes, some bad.

When I started, I would "play the game." AFOI every bad airway etc.

I quickly learned that they aren't so stuck in the old ways, and I was getting burned by them.

Just about every one of them told me to stop "playing the game."

"Tell us what you would really do and be ready to defend it."

It is an exam to see if you can think on your feet.

Not an exam to see if you can regurgitate dogma,

I followed their advice when I took the orals.

I did a few, um, non-traditional things.

So did most of my friends.

We all passed.

- pod

+1....everyone studying for oral should remember this....it's not what you say but how you defend it and what your reasoning behind it is.

Jet....not quite sure where all the hate for academic anesthesiologists comes from...don't forget they are teaching residents not seasoned vets. Would you start a 1st time pilot off on a complicated lear jet? no you'd start with a basic prop plane and keep it simple. You'd play it safe because when you're teaching a resident, especially a first year, they don't know the subtle differences that you and I may see to know when it's ok to push the envelope and when you need to play it safe. Your residency is all about learning the rules and understanding the fundamentals. Academic attendings teach that b/c that's what a resident needs. Once he/she understands the rules and has a deeper understanding of the anesthetic plan they can then learn when to break them. Always remember that PP is a different beast and comparing academics to PP is apples to oranges. It's not fair to slam our academic breatheren out there b/c they have different goals then we do

 

[btbam]

For those who are doing these beach-chair and prone LMAs, which LMA are you using?

Classic/reusable
Classic/disposable
Flexible (love the flexy shaft)
Proseal/reusable (gotta love the seal on these)
Proseal/disposable
Cook-Gas
Fastrach?

I-Gels are my favorite LMAs, not sure if that falls under the category of any of the ones you named.

 

[fakin' the funk]

"Tell us what you would really do and be ready to defend it."

It is an exam to see if you can think on your feet.

Not an exam to see if you can regurgitate dogma,

+1

The only "dogma" that we are taught about the oral boards -- and we are taught this repeatedly and incessantly -- is just what you said:

"Do what you would really do in real life."

 

[jetproppilot]

+1....everyone studying for oral should remember this....it's not what you say but how you defend it and what your reasoning behind it is.

Jet....not quite sure where all the hate for academic anesthesiologists comes from...don't forget they are teaching residents not seasoned vets. Would you start a 1st time pilot off on a complicated lear jet? no you'd start with a basic prop plane and keep it simple. You'd play it safe because when you're teaching a resident, especially a first year, they don't know the subtle differences that you and I may see to know when it's ok to push the envelope and when you need to play it safe. Your residency is all about learning the rules and understanding the fundamentals. Academic attendings teach that b/c that's what a resident needs. Once he/she understands the rules and has a deeper understanding of the anesthetic plan they can then learn when to break them. Always remember that PP is a different beast and comparing academics to PP is apples to oranges. It's not fair to slam our academic breatheren out there b/c they have different goals then we do

Yeah, you're right.
I was too harsh.

 

[Mman]

+1

The only "dogma" that we are taught about the oral boards -- and we are taught this repeatedly and incessantly -- is just what you said:

"Do what you would really do in real life."

The point of oral boards is to make sure you can articulate a safe anesthetic plan for whatever scenario arises. The oral board examiners recognize there are different ways of doing things. They want to make sure you can explain WHY you are doing something and WHAT you are going to do if something goes wrong. It doesn't really matter how you go down the path as long as you have a solid plan.

 

[Jalopycat]

I've done 2 prone LMA cases. The first one was supposed to be an interstim placement under sedation. The patient was agreeable to this. Once we got him positioned and the precedex started, he went completely bonkers and tried to come off the table. I was worried he was going to get hurt so I bolused him with propofol and shoved in an LMA Supreme while he was prone and we did the case under general. Worked fine.

2nd time I did it was for a kyphoplasty in IR with a radiologist who does them very fast. I used an LMA Supreme, made sure it fit perfectly, taped it real good, kept the patient's head turned slight toward me the whole case so I had access to it. Case went fine.

I think it's ok as long as you pick your patients (and surgeons) carefully and always have an emergency plan. Would I do this everyday? No.