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ProPropofol

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As I was pushing a 198kg patient to the OR today for her Mirena insertion under general anesthesia with a known difficult airway, I was wondering what other institutions do for patient transport. At our hospital, the circulating nurse has to see the patient in pre-op before the patient goes to OR to confirm that all the paperwork is done then immediately sprints back to the OR to wait for the patient to arrive leaving me by myself to push the bed to said location. Under certain pretexts (i.e. ICU patient, patient on monitor, first case of the day, etc), the anesthesiologist, resident, or CRNA is the sole person pushing the patient to and fro the OR; 'anesthesia transport' they say. If you beg and plead, you can sometimes get an anesthesia tech to help you. However, I've noticed that when ICU patients are transported around the hospital to non-anesthetizing locations, the nurse always has transport aides push the bed (and I guess the RT might help if the patient requires ventilatory assistance of some sort).

What do other hospitals do? Are you by yourself pushing beds? Nurse helps?
 
GravelRider said:
Are your nurses unionized?
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100%

To the point where they will hold free raffles that are nursing union specific. Can't participate unless you are apart of the union. Very awkward to come to a raffle stand on doctor's day then be turned away from participating because you aren't a unionized nurse.
 
ProPropofol said:
100%

To the point where they will hold free raffles that are nursing union specific. Can't participate unless you are apart of the union. Very awkward to come to a raffle stand on doctor's day then be turned away from participating because you aren't a unionized nurse.
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So in order to get the nurses to help you, it has to be approved by the union.
 
At our primary hospital in the main ORs, the anesthesiologist or CRNA push the patient, along with the circulator. If I'm busy, I can often ask, and they'll bring the patient back from holding themselves. For ICU patients, the unit nurse may push to the elevator, but can't go into the OR proper, and an anesthesia tech may also accompany, if extra hands are needed. At every other site in the hospital (EP, Endo, L&D, IR), as well as all of our outlying hospitals, the nurse will bring the patient to me in the room.
 
Currently, similar to many others here: nurse into OR, nurse plus anesthesiologist or CRNA out of OR.

I prefer anesthesiologist or CRNA plus nurse into OR and out of OR.

I will add that it is an equally d*ck move to make the nurse bring a patient like this alone.
 
OR - Anesthesiologist pushes cart from pre-op to OR/OR to recovery, but circulator is required to do final check before leaving pre-op and must physically assist anesthesiologist with transport to and from OR.

IR/EP/GI - Circulator brings patient to and from the room, anesthesia accompanies to recovery.

Can get additional care tech +/- anesthesia tech to assist with complicated transports (vented, drips, etc). If any sort of mechanical circulatory support, perfusion comes too.
 
Patient transporter would bring outpatient patients in holding to or.

My old hospital for vented patients the patient transporter respiratory tech and nurse would bring down patient with just ekg. No pulse ox or blood pressure cuff …
 
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My training hospital, resident/crna push to OR with circulator. Push to PACU with surgical resident/PA.

My new job, circulator brings patient to room and puts them on monitors, texts you when they get in the room, including from ICU, except when intubated, I'll ventilate while they push. Push to PACU seems a mix of anesthesiologist pushing while circulator accompanies or circulator pushes while anesthesiologist accompanies.
 
anbuitachi said:
here, we transport and surgery resident (every case has surgery resident) either pulls or we steer. for big patients like above, surgery resident is absolutely pulling

you definitely need a new job!

a 198kg patient getting mirena? under GA? definitely leave that job
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Plan to get out of this gig within a year. Starting to be a tad much
 
DrOwnage said:
At my current gig the nurse always brings the patient in. I usually wait in the room or in the lounge then they call me. Airway go ok?
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Airway surprisingly went well. Pre-oxygenated to 90% expiratory O2, Video Laryngoscope, extra set of hands in the room, small tube (no bold moves here), nice shoulder roll to put in sniffing position, etc. Happy it was a a safe intubation. The previous attempt was failed by 3 different attending anesthesiologists
 
Thank you for all your insights! Helpful to see things from a different perspective.
 
ProPropofol said:
Airway surprisingly went well. Pre-oxygenated to 90% expiratory O2, Video Laryngoscope, extra set of hands in the room, small tube (no bold moves here), nice shoulder roll to put in sniffing position, etc. Happy it was a a safe intubation. The previous attempt was failed by 3 different attending anesthesiologists
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Never given GA for an IUD insertion. But some patients are now advocating for it. How did that go?

And you’re at the same place that does GA for TTEs so why not IUDs too? 😉

The biggest question I have is how do you or your department get paid for this stuff?
 
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nimbus said:
Never given GA for an IUD insertion. But some patients are now advocating for it. How did that go?

And you’re at the same place that does GA for TTEs so why not IUDs too? 😉

The biggest question I have is how do you or your department get paid for this stuff?
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I have given GA for multiple IUD insertions as well as just routine pelvic exams with the indication being "difficult body habitus" These cases typically involve an obese patient with a less than favorable airway requiring large amounts of propofol for induction where the induction dose of propofol will usually get you through the entire exam/IUD insertion unless a junior resident is doing it. Then everyone stares at you when they are done in less than five minutes to wake the patient up acting like you are wasting their time when in fact the opposite is true. If you have to tube them, the succinycholine hasn't even worn off by the time they finish or you use a ton of sugammadex. Perhaps I should use something shorter acting for induction.... Etomidate? Methohexital? Remi? A problem for another day.

Yes, same institution that does GA for transthoracic echos intermittently. I'm pretty sure that we don't get reimbursed for the anesthetic for these insane cases. We are all hospital employed and this is just the silliness that comes with being employed by a hospital that just sees anesthesiologists as a service to proceduralists and surgeons. We exist to serve insane requests! The hospital eats the cost to keep surgeons happy. I'm employed so I get paid the same regardless of whether or not the insurance pays for the anesthetic.

A week at my facility would give everyone a cynical view of the specialty.
 
ProPropofol said:
I have given GA for multiple IUD insertions as well as just routine pelvic exams with the indication being "difficult body habitus" These cases typically involve an obese patient with a less than favorable airway requiring large amounts of propofol for induction where the induction dose of propofol will usually get you through the entire exam/IUD insertion unless a junior resident is doing it. Then everyone stares at you when they are done in less than five minutes to wake the patient up acting like you are wasting their time when in fact the opposite is true. If you have to tube them, the succinycholine hasn't even worn off by the time they finish or you use a ton of sugammadex. Perhaps I should use something shorter acting for induction.... Etomidate? Methohexital? Remi? A problem for another day.

Yes, same institution that does GA for transthoracic echos intermittently. I'm pretty sure that we don't get reimbursed for the anesthetic for these insane cases. We are all hospital employed and this is just the silliness that comes with being employed by a hospital that just sees anesthesiologists as a service to proceduralists and surgeons. We exist to serve insane requests! The hospital eats the cost to keep surgeons happy. I'm employed so I get paid the same regardless of whether or not the insurance pays for the anesthetic.

A week at my facility would give everyone a cynical view of the specialty.
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And medicolegally, it would be very difficult to defend a bad outcome after inducing GA in a 400lb patient with a known history of difficult airway for a procedure that is almost universally done in gyn clinic without any anesthesia.

Glad your case worked out but it sounds like the hospital is making medical decisions, not the doctors. How was this patient consented? Crazy.
 
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ProPropofol said:
I have given GA for multiple IUD insertions as well as just routine pelvic exams with the indication being "difficult body habitus" These cases typically involve an obese patient with a less than favorable airway requiring large amounts of propofol for induction where the induction dose of propofol will usually get you through the entire exam/IUD insertion unless a junior resident is doing it. Then everyone stares at you when they are done in less than five minutes to wake the patient up acting like you are wasting their time when in fact the opposite is true. If you have to tube them, the succinycholine hasn't even worn off by the time they finish or you use a ton of sugammadex. Perhaps I should use something shorter acting for induction.... Etomidate? Methohexital? Remi? A problem for another day.

Yes, same institution that does GA for transthoracic echos intermittently. I'm pretty sure that we don't get reimbursed for the anesthetic for these insane cases. We are all hospital employed and this is just the silliness that comes with being employed by a hospital that just sees anesthesiologists as a service to proceduralists and surgeons. We exist to serve insane requests! The hospital eats the cost to keep surgeons happy. I'm employed so I get paid the same regardless of whether or not the insurance pays for the anesthetic.

A week at my facility would give everyone a cynical view of the specialty.
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Could you do a mask anesthetic, or are the airways too bad? Propofol, oral airway, two hand mask, vent on pressure control. Probably wouldn’t even need volatile if it’s truly that fast. Just let the propofol induction be the anesthetic. Maybe give a little bit extra if they get light.

Or just do the same as above but with a size 5 Igel LMA.
 
coffeebythelake said:
Official policy is for the surgical team to accompany transport to the OR. They usually help with pulling the cart.
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100% agree. It’s team effort. Was solo 3x this week. Help push patient to the OR with nurse. It’s no biggie if you don’t have physical problems like back pain to push.

If light patient or outpatient stretcher. Sometimes the nurse does push from same day to mac procedure room like gi patients I did yesterday but if on hospitals bed. I will help them.

Make it an OR policy. That pretty much eliminates the me first attitude.
 
nimbus said:
And medicolegally, it would be very difficult to defend a bad outcome after inducing GA in a 400lb patient with a known history of difficult airway for a procedure that is almost universally done in gyn clinic without any anesthesia.

Glad your case worked out but it sounds like the hospital is making medical decisions, not the doctors. How was this patient consented? Crazy.
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Look the same argument could me made of you decide to sedate this patient, requiring increasing amounts of sedation for a patient who isn't tolerating the procedure, then have a bad outcome that way. They've clearly tried to do this other ways and failed. I don't see the big medicolegal concern. And I would rather secure that airway than mess around trying to sedate an elephant.
 
GassYous said:
If it's that hard to place the iud is the iud even necessary...
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a3775168752_5.jpg
 
Dantrolene FC said:
Could you do a mask anesthetic, or are the airways too bad? Propofol, oral airway, two hand mask, vent on pressure control. Probably wouldn’t even need volatile if it’s truly that fast. Just let the propofol induction be the anesthetic. Maybe give a little bit extra if they get light.

Or just do the same as above but with a size 5 Igel LMA.
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I wouldn't do a huge patient in ?high lithotomy position with a SGA. Even if it seats well all that redundant abdominal tissues pushed cephaladid will mean airway pressures will be quite high to deliver an adequate breath.
 
coffeebythelake said:
I wouldn't do a huge patient in ?high lithotomy position with a SGA. Even if it seats well all that redundant abdominal tissues pushed cephaladid will mean airway pressures will be quite high to deliver an adequate breath.
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You're not delivering a breath they are breathing by themselves
 
I often find success with the passive-aggressive strategy of saying "I'll meet you in the OR, go ahead and bring them when you're ready."

I very, very rarely pretreat anyone with midazolam or anything else in preop so there's never any "monitoring" argument that my presence is needed.

I'll push, if I'm there. I don't really mind, but I'm not going to hang around and wait on them to chat and SBAR and click some clicks and XYZPDQ and sign out, just so I can push a gurney to the same place they're going anyway.
 
GassYous said:
You're not delivering a breath they are breathing by themselves
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Morbidly obese people in lithotomy hypoventilate, get atelectasis, and require my frequent attention. Ain't nobody got time for that! It's so much easier to tube them and be done with it.

For a device that's supposed to "simplify" anesthetics, LMAs can be a real pain in the ass sometimes.
 
coffeebythelake said:
Look the same argument could me made of you decide to sedate this patient, requiring increasing amounts of sedation for a patient who isn't tolerating the procedure, then have a bad outcome that way. They've clearly tried to do this other ways and failed. I don't see the big medicolegal concern. And I would rather secure that airway than mess around trying to sedate an elephant.
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I agree GA/ETT is probably the best option when backed into this corner. But given the info we have, it’s not clear to me that they “tried other ways”. This is the same place where they do TTEs with GA. Is IUD insertion commonly done with GA elsewhere? I’ve been practicing 3 decades and never seen or heard of it. Maybe I need to get out more.
 
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GassYous said:
If it's that hard to place the iud is the iud even necessary...
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Would you rather do the GA for the IUD, or the labor epidural followed by the c-section under epidural or GA when she says she can "feel" the Allis?

The IUD strikes me as a literal ounce of prevention for the later 198 kg (+ baby weight gain) cure.
 
pgg said:
Would you rather do the GA for the IUD, or the labor epidural followed by the c-section under epidural or GA when she says she can "feel" the Allis?

The IUD strikes me as a literal ounce of prevention for the later 198 kg (+ baby weight gain) cure.
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pregnancy will be just the excuse the patient needs to put on another 200 lbs,
 
vector2 said:
It's not. Some poster was talking in another thread about how they're forced to do anesthesia for surface echos.
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This appropriately titled thread. GA for NG tubes too. I’m surprised the patients don’t get GA for foleys.


forums.studentdoctor.net

Anesthesia for dumb cases

Just wanted to see if other groups/departments do anesthesia for completely unnecessary procedures. We provide anesthesia often for port placements (even removals), nephrostomy tubes, bone marrow biopsies, adult MRIs, angiograms. And all in regular patients (not jsut patients with mental...
forums.studentdoctor.net forums.studentdoctor.net
 
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pgg said:
Morbidly obese people in lithotomy hypoventilate, get atelectasis, and require my frequent attention. Ain't nobody got time for that! It's so much easier to tube them and be done with it.

For a device that's supposed to "simplify" anesthetics, LMAs can be a real pain in the ass sometimes.
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It's an iud not a spinal cord stim. 5 min case
 
Yikes I guess I'm lucky and don't realize how bad some of ya'll have it.

Haven't routinely been pushing beds in years. Do my own cases 100%, in Texas.

Usually it goes like this: drop off last pt in PACU --> straight to pre-op to see and consent next patient --> go sit in Drs lounge to eat/drink/restroom --> RN does all their paperwork and hand-off stuff, then brings patient back (and gets help from anesthesia tech if its a big bulky hospital bed) and they'll overhead page me when they're in the room --> I pull up meds while RN / anesthesia tech move patient, apply monitors, pre-oxygenate.

ICU transports I go with them, of course.

Everyone works fast and efficient because the sooner all the cases are done the sooner everyone goes home (including the nurse).
 
Wow. The circulator rolls the patient into my rooms at various hospitals. I’ll get a call or nod depending on the hospital and call room location. I do usually roll the patient from the or to the pacu.

If the case is coming from the icu and the patient is intubated, then I will bring them down personally and bill for the time.
 
Realgassy said:
Wow. The circulator rolls the patient into my rooms at various hospitals. I’ll get a call or nod depending on the hospital and call room location. I do usually roll the patient from the or to the pacu.

If the case is coming from the icu and the patient is intubated, then I will bring them down personally and bill for the time.
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We participate in the handoff from pre-op to circulator, and then both of us push the stretcher/bed to the OR. Not a big deal.

Some of our guys push the stretcher themselves. I don't and won't, especially coming out of the OR to PACU. My attention is and should be focused on the patient, not steering the stretcher. I had a nurse refuse to even do that the other day. My patient was breathing fine and had nasal O2 on so I just stood there in the hallway until she started helping. She told me "I have a bad back". I told her I've had two total hips - and if you can't do what's required as the circulating nurse you need to find another job.

Gassy's point is important. We are required by hospital policy to go get the patient's from the ICU with the OR staff, whether they're all wired up and vented, or just in the ICU as a precaution. That is chargeable time - same for the return trip and the report to the ICU nurses. I write a transport note that includes "pt transported to/from ICU with anesthesia staff per hospital policy". My time is never free.
 
You people are weird, man. I have no qualms about pushing the patient when needed, whether it be a regular stretcher or an ICU bed with two IV poles, 16 pump channels, four transducers, an ECMO circuit, and an Impella in tow. If I can do that and manage a complex, dying patient at the same time with literally zero safety issues ever, I think people in general can push a stretcher without complaining about needing to monitor a spontaneously breathing patient going to PACU three feet down the hall.

If I have help, sure, by all means. If I don’t, well, let’s just take care of the patient and get them where they need to go. If more hands are needed, then I’ll wait for help. No need to make a grand gesture about how I am too much of a physician anesthesiologist male doctor man to lay hands on the stretcher like the help.
 
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