Question about when the SHTF

[punkedoutriffs]

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I understand that anesthesiologists are constantly going over scenarios in the head during cases where things are apt to go awry, planning for different responses and such. My question is, when things go badly, how much of what you end up doing in direct alignment with what you were envisioning in your mental scenario and how much is automatic, intuitive response? Is the constant planning necessary or is it compulsive but not really needed? Or maybe things get more intuitive as you gain more experience and therefore have to think less?

 

[excalibur]

Things become more intuitive and automatic with experience because you've seen more and thought about scenarios more.

The constant planning and going over scenarios is necessary because you need to be prepared and these scenarios do arise and you are likely to see them.

I recall the super crazy scenario "what if you are in the middle of the case and the electricity goes out and the room is pitch black. What would you do?". I recall going over this scenario with colleagues. I then remember reading an article in an anesthesiology journal of where this happened and how the anesthesiologists managed their cases and a review of their methods.

And you know what. This scenario eventually happened to me, albeit for a very short period of time like 5-10 seconds.

Actually this scenario also happened in residency when a patient was on bypass for CABG. From my understanding the bypass pump was on emergency power for about 30 minutes and the electricty came back on before emergency power ran out. I guess after that, it's hand crank time for the perfusionist.

 

[excalibur]

Just last week I had to deal with an intraoperative aspiration right after induction. I have gone through that scenario several times and boom it happened.

These scenarios happen, so you have to go through them in your head.

 

[HollywdAnesth]

There are a few instances such as an airway fire, where you need to have a clear checklist for what to do.

However, the stuff out of left field like a power outage, you just take a moment and determine what the bare minimum is to keep the patient alive. You'd be surprised how sharp the adrenaline makes your thinking.

There was a famous M&M from my training hospital where a fire in the basement made the hospital shut off all of the wall gas sources. That sounded like a good time.

 

[jetproppilot]

I understand that anesthesiologists are constantly going over scenarios in the head during cases where things are apt to go awry, planning for different responses and such. My question is, when things go badly, how much of what you end up doing in direct alignment with what you were envisioning in your mental scenario and how much is automatic, intuitive response? Is the constant planning necessary or is it compulsive but not really needed? Or maybe things get more intuitive as you gain more experience and therefore have to think less?

Dude,

Our profession is in the

HIGH RISK HIGH REWARD

category.

We get paid to be

COOL UNDER FIRE.

When a problem occurs in our business, there is usually no

INTRODUCTORY MUSIC PLAYING, WARNING US OF IMPENDING DANGER like watching the movie JAWS where the music CUES YOU.

Nope.

It just

HAPPENS.

BOOM.

EMERGENCY.

RIGHT NOW.

One minute there you are all Chatty Cathy with the OR staff during an induction, everythings cool, you're telling the circulator about your new car or the restaurant you've got reservations to or how you think her new cell phone is cool and

BOOM

you can't intubate even tho you're a ROKKSTARR

and

EVERYTHING CHANGES IN A FEW SECONDS.


THE SCENARIO HAS GONE FROM CORDIAL TO EMERGENT

IN THIRTY SECONDS..

Calls for help/calls for Glidescope/etc....

AND YOU HAFFTA DEAL WITH IT. RIGHT NOW.

THE CLOCK IS TICKING....YOU NEED TO SOLVE THE PROBLEM RIGHT. NOW,

OR THE PATIENT MAY

DIE.

TICK...TICK...TICK...

OR

You're in the heart room trying to come off pump after a tenuous case and you look at the numbers then you look over the drape at the actual heart which is struggling and

DING!!!!! A LIGHTBULB GOES OFF IN YOUR HEAD

because you were able to put the pieces of the Physiologic Puzzle together so you started milrinone or dobutamine or epinephrine or you asked the Pump Tech to take volume off or you asked the Pump Tech to bring ALOTTA VOLUME RIGHT NOW PLEASE

OR,

(and this takes a BIG NUTSACK to do sometimes..)

YOU SAY TO YOUR HEART SURGEON BUDDY:

"DUDE...WE'RE ALMOST THERE... SIT TIGHT AND LET'S

DO NOTHING"

for ten minutes.

Sometimes DOING NOTHING is the best thing.

The above is kinda a RAMBLE, but with a

GREAT MESSAGE:

ALL THAT GREAT S H IT ABOVE HAS EITHER BEEN

REHEARSED OR EXPERIENCED.

Starting off without experience, you

REHEARSE,

AND LIVE BY YOUR REHEARSALS.

Many years into Private Practice, my experience plays BIG in decision making...but

DON'T THINK FOR A MINUTE THAT I DON'T STILL

REHEARSE

 

[punkedoutriffs]

Thanks for your responses.

 

[periopdoc]

THE SCENARIO HAS GONE FROM CORDIAL TO EMERGENT

IN THIRTY SECONDS.

Everything is spot on except this. You never get 30 seconds. $hit usually goes to hell in les than 3.5 sec.

- pod

 

[periopdoc]

Oh yeah, and the day you have seen it all and done it all and stop running scenarios in your head is the day you should retire IMHO. But the time spent hypothesizing vs chilling in the OR does go down the longer you do it.

- pod