RESIDENTS: Where are you with your skills?

Discussion in 'Anesthesiology' started by jetproppilot, Dec 13, 2008.

  1. jetproppilot

    jetproppilot Turboprop Driver
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    Lets face it.

    Anesthesia is a medical specialty fulla SKILLS.

    Twelve years into private practice, I can report to my resident colleagues looking for lucrative private practice jobs that, well,

    IF YOU DON'T HAVE THE SKILLS, YOU A'INT PRIVVY TO THE BENJAMINS.

    I currently work for an AMC.

    Moneys kinda tight so one of us was UHHHHH.....JUST LET GO.

    Of course theres a caveat.

    Caveat being you will learn alot from your first private practice job from partners that are more than likely eager to bring you up to speed.

    You are not expected to emerge from residency with the deftness of BOND. JAMES BOND.

    YOU ARE, though, as an emerging resident, expected to have a certain SKILL STRENGTH that can be added to....

    ....let me add here that the JUST LET GO DUDE wasn't the most recently hired dude, since the most-recently-hired-dude HAS SKILLS.

    so you've done a buncha interscalene blocks as a resident.

    DO YOU CONSIDER YOURSELF COMPETENT IN INTERSCALENE BLOCKS?

    Can you do a labor epidural in FIVE MINUTES, leaving five more minutes for paperwork?

    Can you do a central line in FIVE MINUTES?

    Can you do a spinal in SEVENTY THREE SECONDS (not accounting for set up time)????

    I'm speaking primarily to CA-3s here.

    THE "DEFTER" YOU ARE COMING INTO A PRACTICE, THE MORE VALUABLE YOU ARE, WHICH TRANSLATES INTO THE-MORE-LIKELY-YOU-ARE-TO-BECOME-PARTNER.

    So I return to the initial question, primarily to CA-3s....

    WHERE ARE YOU ON YOUR SKILL SET?

    Can you do our CORE SKILLS (epidurals, spinals, axillary blocks, interscalene blocks, A lines, central lines, intubations....)

    CDAZY FAST????

    YES?

    NO?

    Here's an insider secret:

    Residents emerging into a new practice that can do these skills FAST and WITHOUT HELP will be REVELED.

    SO,...

    ARE YOU THERE?

    And if you are not,

    its only December.

    I encourage you to work on your efficiency with our specialty's CORE SKILLS before you show up on the doorstep of your new private practice group.

    Always remember that

    FASTER MAKES YOU BETTER. (a concept long ignored by academia)

    You've still got six months.

    Work on your speed NOW.
     
    #1 jetproppilot, Dec 13, 2008
    Last edited: Dec 14, 2008
  2. coprolalia

    coprolalia Bored Certified
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    I'm so fast, I'm done before I even start. (Of course, my gf is also very frustrated.)

    Seriously, just this past week, masked a kid down (2 y.o. big ex-lap) while attending put in PIV, tubed him, flipped him on his side, plunked in a thoracic epidural in about 30 seconds, flipped him back over on his back, and had the case ready to start at 7:42 AM (in the room at 7:26 AM).

    Is that CDAZY FAST enough?

    -copro
     
  3. huktonfonix

    huktonfonix board certified!
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    dont forget the quick emergence and case setup also.
     
  4. Noyac

    Noyac ASA Member
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    And there in lies one big reason not to do LOCUMS as a new grad. You will not progress like the others will.
     
  5. zippy2u

    zippy2u Senior Member
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    Bah, you'll be ready for locums Copro after you've done 25 intubations with a tongue depressor, 25 IV starts at " head of bed" position, 25 "akinetic" eye blocks and 25 prone LMAs(10 in semi jack-knife position to make ya squirm abit). Ok, that'll get ya started for now. Tomorrow, I'll have ya pre-op 60 pts for the ASC in 8-10 hrs (20 of those 60 with be various blocks that you'll have to do). Yup, the CRNAs need pre, lunch and post breaks or they'll be mighty pissed. Regards, -----Zip
     
  6. camkiss

    camkiss Junior Member
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    Dude, Jet...

    You just described the situation with my group as well. Decreased cases, partners decide to cut someone loose. I just joined fresh out of residency 6 months ago. The other non-partner gets cut, and I stay. I agree with you one-hundred percent. You have to be good AND fast with procedures. You have to bring your A-game with every stick, every patient. Use your time as a CA-3 to work on making all your procedures better. Your future partners will appreciate it.
     
  7. jetproppilot

    jetproppilot Turboprop Driver
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    CHALLENGE YOURSELF. MAKE YOURSELF BETTER, STARTING TODAY.

    F uck the residency-standard that you live by, which is that a procedure takes AS LONG AS IT TAKES.

    NOPE.

    CA-3s, THAT AIN'T GOOD ENOUGH OUT HERE.

    Its December.

    You've got six months.

    HEIGHTEN YOUR GAME. STRIVE TO BE FASTER WITH WHATEVER PROCEDURE YOU ARE DOING.

    Lost?

    Latch on to the occasional academic attending who does procedures CDAZY FAST while hung over.

    And does the same procedures faster than the speed of light when not hung over.

    Better yourself, RIGHT NOW.

    Theres BENJAMINS at stake.:thumbup:
     
    #7 jetproppilot, Dec 13, 2008
    Last edited: Dec 14, 2008
  8. jetproppilot

    jetproppilot Turboprop Driver
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    Yes.

    And theres always psychotherapy for your premature ejaculation tendencies, my friend.:laugh:

    (of course, just kidding. And now back to the thread without any hijacking....)
     
  9. zippy2u

    zippy2u Senior Member
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    Really the last 6 months of your CA-3 year, your attending should be put over in the corner in charge of shiit that ain't important. With a peds inhalational induction, YOU should be starting the IV once the kid gets deep, not your attending. Many o' times during a locum gig in BFE I got that "deer in headlight look" when I asked who the helll was startin' my IV on this here tater tot. Ahhh, that be you Zip! Regards, ---Zip
     
  10. cubs3canes

    cubs3canes Senior Member
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    IV quick...induction and emergence quick. Central access, no problem.

    ALINE...slow as molasses...thank goodness I have 18 more months.

    However, what I take pride in is the turnover time. With no help and turning my own room over, I want to go from OR to PACU to Holding to OR in under 10 minutes. I know that I did it well when the nurses yell at me for bringing the patient back to early. It always makes me smile under the mask.

    Cubs
     
  11. SleepIsGood

    SleepIsGood Support the ASA !
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    Dude tell me about that! I do the same thing. I can usually turn the room over so quick that the nurses are telling me to slow down and 'take my time'.

    Cubs, I think you are in the same situation as me, which gives us an advantage in a way. I'm not at a "Big Academic" place, so it's very PP style. Grads from where I'm at say the 'real world' isnt too far off from how we're doing stuff.

    Seriously, at our place we do over 15 phacos on certain days. The ophtho residents from the 'Big University' tell us that the entire day at their place due to turnover issues and such only 4 are done a day:eek:
     
  12. jwk

    jwk CAA, ASA-PAC Contributor
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    Bingo - all the speed at procedures doesn't matter if it takes 20 minutes to get your patient off the table.

    Also - don't neglect your intra-op basics either (as in don't let them move in the mayfield because you like to run them light). Actually saw this a few years ago in a now-former never-made-partner dude.
     
  13. urge

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    Your attending is pretty fast.
    My point exactly. If the attending did the IV, who do think did the thoracic epidural in that 2 yr old?
     
    #13 urge, Dec 14, 2008
    Last edited: Dec 14, 2008
  14. coprolalia

    coprolalia Bored Certified
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    Yeah, haha. He put the PIV in, I did everything else.

    -copro
     
  15. Fastrach

    Fastrach New Member
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    30 seconds is all well & good for an epidural, but that's one skill I don't think I'll ever feel inclined to rush past my standard 5-10 minutes...

    One thing I do love doing in the blink of an eye is spinals... like a samurai with that pencan needle! :ninja:
     
  16. darkmansaad

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    am i the only wondering what cdazy fast means
     
  17. Arch Guillotti

    Arch Guillotti Senior Member
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    30 seconds for a thoracic epidural on a 2 year old....?

    :eyebrow::eyebrow::eyebrow:
     
  18. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    :roflcopter:
     
  19. maceo

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    Ive been doing one handed spinals in 30 secs or less, less than 3 minute epidurals, the patient is usually intubated while he is moving to the or table.. but you know what speed is not the name of the game int he long run.... its your clinical judgement that matters.. period.. I conquered the speed game my ca 3 year. i was doing epidurals faster than most of the attendings.. nobody cares. the surgeon will take his sweet ass time regardless of how much time it took you to put in the epidural. And any group who cuts you because you take 5 mins longer to do an epidural is no group i will be involved with.
     
  20. jetproppilot

    jetproppilot Turboprop Driver
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    5 min? 10min? 15 minutes for an epidural? I agree. All are reasonable.

    I can assure you though that if youre in certain, busy private practices that have a holding area full of blocks, epidurals, lines et al and youre not reasonably efficient, or you leave the floor and head for OB to place an epidural and it routinely takes a "long" time,

    I can assure you your partners will care. And technical prowess is an important part of our specialty, among many other things as above posters pointed out.

    Point of the thread is to make yourself as good as possible during your CA-3 year, OK SLIM?:rolleyes:
     
  21. aredoubleyou

    aredoubleyou Senior Member
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    How is everyone defining their speed? Time the needle enters the skin to the bupiv is intrathecal? Then I might of had a couple 30 s spinals. But starting at identifying the interspaces- I never been less than a minute I'm sure. Often a couple minutes (combination of my relative inexperience and the bigger ladies we see) and I feel like things went ok. More than once Ive been stabbing at their back for at least 5 minutes (not including the 500 pounders that everyone expects you to take a millions stabs at).

    Also not adding in patient positioning, I may have done one or two 5 minute epidurals so far (prep the skin, to applying tegederm to the catheter). If everything goes perfect, prolly 1 minute to set up my stuff, 1 minute to prep, drape, and identify interspaces, 1 minute for LOR (which more times than not becomes 2-5 minutes on moderalty sized people), 1 minute to put in the catheter, remove the needle, and put on the sticky crap and apply the tegederm. Usually it takes AT LEAST twice as long. Granted I'm still a youngin' and realatively new to this - but the routine 5 minute epidural is something I really havent considered as being a possibility.
     
  22. Lonestar

    Lonestar Senior Member
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    We have this crazy pump contraption that takes time to setup so it takes me 15-20 min to do the epidural. Also, the paperwork takes time. My actual time for epidural from needle insertion to catheter secured is less than 3-5 min everytime.
     
  23. huktonfonix

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    I like to think Im pretty fast, but theres no one I know who can get 3-5 minutes in every patient. Maybe 97-99%. Theres always gonna be a hard one once in a while. Is that the spring loaded LOR syringe? Ive seen ads for it and it seems cool but unneccesary unless you dont have a good feel for the ligament.
     
  24. dhb

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    The other day i got a call at 11:30pm for a double lung transplant asap so i tell the senior resident ok but give me 10min for a labor epidural (i was on the 8th floor at that point). So i go down to the 2 floor say "hi mam i don't have time to f**k aroud here's your epidural". At 11:40 i was in the OR :D

    yes

    yes

    Of course you sometimes rrun into difficulties but that's the game

    Often the problem with trying to be fast in academia is that the nurses can't keep up so you'll have the central line the art line and tube done in 15min but all in all it took 45min because they weren't moving as fat as you.
    Anyway a key part is wake up, rarely do i have to wait to wake patient up after a procedure and usually it's because the attending is around and doesn't want to extubate deep.
     
  25. drccw

    drccw ASA Member
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    in our line of work you have to toe the line in terms of speed... you wont get noticed or ackowledged for your fast speed... but if you're slow.. people notice.. and by people I mean the people that sign your paycheck...it's ok to take a little extra time ever now and then with a labor epidural or with a line... but if it's every line and every epidural then you got to get your hands quicker, your mind quicker... dont bother with landmarks before you prep.. it's a waste of time.. you're going to do it again, so do it once... economy of motion.... you know how the kits come with two needles? dont switch.. use the longer needle for subc and deeper structures.. Figure out where you can cut out time in your epidurals and you'll be fine... peripheral nerve blocks- be comfortable with them.. our total knees all get three blocks- fem, sci, and obturator... then they get a GA... we dont have space in the holding area to do blocks so they are all done in the room... our fastest guys can do all three blocks and have the LMA taped in in about 11 minutes from hitting the door... the slower ones are out at 17 mins... I take about 14... there isnt time to draw your landmarks etc etc... you need to be able to look at a guy's butt and know where the sciatic nerve is....

    the goal in private practice is to fly under the radar... don't make yourself a liability, and don't do things that will cause the surgeon to complain... if you take an extra 10 mins than the other guys on your total joints, and the surgeon's doing 4 a day then your slowing him down.. and let's face it, for all bad***** that we act like we are, the surgeon is second on the list of who needs to be happy.... but he or she is first on the list to complain to the powers that be...
     
  26. radslooking

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    not a gas man, but I appreciate the message that faster makes you better. also, it makes you saner. Cambie once said it best, that speed becomes a safety issue as well. If you are taking way too long to do something it impacts how well you can care for other people as well. That goes for a lot of specialties. Practice, practice, practice.

    Also, I appreciate the dictum that residency is being taught by the wrong people many times. The people who mainly couldnt hack the speed of private work teaching the residents.
     
  27. jwk

    jwk CAA, ASA-PAC Contributor
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    Setting up the pump and programming it to YOUR order is the job of the nurse in L&D. Seriously.
     
  28. bigdan

    bigdan SDN Donor
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    Yep. You're the only one.

    FYI, It's Jet-ese for "crazy fast". I actually have my own version, in which I trill the letter "r", like you'd hear in Spanish, so it's "crrrrrrrrrazy fast".

    You're welcome.

    dc
     
  29. pgg

    pgg Laugh at me, will they?
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    Today's case: mask induction, two 16g IVs, ETT, art line, ready to flip in 16 minutes. The longest part was the mask induction because the "kid" was big.

    Sat there while they placed SSEP/MEP electrodes and found pieces to the bed. Cut time 74 minutes after we were in the room and 58 minutes after I was done with my part.


    Oh, man, I wish. I wish.

    They'll get the bag of ropivacaine for us. Usually the tubing, too. On a related topic, our APS routinely gets paged to refill pumps running plain ropivacaine because the nurses don't have keys. Once they forgot to order the refill from the pharmacy and our first clue that something was wrong was a stat APS page for a patient in excruciating 11/10 pain ... because his epidural pump ran dry an hour earlier. "Yeah, I wasn't sure why it was beeping, but we're not supposed to touch those pumps."

    If it's pain related, fluid filled, and connected to the patient by Luer Lock, it's all us.

    There's a 10 minute variable on my labor epidural speediness that is 100% nurse related. The ones that fetch the drugs & tubing, start the fluid bolus, sit up the patient, shoo family members out, and get dad parked on the stool in front of mom before I walk in with the kit are a pleasant treat. If not, add 5-10 minutes of obligatory jibber-jabber at the family, cajoling mom upright, finding tubing or a pump or a vent for the bottle, perhaps looking for the nurse ...

    It's hard to be efficient when you're surrounded by shift workers who view efficiency as a risk factor for getting another patient.


    Just finished up 3 months of cardiothoracic, so I'm comfortable and fast with central lines and a-lines. About 2-3 minutes per a-line now, and probably 6-8 for central lines, about 90% of the time. Add a minute if the patient's awake and needs some lidocaine. Most people don't seem to do this, but I do the poor-man's-CVP-IV-tubing transducer thing with 100% of my IJ sticks before dilating, so that adds to my time. (I've seen two strokes in patients who got their carotids cannulated after the line placer swore the blood was dark and nonpulsatile ... and a third carotid dilation by a guy using ultrasound. So I transduce everybody.)

    I haven't done anywhere near enough non-neuraxial regional in the last 8 months to be efficient at it, but I have a month of blocks coming up.


    But in any case, I'm military, so the odds of winding up anyplace that really (really) values efficiency in the next few years seems low. So I have time to work on speed.
     
  30. Gator05

    Gator05 Resident
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    And that's the difference between academics and private practice. In academics, why would a nurse setup a pump if the resident can?

    My best epidural time, door to bolus, is a little under 10min. This can include pre-op and consent, pulling our supplies from as many as 3 different locations, positioning the patient, prep and drape, needle, catheter, and bolus. Again, different in our block room where the patient is pre-positioned, prepped and the kit opened and ready. Can't even fault the nurses, as they're frequently fighting the same system we are.

    Also remember that certain things do just take time. For instance, an epidural test dose takes 2 full minutes to be negative per the studies. You can go quicker per your clinical judgement, but the 2-min test dose is just that.

    These times are a funny thing. Our CV setups can take upwards of 45 min. 45 min. That's sad. Yet, you take the same resident over to our "private" hospital with a good team, and the same resident will have tube, a-line, introducer, Swan and TEE probe in within 13-15 min. Current record is around 11min from time in the room. (This isn't hurrying; for emergent crash-on-pump from the cath lab, we've been much, much quicker...)

    I'd also like to point out that slamming in that epidural in 90 seconds isn't worth squat if it doesn't work.

    This is a team sport, friends. Don't be the weak link, just be the solid team player. Teams eventually get worried about flashy members.
     
  31. huktonfonix

    huktonfonix board certified!
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    bolus through the needle. If youre intravascular or intrathecal with the tuohy it should be fairly obvious. They get comfortable faster, it dilates the space nicely for the catheter, and you can then thread your catheter, tape, and observe your test dose while you do your paperwork.
     
  32. Gator05

    Gator05 Resident
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    If you bolus through the needle, then what is the point of a test dose? What about your intravascular epidural catheter? Or subarachnoid (yes, even rarer than intravascular, but does happen)? Or do you just mean a little extra lidocaine through the needle?

    Actually, we've taken to doing more CSE's when the pain relief needs to work pronto. Talk about quick relief.
     
  33. huktonfonix

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    The point of the bolus is the same. To get the patient comfortable. The test dose serves the same purpose since youre giving it through your catheter. If your tuohy is somewhere its not supposed to be it will be pretty obvious. I usually bolus 8-10 ml ropivicaine through the needle, thread the catheter and then test dose, tape, paperwork. I usually only do CSEs on ladies that are gonna go quickly since it takes more time to setup.
     
    #33 huktonfonix, Dec 15, 2008
    Last edited: Dec 15, 2008
  34. SleepIsGood

    SleepIsGood Support the ASA !
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    Are you kidding me....3 blocks all that quickly:eek:

    You're not referring to Winnie's 3 in 1 block are you ?

    Otherwise, I must admit...damn!
     
  35. excalibur

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    when do you start your timing for the 5 minute central lines?? From needle insertion?? From opening the gear?? From washing hands (I have a feeling some will not do this)??
     
  36. drccw

    drccw ASA Member
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    start lateral.. classic approach to the sciatic..
    Flip them supine... femoral nerve bock
    Frog leg.. obturator....

    most people use a NRB mask for their blocks...
    after the last of the local
    Propofol LMA
     
  37. bullard

    bullard Senior Member
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    Do those guys who rip through 3 blocks in 10 minutes ever do these cases under MAC? Or is the GA just masking ****ty blocks? :)
     
  38. drccw

    drccw ASA Member
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    The GA is to protect the patients from the loud music, the cursing of the surgeons, and the general unpleasantries that occur during an orthopedic procedure.

    The blocks are for post operative pain. Most of these patients only get the 4 of midaz and 100 of fentanyl upfront for their block and then the LMA. Our orthopods are too unpleasant to do the procedure under "MAC"

    And what do you mean by MAC either?I know a bunch of people who do their total knees under a spinal with "sedation." Let's not fool ourselves... the sedation we give or the "MAC" we give ends up being a general anesthetic. Call it what it is.. Propofol at greater than 80 mcg/kg/min is a general anesthetic... in most adults that probably about equiv to 2/3 MAC Sevo...
     
  39. cchoukal

    cchoukal Senior Member
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    I think, also, that ripping through the block in the OR and expecting them to have "set up" to provide surgical anesthesia in the few minutes it takes to prep and drape may be unrealistic. We occasionally do blocks like this in the OR, induce, insert an LMA, and then when a sufficient amount of time has passed to allow the block to soak and/or the patient looks comfortable on minimal GA, we'll take the LMA out and let them be minimally sedated for the rest of the case.
     
  40. pgg

    pgg Laugh at me, will they?
    Moderator Physician Faculty 10+ Year Member

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    When I time myself, it's from prepping the skin to to drapes off and dressing on. (I prep before opening the kit.) Too much variable stuff prior to skin prep to make the timed period mean something ...
    - consent done or not done?
    - patient anxious and asking questions or intubated?
    - family arguing about leaving the room or already gone?
    Once you're painting the skin, in theory nothing extraneous should mess up the time.

    Anyway, that's how I time myself. Incidentally, I didn't start getting faster until I actually began timing myself and noticed how much time I was wasting rearranging the kit contents or just wasting movement (ie, too many unnecessary turns and reaches for something in the kit that I could have had tucked into a fold in the drape 6 inches from my stick site).
     
  41. coprolalia

    coprolalia Bored Certified
    2+ Year Member

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    I'm ready for private practice. Recent experiences...


    • Big belly case. T7 thoracic epidural in the room with patient sitting awake, supine, intubated, art-line, right IJ triple lumen: 50 minutes from the door to starting surgical prep.

    • I&D of lower extremity blocked in the room with single shots pop/saphenous then LMA - roughly 20 minutes. End of case, LMA out as drapes coming down and patient sitting up and talking on way to recovery. D/C'd from recovery in less than 15 minutes.

    • 350+ pound parturient presenting late in labor for semi-urgent c-section. IV placed by anesthesia (me) when hit the door, 2 liters fluid from admission to OR, on table, monitors on, CSE in about 10 minutes total, kid out, epidural pulled. 1:15 minutes from OR in to skin closure. Patient happier than pig in ****.

    • I told you about the kid.
    I'm ready, dudes/dudettes. But, sorry. Already hired. :D

    -copro
     
  42. ncdoc1974

    7+ Year Member

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    For what it is worth, here is my private practice view: 1) Aim for as few complications as possible...(your partners will definitely remember every complication you have whether you are new or have been in the group for years) 2) have an extremely high success rate for your blocks (surgeons will remember a failed block, and in my experience it takes 15-20 successful blocks in a row to make them forget the one failed block) and 3) remember you don't have to be the absolute fastest person in the world, just try to be faster than at least half your partners...and anytime your patient is emerging slowly b/c you forgot to turn the sevo off, have a story/joke to tell to everyone in the room to distract them from your slow emergence...it can buy you a free & unnoticed 5 minutes if you do it right.
     
  43. ncdoc1974

    7+ Year Member

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    Our L&D nurses are too mentally challenged to set up the pumps as well...but that is not what bugs me the most about them...The charge nurse just tried to cop an attitude with me b/c I told her I wanted to know the platelet count before I placed an epidural in an edematous hypertensive (171/98) patient...The nurses I work with throughout the hospital are awesome everywhere except L&D....I am off on a tangent...anyone want to start a "Why L&D nurses suck" thread?
     

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