RSI or not?

[Gern Blansten]

---

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3. ramp and slight head up on table.

Really. I was always taught that you should lower the head in the event of aspiration in order to facilitate suctioning of the oropharynx and also to use gravity to your advantage to keep the gastric contents from entering the trachea. The ETT is effectively keeping the trachea at risk due to its tenting of the vocal cords to an open position. A respected author's text states that that a head up position should be avoided in obtunded patients for the reason of helping keep gastric contents out of the trachea.
It used to be believed that the trendelenburg position was associated with increased risk of passive regurgitation of gastric contents. I believe that was disproven. Any thoughts?

 

[militarymd]

There are VERY few things that an intensivist can do to prevent Ventilator associated/Nosocomial Pneumonia....

One of them is keep ventilated patients with their head elevated 30 degrees....


This is a level I recommendation based on Class B evidence....doesn't get much better than that.

In case anyone doesn't know, VAP are presumed due to small volume aspiration....hence the effectiveness of supraglottic suctioning in preventing VAPs.

 

[Planktonmd]

Good, you should document that you don't adapt your practice to the clinically relevant literature 👍

At least I have been doing anesthesia more than 2 weeks and I have enough experience to distinguish between what has value and what doesn't when it comes to what you call literature.

 

[Noyac]

Really. I was always taught that you should lower the head in the event of aspiration in order to facilitate suctioning of the oropharynx and also to use gravity to your advantage to keep the gastric contents from entering the trachea. The ETT is effectively keeping the trachea at risk due to its tenting of the vocal cords to an open position. A respected author's text states that that a head up position should be avoided in obtunded patients for the reason of helping keep gastric contents out of the trachea.
It used to be believed that the trendelenburg position was associated with increased risk of passive regurgitation of gastric contents. I believe that was disproven. Any thoughts?

This is once emesis has occurred. The head up position is during RSI to prevent emesis somewhat. At least thats how I understand it.

 

[dhb]

At least I have been doing anesthesia more than 2 weeks and I have enough experience to distinguish between what has value and what doesn't when it comes to what you call literature.

I value your experience but as you know expert opinions don't rank very high in EBM so until you show me something more substantial...

 

[dhb]

Butler J, Sen A.
Department of Emergency Medicine, Manchester Royal Infirmary, Manchester M13 9WL, UK.

A short cut review was carried out to establish cricoid pressure reduced aspiration during rapid sequence induction (RSI) of anaesthesia. A total of 241 papers were identified using the reported search, of which three represented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. There is little evidence to support the widely held belief that the application of cricoid pressure reduces the incidence of aspiration during a rapid sequence intubation.

 

[Gern Blansten]

This is once emesis has occurred. The head up position is during RSI to prevent emesis somewhat. At least thats how I understand it.

So...we are talking about 2 different situations it seems. Once the emesis has occurred, head down is best to facilitate suctioning and use gravity to our advantage.

And in the intubated ICU patient, elevate the head 30 degrees to prevent small volume aspiration and vent assoc. pneumonia.

Is this the general understanding of most on here? Is anyone positioning 30 degrees head up as suggested on routine full stomach cases that are just going to be in the OR a couple of hours? Is there data to support that for these short periods of time?

 

[militarymd]

So...we are talking about 2 different situations it seems. Once the emesis has occurred, head down is best to facilitate suctioning and use gravity to our advantage.

And in the intubated ICU patient, elevate the head 30 degrees to prevent small volume aspiration and vent assoc. pneumonia.

Is this the general understanding of most on here? Is anyone positioning 30 degrees head up as suggested on routine full stomach cases that are just going to be in the OR a couple of hours? Is there data to support that for these short periods of time?

You're asking about different situations.

Head up prevents stuff from coming up....I do that for the intubation...which I try to accomplish as "quickly" as I can....but I don't buy this RSI/Cricoid crap.

Once the ETT is in the trachea, I follow up, also as "quickly" as possible, with a tube into the stomach to suction out anything that can be suctioned out...and I keep suction going until the patient has protective reflexes again....either at the end of the case....or when gi tract is function again.

 

[militarymd]

patient position during an operative case is usually dictated by the type of surgery being performed....

if it were up to me....head up 30 degrees with gastric tube connected to suction.

 

[dhb]

I try to accomplish as "quickly" as I can....but I don't buy this RSI/Cricoid crap.

thank you

 

[Planktonmd]

thank you

So what's the difference between "as quickly as I can" and rapid sequence induction?
Maybe we should call it the as quickly as you can induction!

 

[militarymd]

So what's the difference between "as quickly as I can" and rapid sequence induction?
Maybe we should call it the as quickly as you can induction!

I always mask ventilate.....

I don't insist on cricoid...

 

[Planktonmd]

I always mask ventilate.....

I don't insist on cricoid...

Do you mask ventilate a patient with bowel obstruction?
How about an emergency surgery on a patient who just ate a full meal?

 

[goodoc]

Good and you can document you do not follow standerds of care. Lawyer Dr. ----, can you explain why you dikd not perform a rapid sequence intubation as is normally indicated in this case?"
You " Some literiature did not support it"
Lawyer "thankyou"

 

[militarymd]

Do you mask ventilate a patient with bowel obstruction?
How about an emergency surgery on a patient who just ate a full meal?

I always mask ventilate.....

I don't insist on cricoid...

didn't stutter

 

[Planktonmd]

didn't stutter

Ok,

Good for you.

 

[invitro]

okay guys...

Let me ask you another question.

Screw the cholinesterase problem. Let's say the woman in the above scenario has UNRECOGNIZED (the following) CRF (with a k that is elevated) or is a recent burn patient (>24hours) or has neuromuscular dz (duchenne's, myasthenia gravis, etc), or is an ICU patient for several weeks (debilitated). In most of these cases the ach receptors would be elevated, and you would get an increase in K+.

So you decide to use rocuronium. But you can't get the intubation...and now the patient is paralyzed/can't breath on her own.

So.....do you just go down the difficult airway algorithm...check to see if can ventilate--> try alternate intubation (different blade, intubation lma, FOI scope). What if those all fail--> if you can ventilate-->wake pt up? Or if you can't ventilate-->cric? I guess in either of those situations the patient would probably aspirate quite a bit.

My point is...is it better to use sux, and suffer the consequences of an inc K+, or better to use roc with the possibility that you could burn yourself if you can't get the intubation?

Hopefully you smart attgs can chime in with an answer.

 

[Noyac]

okay guys...

Let me ask you another question.

Screw the cholinesterase problem. Let's say the woman in the above scenario has UNRECOGNIZED (the following) CRF (with a k that is elevated) or is a recent burn patient (>24hours) or has neuromuscular dz (duchenne's, myasthenia gravis, etc), or is an ICU patient for several weeks (debilitated). In most of these cases the ach receptors would be elevated, and you would get an increase in K+.

So you decide to use rocuronium. But you can't get the intubation...and now the patient is paralyzed/can't breath on her own.

So.....do you just go down the difficult airway algorithm...check to see if can ventilate--> try alternate intubation (different blade, intubation lma, FOI scope). What if those all fail--> if you can ventilate-->wake pt up? Or if you can't ventilate-->cric? I guess in either of those situations the patient would probably aspirate quite a bit.

My point is...is it better to use sux, and suffer the consequences of an inc K+, or better to use roc with the possibility that you could burn yourself if you can't get the intubation?

😱
Have you seen what happens when you give sux to the pts you mentioned. It aint good!

Use roc. Deal with the situation

 

[invitro]

sorry, haven't dealt with inc k+ in patients much....I know that you can get arrhymias, peaked t waves, eventually asystole. I guess it was a stupid question, but I'm glad I asked....no question is too stupid as a CA-1, right?

 

[Noyac]

sorry, haven't dealt with inc k+ in patients much....I know that you can get arrhymias, peaked t waves, eventually asystole. I guess it was a stupid question, but I'm glad I asked....no question is too stupid as a CA-1, right?

Thats how we learn.

 

[Planktonmd]

sorry, haven't dealt with inc k+ in patients much....I know that you can get arrhymias, peaked t waves, eventually asystole. I guess it was a stupid question, but I'm glad I asked....no question is too stupid as a CA-1, right?

It's not a stupid question, it's actually a very good question.
It used to be more challenging in the past when we did not have that many tools to handle a difficult airway, things have changed dramatically and now we have so many options to intubate that you can't find a situation where using Sux would make sense in the presence of a risk factor for hyperkalemia.

 

[militarymd]

Good and you can document you do not follow standerds of care. Lawyer Dr. ----, can you explain why you dikd not perform a rapid sequence intubation as is normally indicated in this case?"
You " Some literiature did not support it"
Lawyer "thankyou"

there's that phrase again.

 

[SleepIsGood]

Interesting discussion guys.

As I side note. Last week we had a discussion about RSI. THe PD asked us what's the difference b/w RSI and modified RSI. Essentially it's that you 'ventilate' the pt. Ventilating the pt gives you a little more 'margin' for error. So I poised the question, why not do the modified RSI for everyone?

Then I asked the PD that just left our progrm about this. He said that when Sellick (ie the guy guy tht came up with the Sellick maneuver/cricoid pressre) et al performed cric pressure during RSI he in fact DID try to ventilate the pt. What we now know as "modified" RSI is actually the real thing.

He goes, there's no problem in trying to ventilate patients when doing RSI. It's just tht beginners will ventilate by squeezing the bag very hard, but in actuality you CAN ventilate as long as you keep the airway pressure less than 20 so as not to inflate the stomach.

Also interesting, applying cric or even putting an LMA will reflexively DECREASE the tone of the LES. So when you applying cric you are actually increasing the tone of the Upper Esoph Sphinc.

👍

 

[Noyac]

He goes, there's no problem in trying to ventilate patients when doing RSI. It's just tht beginners will ventilate by squeezing the bag very hard, but in actuality you CAN ventilate as long as you keep the airway pressure less than 20 so as not to inflate the stomach.

Also interesting, applying cric or even putting an LMA will reflexively DECREASE the tone of the LES. So when you applying cric you are actually increasing the tone of the Upper Esoph Sphinc.

👍

This is very true of ventilation during RSI. If you are good at it like just about every seasoned anesthesiologist is then there is no reason not to do it. It gives you a lot of information as well as buys you some time.

I have heard many describe this very thing, that cricoid actually increased the risk of emesis (and therefore, possibly aspiration) by DECREASING LES tone.

I rarely use cricoid unless trying to manipulate the view of the cords. And then it really isn't cricoid now is it.

For sm bowel obstr I may use cricoid but more importantly the tube is going in as the pt is becoming unconscious. I don't wait around.

 

[dhb]

I rarely use cricoid unless trying to manipulate the view of the cords. And then it really isn't cricoid now is it.

Good to know i'm not crazy.

For sm bowel obstr I may use cricoid but more importantly the tube is going in as the pt is becoming unconscious. I don't wait around.

How do you time your curare be it sux or roc?

 

[Planktonmd]

Residency is a great time to observe what other people with more experience do and try to build a knowledge base.Residency is not the right time to adopt radical and controversial practices.The end of residency is actually the beginning of a new learning experience that takes years until an anesthesiologist becomes mature and experienced enough to start chalenging established practice.Before you walk you need to learn how to crawl.

 

[militarymd]

Residency is a great time to observe what other people with more experience do and try to build a knowledge base.Residency is not the right time to adopt radical and controversial practices.The end of residency is actually the beginning of a new learning experience that takes years until an anesthesiologist becomes mature and experienced enough to start chalenging established practice.Before you walk you need to learn how to crawl.

On the other hand, most people just gets INDOCTRINATED in the dogma,,

and then continue to perpetuate it at work, to residents, to other specialties and to other even to strangers on anonymous forums.

 

[Noyac]

Good to know i'm not crazy.



How do you time your curare be it sux or roc?

Unless I'm crazy.


I think you are asking me how I time intubation with relaxation. Not my use of curare specifically, because I don't use curare. Anyhow, I don't necessarily wait for the relaxant to take full effect. Every case is different somewhat but lets say it is a bowel obst that I really think may erupt on me. I will use sux simultaneously with induction agent just like everyone else but as soon as the pt begins to become unconscious the blade is entering the mouth and the sux may not have hit yet. Sort of like Prop/sux/blade/tube. Lets say I can't use sux (K 6.0) then this pt may get roc first followed by propofol shortly after if I don't want to wait 60 sec with an unprotected airway. Every case is dealt with as best as "I" can determine it needs to be done.

 

[dhb]

Have you ever tried the remi 4mcg/kg thing? i didn't think about it for this particular case but i've tried it once when the chief of the department was supervising and it was sweet he was like 😱

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

 

[Gern Blansten]

On the other hand, most people just gets INDOCTRINATED in the dogma,,

My Karma ran over my Dogma

 

[militarymd]

My Karma ran over my Dogma

???

 

[Planktonmd]

On the other hand, most people just gets INDOCTRINATED in the dogma,,

and then continue to perpetuate it at work, to residents, to other specialties and to other even to strangers on anonymous forums.

Teaching strangers Dogma is much better than teaching them to be cowboys when they are still in desperate need to learn the very basics of this field.
Cowboy mentality and grandiose view of one's self should not be transmitted to residents because some of them might confuse it with reality (as evident in this thread).

 

[militarymd]

Teaching strangers Dogma is much better than teaching them to be cowboys when they are still in desperate need to learn the very basics of this field.
Cowboy mentality and grandiose view of one's self should not be transmitted to residents because some of them might confuse it with reality (as evident in this thread).

chicken or the egg.....

You are calling the DOGMA...... the stuff we make fun off.......the "basics of this field"...

You can either part of the solution or part of the "dogma"/problem.

You get to pick.

oh....wait....you picked already.

 

[Planktonmd]

chicken or the egg.....

You are calling the DOGMA...... the stuff we make fun off.......the "basics of this field"...

You can either part of the solution or part of the "dogma"/problem.

You get to pick.

oh....wait....you picked already.

Oh... now I feel rally embarrassed: Napoleon is accusing me of being dogmatic because I don't subscribe to his revolutionary view of the world of medicine.

 

[dhb]

Cowboy mentality and grandiose view of one's self should not be transmitted to residents because some of them might confuse it with reality (as evident in this thread).

I don't know how using cricoid pressure or not translates to a grandiose view of one self??
You still haven't produced any evidence or argument that would make me change my mind.

 

[Planktonmd]

I don't know how using cricoid pressure or not translates to a grandiose view of one self??
You still haven't produced any evidence or argument that would make me change my mind.

When someone who claims to be an experienced anesthesiologist tells the new guys like yourself that they shouldn't do what the overwhelming majority of anesthesiologists do and instead he introduces his own distorted view of the world as a fact this is where the grandiose view of one's self becomes apparent.
You don't have to listen to me or to anyone else but I advise you to learn everything that you can learn about this specialty, become as good as you can get, have a few years of experience under your belt then think about creating your own way of practice.

 

[militarymd]

When someone who claims to be an experienced anesthesiologist tells the new guys like yourself that they shouldn't do what the overwhelming majority of anesthesiologists do and instead he introduces his own distorted view of the world as a fact this is where the grandiose view of one's self becomes apparent.
You don't have to listen to me or to anyone else but I advise you to learn everything that you can learn about this specialty, become as good as you can get, have a few years of experience under your belt then think about creating your own way of practice.

you don't read too good...

I never told anyone not to do cricoid...I just said that I don't "insist on it"...nothing grandiose about that.



Noyac....are you reading this thread too???

 

[Planktonmd]

you don't read too good...

I never told anyone not to do cricoid...I just said that I don't "insist on it"...nothing grandiose about that.



Noyac....are you reading this thread too???

No comment.

 

[dhb]

When someone who claims to be an experienced anesthesiologist tells the new guys like yourself that they shouldn't do what the overwhelming majority of anesthesiologists do and instead he introduces his own distorted view of the world as a fact this is where the grandiose view of one's self becomes apparent.

didn't happen

You don't have to listen to me or to anyone else but I advise you to learn everything that you can learn about this specialty, become as good as you can get, have a few years of experience under your belt then think about creating your own way of practice.

will do although i don't think it takes 5+ years to decide what's BS and what's not
I'm just trying to argue a different pov based on up to date literature and you still haven't back your claims.

 

[Planktonmd]

didn't happen



will do although i don't think it takes 5+ years to decide what's BS and what's not
I'm just trying to argue a different pov based on up to date literature and you still haven't back your claims.

I don't have any claims to prove, I was just trying to convey to you how things are currently done in the real world.
My personal practice:
I do RSI with or without cricoid on a case by case basis because each patient and each situation is unique.
I don't deviate from what is considered to be safe by the majority in our field unless I have very solid reasons.
The point of view you are arguing is valid but unfortunately the evidence that you keep bringing up is insufficient.
You need a study that proves that in patients with high risk for aspiration when general anesthesia is induced the incidence of aspiration is the same with and without RSI with and without cricoid, is there such evidence?

 

[jetproppilot]

didn't happen



will do although i don't think it takes 5+ years to decide what's BS and what's not
I'm just trying to argue a different pov based on up to date literature and you still haven't back your claims.

DHB,

I respectfully disagree with your statement.

It actually does take about five years in a busy private practice to figure out what is BS and what isnt....

...but then again, I didnt have access to a resource like SDN when I was "growing up"...

I hope my resident colleagues out there appreciate the value of a forum like this, where real life attendings speak out about their private practice lives.

It is truly invaluable....academic medicine differs so greatly from private practice. Hearing from MDs in different private practices will put you ahead of the curve....makes you think about what you've been taught.

It is valuable, even if we dont agree all the time. Goes to show you that in most situations there are many safe ways to construct and carry out an anesthetic.

And that brings me to my point.

Plank, Mil, ya'lls beef with each other has really gotten old. I mean REALLY, f u kking old.

Every time you guys interact it turns into a pi s s ing contest.

I respect both of you. And I recognize both of you are passionate about your work.

I hope at some point you guys can PM each other and come to some agreement. Hell, you guys arent married. Y'aint sleeping with each other.

So I pray you can find some truce in the future.

That being said,

I enjoy coming here for many reasons, many of them selfish.

But one unselfish reason is I enjoy interacting with residents who are learning our trade.

I've been doing this long enough that I have figured out most of what is BS, and what is not.

Plank, this is where I disagree with your interaction with Mil.

Lets take the RSI thing.

You discouraged a resident from listening to someone (Mil) who does something that conflicts with "normal practice".....i.e. cricoid pressure.....and encouraged him to do "what the overwhelming majority of anesthesiologists do"......

Honestly, Plank, as you know, alotta what we do is a waste of time!!!! Hmmmm....lemme list some for my colleagues:

Bicitra in OB patients before an epidural

The whole reglan/pepcid/bicitra thing in a full stomach

avoiding LMAs in pts with DM, GERD, obesity, renal problems...no postural reflux symptoms means I use an LMA.

RSIs in pts with DM, GERD, obesity, renal problems, just because

Albuterol pre op in asthmatic/COPDer without evidence of bronchospasm

Placing an IV in a kid getting PETs

Too many awake intubations

Too many awake extubations

The whole, rigid NPO thing, and how some clinicians needlessly delay cases when waiting 2 more hours isnt gonna make a difference. Yes, if the dude ate an Egg McMuffin on the way to his knee scope, ya need to intervene. And no, you don't cancel or postpone a case when dude eats a Whopper an hour before he breaks his arm, and its now three hours later and orthopedist is ready. (my opinion)

LABS LABS LABS. Too many labs. I dont need a post-dialysis K+. I dont need a CXR, no matter what. If I see 'em pre-op and some kinda pulmonary manifestation catches my eye, a CXR is not gonna make the decision for me.
I do like to see a recent INR on coumadin patients.

ETC ETC ETC

Mil argues many ANESTHESIA DOGMAS. And he backs them up with either literature, or lack of literature.


Perpetuate them, Plank, and they'll never change.

Cricoid pressure Full stomach.

Cricoid not necessary IMHO. Whats necessary is to tube someone with a full stomach quickly, and manage their airway as to not insufflate the stomach. I personally dont ventilate true full stomachs unless I have to. But cricoid is a crock. No literature supporting its efficacy. And more important to me, my eleven years in PP have shown me its a waste of time.

SO WHAT DO WE DO AS ATTENDINGS? Propegate something we learned a decade ago because our elders showed us it was the right thing to do? And now that we are seasoned attendings with a decade of experience we should propegate the same, even though we don't believe it makes a difference in outcome?

Thats not education, dude.

How does a profession move forward if noone questions what is being done?

Brings to mind Beta Blockers and the opinion of their indications a decade ago.

WOW, has that changed, huh?

What if noone questioned it?

Would we still be depriving patients of the benefits of beta blockers?

I applaud Mil for not propegating dogmas of our profession.

I do not agree with Plank telling a resident to learn what most anesthesiologists do.

That being said, Mil, maybe you can tone down your antagonism a bit.

Your important message will reach many more people.

 

[Planktonmd]

DHB,

I respectfully disagree with your statement.

It actually does take about five years in a busy private practice to figure out what is BS and what isnt....

...but then again, I didnt have access to a resource like SDN when I was "growing up"...

I hope my resident colleagues out there appreciate the value of a forum like this, where real life attendings speak out about their private practice lives.

It is truly invaluable....academic medicine differs so greatly from private practice. Hearing from MDs in different private practices will put you ahead of the curve....makes you think about what you've been taught.

It is valuable, even if we dont agree all the time. Goes to show you that in most situations there are many safe ways to construct and carry out an anesthetic.

And that brings me to my point.

Plank, Mil, ya'lls beef with each other has really gotten old. I mean REALLY, f u kking old.

Every time you guys interact it turns into a pi s s ing contest.

I respect both of you. And I recognize both of you are passionate about your work.

I hope at some point you guys can PM each other and come to some agreement. Hell, you guys arent married. Y'aint sleeping with each other.

So I pray you can find some truce in the future.

That being said,

I enjoy coming here for many reasons, many of them selfish.

But one unselfish reason is I enjoy interacting with residents who are learning our trade.

I've been doing this long enough that I have figured out most of what is BS, and what is not.

Plank, this is where I disagree with your interaction with Mil.

Lets take the RSI thing.

You discouraged a resident from listening to someone (Mil) who does something that conflicts with "normal practice".....i.e. cricoid pressure.....and encouraged him to do "what the overwhelming majority of anesthesiologists do"......

Honestly, Plank, as you know, alotta what we do is a waste of time!!!! Hmmmm....lemme list some for my colleagues:

Bicitra in OB patients before an epidural

The whole reglan/pepcid/bicitra thing in a full stomach

avoiding LMAs in pts with DM, GERD, obesity, renal problems...no postural reflux symptoms means I use an LMA.

Albuterol pre op in asthmatic/COPDer without evidence of bronchospasm

Placing an IV in a kid getting PETs

Too many awake intubations

Too many awake extubations

The whole, rigid NPO thing, and how some clinicians needlessly delay cases when waiting 2 more hours isnt gonna make a difference. Yes, if the dude ate an Egg McMuffin on the way to his knee scope, ya need to intervene. And no, you don't cancel or postpone a case when dude eats a Whopper an hour before he breaks his arm, and its now three hours later and orthopedist is ready. (my opinion)

LABS LABS LABS. Too many labs. I dont need a post-dialysis K+. I dont need a CXR, no matter what. If I see 'em pre-op and some kinda pulmonary manifestation catches my eye, a CXR is not gonna make the decision for me.
I do like to see a recent INR on coumadin patients.

ETC ETC ETC

Mil argues many ANESTHESIA DOGMAS. And he backs them up with either literature, or lack of literature.


Perpetuate them, Plank, and they'll never change.

Cricoid pressure Full stomach.

Cricoid not necessary IMHO. Whats necessary is to tube someone with a full stomach quickly, and manage their airway as to not insufflate the stomach. I personally dont ventilate true full stomachs unless I have to. But cricoid is a crock. No literature supporting its efficacy. And more important to me, my eleven years in PP have shown me its a waste of time.

SO WHAT DO WE DO AS ATTENDINGS? Propegate something we learned a decade ago because our elders showed us it was the right thing to do? And now that we are seasoned attendings with a decade of experience we should propegate the same, even though we don't believe it makes a difference in outcome?

Thats not education, dude.

How does a profession move forward if noone questions what is being done?

Brings to mind Beta Blockers and the opinion of their indications a decade ago.

WOW, has that changed, huh?

What if noone questioned it?

Would we still be depriving patients of the benefits of beta blockers?

I applaud Mil for not propegating dogmas of our profession.

I do not agree with Plank telling a resident to learn what most anesthesiologists do.

That being said, Mil, maybe you can tone down your antagonism a bit.

Your important message will reach many more people.

Jet,

As usual a great post.

My main point is: I don't think it's appropriate for me or any of us to encourage a resident to do something that might expose him to litigation early in his career.
The concept of "standard of care" that MMD doesn't like is very real and it has nothing to do with science, it simply implies that you are expected by society to do what the majority of professionals with equal education are doing, if you don't and something goes wrong, you will pay.
If you deviate from what is considered a standard of care and you have a bad outcome you will be surprised how many big names in this specialty will be expert witnesses against you and get paid very well in the process.
When I talk about litigation risk, trust me, I know what I am talking about because I have been there personally and I have learned many valuable lessons about the legal system and the whole experience of malpractice litigation.
I wish I could educate every resident about the real world of malpractice litigation since no one educated me when I was a resident.
One thing I have to repeat: being a cowboy is definitely not compatible with the way the system works.

I apologize for any lengthy or unprofessional input on my part and I will be more of a spectator from now on.

 

[jetproppilot]

Jet,

As usual a great post.

My main point is: I don't think it's appropriate for me or any of us to encourage a resident to do something that might expose him to litigation early in his career.
The concept of "standard of care" that MMD doesn't like is very real and it has nothing to do with science, it simply implies that you are expected by society to do what the majority of professionals with equal education are doing, if you don't and something goes wrong, you will pay.
If you deviate from what is considered a standard of care and you have a bad outcome you will be surprised how many big names in this specialty will be expert witnesses against you and get paid very well in the process.
When I talk about litigation risk, trust me, I know what I am talking about because I have been there personally and I have learned many valuable lessons about the legal system and the whole experience of malpractice litigation.
I wish I could educate every resident about the real world of malpractice litigation since no one educated me when I was a resident.
One thing I have to repeat: being a cowboy is definitely not compatible with the way the system works.

I apologize for any lengthy or unprofessional input on my part and I will be more of a spectator from now on.

Appreciate your post.

BUT NO F U KKIN WAY, DUDE!!!

No way is being a spectator the right thing!

98% of your posts are intuitive, educational, and relevant.

uhhh,.....25% of my posts are intuitive, educational, and relevant.

Do not take a disagreement as a request to disengage.

KEEP POSTING, DUDE.

Disagreements will come and go.

Lets move forward.

 

[Noyac]

Like Jet said, No Way Dude. You are a big contributer here.

Anyway, how in the world would those of us cowboys ever be verified as cowboys if you leave and no longer post the "standard of care".😍

 

[jetproppilot]

Jet,

As usual a great post.

My main point is: I don't think it's appropriate for me or any of us to encourage a resident to do something that might expose him to litigation early in his career.
The concept of "standard of care" that MMD doesn't like is very real and it has nothing to do with science, it simply implies that you are expected by society to do what the majority of professionals with equal education are doing, if you don't and something goes wrong, you will pay.
If you deviate from what is considered a standard of care and you have a bad outcome you will be surprised how many big names in this specialty will be expert witnesses against you and get paid very well in the process.
When I talk about litigation risk, trust me, I know what I am talking about because I have been there personally and I have learned many valuable lessons about the legal system and the whole experience of malpractice litigation.
I wish I could educate every resident about the real world of malpractice litigation since no one educated me when I was a resident.
One thing I have to repeat: being a cowboy is definitely not compatible with the way the system works.

I apologize for any lengthy or unprofessional input on my part and I will be more of a spectator from now on.

I respect your desire to propegate litiginous medicine.

I've made a conscious decision to not have the medicine I practice be influenced by our litiginous society.

I live in a state (louisiana) that has a malpractice cap.

And a difficult process for a "victim" to make a case.

Great for doctors.

Except plaintiff attorneys try and make up for the difference with increased frequency of suits.

Albeit suits with no backbone.

Worried me at first...butcha know what?

And you may consider this cowboy but...

as a person, as Jet, I'm proud to say that

MY PRACTICE OF ANESTHESIA IS NOT DICTATED BY PLAINTIFF ATTORNEYS.

I know.

Thats a bold statement.

But it was necessary for me as an individual. A purely selfish decision.

I know I'm a good doctor.

I know I make good decisions.

I know I'm a great needle/procedure jockey.

FLASHBACK eight years ago.

I was named in a suit...albeit a totally BS suit.

Freaked me out.

Because I knew in my heart I didnt do anything wrong.

And the standard of care was optimized, not breached.

So that one went away.

Then another one came. 😱

A lady with preoperative, documented cervical disc disease and arthritic complaints, and resultant extremity symptoms (numbness, pain...documented in some doctors notes) had a carpal tunnel done under axillary block by me.

I remember the case.

It was a quick, easy block.

The surgery took eight minutes with no local needed intraop.

Her PACU/post-op course over the next 72 hours was documented to be without complaint.

Eight months later I get notification I'm being sued because dudette is attributing her extremity symptoms to my axillary block. 😱

Case went to deposition.

I conversed with said plaintiff lawyer for ninety minutes, all formal with my attorney, a court reporter, the whole deal.....

I knew my block was not the cause of her problems.

Plaintiff lawyer tried in vain to put me in a corner.

He failed.

Case dissolved.

Know what?

I'm glad that happened.

Because it showed me that no matter how gooda doctor you are, and no matter how deft you are at procedures, a plaintiff lawyer is probably gonna come sniffing at your crotch at some point in your career.

I had an epiphany.

I said to myself, "Jet, you pay about thirty large a year for malpractice insurance. You are a good doctor. Frivolous stuff is gonna come and go, but you're still a good doctor."

So I figure since I practice good medicine,

SCREW THE ATTORNEYS.

I'm gonna make decisions based on what I think will affect the patient's outcome.

And if some piece-a-s hi t plaintiff attorney wants to challenge that,

well,

thats what I pay thirty-large a year for.

For a stud defense attorney.

To back me up on telling the plaintiff attorney that he's a dirtbag.....

Know what?

If I screw up, patient deserves some benjamins.

But that hasnt happened yet.

And I go to work with inner peace, practicing medicine dictated by what I think is best.

Not dictated by our potentially intimidating litiginous society.

And thats a great feeling.

 

[militarymd]

Jet is, as usual , right....

but, It's SO MUCH FuN!!!!!!🙂

 

[dhb]

My main point is: I don't think it's appropriate for me or any of us to encourage a resident to do something that might expose him to litigation early in his career.
The concept of "standard of care" that MMD doesn't like is very real and it has nothing to do with science, it simply implies that you are expected by society to do what the majority of professionals with equal education are doing, if you don't and something goes wrong, you will pay.
If you deviate from what is considered a standard of care and you have a bad outcome you will be surprised how many big names in this specialty will be expert witnesses against you and get paid very well in the process.

The paradox is we are calling "cowboys" people who deviate from the standard of care even when it has not been validated scientifically 😕
You are not encouraging me to expose myself to litigation since i'm still under the attendings responsibility and will discuss with him the usefulness of cricoid.
I'm just raising questions to see what people out of the realm of academic medicine do.
What i've been asking from the beginning is that you give a better argument than "everybody does it" be it with scientific evidence or for litiginous reasons.

So how about the remifentanil trick? anybody...

ps: keep posting this forum rocks