smooth (sneaky) induction...intubate intubate

[anesthesia11230]

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Just finished a case just now...everything went fine but kinda ironic induction. Simple ortho...ORIF tibia plateau fracture.

Patient just enters the room and as im putting on the standard monitors i see the attending placing around with the IV...im thinking he is flushing the IV making sure it works fine.

I hit the monitor to get the initial BP...the attending walks out the room and mentions..."i gave propofol, fentanyl, versed and sux...good luck 🙂

not sure if i properly heard what he really said, I look at the patient...apneic so i preoxygenate or rather oxygenate (notice the removal of "pre" in preoxygenation

I know the attending has trust in me and just trying to challenge me to be on my toes and be able to defend myself in all challenging situations...so no offense was taken on part.

Reminded me of an experience of when I was a first year with only 2 months experience...was on call with a madman. He made a comment to me as we met for the first time in the evening. Said I like to intubate within 30 secs of the patient entering the room...i laughed taking it as a complete joke.

Later that same evening...patient being assisted from the stretcher to the OR table. Patient gets on the table and as I attempt to put on some monitors...you know like BP, Spo2, and ECG...why bother with this attending

Patient is already sedated paralized and ready to intubate
I start puting on the BP cuff and I hear behind me

WHat are you doing????? intubate intubate man intubate
Gutsy/Ballsy? or simply inappropriate?
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[Tenesma]

malpractice malpractice malpractice

 

[aged2]

This sounds like one of my attendings in school "your f##kin poisining him with the oxygen, get the tube in him". This guy would do the exact same thing. We used to laugh about it all the time, he would walk in the room put all the drugs propofol relaxent narcotic in one syring empty it and leave. Ha-Ha good times.

 

[militarymd]

malpractice malpractice malpractice

nope....malpractice ONLY if some adverse event were to occur as a result of his actions.

Deviation from what many (including the ASA) accepts as the Standard of care...yes.

Malpractice ...no.

Ballsy...with a resident...yes



Sounds like something who knows what NEEDS to be done before induction versus what we ALWAYS do before induction.

ASA1....DO WE REALLY NEED all that jazz before drugs? nope.

ASA4...DO we really need all that jazz before drugs? yes and maybe some more jazz.

The ASA standards is a COOKIE cutter, one size fits all standard that is not tailored to each particular situation......

 

[OB1🤙]

Failing to prepare is preparing to fail.

Or something.

Gambling with other peoples' lives (which is what this boils down to) is pretty uniformly uncool, even for young ASA 1s. For a grizzled attending to do this with his own patients- fine. To leave the room afterward and hope the resident can handle it- not fine.

 

[militarymd]

Failing to prepare is preparing to fail.

Or something.

Gambling with other peoples' lives (which is what this boils down to) is pretty uniformly uncool, even for young ASA 1s.

You won't be saying that after 100,000 or so cases under your supervision.

 

[OB1🤙]

See what I added to my post.

 

[militarymd]

Failing to prepare is preparing to fail.

Or something.

Gambling with other peoples' lives (which is what this boils down to) is pretty uniformly uncool, even for young ASA 1s. For a grizzled attending to do this with his own patients- fine. To leave the room afterward and hope the resident can handle it- not fine.

As an attending with residents (from 1999 to 2004), I've done this a number of times......and when we leave the room, do you really think that we aren't watching you from the window?

 

[OB1🤙]

If you are, fine. If you're grabbing a jelly donut and checking out Drudge on the lounge computer, not fine.

 

[Noyac]

I thought this was routine.

You mean every program doesn't have one or two of these attendings?

If other residents are talking about attendings doing this and they are not doing it in your cases then you might want to figure out why.

 

[coprolalia]

I thought this was routine.

You mean every program doesn't have one or two of these attendings?

If other residents are talking about attendings doing this and they are not doing it in your cases then you might want to figure out why.

Bingo! I have a few attendings like this. We go into the room and I say, "I got this one."

Then, I do everything by myself. They don't leave the room, but one in particular uses this time to check his emails on the computer in the back of the room. I like this because I figure that pretty soon I'm going to have to be doing this on my own, and I need to learn to be self-sufficient instead of having an extra pair of hands there helping/doing everything else for me (pushing drugs, helping put monitors on, etc.).

I hope more residents get experiences like this, especially as they move along in their training. Otherwise, it's going to be a large jump into a very deep, cold pool come July 2nd after their CA-3 year.

-copro

 

[zippy2u]

Hellyeah, maybe gettem a plaque to hang on the wall or a couple of T-shirts that say "Got Cowboy?" Need more attendings like that fo' sure. Drink it up, it's all good. Regards, ----Zippy

 

[Carm]

Induce and intubate like this in heart room, then while scrubbed in for central line and PAC attending announces after I see sagging BP and ask if he can bolus a bit of neo "I am not here, you are in BFE (perhaps he was partners with Jet back in the money printing days🙂) and your nursing suck and won't and can't help, what do you do?

Mainly just trying to make a point that things will be different when we are UT, Mil et al and need to start thinking about how to be self sufficient when we are on our own.

 

[2ndyear]

We call it the "fly-by induction". Attending cruises in, slams some meds in, out the door. You're left to deal with the resulting hypotension, etc.

 

[jwk]

Gutsy/Ballsy? or simply inappropriate?

Gutsy/ballsy/inappropriate = stupid/irresponsible/unacceptable

 

[Teillard]

Gutsy/ballsy/inappropriate = stupid/irresponsible/unacceptable

Why? What is the resident there to learn? If flight instructors never leaned over and cut the engine mid-flight, they wouldn't be doing their job.

 

[pd4emergence]

I had an attending do this to me one time when I was a resident. Unfortunately, the patient had just been moved over to their bed after their surgery was finished. He apparently went into the wrong room. So I got to reintubate them and sit there for an hour until the roc wore off. Not cool.

 

[Gimlet]

I had an attending do this to me one time when I was a resident. Unfortunately, the patient had just been moved over to their bed after their surgery was finished. He apparently went into the wrong room. So I got to reintubate them and sit there for an hour until the roc wore off. Not cool.

Wow, that's super lame! I hope he felt like a huge douchebag after that.

 

[Bertelman]

Bingo! I have a few attendings like this. We go into the room and I say, "I got this one."

Then, I do everything by myself. They don't leave the room, but one in particular uses this time to check his emails on the computer in the back of the room. I like this because I figure that pretty soon I'm going to have to be doing this on my own, and I need to learn to be self-sufficient instead of having an extra pair of hands there helping/doing everything else for me (pushing drugs, helping put monitors on, etc.).

I hope more residents get experiences like this, especially as they move along in their training. Otherwise, it's going to be a large jump into a very deep, cold pool come July 2nd after their CA-3 year.

-copro

What you describe is self-sufficience. What the OP describes is less "I got this one" and more "Your patient is apneic- peace out!" I can't comment on the appropriateness of the situation, because I haven't had the pleasure of being there (yet). Either way, if I walk into the room and ask the attending to run the induction, I'll probably feel a little butterfly, but not much else. If I reach to adjust my monitor and realize the attending is out the door and the patient is down, I'll feel something entirely different.

 

[jwk]

Why? What is the resident there to learn? If flight instructors never leaned over and cut the engine mid-flight, they wouldn't be doing their job.

I turn off the monitors occasionally so students don't get too dependent on them and forget to actually look at the patient. That's totally different than pushing all the induction drugs before the patient is hooked up to the monitors and saying "see ya". Sure you might learn something, but that's putting the patient at increased risk for no reason.

 

[anesthesia11230]

Its different if an attending comes into the room and lets you preoxygenation, induce, intubate (meaning pretty much everything) on your own and just stands by for supervision. That happens on most of my cases.

This situation was different in the fact that there was a missing element of knowledge...you didnt know the patient is "OUT"

attending bails with a parting comment, "Good Luck"

Now what flows in your mind follows:
where is my laryngoscope, tube...although i turned on the o2 first and began to ventilate him...he was already fasiculating...so why not just tube. Was an easy airway. I think the point of this was...was simply to challenge me. Although he is a junior attending, he likes to provoke you intellectually and in abilities of skills. This was just one of his tests. We were on call and was evening with no other attendings around kinda makes it alil more risky. He may have had to answer a page, not sure.

He came back about 4-5 mins later ( I guess about the amount of time the FRC would have ran out...and sats being near ground 0). Came back with a smile on his face...asks if the tube is in the esophagus or trachea, tell him airway. Says ok good, and I didnt see him until the end of the case.

In one sense, this is a compliment bec i generally dont need an attending babysitting me. Although i dont see them I know they are around and know whats going on...meaning as im looking over the drapes, looking at the monitor or (reading my book)...he is prob seldomly looking through that great lil 6x6 window peakhole as MIL eludited to.

I have other attendings challenging me in less dramatic ways as well and take it as a step to a higher learning curve/realm. Have one attending always pull the stylet out of my tubes before intubating,,,saying you not going to always have these around. Another attending makes you do spinals/epidurals in lateral position knowing i prefer sitting position to help break the mold.

Although we talk down about attendings out of fatigue of residency...there are still some great attendings out there that train your properly for the real world.

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