Transition to Private Practice

[Noyac]

---

Members don't see this ad.

With all the talk about matching and some of you entering the next stage of your career I thought it might be good to discuss how one can make a smooth transition into your new group since many of you will be finishing residency soon. This can be one of the more difficult times in your career and you need to make it as easy as possible. Here are some things to think about and I'm sure others will have more.
I found one of the more difficult things to do was dealing with surgeons. These surgeons are accustom to the way your group handles things like NPO, emergencies, add-ons, reginal vs general, etc. A Peds surgeon asked me to add-on an I&D of a 2yr child's buttocks. The child ate about 2 hrs earlier and she wanted to do the case as soon as possible. I said 6hrs and it was already 4pm. She was pissed but I didn't bend. Nobody wanted to do this case at 10pm so the surgeon did it herself without anesth. I now would have handled it differently by asking a partner how he would have handled it. It took a little time to smooth out that relationship with the surgeon but all was forgotten. You learn a ton in residency from your attendings and you probably have noticed that everyone will have a different take of the situation. Today I would do the case no problem and while I haven't forgotten the "rules" of anesthesia I do see the big picture better. Things like this will take time but your partners are a great resource. You don't have to do what they say if you disagree. Remember the surgeons are your clients. Don't kiss ass but keep them happy if possible (not always possible).
I figured this would be the next big topic on this forum and I'm sure the seasoned vet's here will have some pointers. For me the idea is to fit in well, not ruffle feathers and slowly begin to be a voice in the group.

 

[apma77]

it seems that you have buckled to the pressure that now you are willing to do the anesthetic without proper NPO status to "please" the surgeon
if that kid aspirates the surgeon will be the first one ALL over you in court!

 

[supahfresh]

I'll probably get booted from private practice cause I would have told that lady to eat s hit.

 

[UTSouthwestern]

It's always about the way you argue your point.

"Dr. XXX, I would love to get this case completed as quickly as possible, but if the kid ate two hours ago, there is a great risk of vomiting especially in a kid experiencing pain from an infected wound. In the best interest of the kid, we should wait about 4 more hours."

If Dr. XXX could do the procedure without anesthesia, this was a case that probably didn't need to have general anesthesia/MAC for it to get done.

No situation is worth compromising patient safety. That doesn't mean you can't finesse the situation however without crushing toes.

 

[jetproppilot]

it seems that you have buckled to the pressure that now you are willing to do the anesthetic without proper NPO status to "please" the surgeon
if that kid aspirates the surgeon will be the first one ALL over you in court!

If the case is an emergency, waiting hours to go by just because of npo status is serving only to give you a false sense of security. I wholeheartedly agree with Noy here. Dont get it when anesthesiologists delay cases on emergencies because of npo status.

PETS? Breast aug? Sure. Emergency? Nope.

How efficacious is gastric emptying when pain/infection has manifested? How much "emptier" is the kids belly gonna be?

 

[stephend7799]

If the case is an emergency, waiting hours to go by just because of npo status is serving only to give you a false sense of security. I wholeheartedly agree with Noy here. Dont get it when anesthesiologists delay cases on emergencies because of npo status.

PETS? Breast aug? Sure. Emergency? Nope.

How efficacious is gastric emptying when pain/infection has manifested? How much "emptier" is the kids belly gonna be?

im not sure i/d of a buttock is an emergency. please.

I would have done the case too immediately...

general anesthetic with a tube.. regardeless of who the surgeon is.. The kid wont aspirate and die

 

[UTSouthwestern]

If the case is an emergency, waiting hours to go by just because of npo status is serving only to give you a false sense of security. I wholeheartedly agree with Noy here. Dont get it when anesthesiologists delay cases on emergencies because of npo status.

PETS? Breast aug? Sure. Emergency? Nope.

How efficacious is gastric emptying when pain/infection has manifested? How much "emptier" is the kids belly gonna be?

More importantly, if she wanted to get this thing going, why did she let the kid eat, unless it wasn't really that emergent or that infected.

 

[Noyac]

We do full stomachs all the time. What makes this different? If this kid was given opiates for pain then how can you say 6 or 8 hrs NPO. Nobody knows how much is in the kids stomach and especially after opiates. So we put these strict guidelines on NPO status and they keep changing. The fact is you do what you are comfortable with doing. When you get out there and start practicing you begin to get more comfortable with a lot of **** that you wouldn't have necessarily been comfortable doing. If anyone here can say they won't break "the rules" for convenience (if that's what you want to call it) then your a liar. Your son has his first little league game and if you delay the case you will miss it. Are you gonna miss the game cause some arbitrary rule says you can possibly do this case safely? When is the last time you had emesis in the OR? I had it once and it was expected. It was in a small bowel obst case. Trust me your tone will change and if it doesn't you will be the one that surgeons avoid. I don't mean that you need to practice in an unsafe manner but this is a situation that is poorly defined and can make your life miserable if you let it. NPO guidelines suck and that's that. Who had what? Was it clear? do you take any meds? Narcs? Do you have GERD? Hell our surgeons give their pts up to 5 pills with a cup of water b/4 surgery. Do I cancel those pts b/c the pill was a solid? These are protocols in may ambulatory centers these days. Are you gonna come out of residency and say "I'm not doing this case cause you just gave him celebrex, oxycodone 2pills, pepcid, and reglan". You aren't going to be around for long partner.

 

[Noyac]

By the way, I didn't do the kid any favors by delaying the case cause the surgeon did it with ketamine. This probably put the child at greater risk. I know, at least its the surgeons problem now, but if I can make it safer for the kid, shouldn't I?
And your right, its not an emergency but it is urgent. This kid ate just b/4 entering the surgeons office. The surgeon didn't feed him, his mom did.

The topic of this thread is not about NPO status but about making your transition into PP easier. If you want to be rigid go ahead.

 

[UTSouthwestern]

I'll be the first one to say that I don't exactly adhere strictly to the rules, but take two cases from last week and a case with a former classmate of mine as an example:

28 y/o WF for lap banding who has been on a prescribed liquid diet for 10 days, is on no meds whatsoever, and really is only moderately overweight at 5'6" 210 (good running back size). NPO more than 12 hours. After RSI/uneventful start, I put the sizer tube down and suck out . . . air.

Next case is similar to the above except 1 inch shorter and right at 200 lbs and she admitted after waking up to eating one last meal on the morning of surgery (eggs, bacon, four pancakes, shake, coffee - IHOP special), 4.0 hours before surgery. With RSI, she vomitted up half a piece of bacon and a homogenous grayish-brown mix of fluid, of which she aspirated probably just a few cc's as I always have the sucker right next to the head for the lap fat surgeries. After sucking out the lungs (thankfully only a tiny amount of residue), I drop in a large OGT and suck out 45-50 cc's of homogenous goo. I suspect that with another 4 hours she might have cleared the rest of her last (almost literally last) meal.

I don't use the guidelines as a hard and fast template with no room for flexibility, but they are there for a good reason. Still, your point is absolutely correct in that you have to adjust to the situation as you see fit (emergency, clears versus solids versus meds, etc.) but my point would be not to compromise your judgement solely for expediency and good surgeon relationship. One of my classmates has already been served up with his first lawsuit for proceeding on a pediatric (teen) ortho case on a Spanish speaking only patient who did not understand the NPO instruction, was on no pain or any other meds (two month old shoulder injury not responding to non-surgical therapy), ate on the morning of surgery because he was the 1 PM case, aspirated around his LMA (apparently for at least an hour before his sats took a dive), and spent the next week in the ICU resolving a thankfully survivable aspiration pneumonitis. Different circumstance (LMA, language problem, etc.) but my classmate did the case knowing the PO status with pressure from the ortho guy with an interscalene block and the LMA.

After pretrial discovery, the ortho guy was excused from the suit. It is unlikely he admitted to knowledge of the patient's PO status given his removal from the suit. Again a judgement call, but one that my classmate now wishes that he had stuck to.

You future private practice guys will have to approach it with as much tact and finesse as possible, but I have yet to meet a surgeon who will hold a grudge against you for being concerned for a patient's safety unless you become chicken little in every circumstance and block/delay cases for every reason for every minute of time ("Doctor XXX, it's only been 7 hours, 45 minutes from his/her last meal, we'll have to wait before we go back."). If you do meet one who holds a grudge, you are probably best off keeping your distance from him/her in any event.

 

[militarymd]

What's the difference between a MAC and getting sh it faced on tequilas after a big Mexican dinner?

 

[Disse]

What's the difference between a MAC and getting sh it faced on tequilas after a big Mexican dinner?

In the first I get you Sh it faced and I am, therefore, responsible for it (and for you).

In the second you get yourself Sh it faced and I am not responsible for it 🙂.

 

[MDEntropy]

I'll be the first one to say that I don't exactly adhere strictly to the rules, but take two cases from last week and a case with a former classmate of mine as an example:

28 y/o WF for lap banding who has been on a prescribed liquid diet for 10 days, is on no meds whatsoever, and really is only moderately overweight at 5'6" 210 (good running back size). NPO more than 12 hours. After RSI/uneventful start, I put the sizer tube down and suck out . . . air.

Next case is similar to the above except 1 inch shorter and right at 200 lbs and she admitted after waking up to eating one last meal on the morning of surgery (eggs, bacon, four pancakes, shake, coffee - IHOP special), 4.0 hours before surgery. With RSI, she vomitted up half a piece of bacon and a homogenous grayish-brown mix of fluid, of which she aspirated probably just a few cc's as I always have the sucker right next to the head for the lap fat surgeries. After sucking out the lungs (thankfully only a tiny amount of residue), I drop in a large OGT and suck out 45-50 cc's of homogenous goo. I suspect that with another 4 hours she might have cleared the rest of her last (almost literally last) meal.

I don't use the guidelines as a hard and fast template with no room for flexibility, but they are there for a good reason. Still, your point is absolutely correct in that you have to adjust to the situation as you see fit (emergency, clears versus solids versus meds, etc.) but my point would be not to compromise your judgement solely for expediency and good surgeon relationship. One of my classmates has already been served up with his first lawsuit for proceeding on a pediatric (teen) ortho case on a Spanish speaking only patient who did not understand the NPO instruction, was on no pain or any other meds (two month old shoulder injury not responding to non-surgical therapy), ate on the morning of surgery because he was the 1 PM case, aspirated around his LMA (apparently for at least an hour before his sats took a dive), and spent the next week in the ICU resolving a thankfully survivable aspiration pneumonitis. Different circumstance (LMA, language problem, etc.) but my classmate did the case knowing the PO status with pressure from the ortho guy with an interscalene block and the LMA.

After pretrial discovery, the ortho guy was excused from the suit. It is unlikely he admitted to knowledge of the patient's PO status given his removal from the suit. Again a judgement call, but one that my classmate now wishes that he had stuck to.

You future private practice guys will have to approach it with as much tact and finesse as possible, but I have yet to meet a surgeon who will hold a grudge against you for being concerned for a patient's safety unless you become chicken little in every circumstance and block/delay cases for every reason for every minute of time ("Doctor XXX, it's only been 7 hours, 45 minutes from his/her last meal, we'll have to wait before we go back."). If you do meet one who holds a grudge, you are probably best off keeping your distance from him/her in any event.

I like your examples/cases.

I must say UT, I am pretty shocked you started that second elective case on a full stomach. I think the point of your story is that you wish you had waited... But why didn't you wait? Were you feeling production pressure? Do you think the pressure was primarily self-driven or was the surgeon pushing you to do this case?

I am not here to second guess people but I also just want to understand something as I am even more shocked your colleague did a full stomach with an LMA "knowing the PO status". Did he not think either just the block and some hand-holding or a tube and OG +/- a block would be better?

I sure many of us have seen lap gastric bypass patient's mouths fill up with gastric contents including food chunks immediately after an RSI while still taping in the tube. And all of this is in people who have sworn to being NPO. You may not call that vomiting per se, but it certainly seems like some reverse peristalsis. -----------> If you don't wait, in any type of elective situation there better not be any pulmonary complications, because if so you probably won't have a leg to stand on. Of course, most of the time you will get away with it so the tolerance of risk here is very personal.

 

[rn29306]

I like your examples/cases.

I must say UT, I am pretty shocked you started that second elective case on a full stomach. I think the point of your story is that you wish you had waited... But why didn't you wait? Were you feeling production pressure? Do you think the pressure was primarily self-driven or was the surgeon pushing you to do this case?

She admitted to eating after waking up.

I personally find it amusing to see these people after surgery and various individuals rake them over the coals for being idiots. Kind of hard to deny the fact that somehow food (still undigested) came up during induction when all they have to say in PreOp is "I haven't eaten in 12 hours".

 

[ThinkFast007]

MSIV here

but this si jsut my little tit bit. Most times at the places i've rotated through, attendings/rsidents/students woudl tell the pt "please, do not eat anything for the next XXX hours before surg" or "please dont eat after midngiht",etc. I've found that pts really dont know WHY? and so they eat. This is why I usually tell them, "look you really shouldnt eat mr. smith, otherwise there is an increased chance of you throwing up and the contents going into your lungs, thus possibly giving you a pneumonia or even dying".

Personally, i like being blunt, I think pts get it then. Anyone else do this?

 

[stephend7799]

MSIV here

but this si jsut my little tit bit. Most times at the places i've rotated through, attendings/rsidents/students woudl tell the pt "please, do not eat anything for the next XXX hours before surg" or "please dont eat after midngiht",etc. I've found that pts really dont know WHY? and so they eat. This is why I usually tell them, "look you really shouldnt eat mr. smith, otherwise there is an increased chance of you throwing up and the contents going into your lungs, thus possibly giving you a pneumonia or even dying".

Personally, i like being blunt, I think pts get it then. Anyone else do this?

here is the point in private practice

You get paid to DO the case, not to cancel them. so do the freakin case.

if you cancel them you wont get paid.. P and S.. (plain and simple)

thats the kind of model im in now.. So i very rarely cancel cases..

 

[Noyac]

here is the point in private practice

You get paid to DO the case, not to cancel them. so do the freakin case.

if you cancel them you wont get paid.. P and S.. (plain and simple)

thats the kind of model im in now.. So i very rarely cancel cases..

That's what I'm talkin about. 👍
Now Stephend, were you always this way or did you have to learn it over time? The point that I am trying to make is that your academic training is great and it will make you a great anesthesiologist but private practice will challenge you in more ways than just in the OR. You will have to do things that your academic attendings would not do for one reason or another. You will need to adapt and to learn what you are comfortable with and what you are not comfortable with. My example may be a bad one for some of you guys but the message is there.

 

[UTSouthwestern]

here is the point in private practice

You get paid to DO the case, not to cancel them. so do the freakin case.

if you cancel them you wont get paid.. P and S.. (plain and simple)

thats the kind of model im in now.. So i very rarely cancel cases..

Do the cases whenever possible, but not at all costs. That is my point. Had I known that my second patient had eaten four hours before stomach surgery, I would have definitely cancelled that case. My surgeon agreed with me that if that had been the situation, the case would have been cancelled and he would have refused to do the case in the future as well as the patient was obviously too un reliable to carry through with follow up care and adherence to the post banding dieting rules.

As for my classmate and his choice of techniques, that will punish him in the suit. He has no legs to stand on, no backing from his surgical colleague, and too much liability insurance for a lawyer to ignore. I've reviewed his case and have told him it would be better for him and his insurance company to settle out of court.

 

[militarymd]

I 've read and read the ASA's NPO guidelines. It is essentially a legal document that gives one LEGAL grounds to protect YOURSELF, and not much information in protecting your PATIENTS.


UT, your colleagues' case....you're telling me the guy had breakfast, then had a case a 1 pm, and that's why he aspirated?????

You're telling me a young healthy dude has not emptied his stomach by lunch time after breakfast?????

I've reviewed many cases where the NPO times have been satisfied, and there is still complications related to aspiration of gastric contents.

The ASA's document has given lawyers something to nail a clinicians ass with when one exercises JUDGEMENT in determining when it is safe to anesthetize a patient.

I, based on my experiences, think that the 6/8 hours that is listed in the guideline are WAY too conservative.....

they cause:
1) patient discomfort
2) does not prevent aspiration
3) gives lawyers a document to sue you with when unavoidable complications occur.

 

[stephend7799]

I'll be the first one to say that I don't exactly adhere strictly to the rules, but take two cases from last week and a case with a former classmate of mine as an example:

28 y/o WF for lap banding who has been on a prescribed liquid diet for 10 days, is on no meds whatsoever, and really is only moderately overweight at 5'6" 210 (good running back size). NPO more than 12 hours. After RSI/uneventful start, I put the sizer tube down and suck out . . . air.

Next case is similar to the above except 1 inch shorter and right at 200 lbs and she admitted after waking up to eating one last meal on the morning of surgery (eggs, bacon, four pancakes, shake, coffee - IHOP special), 4.0 hours before surgery. With RSI, she vomitted up half a piece of bacon and a homogenous grayish-brown mix of fluid, of which she aspirated probably just a few cc's as I always have the sucker right next to the head for the lap fat surgeries. After sucking out the lungs (thankfully only a tiny amount of residue), I drop in a large OGT and suck out 45-50 cc's of homogenous goo. I suspect that with another 4 hours she might have cleared the rest of her last (almost literally last) meal.

I don't use the guidelines as a hard and fast template with no room for flexibility, but they are there for a good reason. Still, your point is absolutely correct in that you have to adjust to the situation as you see fit (emergency, clears versus solids versus meds, etc.) but my point would be not to compromise your judgement solely for expediency and good surgeon relationship. One of my classmates has already been served up with his first lawsuit for proceeding on a pediatric (teen) ortho case on a Spanish speaking only patient who did not understand the NPO instruction, was on no pain or any other meds (two month old shoulder injury not responding to non-surgical therapy), ate on the morning of surgery because he was the 1 PM case, aspirated around his LMA (apparently for at least an hour before his sats took a dive), and spent the next week in the ICU resolving a thankfully survivable aspiration pneumonitis. Different circumstance (LMA, language problem, etc.) but my classmate did the case knowing the PO status with pressure from the ortho guy with an interscalene block and the LMA.

After pretrial discovery, the ortho guy was excused from the suit. It is unlikely he admitted to knowledge of the patient's PO status given his removal from the suit. Again a judgement call, but one that my classmate now wishes that he had stuck to.

You future private practice guys will have to approach it with as much tact and finesse as possible, but I have yet to meet a surgeon who will hold a grudge against you for being concerned for a patient's safety unless you become chicken little in every circumstance and block/delay cases for every reason for every minute of time ("Doctor XXX, it's only been 7 hours, 45 minutes from his/her last meal, we'll have to wait before we go back."). If you do meet one who holds a grudge, you are probably best off keeping your distance from him/her in any event.

DUDE
Did I hear this correctly?
he aspirated around an LMA after knowing fasting status of the patient..

there are some huge holes in this case.. Number one.. dont do regional blocks on anybody.. especially people who dont speak english.... too many Im numb 1 year after the surgery... dont need the hassle

number 2.. if you are going to ignore fasting rules.. do yourself a favor.. do a rapid seq induction (emphasis on the rapid) get that tube in as fast as possible and throw an og tube in a suck out the stomach.. give reglan etc..

your boy is gonna have a tough time explaining to the lawyer why he put an LMA in....

 

[UTSouthwestern]

I 've read and read the ASA's NPO guidelines. It is essentially a legal document that gives one LEGAL grounds to protect YOURSELF, and not much information in protecting your PATIENTS.


UT, your colleagues' case....you're telling me the guy had breakfast, then had a case a 1 pm, and that's why he aspirated?????

You're telling me a young healthy dude has not emptied his stomach by lunch time after breakfast?????

I've reviewed many cases where the NPO times have been satisfied, and there is still complications related to aspiration of gastric contents.

The ASA's document has given lawyers something to nail a clinicians ass with when one exercises JUDGEMENT in determining when it is safe to anesthetize a patient.

I, based on my experiences, think that the 6/8 hours that is listed in the guideline are WAY too conservative.....

they cause:
1) patient discomfort
2) does not prevent aspiration
3) gives lawyers a document to sue you with when unavoidable complications occur.

Breakfast was 10 am (surgery was done at a surgery center adjacent to the main hospital where you only have to be in by 2 hours before the scheduled case start time) and he ate a very heavy residue breakfast at one of the local Mexican buffets (Pancho's or Gancho's). Quantity is a key here.

I agree that the guidelines put some handcuffs on us, but they are there. 99 times out of 100 this wouldn't have been an issue, but for this kid it was and now my friend is going to pay a heavy price for pushing through. The fact that he knew the kid ate a heavy meal and went ahead is going to get him punished pretty harshly.

Stephend, my friend is screwed and I've told him with about 100 different colorful adjectives (royally screwed, wholly screwed, brokeback screwed, etc.). He'll never do that again, but I fear he'll go to the other extreme and be over conversative. He's a great anesthesiologist and hopefully this isn't something that affects his mindset.

 

[bigdan]

I love the original text of the case for pearls for transit from residency to private practice.

But with the route that this thread has taken, we're also getting a great conversation. One of Jet's old posts comes to mind - he said that (I'm liberally paraphrasing) we should put a research emphasis on clinical actions that anesthesiologists take every single day but do not have great evidence for. So let me ask - what is proven to be safe in prevention of aspiration? What is the evidence for RSI? Would any IRB allow research so that we can find out what really works? My (admittedly naive) interpretation of the above posts is that ASA gives us a "recommendation" that we should use but can likewise be used against us.

Your thoughts?

dc

 

[Noyac]

In 1993, Warner et al studied 215,000 cases and reported pulm asp in 1:3216. For elective cases the incidence was 1:3886 compared to 1:895 for emergencies. Olsson et al in 1986 found similiar results as well as Mellin-Olsen et al in 1996.
The evidence most consistently demonstrates the fact that emergency timing is the greatest risk factor. In 1999, Warner et al demonstrated that intestinal obst lead to the majority of pediatric aspirations. Late term pregnancy is generally considered a significant risk factor. However, not all researchers are in agreement regarding gastric emptying times in this population. The risk is not simply due to gastric contents. Most aspirations in obstetrics occur during laryngoscopy and difficult or failed attempts are important factors. Most obese patients are greater risks for the same reasons- difficult or failed intubations.
In a 1998 editorial, there was no evidence from a randomized controlled trial, cohort study, or case-control study that demonstrates a link b/w gastric vol and an increase in risk of aspiration. At the time of induction, gastric vol is actually quite variable in normal people.
In a controlled study multiple prophylactic regimens for c/s were used. Ranitidine, omeprazole, or metoclopramide alone (but with bicitra) did not reduce gastric vol. Small reductions were seen with combinations (Reglan + ranitidine or omeprazole). Other studies show limited results in reducing vol with reglan however, it may tighten the lower esoph sphincter. Erythromycin is the only thing found to accelerate gastric emptying.
We all know how the fasting guidelines have changed over the years. The studies have been reported and they all differ in some way or another. If you wish to look up the studies, they are by Nygren et al, Soreide et al, and many others. The ASA Task Force on Preoperative Fasting will also have the references. The Task Force was unenthusiastic about the indiscriminate use of chemoprophylaxis to minimize aspiration. The cost was to great for the routine treatment of pts with no apparent increase risks. The Task Force maintained disreet silence when refering to pts with "apparent risks". If they are not going to recommend pretreatment even for the "at risk pts" then the research can't be to convincing.

 

[militarymd]

In 1993, Warner et al studied 215,000 cases and reported pulm asp in 1:3216. For elective cases the incidence was 1:3886 compared to 1:895 for emergencies. Olsson et al in 1986 found similiar results as well as Mellin-Olsen et al in 1996.
The evidence most consistently demonstrates the fact that emergency timing is the greatest risk factor. In 1999, Warner et al demonstrated that intestinal obst lead to the majority of pediatric aspirations. Late term pregnancy is generally considered a significant risk factor. However, not all researchers are in agreement regarding gastric emptying times in this population. The risk is not simply due to gastric contents. Most aspirations in obstetrics occur during laryngoscopy and difficult or failed attempts are important factors. Most obese patients are greater risks for the same reasons- difficult or failed intubations.
In a 1998 editorial, there was no evidence from a randomized controlled trial, cohort study, or case-control study that demonstrates a link b/w gastric vol and an increase in risk of aspiration. At the time of induction, gastric vol is actually quite variable in normal people.
In a controlled study multiple prophylactic regimens for c/s were used. Ranitidine, omeprazole, or metoclopramide alone (but with bicitra) did not reduce gastric vol. Small reductions were seen with combinations (Reglan + ranitidine or omeprazole). Other studies show limited results in reducing vol with reglan however, it may tighten the lower esoph sphincter. Erythromycin is the only thing found to accelerate gastric emptying.
We all know how the fasting guidelines have changed over the years. The studies have been reported and they all differ in some way or another. If you wish to look up the studies, they are by Nygren et al, Soreide et al, and many others. The ASA Task Force on Preoperative Fasting will also have the references. The Task Force was unenthusiastic about the indiscriminate use of chemoprophylaxis to minimize aspiration. The cost was to great for the routine treatment of pts with no apparent increase risks. The Task Force maintained disreet silence when refering to pts with "apparent risks". If they are not going to recommend pretreatment even for the "at risk pts" then the research can't be to convincing.

You beat me to the Warner publication.

 

[militarymd]

DUDE
Did I hear this correctly?
he aspirated around an LMA after knowing fasting status of the patient..

there are some huge holes in this case.. Number one.. dont do regional blocks on anybody.. especially people who dont speak english.... too many Im numb 1 year after the surgery... dont need the hassle

number 2.. if you are going to ignore fasting rules.. do yourself a favor.. do a rapid seq induction (emphasis on the rapid) get that tube in as fast as possible and throw an og tube in a suck out the stomach.. give reglan etc..

your boy is gonna have a tough time explaining to the lawyer why he put an LMA in....

One of the most common myths in anesthesia....that an endotracheal tube prevents aspiration....I thought that myth has been stamped out in the last 5 years....I guess not.

 

[Noyac]

One of the most common myths in anesthesia....that an endotracheal tube prevents aspiration....I thought that myth has been stamped out in the last 5 years....I guess not.

Hey Mil, I remember a Critical Care study that suggested that if the ETT was lubed at the cuff, it diminished the rate of aspiration. Is there any truth to this as far as you know?

 

[militarymd]

Hey Mil, I remember a Critical Care study that suggested that if the ETT was lubed at the cuff, it diminished the rate of aspiration. Is there any truth to this as far as you know?

I have not read that paper, but that sounds reasonable.....for the short term..ie before the lube dries up.

 

[stephend7799]

One of the most common myths in anesthesia....that an endotracheal tube prevents aspiration....I thought that myth has been stamped out in the last 5 years....I guess not.

certainly reduces the risk for aspiration and surely is superior to the LMA Professor

 

[supahfresh]

One of the most common myths in anesthesia....that an endotracheal tube prevents aspiration....I thought that myth has been stamped out in the last 5 years....I guess not.

but it helps, doesn't it? and if you drop an OG tube, does that not also help in this situation?

 

[militarymd]

certainly reduces the risk for aspiration and surely is superior to the LMA Professor

Is that right?

 

[supahfresh]

I 've read and read the ASA's NPO guidelines. It is essentially a legal document that gives one LEGAL grounds to protect YOURSELF, and not much information in protecting your PATIENTS.


UT, your colleagues' case....you're telling me the guy had breakfast, then had a case a 1 pm, and that's why he aspirated?????

You're telling me a young healthy dude has not emptied his stomach by lunch time after breakfast?????

I've reviewed many cases where the NPO times have been satisfied, and there is still complications related to aspiration of gastric contents.

The ASA's document has given lawyers something to nail a clinicians ass with when one exercises JUDGEMENT in determining when it is safe to anesthetize a patient.

I, based on my experiences, think that the 6/8 hours that is listed in the guideline are WAY too conservative.....

they cause:
1) patient discomfort
2) does not prevent aspiration
3) gives lawyers a document to sue you with when unavoidable complications occur.

I'm still bothered by this. I'm willing to accept that the NPO guidelines are too conservative, do not prevent aspiration, and that gastric emptying is totally unpredictable. I'm sure I will also change once into private practice. But, if Noyac did the case without waiting and the patient aspirated, how can he defend that in court? and if he waited and the kid still aspirated, doesnt that help protect him court? so, I want to know why in non-emergency cases I shouldn't wait because I dont want to give the damn lawyers any extra reason to come after me.

 

[supahfresh]

Do the cases whenever possible, but not at all costs. That is my point. Had I known that my second patient had eaten four hours before stomach surgery, I would have definitely cancelled that case. My surgeon agreed with me that if that had been the situation, the case would have been cancelled and he would have refused to do the case in the future as well as the patient was obviously too un reliable to carry through with follow up care and adherence to the post banding dieting rules.

As for my classmate and his choice of techniques, that will punish him in the suit. He has no legs to stand on, no backing from his surgical colleague, and too much liability insurance for a lawyer to ignore. I've reviewed his case and have told him it would be better for him and his insurance company to settle out of court.

So the better malpractice plan increases the chance you may get sued?

 

[militarymd]

So the better malpractice plan increases the chance you may get sued?

yes...lawyers go after the deep pockets...always.

 

[militarymd]

I'm still bothered by this. I'm willing to accept that the NPO guidelines are too conservative, do not prevent aspiration, and that gastric emptying is totally unpredictable. I'm sure I will also change once into private practice. But, if Noyac did the case without waiting and the patient aspirated, how can he defend that in court? and if he waited and the kid still aspirated, doesnt that help protect him court? so, I want to know why in non-emergency cases I shouldn't wait because I dont want to give the damn lawyers any extra reason to come after me.

You have to ask yourself these questions.....Am I doing what's "right" or what's "medicolegally defensible"?

I believe in what's "right". My feelings are mixed on decisions that are always "medicallegally" based.

I'll repeat it again....the NPO guidelines ARE NOT helpful....read it again...It is essentially worthless except to lawyers when there is an adverse outcome and you have deviated from the guidelines....or it helps you when there is an adverse outcome and you have not deviated.....

The information contained DOES NOT help the patient.

Timing of surgery and anesthesia as it relates to the time of last oral intake and risk to the patient is a JUDGEMENT call.

Overall, the risk of aspiration as it relates to last oral intake is VASTLY over estimated.

 

[supahfresh]

So if you believe you're doing what is right for the patient and you get sued, is that what you say in your defense? you did what you felt was best for the patient.

 

[militarymd]

So if you believe you're doing what is right for the patient and you get sued, is that what you say in your defense? you did what you felt was best for the patient.

What else can you say? Physicians make judgements all the time....that's your job, some of your judgements WILL BE WRONG....hence...art of medicine.

I 'm pretty sure NO ONE does what is WRONG for their patients.

 

[jetproppilot]

Late term pregnancy is generally considered a significant risk factor. However, not all researchers are in agreement regarding gastric emptying times in this population. The risk is not simply due to gastric contents. Most aspirations in obstetrics occur during laryngoscopy and difficult or failed attempts are important factors. Most obese patients are greater risks for the same reasons- difficult or failed intubations.

And herein lies the unquantifiable.

How can you stratify a study when laryngoscopist prowess varies so greatly?

I've been in this business ten years.

And I can swear to you that laryngoscopist prowess makes a difference.

Some people (independent of years practiced) have THE FORCE.

And some don't.

If I did a randomized, prospective study of this subject ONLY utilizing laryngoscopists that possess THE FORCE, the numbers would be different.

Lets see. I'm gonna replicate the study, but this time I'm gonna use Mitch LeBlanc CRNA, Yvette SRNA, and several MD force possessors.

Laugh at will, but its true.

Studies dont stratify intubation prowess. One has to assume the laryngoscopists were skilled, when most likely more than half of them were s hitty-to-average.

 

[Noyac]

I gotta say one thing. I don't practice worrying if I'm gonna be sued. I do what I feel is right. I can say that I rarely ever think or worry about being sued. If you do what you feel is the right thing for your pt then you will not worry about these things. Sure, there will be times that you are named in a suit but if you did it right, that will be the end of it- just named not sued.

But this thread diffinitely did not head in the direction that I was hoping it would. Oh well. Carry on.

PS: you are absolutely right, Jet.

 

[supahfresh]

right. you started off saying one of the most difficult things is to deal with surgeons. So how do you deal with them?

I gotta say one thing. I don't practice worrying if I'm gonna be sued. I do what I feel is right. I can say that I rarely ever think or worry about being sued. If you do what you feel is the right thing for your pt then you will not worry about these things. Sure, there will be times that you are named in a suit but if you did it right, that will be the end of it- just named not sued.

But this thread diffinitely did not head in the direction that I was hoping it would. Oh well. Carry on.

PS: you are absolutely right, Jet.

 

[jetproppilot]

right. you started off saying one of the most difficult things is to deal with surgeons. So how do you deal with them?

If I may rudely butt in, Supah,

you tolerate most bulls hit.

But when they deteriorate to the point where efficiency/employee morale/patient safety & satisfaction

is jeapordized,

you bring surgeon-dude into your office with your partners present, tell him your gripes, and INFORM him of his shortcomings, TELL him his behavior is intolerable, and TELL him his business, surprisingly to him, means nothing to you and your partners, and if he continues with said behavior, he can find someone else to put his patients to sleep for his cases.

And, by the way, we've got an exclusive contract at this hospital.

Yes, we're a VERY able/efficient/knowledgable/catering group of anesthesiologists at this hospital, surgeon-dude.

But you've pushed us, and our staff too far.

SO,

f uck you.

Shape up, or work elsewhere.

as an aside, this is an EXTREME case. But it is a case that is quoted word for word.

Has happened before, and will probably happen again.

If an anesthesia group runs a tight ship, only abusive, a sshole surgeons find themselves in this predicament.

 

[Noyac]

First of all, you need to gain their respect. Secondly, you need to be better informed (more knowledgeable) than them. If you got those 2 covered then its easy.

So what I was trying to get across in the original post was that you will be in awkward positions from time to time when you first get into PP. They will test you. You should have mentors (partners) to bounce things off of and if you are not comfortable with something then go to your partners and let them help.
At first, I wanted to be able to handle everything myself. It just doesn't work that way. You need to gain their respect. But if you are smart and well informed/knowledgeable, things will be easier. Bottomline, know your ****. And a good personality helps.

 

[jetproppilot]

At first, I wanted to be able to handle everything myself. It just doesn't work that way

Noyac,

this says it all.

I've been in this biz ten years now, and I continue to give thanks for my partner's presence, two-of-which have been out of residency less than five years.

Two/three/four board-certified anesthesiologists opinions/technical prowess are certainly better than one.

 

[UTSouthwestern]

Bottomline, know your ****. And a good personality helps.

I'd call these points 1 and 1A in skills needed in PP. Being a good conversationalist is a highly prized skill because it makes the surgeons want to work with you and makes you a likely individual that is often requested provided #1 is covered along with #1A.

Of course a jackass might also like you and also request you, so watch out.

 

[militarymd]

I'd call these points 1 and 1A in skills needed in PP. Being a good conversationalist is a highly prized skill because it makes the surgeons want to work with you and makes you a likely individual that is often requested provided #1 is covered along with #1A.

Of course a jackass might also like you and also request you, so watch out.

That's happened to me....and that sucks

 

[rn29306]

If I may rudely butt in, Supah,

you tolerate most bulls hit.

But when they deteriorate to the point where efficiency/employee morale/patient safety & satisfaction

is jeapordized,

you bring surgeon-dude into your office with your partners present, tell him your gripes, and INFORM him of his shortcomings, TELL him his behavior is intolerable, and TELL him his business, surprisingly to him, means nothing to you and your partners, and if he continues with said behavior, he can find someone else to put his patients to sleep for his cases.

And, by the way, we've got an exclusive contract at this hospital.

Yes, we're a VERY able/efficient/knowledgable/catering group of anesthesiologists at this hospital, surgeon-dude.

But you've pushed us, and our staff too far.

SO,

f uck you.

Shape up, or work elsewhere.

as an aside, this is an EXTREME case. But it is a case that is quoted word for word.

Has happened before, and will probably happen again.

If an anesthesia group runs a tight ship, only abusive, a sshole surgeons find themselves in this predicament.

Not that you probably asked them prior to the meeting, but what repercussions from the hospital management did you have, if any? Also, not that you probably care, but hospital management doesn't exactly deal this way with ahole surgeons. We have one that acts like a spoiled two year old on a regular occasion, right in front of soon-to-be-propofoled patients in PreOp for the world to see. Hospital management often will bend rules and let most surgeons get a way with crap just because of the revenue he or she brings to the table and are very protective of keeping him/her happy. I would imagine if the HMFIC of the hospital got wind of your meeting, they wouldn't be too happy.

Just wondering how they took it if aware of the surg vs anesth meeting.

I am guessing your answer, but wanna see what you say.

 

[jetproppilot]

Not that you probably asked them prior to the meeting, but what repercussions from the hospital management did you have, if any? Also, not that you probably care, but hospital management doesn't exactly deal this way with ahole surgeons. We have one that acts like a spoiled two year old on a regular occasion, right in front of soon-to-be-propofoled patients in PreOp for the world to see. Hospital management often will bend rules and let most surgeons get a way with crap just because of the revenue he or she brings to the table and are very protective of keeping him/her happy. I would imagine if the HMFIC of the hospital got wind of your meeting, they wouldn't be too happy.

Just wondering how they took it if aware of the surg vs anesth meeting.

I am guessing your answer, but wanna see what you say.

Didnt hear any response from hospital administration. And they knew about the meeting.

And not trying to sound arrogant, but with our group's hard-working/catering reputation, I'm not intimidated by a hospital's administration. Went to school way too long to worry about that. Especially when we did what was right. The dude needed an intervention.

I think you'd be surprised how many administrators realize how valuable a repected, hard working anesthesia group is.

We are not bullies. Quite the contrary. We view the OR as our hardware store. We are catering to surgeons and patients. We are respected for our work.

This surgeon dude had taken things WAY too far. We had had several interactions with him about issues in a friendly fashion...i.e. "Cmon Dude, it really doesnt do any good to speak to the scrub that way....or the CRNA that way...." etc

One evening he added on a case. Pt was an inpatient. About ninety minutes before the anticipated start time, my partner sent for the patient. Transporter goes to get the patient, brings patient to holding.

A pt/ptt was ordered by the surgeon (cant remember why) which hadnt been drawn yet, so my partner draws it himself and sends it to the lab. Still about 30 minutes before anticipated start time. Lab results arrive before time to go back to the OR. Normal.

Surgeon gets the heads-up call...we'll be ready for you soon. He throws a major fit about us calling for the patient without him knowing. He was majorly pissed because we had taken the initiative to get his case ready for him, my partner even going the extra mile by drawing a lab himself to make sure nothing delayed the case.

He comes to the OR and gives my partner a major lecture, how we had screwed up by calling for the patient without his knowledge. ?????

Never really made any sense...my partner was like...HUH? You added on the case, right? You were given an approximate time which you agreed with, right?

Utter nonsense. During the case he was abusive to the scrub, the circulator, and the CRNA.

We avoid/downplay most petty stuff. But sometimes you've gotta draw a line in the sand.

This topic has been covered before here.

Ask UT to post his similar story(s), and how he handled them.

 

[militarymd]

Man, I guess I'm lucky....I've never had anyone THAT bad.

 

[Noyac]

Actually, my current gig is pretty good about ahole surgeons. i am a hosp. employee so I can't just tell the surgeon to go *uck himself. So we went to the administration (not the first people or group to complain about these 2 surgeons) and said that working with these guys was becoming a "hostile environment". This got their attention since they a lawyers and they realized that this was a legal issue now. The 2 surgeons were brought into the CEO,CFO,CMO's office read the riot act and then had to have a psych consult. That really straightened them out. One of them is a joy to work with and the other is just fine but with a crappy personality now.

 

[militarymd]

"hostile environment".....gets their attention everytime.

 

[supahfresh]

Let's hear your story UT.