trauma and gastroparesis

Discussion in 'Anesthesiology' started by Trisomy13, Dec 25, 2008.

  1. Trisomy13

    Trisomy13 ultra
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    What is everyone's take on gastroparesis following trauma? Consider an otherwise healthy patient, PMH only of "mild GERD, takes OTC prilosec sometimes", reports he has been NPO since breakfast at 09:30, slipped and fell from his deck at 13:30 and presents at 21:30 in the holding area for a quick IM tibia nail per your ortho service. Are you concerned about significant gastroparesis following his fall, effectively making him only 4 hours NPO (09:30-13:30)? Or would you proceed as if he were NPO 12 hrs? ETT? LMA? Neuraxial/regional? Just wondering because we turned a potentially very easy case into an, uh.. "educational experience" tonight.
     
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  2. dhb

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    he's npo in my book
     
  3. 9french

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    I'd use an LMA. He is NPO. He is not a "massive" trauma. I wouldn't even give him reglan.
     
  4. coprolalia

    coprolalia Bored Certified
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    I've seen far too many CT scans of people with supposedly "minor" trauma that "haven't eaten anything since yesterday" presenting to the trauma bay. Almost without fail, all of their stomachs are full when you look at the belly scans.

    Proceed with caution. Our policy (and my training) is propofol, sux, tube, bag, OGT, extubate. In the cases where I've done this on a puportedly "NPO" patient, it has not been unusually to get 300-400 mL of stomach contents in the vaccuum container.

    -copro
     
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  5. bostonblaz

    bostonblaz ASA Member
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    my rule of thumb is to ask them if they are hungry. I started doing this as a first year and have stuck by it and not been burnt as of yet. I dont mind how long ago the trauma happened, if they are not hungry I take it as they have something in their stomach and they buy a tube. If they say they are hungry(not thirsty) then mac or lma has been okay. I started doing this because getting sux as a muscular young person really hurts for two to three days(i have personal experience).
     
  6. huktonfonix

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    Aspiration hurts for a lot longer. Just because you get lucky with something doesnt mean you wont get burnt eventually. If youre that concerned with using succ, you can always use roc or try remi. I just use lidocaine prior to succ. It doesnt prevent all the myalgias, but I dont seem to get many complaints about it. pain as well as narcotics will factor in to their full stomach status as well, not just the last time they ate.
     
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  7. Planktonmd

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    This is for me equivalent to an elective case with NPO since the morning.
    Any anesthetic would be OK.
    This patient has a broken leg but he probably does not have that much pain because his leg has been most likely stabilized since he arrived to the ER.
    So there is no difference between this patient now or this same patient if I send him home with a cast and do the surgery in a couple of days, He has a broken leg that doesn't hurt that much because it's stabilized and his stomach would function the same now or later.
    If the case was multiple trauma with excruciating pain requiring multiple doses of Narcotics then I might treat it differently.
     
  8. isoman2000

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    seems NPO to me.
     
  9. SleepIsGood

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    This patient needs a tube, period. If you want to do a spinal fine, airway reflexes are intact.

    If one is concerned about myalgies,etc just use a higher dose of roc.

    What's the big deal about putting in a tube? Once it's in, treat it like a LMA and have the pt breathing on their own. Simple. Why take the risk of aspiration on? Trauma victim....delayed gastric emptying is POSSIBLE, pt must be in some pain...he cant be in NO pain.

    Tube baby Tube
     
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  10. jwk

    jwk CAA, ASA-PAC Contributor
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    As many find out eventually, you never regret putting in a tube, but at some point you will regret not putting one in.
     
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  11. Planktonmd

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    I humbly disagree.
     
  12. Planktonmd

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    If we are going to say that this guy is full stomach so he needs to be intubated this means that we are considering this case an emergency and that we are going to do GA on a full stomach for some compelling reason.
    In my opinion this case is not an emergency and can be done anytime.
    So If you are concerned about the gastric emptying could you tell me when you will stop being concerned?
    In 24 hours?
    In 48 hours?
    Next week?
    When he stops having pain??
    You do this case when you stop being concerned about stomach emptying unless there a life or limb threatening situation.
    And since we are talking about what text books say here let's not forget that text books don't say that you can do regional anesthesia on a patient you consider full stomach unless it is an emergency.
     
  13. dhb

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    I disagree too. If he's a full stomach and you are concerned about aspiration risk you should postpone. Tubing someone doesn't prevent aspiration (it causes it).
    What happens if your spinal doesn't work? or if you have a high spinal (board speaking here).
     
  14. SleepIsGood

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    I suppose this is a good discussion.

    First, what's the issue with tubing this guy? Would you agree that it is better (and safer) than a LMA in this case atleast? This guy has GERD apparently treated with Prilosec....

    I think in this case, d/t h/o GERD, potential trauma induced gastroparesis,etc no one could fault you for putting a tube in this gentleman.

    Plank--I cant tell you that I know, or can even site the evidence for how long to wait until a trauma victim can by pass RSI. If I had to hypothesize, I would say if 24 hours has gone by, then you dont have to do RSI for sure. I think it's safter to RSI if the elective procedure is scheduled sometime on the same day.

    I know, I know, where's the evidence based medicine. To me it's just a question of saftey and being more conservative. The dude aspirates and you have a LMA in..your in big trouble. The dude aspirates and he has a tube in place via RSI, you have some more grounds to stand on.
     
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    #14 SleepIsGood, Dec 25, 2008
    Last edited: Dec 25, 2008
  15. jennyboo

    jennyboo Senior Member
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    Suppose he ate at 20:00, fell at 2200, your emergency room somehow processed him quickly and he got admitted to the ortho floor, and the ortho intern wrote his H&P and put in the order "NPO after midnight for surgery in AM" and he showed up to your holding area with confirmed 'NPO after midnight' at 0800?
     
  16. Trisomy13

    Trisomy13 ultra
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    as jwk put it.. "As many find out eventually, you never regret putting in a tube, but at some point you will regret not putting one in."



    I'm happy to see a variety of answers. Here is what played out...

    For reasons unclear to me, we were proceeding with this case last night at 21:30 instead of rolling it over to the morning. I don't believe it was classified as an emergency, i.e. it was not an open fracture. I think ortho had a busy day yesterday and it was carried over from the day's add-on schedule. I mean, he was NPO, right?

    Junior resident is out in holding doing the pre-op assessment, discussing case with our attending, who btw is one of our good guys - trustworthy, smart, great skills, etc. My gut tells me RSI and tube, if only because it's a "trauma", and our ortho boys usually ask for "zero twitches", for the most ridiculously simple cases. However, the attending and other resident had discussed GA with LMA, and we proceed to the OR, induce with propofol, LMA #5 in without problem. Sevoflurane on, pt breathing. Ortho boys scrubbing and prepping.

    Attending is out to holding seeing our next ortho case. About 5 minutes after LMA placement, I turn around from drawing up drugs for the next case, and at the same time hear junior resident say "oh $hit", and I see copious vomit coming up through the LMA into the circuit. Not bile, but chunky oatmeal-looking vomit. 300 cc easy. I place the SOS call to attending - "Here. Now. Vomit." Within the next few seconds, he is in the room, LMA has been removed, suctioning oropharnyx, and ETT 8.0 goes in under DL. Bronchoscopy by us. Whistle-tip catheter suctioning through ETT reveals a large amount of vomit. Irrigation with saline until the suction runs clear. Intra-op pulmonary consult, formal bronchoscopy by the pulmonary/CCM attending.

    Pulmonary/CCM attending is impressed with how clear the lungs sound and look after bronchoscopy, thinks we might have dodged a bullet and thinks we might be able to extubate. We attempt, but he is unable to maintain sats >85 in PACU and gets reintubated (with significant airway edema now), buys himself an art line, cent line and trip to the unit.

    CXR immediately post-op shows significant white out on left compared to pre-op. One hour post-op shows worsening infiltrates on the right now as well.

    Going to check up on him tomorrow.




    Our first thought was "this guy clearly lied and had eaten". We questioned his wife who swore she was with him, and he was NPO. So was it gastroparesis from trauma? Narcotics in the ED? My attending said it was the worst vomiting he had seen in 18 years of practice.

    In retrospect I wish I had pushed for an ETT, but I can't say an LMA was a clearly wrong choice. More importantly, we should have just left him intubated instead of the trial of extubation. Attdg was kicking himself the rest of the night, and I was just happy to see that now instead of "Day One" as an attending myself...
     
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  17. SleepIsGood

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    Sucks man that that happened. No worries though, WE learned something. Atleast I did.

    My take on the case was, perhaps you should wait and do RSI d/t gastroparesis. But you bring up another factor for which we have no control...ie..the pt coming in and straight up lying or just forgetting to tell us when he ate.

    Something to keep in mind.

    :thumbup:
     
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  18. Trisomy13

    Trisomy13 ultra
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    The part bugging me was that there was about 10-15 seconds when I hesitated yanking the LMA after calling the attending. I knew what to do but had not been in the situation before. Spoke with my attending tonight as he is on call again and it sounds like the pt is doing much better and the ICU team is talking about weaning to extubation tomorrow. :thumbup:
     
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  19. coprolalia

    coprolalia Bored Certified
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    Ditto.

    Thanks for sharing this case, Trisomy.

    -copro
     
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  20. coprolalia

    coprolalia Bored Certified
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    I'd treat it like a full stomach. I don't believe that, like Cinderella, after midnight the stomach necessarily and magically empties and everything is alright, especially in a trauma patient.

    Do I RSI everyone? No.

    -copro
     
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  21. Planktonmd

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    The most common reason for vomiting when you have an LMA in place is light anesthesia.
    Otherwise people vomit on induction or emergence not while they are deeply anesthetized waiting for surgery.
     
  22. dhb

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    Well the issue is if you give him GA he's at risk for aspiration and probably a higher risk than a standart patient.

    YES

    I don't worry about GERD

    True

    I guess but i don't like lawyer dictating medical practice
     
  23. zippy2u

    zippy2u Senior Member
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    Like Plankton said, Problem here was that the pt. was light and that's why ya had the vomit. Gettum deep prior to the surg. stimulus. Oh yeah, throw away the LMA #5s, the typical man takes a #4 despite what those goofy brits tell ya. They speak funny, drive on the wrong side of the road and all British cars leak oil at some point in their lifetime... ---Regards, --Zip
     
  24. Trisomy13

    Trisomy13 ultra
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    the pt most likely was light, although this happened prior to any surgical stimulus other than some betadine prep :(
     
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  25. coprolalia

    coprolalia Bored Certified
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    Dudes/Dudettes:

    With all due respect, who cares if the patient was "light"? Can we at the very least agree that, in retrospect, it was a bad idea not to tube this patient?

    I would hate it if people came away with the idea that what happened to Trisomy13 was ultimately okay and an "acceptable risk" in this patient population. If there is any question at all, stick a tube in. I don't understand why people make intubating someone (especially by us, the purported airway experts) such a bid deal. This was not going to be a quicky case. Stick the tube in.

    -copro
     
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  26. Laryngospasm

    Laryngospasm Trench Dog
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    You guys sound like a bunch of internal medicine guys. The fact is this guy should have gotten a tube, who gives a **** about muscle pain, Ive been burned to many times with LMAs, when there is doubt put a tube in. So you think if you use a tube it means the case is an emergency? Heres a question for you, if this had been the president would you have put an LMA in?

    And to dhb, you dont care about gerd? Have you ever had a pt. tell you they have mild gerd only to find out upon intubating that there ge sphincter is so loose that acid just flows up into their throat when supine? Your going to get into big trouble "not caring about gerd" as you put it. Oh and feel free to tell the board examiners that as well. Also, no harm equals no lawsuit.
     
    #26 Laryngospasm, Dec 27, 2008
    Last edited: Dec 27, 2008
  27. dhb

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    Everybody has gerd so unless the patient states that it's that bad that each time they lay down a mouthfull comes up is doesn't matter. Do you tube everybody that has gerd?
    Maybe it's Europeans not being as fat as Americans but over here gerd is a non factor.
    And don't worry i know the "right" answers for the boards.

    Cop: hindsight is 20/20 was it an error to go with an LMA i don't think so. What does this case teach us? Well people coming for unplanned surgery are likely to have a higher gastric content then the usual NPO patient. Does it mean they have a much higher risk of aspiration i'm not convinced. Are you safer with an ETT? yes, does an ETT prevent aspiration? no if you're putting in an ETT it means you've induced GA which is the primary cause for aspiration.

    It doesn't answer the question after how long will this patient void his stomach? After how long is it ok to go the LMA route? Maybe we should allow patient to drink clear fluids to promote gastric emptying..?
     
  28. Laryngospasm

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    Everyone has GERD? Interesting. News to me. My point still stands, someday gerd will come back to bite you in the ass if you ignore it. You are the one who said "i dont worry about gerd", I never said I tube everyone with gerd, I evaluate it on a case by case basis. So when you say "I dont worry about gerd" do you really mean that you carefully evaluate each case when considering a tube vs lma? I never was good at reading comprehension.
     
  29. Planktonmd

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    You are missing the point.
    If this patient was going to vomit and aspirate it would have happened on induction or emergence and your ETT would not have helped.
    You are basically saying that everyone who has a broken bone is full stomach regardless of the time frame and that my friend makes zero sense.
    If you think that this patient has a high risk to aspirate then you shouldn't have done the case, If you chose to proceed then that means that you are considering this an elective case and you are not considering him full stomach.
    We don't intubate full stomach patients for elective surgery do we???
     
  30. Planktonmd

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    There is no data showing that the GE sphincter remains competent under GA and prevent reflux in patients who do not have a diagnosis of GERD.
    There is no studies showing increased risk of aspiration under GA in patients with diagnosis of GERD.
     
  31. BLADEMDA

    BLADEMDA ASA Member
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    For what its worth I agree with Plankton. Sorry to read about your aspiration in this case but it wont be your last one.

    As for this INDIVIDUAL patient needing an ET tube over an LMA that was a judgement call. Until you get a few thousand more cases under your belt I don't blame you for wanting an ET tube in these situations
     
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  32. dhb

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    Thx.

    What i'm saying is that in my part of the world (where patient aren't as fat but where nervertheless a high percentage are on PPI) i've never heard about anesthesiologist paying as much attention to gerd as you seem to in the US. And aspiration does not seem to be more prevalent because of that. Another POV take it or leave it...
     
    #32 dhb, Dec 27, 2008
    Last edited: Dec 27, 2008
  33. Laryngospasm

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    All im saying is that the patients I have seen who have acid build up in the pharynx during the case had GERD. Not cases of "hey, i think Ill stop by mcdonalds on the way in for surgery". As for the GE junction thing, I personaly believe that if it wasnt somewhat intact then we would have many more incidences of aspiration under ga with lma. just my opinion. Dhb I respect your viewpoint.
     
  34. dhb

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    Likewise
     
  35. coprolalia

    coprolalia Bored Certified
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    That's not what happend in this case, Plank. The LMA was in, and had been in. In the time it took them to put it in, I could've had an ETT in. And, I also could've passed an OGT after intubation and succtioned the stomach. Nonethless, that ETT would've been a hell of a lot better even with the aspiration event. The cuff would've clearly prevented the gross aspiration that occurred.

    The only argument you have is that, if the choice was gonna be LMA, it should've been a ProSeal or Supreme.

    -copro
     
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  36. Trisomy13

    Trisomy13 ultra
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    Stopped in to check on the pt this morning and he is extubated, sitting up in bed having breakfast, waiting for transport to come take him from the ICU to a regular floor bed... on the ortho service, which means he is healthy enough that they think he can survive being rounded on by ortho interns.

    Got lucky, this time. :luck:
     
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  37. Planktonmd

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    You should not say that because you think this guy is full stomach then an ETT is the answer, because if you think that he is full stomach then you shouldn't have done the case and you should have waited until he is not full stomach anymore, although you don't seem to know when this guy is going to stop being full stomach, do you??
    I actually feel that you think that he will be full stomach until his fracture has healed. :D
    Who told you that it's OK to place a proseal or whatever exotic flavor of LMA if you think the patient is full stomach??
    Are you being taught that?
     
  38. Planktonmd

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    What you did was perfectly acceptable management in this case.
    You have to understand that in this business things don't go as planned 100 % of the time regardless of what you do, we are physicians not mathematicians.
    One point to highlight here: Light anesthesia causes people who have LMA's in their throat to gag and vomit.
     
  39. huktonfonix

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    Kinda depends on open or closed fracture as far as waiting for "NPO" status. I think the LMA was reasonable although I would have preferred a proseal if I was using an LMA. If the patient looked like he was in a lot of pain or had been giving opioids, I probably woulda just tubed him or done a regional.
     
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  40. Planktonmd

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    Correct, but this was not an open fracture.

    Why?
    If you think he is full stomach and it's not an emergency why would you put him to sleep?
     
  41. Trisomy13

    Trisomy13 ultra
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    True, I understand all this. I'm just feeling lucky that he rebounded so quickly and didn't go the ARDS or pneumonia route. :thumbup:
     
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  42. huktonfonix

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    I musta missed the post saying it was closed. That part kinda depended on the open/closed thing.
     
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  43. 9french

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    Not exceptionally lucky. Most people nowdays do rather well after an aspiration event. Death is fairly unusual. Back when Mendelson first described aspiration in the 1940's, positive pressure ventilation was just in its infancy and PCN was the state of the art antibiotic. Back then mortality was much, much higher.
     
  44. coprolalia

    coprolalia Bored Certified
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    This is what it often feels like trying to have a dialogue with you: :bang:

    (1) If the dude is in pain, treat the pain. That's why his stomach ain't emptying. If you use narcotics, you may actually make the gastroparesis (at least temporarily) worse, though.

    (2) If it is not an emergent, urgent, or semi-urgent case, you postpone the case.

    (3) Always use a ProSeal or a Supreme LMA, if you can. They are superior devices. This has nothing to do with "full" stomach status.

    (4) When in doubt, stick a tube in... and THAT IS THE F***ING POINT!

    (I sometimes feel like I'm having a discussion with a 4-year-old who's being purposefully obfuscatory.)
    -copro
     
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  45. Planktonmd

    Moderator Emeritus Lifetime Donor Verified Account 10+ Year Member

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    Don't give me this BS.
    You criticized the other resident for not intubating this patient and basically told him that this was a terrible error.
    I demonstrated to you why you are wrong and why there is nothing wrong with proceeding the way he did.
    All I can do is tell you my opinion and what my years of experience have taught me, If you choose not to listen I can't help you.
    You can only take the horse to the water...
     
  46. coprolalia

    coprolalia Bored Certified
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    :bang:

    You love to put words in people's mouth. "Terrible error"? Give me a break, Plank. You're projecting.

    -copro
     
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  47. Planktonmd

    Moderator Emeritus Lifetime Donor Verified Account 10+ Year Member

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    You called it unacceptable risk, this is where you need to choose your words better.
    I recently had to give a deposition where the plaintiff attorney took a post from another anesthesia web site and used it to support his accusations to a physician of negligence.
     
  48. coprolalia

    coprolalia Bored Certified
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    I would not have put an LMA in this patient. That is consistent with my training. I did not call this a "terrible error". But, I still don't think the risk-to-benefit profile was acceptable in this case.

    Deal with it
    .

    And stop trying to put words in my mouth in an attempt to win what you perceive is an argument. You are the one making yourself look like the fool, not me.

    Furthermore, this is an educational forum. If some lawyer prints out what I write here to support a legal argument, I'm sure he'd get laughed out of court.

    -copro
     
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  49. Planktonmd

    Moderator Emeritus Lifetime Donor Verified Account 10+ Year Member

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    I already did.
     
  50. dhb

    dhb Member
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    The ones that died in the Medelson serie choked on the chunks, the ones with pneumonitis survived.
     
    #50 dhb, Dec 28, 2008
    Last edited: Dec 28, 2008

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