ucsfgaspain

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So I've been out of residency and fellowship for about 5 years. Split my time between pain and OR. I cover 2 hospitals one with CRNA's, one where the MD's cover alone.

The hospital with CRNA's gets the majority of big cases: ruptured AAA's, horrendous OB, etc. etc. Not a big deal here since there are plenty of people around. I've got 2 CRNA's in house and when we get badness coming in, we tag team all the tasks.

Well this case on the weekend at the other hospital, showed me that it ain't easy going it alone.

Get a call from my g surg buddy. 80 y.o. vasculopath pt. s/p cabg, stent, right CEA who had undergone a partial colectomy earlier in the week. This am had found him obtunded. CCM intubated him in the unit. Now he's got new onset afib, St depression's in inferior leads(trops not back yet, but will ineveitably come back positive), not moving his left side. G surg needs to open him up to check to see if there is an anastomotic leak that caused him to crump.

I go up to transport him. Pressures 80/50's HR 150. Pulse ox not picking up anything cuz his extremities are clamped down. No A line despite numerous tries by CCM. RT states that pH was normal and PaO2 was 200 on an FIO2 of 1. Access wise only an 18 on the left and a 20 on the right.

Take him down to the OR. Put him on my vent. Still can't get a pulse ox despite moving it everywhere nose, ear lobe, finger, foot. Start TV at 700 and PIP of 25 or so. Feel for a place to start an a line: nothing at the radial, nothing in the antecubital, can't feel much at the brachial. Not enough anyways to confidently think that I can get an a line.

Crack on some vapor. Relax him. Set BP to cycle every minute. Do you insist on an a line? Where? We've got a site rite at this hospital for a central line. No TEE (and by now having not done a TEE since residency, I probably wouldn't know how to turn on the machine, let alone get a view) No swan in this OR.

What to do? what to do?

My question for everyone is how would you prioritize your tasks? Keeping in mind, that you are alone. The circulator and surgeon are nice people but pretty much useless in terms of helping.

FYI I didn't insist on an a line before we started...something that I did regret to a degree afterwards.
 

Jeff05

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i don't see any reason to think that there is an anastomotic leak. is he febrile, white count? it looks like he's having an AMI +/- CVA (maybe he's just hypotensive or threw a left atrial thrombus).

he could also be hypotensive because of a-fib, loss of atrial kick. this seems to be new onset unstable afib. he may need to be cardioverted.

the priority here does not seem to be surgical exploration.

#1. get a line - you can use ultrasound to place axillary
#2. start central line for pressors, etc
#3. get some labs - hct, abg, lytes - optimize K+, Mg++, hct.
#4. slow his rate - esmolol would be a good choice here. you could try to cardiovert as well. an atrial kick would help.

i don't know. he's hypotensive and tachycardic and the surgeon wants to explore god knows what. i think it would be important to figure out what's going on before taking him to the OR.
 

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So I've been out of residency and fellowship for about 5 years. Split my time between pain and OR. I cover 2 hospitals one with CRNA's, one where the MD's cover alone.

The hospital with CRNA's gets the majority of big cases: ruptured AAA's, horrendous OB, etc. etc. Not a big deal here since there are plenty of people around. I've got 2 CRNA's in house and when we get badness coming in, we tag team all the tasks.

Well this case on the weekend at the other hospital, showed me that it ain't easy going it alone.

Get a call from my g surg buddy. 80 y.o. vasculopath pt. s/p cabg, stent, right CEA who had undergone a partial colectomy earlier in the week. This am had found him obtunded. CCM intubated him in the unit. Now he's got new onset afib, St depression's in inferior leads(trops not back yet, but will ineveitably come back positive), not moving his left side. G surg needs to open him up to check to see if there is an anastomotic leak that caused him to crump.

I go up to transport him. Pressures 80/50's HR 150. Pulse ox not picking up anything cuz his extremities are clamped down. No A line despite numerous tries by CCM. RT states that pH was normal and PaO2 was 200 on an FIO2 of 1. Access wise only an 18 on the left and a 20 on the right.

Take him down to the OR. Put him on my vent. Still can't get a pulse ox despite moving it everywhere nose, ear lobe, finger, foot. Start TV at 700 and PIP of 25 or so. Feel for a place to start an a line: nothing at the radial, nothing in the antecubital, can't feel much at the brachial. Not enough anyways to confidently think that I can get an a line.

Crack on some vapor. Relax him. Set BP to cycle every minute. Do you insist on an a line? Where? We've got a site rite at this hospital for a central line. No TEE (and by now having not done a TEE since residency, I probably wouldn't know how to turn on the machine, let alone get a view) No swan in this OR.

What to do? what to do?

My question for everyone is how would you prioritize your tasks? Keeping in mind, that you are alone. The circulator and surgeon are nice people but pretty much useless in terms of helping.

FYI I didn't insist on an a line before we started...something that I did regret to a degree afterwards.
You are flying solo so here is the plan:
Central access. that's it!
correct the volume, start pressors, warm him up, give fluids and/or blood products.....
Do whatever you need to prevent him from dying.
Then when he is not trying too hard to die you can dig for an an A line or whatever else you need.
If you are worried about not getting SPO2 signal just do whtever you can do to oxygenate and ventilate the patient sufficiently, if still no signal, so what ?
Sometimes the nose could be the best place for SPO2 in these shocky patients.
 
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Jeff05,

Discussed your thoughts with the surgeon who is a personal friend of mine. Sorry forgot to mention febrile with a white count. She thought that there was a high likelihood of a leak and I'd let her operate on me in a second. So I went with her decision. And in the end, she was right. Total colectomy with ileostomy at the end. Dead gut smells horrible.
 

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Plankton,

That's what I did. Threw in a cordis and just resuscitated as best as I could. This hospital is pretty thinly stocked. My istat didn't have ABG capability. SO i couldn't draw VBG's. I figured that the blood I saw on the field looked pretty well oxygenated and he didn't brady down on me so he was oxygenating well enough. Not much else I could do.

Here's a question for you though. When drapes are up, how are you really able to keep sterile while trying to get central access? Also I had a site right with me which made placement a lot easier especially given the history of his CEA on this side and now with left sided deficit. However, if I didn't have one, and often when they are in that cramped position on the OR, what landmarks do you use. Just go lateral to where you palpate the carotid? In this case, with the site right of course the IJ is on top of the carotid.

Another question for you. Can you use ETCO2 levels as a pseudo surrogate for cardiac output? I had the BP going every minute since he was unstable and had him on massive amount of pressors as I resusitated. I'd get intermittently decent pressures. I figured as long as the ETCO2 levels stayed stable, I was providing constant C.O. and hopefully decent flow to his end organs. Too busy to try to chase every change in BP of the cuff as I was checking in blood and pumping it in as well as replacing calcium empirically and giving bicarb. What do you think? Valid hypothesis or not?
 

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Pray that the hospital has one of them Deep South Baptist preachers like T.D. Jakes not one of them Nancy boy Catholic dudes. Speed dial em and hook him in tight with the family. Dammit, I want Fire and Brimstone shiit. If ya cardiovert him do it in the ICU and not in OR, let CCM dude take fall if it's unsuccessful or rhythm worsens. You need to keep this dude alive for 1-2 hrs until ya dump him back in the ICU. You need 1 more line and the preference is cordis>2-3LumenCatheter>16GIV. Blow off a line, PAC and pulse oximeter. Make sure ya get at least 1, preferably 2 ABGs during case to show proof that ya were oxygenating and ventilating him. Get a poor man's drip goin'---1 amp phenylephrine in 250 bag on pedi IV and "finger" it in. No need for infusion pump. Your volume will be PRBCs--2 units sir mixed with NaCl. Periodically bang in some epi via syringe. Titrate in 2 of versed, 10mls of fentanyl and 10 of vec, crack the sevo if ya must. For shiits and giggles, bang in some CaCl and hydrocortisone. Regards, ----Zip
 

urge

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1 Volume and neo drip. Crank the BP to 200 if needed. Pray it's not a hemorrhagic stroke
2 Femoral a-line? cut down?
3 Subclavian cordis?
4 Blood gas from central lab?
 

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Are you telling me that this hospital doesn't have swan capabilities? If this is true then they shouldn't be doing surgeries there.

As far as sterility under drapes, it can be done. If you can then have the surgeon wait just a few minutes while you place the line.

A-line, have the nurse prep the groins on both sides while prepping the belly. Tell the surgeon you need a fem aline first.

No you can't use ETCO2 as a CO monitor but if thats all you got then so be it. I'd swan this guy and use the SvO2 as well as CI. THis guy is dry first and needs volume and a slower rate whether its a fib or sinus.

Are you really an MD? Things seem a little fishy here.
 

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agree with above, try to get in central access, right subclavian tlc or cordis can be done under drapes. i'd try to be sterile, but these are trying times so the line has to go in and can be changed in icu. rescuscitate with blood, neo and cacl2. once the pressure is up and the volume is better have a better shot at the aline , yes, using the etco2 as guide for perfusion/ bp is a good idea , assuming you dont ventilate 4 times/ min....
fun case, did the patient survive? fasto
 

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Sounds like a weekend gas warrior to me, just stuck in the pit swingin' his way out with a butter knife, it'll turn out all right. Regards, ----Zip
 

pd4emergence

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So I've been out of residency and fellowship for about 5 years. Split my time between pain and OR. I cover 2 hospitals one with CRNA's, one where the MD's cover alone.

The hospital with CRNA's gets the majority of big cases: ruptured AAA's, horrendous OB, etc. etc. Not a big deal here since there are plenty of people around. I've got 2 CRNA's in house and when we get badness coming in, we tag team all the tasks.

Well this case on the weekend at the other hospital, showed me that it ain't easy going it alone.

Get a call from my g surg buddy. 80 y.o. vasculopath pt. s/p cabg, stent, right CEA who had undergone a partial colectomy earlier in the week. This am had found him obtunded. CCM intubated him in the unit. Now he's got new onset afib, St depression's in inferior leads(trops not back yet, but will ineveitably come back positive), not moving his left side. G surg needs to open him up to check to see if there is an anastomotic leak that caused him to crump.

I go up to transport him. Pressures 80/50's HR 150. Pulse ox not picking up anything cuz his extremities are clamped down. No A line despite numerous tries by CCM. RT states that pH was normal and PaO2 was 200 on an FIO2 of 1. Access wise only an 18 on the left and a 20 on the right.

Take him down to the OR. Put him on my vent. Still can't get a pulse ox despite moving it everywhere nose, ear lobe, finger, foot. Start TV at 700 and PIP of 25 or so. Feel for a place to start an a line: nothing at the radial, nothing in the antecubital, can't feel much at the brachial. Not enough anyways to confidently think that I can get an a line.

Crack on some vapor. Relax him. Set BP to cycle every minute. Do you insist on an a line? Where? We've got a site rite at this hospital for a central line. No TEE (and by now having not done a TEE since residency, I probably wouldn't know how to turn on the machine, let alone get a view) No swan in this OR.

What to do? what to do?

My question for everyone is how would you prioritize your tasks? Keeping in mind, that you are alone. The circulator and surgeon are nice people but pretty much useless in terms of helping.

FYI I didn't insist on an a line before we started...something that I did regret to a degree afterwards.

I hope the surgeon has a really good reason for bringing this guy to the OR (like poop coming out of his drains or free air somewhere). If not this could be a nonsurgical issue ie hypotension due to ischemia/afib with RVR, sepsis from another source (uti), PE, hypovolemia. I will assume the above since he is in the OR.

Issues with this guy
1: tachycardia/probable ongoing cardiac ischemia
2: hypotension/sepsis
3: possible CVA

I think the first thing to do is try control his rate and fix his hypotension. Pour the fluids through those small IV while getting some lines. I would get the surgeon working on a femoral aline while I prayed to Jesus/Allah/Buddha and tried blindly for an upper extremity line. Get your own ABG, Hgb/Hct, get some lytes too. I am suprised that the above ABG was reported to you as pretty much normal. I bet it sucks now (if he is truly septic). I would start some levophed and work on getting a cardizem drip going (dig would also be an option here). He's not going to tolerate that rate for long. I am not great with the TEE either. I think a swann would be nice if someone could get the monitor and the transducers in the room. If that is not possible I would do the best I could watching the trend of the CVP and urine output (I know these will be inaccurate but you have to work with what you have). I would not mess with one of those crappy 7fr lines, I would go for the 9fr swann introducer or a 12fr line if available. If he truly has an intraperitoneal infection he is going to third space like there is no tomorrow (and there may not be for him). I would give him some versed and as much gas as he would tolerate and pray to the above deities that his BP and HR stabilize to something that is compatable with life. At some point I would also make sure that he got appropriate antibiotic coverage. I think his possible CVA takes a back seat to his acute abdomen/sepsis but I would do my best to not over do the fluids that is why I think having a swann would be helpful (although the swann numbers won't be totally accurate because of his ischema it is the best I could do). How did it turn out?
 

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Plankton,

That's what I did. Threw in a cordis and just resuscitated as best as I could. This hospital is pretty thinly stocked. My istat didn't have ABG capability. SO i couldn't draw VBG's. I figured that the blood I saw on the field looked pretty well oxygenated and he didn't brady down on me so he was oxygenating well enough. Not much else I could do.

Here's a question for you though. When drapes are up, how are you really able to keep sterile while trying to get central access? Also I had a site right with me which made placement a lot easier especially given the history of his CEA on this side and now with left sided deficit. However, if I didn't have one, and often when they are in that cramped position on the OR, what landmarks do you use. Just go lateral to where you palpate the carotid? In this case, with the site right of course the IJ is on top of the carotid.

Another question for you. Can you use ETCO2 levels as a pseudo surrogate for cardiac output? I had the BP going every minute since he was unstable and had him on massive amount of pressors as I resusitated. I'd get intermittently decent pressures. I figured as long as the ETCO2 levels stayed stable, I was providing constant C.O. and hopefully decent flow to his end organs. Too busy to try to chase every change in BP of the cuff as I was checking in blood and pumping it in as well as replacing calcium empirically and giving bicarb. What do you think? Valid hypothesis or not?
1- I would have placed a subclavian before they started surgery.
2- ETCO2 wouldn't drop until the cardiac output is really low so the presence of ETCO2 will tell you that there is ventilation and circulation but that's about it.
3- CVP might not be ideal but watching the CVP trend could help you plan your volume replacement and pressor use.
 
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Zippy,

Good to know that we think a like. I did the old school 1 amp in 100c bag and poured that in on a minidripper. Funny thing is that when this ran out, I double the dosage in the second. Intermittent epi dosages were needed as well.

Fasto,

Pt. survived to the unit. Actually converted back to sinus at 85 or so. Fun? Yeah, I guess you could say that:)


Noyac,

You don't think I'm an MD? Interesting? What is is that gives you pause? Let's see how could I prove that I'm an MD? Went to med school at UCSF, residency and fellowship there as well. I can see that you are a moderator of this forum. If you really don't think that I am, I could send you PM of my ABA board certificates in anesthesia and pain as long as you keep this between us since I do value my privacy.

Also there is swan capability up in the ICU but not in the OR, I don't have the transceiver and really what would it show that I don't know all ready? Volume down. SVR likely up. CI probably decent since he's not in overt failure.

Zippy,

Ha ha . Weekend gas warrior. Yeah, that's how I feel. Trying to balance a pain practice with OR responsibilities is tough to stay on top of both fields. Just trying my best with the tools that I got. Not sure where all this suspicion is coming from?
 

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Noyac,

You don't think I'm an MD? Interesting? What is is that gives you pause? Let's see how could I prove that I'm an MD? Went to med school at UCSF, residency and fellowship there as well. I can see that you are a moderator of this forum. If you really don't think that I am, I could send you PM of my ABA board certificates in anesthesia and pain as long as you keep this between us since I do value my privacy.

Also there is swan capability up in the ICU but not in the OR, I don't have the transceiver and really what would it show that I don't know all ready? Volume down. SVR likely up. CI probably decent since he's not in overt failure.

First, I am not a mod any longer. If you want to prove that you are an MD then send your info to Jet, he will keep it confidential. That is if he wants to see it. I get suspicious b/c of the detail in your posts. I'm not trying to attack, just making an observation.

Second, I wasn't calling for a swan in this case. I was gettingthe impression that the capabilities were not available w/c you confirmed and therefore, I made a general comment that they probably shouldn't be doing cases there beyond the ambulatory type. Sorry for the confusion here.

Third, I agree that the swan in this case is not necessary, yet. But it will be useful soon enough.
 

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No offense taken. It was kind of funny when you ask if I'm an MD. Like I said I'm new to posting here not sure how much detail whatever people want.

My group covers two hospitals. One is as I stated the deathstar with all the fun tools that we need to do big cases. The second is a small hospital where most of the cases are 72 hour stay type cases. However, we get the occasional nightmare here as well.

I'm a realist here. Given the split between pain and OR, I'm not going to be as slick as some of you guys. I'm not doing cardiac so time with TEE is nill and placing a PA line is a rarity. If I had all the answers, I wouldn't post to get pointers.

And really the point of this whole post is to reflect how much easier anesthestics are when you have a second pair of hands to help when **** hits the fan.
 

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Are you telling me that this hospital doesn't have swan capabilities? If this is true then they shouldn't be doing surgeries there.

As far as sterility under drapes, it can be done. If you can then have the surgeon wait just a few minutes while you place the line.

A-line, have the nurse prep the groins on both sides while prepping the belly. Tell the surgeon you need a fem aline first.

No you can't use ETCO2 as a CO monitor but if thats all you got then so be it. I'd swan this guy and use the SvO2 as well as CI. THis guy is dry first and needs volume and a slower rate whether its a fib or sinus.

Are you really an MD? Things seem a little fishy here.



Another CRNA. FBI profile check is positive. Terminate troll with prejudice.
 

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HawaiiBruin and Toughlife,

Now I'm getting a little pissed when you call me out like this. If I prove what I've claimed, will you come out and publicly apologize?

Sheesh. I didn't go through all this damn training to get called out by residents especially when you guys now get a cake 80 hour work week rule.

However I still have to do the damn MOCA thing cuz I wasn't lucky enough to grandfather in and have to recert for pain as well.
 

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HawaiiBruin and Toughlife,

Now I'm getting a little pissed when you call me out like this. If I prove what I've claimed, will you come out and publicly apologize?

Sheesh. I didn't go through all this damn training to get called out by residents especially when you guys now get a cake 80 hour work week rule.

However I still have to do the damn MOCA thing cuz I wasn't lucky enough to grandfather in and have to recert for pain as well.


ok send me your info and I will verify it. Starting with your ASA membership # and where you went to medical school.
 
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It's obvious when the top posts states that the hospital with all the CRNA's dominates the hospital with all the MD's in case complexity, etc etc.
:sleep:
 

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Arghh...I'm sitting here waiting in between doing selective nerve blocks and stellates for my vindication. Toughlife just pm'd me and confirmed my id. I can't believe that I'm doing all this to prove that I'm who I say I am on an anonymous forum. My nurses in the clinic think that this is hilarious (and somewhat pathetic that I'm being distracted by this).
 

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so far the info that UCSFGASPAIN has provided checks out. I ran the ABA IDN number and name he provided and came up with a name that also checked out.

So far the info appears credible.


i'll be the first to apologize and say I am aggressive because I am tired of midlevels impersonating physicians.
 

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I happily apologize as well. I did say initially that I'd be happy to be shown that it weren't true, and I'm glad to be wrong in this case.

Your posting style seemed similar to the poster I mentioned, who came in here posting cases pretending to be a physician. The way you phrased your title raised a little suspicion, and for me, the way you worded things after things were questioned was similar in style to that aforementioned poster. Since this seems to be nothing more than coincidence, like I said, I'm happy to be wrong.

I again apologize, and look forward to learning from your future posts.
 

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Reading UCSFGASPAINs post made me think everyone missed the point of what he said....

Life is a whole hell of a lot easier when you've got more people to do things... that's just a plain fact. The case that he had to do would have been horrible no matter if he did it on the moon, or in the middle of the most amazing hospital with the most amazing operating room and all sort of facilities.

He wasnt saying that CRNAs are god's gift to everyone, he was saying when the fan is hit he's got the people available to help.... and he missed having those hands in this situation... at the trauma center where I trained when a crash came in you had your attending, your anesthesia tech, sometimes another resident to help get things sorted out..... in contrast to the large university hospital when a bleeding liver happens in the middle of the night it was you and your attending- no anesthesia tech, no other help....


we're trained to be good at our job, and we are.... but we've only got two hands... and they get tied up quickly if you need an airway, an arterial line, vascular access, and to check blood... and the patient is in AFib, and hypotensive, and they are trying to crash open the belly...

those jobs where they pay you the big bucks in exchange for living in the middle of nowhere-> you're probably alone in the middle of the night, and yes sometimes the fan is hit no matter where in the world you are... I looked at a place-> 80 beds, borderline dangerous ICU, no resources available at night (limited labs as well) and guess what they did a lot of? Tons of bariatic surgery, which we all know can go sour... The docs there told me that it had the opportunity for things to go sour....

what's the first thing you're taught to do in a crisis: call for help.... it doesnt matter if its a CRNA or another MD; it's help...
 

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those jobs where they pay you the big bucks in exchange for living in the middle of nowhere-> you're probably alone in the middle of the night

Not always true.

My **** you account was funded by previous gig out in the middle of nowwhere...

...I had plenty of help...

Trinity was there, along with many other skilled professionals.
 

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Reading UCSFGASPAINs post made me think everyone missed the point of what he said....

Life is a whole hell of a lot easier when you've got more people to do things... that's just a plain fact. The case that he had to do would have been horrible no matter if he did it on the moon, or in the middle of the most amazing hospital with the most amazing operating room and all sort of facilities.

He wasnt saying that CRNAs are god's gift to everyone, he was saying when the fan is hit he's got the people available to help.... and he missed having those hands in this situation... at the trauma center where I trained when a crash came in you had your attending, your anesthesia tech, sometimes another resident to help get things sorted out..... in contrast to the large university hospital when a bleeding liver happens in the middle of the night it was you and your attending- no anesthesia tech, no other help....


we're trained to be good at our job, and we are.... but we've only got two hands... and they get tied up quickly if you need an airway, an arterial line, vascular access, and to check blood... and the patient is in AFib, and hypotensive, and they are trying to crash open the belly...

those jobs where they pay you the big bucks in exchange for living in the middle of nowhere-> you're probably alone in the middle of the night, and yes sometimes the fan is hit no matter where in the world you are... I looked at a place-> 80 beds, borderline dangerous ICU, no resources available at night (limited labs as well) and guess what they did a lot of? Tons of bariatic surgery, which we all know can go sour... The docs there told me that it had the opportunity for things to go sour....

what's the first thing you're taught to do in a crisis: call for help.... it doesnt matter if its a CRNA or another MD; it's help...

Amen...my brother.

You know the funny thing is that I live and work in a major metropolitan city not in the boondocks.

I was talking to one of my junior colleagues, and one of the things that we talked about is how as anesthesiologists we are so used to working alone. You put in all the lines yourself...intubate yourself and don't rely on anyone. Surgeons are used to having things handed to them...etc. We on the other hand expect to be alone. It was kind of how we were trained.

Since you are so used to being self reliant, you often make things tougher on yourself to be a team player. i.e. not delaying the case so you throw in the aline under the drapes, you'll put in IV's left handed cuz you are cramped in by the laparascopic monitors..etc. It ends up, that after a while you really don't even think of asking for help. If I'm honest with myself, I still struggle with asking for help cuz I do in part think that it's a sign of weakness. I know that this isn't the PC thing to say but it's the dead honest truth.
 

jetproppilot

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If I'm honest with myself, I still struggle with asking for help cuz I do in part think that it's a sign of weakness.

Agreed.

I'm past the hero days, though.

If I'm struggling, I call for help.

And about five colleagues show up likkity split...since they know if I'm calling, the sky really is falling. :scared:
 

drccw

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Doesnt seem like there was too much help available... Jimmy the janitor can't help ya too much..

I probably would have asked the gen surg to either put the line in or a femoral a-line.. she's got to be able to do that right?
 

Planktonmd

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It is ok to ask for help but it is more important to know how to prioritize when there is no help.
It is also important to know how to distinguish between true emergency surgery and urgent surgery where you have time to plan ahead and get ready.
 

Laurel123

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I feel your pain. I also take call at a community hospital in a suburb of a biggish city. Weekends are bare bones. No secretary, one nurse, and one tech that are called in from home. And they are allowed to live up to 30 miles away. So sometimes the nurse will take 45 mintues to arrive. And this is fine for your healthy fractures and appys. But once in a while a ruptured AAA comes in or a stat crani. Then what an adventure. I basically run around setting up everything on my own. And with cases like these, its more about an extra set of hands, like to set up the a line while I make drips, or to check in blood products while I start some big access.
 
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