Worst job in America

[deleted875186]

They can definitely happen.

I’ve had an intravascular catheter with a positive test dose twice personally. And that’s having placed around 500 or fewer epidurals in my life. Robust tachycardic response shortly after injection.

Had a former co-resident take over OB once. Got called to assess a catheter placed just a little before shift change. Patient had never really got comfortable. First thing they did was draw back on the catheter and got frank blood.

I’ve had aspiration of blood, in which case I take the catheter out and replace before getting to a test dose, but never a positive response with tachycardia and no blood.

I beleive you’ll be alerted tot he catheter not working which will prompt replacement, no epinephrine test dose is truely needed. We don’t use high doses of bupi anymore so really not necessary.

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[MirrorTodd]

I saw a positive intravascular test dose once on my first OB rotation as a CA1. I placed the epidural, it worked, negative test dose. A few hours later it stopped working. So my attending and I came back to troubleshoot it. I did another test dose, aspirated, nothing, but when I injected, her HR shot up and she got the metallic taste. I haven't seen it since that's been over 10 years ago.

Oh and I heard of TXA being given in a spinal. I don't know the outcome. Not my case, but with an AA and right before I started working at the former job. The AA was gone before I got there. Also mixed up phenylephrine 10mg and zofran.

There's this review: TLDR don't put TXA into the central nervous system.

Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia​

S Patel 1, B Robertson 2, I McConachie 3
Affiliations expand

• PMID: 30985928
• DOI: 10.1111/anae.14662

Free article

Abstract​

We have reviewed accidental spinal administration of tranexamic acid. We performed a MEDLINE search of cases of administration of tranexamic acid during epidural or spinal anaesthesia between 1960 and 2018. No reports of epidural administration were identified. We identified 21 cases of spinal tranexamic acid administration. Life-threatening neurological and/or cardiac complications, requiring resuscitation and/or intensive care, occurred in 20 patients; 10 patients died. We used a Human Factors Analysis Classification System model to analyse any contributing factors, and the reports were also assessed using four published recommendations for the reduction in neuraxial drug error. In 20 cases, ampoule error was the cause; in the last case a spinal catheter was mistaken for an intravenous catheter. All were classified as skill-based errors. Several human factors related to organisational policy; dispensing and storage of drugs and preparation for spinal anaesthesia tasks were present. All errors could have been prevented by implementing the four published recommendations.

 

[Southpaw]

Inadvertent IT TXA was in an APSF newsletter a year or so ago. It seemed catastrophic.

 

[pgg]

I had never had an epidural catheter go intravascular ... until supply issues resulted in our nice soft spring-wound Arrow catheters getting replaced with those very stiff Braun catheters. Then I had several within about a year. All readily aspirated blood so I never even did test doses.

I agree with the earlier comment by dipriMAN - a local-only test dose is OK. The only risk with an intravascular catheter getting an infusion of 0.125% bupivacaine is that the epidural won't work and you'll get called back to fix it.

 

[Twiggidy]

I’ve had aspiration of blood, in which case I take the catheter out and replace before getting to a test dose, but never a positive response with tachycardia and no blood.

I beleive you’ll be alerted tot he catheter not working which will prompt replacement, no epinephrine test dose is truely needed. We don’t use high doses of bupi anymore so really not necessary.

I’ll sort of support your take a bit. I had an attending that preached the test dose wasn’t very necessary. I’ve seen an intravascular catheter and when we aspirated the blood flood quite freely so it was without a doubt. I think you’re more likely to have a catheter go intrathecal which as you said they will get super relieved with just like 2 cc of lido or marcaine

 

[Beeftenderloin]

I’ve had aspiration of blood, in which case I take the catheter out and replace before getting to a test dose, but never a positive response with tachycardia and no blood.

I beleive you’ll be alerted tot he catheter not working which will prompt replacement, no epinephrine test dose is truely needed. We don’t use high doses of bupi anymore so really not necessary.

FWIW I was unable to aspirate blood when I had my 2 positive test doses. Was probably just collapsing the vein with aspiration attempts. HR jumped 20-30 BPM, not associated with contractions.

 

[Dr. Rude]

One trick I came up with for salvaging an intravascular catheter. If you aspirate frank blood take a 3 or 5ml syringe and fill with saline and flush hard to deliberately "blow" the IV catheter.. Afterwards if negative aspiration for blood and negative test does, I would use the catheter. Almost always worked.

 

[Onefellswoop87]

One trick I came up with for salvaging an intravascular catheter. If you aspirate frank blood take a 3 or 5ml syringe and fill with saline and flush hard to deliberately "blow" the IV catheter.. Afterwards if negative aspiration for blood and negative test does, I would use the catheter. Almost always worked.

Poiseuille’s law has me skeptical to generate enough force through a 30+ cm 19 gauge (and some are smaller at 21g I think) epidural catheter that it’ll blow the vein.

And if you have a multi-orifice cather, I’d imagine path of least resistance would be any hole in an epidural potential space vice a small vein or capillary, leading me to be even more skeptical that you’d blow to vein to salvage your epidural.

I’m glad it’s worked for you in the past, but that’s a long winded way to say if I aspirated frank blood, I’d move levels.

 

[GassYous]

I saw a positive intravascular test dose once on my first OB rotation as a CA1. I placed the epidural, it worked, negative test dose. A few hours later it stopped working. So my attending and I came back to troubleshoot it. I did another test dose, aspirated, nothing, but when I injected, her HR shot up and she got the metallic taste. I haven't seen it since that's been over 10 years ago.

Oh and I heard of TXA being given in a spinal. I don't know the outcome. Not my case, but with an AA and right before I started working at the former job. The AA was gone before I got there. Also mixed up phenylephrine 10mg and zofran.

Probably seizure -> intubation -> prolonged icu stay with significant neurologic damage

 

[abolt18]

2 positive test doses. Negative aspiration both times. One was a labor epidural and the lady shouted "ohhhh mi corazon!" As she tach'd up to like 150 from 90s. Other one was doing a caudal on a kid. Negative aspiration, but HR shot way up. Don't remember if he had the classic "peaked T-waves".

 

[jjm285]

I’ve had 1 positive test dose on a thoracotomy patient; easy LOR—> negative aspiration—> HR up about 30 points—> aspirated again w/ blood return. Never had any blood return from the needle prior to threading the catheter.

 

[Beach bum]

Thought this was a thread on “worst job”…. Does this mean it is doing epidurals or just OB epidurals?!!!

 

[Dr. Rude]

Poiseuille’s law has me skeptical to generate enough force through a 30+ cm 19 gauge (and some are smaller at 21g I think) epidural catheter that it’ll blow the vein.

And if you have a multi-orifice cather, I’d imagine path of least resistance would be any hole in an epidural potential space vice a small vein or capillary, leading me to be even more skeptical that you’d blow to vein to salvage your epidural.

I’m glad it’s worked for you in the past, but that’s a long winded way to say if I aspirated frank blood, I’d move levels.

try it with a 3cc syringe, you generate lots more pressure than with a 20 ml syringe. I have done successful epidural blood patches via catheter with 5ml syringes as opposed to 20 ml.

 

[Gasworks]

. I have never seen a positive intravascular test dose before.

Exactly 2 in ~15 years of practice.. fyi I love people who use the words “always” and “never” in medicine.. let’s me know I can tune them out and go back to killing zombies on my phone.

 

[deleted875186]

Exactly 2 in ~15 years of practice.. fyi I love people who use the words “always” and “never” in medicine.. let’s me know I can tune them out and go back to killing zombies on my phone.

Ok, fair enough.

Follow up question, those two positive test doses were probably pulled catheters before even dosing them. How do we know they were actually intravascular. How sensitive is a positive test dose. Would any harm have come from simply hooking up the low dose epidural infusion?

I maintain that the epinephrine test dose is not needed.

 

[DocVapor]

Ok, fair enough.

Follow up question, those two positive test doses were probably pulled catheters before even dosing them. How do we know they were actually intravascular. How sensitive is a positive test dose. Would any harm have come from simply hooking up the low dose epidural infusion?

I maintain that the epinephrine test dose is not needed.

My one positive test dose was extremely clearly positive. No blood return on aspiration prior to test dose.

Would there have been any harm to just hooking it up?

No, unless you count 30 minutes to an hour of continued labor pain and "troubleshooting" the catheter before the patient and you get fed up enough that you finally just pull it and do another one anyway.

The epinephrine isn't necessary, but it's helpful, and it's not like the 1.5% lido is doing nothing - it's actually getting analgesia started.

 

[Gasworks]

My one positive test dose was extremely clearly positive. No blood return on aspiration prior to test dose.

Would there have been any harm to just hooking it up?

No, unless you count 30 minutes to an hour of continued labor pain and "troubleshooting" the catheter before the patient and you get fed up enough that you finally just pull it and do another one anyway.

The epinephrine isn't necessary, but it's helpful, and it's not like the 1.5% lido is doing nothing - it's actually getting analgesia started.

Thank you.. who wants to screw around with an iffy catheter while the patient screams at 3am? Any doubt, draw up more local, move up a level and try again. The 2 positives I had only 1 had blood return. I don’t remember how high the HR went but it was dramatic and utterly unequivocal.

All this OB chatter is triggering my ptsd. I just flashed back to a colleague signing out an intrathecal catheter that he left in place postpartum “in case the patient got a headache and needed a blood patch”. Next job.. NO OB!

 

[repititionition]

Inadvertent IT TXA was in an APSF newsletter a year or so ago. It seemed catastrophic.

I cared for a patient who received intrathecal TXA. Status epilepticus. Prolonged ICU stay. Patient was extremely high functioning prior to the event, and never regained full cognitive function.

I won’t go in to the many things that went wrong along the way that led this to happen, but it made me sad and solidified my desire to be in an all physician practice.

 

[Bryan O’Blivion]

Ok, fair enough.

Follow up question, those two positive test doses were probably pulled catheters before even dosing them. How do we know they were actually intravascular. How sensitive is a positive test dose. Would any harm have come from simply hooking up the low dose epidural infusion?

I maintain that the epinephrine test dose is not needed.

Disagree. Had a positive test dose about 3 months ago. Had aspirated, perhaps too briefly, then injected standard test dose. HR went from 90s to 140s. I aspirated again, for a longer period of time, had frank blood return in the catheter. Replaced at a different level.

It’s good practice

 

[Arch Guillotti]

I have never seen a positive intravascular test dose before.

I have.

 

[Simba1711]

I’ve had it happen in residency. Negative aspiration but positive heart rate increase. Luckily I don’t do ob anymore.

 

[Southpaw]

I’ve never had a positive with the soft spring wound type of catheter. But I’m sure it’ll happen. My first job had stiff catheters with a stylet. Those things were trash. Parasthesias on almost every advancement. Both intravascular and intrathecal catheters with tuohy in the epidural space. I hope I never see those again in my lifetime.

 

[Twiggidy]

This thread is giving second thoughts about an offer I have on the table. Not that I would do OB but now I’m worried some resident or nurse is going to give a patient a vial of Neo thinking it’s Zofran. Can’t figure out if a better lifestyle is worth that worry

 

[ambiturner]

This thread is giving second thoughts about an offer I have on the table. Not that I would do OB but now I’m worried some resident or nurse is going to give a patient a vial of Neo thinking it’s Zofran. Can’t figure out if a better lifestyle is worth that worry

I work in an academic supervisory practice. You always have a trump card for errors like this: “systems issue”

 

[pgg]

This thread is giving second thoughts about an offer I have on the table. Not that I would do OB but now I’m worried some resident or nurse is going to give a patient a vial of Neo thinking it’s Zofran. Can’t figure out if a better lifestyle is worth that worry

Solo work is great for my mental health. I don't know how you full-time 1:4 guys do it. High dose omeprazole, maybe?

 

[Dr. Rude]

Solo work is great for my mental health. I don't know how you full-time 1:4 guys do it. High dose omeprazole, maybe?

Some people have a zen-like ability to mentally disengage. I used to overeat and drink too much. I also took solace on pay day.

 

[Gasworks]

Solo work is great for my mental health. I don't know how you full-time 1:4 guys do it. High dose omeprazole, maybe?

All depends where you work and what type of cases. Supervising 3-4 seasoned mid levels in a community setting where it’s hernias, cystos and knee scopes all day is about as easy and mindless of a job as I can imagine.

 

[neutro]

Recently got this email. 4 calls per week and 72hrs in-house call/week? Independent CRNAs? In Stockton?? It’s got to be some kind of prank.



Good Morning Dr. ,

I hope this message finds you well!

Dignity St. Joseph’s Medical Center in Stockton, CA is developing an anesthesia residency program and is seeking core faculty to build the department. Our faculty will be extremely engaged with resident education and career development.New grads welcomed! $25k stipend!

We have the following positions available:

Core Faculty Regional & Pain
Core Faculty OB
Core Faculty General Anesthesiologist

Job Summary
• St. Joseph’s Medical Center | Stockton, CA | (St. Joseph's Medical Center Stockton)
• 8 ORs | 357 Beds
• OR Start times between 7 AM – 7:15 AM
• 12,500 cases | General, Colorectal, Ortho, Spine, Thoracic, Cardiac, Vascular, Cath lab, IR, Endo, OBGYN, ENT, Podiatry, Plastics, some Peds | OB 2,500 cases
• Case mix - Hospital and ASC environment with fair schedule
• Four calls per week: 1st call in house one time per week, 2nd call one time per week from home, 24-hour OB call one time per week, 24-hour OB call one time during weekend.
• Post call off after 1st call not 2nd
• Independent CRNA practice in a collaborative MD/CRNA model
• We offer flexible schedule (Full Time, Part Time, Per Diem, No Call contracts offered)

Anesthesia Residency Program, Core Faculty:
1. Anesthesia Residency, Core Faculty in the daily leadership, oversight, and direction of the anesthesiology residency program to ensure that the residents compliantly meet and exceed the necessary training requirements.
2. Provide evidence of progressive and increasing responsibility by the resident as his/her training.


If you or someone you know is interested, please send your CV to [email protected].
I look forward to hearing from you soon!


Recruitment Marketing Manager
Somnia Anesthesia

Ofcourse the name of the hospital would be “dignity”

 

[ranvier]

All depends where you work and what type of cases. Supervising 3-4 seasoned mid levels in a community setting where it’s hernias, cystos and knee scopes all day is about as easy and mindless of a job as I can imagine.

That sounds like my typical day except I just do those cases myself and probably make less money.

 

[kidthor]

Some people have a zen-like ability to mentally disengage.

A lot of people I work with are completely mentally zoned out. They accept all the koolaid and don’t complain. 1:4 with sick patients and brand new crnas? If that’s what the hospital wants “to be financially responsible” then they’ll just do it.

I don’t know if it’s better to care and recognize what makes sense and what doesn’t, or to just be so tuned out as to not be bothered.

 

[Twiggidy]

A lot of people I work with are completely mentally zoned out. They accept all the koolaid and don’t complain. 1:4 with sick patients and brand new crnas? If that’s what the hospital wants “to be financially responsible” then they’ll just do it.

I don’t know if it’s better to care and recognize what makes sense and what doesn’t, or to just be so tuned out as to not be bothered.

This is the part I'm trying to figure out

 

[cchoukal]

I was in a supervision practice for years, granted not 4:1, but with great CRNAs and very junior residents with generally very sick patients. I definitely tried to be more of the former, but noticed gravitating toward the latter in the last year or two. Big part of why I recently shifted paths and am now in an MD practice. I've never felt more engaged or professionally rewarded by patient care and am really happy I made the jump.

 

[jon stewart]

They are both ampules of similar size. Change in vendor, not reading the label, pharmacy tech vending to wrong slot in the Pyxis, other “holes in the Swiss cheese lining up”, etc.



ETA: Just speculation on my part.. I have no specific knowledge of the incident.

How do you give IT dig?

This is not new...this has happened before,I know of an instance personally. When I heard it I thought how does that happen. There are case reports about if. Very sad.

 

[vector2]

I don’t know if it’s better to care and recognize what makes sense and what doesn’t, or to just be so tuned out as to not be bothered.

In Zero Dark Thirty, one of the CIA dudes is torturing a detainee and he says: “In the end, everybody breaks. It's biology.”

I try to stress to residents there's a multitude of things which successful anesthesiologists exhibit, but three tenets I put near the top of my list are preparation, attention to detail, and situational awareness.

I've been supervising for 5 years, and it's just so, so rare that I find CRNAs who really demonstrate those traits to a high degree. Which is not surprising because, at the end of the day, their training is less rigorous, their knowledge base is smaller, and they have more of a cookie cutter mentality. It is what it is.

Which is to say, imo, it's almost an impossibility for people like me, after years of doing it, not to "tune out" when I'm supervising CRNAs. You'd go literally insane (and probably be labeled a troublemaker and get fired) if you tried to apply "full caring" and a type A style of anesthesia to supervision for years on end. Ultimately, I think every anesthesiologist lets relatively unimportant details of the supervised anesthetic go- even if it's not the very best thing for the patient. That is to say, everybody breaks.