Your first day as a CA-1!

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jetproppilot said:
C'MON YA'LL GIVE IT UP!!!!!!!
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At Columbia (where I finally met Platysma and Dukeybootie!) we had orientation, the highlight of which was receiving personally monogramed laryngescopes and blades - with the caveat that we have to sterilize our equipment between cases. :( We took a version of the AKT, for which I'm not sure I've ever been LESS prepared for any other exam. I was supposed to be on call overnight, but the attending sent me home. I was excited to start right away, but I'm exhausted from this past week of moving and finishing internship, so this was much appreciated. My first two cases will be laminectomies on Tuesday. My head is spinning from all the new logistical stuff we have to assimilate to function at Columbia, which is a freaking huge-ass place.
 
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I have a good one...except this was when I was an "experienced CA-2"

I was showing a rotating MSIII how to intubate. The attending let me take the patient back without him. I go ahead and put the guy to sleep with 200mg of the white stuff. I paralyzed him with 0.25 mg/kg of miv....waited only 45 secs or so....I perform laryngoscopy....the patient (ASAI 25 year old buffed marine who I thought was anesthetized and paralyzed) reaches up, takes the blade out of my hands, and toss it across the OR :eek: :eek:

After several moments of silence....everyone in the OR was rolling on the floor laughing.
 
militarymd said:
I have a good one...except this was when I was an "experienced CA-2"

I was showing a rotating MSIII how to intubate. The attending let me take the patient back without him. I go ahead and put the guy to sleep with 200mg of the white stuff. I paralyzed him with 0.25 mg/kg of miv....waited only 45 secs or so....I perform laryngoscopy....the patient (ASAI 25 year old buffed marine who I thought was anesthetized and paralyzed) reaches up, takes the blade out of my hands, and toss it across the OR :eek: :eek:

After several moments of silence....everyone in the OR was rolling on the floor laughing.
Click to expand...

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHHA

Guess he showed you, huh?
 
militarymd said:
I have a good one...except this was when I was an "experienced CA-2"

I was showing a rotating MSIII how to intubate. The attending let me take the patient back without him. I go ahead and put the guy to sleep with 200mg of the white stuff. I paralyzed him with 0.25 mg/kg of miv....waited only 45 secs or so....I perform laryngoscopy....the patient (ASAI 25 year old buffed marine who I thought was anesthetized and paralyzed) reaches up, takes the blade out of my hands, and toss it across the OR :eek: :eek:

After several moments of silence....everyone in the OR was rolling on the floor laughing.
Click to expand...

:laugh: :laugh: :laugh: :laugh: :laugh:
 
HAHA Aww man that is freakin hilarious!!!

militarymd said:
I have a good one...except this was when I was an "experienced CA-2"

I was showing a rotating MSIII how to intubate. The attending let me take the patient back without him. I go ahead and put the guy to sleep with 200mg of the white stuff. I paralyzed him with 0.25 mg/kg of miv....waited only 45 secs or so....I perform laryngoscopy....the patient (ASAI 25 year old buffed marine who I thought was anesthetized and paralyzed) reaches up, takes the blade out of my hands, and toss it across the OR :eek: :eek:

After several moments of silence....everyone in the OR was rolling on the floor laughing.
Click to expand...
 
LMAO :laugh:
 
I can't believe that I'm the only one with a funny/embarrassing story.
 
powermd said:
.....the highlight of which was receiving personally monogramed laryngescopes and blades - with the caveat that we have to sterilize our equipment between cases......
Click to expand...

How do they expect you to personally sterilize your equipment? Usually
-- Cidex soak (requires vented room and is on JCAHO "hit list")
-- Steris liquid bath (requires vented room and 20 minutes run time)
-- Steam autoclave (requires time)
-- Ethylene oxide gassing, which requires 24 hour airing-out.

Unless Columbia gave you half-dozen of each blade, how are they giving you time to sterilize your equipment between cases? What technique? I know several folks who today cannot step foot in an OR suite, due to severe anaphylaxis to Cidex fumes.
 
No horror stories as of yet but a little friendly intimidation from a few of the uppers. I stayed after a little late to goof around with the Omeda. They should put a clutch on that bad boy for switching from mech to bag.
 
VentdependenT said:
No horror stories as of yet but a little friendly intimidation from a few of the uppers. I stayed after a little late to goof around with the Omeda. They should put a clutch on that bad boy for switching from mech to bag.
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Hey, dude.......

How are Rothenberg, O'Connor, Ganzouri and Birmingham? Tell Murphy to get with the times!

Best a luck, kid...

:love:
 
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My favorite attendings were the ones who remembered what it was to be a resident.. I rotated 6 months at the university and 6 months at the private hospital that did just about any case imaginable.. The university attendings were such dinguses. I mean if i showed up 16 minutes after my morning break i woul dbe chewed out. at the private hospital I was given much more leeway to work with
 
Here's one. I don't know all the details since it was a few years back and my info came from friends in the Ortho Residency and nurses in the room. A fellow resident of mine was doing a shoulder case in the beach chair position when in the middle of the case the pt. (a large young male) reached up with his non-operative arm and extubated himself. He threw the ETT down and tried to walk out of the room. I don't remember the remaining details unfortunately.
 
VentdependenT said:
No horror stories as of yet but a little friendly intimidation from a few of the uppers. I stayed after a little late to goof around with the Omeda. They should put a clutch on that bad boy for switching from mech to bag.
Click to expand...

Older Narkomeds are much more pleasurable to switch from mech to bag. Has the feel of a finely-crafted German car transmission shifter.
 
Don't many programs keep the newbies out of the ORs for the first week?

Curious to see how the first month goes.
 
Well here's today's funtime happytime stories:

67 y/o male with DM sin CAD hx/sx/-ekg in for "reducible inguinal hernia." MAC. Propofol on. Now "incarcerated hernia" found after incision under local. Up next bowel getting pulled on so hard it wakes my guy up. Gave 2 small bolus. Next, PUKE EVERYWHERE.....airway reflexes intact as guy is coughing, suction, call attending, induction, laryngoscope (which was fun because the guy was ONLY missing his 4 front teeth), see cords but no room for ett (cause I'm a novice...now I'll scoop that tongue all da way to the left), attending gets it. Sats never dipped on low fio2.

I took a coffee break.

Next case: dilated cardiomyopathy with open cholecystectomy and perihepatic abscess drainage. Case went well. Moving guy over. Art line transducer pops off under guys body during the move (had neck IV, and additional arm IV, got em confused I guess). Attending looks at bleeding open line and says "well...thats bad."

Ate quick lunch

Last case: 48kg young man with Neurofibromatosis sin cervical spine involvement with gastric sarcomas, TPN with alb of 2 (up from 1), moderate bilat pleural effusions, CRI, bladder CA, fever of 103, tachycardic (SIRS. Not hypotensive), neg blood cx, in for open abd drainage of abscess s/p bowel resection under x-lap for abd compartment syndrome....anes team said wry prayers. MAC. Surg on case since day one, so I's & O's look decently positive. 40 cc propofol and 50mcg fentanyl later pressure hits 68/15, rpt pressure too weak for cuff, pt ventilating adequately. Neo, fluids, wake up, stay awake, no more for you. Just baby versed wiffs.


Not quite like the hysteroscopies and D&C's I was doing a few weeks ago.
 
Another funny from Rush's OR today: 40 yo big, black lady (Not fat, but big boned, ya know like friggin acromegaly hands and face) for a regular TAH with BSO. Case went smoothly until the end during emergence. Goes into stage II and starts fighting and thrashing big time. Damn this woman is strong! Me and the supervising CA-2 resident try to hold this woman down. I'm holding down her head, and the OR nurse is holding down the right side. I look over to my CA-2 resident and he has this very funny but pained look on his face as he's trying to hold down the left side. "Dude, I'm being violated!" he keeps saying. I look behind him and see the patient had reached up with her huge left hand and had his right butt cheek in a pincer grip. The more we tried to restrain her, the tighter her grip got. It was kinda funny watching him wince in pain and trying in vain to wiggle his ass out of her grip. She finally let go after a few minutes.
 
Little humbling moment of having to slap in ye old LMA mid case for our failed neuraxial block. Damn crunchy spines in these older folks.
 
Just a reminder that even us old folks can still get the weird cases. Yesterday, 6-5, 250 pound guy for back surgery. Balanced anesthetic, no physical signs of pain. Gas eliminated and patient breathing at a comfortable 16 per minute with great tidal volumes. Roll patient to gurney, extubate, patient (with absolutely NO gas on board and all narcotics given at start of case only) wakes up confused and belligerent, dropping F bombs, swinging both arms and sitting up trying to get off the gurney and walk out of the OR.

Took every ounce of strength to slam him back down onto the gurney without hitting his head on the rail and pin him, waiting for more help to arrive.

Left arm gets free and he picks up a 180 pound nurse like a rag doll tries to shot put him against the wall.

Finally calms down when I use a soft comforting voice to reassure him. He then begins to cry and apologize.

Moral of the story: Wake up King Kong on the OR table with the arms and legs still restrained.
 
UT, Don't load all the fentanyl up front. Use judicious titration throughout case. The resp rate should be around 8-10 for these big evil looking guys. Exp. gas% should be 0 or nearly so. Sevo not Des for the gas. Lubrication of ETT with 2% lido jelly. 2% lido IV for the flip. Remember, fentanyl is your chemical straight jacket for these big evil dudes. In the real world don't let this happen to you as you'll be derided mercilessly; it screams of "rookiness". Regards, ---Zippy
 
zippy2u said:
UT, Don't load all the fentanyl up front. Use judicious titration throughout case. The resp rate should be around 8-10 for these big evil looking guys. Exp. gas% should be 0 or nearly so. Sevo not Des for the gas. Lubrication of ETT with 2% lido jelly. 2% lido IV for the flip. Remember, fentanyl is your chemical straight jacket for these big evil dudes. In the real world don't let this happen to you as you'll be derided mercilessly; it screams of "rookiness". Regards, ---Zippy
Click to expand...

RR was 12, ET Sevo: 0, lido given, toradol given, patient in no pain whatsoever. After his confusion resolved, his pain scale was zero. Twenty minutes later, he told me "Doc, I told you I always wake up swinging."
 
zippy2u said:
In the real world don't let this happen to you as you'll be derided mercilessly; it screams of "rookiness". Regards, ---Zippy
Click to expand...

:barf:


Geez, Zip thinks he's John Tinker.
 
Well, originally you said the RR was 16, now it's 12? What gives? ---Zippy
 
PreOp June 31, starting tomorow Ca-1, this year
-first case: lap arcuate ligament release(in the abdomen)--what the hell is that! Shes 76 DJD/OSA
Day one
-setup? Hmmm
-take a leak, see patient
-cant get IV, CRNA helps, ouch!
-finally get em asleep...Attending leaves me with CRNA
-strike up small talk with surgeon about what the hell he is going to do. I have had 2 years of general Sx and I read last night and still had little idea. neither did he...prep teets to pube/lithotomy/stirrups/no belt.
-sx start 0715, ports in, insuflation, reverse-trund, Surgeon between legs
-Im avidly trying to chart (thats hard 1st day out of Sx)
-Im also glued to monitor(bad move)
-I freak out cus my ECG monitor fails
-Surgeon screams
-72F with brittle bones is in his lap, foot of bed at mid back, ECGs must have just pulled off, yup
-repositioned with bean bag, case continued
-PACU, ok, no neuro deficits, no pain....Wheewww!
Lessons:
Gas is in charge of position, I thought I knew that
Know what restraints you have on
refuse trund/rev if surg doesnt want belt
Look at patient sometimes too
Trust no one
Sometimes u really need that morning (cleanup) break
j
 
This one time as a CA-1, I did an axillary block on an 18 yo ASAI teenager. In the OR, I start him on a propofol drip so he can sleep during the case. Shortly after surgeon starts, the kid starts squirming under the drapes. I ask him if he's having any pain but he's too obtunded from the propofol/versed to respond. So I start to deepen him with a little more propofol and fentanyl. But no joy, he's still squirmy under the drapes and the surgeon is getting pissed.

At that point, a CA-3 comes in to relieve me for the day. But I couldn't leave anyone faced with a suboptimal anesthetic. So I explain the problem to him and he says, "don't worry, we can fix it." He then puts a face mask and strap around the kid's head and puts him on nitrous and oxygen, 50/50. The CA-3 says, "you'd be surprised at how potent nitrous is."

And then a couple of minutes later the kid obstructs. So I'm under the drapes now trying to do the jaw thrust while my colleague is giving positive pressure breaths with the bag. Sats are hovering in the low 90's.

At this point, the Attending comes in and he's like, "wtf?!" So he shoves the both of us out of the way, turns the nitrous off, puts him on a 100% oxygen, boluses propofol, and smoothly inserts an LMA.

And then he turns to the CA-3 and says, "How could you let him do this?" And then he grumbles out of the room mumbling something about "the bastardization of anesthesia."
 
I've got a horror story, actually two.

Week two. Ambulatory surgery
Hemorrhoidectomy (in prone position)--> asystolic arrest, cause (still) unknown.

next case, same day, same surgeon, same attending
inguinal hernia repair, GA ETT propofol succs
-->Pseduocholinesterase deficiency, new diagnosis

I got pretty handy with putting together the ambu bag and transporting intubated patients. Not what I expected with outpatient surgery.
 
Had to dig out this post since i started this week :cool:
No horror stories yet apart from my inability to put in an iv (didn't do enough during med school).
My attending likes to induce the patient, talk 10min about the vent and then leave for like an hour :scared: patients have been rock steady though but wake up time is pretty wild. :oops:
One day i'll be as smooth as a baby's rear end :D :laugh:
 
As a CA-1 1st month: Doing a cysto and stent placement under GA with ETT. Pt paralized with cis. After case, pt has no twitches on ulnar monitor. No return of twitches after 20min so cant give reversal. Surgeons, nurses all waiting in room. I'm thinking pt has pseudo cholinesterase deficiency since no return of twitches. Attending comes in. Changes the battery on the nerve twitch monitor....pt has all 4 twitches, all strong. I feel like idiot. Pt is reversed and extubated.
 
Intheair said:
As a CA-1 1st month: Doing a cysto and stent placement under GA with ETT. Pt paralized with cis. After case, pt has no twitches on ulnar monitor. No return of twitches after 20min so cant give reversal. Surgeons, nurses all waiting in room. I'm thinking pt has pseudo cholinesterase deficiency since no return of twitches. Attending comes in. Changes the battery on the nerve twitch monitor....pt has all 4 twitches, all strong. I feel like idiot. Pt is reversed and extubated.
Click to expand...

Two points:

It doesn't matter if the patient has a pseudocholinesterase deficiency, that won't affect the breakdown of Cis (Hoffman nonenzymatic degradation), and if the patient has all 4 twitches with no fade and sustained 5 second tetany, especially with Cis, reversal was likely unnecessary.
 
not a first day thing but I feel like bitchen and this looks like the place.

With an orthopod today and he started freaken out about one cuff pressure of 127/65 while doing a total hip. I had an epidural in, dosed, and the patient in the lat position with an lma in. Pressure got like that from the 15mg of ephedrine I gave him for a bp of 80/50 (59 y/o dude who has hx of htn).

I didn't even say anything except "I got it." next pressure 117/55. "CALL THE ATTENDING!!! I can't see ****!" Nurse comes up to me and asks if she should call the attending. I say "pffffff its not a big deal." Attending comes in and the pressure is 90/60. Poor guy then has to sit in the room and pseudo-babysit the case till the surgeon is done so he doesn't blow his friggen gasket.

blood loss for the case: 300 ml.

Dude I was pissed.
 
VentdependenT said:
not a first day thing but I feel like bitchen and this looks like the place.

With an orthopod today and he started freaken out about one cuff pressure of 127/65 while doing a total hip. I had an epidural in, dosed, and the patient in the lat position with an lma in. Pressure got like that from the 15mg of ephedrine I gave him for a bp of 80/50 (59 y/o dude who has hx of htn).

I didn't even say anything except "I got it." next pressure 117/55. "CALL THE ATTENDING!!! I can't see ****!" Nurse comes up to me and asks if she should call the attending. I say "pffffff its not a big deal." Attending comes in and the pressure is 90/60. Poor guy then has to sit in the room and pseudo-babysit the case till the surgeon is done so he doesn't blow his friggen gasket.

blood loss for the case: 300 ml.

Dude I was pissed.
Click to expand...

In private practice...my orthopod doesn't really care what the bp is.
 
VentdependenT said:
not a first day thing but I feel like bitchen and this looks like the place.

With an orthopod today and he started freaken out about one cuff pressure of 127/65 while doing a total hip. I had an epidural in, dosed, and the patient in the lat position with an lma in. Pressure got like that from the 15mg of ephedrine I gave him for a bp of 80/50 (59 y/o dude who has hx of htn).

I didn't even say anything except "I got it." next pressure 117/55. "CALL THE ATTENDING!!! I can't see ****!" Nurse comes up to me and asks if she should call the attending. I say "pffffff its not a big deal." Attending comes in and the pressure is 90/60. Poor guy then has to sit in the room and pseudo-babysit the case till the surgeon is done so he doesn't blow his friggen gasket.

blood loss for the case: 300 ml.

Dude I was pissed.
Click to expand...


:confused: with chronic hypertensive old folks, poorly controled, i actually aim for a map in the high 60's to low 70's, since their autoregulation is out of wack and low 60's should theoretically be too low for these folks. should i be aiming for a lower map ?

( i know the map should be 2/3 pulse pressure pluse diastolic, but from my experience with automated cuffs, 117/55 will usually place map at most in the 70's)
 
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