rn29306 6,011 Views
Joined: Sep 15, '04;
Posts: 530 (2% Liked)
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Im also in that transition, but my situation is a little different. Im at a smaller facility with only 2 crna's at a time. It could be worse, I got called in the other night for a 350 lb incarcerated ventral hernia, I was the only anesthesia in house, I put the pt to sleep, couldn't tube, was able to vent, then the attempt at a bougie failed, then I couldnt vent, lma didnt work, had to wake the pt up, and do awake fiberoptic by myself with no anesthesia help, just a useless surgeon and scared nurses. It was a great learning experience for me, but a little backup at times is nice.
Not that I was there, so don't kill the messenger.
I've intubated several 400 'pounders using the Glidescope right off the bat, one of them was a post-op carotid rebleed. I felt in those couple certain circumstances that performing DL would have been just about impossible for anyone to get a straight visual to the cords. The amount of tissue was uttlerly amazing, esp the tongue and depth to the cords.
I had a CRNA while I was in school tell me...."Son, do ya think they are gonna be skinny on the inside or something?"
While fiber optic would probably have been pretty much useless at this point considering the intubation attempts (and at times like these, you have to be rather forceful) the GS would have been great. Do you guys have a difficult airway cart? If so, consider an intubating LMA...Even if you can't get the best seal for a few minutes, throw a tube down it ASAP.
People complain about the price of a GS...but if this man had a hypoxic injury, the 10-14K would have been chump change compared to everyone's payout.
Sounds like you guys had a horrible situation and you handled it to the best of your ability. Think about having anesthesia set up a difficult airway cart, either on your floor or you having access to it while they are coming in for something like this next time. Great job!
??-- respiro profundo -- ??
This IS an issue. I trained at hospitals with, and without residents. Believe me, this is absolutely an issue. as for the reply that there are plenty of cases to go around.... yeah, the residents will do the bigger, better, more involved cases while the srna's will do the hernias and gallbladders. Even if the srna has more experience than the resident. I have been kicked out of more than one OR to make way for the resident to get "their numbers". I enjoyed the residents themselves, they are in the same boat as SRNA's but their attendings will be the ones that kick you out and send in the resident. In my opinion, it will always be better to be the only "learner" wherever you go. university hospitals are great for experience if it is set up to benefit all trainees and not just the residents. Kaiser students go to Loma linda university and this was the only facility where I was treated the same as the residents as far as what cases I got, and the respect I got, with that respect came the expectation that I got the job done.
this phrase is accompanied best by a couple good chest rubs:
means to breathe deep.
If I might interject, I am a MD pain physician now in AA (anesthesiologists anonymous) that has had RNs inject propofol for over 12,000 cases in the prone position with an unprotected airway. Used in small doses for conscious sedation, or even deep sedation, airway obstruction in the prone position is much less common than the supine position due to airway mechanics, but one must remain vigilant regarding the airway and exchange of air. There have been zero incidences of patient awareness, zero incidences of intubation, 4 incidences that required the patient to be turned to the supine position for further airway management, zero admissions to the hospital, zero aspirations, and zero other complications.
I am not suggesting this as a modus operandi but am saying there is a proven track record here for very short cases (most <5 min) and some longer cases (up to 30 min). The patients are profoundly happy not to be drugged out all day as with versed/fentanyl, are sitting in a chair awake alert after 10 min, drinking after 15min, and usually go home within 25 min.
For us, the procedure has become so safe that we now use an office procedure room (fully equipped of course) for these procedures. The key is not to use any other IV or inhalational agent...pure propofol only. The purpose of this post is not to make claims the technique may be used safely in all situations, but that under controlled conditions, propofol has a remarkable safety record when administered by non-MDs.
This is a good thread, I will be looking these drugs up to see what they do.
There are two drugs used when they are going to intubate a pt. One of them is sux and the other begins with an "A", can anyone tell me what that other drug is? Thanks,
Our EP lab, when doing implanted debifs, does their own sedation with EP RNs doing fent / versed CS and the surgeon uses liberal amounts of local in the pocket. For testing and sensing, they call us for the propofol administration and we set up shop (ie, ready to intubate). We stay with patient until they are awake and then we leave.
We also do the CV with propofol and are completely set up for those as well.
I know mercer is incredibly competative. I also know the director there. He used to be our assistant director. Everything he has told me has been extremely promising about the program.
what if the pt iwas allergic to eggs and you didn't know that? do you have solumedrol and and benadryl also drawn up every time you use propofol?
Tridil2000 related the following experience: "once, we had a mentally challenged adult who fell and hit his head. we could not get a line in him and we needed to ct his head. he was wild! we used ketamine im on him and got out ct."
Were I called as an anesthesia provider to do deep sedation for such a patient, ketamine is the last drug I would choose. I wouldn't even bring it with me. First of all, imagine this same, combative patient, having frightening hallucinations. A bad situation just got worse. But there is an even better reason not to use this drug in this case. Go back to the post of janfrn, and look at Adverse Reactions/Side Effects, particularly the CNS section. Ketamine elevates intracranial pressure. Whatever you might be looking for on a head CT, I can't think of any cranial pathology that cannot be worsened by elevating the ICP. Every anesthesia provider knows this, and knows that for any suspected head pathology, ketamine is contraindicated.
The only area is most hospitals to NOT use pumps is in OR, where you have an anesthesiologist at the head of bed to monitor everything continuously.
I'm graduating at the end of August! YIPPEE! Can't believe this past 2 years have gone by quickly. Eventhough I am still a couple of months away from taking the board exam, I'm already stressing out about it. I attended the Valley review in March and have since read the sweat book 3 times and had just finished reading the entire memory master book once. I intend to read it again 2 more times.
Yet, I still feel like I won't be ready. Paranoia? Maybe. I tend to read into questions too deeply. I did the same thing when I took my NP board exam. I thought I failed it, since I went over the minimum questions asked but I passed it thankfully.
I guess what I am looking for is for input from those who have taken boards recently, on whether or not you felt you were prepared to take the exam after going over the sweatbook and memory master alone, or did you read beyond these two study aides?
State boards can be fairly rough, but hospital credentialing agencies are TOUGH.
Background investigation by credentialing boards of hospitals makes state board inquiries look like cake.
Not saying you can't get credentialed, but you will have much more explaining to them than the state boards. You might have to attend the credentialing meetings and explain your situation.
The article talks of a dog study that was conducted, 12 total. 6 received the lipid emulsion treatment and lived after an bupivacaine administration. The six that did not receive lipid therapy died.
A follow up sheep study should be interesting.
PETA will have a damn fit.
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