Friday, February 21, 2014

Anesthesia Truisms

After practicing anesthesiology for many years, I've developed a list of observations and advice that I think will help anesthesiologists or anyone thinking about going into the field. Obviously most anesthesiologists probably have already reached the same conclusions as me. But passing around some common nuggets of knowledge that isn't found in any anesthesia texts will surely help.

1. Never trust a surgeon. If you think a case might produce a lot of blood loss but he says there will be minimal EBL, always draw up some blood to send to the blood bank, just in case. The little bit of extra time and cost put into that effort won't be missed and could potentially save a patient's life. Otherwise when you need the blood, as you eventually will, you will have poor access to draw a specimen and it will take the blood bank 45 minutes to get the blood ready.

2. If you are even thinking about intubating a patient for a procedure, just do it. Inevitably the patient will get into respiratory difficulties during the middle of a case and you'll have to scramble to get an endotracheal tube inserted, sometimes in an awkward position with poor visibility. If the patient got intubated before the case started and the case proceeded smoothly, then at least the patient got the safest anesthetic and airway protection you could provide. As one of my residency attendings once said, he would declare that a victory.

3. Don't make enemies of the nurses. They will always have more power and influence than you. They can make or break the OR schedule while you, the anesthesiologist, is easily replaceable.

4. Invasive monitoring is your best friend. Don't hesitate to put in an arterial line or central line just because you don't feel like doing a little extra work that morning even though the patient has all the indications for needing one. Patient safety is numbers one, two, and three in how we practice anesthesia.

5. You should be as proficient with a fiberoptic intubation as a direct laryngoscopy. Sometimes even a video MAC is not effective. I had a patient recently who came in with Ludwig's angina who could barely open his mouth more than one centimeter. No video MAC could have intubated that patient.

6. If you are running late for your next case, inevitably the patient will have no veins to start an IV.

7. When a surgeon says that only a MAC anesthetic will suffice, he really means he wants the patient as motionless as a general anesthetic.

8. If you have an important engagement to attend to after work, invariably the last patient of the day will crump in the recovery room. You will be stuck there for the next two hours reviving the patient while your spouse sits at home fuming over another missed birthday dinner and thinking she should have married the future Goldman Sachs banker who tried to woo her in college.

9. You can do 99 perfect anesthetics in a row but it will be the one patient that has a complication (broken tooth, aspiration, MI) that people will remember and you'll lose your sleep over. You'll get called to a hospital Quality Assurance meeting and get raked over the coals and feel like a total anesthesia impostor.

10. And finally, just to keep us humble, remember that when a surgeon is running 30 minutes late for his case there is nothing you can do but sit back and cool your heels until he arrives, usually without an explanation for his tardiness nor an apology. However if the anesthesiologist is 5 minutes late, there will be a huge outcry from the surgeon to find another anesthesiologist.

1 comment:

  1. #2 - An attending of mine in residency would say, Doctor!, I have 3 absolute rules on call. No Strokie, strokie, No heart attack'ee and NO LMA! He was fun, a great doctor, and I still very, very rarely use an LMA on call. They are invariably sicker than paper indicates and an ASA class higher than the most conservative surgeon relays to you over the phone!!

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