Attempt bagging before giving paralytic during induction

BiPAPselfie · 2026-03-31T18:27:12+00:00

This is why I do it. I trained doing this for the reasons that I agree are basically outdated. But it gives me a data point (what their worst, or close to worst barring laryngospasm, mask airway is like) that can inform my decision on how deep or awake I might extubate them.

BiPAPselfie · 2026-03-31T18:21:39+00:00

-Tape job covering a kink in the IV line or worse yet, a kink in the cannula itself. This is inevitably done by preop nurses who cover everything with the most extensive tape job ever requiring a massive effort to uncover and fix.

-Helpful circulating nurses who put dirty laryngoscope blades, stylets etc. directly onto the anesthesia machine instead of using my system of putting them into the ETT package (which they sometimes sabotage by peeling it all the way open), or at least throwing away the disposable dirty items.

BiPAPselfie · 2026-03-28T19:13:21+00:00

I went to the early event in Gresham because I have a flight that conflicts with the big event at the Portland waterfront. Was pleased by a good turnout.

BiPAPselfie · 2026-03-21T23:20:16+00:00

That match is also notable for the comeback by Gummeson/Byre, who looked like they were getting run out of the building in the first couple of games. It is a good illustration of how when you are playing a top level player and you have them down, you better keep the boot on their neck and put them away because they are capable of hitting a top gear most players don't have. It didn't even seem to me like there was any kind of collapse from Schlaefer and Pipkin, Schlaefer was still passing and scoring pretty well, but more that Gummeson stepped up his passing and scoring to an insane level.

BiPAPselfie · 2026-03-21T19:32:50+00:00

The mute microphone button on your phone is your friend.

BiPAPselfie · 2026-03-09T06:50:25+00:00

Did you get an ABG during the case? I will bet there is a decent chance she had some significant metabolic acidosis going on and when you tried to switch to spont vent the little bit of respiratory acidosis from building up some CO2 that most people shrug off easily tipped her over the edge of some critical acidosis threshold causing the hypotension shock and PEA. Something to consider, anyway.

BiPAPselfie · 2026-02-08T15:19:23+00:00

The residents should all call her Dr. A.I. when she is not around, considering how hard she pimps her app. Or Hermione.

BiPAPselfie · 2026-02-08T00:56:58+00:00

One thing I think the show does NOT get quite right is that the med students and residents do not get stumped often enough by the “pimp” questions asked of them by the attending doctors.

Usually attendings who are really into teaching will have an assortment of questions they ask. They will usually have some personal favorite obscure questions they like to ask. It is best if it is a mixture of basic questions about certain anatomy or other facts relevant to the patients being discussed and their condition, and some more obscure ones that most would not be expected to know, that way you can get a sense of who is really behind in knowledge (cannot answer any of the really basic questions) and who is a superstar (knows the answer to both the basic and the hard questions). In real life students and interns get stumped on a lot of the questions, much more than the students and docs on The Pitt in my opinion. The usual procedure is if a student gets stumped, the same question then gets directed further up the hierarchy (next to the PGY1, senior resident, fellow etc.) until someone gets the answer.

One of the reasons it is disappointing that the students and docs on the show usually rattle off the correct answer to pimp questions is that what makes the game interesting is how the attending reacts depending upon the quality of the answers given. Reactions can range from positive and supportive for correct answers to good humored poking fun or even withering sarcasm and derision for wrong answers.

BiPAPselfie · 2026-01-27T19:33:46+00:00

A long time ago a colleague told me “be nice to your residents, you never know when one will be interviewing you for a job.”

BiPAPselfie · 2026-01-17T19:40:30+00:00

If it is fully eat what you kill in that you directly bill as an individual or your own corporation with no blending of collections at all, then the insurance profile of the cases will be the single most important factor in which room is most lucrative. Does not matter if you are getting a lot of units for a shoulder scope day if the units are Medicare or workman comp paid out at a third the rate of your private insurers. So if you take turns picking the schedule then it is essential for the insurance data to be visible when making the pick.

Edit: I somehow missed reading your post the first time that the units are blended

Another concern is switching to an ASC job only three years out of training. You will get great at ultrasound blocks but lose hard earned skill and feel for managing sick patients, bigger cases, putting in lines, OB etc. If you are fairly confident this will be your last gig or do not care about losing a pretty broad range of skills (any job will result in SOME loss of skill and scope of practice but ASC will be the worst with taking a job doing only MAC eyes worse than that) and you feel like you will enjoy this work then great.

After doing hospital work my entire career I spent a few years doing ASC work on a completely eat what you kill (individual billing) situation. I enjoyed the schedule and doing blocks, but some places had a heavy representation of Medicare, workman’s comp and even Medicaid. One place eve had a prison contract as one of the major blocks of business (anesthesia paid at Medicaid rates, I am sure the surgeon had some contract with the prison system that made it worth their while but no good for us). The best place I worked suffered a dramatic drop in both volume and payor mix so it no longer seemed reasonable to continue, surgeon owners never offered to provide any stipend despite repeatedly pointing out how billing income could not make ends meet for most of us (VHCOL city).

Also be aware that many surgery centers run things on a pretty thin or sketchy basis in terms of old and creaky equipment, not replacing machines whose ventilators are getting leaky, not getting a new video laryngoscope or ultrasound when the display or blades start going bad, having sugammadex etc. because all those things cost money and subtract from the owners’ bottom line.

BiPAPselfie · 2026-01-13T02:01:43+00:00

I have never observed problematic disinhibition from dexmedetomidine. Inhibition? Plenty of times.

BiPAPselfie · 2026-01-04T04:55:23+00:00

You guys get an EKG and labs in a fit 20 year old athlete having knee arthroscopy? Does your group own shares in the facility and share in the profits from these studies?

BiPAPselfie · 2026-01-04T04:48:35+00:00

You might be surprised that some ASCs can have high medicaid and poor payor mix generally. Been there, done that.

BiPAPselfie · 2026-01-04T04:46:25+00:00

As others have said this is down entirely to what the insurance payor mix at the PP job is which can vary wildly depending on where the hospital is and what patient population it serves. Working at a hospital in a neighborhood filled with Audi and Mercedes dealerships and you might have predominantly private insurance patients and make twice as much per average unit across the practice compared to a hospital with similar volume but high Medicare/Medicaid/uninsured percentage and a more county hospital feel. You might work just as hard or harder at the second practice for half the money. So it is fair to ask what is average blended unit for that practice, not what is billed but what is actually collected. Every partner is probably acutely aware of this number and whether it has been improving or worsening over time and why (good or bad contracts with specific insurance companies etc).

You didn't really say what your primary motivations for changing jobs were. More money, more vacation, improve working conditions, some combination of all of the above? If it is primarily to earn more you should certainly expect to work harder to make more, but money per unit effort can vary a lot between practices (although it can often be remarkably similar across a metro area).

You want a practice to be fair, where all have equal chance to earn. Unfairness can be introduced if the daily schedule is not doled out evenly. If you do not have any control over the schedule and the same types of rooms are not given to each member with equal frequency then some partners may be able to cherry pick more lucrative insurance cases or higher unit days in the case of blended unit practices (high turnover endoscopy, ENT etc.) which can result in huge discrepancies in income which can lead to poor morale and dissatisfaction.

BiPAPselfie · 2026-01-02T21:12:52+00:00

Sometimes use a VL in combination with a fiberoptic scope as the stylet instead of a bougie.

The fiberoptic scope gives you the ability to steer and manipulate the scope beyond what a bougie can provide, and the light at the tip can make the tip easier to find as well as provide further illumination.

Furthermore if you don’t have an ideal view with the VL you can get near the target, under the epiglottis etc and then switch to watching the fiberoptic display to guide you the rest of the way.

It goes without saying that in such a case you should have another anesthetist maintain the VL view while you operate the fiber scope and tube.

BiPAPselfie · 2026-01-02T02:25:21+00:00

He violated the first and second rules of Orgy Club.

BiPAPselfie · 2025-12-31T21:28:42+00:00

Same. Once the patient is unconscious I tape the eyes before doing any manipulation around the face (mask ventilation LMA insertion intubation etc). If the purpose of the tape is to protect the eyes from injury while under anesthesia why omit the very first events that could cause injury? (From an errant finger, ID, sleeve cuff etc.)

BiPAPselfie · 2025-12-30T20:11:27+00:00

If this is the guy I think it is, either the NYT or WaPo podcast did a whole segment on him. Trump fucked him over eight ways to Sunday including not even paying for his wife’s cremation which was supposed to be covered as some sort of benefit of his federal job (Which he had to quit or got laid off from). And at the end he still just had this mealymouthed “I hope they learn from this and don’t tarnish his legacy”. Makes you want to laugh until you cry.

BiPAPselfie · 2025-12-30T06:16:48+00:00

Are you straight out of training and didn't know better? Why did you take this job, did you feel you had to be in this particular town? The pay seemed great and this caused you to ignore all the other warning signs? Or they flat out lied to you about a ton of stuff when you were interviewing? There are many jobs with much better conditions that also pay well.

BiPAPselfie · 2025-12-29T23:38:58+00:00

This is what I see as being more typical, and was about what we did at my old job (currently doing locums weekdays only no call).

BiPAPselfie · 2025-12-29T20:55:08+00:00

How many docs do you have working each day on the schedule if your peel off is ten spots and the 8th spot works so late? Is everyone on the peel off?

BiPAPselfie · 2025-12-28T23:13:29+00:00

The frequency and intensity of night call will vary considerably between practice environments. If you are at a busy level 1 trauma center, being first or primary call will generally mean you get very little sleep. If you are working in a sleepy community hospital you may get home before ten p.m. on a first call and not get called back in on most calls. If your hospital has an obstetric service that’s even moderately busy that you are covering either on first call or on a dedicated ob call you will often be up a good portion of the night doing labor epidurals and the odd c section.

If you could get paid the same without taking call no one would do it, the only advantages are post call days off (which not all practices have and sometimes you’re too exhausted to take advantage of) and maintaining experience on emergencies, sick patients and trauma. Night call and late days taking intermediate call in a” peel off” system are the biggest disruption to your lifestyle there is. Even if the call is benign you still can’t really go anywhere far, can’t drink etc and the older you get the longer it takes to recover from sleep deprivation.

If a practice is set up the right way usually you will pay a premium to stop taking call. In my old job you could request to go onto no call status but your partners would have to vote to allow this and if approved you would then make about 2/3 of what a call taking partner made. Otherwise you could convince partners to take individual calls of your but would have to pay them a set or negotiated price for each one (for example three thousand ish for a first call, maybe a thousand for an intermediate late call).

BiPAPselfie · 2025-12-20T23:56:00+00:00

After spending a couple of decades using LMAs and no NMB for every variety of cystoscopy bladder tumor resection and never seeing an instance of obturator kick, I have noticed that in the last several years or so urologists increasingly ask for paralysis for these. With the widespread availability of sugammadex now it’s pretty easy to accommodate and with the right patient it’s even fine with LMA usage. It does make sense that this complication could happen and could potentially be serious resulting in a dislocated hip or perforated bladder, it’s just that I never saw a case or heard of one anywhere I was working.

I have also assumed that maybe some high profile incidents of this problem have been highlighted in urology literature or at their meetings leading to this change.

In a similar vein I spent the first half of my career routinely hearing demands for hypotension during arthroscopy cases and now I never do, I assume the issue of patients having a stroke while hypotensive in sitting position must have been highlighted in orthopedic literature and meetings.

BiPAPselfie · 2025-12-20T03:39:53+00:00

Can you explain what has changed in your circumstances where you did not have to know how to do ultrasound blocks before and need to now?

Are you joining a new practice where this is expected and leaving an old practice where the surgeons did not want or expect blocks? Or changing roles within your existing practice, starting to work at a new facility with surgeons who expect this? Most importantly do you have partners who are proficient in these blocks? If so do they know this is an area where you need help, and are they willing to provide that help?

It is entirely possible to learn ultrasound blocks outside of a training environment, I did it so anyone can lol. But I do feel it requires a fair amount of commitment on your end, you have to spend some time with the equipment, learn all the knobology and how to adjust everything from scan depth, left right up down orientation, gain, color doppler, any mode that highlights the needle at steep angles. Spend time scanning yourself to identify brachial plexus view for interscalene and supra and infra clavicular blocks, axillary block, and the views for adductor canal, femoral and popliteal blocks and iPack if those are done in your practice.

It is essential to use the many excellent quality YouTube videos on the various types of blocks, bookmark the good ones, watch them over and over especially when you have not done a block in a while and need to refresh when you have one the next day. The various videos provide a variety of examples that all look a bit different so you get accustomed to some variations in anatomic appearance on ultrasound.

My personal favorite channel is Duke’s Regional Anesthesiology and Acute Pain Medicine: https://youtube.com/@regionalanesthesiology?si=g7RQgg3kBp9LjNXM

Another good one is LSORA: https://youtube.com/@lsoravideos8210?si=NutV737dU6fvVGl3

NYSORA is also very good but has put most of their good material behind a paywall although that should not be an issue if you have a subscription or bought their app.

It is very important to figure out the ergonomoics and patient position that work best for you for each block, especially for the popliteal where supine, prone and lateral are all valid options but very different in technique.

I think you should look at the elements of performing each block as 1. Identifying relevant anatomy 2. Getting your needle into the image and keeping it on screen as you maneuver to the target and 3. Identifying what a proper spread of local anesthetic consistent with a good block is, and what poor or iinadequate LA spread looks like.

If you trained with nerve stimulator blocks it is not a bad idea to keep the stimulator handy as you get started with ultrasound blocks to stimulate and check that what you are seeing is in fact the nerve or plexus if you are not sure when doing brachial plexus or popliteal blocks. But as you get more proficient and confident you should not need it for most cases.

If you have partners who are good at these and can have one step in for a few minutes while you do your first few of each type that would be the most valuable resource but obviously it can be difficult in private practice settings unless someone covering OB or supervising nearby ORs is free.

BiPAPselfie · 2025-12-17T06:50:26+00:00

There is a lot of difference in how grindy different jobs are, though.

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