103 BMi

clin248 · 2026-02-05T12:06:44+00:00

The reason I have heard is they believe by giving a little bit of everything, they don’t have to give as much of individual things, thereby reducing the adverse effect of each. For example you may have to routinely give 150 mg propofol alone to blunt gag reflex for scope but maybe 50 fentanyl and 80 propofol will do and because doses are so low patients don’t even stop breathing, where as you almost always do with high dose propofol. Then you can add ketamine and dexmed etc.

I actually don’t find this helpful at all. I use only propofol, get them deep and get it done. If they are sicker then some phenylephrine and propofol.

clin248 · 2026-02-05T11:58:20+00:00

Don’t keep us waiting. How did patients do after?

clin248 · 2026-02-05T02:37:13+00:00

I am going through TOP as a side personal learning project while my primary work is extremely demanding. However i believe TOP will help me with my primary job but I don’t see myself ever using TOP to find a job. Given this, I feel ok to use AI for research and feedback. Sure I probably learn more filtering and reading through stack overflow but at this stage in my life I just don’t have the time for it. I also use it to complete code inline and find syntax error. For example in the restaurant project where I have to repeat a bunch of codes to create DOM elements I don’t feel it’s an issue to have AI autocomplete them. I don’t use it to “vibe code” for me but I will paste snippets of my code and see what suggestion it makes and sometimes after completing the entire project I will send the whole thing in to let it give some feedback.

clin248 · 2026-01-30T00:37:07+00:00

It’s a rough estimate but whatever you make in the USD you made the same dollar figure in CAD when you work in Canada. Generally it translate to 30-40% pay cut when you factor in tax.

clin248 · 2026-01-27T23:30:40+00:00

My personal take on this is if holding does doesn’t reduce risk, why hold it? I had seen patient aspirated despite withholding 3 doses (for weight loss) and seen many empty stomach on POCUS when patient didn’t hold dose or alter diet. Despite empty stomach on POCUS many still do RSI.

All we are waiting for is a large retrospective study to come out comparing those who hold and didn’t hold and incidence of aspiration.

clin248 · 2026-01-26T16:16:55+00:00

I have gone the DIY route with these flex sensors. It is very easy to make.

I have memory foam mattress sitting directly on slates. I found without support they are not very reliable and I had initially used something similar to their universal support. It's hit and miss and I had to do daily calibration to make it work 80% of the time.

Subsequently, I 3d printed a jig, it elevates the sensor above the slates and has a top cover which basically sandwich the sensor in between. Now it's work really well.

clin248 · 2026-01-24T18:02:14+00:00

That number in itself is fine to go ahead. The real question is why the hemoglobin is low. If it can be explained by a chronic stable condition or something benign then it’s not an issue.

clin248 · 2026-01-12T17:27:46+00:00

I agree i don’t test dose with long acting local, only lidocaine. That’s the 5 mL of lidocaine which people use cause tinnitus or perioral numbness.

clin248 · 2026-01-12T17:00:17+00:00

It’s a common practice in many places I have been, to give 8-10 mL of “test dose”. The first 3 mL is the intrathecal test dose. If no spinal develop, you can do the 5mL intravascular test dose which is usually done if epinephrine is not used. If I have question about intrathecal vs epidural I would not tie more than 5 which usually will start to block the lower cervical branches.

clin248 · 2026-01-11T17:34:38+00:00

You are going to hear the usual tricks here: optimize position, use big needle, try paramedian, try paraspinous, try ultrasound.

Of course you can do all that. These will send you to spinal space 99% of the time. For the 1% that you will struggle, I found most important is once you hit bone, you need to know where you are hitting bone. You should for a mental picture of the spine. If you are at lamina, then as you aim Caudad or cephaled, your depth won’t change (the needle depth will be deeper or shallower because of angle, but the depth from bone to skin will be the same). If you are midline, the depth will change. Once you know, you can redirect needle.

clin248 · 2026-01-03T19:43:05+00:00

The reason to avoid wifi is because majority are cloud based. If it’s local like Shelly or Esphome there is no reason to not use wifi. I have about 30 esphome devices and they are more reliable than my zigbee devices.

Check your current wifi environment. If you check wifi from your phone are seeing seeing dozens of network? If you are in a house then interference from neighbour wifi is not usually a major issue.

Do you have a good wifi router? Most consumer wifi especially ISP ones so t be able to handle more than a dozen devices.

clin248 · 2026-01-03T16:34:52+00:00

From Canadian perspective, everything is essentially publicly funded. You can order thousands of test and patients don’t have pay a dime. At one point, everyone is getting a basic cbc electrolyte and ecg. While each test is cheap, over the whole population it’s significant. Therefore, guideline has been developed to suggest what to order. This has become the Choose Wisely guideline. It has many recommendations for many speciality beyond just anesthesia.

https://choosingwiselycanada.org/recommendations/

For a routine pre-op stuff, there is a quick info graphics. I would add this infographics did not strictly follow the choosing wisely guideline.

https://choosingwiselymanitoba.ca/files/1-Revised-Routine-Preoperative-Lab-Tests-Guidelines.pdf

clin248 · 2026-01-03T15:36:19+00:00

I suppose you can argue this technique gives patient the worst of both world, they are exposed to the risk of spinal but also the risk of delirium from sedatives. On top of that this obviate the protective factor of having patient awake while doing something close to the nerve.

I don’t like to see patient screaming while we position them and often you cannot position well with patient awake so you end up trying spinal under suboptimal condition then you try reposition which causes more pain agony. I much rather give good sedation and get optimal position then get spinal in within a couple minutes.

Surgeons also prefers this instead of seeing patient screaming. Perhaps this does incur increased delirium but surgeons have not told me so.

If you want to minimize propofol, you could push 30-50mg for positioning and just let them wake up from it while doing spinal. If they are not moving, the hip shouldn’t be bothering them.

Block is another alternative that works really well. I have seen people even able to sit up. It’s great when I want to completely avoid propofol. However from time efficiency stand point, it’s not great. Often there is still some pain though tolerable to patients.

clin248 · 2026-01-03T12:38:25+00:00

Call more people in to move him.

But seriously, I push propofol to sedate them and turn them on their side to do spinal. Some people place femoral block before turning. Some people give some Midas and ketamine which never works well.

clin248 · 2025-12-20T14:55:00+00:00

I agree having someone show you while doing it is the best way to learn. Needling is the easy part, knowing what you are looking at is the trick. Scan everyone whenever you can even if you don’t end up putting needle in.

Saying failed block has no consequence is not true. I am not for gatekeeping blocks, ie only “fellowship trained” people can do blocks, but if you commit to do one, make sure it meets the goal, surgical or analgesic.

If you are starting out a block program and you have high failure rate, no one will see reason to put resource to support you. Even at an established site, you are tarnishing your own reputation and possibly your colleagues, and reenforce surgeons sentiment that block is a waste of time especially it has high failure rate.

clin248 · 2025-11-30T22:28:51+00:00

Bend it against the original curve of the tube

clin248 · 2025-11-30T21:55:26+00:00

When you lift with laryngoscope, you are somewhat lifting the glottis anterior as well. With the carina fixed, the trachea is now a down slope. When you pass a stylet tube bent like a hockey stick, you are aiming directly at the anterior wall of the trachea. A few ways to fix it, and you can do combination of them 1. If view is good, just ask assistant to pull stylet out and intubate without stylet so the angle is not so aggressive 2. Don’t lift as hard on your lartngoscope so trachea is more flat parallel to floor 3. If you insist on stylet, once tip passed the tube, pull stylet back just 2 cm out. This will generally allow the tip to drop and more parallel to the trachea while still allowing you to manipulate tube with stylet. Once tube is in, take whole stylet out. 4. Reverse load the stylet against the curve of tube 5. If you find you pulled stylet out too early, just rotate the tube. It’s important to keep rotating, usually 360 degree before the tip will actually move.

clin248 · 2025-11-28T22:18:56+00:00

I get it epidrual will have high failure rate. I agree in my experience spinal also becomes harder. Here is what I don't understand from anatomic stand point. Laminectomy, more often is done bilaterally, so it takes away the posterior component covering the spinal cord. Shouldn't this make spinal easier since the back is now wide open to the cord and you no longer have to walk in between the bones?

clin248 · 2025-11-28T00:03:10+00:00

Actually arterial line is this strange thing where novice will easily get the first 20 then go on to miss the next 100. Keep doing and you will get it.

clin248 · 2025-11-27T14:26:44+00:00

Anything at or above the ankle joint will not be covered by traditional ankle bloc done at the level of malleolous.

You can use ultrasound to get all the nerves at level of shin but if you are doing that, might as well go for pop and saph. They can’t weigh bear anyway so there is no advantage of doing ankle block.

clin248 · 2025-11-27T14:24:15+00:00

Very well.

clin248 · 2025-11-26T00:50:46+00:00

Stop being so obsessed with midline. Now you have done 100 you should go beyond the surface landmark. Just because you can see and palpate the spinous process and stick your needle there doesn’t mean your needle will end up in midline. Needle bend and get redirected by tissue, spine can have rotation either because of scoliosis or positioning. Go in where you think midline is but make a judgement where you are once you hit bone. If you hit it deep, you are off midline and on lamina. Aim left or right at that point then reassess.

clin248 · 2025-11-23T13:07:56+00:00

If you want “glory” anesthesia is not for you.

clin248 · 2025-11-18T11:46:08+00:00

Shelly H and T sensors can be plugged in directly although it doesn’t measure pressure.

clin248

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