Man I hope this is wrong, RIP Matthew Perry

The Coffee Shop
41

I am literally lying in a ward bed post surgery with a fentanyl PCA and musing about life in general!)

Wow, hope everything went ok. The internet is a great recovery device for sure.

2020 was a blur, honestly, and most of the stories I’d otherwise have to tell I drank away. I was going through divorce at the time, my life was upside down and when the world went crazy it somehow made my crazy feel normal, if that makes any sense. My wife today is actually a former PA program classmate who was going through the same thing at the same time, and also working as a Hospitalist in a COVID hospital (they were all pretty much COVID hospitals in the summer of 2020 I suppose) so in a world gone mad, we found sanity and comfort. That’s the story I took from the pandemic…Love in the Time of COVID-19.

Regarding propofol, I have to confess, I have a not-so-friendly relationship with anesthesia in my hospital and propofol is the main reason why. I’ve been managing airways since 1999 when I worked 911 as a medic, so twenty plus years later I’m as good as anyone in managing easy and difficult airways, up to the point of emergency tracheostomy. I don’t touch propofol for induction because most of our patients are in failure by the time of intubation, I know their medical history, their potassium levels, I check their anatomy on x-ray before when I have time so I know the depth of the carina, and I take care not to bottom out their BP on induction. At least half of the time when anesthesia is called to intubate without my knowledge, they bolus propofol, bottom out their BP, patient ends up on pressors, and I end up doing preventable central lines for administration of levophed. My go-to is etomidate and roc in 9 out of 10 cases; they use propofol in 9 of 10 cases and 50% end up on pressors. It drives me absolutely insane. And then there’s the CRNA issue which I’ll leave at that.

Anyway, rant over. I hope your recovery is uneventful and your PCA/internet companions make it less tedious.

42

Anaesthesiologist here…

Hmmm. An anaestesiologist named Amnesia. I don’t know about that. :slight_smile:

The job is such that you are not supposed to remember all of that!!
America: Anesthesiologist
Downunder: Anaesthetist
Patients: So are you actually a doctor
Me; Yes well, 6 years of medical school, minimum 2 years of junior doctor work, 5 year training program plus post training fellowship, plus 2 exams that require 1000-1200 hours of study each, whilst working 50-60 hours a well.
Yes, I think I qualify!!

What’s your thought regarding Nurse Anesthesiologists? Can I (generally) assume going into back surgery (fusion) I get someone like you? Not like I have a choice like the surgeon…

43

I am literally lying in a ward bed post surgery with a fentanyl PCA and musing about life in general!)

Wow, hope everything went ok. The internet is a great recovery device for sure.

2020 was a blur, honestly, and most of the stories I’d otherwise have to tell I drank away. I was going through divorce at the time, my life was upside down and when the world went crazy it somehow made my crazy feel normal, if that makes any sense. My wife today is actually a former PA program classmate who was going through the same thing at the same time, and also working as a Hospitalist in a COVID hospital (they were all pretty much COVID hospitals in the summer of 2020 I suppose) so in a world gone mad, we found sanity and comfort. That’s the story I took from the pandemic…Love in the Time of COVID-19.

Regarding propofol, I have to confess, I have a not-so-friendly relationship with anesthesia in my hospital and propofol is the main reason why. I’ve been managing airways since 1999 when I worked 911 as a medic, so twenty plus years later I’m as good as anyone in managing easy and difficult airways, up to the point of emergency tracheostomy. I don’t touch propofol for induction because most of our patients are in failure by the time of intubation, I know their medical history, their potassium levels, I check their anatomy on x-ray before when I have time so I know the depth of the carina, and I take care not to bottom out their BP on induction. At least half of the time when anesthesia is called to intubate without my knowledge, they bolus propofol, bottom out their BP, patient ends up on pressors, and I end up doing preventable central lines for administration of levophed. My go-to is etomidate and roc in 9 out of 10 cases; they use propofol in 9 of 10 cases and 50% end up on pressors. It drives me absolutely insane. And then there’s the CRNA issue which I’ll leave at that.

Anyway, rant over. I hope your recovery is uneventful and your PCA/internet companions make it less tedious.

Thank you for sharing!!
We no longer have access to etomidate but it used to be my go to agent as well.
It is like anything, you need to know how to use it properly. I can’t speak for your experiences, but I bet they are not titrating their propofol and using co-induction agents appropriately.
My last experience with etomidate was a bit like your experiences with propofol. Called to ED to assess a trisomy 21 patient in severe sepsis (I was ICU rotation as a senior reg in anaesthesia at the time). Needs intubation in ED. I drew up my propofol and sux for a careful RSI with modifications, I was designated airway doc. ED specialist wonders along, sees the haemodynamic instability and in typical arrogant ED fashion said he will use etomidate not propofol as it is better. Patient weighed like 50kg. So for us we would use 0.2-0.3 mg/kg as an induction dose, so about 5-7.5mL of the standard 2mg/ml solution. He rocks up, just gives the entire ampoule and wonders why we run into severe MAP issues post induction…
The classic old saying/song…“it’s not what you do but the way that you do it…”
https://youtu.be/0_kjctTbMHA?si=AToXruCIHtXrHGPM

44

Anaesthesiologist here…

Hmmm. An anaestesiologist named Amnesia. I don’t know about that. :slight_smile:

The job is such that you are not supposed to remember all of that!!
America: Anesthesiologist
Downunder: Anaesthetist
Patients: So are you actually a doctor
Me; Yes well, 6 years of medical school, minimum 2 years of junior doctor work, 5 year training program plus post training fellowship, plus 2 exams that require 1000-1200 hours of study each, whilst working 50-60 hours a well.
Yes, I think I qualify!!

What’s your thought regarding Nurse Anesthesiologists? Can I (generally) assume going into back surgery (fusion) I get someone like you? Not like I have a choice like the surgeon…

I had to have a tumor out of my spine a few years ago. It was late on a Friday before a 3 day weekend. Once they took me back, I first had on older anesthesiologist come and talk to me about everything, sat around for a while and a middle aged anesthesiologist came and talked to me, but the IVs in, etc. sat around for a while longer until they were ready to take me in and a 3rd anesthesiologist, young pregnant woman who looked like she was fresh out of med school, came and said she would be with me in the OR.

Certainly seemed as I was moving down the pecking order the later it got on Friday evening.

45

so about 5-7.5mL

I can only dream of such a world. I swear our anesthesia group measures by the liter.

Regarding sepsis, I recently did an online difficult airway course for the CME, and as a reference point for training our Kaiser Permanente residents in airway management, and they referenced worse outcomes with etomidate in the setting of sepsis. Just a few weeks ago I came across a new large retrospective study that showed no increase risk for bad outcomes when using etomidate over other induction agents, and sepsis was pretty much the last relative contraindications for etomidate induction, so there are very few if any situations now when I won’t use it for RSI. To my knowledge it remains the least hemodynamic-affective drug in our arsenal and always accomplishes the task.

46

Completely agree re etomidate. I cannot remember why we lost it here in Australia as opposed to NZ where I train. Will need to google search!
And as for the anesthesiology measuring in liters, I would love to tongue in cheek say that it reflects the difference of a 5 year training program with a Part One exam which is 50% pharmacology so around 5-600 hours of dedicated pharmacology study.

47

What’s your thought regarding Nurse Anesthesiologists? Can I (generally) assume going into back surgery (fusion) I get someone like you? Not like I have a choice like the surgeon…

I cannot in fairness answer that question properly. We do not have nurse anaesthetists in Australia or New Zealand.

The main rub for me is that a CRNA misses the holistic training in medicine that you get from an anesthesiologist.

But they appear to have rigorous training and are common place in the USA. I don’t know what sort of case mix they are allowed to do so cannot comment on your fusion (I am sitting here 18 hours post lumbar discectomy). It is best you ask your treating team how they work.

I have no firm views for and against when. Just here in Australia our representative bodies firmly oppose them as basically the governments see them as a cheaper source of labour, without the same training etc. There is a significant COI as our training bodies want the exclusivity they get with a single provider model to take in all our training, examination and then yearly membership fees. We don’t really “need” from a workforce shortage perspective, whereas in ‘merica with your “amazing” healthcare system (yes absolutely tongue in cheek because let’s face it, it’s a dogs breakfast when you look at costs, some outcomes, equality of healthcare access etc etc) you need them.

48

Per NYT:

Dealer Who Sold Ketamine to Matthew Perry Is Sentenced to 15 Years

Prosecutors say Jasveen Sangha’s customers knew her as the Ketamine Queen. She sold the ketamine that killed the “Friends” star in 2023.