(Please note this is posted in the passing gas forum for a reason).
So, I'm at yet another new clinical site. Overall, it's pretty good so far. The MDAs are very hands off for the most part (I'm used as staff here). Some of them will discuss the anesthetic plan with me, but for the most part they say "it's your anesthetic do what you want." Of course, I will be held accountable for the results of the plan, but there is pretty much no hand holding.
The only thing that is bothering me has been the inductions. I was told the first day that they only give sux here if there is an indication (full stomach precautions, motor testing, etc). It wasn't clear to me if this was due to the sux shortage or just this group of practitioners' preference.
So, we have been using roc for induction (there is no vec). The induction (to jump in at the point that we are ready to go to sleep) goes as follows:
MDA pushed the prop, I give a squeeze or two on the bag and report to him that I can ventilate. He then (without variation in terms of the dose) pushes 50mg of roc. Out of habit, I always look at my watch when the roc goes it. Then what happens is the MDA stares at me and then says " well, take a look." This is happening between 40-90secs (one time I remember thinking that even if we were using sux that this guy was jumping the gun). These are average to large sized patients.
If I were running the show, I would ventilate the patient for three minutes before DL (this text book number has, for me, been borne out when I have put the nerve stim on patients in the past). I would redose the prop at around 2 mins (probably 50mg for an average patient).
In the past, when I have realized that the MDA was either not going to let me wait 3min or was going to let me wait 3 mins but was not going to give more prop, I have turned on the sevo at 8% and given a few big breaths before DL. BUT, this place does not have sevo (just iso and des).
So, here's my choice:
-go early (30seconds after the roc is in) and intubate with prop alone. Not a bad option at all in many patients. However some of these patients don't have super easy airways and I might actually need the paralytic (and for these patients I want my first shot to be my best shot).
-go late, what for the roc to kick in and hope enough prop is left so that the patient is not to light. I do give versed, but I don't want to rely on that for amnesia in the setting of an elective intubation. Plus I don't want my first BP after intubation to be through the roof.
Unfortunately, what I think I'm doing most of the time is splitting the difference so I'm performing a DL on a light patient without the benefit of paralysis As a result I've run into closed cords and struggled with a few easy airways.
Not much I can do as a student, but I still felt like venting!