Anesthesia for dumb cases

[DocMcCoy]

Speaking of anesthesia in dumb cases, I think I have one that tops all of yours. In residency there was a young girl with some psych condition that apparently got better after she underwent GA. The psychiatrists “prescribed” her therapeutic general anesthesia. We would bring her down to the OR a few times a week, put an LMA in, sit in the OR with her for an hour, then wake her up and leave the OR.

How’s that for a waste of resources?

NO. EFFING. WAY.

It pains me because most of these issues are self inflicted. Some colleagues will do anything when they can get paid for it. It sets a nasty president, and it is really hard to back step after the ball gets rolling.

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[nimbus]

Speaking of anesthesia in dumb cases, I think I have one that tops all of yours. In residency there was a young girl with some psych condition that apparently got better after she underwent GA. The psychiatrists “prescribed” her therapeutic general anesthesia. We would bring her down to the OR a few times a week, put an LMA in, sit in the OR with her for an hour, then wake her up and leave the OR.

How’s that for a waste of resources?

Nowadays it’s called a ketamine clinic.

And there was that one guy who had a remission of schizophrenia after a BMT.

Remission of Psychosis in Treatment-Resistant Schizophrenia following Bone Marrow Transplantation: A Case Report

The authors present the case of a 24-year-old male with treatment-resistant schizophrenia, with predominant severe delusion and hallucination, who received bone marrow transplantation (BMT) for acute myeloid leukemia. After BMT, he showed a remarkable ...

www.ncbi.nlm.nih.gov

 

[Urzuz]

And you or your attending didn’t refuse?

As a CA-whatever I was, no

 

[The Duck Knows]

Anyone have neurosurgeons requesting general anesthesia for epidural steroid injections in the hybrid room? Some patients were shocked to find out it’s the exact same procedure they had received in the pain clinic

 

[vector2]

Yep, TTEs. "Patient does not tolerate pressure from probe." "Patient anxious about results and will not hold still with prior attempts."

hahahhaha, omfg

 

[coffeebythelake]

Anyone have neurosurgeons requesting general anesthesia for epidural steroid injections in the hybrid room? Some patients were shocked to find out it’s the exact same procedure they had received in the pain clinic

Neurosurgeons request general anesthesia for carpal tunnel surgery.

 

[deleted875186]

Anyone have neurosurgeons requesting general anesthesia for epidural steroid injections in the hybrid room? Some patients were shocked to find out it’s the exact same procedure they had received in the pain clinic

It’s not, it’s probably a poorly placed trans foraminal epidural with a blobogram being called a TFESI.

 

[neutro]

Typically, it involves a patient with dysphagia needing a NG/Keofeed for enteral access i.e. feeds, meds, etc. The story is often: bedside nurse tried, other bedside nurse tried, charge nurse tried, primary team requested anesthesia to place NG tube. When we somehow get suckered into this, the first move is to try it yourself without anesthesia but the patient has often been told that they will be put to sleep for this after so many tries so some patients just aren't interested in trying too hard.

The best is when the bedside nurse also throws in some extra work like: "Patient is a difficult IV stick, can you get labs and an IV?" We have bred a new species of invertebrates at this hospital so they have come to expect that to be done too.

This happened to me last month. SBO/ full stomach and asked me to place an NG tube in ICU because the nurse tried and couldn't get it multiple times. Then they asked the GI doc who couldn't get it.

I went to evaluate the patient and the nurse tells me "here is anesthesia, he will put you to sleep for the NG tube".

I declined for obvious reasons. What pissed me off is that this was a new/ travelers nurse and not known to me. How can she make that determination. She said that as soon as I entered.

4 hours later, surgeon called me to proceed to OR for diagnostic lap. RSI, OG tube and suctioned out 2.5 L of crap.

Imagine me trying to "sedate" her in ICU for an NG tube.

We are being pushed to deal with non-sense and it's getting worse everyday. The quality of nurses is going downhill.

Customer service does not exist anymore. Skilled workers are like a unicorn in an already short staffed environment.

 

[neutro]

Speaking of anesthesia in dumb cases, I think I have one that tops all of yours. In residency there was a young girl with some psych condition that apparently got better after she underwent GA. The psychiatrists “prescribed” her therapeutic general anesthesia. We would bring her down to the OR a few times a week, put an LMA in, sit in the OR with her for an hour, then wake her up and leave the OR.

How’s that for a waste of resources?

I'm curious, what is the rationale behind this? I have never heard of this.

I know there is some evidence behind ketamine infusions working for PTSD but its hard to separate that from placebo effect. What exactly is general anesthesia with inhaled agents are treating here?

 

[sanityonleave]

Yep, TTEs. "Patient does not tolerate pressure from probe." "Patient anxious about results and will not hold still with prior attempts."

Plenty of case volume for residents. Problem is the surgeons are slow so elective cases routinely go till 7PM during the week and often scheduled cases will finish at 8/9PM. Our Saturdays and Sundays are filled with elective/urgent cases from 8AM to 4PM like an abbreviated OR day with four rooms booked for these hours. (This is separate from the elective MRI cases running on Saturdays.) Subsequently, the call team is basically trying to navigate emergency cases between these elective/urgent cases. This leads to upset surgeons when they are told their cases are delayed for an emergency; they don't understand as they see their weekend booked cases as reserved block time like any other OR day. Quite exhausting and questionable use of call team IMO.

Jesus, your job sucks lol.

I have nothing else to add.

Yeah, I have to agree with teacher2md on this one.

I work in academia and slow surgeons / trainees are part of the game, but none of the rest of these cases would be tolerated at my shop. We do have busy Saturdays but we've staffed up accordingly (hospital capacity issues mean the hospital helps pay for extra teams on the weekend if it'll free up some bed space). NG tubes? TTEs?! Absolutely not. We only do MRIs when we have staff free and only inpatients except pedi. The floor could call to book a weekend MRI if they wanted to, but I doubt I'd ever get to it... sometimes if it's a barrier to discharge the medicine service will make a stink about it to the capacity overlords and we'll have to find resources, but again, that's rare.

IR and GI are our worst offenders (some of the endo nurses do everything short of exhuming dead relatives and interviewing them to find history that allows them to refuse to sedate a patient), but even then I don't find the requests super unreasonable.

Just a counterpoint to say that not all academic jobs suck like this.

 

[kidthor]

transthoracic echocardiograms

I had cardiology regularly arrange for peds TTEs under “sedation” (which was always actually general anesthesia). Of course this would always be echo techs doing the TTE and the cardiologists would never be easy to find for questions.

In one case I had them order a TTE for a 6mo to “rule out congenital cardiac defects”. Then when I called the cardiologists to get the story they yelled at me because I was “interrupting morning conference”. Needless to say I don’t work there anymore…

 

[2Fast2Des]

How the hell does your leadership not have the gall to tell these outrageous requests no way? NGTs, TTEs, ESIs... That can't be real...

 

[nimbus]

primary team requested anesthesia to place NG tube.

Did the primary team try?


Thankfully I have never been called for an NG tube. That would be super annoying. We are not the NG tube service.

 

[GassYous]

Speaking of anesthesia in dumb cases, I think I have one that tops all of yours. In residency there was a young girl with some psych condition that apparently got better after she underwent GA. The psychiatrists “prescribed” her therapeutic general anesthesia. We would bring her down to the OR a few times a week, put an LMA in, sit in the OR with her for an hour, then wake her up and leave the OR.

How’s that for a waste of resources?

A lot of psych patients get better under general anesthesia.

 

[ProPropofol]

Did the primary team try?


Thankfully I have never been called for an NG tube. That would be super annoying. We are not the NG tube service.

The orthopedic surgery team did not try to place the NG tube nor did their team of internal medicine monkeys. They even used the lack of an NG tube as an excuse to make the patient ICU since “no enteral access to give meds” and “we don’t manage NG tubes”. I told them that lack of an NG tube or need to place one does not qualify as ICU level of care which rubbed people the wrong way and prompted an apology from the anesthesia department for poor communication on our part. Again, we are breeding a new type of invertebrates at this hospital. I hope other academic centers are not like this.

 

[pocafx]

I did some toe nail cases the other day. Seemed useless as he did toe blocks for everything and patient moved like crazy despite propofol with the blocks.

 

[Southpaw]

I had cardiology regularly arrange for peds TTEs under “sedation” (which was always actually general anesthesia). Of course this would always be echo techs doing the TTE and the cardiologists would never be easy to find for questions.

In one case I had them order a TTE for a 6mo to “rule out congenital cardiac defects”. Then when I called the cardiologists to get the story they yelled at me because I was “interrupting morning conference”. Needless to say I don’t work there anymore…

‘Cool. Sorry to interrupt your conference. The case is cancelled. Call me when you have time to talk and be professional. Thanks have a good day.’

 

[gcc322]

Got an OB who requests general for LEEP’s…

 

[nimbus]

The orthopedic surgery team did not try to place the NG tube nor did their team of internal medicine monkeys. They even used the lack of an NG tube as an excuse to make the patient ICU since “no enteral access to give meds” and “we don’t manage NG tubes”. I told them that lack of an NG tube or need to place one does not qualify as ICU level of care which rubbed people the wrong way and prompted an apology from the anesthesia department for poor communication on our part. Again, we are breeding a new type of invertebrates at this hospital. I hope other academic centers are not like this.

You can join ortho and IM in the “not my job” chorus. If you become the de facto NG tube/IV service for the hospital, you would have no time to do actual anesthesia.

 

[Beeftenderloin]

This happened to me last month. SBO/ full stomach and asked me to place an NG tube in ICU because the nurse tried and couldn't get it multiple times. Then they asked the GI doc who couldn't get it.

I went to evaluate the patient and the nurse tells me "here is anesthesia, he will put you to sleep for the NG tube".

I declined for obvious reasons. What pissed me off is that this was a new/ travelers nurse and not known to me. How can she make that determination. She said that as soon as I entered.

4 hours later, surgeon called me to proceed to OR for diagnostic lap. RSI, OG tube and suctioned out 2.5 L of crap.

Imagine me trying to "sedate" her in ICU for an NG tube.

We are being pushed to deal with non-sense and it's getting worse everyday. The quality of nurses is going downhill.

Customer service does not exist anymore. Skilled workers are like a unicorn in an already short staffed environment.

How on earth do NG tubes somehow fall to anesthesia and not GI, gen surg, colorectal, IR, ENT, etc. literally all of those people are eminently more qualified to place an NG in an awake patient than I am. Most notably because I’ve literally never ever had to do that before. If they need one before going to sleep, it’s getting placed by the service whose job it is (ie. not me) and I’ll happily delay the case until that happens. I place them in relaxed, anesthetized patients as a courtesy because it’s very easy under those conditions, not because it’s my job.

 

[pgg]

We routinely do general anesthesia for adult MRI's 7 days a week (sometimes even in the middle of the night). We even have people pick up extra hours for more pay to do elective adult MRI's on Saturdays because of how backed up we are.

Other procedures we do general anesthesia for that come to mind: transthoracic echocardiograms, blood draws for pediatric patients, lumbar punctures in adults with "needle phobia", NG tube placement, and saphenous vein ablation. I can kind of understand the saphenous vein ablation but the others are silly IMO. Thankfully, the other ones only pop up a couple times a month but we are doing saphenous vein ablations routinely in the OR every week.

This is at a large academic center FYI.

I thought I knew who had the worst job on SDN but now I'm not so sure.

 

[neutro]

How on earth do NG tubes somehow fall to anesthesia and not GI, gen surg, colorectal, IR, ENT, etc. literally all of those people are eminently more qualified to place an NG in an awake patient than I am. Most notably because I’ve literally never ever had to do that before. If they need one before going to sleep, it’s getting placed by the service whose job it is (ie. not me) and I’ll happily delay the case until that happens. I place them in relaxed, anesthetized patients as a courtesy because it’s very easy under those conditions, not because it’s my job.

Well I blame the pandemic. This is all just a remnant. From intubations, to IVs, central lines to helping with prone positions to everything in between.

This isn’t just my hospital - it’s everywhere.

The rationale appears to be - well Anesthesia is an expensive contracted service so let’s use them as much as possible.

I’m all for service and patient care but there are limits to this stuff.

If **** happens in the hospital at 2 AM - really who are you going to call?

Trust me it’s not the pathologist.

 

[nimbus]

How on earth do NG tubes somehow fall to anesthesia and not GI, gen surg, colorectal, IR, ENT, etc. literally all of those people are eminently more qualified to place an NG in an awake patient than I am. Most notably because I’ve literally never ever had to do that before. If they need one before going to sleep, it’s getting placed by the service whose job it is (ie. not me) and I’ll happily delay the case until that happens. I place them in relaxed, anesthetized patients as a courtesy because it’s very easy under those conditions, not because it’s my job.

To be fair, I think IR has become the dumping ground at our hospital. They take all kinds of nonsense at all hours. They are too nice.

 

[Iso4ane]

The rationale appears to be - well Anesthesia is an expensive contracted service so let’s use them as much as possible.

That is very true, but we help the hospital make money by facilitating surgery. If it’s not facilitating surgery, then GTFO.

 

[neutro]

To be fair, I think IR has become the dumping ground at our hospital. They take all kinds of nonsense at all hours. They are too nice.

Nothing better than a dumpy IR prone case for which anesthesia is called for sedation lmao

 

[deleted875186]

This NG tube thing is insane. It’s 100% easier to place in an awake person when they can swallow. Honestly, I would decline these cases, not only is anesthesia an unnecessary risk, I think it’s more dangerous to start jamming an NGT while asleep.

 

[IlDestriero]

That’s 1/2 of pediatric anesthesia.

 

[kidthor]

I've placed exactly one NG tube in an awake patient, and it ended up in their trachea. So we're not the right team to put things into the esophagus.

 

[gunnershow]

How did you guys make it through intern year without placing dozens of awake NG tubes?

 

[Iso4ane]

How did you guys make it through intern year without placing dozens of awake NG tubes?

By letting the surgical intern do it.

 

[patriot6]

Y’all never have an SBO show up to holding without an NG, ie pulled it out and RN didn’t replace? I do a handful of those every year. Awake NG is ezpz.

 

[Gern Blansten]

Got an OB who requests general for LEEP’s…

You could suggest that they use the "flying" technique for their LEEPs...as in, "why don't you go take a flying LEEP?"

 

[Arch Guillotti]

Y’all never have an SBO show up to holding without an NG, ie pulled it out and RN didn’t replace? I do a handful of those every year. Awake NG is ezpz.

I have and it is a pain. I do it anyway.

 

[jwk]

Got an OB who requests general for LEEP’s…

We do those all the time. I don't even have a cervix, but I'd want GA for mine if I did.

 

[kidthor]

We do those all the time. I don't even have a cervix, but I'd want GA for mine if I did.

Yeah for us they request them under "MAC" which means I'm doing TIVA-GA natural airway with tylenol, toradol, fentanyl, etc. Seems like a reasonable thing to get anesthesia for (compared to say an MRI).

 

[GassYous]

Well I blame the pandemic. This is all just a remnant. From intubations, to IVs, central lines to helping with prone positions to everything in between.

This isn’t just my hospital - it’s everywhere.

The rationale appears to be - well Anesthesia is an expensive contracted service so let’s use them as much as possible.

I’m all for service and patient care but there are limits to this stuff.

If **** happens in the hospital at 2 AM - really who are you going to call?

Trust me it’s not the pathologist.

You better not be calling me at home for some non surgical bull**** at 2 am

 

[neutro]

You better not be calling me at home for some non surgical bull**** at 2 am

I would if you were a pathologist - just to mess with you.

 

[Arch Guillotti]

Awake NG is ezpz.

Disagree. There are times when it can be painful and a huge hassle. Always worth it though.

 

[2Fast2Des]

Disagree. There are times when it can be painful and a huge hassle. Always worth it though.

I once had a pt where I couldn't pass the tube in either nare, so I just put it in awake OG and worked with that. I think I tried it again after inducing and it was just no go, So brought the patient to PACU with the OG awake after the case. No regrets

 

[norski]

Awake NG/OG? Please, any day. The IMs and their trainees actually want to do them, but require anesthesia supervision (yes, even nurse anesthetists) for doing any of them. It's rewarding.

PVCs, CVCs, piccs and mids for patients that are going to remove them all by themselves due to crappy nursing coverage, vigilance and laziness? Hell no. We introduced the word "no" if a written promise of 1:1 coverage is not provided. Works for any real line, not for PVCs, which are my money makers. I'd rather make 25% less than placing another peripheral on the ward, ever again.

Now, actual anesthesia dumb work? Circumcisions for adults. Even doing proper circumcisions paid by the public is dumb. Vasectomies are pretty dumb, too. Even dumber is reattaching the vas. In a public health care system.

 

[Mofeen]

Neurosurgeons request general anesthesia for carpal tunnel surgery.

Have a NS that requests this. A few times, a foley was requested.........

 

[nimbus]

Have a NS that requests this. A few times, a foley was requested.........

We had an ortho hand surgeon in residency. His entire lineup which ran from 7am until 3-4pm would be 3 carpal tunnels. Somehow he managed to stretch a 10min case to 2.5-3hrs.

 

[GassYous]

Have a NS that requests this. A few times, a foley was requested.........

How much urine could you possibly make in 5 minutes?

 

[2Fast2Des]

We had an ortho hand surgeon in residency. His entire lineup which ran from 7am until 3-4pm would be 3 carpal tunnels. Somehow he managed to stretch a 10min case to 2.5-3hrs.

That's insanity... How is that even possible...

 

[nimbus]

That's insanity... How is that even possible...

I didn’t realize how crazy it was until after residency.

 

[Mofeen]

How much urine could you possibly make in 5 minutes?

3 hours on occasion. yup.

 

[pgg]

Once upon a time I worked at a place that scheduled wisdom teeth extractions and vasectomies in the main OR, just to game the OR utilization numbers.

 

[DonFL]

The fact that we're still reimbursed for cataract sedation is # 1 on the "dumb" list. GI follows as a close 2. Facilities all over the nation are clamoring to condense as their anesthesia costs go through the roof. Its only a matter of time before some of this crap just falls away

 

[GaseousClay]

cataracts are 99% unnecessary for anesthesia to be present. tons of waste especially of medicare dollars there.

 

[dannyboy1]

The fact that we're still reimbursed for cataract sedation is # 1 on the "dumb" list. GI follows as a close 2. Facilities all over the nation are clamoring to condense as their anesthesia costs go through the roof. Its only a matter of time before some of this crap just falls away

Disagree about GI. You do these cases with propofol, you most definitely need anesthesia