u/bigeman101

CA3 here,

I’m about 150 epidurals in and I always struggle with those difficult patients who are screaming at every little part of the procedure. I do my best to numb up the skin and a little bit on either side of the ligament but they still complain and start arching their back on me. Of course this makes placement even worse and then it becomes a truly terrible experience for everyone. Even when I feel like I’m midline and in ligament they are screaming.

Any tips for these patients?

CA3 here,

I’m wrapping up my last time on OB and am kind of nervous about the thought of doing this on my own next year. I’m comfortable with the procedures but it’s dealing with the nurses and OB’s that I dread.

What are your tips for OB that you think a new grad should know?

I recently had a patient that came to me with a femoral art line that I assume was clotting off because it would flush fine but would never draw back and eventually just stopped working altogether. I placed another in a radial and the same thing happened within 30 minutes.

We use the standard pressure bags and transducers that flush 3 mL/hr.

Any tips on preventing clotted off a lines? Anyone have experience with using low dose heparin in the flush line?

CA2 here,

I always want to try to extubate my patients if I think they have a real shot. I don’t want anyone to stay tubed in the ICU unless they really need to. Today I had an endovascular AAA repair that lost about a liter of blood and was resuscitated with 3 RBCs, 750 ml of 5% albumin and 1L crystalloid. My attending didn’t want to try to extubate simply due to “fluid shifts”. The patient seemed to be appropriately resuscitated and it didn’t seem like an overly aggressive net positive fluid balance.

When people are worried about fluid shifts I usually take that to mean concerns for pulmonary edema, airway edema, TACO, etc.

What’s your approach to this?

CA2 here,

Our institution (anesthesiologists and surgeons) always want the quickest wake-up possible for neuro cases. I understand the surgeon wants the quickest possible exam but does that really mean they need the patient fully awake and following commands before the tube is out??

What’s your practice for neuro wake ups?

CA2 on peds here,

What are your tips for US IVs on these tiny babies? I can find the vessels just fine but their thick skin and subq really seem to impede my trajectory/ability to get to the vein. The flimsy 22g IVs don’t help either.

CA2 on peds here,

Recently I’ve been struggling to DL these 12 month olds and younger. I use a miller 1 and get an easy grade 3 view but then struggle to pin the epiglottis. I advance a little more or try to come to the side but the epiglottis just doesn’t want to get out of the way for some reason.

What are your tips on DLing infants?