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Article
Helps Doc Breathe Easier
In my 30 years of anesthesia practice, I have given
succinylcholine twice into a childs tongue with a
25-gauge needle. Response was rapid. As with myringotomies
being very brief, starting an I.V. often would take
three to five times the normal surgical time. An I.V.
is not the only alternative to being unable to quickly
resolve total laryngospasm. (I have since heard and
believe that into the deltoid site works equally rapidly
and effectively without the possibly more alarming
“injury” to the tongue.)
I cannot recall where I heard it (or read it) that
postoperative mortalilty is five-fold to six-fold
greater in patients who have not had paralyzing agents
reversed. The comment was incredible in that, even
if off by a factor of 200 percent, was riveting. Some
three weeks after my awareness was raised, I gave
a 10 mg dose of atracurium to a healthy, vigorous
30-year-old woman who was breathing quite well (unreversed)
in the recovery area. Oxygen saturation was 100 percent.
She stated she was doing well. Some three hours after
adminstering the atracurium, I went by her bed in
the ambulatory discharge area as she was about to
have the I.V. removed and leave. I inquired how she
was doing. She surprised me by saying she was fine,
“...but it is a bit difficult to take a really
deep breath.” I was amazed at the implication,
but suspicious ONLY because of my recent information.
I gave (if I recall correctly) 2 mg of neostigimine
with glycopyrrolate. In about two minutes she said,
“now I can take a really deep breath.”
I wonder how many patients with some “minor”
degree of illness or reduced vigor, be it age, COPD,
infancy or sedation, cannot convey such “minor”
degrees of residual neuromuscular blockage as to show
a strong TOF, head lift, etc., and still be compromised
at an unexpectedly long time interval. The excellent
discussion and references by Juraj
Sprung, M.D., Ph.D., in the May 2005 NEWSLETTER
clearly “answers” my questioning, “how
many” may have that hidden, but now documented,
pitfall.
Thanks for some great correspondence.
Doug L. Cone, M.D.
Lubbock, Texas
References:
1. American Society of Anesthesiologists Relative
Value Guide, 2005.
Practicing
What You Teach
II cannot allow the letter “Ivory
Tower Needs to Open Its Doors,”
September 2005, from Stephanie Jo Dyer, M.D., go without
comment. I spent the first 10 years of my professional
career in academics and the last six in private practice.
When I acted as a program director, we knew that 80
percent to 90 percent of our residents would go into
private practice. We had even started a lecture series
for them on issues in private practice: contracts,
reimbursement, etc. In the lean years of 1995-96,
we guided our residents away from private practice
“predators” who took advantage of the
poor job situation (sample offer: $80K salary, no
chance for partnership, 1 in 3 call).
I also tried to get local private practitioners to
take CA-3 residents for elective rotations in “private
practice,” as suggested by Dr. Dyer. Not
one private practitioner would agree to do so.
The most common excuse was the resident would “slow
down the O.R.” I find it disingenuous to blame
the residents’ absence on the training programs,
as Dr. Dyer does in her letter.
Dr. Dyer says she wants to contribute; maybe she could
lead by “walking the walk” that her colleagues
refuse to do. Offer your time to mentor residents
in finding good jobs, show how you balance work and
family and invite them to observe your anesthesia
practice (getting them privileges to provide patient
care can be difficult). Besides the exposure to academics
on your terms, you may find it to be an excellent
recruiting tool — you can cherry pick the best
of each class!
Gregory C. Allen, M.D.
Olympia, Washington
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