Transcript
Gianluca Bini: All right, guys. So too tonight it's Tasha's turn and picking the topic. What's going to be, Tasha?
Annatasha: You know, I went back and forth about this for a bit.
Ryan Bailey: Thank
Annatasha: And originally, i was going to really stick it to you guys. And we were going to talk about physics and the various, like, all the various, I know that's was like, we should study.
Gianluca Bini: Fuck me.
Annatasha: But I felt like we actually should study if we talk about that, because I was going to be like, let's talk gas laws. Let's talk Venturius.
Gianluca Bini: Oh,
Annatasha: Let's talk Bernoulli. Let's talk Laplacque.
Gianluca Bini: Jesus.
Annatasha: and talk about why all that very like seemingly theoretical stuff is clinically relevant. But then I thought that that would be a cheap shot without any warning. So instead tonight, we're going to play a game because it's Halloween week.
Annatasha: We actually, so foolishly, we should have worn costumes. Anyway, I am, yeah, I'm kind of dressed up like a lumberjack elf. But anyway, besides the point. Also, I do want to show you this. Look, I'm making little
Ryan Bailey: I mean, I've got something to scare you.
Gianluca Bini: well Thank you.
Gianluca Bini: The only one that doesn't have anything Halloween related here.
Annatasha: yes all right you have two cute golden retrievers anyway so instead of tonight we're going to play a game we're going play never have i ever the anesthesia version you need you know how to play never have i ever
Gianluca Bini: There you
Ryan Bailey: Oh, God.
Ryan Bailey: Oh, God.
Gianluca Bini: go. I need a little bit refreshing.
Annatasha: Okay. So what one person says, never have I ever, and then follows it with a statement. And then whoever has done it has to admit to it and then provide the relevant anecdote. So for example, this will be an anesthesia version.
Annatasha: know what you guys do in your weird personal lives, but yeah. So I thought I would start with, and it's kind of a fun way to talk about stuff that's maybe a little bit more controversial, maybe help dispel some of those, you know,
Ryan Bailey: Thank you.
Annatasha: hardcore anesthesia urban legends. But I'm going to start tonight with never have I ever masked a patient down.
Gianluca Bini: So this is the moment...
Annatasha: So if you've done it, if you've done it,
Gianluca Bini: Wait, wait, wait. If I understand correctly, this is the moment where...
Annatasha: and this is excluding exotics, Bailey, before I get that...
Ryan Bailey: Okay, I was like, well, I've definitely done it. I've got numerous stories of how I have masked it.
Annatasha: Now, never have I ever masked a cat or a dog down. Let's say that.
Ryan Bailey: Ooh, can't remember. got things.
Gianluca Bini: Done that for research.
Annatasha: yeah
Ryan Bailey: Yeah, I was just saying, what about box induction?
Annatasha: Yeah, we'll count a box induction as a mask down because it's really just a big mask.
Ryan Bailey: what if it was a rabbit?
Annatasha: We can use a rabbit.
Ryan Bailey: What if it was for research? What if it was for a math study?
Annatasha: Wow, this this game's turning sour quickly.
Ryan Bailey: yeah
Ryan Bailey: That backfired so hard.
Annatasha: No, just never have I ever in normal everyday practice, either when we were GPs or what have you, have you masked a patient down outside of research, outside of exotics, where for example, like today I was involved with a Tamandua and you cannot intubate those, so fair enough.
Ryan Bailey: okay, okay. I was
Ryan Bailey: he's gonna say, I'm sure that was impossible. And you're talking in our anesthesia careers.
Annatasha: veterinary careers.
Ryan Bailey: Well, then for sure, for sure. As an assistant, I am sure I was involved in box inductions for Mean Cats back in the like 90s when I first got my job.
Annatasha: nineteen hundred 1900s.
Ryan Bailey: And as a lowly assistant, cleaning up the kennels and like, you know, scooping shit and painting the back hallways and all the little gopher jobs I had to do.
Annatasha: Did you start as like an ACA, like an attendant, like an animal care attendant?
Gianluca Bini: We... We
Ryan Bailey: Yeah, for sure.
Gianluca Bini: will... We will...
Ryan Bailey: Like in high school, that was my first high school job was in the back, holding, restraining, watching cats.
Annatasha: I started as a receptionist.
Ryan Bailey: Like we had a cat that was like, I, we, where i worked, we did like a, adult like they started as like a like mobile service. So they bought an ambulance from a local fire station that was like decommissioning it. And so they used to go do house calls. That was like their main business. And then they got a standalone practice. And that's when I joined them shortly after that.
Ryan Bailey: And so they still used to go to clients' houses and pick up their pets and bring them. So one time i had to go pick up this like feral cat it like i was like guys just you know this cat's like super feral it was like bouncing between the windows when i was going to like try and grab it with a quilt and shove it into this carrier it was a mess and then uh i was like just you know this cat's feral they like opened it up and the cat like a like a like a jack-in-the-box just like boom like into the air and he's like all over the clinic he like ran under the x-ray table for a while he like got into the bathroom and we had to like catch him with the trash can
Ryan Bailey: I think that cat ended up going home without anything that day because it was too much of a mess.
Gianluca Bini: No,
Annatasha: Did you box act that down?
Ryan Bailey: I think we decided after all the commotion that we were not going to box that particular cat down, but there were definitely animals that got boxed down at that clinic.
Annatasha: So question really then in terms of those kinds of, okay, this is this about the game?
Gianluca Bini: no, I have a question first. You said the 90s. You said the Ryan.
Ryan Bailey: I guess, yeah, well, let me think. Yeah.
Gianluca Bini: How old are you?
Ryan Bailey: I mean, i started working when 14. So like this was in high school for sure.
Gianluca Bini: wow.
Ryan Bailey: And I graduated high school in 2002. So it's almost assured that there were some like maybe 1999, maybe 2000. So yeah. so
Gianluca Bini: Wow.
Ryan Bailey: Yeah.
Annatasha: Turn of the century, we'll call it.
Gianluca Bini: but
Ryan Bailey: I mean, it was, it was like walking distance from where I live so I could walk to work.
Annatasha: Well, you would have had to, because at 14, you weren't driving.
Ryan Bailey: Well, I had a family with a car. also had a bike. was on the bike?
Annatasha: Back to the boxing down. Beanie, have you done this?
Gianluca Bini: i
Gianluca Bini: in my veterinary career, i if we exclude research, I've never masked down an animal.
Annatasha: Not even like a hamster.
Gianluca Bini: No.
Ryan Bailey: I was actually just advising someone on masking down a gorilla.
Gianluca Bini: That's solid. How would that go?
Ryan Bailey: You give them a heavy eye in pre-med, and then what I remember...
Gianluca Bini: the wall
Ryan Bailey: my mentor well for safety so what my mentor did was he would get an lma and because gorilla's faces are kind of flat if remember correctly he would place the lma on their nose until they had breathed enough uh he used sevo in these cases most of the time until they breathe enough sevo that they became sleepy enough that could then stick the lma into their airway and kind of finish off the induction and then reach for the endotracheal tube so so you didn't have to get Venus access right away.
Ryan Bailey: yeah
Ryan Bailey: just want to add in it is not uncommon to induce children through a mask induction. They use SIBO because it's a little bit more pleasant, I think, on the airways or whatever.
Ryan Bailey: And like, you can tell a child to take a deep breath. But, you know, honestly, the ones I saw were like really little and they were just screaming in in a patient. and they They were like babies.
Ryan Bailey: Like this was when I was doing my pediatric rotation. And I was like, this is I'm not coming back here for sure. I don't like this.
Annatasha: really not bringing my children.
Ryan Bailey: Yeah. So I think there are situations where like with a heavy iron premed, a box or mass conduction is not the end of the world in the right situation. But I do think there are a litany of other options that we should probably pursue.
Ryan Bailey: i think dealing with the patients that I deal with, yeah, it's not going to happen. But I'm also...
Annatasha: I wish we could mask down some of the clients.
Ryan Bailey: Sure.
Annatasha: That would really make my life easier.
Gianluca Bini: and I think, to be honest with you, I mean, it's not pleasant for the animal, right? Like, you know, that let's put it this out there.
Ryan Bailey: I agree.
Gianluca Bini: Like, it's not pleasant for the animal. Oftentimes, it's done in places to the contrary to what Ryan is saying. You know, it's done in places where, They don't give an IM pre-med. The cats are fully awake or the animals are fully awake.
Gianluca Bini: Some people were are less skilled than others, right? And so, you know, it's not done in a safe manner.
Annatasha: because there's a mask sedation or a mask induction because, for example, you might have limited resources or staffing or or you've actually gone through the textbook and you're like, my God, like what like literally what is next?
Ryan Bailey: Mm-hmm.
Annatasha: As opposed to I'm just, I can't be bothered to modernize my practice or like to make the effort to to to make some considerate decisions like Ryan's at oral pre-meds or i am what have you. But yeah, no, I just, i was just wondering because I mean,
Annatasha: it's still technically it like a technique in the box. And I know it obviously it has its disadvantages and
Gianluca Bini: No pun intended. No. the box
Annatasha: and never, ever use a dongement. And entendre for the French Canadians was a dongement. But anyway, yes, no, I was just you know curious to see. i suspected that both of you probably don't use this as like your first line, but it used to be such a strong anti-sentiment.
Gianluca Bini: no
Annatasha: i was actually more interested to see whether you would land maybe a little bit more towards the middle, which you did, than perhaps we might have 10 years ago. So that was really my question there.
Ryan Bailey: I will say, I think the, i like, the I'm trying to figure out how to phrase this correctly, but, like, I just think there's there is there is a reliance in certain situations on a box induction where like,
Annatasha: Because this is the episode where we're going to start being politically correct. Oh, okay. Okay.
Ryan Bailey: we could combine drugs to make the box induction better for the patient because like the box is very stressful. Like they're often trapped in there.
Gianluca Bini: like
Ryan Bailey: They go through a hyper excitable phase and the light plane of anesthesia, which for the record, we see all day, every day with people pushing propofol where they don't push it enough and the animal starts to get light. And then you're like now slam it in because you push too little or you push it too slow because you're nervous.
Ryan Bailey: So like, it's not to say like the hyper excitability we see both with IV and box induction. So like, I'm not sure I can buy the argument of like, well, it's worse for them, but you have the immediate solution in your hand with the injectable technique that you can like make up for those patients who are developing that where the excitable phase in those box inductions, you're then like their minute ventilation gets all out of whack. And then they may, maybe they're taking big, deep breaths and you're going to get lucky and they go down fast. Maybe they start taking short, shallow breaths because they're panting because they're so scared.
Ryan Bailey: And then their induction takes longer and longer and longer and everything gets worse worse and worse. So it's like, I feel like using an IM pre-med in those situations would probably make that, I just wonder if it would make it a more equivalent induction. And it's just like out of like, just like simplicity and not keeping up a little bit that we don't, that people are not using IM pre-meds those. I mean, in some of those cases are probably not ones where we're going to get them, but I just feel like there's so many patients who can get at least a little IM pre-med in them.
Annatasha: Yeah, I agree.
Gianluca Bini: Yeah.
Ryan Bailey: That's, don't know that's my little soapbox.
Annatasha: i think unless it's, it's, you know, a ton of an animal who's who will kill you, you know, and you don't have capacity for like remote sedation.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah.
Ryan Bailey: But you also say math is down your line.
Annatasha: really struggle to think in our day to day dog and cat situation, even horses and what have you that you can't get some form of IM in.
Ryan Bailey: I will say, i do want to share an anecdote. I did once try and mask down a patient and I thought i immediately was like, this is the dumbest decision I've ever made. It was a patient who, through a variety of different circumstances, had bitten his tube in half and ripped out his IV catheter.
Gianluca Bini: Mark.
Annatasha: Hooray.
Ryan Bailey: And we were in a situation where I could not have a lot of items with me, if you know what I mean. And so I just grabbed a mask and I put it on the circuit and I attached it to the dog's face and cranked up everything to try and get it down.
Ryan Bailey: And I was like, this is not working. I need something with injections. So ketamine did the trick. Dog went down real smooth after that. We got the rest of stuff.
Annatasha: had a similar one. We had a wiener dog on the table having like a hemulaminectomy was when I was a resident. And so I was circulating between cases and students around the case. and you know, I could so I came back in the room and like, you know how when you leave an hour and everything's like, you've got that chill and then you come back in and the instant vibe is that there's some catastrophe that's unraveling, like while you're just walking over.
Ryan Bailey: Yes. Yes.
Annatasha: I got that. And I realized like the dog, I guess, had, had not just gotten light, but woken up bit through the tube.
Ryan Bailey: yeah
Annatasha: It somehow actually extubated the bitten part of the tube, which was a Christmas miracle. And because it was a wiener dog and it had thrashed, with it like an exposed spinal cord, it had ripped its own catheter out, right? So now I got a wiener dog with an exposed spine who's extubated no IV catheter. And I was like, well,
Gianluca Bini: I'm just proxie.
Annatasha: And the neurologist is looking at me and I'm like, just going to need a minute. And so that's what I did is, right? Like I just cranked isofluorine up. I cranked oxygen flow up. I put it on flow by until the patient, you know, was re-anesthetized.
Annatasha: And then I was able to, you know, sort of regain control of this catasinous infection.
Ryan Bailey: Yes.
Annatasha: And then I was informed I was never allowed to leave the OR again. And I was like, yeah, no, I'm not going to. But so yeah, I did.
Ryan Bailey: yeah
Annatasha: I did. I mean, it is an emergency technique too for that.
Ryan Bailey: Yes.
Annatasha: Cause you have an open abdomen and open chest or what have and you lose control of the airway and you lose control, especially if they're thrashing, like if they've actually gotten to that light plane where they've gone from movement to actual consciousness,
Gianluca Bini: Yeah, you're fine.
Ryan Bailey: Oh my God.
Annatasha: you're going to make the break to escape. And in which case they will pull their line, they will extubate themselves. And then you're, you're like, you're really scraping shit off the ceiling at that point. So, you know, just for the listeners, like a, like a high fast flow volume of an inhalant will bring the patient back down as opposed to trying to like, let's see if we can hit an IV and something that's moving or like,
Annatasha: I am poke it, which won't be fast enough. Or, or can you get a jugular draw? And I'm like, can you get a jugular draw?
Ryan Bailey: i
Annatasha: Like, like I haven't recently fallen from heaven. So no. But yeah, anyway, but okay. So that was that.
Gianluca Bini: So to the listeners, the trick is not let them wake up.
Annatasha: the
Ryan Bailey: For the record, was not actually on the case. I was supervising and a very junior person was on the case.
Gianluca Bini: Excuses, Ryan. Excuses.
Ryan Bailey: Yeah, it's it's a routine thing for me to let my patient just fully extubate itself, pull out its line and just like shrug, throw my hand out.
Annatasha: Yeah, i just feel when things get a little boring, I really like to live on that edge of losing my license and being fired.
Ryan Bailey: Yeah, it's
Annatasha: It's thrill.
Ryan Bailey: yeah
Annatasha: Okay. Never have I ever round two Never have I ever accidentally overdosed a patient causing harm.
Ryan Bailey: 100% I've done it for sure.
Gianluca Bini: Oh, closing arm?
Annatasha: hundred percent. I've done it.
Gianluca Bini: No.
Annatasha: And a harm doesn't necessarily mean like mortality beat me.
Ryan Bailey: Oh yeah.
Annatasha: Like I once set my fentanyl pump CRI and I missed the decimal place.
Gianluca Bini: Oh, OK.
Annatasha: And so I was getting a 10 times overdose. And I spent like a good 20 minutes being like, why is this patient so bradycardic? I was just like, I don't understand what this dog is doing.
Annatasha: And then I finally, I was like, I mean, again resident like three o'clock in the morning, like what? And I was like, oh, I am the dumbest person on earth. So I don't necessarily mean that you caused harm as in like fatality, but you may have caused like a morbid complication per se. Never, never this.
Gianluca Bini: We definitely overdose Propofol every time we lose.
Annatasha: call out but you Oh
Ryan Bailey: I
Gianluca Bini: Isn't that true, though?
Annatasha: Not in Bartel's world, but because I always meet my co-induction agent.
Gianluca Bini: mean,
Ryan Bailey: and don't use Provo Balls, so am I the problem in my world?
Annatasha: i have my nice 90 second co-induction agent window.
Gianluca Bini: oh, at it.
Ryan Bailey: I just mask them all down. Wow.
Annatasha: I'll exercise patience during the induction of anesthesia. Patients for my patients. But you've really, Beanie, you've never...
Ryan Bailey: wow
Gianluca Bini: I, no, I had that a, I had a technician do that.
Annatasha: like mistaken ketamine for blush, for example.
Gianluca Bini: Like she gave 10 times the dose of methadone, you know, again, decimal place. now did anything happen to the patient? If she didn't tell me, i would have never known.
Ryan Bailey: The tendons dose of methadone could still be a regular dose of methadone depending on your dose of
Annatasha: a fair point, Bailey.
Gianluca Bini: That's fair. If it's a Davis dose.
Annatasha: Be a hundred times, could be a hundred times.
Ryan Bailey: sleep. Yeah. I mean, I gave a pug dog like a mig per kg of methadone one time because he needed like an emergency eye surgery and I didn't want him to yak on some sort of other opioid. That's okay. Yeah.
Gianluca Bini: You gave him a make the cake of methadone to pursue.
Ryan Bailey: Yeah.
Ryan Bailey: For eye incination.
Annatasha: I'm
Ryan Bailey: For a catheter, because he was like screaming and being a...
Gianluca Bini: Oh, gotcha. Okay.
Annatasha: being a pug.
Ryan Bailey: It was a little pug with like an ocular, some sort of ocular. Ocular emergency!
Gianluca Bini: Don't they make Gax mad in your world?
Ryan Bailey: Well, that could cause them to throw up, Dr. Beeney, so we were not going to use that.
Gianluca Bini: How often do you see that?
Ryan Bailey: Often enough, for sure. For sure.
Annatasha: That's a great question, Beanie. How often do we actually see it
Gianluca Bini: I never see it.
Ryan Bailey: I see it.
Annatasha: If you get an opioid alpha two combo in pre-med.
Ryan Bailey: my God.
Gianluca Bini: Unless I put hydra in the mix or morphine in the mix with buprenorphine or medidone or fentanyl, I never see it. Like I know it's described and there is out there.
Ryan Bailey: Yeah.
Gianluca Bini: i don't know if it's a dosage.
Annatasha: haven't had a patient yak on pre-med since I don't know why not either.
Ryan Bailey: and Are you giving them Sirenia as well?
Gianluca Bini: No. Like they get it usually at induction or I don't, because at that point I always tell them, I was like,
Ryan Bailey: Just.
Ryan Bailey: Yeah.
Annatasha: What are you giving sub cue or something wild Like what are you doing over there?
Ryan Bailey: I don't see it all the time. i just, I saw it like literally today we had a patient. don't remember what was for, but it got dexmed and methadone IM as a pre-med and I walked by the cage and there was like little bit of spit up in the cage.
Ryan Bailey: And I was like, oh, patient, patient bottomed.
Gianluca Bini: pit? Like, is it saliva or is it like
Ryan Bailey: It was like food tinged. Like, i don't know. I don't, I mean, I was feeling the patient.
Annatasha: you're not seeing like the full like the old like the old hydro pre-med that you use like hydro ace that you used to see when you did the cool cover and then they like would evacuate from the jejunum forward like you're not seeing that
Ryan Bailey: Yeah. Yeah, mean, it wasn't a lot of that. You know, like, there's a variety of throwing up, Bartell. You can definitely attest to this, especially with your recent incident.
Annatasha: okay rude
Ryan Bailey: You should understand all the litany of throw up. I mean, we in America have, like, probably, like, a few words, like, vomit, throw up, whatever. But, like, I'm sure there's some place where they have, like, 27 words for throw up, like, you know, the Inuit people have for snow or whatever.
Gianluca Bini: Again, I, you know,
Annatasha: but Don't drag Canadians into this conversation.
Annatasha: no i just, you know, like back, you know, if you've used morphine, even if you've used oxymorphone, if you've used hydromorphone, you know, and I still remember like sub-Q is a pretty common thing when I first started this schtick too.
Annatasha: And like almost every patient at that point would hurl, right?
Ryan Bailey: you.
Ryan Bailey: Yeah.
Annatasha: like And like, I would just, I remember when I was in GP, actually, I was going to go neuter this massive doodle called, this was long time ago, so I would imagine Bruno has since crossed the Rainbow Bridge, but Bruno was just there for a neuter and he vomited from the pre-med and he brought up like eight pairs of full size like knee length socks.
Ryan Bailey: Gross.
Annatasha: And because remember it used to be like an intentional technique to induce vomiting so that you would have an empty stomach.
Ryan Bailey: Fucking gross.
Ryan Bailey: Oh, I have been there.
Annatasha: Yes, I know because you went to Davis where they still think that that's a jam.
Ryan Bailey: that's not what else we did that.
Ryan Bailey: The puppy section and it was the puppies were very tall. I remember.
Annatasha: But you don't see that kind of like that like violent type of vomiting on methadone.
Ryan Bailey: No, no,
Ryan Bailey: no, no, no. no no no
Annatasha: Certainly like I don't even think i've ever seen anything vomit on buprenorphine or butorphanol.
Ryan Bailey: yeah No, no,
Gianluca Bini: yeah
Annatasha: But yeah, like you don't see that anymore. So that was I think Beanie and I thought maybe you were seeing like old school hydro barfs with methadone.
Ryan Bailey: no. no, no.
Annatasha: Like what the hell are you doing?
Ryan Bailey: Okay, so first of all, I have definitely overdosed a patient. I'll tell you the story. But one question before I do that.
Annatasha: Yeah.
Ryan Bailey: Do you ever see excessive drooling with butorphanol? Someone asked me this the other day, and I was like, I didn't see.
Gianluca Bini: In cats sometimes, yes.
Ryan Bailey: Okay, okay.
Annatasha: Why is I've had seizures induced from IV butorphanol?
Gianluca Bini: Yeah.
Ryan Bailey: Yeah, I gave IV Bajorfoil to a dog with a big old brain tumor and he like did not enjoy it very
Annatasha: Yep.
Gianluca Bini: Also FYI.
Annatasha: I've seen a seizure on almost every drug that I can name, to be honest. like That's always my thing where I'm like, if you get in there and you disrupt brainwave activity and like they have something underlying or well or untreated, you're going to see it.
Ryan Bailey: much. Yeah.
Annatasha: but
Gianluca Bini: Yeah. Bidorphine will definitely, I've seen it in cats for sure.
Ryan Bailey: Interesting. Yeah, this was a cat and I was like, hmm, not something I really think about a lot, but I would still not hesitate to use it and don't know.
Gianluca Bini: I don't use a lot of Torb, but if I do, I have smitten gets.
Ryan Bailey: Yeah. Like, like procedure, know, all that kind of stuff.
Gianluca Bini: Yeah.
Ryan Bailey: So I tell you my story about overdosing a patient? Because it's a, it's a doozy.
Gianluca Bini: Go for it.
Ryan Bailey: So, was, it was back in residence.
Annatasha: He's so excited to tell us about the mistake he made.
Ryan Bailey: Well, it's,
Annatasha: Like, this is hilarious.
Ryan Bailey: Yeah, oh for sure. I have thought about it a lot ever since. So it was in residency. we were doing an epidural in like a goat, as you will. And we were doing a morphine only.
Annatasha: Locked goat?
Ryan Bailey: I don't i I'll be honest, I have no idea what the procedure.
Gianluca Bini: Right.
Ryan Bailey: I'm guessing it was like an abdominal thing. It probably was a black goat. But we did the epidural and we gave morphine. it was a morphine only epidural. And I was handed the drug. And I did not double check because like it was pretty routine that when someone handed you the epidural drugs, they were like already like ready to go.
Ryan Bailey: and so I didn't double check it and it mistered the whole thing into the epidural space. That goat had a super intense puritis.
Ryan Bailey: Like, so
Annatasha: What was, was it, but was it the right drug?
Ryan Bailey: it was the right drug. It was like,
Annatasha: oh okay.
Ryan Bailey: Like it was a, it was all the volume that they had bought for the patient.
Annatasha: Cause remember there was a kerfuffle not directly involving me, but where there was a mix up between what the, what the syringe for the inject it was for, I think it was either it was either a cow or a horse. And instead of it getting X amount of lidocaine, it got X amount of xylosine.
Ryan Bailey: Hell yeah.
Annatasha: And that was a great time for that, that particular.
Gianluca Bini: Yeah.
Annatasha: Yeah. h
Ryan Bailey: Yeah, this was this was like, you know you bought the morphine by the vial and they drew it all up. And so I just like, so thought it was like, yep.
Annatasha: Well, this is always thing. Like I was always trained when I was a resident, like you never should, you know how people will be like, well, it's propofol doses, four mils, but I'm just going pull up 10 because I may need more.
Ryan Bailey: Yep.
Annatasha: And I was always taught to never, ever do that because for this exact reason that some people might make the assumption that what's in the syringe is the dose.
Ryan Bailey: Yep.
Ryan Bailey: one
Annatasha: And then all of a sudden they're pushing three, six, 10 times what they should be because they didn't realize they were meant to, you know, either aliquot that dose out or they were meant to titrate accordingly.
Ryan Bailey: Yes. Yep.
Ryan Bailey: Yep.
Annatasha: So I generally don't, uh, let the technicians or the team, the interns do that.
Ryan Bailey: yeah
Annatasha: I'll ask them to pull a second syringe, so that you don't have someone who, who doesn't know any better, like all of a sudden give a cat like 10 ZCs of propofol. Cause you're like, oh thanks for that.
Ryan Bailey: ye
Annatasha: I really, it's about fixing this.
Ryan Bailey: yeah
Gianluca Bini: So I'm wondering if, did all your, so this, you know, episodes that you guys experienced happened during your residency or afterwards?
Ryan Bailey: This particular one did happen in my residency. Yeah.
Annatasha: I have, I mean, I've seen crazy my mistakes when I've been in academic institutions, because you do have a large student population.
Ryan Bailey: You
Gianluca Bini: Right.
Annatasha: But personally, I've made, i mean, the next question is never have I ever left the pop-off closed. And ive I think, yeah, if you haven't left the pop-off closed, you're lying.
Ryan Bailey: haven't lived.
Annatasha: But yeah, like I think you see a higher percentage in training facilities also because I think just generally they're, bigger population numbers. So we have to normalize the data for that.
Ryan Bailey: That
Annatasha: But I've made all some of these fucking dumb mistakes, you know, in the last 11 years of of private practice for...
Gianluca Bini: Yeah.
Gianluca Bini: Yeah. Do you... so
Annatasha: that a dog lapping?
Ryan Bailey: dog definitely got Dexamato and he's yakking in the background. I know it. I know it.
Annatasha: But I hope the readers can hear the dogs gagging.
Gianluca Bini: Come
Annatasha: yeah Welcome to our podcast.
Ryan Bailey: Oh.
Gianluca Bini: here. This is not chole. Aww.
Annatasha: so cute.
Gianluca Bini: and It means azonuts in Italian.
Annatasha: I already knew that because I eat a lot of Nutella.
Gianluca Bini: Aww.
Ryan Bailey: that happening
Gianluca Bini: Aww. Me too.
Annatasha: yeah
Gianluca Bini: You know what's the best this time of the year? if you If you get like panettone and then you cut a slice and you spread Nutella on top, I mean, it's like, it's 3,000 galleries right there, but it's so good. So good.
Ryan Bailey: Hi, Renee for winter here, you know.
Annatasha: Yeah, we live up in the North Beanie where you want to lay some fat down for the cold months ahead.
Ryan Bailey: Oh, yeah.
Annatasha: Like...
Ryan Bailey: Yeah, it's kind of
Gianluca Bini: Till last week, it was like 90 degrees here.
Ryan Bailey: hot. The weather here turned in like a heartbeat. It was like shorts and a t-shirt, and now it's like frigid. I like have to think about it.
Annatasha: You must have frost on the ground, because we've already switched over to like me scraping my car window from frost in the morning.
Ryan Bailey: No, we don't have that yet. We haven't had frost yet. I'm sure it's coming, but it was, yeah. I mean, who knows?
Gianluca Bini: Glad have you.
Ryan Bailey: We had snow a few years ago when... Oh, hell yeah.
Annatasha: When I grew up, every Halloween costume I ever had was ruined because I had to wear it with snow pants.
Ryan Bailey: Hell yeah.
Annatasha: Every Halloween costume you either had to wear under your winter coat or over your snowsuit.
Ryan Bailey: Absolutely.
Annatasha: And I was like, this is not how ballerinas dress, mom.
Gianluca Bini: unless you Unless you dress up as an astronaut every time.
Annatasha: Yeah, or a skier. But no, I always wanted to be things like ballerinas and pirates and things that did not align well with snow outfits. And so I would just be like, no, I'm just going to be cold.
Annatasha: And then you do like two houses and you'd be like, we're going to need that snow suit.
Ryan Bailey: Yeah.
Annatasha: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: That's awesome. So the reason I was asking, though, about, you know, whether it was during the residency. So where I did my residency, there was a huge emphasis on like checklists.
Ryan Bailey: yeah
Gianluca Bini: Like, you know, there was a huge emphasis on we all had our own like drug sheet. it was pre-calculated, you know. So I think that a lot of that was taken away. You know, that chance of mistake was taken away there. Yeah.
Ryan Bailey: Sure? Yeah. Yeah.
Gianluca Bini: like We would have the students calculate the drugs, but we wouldn't we wouldn't use their sheet.
Ryan Bailey: sir
Gianluca Bini: you We would use our sheet.
Ryan Bailey: yeah
Gianluca Bini: we And the students weren't really... you know Depending on the institution, some institutions give them more degree of freedom than others, and the state is definitely not one of those that gave them, at that time, a lot of degrees of freedom.
Ryan Bailey: yeah
Gianluca Bini: You know, they the technicians or the residents were, you know, running the cases and the students were helping, but it they weren't, and you know, pulling up drugs or doing any of that, you know.
Gianluca Bini: Yeah.
Ryan Bailey: I also would like add in that we, the collective we, have been practicing anesthesia for almost 10 years now. And like, there has been, i would say one of the biggest shifts in anesthesia is towards a culture of safety. And so like,
Ryan Bailey: everything, like a lot of what we're doing is moving towards safer and safer and safer and safer anesthetic plans. And so there are like things that we are doing from these experiences that have led us to different practices that prevent these kinds of mistakes.
Ryan Bailey: from happening. So, you know, like, I don't whenever I drop a drug for an epidural, I drop the drugs, and I tell people like what they are like the mills of each and the milligrams of each and combine them together.
Ryan Bailey: And like, you know, I hand a syringe to someone, I say this is x amount of drug, and this is the mills. And like, so I wonder too, if like,
Gianluca Bini: Yeah.
Ryan Bailey: maybe that's why Beanie hasn't seen it as much as like you and i because, you know, we're a little older.
Annatasha: Yeah. And like, I really honestly, like I was just like went rogue, really.
Gianluca Bini: Yeah.
Ryan Bailey: Yeah. Yeah.
Annatasha: I mean, 50% of my residency was at night by myself and I would sometimes have like seven or eight cases going.
Gianluca Bini: think
Ryan Bailey: I mean,
Annatasha: At the same time, and I was the only, like, you know, it would be me and maybe two students trying to get through seven cases at three o'clock in the morning.
Ryan Bailey: yeah.
Annatasha: And it would, you know, it would range anything from equine colic I once had a V slot on the table that started to bleed out at the same time that the splenectomy was bleeding out.
Gianluca Bini: Yeah. Yeah.
Ryan Bailey: yes
Annatasha: And so I'm bouncing between two rooms, just like throwing blood at everything.
Ryan Bailey: right
Annatasha: And so was a lot more rogue and less controlled, but...
Gianluca Bini: yeah
Ryan Bailey: I mean, it also like, I was thinking about, like, we also see, like, over, like, relative overdoses with, like, negative consequences all the time.
Ryan Bailey: Like, you're giving a presser, and you end up giving a little extra fluid in the line, and the patient becomes wildly tacky for five minutes.
Gianluca Bini: Yeah.
Ryan Bailey: Their heart rate approaches 300. Their systolic is approaching 200. Like, that is a negative consequence, and there are patients who will succumb to that, unfortunately. It is, like...
Annatasha: Actually, it was at Davis, one of your resident mates accidentally flushed Nora Eppie in like
Ryan Bailey: Hell yeah. I just did it today and I was like, no big deal.
Annatasha: like And it was so funny because said resident was like, oh my God, oh my God, Bartell, Bartell, Bartell. And it was actually the first time we achieved normotension.
Ryan Bailey: Yeah.
Annatasha: and but
Ryan Bailey: Yep.
Gianluca Bini: Thank you.
Annatasha: and i was And I was just like, no, this is a win.
Ryan Bailey: look
Annatasha: Like you titrate to a effect.
Ryan Bailey: yeah
Annatasha: I was like, we did it. you know And meanwhile, it was like a 10cc flush that like slammed a norepian. And I was like, let's see how this goes.
Ryan Bailey: yes
Annatasha: And I was expecting like crazy tag, your arrhythmias. And, you know, and and the surgeon should just go wild about like blood spurting out of everything.
Ryan Bailey: Oh my god, yeah.
Annatasha: And anyway, it kind of fixed it. And I was like, that's between you and I. And I was just like, this conversation does not need to go outside of just that you and I.
Ryan Bailey: Yeah.
Annatasha: And I was like, don't even sweat it. Like titrate to effect, like high five, like I'm out of here. yeah
Ryan Bailey: Yep.
Annatasha: Yeah, that was a memorable moment.
Ryan Bailey: Yeah. Yeah.
Annatasha: All right. Never have I ever lied to a surgeon just to keep them quiet. And actually really, I've done nothing anesthetic.
Ryan Bailey: Literally all the time. My favorite maneuver is they say the patient's getting light. And so I stand up and I put my hand on the vaporizer like I'm doing something.
Ryan Bailey: And I stand there for a minute looking concerned, consternated even. m Sometimes maybe I like cross my arms and look very serious.
Ryan Bailey: Or maybe I like grab the syringes and I like lean on the table a little bit.
Annatasha: I love how you actually like put so much dramatic flair in it.
Gianluca Bini: You put so much effort into this.
Ryan Bailey: Oh yeah, for sure.
Gianluca Bini: Awesome.
Ryan Bailey: And I'm like, is it, is it better now? And they'll say, yeah, yeah, yeah, yeah. It's great. It's great. I'm like, okay, cool. Good. Thanks. Let me know if it gets bad again.
Annatasha: You know what I do, Bailey?
Gianluca Bini: That placebo effect is used.
Annatasha: i I often, like, I've had, you know, like the RVT will call me and like, oh, we're really struggling with this.
Ryan Bailey: Yes.
Annatasha: butda And I'm kind of in my head, I'm like, there's absolutely fucking nothing wrong. It's just somebody is just being really obnoxious.
Ryan Bailey: yes
Annatasha: And my favorite thing to do is what I do is I go onto the ECG and I boop it from like lead two to three. And then I give it a couple seconds and I boop it back. And then I do what you do.
Ryan Bailey: Yeah.
Annatasha: And I'll be like, how are we doing down there? And they'd be like no, that's great. That's great. Thank you so much. And then I just say nothing and I just quietly leave the OR. And then I laughed so hard because the the technician was like, after this particular case she was like bartell what it what did you do and i was like oh nothing i just booped the monitor and fobbed them off really and she just started to laugh and laugh and she's like because she was like i swear you hadn't done anything and i thought man bartell is like like she must have done something and i just like blinked and missed it and i was like i did absolutely nothing
Ryan Bailey: yeah
Gianluca Bini: Thank you.
Ryan Bailey: I'm so fast.
Annatasha: I was like, I did absolutely nothing. Cause like there was nothing to do. so Cause I have learned the hard way not to listen to surgeons about things like abdominal tension, gut color, like that kind of stuff.
Ryan Bailey: Yep. Yeah.
Annatasha: So I will give them concession, but when it's just like bullshit fussing around, cause it's like, they almost have nothing else to complain about.
Ryan Bailey: Yep.
Ryan Bailey: yeah
Annatasha: I just go in there and I'm like, yeah, and then I fool around with like the ECG leads and I make some comments and i will and then I just walk out and I've done nothing.
Ryan Bailey: yep
Annatasha: Maybe?
Gianluca Bini: So this typical, right? So i think there is some...
Gianluca Bini: I was reading... i forgot where.
Ryan Bailey: Thank you.
Gianluca Bini: But so somebody actually did the paper on this where in when... i think they recorded the OR and they were looking at like how often yeah the surgeons ask you...
Gianluca Bini: ask an anesthesiologist how the patient is doing, right?
Annatasha: and
Gianluca Bini: And the they shittier is their procedure going, the more times they ask you how the patient is doing. like
Ryan Bailey: at all.
Gianluca Bini: Because they're folk there you know they are so worried about their procedure or the you know the patient is not going the way it's supposed to go,
Gianluca Bini: They try, their tendency is to ask how the patient is doing just to get their mind off of the fact that the procedure isn't going as planned. And so there is some psychology behind this.
Gianluca Bini: And so then, yes, that's where the placebo effect comes in. And you're like, okay, yeah, sure, I fixed it. even though there was absolutely nothing to fix. But yeah, I mean, we've all done it, you know, in residency, especially, you know, you know, or yeah, I mean, even as a faculty, you know, you, you do it like, you know, you go in and they ask you about it and there's nothing to actually fix.
Ryan Bailey: yeah
Gianluca Bini: The patient is doing perfectly fine. And you're just like, oh yeah, is it better? Is it, yeah, sure.
Ryan Bailey: Like the dog...
Annatasha: Yeah, no, you're right. You're right. Yeah, no, i just, yep. Perfect. I've adjusted that a couple of things. Let me know how we're doing. I'll check in in a couple of minutes.
Gianluca Bini: Yeah.
Annatasha: And they're like, no, it's much, much better.
Ryan Bailey: Yeah.
Annatasha: And you're like, amazing.
Ryan Bailey: Or you walk in and the end tunnel is at like 1.6. The dog has a block on board and the surgeon's complaining about something. You're like, what's going on now? And then the thing you do is you turn the vaporizer down. What's that?
Ryan Bailey: Gonna take out some of the gas here, guys. Didn't know we were gonna send this dog straight to hell.
Gianluca Bini: But so, and yeah, that's awesome. How did that go?
Ryan Bailey: are staring at you like this.
Annatasha: Well, I recently had a surgeon say, like, I think that you guys should run all your anesthesia decisions by me before you actually do anything. And I laughed. him
Gianluca Bini: hadtenka
Annatasha: I laughed. You should ask him that question, not me.
Ryan Bailey: to
Annatasha: About as well as you would guess it would.
Ryan Bailey: Yeah.
Annatasha: But I was like, yeah, i was like, I'll get right on that.
Ryan Bailey: I remember a specific moment where you had to run an anesthesia decision by a resident surgeon when you were at Davis. And I remember how well that went. And i there was one of it was one of many life-changing events that occurred in the briefs that you were at Davis and I was dying.
Annatasha: yeah
Gianluca Bini: How did that go? Tell me more about this.
Annatasha: I wanted to do an epidural and a cat who was having a PU, right? Reasonable. And the first year surgery resident, AKA twat face, came in and was like, no, you're not allowed to do that.
Annatasha: and and and And I was like, who the fuck is this kid? and and and And I was like, oh, sorry, how long have you been a vet? Five minutes. And I was like, yeah, no, I'm board certified and I don't need your permission.
Ryan Bailey: They had it.
Annatasha: So they left and they came back and they had their attending. And I was like, oh, this is, this is, this is upregulating fast and I'm confrontational. So I was like, here we go. Anyway. And so they sat down and then I was like, and they like, just have these concerns blah, blah, blah. And I said, well, talk, talk through your concerns.
Annatasha: You know, we don't want to have urinary retention. And I said, well, I said, you know, it's not really the epidural. And I sort of explained that it's not the process of the epidural and,
Gianluca Bini: Yes.
Annatasha: Sideways also had to make a couple notes on the innervation of the bladder. And then I also said that i wasn't going I was going to use a buprenorphine based protocol and that buprenorphine has not been correlated with urinary retention. And then I think I landed it with really, if you don't know what you're talking about, you should say the fuck out of my induction area.
Gianluca Bini: shit
Annatasha: But I was like, there is zero chance in this lifetime that I'm going to ask permission from a resident in a different specialty to do what I think is best for a patient anesthetically, which was actually a real culture shift at Davis because back in those days, like even like the 30 year, like 10 year ones were like, well, we should ask surgery if we can do the block.
Ryan Bailey: groups.
Ryan Bailey: three
Annatasha: And I was like, I'd rather swallow glass. Like i was like, I'm absolutely not going to do this, which I think to Bailey's point was the first time he'd ever seen an anesthesiologist push back.
Annatasha: and really sort of draw that line in the sand, which has really been like the team.
Ryan Bailey: I mean, maybe push back so forcefully, like so directly and so intensely, which is like more my confrontation style. I tend not to be a like around the bush.
Annatasha: I'm what people sometimes refer to as a type B Canadian.
Gianluca Bini: So is the tech-canadian denies ones? And you are?
Annatasha: Yeah, most Canadians are falling into that typing, like jolly, apologetic, don't impartial confrontation, but I've been called a type B Canadian. So there you go.
Ryan Bailey: Yeah, sometimes people say I speak too directly sometimes because I'm like, let's not, you don't need to say hello, you have a question for me, please just direct your question at me and I will answer it.
Annatasha: should I should have been a hockey defenseman. That's really, really should have, what my life should have gone.
Gianluca Bini: awesome.
Ryan Bailey: Like there's no need to explain exchange of pleasantries here. Let's just like get on with it.
Annatasha: You're definitely getting crankier in your middle age, Bailey, that's for sure.
Gianluca Bini: Okay.
Ryan Bailey: I've always been cranky, let's be honest.
Annatasha: Fair point.
Ryan Bailey: I just was a trainee, so I got to have fun. Now now I'm no longer a trainee and I have you know, crack the whip. My time is money, man.
Annatasha: Okay. Okay.
Gianluca Bini: Okay,
Annatasha: Linda Evangelista, you don't get off the sofa for less than 10 grand.
Gianluca Bini: okay okay Ryan.
Ryan Bailey: I wish.
Annatasha: right. Last never have I ever.
Ryan Bailey: wish.
Gianluca Bini: but
Annatasha: right last never have i ever Hmm. Never have I ever panicked because I genuinely felt like I was losing the patient and I didn't know what was going on.
Gianluca Bini: who
Annatasha: Ooh.
Gianluca Bini: I mean,
Gianluca Bini: I don't know about panicked, panic there's been plenty of situations where I'm like, okay, this could be a variety of things and I'm not 100% sure which one of this is this.
Ryan Bailey: Yeah.
Gianluca Bini: Right. I mean, and and of course you go through your list usually, right? Like, I mean, some of it, it's sometimes it's fucking crazy. Like, you know, we had this dog, I think it was Ohio State, a seven-year-old,
Gianluca Bini: Nobody has ever, ever heard the murmur on this dog, been at the vet regularly, been seen out of Ohio State to regularly too. And we anesthetized this dog and without any reason, it's hypoxemic.
Gianluca Bini: And I was like, okay. So we go through you know our list of you know five causes of hypoxemia, blah, blah, blah.
Annatasha: I
Gianluca Bini: And then at the end, I was like, okay, just let's let's grab cardio. And turns out that this dog had fucking VSD.
Annatasha: i was about to say, massive shunt, right?
Ryan Bailey: Yeah. Yeah.
Annatasha: Yeah.
Ryan Bailey: Yep.
Gianluca Bini: And nobody has fucking heard it for seven years.
Ryan Bailey: yeah
Gianluca Bini: And, you know, turns out.
Annatasha: It's because when the defect is so big, there's no more turbulence. This happened to me with the dog at DCM.
Gianluca Bini: Yeah, yeah, yeah.
Annatasha: It's DCM was so advanced. that it didn't generate turbulent flow because it just quivered.
Ryan Bailey: yes
Gianluca Bini: crazy.
Annatasha: And I didn't realize this and I gave it a whole whack ton of dexmedetomidine because it was also bananas.
Gianluca Bini: Yeah,
Ryan Bailey: Thank you.
Annatasha: In my defense, it did fine.
Annatasha: Did fine.
Gianluca Bini: yeah I mean, and we fixed it, but like, you know, we stepped in the rugby and, you know, whatever, but like, You know holy shit, right? So there is plenty of moments where you're like, okay, I'm not sure which one of these it is, but we go through the list and we figure it out. So i don't know if panic is the right word, but definitely situations where panic
Annatasha: not panic, but you know that feeling where you feel like, I don't know if I'm going to vomit or pee my pants, that kind of vibe.
Ryan Bailey: I guess so.
Annatasha: mean, I, I've had, the pop-off left closed, uh, and, and had attention pneumothorax from a rupture and an arrest from it.
Ryan Bailey: Yeah. Yeah.
Annatasha: And I didn't, I didn't get that impact, but you know,
Gianluca Bini: It's weird, though. Like, usually they die.
Gianluca Bini: usually die before that. They die before the barotrauma, usually.
Annatasha: they die before the rupture because of the car, the impeded cardiac return.
Gianluca Bini: Yeah.
Ryan Bailey: Yeah. I mean, unless it's a, unless it's a Bane or whatever.
Annatasha: Right. Yeah, I mean, I've left my pop-off closed and I've been lucky enough that I've caught it before I caused.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah. This one, I was not standing there. I was called in to the OR after it had passed.
Annatasha: That's right. The cases where I've seen it really go like worst case scenario has been like where I'm in the supervisory capacity because I happen to have a personal fixation with the pop-off where I, whereas you like to hang your hand on the vaporizer, actually usually hang mine on the pop-off so that nobody else can fool around with it and not, you know, it's open all the time or it's closed because I'm on a ventile or whatever.
Ryan Bailey: Yes.
Ryan Bailey: Yes.
Ryan Bailey: Yeah.
Ryan Bailey: We have safety ones now, but because of that.
Annatasha: we do too but even still like you'll actually see me like hang out like that's where i kind of rest my hand just like i i hook my wrist on the pop-off so i'm like it's like so it's a personal and tactic to avoid the mistake of the the accidental closure yeah yeah i'm like the pop-off just that one always makes my like internal sphincters clench quite badly so
Ryan Bailey: Oh, yeah, for sure. I do the same thing.
Ryan Bailey: Yeah, for sure. Yeah.
Gianluca Bini: Yeah.
Ryan Bailey: yeah
Gianluca Bini: I mean, I... And again, we've cut all of this out, but the... I think that nowadays...
Gianluca Bini: every single practice should get one of the new machines with like, you know, like the Vita 5 or whatnot.
Annatasha: with a selection.
Gianluca Bini: There's so much fucking safer because they the the huge risk, and these people don't fucking understand, is like when you come off the ventilator, right?
Ryan Bailey: ye
Gianluca Bini: You disconnect the fucking ALO.
Ryan Bailey: That's exactly what happened is someone broke the machine down
Gianluca Bini: You put the bag on. You forget the screen.
Gianluca Bini: Yeah, yeah. yeah
Ryan Bailey: and no one had checked it.
Ryan Bailey: Oh,
Ryan Bailey: it's insane. It's insane.
Gianluca Bini: Way too long. You know. Actually...
Ryan Bailey: Oh, okay. I've got one. I've got one I can talk about where I did panic and I did almost shit my pants. And, uh... I can, and it's like one I can talk about because there was nothing, no disaster struck, but it felt like disaster could strike.
Ryan Bailey: So I can, i I just felt like that story should be shared, but like, gosh, it just feels like, does it create a particular problem?
Gianluca Bini: I agree with you.
Ryan Bailey: You know what I'm saying? Does that make sense?
Gianluca Bini: no, I agree with you. and i agree with you
Ryan Bailey: What about you, Martel? Yeah.
Annatasha: Oh, i've had a de I've had a couple ones, although most of them have been the surgeon's fault. I mean...
Ryan Bailey: No, no, I mean about what I was saying about the story I was trying to tell.
Annatasha: Oh, no. No, I think the story is saying like, yeah, the pop-off closed and the patient arrested and we weren't able to resuscitate is reasonable. I think that that's happened to
Ryan Bailey: Yeah.
Annatasha: a lot of us in this particular specialty, whether directly or indirectly, i mean, the reason that the pop-off is the fastest way to kill a patient on the machine is this is why, right?
Ryan Bailey: Yeah.
Annatasha: And like, I always teach it, like, you know, that and the O2 flush valve are, are on failure to recognize you haven't intubated.
Ryan Bailey: Yeah.
Ryan Bailey: yeah
Annatasha: It's like the triumvirate of, of arrest. So it happens. I think you could enact every possible safety measure,
Annatasha: known to humankind and unless you have human error removed from the circumstance entirely, you were still going to see it.
Ryan Bailey: Yeah.
Annatasha: And I think that knowing how to address, to recognize it and to address it is still important. And I think knowing too, that sometimes we do lose patients despite best efforts and that's not something we should shirk from or hide away from, right?
Ryan Bailey: Yeah. Yeah.
Annatasha: Like you can do everything wrong and the patient can live and you can do everything perfectly. And it can still absolutely die. And I think know we need we need to understand that from the point of view of mitigating blame, shame and guilt.
Annatasha: So I have no issue with that.
Ryan Bailey: Yeah.
Annatasha: But like, I've had a lot of moments before where I've literally been like, oh, o I, you know, I go from a very tight sphincter state to a very loose one very quickly.
Gianluca Bini: Thank you.
Annatasha: but in particular, i remember I was auto transfusing a cat who was a poly trauma and it was a hemo abdomen and, you know, we're in there and like, you know, I've already put, like, I don't even know, like half this cat circulating volume back in it. And, and the surgeon says, actually the kidney has been rented off. And so it's a uro abdomen and and we've been put, I've been putting urine back in this goddamn cat.
Annatasha: you know, right into its vascular space.
Ryan Bailey: Ooh.
Annatasha: You know, and the cat lived and I don't really understand why.
Ryan Bailey: Oh, yeah.
Annatasha: don't understand anything about that case.
Ryan Bailey: Cats are weird.
Ryan Bailey: But yeah, we don't know.
Annatasha: But yeah, like that was the kind where it's like my heart sank into my colon.
Ryan Bailey: Yeah.
Annatasha: And then everything below that kind of what got loosey goosey. And I was like, oh, shit, like, I don't even know you know, you don't, in that moment you have, don't have time to consider like the nuance of the physiology.
Ryan Bailey: Right.
Annatasha: What have I actually done? Like, am I going to have a vasculitis? Am I going to cause like an arrest?
Ryan Bailey: Right. Classic. Yeah.
Annatasha: Like, I didn't fucking cat live. Like, thank God.
Ryan Bailey: i like
Annatasha: I guess I felt like such a weenus, but I mean, other things too, like it wasn't my fault and it wasn't really anybody's fault, but I was like, i kind of was like, shit, like what what do you do?
Gianluca Bini: I mean, it wasn't even full. You didn't know.
Annatasha: Like, what do you do when you've infused a hundred mils of urine into a cat's vascular? don't fucking know. And then, i yeah, and then o and I was like, me and you know, what i actually did is my only other recourse, because the cat cat continued to bleed.
Gianluca Bini: didn't look like hearing, I hope.
Annatasha: And of course, I had to put in a whole bunch of contaminated garbage into it. had to give a dog blood. So we're just going from bad to worse. Like it was just such a cluster. But anyway, it lived. Not my finest hour. But, you know, I've also had other things like a very skilled and very experienced surgeon that I respect was basically doing like a staff pet OVH.
Annatasha: you know, like spay. And when he went to ligate, like the body of the uterus at the like top of the cervix, right through all the uterine vessels and the cat's just bleeding out. And he looks at me and he went and he went, well, this is gonna die.
Ryan Bailey: Yeah. Right.
Annatasha: And I was like, oh, not today, Satan.
Gianluca Bini: Thank you.
Annatasha: So I was like, you put your finger in the hole in that dam until you figure out what you're going to do about it. And the meantime, I'm going to go get some more blood. But that, you know, I actually, because it was a staff pet and because you weren't anticipating that at all, like healthy cat, straightforward spay, board certified 30 year surgeon, me.
Ryan Bailey: yeah
Annatasha: So of course it almost died. and And I was just like, that was definitely another one where I was like, I think I just tinkled in my pants a bit.
Ryan Bailey: right
Annatasha: So, you know, Yeah.
Gianluca Bini: It's always stuffed pet.
Annatasha: It's always a staff pet.
Gianluca Bini: Oh.
Annatasha: I've stopped agreeing to do them.
Ryan Bailey: i mean
Annatasha: They're like Tasha. And I'll be like, Oh no, no, that I'm definitely, I'm going to be sick that day. Like, yeah. Like,
Gianluca Bini: Refer him out.
Annatasha: no yeah like
Ryan Bailey: I think the the big things I've had where I've like felt like i'm gonna crap my pants is where I'm the equipment is either not where it needs to be, or you don't have all the little bells and whistles that we think about. So like I had a patient, it was an endoscopy. It was a relatively straightforward case, patient pulmonary hypertension, which is like usually a nothing burger.
Ryan Bailey: But we, and I chose a plan that was like cardio safe and this and that. And we induced anesthesia and the dog immediately just like desaturated, like in front of my eyes, like purple is the day, is the night.
Ryan Bailey: And, I had nothing. Like I just had the anesthesia machine in my hands.
Gianluca Bini: ye
Ryan Bailey: And I was like, what do I do?
Gianluca Bini: I had one of my mentors during my residency, I remember it clearly, for very first case with pulmonary hypertension and she was like, these are the ones that die.
Ryan Bailey: Yep.
Gianluca Bini: Period. this was like, everything else you can play with, these are the ones that die. I was like, cool. And that stuck to my brain so hard. you know, now, you know, every time we have a case with that, like I straight up call the vets and like, hey, you know, to be, you know, the honor is to be aware these die.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: So, you know, it could go well, but maybe not.
Ryan Bailey: After initial.
Gianluca Bini: So.
Annatasha: We should write a blog on like the top, like, cause you know, you always have like a mentor or somebody will just say something and it's almost like it's tattooed on you, right?
Ryan Bailey: Yeah.
Annatasha: Like you just, I just remember like, just like you say, the pulmonary hemorrhage and these ones die.
Ryan Bailey: yeah
Annatasha: One of my chiefs at Cornell said to me once, they're like,
Gianluca Bini: Yeah.
Annatasha: liver lobectomies, they only go two ways. They either go fine or they go shit, right?
Ryan Bailey: Yeah. Mm-hmm.
Annatasha: and And like, there's there's no, it's not like, you know, an enterotomy where you can be like, oh, it's a little septic. So it's a little rock and roll, but you kind of like pull it back up and everything looks great at the end. No, no, no, liver lobectomies, you either, it's fine or you're dead.
Annatasha: And like, that was all like that.
Gianluca Bini: yeah
Annatasha: Cause like, you know, my texts will be like, oh, it's a liver, you know, we're going do a lobectomy. And I'm like, second catheter. And they're like, everyone. And I'm like, everyone. And because when it goes shit, goes shit fast.
Annatasha: And it's usually going to be hemorrhagic. And I'm just like, you know what, and like, that's one of those like mentory things that got said. And I'm like, I'm just not going to budge on this. I'm just we're just second cathetering liver lobectomy is like, that's just the way it is for me.
Gianluca Bini: Yeah. Yeah.
Ryan Bailey: I mean, like, for me, it's like cat pancreas surgery. It's like you touch that cat's pancreas and their pressures will just bottom out and there's nothing you can do. You just have to pray they they survive and, like, get the epi, get the norepi, push everything you got and, like, just hope and, like, fingers crossed.
Gianluca Bini: yeah
Ryan Bailey: Yeah.
Annatasha: yeah
Ryan Bailey: I think for this pH dog though, I did get to use my brain and i fucking made a pee valve with a bucket of water and the exhaust hose. And I got, I got his sats up, but we woke the dog up because we were not equipped to deal with that situation.
Ryan Bailey: And like,
Annatasha: Well, those were all the right decisions.
Gianluca Bini: Doesn't sound like
Annatasha: Those were all the right decisions. So you did a great job.
Ryan Bailey: yeah.
Annatasha: It's not like me over here and giving urine and dog blood do a cat like what? who Whoa, whoa, what's happening?
Ryan Bailey: Yeah.
Annatasha: Bartell doing
Ryan Bailey: Yeah.
Gianluca Bini: We had a student, I mean, not not we anesthesia, but like one of the vet schools I worked at that gave go lightly. Yeah.
Ryan Bailey: Oh, yeah.
Gianluca Bini: Anima Prep IV.
Annatasha: IV.
Ryan Bailey: Yep. we had a We had that in my...
Annatasha: I've seen that.
Ryan Bailey: We had that as well. And that patient had to come back in for different procedures. And we had to like re-anesthetize it. So I remember reading through the record and being like, the patient's potassium was... Or sodium was like infinity at one point. Like, what happened? And then I started like digging into it i was like, oh oh, it got the Golily IV. I see. I see.
Ryan Bailey: Yeah.
Annatasha: It's also amazing too, you like sometimes shit like happens and
Gianluca Bini: They live. They live.
Ryan Bailey: yeah
Gianluca Bini: and
Annatasha: I know. That's the thing. Like I said, you can do really dumb stuff and they live. And also too, like there's some stuff that sometimes has happened where I'm like, I get you, someone looks at you with that like, look of like, what should we do? And in your head, you're like, just pretend you know what you're doing. And, and, the and, but in yourself, i like, I haveve no idea.
Annatasha: I had a tech once flushed 10 CCs of ketamine into the IV line of a Shih Tzu's like, it's art, art line, sorry. It's art line.
Ryan Bailey: Yeah.
Annatasha: Right. and And she was like, Oh my God, Oh my God, Oh my God, Oh my God. And I was like,
Annatasha: just, we're going to see what happens because I is going to happen?
Ryan Bailey: Yeah. Yeah.
Annatasha: And I was like, what am I going to do? Right. And I was like, we're just going to give this a minute just to play itself out. Because like, I have no idea of like, there's not something you can jump in. Like I can't go in and give an antagonist and like, ho of like it's in there, it's been circulated. Like this is happening. And I was just like, what?
Annatasha: Uh, yeah, no, I think, and it was fine.
Gianluca Bini: It probably the Beijing was totally fine.
Annatasha: It was very deep on an anesthetic plane.
Ryan Bailey: yeah
Annatasha: So we were really able to back off on our Mac value.
Gianluca Bini: Of course.
Annatasha: Big Mac reduction I find, find, yeah, when you give, you know, thousand milligrams, thousand milligrams of ketamine to a Shih Tzu, they really lie still for a bit.
Ryan Bailey: Big Mac reduction. Big time.
Gianluca Bini: I fucking wanted to stay.
Ryan Bailey: Jesus.
Annatasha: But I was totally like, you know, in my head, I'm like, well, what happens if we give it arterially? Like, I guess it goes to the capillary bed and back into the venous circulation and,
Ryan Bailey: His foot probably fell off, but that didn't happen for a while, I bet.
Annatasha: It did not fall off within my known time frame of dealing with that pet.
Ryan Bailey: That's good.
Annatasha: So yeah, no, but sometimes that happens too, where something happens where you're just like,
Ryan Bailey: That's good.
Ryan Bailey: Yeah.
Annatasha: what am I going to do right now? And the answer is going to do whole lot of nothing and try not to panic until we figure out what's actually going to happen.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah, for sure.
Gianluca Bini: That's awesome.
Annatasha: Yeah, like, don't know.
Gianluca Bini: Well, I mean, yeah. yeah
Annatasha: That's it. That's the never have I ever game.
Gianluca Bini: Yay.
Annatasha: Hey, happy Halloween.
Ryan Bailey: What are the experience to discuss?
Gianluca Bini: If I'm more like a therapy session.
Annatasha: Well, that's okay too, right?
Ryan Bailey: Yeah.
Annatasha: Because I think if people hear us and normally we're, you know, really extroverted and confident and for us to be like I don't know what the fuck I'm doing and we fuck up all the time. i think that's also part of It's a good thing to do, right?
Gianluca Bini: Yeah.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah, I mean, we're all humans in the end, right? Like, you know, I wish I was like, you know...
Annatasha: I wish I were PJP.
Ryan Bailey: Yeah.
Gianluca Bini: I think, to be honest with you, i if BJP was here, it would tell you that sometimes he fucks up too.
Ryan Bailey: I mean, i can I can tell you sometimes, sometimes I saw one time where he made mistake.
Gianluca Bini: He doesn't.
Ryan Bailey: He was helping me in dentistry place an arterial catheter and he got it in and it was a small, small little like chihuahua rat dog kind of thing.
Ryan Bailey: And he liked to use his little hemostats to like grip it and put the tape on.
Gianluca Bini: Hmm. Hmm.
Ryan Bailey: And he did that and he, I think he was like gripping it and putting on the T set and he twisted it and the catheter just went across the room.
Ryan Bailey: And i was like, so guess we won't do this one with an art line, huh? He goes, no, i don't think so. And i was like, okay, thanks.
Annatasha: Thanks for your help. Okay,
Ryan Bailey: and I'd already messed up the other leg, let's be honest. So he was trying to save me and I was like, okay.
Annatasha: Yeah, thanks. Yeah, sometimes my technicians are like, you're not actually helping right now, Bartel. And I'll be like, yeah, I know. It's like 50% helpful at best. I'll just go.
Ryan Bailey: Yeah.
Gianluca Bini: holy shit that's amazing no i mean it's it's normal right we're all we're all humans we're all practicing medicine right i was not actually like this isn't math this isn't one plus one equal two this is you know and and you know a lot of patients don't talk about
Annatasha: and I'll just go.
Annatasha: too many things happening at a level that we don't understand and can't and monitor or even interpret for us.
Gianluca Bini: I mean, to be honest with you, there is a lot of shit that, you know, a few years ago we didn't even know, right?
Annatasha: for
Gianluca Bini: Glycogalics, 2016, right? Like, this isn't, like, something that, you know, we knew beforehand.
Annatasha: a point.
Gianluca Bini: you know how many fucking patients got 10 ml per kg per hour of fucking fluids? How many patients got... believe
Ryan Bailey: Oh my God,
Gianluca Bini: Bollus didn't do oblivion, right? Like, this is like, you know, we didn't know about it, right? Like, and, and but, and and a lot of it is also that a lot of patients don't fucking read the textbook.
Ryan Bailey: yeah.
Annatasha: Especially cats.
Gianluca Bini: That's how it is.
Ryan Bailey: Yeah. Yeah. heard a story recently where someone a patient like a two kilo dog, like 200 bolus.
Gianluca Bini: Fuck me.
Ryan Bailey: over like a minute and somehow the dog was alive.
Gianluca Bini: cool
Annatasha: I hope it had functioning kidneys.
Gianluca Bini: Yeah, and a piece of view of, like, five. but yeah
Ryan Bailey: I mean, his microvascular circulation, that was hella good. That blood was like probably whipping around.
Annatasha: Oh yeah, he was peripherally oxygenating like he was a fucking alpaca in Peru. Like, problem. Fuck.
Ryan Bailey: Oh
Gianluca Bini: Jesus Christ.
Annatasha: Wow.
Gianluca Bini: Holy shit.
Ryan Bailey: Realizing all this like you know high stress anesthesia questions about like when did you fuck up, I have failed somehow to discuss hot dogs.
Annatasha: This is our first hot dog free episode until this moment.
Ryan Bailey: no No, we're talking about hot dogs right now.
Annatasha: Yeah. yeah
Gianluca Bini: give you
Ryan Bailey: in the I went camping recently and had some fucking good hot dogs because that's our go-to camping snack now.
Gianluca Bini: you
Gianluca Bini: Did you ever fuck up your old dog?
Ryan Bailey: Yeah, for sure. I mean, grilling a hot dog is a bit of an art. You know, you don't want it. You want a little bit of char, but you don't want to like burn the shit out of it and like blacken it to hell.
Ryan Bailey: Like you hate it because, you know, it's always good.
Annatasha: Have you ever done the milk carton cooking of a hot You cook it with a milk carton?
Gianluca Bini: So...
Ryan Bailey: What? What? No, I don't know what you're talking about.
Annatasha: Were you not like a Boy Scout or a...
Ryan Bailey: No, I was i was not. I was the game.
Annatasha: Take the hot dog, wrap it in foil. You can take a couple hot dogs, whatever. Put it in like a small milk carton, light the carton on fire, like in the campfire pit. As it burns down, it slowly, gently charges the hot dog in the foil, ready to eat.
Ryan Bailey: I mean, hot dog is already ready to eat if you think about it, you know?
Annatasha: You know, you want to put that nice flavor on it and you want to heat it up.
Ryan Bailey: mean I I ate some cold hot dogs growing up. i'm not afraid to I'm not afraid to tell about it.
Annatasha: This is why people listen to the podcast and they're like, are you actually friends with the hot dog guy?
Gianluca Bini: Yeah.
Annatasha: When I'm like, yeah, I'm actually friends with the hot dog guy.
Ryan Bailey: know it is all crimeing
Gianluca Bini: So we, you know, one of the one of our clinics called Ryan, Dr. Hot Dog. So that was awesome.
Ryan Bailey: i I have a hot dog scrub cap that was given to me by one of my anesthesia friends. She was a mentee post-residency.
Annatasha: Listen, Bailey, i think you should pick your two favorite Chicago hot dog companies, reach out to them, say, we are seeking sponsorship. have Beanie like generate some sort of like clip montage of all our hot dog conversations and and we we'll wear their hats.
Gianluca Bini: Yeah.
Annatasha: Like I will sell my soul.
Ryan Bailey: Oh, know.
Annatasha: i don't even care. Let's get on top of this. Like hot dogs bringing, you know, whatever Schneider's hot dogs bringing veterinary anesthesia.
Gianluca Bini: Bien.
Annatasha: Very
Ryan Bailey: I've been thinking a lot about what I'm going to do when I decide to leave veterinary medicine. And I think there's a thing called Hot Dog U, where you get to go to the Vienna Bee factory and you learn about selling hot dogs. And maybe I'll open my own hot dog cart.
Annatasha: I feel like you would be so happy.
Ryan Bailey: I mean, i'd be a lot happier than doing it.
Annatasha: You'd also be that weird person that when a normal person just wants to buy a fucking hot dog and you start going off on a hot dog tangent and they're like, oh God, I just want to buy my hot dog and get away.
Ryan Bailey: Yeah.
Ryan Bailey: I think that's how we are when someone asks us an anesthesia question. We're like, let me tell you about the microvascular circulation, the glycocalyx. Let's talk alveoli. Let's work through the five different causes of hypoxemia.
