Transcript
Annatasha: be hosting, right?
Gianluca Bini: It is. It is Tasha. It's your turn.
Gianluca Bini: for it.
Annatasha: All right. And okay, so tonight, we're going to do a little bit of a potpourri. And I have a set of hypothetical questions that I sometimes cogitate on in moments of boredom or procrastination. But the first question I have for tonight's talk is if you were trapped on a desert island indefinitely, indefinitely, you could only go with one drug for anesthesia, which drug would you pick?
Gianluca Bini: Oh, Jesus Christ.
Ryan Bailey: One drug.
Gianluca Bini: You get one shot, one opportunity.
Annatasha: Yeah, that's right.
Gianluca Bini: You know what? I'm debating with inulfaxolone and ketamine.
Annatasha: Yeah, for whatever reason on this desert island, we also have a veterinary hospital where we do TPLOs.
Gianluca Bini: Okay.
Annatasha: And need to know, what drug, the one drug that you're going to take to this TPLO only desert island?
Gianluca Bini: Okay, 100%.
Annatasha: Interesting.
Gianluca Bini: How about you, Ryan?
Annatasha: Bailey?
Ryan Bailey: I mean, I don't know, like... If it's not painful, I feel like propofol because it's just so smooth and nice and you get a good anesthetic plane and hemodynamic stability. But like if I don't have any analgesic drugs, what am I going to do?
Ryan Bailey: I mean, so I feel like you're almost forced to be ketamine. Dexmed isn't powerful enough to like provide everything like it can't provide. mean, I think you have to choose ketamine.
Annatasha: I mean, you could go with a very potent opioid, right? I mean, you can use opioids for an induction.
Ryan Bailey: But that's only if you're working with dogs.
Annatasha: True.
Gianluca Bini: Oh, because now we go back to cat, sympathetic tone.
Ryan Bailey: Plus, you can't anesthetize a cat with enough fentanyl, from what I hear.
Annatasha: Oh, Ryan.
Annatasha: I thought for sure, Ryan, you'd pick Alphax because at least Alphax, too, you can give IM, right?
Ryan Bailey: Yeah.
Annatasha: Because I never...
Ryan Bailey: Alphax is a good, just feel like with Provo, it's just, Provo is so reliable and so smooth and there's no jitteriness and like, it is just like, that's where all the evidence is, especially from the human side for the like Teva stuff. So like, love it.
Ryan Bailey: Love it.
Gianluca Bini: Yeah.
Annatasha: Yeah.
Ryan Bailey: We, ever since I,
Annatasha: I mean, don't me wrong. I'm a propofol fan. I have like, you those little like chemical symbol necklaces that I wear sometimes.
Gianluca Bini: Aww.
Annatasha: I know. Word alert. Wow.
Ryan Bailey: Yeah, nerd alert. I mean, ever since my Teva podcast, were like, some days it's like 50% or some weeks it's 50% of the cases are run under propofol Teva.
Annatasha: Wow.
Gianluca Bini: Nice.
Ryan Bailey: Yeah. I don't know. The techs love it. They're like, let's do it. And I'm like, again, do we have to?
Gianluca Bini: Yeah.
Ryan Bailey: Can we like, just go back to ISO? Let's just like do some ISO today.
Gianluca Bini: Yeah. Iza is overrated.
Ryan Bailey: It is.
Annatasha: Oh, the root of all evil. We know that. Everything.
Ryan Bailey: It is.
Annatasha: Yeah.
Ryan Bailey: And they are just so smooth. Like, it's so rare I have to do anything with those cases. It's just like all...
Annatasha: Are you sure you don't want to pick iso so you can mask them down?
Gianluca Bini: Yeah.
Annatasha: You can box them down, Bailey. Like, I know you love that.
Ryan Bailey: The open drop technique, the, like, liquid injection...
Gianluca Bini: Oh, Oh, geez. I think you just...
Annatasha: You can bubble it through the water. You could paint it on the amphibians. Like...
Ryan Bailey: I wish I was one of those more seasoned, I'll say, anesthesiologists, and I could be like, I wish we still had palithane or urethane or whatever.
Annatasha: Ether?
Ryan Bailey: Yeah.
Ryan Bailey: about nitrous?
Annatasha: God, I wish had ether.
Ryan Bailey: That's a...
Annatasha: It's such a good drug.
Gianluca Bini: Gross.
Annatasha: We use nitrosol through my residency and no issues. Mm-hmm.
Ryan Bailey: Yeah. I use NyTest couple times.
Gianluca Bini: That's
Ryan Bailey: It's nice. But, again, if you're doing anything that's not a dog or a cat, there are some issues.
Annatasha: Yeah, I mean, I'm not going to crank my cow with bloat full of nitrous, but there are no cows on this island, so don't make sense.
Annatasha: Yeah, there are no cows.
Ryan Bailey: You're not doing cheap billows on these horses?
Annatasha: Also, side note, I'm trying to be calmer tonight because last week's podcast clips, I was like, oh, I need bring my blood pressure down about work. So I'm just going to be nice and calm, courtesy of Italian white wine.
Annatasha: Yeah.
Ryan Bailey: Lovely. Of
Gianluca Bini: So what's your favorite wine?
Annatasha: Oh, that's a good
Gianluca Bini: you had to bring a wine bottle on the island, which one would it be?
Ryan Bailey: course.
Annatasha: I'm going to pick a Viennese Gemishtesatz.
Gianluca Bini: I would what?
Ryan Bailey: Of course.
Gianluca Bini: Sure.
Annatasha: It's a blended white varietal from the Viennese Hills. usually like it's old school, it's family made, it's a table wine, but you know, really it goes down smoothly it, you know, there's so little sugar content and sulfite content because they don't export it that you don't get a hangover. So that's my pick.
Ryan Bailey: Does it have another name, the grape? Or like the wine side?
Annatasha: No, cause it's a blend of multiple grapes, right?
Ryan Bailey: What grapes are in it?
Annatasha: Yamishta means mixed. So yeah.
Ryan Bailey: Oh. Learn something new.
Annatasha: How about you? How about you Beanie?
Annatasha: Hold on second. My dad is blasting the TV in the background, so I'm going to move locations.
Ryan Bailey: It sounds so nice.
Gianluca Bini: I probably, I mean, I really like Malbecs.
Ryan Bailey: anything in the Gamay family is just like, I love a lightly chilled red.
Ryan Bailey: It's like one my favorite things.
Gianluca Bini: Okay.
Ryan Bailey: Just like,
Annatasha: A petit verdot, like...
Ryan Bailey: like a red wine that you can just like slug down is just like the bomb.
Annatasha: That's exactly how you're supposed to drink wine. Just, like, open your gullet and neck it.
Ryan Bailey: Yeah, yeah, exactly. That's my jam.
Gianluca Bini: Sure.
Ryan Bailey: I don't need those big, bold California Cabernets like Zimpandel or anything like that. Just give me like a nice lighter bodied red. I mean, I love a Malbec, but like the thing I drink the most is like Gamay, Beaujolais, anything in that family is just like, it's my jam.
Ryan Bailey: It's my jam.
Annatasha: I do like a lighter red. Some of like blackberry, like heavy, like the Cab Francs and all that kind of stuff.
Ryan Bailey: Yeah. Yeah.
Annatasha: I don't mind those with the right meal, but I usually get like a spanking headache. So...
Gianluca Bini: Yeah, hate when they have like eye tenons and stuff, but like I really hate that. I can't deal with that.
Annatasha: There are some filters that you can get that where you just pour the wine through, right? And it like, it will take the tannin and then there's a separate one for the sulfite.
Annatasha: Cause the sulfite is the preservative for shipping, right?
Ryan Bailey: Right.
Annatasha: Which is why it's always better to drink the local wine if you're wherever you are than it is to drink the imported wine because then you don't get that sulfite content.
Ryan Bailey: Yeah.
Annatasha: And that's a big contributor to that like hangover headache situation.
Gianluca Bini: Yeah. I mean, I don't drink enough wine to like actually care, but I get it.
Annatasha: but you're Italian.
Ryan Bailey: Yeah.
Gianluca Bini: get it. No, I'm not. I'm not actually, think my transformation to American just, you know, we went to Saturday for the first time. went to the range.
Gianluca Bini: Right. So I know I never shot before.
Ryan Bailey: Wow.
Annatasha: Oh.
Ryan Bailey: Wow.
Gianluca Bini: And so like,
Annatasha: Oh. So it was just a gun range or like you got to like lasso like burrows.
Gianluca Bini: No, it's just a Gant range. So yeah, we shot a 9mm and a revolver.
Gianluca Bini: It was my first time.
Annatasha: Handguns.
Gianluca Bini: I was like, actually, pretty nice. We may go back for some rifles, I guess.
Gianluca Bini: So this is
Annatasha: Drinking the Kool-Aid.
Gianluca Bini: this
Annatasha: I got to get you up to Canada before this gets worse. Like before you know it, you'll be eating like pizza on crackers and.
Gianluca Bini: Wait, wait, wait. So this place, so this range actually has a bar inside, right? So you could drink...
Annatasha: Perfect. Alcohol and guns. Nothing bad ever happened with that combo.
Ryan Bailey: nothing.
Gianluca Bini: And we were like, is there any rule about this? Like, you know, can you like... drinking and I was like, there's no role. Like you just, whatever. was like, okay.
Ryan Bailey: Oh, yeah.
Gianluca Bini: And then like right beside us, there was like a family with like an 80 year old just shooting like these massive rifles and the kid was shooting too. And I was like, holy God, I've never seen this.
Ryan Bailey: Wow.
Annatasha: It's just like in parts of Southeast Asia where you can go and like, like fire off bazookas you know, like, like relics from the Vietnam War. And you're like, you know, I'm okay. I'm just gonna go for like, foot massage.
Annatasha: Like, I don't Yeah, I didn't feel like, you know.
Ryan Bailey: On the side of local cuisine, that's plenty for me.
Gianluca Bini: I definitely felt...
Annatasha: The local cuisine tends to be exploded cow.
Gianluca Bini: I definitely felt really maricott.
Ryan Bailey: that's fine. Somebody it.
Gianluca Bini: I definitely felt really maricott.
Annatasha: Yeah. All right.
Ryan Bailey: Get out of here.
Annatasha: So back to our hypothetical desert island where we're drinking Gamay, Malbec, and Viennese Gnischten Satz.
Gianluca Bini: Sure.
Ryan Bailey: We least have good wine.
Annatasha: Yeah, fuck yeah. And ketamine.
Ryan Bailey: mean, we're going to need because we can only use one drug.
Annatasha: And ketamine.
Gianluca Bini: You need...
Ryan Bailey: Wow.
Annatasha: Okay. Now, if you, same island, same scenario, you're stuck there and you can only take one piece of anesthetic monitoring equipment, which one would you take?
Gianluca Bini: Botox.
Ryan Bailey: Oh, interesting. I...
Annatasha: Pulse ox, huh?
Ryan Bailey: What would I take? I mean, I guess I'd probably go with like a Doppler. It gives you so much.
Annatasha: Oh,
Gianluca Bini: What the fuck?
Annatasha: I cannot express to you the depth of my hatred for a Doppler. I mean, what a finicky piece of bullshit machinery that is.
Ryan Bailey: Wow.
Ryan Bailey: and a pulse ox is not finicky.
Annatasha: didn't vote for Paul Sox.
Ryan Bailey: The pulse ox I have, if it doesn't go on the tongue, it doesn't fucking read. And it's like the good quality one.
Annatasha: I didn't vote Paul Sox. I would vote CO2. I'd pornography.
Ryan Bailey: Another solid answer. You know what? That's a good... Yeah.
Annatasha: That's my choice.
Ryan Bailey: Oh,
Annatasha: You can keep ECGs because they read on dead things. You can keep pulse hoxes because they don't read on dead things.
Ryan Bailey: obviously. I
Annatasha: I hate Dopplers. And, I always feel like when I'm putting a Doppler on, like, what is this like 1850?
Ryan Bailey: hate that one.
Annatasha: Like, are we using sonar?
Ryan Bailey: Oh my god.
Annatasha: Like, I just know.
Ryan Bailey: Love the Doppler.
Ryan Bailey: Get the signal. I like... I am still proud of my ability to one-shot a Doppler in any animal. Like...
Gianluca Bini: Yeah, but what do you do with it? Like you hear
Ryan Bailey: I mean, I take blood crushes with it. When the... When...
Gianluca Bini: The number you get, it's super unreliable, right?
Ryan Bailey: When, like, literally...
Gianluca Bini: Like you know that
Ryan Bailey: Today, techs are like, oh, the blood pressure's here, and it was here, and da-da-da-da. I'm like, put a Doppler on. Let's see what the Doppler says. Let's see which one it agrees with. And then they mess with the cuff, and sure enough, the cuff was like totally malpositioned.
Ryan Bailey: It's like, I just threatened the Doppler.
Annatasha: The Doppler is bullshit, especially Bailey and cats.
Ryan Bailey: Sure. Sure.
Annatasha: You know it is.
Ryan Bailey: I'm not, like, I get one piece of equipment. It's like CO2 only tells you the animal's breathing.
Annatasha: No, it doesn't. It tells you about cardiac output and it tells you about employment integrity.
Ryan Bailey: No, not on spontaneous respiration. Come on.
Annatasha: Come on.
Ryan Bailey: Come
Annatasha: Come on. The Doppler does not tell you anywhere as much as the CO2.
Ryan Bailey: Come. We don't have a ventilator here, Bartell.
Annatasha: The CO2 tells you about equipment integrity, airway patency. It tells you about circulatory capability, and it tells you about ventilation.
Ryan Bailey: Sure, I'm not disagreeing.
Annatasha: And you know what Doppler tells me?
Ryan Bailey: It doesn't do well.
Annatasha: This.
Ryan Bailey: No, not if you're good.
Annatasha: That's what the Doppler tells
Ryan Bailey: If you're an expert Doppler placer, like myself, big crystal, all animals, never using that little crystal.
Annatasha: don't know.
Ryan Bailey: I get it 100% of the time, every time.
Annatasha: 100% of 100% of the time. That's not even statistically possible.
Ryan Bailey: Yeah, I'm fucking that good.
Gianluca Bini: You guys, I'm just sitting here and like seeing, watching the debate, know, it's, it's...
Ryan Bailey: You can potentially tell pulse quality from it. You can listen for their response to the
Annatasha: Sure, you can potentially interpret mean and diastolic pressure, but then sometimes it's a false systolic pressure.
Gianluca Bini: What do you think of it?
Ryan Bailey: Sure.
Annatasha: But if you get the systolic, how do you know you're still not hypotensive because you can't actually read the pressures that matter, which are really mean and diastolic?
Ryan Bailey: Sure.
Ryan Bailey: I mean, I never asked for a sphygno-menometer. I just asked for a Doppler.
Annatasha: Oh, oh, okay.
Gianluca Bini: So then, I mean, I guess you can just.
Annatasha: So even more irritating.
Gianluca Bini: Okay. You guys.
Ryan Bailey: At least I get to hear the patient's heartbeat.
Annatasha: Even more annoying.
Ryan Bailey: I don't have to, like, get my stethoscope and be like, going to reach under the drapes, see if the dog's alive.
Annatasha: I mean, if you have CO2, you don't have to do that either.
Ryan Bailey: That's true.
Annatasha: Also, the Doppler's affected if you give potent peripheral vasoconstrictors.
Ryan Bailey: That's true.
Ryan Bailey: Oh yeah,
Annatasha: Now, back to Bini's shit choice of the pulse ox.
Annatasha: Bailey, let's hang up on him and discuss that because that was the worst answer ever.
Ryan Bailey: Which Pulse Ox though? Name the brand.
Gianluca Bini: Okay, don't know if we can do this, but you know, I love Massimo. Yeah,
Ryan Bailey: Sure. Yeah. That's, I mean, if you're going to get one, that's the one to get. Although, I don't know what is with Oz. It has to be on the top.
Gianluca Bini: this is totally, this is, for whoever's listening, this is totally non-sponsored.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: We're not getting any money for this.
Annatasha: Clearly this isn't sponsored.
Annatasha: Who would sponsor us? Like, you know what?
Ryan Bailey: Yeah.
Gianluca Bini: Nobody.
Annatasha: The wine companies.
Gianluca Bini: There we go.
Gianluca Bini: But I would use a reflectance probe.
Ryan Bailey: Oh my gosh.
Ryan Bailey: Oh my gosh.
Annatasha: Oh, look at you.
Ryan Bailey: God.
Annatasha: Oh, Bailey's cute new cat is here.
Ryan Bailey: When the text string...
Annatasha: Grease ball.
Ryan Bailey: Whoa, Greaseball! Carol's going to love when that happens. Oh my god. I don't want to grab you.
Annatasha: Oh yeah, he does look like he's a little touch hyperthyroid there, Maylee. Look at that tail.
Ryan Bailey: I know. I know, yeah. That's why his name is Greaseball.
Ryan Bailey: We're debating... I think the top contenders are Marv, as in Home Alone, and Moe, as in
Annatasha: I like Marge.
Ryan Bailey: M-A-R-V.
Annatasha: Yeah, I like that.
Ryan Bailey: Mo, as Mo Cara, which is the Irish phrase for my friend, because we always refer to him as my friend, and we got him around St. Patrick's Day.
Ryan Bailey: Yeah. Those are the leading contenders.
Annatasha: You see, he's got a Marv vibe about him. Look at him.
Gianluca Bini: He does.
Ryan Bailey: He does. think Marv's going to win it.
Gianluca Bini: He's cute.
Annatasha: Yeah.
Ryan Bailey: But Greaseball for now.
Gianluca Bini: So are you so against cold success? Like, what's your... It really fails me, right? Like I never, rarely have issues, especially if you use the right tool, which is, you know, usually a reflectance probe does the trick, you know.
Annatasha: Well, he.
Annatasha: If you are on a hundred percent oxygen on our desert island where they have a hundred percent oxygen, what does the 98% pulse ox really tell you though?
Gianluca Bini: That it has enough oxygen.
Annatasha: Does it though? I mean, it tells you that technically clinically you're not going to be hypoxemic, but relatively speaking, you might be based on your inspired fraction.
Ryan Bailey: I was
Gianluca Bini: It has.
Ryan Bailey: like, what are the
Gianluca Bini: Does it matter? I've seen
Ryan Bailey: Like, what are the odds of dealing with hypoxemia in small animal patient?
Ryan Bailey: Come on.
Ryan Bailey: Like, what the percentages of small animal patients that are developing hypoxemia under anesthesia?
Annatasha: Well, if you're doing actually hard cases, Bailey, more than you think.
Gianluca Bini: it. I've seen it.
Ryan Bailey: Okay, on this desert island where we have one drug and one monitor, we're going to YOLO and fucking do like an open chest with manual ventilation a pulse oximeter.
Annatasha: Oh, I didn't say there wasn't a ventilator on the magical island.
Ryan Bailey: Cool. I'm going to go drown myself in the ocean and hope a shark eats me.
Gianluca Bini: Okay. But, you know, I've definitely seen it. Like, you know, I've seen patients that, you know, where nobody actually ever heard VSD and we and we couldn't, you know, we tried troubleshoot lot of things and then ultimately were like, okay, let's put the probe on. And like, it had right to left shunt.
Gianluca Bini: And so, you know, we put on the right B, we fixed it, but, you know, It does happen, right? I mean, it's not probably common, right? It's not someone that you see every day, but shit does happen.
Ryan Bailey: Yeah.
Gianluca Bini: I mean, you patients that you anesthetize and they have small amounts of chaludorax and you don't know about it, right?
Ryan Bailey: Yeah. Yeah.
Annatasha: I don't know.
Gianluca Bini: Maybe. You know what I mean? Like, there is a lot of patients that don't...
Annatasha: Pulse walks also, you know, I just don't like finicky things. That's why I dislike the Doppler. And sometimes the pulse walks are real jackass.
Gianluca Bini: How finicky is that? Like, what kind of pulses do you use?
Annatasha: And, you know, it doesn't work if you're dysrhythmic.
Ryan Bailey: What? Let me talk about capnography is not finicky. Oh my God. The moisture trap has the skosh of water. Every patient, 10 inspired CO2.
Ryan Bailey: Unable to resolve the inspired CO2. The little, the little...
Annatasha: I would say the percentage of time where I have to fart around with the pulse ox to make it work appropriately versus the CO2, that's probably a tenfold.
Ryan Bailey: We...
Annatasha: The pulse ox way more persnickety.
Ryan Bailey: I do have one machine that's like every, I have to change the water trap every single case because it's just like, oh, the vapors, they've got me.
Annatasha: Okay. It's not Sunset Boulevard, Bailey. It's a desert
Annatasha: think all of these pieces of equipment have a role to play comprehensive monitoring, but that's why I specifically said you can only have the one thing. And I stand by my CO2 after that discussion.
Ryan Bailey: Which style?
Annatasha: Sidestream, Bailey. I don't give a fuck, right? Like,
Ryan Bailey: I mean, there's merits to both, right?
Annatasha: yes, I wrote that essay on the exam and I'm not writing it again.
Gianluca Bini: the rhythm. I think that the merit of the mainstream is that it gets trashed really fast.
Ryan Bailey: did not have that essay.
Ryan Bailey: Yeah, that thing would get destroyed in your desert island.
Annatasha: Yeah, it's going to get sandy. It's going to cause drag.
Ryan Bailey: Yeah.
Annatasha: They're going to extubate. Like they'll have to give them more ketamine. Like, no, no, no, no. Okay. Next desert island scenario question.
Annatasha: You've landed on the desert island with another person who's decided that they've got nothing else to do but qualify as an anesthesia technician.
Annatasha: What are top three tips or tricks that you would teach your new assistant or your new training technician?
Ryan Bailey: Wow.
Ryan Bailey: Okay. Number one.
Annatasha: Number one, get the Doppler, get the Doppler.
Ryan Bailey: I just got one. Number one. Get the Doppler. Number two. Only use Propofol. Number three. Fuck the pulse oxen. No. Me.
Ryan Bailey: Just the number one for me. And this is the really. It's going to be really boring. And it's like. But do every case. Like the way you physically do the tasks.
Ryan Bailey: Do them the same every single time and establish your own routine.
Annatasha: Love that.
Ryan Bailey: And like, yeah.
Annatasha: Love that. Get faster, you get safer, you get more efficient.
Gianluca Bini: So you basically want the robot.
Ryan Bailey: What's that?
Gianluca Bini: You basically want the...
Ryan Bailey: Yeah. Oh yeah. Like feel like am an anesthesia robot. Like every way it's the same every single time. And I can just like, you know, when shit goes wrong, you know it in your bones because the muscle memory is suddenly different. You're like, something's wrong.
Ryan Bailey: And then like immediately you start working through it because something's just, there's a slight variation in the normal.
Gianluca Bini: Yeah.
Ryan Bailey: I mean,
Annatasha: like that. Yeah.
Ryan Bailey: what other, I mean, That's like my biggest one.
Annatasha: It's a good one.
Ryan Bailey: got to think about the other two.
Annatasha: right, Beanie.
Gianluca Bini: I think definitely, you know, get used to like touch the patient, like, you know, make sure that you like, you know, get, you know, you're not getting too comfortable with just, you know, the monitor sometimes.
Gianluca Bini: The other thing is probably you want to make sure that you're, you know, you're actually knowing what the drugs do, right?
Gianluca Bini: This is a random thing.
Annatasha: I don't if that's a tip or a trick. I feel like that's just a bug standard expectation, but yeah.
Gianluca Bini: But, you know, that's not always the case, right? Like it's
Annatasha: A hundred percent.
Gianluca Bini: And then the third thing is probably like,
Gianluca Bini: you know, I would treat, probably this is the most important, I would treat them the way you want them to be treated, right? Like the fact that they can't speak, it doesn't mean that they don't feel pain. It doesn't mean that they don't deserve to be treated like, you know, like we are, right? Like I know that, you know, there are animals, but we're animals too, right? Like, yeah.
Annatasha: Yeah, we're the worst kind of animals.
Ryan Bailey: Truly.
Gianluca Bini: Exactly.
Ryan Bailey: Oh.
Gianluca Bini: Right. And probably the most destructive of all them.
Annatasha: Ugh.
Gianluca Bini: But, you know, unfortunately, sometimes I think there is a disconnect. Right. And do like, you know, yeah, that procedure is not painful.
Gianluca Bini: was like, yeah, if they chop your balls off, isn't painful?
Annatasha: I mean, just do some horse anesthesia and get into it with the horse surgeons about butorphanol and analgesia and you'll be like, yeah.
Gianluca Bini: Well, thankfully, you know, I'm glad and I'm thankful that I work in a place where they do value that. And they, you know, we use morphine on, you know, almost any horse, like, you know, that it's getting a decent procedure, like, you know, anything that's orthopedic, anything that's a major soft tissue, they get definitely, know, morphine. Even constrictions, they do get morphine, right? Like, I don't think they're chopping somebody's balls off. It's,
Gianluca Bini: not painful, right? I don't know who thought that, you know, when you neuter a cat, it's okay to use kitty magic with Torben in it.
Gianluca Bini: I also, what the fuck is kitty magic? I hate that shit, right?
Ryan Bailey: I
Ryan Bailey: got my other two.
Gianluca Bini: The fuck is that?
Ryan Bailey: Alright, so one of them is learn to do nothing.
Annatasha: Oh, okay. All right, Bailey, hit us.
Annatasha: Oh, yeah, yeah.
Ryan Bailey: Like
Annatasha: Just sweat it out.
Ryan Bailey: There is just like, there's two sides that coin is.
Ryan Bailey: One, good anesthesiologist knows when and how to intervene. Like we are interventionists. Like we loved intervening. We loved to fluid bolus, atropine, start a presser, add more drugs.
Ryan Bailey: But like, we love to do all that. But then we also know when to just sit back and watch and let something develop. And then like, don't like...
Ryan Bailey: so many people have this knee jerk reaction to react and intervene. And sometimes just step back, reassess, reevaluate, like Beanie said, get your hands on that patient. And it's not like, no, like be okay, not always intervening.
Ryan Bailey: Like, I think that's, sometimes I just sit there and I just quietly watch to see what's going to happen when people are like, what do we do? And I'm like,
Ryan Bailey: We're just going to sit here right now and we're just going to...
Annatasha: Yeah, just patients. Like my technicians told me last week when I was on clinics with them, they were like, we, they, they're like, Tasha, we know that you're more of a watch and see anesthesiologist. And I was just like, yes and no.
Ryan Bailey: Yeah.
Annatasha: It's just, I have patients for letting things flush themselves out.
Ryan Bailey: Yes.
Annatasha: Like if you bowl as propofol really quickly and they go apneic, I'm not going to flip the ventilator on.
Ryan Bailey: Yes.
Annatasha: If you're saturating, I'm going to wait until the propofol redistributes and then I'm going to let you breathe on your own.
Ryan Bailey: Yes.
Annatasha: And So they called me wait and see anesthesiologist, which made me laugh. But I agree, like I have a little motto that that I always tell when I'm training, which is anytime you intervene and you, quote, fix a problem, most of the time you also make another problem.
Ryan Bailey: Yeah.
Annatasha: Right. And then you spend the entire procedure chasing your own tail, no pun intended. Because you fixed a problem, made a problem, fixed a problem, made a problem, fixed a problem, made a problem, you know?
Ryan Bailey: Yeah.
Annatasha: So, you know, sometimes less is more. And so I think that tip is, God, we're agreeing a lot tonight, guys.
Ryan Bailey: Totally.
Gianluca Bini: Yeah.
Annatasha: Like, whoo.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: Well, I think that's a good point, but there are things where you do need to intervene, right? So if your blood pressure is shit, you can be waiting 20 minutes because you want to rub it up.
Ryan Bailey: Oh, yeah. Yes.
Ryan Bailey: Yeah.
Annatasha: I've taken lots of things off the table before with unreadable pressures that survived to discharge.
Ryan Bailey: There you The only metric. Yeah.
Annatasha: I don't do it on purpose, but it's just the way things go sometimes. But I'm going to interview with one of my tips before we get to Bailey's third one, which I find that and this is almost a carry on from your comment, Bailey, about just leave things alone and also a little bit John Luca, like understand what's going on.
Annatasha: But I'm a big believer in stop treating numbers on the screen. Right. Like, so, you know, like hands on the patient waiting to do nothing. Like I like to think about what's happening in the greater context of patient physiology.
Annatasha: Right.
Ryan Bailey: hmm.
Annatasha: So, you know, for example, you slam whole bunch of, you know, peripheral vasoconstrictors in there.
Ryan Bailey: Yep.
Annatasha: Sure. You get a good number on the screen, but let's talk about what's happening to perfusion. You know, or, you know, you want to ventilate a patient maybe who,
Annatasha: know, has been chronically alkalemic and you want to, you know, drive CO2 into a normal range and then you completely like throw off their compensated blood pH, right? So, you know, taking that moment to not just, like you said, knee jerk and taking that moment to put your hands on the patient. And it's not just about the numbers on the screen. It's how are those numbers being generated and what does it really mean in the face of what's happening in this patient in this moment?
Ryan Bailey: That's my other one. Do not monitor the monitors because they will lie to you so many times. There are so many times I walk in and I look at the CO2 waveform it's just a little like this.
Ryan Bailey: And I'm like,
Annatasha: Can we talk about the problems you have with your CO2 at your hospital? Like, can you a new CO2 monitor?
Ryan Bailey: when the patients are tachypneic or you're on a rapid respiratory rate and you don't get like that plateau phase and it's like well CO2 is only 50 and then I'm like yeah crank up the vent all a sudden CO2 is like 105 and I'm like you need like we need to address the ventilation this waveform doesn't give you any information this waveform gives you garbage and when you read garbage you like do garbage
Annatasha: It's very subversive attack on my CO2 comment from earlier and you trying to self promote Doppler's, but,
Annatasha: but yeah, no, I don't monitor the monitor, right?
Ryan Bailey: Yeah, the top level would cut stuff for sure.
Annatasha: Don't react only to numbers. Like what does the number tell you and what, in the face of what's happening with that particular patient?
Ryan Bailey: Yep.
Annatasha: Like, is this patient bleeding? Is this patient profoundly hypothermic? Is this patient have good peripheral pulses? What color are its guts? Like, are you shunting in your lungs? Like, It's that whole comprehensive way of pulling together and trying to think your way through it.
Annatasha: And I feel like that's, I know that comes with experience and more advanced training too, but like jumping down the throat of every number on the screen, I think is bad anesthesia.
Ryan Bailey: Yep.
Ryan Bailey: The drive to make every individual number perfect.
Annatasha: But with no context of what's really happening or what might be appropriate, like a CO2 of 35 might not be appropriate for that patient based on
Ryan Bailey: You know?
Ryan Bailey: Right. Yeah.
Ryan Bailey: For sure.
Annatasha: chronic pH or like acid-based status or whatever's happening intracranially or what have you.
Ryan Bailey: Yeah.
Annatasha: So anyway, my other one is, by the way, is you have to understand the machine.
Ryan Bailey: Mm-hmm.
Gianluca Bini: I have a question for you, right?
Annatasha: You have to understand the damn machine.
Gianluca Bini: Yeah.
Annatasha: And I know it looks intimidating. It used to freak me out too. Like understanding the machine, like the flow, what everything means, what it means when the various parts break, you know, like what are your various safety mechanisms? But like, I teach this real life machine talk, you know, it takes me like an hour and a half and people will be like, that's more than I've ever heard about the machine in my life. And I'm like, but that's the fundamental thing. Like,
Annatasha: In theory, you should be able to build essentially a pneumatic machine from like parts in your garage.
Ryan Bailey: Yep.
Annatasha: Like, and if you can't understand flow and if you can't understand safety mechanisms and you don't understand the machine, then you really fundamentally don't understand lot of the physics and the mechanics of ventilation.
Annatasha: and also, you know, things like inhalant uptake and all that kind of stuff.
Annatasha: So, you know, going through that machine is something I hammer at like once a month, I'm like back to the flow meter, back to the vaporizer, like all that kind of stuff. Like what are the safety mechanisms and what do they mean?
Annatasha: And this alarm and that alarm. And you know, what happens if you knock the machine over, which, you know, always happens with those stupid pole machines that are top heavy and,
Ryan Bailey: That's what we have. I mean, the nice thing they're so... was thinking about your comment about understand the machine. The machine I have is so easy to understand.
Ryan Bailey: You can basically see all the parts of it.
Annatasha: Yeah. You can follow the flow of oxygen, right?
Ryan Bailey: But these really nice human machines, the anesthesia workstations, it's like...
Annatasha: You can't see anything.
Ryan Bailey: Which, you know, there's pros and cons. Like, that is why...
Gianluca Bini: I love
Ryan Bailey: I love them, too. I think they are far superior the, like, garbage machine I have.
Gianluca Bini: them. We have eight Veta 5s from Mindray and they're the most gorgeous, beautiful.
Gianluca Bini: Actually, no, we have six and we have two Wados, which are the big brother of thing.
Ryan Bailey: Yeah. Yep.
Annatasha: Thank
Gianluca Bini: But they're amazing. Like if you want the idiot proof machine, that is it.
Ryan Bailey: Yeah.
Ryan Bailey: Well, that's the funny thing is those human machines are so much safer.
Gianluca Bini: It is.
Ryan Bailey: They're designed with safety in mind, whereas the veterinary does not have the same standards, obviously. And so the flush valve is needed in a certain...
Annatasha: Obviously. Obviously we're shit.
Ryan Bailey: mean, we just don't the same regulation because, again, it's dogs and cats, right? And, like, horses and whatever. And, like, I've seen anesthesia machines where the flush goes right through the vaporizer.
Annatasha: Oh, that's exciting and horrifying at the same time.
Gianluca Bini: Let's clear this one.
Ryan Bailey: I have seen people jerry-rig a machine to have two vaporizers in series without an interlock.
Gianluca Bini: Oh, that happens all the time.
Ryan Bailey: Yeah, and it's incredibly dangerous.
Annatasha: Yeah.
Gianluca Bini: Yes.
Annatasha: But if you understand the machine, then you recognize that.
Ryan Bailey: like the fastest way to kill patient.
Annatasha: I don't agree it's the fastest way to kill a patient, but it's up there. But I think knowing that machine too, because if you understand, and this ties into my third one, which is it's a know your basic principles, right? People get so tied up in like the fancy details of stuff. And it's like, do you understand oxyhemoglobin dissociation curve? Do you understand like the carbonic acid equation? Like it's really basic fundamental understanding so that when things go potty, or like you said, you get that weird feeling, you know, where you're just like, Ooh, something's going wrong. Like can just tell that this is going to go south.
Annatasha: also too, like if you work in different clinics, like if you do a lot of locum work or you travel or what have you, like half the time I rock up and I'm like, this is the first time I'm seeing this, right?
Ryan Bailey: Yep. Good.
Annatasha: Like there'll be some crazy like setup and like, know, a GP practice where I've gone in to teach,
Annatasha: But if I can walk my way through like basic principles, like funnel and reminiscating of the machine, like I can follow the flow of the gas, then I don't have to have a panic about looking at something that I've never seen before.
Annatasha: Cause I'm totally like, how does this doodow work? Right. And I'll like, you know, fiddle around with it, but basic principles, right?
Annatasha: Like people get, they want anesthesia. I don't know. They want it to be like fancy or they, you know, they want it to be, you know, every case is so wildly different.
Gianluca Bini: Yeah.
Annatasha: And, you know, we want to do all these crazy things. And that's fine, but you can't fly until you know how to walk and then run. And if you don't have that strong grounding of the basic understandings of things like inhalant uptake, what causes hypothermia? Do you understand differentials for bradycardia?
Annatasha: Please don't ask me to teach you an ultrasound guided block. It ain't going to happen, right? If you can't give me 10 differentials for bradycardia, I'm not teaching you a femoral sciatic ultrasound guided block. Sorry.
Ryan Bailey: The thing that blows my mind is how few people... understand like the physics and uptake and like removal of inhalant anesthetics.
Ryan Bailey: Like how it all, it's just like this grand mystery box of inhalant anesthesia, even though we do it literally every day.
Gianluca Bini: Thank you.
Ryan Bailey: Like it is,
Annatasha: I get, I get really like uppity, like my hackles go up when someone says like, oh, I really want to learn like ultrasound guided, like so is compartment or, you know, like erector spinae. And I'm just like, can you explain to me the mechanism of action of propofol?
Annatasha: And then you get like the blank stare. And I'm like, then no. Right. Like, I'm just like, he's like, sorry, like you don't know how the drug that you use every day works. That is not safe. Go learn about that drug. Then we'll talk about like the bells and whistles.
Ryan Bailey: Yeah.
Gianluca Bini: Yeah. No, I mean, I think that some, you know, sometimes people get wrapped up and they want to go straight to the fancy things when, you know, actually a back to basic kind of approach is probably better, right?
Gianluca Bini: Like, but, you know, if you don't have the base, you can build a pyramid, right? Like you need to have a solid base.
Ryan Bailey: Yeah.
Gianluca Bini: But, you know, some people don't care and some people hate the, you know, pharmacology aspect of it. And like, But then, you know, again, if you don't know what the drugs do, what the hell, like, what are you doing?
Gianluca Bini: Is it trying to be a mechanic without knowing how the hand-in works? You know what mean? Like, you can't really do that, you know?
Annatasha: I like that little analogy.
Annatasha: Yeah, that's exactly what it is.
Gianluca Bini: Yeah.
Annatasha: It's...
Gianluca Bini: I mean, this is what I always tell, like, you know, some of the practices we work with, right? Like we, you know, there is services out there that would sell you an anesthesia protocol, right?
Ryan Bailey: Mm-hmm.
Gianluca Bini: I can do that. Like that's a PDF, probably pre-made. It's so easy, right? Like, but it's snake oil, right? Like, you know, you can buy all the parts, right? for, for, to fix your car. But if know what you're doing, you're going to fuck it up.
Gianluca Bini: Right. Like the, the, what's important in anesthesia is the monitoring, right?
Gianluca Bini: the first question I always get asked is like, what's your protocol for this? What's your protocol for that? And my answer is it doesn't fucking matter.
Gianluca Bini: Like, you know, in 99% of cases, you can anesthetize whatever with whatever drug, as long as you stay within the dose range.
Ryan Bailey: Yeah.
Gianluca Bini: And it doesn't fucking matter. What matters is that, you know, how the drugs work and B, what to do if shit happens.
Ryan Bailey: Yeah.
Gianluca Bini: That's what you need to know. Like...
Annatasha: We have to understand that they always want the perfect answer to you noticed that like they'll give you a list of every drug and all the problems and you're like, every drug causes a problem that whole thing is, is, are you anticipating it and are you set up to support it?
Ryan Bailey: Right.
Ryan Bailey: Oh, yeah.
Annatasha: And will you understand it when it happens?
Ryan Bailey: Right.
Annatasha: But yeah, I think people get.
Ryan Bailey: Yep.
Gianluca Bini: Any drugs, including fluids, you know, including fluids.
Ryan Bailey: Yeah. I mean, that's like, to the point about doing it the same every time, like, you know, we all essentially have like, if you will, a plan like plan A is this essentially, like we're going to use, like, this is my generic plan that I'm going to work off of to like run any case. And I know exactly how to time it. I know way it looks.
Ryan Bailey: I know the drugs and like the dosing that
Annatasha: I call mine the bartini, right?
Gianluca Bini: Thank
Ryan Bailey: Exactly. Like, everyone has...
Annatasha: Like have a bartini cocktail and you could do 99.999% of every single case that comes in front of me with a bartini and it will be fine.
Ryan Bailey: Yeah. Yes.
Ryan Bailey: Yep. Right.
Annatasha: you just, you know, when things go potty under GA, either because of what's happening procedurally or because the patient is, you know, exceeded compensation, then that's really where the magic comes in.
Ryan Bailey: Right.
Annatasha: So.
Ryan Bailey: Right, exactly. it's like, you can't like again, like that run, like walk or like walk before you fly, like walking is figuring out your plan and getting doses you're comfortable with drugs are comfortable with, like reliability, and then then starting to build in, you know, change one thing at a time change, you know, once you get comfortable with that change another thing at a time.
Ryan Bailey: you know, with, with supervision, know, like, I'm not saying like, just only do one case, like one thing all the time, never change.
Annatasha: Yeah.
Gianluca Bini: Yeah.
Ryan Bailey: Like that's the way to do it. But like, at least until you're really super comfortable. And then when you're in a situation where you're not comfortable with the case or something, you at least have pharmacology and like a way the, you know, drugs work to fall back on.
Annatasha: Yeah. also find too, like people, when they talk you about anesthesia and like writing the protocol, it is like such tunnel vision about the drugs and the doses. And to me, the protocol is everything from basically like patient admission, if not before, you know, like how is that patient prepped to come in?
Ryan Bailey: Right.
Annatasha: Is it stressed? Is it fractious? You know, like, was it fasted appropriately all the way till survival to discharge, which we, you know, they used to count it two weeks. Now we count it four weeks. So, You know, it's everything about how you handle the patient, how you comfort the patient, how you nurse the patient.
Annatasha: Like the protocol is not just methadone, dexamide, propofolketamine, right?
Annatasha: The protocol is the entire management of the patient to mitigate stress, to mitigate pain, and to optimize outcomes, right? Anesthesia doesn't end when you just pull the tube. It's not salt burn, right?
Annatasha: Like it's, you know...
Ryan Bailey: Although that tube is definitely a veterinary tube, for the record.
Gianluca Bini: Thank you.
Ryan Bailey: 100%. That's like a 51 French or something like that.
Annatasha: Out of all the horror movies I've ever watched, and I don't like horror movies, when he extubated her in salt burn, I almost vomited.
Ryan Bailey: It's so long.
Annatasha: Like, I was just like, oh!
Ryan Bailey: That was insane.
Annatasha: That scene is so disgusting to me. I hated
Ryan Bailey: That tube is so long.
Annatasha: gross. But yeah, no, the protocol is not just drug selection. The protocol is patient management and increasing survivability or ensuring survivability. So... Like I said, it's like, are going to put your catheter?
Annatasha: Like, what if they have, what if it's a bulldog and it has skin disease and like it's wrinkly and it's obese and it can't breathe.
Gianluca Bini: Thank you.
Annatasha: And when you sedate it, it turns blue. Like all of that is the protocol.
Ryan Bailey: And we're doing a four limb mass removal and like... Yeah.
Annatasha: Yeah, like the cow has a fractured tibia and they brought it in here and my induction stall is half a kilometer away. Like that is the anesthetic protocol.
Ryan Bailey: Yeah.
Annatasha: So I think that there's such tunnel vision about like the drugs and like what to pick and how to pick and not nearly enough focus on everything else that has, you actually a much bigger impact.
Annatasha: So yeah.
Ryan Bailey: Just like the Jaha anesthesia guidelines from like, I don't know, 2020, 2022, are like, anesthesia starts at home.
Annatasha: Great.
Ryan Bailey: Which, you know, it does. Like, especially with the advent of oral anxiolytics and sedatives and stuff, like, anesthesia starts at home.
Annatasha: It does.
Annatasha: Right? Yeah. Like, are you going to sedate it? Is going to vomit in the car? Is it painful? Is it decompensating? Do you need to have it
Ryan Bailey: I know we're going to start starving it. Everyone can't wait to starve it. Let's starve it.
Annatasha: already?
Ryan Bailey: was so fixated on starving these goddamn animals.
Annatasha: Yeah.
Annatasha: Well, yeah.
Gianluca Bini: Yeah, no, agree.
Ryan Bailey: I mean...
Gianluca Bini: It's crazy, right? Like people don't have this... Yeah, they're so focused, right? They're so focused on the fucking drugs.
Annatasha: And they're so worried that like, they're like, well, would you give two of dexameta? Would you give three? And real honest to God, no one cares.
Gianluca Bini: It doesn't fucking matter.
Ryan Bailey: Yeah.
Gianluca Bini: It doesn't fucking matter.
Ryan Bailey: I'm going to round it up to the next whole integer.
Annatasha: I do laugh though when people do things like, well, I gave 2.5 micrograms per kilogram of dexameta to me. And I'm like, oh, did you?
Gianluca Bini: It's crazy.
Annatasha: Or when they turn the isoflavor and vaporizer, I turn it from one to 1.1. And I'm like, oh, did you?
Ryan Bailey: This 4.5 kilogram cat, I gave it exactly one microgram per kilo of dexamethonamine. No, you didn't. You gave five micrograms and you moved on with your life because you have better things to do, or at least I fucking hope so.
Annatasha: yeah anyway those are my random stuck on anesthesia only island questions and i do want to shout out to our number one fan leslie b who gave me the idea for tips and tricks too
Ryan Bailey: Hmm.
Gianluca Bini: Aww.
Annatasha: There's a vet tech out there who absolutely loves our podcast and like shares it every week.
Ryan Bailey: Yeah.
Annatasha: And like, it's so enthusiastic.
Ryan Bailey: Oh, God.
Annatasha: And I told her I do our shout out to her in this podcast. So Leslie we appreciate We love you.
Gianluca Bini: Aww.
Annatasha: And thank you for sharing our, thank you for sharing our little sessions here on veterinary anesthesia and all the wonders of the culinary world.
Ryan Bailey: Yeah. Thank you.
Gianluca Bini: Thank you.
Ryan Bailey: Wow, we have a fan. It feels very exciting.
Annatasha: Yeah, we
Gianluca Bini: Yeah. I think some...
Ryan Bailey: Like that one guy's no taste in food.
Annatasha: I mean, have a couple of friends who listen to it and they're neither vets nor anesthetists and they really enjoy it. And they're like, wow, I really learn a lot about things I don't understand at all. And I'm like, great.
Ryan Bailey: I mean, I've had a friend who is a professor in like engineering or some very, like he does, you know, laser and quantum computing and he's like super, super smart.
Annatasha: Yeah.
Ryan Bailey: And he listens to this podcast. He's like, understand none of it, but I love it. He also loves wine. So I'm sure he'll be, I'll be interested to hear his feedback on our desert island wine discussion.
Ryan Bailey: Yeah.
Annatasha: Honestly, I could have a whole podcast just about, I could do a wine podcast separately.
Gianluca Bini: to be home.
Annatasha: Like I love talking about viniculture, but yeah.
Gianluca Bini: I was there.
Annatasha: Oh, yeah.
Ryan Bailey: I actually brought our podcast up today because were anesthetizing a patient and the technician had chosen lidocaine as part of her plan, lidocaine CRI, of course.
Ryan Bailey: And I was like, yeah, it's fine. And then the pink was a little hypotensive under anesthesia, whatever, no big deal. She's like, well, should turn the lidocaine up to further reduce the inhalant? I was like, well, you could, but my colleague thinks it's a fucking waste of a pump.
Ryan Bailey: So I wouldn't worry about it. And I was like, plus the reduction cardiac output and like the MAC reduction you get tends not to outweigh the reduction cardiac output. So I would just move on to pressers at this point.
Ryan Bailey: mean, in humans, it's crazy. Like if you, cause I know what happened to Brosnan when he was like, he reported a story at Davis, I think when he was getting like a toenail removed or something. And he said he started to feel woozy. And then the next thing he knows he woke up because like we were in a lecture for human anesthesia residents and they were discussing local anesthetic toxicity.
Ryan Bailey: And they said, you know, if the, if the patient reports ringing in their ears, the next step is induce anesthesia.
Annatasha: Oh, interesting. I mean, there's a huge amount local anesthetic allergy to not just toxicity, but
Ryan Bailey: Because, because,
Annatasha: Like think 37% of women who receive epidurals for, for birth have an allergic reaction.
Ryan Bailey: Yeah. Oh,
Annatasha: Like some, that's a monster number of people.
Ryan Bailey: wow. Yeah, that's huge.
Gianluca Bini: That's crazy.
Annatasha: And like they often report, like they'll get tingling in one limb and not another, know, or like they're only hemi, like hemiplegic type thing, but it's very, very common.
Ryan Bailey: Oh.
Annatasha: Like people do not do well with locals. We have a lot more forgiveness, for example, in like dogs.
Ryan Bailey: Yeah.
Annatasha: And I mean, how much LidoCain do you give a cow for a standing cesarean, like a bottle
Ryan Bailey: Right.
Annatasha: yeah yeah
Ryan Bailey: Well, like, humans, I guess they do because they need to secure your airway. Because if you get local anesthetic toxicity, the first step is secure the airway. And that's why they induce anesthesia. Just so they can have your airway in case you have, like, respiratory arrest.
Ryan Bailey: They can, like, be ready to intervene at the jump. So I was like, whoa, that is, like, crazy.
Gianluca Bini: Yeah. Yeah.
Ryan Bailey: Because they also report, like, you know, surgeons essentially just, like, injecting local anesthetic without abandon.
Ryan Bailey: You know, for...
Annatasha: I had that happen once in a dental case where basically was just Mipivacaine in a cat and it was just like hosing it down, like, you know, because it was full mouth extractions and the cat actually fibrillated from a local anesthetic.
Ryan Bailey: Yeah.
Annatasha: It started getting like, you know, weird twitching under anesthesia. And then, and I was like, that's not the alfaxalone. And then it went into fibrillation.
Ryan Bailey: Nice.
Annatasha: so, uh, so I ended up, I gave that cat intralipid.
Gianluca Bini: Yeah.
Annatasha: that's how I treated that cat. did, that one did live, but it was, it was a Mepivacan arrest from just, you know, just the volume and like the rapid uptake of, from a hylovascular area, um,
Ryan Bailey: saw on another note, I saw something I have only theorized should occur in cases, and I was like, dang, that's cool.
Gianluca Bini: I'm going what?
Ryan Bailey: We had a patient
Annatasha: It's less cool when you say dang.
Ryan Bailey: We had a patient for a hemilaminectomy and it was on fentanyl as they are. And we gave atropine to try and increase heart rate slightly, but you know, the low, low dose and we slowed his heart rate down enough that he went into escape.
Ryan Bailey: And I was like, just like the usual, like I usually do the 0.01 mix per keg of atropine.
Gianluca Bini: What those did you give?
Ryan Bailey: per dose. I know. I know. More likely. I know. The presynaptic effect. I know. But like generally it works well. I've done it forever. I've been And I was like, I walked in like the ECG is doing something weird.
Gianluca Bini: And.
Ryan Bailey: I walked in. I was like, cool.
Gianluca Bini: Your ship.
Ryan Bailey: We're in like third degree with escape.
Annatasha: Time to get more.
Ryan Bailey: I was like, yeah,
Gianluca Bini: So wait, what was your next step?
Ryan Bailey: So, well, I walked in the room and I initially noted the P waves.
Ryan Bailey: I was like, right, we got hella P waves. We'll be fine. And then I was like, oh, dang, that's an escape rhythm on top of what probably is an atrial rate of 120. So was yeah like, what do I do?
Ryan Bailey: Am I patient enough to like watch a patient third degree AV block without creating a hella blue in the OR?
Gianluca Bini: What
Ryan Bailey: I mean, it's always a great question. It's like a Frenchie, so like how accurate is the blood pressure in the first place? You know, like, I mean, was like, maybe we should put the Doppler over the patient just to check these questions.
Annatasha: Maybe you should put the Doppler on
Gianluca Bini: it matter?
Ryan Bailey: Yeah, I've only, it's never made sense to me how you can slow the heart rate down to 30 to 40 in a dog and not go into an escape. And like, finally I did. And I was like, dang, those are, everyone's like VPCs.
Gianluca Bini: She does.
Ryan Bailey: And I was like, they're not premature though.
Ryan Bailey: There's nothing else going on. It's all ventricular rhythm. This is an escape.
Gianluca Bini: Jesus.
Annatasha: Exciting.
Gianluca Bini: Awesome.
Ryan Bailey: That was cool. That was cool. If the dog had been escape, I probably have let it I'd probably be like, just wait. Those atrial beats will kick.
Gianluca Bini: Yeah.
Ryan Bailey: That atrial rate will start going through the node.
Gianluca Bini: So why the.01? What's your, what's your process?
Ryan Bailey: It works.
Annatasha: That's not, that's such a bunch crap, especially in a state of low cardiac output. It for sure does what you just said.
Ryan Bailey: It works.
Annatasha: yeah
Ryan Bailey: It works.
Annatasha: It
Ryan Bailey: It does. And then I don't have their heart rate skyrocket to 200.
Ryan Bailey: I'm less likely to get their heart rate.
Annatasha: must be fancy Chicago atropine because
Ryan Bailey: I mean, it's also the fancy California atropine.
Gianluca Bini: Is it like...
Gianluca Bini: Is it like tavern style hadroping?
Ryan Bailey: Yeah, exactly.
Annatasha: Bring back Marv.
Gianluca Bini: You get it.
Ryan Bailey: He's hanging out in his box. He was here. He was scratching me on the back of the neck because he wanted to get on the podcast.
Annatasha: Well, Marv is our special guest tonight, everybody.
Annatasha: And Marv also hates the toddler.
Ryan Bailey: Old police ball.
Gianluca Bini: special guest.
Ryan Bailey: Old cat.
Gianluca Bini: Oh, Jesus, guys.
Ryan Bailey: Yeah.
Gianluca Bini: Unbelievable.
Ryan Bailey: Yeah.
Gianluca Bini: So here's my last question, and then I think we've reached the hour, so we probably should let the listeners go. So, you know, you were talking before, Ryan, about how, you know, sometimes they may not give you the right information
Ryan Bailey: Oh god.
Ryan Bailey: Don't get me started on the monitor real quick because I got a lot of feelings about monitoring equipment if you want my honesty in the end.
Gianluca Bini: Well, I mean, here's the deal. So first off, I'm not... The moment you said that your favorite piece of equipment is the doctor, you lost all credibility.
Gianluca Bini: So I'm not going to listen to your BS. But the question is...
Ryan Bailey: Christine will support me.
Annatasha: Who will?
Ryan Bailey: Christine, my resident man.
Annatasha: Oh, Christine. Yeah, I know who Christine, yeah, she probably will because she also, you know, went to the same school, but.
Gianluca Bini: but so if you see, let's say, you know, you see a blood pressure and you're like, Hmm, it may not be real. You know, you believe it, may not believe it.
Ryan Bailey: Yeah.
Gianluca Bini: Right. Like, do you still record it?
Ryan Bailey: So that's a great question, and I wrestle with that all the time. Like, the Frenchie who's...
Annatasha: I only record values that make me look like a great anesthesiologist as a quick.
Ryan Bailey: Oh, yeah.
Annatasha: And
Ryan Bailey: Opportunistically, we only have to record every five minutes, guys. So, like, yeah.
Annatasha: we only write down the good numbers.
Ryan Bailey: Yeah, if like blood pressures hang out in 40, you know, 40 map for like four minutes and 59 seconds, but one reading came in under the wire at a map of like 70, it's like, dang, look at the normal tension.
Ryan Bailey: Just kidding.
Gianluca Bini: Okay, okay.
Ryan Bailey: No, but that's it.
Gianluca Bini: Whoever is listening, believe in this is a joke.
Ryan Bailey: Yeah.
Ryan Bailey: No, but like what we, it happens all the time, right? Like chondrodystrophic dog, cat who's shocky, your volume recess, you're doing things under anesthesia to support this patient, but like you're not getting a reading and you're, you're trying to balance like, gosh, we went from prep to the OR, two different monitors.
Ryan Bailey: Now we've got different readings that are super discordant. How do we treat this patient without intervening? So in like, think that's a really good question.
Gianluca Bini: Yeah. Right.
Ryan Bailey: I wrestle with all the time is the honest answer. But usually in that situation, if I have blood pressures, you know, cause you can, on the modern equipment, you can watch the little bar, like some of ours, you get little bar and you see the bar go up and then goes down and that goes up again.
Ryan Bailey: You're like, all right, well now we have some trouble. I usually note in the record, like, non-invasive blood pressure, you know, not reading or giving artifacts, suspect, da-da-da.
Gianluca Bini: Gotcha. So you make a note of it for liability purposes.
Ryan Bailey: Yeah, that's what I do. I mean, I write the numbers down if there are numbers given to me. I will say some of our equipment will just, like, I don't know, like, just not read.
Ryan Bailey: And I find it, again, it's always –
Gianluca Bini: It sounds to me that you need new monitors.
Ryan Bailey: Yeah. Well, it's the same culprits, though. It's the dachshund with the leg that's like, you know, a hook. And like the Frenchie who's, you know, the right above the paw is this wide, but right at the elbow, it's this wide.
Ryan Bailey: And you're like, which cuff size do I select?
Ryan Bailey: The five?
Gianluca Bini: It sounds like you need either buy new monitors or place more art - lines.
Ryan Bailey: Well...
Ryan Bailey: Yeah, but like, are you really placing an art line for like a straightforward like Frenchy hemilaminectomy? Like, come on.
Gianluca Bini: Yeah.
Ryan Bailey: Come on.
Gianluca Bini: Yeah.
Ryan Bailey: It's not a benign procedure. There are complications.
Gianluca Bini: Not knowing what de facto blood pressure is doing, it's also non-benign.
Ryan Bailey: And...
Ryan Bailey: But blood pressure, like invasive blood pressure is always the most accurate. Like there are tons of times where the blood pressure readings aren't accurate on the invasive. I mean, not as often, but like that monitor is also...
Gianluca Bini: But nap is accurate, which is the only value you care.
Ryan Bailey: errors. Do you re-sterilize your equipment though? Your blood pressure equipment?
Gianluca Bini: You do what?
Ryan Bailey: Do you re-sterilize your invasive blood pressure equipment?
Gianluca Bini: don't know. Trash
Ryan Bailey: I mean, that's nice. That's nice. Must be nice.
Ryan Bailey: a, like a, like when you have a barren blood pressure readings or you're like, blood pressure equipment is cycling, cycling, cycling, and you're in the, you know, you're, you're committed to the case at this point.
Gianluca Bini: I mean, I'm always committed to the case.
Ryan Bailey: No, but like, you're, you're in the OR, you know, you're not still in prep, you know, getting ready.
Gianluca Bini: Oh, I see.
Ryan Bailey: Like, You're like a point where like placing an art line will be a technical challenge.
Gianluca Bini: So yeah, usually, know, our brand new monitors, they work really, really well.
Ryan Bailey: The one we have trouble with the most is the MRI, but it generally reads really well.
Gianluca Bini: Yeah.
Ryan Bailey: It's just, I mean, MRI obviously prone to a lot of technical challenges in of itself.
Gianluca Bini: It's, unfortunately, those are pieces of shit. Right?
Ryan Bailey: Yeah.
Gianluca Bini: Those monitors are,
Ryan Bailey: Yeah.
Annatasha: Agreed.
Ryan Bailey: Yeah.
Gianluca Bini: they're straight pieces.
Ryan Bailey: I mean, it's hard. Like, it's got to be all fancy and like, super long lines, which just then creates like all this, like you're talking about, know, the blood pressure.
Gianluca Bini: I mean, oscillometric, once you have, you know, intrinsically, if you make the tubing longer, you're going to have way bigger variability, right?
Ryan Bailey: Yeah.
Gianluca Bini: Like your deviation is going to be huge.
Ryan Bailey: Yeah.
Ryan Bailey: Yeah. Yeah.
Gianluca Bini: Just because, you know, the oscillations of pressure that they're looking at, they're so tiny that intrinsically they're going to be shit.
Gianluca Bini: So...
Gianluca Bini: Those are the ones where,
Gianluca Bini: you know, it's, yeah, I always struggle with those.
Gianluca Bini: No. But anyway, well, thank you everybody for listening. Next time is going to probably my turn for the next topic.
Gianluca Bini: We may have a special episode in between, so we'll keep you posted on that on our Facebook, Instagram, and all that. Thank everybody for listening.
Annatasha: Thanks, guys.
Gianluca Bini: next time.
Ryan Bailey: Thank you.
