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S1E7 - Must-haves: Desert Island Anesthesia Essentials
142 Plays2 months ago
In this episode of the Random Anesthesia Topic podcast, our trio of veterinary anesthesiologists faces the ultimate hypothetical: What drug, piece of equipment, and training would you bring to a desert island?
From must-have meds to life-saving monitors, we explore what really matters when resources are limited. We also dive into what we believe is the most essential training for anyone assisting with veterinary anesthesia. Join us for this mix of serious insights and not-so-serious scenarios. Because even on a desert island, anesthesia matters!
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Transcript
Intro
Introduction & Hypotheticals
00:00:38
Annatasha
be hosting, right?
00:00:40
Gianluca Bini
It is. It is Tasha. It's your turn.
00:00:44
Gianluca Bini
for it.
00:00:46
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?
00:01:08
Gianluca Bini
Oh, Jesus Christ.
00:01:21
Ryan Bailey
One drug.
00:01:23
Gianluca Bini
You get one shot, one opportunity.
Propofol Discussion
00:01:27
Annatasha
Yeah, that's right.
00:01:31
Gianluca Bini
You know what? I'm debating with inulfaxolone and ketamine.
00:01:36
Annatasha
Yeah, for whatever reason on this desert island, we also have a veterinary hospital where we do TPLOs.
00:01:39
Gianluca Bini
Okay.
00:01:42
Annatasha
And need to know, what drug, the one drug that you're going to take to this TPLO only desert island?
00:01:43
Gianluca Bini
Okay, 100%.
00:01:50
Annatasha
Interesting.
Guns & Alcohol: An Unlikely Pair
00:01:53
Gianluca Bini
How about you, Ryan?
00:01:53
Annatasha
Bailey?
00:01:53
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?
00:02:11
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.
Desert Island Wine Picks
00:02:22
Annatasha
I mean, you could go with a very potent opioid, right? I mean, you can use opioids for an induction.
00:02:29
Ryan Bailey
But that's only if you're working with dogs.
00:02:32
Annatasha
True.
00:02:33
Gianluca Bini
Oh, because now we go back to cat, sympathetic tone.
00:02:39
Ryan Bailey
Plus, you can't anesthetize a cat with enough fentanyl, from what I hear.
00:02:41
Annatasha
Oh, Ryan.
00:02:44
Annatasha
I thought for sure, Ryan, you'd pick Alphax because at least Alphax, too, you can give IM, right?
00:02:44
Ryan Bailey
Yeah.
00:02:48
Annatasha
Because I never...
00:02:50
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.
00:03:05
Ryan Bailey
Love it.
00:03:06
Gianluca Bini
Yeah.
00:03:07
Annatasha
Yeah.
00:03:07
Ryan Bailey
We, ever since I,
00:03:08
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.
00:03:14
Gianluca Bini
Aww.
00:03:15
Annatasha
I know. Word alert. Wow.
00:03:18
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.
00:03:31
Annatasha
Wow.
00:03:32
Gianluca Bini
Nice.
00:03:32
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?
00:03:37
Gianluca Bini
Yeah.
00:03:38
Ryan Bailey
Can we like, just go back to ISO? Let's just like do some ISO today.
00:03:44
Gianluca Bini
Yeah. Iza is overrated.
00:03:46
Ryan Bailey
It is.
00:03:47
Annatasha
Oh, the root of all evil. We know that. Everything.
00:03:49
Ryan Bailey
It is.
00:03:50
Annatasha
Yeah.
00:03:50
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...
00:03:54
Annatasha
Are you sure you don't want to pick iso so you can mask them down?
00:03:55
Gianluca Bini
Yeah.
00:03:57
Annatasha
You can box them down, Bailey. Like, I know you love that.
00:04:00
Ryan Bailey
The open drop technique, the, like, liquid injection...
00:04:04
Gianluca Bini
Oh, Oh, geez. I think you just...
00:04:06
Annatasha
You can bubble it through the water. You could paint it on the amphibians. Like...
00:04:10
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.
00:04:23
Annatasha
Ether?
Anesthesia Monitoring Essentials
00:04:24
Ryan Bailey
Yeah.
00:04:24
Ryan Bailey
about nitrous?
00:04:26
Annatasha
God, I wish had ether.
00:04:26
Ryan Bailey
That's a...
00:04:27
Annatasha
It's such a good drug.
00:04:30
Gianluca Bini
Gross.
00:04:32
Annatasha
We use nitrosol through my residency and no issues. Mm-hmm.
00:04:37
Ryan Bailey
Yeah. I use NyTest couple times.
00:04:38
Gianluca Bini
That's
00:04:39
Ryan Bailey
It's nice. But, again, if you're doing anything that's not a dog or a cat, there are some issues.
00:04:47
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.
00:04:57
Annatasha
Yeah, there are no cows.
00:04:57
Ryan Bailey
You're not doing cheap billows on these horses?
00:05:00
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.
00:05:14
Annatasha
Yeah.
00:05:14
Ryan Bailey
Lovely. Of
00:05:16
Gianluca Bini
So what's your favorite wine?
00:05:21
Annatasha
Oh, that's a good
00:05:21
Gianluca Bini
you had to bring a wine bottle on the island, which one would it be?
00:05:26
Ryan Bailey
course.
00:05:27
Annatasha
I'm going to pick a Viennese Gemishtesatz.
00:05:30
Gianluca Bini
I would what?
00:05:31
Ryan Bailey
Of course.
00:05:35
Gianluca Bini
Sure.
00:05:36
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.
00:05:57
Ryan Bailey
Does it have another name, the grape? Or like the wine side?
00:06:01
Annatasha
No, cause it's a blend of multiple grapes, right?
00:06:02
Ryan Bailey
What grapes are in it?
00:06:04
Annatasha
Yamishta means mixed. So yeah.
00:06:06
Ryan Bailey
Oh. Learn something new.
00:06:09
Annatasha
How about you? How about you Beanie?
00:06:13
Annatasha
Hold on second. My dad is blasting the TV in the background, so I'm going to move locations.
00:06:20
Ryan Bailey
It sounds so nice.
00:06:22
Gianluca Bini
I probably, I mean, I really like Malbecs.
00:06:29
Ryan Bailey
anything in the Gamay family is just like, I love a lightly chilled red.
00:06:35
Ryan Bailey
It's like one my favorite things.
00:06:37
Gianluca Bini
Okay.
00:06:38
Ryan Bailey
Just like,
00:06:39
Annatasha
A petit verdot, like...
00:06:41
Ryan Bailey
like a red wine that you can just like slug down is just like the bomb.
00:06:47
Annatasha
That's exactly how you're supposed to drink wine. Just, like, open your gullet and neck it.
00:06:51
Ryan Bailey
Yeah, yeah, exactly. That's my jam.
00:06:54
Gianluca Bini
Sure.
00:06:54
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.
00:07:12
Ryan Bailey
It's my jam.
00:07:13
Annatasha
I do like a lighter red. Some of like blackberry, like heavy, like the Cab Francs and all that kind of stuff.
00:07:17
Ryan Bailey
Yeah. Yeah.
00:07:20
Annatasha
I don't mind those with the right meal, but I usually get like a spanking headache. So...
00:07:26
Gianluca Bini
Yeah, hate when they have like eye tenons and stuff, but like I really hate that. I can't deal with that.
00:07:32
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.
00:07:38
Annatasha
Cause the sulfite is the preservative for shipping, right?
00:07:40
Ryan Bailey
Right.
00:07:41
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.
00:07:41
Ryan Bailey
Yeah.
00:07:48
Annatasha
And that's a big contributor to that like hangover headache situation.
00:07:52
Gianluca Bini
Yeah. I mean, I don't drink enough wine to like actually care, but I get it.
00:07:57
Annatasha
but you're Italian.
00:08:01
Ryan Bailey
Yeah.
00:08:03
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.
00:08:14
Gianluca Bini
Right. So I know I never shot before.
00:08:14
Ryan Bailey
Wow.
00:08:14
Annatasha
Oh.
00:08:14
Ryan Bailey
Wow.
00:08:17
Gianluca Bini
And so like,
00:08:17
Annatasha
Oh. So it was just a gun range or like you got to like lasso like burrows.
00:08:23
Gianluca Bini
No, it's just a Gant range. So yeah, we shot a 9mm and a revolver.
00:08:31
Gianluca Bini
It was my first time.
00:08:31
Annatasha
Handguns.
00:08:32
Gianluca Bini
I was like, actually, pretty nice. We may go back for some rifles, I guess.
00:08:37
Gianluca Bini
So this is
00:08:38
Annatasha
Drinking the Kool-Aid.
00:08:39
Gianluca Bini
this
00:08:40
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.
Wine & Lifestyle Anecdotes
00:08:47
Gianluca Bini
Wait, wait, wait. So this place, so this range actually has a bar inside, right? So you could drink...
00:08:54
Annatasha
Perfect. Alcohol and guns. Nothing bad ever happened with that combo.
00:08:56
Ryan Bailey
nothing.
00:08:58
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.
00:09:08
Ryan Bailey
Oh, yeah.
00:09:08
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.
00:09:18
Ryan Bailey
Wow.
00:09:18
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.
00:09:29
Annatasha
Like, I don't Yeah, I didn't feel like, you know.
00:09:31
Ryan Bailey
On the side of local cuisine, that's plenty for me.
00:09:33
Gianluca Bini
I definitely felt...
00:09:36
Annatasha
The local cuisine tends to be
00:09:36
Gianluca Bini
I definitely felt
Anesthesia Techniques & Education
00:09:37
Gianluca Bini
really maricott.
00:09:37
Annatasha
exploded cow.
00:09:39
Ryan Bailey
that's fine. Somebody it.
00:09:41
Gianluca Bini
I definitely felt really maricott.
00:09:41
Annatasha
Yeah. All right.
00:09:42
Ryan Bailey
Get out of here.
00:09:42
Annatasha
So back to our hypothetical desert island where we're drinking Gamay, Malbec, and Viennese Gnischten Satz.
00:09:46
Gianluca Bini
Sure.
00:09:50
Ryan Bailey
We least have good wine.
00:09:51
Annatasha
Yeah, fuck yeah. And ketamine.
00:09:53
Ryan Bailey
mean, we're going to need because we can only use one drug.
00:09:57
Annatasha
And ketamine.
00:09:58
Gianluca Bini
You need...
00:09:59
Ryan Bailey
Wow.
00:09:59
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?
00:10:11
Gianluca Bini
Botox.
00:10:13
Ryan Bailey
Oh, interesting. I...
00:10:15
Annatasha
Pulse ox, huh?
00:10:19
Ryan Bailey
What would I take? I mean, I guess I'd probably go with like a Doppler. It gives you so much.
00:10:25
Annatasha
Oh,
00:10:26
Gianluca Bini
What the fuck?
00:10:26
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.
00:10:30
Ryan Bailey
Wow.
00:10:34
Ryan Bailey
and a pulse ox is not finicky.
00:10:36
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.
00:10:36
Annatasha
didn't vote for Paul Sox.
00:10:44
Annatasha
I didn't vote Paul Sox. I would vote CO2. I'd pornography.
00:10:48
Ryan Bailey
Another solid answer. You know what? That's a good... Yeah.
00:10:54
Annatasha
That's my choice.
00:10:54
Ryan Bailey
Oh,
00:10:55
Annatasha
You can keep ECGs because they read on dead things. You can keep pulse hoxes because they don't read on dead things.
00:10:57
Ryan Bailey
obviously. I
00:11:00
Annatasha
I hate Dopplers. And, I always feel like when I'm putting a Doppler on, like, what is this like 1850?
00:11:02
Ryan Bailey
hate that one.
00:11:06
Annatasha
Like, are we using sonar?
00:11:06
Ryan Bailey
Oh my god.
00:11:07
Annatasha
Like, I just know.
00:11:09
Ryan Bailey
Love the Doppler.
00:11:10
Ryan Bailey
Get the signal. I like... I am still proud of my ability to one-shot a Doppler in any animal. Like...
00:11:18
Gianluca Bini
Yeah, but what do you do with it? Like you hear
00:11:21
Ryan Bailey
I mean, I take blood crushes with it. When the... When...
00:11:24
Ryan Bailey
When, like, literally...
00:11:24
Gianluca Bini
The number you get, it's super unreliable, right?
00:11:28
Gianluca Bini
Like you know that
00:11:29
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.
00:11:41
Ryan Bailey
It's like, I just threatened the Doppler.
00:11:44
Annatasha
The Doppler is bullshit, especially Bailey and cats.
00:11:48
Ryan Bailey
Sure. Sure.
00:11:49
Annatasha
You know it is.
00:11:50
Ryan Bailey
I'm not, like, I get one piece of equipment. It's like CO2 only tells you the animal's breathing.
00:11:56
Annatasha
No, it doesn't. It tells you about cardiac output and it tells you about employment integrity.
00:11:58
Ryan Bailey
No, not on spontaneous respiration. Come on.
00:12:02
Annatasha
Come on.
00:12:02
Ryan Bailey
Come
00:12:04
Annatasha
Come on. The Doppler does not tell you anywhere as much as the CO2.
00:12:05
Ryan Bailey
Come. We don't have a ventilator here, Bartell.
00:12:09
Annatasha
The CO2 tells you about equipment integrity, airway patency. It tells you about circulatory capability, and it tells you about ventilation.
00:12:18
Ryan Bailey
Sure, I'm not disagreeing.
00:12:19
Annatasha
And you know what Doppler tells me?
00:12:19
Ryan Bailey
It doesn't do well.
00:12:20
Annatasha
This.
00:12:23
Ryan Bailey
No, not if you're good.
00:12:23
Annatasha
That's what the Doppler tells
00:12:24
Ryan Bailey
If you're an expert Doppler placer, like myself, big crystal, all animals, never using that little crystal.
00:12:25
Annatasha
don't know.
00:12:31
Ryan Bailey
I get it 100% of the time, every time.
00:12:35
Annatasha
100% of 100% of the time. That's not even statistically possible.
00:12:38
Ryan Bailey
Yeah, I'm fucking that good.
00:12:41
Gianluca Bini
You guys, I'm just sitting here and like seeing, watching the debate, know, it's, it's...
00:12:47
Ryan Bailey
You can potentially tell pulse quality from it. You can listen for their response to the
00:12:51
Annatasha
Sure, you can potentially interpret mean and diastolic pressure, but then sometimes it's a false systolic pressure.
00:12:51
Gianluca Bini
What do you think of it?
00:12:55
Ryan Bailey
Sure.
00:12:56
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?
00:12:57
Ryan Bailey
Sure.
00:13:03
Ryan Bailey
I mean, I never asked for a sphygno-menometer. I just asked for a Doppler.
00:13:07
Annatasha
Oh, oh, okay.
00:13:08
Annatasha
So even more irritating.
00:13:09
Gianluca Bini
So then, I mean, I guess you can just.
00:13:11
Gianluca Bini
Okay. You guys.
00:13:12
Ryan Bailey
At least I get to hear the patient's heartbeat.
00:13:12
Annatasha
Even more annoying.
00:13:15
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.
00:13:22
Annatasha
I mean, if you have CO2, you don't have to do that either.
00:13:26
Ryan Bailey
That's true.
00:13:26
Annatasha
Also, the Doppler's affected if you give potent peripheral vasoconstrictors.
00:13:27
Ryan Bailey
That's true.
00:13:30
Ryan Bailey
Oh yeah,
00:13:32
Annatasha
Now, back to Bini's shit choice of the pulse ox.
00:13:38
Annatasha
Bailey, let's hang up on him and discuss that because that was the worst answer ever.
00:13:40
Ryan Bailey
Which Pulse Ox though? Name the brand.
00:13:46
Gianluca Bini
Okay, don't know if we can do this, but you know, I love Massimo. Yeah,
00:13:51
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.
00:13:57
Gianluca Bini
this is totally, this is, for whoever's listening, this is totally non-sponsored.
00:14:02
Ryan Bailey
Yeah. Yeah.
00:14:03
Gianluca Bini
We're not getting any money for this.
00:14:05
Annatasha
Clearly this isn't sponsored.
00:14:06
Annatasha
Who would sponsor us? Like, you know what?
00:14:08
Ryan Bailey
Yeah.
00:14:08
Gianluca Bini
Nobody.
00:14:09
Annatasha
The wine companies.
00:14:09
Gianluca Bini
There we go.
00:14:14
Gianluca Bini
But I would use a reflectance probe.
00:14:14
Ryan Bailey
Oh my gosh.
00:14:17
Ryan Bailey
Oh my gosh.
00:14:18
Annatasha
Oh, look at you.
00:14:19
Ryan Bailey
God.
00:14:21
Ryan Bailey
When the text string...
00:14:21
Annatasha
Oh, Bailey's cute new cat is here.
00:14:23
Annatasha
Grease ball.
00:14:24
Ryan Bailey
Whoa, Greaseball! Carol's going to love when that happens. Oh my god. I don't want to grab you.
00:14:33
Annatasha
Oh yeah, he does look like he's a little touch hyperthyroid there, Maylee. Look at that tail.
00:14:36
Ryan Bailey
I know. I know, yeah. That's why his name is Greaseball.
00:14:42
Ryan Bailey
We're debating... I think the top contenders are Marv, as in Home Alone, and Moe, as in
00:14:50
Annatasha
I like Marge.
00:14:51
Ryan Bailey
M-A-R-V.
00:14:53
Annatasha
Yeah, I like that.
00:14:54
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.
00:15:05
Ryan Bailey
Yeah. Those are the leading contenders.
00:15:08
Annatasha
You see, he's got a Marv vibe about him. Look at him.
00:15:11
Gianluca Bini
He does.
00:15:12
Ryan Bailey
He does. think Marv's going to win it.
00:15:14
Gianluca Bini
He's cute.
00:15:16
Ryan Bailey
But Greaseball for now.
00:15:16
Annatasha
Yeah.
00:15:18
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.
00:15:31
Annatasha
Well, he.
00:15:35
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?
00:15:45
Gianluca Bini
That it has enough oxygen.
00:15:48
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.
00:15:50
Ryan Bailey
I was
00:15:51
Gianluca Bini
It has.
00:15:57
Ryan Bailey
like, what are the
00:15:57
Gianluca Bini
Does it matter? I've seen
00:15:59
Ryan Bailey
Like, what are the odds of dealing with hypoxemia in small animal patient?
00:16:03
Ryan Bailey
Come on.
00:16:05
Ryan Bailey
Like, what the percentages of small animal patients that are developing hypoxemia under anesthesia?
00:16:10
Annatasha
Well, if you're doing actually hard cases, Bailey, more than you think.
00:16:11
Gianluca Bini
it. I've seen it.
00:16:13
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.
00:16:25
Ryan Bailey
Cool. I'm going to go drown myself in the ocean and hope a shark eats me.
00:16:25
Annatasha
Oh, I didn't say there wasn't a ventilator on the magical island.
00:16:31
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.
00:16:56
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.
00:17:06
Ryan Bailey
Yeah.
00:17:09
Gianluca Bini
I mean, you patients that you anesthetize and they have small amounts of chaludorax and you don't know about it, right?
00:17:14
Ryan Bailey
Yeah. Yeah.
00:17:16
Annatasha
I don't know.
00:17:16
Gianluca Bini
Maybe. You know what I mean? Like, there is a lot of patients that don't...
00:17:17
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.
00:17:22
Gianluca Bini
How finicky is that? Like, what kind of pulses do you use?
00:17:25
Annatasha
And, you know, it doesn't work if you're dysrhythmic.
00:17:28
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.
00:17:39
Ryan Bailey
Unable to resolve the inspired CO2. The little, the little...
00:17:43
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.
00:17:43
Ryan Bailey
We...
00:17:52
Annatasha
The pulse ox way more persnickety.
00:17:54
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.
00:18:05
Annatasha
Okay. It's not Sunset Boulevard, Bailey. It's a desert
00:18:17
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.
00:18:29
Ryan Bailey
Which style?
00:18:32
Annatasha
Sidestream, Bailey. I don't give a fuck, right? Like,
00:18:36
Ryan Bailey
I mean, there's merits to both, right?
00:18:39
Annatasha
yes, I wrote that essay on the exam and I'm not writing it again.
00:18:39
Gianluca Bini
the rhythm. I think that the merit of the mainstream is that it gets trashed really fast.
00:18:44
Ryan Bailey
did not have that essay.
00:18:48
Ryan Bailey
Yeah, that thing would get destroyed in your desert island.
00:18:53
Annatasha
Yeah, it's going to get sandy. It's going to cause drag.
00:18:55
Ryan Bailey
Yeah.
00:18:56
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.
00:19:05
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.
00:19:17
Annatasha
What are top three tips or tricks that you would teach your new assistant or your new training technician?
00:19:25
Ryan Bailey
Wow.
00:19:29
Ryan Bailey
Okay. Number one.
00:19:32
Annatasha
Number one, get the Doppler, get the Doppler.
00:19:32
Ryan Bailey
I just got one. Number one. Get the Doppler. Number two. Only use Propofol. Number three. Fuck the pulse oxen. No. Me.
00:19:43
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.
00:19:57
Ryan Bailey
Do them the same every single time and establish your own routine.
00:20:04
Annatasha
Love that.
00:20:04
Ryan Bailey
And like, yeah.
00:20:07
Annatasha
Love that. Get faster, you get safer, you get more efficient.
00:20:08
Gianluca Bini
So you basically want the robot.
00:20:12
Ryan Bailey
What's that?
00:20:13
Gianluca Bini
You basically want the...
00:20:13
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.
00:20:29
Ryan Bailey
And then like immediately you start working through it because something's just, there's a slight variation in the normal.
00:20:32
Gianluca Bini
Yeah.
00:20:36
Ryan Bailey
I mean,
00:20:36
Annatasha
like that. Yeah.
00:20:39
Ryan Bailey
what other, I mean, That's like my biggest one.
00:20:44
Annatasha
It's a good one.
00:20:47
Ryan Bailey
got to think about the other two.
00:20:48
Annatasha
right, Beanie.
00:20:54
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.
00:21:12
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?
00:21:24
Gianluca Bini
This is a random thing.
00:21:25
Annatasha
I don't if that's a tip or a trick. I feel like that's just a bug standard expectation, but yeah.
00:21:30
Gianluca Bini
But, you know, that's not always the case, right? Like it's
00:21:34
Annatasha
A hundred percent.
00:21:38
Gianluca Bini
And then the third thing is probably like,
00:21:41
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.
00:22:07
Annatasha
Yeah, we're the worst kind of animals.
00:22:08
Ryan Bailey
Truly.
00:22:08
Gianluca Bini
Exactly.
00:22:09
Ryan Bailey
Oh.
00:22:09
Gianluca Bini
Right. And probably the most destructive of all them.
00:22:10
Annatasha
Ugh.
00:22:13
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.
00:22:25
Gianluca Bini
was like, yeah, if they chop your balls off, isn't painful?
00:22:27
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.
00:22:35
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,
00:23:02
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.
00:23:12
Gianluca Bini
I also, what the fuck is kitty magic? I hate that shit, right?
00:23:16
Ryan Bailey
I
00:23:20
Ryan Bailey
got my other two.
00:23:20
Gianluca Bini
The fuck is that?
00:23:21
Ryan Bailey
Alright, so one of them is learn to do nothing.
00:23:22
Annatasha
Oh, okay. All right, Bailey, hit us.
00:23:31
Annatasha
Oh, yeah, yeah.
00:23:31
Ryan Bailey
Like
00:23:32
Annatasha
Just sweat it out.
00:23:33
Ryan Bailey
There is just like, there's two sides that coin is.
00:23:37
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.
00:23:49
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...
00:24:01
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.
00:24:18
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,
00:24:29
Ryan Bailey
We're just going to sit here right now and we're just going to...
00:24:31
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.
00:24:41
Ryan Bailey
Yeah.
00:24:44
Annatasha
It's just, I have patients for letting things flush themselves out.
00:24:46
Ryan Bailey
Yes.
00:24:48
Annatasha
Like if you bowl as propofol really quickly and they go apneic, I'm not going to flip the ventilator on.
00:24:48
Ryan Bailey
Yes.
00:24:52
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.
00:24:52
Ryan Bailey
Yes.
00:24:58
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.
00:25:02
Ryan Bailey
Yeah.
00:25:14
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?
00:25:18
Ryan Bailey
Yeah.
00:25:22
Annatasha
So, you know, sometimes less is more. And so I think that tip is, God, we're agreeing a lot tonight, guys.
00:25:25
Ryan Bailey
Totally.
00:25:26
Gianluca Bini
Yeah.
00:25:28
Annatasha
Like, whoo.
00:25:28
Ryan Bailey
Yeah. Yeah.
00:25:30
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.
00:25:35
Ryan Bailey
Oh, yeah. Yes.
00:25:41
Ryan Bailey
Yeah.
00:25:45
Annatasha
I've taken lots of things off the table before with unreadable pressures that survived to discharge.
00:25:49
Ryan Bailey
There you The only metric. Yeah.
00:25:52
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.
00:26:09
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.
00:26:21
Annatasha
Right.
00:26:22
Ryan Bailey
hmm.
00:26:22
Ryan Bailey
Yep.
00:26:22
Annatasha
So, you know, for example, you slam whole bunch of, you know, peripheral vasoconstrictors in there.
00:26:28
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,
00:26:38
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?
00:27:04
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.
00:27:18
Ryan Bailey
And I'm like,
00:27:19
Annatasha
Can we talk about the problems you have with your CO2 at your hospital? Like, can you a new CO2 monitor?
00:27:23
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
00:27:49
Annatasha
It's very subversive attack on my CO2 comment from earlier and you trying to self promote Doppler's, but,
00:27:57
Annatasha
but yeah, no, I don't monitor the monitor, right?
00:27:57
Ryan Bailey
Yeah, the top level would cut stuff for sure.
00:28:01
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?
00:28:03
Ryan Bailey
Yep.
00:28:07
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.
00:28:20
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.
00:28:20
Ryan Bailey
Yep.
00:28:31
Ryan Bailey
The drive to make every individual number perfect.
00:28:37
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
00:28:37
Ryan Bailey
You know?
00:28:40
Ryan Bailey
Right. Yeah.
00:28:44
Ryan Bailey
For sure.
00:28:44
Annatasha
chronic pH or like acid-based status or whatever's happening intracranially or what have you.
00:28:48
Ryan Bailey
Yeah.
00:28:49
Annatasha
So anyway, my other one is, by the way, is you have to understand the machine.
00:28:50
Ryan Bailey
Mm-hmm.
00:28:51
Gianluca Bini
I have a question for you, right?
00:28:59
Annatasha
You have to understand the damn machine.
00:29:00
Gianluca Bini
Yeah.
00:29:01
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,
00:29:27
Annatasha
In theory, you should be able to build essentially a pneumatic machine from like parts in your garage.
00:29:32
Ryan Bailey
Yep.
00:29:32
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.
00:29:46
Annatasha
and also, you know, things like inhalant uptake and all that kind of stuff.
00:29:49
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?
00:29:59
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,
00:30:07
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.
00:30:16
Ryan Bailey
You can basically see all the parts of it.
00:30:18
Annatasha
Yeah. You can follow the flow of oxygen, right?
00:30:19
Ryan Bailey
But these really nice human machines, the anesthesia workstations, it's like...
00:30:27
Annatasha
You can't see anything.
00:30:29
Ryan Bailey
Which, you know, there's pros and cons. Like, that is why...
00:30:33
Gianluca Bini
I love
00:30:34
Ryan Bailey
I love them, too. I think they are far superior the, like, garbage machine I have.
00:30:36
Gianluca Bini
them. We have eight Veta 5s from Mindray and they're the most gorgeous, beautiful.
00:30:51
Gianluca Bini
Actually, no, we have six and we have two Wados, which are the big brother of thing.
00:30:55
Ryan Bailey
Yeah. Yep.
00:30:56
Annatasha
Thank
00:30:57
Gianluca Bini
But they're amazing. Like if you want the idiot proof machine, that is it.
00:31:00
Ryan Bailey
Yeah.
00:31:06
Ryan Bailey
Well, that's the funny thing is those human machines are so much safer.
00:31:11
Gianluca Bini
It is.
00:31:12
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...
00:31:21
Annatasha
Obviously. Obviously we're shit.
00:31:25
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.
00:31:36
Annatasha
Oh, that's exciting and horrifying at the same time.
00:31:38
Gianluca Bini
Let's clear this one.
00:31:39
Ryan Bailey
I have seen people jerry-rig a machine to have two vaporizers in series without an interlock.
00:31:47
Gianluca Bini
Oh, that happens all the time.
00:31:49
Ryan Bailey
Yeah, and it's incredibly dangerous.
00:31:52
Annatasha
Yeah.
00:31:52
Gianluca Bini
Yes.
00:31:52
Annatasha
But if you understand the machine, then you recognize that.
00:31:54
Ryan Bailey
like the fastest way to kill patient.
00:31:57
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.
00:32:32
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?
00:32:35
Ryan Bailey
Yep. Good.
00:32:41
Annatasha
Like there'll be some crazy like setup and like, know, a GP practice where I've gone in to teach,
00:32:46
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.
00:32:58
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?
00:33:04
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.
00:33:12
Gianluca Bini
Yeah.
00:33:12
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?
00:33:32
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.
00:33:43
Ryan Bailey
The thing that blows my mind is how few people... understand like the physics and uptake and like removal of inhalant anesthetics.
00:33:57
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.
00:33:59
Gianluca Bini
Thank you.
00:34:07
Ryan Bailey
Like it is,
00:34:07
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?
00:34:21
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.
00:34:34
Ryan Bailey
Yeah.
00:34:35
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?
00:34:49
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.
00:34:54
Ryan Bailey
Yeah.
00:34:57
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?
00:35:11
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?
00:35:19
Annatasha
I like that little analogy.
00:35:20
Annatasha
Yeah, that's exactly what it is.
00:35:22
Gianluca Bini
Yeah.
00:35:22
Annatasha
It's...
00:35:23
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?
00:35:36
Ryan Bailey
Mm-hmm.
00:35:37
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.
00:35:51
Gianluca Bini
Right. Like the, the, what's important in anesthesia is the monitoring, right?
00:35:57
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.
00:36:05
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.
00:36:05
Ryan Bailey
Yeah.
00:36:12
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.
00:36:14
Ryan Bailey
Yeah.
00:36:19
Gianluca Bini
That's what you need to know. Like...
00:36:20
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?
00:36:23
Ryan Bailey
Right.
00:36:30
Ryan Bailey
Oh, yeah.
00:36:34
Ryan Bailey
Right.
00:36:34
Annatasha
And will you understand it when it happens?
00:36:35
Annatasha
But yeah, I think people get.
00:36:36
Ryan Bailey
Yep.
00:36:38
Gianluca Bini
Any drugs, including fluids, you know, including fluids.
00:36:41
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.
00:37:05
Ryan Bailey
I know the drugs and like the dosing that
00:37:08
Annatasha
I call mine the bartini, right?
00:37:09
Gianluca Bini
Thank
00:37:10
Ryan Bailey
Exactly. Like, everyone has...
00:37:11
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.
00:37:11
Ryan Bailey
Yeah. Yes.
00:37:18
Ryan Bailey
Yep. Right.
00:37:21
Ryan Bailey
Right.
00:37:22
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.
00:37:33
Annatasha
So.
00:37:33
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.
00:37:55
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.
00:37:56
Annatasha
Yeah.
00:37:58
Gianluca Bini
Yeah.
00:38:02
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.
00:38:17
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?
00:38:31
Ryan Bailey
Right.
00:38:33
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.
00:38:49
Annatasha
Like the protocol is not just methadone, dexamide, propofolketamine, right?
00:38:54
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?
00:39:05
Annatasha
Like it's, you know...
00:39:07
Ryan Bailey
Although that tube is definitely a veterinary tube, for the record.
00:39:08
Gianluca Bini
Thank you.
00:39:10
Ryan Bailey
100%. That's like a 51 French or something like that.
00:39:13
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.
00:39:13
Ryan Bailey
It's so long.
00:39:19
Annatasha
Like, I was just like, oh!
00:39:19
Ryan Bailey
That was insane.
00:39:22
Annatasha
That scene is so disgusting to me. I hated
00:39:24
Ryan Bailey
That tube is so long.
00:39:26
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?
00:39:37
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.
00:39:38
Gianluca Bini
Thank you.
00:39:43
Annatasha
And when you sedate it, it turns blue. Like all of that is the protocol.
00:39:47
Ryan Bailey
And we're doing a four limb mass removal and like... Yeah.
00:39:50
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.
00:39:56
Ryan Bailey
Yeah.
00:39:59
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.
00:40:09
Annatasha
So yeah.
00:40:10
Ryan Bailey
Just like the Jaha anesthesia guidelines from like, I don't know, 2020, 2022, are like, anesthesia starts at home.
00:40:11
Annatasha
Great.
00:40:22
Ryan Bailey
Which, you know, it does. Like, especially with the advent of oral anxiolytics and sedatives and stuff, like, anesthesia starts at home.
00:40:24
Annatasha
It does.
00:40:27
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
00:40:35
Ryan Bailey
I know we're going to start starving it. Everyone can't wait to starve it. Let's starve it.
00:40:40
Annatasha
already?
00:40:43
Ryan Bailey
was so fixated on starving these goddamn animals.
00:40:43
Annatasha
Yeah.
00:40:47
Annatasha
Well, yeah.
00:40:50
Gianluca Bini
Yeah, no, agree.
00:40:50
Ryan Bailey
I mean...
00:40:52
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.
00:41:01
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.
00:41:05
Gianluca Bini
It doesn't fucking matter.
00:41:06
Ryan Bailey
Yeah.
00:41:06
Gianluca Bini
It doesn't fucking matter.
00:41:07
Ryan Bailey
I'm going to round it up to the next whole integer.
00:41:10
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?
00:41:16
Gianluca Bini
It's crazy.
00:41:19
Annatasha
Or when they turn the isoflavor and vaporizer, I turn it from one to 1.1. And I'm like, oh, did you?
00:41:25
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.
00:41:38
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
00:41:51
Ryan Bailey
Hmm.
00:41:51
Gianluca Bini
Aww.
00:41:52
Annatasha
There's a vet tech out there who absolutely loves our podcast and like shares it every week.
00:41:55
Ryan Bailey
Yeah.
00:41:56
Annatasha
And like, it's so enthusiastic.
00:41:57
Ryan Bailey
Oh, God.
00:41:58
Annatasha
And I told her I do our shout out to her in this podcast. So Leslie we appreciate We love you.
00:42:03
Gianluca Bini
Aww.
00:42:03
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.
00:42:11
Ryan Bailey
Yeah. Thank you.
00:42:13
Gianluca Bini
Thank you.
00:42:13
Ryan Bailey
Wow, we have a fan. It feels very exciting.
00:42:16
Annatasha
Yeah, we
00:42:16
Gianluca Bini
Yeah. I think some...
00:42:17
Ryan Bailey
Like that one guy's no taste in food.
00:42:21
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.
00:42:30
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.
00:42:30
Annatasha
Yeah.
00:42:39
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.
00:42:50
Ryan Bailey
Yeah.
00:42:51
Annatasha
Honestly, I could have a whole podcast just about, I could do a wine podcast separately.
00:42:51
Gianluca Bini
to be home.
00:42:54
Annatasha
Like I love talking about viniculture, but yeah.
00:42:56
Gianluca Bini
I was there.
00:42:59
Annatasha
Oh, yeah.
00:42:59
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.
00:43:09
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.
00:43:25
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.
00:43:37
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.
00:43:57
Ryan Bailey
And they said, you know, if the, if the patient reports ringing in their ears, the next step is induce anesthesia.
00:44:04
Annatasha
Oh, interesting. I mean, there's a huge amount local anesthetic allergy to not just toxicity, but
00:44:05
Ryan Bailey
Because, because,
00:44:11
Annatasha
Like think 37% of women who receive epidurals for, for birth have an allergic reaction.
00:44:11
Ryan Bailey
Yeah. Oh,
00:44:17
Annatasha
Like some, that's a monster number of people.
00:44:18
Ryan Bailey
wow. Yeah, that's huge.
00:44:20
Gianluca Bini
That's crazy.
00:44:20
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.
00:44:24
Ryan Bailey
Oh.
00:44:29
Annatasha
Like people do not do well with locals. We have a lot more forgiveness, for example, in like dogs.
00:44:31
Ryan Bailey
Yeah.
00:44:33
Annatasha
And I mean, how much LidoCain do you give a cow for a standing cesarean, like a bottle
00:44:38
Ryan Bailey
Right.
00:44:39
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.
00:44:39
Annatasha
yeah yeah
00:44:52
Ryan Bailey
They can, like, be ready to intervene at the jump. So I was like, whoa, that is, like, crazy.
00:44:57
Gianluca Bini
Yeah. Yeah.
00:44:59
Ryan Bailey
Because they also report, like, you know, surgeons essentially just, like, injecting local anesthetic without abandon.
00:45:07
Ryan Bailey
You know, for...
00:45:07
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.
00:45:13
Ryan Bailey
Yeah.
00:45:18
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.
00:45:26
Ryan Bailey
Nice.
00:45:27
Annatasha
so, uh, so I ended up, I gave that cat intralipid.
00:45:27
Gianluca Bini
Yeah.
00:45:31
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,
00:45:46
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.
00:45:55
Gianluca Bini
I'm going what?
00:45:57
Ryan Bailey
We had a patient
00:45:57
Annatasha
It's less cool when you say dang.
00:45:59
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.
00:46:15
Ryan Bailey
And I was like, just like the usual, like I usually do the 0.01 mix per keg of atropine.
00:46:16
Gianluca Bini
What those did you give?
00:46:22
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.
00:46:31
Gianluca Bini
And.
00:46:35
Ryan Bailey
I walked in. I was like, cool.
00:46:36
Gianluca Bini
Your ship.
00:46:38
Ryan Bailey
We're in like third degree with escape.
00:46:41
Annatasha
Time to get more.
00:46:41
Ryan Bailey
I was like, yeah,
00:46:42
Gianluca Bini
So wait, what was your next step?
00:46:45
Ryan Bailey
So, well, I walked in the room and I initially noted the P waves.
00:46:49
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?
00:47:03
Ryan Bailey
Am I patient enough to like watch a patient third degree AV block without creating a hella blue in the OR?
00:47:27
Gianluca Bini
What
00:47:28
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.
00:47:34
Annatasha
Maybe you should put the Doppler on
00:47:36
Gianluca Bini
it matter?
00:47:40
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.
00:47:51
Gianluca Bini
She does.
00:47:52
Ryan Bailey
And I was like, they're not premature though.
00:47:55
Ryan Bailey
There's nothing else going on. It's all ventricular rhythm. This is an escape.
00:48:01
Gianluca Bini
Jesus.
00:48:01
Annatasha
Exciting.
00:48:02
Gianluca Bini
Awesome.
00:48:02
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.
00:48:10
Gianluca Bini
Yeah.
00:48:10
Gianluca Bini
So why the.01? What's your, what's your process?
00:48:10
Ryan Bailey
That atrial rate will start going through the node.
00:48:15
Ryan Bailey
It works.
00:48:17
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.
00:48:21
Ryan Bailey
It works.
00:48:22
Annatasha
yeah
00:48:22
Ryan Bailey
It works.
00:48:24
Annatasha
It
00:48:25
Ryan Bailey
It does. And then I don't have their heart rate skyrocket to 200.
00:48:31
Ryan Bailey
I'm less likely to get their heart rate.
00:48:32
Annatasha
must be fancy Chicago atropine because
00:48:35
Ryan Bailey
I mean, it's also the fancy California atropine.
00:48:35
Gianluca Bini
Is it like...
00:48:39
Gianluca Bini
Is it like tavern style hadroping?
00:48:41
Ryan Bailey
Yeah, exactly.
00:48:48
Annatasha
Bring back Marv.
00:48:50
Gianluca Bini
You get it.
00:48:52
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.
00:48:57
Annatasha
Well, Marv is our special guest tonight, everybody.
00:49:00
Annatasha
And Marv also hates the toddler.
00:49:00
Ryan Bailey
Old police ball.
00:49:00
Gianluca Bini
special guest.
00:49:04
Ryan Bailey
Old cat.
00:49:06
Gianluca Bini
Oh, Jesus, guys.
00:49:07
Ryan Bailey
Yeah.
00:49:08
Gianluca Bini
Unbelievable.
00:49:08
Ryan Bailey
Yeah.
00:49:09
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
00:49:20
Ryan Bailey
Oh god.
00:49:26
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.
00:49:31
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.
00:49:46
Gianluca Bini
So I'm not going to listen to your BS. But the question is...
00:49:54
Ryan Bailey
Christine will support me.
00:49:57
Annatasha
Who will?
00:49:58
Ryan Bailey
Christine, my resident man.
00:49:59
Annatasha
Oh, Christine. Yeah, I know who Christine, yeah, she probably will because she also, you know, went to the same school, but.
00:50:08
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.
00:50:15
Ryan Bailey
Yeah.
00:50:16
Gianluca Bini
Right. Like, do you still record it?
00:50:21
Ryan Bailey
So that's a great question, and I wrestle with that all the time. Like, the Frenchie who's...
00:50:26
Annatasha
I only record values that make me look like a great anesthesiologist as a quick.
00:50:30
Ryan Bailey
Oh, yeah.
00:50:30
Annatasha
And
00:50:31
Ryan Bailey
Opportunistically, we only have to record every five minutes, guys. So, like, yeah.
00:50:34
Annatasha
we only write down the good numbers.
00:50:36
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.
00:50:50
Ryan Bailey
Just kidding.
00:50:51
Gianluca Bini
Okay, okay.
00:50:53
Ryan Bailey
No, but that's it.
00:50:54
Gianluca Bini
Whoever is listening, believe in this is a joke.
00:50:58
Ryan Bailey
Yeah.
00:50:59
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.
00:51:20
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.
00:51:29
Gianluca Bini
Yeah. Right.
00:51:30
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.
00:51:46
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.
00:52:00
Gianluca Bini
Gotcha. So you make a note of it for liability purposes.
00:52:04
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.
00:52:14
Ryan Bailey
And I find it, again, it's always –
00:52:17
Gianluca Bini
It sounds to me that you need new monitors.
00:52:18
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.
00:52:35
Ryan Bailey
And you're like, which cuff size do I select?
00:52:38
Ryan Bailey
The five?
00:52:38
Gianluca Bini
It sounds like you need either buy new monitors or place more art - lines.
00:52:39
Ryan Bailey
Well...
00:52:44
Ryan Bailey
Yeah, but like, are you really placing an art line for like a straightforward like Frenchy hemilaminectomy? Like, come on.
00:52:51
Gianluca Bini
Yeah.
00:52:52
Ryan Bailey
Come on.
00:52:53
Gianluca Bini
Yeah.
00:52:54
Ryan Bailey
It's not a benign procedure. There are complications.
00:52:58
Ryan Bailey
And...
00:52:58
Gianluca Bini
Not knowing what de facto blood pressure is doing, it's also non-benign.
00:53:02
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...
00:53:12
Gianluca Bini
But nap is accurate, which is the only value you care.
00:53:14
Ryan Bailey
errors. Do you re-sterilize your equipment though? Your blood pressure equipment?
00:53:21
Gianluca Bini
You do what?
00:53:22
Ryan Bailey
Do you re-sterilize your invasive blood pressure equipment?
00:53:24
Gianluca Bini
don't know. Trash
00:53:27
Ryan Bailey
I mean, that's nice. That's nice. Must be nice.
Cost & Equipment Challenges
00:53:34
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.
00:53:45
Gianluca Bini
I mean, I'm always committed to the case.
00:53:48
Ryan Bailey
No, but like, you're, you're in the OR, you know, you're not still in prep, you know, getting ready.
00:53:53
Gianluca Bini
Oh, I see.
00:53:54
Ryan Bailey
Like, You're like a point where like placing an art line will be a technical challenge.
00:54:01
Gianluca Bini
So yeah, usually, know, our brand new monitors, they work really, really well.
00:54:06
Ryan Bailey
The one we have trouble with the most is the MRI, but it generally reads really well.
00:54:09
Gianluca Bini
Yeah.
00:54:11
Ryan Bailey
It's just, I mean, MRI obviously prone to a lot of technical challenges in of itself.
00:54:16
Gianluca Bini
It's, unfortunately, those are pieces of shit. Right?
00:54:21
Ryan Bailey
Yeah.
00:54:21
Gianluca Bini
Those monitors are,
00:54:23
Ryan Bailey
Yeah.
00:54:24
Annatasha
Agreed.
00:54:26
Ryan Bailey
Yeah.
00:54:27
Gianluca Bini
they're straight pieces.
00:54:27
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.
00:54:34
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?
00:54:45
Ryan Bailey
Yeah.
00:54:47
Gianluca Bini
Like your deviation is going to be huge.
00:54:50
Ryan Bailey
Yeah.
00:54:50
Ryan Bailey
Yeah. Yeah.
00:54:51
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.
00:54:59
Gianluca Bini
So...
00:55:02
Gianluca Bini
Those are the ones where,
00:55:05
Gianluca Bini
you know, it's, yeah, I always
Conclusion & Social Media Updates
00:55:09
Gianluca Bini
struggle with those.
00:55:11
Gianluca Bini
No. But anyway, well, thank you everybody for listening. Next time is going to probably my turn for the next topic.
00:55:24
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.
00:55:36
Annatasha
Thanks, guys.
00:55:37
Gianluca Bini
next time.
00:55:38
Ryan Bailey
Thank you.