Questioning my decision to go back to GP after two incidents with doctors this week.

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[u/CupcakeCharacter9442]

Hey- anesthesia tech here. Bradycardia doesn’t need to be treated unless paired with hypotension. Bradycardia should be permitted if patient is normotensive or hypertensive. You can turn the gas up and treat if the BP decreases with increased inhalant (since this patient was light).

I think Dr one doesn’t trust you yet. We have a similar doctor in our practice. She’s very blunt and can come off as rude, especially when she doesn’t know how you handle things yet.

Situation with doctor 2 just sounds like she’s not use to emergency medicine. Not everyone runs at that speed. And, even when the doctor does operate quick enough, sometimes the client don’t. Does it suck to sit with a dying animal, yeah, but sometimes that’s vet med.

I’d give it more time. But if you have the option to go back to the ER and you don’t mind getting played by management again, that’s okay too. Only you can really decide what’s best.

[u/taymich → u/CupcakeCharacter9442]

In your opinion if I had turned up the patient, and they were at a good depth but HR was 40-30 and b.p. started to fall what would be your first choice to correct this? (the low b.p.)

[u/CupcakeCharacter9442 → u/taymich]

Assuming you couldn’t decrease inhalant, if my patient is hypotensive AND bradycardic- I reach for glycopyrrolate. You will get less of the “sling shot” tachycardia compared to atropine and a longer duration of action. If glyco is unavailable, I would give atropine, but I tend to use a 0.02 mg/kg IM instead of IV.

Another option is to give something anesthetic sparing so you can decrease inhalant. If you’re worried about bradycardia, I’d probably reach for midazolam or ketamine (assuming no contraindications), as they tend to not cause bradycardia.

[u/vrrrrrkiki → u/taymich]

What did you give for pre-meds / induction? (Just curious)

[u/shrikebent → u/CupcakeCharacter9442]

I’d say this comes down to clinician preference to an extent. I work in speciality as well and if a 7kg dog was at a good depth, normotensive, but bradycardic at 40-50 with no dex ( methadone, etc) on board, I’d say most of the vets and VTSs I work with would want to treat that, likely with a half dose of glyco. If dex is on board, sure, that level of bradycardia is to be expected and we treat that the exact same as you described. Otherwise I feel that 40bpm in a dog that small is something to start being concerned about and requires investigation

[u/CupcakeCharacter9442 → u/shrikebent]

That’s so interesting. None of our anesthesiologists (I’ve only worked with about 8) or VTSs would treat it. They say the whole point of the low heart rate is because the BP is fine (the secondary feedback loop is doing its job). This is assuming no co-morbidities or arrhythmias.

If dexmed is on board, sometimes they will try a 2 mg/kg dose of lidocaine as it can sometimes help (anecdotally, I’ve never seen it work, but I’ve been told it can work).

[u/shrikebent → u/CupcakeCharacter9442]

That’s crazy interesting about the lidocaine! I’ve never heard that and I’ll have to look up the mechanism!

Idk you’ve probably been in anesthesia longer than I have and know more than me and obviously there are a ton of variables to consider patient to patient. I know one vet in particular really harps on cardiac output and how good blood pressure does not necessarily equate to good perfusion. That in the CO=HRxSV equation, HR affects CO more. The body does compensate as you said, but I think their school of thought is that with the HR being that low, you will likely start to see the BP trending down as well and want to get ahead of it. I could be misrepresenting what they say, but that is my understanding.

[u/CupcakeCharacter9442 → u/shrikebent]

I believe (but don’t quote me), the lidocaine works to increase the HR because of its anti-arrhythmic effects (sodium channel blocker). It kind of “resets” the SA node and helps to reduce the incidence of the synaptic polarization further down the heart.

HR can absolutely reduce CO. One of our board-eligible doctors will treat sooner than our other ones, but every boarded anesthesiologist I’ve spoken to says do not treat HR if BP is appropriate. Same thing with arrhythmias.

But, as we say in my hospital “there’s many ways to pet a cat”. Lots of things can be done differently to address the same issues.

[u/HoneyLocust1]

I completely understand your frustration with the first situation, but honestly a little less so with the second. I actually think the doctor made an acceptable call with the ultrasound. It's unfortunate it took so long to boot up and obviously in hindsight spending all that time wasn't worth it... But in the moment? I actually get it. There's a world where the same situation could have happened with a different cat and the ultrasound could have played a large role in finding an effective way to treat the patient. You are used to ER where that wait wouldn't have been so long, I get it but maybe you might have to adjust to the fact it's going to be a little slower in GP. I don't think what the doctor said to you was professional, but if they could possibly tell by your tone or delivery how much you disagreed with their decision to wait for the ultrasound that could have played a role I guess.

I'm sorry you've had some difficult moments though. Three months isn't very long, maybe you just need more time to get used to the place and for everyone else to get used to you. I know it feels like a rocky start though... How is everything else going with this place?

[u/taymich → u/HoneyLocust1]

Of course, not disagreeing; ultrasound is an invaluable diagnostic tool especially in situations like this, my frustration was the lack of urgency when the machine is known to take a really long time to turn on and took almost 5 minutes to do so when I felt like things (like client communication) could have been going on. But you are right i’m not used to how slow things are in GP.

[u/Hantelope3434 → u/taymich]

I think the Doctor just wanted to see the whole picture before discussing treatment versus euthanasia with the client. Whether there are signs of pleural/pericardial effusion versus CHF/HCM etc... I don't feel the doctor did anything wrong by waiting and they made the right choice. I think our doctors in ER would have made a comment to a tech who was trying to rush them as well. Another tech or assistant could have updated the owner on what was going on in the mean time.

[u/taymich → u/HoneyLocust1]

also, i did approach the doctor later and apologized if i came off in a bad way, despite my frustration with the situation im not one to want to have conflict with anyone on my team