EGD for GI Bleed: Tube or not?

[Lecithin5]

My decisions vary on why they are doing the EGD. If this is a rule out GI bleed or the patient likely has a bleed but we don't know where I will rarely intubate. If this is someone who had hematemesis or has something like a variceal bleed then I will intubate in 99% of situations. For reference I don't do a ton of endoscopy, I likely average ~100 GI endoscopy cases a month.

The only near aspiration I have had so far in these scenarios was during an RSI for a concern for a gastric outlet obstruction.

Well put. We have some great honest endoscopists, and I usually trust them when tell me whether it is an unlikely, rule-out bleed (ie MAC), or whether there is a likelihood of bleed (or if they are obviously bleeding in front of me, hence GA).

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[getdown]

You do you buddy. If you’re worried then you should tube. From GI standpoint we don’t care at all as long as you don’t postpone or delay cases.

Let's turn the tables a bit. How about I tell you to do something that you know for sure deviates from the standard of care for your case and know that the complications are quite devastating and you assume all the risks of said deviation just so that I can take my lunch break sooner? Your answer will be our answer. I don't give a damn about your cases being delayed when it comes to patient safety. Furthermore, once you start ****ing with my income and my livelihood that I need to support my family because you just want get cases done my answer is go **** yourself. Either learn to move faster, schedule your day better or pay more to have some other schlub cover you.

 

[Hoya11]

So you let a trainee from another specialty dictate how you did your job?

When you make a decision that is in agreement with another doctors preference it doesnt mean that the other doctor dictated that decision to you, it meant you agreed with it in your own mind enough to try it

These cases are always going to be judgement calls, and lots of that judgement comes with experience, and sometimes bad things happen with little predictability despite good judgement

 

[caligas]

So those that usually intubate, what about patients with anemia and blood in stool but no nausea/vomiting and good NPO status?

 

[anbuitachi]

My point to all of this was my perspective as “a proceduralist”. If we are looking for a slow occult GI bleed or history of minor recent bleed that the odds of finding a significant amount of blood is very low. If you want to intubate everyone as a rule I don’t think anyone would ever blame you from a safety standpoint. But if you do shift work and are done at 4pm on the dot as a service, for a particularly busy day, I’ve had situations where these little things add up and I’ve pushed cases to the next day or even the next week if it’s a Friday because we have run out of time with anesthesia. Just something to keep in mind.

honestly dont think intubating/extubating takes that much longer. maybe adds 10 minutes to your day. no one is tubing everyone that comes in the door. we are talking about UGIB/Full stomachs. unless thats all you scope.. not sure where you are finding so many bleeders. and honestly if you have issues with the 4pm thing at whereever you work, id say either predict the situation (eg know that a UGIB will take longer than a regular scope) or stop letting the fellow do it.

One thing i dont get is how a lot of 'proceduralists' were good medicine doctors prior to going to fellowship and becoming proceduralists, and once they become proceduralists it seems like patient safety is now out the window and its all about your paycheck and when you are leaving the hospital. it's a shame.

Either way, aside from the obvious UGIB bleeders which get tubed. if the patient had an acute drop and they are concerned it may be UGIB, then i tube. if it hct trended down over months and they are ruling out UGIB, then i dont tube.

So those that usually intubate, what about patients with anemia and blood in stool but no nausea/vomiting and good NPO status?

depends on how acute the anemia is. how bloody the stool is. and what the proceduralist thinks. it's a decision from these combo of informations

 

[Twiggidy]

So those that usually intubate, what about patients with anemia and blood in stool but no nausea/vomiting and good NPO status?

Likely a sedation since it’s likely coming from the other end but it also factors in patient comorbiditoes, PE, and who’s running the scope. If the stars aligned nice I’d be cool with prop with a fellow driving. Hemoptysis and hematasis changes the game

 

[Twiggidy]

One thing i dont get is how a lot of 'proceduralists' were good medicine doctors prior to going to fellowship and becoming proceduralists, and once they become proceduralists it seems like patient safety is now out the window and its all about your paycheck and when you are leaving the hospital. it's a shame.

Valid observation

 

[facted]

So those that usually intubate, what about patients with anemia and blood in stool but no nausea/vomiting and good NPO status?

I think this is the best part about the thread. Everyone is so black and white, but the clinical scenarios are not. If the pt is vomiting blood, I think we all intubate. But you guys intubate for an upper/lower with anemia and possible bleed?

 

[Robotic Wis-Hipple]

I think this is the best part about the thread. Everyone is so black and white, but the clinical scenarios are not. If the pt is vomiting blood, I think we all intubate. But you guys intubate for an upper/lower with anemia and possible bleed?

No. Acuity of the bleed and the current sxs. Nausea, upset stomach, bloated feeling, etc and I’m much more likely to secure the airway and go on with my day. If they pass the door test, are NPO appropriate, and they haven’t been acutely bleeding I typically MAC (recognizing that there is still the off chance they have a not insignificant amount of blood in the stomach but my mental calculus of risk allows most to get MACs).

 

[DM27]

So those that usually intubate, what about patients with anemia and blood in stool but no nausea/vomiting and good NPO status?

Frank blood in the stool should indicate either a lower GI bleed or an incredibly brisk UGI bleed that is overcoming the stomachs ability to metabolize the blood volume, the latter should have declared itself, so I would not really consider intubating in this scenario.

If you mean blood in the stool as in "dark/tarry stool", then I would consider this UGI vs. slow lower and would not strongly consider intubating unless other factors were at play (hematemesis, etc).

 

[rakotomazoto]

Story time. Here's why I have a low threshold for intubating in the UGIB scopes. I was board runner for the day as a CA3 (part of our "periop management" rotation, that's a rant for another time). Got a call from a new attending, she was a couple years ahead of me in training. She had done pain fellowship then stayed and was working in endoscopy. She asked me to help start her case, 60 y/0 M with widely metastatic pancreatic cancer, INR around 2, being transfused for suspected UGIB. Wealthy hospital donor family was totally unwilling to accept the reality of the situation, they were pushing everyone to "do everything" so GI agreed to scope him and see if they could find and treat a source. We could have refused to do it, but it was Friday afternoon and our sense was that it would be better to do it now rather than be called in do deal with an even worse situation over the weekend. In the moment it seemed that the case was going to go one way or another, so it was a question of when and how so we opted to go for it now, under general anesthesia. We had started some nasty cases as residents and this was clearly going to be another. NG tube had come out while he was vomiting earlier in the day.

Despite keeping the head elevated, pressure on the neck (what is cricoid pressure? Who is John Galt?) he had high volume hematemesis on induction. When I DL'ed, all I could see was a fluid level. After a few very long seconds of suctioning, the vocal cords emerged from the middle of a murky, dark lake. After connecting to the circuit, my attending tried to hand ventilate and there was no end tidal CO2 and she was unable to move any air. It was exactly what you would expect if you were in the esophagus, but my view had been easy so I inserted the soft suction into the ETT and suctioned. And suctioned. And suctioned. This time, after reconnecting we were able to ventilate.

He survived the procedure, which as a result of his aspiration included a formal bronchoscopy by a pulm intensivist to really clean and wash out the airways. He returned to the ICU intubated. I checked on him and he made it through the weekend, but I doubt that he lived for long. In hindsight, we could have approached the case differently. I am grateful that we were prepared for disaster since that is exactly what happened. However; I suspect the outcome would have been similar no matter what our plan was. Prior to that, I had done quite a few EGD's and rarely intubated for them, most of them were very low risk compared to this patient. As others above have stated, you can get away with doing a lot of these cases, but one unexpected aspiration could be a disaster. I have some partners who routinely intubate for any EGD. That is a bit extreme for me, but I take the risk of aspiration very seriously.

 

[dhb]

I have some partners who routinely intubate for any EGD.

 

[anbuitachi]

Story time. Here's why I have a low threshold for intubating in the UGIB scopes. I was board runner for the day as a CA3 (part of our "periop management" rotation, that's a rant for another time). Got a call from a new attending, she was a couple years ahead of me in training. She had done pain fellowship then stayed and was working in endoscopy. She asked me to help start her case, 60 y/0 M with widely metastatic pancreatic cancer, INR around 2, being transfused for suspected UGIB. Wealthy hospital donor family was totally unwilling to accept the reality of the situation, they were pushing everyone to "do everything" so GI agreed to scope him and see if they could find and treat a source. We could have refused to do it, but it was Friday afternoon and our sense was that it would be better to do it now rather than be called in do deal with an even worse situation over the weekend. In the moment it seemed that the case was going to go one way or another, so it was a question of when and how so we opted to go for it now, under general anesthesia. We had started some nasty cases as residents and this was clearly going to be another. NG tube had come out while he was vomiting earlier in the day.

Despite keeping the head elevated, pressure on the neck (what is cricoid pressure? Who is John Galt?) he had high volume hematemesis on induction. When I DL'ed, all I could see was a fluid level. After a few very long seconds of suctioning, the vocal cords emerged from the middle of a murky, dark lake. After connecting to the circuit, my attending tried to hand ventilate and there was no end tidal CO2 and she was unable to move any air. It was exactly what you would expect if you were in the esophagus, but my view had been easy so I inserted the soft suction into the ETT and suctioned. And suctioned. And suctioned. This time, after reconnecting we were able to ventilate.

He survived the procedure, which as a result of his aspiration included a formal bronchoscopy by a pulm intensivist to really clean and wash out the airways. He returned to the ICU intubated. I checked on him and he made it through the weekend, but I doubt that he lived for long. In hindsight, we could have approached the case differently. I am grateful that we were prepared for disaster since that is exactly what happened. However; I suspect the outcome would have been similar no matter what our plan was. Prior to that, I had done quite a few EGD's and rarely intubated for them, most of them were very low risk compared to this patient. As others above have stated, you can get away with doing a lot of these cases, but one unexpected aspiration could be a disaster. I have some partners who routinely intubate for any EGD. That is a bit extreme for me, but I take the risk of aspiration very seriously.

i dont think it sounded like an unexpected aspiration.. it was a high risky aspiration risk case and he aspirated. thats why we take all these precautions.

 

[WholeLottaGame7]

You do you buddy. If you’re worried then you should tube. From GI standpoint we don’t care at all as long as you don’t postpone or delay cases.

Yeah man, it's the two extra minutes to tube 2 patients that I'm worried about that's going to slow down the GI suite, and not the fact that the 80yo lower GI bleeder with a history of CAD and a hemoglobin of 6.5 (6 hours ago) not only doesn't have blood ready, but the blood's not even ordered, because the patient DOESN'T EVEN HAVE A TYPE AND SCREEN. But don't worry, the medicine intern wrote "transfuse 2 uPRBC" in their daily note, which obviously means the magical blood fairies will do all the work necessary to adequately optimize the patient.

Granted, that's not all on a GI proceduralist, since really you're just a different kind of tube jockey, but the point is, there are a lot of reasons for delays, and some (if not most) of them are outside the realm of anesthesia. Trust me, we all want to get out of there as much as you do (if not more).

And no, we didn't tube that guy.

 

[Hoya11]

One thing i dont get is how a lot of 'proceduralists' were good medicine doctors prior to going to fellowship and becoming proceduralists, and once they become proceduralists it seems like patient safety is now out the window and its all about your paycheck and when you are leaving the hospital. it's a shame.

The most unreasonable discussions about anesthesia that I have had have been with "proceduralists" ie interventional cardiology, GI, and IR..

I think its because they never really entered the OR environment, they were the kings of the wards, and step into the OR/Procedure room completely clueless as to risks of procedures yet act all-knowing as they were on the floor.. they are thinkers trying to do, and they have no frame of reference to actual successful doers (good surgeons) to understand how bad/clueless they are at doing

 

[GastriqueGraffin]

Wow I was actually trying to help see where we are coming from as another perspective but I have never met anyone more sensitive than MDAs. You went to medical school but have no concept of the medicine to understand an evidence based approach or reasonable thinking to the pathology of what you’re taking care of. I can give all the anecdotes of “I know a guy who this or that happened to”. Might as well be a nurse with that reasoning, which is why I don’t mind more CRNAs running independently in GI labs unless there is more to the case than a GI bleed. I am telling you do whatever you want if it makes you feel better or more secure... like a PCP that orders every test they can think of because they may theoretically catch that random cancer in an asymptomatic patient not thinking of the evidence behind this approach.

 

[Hork Bajir]

You have no idea what you're talking about. Yet you choose to come to an anesthesia forum, to tell attending anesthesiologists how to do their jobs (or that nurses are just as good as them). But don't worry, you're just "giving us another perspective".

Not sure if you're being sincere and don't understand how much you're acting like a tool, or if you are intentionally trying to be a troll. Either way, it's clear that you're ignorant about anesthesia. But you can feel free to keep saying and doing "whatever you want if it makes you feel better or more secure".

By the way, how long would it take to train a nurse to do straightforward colos and EGDs? I bet not that long, and if they do it day in and day out, they'd probably be pretty good at it. You might feel as though you bring more to the table, since you are (presumably) a physician who completed medical school and residency program as well as a fellowship. Turns out, so are we. But you know, "you do you".

 

[Arch Guillotti]

Wow I was actually trying to help see where we are coming from as another perspective but I have never met anyone more sensitive than MDAs.

lol dude first of all most of us hate the term MDA

 

[getdown]

Wow I was actually trying to help see where we are coming from as another perspective but I have never met anyone more sensitive than MDAs. You went to medical school but have no concept of the medicine to understand an evidence based approach or reasonable thinking to the pathology of what you’re taking care of. I can give all the anecdotes of “I know a guy who this or that happened to”. Might as well be a nurse with that reasoning, which is why I don’t mind more CRNAs running independently in GI labs unless there is more to the case than a GI bleed. I am telling you do whatever you want if it makes you feel better or more secure... like a PCP that orders every test they can think of because they may theoretically catch that random cancer in an asymptomatic patient not thinking of the evidence behind this approach.

What evidence based medicine are we talking about? There are randomized controlled trials about the risk for aspiration in EGD/colos in patients that are tubed vs unprotected airways? I'd like to see that. The issue here isn't about evidence based on understanding pathology. The issue here is understanding risk and mitigating it. As a field, we're trained to anticipate the worst possible scenario in each different service. Why? Because the times that complications happen, they're devastating. You can't intubate? The patient dies. The patient has severe aspiration? They go into full blown ARDS, MICU stay, and may die. You want to be blase about these things? Fine, until it's your ass or your loved ones laying on that table. Then you'd want someone who gives a damn.

What people have an issue with you is that you come into the ANESTHESIA forum and then proceed to tell us how to do our job in the guise of "from a proceduralists perspective". Not only that, your condescending attitude just screams your lack of understanding of what exactly goes on in our profession. You wanna talk about not understanding the pathology? When was the last time you even bothered looking up your patients full medical history that's not related to GI? We actually do. So before you start talking about not knowing pathology, maybe you should know more about your patients besides how long their last colonoscopy was. You want to hire CRNAs to do your bidding go ahead. Just be ready for more complications.

 

[anbuitachi]

Wow I was actually trying to help see where we are coming from as another perspective but I have never met anyone more sensitive than MDAs. You went to medical school but have no concept of the medicine to understand an evidence based approach or reasonable thinking to the pathology of what you’re taking care of. I can give all the anecdotes of “I know a guy who this or that happened to”. Might as well be a nurse with that reasoning, which is why I don’t mind more CRNAs running independently in GI labs unless there is more to the case than a GI bleed. I am telling you do whatever you want if it makes you feel better or more secure... like a PCP that orders every test they can think of because they may theoretically catch that random cancer in an asymptomatic patient not thinking of the evidence behind this approach.

I think opinions from other people are always welcome but to a lot of people the way you phrased it whether you meant it or not hit people here the wrong way. you made it sound like your schedule/paycheck trumps the patients safety. the #1 goal in our field is patient safety, and if you are saying it's more important that the GI docs get out early than patient safety you are going to get a lot of bashing.

And also i dont think you understand very well what we do (its not just you, but many proceduralist). to you we may be just propofol pushers and are only there so you can get your case done, which is why you may prefer CRNAs who dont think as much and just push propofol (probably also why you call us MDAs) . personally i hate being in Endo cause its mostly mind numbing

 

[2Fast2Des]

Wow I was actually trying to help see where we are coming from as another perspective but I have never met anyone more sensitive than MDAs. You went to medical school but have no concept of the medicine to understand an evidence based approach or reasonable thinking to the pathology of what you’re taking care of. I can give all the anecdotes of “I know a guy who this or that happened to”. Might as well be a nurse with that reasoning, which is why I don’t mind more CRNAs running independently in GI labs unless there is more to the case than a GI bleed. I am telling you do whatever you want if it makes you feel better or more secure... like a PCP that orders every test they can think of because they may theoretically catch that random cancer in an asymptomatic patient not thinking of the evidence behind this approach.

LOL are you f***ng serious?? Because we call you out and try to educate you on your ignorance you resort to disrespect? Is that what they teach you in fellowship? Or let me guess do you talk back or put down advice you get from your attendings when they teach you a different perspective or give advice? Why don't you work on becoming the best MDG or DOG (whichever med school you came from) or actually also use half of the knowledge you may or may not have picked up on the wards/ICU as an MDIM/DOIM before you decided to become a human plumber and understand why and how we use our "medical knowledge" from the doctor school you and we also went to. We guide a patient through a safe anesthetic to keep them alive and keep you from having to explain why you chose to send granny to an early grave. If you think ETT is the same as Dr House ordering every lab known to mankind then dear lord you have much to learn and you will learn the hard way when you're slow and ****ty and you're the guy no one wants to work with. Let me ask you, what is the difference between MAC vs GA? Or the airways, and benefits of each? You want independent crna's so you can tell them how you want things done, but when s**t hits the fan you want someone who knows what the hell they're doing? Hypocritical much?

You have no idea what you're talking about. Yet you choose to come to an anesthesia forum, to tell attending anesthesiologists how to do their jobs (or that nurses are just as good as them). But don't worry, you're just "giving us another perspective".

Not sure if you're being sincere and don't understand how much you're acting like a tool, or if you are intentionally trying to be a troll. Either way, it's clear that you're ignorant about anesthesia. But you can feel free to keep saying and doing "whatever you want if it makes you feel better or more secure".

By the way, how long would it take to train a nurse to do straightforward colos and EGDs? I bet not that long, and if they do it day in and day out, they'd probably be pretty good at it. You might feel as though you bring more to the table, since you are (presumably) a physician who completed medical school and residency program as well as a fellowship. Turns out, so are we. But you know, "you do you".

He's butthurt to be called out. Its the pompous attitude he gained from losing perspective of the big picture, but hey as long as it doesn't delay his day. I'm actually surprised nurses haven't replaced these guys, fiddling a camera in the stomach and intestines is really all about dexterity and finesse, and the good GI nurses know what tools to have ready when they see certain things on the screen.

https://www.cghjournal.org/article/S1542-3565(12)01305-5/fulltext

"The NPs are trained to perform colonoscopy in an identical fashion to their contemporary gastroenterology fellows. Competency was achieved by using national standards in accordance with ASGE guidelines. Table 1shows the performance of our index NP. Her performance exceeded all benchmarks expected of fully trained gastroenterologists. The NPs also produce cost savings because they are reimbursed at 85% of the physician fee schedule. All 3 NPs are board-certified in Maryland to perform colonoscopies and achieved this certification after 1 year of training."

Apparently its happening. Look out @GastriqueGraffin ....

 

[2Fast2Des]

lol dude first of all most of us hate the term MDA

I think he meant MD-Awesome, I'm working on having security dept reprint my badge to say that. Who wants a boring vanilla MD?? MD-Amazing/Awesome/Astounding is way better!

 

[siliso]

Is it heme positive stool or unexplained anemia being investigated - or frank blood burbling up/maroon burbling from below? Is it add on because there’s a medical emergency for the patient right now or because it’s Friday and they’re fixing to run out of hospital days for that unexplained anemia and need to get the job done with efficiency? I’d not presume to tell you how to do your job either way, but there does seem to exist a range of possibilities and risk levels in the add on suspected GIB category.

 

[Mman]

Wow I was actually trying to help see where we are coming from as another perspective but I have never met anyone more sensitive than MDAs. You went to medical school but have no concept of the medicine to understand an evidence based approach or reasonable thinking to the pathology of what you’re taking care of. I can give all the anecdotes of “I know a guy who this or that happened to”. Might as well be a nurse with that reasoning, which is why I don’t mind more CRNAs running independently in GI labs unless there is more to the case than a GI bleed. I am telling you do whatever you want if it makes you feel better or more secure... like a PCP that orders every test they can think of because they may theoretically catch that random cancer in an asymptomatic patient not thinking of the evidence behind this approach.

coming from an MDG....

 

[DM27]

I would much rather assume this guy/girl is a troll rather than a practicing GI Physician.

 

[Southpaw]

which is why I don’t mind more CRNAs running independently in GI labs

At least you’re honest. In some ways you’re right to touch on anecdote. Please though, I went to medical school like you so be respectful enough to call me simply another MD. Should I call you MDG?

I’m glad you mentioned CRNAs because I so badly wanted to bring it up with you earlier. GIs I work with use CRNAs in their office not for any sort of safety belief (though maybe they’re like you and believe doctors aren’t safer than nurses), but because they make money off of them! So guess what I get to take care of in the big house?

 

[chocomorsel]

Perspective from a GI fellow:

When it’s a severe enough upper GI bleed that they need to be intubated then they are usually in the ICU and usually intubated. If they are in GI endoscopy lab usually it’s a slow bleed or one that stopped. In those cases we can do conscious sedation but will ask for anesthesia help because of other comorbidities not related to the acute bleed.

There are exceptions to everything but that’s just been my experience and overall makes sense.

What is the big deal in allowing an extra 1- 2 min to properly secure an airway?
You guys don’t have to deal with airway complications. We do. And these people can die because you are what? Trying to save yourself a minute?

 

[Southpaw]

What is the big deal in allowing an extra 1- 2 min to properly secure an airway?
You guys don’t have to deal with airway complications. We do. And these people can die because you are what? Trying to save yourself a minute?

In my opinion, GIs who work in offices w CRNAs get what they want when they want it. They don’t care for another physician ( like the MDA!) who has to hit the brakes for some god awful GI bleed they wanna tube. The GI has no tolerance for that. They wanna get back across the street where their 20 healthy scopes and ‘yes doctor!’ CRNA are waiting on them.

If I never worked another GI day in my whole life I’d be fine with it. I’m sure the feelings are mutual.

 

[Southpaw]

And of course in MD only practices none of this matters as there’s infinitely more mutual respect.

 

[Twiggidy]

Wow I was actually trying to help see where we are coming from as another perspective but I have never met anyone more sensitive than MDAs. You went to medical school but have no concept of the medicine to understand an evidence based approach or reasonable thinking to the pathology of what you’re taking care of. I can give all the anecdotes of “I know a guy who this or that happened to”. Might as well be a nurse with that reasoning, which is why I don’t mind more CRNAs running independently in GI labs unless there is more to the case than a GI bleed. I am telling you do whatever you want if it makes you feel better or more secure... like a PCP that orders every test they can think of because they may theoretically catch that random cancer in an asymptomatic patient not thinking of the evidence behind this approach.

Well since you know everything about medicine......then you sedate the patient for your procedure

 

[vector2]

Just lmao'ing at our GI fellow troll talking about evidence based medicine. Per uptodate:

"
General support — Patients should receive supplemental oxygen by nasal cannula and should receive nothing per mouth. Two large caliber (18 gauge or larger) peripheral intravenous catheters or a central venous line should be inserted. For patients who are hemodynamically unstable, two 16 gauge intravenous catheters and/or a large-bore, single-lumen central cordis should be placed.

Elective endotracheal intubation in patients with ongoing hematemesis or altered respiratory or mental status may facilitate endoscopy and decrease the risk of aspiration. However, among patients who are critically ill, elective endotracheal intubation has been associated with worse outcomes. A case control study with 200 patients with upper GI bleeding who were critically ill found that patients who had elective endotracheal intubation were more likely than patients who were not intubated to have adverse cardiopulmonary outcomes based on a composite outcome that included pneumonia, pulmonary edema, acute respiratory distress syndrome, and cardiac arrest [25]. Of note, the presence of respiratory distress prior to intubation was not reported and the mean Glasgow Coma Scale score was 14.7 (+/- 0.95), indicating that altered mental status was absent in the majority of patients. Patients who were electively intubated were more likely to suffer cardiopulmonary complications compared with patients who were not intubated (20.0 versus 6.0 percent). In particular, patients who were intubated were more likely to be diagnosed with pneumonia within 48 hours (14.0 versus 2.0 percent). Pending additional studies in broader patient populations, our approach is still to proceed with intubation in patients deemed high-risk for aspiration, including those with massive upper GI bleeding or altered mental status."

Pretty much every GI and their brother is citing this single, observational, case-control study when talking about how intubating leads to poorer outcomes. Gimme a break.

 

[WholeLottaGame7]

Wow I was actually trying to help see where we are coming from as another perspective but I have never met anyone more sensitive than MDAs. You went to medical school but have no concept of the medicine to understand an evidence based approach or reasonable thinking to the pathology of what you’re taking care of. I can give all the anecdotes of “I know a guy who this or that happened to”. Might as well be a nurse with that reasoning, which is why I don’t mind more CRNAs running independently in GI labs unless there is more to the case than a GI bleed. I am telling you do whatever you want if it makes you feel better or more secure... like a PCP that orders every test they can think of because they may theoretically catch that random cancer in an asymptomatic patient not thinking of the evidence behind this approach.

Lol. I know more about the medical history and (non-GI) pathology of the patients than any of the proceduralists in the room.

But you do you, man. Just keep on scoping until the PA/NP/DNP/RNPhD takes the scope right out of your hands. Maybe it'll be for the best. Might be nice to have someone driving the camera who actually listens to a physician who knows what they're doing.

 

[getdown]

This would have been an interesting thread for Psai to chime in on. Always enjoyed his snarky comments.

 

[Gastrapathy]

@GastriqueGraffin

Don’t sweat it. Just pick a practice where you have control and can work with folks whose interests are aligned with yours. There are lots of good anesthesiologists who will work with you happily. The “in the name of patient safety” stall tactic shift workers aren’t actually that prevalent in the real world.

 

[Gastrapathy]

@Southpaw not exactly “mutual respect” in the post you wrote right above the “mutual respect” post.

@Twiggidy thats exactly right. We should sedate the vast majority of these patients.

@WholeLottaGame7 We aren’t giving our specialty away, don’t worry about us. There is next to no encroachment and actually less now than ever. FPs, surgeons, etc have been able to do colons forever. The number of midlevels getting training is minuscule. Everyone always posts the Kaloo paper. Somehow, when the GI bashing starts, you guys always go here. It’s kinda sad.

You guys call yourselves MDAs in other threads. Feel free to post some trigger warnings. He wasn’t trolling.

 

[nimbus]

@GastriqueGraffin

Don’t sweat it. Just pick a practice where you have control and can work with folks whose interests are aligned with yours. There are lots of good anesthesiologists who will work with you happily. The “in the name of patient safety” stall tactic shift workers aren’t actually that prevalent in the real world.

Agreed except taking an extra 5 min to do it right is not a stall tactic.

 

[2Fast2Des]

@Southpaw not exactly “mutual respect” in the post you wrote right above the “mutual respect” post.

@Twiggidy thats exactly right. We should sedate the vast majority of these patients.

@WholeLottaGame7 We aren’t giving our specialty away, don’t worry about us. There is next to no encroachment and actually less now than ever. FPs, surgeons, etc have been able to do colons forever. The number of midlevels getting training is minuscule. Everyone always posts the Kaloo paper. Somehow, when the GI bashing starts, you guys always go here. It’s kinda sad.

You guys call yourselves MDAs in other threads. Feel free to post some trigger warnings. He wasn’t trolling.

Hi MDG\DOG. Where do we call each other MDAs? We may call it in jest knowing what a joke\derogatory term it is.

Mutual respect is that, "mutual" , gotta give to get.

 

[2Fast2Des]

Agreed except taking an extra 5 min to do it right is not a stall tactic.

5 minutes is an extra case that can be done. Or an ICU admission and all the costs, complications to save 5 minutes, but nah better to provide inferior care

 

[vector2]

@Twiggidy thats exactly right. We should sedate the vast majority of these patients.

Hi MDG\DOG. Where do we call each other MDAs? We may call it in jest knowing what a joke\derogatory term it is.

Mutual respect is that, "mutual" , gotta give to get.

I bet there are a fair number of GIs out there who, like the clown who wrote the editorial above, think the obvious "solution" to the "problem" of anesthesiologist involvement in endoscopy is for GIs to take a weekend sedation course and start administering propofol themselves. I mean sure, it takes an anesthesiology trainee close to a year to get basic competence with general w/o ETT, deeeep sedation, advanced airway management, and it takes pulm/ccm fellows and EM trainees years to reach similar competence, but sure, let's let the endoscopist start pushing propofol cause he bag-mask-ventilated a dummy for a couple hours and had some nurse mark a checkbox saying he's now certified

 

[IMGASMD]

I bet there are a fair number of GIs out there who, like the clown who wrote the editorial above, think the obvious "solution" to the "problem" of anesthesiologist involvement in endoscopy is for GIs to take a weekend sedation course and start administering propofol themselves

Isn’t that what happened with Joan Rivers? Isn’t the guy who ran the place was a proponent of the automatic anesthesia machine? Or something?

 

[Southpaw]

@Southpaw not exactly “mutual respect” in the post you wrote right above the “mutual respect” post.

@Twiggidy thats exactly right. We should sedate the vast majority of these patients.

@WholeLottaGame7 We aren’t giving our specialty away, don’t worry about us. There is next to no encroachment and actually less now than ever. FPs, surgeons, etc have been able to do colons forever. The number of midlevels getting training is minuscule. Everyone always posts the Kaloo paper. Somehow, when the GI bashing starts, you guys always go here. It’s kinda sad.

You guys call yourselves MDAs in other threads. Feel free to post some trigger warnings. He wasn’t trolling.

How does stating that I don't want to do GI anesthesia disrespect you or @GastriqueGraffin? Especially when you have no problem telling @Twiggidy, a board certified anesthesiologist, how he should do the anesthesia for GI patients? Tell me what exactly about intubating a patient increases procedural risk, when they're extubated at the end? Does it extend into other procedural areas where patients are ROUTINELY intubated/extubated and go home the same day?

I respect you as a gastroenterologist and physician. I simply don't enjoy doing endoscopy, for the exact reasons @GastriqueGraffin stated. He sees no difference between me and a CRNA. And he's stating as such IN OUR FORUM. Notice, I am not posting in the GI forum. I NEVER have to my recollection. And I have NO tolerance for you guys coming here if it isn't in acquiescence. I've sat at the table with GI and tried to offer my assistance and expertise. They want their CRNAs. And I know EXACTLY why. And it has nothing to do with safety.

 

[vector2]

Isn’t that what happened with Joan Rivers? Isn’t the guy who ran the place was a proponent of the automatic anesthesia machine? Or something?

Yes, the GI in charge of that clinic Dr. Cohen is a proponent of propofol being administered by his RNs under his direction. Unfortunately there was an anesthesiologist taking part in Rivers' care. No ETCO2, minutes spent ignoring deteriorating BPs, possibly erroneous pulse ox, and doing ENT laryngoscopy, then EGD, then unplanned repeat laryngoscopy again without an airway in place probably all contributed to the code. If this kind of malpractice can occur when a (probably incompetent) board-certified anesthesiologist is providing a propofol anesthetic, just imagine what could happen without any anesthesia involvement.

Joan Rivers’ anesthesiologist identified

 

[nimbus]

Yes, the GI in charge of that clinic Dr. Cohen is a proponent of propofol being administered by his RNs under his direction. Unfortunately there was an anesthesiologist taking part in Rivers' care. No ETCO2, minutes spent ignoring deteriorating BPs, possibly erroneous pulse ox, and doing ENT laryngoscopy, then EGD, then unplanned repeat laryngoscopy again without an airway in place probably all contributed to the code. If this kind of malpractice can occur when a (probably incompetent) board-certified anesthesiologist is providing a propofol anesthetic, just imagine what could happen without any anesthesia involvement.

Joan Rivers’ anesthesiologist identified

Yeah she was knocked off by a board certified anesthesiologist. Probably thought she could get away with a sketchy airway. If only there was a way to secure an airway....hmmm

 

[Gastrapathy]

@Southpaw
What I said to @Twiggidy is that I totally agree that GI (we) should sedate nearly all of the patients ourselves.

You want a GI fellow to be able to tell the difference between you and a CRNA? Good luck. They’re learning their craft. They know whether you are friendly and helpful. I was following this thread with bemusement until you guys started attacking a trainee.

I get along with all my anesthesiologists well. We trust each other. It’s all good. If you and your GIs mutually wish you weren’t there...well, they can’t leave.

If you think your tone in those posts was mutually respectful, I disagree. You require our acquiescence? In your 10 years on the forum, you’ve never even donated a dime. Not sure why you think you own the place.

 

[Southpaw]

@Southpaw
What I said to @Twiggidy is that I totally agree that GI (we) should sedate nearly all of the patients ourselves.

You want a GI fellow to be able to tell the difference between you and a CRNA? Good luck. They’re learning their craft. They know whether you are friendly and helpful. I was following this thread with bemusement until you guys started attacking a trainee.

I get along with all my anesthesiologists well. We trust each other. It’s all good. If you and your GIs mutually wish you weren’t there...well, they can’t leave.

If you think your tone in those posts was mutually respectful, I disagree. You require our acquiescence? In your 10 years on the forum, you’ve never even donated a dime. Not sure why you think you own the place.

The GI fellow said this:

Wow I was actually trying to help see where we are coming from as another perspective but I have never met anyone more sensitive than MDAs. You went to medical school but have no concept of the medicine to understand an evidence based approach or reasonable thinking to the pathology of what you’re taking care of. I can give all the anecdotes of “I know a guy who this or that happened to”. Might as well be a nurse with that reasoning, which is why I don’t mind more CRNAs running independently in GI labs unless there is more to the case than a GI bleed. I am telling you do whatever you want if it makes you feel better or more secure... like a PCP that orders every test they can think of because they may theoretically catch that random cancer in an asymptomatic patient not thinking of the evidence behind this approach.

Trainee or not, that's not cool. But I'm sure @GastriqueGraffin appreciates you trying to help him dig out of the hole he put himself into. I don't own the place, and I don't go into other forums to insult the physicians there. So glad to have you and @GastriqueGraffin providing such expertise for us.

 

[Southpaw]

@Southpaw
What I said to @Twiggidy is that I totally agree that GI (we) should sedate nearly all of the patients ourselves.

In your 10 years on the forum, you’ve never even donated a dime.

Done. Now I'll see you in the GI forum where I'll promptly trash everyone there. Oh wait....

 

[dhb]

Done. Now I'll see you in the GI forum where I'll promptly trash everyone there. Oh wait....

I like that yellow line Southie

 

[Gastrapathy]

I like the yellow line too.

I didn’t insult anyone. In the recent GI threads here in your forum, my profession has been called jockey, monkey, clown, unethical, motivated only by money, dangerous and worse.

Then you posted about mutual respect. There clearly isn’t any. But how can you act surprised that a fellow has figured that out and decided to go with your less capable replacements. If his practice is anything like the reception here, I understand that choice. Im lucky to practice with good anesthesiologists and if he has that experience, maybe it will overcome.

 

[IM2GI]

I understand what you’re saying and appreciate the perspective you’re trying to provide. But the difference is many GI docs equate “MAC” with “better sedation” with an Anesthesiologist involved for “other comorbidities” and this is mostly false. These propofol “MACs” are GAs with an unprotected airway that by definition we are calling full stomach. A bleed that stopped is not equal to no blood in the stomach. If you want to do “conscious sedation” by all means go ahead, don’t ablate protectives and you’re good, but when you guys expect them to be asleep and I’m involved then my standard of care trumps your efficiency.

And in regards to the done at 4pm comment, many anesthesia departments are pulled in 3-5 different directions with the multiple offsites in addition to the main OR and quite simply can’t staff an offsite till late evening. If your case is emergent and it’s late we can try to accommodate or you can come to the main. Again, patient safety trumps all of our scheduling, efficiency, and priority logistical considerations.

Attending GI. Its interesting how both the food impaction and UGI bleeding threads have taken off.

Unlike a food impaction where I agree that I would always like a secured airway, it is not nearly as straightforward in the setting of upper GI bleeding. In fact, this has been recently looked at and there were MORE complications in the group that was prophylactically intubated. These were ivory tower Cleveland Clinic patients:

Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events. - PubMed - NCBI

"RESULTS:

Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P = .008), which remained significant (P = .012) after adjusting for the presence of esophageal varices."

This is a high quality journal from a high quality author.

We need to think more critically about these situations other than tube = good.

 

[IM2GI]

Hi MDG\DOG. Where do we call each other MDAs? We may call it in jest knowing what a joke\derogatory term it is.

Mutual respect is that, "mutual" , gotta give to get.

I legit didn't know "MDA" was considered a derogatory term. Good to know.