Just what the neurologist ordered "a spinal tap"

[turnupthevapor]

Started at a new place and am seeing a new order in the charts. "please have anesthesia do a lumbar puncture with opening pressure and fluid collection"....and there is no please I added that in

What is the opinion of you all. Is this in my scope of practice? Will my peers on a jury feel I should have been doing this? What if there is a herniation or hematoma? Malpractice going to cover me?

Should I insist the neurologist be there or attempt first? I am not sure....reality is I can do it better than him but usually don't feel like hanging out in the room of a meningitis pt. also don't want to deal with a patient who came in w headache, got an lp and a week later has a worse headache


Could use some guidance

Thanks

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[typhoonegator]

I'm a neurologist. That is weak sauce. However, I've done teleneurology consults with community hospitals where the consulting neurologist said they were going to have anesthesia do the tap, so I can't say I'm surprised.

I'm a neurocritical care doc and I do intubations and lines and chest tubes and bronchs, so maybe I'm a bit skewed in my perception of standard practice. However, it is hard for me to think that any neurologist would consider an LP to be outside the scope of his/her practice. I did literally hundreds of them during residency.

If it makes you feel better, even if this neurologist had done the tap and the patient got a post-LP headache, you still would have had to do that consult for a patch

 

[DrRobert]

It depends what is customary at your new place. If your group has agreed to do these procedures then you will probably have to follow suit.

Our group would refuse to do LPs because that would open the door and suddenly we would be flooded with requests... and we are too busy in the OR to do them.

You would have to check with your malpractice carrier with regards to them covering specific procedures.

 

[pgg]

Can you get an opening pressure through a 25g needle? I would think probably, but maybe too slowly for it to be practical. Always felt guilty doing LPs with the big cutting needle in the tray. I give my brother the EM doc crap all the time for using those barbaric PDPH-generating needles, but I wonder if there's a method to the neurologists' madness.

OP, that seems kind of crappy for the neurologist to order an LP with less courtesy than he'd use ordering a pizza. Maybe there's some longstanding agreement with your group? I'd probably do the LP all smiles and then ask someone more senior to you in the group what's up. Picking fights or making waves as the new guy has a risk all its own. It's not like RT is asking you to draw an ABG direct from the left ventricle ...

 

[rsgillmd]

It depends what is customary at your new place. If your group has agreed to do these procedures then you will probably have to follow suit.

Our group would refuse to do LPs because that would open the door and suddenly we would be flooded with requests... and we are too busy in the OR to do them.

You would have to check with your malpractice carrier with regards to them covering specific procedures.

During residency I got asked for help by an ER attending once, and a few times by medicine residents. When I asked my attending how to handle this, she told me to ask for a formal consult. They promptly wrote the request in the chart. Then I went, did the tap, wrote up a consult sheet to be billed, and got out of there.

But it was hardly common -- 4-5 times in 3 years.

 

[lobelsteve]

PMR/Pain here.

I've been asked to get CSF from my Neurologist before because the patient had scoliosis and a pretty degenerative spine. The use of fluoroscopy makes the LP a snap. Easy in and out using a 20G Tuohy. No idea on billing but that's what my Laurel is for.

 

[nap$ter]

PMR/Pain here.

I've been asked to get CSF from my Neurologist before because the patient had scoliosis and a pretty degenerative spine. The use of fluoroscopy makes the LP a snap. Easy in and out using a 20G Tuohy. No idea on billing but that's what my Laurel is for.

the blood patch under fluoro should be a snap as well, and you can even use the same needle!

 

[RussianJoo]

As said above, I too have been asked by medicine residents in the ICU to do an LP. A lot of times they ask us to do them because they don't want to torture the patient and just want someone who know what they're doing do it, or they're too busy to do the procedure or don't have any interest in doing the procedure. So it's pretty common at least in places with residency programs, but once again you're left with unanswered questions of billing and malpractice coverage, two very important things for attendings in private practice which aren't as important for residents.

 

[Goldenyak2]

Our neurologists don't do LP's. So we end up doing all of them. An LP is not part of the scope of practice of an anesthesiologist although injecting into the intrathecal space is. Unfortunately, my chief hasn't done/won't do anything about it. And we occasionally get called to the ED for LP's when the docs fail. Most times I notice the ED docs' attempts are at the sacrum or iliac crest. Who trains these people?

 

[proman]

How is it not part of our scope of practice (what does that mean anyway?). We access the intrathecal space more than anyone else, and are probably the most proficient at it. I do lumbar drains, but I shouldn't do an LP if my assistance is requested (consulted)?

Neurologists don't want to do LPs because it doesn't reimburse well and they want to punt to someone else.

 

[Goldenyak2]

How many LP's to rule out meningitis did you do during your anesthesiology residency? I did exactly zero. Sure, anesthesiologists are the most proficient at accessing the intrathecal space but we don't do it on a daily basis for diagnostic tests. I don't have a problem helping out a colleague who can't get the LP but to rely on an anesthesiologist to do them because you're lazy or cheap is unacceptable. Not to mention the added risk of performing such a procedure.

 

[lobelsteve]

the blood patch under fluoro should be a snap as well, and you can even use the same needle!

Oops.

22G Quinke.

Tuohy for the patch.

 

[sevoflurane]

I do a handful a year when our neurologists can't get it. Measuring opening pressures and filling a coupla tubes is a snap. The current contract with our hospital would put $500 in my pocket...so everybody is happy.

 

[proman]

How many LP's to rule out meningitis did you do during your anesthesiology residency? I did exactly zero. Sure, anesthesiologists are the most proficient at accessing the intrathecal space but we don't do it on a daily basis for diagnostic tests. I don't have a problem helping out a colleague who can't get the LP but to rely on an anesthesiologist to do them because you're lazy or cheap is unacceptable. Not to mention the added risk of performing such a procedure.

Between med school, internship and critical care rotations (including one in a neuro ICU), I've done quite a few. No one's asking for an interpretation of the fluid. I agree we shouldn't do them because the neurologist is lazy, but I disagree that it's not a procedure within our realm. I'll do LPs all day long for $500 cash.

 

[inmyslumber]

What is the opinion of you all. Is this in my scope of practice? Will my peers on a jury feel I should have been doing this? What if there is a herniation or hematoma? Malpractice going to cover me?

I do not do LPs for Neuro as you will be responsible for sequelae.

 

[B-Bone]

I did an LP one day up in our crappy little excuse for an ICU. It happenend like this: 90 yo demented guy with a crappy heart and what they think is herpes encephalitis needs an LP. I get called to put the guy under GENERAL ANESTHESIA so the IR dudes can do it (cuz he is "too squirrely" to do it with just sedation or even, God forbid, without sedation). Apparently our neurologists don't do this and the entire hospital staff thinks I'm off my rocker when I suggest they don't need fluoro to do an LP. The neurologist, internist and intensivist all refuse to do the procedure. I didn't want to GETA/prone this dude with a ****ty heart (and it would F up our OR schedule for like 45 minutes) so I just went up to his room, asked him to sit still, and got their fluid in like 5 minutes. The ICU guys/nurses/neurologist were in shock. I suggested that at least the neurologist and ICU guy should be doing these. They agreed to disagree, and IR still does all the LPs at this place. Great system, right?

 

[Apollyon]

You guys doing LPs for neurology is bogus. It is bogus because it is clearly within the scope of practice for neuro. Clearly. At the same time, to call anesthesiology because I can't get the tap doesn't even come to mind for me. Notwithstanding the obligatory dig at EM (what would a thread be on SDN without it?), in the rare instances I couldn't get it, I called radiology to do it under fluoro. Nowhere does anesthesiology come into the equation. However, if you are going to do it, I support you unequivocally if you can get $500/each for them.

(And, for the record, entering at the L3-L4 interspace, I've never stabbed anyone in the cord yet.)

 

[epidural man]

Started at a new place and am seeing a new order in the charts. "please have anesthesia do a lumbar puncture with opening pressure and fluid collection"....and there is no please I added that in

What is the opinion of you all. Is this in my scope of practice? Will my peers on a jury feel I should have been doing this? What if there is a herniation or hematoma? Malpractice going to cover me?

Should I insist the neurologist be there or attempt first? I am not sure....reality is I can do it better than him but usually don't feel like hanging out in the room of a meningitis pt. also don't want to deal with a patient who came in w headache, got an lp and a week later has a worse headache


Could use some guidance

Thanks

I'm not sure you can compare private practice to residentville, but we often do LP's for medicine, ID, Neuro rarely, and ER. They usually have a 'few' holes in the back before we try - so kudos for those guys to at least give it a good college try.

The problem I always have is just the mechanics of the whole thing since I'm not used to doing LP's (opening pressure, stewardship of the tubes and correct manner to collect, etc.) Anyway, I always tell the requesting service that we will access the space, but they have to do all the rest. In other words, once the needle is in place, I step out, they step in.

I like that way of doing it. Should we offer it? Who knows.

An even harder question for us to answer - is starting IV's - which we do frequently.

I was SOOOO pissed the other night when my senior resident calls me at 4 in the morning to start an IV. Do I need to repeat that? 4am. I gave him a good earful telling him that for one, we don't HAVE to start other IV's and we do it because we are kind and helpful people.....and saying "We would love to help you out - because we are wonderful people us anesthesiologist. Bring the patient to the hold area at 8am" is a more appropriate response. Anyway, so I'm pissed - and my residents have tried like 8 times, and can't get it. In 3 minutes, I get the ultrasound and find this huge vein, stick in the IV catheter, and without hooking it up and securing it or anything, (I think blood may have been dripping as well) say "there ya go...." and walk away.

 

[Hamhock]

You guys doing LPs for neurology is bogus. It is bogus because it is clearly within the scope of practice for neuro. Clearly. At the same time, to call anesthesiology because I can't get the tap doesn't even come to mind for me. Notwithstanding the obligatory dig at EM (what would a thread be on SDN without it?), in the rare instances I couldn't get it, I called radiology to do it under fluoro. Nowhere does anesthesiology come into the equation. However, if you are going to do it, I support you unequivocally if you can get $500/each for them.

(And, for the record, entering at the L3-L4 interspace, I've never stabbed anyone in the cord yet.)

Interestingly, before even reading this thread, I thought to myself (EM-trained):
Why would I call neuro if I can't get a tap? Wouldn't anesthesiology be much more skilled? I have done just as many (probably many more) LPs than some neuro PGY2.

Then an EM friend told me the policy at his place is: must get a neuro consult for a tap before calling IR.

Makes no sense.

Prior to reading this thread, I had planned on consulting anesthesiology for the next LP I couldnt get.

I'll report back regarding the response; if I remember.


HH

 

[rsgillmd]

........
The problem I always have is just the mechanics of the whole thing since I'm not used to doing LP's (opening pressure, stewardship of the tubes and correct manner to collect, etc.) Anyway, I always tell the requesting service that we will access the space, but they have to do all the rest. In other words, once the needle is in place, I step out, they step in.......

Same here.

 

[C.P.]

this is a pretty common issue/problem.
It all comes down to two things:
1) professional courtesy
2) "scope of practice"

1) I've been at places where the Anesthesiology department becomes the difficult IV access, central line placement, a-line guru, or spinal tap maestros. It's always a balance of being helpful but not being abused. When I get a polite call from an exasperated nurse on a kids ward, an internist in the ICU that's struggling with an a-line, or a neuro buddy that's become more of an accupuncturist after multiple neuraxial attempts, I'm always happy to help out (if I have time). It's when I get a call, they forget I'm doing them a big favour, and they impatiently expect me to drop everything. . . then I get a bit annoyed and remind them that the "MD" after their name means they should be able to handle it themselves.

2) I don't really know that "scope of practice means," but I know I can generally throw in a spinal, a-line, or IV like a game of darts. Whether my malpractice covers it or I can bill for it is another thing though, and if you're doing a few of these, I'd definitely want some financial reimbursement (especially if the neurologist/internist/etc is billing for it instead when I've done the work).

my 2 cents

 

[drccw]

I've been consulted by medicine and the ED for assistance with spinals.....

it's not a priority for me, but if I'm not busy I'll give them a hand...

Most of the time, they are very grateful and really recognize my expertise as a consultant.

I did get consulted once by a medicine attending who was not so grateful and I had to remind her that I was doing her a big favor....

In addition, I just drive the needle. I don't know how to do that other crap.

drccw

 

[dhb]

In addition, I just drive the needle. I don't know how to do that other crap.

drccw

Yeah i'm just a needle jockey too

 

[leaverus]

Bah! This sickens me. Writing an order like that in the chart is just another sign of disrespect towards anesthesiologists - it wasn't even a freakin' consult! The neurologist was the consultant and should have done his own LP, but if he felt it was beyond his abilities he should have directly asked you or one of your colleagues NICELY - you're doing HIM the favor. Orders in the chart are for nurses to carry out.

 

[RoundingError]

Up front: I am not a med student. apologies if this comment is not welcome. I was given an LP 7 years ago today. Results were negative, minor neurological symptoms soon resolved. I had a sensation of intense pressure but not pain after the procedure for 2 months. It returned 3 years later, and 3 years after that (last April) turned into pain. Within a few weeks my entire mid-section (front and back) started burning intensely, from hips to rib cage. Since last May I have needed Gabapentin, Tramadol, and *lots* of ibuprofen to tolerate it. I can no longer run or participate in ultimate frisbee without causing major flare lasting a couple of days.

Apart from this I never had any back problems or procedures, or any other issues. MRIs are negative according to radiologists and neurosurgeons. My doctor has diagnosed me with Arachnoiditis as it is the only explanation or by far the best.

Prior to this I was active, mid-40s male, never smoked or any other health issues (apart from short term facial neuralgia that led to doctor ordering LP).

My question: the LP needle was inserted between L2-L3 (according to fluoroscopy image - doctor's note incorrectly says L3-L4).

Should I be filing malpractice claim or is L2-L3 needle insertion not "below the standard of care" for lumbar puncture??

 

[Jimmy Chitwood]

Up front: I am not a med student. apologies if this comment is not welcome. I was given an LP 7 years ago today. Results were negative, minor neurological symptoms soon resolved. I had a sensation of intense pressure but not pain after the procedure for 2 months. It returned 3 years later, and 3 years after that (last April) turned into pain. Within a few weeks my entire mid-section (front and back) started burning intensely, from hips to rib cage. Since last May I have needed Gabapentin, Tramadol, and *lots* of ibuprofen to tolerate it. I can no longer run or participate in ultimate frisbee without causing major flare lasting a couple of days.

Apart from this I never had any back problems or procedures, or any other issues. MRIs are negative according to radiologists and neurosurgeons. My doctor has diagnosed me with Arachnoiditis as it is the only explanation or by far the best.

Prior to this I was active, mid-40s male, never smoked or any other health issues (apart from short term facial neuralgia that led to doctor ordering LP).

My question: the LP needle was inserted between L2-L3 (according to fluoroscopy image - doctor's note incorrectly says L3-L4).

Should I be filing malpractice claim or is L2-L3 needle insertion not "below the standard of care" for lumbar puncture??

L2-3 needle placment is not likely to be the cause of your arachnoiditis. Hopefully you get better soon though.

 

[Urzuz]

Up front: I am not a med student. apologies if this comment is not welcome. I was given an LP 7 years ago today. Results were negative, minor neurological symptoms soon resolved. I had a sensation of intense pressure but not pain after the procedure for 2 months. It returned 3 years later, and 3 years after that (last April) turned into pain. Within a few weeks my entire mid-section (front and back) started burning intensely, from hips to rib cage. Since last May I have needed Gabapentin, Tramadol, and *lots* of ibuprofen to tolerate it. I can no longer run or participate in ultimate frisbee without causing major flare lasting a couple of days.

Apart from this I never had any back problems or procedures, or any other issues. MRIs are negative according to radiologists and neurosurgeons. My doctor has diagnosed me with Arachnoiditis as it is the only explanation or by far the best.

Prior to this I was active, mid-40s male, never smoked or any other health issues (apart from short term facial neuralgia that led to doctor ordering LP).

My question: the LP needle was inserted between L2-L3 (according to fluoroscopy image - doctor's note incorrectly says L3-L4).

Should I be filing malpractice claim or is L2-L3 needle insertion not "below the standard of care" for lumbar puncture??

With all due respect, an anonymous anesthesiology Internet forum is not the place to get medical advice, much less legal advice. I'm also fairly certain that it violates the TOS you signed to create your account.

Wish you the best of luck.

 

[Ronin786]

I wish I could file a claim against my mechanic three years after he works on my car.

 

[RoundingError]

L2-3 needle placment is not likely to be the cause of your arachnoiditis. Hopefully you get better soon though.

The severe pain which emanates from the LP site and is accompanied by widespread neuropathic pain with a normal MRI does not leave much in the way of alternative diagnoses.

Thank you for the well wishes. Unfortunately my pain is gradually increasing... life has become a very difficult struggle for me. :-(

 

[pgg]

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