Post a good case, dammit.

[Apollyon]

You guys have clearly honed your skills to the point where you can prognosticate based on no history, some vitals and a lactate, I can’t say the same for myself.

That's harsh, dude.

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[RoyBasch]

I disagree. I've been part of these kinds of procedures. If they go to gi, you give them a whiff of basically anything and they code. I've had patients just crash after being given a drop of prop. Then they get intubated, lined, tons of pressors, gi scopes and there's too much bleeding to see anything and you can't get source control if you can't find the source.

Then these guys go to icu if IR says no or to IR and you're basically emptying the blood bank for a guy who will officially "die" after a week of wasted resources in ICU. If by chance you happen to get to the point where they miraculously walk out of the hospital, they will go home, drink again, bleed again and the same thing will happen a few weeks later. The long term prognosis is horrible for this self inflicted, irreversible illness. It's better to say no from the beginning.

I'm asking this out of a genuine curiosity, not trying to challenge you.

I understand GI probably cannot help much here because they will not be able to visualize given the pace of bleeding. It seems the patient probably truly is too unstable for a surgical procedure, and will code with the operation, but it seems IR is an option here.

Is doing an IR procedure any more destabilizing in this case compared to what the patient has already undergone (intubation, Blakemore tube, I presume aggressive vascular access such as a CVC and a line)?

I understand the prognosis here is VERY bad based on the data provided and most likely outcome regardless is death.

 

[NITRAS]

I'm asking this out of a genuine curiosity, not trying to challenge you.

I understand GI probably cannot help much here because they will not be able to visualize given the pace of bleeding. It seems the patient probably truly is too unstable for a surgical procedure, and will code with the operation, but it seems IR is an option here.

Is doing an IR procedure any more destabilizing in this case compared to what the patient has already undergone (intubation, Blakemore tube, I presume aggressive vascular access such as a CVC and a line)?

I understand the prognosis here is VERY bad based on the data provided and most likely outcome regardless is death.

Several. Potentially changing to portable vent. Physically moving to Angio suite, which often involves an elevator ride. You are placing an arterial catheter in the femoral artery on a guy who can’t clot. You are also moving the patient further away from the “normal” supply of meds/drugs and put the nurses in a different environment. More chance for things to get messed up and for things to take longer.

 

[dchristismi]

I probably would have done the same with the 34yo. Give him the old college try. 20 units of blood is a lot, but certainly not drain-the-blood-bank level. That's a kid. You have to try. The regret level would be too high not to. And after 12 hours of trying, THEN you have the palliative talk.

Or you get me and my HPM hat involved. I had THAT talk with an angiosarcoma patient this last weekend. A loooong talk. (like several hours over several days.) She's young. She has a young family. It's horrible. But she's now ready to forgo further transfusions, which means it was worth it.

One of my buddies in residency had a cop struck by a fleeing suspect if I remember right, open book pelvis, nasty trauma, you know, the works. Worked all night to save the guy, 110+ units of blood products. (And I am now old enough that these were the days before we HAD massive transfusion protocols.)
Was THAT too much? In retrospect, maybe. But given that he was an officer, and given the situation, at the time, the guy got everything and no one regretted it.

 

[thegenius]

Another classic case of interventionalists who refuse to do their job. “He’s too unstable to give him the treatment that will stop him from being unstable.”

Yea it's really sad. They probably didn't even put a note in either...so if this ever makes post-mortum rounds or given to the lawyers it just looks bad on them.

 

[The Knife & Gun Club]

Or you get me and my HPM hat involved. I had THAT talk with an angiosarcoma patient this last weekend. A loooong talk. (like several hours over several days.) She's young. She has a young family. It's horrible. But she's now ready to forgo further transfusions, which means it was worth it.

Our ICU sees a ton of cancer. Man, those young cancer patients are so freaking sad. You know their disease, you know the prognosis is 100% fatality. And then you just watch a 20-30-something waste away while their spouse and kids watch. Good HPM docs help with the comfort and emotional transition, but it’s still so sad.

 

[MechEDoc]

Roughly 1+ Liters of hard alcohol daily is where I've seen this. I don't see a ton of drug use in my neck of the woods. Occasional fent ODs. No meth to speak of. TONS of alcoholism though. I also trained somewhere where we saw a LOT of liver patients so the idea of a 30 yr old cirrhotic with varices is unfortunately not surprising.

Did you train in Wisconsin?

 

[nikolaite]

Yea it's really sad. They probably didn't even put a note in either...so if this ever makes post-mortum rounds or given to the lawyers it just looks bad on them.

It’s not a laughing matter, but this comically reminds me of when I had to contact on-call IR about some nonsense in a patient record. The APRN coordinating the telemetry unit wrote that she consulted with neurology about an AIS patient, CTA resulted in essential occlusion of M1 segment of MCA with distal reconstitution giving radiologist an impression of a high grade stenosis. Pt presented with NIHSS of like 15. GCS of like 12. Neuro told her to call IR for perfusion study and MT. She wrote that IR told her patient was not an MT candidate due to high grade stenosis. 😶 Ridiculous! I don’t know how she got put in charge of anything.

Neuro APRN on next day wrote basically the same thing. How is that even possible?

IR put no note on the consult in the patient record. I had to dig out of him later that he “felt like” he was looking at an atherosclerotic narrowing rather than a thrombotic occlusion, and MT is not used to deal with LVO due to large artery atherosclerosis.

I thought personally that the view sounded narrow, since folks have been studying the use of stent retrievers, asp catheters, etc. to rescue pts from AIS due to LAA since like 2014 at least.

This pt is still effed on follow up with outpatient neuro. I keep harping on documentation to people, but it’s not getting through much. It’s like there’s no concept of someone else reviewing the record.