Brain Injury / Trach ASC?

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Versed0101

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A patient was just referred to me for comprehensive dental rehab and third molar removal who had an emboli during a cerebral angiography in May. She is paralyzed below the waist and still has a tracheostomy in place. Otherwise in good health. She will need GA because of her spacisity. Would you treat her in an ASC or the hospital?
 
Would probably hedge my bets and treat her in a hospital as an outpatient. If all goes well, as it likely would, let her go home the same day, but if something odd did come up at least she'd already be at the right place.
 
Versed0101 said:
A patient was just referred to me for comprehensive dental rehab and third molar removal who had an emboli during a cerebral angiography in May. She is paralyzed below the waist and still has a tracheostomy in place. Otherwise in good health. She will need GA because of her spacisity. Would you treat her in an ASC or the hospital?
Click to expand...
Hospital.
 
Planktonmd said:
🙂
What if the ASC is free standing and not attached to a hospital??
What if you are the only physician taking care of this patient in a 20 miles diameter?
(you and the dentist).
Why did this patient need a brain angiogram to start with?
Why did she need a tracheostomy?
Click to expand...

What's going to go wrong?
 
Ooh ooh ooh! I want to go next...


Why do some folks insist on giving every C-section bicitra, even the routine scheduled ones?
 
Planktonmd said:
🙂
What if the ASC is free standing and not attached to a hospital??
What if you are the only physician taking care of this patient in a 20 miles diameter?
(you and the dentist).
Why did this patient need a brain angiogram to start with?
Why did she need a tracheostomy?
Click to expand...

This is about as simple as it gets.

Bring the unfortunate soul back to the back, hook up the circuit to the trach, or if the trach she has isnt worthy, whip it out and insert a 7.0 tube, secure the tube, turn the sevo all the way up along with the O2 flow, leave it there for a while, crank it back a bit, chart for an hour and a half, turn sevo off, bring to recovery room.

You can do the whole case with volatile.

No NMB, no opiod.

Just gas.

It doesnt matter if you are the only doctor within five thousand miles.

It doesnt matter why she had a brain angiogram.

It doesnt matter why she has a trach.

Actually I think you could do this case in the parking lot...:laugh:
 
Noyac said:
What's going to go wrong?
Click to expand...

Is she going to require to remain ventilated after GA?
Why would someone with a cerebral ebmolus during an angiogram become paraplegic? you would think they should become hemiplegic, wouldn't you?
(He said she was paralyzed from the waist down), doesn't make much sense does it?
There is more to this story than what was presented and I deal with situations like this daily when someone calls and presents a partial story that doesn't make much sense and asks if the patient can be done at the ASC.
My answer is usually:go to the hospital.
 
jetproppilot said:
This is about as simple as it gets.

Bring the unfortunate soul back to the back, hook up the circuit to the trach, or if the trach she has isnt worthy, whip it out and insert a 7.0 tube, secure the tube, turn the sevo all the way up along with the O2 flow, leave it there for a while, crank it back a bit, chart for an hour and a half, turn sevo off, bring to recovery room.

You can do the whole case with volatile.

No NMB, no opiod.

Just gas.

It doesnt matter if you are the only doctor within five thousand miles.

It doesnt matter why she had a brain angiogram.

It doesnt matter why she has a trach.

Actually I think you could do this case in the parking lot...:laugh:
Click to expand...
Sure, you can do anything but why would you?
 
Planktonmd said:
Sure, you can do anything but why would you?
Click to expand...

Because like I said, this is about as easy as it gets.

Despite her unfortunate previous medical history a very simple anesthetic plan can be conjured for a very simple procedure.

Her airway is already established.

All you have to do is hook a hose up to it and rotate the vaporizer counterclockwise. Then turn it clockwise at the end.

Its an oral procedure with an established trach.

OP didnt mention any sinister comorbidities which would make me leery of doing this case at an ASC.
 
Planktonmd said:
Are you a 100% sure? 🙂
Click to expand...

Dude, what are you?

Sometimes your responses remind me of those annoying NURSE ADMINISTRATOR TYPES who want EVERYTHING documented. Everything explained. Every decision questioned. Every drug withdrawal documented.

I'm tired of wasting my f ukking time at the PYXIS.

As you know, Doctor, there is no such thing as 100%.

OK.

I'M PRETTY F UKKING SURE.....does that fit your micromanaging profile a little better?

Perhaps you should call Penny Maze, RN, BSN, MSH, MPH, RSVP, LMFAO and discuss the meaning of being a hundred percent sure.🙄

I've been in this biz for twelve years.

I'm confident I can take this case from beginning to end in an ASC, and discharge her at the end.

Theres no such thing as 100%, SLIM.

If I'm wrong, well, it aint the end of the world.

We'll call an ambulance to transport her to the hospital.

But the percentage for success is WAY IN MY FAVOR.

And ya know what, Doctor?

The patient will have a far superior experience at an ASC. She'll be in and out CDAZY fast.

Sans hospital B.S.

I think the spread on this case right now is JET PLUS TWENTY EIGHT.:meanie:
 
Last edited:
given the information we have I would have to agree that an ASC is just fine, as pointed out the airway is established and it is a case that requires agent only, now if some other juicy tidbit rears its ugly head .....
 
Well, Slim You do what you want but ASC's are not for solving mysteries and figuring out why a patient 5 months ago became paraplegic during a cerebral angiogram for an unknown reason.

I did not say cancel the case, i said do it in the hospital where they specialize in solving mysteries.
And SLIM it doesn't matter how many years you practiced, we are talking about ambulatory surgicenters where if anything goes wrong you are on your own SLIM.
 
Versed0101 said:
A patient was just referred to me for comprehensive dental rehab and third molar removal who had an emboli during a cerebral angiography in May. She is paralyzed below the waist and still has a tracheostomy in place. Otherwise in good health. She will need GA because of her spacisity. Would you treat her in an ASC or the hospital?
Click to expand...

That's a FLK most likely. Why does she have a trach first of all? Why did she need an angiogram? Why does her leg paralysis/spasticity require GA to work on her mouth? I say hospital. There is too much stuff going on.
 
Planktonmd said:
Well, Slim You do what you want but ASC's are not for solving mysteries and figuring out why a patient 5 months ago became paraplegic during a cerebral angiogram for an unknown reason.

I did not say cancel the case, i said do it in the hospital where they specialize in solving mysteries.
And SLIM it doesn't matter how many years you practiced, we are talking about ambulatory surgicenters where if anything goes wrong you are on your own SLIM.
Click to expand...

You are arguing for the sake of argument.

You remind me of this attending I had....Mel Gitlin....dude would keep 3 or 4 extra residents around all the time just in case a busload of hemophiliacs crashes (his words, not mine).

Risk stratification is something we do every day.

You are speaking in tongue, here, Plank.

You've gotta patient who is apparently AT HOME, living AT HOME.

She experienced an unfortunate event previously.

Now she has a trach, she's paralyzed, and she's gonna have someone drive her FROM WHEREVER SHE LIVES to WHEREVER THE PROCEDURE IS DONE.

Per the OP, she is otherwise in good health.

Please inform me why hooking up an ASC circuit to a dudette with a trach who is otherwise healthy is much more dangerous than hooking up a HOSPITAL circuit.

Like Noy said, whats gonna happen?

Whats gonna happen that an anesthesiologist at an ASC can't handle?
 
jetproppilot said:
You are arguing for the sake of argument.

You remind me of this attending I had....Mel Gitlin....dude would keep 3 or 4 extra residents around all the time just in case a busload of hemophiliacs crashes (his words, not mine).

Risk stratification is something we do every day.

You are speaking in tongue, here, Plank.

You've gotta patient who is apparently AT HOME, living AT HOME.

She experienced an unfortunate event previously.

Now she has a trach, she's paralyzed, and she's gonna have someone drive her FROM WHEREVER SHE LIVES to WHEREVER THE PROCEDURE IS DONE.

Per the OP, she is otherwise in good health.

Please inform me why hooking up an ASC circuit to a dudette with a trach who is otherwise healthy is much more dangerous than hooking up a HOSPITAL circuit.

Like Noy said, whats gonna happen?

Whats gonna happen that an anesthesiologist at an ASC can't handle?
Click to expand...
Again:
Something happened 5 months ago that required this woman to have a cerebral angiogram that was complicated by an embolic event and she is now paraplegic.
She also has a tracheostomy for some mysterious reason.
I have no idea what her diagnosis is.
I have no idea why she has a tracheostomy or what her respiratory status is.
All I know is that she is spastic and a dentist wants to fix her teeth under GA.
Usually this is the info you will get the day before the surgery from the dentist's office and with this type of information I wouldn't make the patient come to the ASC so I can find out what really is going on with her I will just ask them to do the case at the hospital because she does not belong in my surgicenter with the above mentioned mysterious history.
What can happen that I can't handle at the ASC?
I will answer this question when I know the patient's real history.
 
Most important is: what do you gain by doing the case in an ASC?

Assuming the dentist has privileges at both the hosp and ASC, why bother doing the case at the ASC?
 
urge said:
Most important is: what do you gain by doing the case in an ASC?

Assuming the dentist has privileges at both the hosp and ASC, why bother doing the case at the ASC?
Click to expand...

Look, I'm all for calling out B.S. when it comes to clinical scenerios.

And the need for a higher-level-of-care-place for cases on a case-to-case basis.

I'm just not seeing it on this case.

I feel I could provide a safe anesthetic to this individual at an ASC without the need for tertiary backup.

Like I said,

oooops....sorry....

Like the OP said,

the airway is foolproof.

There are no sinister comorbidities.

What we've got is a patient paralyzed from the waste down witha trach who needs some dental s hit done.

I don't see the problem.

But then again I'm not a NURSE ADMINISTRATOR.😆😆😆😆
 
jetproppilot said:
Dude, what are you?
Penny Maze, RN, BSN, MSH, MPH, RSVP, LMFAO and discuss the meaning of being a hundred percent sure.🙄
Click to expand...

😍
I need one of those behind my MD.

How do I get that degree? Or does reading this thread count for my LMFAO degree?
 
A "fool proof" airway is not the only requirement to do a case in an ASC.
You have to develop a screening policy and know that one complication can effectively bring the whole day to a painful stop and make everyone unhappy.
ASC's are there to make money and be efficient and this is why you can not waste time trying to figure out mysterious patients with significant morbidities.
Even a nurse administrator would know that an embolus during a cerebral angiogram should not cause paraplegia.
 
Planktonmd said:
A "fool proof" airway is not the only requirement to do a case in an ASC.
You have to develop a screening policy and know that one complication can effectively bring the whole day to a painful stop and make everyone unhappy.
ASC's are there to make money and be efficient and this is why you can not waste time trying to figure out mysterious patients with significant morbidities.
Even a nurse administrator would know that an embolus during a cerebral angiogram should not cause paraplegia.
Click to expand...

It doesnt matter if theres holes in the history.

So youre telling me, Plank, that you've never done a case where the patient's history is kinda NIMBLY BIMBLY?

Where you cant really put all the pieces together, but...

you know what you are presented with.

Thats where the moneys at.

Here is what the clinician needs to know for this case. No more, no less.

You know it.

And I know it.

She's paraplegic, so I won't use sux no matter what.

Her airway is secured. If you need to secure it more, you could use my high school cafeteria working mom to aim a tube into an already established tracheal conduit. Or maybe my five year old left handed batting, right handed throwing-future-NEW YORK METS phenom (NOY, DIDGA READ THAT?:laugh:)

Using gas only eliminates a buncha potential sequalae.

Again, I feel I could do this anesthetic in a parking lot.

With a circuit and a sevo vaporizer.

As much as you say, Plank, "What can go wrong?"

As much as you can say that, I can say in rebuttal, Plank,

theres very few things that can go awry. I can hook up a circuit to the already established trach and provide a safe anesthetic for a relatively low risk procedure. I can do this in an ambulatory surgery center because I'm convinced the risk stratification is in my favor. Yes, Nurse, (metaphorically of course, but you are reminding me of a nurse administrator) I don't know if my logic meets JCH standards. But since we're doing it at an ASC, JCH can BLOW me.

With all due respect.😆😆
 
Hey, it's OK, you can do it in the parking lot or wherever you like.
I am just stating my point of view which happens to be the opposite of your's.
I wouldn't do a case with so many unknown issues at the ASC but that's me.
You don't need to call me slim or nurse to prove your point.
 
Plank, I think if you are going to tell everyone here that you are not doing the case then you need to tell us what it is you are worried about and why. I know you say there are holes in the history but what is it that makes you think these holes are serious enough to move the case b/c "what' is going to happen? Holes in the history is not enough for me. I just did a case with holes in the history but it went fine. You are going with gut feelings here just like Jet and I are. But we are telling you that there is nothing thats going to happen out of the ordinary. Sure **** can happen but our job is based on risk stratification and I put this pt in the low risk catagory. Minimally invasive surgery, with known entities like paralysis but good heart and lungs (Op states otherwise healthy). I'll admit that I am curious as to why the trach. But I can figure this out in 5 minutes or less and it probably won't change a thing.

So tell us what you are worried about.
 
Noyac said:
😍
I need one of those behind my MD.

How do I get that degree? Or does reading this thread count for my LMFAO degree?
Click to expand...

HAHAHAHAHAHAHAHAHAHAHAH

Judging from the degrees that RN's tout behind their names, I'd say

YES, MIKEY. CONGRATS.

You've just fulfilled the requirements for the LMFAO degree!!!!

I expect to now see MIKEY NOYAC MD, LMFAO whenever you sign off.:laugh:
 
Planktonmd said:
Is she going to require to remain ventilated after GA?
Why would someone with a cerebral ebmolus during an angiogram become paraplegic? you would think they should become hemiplegic, wouldn't you?
(He said she was paralyzed from the waist down), doesn't make much sense does it?
There is more to this story than what was presented and I deal with situations like this daily when someone calls and presents a partial story that doesn't make much sense and asks if the patient can be done at the ASC.
My answer is usually:go to the hospital.
Click to expand...

can we say...artery of adam kiwi
 
Noyac said:
So tell us what you are worried about.
Click to expand...

This is a patient that does not fit the profile of an ASC patient because:
1- She had an undetermined brain injury of unknown etiology during the performance of an exam to diagnose some mysterious problem, this is all we know about her and it is very unlikely for the dentist bringing her to have any further information to help us.
2- She still has a trcheostomy 5 months after her brain injury and we have zero information about her respiratory status or why she needed a tracheostomy to start with.
3- His indication to do it under GA is spsticity which makes it likely that he is expecting you to give a muscle relaxant.
So considering the above I would be worried about the following:
I am going to do GA to a patient with possibly marginal respiratory function who could require respiratory support after the procedure.
I also might have to give a muscle relaxant to a patient with some undetermined motor deficit and I have no idea how she is going to recover.
If she does not breath well enough after the procedure I don't even have a ventilator in the recovery room to maintain her until the EMS arrive to drive her to the hospital which means I have to keep her in the OR and paralyze the whole ASC.
Now I know we all like to be cowboys sometimes but I don't see why I should do that in this case.
She can be done safely at the hospital.
Or, Jet can do her in the parking lot.
 
militarymd said:
and if not....Who the f uc k cares?

it was the angio that caused the problem...NOT anesthesia.

I would do this case at Walmart.
Click to expand...

We care for these reasons:


Planktonmd said:
This is a patient that does not fit the profile of an ASC patient because:
1- She had an undetermined brain injury of unknown etiology during the performance of an exam to diagnose some mysterious problem, this is all we know about her and it is very unlikely for the dentist bringing her to have any further information to help us.
2- She still has a trcheostomy 5 months after her brain injury and we have zero information about her respiratory status or why she needed a tracheostomy to start with.
3- His indication to do it under GA is spsticity which makes it likely that he is expecting you to give a muscle relaxant.
So considering the above I would be worried about the following:
I am going to do GA to a patient with possibly marginal respiratory function who could require respiratory support after the procedure.
I also might have to give a muscle relaxant to a patient with some undetermined motor deficit and I have no idea how she is going to recover.
If she does not breath well enough after the procedure I don't even have a ventilator in the recovery room to maintain her until the EMS arrive to drive her to the hospital which means I have to keep her in the OR and paralyze the whole ASC.
Now I know we all like to be cowboys sometimes but I don't see why I should do that in this case.
She can be done safely at the hospital.
Or, Jet can do her in the parking lot.
Click to expand...
 
Hey, OP: Any chance you could provide some more info regarding this patient's history?

Unitl then, I don't see this discussion heading anywhere. Mil, JPP and Plank have dug into their trenches.
 
Could have had an insult to the brain stem and cerebellum through the vertebral artery which would have effected respirations and coordination (spasticity) which the dentist is describing incorrectly. When I get these requests for the asc I get the information I need from the PCP and whatever consults are involved.
You are not going to need muscle relaxants for the spasticity. It dental work not surgery.
 
Noyac said:
Could have had an insult to the brain stem and cerebellum through the vertebral artery which would have effected respirations and coordination (spasticity) which the dentist is describing incorrectly. When I get these requests for the asc I get the information I need from the PCP and whatever consults are involved.
You are not going to need muscle relaxants for the spasticity. It dental work not surgery.
Click to expand...
Hopefully not, but some people stay fairly clenched even under GA, and a dentist can't accomplish much if he can't get the patient's mouth open.
 
aphistis said:
Hopefully not, but some people stay fairly clenched even under GA, and a dentist can't accomplish much if he can't get the patient's mouth open.
Click to expand...

Really?

So is the spasticity in the legs or what? I have not seen trismus in an otherwise healthy pt without a reason for it like a broken jaw, or an abscess. GA will relax the jaw.
 
Bertelman said:
Hey, OP: Any chance you could provide some more info regarding this patient's history?

Unitl then, I don't see this discussion heading anywhere. Mil, JPP and Plank have dug into their trenches.
Click to expand...


O.K., just spoke with the patient's PCP. Had some difficulty understanding his English. Patient was admitted to hospital in May for UTI. While there she became septic and ended up in the ICU. While there she suffered a cardiac arrest and was resuscitated although she did suffer some anoxic brain damage. Patient was in a coma for 4 months. She is currently at home with a trach and peg. She can move her legs arms and legs somewhat but not in any useful fashion. She currently alert and oriented and responds meaningfully to verbal commands.

I was hoping to be able to do this case in an ASC because the hospital is not set up for dental cases and getting OR time for "trivial" dental cases in the hospital is very difficult.

Thanks for all of your responses.
 
Versed0101 said:
O.K., just spoke with the patient's PCP. Had some difficulty understanding his English. Patient was admitted to hospital in May for UTI. While there she became septic and ended up in the ICU. While there she suffered a cardiac arrest and was resuscitated although she did suffer some anoxic brain damage. Patient was in a coma for 4 months. She is currently at home with a trach and peg. She can move her legs arms and legs somewhat but not in any useful fashion. She currently alert and oriented and responds meaningfully to verbal commands.

I was hoping to be able to do this case in an ASC because the hospital is not set up for dental cases and getting OR time for "trivial" dental cases in the hospital is very difficult.

Thanks for all of your responses.
Click to expand...

:corny:
 
Wow, way to have a UTI! Any idea on why she arrested? What was her heart like at discharge? if she's a quad with a trach and peg she doesn't need a whole lot of function to get by.
 
If shes alert, oriented, and cooperative why does she even need general anesthesia? Do your usual blocks and go. If her jaw is "tight" , then you need to figure out if its spasticity or fibrosis. If its fibrosis anesthesia aint gonna help.
 
Versed0101 said:
O.K., just spoke with the patient's PCP. Had some difficulty understanding his English. Patient was admitted to hospital in May for UTI. While there she became septic and ended up in the ICU. While there she suffered a cardiac arrest and was resuscitated although she did suffer some anoxic brain damage. Patient was in a coma for 4 months. She is currently at home with a trach and peg. She can move her legs arms and legs somewhat but not in any useful fashion. She currently alert and oriented and responds meaningfully to verbal commands.

I was hoping to be able to do this case in an ASC because the hospital is not set up for dental cases and getting OR time for "trivial" dental cases in the hospital is very difficult.

Thanks for all of your responses.
Click to expand...

Dude you got bigger issues than doing this at an ASC. This doesn't resemble the original pt you described one bit. This is not "otherwise healthy" in my book but still can be a candidate for ASC. You need to know her cardiac fxn, respiratory fxn, if she has had a recent pneumonia, etc etc.

So why do you need a GA for this?

I wouldn't have a setup for dental procedures at my hospital either if I could. Oh wait, I don't have a dental setup and hope to never get one. Unless of course you want to pay me to take care of these pts. Then we can talk. You can have the time nobody wants. For $450/hr anesthesia charge.
I hope you get the idea, I never got paid **** for these cases and have made it my mission to never do them again if I ain't gettin paid. We managed to send these cases down the road when we opened our new hospital. 👍
 
Versed0101 said:
O.K., just spoke with the patient's PCP. Had some difficulty understanding his English. Patient was admitted to hospital in May for UTI. While there she became septic and ended up in the ICU. While there she suffered a cardiac arrest and was resuscitated although she did suffer some anoxic brain damage. Patient was in a coma for 4 months. She is currently at home with a trach and peg. She can move her legs arms and legs somewhat but not in any useful fashion. She currently alert and oriented and responds meaningfully to verbal commands.

I was hoping to be able to do this case in an ASC because the hospital is not set up for dental cases and getting OR time for "trivial" dental cases in the hospital is very difficult.
Click to expand...

Not a good candidate for ASC.
Send her to the hospital.
 
Planktonmd said:
Not a good candidate for ASC.
Send her to the hospital.
Click to expand...

Dude, is that all you have to say?:laugh:
Why not say "I told you so"?

So here's how I see it. I was curious as to why the pt was trach'd from the start but that has nothing to do with my anesthetic if "otherwise healthy". The paralysis is not an issue as far as I'm concerned either. But now we get the story that she had an MI, coma and ICU stay in the recent past. This is what happens when a non physician tries to evaluate a case. Don't worry, I'm not knocking on you dentists, you are trained to do something completely different and can't be expected to pre-op a pt for an anesthetic. But I will ask, DO YOU REALLY NEED A GENERAL ANESTHETIC FOR THIS. The pt is cooperative. Is this for your convenience? I think so.

DO it in your officeand leave us out of it. Unless of course you are paying me😀
It's only $450/hr.
DEAL?
 
Dude..Ok this case was a total setup. First off I doubt versed0101 is a dentist. Second off if he is a dentist what kind of clown is going to do elective surgery of some f@cked up chick who was admitted in may in a coma for four months which would put her to at least sept. and is at home now ready to have her "dental rehab" That's the least of this mush brains worries.
 
Planktonmd said:
Well, Slim You do what you want but ASC's are not for solving mysteries and figuring out why a patient 5 months ago became paraplegic during a cerebral angiogram for an unknown reason.

I did not say cancel the case, i said do it in the hospital where they specialize in solving mysteries.
And SLIM it doesn't matter how many years you practiced, we are talking about ambulatory surgicenters where if anything goes wrong you are on your own SLIM.
Click to expand...

Im with Jet on this one. In fact we can do it at her house.
 
MAC10 said:
Hows about she became paralyzed 5 MONTHS ago because they knocked a clot loose, or a plaque loose, or ripped open a vessel. Who cares? If shes been stable for 5 months. Im with Jet on this one. In fact we can do it at her house.
Click to expand...


You may want to read post # 41 above. I guess you could say she was in a stable coma for 4 months.

Despite Jet's propensity for large fonts, the meat of these threads is usually in the small print.

**sweet...in before the edit
 
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