Clinical Scenario - Fractured Femur

heartICU · Jul 22, 2005

Another clinical scenario for those interested:

Man in his 60s with a PMHx of CAD, s/p MI 15 yrs ago, IDDM, obesity, OA, s/p R THR 4 years ago. He was loading some stuff into his truck and slipped and fell...ended up with a periprosthetic femur fracture. (This all took place on a Saturday). Son takes him to the hospital, patient is placed in Buck's traction. Somehow cannot get onto OR schedule until that following Wednesday, 4 days later. Over those three days, blood sugar begins to climb, and the patient is requiring more insulin that usual to maintain normoglycemia. Monday morning, 02 sats begin to drop, 89% on room air. Floor nurses place him on 2L 02 nasal cannula.

Wednesday morning at 0630 (day of surgery), patient's blood sugar is 306. Floor nurses treat with 8u RHI SQ as per sliding scale. Patient arrives outside the OR at 0730. What is your next step?

jetproppilot · Jul 22, 2005

heartICU said:
Another clinical scenario for those interested:

Man in his 60s with a PMHx of CAD, s/p MI 15 yrs ago, IDDM, obesity, OA, s/p R THR 4 years ago. He was loading some stuff into his truck and slipped and fell...ended up with a periprosthetic femur fracture. (This all took place on a Saturday). Son takes him to the hospital, patient is placed in Buck's traction. Somehow cannot get onto OR schedule until that following Wednesday, 4 days later. Over those three days, blood sugar begins to climb, and the patient is requiring more insulin that usual to maintain normoglycemia. Monday morning, 02 sats begin to drop, 89% on room air. Floor nurses place him on 2L 02 nasal cannula.

Wednesday morning at 0630 (day of surgery), patient's blood sugar is 306. Floor nurses treat with 8u RHI SQ as per sliding scale. Patient arrives outside the OR at 0730. What is your next step?

As long as he's not in DKA, which with a sugar of 300 hes probably not, and he doesnt have pulmonary edema, I'd do it. For all you conservatives who wanna delay a case for whatever reason, keep in mind a dude like this laying in bed is gonna eventually die of a pulmonary embolism if you dont fix his problem. And his glucose will continue to be uncontrollable.
propofol 50 mg, sit him straight up and use a 22" spinal needle. Bupiv 15mg withha slash of epi. I do this all the time with broken hips.
If he's been placed on LMWH then you've gotta put him to sleep. Rocuronium 5mg, Propofol/etomidate, fentanyl, sux, tube, des/sevo. Insulin 10U iv. Recheck sugar 30 minutes later. More insulin if needed. Start an infusion if you wanna be like the New England Journal dudes.
If you're worried about risk, how risky do you think it is for him to lay in bed for days while the fleas round on him twice a day adjusting all his medicines so he's "optimized"?

heartICU · Jul 22, 2005

jetproppilot said:
As long as he's not in DKA, which with a sugar of 300 hes probably not, and he doesnt have pulmonary edema, I'd do it. For all you conservatives who wanna delay a case for whatever reason, keep in mind a dude like this laying in bed is gonna eventually die of a pulmonary embolism if you dont fix his problem. And his glucose will continue to be uncontrollable.
propofol 50 mg, sit him straight up and use a 22" spinal needle. Bupiv 15mg withha slash of epi. I do this all the time with broken hips.
If he's been placed on LMWH then you've gotta put him to sleep. Rocuronium 5mg, Propofol/etomidate, fentanyl, sux, tube, des/sevo. Insulin 10U iv. Recheck sugar 30 minutes later. More insulin if needed. Start an infusion if you wanna be like the New England Journal dudes.
If you're worried about risk, how risky do you think it is for him to lay in bed for days while the fleas round on him twice a day adjusting all his medicines so he's "optimized"?

This patient was on lovenox, but it had been held for the last 24 hours in anticipation of surgery. Also, he adamantly refused a regional technique of any kind.

What lines would you choose?

jetproppilot · Jul 22, 2005

heartICU said:
This patient was on lovenox, but it had been held for the last 24 hours in anticipation of surgery. Also, he adamantly refused a regional technique of any kind.

What lines would you choose?

A good peripheral IV.

heartICU · Jul 22, 2005

jetproppilot said:
A good peripheral IV.

Here is my situation. This was my case from a few weeks ago. My staff, (who is relatively new, for what it's worth), wanted to cancel the case because of his glucose and because he had a hx of CAD & MI with no stress echo. He consulted with a few other staff physicians, and they told him to document is as urgent, emphasize the risks to the patient, beta block him well, and do the case. I had placed a second IV and an arterial line (per his request), and then he decided to cancel the case.

The surgical team warned him (my staff) that the patient could not be fit in the OR schedule until the following TUESDAY (making this ten days post fracture), and he still cancelled.

The patient ended up having a cards and endo consult, got a dobutamine stress echo, and better glycemic control by the time he made it back to the OR. Turns out the DSE was negative for ischemia at 86% MPHR. Blood sugar was better controlled, but still not optimal (mid 200s). Patient is now on 5L 02 nasal cannula, sats 94% on room air. Incidentally, the case went fairly well, femur repaired, patient currently recovering. However, now my staff and I have to present this at our weekly M&M.

Had it been up to me, I would have done the case. My rationale was that this patient is as optimized as he is going to get. Even if he had a positive stress test, I find it hard to believe that you would cath him or stent him before you fixed his femur. That combined with the fact that he either has substantial atelectasis or a PE from laying in bed for over a week and now needs supplemental oxygen...

I guess my question is...what is your window for fixing a fracture like this? I know the sooner, the better, but do you get to a point where it's too late?

jetproppilot · Jul 22, 2005

heartICU said:
Here is my situation. This was my case from a few weeks ago. My staff, (who is relatively new, for what it's worth), wanted to cancel the case because of his glucose and because he had a hx of CAD & MI with no stress echo. He consulted with a few other staff physicians, and they told him to document is as urgent, emphasize the risks to the patient, beta block him well, and do the case. I had placed a second IV and an arterial line (per his request), and then he decided to cancel the case.

The surgical team warned him (my staff) that the patient could not be fit in the OR schedule until the following TUESDAY (making this ten days post fracture), and he still cancelled.

The patient ended up having a cards and endo consult, got a dobutamine stress echo, and better glycemic control by the time he made it back to the OR. Turns out the DSE was negative for ischemia at 86% MPHR. Blood sugar was better controlled, but still not optimal (mid 200s). Patient is now on 5L 02 nasal cannula, sats 94% on room air. Incidentally, the case went fairly well, femur repaired, patient currently recovering. However, now my staff and I have to present this at our weekly M&M.

Had it been up to me, I would have done the case. My rationale was that this patient is as optimized as he is going to get. Even if he had a positive stress test, I find it hard to believe that you would cath him or stent him before you fixed his femur. That combined with the fact that he either has substantial atelectasis or a PE from laying in bed for over a week and now needs supplemental oxygen...

I guess my question is...what is your window for fixing a fracture like this? I know the sooner, the better, but do you get to a point where it's too late?

its never too late, but with every day that goes by the pats risk of pulmonary embolus or some other bad stuff happening from his glucose outta control from the stress of the situation increases. Tell your staff he shouldve done the case, and since hes the one who cancelled it, he's gotta absorb all the critisicm at M&M, not you. :laugh:

jetproppilot · Jul 22, 2005

heartICU said:
The surgical team warned him (my staff) that the patient could not be fit in the OR schedule until the following TUESDAY (making this ten days post fracture), and he still cancelled.

This is what is wrong with most academic institutions. Most attendings are obstructionalists who look for anything to cancel a case. Hey, medicine is risky sometimes, but you've gotta weigh the risk of the surgery vs not doing the surgery. Yes, medicine is litiginous these days, but practicing like that is not for me, nor do I believe, more importantly, it is in the best interest of the patient.

anesthesiadrew · Jul 22, 2005

You might as well be a public relations / HR / hiring guru for your group.
Sounds like an awesome practice to work for.

Lonestar · Jul 22, 2005

jet,
you took the words right out of my mouth. Eventhough i have done anesthesia for only 20 days, i see the obstructionalist attitude of academic anesthesia very prevalent. Hell, many times people got echos and stress tests for having normal EKGs and no chest pain or cardiac history. Just frustrating to see "academic" dudes acting "clinical." No wonder these pts get upset at us for ordering unnecessary tests. Can't wait till private practice. peace out.

Disse · Jul 22, 2005

My staff, (who is relatively new, for what it's worth), wanted to cancel the case because of his glucose and because he had a hx of CAD & MI with no stress echo.

Sounds like this patient may have already had a stress test...

He was loading some stuff into his truck and slipped and fell...ended up with a periprosthetic femur fracture. (This all took place on a Saturday).

It would be nice to know what he was loading, how far he was walking, blah blah blah. Good to know prior to starting the case but the case still needed to be done promptly.

But.. despite not having access at home to any of the good medical sites this is kind of interesting (still would need to check out the references and such).

http://www.clevelandclinicmeded.com/ccjm/march05/whinney.htm

militarymd · Jul 22, 2005

heartICU said:
Another clinical scenario for those interested:

Man in his 60s with a PMHx of CAD, s/p MI 15 yrs ago, IDDM, obesity, OA, s/p R THR 4 years ago. He was loading some stuff into his truck and slipped and fell...ended up with a periprosthetic femur fracture. (This all took place on a Saturday). Son takes him to the hospital, patient is placed in Buck's traction. Somehow cannot get onto OR schedule until that following Wednesday, 4 days later. Over those three days, blood sugar begins to climb, and the patient is requiring more insulin that usual to maintain normoglycemia. Monday morning, 02 sats begin to drop, 89% on room air. Floor nurses place him on 2L 02 nasal cannula.

Wednesday morning at 0630 (day of surgery), patient's blood sugar is 306. Floor nurses treat with 8u RHI SQ as per sliding scale. Patient arrives outside the OR at 0730. What is your next step?

This is no clinical scenario 🙂 ....this is what you get every night on call when you are in private practice.

1) make sure you can intubate.
2) iv, nibp
3) propofol, sux, tube
4) beta block, but avoid hypotension
5) DO the case now, so it doesn't come back later.
6) DO the case, so that when you have something that REALLY needs to be cancelled, the surgeons will respect your opinion.

zippy2u · Jul 22, 2005

Here's what is sweet. Ya find yourself a reasonable orthopod ( usually they don't know shiit from shinow about medical problems other than bones) and tell him if the pt. has a lot of medical problems to automatically consult IM and let IM optimize the pt. Once IM clears the pt then you do the case. If IM or cardiology or pulm say we don't go then we don't go. This pt would have immediately gotten an IM consult upon admission, and even better, the pt would have been admitted to IM and ortho consulted. When all parties are on the same side of the fence then you do the case. Ortho pricks will sometimes want anesthesia to do the case without the approval of IM. Remember, get everybody on same side of fence when you do the pt. Less headaches for you and keeps the lawyers at bay. ---Zippy

jetproppilot · Jul 22, 2005

zippy2u said:
Here's what is sweet. Ya find yourself a reasonable orthopod ( usually they don't know shiit from shinow about medical problems other than bones) and tell him if the pt. has a lot of medical problems to automatically consult IM and let IM optimize the pt. Once IM clears the pt then you do the case. If IM or cardiology or pulm say we don't go then we don't go. This pt would have immediately gotten an IM consult upon admission, and even better, the pt would have been admitted to IM and ortho consulted. When all parties are on the same side of the fence then you do the case. Ortho pricks will sometimes want anesthesia to do the case without the approval of IM. Remember, get everybody on same side of fence when you do the pt. Less headaches for you and keeps the lawyers at bay. ---Zippy

Geez, dude, are you a doctor? Of course you are. You dont need an IM dude to clear every patient with alotta medical problems. You know better than the flea whether or not the pt can undergo surgery. And more importantly, the incidence of a patient newly admitted to the hospital that cant undergo surgery urgently is VERY VERY LOW. Like ACTIVE myocardial induced chest pain, a ventricular arrythmia, pulmonary edema, an INR off the charts, an acute change in K with the current reading 6.8,hmmmm.....I'm sure theres a few more that worry me but thats about it.
So the pt has CAD, HTN, DM, and has a broken hip....whatcha gonna do? Consult IM so they can mentally masturbate for a cuppla days, order a buncha needless tests so you can do the case 5 days from now?
Sorry dude, your post is pro-obstructionalist. Its time to step up to the mike with micatin and HELP, not HINDER the case.
The way to do it is to consult IM AFTER the case.

zippy2u · Jul 22, 2005

So hypothetically, if IM has seen pt and has written on chart that pt is not cleared for surgery and ortho wants to do case ,are ya goin' to be a hero and take him to surgery? Oh, I forgot to tell you that the internist has been the pt's family doctor for 20 years and they trust him with all their heart and soul and he has adamantly told the pt, his wife and the large Italian family in the room that he ain't ready... So Hero, ya goin' to be pushin' that stetcher to surgery? --Zippy

jetproppilot · Jul 23, 2005

zippy2u said:
So hypothetically, if IM has seen pt and has written on chart that pt is not cleared for surgery and ortho wants to do case ,are ya goin' to be a hero and take him to surgery? Oh, I forgot to tell you that the internist has been the pt's family doctor for 20 years and they trust him with all their heart and soul and he has adamantly told the pt, his wife and the large Italian family in the room that he ain't ready... So Hero, ya goin' to be pushin' that stetcher to surgery? --Zippy

Nope, I'm no hero, Slim. And your "hypothetical" situation is totally different than what you initially wrote.
If IM has ALREADY seen the patient its a different ballgame. You endorsed telling the ortho dude to consult medicine on ALL patients with multiple medical problems, which is different then your story above, wouldnt you say, Slim?
Youre gonna be Zippin nowwhere except the doctors lounge if you endorse your initial brilliant idea.

asdash · Jul 23, 2005

Warning: 4th year med student who doesn't even do his first anesthesiology rotation until August questions!

Flea? What's the etymology?

What's the point of consulting IM AFTER the case?

jetproppilot said:
Geez, dude, are you a doctor? Of course you are. You dont need an IM dude to clear every patient with alotta medical problems. You know better than the flea whether or not the pt can undergo surgery. And more importantly, the incidence of a patient newly admitted to the hospital that cant undergo surgery urgently is VERY VERY LOW. Like ACTIVE myocardial induced chest pain, a ventricular arrythmia, pulmonary edema, an INR off the charts, an acute change in K with the current reading 6.8,hmmmm.....I'm sure theres a few more that worry me but thats about it.
So the pt has CAD, HTN, DM, and has a broken hip....whatcha gonna do? Consult IM so they can mentally masturbate for a cuppla days, order a buncha needless tests so you can do the case 5 days from now?
Sorry dude, your post is pro-obstructionalist. Its time to step up to the mike with micatin and HELP, not HINDER the case.
The way to do it is to consult IM AFTER the case.

jetproppilot · Jul 23, 2005

asdash said:
Warning: 4th year med student who doesn't even do his first anesthesiology rotation until August questions!

Flea? What's the etymology?

What's the point of consulting IM AFTER the case?

To take care of the patients medical problems while they are in the hospital recuperating from their surgery.

"Pre-op clearances" are overblown and overused, mostly for the good ole boy referral stuff. We are per-operative physicians, and no better than anyone if someone needs a consult before surgery, which 99.5% of the time they do not.

jetproppilot · Jul 23, 2005

jetproppilot said:
To take care of the patients medical problems while they are in the hospital recuperating from their surgery.

"Pre-op clearances" are overblown and overused, mostly for the good ole boy referral stuff. We are per-operative physicians, and no better than anyone if someone needs a consult before surgery, which 99.5% of the time they do not.

typographical errors....."peri-operative physicians" and "we know better than anyone".....sorry.

Noyac · Jul 23, 2005

Just a thought, at the risk of offending some of the crowd, if you can't clear a pt for surgery yourself as an anesthesiologist, you lose a very important skill that separates us from the non-MD crowd. See the pt. If he needs more workup or tuneup then get the others involved. You are a doctor, act like one.

With regards to the M&M. Stand there, take the abuse of the crowd and I wouldn't say "I wanted to do the case" unless you are pushed into a corner. The other staff (if they are like mine was) will give your staff member a verbal ass wippin through you. But they will not hold it against you. Some (definitely not all) people are in academics for reasons, if you know what I mean. Also, just think how much you learned now by cancelling the case. Maybe not.

UTSouthwestern · Jul 23, 2005

Just a side note, but this is one reason I think doing a medicine prelim or categorical residency is good for anesthesiology. You gain the insight into disease pathology and are better able to manage your patient without "IM clearance" = beta block, tight glucose control, judicious fluid use, and everything else that makes common sense already.

zippy2u · Jul 23, 2005

I use to work in a hospital where the greenling orthopod did that very same thing you're talking about-- consulted IM after surgery done. Well, after a couple of cases where pt was dumped in ICU on ventilator and the first time IM sees pt is after surgery and he's to manage vent and correct electrolyte abnormalities and other sundry crap, the internist good ole boy who had been there 20 years took the greenling aside and "straightened" him out. Also you takin' coin out of the internist's pocket( with Medicare, it ain't much but every bit helps) by cheatin him out of seein' the pt that extra 1-2 days. As an aside, I was hoping that you'd take that femur fx to surgery without clearance from IM cause ole Zip was goin' to paint a nice scenario... one that would suck the oxygen outta your balls sack... ----Zippy

militarymd · Jul 23, 2005

I must side with JPP on the IM clearance issue. Fully trained anesthesiologists know when you cannot take a patients to the OR. We don't need a non-operative specialist to tell us when a patient is "cleared".

I also agree with getting IM afterwards. The most stressful part of surgery is the few days AFTER surgery, not during surgery. If you look at stress hormone responses (ACTH, cortisol, ADH, ATT, aldosterone, etc.), they come up after surgery is complete, and stays up for up to a week....these hormones wreak havoc and cause peri-operative complications that get blamed on anesthesia!! A sick guy needs an doctor, not orthopod, to take care of these issues after surgery.

I disagree with UT's comment on "judicious fluids"....I'm not sure what that means. You give what is needed. The same that you would do with any case or patient.

militarymd · Jul 23, 2005

zippy2u said:
As an aside, I was hoping that you'd take that femur fx to surgery without clearance from IM cause ole Zip was goin' to paint a nice scenario... one that would suck the oxygen outta your balls sack... ----Zippy

What's that mean??

zippy2u · Jul 23, 2005

Boy, let's make a comic strip outta this one... orderlies: Hey Jetpro, I say hey Rocket man, I'd thought you were wheelin' the patient down for surgery? What happened? Yada,yada,yada anesthesia is the internist in the OR, yada, yada, yada ...We sent a man to do a man's job and the job's not done... snicker....snicker seasoned locum tenens anesthesia sharks#1 and#2 (with silver dollar coins jangling in back pocket): The guy's still a rookie even tho he's 10 years out, strange.... snicker.... snicker... Jetpro: grumble..., grumble... ( as he walks to OR#1 to check on the CRNA ,with humble pie as tho his favorite dog just got run over by a car)... ------Zippy

militarymd · Jul 23, 2005

zippy2u said:
Boy, let's make a comic strip outta this one... orderlies: Hey Jetpro, I say hey Rocket man, I'd thought you were wheelin' the patient down for surgery? What happened? Yada,yada,yada anesthesia is the internist in the OR, yada, yada, yada ...We sent a man to do a man's job and the job's not done... snicker....snicker seasoned locum tenens anesthesia sharks#1 and#2 (with silver dollar coins jangling in back pocket): The guy's still a rookie even tho he's 10 years out, strange.... snicker.... snicker... Jetpro: grumble..., grumble... ( as he walks to OR#1 to check on the CRNA ,with humble pie as tho his favorite dog just got run over by a car)... ------Zippy

Huh??? 😕

UTSouthwestern · Jul 23, 2005

militarymd said:
I must side with JPP on the IM clearance issue. Fully trained anesthesiologists know when you cannot take a patients to the OR. We don't need a non-operative specialist to tell us when a patient is "cleared".

I also agree with getting IM afterwards. The most stressful part of surgery is the few days AFTER surgery, not during surgery. If you look at stress hormone responses (ACTH, cortisol, ADH, ATT, aldosterone, etc.), they come up after surgery is complete, and stays up for up to a week....these hormones wreak havoc and cause peri-operative complications that get blamed on anesthesia!! A sick guy needs an doctor, not orthopod, to take care of these issues after surgery.

I disagree with UT's comment on "judicious fluids"....I'm not sure what that means. You give what is needed. The same that you would do with any case or patient.

The judicious fluids comments is a comment that always shows up on the preop IM clearance H&P. It bugs the hell out of me. If a patient is exsanguinating and I give 10 units of PRBC's to a patient with preop CHF, will that comment on the IM report become cannon fodder for a lawyer? I have actually called the IM residents/attendings who wrote those comments and told them to come down to preop holding to remove that line.

zippy2u · Jul 23, 2005

OK, on a serious note, Jetpro and Military are spot on with what they are saying. I was just trying to provide a little comic relief for the weekend crowd.... Warmest regards, ---Zippy

jetproppilot · Jul 23, 2005

zippy2u said:
Boy, let's make a comic strip outta this one... orderlies: Hey Jetpro, I say hey Rocket man, I'd thought you were wheelin' the patient down for surgery? What happened? Yada,yada,yada anesthesia is the internist in the OR, yada, yada, yada ...We sent a man to do a man's job and the job's not done... snicker....snicker seasoned locum tenens anesthesia sharks#1 and#2 (with silver dollar coins jangling in back pocket): The guy's still a rookie even tho he's 10 years out, strange.... snicker.... snicker... Jetpro: grumble..., grumble... ( as he walks to OR#1 to check on the CRNA ,with humble pie as tho his favorite dog just got run over by a car)... ------Zippy

Dude, that crackrock is really affecting your posts. :laugh:

heartICU · Jul 23, 2005

militarymd said:
I must side with JPP on the IM clearance issue. Fully trained anesthesiologists know when you cannot take a patients to the OR. We don't need a non-operative specialist to tell us when a patient is "cleared".

I also agree with getting IM afterwards.

For what it's worth, this patient was seen and cleared by IM in the few days he was in the hospital before the first scheduled OR date. At the time he was seen, his blood sugar had not climbed as high as it was, and he had not been placed on 02 yet.

jetproppilot · Jul 23, 2005

heartICU said:
For what it's worth, this patient was seen and cleared by IM in the few days he was in the hospital before the first scheduled OR date. At the time he was seen, his blood sugar had not climbed as high as it was, and he had not been placed on 02 yet.

High glucose low glucose, O2 no O2, the dude still needed an operation, and the quicker the better.

militarymd · Jul 23, 2005

heartICU said:
For what it's worth, this patient was seen and cleared by IM in the few days he was in the hospital before the first scheduled OR date. At the time he was seen, his blood sugar had not climbed as high as it was, and he had not been placed on 02 yet.

hyperglycemia and hypoxia are NOT contraindications to surgery....They are metabolic derangements that are associated with disease processes that need to be addressed....not indications for cancelling surgery.

I suspect that pain, stress, inflammmation associated with the fx is causing the hyperglycemia, and would be easier to treat with corrective surgery.

Noyac · Jul 23, 2005

You've got Military. We all should be aware of what happens to a diabetic when you throw some stress their way. HYPERGLYCEMIA

HomerSimpson · Jul 24, 2005

I only consult a specialist because I want something done (stress echo, cath, MRI's etc) The last thing I want is one of those guys to do is try and give me advice about periop management. Therefore, consults are there to get SPECIFIC pieces of info. (Severity of ischemia, origin of a dysrythmia, ejection fraction etc.) This info is then used to plan and implement your anesthetic plan. Hey, I mean they don't tell the surgeons **** like"when taking out the gallbladder avoid bagging the cystic artery" So why should I or you listen to a cardiologist tell you " in this patient with CAD. on induction avoid tachcardia and hypotension."? I mean duh... :laugh:

militarymd · Jul 24, 2005

HomerSimpson said:
I only consult a specialist because I want something done (stress echo, cath, MRI's etc) The last thing I want is one of those guys to do is try and give me advice about periop management.

You know what? Most of those specialists also feel the same way about evaluating a patient. The last thing they want is to have one of us tell them to order a stress echo, cath someone, or get an MRI.

I think that if you don't want them to tell you how to administer an anesthetic, then you shouldn't tell them how to evaluate and treat a patient.

They have their organizational guidelines which they know much better than us on how to evaluate a patient's disease.

HomerSimpson · Jul 25, 2005

militarymd said:
You know what? Most of those specialists also feel the same way about evaluating a patient. The last thing they want is to have one of us tell them to order a stress echo, cath someone, or get an MRI.

I think that if you don't want them to tell you how to administer an anesthetic, then you shouldn't tell them how to evaluate and treat a patient.

They have their organizational guidelines which they know much better than us on how to evaluate a patient's disease.

Yeah I know. I'm not saying that they cannot provide good pieces of information that we may miss. I'm also not saying that they are not collegues. What I am saying is that specialists are not there to tell you how to do the anesthetic. That is our job. In my opinion the role of a specialist for any physician getting a consult is to get specific pieces of information so WE(primary) can manage the patient. How they do it is up to them. I can only suggest to them the things that may help me with the patient. But I do understand what you are saying. That's like a surgeon telling me he wants a spinal because of whatever reason.

peace

Clinical Scenario - Fractured Femur

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