Addressing Cocky Surgeons

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jetproppilot

jetproppilot

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I'm in this business to do work.

Take good care of patients.

Make the surgeons happy.

Keep the ball rolling.

The word is out, at least across Louisiana, that Jet is NOT an obstructionalist.

Keep that thought in your mind as you read on.



SO I'M THE UNLUCKY ON-CALL DOC LAST WEDNESDAY...our calls start at 3pm....I think this incident started about 4...

"Emergency ELAP" per Juan RN at the front desk.

Juan doesnt bulls hit. Solid dude.

"No problem," I reply.

I'm well staffed tonite.

Page colleague about case. Ask him to proceed to the ICU and transport patient to OR #8.

As expected, John CRNA delivers. Patient is in OR 8 in less than 30 minutes.

SO HERES WHERE THE WATERS START TO GET MUDDY.

LOOK, I'M HERE TO DO YOUR CASE, Mr/Mrs SURGEON.....

......is pretty much my philosophy.

But lets back up a minute on this case, since it involves one of the very few surgeons I work with who are famous for calling for the patient, requesting you put them to sleep for whatever case, and showing up AN HOUR later.

I'm the anesthesia dude on call.

I'm an easy going dude who will wax your car while you operate if you're nice enough.

But I'll RIP YOUR HEAD OFF if you're an arrogant, entitled individual.

SO IT GOES LIKE THIS:

CRNA arrives in OR 8 at, lets say, 6pm.

Surgeon dude sends word to put patient to sleep.....

C'MON DUDE.......MY GIRLFRIEND IS A SURGEON THATS IN THE CLUB THATS BITING AT THE BIT WHEN WE INDUCE.....AND...UHHHH.....YOU'RE NOT IN DA CLUB.......

in other words,

we know what surgeons will show up on time if we induce with them outta the room.

and we know what surgeons will not.

So I'm on call for this ELAP.

Surgeon falls into the TRUANT column.

Pt in the room, CRNA doing his thing, I put in an a line, TLC....

still no surgeon.

I leave to take a whiz, then return...

surgeon then presents... pt hasnt been put to sleep yet...

"I THOUGHT I SAID TO PUT THE PATIENT TO SLEEP TWENTY MINUTES AGO, HUH?"...surgeon barks into the room.

oh my god i cant believe this is happening! I think with elation......since this dude has a past of GETTING PHYSICAL with people in the past......I'm PRAYING dude shows ANY SIGN of AGGRESSION.....


what follows is WORD FOR WORD...

"Can I speak with you in the hall?" I said.

"Yep," surgeon replies.

We both leave OR 8 and saunter into the OR hall.

Jet: "Dude, I'm really not trying to be an a sshole but....."

Surgeon: "BUT YOU ARE BEING ONE."😱

HAHAHAHAHAHAHAHAH!!!! DUDE INDIRECTLY CALLED ME AN A SSHOLE!!!! TIME TO PULL THE TRIGGER??? nope.

Jet: "Hehehe....Dude I'm gonna level with you.....I work with about thirty surgeons....ninety nine percent when they say sleep, I sleep......unfortunately I've PERSONALLY had run-ins with you about timeliness issues.....I mean CUMMON DUDE....I've put a cuppla your lap chole's to sleep and waited an hour for you to show up...."

SURGEON DUDE MADE A STRATEGIC MISTAKE AT THIS POINT.

HE TRIED TO LIE.

He adamantly denied my allegations of his known-truancy by me and my peers.

My response?

Literally, word for word...

"Dude, WHY WOULD I LIE ABOUT THAT? WHY WOULD I WANNA DELAY YOUR CASE HERE TONIGHT? I wanna get these cases done as much as you do! I'M ON YOUR SIDE. I HESITATED PUTTING DUDE TO SLEEP BECAUSE YOU ARE TRADITIONALLY LATE, AND YOU'RE GONNA SIT HERE AND CRUCIFY ME FOR THIS?"

My head is three inches from this dudes head.......

"YOU'RE RIGHT," surgeon says.

I don't know what he keyed in on....probably the fact that I was telling the truth and wasnt relenting under his bulls hit.......or maybe that I was 10 years his junior outweighing his outta shape body by about thirty pounds...

SOMETIMES YA GOTTA STEP UP TO THE MIKE WITH MICATIN....


right Gern?:laugh:
 
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Jet,

Do you put up with this person because they bring in a lotta biz cuz' I don't know if I could have been as nice.
 
He gets physical w/ his colleagues? If he happened to in this case, jet, what would happen? How would that go?😀
 
I would document in the chart that this was called an E-Lap, that the surgeon requested that the patient be anesthetized, that the decision was made to wait until the surgeon showed up --- i would document the time of phone call, the time the patient was in the OR and the amount of time spent waiting for the surgeon to show up in the OR.

if you don't document, and this guy is a dill-weed, and there is a bad outcome for the patient, he may want to say that your delay was the cause of all problems... watch your back... document
 
Tenesma said:
I would document in the chart that this was called an E-Lap, that the surgeon requested that the patient be anesthetized, that the decision was made to wait until the surgeon showed up --- i would document the time of phone call, the time the patient was in the OR and the amount of time spent waiting for the surgeon to show up in the OR.

if you don't document, and this guy is a dill-weed, and there is a bad outcome for the patient, he may want to say that your delay was the cause of all problems... watch your back... document
Click to expand...

My money is on Jet as well...

We have the same problem with habitually late surgeons. We have the 7:15 go-to-the-OR rule as well, but I NEVER put the patient to sleep, whether it's the first case of the day or late in the evening, until I have been told the surgeon is here. And if I catch the OR staff or the surgeon lying about actually being here, then I refuse to induce the patient forevermore until I have personally laid eyes on the surgeon. Our current issue is with some surgeons who get two OR's so they can flip-flop rooms. Of course the problem comes in when we put that patient to sleep and then wait for them to finish their previous procedure (they're legends in their own mind and not NEARLY as good or fast as they think they are).

However, Tenesma makes an excellent point about documentation. ALL times get documented for these habitually late people on the anesthesia record. We have concerns about compliance issues and billing with these late surgeons. Our time with the patient is legitimately billable, but if the records are reviewed, that 60 minutes between in-OR time and surgery start time for a 10 minute procedure doesn't look good. If we're not in a particularly convivial mood that day, and assuming we haven't given the patient any meds, we'll even sign off and leave the patient on the OR table and have the circulator call us when the surgeon finally graces us with his presence.
 
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This kind of stuff happens very frequently and it used to annoy me to a degree that I got into real heated situations with a few surgeons.
My attitude has changed over the years and my main principal is:
I am not going to allow you to raise my blood pressure no matter what you do.
This means: I will put the patient to sleep on my terms and whenever I feel is the right time, If you are a surgeon that likes to show up late this will be taken into consideration when I decide the right time to put the patient to sleep.
Then I will finish the induction and walk away and if you would like to express your unhappiness to the OR staff or to the CRNA go right ahead because I am going to filter out your comments, Now if you decide to get "physical" then that's a different story, but it usually doesn't happen.
Once they realize that their tantrums are futile they usually quit doing them.
 
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Planktonmd said:
Once they realize that their tantrums are futile they usually quit doing them.
Click to expand...
Kinda like that "don't feed the trolls" concept? 😉
 
Reading this makes me wonder how I would react in this situation. I was a pod student that was called back to hell and now I've decided to do AA school. Would a surgeon address the MDA or AA if the AA was the administrator? What if I would have done this? Another thing, I would rip off his head and s h i t down his throat. Once a marine, always a marine.
 
Nice dude! Way to take care of business in the hall without letting the situation escalate inside the OR. Once in a while some people need to be reminded that we're all professionals and we need to act like it 👍

jetproppilot said:
...bulls hit.......
Click to expand...

:laugh:

Hahaha! I had to reread that. First time I looked at it I went "bulls hit.... WTF is a bulls hit... oh, wait... I'm an idiot."
 
I've only been really pissed once or twice in the past with a surgeon. The other times, its mostly that I'm just really annoyed. I will usually strike at their ego's, "Hey old man, don't let your childish behavior get in the way of caring for this pt." This either shuts them up or really pisses them off at which time they have a few options, go to administration (a battle that I will win if they acted like an arse), try to get physical (not one surgeon here with an attitude is ready for that), they can request I don't do any more of their cases w/c is fine by me cause I don't want to be in their cases either, plus I'm salaried so it makes no difference to me. None of these have really needed to come up though. They usually shut up.
 
Good for you Jet (and others).

Interestingly enough, I do not like it when the patient is put to sleep and I'm not around. I even posted a thread about my first "attending fit" which occured when a patient was taken back, prepped and draped without me knowing about it. I do not like to keep people waiting.

OTOH, maybe once I am busy enough to run two rooms this may change but to keep people waiting for an hour? Ridiculous.

In the end, its all about the patient rather than our mutual convenience, right?

As an aside, for those of you in PP, do you bill for anesthesia time or per case? When does the clock start? With the patient in the room?
 
Winged Scapula said:
As an aside, for those of you in PP, do you bill for anesthesia time or per case? When does the clock start? With the patient in the room?
Click to expand...

It depends on the case. Cosmetic surgery cases are frequently flat-rated. The rate is less than the usual full per-unit charge, but of course we get 100% of that fee. Hospitals or ASC's frequently do the same thing. This allows the plastic surgeon to quote a total price to the patient for a given procedure.

Otherwise, billable time usually starts when you enter the OR with the patient and ends when you release the patient to the care of the PACU nurse. Exceptions to that could include placement of epidurals or blocks. For epidurals used for the case, time starts when we start epidural placement and continues to the PACU admit. That time is continuous.

You can bill "discontinuous" time for blocks placed for the procedure, such as an interscalene placed in the holding area. You charge for time placing the block, and the clock starts again when you enter the OR. If the block is placed solely for post-op pain, then the block itself is usually billed as a separate procedure without a time charge.

It may not make a difference in some places, but we're very picky about time. We want to bill every minute we're entitled to, but no more. Our hospital, like most, wants a surgery start and end time. The definitions of those vary. If a surgeon wants to do an EUA after induction but prior to the prep, to me, that's part of the procedure, and that's when the surgery start time is. Ditto for extended time making measurements and marks after the prep for some reconstruction cases like breast TRAM's. I'll then put a separate note for the incision time. The surgery end time for us is when the patient is supine and dressings on. Just because the incision is closed means nothing. If they're prone, I can't wake them up until they're flipped supine, and getting them flipped is a function of how many OR staff come into the room to help. Of course if they're in lithotomy, the tube will be out and if I'm on my game that day, the patient will open their eyes about the time the legs come down. Don't forget though that if you have extended time in the PACU with the patient, all that time is legitimately billable. You may have to help get the patient settled, wait for a PACU nurse, help zero transducers, finish your paperwork if you have been unable to do so, or whatever. Anesthesia END time is when you're ready to leave the patient, NOT when you arrive in the PACU.

These may seem like minor points, but the bean counters want to know about TURNOVER time. Make sure YOU understand how that is defined for your facility. At our hospital, turnover time is from the SURGERY END time of one case (not patient out of room time) and SURGERY START time for the next case (not patient in the room time). You can see from the previous paragraph that how WE define those times can make a big difference in the turnover time. That also means that for JPP and his socially-challenged and habitually late colleague, and again as Tenesma indicated, DOCUMENTATION is critical. It's just like taking income tax deductions - you're not going to be in trouble for billing/claiming every minute/deduction you're legitimately entitled to, but you may have to provide data/reciepts to support it.
 
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igcgnerd said:
He gets physical w/ his colleagues? If he happened to in this case, jet, what would happen? How would that go?😀
Click to expand...

Ever watched a major league baseball game where the head coach is really p issed off and kinda body-butts the ump?

This dude has done it before....albeit once....several years ago....

I WAS PRAYING FOR HIM TO DO IT AGAIN.

How would I have responded?

Its more important for he to know that I could kick his a ss, which he obviously does.

And knowing that he knows that I know that he knows wow that sounds alot like Texas No Limit, huh?

I wouldda walked away.

No sense getting all riled up for what everyone knows what the conclusion would be.👍

Mosta the time, when warranted, you can show force.

Without showing force.
 
It would be stupid to go head to head with you, you're the one with the syringes full of poison!
 
I was doing a case last night on call that got me thinking about this thread.

It was an ex-lap for dead bowel on some old sick dude with ARF. The surgeon was George (Chief of Staff) .

So little old me (mil - Chief of Anesthesia) and George plan to do this case at 2130 after the old sick dude finishes dialysis.

So....I go to look see this patient...and things look bad. I know this old guy. I anesthetized him a couple of years ago for SBO, and we have greeted each other frequently in the hospital since then when he comes in for recurrent partial SBO.

He gives me crap about how I messed him up in the OR, and I give him crap about how he needs to lose weight. He's always made it out without having to have surgery again.

His wife was there, and she hugs me....happy to see that I'm the dude on call.

So...as I review the chart, this is what I see:

- hct goes from 40 to 50 in 48 hours
- cr goes from 1.1 to 5 in the same time period
- K+ goes from normal to 8+ in that time period
- lactic acid....5
- neosynephrine is running
- bicarb infusion is running to treat acidosis
- dialysis being run a second time today for K's above 5
- no urine output

Apparently, a nephrologist is managing him...and his management is:

- dialysis for increased k
- bicarb for acidosis
- neo for hypovolemic shock.


After I sprinkle some dirt on my old friend (that ways he would be used to being 6 feet under), I give his wife a hug, and told her I would do my best to take care of him in the next several hours.

I put a line in (he didn't have a central one)...and bolused him with a couple liters of LR in the last 30 minutes of dialysis before surgery.

5 minutes before I take the dude to the OR from SICU, I get a call from the pee doctor....the fuc kin fmg gets me on the phone and starts chewing me out (in a thick accent) about how I'm trying to kill his patient while he's working his ass off (from home) to get the K down to normal with dialysis (done by a tech)...because I used LR.

I told him I was busy...please talk to "George"...and that I needed to take care of the patient.

So, when we were in the OR, the pee doctor pages George to tell on me. I told George that the pee doctor is a fool for practicing medicne circa 80's medicine (even though he didn't graduate from Tehran school of medicine until 1999).

George...being a diplomat...as Chief's of Staffs need to be...agreed that for the rest of the night, the patient will get what I want to give, but the record will reflect what the fmg thinks the patient should get.
 
I like the use of LR in the hyperkalemic patient. I've been told there's evidence to suggest that NS, by way of acidosis, increases K more than does LR, but I've been unable to find it. Do you have any references?

In any case, how'd the guy do?
 
I don't know about the specifics of this case, but from what I've been told, it's extremely competitive to get into medical school over there, and supposedly only the top candidates from those being accepted into medical school are allowed to attend the University in Tehran.
 
Dear mil, I don't think you know how things really work in the hospital. The anesthesiologist is really an anesthetist who does the bidding of the MD surgeon. Thats what this poor FMG was thinking. He was only thinking about maintaining the stats quo. That being he is a real doctor and you are not. I mean who seriously wants to resucitate an underresucitated pt. His treatment involves bicarb and neo. Come on man get with the program. 😉


militarymd said:
I was doing a case last night on call that got me thinking about this thread.

It was an ex-lap for dead bowel on some old sick dude with ARF. The surgeon was George (Chief of Staff) .

So little old me (mil - Chief of Anesthesia) and George plan to do this case at 2130 after the old sick dude finishes dialysis.

So....I go to look see this patient...and things look bad. I know this old guy. I anesthetized him a couple of years ago for SBO, and we have greeted each other frequently in the hospital since then when he comes in for recurrent partial SBO.

He gives me crap about how I messed him up in the OR, and I give him crap about how he needs to lose weight. He's always made it out without having to have surgery again.

His wife was there, and she hugs me....happy to see that I'm the dude on call.

So...as I review the chart, this is what I see:

- hct goes from 40 to 50 in 48 hours
- cr goes from 1.1 to 5 in the same time period
- K+ goes from normal to 8+ in that time period
- lactic acid....5
- neosynephrine is running
- bicarb infusion is running to treat acidosis
- dialysis being run a second time today for K's above 5
- no urine output

Apparently, a nephrologist is managing him...and his management is:

- dialysis for increased k
- bicarb for acidosis
- neo for hypovolemic shock.


After I sprinkle some dirt on my old friend (that ways he would be used to being 6 feet under), I give his wife a hug, and told her I would do my best to take care of him in the next several hours.

I put a line in (he didn't have a central one)...and bolused him with a couple liters of LR in the last 30 minutes of dialysis before surgery.

5 minutes before I take the dude to the OR from SICU, I get a call from the pee doctor....the fuc kin fmg gets me on the phone and starts chewing me out (in a thick accent) about how I'm trying to kill his patient while he's working his ass off (from home) to get the K down to normal with dialysis (done by a tech)...because I used LR.

I told him I was busy...please talk to "George"...and that I needed to take care of the patient.

So, when we were in the OR, the pee doctor pages George to tell on me. I told George that the pee doctor is a fool for practicing medicne circa 80's medicine (even though he didn't graduate from Tehran school of medicine until 1999).

George...being a diplomat...as Chief's of Staffs need to be...agreed that for the rest of the night, the patient will get what I want to give, but the record will reflect what the fmg thinks the patient should get.
Click to expand...
 
cchoukal said:
I like the use of LR in the hyperkalemic patient. I've been told there's evidence to suggest that NS, by way of acidosis, increases K more than does LR, but I've been unable to find it. Do you have any references?

In any case, how'd the guy do?
Click to expand...

google " hyperkalemia " and " lactated ringer"

He was more awake after surgery than he was before.
 
frank51 said:
I don't know about the specifics of this case, but from what I've been told, it's extremely competitive to get into medical school over there, and supposedly only the top candidates from those being accepted into medical school are allowed to attend the University in Tehran.
Click to expand...


sort of like being a gold medalist at the special Olympics?
 
.
militarymd said:
I was doing a case last night on call that got me thinking about this thread.

It was an ex-lap for dead bowel on some old sick dude with ARF. The surgeon was George (Chief of Staff) .

So little old me (mil - Chief of Anesthesia) and George plan to do this case at 2130 after the old sick dude finishes dialysis.

So....I go to look see this patient...and things look bad. I know this old guy. I anesthetized him a couple of years ago for SBO, and we have greeted each other frequently in the hospital since then when he comes in for recurrent partial SBO.

He gives me crap about how I messed him up in the OR, and I give him crap about how he needs to lose weight. He's always made it out without having to have surgery again.

His wife was there, and she hugs me....happy to see that I'm the dude on call.

So...as I review the chart, this is what I see:

- hct goes from 40 to 50 in 48 hours
- cr goes from 1.1 to 5 in the same time period
- K+ goes from normal to 8+ in that time period
- lactic acid....5
- neosynephrine is running
- bicarb infusion is running to treat acidosis
- dialysis being run a second time today for K's above 5
- no urine output

Those numbers are clear evidence the pt was dry. He was hemoconcentrated, likely with a base deficit in his ABG along with high lactate, acidotic, etc, etc. How much fluid had the tech pulled? I think you made the right call.

Apparently, a nephrologist is managing him...and his management is:

- dialysis for increased k
- bicarb for acidosis
- neo for hypovolemic shock.

That is a new one for me. Why not just give the patient fluid back through the dialysis? Bicarb for acidosis? I know renal failure patients typically have metabolic acidosis but I have yet to see them be put on a bicarb gtt for it.

After I sprinkle some dirt on my old friend (that ways he would be used to being 6 feet under), I give his wife a hug, and told her I would do my best to take care of him in the next several hours.

I put a line in (he didn't have a central one)...and bolused him with a couple liters of LR in the last 30 minutes of dialysis before surgery.

5 minutes before I take the dude to the OR from SICU, I get a call from the pee doctor....the fuc kin fmg gets me on the phone and starts chewing me out (in a thick accent) about how I'm trying to kill his patient while he's working his ass off (from home) to get the K down to normal with dialysis (done by a tech)...because I used LR.

I told him I was busy...please talk to "George"...and that I needed to take care of the patient.

So, when we were in the OR, the pee doctor pages George to tell on me. I told George that the pee doctor is a fool for practicing medicne circa 80's medicine (even though he didn't graduate from Tehran school of medicine until 1999).

George...being a diplomat...as Chief's of Staffs need to be...agreed that for the rest of the night, the patient will get what I want to give, but the record will reflect what the fmg thinks the patient should get.
Click to expand...
 
The dude was dialyzing him to remove the K...no fluid removed...because according to the tech....the patient was getting MORE hypotensive.....imagine that.
 
militarymd said:
The dude was dialyzing him to remove the K...no fluid removed...because according to the tech....the patient was getting MORE hypotensive.....imagine that.
Click to expand...

That's amazing. Worst part is that this nephrologist was using bicarb to improve the pt's acid base status but the patient had a clear reason to be acidotic that can't be fixed through dialysis..a dead gut. He needed an anesthesiologist and a surgeon to take him to the OR.
 
fastosprintini said:
now now, no name calling of fmg's please ! because.... ve haff vays to make you talk...!
(insert evil laughter)
fasto
Click to expand...

It's a conspiracy man, The Iranians are intentionally sending their doctors to this country and they are particularly targeting the south.
We need to be vigilant.:scared:
 
militarymd said:
sort of like being a gold medalist at the special Olympics?
Click to expand...


All I'm saying is that you can't automatically assume that every doc who happens to be a FMG is somehow inferior in terms of education or intelligence to the U.S educated docs.
 
frank51 said:
All I'm saying is that you can't automatically assume that every doc who happens to be a FMG is somehow inferior in terms of education or intelligence to the U.S educated docs.
Click to expand...

Did I say ALL FMGs?

I said this particular particular "fuc king fmg".

and you guys are missing the point of the thread.

addressing "cocky" doctors.
 
as a patient I appreciate someone like you. I would like to be asleep for the LEAST amount of time possible. Luckily I go to a pediatric hospital (have been there since I was a toddler) so it is not as much of an issue
 
One of my earliest calls as a fellow - when I was still trying to learn how to read between the lines of the OSH physician's presentation - was about some poor schmuck who had the misfortune of landing in an outside hospital with the audacity to be both in DKA & have ESRD (HD dependent). This dude's Doc (barely able to understand him due to a phenomenal accent) was insisting that I take him in transfer for emergent CVVH-D. Mind you, the pt was hemodynamically stable with Cr > 5 & a K of only 6-ish with a Hgb upwards of 16...

In my naivete, I was trying to dissuade this cat from dialing the pt because he was in DKA & would most likely end up needing K because for a DKA, his K was not all of that elevated plus the pt was way hemoconcentrated. I got the screaming, bug-eyed fit in response lecturing me on how he'd been managing DKAs for x-number of years (the Doc was also a pee-doctor) and that he knew better, but I absolutely had to take this patient. I was a bit taken aback that he could not/would not understand my point: dial off all of the K while they are in DKA & when the DKA was corrected, he would arrest from having no f-ing K!

In a flash, I all of the sudden realized that even though this pt, who did not truly meet my ICU's admissions criteria - could have easily been managed in our stepdown or even on the floor (remember, this pt is - THANK GOD - both resp & hemodyn stable) - I HAD to ACCEPT the patient for the pt's own safety. This ****** was gonna kill him if I didn't take him.

Jesus, I had just - literally - finished my anesthesia training & had been an ICU fellow a couple of weeks vs. this shi thead's having been out there for "years". I wonder how many of the "100,000 lives" he was responsible for bumping off?
 
OldManDave said:
One of my earliest calls as a fellow - when I was still trying to learn how to read between the lines of the OSH physician's presentation - was about some poor schmuck who had the misfortune of landing in an outside hospital with the audacity to be both in DKA & have ESRD (HD dependent). This dude's Doc (barely able to understand him due to a phenomenal accent) was insisting that I take him in transfer for emergent CVVH-D. Mind you, the pt was hemodynamically stable with Cr > 5 & a K of only 6-ish with a Hgb upwards of 16...

In my naivete, I was trying to dissuade this cat from dialing the pt because he was in DKA & would most likely end up needing K because for a DKA, his K was not all of that elevated plus the pt was way hemoconcentrated. I got the screaming, bug-eyed fit in response lecturing me on how he'd been managing DKAs for x-number of years (the Doc was also a pee-doctor) and that he knew better, but I absolutely had to take this patient. I was a bit taken aback that he could not/would not understand my point: dial off all of the K while they are in DKA & when the DKA was corrected, he would arrest from having no f-ing K!

In a flash, I all of the sudden realized that even though this pt, who did not truly meet my ICU's admissions criteria - could have easily been managed in our stepdown or even on the floor (remember, this pt is - THANK GOD - both resp & hemodyn stable) - I HAD to ACCEPT the patient for the pt's own safety. This ****** was gonna kill him if I didn't take him.

Jesus, I had just - literally - finished my anesthesia training & had been an ICU fellow a couple of weeks vs. this shi thead's having been out there for "years". I wonder how many of the "100,000 lives" he was responsible for bumping off?
Click to expand...

ha ha ha ha ha......
 
OldManDave said:
One of my earliest calls as a fellow - when I was still trying to learn how to read between the lines of the OSH physician's presentation - was about some poor schmuck who had the misfortune of landing in an outside hospital with the audacity to be both in DKA & have ESRD (HD dependent). This dude's Doc (barely able to understand him due to a phenomenal accent) was insisting that I take him in transfer for emergent CVVH-D. Mind you, the pt was hemodynamically stable with Cr > 5 & a K of only 6-ish with a Hgb upwards of 16...

In my naivete, I was trying to dissuade this cat from dialing the pt because he was in DKA & would most likely end up needing K because for a DKA, his K was not all of that elevated plus the pt was way hemoconcentrated. I got the screaming, bug-eyed fit in response lecturing me on how he'd been managing DKAs for x-number of years (the Doc was also a pee-doctor) and that he knew better, but I absolutely had to take this patient. I was a bit taken aback that he could not/would not understand my point: dial off all of the K while they are in DKA & when the DKA was corrected, he would arrest from having no f-ing K!

In a flash, I all of the sudden realized that even though this pt, who did not truly meet my ICU's admissions criteria - could have easily been managed in our stepdown or even on the floor (remember, this pt is - THANK GOD - both resp & hemodyn stable) - I HAD to ACCEPT the patient for the pt's own safety. This ****** was gonna kill him if I didn't take him.

Jesus, I had just - literally - finished my anesthesia training & had been an ICU fellow a couple of weeks vs. this shi thead's having been out there for "years". I wonder how many of the "100,000 lives" he was responsible for bumping off?
Click to expand...
I am not sure I understand your point:
This is a patient who is in ESRD and normally gets HD even when he is not in DKA, so now that he is in DKA you want to deny him dialysis because when the DKA is fixed the potassium will be low?
If someone needs HD and they happen to develop DKA they still need HD.
 
jetproppilot said:
I'm in this business to do work.

Take good care of patients.

Make the surgeons happy.

Keep the ball rolling.

The word is out, at least across Louisiana, that Jet is NOT an obstructionalist.

Keep that thought in your mind as you read on.



SO I'M THE UNLUCKY ON-CALL DOC LAST WEDNESDAY...our calls start at 3pm....I think this incident started about 4...

"Emergency ELAP" per Juan RN at the front desk.

Juan doesnt bulls hit. Solid dude.

"No problem," I reply.

I'm well staffed tonite.

Page colleague about case. Ask him to proceed to the ICU and transport patient to OR #8.

As expected, John CRNA delivers. Patient is in OR 8 in less than 30 minutes.

SO HERES WHERE THE WATERS START TO GET MUDDY.

LOOK, I'M HERE TO DO YOUR CASE, Mr/Mrs SURGEON.....

......is pretty much my philosophy.

But lets back up a minute on this case, since it involves one of the very few surgeons I work with who are famous for calling for the patient, requesting you put them to sleep for whatever case, and showing up AN HOUR later.

I'm the anesthesia dude on call.

I'm an easy going dude who will wax your car while you operate if you're nice enough.

But I'll RIP YOUR HEAD OFF if you're an arrogant, entitled individual.

SO IT GOES LIKE THIS:

CRNA arrives in OR 8 at, lets say, 6pm.

Surgeon dude sends word to put patient to sleep.....

C'MON DUDE.......MY GIRLFRIEND IS A SURGEON THATS IN THE CLUB THATS BITING AT THE BIT WHEN WE INDUCE.....AND...UHHHH.....YOU'RE NOT IN DA CLUB.......

in other words,

we know what surgeons will show up on time if we induce with them outta the room.

and we know what surgeons will not.

So I'm on call for this ELAP.

Surgeon falls into the TRUANT column.

Pt in the room, CRNA doing his thing, I put in an a line, TLC....

still no surgeon.

I leave to take a whiz, then return...

surgeon then presents... pt hasnt been put to sleep yet...

"I THOUGHT I SAID TO PUT THE PATIENT TO SLEEP TWENTY MINUTES AGO, HUH?"...surgeon barks into the room.

oh my god i cant believe this is happening! I think with elation......since this dude has a past of GETTING PHYSICAL with people in the past......I'm PRAYING dude shows ANY SIGN of AGGRESSION.....


what follows is WORD FOR WORD...

"Can I speak with you in the hall?" I said.

"Yep," surgeon replies.

We both leave OR 8 and saunter into the OR hall.

Jet: "Dude, I'm really not trying to be an a sshole but....."

Surgeon: "BUT YOU ARE BEING ONE."😱

HAHAHAHAHAHAHAHAH!!!! DUDE INDIRECTLY CALLED ME AN A SSHOLE!!!! TIME TO PULL THE TRIGGER??? nope.

Jet: "Hehehe....Dude I'm gonna level with you.....I work with about thirty surgeons....ninety nine percent when they say sleep, I sleep......unfortunately I've PERSONALLY had run-ins with you about timeliness issues.....I mean CUMMON DUDE....I've put a cuppla your lap chole's to sleep and waited an hour for you to show up...."

SURGEON DUDE MADE A STRATEGIC MISTAKE AT THIS POINT.

HE TRIED TO LIE.

He adamantly denied my allegations of his known-truancy by me and my peers.

My response?

Literally, word for word...

"Dude, WHY WOULD I LIE ABOUT THAT? WHY WOULD I WANNA DELAY YOUR CASE HERE TONIGHT? I wanna get these cases done as much as you do! I'M ON YOUR SIDE. I HESITATED PUTTING DUDE TO SLEEP BECAUSE YOU ARE TRADITIONALLY LATE, AND YOU'RE GONNA SIT HERE AND CRUCIFY ME FOR THIS?"

My head is three inches from this dudes head.......

"YOU'RE RIGHT," surgeon says.

I don't know what he keyed in on....probably the fact that I was telling the truth and wasnt relenting under his bulls hit.......or maybe that I was 10 years his junior outweighing his outta shape body by about thirty pounds...

SOMETIMES YA GOTTA STEP UP TO THE MIKE WITH MICATIN....


right Gern?:laugh:
Click to expand...

Great Story👍. Great reply👍👍
 
I wonder if surgeons forget that anesthesiologist are doctors too; Some of them come off sooo arrogant, I have to ask them if they are serious!!! There have been plenty of times during a case that I remind the surgeon when he is acting a fool that: If we both are crossing the street and a bus runs us over, we are BOTH dieing.....Whether he is a surgeon or not makes absolutely NO difference.....In the grand scheme of things he is a NOBODY.... I guess it all depends on the circumstance, I have worked with these(fill in the blank) for almost 10 years. After a while, they start to listen......
 
Planktonmd said:
I am not sure I understand your point:
This is a patient who is in ESRD and normally gets HD even when he is not in DKA, so now that he is in DKA you want to deny him dialysis because when the DKA is fixed the potassium will be low?
If someone needs HD and they happen to develop DKA they still need HD.
Click to expand...



Plankton,

No, I am not saying you should deny him HD. The point is/was that the referring Doc wanted to emergently dial this cat to normalize his K PRIOR to treating the DKA. Furthermore, for someone in DKA, his serum K was not all of that high. That signifies a high-probability that he is total-body K-depleted & will most likely need K-repletion as his DKA resolve - without any sort of HD. Had he dialed the K to normal & then treated his DKA, his K would have plummeted to extremely critical levels causing major, if not fatal problems.
 
OldManDave said:
One of my earliest calls as a fellow - when I was still trying to learn how to read between the lines of the OSH physician's presentation - was about some poor schmuck who had the misfortune of landing in an outside hospital with the audacity to be both in DKA & have ESRD (HD dependent). This dude's Doc (barely able to understand him due to a phenomenal accent) was insisting that I take him in transfer for emergent CVVH-D. Mind you, the pt was hemodynamically stable with Cr > 5 & a K of only 6-ish with a Hgb upwards of 16...

In my naivete, I was trying to dissuade this cat from dialing the pt because he was in DKA & would most likely end up needing K because for a DKA, his K was not all of that elevated plus the pt was way hemoconcentrated. I got the screaming, bug-eyed fit in response lecturing me on how he'd been managing DKAs for x-number of years (the Doc was also a pee-doctor) and that he knew better, but I absolutely had to take this patient. I was a bit taken aback that he could not/would not understand my point: dial off all of the K while they are in DKA & when the DKA was corrected, he would arrest from having no f-ing K!

In a flash, I all of the sudden realized that even though this pt, who did not truly meet my ICU's admissions criteria - could have easily been managed in our stepdown or even on the floor (remember, this pt is - THANK GOD - both resp & hemodyn stable) - I HAD to ACCEPT the patient for the pt's own safety. This ****** was gonna kill him if I didn't take him.

Jesus, I had just - literally - finished my anesthesia training & had been an ICU fellow a couple of weeks vs. this shi thead's having been out there for "years". I wonder how many of the "100,000 lives" he was responsible for bumping off?
Click to expand...

What if the pt was in ESRD HD dependent in septic shock with a K of 6.7 and normal glucose? would you dialyze?
 
so i thought of something while reading this thread - for any of the people you knew in med school who became surgeons - did residency turn them into a-holes? or were they like that before?

i only ask because there are some really cool and funny people in my class who are going to pursue surgery and i'd hate to think that residency would be responsible for them turning into a total jackoff.
 
KNC said:
I wonder if surgeons forget that anesthesiologist are doctors too; Some of them come off sooo arrogant, I have to ask them if they are serious!!! There have been plenty of times during a case that I remind the surgeon when he is acting a fool that: If we both are crossing the street and a bus runs us over, we are BOTH dieing.....Whether he is a surgeon or not makes absolutely NO difference.....In the grand scheme of things he is a NOBODY.... I guess it all depends on the circumstance, I have worked with these(fill in the blank) for almost 10 years. After a while, they start to listen......
Click to expand...

Absolutely!
Got a gynae reg where I am now who seems to think that telling anaesthesia about the D+C they want to do the next morning is an afterthought. So she tells us
1) AFTER they have written it in the book (it ain't supposed to go in the book unless it's been discussed with the duty anaesthetist or duty anaesthesia registrar of the day)
2) AFTER the patient has left the hospital - and she doesn't get that if there are anaesthetic issues we may be able to sort it out before the patient goes home for the night, rather than at 8am the next morning when they are wanting to do the case (lets be honest - D+C for missed abortion without significant bleeding is a semi elective procedure
3) when she seems unable to tell us anything else about the patient. Conversation about one of these patients
Me: "Can you tell me anything more about her?" (all I knew so far was D+C for blighted ovum....I assumed the patient was female....)
her: "No"
Me: eyebrows rising...getting annoyed "How old is she? Does she have any medical problems?"
Her: "Not old, she's heathy, I think"

I almost told her to remove the name from the book and come and talk to me later when she could tell me about the patient properly (not because I thought it would make a difference for this case, but because as a mater of principle I don't want them to get into the habit and think they can supply so little informaiton about ALL cases)! Honestly, they would NEVER ask for a gen surg or medical consult with so little information - but it doesn't occur to them that in taking a patient to theatre they are requesting a consult from anaesthesia and that they should have that sort of information available - particularly if they wan to send the patient home and not be delayed the next day.
 
would this change if you were in academic anesthesiology?

i like the way you handled it.
 
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