Addressing Cocky Cardiologists

[Planktonmd]

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Here is the story:
I get a call from PACU for a "hypotensive" patient I get there and there is 80Y/O lady who just had a laminectomy with not that much blood loss but her BP in is 75/40.
I just came to work because I am on call and don't really know the patient.
The monitor shows what looks like ST depression in V5.
CRNA already gave Phenylephrine a few seconds ago.
I ask a few questions and find out that the patient has known CAD, had an MI 20 years ago, CABG 15 years ago, and bare metal stents placed 2 months ago in the RCA and LAD.
She was taken off Plavix and Aspirin 7 days ago for this surgery.
She was drowsy but not complaining of chest pain.
2 minutes after giving the Phenylephrine the BP is 100/60 and still asymptomatic but still with ST depression on monitor.
I order an EKG that shows significant ST depression and T inversion in V3 through V6.
My impression at that point: Ischemic episode causing the transient low BP so i start treating for acute coronary syndrome:
Metoprolol, ASA, SL NTG.....
And I send a troponin level.
The patient remains stable and her pressure actually improves.
She never complains of chest pain or S.O.B.
30 minutes later I order another EKG and the ST change had completely resolved.
I ask to admit the Pt. to ICU, continue to R/O MI and notify surgeon and cardiologist.
Later I was told that the cardiollogist when called on the phone, the first thing he said: it must be something anesthesia screwed up!
And then proceeded to tell the nurse how wrong it is to give NTG when there is low BP.
Then he told her that he doesn't believe this was ischemia and that we must have misinterpreted the EKG (although he did not see the EKG in question).
When he came to see the patient 6 hours later he continued his drama and told the patient that all what happened was our fault and the ischemia on the EKG (that he now acknowledges because he saw the EKG) is a direct result of anesthesia (us) causing a post-op hypotension.
I was told the story by nurses because he did not have the balls to come and talk to me directly.
What would you do??

 

[Gern Blansten]

Give his dog antifreeze. That'll teach him.
I kid, I kid.

 

[ChrisA]

Time to pull him aside and have a "come to jesus" meeting. His actions are entirely inappropriate especially what he said to the patient.

 

[ssmallz]

Just curious but what was the rationale for giving nitro to a hypotensive patient?

 

[pgg]

Just curious but what was the rationale for giving nitro to a hypotensive patient?

Coronary vasodilation. You can use other agents (eg phenylephrine) to keep systemic pressure up, but the coronary vasodilation is important for treating the ischemia.

 

[Planktonmd]

Just curious but what was the rationale for giving nitro to a hypotensive patient?

She was not hypotensive anymore when the NTG was given.
Are you a cardiologist? 😀

 

[fakin' the funk]

Coronary vasodilation. You can use other agents (eg phenylephrine) to keep systemic pressure up, but the coronary vasodilation is important for treating the ischemia.

I though during ACS the coronaries were already maximally dilated and SL NTG had its primary effect via venodilation and dropping preload...hopefully with a leftward-and-upward movement on the Frank-Starling curve. Thoughts?

 

[leaverus]

That's just unprofessional to bad-mouth a colleague to the patient, regardless of whether he thinks the management was right or not. He also sounds like a pretty crappy cardiologist if he's making a diagnosis before even evaluating the patient and data. Is the guy a well-respected cardiologist at your hospital?

 

[proman]

I though during ACS the coronaries were already maximally dilated and SL NTG had its primary effect via venodilation and dropping preload...hopefully with a leftward-and-upward movement on the Frank-Starling curve. Thoughts?

Correct. Concern is with inferior MIs that are preload dependent. Also, lower wall tension decreases myocardial oxygen demand. Clearly not this case. But also a rule out MI doesn't need ICU level care.

 

[maceo]

sounds like he has got issues. Dont make his issues your issues. If it really bothers you, go to the medical staff office and the ceo and bring up your grievances with them. If you dont wanna do that, move on. I think what you did was perfectly appropriate, he is the cardiologist however.you can confront him and tell him how bad of a person he is.. but im afraid that would be futile. So do nothing and move on with your life. and give his dog anti freeze.

 

[bellatrix]

Cardiologist...grr. What a malignant drama queen.

Pt's ischemia in the setting of hypotension likely technically not ACS unless EKG showed ST elevation in inferior leads (=inferior wall MI w/ RV infarction leading to hypotension). ST depression in lateral leads warrants treating the hypotension and medicine admission for ROMI. Nitro usually not needed in this scenario unless pt is hypertensive and complaining of chest pain. It decreases cardiac demand through preload decrease -- there is much less direct effect on coronary arteries.

Nothing wrong with your management, tho, and the cardiologist should know that transient hypotension can be part of the perioperative period and is the reason for cardiac risk stratification. Not the fault of anesthesia. This is probably a dude who writes "avoid hypotension and hypoxia" on his periop evals. No s***.

/IM
//hoping to be an anesthesiologist

 

[Noyac]

sounds like he has got issues. Dont make his issues your issues. If it really bothers you, go to the medical staff office and the ceo and bring up your grievances with them. If you dont wanna do that, move on. I think what you did was perfectly appropriate, he is the cardiologist however.you can confront him and tell him how bad of a person he is.. but im afraid that would be futile. So do nothing and move on with your life. and give his dog anti freeze.

Welcome back maceo. I agree with your approach. Let me offer another way.

Plank, does your group have a monthly mtg? If so I'd recommend extending an invitation to the cardiologist. Don't confront him one on one unless you are sure of the outcome. Have your support basis (as long as your partners are up to it). This way you can keep it profession, put it in the minutes for future problems with this cardiologist, and you might consider inviting someone from administration to the mtg. Trust me, this will get his attention and now you have started a "paper trail" in so many words.

This activity is unacceptable and you need to show him that you and your partners will not stand for it. This will also show others the strength of your group.

 

[DO4lifer]

what would differentiate ST depression secondary to hypotension rather than the other way around?

my first thoughts when i saw the low BP with ST depression was that myocardium not being perfused (diastolic of 40 in pt with known CAD).

maybe?

results of trop I? although i know trops can be elevated in any stressful situation. if trop I was negative, we can assume no infarction... no harm no foul right?

 

[Planktonmd]

Cardiologist...grr. What a malignant drama queen.

Pt's ischemia in the setting of hypotension likely technically not ACS unless EKG showed ST elevation in inferior leads (=inferior wall MI w/ RV infarction leading to hypotension). ST depression in lateral leads warrants treating the hypotension and medicine admission for ROMI. Nitro usually not needed in this scenario unless pt is hypertensive and complaining of chest pain. It decreases cardiac demand through preload decrease -- there is much less direct effect on coronary arteries.

Nothing wrong with your management, tho, and the cardiologist should know that transient hypotension can be part of the perioperative period and is the reason for cardiac risk stratification. Not the fault of anesthesia. This is probably a dude who writes "avoid hypotension and hypoxia" on his periop evals. No s***.

/IM
//hoping to be an anesthesiologist

I actually think that the hypotension in this patient was secondary to the ischemia not the other way around.
In an acute ischemic episode NTG is still a valid drug as long as you keep an eye on the BP.
Most likely her LAD stent is partially thrombosed but her cardiologist is not going to investigate that because it would mean that he has to admit that this was not our fault and I doubt that his ego would allow it.
So, she will most likely get discharged home and die of an MI sometime in the next few months.

 

[Planktonmd]

what would differentiate ST depression secondary to hypotension rather than the other way around?

my first thoughts when i saw the low BP with ST depression was that myocardium not being perfused (diastolic of 40 in pt with known CAD).

maybe?

results of trop I? although i know trops can be elevated in any stressful situation. if trop I was negative, we can assume no infarction... no harm no foul right?

The ST depression persisted after the BP was treated.

 

[coprolalia]

Man, even after you finish residency, you're still someone else's b!tch.

🙁

I agree with Noyac's plan.

-copro

 

[radslooking]

That's just unprofessional to bad-mouth a colleague to the patient, regardless of whether he thinks the management was right or not. He also sounds like a pretty crappy cardiologist if he's making a diagnosis before even evaluating the patient and data. Is the guy a well-respected cardiologist at your hospital?

Not only is it poor form, but I would think stupid because patients will sue, and drag you along with the ride. Best to do your job and shut up.

 

[radslooking]

Correct. Concern is with inferior MIs that are preload dependent. Also, lower wall tension decreases myocardial oxygen demand. Clearly not this case. But also a rule out MI doesn't need ICU level care.

I guess i would argue that sig. ST depressions are more important than your standard "rule out" but I see your point. if you have a competent floor nursing staff then maybe not ICU.

 

[Noyac]

I guess i would argue that sig. ST depressions are more important than your standard "rule out" but I see your point. if you have a competent floor nursing staff then maybe not ICU.

Yep, if this is my pt she goes to the unit.

 

[ssmallz]

She was not hypotensive anymore when the NTG was given.
Are you a cardiologist? 😀

nah, just a curious CA-1 whose looking to generate good discussion rather than the typical poo throwing that these threads can degenerate into 😀

F/U Q: this seems like an elective case, why scheduel the case only 2 months after a stent. I know these patients are supposed to be on antiplatlet meds for at least 6 months b/c of risk of restenosis. Why not delay this surgery so the patient can be optimized. D/c'ing her asprin and plavix might have contributed to the ischemic episode

 

[proman]

Yep, if this is my pt she goes to the unit.

Does your hospital have a cardiac step down unit? Or is your choice ICU vs unmonitored floor?

 

[SleepIsGood]

nah, just a curious CA-1 whose looking to generate good discussion rather than the typical poo throwing that these threads can degenerate into 😀

F/U Q: this seems like an elective case, why scheduel the case only 2 months after a stent. I know these patients are supposed to be on antiplatlet meds for at least 6 months b/c of risk of restenosis. Why not delay this surgery so the patient can be optimized. D/c'ing her asprin and plavix might have contributed to the ischemic episode

PRECISELY my thoughts.

I thought you have to wait a minimum of 8 weeks however....check out Yao's book.

 

[lane]

this cardiologist's name wasn't Amy Tuteur, was it?

 

[Planktonmd]

nah, just a curious CA-1 whose looking to generate good discussion rather than the typical poo throwing that these threads can degenerate into 😀

F/U Q: this seems like an elective case, why scheduel the case only 2 months after a stent. I know these patients are supposed to be on antiplatlet meds for at least 6 months b/c of risk of restenosis. Why not delay this surgery so the patient can be optimized. D/c'ing her asprin and plavix might have contributed to the ischemic episode

The patient had bare metal stents not drug eluting stents.
So Plavix could actually be discontinued after 1 month per the current recomendations.

 

[Planktonmd]

Does your hospital have a cardiac step down unit? Or is your choice ICU vs unmonitored floor?

A patient who had dynamic ST changes on the EKG post OP with hypotension and who is 1 month post coronary stenting belongs in the ICU IMHO.
The floor is good enough for your typical homeless guy who comes to the ER complaining of chest pain with no EKG changes for the third time in 1 month.

 

[Scrub MD]

this cardiologist's name wasn't Amy Tuteur, was it?

 

[OB1🤙]

The patient had bare metal stents not drug eluting stents.
So Plavix could actually be discontinued after 1 month per the current recomendations.

Even bare metal stents can thrombose after that period of time when plavix is held for surgery, as we unfortunately found out fairly recently with a fatality.

Recent article in Anesthesiology looked at this issue and recommended waiting at least 90 days.

http://journals.lww.com/anesthesiol...rdiac_Risk_of_Surgery_after_Bare_metal.5.aspx

 

[Noyac]

My personal opinion for bare metal stents is 6 months b/4 elective surgery. But i haven't seen a bare metal stent in quite a while now. It's 1 yr for DES. I think the 3 month period for the bare metal stents is too lenient personally. And never stop the ASA, not even for surgery.

 

[UMMS FMD]

results of trop I? although i know trops can be elevated in any stressful situation. if trop I was negative, we can assume no infarction... no harm no foul right?

As this was a trop I drawn in the middle of an acute event, I'd expect the initial value to be within the normal range. The second set drawn 6 hours later would give you more info...

 

[Planktonmd]

My personal opinion for bare metal stents is 6 months b/4 elective surgery. But i haven't seen a bare metal stent in quite a while now. It's 1 yr for DES. I think the 3 month period for the bare metal stents is too lenient personally. And never stop the ASA, not even for surgery.

Agree.

 

[ssmallz]

My personal opinion for bare metal stents is 6 months b/4 elective surgery. But i haven't seen a bare metal stent in quite a while now. It's 1 yr for DES. I think the 3 month period for the bare metal stents is too lenient personally. And never stop the ASA, not even for surgery.

Agree.

If we all agree that we should wait 6 months for bare metal stents and 1 year for DES then why are we proceeding with the case?

 

[Planktonmd]

If we all agree that we should wait 6 months for bare metal stents and 1 year for DES then why are we proceeding with the case?

I was not the one who started the case but the cardiologist was the one who decided that it was OK to proceed and wrote in the chart that he thinks that this patient was optimized for surgery.
Although you might like to wait longer you can't say that you are not going to do the case unless you have clear evidence to support your opinion.
It is now considered acceptable to do 1 month only of Plavix for bare metal stents.

 

[Mista Suprane]

you have a competent floor nursing staff then maybe not ICU.

less an issue of competence, and more an issue of patient:nursing ratio and telemetry. if your choices are 8:1 patient:nurses and no telemetry, vs. 2:1 or 1:1 monitored floor, the choice is obvious. there are clearly in-betweens that are acceptable (but might not be available in all hospitals).

 

[dhb]

What would you do??

Kick him in the nutz

 

[nitroglycerine]

I was not the one who started the case but the cardiologist was the one who decided that it was OK to proceed and wrote in the chart that he thinks that this patient was optimized for surgery.
Although you might like to wait longer you can't say that you are not going to do the case unless you have clear evidence to support your opinion.
It is now considered acceptable to do 1 month only of Plavix for bare metal stents.

If a stented patient arrives for a non-urgent surgery and his antiplatelet meds were stopped by a non-cariologist that's exactly what I would do: cancel or hold the case until a cardiologist tells me it is safe to proceed.

 

[IN2B8R]

Here is the story:
I get a call from PACU for a "hypotensive" patient I get there and there is 80Y/O lady who just had a laminectomy with not that much blood loss but her BP in is 75/40.
I just came to work because I am on call and don't really know the patient.
The monitor shows what looks like ST depression in V5.
CRNA already gave Phenylephrine a few seconds ago.
I ask a few questions and find out that the patient has known CAD, had an MI 20 years ago, CABG 15 years ago, and bare metal stents placed 2 months ago in the RCA and LAD.
She was taken off Plavix and Aspirin 7 days ago for this surgery.
She was drowsy but not complaining of chest pain.
2 minutes after giving the Phenylephrine the BP is 100/60 and still asymptomatic but still with ST depression on monitor.
I order an EKG that shows significant ST depression and T inversion in V3 through V6.
My impression at that point: Ischemic episode causing the transient low BP so i start treating for acute coronary syndrome:
Metoprolol, ASA, SL NTG.....
And I send a troponin level.
The patient remains stable and her pressure actually improves.
She never complains of chest pain or S.O.B.
30 minutes later I order another EKG and the ST change had completely resolved.
I ask to admit the Pt. to ICU, continue to R/O MI and notify surgeon and cardiologist.
Later I was told that the cardiollogist when called on the phone, the first thing he said: it must be something anesthesia screwed up!
And then proceeded to tell the nurse how wrong it is to give NTG when there is low BP.
Then he told her that he doesn't believe this was ischemia and that we must have misinterpreted the EKG (although he did not see the EKG in question).
When he came to see the patient 6 hours later he continued his drama and told the patient that all what happened was our fault and the ischemia on the EKG (that he now acknowledges because he saw the EKG) is a direct result of anesthesia (us) causing a post-op hypotension.
I was told the story by nurses because he did not have the balls to come and talk to me directly.
What would you do??

Just like you, cardiologists are only consultants. Their words are not etched in stone and, in the past, I did go against their judgement (happened twice over the last 4 years).... They may make a recommendation, but it is up to me if I want to accept their recommendation, be it the simple "clearned for surgery" bull $hit note, or a full blown report detailing why someone is ready for surgery--I make the decision whether or not to proceed.... That is how I personally would engage the douchbag who blamed you for the patient's episode: yes, that is confrontational, but it gets the message across.... Having said that, on both occasions that I have disagreed with cardiologists over the last four years, I picked up the phone and had a mature, professional conversation with both and, in the end, came out on top with colleagues who respected my opinion and agreed with my judgement after I explained, throughly, my concerns to them.

 

[joshmir]

IN2B8R

May I trouble you to relate briefly the salient points of the 2 situations you described?

Times when a cards was wrong and gas was right (simplification) can be excellent learning opportunities for us...

 

[IN2B8R]

IN2B8R

May I trouble you to relate briefly the salient points of the 2 situations you described?

Times when a cards was wrong and gas was right (simplification) can be excellent learning opportunities for us...

Scenario 1: a drug eluting stent placed within a 4.5 month period for a patient who was coming to an outpatient surgery center for bilateral CTR under "regional + sedation." Reason patient "had to have" the surgery was that he was sick of dealing with the bilateral hands pain.... Cardiologist was completely under the impression that there would be "no" stress response under regional anesthesia + sedation and was actually willing to take the patient off the plavix (but maintain his ASA) and proceed with the "nerve" sparring surgery.... His thoughts: patient "needs" the surgery and it would be completely stress free under regional "anesthesia and sedation..." My differing thoughts: regional anesthesia (done by surgeon in this case) always runs the risk of failing. Regional anesthesia alone does not obliterate the stress response. I obviously was concerned about in-stent thrombosis in a patient who was taken off the plavix (but cardiologist didn't "think" that the patient was terribly dependent on that particular stent--and I never got an adequate response as to why it was placed if the patient was not "terribly" dependent on it..). End result: patient does not undergo the surgery because he felt that his risk was too great after discussion with myself and the orthopod (alive with pain is better than dead). Four days after withholding the plavix (precisely one day after I cancelled his surgery), I get a phone call from the orthopod stating "we just dodged a bullet, the guy is in the cath lab with CP..."

Scenario 2: took over a case from a collegaue of mine. Pt in for a knee (outpatient) arthroscopy. Guy in his mid 50s, not an athletic specimen, with a resting HR of 50 (from prior EKG). Partner gave intra-op glyco (0.4mg) to speed the HR when it dipped down to high 30's. I basically met the patient in PACU (I was floor guy) and he is resting comfortably in PACU (pain free with a stable BP of 110/60), but HR again in the low-mid 30s. Clearly glyco has worn off. Pt was asymptomatic, yet he was in stretcher all the time and no attempt to check for orthostasis was made.... Patient wanted to just go home. I consult his cardioloogist 'cause I wanted pt evaluated for a pacer. Pt's Cardiologist wanted the pt to go home and handle this appointment as an outpt (I later found out that his cardiologist had no admitting privilges at our facility). I call our hospital's on-call cardiologist: he comes in, admits the patient and books the orthostatic patient for a pacemaker in the AM. He also thanks me for not sending the patient home and doing what was right. Moral of the story: you cannot trust everyone's judgement--if a consultant is sound, you will know it and you will trust him/her. If it sounds like BS, smells like BS, then it IS likely BS!

Best regards!

 

[kmurp]

Regarding the cardiologist is speak to my dept. chief and ask him to speak to the chief of cardiology. I have never liked one of us directly confronting a member of another department. Too much of a chance it could end badly and needlessly inflame the situation or even possibly reflecting negatively on the offended anesthesiologist or his department. By going through channels and having the cardiology chief informed, you not only avoid this, but you inform the other chief that he may have a problem doctor in his own department. We only have one cardiology group and they are good but that's what I would do at my place.
(also didn't understand the earlier comment on nitro moving the starling curve leftward and upward. Thought this applied to arterial vasodilators, not venodilators).

 

[Arch Guillotti]

If a stented patient arrives for a non-urgent surgery and his antiplatelet meds were stopped by a non-cariologist that's exactly what I would do: cancel or hold the case until a cardiologist tells me it is safe to proceed.

What if the stent is over a year old?