An appy, an ectopic, and an open tibia

[Crabbygas]

All three show up at the ER at more or less the same time. There is only one OR available until regular hours start the next morning when there will be ample space. For some god awful reason the anesthesiologist gets to pick which two surgeons to piss off and in what order. So, who goes first and why? Just to make it more interesting estimated skin to skin times are appy 45 min, ectopic 60 min, tibia 120 min.

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[jeesapeesa]

worse case? ruptured ectopic - first/get it out of the way, perforated appendix - second, open tibia last

 

[Arch Guillotti]

All three show up at the ER at more or less the same time. There is only one OR available until regular hours start the next morning when there will be ample space. For some god awful reason the anesthesiologist gets to pick which two surgeons to piss off and in what order. So, who goes first and why? Just to make it more interesting estimated skin to skin times are appy 45 min, ectopic 60 min, tibia 120 min.

Avoid the drama. Make the surgeons actually talk to each other.

 

[dchz]

Do all 3 at the same time in the same OR with 3 different operating tables and 1 anesthesiologist managing all 3 cases.

#KobayashiMaru

 

[Crabbygas]

dchz: Haha! My version of that would be give all 3 antibiotics and do the cases in the morning when OR's are available. Sure it won't do much for the ectopic, but it's been an ectopic for like 12 weeks. Another 8 hours won't matter much and if it ruptures then head of the line.

 

[MirrorTodd]

Isn’t there a move to treat more appy’s nonsurgically these days?

 

[facted]

Surgeons discuss among themselves, you stay out of it.

Imo though, ectopic first, appy next, tibia last.

 

[Crabbygas]

facted and Arch: Easy in theory not so much when the surgeons can't agree and it gets bumped up to the Chief of the Surgery Department....who happens to be the anesthesiologist because nobody else would do it. Sure any order would probably be fine. Just looking to see of anybody has any actual medical reason for choosing one over the other.

 

[pgg]

Do all 3 at the same time in the same OR with 3 different operating tables and 1 anesthesiologist managing all 3 cases.

We set up some ORs in Afghanistan and Iraq with two tables head to head, if there came a day when surgeons & patients outnumbered anesthesiologists. Never saw it happen though.

 

[deleted162650]

Guidelines for open Fx’s give you 6hrs IIRC so it’s an easy call to park that one at the end of the line.

As for the appy and the ectopic, I’d say ectopic first.

A more fun alternative however would be to lock the surgeon and the gyn in an OR with one 10 blade in the middle of the room. 2 surgeons enter - 1 surgeon leaves.

 

[anbuitachi]

All three show up at the ER at more or less the same time. There is only one OR available until regular hours start the next morning when there will be ample space. For some god awful reason the anesthesiologist gets to pick which two surgeons to piss off and in what order. So, who goes first and why? Just to make it more interesting estimated skin to skin times are appy 45 min, ectopic 60 min, tibia 120 min.

probably ectopic first, then open fx, then appy.

none are that emergent so it probably doesn't matter much since none are super long cases

 

[nimbus]

Appy’s often wait til 7am or the end of a lineup where I am. Can’t remember the last time I did an appy between midnight and 7 am.

 

[Sonny Crocket]

Retrograde wire

 

[facted]

@Crabbygas I've been at 3 institutions. Cases go in order booked unless surgeon calls the other surgeon and explains why they're bumping them. That's the way it was at each place.

Medically speaking, ectopic is really only the only one of those that's even remotely life threatening. Could rupture and patients could get unstable (had one just the other night).

Appy could rupture too, but that's not really life threatening if it does, though clearly no ideal. But there are lots of places where those get ABX and we'll deal with it in the morning.

Open fracture gets abx and we'll fix it when we can.

 

[Noyac]

My response would have been (even as surgery Dept chair), “I’ll be in OR #1 ready to do whichever case rolls through the doors, you guys decide which one that is.” Period, end of discussion on my part.

And the way I see it, this is how they should line up:
Ectopic first
Appy to follow especially if there are any comorbidities
Wash out the tibia in the ER while waiting for your turn. With a good washout that case can go the next day but I wouldn’t push that.

 

[IlDestriero]

Avoid the drama. Make the surgeons actually talk to each other.

That’s what we do. It’s not our place to determine what is the most emergent case, what can wait an hour, or 6. They need to figure that out amongst themselves, at the attending to attending level. Then I decide if I need to call the back up call person in or not to run another room. We can run 2 rooms after hours, but that means I have to call in the 2nd call person because I can’t respond to a trauma. The OR nurses will also have to call in their trauma back up.
I’m happy to give surgeons the bad news, like when the ruptured aneurysm is bumping the pyloromyotomy, but as to who’s actual emergent/urgent case trumps another’s, that’s their decision.

PS. I can’t imagine what would happen if they called the head of surgery after hours to sort out the order. OMG I’d pay $1000 to listen to that conversation. Heads would roll.
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Il Destriero

 

[Arch Guillotti]

probably ectopic first, then open fx, then appy.

none are that emergent so it probably doesn't matter much since none are super long cases

Depending on the circumstances, the ectopic absolutely can be considered an emergency.

 

[Twiggidy]

My response would have been (even as surgery Dept chair), “I’ll be in OR #1 ready to do whichever case rolls through the doors, you guys decide which one that is.” Period, end of discussion on my part.

And the way I see it, this is how they should line up:
Ectopic first
Appy to follow especially if there are any comorbidities
Wash out the tibia in the ER while waiting for your turn. With a good washout that case can go the next day but I wouldn’t push that.

This.

Don't ever as an anesthesiologist put yourself in the middle of the decision making when it comes to these things. It happened often when I was a resident and we quickly learned to give it the good ol' Yeezy shrug

 

[pjl]

Ideally, as an anesthesiologist in the moment, surgeons can discuss, and bring their cases in an agreed on order.
In practice, if general or ortho tries to push ahead of the ectopic, I would call them on it.

My only decision is whether or not I feel that any 2 are urgent enough to open a second room, which means waking up one of my partners. Realistically, we could be done with the ectopic before the second surgical team showed up at the hospital.
In this setting, with these cases, I would not open another room.

As the head of department of surgery, that anesthesiologist has to give an opinion. The order discussed on this thread by everyone else is the most right answer in my mind.

 

[Noyac]

“If” I had to give an opinion in this situation as the Director I was pull the orthopod aside and say, “ if you go last you can fix the tibia, if you go 1st or 2nd then all you can do is a washout and return to the OR in the day light.”

That might help arrange the lineup.

 

[Twiggidy]

I just think no one wants to find themselves in a deposition being asked “why did you make the decision you did doctor?” Leave that to the surgeons. They’re all board certified and know who is most critical.

As was said earlier, I’m sitting in the OR and waiting for the first customer (and if I have it, I’ll call my backup for a second room)

 

[Mman]

I just think no one wants to find themselves in a deposition being asked “why did you make the decision you did doctor?” Leave that to the surgeons. They’re all board certified and know who is most critical.

Medicolegally, how is an orthopedic surgeon able to comment on the urgentness of an appendectomy or ectopic pregnancy? Similar question for the general surgeon or ob/gyn about surgeries they know nothing about. They are all board certified and none of their board certified expert opinion is relevant to the other cases.

I mean we also make the surgeons talk to each other, but when it's between different specialties they often default to asking us to weigh in. I'd say ectopic then open fx then appy, but that's just me. Ectopics always go now. Open fractures always go soon. Appys often just put on for the next day when they come in over night.

 

[Iso4ane]

Medicolegally, how is an orthopedic surgeon able to comment on the urgentness of an appendectomy or ectopic pregnancy? Similar question for the general surgeon or ob/gyn about surgeries they know nothing about. They are all board certified and none of their board certified expert opinion is relevant to the other cases.

I mean we also make the surgeons talk to each other, but when it's between different specialties they often default to asking us to weigh in. I'd say ectopic then open fx then appy, but that's just me. Ectopics always go now. Open fractures always go soon. Appys often just put on for the next day when they come in over night.

Get the surgeons together and pose the question to them as a group.

If you were in the middle of nowhere, but en route to the hospital and had the tools to operate, how long would you wait?

And technically, an appy could be done with just local. Been done at least twice.

 

[Mman]

Get the surgeons together and pose the question to them as a group.

I'm not disagreeing, just pointing out it's like asking a cardiologist to comment on the urgentness of a heart cath for an NSTEMI patient vs a colonoscopy for a lower GI bleed. They know their own specialty well but aren't qualified to comment on the relative urgentness of the other (except that cardiologist did do a medicine residency first).

None of them can give you an expert opinion about those other cases.

 

[Twiggidy]

I'm not disagreeing, just pointing out it's like asking a cardiologist to comment on the urgentness of a heart cath for an NSTEMI patient vs a colonoscopy for a lower GI bleed. They know their own specialty well but aren't qualified to comment on the relative urgentness of the other (except that cardiologist did do a medicine residency first).

None of them can give you an expert opinion about those other cases.

I would argue they can and that’s part of their surgical training. That’s why you leave it to them. It could be argued that we as anesthesiologists can provide the least expert opinion because we’re not surgeons. These questions come up on their exams, not ours.

I get where you’re coming from, but technically order of emergent cases isn’t our call. That puts us in a bad spot

 

[Mman]

I would argue they can and that’s part of their surgical training. That’s why you leave it to them. It could be argued that we as anesthesiologists can provide the least expert opinion because we’re not surgeons. These questions come up on their exams, not ours.

I get where you’re coming from, but technically order of emergent cases isn’t our call. That puts us in a bad spot

Where on the ortho boards are they asked about ectopic pregnancies or appendectomies? When do OB/GYNs learn about open fractures?

That's my point. Unlike them, we actually do routinely take care of those patients across other specialties.

 

[Twiggidy]

Where on the ortho boards are they asked about ectopic pregnancies or appendectomies? When do OB/GYNs learn about open fractures?

That's my point. Unlike them, we actually do routinely take care of those patients across other specialties.

Like I said, I get what you're coming from, but I'm also saying there's a reason that just about every residency program teaches you to stay out of the way of these situations. We all know the correct answer, true, but what I'm getting at is you don't want to have to answer questions in the future. That's for all the youngsters on this board. If you do find yourself he, you better be documenting every service's agreement to the terms because if some guy loses his leg and the orthopod says "well anesthesia said they had to go first" ......now you're having to explain your expertise on ortho trauma as an anesthesiologist.

this is all an extreme hypothetical situation, again, which is why we're taught to stay out of it.

 

[Twiggidy]

The same situations probably happen on OB more than this situation.....
OB 1: my lady is having decels and needs an urgent section
OB 2: my lady is also having decels and needs an urgent section

like Salty said.....here's a room. he's a scalpel. last man standing wins, but it's up to you two. i'll be in the OR with the 2% ready (and i'll call my colleague for the loser)

 

[IlDestriero]

Where on the ortho boards are they asked about ectopic pregnancies or appendectomies? When do OB/GYNs learn about open fractures?

That's my point. Unlike them, we actually do routinely take care of those patients across other specialties.

They know what the literature says is emergent, can wait 2 hours, can be temporized with antibiotics, can be washed out today and fixed within 48 hours, etc. We don’t know any of that.


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Il Destriero

 

[rakotomazoto]

In an ideal world, the three surgeons would make the case for the level of urgency for his or her case and then the three of them would compare and come to a consensus on the order they should go. I agree that ortho may not understand ectopics like an OB, but if the three of them talk it out and discuss among themselves, seems like you would get the combined wisdom of their respective specialty training.

 

[sethco]

Oh, I want to play...

Kill the Appy
Sex with the Ectopic
Marry the Tibia

Oh wait, wrong game?

 

[Mman]

The same situations probably happen on OB more than this situation.....
OB 1: my lady is having decels and needs an urgent section
OB 2: my lady is also having decels and needs an urgent section

like Salty said.....here's a room. he's a scalpel. last man standing wins, but it's up to you two. i'll be in the OR with the 2% ready (and i'll call my colleague for the loser)

correct but in that situation they are all board certified obstetricians and can understand the situation with the other patient. In a situation where none of them understands the urgency of the situation of the others, the only person board certified to care for all 3 is the anesthesiologist. I guarantee if the patient's leg fell off, your defense being that the general surgeon said their appy was really important isn't going to hold a lot of weight.

As I said, I make the surgeons talk to each other but in a situation like this it is often going to have them all turning around and looking back at me admitting they don't know the first damn thing about those other situations and what the heck should we do.

Let's be honest, nobody is getting sued over this sort of thing. In the world of emergencies, there is only stuff that needs to go right now (GSW chest, aortic dissection, ruptured aneurysm, stat c-section, etc) and then everything else is varying levels of urgency. If you work in a place that can only do one case at a time, everybody already knows this ahead of time and the surgeons will be well used to the way it has to get worked out. Just need to make sure the actual policy for how this is handled is spelled out ahead of time.