Case for Military MD

[toughlife]

---

Members do not see this ad.

This is a patient I am caring for now:

60yo F, nursing home resident, with hx signficant for:
-IDDM with retinopathy s/p OS pars plana vitrectomy 5/05
-Remote DVT/PE s/p IVC filter '04
-CM (nonischemic) with EF 30%
-CAD
-hx PAF & complete heart block--pacemaker dependent.
-HTN
-Non-oliguric renal failure with baseline creatinine of 2.5 on HD 3x/wk
-hyperlipidemia
-PVD
-s/p left toe amputations , 1st & 2nd digits
-s/p hysterectomy

Xferred from outside hospital with fevers of 102.9/chills, urinary symptoms, lethargy, SOB and hypotension found to have mulitiple +BCxs with MRSA 12/27 -1/1/07 and UCx 12/27/06 with Citrobacter amalonaticus, and foot/toe wound cxs 12/29/06 with GBS and MRSA. TEE at outside hospital revealed RA pacemaker lead with 2 mobile vegetations of 0.5 x 0.75cm and RV lead encased with large superior venocaval thrombus-approx 2.5 cm long x 1.0 cm mobile thumb-like appearing thrombus arising from the SVC and mobile within the RA and patent foramen ovale.

Repeat TEE now showing extensive vegetations in triscupid and mitral valve requiring surgery. Cardiology/electrophysiology folks consulted--Plan: valve replacement, pacemaker removal and epicardial pacing in the interim, .

Patient also presented with weakness of left upper extremity--Head CT on admission(1/2/07): 1.4 x 1.0 cm area of increased attenuation is present in the inferior mesial aspect of the left cerebral hemisphere which is concerning for hemorrhage.

Repeat Head CT 1/6/07: "Previously noted increased attenuation in inferior mesial left cerebellar hemisphere not visualized on current examination
suggesting that it was artifactual"


Left Foot X-ray showing increased radiolucency involving the first metatarsal shaft with active periostitis, likely osteomyelitis.

Carotid u/s with moderate atherosclerotic changes with 50-60% narrowing bilaterally

Labs: 133/ 3.9/ 95/ 28/ 10/ 77/ 1.7/ 60 INR: 1.0
MRSA bacteremia on IV vanco and gentamycin
Vital signs stable

 

[nutmegs]

consult carpenter.

 

[VolatileAgent]

ASA 4E. if the surgeons are ready to go, you go to sleep. invasive monitors. tell patient there's a good chance he'll die on the table.

unless, of course, they want to try to treat his infections first and "optimize" his current therapy. but, with all that crap going on, he might die while waiting.

major catch 22.

 

[toughlife]

ASA 4E. if the surgeons are ready to go, you go to sleep. invasive monitors. tell patient there's a good chance he'll die on the table.

unless, of course, they want to try to treat his infections first and "optimize" his current therapy. but, with all that crap going on, he might die while waiting.

major catch 22.

I hear you. CT surgery and anesthesia scratching their head and grabbing their cojones deciding right now.

 

[Gern Blansten]

I would tell him not to buy any green bananas.

 

[Gern Blansten]

sorry, her.

 

[militarymd]

These cases are great....you can ONLY win when you do a case like this.

Muliple risks....they are, for the most part, not modifiable.

If the CT surgeons do nothing, the patient will likely die.

If they operate, the patient will likely die.

Other option is medical therapy...which one can argue is a better option.

Bottom line, there aren't enough patients like this out there for PRCT to be performed so that one can say "Mrs. Schmuckatelli, if you go to the OR you have a better chance of coming out of all this".

In this case, as the anesthesia team, you are essentially on the sidelines...meaning, you don't decide whether the patient comes to the OR or not....just be prepared for a long hard case should they (surgenon, family, intensivist) opt to come to the OR.

 

[The_Sensei]

These cases are great....you can ONLY win when you do a case like this.

So true. If the patient survives everyone will say "what a great anesthesiologist you are!" If the patient dies, everyone will say "well, you know, they were really sick"

 

[Noyac]

So why do we (I mean surgeons, anesthesiologists, and everyone else involved) do these cases? Its not like we are going to make a big improvement in the pts quality of life. She has no quality of life. She is at the end. Why do we prolong the inevitable? This is the most ridiculous part of our healthcare system. You want healthcare reform? This is a great example of where to begin.

 

[VolatileAgent]

So why do we (I mean surgeons, anesthesiologists, and everyone else involved) do these cases? Its not like we are going to make a big improvement in the pts quality of life. She has no quality of life. She is at the end. Why do we prolong the inevitable? This is the most ridiculous part of our healthcare system. You want healthcare reform? This is a great example of where to begin.

i couldn't agree more. the time to intervene with this patient was about 20 years ago.

 

[nutmegs]

You want healthcare reform? This is a great example of where to begin.

amen.

 

[zippy2u]

I double amen this thread. You need to ship this gomer on a straight flight to Amsterdam. The Dutch know how to deal with this crap. Why, they'll wheelchair her a$$ to the nearest coffee shop, roll her up some big doobers and let her watch some classic movies like "Gone with the Wind" . You will not learn anything from this case. You, as a human being, have failed society if this pt gets taken to the OR. Tell the surgeon that Zippy says the pt should have a one way ticket to Amsterdam rather than those shiny heart valves. Let us know how this case plays out. Regards.... ----Zippy

 

[zippy2u]

I

 

[toughlife]

Patient will have pacemaker removed tomorrow with transvenous pacing in the interim. CT decision pending.

Difficult decisions to make given quality of life likely won't improve despite aggresive medical intervention. However, from a learning perspective it will be a great case for an anesthesia resident who will likely not be doing many of these cases once out in PP. Lap choles and herniorrhaphies will be mind-numbing when you are used to cases like this.

This case is unique in that I was primary so attending and I got to decide what the course of action would be.

Will keep you posted.

 

[Planktonmd]

Why can't you die with dignity in this country?
They will likely give her a nice PE while they are pulling the pacer leads out.
If that fails then they will find another creative way to butcher her before her death.

 

[CremeSickle]

i believe that 'dying with dignity' is against the religious right rules this country is dictated by.

 

[TheSandMan]

These cases are great....you can ONLY win when you do a case like this.

.

I have an attending who jokes that its the ASA 1's that really make him nervous, because you have no room to make them better, only worse 😉

 

[Bougie]

palliative care consult and one way ticket for the Jesus bus.

 

[bigdan]

Surgeons can't bill for "dying with dignity".

dc