Consulting other services for "basic" skills

[vhawk]

A few years ago I was consulted on a patient incidentally found to have the tip of the NGT in an extraluminal position on CT scan. I found that it had perforated into the retropharyngeal space via the nasopharynx and was pushed down below the diaphragm somehow. Had he gotten tube feeds or meds it probably wouldn't have ended well for him. I placed it on suction for a short time and then pulled it. He did fine.

One of my co-residents put one into and then ultimately through the left main stem bronchus and ended up giving almost a full days worth of tube feeds into the pleural space.

It....did not end well

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[VisionaryTics]

We put enough Dobhoffs in anesthetized patients (no cough reflex) that every resident in our program has put at least one into the lungs.

However, there was the time that the tube used to stent open the tracheoesophageal puncture fell out. The resident replaced the tube, unfortunately managed to thread it between trachea and esophagus into mediastinum. The CXR looked fine, tube midline below diaphragm.

Turns out the mediastinum does not like tube feeds.

 

[TypeADissection]

Speaking of NGTs, I don’t know how to write orders any clearer that my aortomesenteric bypasses keep their NGT in and on LIWS and strict NPO no clamping no meds unless the vascular fellow or attending orders otherwise. why are intensivists and nurses and the whole hospital trying to find loopholes in this order?

ICU Nurse: Hi Dr. Splash, did you want the NGT to LIWS?
LS: Uh...yes. What do the orders say?
ICU Nurse: It says to do it. I just wanted to call and make sure.
LS: Yes please and thank you.
ICU Nurse: Just one more thing. Can we put meds down it and clamp it? The patient is passing flatus.
LS: Uh...what do the orders say?
ICU Nurse: It says not to. Just wanted to call and make sure.
LS: Please just do what the orders say... Please.

True or false: This conversation has happened recently.

 

[Winged Scapula]

ICU Nurse: Hi Dr. Splash, did you want the NGT to LIWS?
LS: Uh...yes. What do the orders say?
ICU Nurse: It says to do it. I just wanted to call and make sure.
LS: Yes please and thank you.
ICU Nurse: Just one more thing. Can we put meds down it and clamp it? The patient is passing flatus.
LS: Uh...what do the orders say?
ICU Nurse: It says not to. Just wanted to call and make sure.
LS: Please just do what the orders say... Please.

True or false: This conversation has happened recently.

TRUE.

I remember those conversations from residency very very well and it still annoys me to read that others are getting these calls.

In fact, I still get them. Mine was more:

Floor Nurse: Hi, is this Dr W.S.? (she is calling my cell phone)

W.S: Yes, hi.

Floor Nurse: This is Floor Nurse X. I"m calling about (fumbles for name of patient)...

W.S.: Yes, I discharged her this morning (its now 1130 am); what's the issue

Floor Nurse: Well it was a Conditional Discharge, saying she could go if she tolerated breakfast and controlled her pain with the Percocet

W.S. Ok....is there a problem

Floor Nurse: no I was just checking if it was ok to discharge her

W.S. If she has met the conditions, yes. I would have expected she was discharged several hours ago and that the orders were followed without having to call me

Floor Nurse: I just wanted to make sure

 

[vhawk]

We had a resident in our program who made it a point of pride to force the nurses to log into the patients chart and read the orders, verbatim, to her over the phone, every time they called with one of those "just wanted to make sure" calls.

It...did not end well.

 

[LucidSplash]

ICU Nurse: Hi Dr. Splash, did you want the NGT to LIWS?
LS: Uh...yes. What do the orders say?
ICU Nurse: It says to do it. I just wanted to call and make sure.
LS: Yes please and thank you.
ICU Nurse: Just one more thing. Can we put meds down it and clamp it? The patient is passing flatus.
LS: Uh...what do the orders say?
ICU Nurse: It says not to. Just wanted to call and make sure.
LS: Please just do what the orders say... Please.

True or false: This conversation has happened recently.

VERBATIM

 

[ThoracicGuy]

We had a resident in our program who made it a point of pride to force the nurses to log into the patients chart and read the orders, verbatim, to her over the phone, every time they called with one of those "just wanted to make sure" calls.

It...did not end well.

Sadly, I assume poorly for the resident....

 

[deleted547339]

ICU Nurse: Hi Dr. Splash, did you want the NGT to LIWS?
LS: Uh...yes. What do the orders say?
ICU Nurse: It says to do it. I just wanted to call and make sure.
LS: Yes please and thank you.
ICU Nurse: Just one more thing. Can we put meds down it and clamp it? The patient is passing flatus.
LS: Uh...what do the orders say?
ICU Nurse: It says not to. Just wanted to call and make sure.
LS: Please just do what the orders say... Please.

True or false: This conversation has happened recently.

I'm sure this is the case, but I've also seen many surgical patients who have PRN oxy for pain control and NPO orders....

 

[LucidSplash]

I'm sure this is the case, but I've also seen many surgical patients who have PRN oxy for pain control and NPO orders....

What bearing does that have on this situation/discussion? There are graduations of NPO, for certain. There’s a big difference between NPO with an NGT after an aortomesenteric bypass and NPO except meds without an NGT because a patient is nauseous or distended after a Lap chole. And if someone needs meds and they are NPO then they can call about that because God knows occasionally I forget to adjust a pain Med order on post op meds or write conflicting orders in the 76 boxes that need clicking since I’m not allowed to write them out on paper anymore.

But that’s different than if specific orders are written “Strict NPO, NGT to LIWS, no clamping of tube for meds, ngt orders only by vascular fellow or attending, do not remove or clamp without orders” with a PCA order to boot, then that seems pretty clear to me. As do the orders mentioned by others above.

 

[SLUser11]

What bearing does that have on this situation/discussion? There are graduations of NPO, for certain. There’s a big difference between NPO with an NGT after an aortomesenteric bypass and NPO except meds without an NGT because a patient is nauseous or distended after a Lap chole. And if someone needs meds and they are NPO then they can call about that because God knows occasionally I forget to adjust a pain Med order on post op meds or write conflicting orders in the 76 boxes that need clicking since I’m not allowed to write them out on paper anymore.

But that’s different than if specific orders are written “Strict NPO, NGT to LIWS, no clamping of tube for meds, ngt orders only by vascular fellow or attending, do not remove or clamp without orders” with a PCA order to boot, then that seems pretty clear to me. As do the orders mentioned by others above.

I don't necessarily disagree with you, but I think you'll find that other surgeons/teams will have more inconsistencies, with the orders saying one thing, and them wanting another, especially if they're not aces with order sets/EMRs, etc. I personally don't get too worked up when they ask seemingly stupid questions, especially when clarifying or confirming an order that they find unusual, as I don't want an environment where my orders are not to be questioned....that's eliminating a line of defense in the swiss cheese model.

 

[LucidSplash]

I don't necessarily disagree with you, but I think you'll find that other surgeons/teams will have more inconsistencies, with the orders saying one thing, and them wanting another, especially if they're not aces with order sets/EMRs, etc. I personally don't get too worked up when they ask seemingly stupid questions, especially when clarifying or confirming an order that they find unusual, as I don't want an environment where my orders are not to be questioned....that's eliminating a line of defense in the swiss cheese model.

I don’t mind clarification. I mind asking if I want the specific thing I wrote for in excruciating detail and explained the reasons why to the nurse who received the patient from the OR/was there when I rounded. It is one thing if you don’t understand what the order means it is another if you just want to do something different. Like clamping the NGT overnight without an order “just to see if he could tolerate it” on POD 1.

 

[DrfluffyMD]

Pseudo aneurysms are not uncommon after partial nephrectomies, should I learn how to embolize them, or should I consult IR?

Accidental enterotomy can happen during a CT drain, should I learn how to do general surgery or should I consult surgery as an IR guy?

I think there is a limit to level of expertise in each physician. I am not sure if crossing a pseudoaneurysm or embo is a part of the regular urology training.

Placing an NG should be though.

 

[vhawk]

Accidental enterotomy can happen during a CT drain, should I learn how to do general surgery or should I consult surgery as an IR guy?

I think there is a limit to level of expertise in each physician. I am not sure if crossing a pseudoaneurysm or embo is a part of the regular urology training.

Placing an NG should be though.

Agree with this, I frequently hear surgeons being dismissive of for example GI colleagues for calling us for their complications and I've heard "you shouldn't do a procedure if you can't handle it's complications" a hundred times and always thought it was dumb. I can, for the most part, handle the SURGICAL complications of the procedures I do but there are tons of possible complications that I can't really handle. I can't really handle an acute post op STEMI. I can't really handle post op renal failure. I mean I guess in theory I "can" handle something like hemobilia but certainly not in any standard of care way.

Honestly I can't even really handle a major ureter injury. Could I fix it if I was alone and forced to in the middle of the night? Sure, probably but it would suck.

 

[deleted547339]

Agree with this, I frequently hear surgeons being dismissive of for example GI colleagues for calling us for their complications and I've heard "you shouldn't do a procedure if you can't handle it's complications" a hundred times and always thought it was dumb. I can, for the most part, handle the SURGICAL complications of the procedures I do but there are tons of possible complications that I can't really handle. I can't really handle an acute post op STEMI. I can't really handle post op renal failure. I mean I guess in theory I "can" handle something like hemobilia but certainly not in any standard of care way.

Honestly I can't even really handle a major ureter injury. Could I fix it if I was alone and forced to in the middle of the night? Sure, probably but it would suck.

Agreed. This sounded very intelligent to me when I heard it as a med student and intern, but the more medicine I learn, the more I realize it's a silly concept perpetuated by people who want to thump on their own chest. Medicine is so hyper-specialized that if we decided to only do procedures for which we can handle the complications, no one would ever do anything. No one would argue that cardiologists should stop cath'ing STEMIs because they can't may cause a problem that needs a CT or vascular surgeon because everyone understands the value that is brought to the patient when cardiologists perform this procedure. Or an orthopedic surgeon shouldn't operate because they could cause vascular injury. Or an ER docs place a chest tubes but can't do a thoracotomy/VATS in the event of a complication. Trauma surgeon doing a trach which gets stenosed and needs reconstruction. Post-op abdominal surgery gone wrong needs vent management, something an intensivist is best at.

Everyone should just try to achieve the highest level of competence possible for those procedures that are within the perview of their speciality and practice cautiously. The more bravado in medicine, the worse it is for patients.

 

[Jolie South]

Agreed. This sounded very intelligent to me when I heard it as a med student and intern, but the more medicine I learn, the more I realize it's a silly concept perpetuated by people who want to thump on their own chest. Medicine is so hyper-specialized that if we decided to only do procedures for which we can handle the complications, no one would ever do anything. No one would argue that cardiologists should stop cath'ing STEMIs because they can't may cause a problem that needs a CT or vascular surgeon because everyone understands the value that is brought to the patient when cardiologists perform this procedure. Or an orthopedic surgeon shouldn't operate because they could cause vascular injury. Or an ER docs place a chest tubes but can't do a thoracotomy/VATS in the event of a complication. Trauma surgeon doing a trach which gets stenosed and needs reconstruction. Post-op abdominal surgery gone wrong needs vent management, something an intensivist is best at.

Everyone should just try to achieve the highest level of competence possible for those procedures that are within the perview of their speciality and practice cautiously. The more bravado in medicine, the worse it is for patients.

There is a difference between not being able procedurally to handle a complication and being a straight a$$ who refuses to even examine or see YOUR patient that had complication from YOUR procedure. If a GI guy perfs a colon and calls me and says “hey I am concerned about this patient, will you take a look? I think they may need surgery.” That is a far cry from a cardiologist doing a radial artery access, having bleeding, applying some ridiculous pressure device for hours, such that the patient gets a median neuropathy and then refuse to see the patient in clinic with their complaints such that they end up in the ER with a vascular surgery consult. Not that I speak from personal experience on that one or anything.

I see a lot of consultants stop caring about patients once the cash flow stops. They want to just dump the patient. We have all been in a place of needing assistance, but don’t be that guy.

 

[DrfluffyMD]

There is a difference between not being able procedurally to handle a complication and being a straight a$$ who refuses to even examine or see YOUR patient that had complication from YOUR procedure. If a GI guy perfs a colon and calls me and says “hey I am concerned about this patient, will you take a look? I think they may need surgery.” That is a far cry from a cardiologist doing a radial artery access, having bleeding, applying some ridiculous pressure device for hours, such that the patient gets a median neuropathy and then refuse to see the patient in clinic with their complaints such that they end up in the ER with a vascular surgery consult. Not that I speak from personal experience on that one or anything.

I see a lot of consultants stop caring about patients once the cash flow stops. They want to just dump the patient. We have all been in a place of needing assistance, but don’t be that guy.

People who no longer take care of their patients after they do their procedures invariable have those procedures take away from them by people who are willing to own those patients.

 

[deleted547339]

There is a difference between not being able procedurally to handle a complication and being a straight a$$ who refuses to even examine or see YOUR patient that had complication from YOUR procedure. If a GI guy perfs a colon and calls me and says “hey I am concerned about this patient, will you take a look? I think they may need surgery.” That is a far cry from a cardiologist doing a radial artery access, having bleeding, applying some ridiculous pressure device for hours, such that the patient gets a median neuropathy and then refuse to see the patient in clinic with their complaints such that they end up in the ER with a vascular surgery consult. Not that I speak from personal experience on that one or anything.

I see a lot of consultants stop caring about patients once the cash flow stops. They want to just dump the patient. We have all been in a place of needing assistance, but don’t be that guy.

Yea...some people just suck, regardless if MD is after their name.

 

[ThoracicGuy]

There is a difference between not being able procedurally to handle a complication and being a straight a$$ who refuses to even examine or see YOUR patient that had complication from YOUR procedure. If a GI guy perfs a colon and calls me and says “hey I am concerned about this patient, will you take a look? I think they may need surgery.” That is a far cry from a cardiologist doing a radial artery access, having bleeding, applying some ridiculous pressure device for hours, such that the patient gets a median neuropathy and then refuse to see the patient in clinic with their complaints such that they end up in the ER with a vascular surgery consult. Not that I speak from personal experience on that one or anything.

I see a lot of consultants stop caring about patients once the cash flow stops. They want to just dump the patient. We have all been in a place of needing assistance, but don’t be that guy.

Or cause a pseudoaneurysm, consult surgery, and then leave the hospital... Or just tell them to go to the ER and have the ER consult surgery and then never see the patient during the admission...

 

[vhawk]

Obviously I don't know either of your specific situations but there can often be a high degree of shame and anxiety when a patient of hours has a complication and this can lead to strong feelings of aversion for the physician. This doesn't excuse the behavior by any means and they should still feel morally obligated (and medicolegally strongly advised) to be very involved when a patient has a complication but to some degree it is just human nature.

 

[Jolie South]

Or cause a pseudoaneurysm, consult surgery, and then leave the hospital... Or just tell them to go to the ER and have the ER consult surgery and then never see the patient during the admission...

Or back wall the common femoral artery with an angioseal and totally obliterate flow to the leg...

Or put a patient on aspirin, brilinta, heparin gtt, and eliquis and wonder why the femoral access site got a hematoma, put sand bags on it, then call days later when the hematoma decompresses and call it “arterial bleeding”...

Or tie a catheter in a knot subcutaneously...

Or put a balloon pump in, kill the leg, and call for fasciotomy for compartment syndrome on a Rutherford 3 leg...

But who’s counting?

 

[deleted547339]

Obviously I don't know either of your specific situations but there can often be a high degree of shame and anxiety when a patient of hours has a complication and this can lead to strong feelings of aversion for the physician. This doesn't excuse the behavior by any means and they should still feel morally obligated (and medicolegally strongly advised) to be very involved when a patient has a complication but to some degree it is just human nature.

Yea, some people don’t get this. I’m EM and in residency I had a surgical patient who came in with a medical complication from a prescription written by the surgical service at discharge (that probably shouldn’t have been written considering their comorbidities and other medications). I called the surgical service before admitting to medicine and got chewed out by the chief resident about consulting a surgeon for a medical issue. No amount of explaining my point made him understand that 1) it is good from a Med/mal standpoint to get some face time and at least shake the patients hand and apologize because your service caused this problem and 2) if you’re admitting an immediate post-op patient to the hospitalist service, they would like the surgeon to at least see the patient and say that everything is ok from a surgical perspective.

 

[Vandalia]

I was wondering if these expectations that urology place their own NG tubes holds at the attending level. I guess it's one thing to expect residents to do something at an academic hospital, but what about a private practice urologist?

It is interesting that you raise that question. It is time for a history lesson. Close your eyes and imagine 'Grandpa Simpson' reading this to you.

Decades ago, before many of you were born, I was in the military moonlighting at a civilian ER (as they were called back in those days.) One day I had a patient who needed a foley. After placing as easy a foley as you can imagine, I was accosted by a purple-faced urologist who accused me of "taking money out of his pocket." After some more time there, and seeing some of the medical records, it was clear that everyone consulted everyone for everything. The surgeon would not dream of treating hypertension by himself; if he didn't consult it back to IM, he would never get any referrals himself. Urology incisions routinely generated a consult for surgery to "look at the wound, just in case." A foley was a $20 bill in the urologist's pocket. After talking with my military colleagues who had worked in the civilian world back then, they said this was absolutely the norm. Remember this was way, way before CPT codes, and the Medicare fee schedule. If a physician violated the "shop rules" he would be frozen out by his peers.

So, knowing the training back in those days, I am sure surgeons (as the example here) definitely knew how to do all those procedures, but the nature of private-practice virtually guaranteed that they never did them once they left residency. So the idea hinted at in some of these posts that the "old-school" surgeons managed every aspect of their patient's care is not exactly reality.

 

[ThoracicGuy]

Yea, some people don’t get this. I’m EM and in residency I had a surgical patient who came in with a medical complication from a prescription written by the surgical service at discharge (that probably shouldn’t have been written considering their comorbidities and other medications). I called the surgical service before admitting to medicine and got chewed out by the chief resident about consulting a surgeon for a medical issue. No amount of explaining my point made him understand that 1) it is good from a Med/mal standpoint to get some face time and at least shake the patients hand and apologize because your service caused this problem and 2) if you’re admitting an immediate post-op patient to the hospitalist service, they would like the surgeon to at least see the patient and say that everything is ok from a surgical perspective.

In private practice, you'd never get that type of feedback. If my patient bounces back for any reason, I'd like to know. When I was a resident? My goal was to get the list down and minimize extra work.

 

[cpants]

Agree with this, I frequently hear surgeons being dismissive of for example GI colleagues for calling us for their complications and I've heard "you shouldn't do a procedure if you can't handle it's complications" a hundred times and always thought it was dumb. I can, for the most part, handle the SURGICAL complications of the procedures I do but there are tons of possible complications that I can't really handle. I can't really handle an acute post op STEMI. I can't really handle post op renal failure. I mean I guess in theory I "can" handle something like hemobilia but certainly not in any standard of care way.

Honestly I can't even really handle a major ureter injury. Could I fix it if I was alone and forced to in the middle of the night? Sure, probably but it would suck.

Agreed. This sounded very intelligent to me when I heard it as a med student and intern, but the more medicine I learn, the more I realize it's a silly concept perpetuated by people who want to thump on their own chest. Medicine is so hyper-specialized that if we decided to only do procedures for which we can handle the complications, no one would ever do anything. No one would argue that cardiologists should stop cath'ing STEMIs because they can't may cause a problem that needs a CT or vascular surgeon because everyone understands the value that is brought to the patient when cardiologists perform this procedure. Or an orthopedic surgeon shouldn't operate because they could cause vascular injury. Or an ER docs place a chest tubes but can't do a thoracotomy/VATS in the event of a complication. Trauma surgeon doing a trach which gets stenosed and needs reconstruction. Post-op abdominal surgery gone wrong needs vent management, something an intensivist is best at.

Everyone should just try to achieve the highest level of competence possible for those procedures that are within the perview of their speciality and practice cautiously. The more bravado in medicine, the worse it is for patients.

Agree that bravado is no good for anyone. Also, agree that if the OP didn't know how to place an NG tube, then asking for help was appropriate and the only option.

However, you are equating postop ileus and NG tube placement with managing a STEMI (although you should be able to at least get the ball rolling) or performing a ureteral reconstruction. A more apt comparison would be something like needing to consult ID to manage a postop wound infection or needing to consult surgery to remove a central line.

Obviously, no one should or could be able to manage ANY possible complication. But you are knocking down a straw man. Nobody is arguing that. What I and others are saying is that a urologist/abdominal surgeon should be able to manage ileus and place an NGT tube. This is a common complication which is easy to manage and a basic surgical skill which the surgeon should have mastered during intern year if not medical school.

 

[dpmd]

Agree that bravado is no good for anyone. Also, agree that if the OP didn't know how to place an NG tube, then asking for help was appropriate and the only option.

However, you are equating postop ileus and NG tube placement with managing a STEMI (although you should be able to at least get the ball rolling) or performing a ureteral reconstruction. A more apt comparison would be something like needing to consult ID to manage a postop wound infection or needing to consult surgery to remove a central line.

Obviously, no one should or could be able to manage ANY possible complication. But you are knocking down a straw man. Nobody is arguing that. What I and others are saying is that a urologist/abdominal surgeon should be able to manage ileus and place an NGT tube. This is a common complication which is easy to manage and a basic surgical skill which the surgeon should have mastered during intern year if not medical school.

The same could be argued for gyn, but in practice they call general surgery.

 

[deleted547339]

Agree that bravado is no good for anyone. Also, agree that if the OP didn't know how to place an NG tube, then asking for help was appropriate and the only option.

However, you are equating postop ileus and NG tube placement with managing a STEMI (although you should be able to at least get the ball rolling) or performing a ureteral reconstruction. A more apt comparison would be something like needing to consult ID to manage a postop wound infection or needing to consult surgery to remove a central line.

Obviously, no one should or could be able to manage ANY possible complication. But you are knocking down a straw man. Nobody is arguing that. What I and others are saying is that a urologist/abdominal surgeon should be able to manage ileus and place an NGT tube. This is a common complication which is easy to manage and a basic surgical skill which the surgeon should have mastered during intern year if not medical school.

I don't think it's a straw man. Obviously there are different levels of complications that require different level of expertise, but I've heard MANY surgeons tell me MANY times that I shouldn't do <insert x/y/z procedure that falls within the purview of my specialty> because I can't handle the complication.

 

[vhawk]

Agree that bravado is no good for anyone. Also, agree that if the OP didn't know how to place an NG tube, then asking for help was appropriate and the only option.

However, you are equating postop ileus and NG tube placement with managing a STEMI (although you should be able to at least get the ball rolling) or performing a ureteral reconstruction. A more apt comparison would be something like needing to consult ID to manage a postop wound infection or needing to consult surgery to remove a central line.

Obviously, no one should or could be able to manage ANY possible complication. But you are knocking down a straw man. Nobody is arguing that. What I and others are saying is that a urologist/abdominal surgeon should be able to manage ileus and place an NGT tube. This is a common complication which is easy to manage and a basic surgical skill which the surgeon should have mastered during intern year if not medical school.

I don't really disagree with you and I wasn't trying to knock down a strawman I was knocking down an aphorism that is overly broad and is perhaps a strawman of its own making.

But a reductionist way of rephrasing YOUR point is something like "you should be able to manage the complications that you should be able to manage." True but more truism. The whole point then is where you draw the line. The guys I was calling dumb draw the line at "all complications." That's clearly wrong. The private guys in the anecdote above draw the line at "no complications." Also clearly wrong. The OP made the thread because he was rudely confronted with the fact that the line that seems obvious to him was in fact not obvious to those around you.

It would be interesting to see if we could come to some sort of consensus on what the correct line should be, or if failing that, at least some agreement on a strategy for finding such a line or defending it

 

[DrfluffyMD]

I don't really disagree with you and I wasn't trying to knock down a strawman I was knocking down an aphorism that is overly broad and is perhaps a strawman of its own making.

But a reductionist way of rephrasing YOUR point is something like "you should be able to manage the complications that you should be able to manage." True but more truism. The whole point then is where you draw the line. The guys I was calling dumb draw the line at "all complications." That's clearly wrong. The private guys in the anecdote above draw the line at "no complications." Also clearly wrong. The OP made the thread because he was rudely confronted with the fact that the line that seems obvious to him was in fact not obvious to those around you.

It would be interesting to see if we could come to some sort of consensus on what the correct line should be, or if failing that, at least some agreement on a strategy for finding such a line or defending it

I think the line would be what you would be reasonably expected to do in an internship/residency.

For example, say I am supervising a IR g tube placement as an attending. My resident made a 3 inch superficial incision when 1 inch is needed

I clearly would not consult surgery. In fact, I would probably have him/her close the unnecessary superficial incision.

Say this resident somehow manage to expose the peritoneal cavity, then I would call a surgeon to close because I have never been trained to close such a deep incision.

The gray area arises when say, the resident nicked a superficial epigastric artery somehow. I suppose I can embolize the vessel But vascular surgery can also do that or do a repair. I think those gray areas are what I still have to learn as a trainee and may be determined by local politics such as how friendly departments are with each other.

 

[dpmd]

I think the line would be what you would be reasonably expected to do in an internship/residency.

For example, say I am supervising a IR g tube placement as an attending. My resident made a 3 inch superficial incision when 1 inch is needed

I clearly would not consult surgery. In fact, I would probably have him/her close the unnecessary superficial incision.

Say this resident somehow manage to expose the peritoneal cavity, then I would call a surgeon to close because I have never been trained to close such a deep incision.

The gray area arises when say, the resident nicked a superficial epigastric artery somehow. I suppose I can embolize the vessel But vascular surgery can also do that or do a repair. I think those gray areas are what I still have to learn as a trainee and may be determined by local politics such as how friendly departments are with each other.

Except things vary greatly by training location and include things that don't make sense everywhere.

 

[ThoracicGuy]

I think the line would be what you would be reasonably expected to do in an internship/residency.

For example, say I am supervising a IR g tube placement as an attending. My resident made a 3 inch superficial incision when 1 inch is needed

I clearly would not consult surgery. In fact, I would probably have him/her close the unnecessary superficial incision.

Say this resident somehow manage to expose the peritoneal cavity, then I would call a surgeon to close because I have never been trained to close such a deep incision.

The gray area arises when say, the resident nicked a superficial epigastric artery somehow. I suppose I can embolize the vessel But vascular surgery can also do that or do a repair. I think those gray areas are what I still have to learn as a trainee and may be determined by local politics such as how friendly departments are with each other.

Why would vascular ever want to repair a superficial epigastric artery? They would tie it off or you could coil it if holding pressure doesn't stop the bleeding.

 

[DrfluffyMD]

Why would vascular ever want to repair a superficial epigastric artery? They would tie it off or you could coil it if holding pressure doesn't stop the bleeding.

I am not familiar with management of those type of injuries because they are very rare and I haven’t started fellowship yet. Lack of knowledge can also contribute to overconsult as seen here.

 

[Jolie South]

Why would vascular ever want to repair a superficial epigastric artery? They would tie it off or you could coil it if holding pressure doesn't stop the bleeding.

Good ole 3-0 silk can fix dis.

 

[ThoracicGuy]

I am not familiar with management of those type of injuries because they are very rare and I haven’t started fellowship yet. Lack of knowledge can also contribute to overconsult as seen here.

If a blood vessel is not essential, it's not likely to be repaired.

 

[LucidSplash]

I am not familiar with management of those type of injuries because they are very rare and I haven’t started fellowship yet. Lack of knowledge can also contribute to overconsult as seen here.

For knowledge sake, other things that do not need a vascular consult:

-frostbite (the never ending consults for such that I never imagined when I was a resident in the south)
-liver tumors (even if radiology describes them as “highly vascularized” in their read)
-intracranial tumors (even if radiology describes them as “highly vascularized” in their read)
-patients with “cold feet” but also palpable pulses and no foot or leg pain/numbness (please don’t transfer your patients with COPD exacerbation and PNA 3 hours away to Mecca medical center for this. Give them socks.)
-carotid stenosis at the skull base/intracranially (maybe neurosurg instead if you’re at a place where they get fancy)

 

[ThoracicGuy]

For knowledge sake, other things that do not need a vascular consult:

-frostbite (the never ending consults for such that I never imagined when I was a resident in the south)
-liver tumors (even if radiology describes them as “highly vascularized” in their read)
-intracranial tumors (even if radiology describes them as “highly vascularized” in their read)
-patients with “cold feet” but also palpable pulses and no foot or leg pain/numbness (please don’t transfer your patients with COPD exacerbation and PNA 3 hours away to Mecca medical center for this. Give them socks.)
-carotid stenosis at the skull base/intracranially (maybe neurosurg instead if you’re at a place where they get fancy)

-intramuscular hematomas
-portal vein problems

 

[Winged Scapula]

For knowledge sake, other things that do not need a vascular consult:

-frostbite (the never ending consults for such that I never imagined when I was a resident in the south)
-liver tumors (even if radiology describes them as “highly vascularized” in their read)
-intracranial tumors (even if radiology describes them as “highly vascularized” in their read)
-patients with “cold feet” but also palpable pulses and no foot or leg pain/numbness (please don’t transfer your patients with COPD exacerbation and PNA 3 hours away to Mecca medical center for this. Give them socks.)
-carotid stenosis at the skull base/intracranially (maybe neurosurg instead if you’re at a place where they get fancy)

I lold over your Facebook post and the “acute sock deficiency“

 

[vhawk]

I am not familiar with management of those type of injuries because they are very rare and I haven’t started fellowship yet. Lack of knowledge can also contribute to overconsult as seen here.

Oh man I wish it were rare for me to injure an epigastric! If it happens to you just call me I know at least 5 ways to fix it, and 3 of them even work (usually)

I've put a half dozen ports through the epigastric, I've put drains through it, I've put the suture passer through it, I've put an 11 blade through it. I've injured it open, I've injured it lap, I've injured it robotic. I've clipped it, I've sutured it, I've coiled it (that one was less fun) I've held pressure on it, I've watched it turn into a baseball sized hematoma and eventually tamponade. I've transfused prbcs for it I've transfused ffp for it I've given vitamin k for it.

You'd think eventually I'd just learn to avoid it

 

[dpmd]

Oh man I wish it were rare for me to injure an epigastric! If it happens to you just call me I know at least 5 ways to fix it, and 3 of them even work (usually)

I've put a half dozen ports through the epigastric, I've put drains through it, I've put the suture passer through it, I've put an 11 blade through it. I've injured it open, I've injured it lap, I've injured it robotic. I've clipped it, I've sutured it, I've coiled it (that one was less fun) I've held pressure on it, I've watched it turn into a baseball sized hematoma and eventually tamponade. I've transfused prbcs for it I've transfused ffp for it I've given vitamin k for it.

You'd think eventually I'd just learn to avoid it

Don't you love it when it decompresses into the peritoneal cavity so you have to go back and look for bleeding but by that time it has stopped so you just spend forever trying to suck out clot?

It really is positioned poorly for where we like our ports to go.

 

[vhawk]

Don't you love it when it decompresses into the peritoneal cavity so you have to go back and look for bleeding but by that time it has stopped so you just spend forever trying to suck out clot?

It really is positioned poorly for where we like our ports to go.

My favorite was when, as a pgy3, I was taking an intern through an appy at like 2am. My attending was literally asleep in the corner of the room. It was a chipshot and I think from incision to closing it was like 21 minutes or something, so I've got the suture passer closing up the 12 port site in LLQ, and I put it through to grab the suture, look over my shoulder and say "hey Dr. So-and-so, 20 minutes with an intern helping me, pretty great huh?" This wakes him from his slumber and he replies "that's pretty good but is there a reason the abdomen is filling up with blood?" I quickly look back at the monitor and that sumbitch is literally fire-hosing into the abdomen. Of course I literally have the solution ALREADY IN PLACE as I've put the fascial closure stitch in and all I have to do is pull up on it. But what do I ACTUALLY do? I panic and pull everything out, suture passer, suture and all. Dr so-and-so says "well...that was dumb. Ligate it again."

Needless to say my interns awe of my surgical skill took a modest hit

 

[mimelim]

For knowledge sake, other things that do not need a vascular consult:

-frostbite (the never ending consults for such that I never imagined when I was a resident in the south)
-liver tumors (even if radiology describes them as “highly vascularized” in their read)
-intracranial tumors (even if radiology describes them as “highly vascularized” in their read)
-patients with “cold feet” but also palpable pulses and no foot or leg pain/numbness (please don’t transfer your patients with COPD exacerbation and PNA 3 hours away to Mecca medical center for this. Give them socks.)
-carotid stenosis at the skull base/intracranially (maybe neurosurg instead if you’re at a place where they get fancy)

"We have a consult for you, it is a bleeding tunneled dialysis catheter."
"Who put the catheter in?"
"Interventional radiology
"Have you let them know that their patient is bleeding?"
"But the patient is bleeding, so we called vascular surgery."

After 10 or so of these identical conversations a junior resident got pissed and reported the phenomenon to the state medical board for patient abandonment. It didn't end well for really anyone, but it was a great, "you did what?!?!" at a morning report.

 

[mikeGR]

My favorite was when, as a pgy3, I was taking an intern through an appy at like 2am. My attending was literally asleep in the corner of the room. It was a chipshot and I think from incision to closing it was like 21 minutes or something, so I've got the suture passer closing up the 12 port site in LLQ, and I put it through to grab the suture, look over my shoulder and say "hey Dr. So-and-so, 20 minutes with an intern helping me, pretty great huh?" This wakes him from his slumber and he replies "that's pretty good but is there a reason the abdomen is filling up with blood?" I quickly look back at the monitor and that sumbitch is literally fire-hosing into the abdomen. Of course I literally have the solution ALREADY IN PLACE as I've put the fascial closure stitch in and all I have to do is pull up on it. But what do I ACTUALLY do? I panic and pull everything out, suture passer, suture and all. Dr so-and-so says "well...that was dumb. Ligate it again."

Needless to say my interns awe of my surgical skill took a modest hit

Also (off topic), who places a 12mm LLQ port for an appy?

 

[dpmd]

Also (off topic), who places a 12mm LLQ port for an appy?

They must like putting the stapler in through there instead of the umbilicus?

 

[vhawk]

Also (off topic), who places a 12mm LLQ port for an appy?

Thats how we did them. 5mm Veress at umbo, 5mm port suprapubic, 12 in the LLQ (really more or less at level of umbo) for the stapler. The angle from that port is usually much better for the stapler. I've done it lots of ways, but thats the way we did it in residency.

 

[Apollyon]

For knowledge sake, other things that do not need a vascular consult:

-frostbite (the never ending consults for such that I never imagined when I was a resident in the south)
-liver tumors (even if radiology describes them as “highly vascularized” in their read)
-intracranial tumors (even if radiology describes them as “highly vascularized” in their read)
-patients with “cold feet” but also palpable pulses and no foot or leg pain/numbness (please don’t transfer your patients with COPD exacerbation and PNA 3 hours away to Mecca medical center for this. Give them socks.)
-carotid stenosis at the skull base/intracranially (maybe neurosurg instead if you’re at a place where they get fancy)

Gas expands to fill the space available. You're there, so you get the call from timid academic EM attendings and hapless residents. The closest vascular surgeons to me are ~100 miles away. I gotta be a LOT more sanguine with whom I send them.

 

[mikeGR]

Thats how we did them. 5mm Veress at umbo, 5mm port suprapubic, 12 in the LLQ (really more or less at level of umbo) for the stapler. The angle from that port is usually much better for the stapler. I've done it lots of ways, but thats the way we did it in residency.

Interesting. It prob also has a lower risk for an incisional hernia in the future.

 

[LucidSplash]

Gas expands to fill the space available. You're there, so you get the call from timid academic EM attendings and hapless residents. The closest vascular surgeons to me are ~100 miles away. I gotta be a LOT more sanguine with whom I send them.

That’s why I said “for knowledge sake” in response to the guy who said lack of knowledge lead to over consult.

 

[SLUser11]

Also (off topic), who places a 12mm LLQ port for an appy?

I did, historically...don't take out an appendix anymore unless it has cancer, or is simply attached to the right colon.

LLQ 12mm port for stapling, is faster overall, and has a lower hernia rate compared to 12mm at the midline. I had a few friends over the years who would dissect with the suprapubic and LLQ ports, camera at umbilicus, then switch to a smaller camera for the LLQ port and staple from umbilicus...I always thought it was an unnecessary extra step, and additionally you dissect from one angle and then staple from another, which seems silly.

LLQ stapling can be ultra-fast if you get the cadence down, surgeries less than 10 minutes skin-to-skin.

 

[dpmd]

I did, historically...don't take out an appendix anymore unless it has cancer, or is simply attached to the right colon.

LLQ 12mm port for stapling, is faster overall, and has a lower hernia rate compared to 12mm at the midline. I had a few friends over the years who would dissect with the suprapubic and LLQ ports, camera at umbilicus, then switch to a smaller camera for the LLQ port and staple from umbilicus...I always thought it was an unnecessary extra step, and additionally you dissect from one angle and then staple from another, which seems silly.

LLQ stapling can be ultra-fast if you get the cadence down, surgeries less than 10 minutes skin-to-skin.

Or you can switch to a 5mm camera at the LLQ right at the start and do all the dissecting and stapling from the same place with a little more freedom of movement if it isn't the easy hold the appy starting right at you up and fire a stapler across kind of case. Is the hernia rate differential based on people closing fascia or leaving it open like gyn and other folks do?

 

[vhawk]

I just use a 5/30 for the whole case, put it through the umbo port, and do the dissection through suprapubic and LLQ. That way the stapler is the exact same angle as the Maryland. No switching or anything.

Honestly I rarely use anything other than the 5/30. It's wasteful to open more than one scope and in case I need to move around the 5/30 fits anywhere. The image quality is definitely a bit worse but almost never enough that it is a dealbreaker. Only time I open two scopes is when using optical trochar since I cannot stand using a 0 degree for anything

 

[dpmd]

I just use a 5/30 for the whole case, put it through the umbo port, and do the dissection through suprapubic and LLQ. That way the stapler is the exact same angle as the Maryland. No switching or anything.

Honestly I rarely use anything other than the 5/30. It's wasteful to open more than one scope and in case I need to move around the 5/30 fits anywhere. The image quality is definitely a bit worse but almost never enough that it is a dealbreaker. Only time I open two scopes is when using optical trochar since I cannot stand using a 0 degree for anything

I think I learned to put the LLQ port much lower than you guys which is great for hiding under a bikini but makes the dissection less easy than using the umbi and suprapubic ports for me at least. But different stuff works for different folks. We have one attending who taught us "south African style" with a right sided port instead of left and I hated it with a passion but he does a nice quick appy with it.