Consults- Memorable/Dismal/Ridiculous/Unique

[dpmd]

Dude, as a non-surgeon, I can’t thank you enough for this. I’m EM/CCM and sometimes a family just doesn’t want to hear from anyone other than the surgeon that dying with a surgery is a worse option than dying without it. I actually really enjoy palliative care and am fairly aggressive with my goals of care conversations, but sometimes it just takes the surgeon or just a second, unbiased doctor. Thank you for this. I know these consults suck, but they help immensely. And having people who understand the importance of them and don’t give me crap for them is great. Thanks.

It helps if the crepe has already been laid. Unfortunately not everyone is as on board with palliative care conversation (or I suppose they might just not realize that the person is moribund)

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[mimelim]

Patient supposed to get an angio by a private IR guy for left leg wound.
Pre-op labs show Hgb of 6, so patient is sent to ER.
Patient gets transfusion and arterial duplex study.

Consult to vascular surgery. "We have a patient with a foot wound."
Any studies?
Yes, it says normal study with toe pressures in the 70s.
Can you feel the pulses in their feet?
Yes.
What is the consult for again?
Leg wound.
In a patient without vascular disease?
Yes, but the patient has a leg wound.
And the patient has someone addressing their leg wound and doing an arteriogram on them as an outpatient 2 days from now?

STOP ASKING QUESTIONS AND GO SEE THE ****ING CONSULT (vascular fellow listening to the conversation on the speakerphone of the junior resident)


I'm not sure who I am shaking my head at for more... The IR doc doing a non-indicated procedure, the IM guy calling a clearly unnecessary consult, the junior resident playing 20 questions and wasting their own time or the fellow who screamed profanity while a referring doctor was on the phone.

 

[Jolie South]

Who does this!?!? The only scenario I can see this making sense is if you diagnose a new breast cancer as an inpatient and the patient is going to be hospitalized for a very long time for another reason which would be an exceedingly rare occurance....even then, that’s a stretch. In the ER, I’ve made a call to an oncologist and begged them to see an uninsured patient, but what good does a consult in the ER do....you gonna start giving chemo in the waiting room after discharge???

On behalf of my specialty, I apologize for this nonsense.

Worse was when I would have to go through the whole “really, this is a consult?” with the ER then relive it all over with the attending.

 

[Wordead]

Sterilization is not just any procedure. I can't think any anything the PCP would need to screen for aside from does this person have testicles and do they want to be sterilized. But even that is a conversation the urologist is going to have to have with the patient anyway (well not the testicle part-that becomes evident on exam). Unless I am confused and VA was asking for an appointment for the actual procedure rather than the consult regarding the procedure in which case I agree that is inappropriate.

Right but where do you draw the line for a procedure? What if a patient wants his tonsils out - should he just come to me even though he meets no indication for them to be out? Wasting everyones time and money in the process? Not to mention if they're old, ton of comorbidities, on anticoagulation, etc, the PCP should be seeing them for preop anyway. So why not require a PCP referral? Then all the ducks can be in a row and patient can be scheduled for the procedure. Safer for everyone.

 

[dpmd]

Right but where do you draw the line for a procedure? What if a patient wants his tonsils out - should he just come to me even though he meets no indication for them to be out? Wasting everyones time and money in the process? Not to mention if they're old, ton of comorbidities, on anticoagulation, etc, the PCP should be seeing them for preop anyway. So why not require a PCP referral? Then all the ducks can be in a row and patient can be scheduled for the procedure. Safer for everyone.

There is no indication for sterilization other than not wanting to have kids. That is why I consider it separate (as I would for a female looking to discuss tubal ligation). The appointment is just for a consult. If the patient is too old, infirm, or whatever, the urologist can advise then of that and decide that it shouldn't proceed, can proceed if certain things are done (like stopping anticoagulation for x amount of time), or can proceed only with PCP ok after whatever workup/management is required. I often get people referred from pcp's that still require PCP tune up (my favorite is the uncontrolled diabetic with some exceedingly elective issue). I consider it a win of the PCP has identified the problem and has referred to the right specialty. Since fertility is a self identified problem and there is only one specialty for each gender that wants to stop it there isn't anything else I expect the PCP to do.

 

[cpants]

Right but where do you draw the line for a procedure? What if a patient wants his tonsils out - should he just come to me even though he meets no indication for them to be out? Wasting everyones time and money in the process? Not to mention if they're old, ton of comorbidities, on anticoagulation, etc, the PCP should be seeing them for preop anyway. So why not require a PCP referral? Then all the ducks can be in a row and patient can be scheduled for the procedure. Safer for everyone.

Yea I can't remember ever getting preop clearance on a vasectomy. They are generally in the 25-45 range and healthy. It's done under local in the office. A referral is wholly unnecessary for a vasectomy consult, but in offices where this happens it is likely due to a blanket policy and/or wanting to be able to slightly upcharge for a "consult" visit instead of a "new patient" visit.

 

[VA Hopeful Dr]

So you think people should be able to self refer themselves for any procedure they want or differentiate which procedures should be seen by a PCP first? Does a layman know the contraindications for anything? I assumed you mentioned you were a doctor because to think that a busy urologist should be able to see any joe off the street - well, I gave you too much credit I suppose. Maybe in a new practice that's fine but it seems more than reasonable to have a PCP screen and refer. Not sure why you'd think otherwise - isn't that the whole benefit of your job? People getting centralized care that's coordinated by one PCP?

Oh my God, it's a goddamned vasectomy. As a PCP I don't need to be involved in that. The only reason one of my patients should come to me before getting a vasectomy is if they want to know who I think is good at it. That should be the extent of it.

Seems the other office in town agrees with me too.

 

[dpmd]

Oh my God, it's a goddamned vasectomy. As a PCP I don't need to be involved in that. The only reason one of my patients should come to me before getting a vasectomy is if they want to know who I think is good at it. That should be the extent of it.

Seems the other office in town agrees with me too.

Or the insurance thing if that is a legitimate issue.

 

[Raryn]

Oh my God, it's a goddamned vasectomy. As a PCP I don't need to be involved in that. The only reason one of my patients should come to me before getting a vasectomy is if they want to know who I think is good at it. That should be the extent of it.

Seems the other office in town agrees with me too.

Shrug.

If I need a referral for something I send a message to my PCP and he fills one out and faxes it. Takes a minute. It's not that much of a hardship to call yours just to make sure the visit is covered by insurance.

 

[VA Hopeful Dr]

Shrug.

If I need a referral for something I send a message to my PCP and he fills one out and faxes it. Takes a minute. It's not that much of a hardship to call yours just to make sure the visit is covered by insurance.

Don't have one yet. We moved a few months ago and since I am a PCP (and otherwise healthy) it's pretty low on my priority list.

 

[VA Hopeful Dr]

Or the insurance thing if that is a legitimate issue.

And if that's the only reason I'm OK with that.

 

[dpmd]

Don't have one yet. We moved a few months ago and since I am a PCP (and otherwise healthy) it's pretty low on my priority list.

Well, if you had an hmo plan that is the usual kind that require a referral you would have been assigned one, though I guess it would be reasonable for them to balk at referring someone they had never seen even if it was just for vasectomy.

 

[Gastrapathy]

Enough! I cringe every time I see the word vasectomy. I wasn’t what you might call a “good” patient or a “compliant” patient or anything other than a “dip****.” I did 10 procedures afterwords before going home. That wasn’t a good weekend.

The urologist who did it is a few doors down, he tells the story too often to scare others.

 

[Winged Scapula]

Omg, inpatient or ER breast cancer consults are the worst.

Like I appreciate the fact that this lady is uninsured and concerned but literally I couldn’t get her a mammogram from the ER if I tried.

I get those from time to time.

Most of the time the consult is reasonable in that they don’t expect me to come and see the patient because surprisingly they're usually presenting for something unrelated to their fungating breast cancer.

The oncologist are pretty good at letting me know that they’ll consult me only for the uninsured patient while they’re in house so I’ll get paid for the biopsy rather than sending them to my office where I won’t. The problem I usually have is with the new hospitalist who don’t understand that getting an outpatient study like a mammogram is not going to be done because the hospital won’t be paid and that sending an uninsured patient to my office for evaluation is not in their best interest unless they have cash to pay. If the oncologist get to the patient first they’ll usually sort these things out for me and I don’t need to get involved.

 

[armybound]

Enough! I cringe every time I see the word vasectomy. I wasn’t what you might call a “good” patient or a “compliant” patient or anything other than a “dip****.” I did 10 procedures afterwords before going home. That wasn’t a good weekend.

The urologist who did it is a few doors down, he tells the story too often to scare others.

I tried to scrub in to a ureteroscopy right after my vasectomy. I was on valium. Thankfully my attending (who was staffing the ureteroscopy and who had just done my vasectomy) told me I was an idiot and to go away.

 

[cpants]

I tried to scrub in to a ureteroscopy right after my vasectomy. I was on valium. Thankfully my attending (who was staffing the ureteroscopy and who had just done my vasectomy) told me I was an idiot and to go away.

Seriously? You didn't know you shouldn't be operating with Valium on board.......??

 

[Dr.LeoSpaceman]

This one goes out to @Pir8DeacDoc

Elective OR patient today has a chronic uncuffed trach for a proximal stenosis. Anesthesia makes us consult ENT (who has to come from another site down the street) to change the trach to a cuffed trach. I was dumbfounded. I tried to convince them to give me a trach and turn their heads in preop to no avail.

 

[dpmd]

This one goes out to @Pir8DeacDoc

Elective OR patient today has a chronic uncuffed trach for a proximal stenosis. Anesthesia makes us consult ENT (who has to come from another site down the street) to change the trach to a cuffed trach. I was dumbfounded. I tried to convince them to give me a trach and turn their heads in preop to no avail.

Like the stenosis is above where the trach is, or the trach acts like a stent for the stenosis? I can see being more worried about things in the second case (but just enough to change it over a bougie or something)

 

[Pir8DeacDoc]

This one goes out to @Pir8DeacDoc

Elective OR patient today has a chronic uncuffed trach for a proximal stenosis. Anesthesia makes us consult ENT (who has to come from another site down the street) to change the trach to a cuffed trach. I was dumbfounded. I tried to convince them to give me a trach and turn their heads in preop to no avail.

Oh wow..that's a good one. So general surgery nor anesthesia are qualified to change out a chronic trach to a slightly different one? Or better still, just place an endotracheal tube into the hole. Easiest airway they'll have all day.
Man, it's like everyone loses their mind the minute a patient has a trach. But I appreciate that you at least put up some resistance.

 

[armybound]

Seriously? You didn't know you shouldn't be operating with Valium on board.......??

Turns out your judgment is slightly impaired on valium. I also sent a snapchat of my incision/balls to the other residents.

 

[cpants]

Oh wow..that's a good one. So general surgery nor anesthesia are qualified to change out a chronic trach to a slightly different one? Or better still, just place an endotracheal tube into the hole. Easiest airway they'll have all day.
Man, it's like everyone loses their mind the minute a patient has a trach. But I appreciate that you at least put up some resistance.

I have noted similar panic with regard to SP tubes.

 

[Psai]

Turns out your judgment is slightly impaired on valium. I also sent a snapchat of my incision/balls to the other residents.

Were they impressed

 

[startswithb]

I have noted similar panic with regard to SP tubes.

Consult to urology "has SPT, recs for management."

Do nothing. Just let it drain. Or ask the nurses. It'll be OK, medicine intern!

 

[startswithb]

My favorite so far:
EM resident rotating through SICU "17 year old male with priapism."
Me "Priapism or an erection? How long has it lasted? Is it rock hard?"
"Well, the nurses said since last night. It's actually not that hard."
"Is he complaining of pain?"
"No."
"Ok, we'll send someone down."
MS4 rotating in urology, "It's pretty hard but I don't know if it's priapism."
Ok. I go down there and talk to the nurse who says, "it became erect after foley placement but now it's down." Agreed.

"Normal physiologic erection due to stimulation from foley placement. Resolved. No evidence of priapism. Urology to sign off."

Every erection in the hospital is priapism I guess.

 

[Psai]

My favorite so far:
EM resident rotating through SICU "17 year old male with priapism."
Me "Priapism or an erection? How long has it lasted? Is it rock hard?"
"Well, the nurses said since last night. It's actually not that hard."
"Is he complaining of pain?"
"No."
"Ok, we'll send someone down."
MS4 rotating in urology, "It's pretty hard but I don't know if it's priapism."
Ok. I go down there and talk to the nurse who says, "it became erect after foley placement but now it's down." Agreed.

"Normal physiologic erection due to stimulation from foley placement. Resolved. No evidence of priapism. Urology to sign off."

Every erection in the hospital is priapism I guess.

How attractive was this ms4

 

[Arcan57]

I get those from time to time.

Most of the time the consult is reasonable in that they don’t expect me to come and see the patient because surprisingly they're usually presenting for something unrelated to their fungating breast cancer.

The oncologist are pretty good at letting me know that they’ll consult me only for the uninsured patient while they’re in house so I’ll get paid for the biopsy rather than sending them to my office where I won’t. The problem I usually have is with the new hospitalist who don’t understand that getting an outpatient study like a mammogram is not going to be done because the hospital won’t be paid and that sending an uninsured patient to my office for evaluation is not in their best interest unless they have cash to pay. If the oncologist get to the patient first they’ll usually sort these things out for me and I don’t need to get involved.

From the ED side it can be tough because we have little to no idea how to navigate getting an outpt cancer workup in a patient without resources. We realize that there aren't any magic fixes available but it seems almost morally wrong to tell a patient with the kind of cancer an ED doc can diagnosis with the naked eye to start cold-calling overwhelmed public health resources that are going to be offering appointment 2-3 months away to get further evaluated. So I call up the surgeon and ask if they can see the patient in clinic (not ED). The surgeon invariably says yes. The surgeon's office staff then tell the patient to F%^# off when they don't have the $500 cash for initial eval and the patient represents to the ED when it's convenient for them (usually late at night on a weekend when the next social worker available to the ED is >12hrs away). And the circle of life continues.

 

[Arcan57]

My favorite so far:
EM resident rotating through SICU "17 year old male with priapism."
Me "Priapism or an erection? How long has it lasted? Is it rock hard?"
"Well, the nurses said since last night. It's actually not that hard."
"Is he complaining of pain?"
"No."
"Ok, we'll send someone down."
MS4 rotating in urology, "It's pretty hard but I don't know if it's priapism."
Ok. I go down there and talk to the nurse who says, "it became erect after foley placement but now it's down." Agreed.

"Normal physiologic erection due to stimulation from foley placement. Resolved. No evidence of priapism. Urology to sign off."

Every erection in the hospital is priapism I guess.

Favorite consultant line that was actually part of the official medical record:
"If it's bendable, it's not priapism"

Teenager with sickle cell disease that would self-stimulate in order to wheedle more narcs out of the hematologists pending uro consult.

 

[dr zaius]

Turns out your judgment is slightly impaired on valium. I also sent a snapchat of my incision/balls to the other residents.

A real urologist does his own vas.

(I know of 2 residents and an attending that did their own)

 

[mimelim]

2am medicine resident - Patient has chest pain. I took their blood pressure in both arms and the right is 210, the left is 180, do you want to have someone see the patient, I'm worried about the patient having an aortic dissection, I can get a CTA.
mimelim - What else is going on?
2am medicine resident - I don't know, we just got the admission, they had heart surgery at some point.
mimelim - What kind and when?
2am medicine resident - I'm not sure.
mimelim - Where was it done?
2am medicine resident - Here.
mimelim - Is the EMR working?
2am medicine resident - Yes, why?
mimelim - Maybe they wrote something down after doing surgery.

 

[cpants]

My favorite so far:
EM resident rotating through SICU "17 year old male with priapism."
Me "Priapism or an erection? How long has it lasted? Is it rock hard?"
"Well, the nurses said since last night. It's actually not that hard."
"Is he complaining of pain?"
"No."
"Ok, we'll send someone down."
MS4 rotating in urology, "It's pretty hard but I don't know if it's priapism."
Ok. I go down there and talk to the nurse who says, "it became erect after foley placement but now it's down." Agreed.

"Normal physiologic erection due to stimulation from foley placement. Resolved. No evidence of priapism. Urology to sign off."

Every erection in the hospital is priapism I guess.

Once had urgent consult to the cath lab for priapism when I was a resident.

"How long has the patient had an erection?"
"15 minutes"
"OK. That's not a concern. Call me if it's still hard in 3 hours 45 minutes."
"Dr. Smith is extremely concerned. He insists you come down right now to evaluate the patient or he is calling your attending."
"Tell him to call my attending."

Never heard back.

 

[vhawk]

2am medicine resident - Patient has chest pain. I took their blood pressure in both arms and the right is 210, the left is 180, do you want to have someone see the patient, I'm worried about the patient having an aortic dissection, I can get a CTA.
mimelim - What else is going on?
2am medicine resident - I don't know, we just got the admission, they had heart surgery at some point.
mimelim - What kind and when?
2am medicine resident - I'm not sure.
mimelim - Where was it done?
2am medicine resident - Here.
mimelim - Is the EMR working?
2am medicine resident - Yes, why?
mimelim - Maybe they wrote something down after doing surgery.

def stealing that last line

 

[OrthoTraumaMD]

I get this kind of consult often:

Me: (2am) “Hello?”
Transfer center: “This patient is in the ER at (our satellite hospital), he had orthopaedic surgery by dr X at (outside unrelated hospital) yesterday. He has a splint on his arm and it hurts. Do you want the ER to remove it? Should they transfer the patient to (my hospital)?”
Me: (biting back curses) “Did they, oh, I don’t know, try calling Dr X, the actual surgeon who operated on the patient?”
Transfer center: “well no, cause it’s after hours.”
Me: ........


Sent from my iPhone using SDN mobile

 

[vhawk]

I was on general surgery call and got this consult over the weekend.

Transfer center: we have Dr hospitalist on the line to discuss a transfer
Me: ok sounds good
DH: we have a guy with acute cholecystitis who we need to transfer. Our surgeon saw him and booked him for lap chole but anesthesia refuses due to bleeding risk so he needs to be transferred.
Me: hmmmm ok. Why is he such a bleeding risk?
DH: well his bili is 12. He has a palpable gallbladder. But otherwise he is fine, white count normal, no fevers
Me:
Me: yeah ok send him over

In case that's not obvious, dude has (unresectable) pancreas cancer. Incidentally he has child's b cirrhosis from hep c as well. What he don't have is acute cholecystitis. Anesthesia to the rescue for this guy. Would have likely been an absolute ****show chole which would have helped this guy 0%

I was like one sentence into trying to explain this to this hospitalists when I realized, she isn't my resident, this guy needs to be seen at a bigger center, who cares just say Yes.

 

[evilbooyaa]

I don't get how a bili of 12 makes you a bleeding risk? I mean I get it's a sign of badness in somebody with acute cholecystitis (not even choledocolithiasis!) but how does bili of 12 = bleeding risk?

Anyways, fully agree with the bolded!

I was like one sentence into trying to explain this to this hospitalists when I realized, she isn't my resident, this guy needs to be seen at a bigger center, who cares just say Yes.

 

[Jolie South]

Isn't it moreso that he's a child B cirrhotic?

I would say probably more like secondary to some degree of underlying portal hypertension relating to cirrhosis.

I did lap chole on a patient with undiagnosed hepatic disease. Labs weren’t bad maybe borderline class B. We had plasma on hold for OR.

The moment I peeled that first leaf of peritoneum with a Maryland, jets of bleeding were shooting at the camera. I thought I had hit the hepatic artery or portal vein or something with just the degree of bleeding from these tiny varices. More I touched the more it bled. Anyways, we opened and had a hell of a time controlling the bleeding.

 

[dpmd]

I would say probably more like secondary to some degree of underlying portal hypertension relating to cirrhosis.

I did lap chole on a patient with undiagnosed hepatic disease. Labs weren’t bad maybe borderline class B. We had plasma on hold for OR.

The moment I peeled that first leaf of peritoneum with a Maryland, jets of bleeding were shooting at the camera. I thought I had hit the hepatic artery or portal vein or something with just the degree of bleeding from these tiny varices. More I touched the more it bled. Anyways, we opened and had a hell of a time controlling the bleeding.

This is why I try to never operate on cirrhotics

 

[vhawk]

I don't get how a bili of 12 makes you a bleeding risk? I mean I get it's a sign of badness in somebody with acute cholecystitis (not even choledocolithiasis!) but how does bili of 12 = bleeding risk?

Anyways, fully agree with the bolded!

Think fat-soluble vitamins. Bili of 12 implies long-standing biliary obstruction, which implies vitamin K deficiency. If you check an INR on new panc cancers with bili of 12 you will find it elevated.

The classic teaching is that you only stent new panc cancers is bili is greater than 10, because in that setting just taking them to OR has increased risk of bleeding and infection.

 

[Jolie South]

This is why I try to never operate on cirrhotics

Which is funny because I prepared an M&M on the patient and all the literature was like “just operate” for true cholecystitis.

 

[dpmd]

Which is funny because I prepared an M&M on the patient and all the literature was like “just operate” for true cholecystitis.

Have treated many a cirrhotic for acute chole with just antibiotics and a low fat diet. Might just be the fact we have a lot of high meld people who are not transplant candidates but I learned early on in residency to plug their numbers into the Mayo postop mortality in cirrhotics calculator so I could use things like high expected 7 day mortality when asked for surgical consultation on cirrhotics. Doesn't mean the occasional secret cirrhotic doesn't slip through (basically the child A patient who hadn't received a cirrhosis diagnosis yet) and the known child a would probably be fine to do (haven't had one of these yet). I am just not interested in operating on the ones with 3 times higher (or more) operative mortality when I have seen nonoperative work well for them.

 

[balaguru]

I was on general surgery call and got this consult over the weekend.

Transfer center: we have Dr hospitalist on the line to discuss a transfer
Me: ok sounds good
DH: we have a guy with acute cholecystitis who we need to transfer. Our surgeon saw him and booked him for lap chole but anesthesia refuses due to bleeding risk so he needs to be transferred.
Me: hmmmm ok. Why is he such a bleeding risk?
DH: well his bili is 12. He has a palpable gallbladder. But otherwise he is fine, white count normal, no fevers
Me:
Me: yeah ok send him over

In case that's not obvious, dude has (unresectable) pancreas cancer. Incidentally he has child's b cirrhosis from hep c as well. What he don't have is acute cholecystitis. Anesthesia to the rescue for this guy. Would have likely been an absolute ****show chole which would have helped this guy 0%

I was like one sentence into trying to explain this to this hospitalists when I realized, she isn't my resident, this guy needs to be seen at a bigger center, who cares just say Yes.

I'd like to think I would have been able to pick up that this might have been cancer but if the patient hadn't known he was jaundiced for a while and had a H&P and US consistent with choledocholithiasis I probably would have posted him too.

Throw me in the "just operate" camp with respect to cirrhotic patients. After having done a number of them for both acute chole and even biliary colic my one pearl is to have a low threshold for leaving the back wall of the gallbladder on the liver if you can't find a plane. You can get into some scary bleeding. If you find yourself in that situation, grab the gallbladder with your gasper and push it up onto the source of bleeding while you get the OR ready.

 

[vhawk]

I would consider jaundice to be a relative contraindication for lap chole as a general rule. What is the rationale for thinking that the patient has cholecystitis? There are about the 10 things that could be going on in these patients, and mirizzis is the only one for which lap chole will be the answer, and even in that situation, if they are truly JAUNDICED and not just a mild bili elevation, I'd give serious pause to trying lap chole as your chances of needing cbd repair are not low.

Choledocholithiasis, cholangitis, malignancy, hepatitis, liver failure....All of those can cause sx similar to cholecystitis and none will be made better by lap chole.

 

[balaguru]

I would consider jaundice to be a relative contraindication for lap chole as a general rule. What is the rationale for thinking that the patient has cholecystitis? There are about the 10 things that could be going on in these patients, and mirizzis is the only one for which lap chole will be the answer, and even in that situation, if they are truly JAUNDICED and not just a mild bili elevation, I'd give serious pause to trying lap chole as your chances of needing cbd repair are not low.

Choledocholithiasis, cholangitis, malignancy, hepatitis, liver failure....All of those can cause sx similar to cholecystitis and none will be made better by lap chole.

I can't say that I've even seen a bili of 12 from choledocholithiasis and I would like to think I would have suspected something was up in your patient to cause me to order a CT scan but we will have to agree to disagree about your point regarding jaundice. Jaundice and a bili of 8 is not that uncommon in my practice for choledocho. I was once pretty aggressive about lap CBDE (both with a ureteroscope and then later under just flouro) so I was always taking these patients to the OR first. If the IOC was negative the gallbladder was removed and the patient was discharged the same day. If the IOC was positive then I would attempt to clear the duct which I usually did. If I failed then I removed the gallbladder and ligated the duct with a PDS endoloop leaving a long tail in case I needed to find the stump again and consulted GI postop for ERCP. I once tried to leave the wire in the duct with the tip in the duodenum so that GI would have an easier time cannulating the duct but I found it was pretty hard to keep the wire from falling out. This type of management was to me the most sensible use of resources and mitigation of risk. I have no good reason for why I started just giving these patients to GI for postop ERCP instead of trying to clear the duct myself; however, we have recently had a rash of post-ERCP pancreatitis complications so I might go back to doing lap CBDEs.

I am certainly sensitive to the fact that malignancy is always in the differential with these ER patients. I get some rare or surprising malignancies in my community hospital. Just last week I had my second incidental goblet cell carcinoid of the appendix in the last year.

Also, I don't want to come off as too flippant about gallbladder disease. It's real surgery and 2 of my classmates have already had a CBD injury in their practices. I am not shy about refusing to operate when I am not convinced that a patient's symptoms are due to their gallbladder or temporizing a situation with a C tube to optimize the patient for definitive therapy later.

 

[dpmd]

I can't say that I've even seen a bili of 12 from choledocholithiasis and I would like to think I would have suspected something was up in your patient to cause me to order a CT scan but we will have to agree to disagree about your point regarding jaundice. Jaundice and a bili of 8 is not that uncommon in my practice for choledocho. I was once pretty aggressive about lap CBDE (both with a ureteroscope and then later under just flouro) so I was always taking these patients to the OR first. If the IOC was negative the gallbladder was removed and the patient was discharged the same day. If the IOC was positive then I would attempt to clear the duct which I usually did. If I failed then I removed the gallbladder and ligated the duct with a PDS endoloop leaving a long tail in case I needed to find the stump again and consulted GI postop for ERCP. I once tried to leave the wire in the duct with the tip in the duodenum so that GI would have an easier time cannulating the duct but I found it was pretty hard to keep the wire from falling out. This type of management was to me the most sensible use of resources and mitigation of risk. I have no good reason for why I started just giving these patients to GI for postop ERCP instead of trying to clear the duct myself; however, we have recently had a rash of post-ERCP pancreatitis complications so I might go back to doing lap CBDEs.

I am certainly sensitive to the fact that malignancy is always in the differential with these ER patients. I get some rare or surprising malignancies in my community hospital. Just last week I had my second incidental goblet cell carcinoid of the appendix in the last year.

Also, I don't want to come off as too flippant about gallbladder disease. It's real surgery and 2 of my classmates have already had a CBD injury in their practices. I am not shy about refusing to operate when I am not convinced that a patient's symptoms are due to their gallbladder or temporizing a situation with a C tube to optimize the patient for definitive therapy later.

Why not go for the ercp preop?

 

[balaguru]

Why not go for the ercp preop?

Because if there is only mild elevation of bili or a mildly dilated duct preop to suggest choledocho and the IOC is negative the stone likely passed and you have spared the patient from an unnecessary ERCP. And if the IOC is positive and you clear the duct in the OR then again you have spared the patient an unnecessary ERCP. This usually shaves 1-2 days off their hospital stay not to mention the cost of another procedure and the risks of ERCP. An ERCP can be pretty challenging for the endoscopist. Especially if there is a periampular diverticulum.

I once had a patient develop such severe post-ERCP pancreatitis that he thrombosed his SMV and developed large pseudocysts that appeared to originate from the head of the pancreas because instead of localizing to the lesser sac they grew down the right retroperitoneum and mesentery. I nursed him to discharge which took about 3-4 weeks and knew we would probably have to do something about his pseudocysts. I followed him for several months in clinic then 2 weeks before he was to get insurance so we could a cystjejunostomy he presented to the ER with sepsis from infection of his pseudocysts. I had to emergently debride him. He recovered unexpectedly well and was discharged a week later. His drains were removed several months later and he made a full recovery. The case gave me a whole new appreciation for ERCP's.

 

[vhawk]

I can't say that I've even seen a bili of 12 from choledocholithiasis and I would like to think I would have suspected something was up in your patient to cause me to order a CT scan but we will have to agree to disagree about your point regarding jaundice. Jaundice and a bili of 8 is not that uncommon in my practice for choledocho. I was once pretty aggressive about lap CBDE (both with a ureteroscope and then later under just flouro) so I was always taking these patients to the OR first. If the IOC was negative the gallbladder was removed and the patient was discharged the same day. If the IOC was positive then I would attempt to clear the duct which I usually did. If I failed then I removed the gallbladder and ligated the duct with a PDS endoloop leaving a long tail in case I needed to find the stump again and consulted GI postop for ERCP. I once tried to leave the wire in the duct with the tip in the duodenum so that GI would have an easier time cannulating the duct but I found it was pretty hard to keep the wire from falling out. This type of management was to me the most sensible use of resources and mitigation of risk. I have no good reason for why I started just giving these patients to GI for postop ERCP instead of trying to clear the duct myself; however, we have recently had a rash of post-ERCP pancreatitis complications so I might go back to doing lap CBDEs.

I am certainly sensitive to the fact that malignancy is always in the differential with these ER patients. I get some rare or surprising malignancies in my community hospital. Just last week I had my second incidental goblet cell carcinoid of the appendix in the last year.

Also, I don't want to come off as too flippant about gallbladder disease. It's real surgery and 2 of my classmates have already had a CBD injury in their practices. I am not shy about refusing to operate when I am not convinced that a patient's symptoms are due to their gallbladder or temporizing a situation with a C tube to optimize the patient for definitive therapy later.

Why not go for the ercp preop?

Yeah I guess this is what I had in mind with my comment, more that choledocholithiasis is an endoscopic problem, but if you are facile with lap cbd explorations that's definitely different and makes a lot more sense.

 

[vhawk]

If they aren't sick and you just check their bili the next day you save them an ercp as well

 

[balaguru]

If they aren't sick and you just check their bili the next day you save them an ercp as well

Many of my patients, including gallbladder patients with mildly elevated bili, will go from ER to OR to discharge home from PACU. My office is a 5 minute walk from my main ER and OR and my wife is available to pick up the kids from school if I can't so fitting a short case in during the day isn't hard. Also, even if I admit and recheck the bili and it is coming down I will do an IOC anyway and then the same algorithm above applies.

 

[dpmd]

Yeah I guess this is what I had in mind with my comment, more that choledocholithiasis is an endoscopic problem, but if you are facile with lap cbd explorations that's definitely different and makes a lot more sense.

Yeah, we have no equipment to even try lap cbde. And with the one I assisted with in residency I didn't feel any burning desire to have them buy some since no one else in town does them either. So if they are jaundiced and sick or failing to improve labwise I want gi to ercp them.

 

[balaguru]

Yeah, we have no equipment to even try lap cbde. And with the one I assisted with in residency I didn't feel any burning desire to have them buy some since no one else in town does them either. So if they are jaundiced and sick or failing to improve labwise I want gi to ercp them.

If you ever want to try it under flouro you can raid the urology stock and look for a 6F ureteral catheter, 0.035" hydrophilic wire and 1.9F wire basket. I've had some luck treating small stones in a trans-cystic fashion with just those items. The hydrophilic wire and basket fit through the 6F catheter.

 

[vhawk]

Many of my patients, including gallbladder patients with mildly elevated bili, will go from ER to OR to discharge home from PACU. My office is a 5 minute walk from my main ER and OR and my wife is available to pick up the kids from school if I can't so fitting a short case in during the day isn't hard. Also, even if I admit and recheck the bili and it is coming down I will do an IOC anyway and then the same algorithm above applies.

Fair enough. However, for all the choledocholithiasis you've treated, how many of them are actually JAUNDICED? I'd guess close to zero