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Consults- Memorable/Dismal/Ridiculous/Unique

Discussion in 'Surgery and Surgical Subspecialties' started by surgres88, May 18, 2009.

  1. HighPriest

    HighPriest insert "clever" statement
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    That may be true. I don’t know. I’ve never tapped a joint or done an EM residency. Apparently that ortho doc felt differently.
     
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  3. HighPriest

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    Agree. It’s his call if he wants the extra hassle, and it’s also BS if he can’t remember having had this conversation with you.
     
  4. HighPriest

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    Sure. That also makes sense. It depends upon the situation. Again, as I mentioned above, the availability of the better equipped surgeon plays a role. If the guy was 4 hours away and 4 weeks booked out, that’s a heavy weight towards doing something yourself. If he’s willing to see someone the next morning, that’s another thing. If he’s willing to come in immediately, that’s another thing as well.

    In this example, if the ortho guy was willing to see and tap all of these joints in a reasonable timeframe, then give them to him. If he isn’t, then he’s being unreasonable.

    As I said, things should be referred to the most skilled person, so long as that person is reasonably available.

    Consider the FB in the nose that I mentioned. I will always see those kids immediately (during business hours) or first thing in the morning (0730 or as soon as the parents can get there). That is very safe and certainly less dangerous and uncomfortable for the patient than being held down in an ER by three RNs while a PA digs around through a puddle of blood and snot for 20 minutes before they send them to me anyway.

    If I couldn’t see them for two weeks? Well, that’s a different story.
     
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  5. tkim

    tkim 10 cc's cordrazine
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    What I think it came down to for this particular ortho was the time that I called. Always seems to be about 3am. Anecdotally seems to me that that's when people can wait until the morning, be discharged with close followup, or admitted to someone else's service. I try hard to keep consultants in bed, and when the hospitalist insists on 'making sure XXXX service is on board before admitting' on the overnight I wait until 6am to make those calls, even if I have to wait after my shift for them to call back. I've brokered some good will with this tactic so when I call ... at 3am, and say "I need you to come in now", they come in a little less grumbly than perhaps otherwise.
     
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  6. HighPriest

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    And I certainly appreciate that sentiment from my ER colleagues. I suppose my point is that there are things that are clearly within a scope of practice where there’s really no benefit to sending a patient elsewhere. There are things that are in between. There are things that really would benefit from being sent to a specialist. The issue is with the second batch. There will always be discrepancies and disagreements. If the subspecialist feels like he ought to be involved with every case of something that you technically could do, then I think you ought to oblige him. But, he’s also gotta put on his big boy pants and accept that this means you’re going to call him a lot more often, and not be out in the position of making a patient wait an unreasonable amount of time just because the specialist is now too busy to deal with the work he’s asked for.
    If I got to the point where I couldn’t see kids with FBs in the nose rapidly, I certainly wouldn’t continue to ask my ER colleagues to be hands off. That wouldn’t be fair.

    But it’s not just about whether they’re trained to do it or not either. I mean, they’re trained to do an emergent airway too, but I still always get called (and rightly so).
     
  7. TimesNewRoman

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    I think the argument presented above is flawed. And I don’t think I’m being arrogant, simply defending my specialty.

    If the argument is that the best person at something should do it, let’s close all the ERs. ER docs are second best at everything. An orthopod could come down and tap a joint, but then I’m keeping someone in a bed for 4 hours while a septic lady is sitting in the waiting room. And you could literally make this argument for everything we do that won’t result in death in the next 30 minutes. Should all COPD exacerbations been seen by pulm? Afib by electrophysiologists? DVTs by vascular surgeons? Pneumonia by ID? Headaches by neuro? Back pain by spine? Why not? I have all of those on call? This isn’t a straw man argument. EPs are trained to handle most emergent and urgent medical issues. The field has developed over the last 50+ years because it’s the best model we’ve found to care for these folks. If you want your family taken care of in an ER by a moonlighting ophthalmologist or an nurse who calls the consults he or she things are appropriate, be my guest.

    I would argue that it is arrogant for one department to think they can and should be able to make policies dictating how other departments function and thinking that you know how an ER should be run better than someone who is board certified in EM. If your ER isn’t competent at dealing with fractures, they need new staff and/or y’all need to work together on it. I don’t tell you how to run your clinic or how to operate. Heck, I don’t even make any requests before you send your patients to the ER. I say “thanks, we’ll see them when they get here.”

    I’m also an intensivist - I think things could be better for me if I made some policies on how the hospitalists manages certain things, but it’s not my place to dictate how another board certified physician in another department does their job. If they ask me what I think or we have serious problems, we may have some meetings, but I’m not going to walk in and tell them how to do their jobs.

    Sorry to derail. I’ll leave this alone.
     
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  8. HighPriest

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    Well, we're going to disagree here, unfortunately. It's a fallacy of extremes. The argument is "well, either I should be able to do everything I think I can do, or we should just not have my specialty" is a fallacious argument. There are middle grounds. And not being willing to compromise on those is not being willing to work with your colleagues.

    In days yonder, the local family doc would do appendectomies, but they don't anymore because it doesn't make sense for them to do that. The general surgeon would do orthopedic cases. They don't anymore because it doesn't make sense for them to do that. It didn't mean we stopped having family docs and general surgeons, it just meant that we tailored their practices based upon available specialty resources.

    I certainly don't feel that I know how an ED should run. BUT, I do know how medical problems within my field should be managed. Better than the ER. I trust them in some cases to make good judgment calls, and in other cases I ask them to involve me earlier for the sake of the patients. That is, in fact, being collegiate.

    Yes, but I have absolutely no say in who they hire. So I do try to work with them, and in some cases that is by asking them not to do something.

    Except that, in some cases you indirectly do. Because when I get the kid with the FB in the nose who is totally inconsolable, and who cannot be managed in any way other than sedation simply because he wasn't managed in my office to begin with, that is dictating how I run my practice. Or at least, it's burning some bridges that I would have otherwise had. This, of course, goes back to working together to come up with appropriate treatment plans for patients.

    Another example with which I am familiar would be PTAs. For years the management of PTAs went as follows: guy comes in with a PTA, guy gets a CT with contrast, ENT gets called, guy follows up with ENT. Occasionally, an ER doc would drain the PTA first, but very rarely. The vast majority of these patients never need draining and get better with appropriate conservative management, regardless of how their CT looks. And that's fine. That pathway is ok. BUT, we went to the ER and asked them to start a protocol by which they would start suspected PTAs on steroids and appropriate antibiotics, and have them follow up with us in 48 hours. Now, far fewer people get CTs, far fewer people get stabbed in the throat, and most of them call the clinic and simply cancel their appointments.

    Now, there are two ways to look at that: 1 - I'm telling the ED how to run itself, or 2 - I'm asking them to work with us to try to provide the best care for patients (lowest cost, fastest recovery, least amount of pain).

    When it comes to this draining the knee issue, admittedly to some extent I'm playing devil's advocate because I'm not an orthopedic surgeon and I don't know the guy who made the request for the ED to stop tapping. But, I don't think its unreasonable to work with the ED to have a policy that may or may not also mean that the ER doc doesn't do certain procedures, so long as patients are managed appropriately, and in an timely fashion. Once we start telling the consultants that we're not willing to work with them on the front end of a patient complaint, that leaves the door open for them being unwilling to take care of the tail-end complications. I don't think either is reasonable.
     
  9. MediCane2006

    MediCane2006 Living the dream
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    This is my general view of things as well. I pretty much never fault our ER colleagues for trying their hand first, and I’m always much happier to come in if someone has already given it the old college try.
     
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  10. MediCane2006

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    Not ortho but I used to moonlight to cover gen surg/ortho/ENT at our community affiliate during surgery residency at our community affiliate in a big Northeast city during surgery residency. The ER would never tap any joint, and would page “ortho” anytime it was indicated. I had to watch a YouTube video the first couple times I tapped a knee, hip, or elbow but I got pretty slick (especially with knees) by the end of residency
     
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  11. dpmd

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    Yeah, it isn't that hard of a procedure. If they let me do it as a med student I don't see getting too bent out of shape if an EM attending who had to get signed off on them during residency does it. I mean unless it didn't seem indicated
     
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  12. Winged Scapula

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    Same-sies.

    We rotated at the hospital that despite having urology, Ortho, and ENT residents, the general surgery residents were first called for the specialties. No idea how that ever even got decide upon.
     
  13. Jolie South

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    If anyone couldn’t get a hold of or didn’t like the response of a subspecialty consultant, Gen Surg got called in my residency.

    “Hand surgery won’t do this hand biopsy. Will you do it?” No

    “Gyn onc is refusing this patient they operated on with a malignant bowel obstruction? Will you guys take it?” No

    “This patient has a breast infection. Did I mention she has an implant under there? Will you take it?” No.

    “This patient has a rash. We don’t have derm. Will you take care of it? There is no abscess or anything that needs to be debrided.” No.

    Also, if there was a medical train wreck with some tangentially related elective surgical problem, Gen Surg got the call first, bc we actually see our patients in a timely fashion.
     
    #1662 Jolie South, Nov 5, 2018
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  14. Winged Scapula

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    That's probably what it was - somewhere, someone from a sub didn't do well because there was a delay in response so it was decided that GS would take the calls.
     
  15. dpmd

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    I still get a little of that in private practice.
    Throat cancer who for some reason didn't get a trach before starting radiation now completely obstructed and er cric'ed but the itty bitty tube they used is causing trouble ventilating so you want it converted to a trach and there is no ENT on call? I'll give it a go

    Patient got a tummy tuck/breast implants/other cosmetic procedure in Mexico that is now infected and plastics won't see her? I guess i'll take a look to see if I can help get them out of the hospital.

    Bariatric surgery patient has an internal hernia and bariatrics doesn't take call? Guess I will fix it.

    Though sometimes they go beyond what I can even pretend to do and then they get sent out.
     
  16. VincentAdultman

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    Tkim you’re ruining our thread
     
  17. tkim

    tkim 10 cc's cordrazine
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    C'mon, you give me that much power? Y'all could just put me on 'ignore' and go about your merry ways.
     
  18. VA Hopeful Dr

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    My guess would be either one of more of the orthos threw a fit when the ED had an inevitable complication from tapping a joint at some point and so the ED decided to consult ortho for every joint going forward or since it was a teaching hospital they wanted their surgeons to get plenty of experience with the bread and butter ortho stuff.
     
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  19. VincentAdultman

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    Im not going to white knight for ortho on the EM board anytime soon. Which was kind of my point.
     
  20. TimesNewRoman

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    I apologize. Didn’t mean to derail. Carry on with your regularly schedule programming.
     
  21. evilbooyaa

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    Think he was mostly talking about tkim, FWIW
     
  22. tkim

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    I'd disagree that I was 'white-knighting' EM on this thread, in fact from the get-go, I've said that the consult discussed that brought me into this part of the thread was inappropriate but so were the recommendations made for labs and imaging by the consultant. This drifted towards joint taps and how many orthopedists expressed surprise that ER docs do them, which was supported by other EM docs on this thread who say they do them as well. If you view this as 'white-knighting' versus a correction of what happens locally to be taken as what happens everywhere, well, you do you.

    But whatev, the original intent of my posts was lost long ago and too nit-picky for anyone to give a crap about, so y'all can go back to making fun of non-surgeons in the 'kinder and gentler' SDN.
     
  23. HighPriest

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    I didn't get the impression that anyone was white knighting. No one was defending the ER point-by-point. There were some disagreements on policy. we (myself included) hijacked the threat a bit, to be sure.
     
  24. Raryn

    Raryn Infernal Internist / Enigmatic Endocrinologist
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    Back on track with ridiculous consults - I'm not a surgeon but here's one I've had twice in the last month

    Young woman comes to her PCP and says she gets somewhat shakey 2-3 hours after meals.

    PCP Assessment: Hypoglycemia

    PCP Plan: encourage patient to eat more frequently

    When that doesn't work, Endocrine consult.

    Step that is skipped? Ever checking a single blood sugar.
     
  25. HighPriest

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    Step that is skipped? All.

    That kind of thing is about half of my consults.

    "Patient with stuffy nose. placed on saline. Didn't work. Better go see ENT, because in all the years I've practiced family medicine I've never heard of any other treatment for stuffy nose, and I can think of no other causes."
     
  26. Pir8DeacDoc

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    At some point it's clear they just want to punt. And as aggravating as it is, I suppose it's an easy consult. But mind numbing too.
     
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  27. VA Hopeful Dr

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    I wish I could say that's an insane outlier, but the longer I do FM the more I realize at least half of my colleagues haven't picked up a book/journal since they finished residency in 1980 (and somehow forgot at least half of what they learned back then).

    That said, I will punt ear pain to you all the time. If it hurts and I don't see a reason why, they're coming to you. I don't expect you to do anything other than tell the patient that their ear looks OK and not to worry (or, you know, if you find something then please fix it).
     
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  28. HighPriest

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    To be fair, it’s usually an PA or NP, and often they’ve been on 9 consecutive z-packs in 6 months. I don’t mind. Like pir8 said, it’s easy money.

    And I don’t blame you for the ear thing. Ears are hard. I don’t think most ENT residents can do a proper ear exam until R3, and otoscopes suck, frankly.
     
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  29. TimesNewRoman

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    Consult to me in the MICU. Patient that was on medicine service pre-op goes to surgery. Has baseline afib. Got hypotensive with RVR. Anesthesia started epi for the AF-RVR induced hypotension then called me when things went off the rails.
     
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  30. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    I trust myself for obvious infections/perforations, but that's about it. Serous otitis sometimes, though I'm sure I over-call that just like everyone else.

    One of those fancy operating otoscopes is on my wish list. Might at least cut down on the ear wax referrals I send (I refuse to blindly curette).
     
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  31. MoMoGesiologist

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    As an anesthesiologist, that's kind of embarrassing... maybe there were extenuating circumstances why they used epi? Or does this kind of thing often happen with your anesthesia providers...
     
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  32. TimesNewRoman

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    I’ve never heard of it happening. No extenuating circumstances I could tell. Our anesthesia program has a great reputation. It was a CRNA fwiw.
     
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  33. HighPriest

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    You can't believe everything you read in a medical textbook, or the literature, or hear from your staff, or what just makes sense physiologically. Sometimes you just gotta try it to see what happens.
     
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  34. dpmd

    dpmd Relaxing
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    Someone didn't look at the monitor more closely than just seeing the hypotension I bet.
     
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  35. VisionaryTics

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    Routine consult for "trach care" comes in at the VA. I do a quick chart review. The guy is a first time visitor to our VA, seems to have a history of "laryngeal cancer s/p trach many years ago" (the ENTs in the room know what is coming) with care at a local university. He's on the medical floor for polysubstance withdrawal (heroin, crack, alcohol). Clinic coordinator wants to know if I want to see him in clinic or whether I'll see him on the floor. No way in hell I'm having some trach'ed guy withdraw from heroin in my clinic waiting room.

    I head to his room and find a passed out veteran with a very well-healed laryngectomy stoma. No issues. Whatever, easy consult note. I leave.

    Deeper chart review while writing the note reveals the guy had a CT thorax a few days ago for possible aspiration pneumonia as cause of his somnolence. It picked up a foreign body right lower lobe. Pulmonary was consulted who stated "flexible bronchoscopy is unable to remove foreign bodies, only to visually document disease process". They recommended consult to thoracic surgery for rigid bronchoscopy. Thoracic surgery stated no optical forceps were available at our VA, and GASTROENTEROLOGY should be consulted to attempt removal of pulmonary foreign body using pediatric gastroscope. Gastroenterology obvious refused to remove a pulmonary foreign body, and they recommended transfer to a local university. This all happened two days prior to our consultation for "trach care".

    I got a bronchoscopic biopsy forceps from the OR, headed up to the veteran's room, and removed the "foreign body" (calcified mucus plug) from the right lower lobe using a flexible bronch from our clinic.
     
  36. Arcan57

    Arcan57 Junior Member
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    That’s better than the cardiologist that ordered diltiazem to treat sinus tach in the guy I had just got done coding because of septic shock and post-op hypovolemia. Ca was (a corrected for albumin) of 6.2 at time of order, not that it would have been indicated with a normal calcium either...
     
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  37. vhawk

    vhawk 2K Member
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    Sounds like that guy needed a doctor
     
  38. HighPriest

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    You should order a swallow study. To check on that aspiration risk.
     
  39. HighPriest

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    It really is quite remarkable how often I've been consulted for various unreasonable issues surrounding patients who've had a total laryngectomy.

    Concerned that the patient is aspirating .
    Concerned that the patient can't speak. Please scope to evaluate vocal cord functionality.
    Concerned that the ER hasn't been able to intubate the patient transorally, and they've been trying for the last half hour.
    Concerned that this patient with a tracheostomy showed up and there's no trach tube, please come place a trach tube.
    Concerned that when he tilts his head all the way forward he can't breathe (fat guy).
    Inpatient consultation to see if the patient still needs his "tracheostomy."

    However, my favorite one was a call from the ICU nurses a number of years ago. It wasn't unreasonable, but it was unusual. We had a patient who was TL after a malignancy. He had a partial pharyngectomy as well, and so he had a radial forearm free flap in his neck, and it wasn't doing so hot (congested), so the staff doc had recommended that we put leeches on the thing. So this poor feller has leaches all over his neck, around his stoma....You can see where this is going....
    The nurses are supposed to keep an accurate count of all of the medical grade leeches when they put them on the patient, and when they take them off, and one turned up missing. Add to this that the patient was regularly coughing up small clots (because his flap was oozing into the stoma, because he had leeches injecting it with anticoagulants for days and days. As it turns out, a blood clot can look a lot like a leech when you are too freaked out by the scenario to look at it closely. So somewhere along the lines, a clot and a leech must have gotten mixed up and they were utterly convinced that a leech had crawled or fallen into his lungs. He never desaturated, so that seemed unlikely. But he got a bronch anyway. No leeches. Then the nurses realized they were all accounted for. After the bronch, of course. Why would you triple check your math before a procedure?
     
  40. VisionaryTics

    VisionaryTics Señor Member
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    I would've put a cuffed trach in that stoma to prevent any shenanigans.


    Favorite leech story:
    Lady with a total glossectomy and ALT free flap reconstruction. Flap gets congested, needs intraoral leeches. She also has a history of schizophrenia, on a bunch of psych meds. We notice the leeches are really sluggish and decide the leeches are being doped up by the Ativan/Seroquel/etc. Hold the psych meds during leeching.

    She goes into florid psychosis, completely out of it.

    She scribbles a message to our attending when he asks her how she's doing.

    "When will the magic animals leave my mouth?"
     
  41. LucidSplash

    LucidSplash Bloody Plumber
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    We found a medical leach in the hall once, one room down from it’s starting point. Somewhere I have a picture of the slime trail it left from the intended patient’s room as it tried to escape, before the jailbreak was noticed.
     
    #1690 LucidSplash, Nov 9, 2018
    Last edited: Nov 10, 2018 at 4:51 PM
  42. HighPriest

    HighPriest insert "clever" statement
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    If I remember correctly (and this was about 8 years ago, so maybe I’m not) the exposed paddle was close enough to the stoma and small enough that a trach covered it, and an ET tube without a bridle kept popping out.
     
  43. OrthoTraumaMD

    Physician Faculty Gold Donor Classifieds Approved

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    Well.... she’s not wrong.




    Sent from my iPhone using SDN mobile
     
  44. Psai

    Psai Snitches get zero vicryl
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    Florid psychosis? She's more with it than half the staff
     
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  45. ThoracicGuy

    Physician 5+ Year Member

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    [​IMG]

    There's no excuse for thoracic surgery to punt on that.

    Weak, weak, weak.
     
  46. TimesNewRoman

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    I read that quickly and thought you wrote Florida psychosis. Sadly, also makes sense.
     
  47. Pir8DeacDoc

    Pir8DeacDoc Cerumen Extractor
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    I enjoy cases on my total laryngectomy patients where anesthesia puts the mask over their mouth. Gotta pre-oxygenate their stomach prior to doing that crazy hard ett placement into a huge hole in the neck.
     
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  48. ThoracicGuy

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    Fellow resident was operating on a patient who was going under anesthesia. The guy started freaking out because he couldn't breathe. The anesthesiologist was covering his trach hole to get good preoxygenation.... He was s/p laryngectomy.

     
    Apollyon and TimesNewRoman like this.
  49. MoMoGesiologist

    MoMoGesiologist ASA Member
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    How... how do these people graduate from a residency? Anesthesia is literally all about the airway!
     
    Winged Scapula likes this.
  50. HighPriest

    HighPriest insert "clever" statement
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    Otherwise healthy patient with a history of anaphylactic reactions to unknown stimulant (x2). They referred her to an allergy clinic for workup of her allergies (even though we also do that), but referred her to us to see if maybe a surgery to widen her throat would prevent her from needing her epipen when she had an allergic reaction....

    I told her there is one surgery that can help with that, but I don't think she wants it.
     
  51. Raryn

    Raryn Infernal Internist / Enigmatic Endocrinologist
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    I should totally recommend elective trach's for all my patients with allergies!

    /s
     

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