Consults- Memorable/Dismal/Ridiculous/Unique

[ThoracicGuy]

Definitely an interesting population to work with. I essentially had 2 months of it this year, and when rounding it seemed like it was about a 20% chance they were at dialysis, 10% chance they'd be out smoking, and 5% chance I could get palpable pulses.

That high?

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[ThoracicGuy]

Yeah this is not the norm. I think that’s why I got a 230am urgent consult. Someone realized “oh ****, we dun effed up.”

Transfer to medicine!

 

[LucidSplash]

That high?

Those are the ones medicine consults us on for “cold feet” wherein the patient has acute sockemia. I see about 1 a week.

 

[Smurfette]

Those are the ones medicine consults us on for “cold feet” wherein the patient has acute sockemia. I see about 1 a week.

"Dx: acute sockemia. Plan: socks prn, orders placed".
Well, I guess the feet are indeed cold, so they're not wrong...

 

[dpmd]

Wouldn't it be sockopenia?

 

[mimelim]

Size mismatch isn’t an issue if you know what you’re doing from a technical standpoint and you’re used to doing it. Orthograde rather than reverses helps. Doing your own vein harvest instead of endoscopic by a PA is best for these IMHO. There are a lot of factors including patient selection, for example ESRD much worse outcomes than non ESRD. But I can tell you our data going on 35 years here is about what is in the paper I linked to which details the first 10 years.

Most people who haven’t been affiliated with a limb salvage program are skeptical, I get it. The patency with these is obviously lower than with a proximal tibial or a pop, but it isn’t anywhere near zero. I know a lot of vascular surgeons don’t want to deal with this and that’s fine, but they should be willing to refer their patients to eval in a limb salvage center before proceeding to a major amp if that’s the case.

I feel guilty, two guillotine BKAs last week. Another two AKAs this week . I feel like I'm willing to push pretty hard both endo and open, but sometimes you just can't win =/

 

[LucidSplash]

I feel guilty, two guillotine BKAs last week. Another two AKAs this week . I feel like I'm willing to push pretty hard both endo and open, but sometimes you just can't win =/

Guillotines are for a different subset. Lol. Not trying to make anyone feel guilty. There was a Charcot foot dripping pus that needed an amp last night but he refused. He’s still alive and we’re waiting to see if he changes his mind when he gets sicker.

 

[HighPriest]

Guillotines are for a different subset. Lol. Not trying to make anyone feel guilty. There was a Charcot foot dripping pus that needed an amp last night but he refused. He’s still alive and we’re waiting to see if he changes his mind when he gets sicker.

Sounds like throat cancer patients and trachs. I mean, losing a limb is definitely a bigger deal. But the most common situation is that I get some guy with a large oropharyngeal or laryngeal mass and I recommend a trach due to what will undoubtedly become a compromised airway. They almost always refuse. I always tell them they're going to be in the ER at 0300 begging to have one placed and by then it'll have to be done awake. They never believe me. Like I'm making this stuff up.

 

[deleted547339]

Sounds like throat cancer patients and trachs. I mean, losing a limb is definitely a bigger deal. But the most common situation is that I get some guy with a large oropharyngeal or laryngeal mass and I recommend a trach due to what will undoubtedly become a compromised airway. They almost always refuse. I always tell them they're going to be in the ER at 0300 begging to have one placed and by then it'll have to be done awake. They never believe me. Like I'm making this stuff up.

As an ER doc, I can attest to this being 100% the truth.

 

[deleted547339]

Those are the ones medicine consults us on for “cold feet” wherein the patient has acute sockemia. I see about 1 a week.

Ugh. That was the worst in residency. I have a patient with known vascular disease and unchanged ABIs then have an attending “get vascular on board” because of cold feet. Calling that consult was always difficult - you don’t want to completely bag the attending for fear of repercussions/them overhearing you, but you also don’t want the vascular resident thinking your a ******* and blowing off the next time you call them with a real issue.

 

[Jolie South]

Guillotines are for a different subset. Lol. Not trying to make anyone feel guilty. There was a Charcot foot dripping pus that needed an amp last night but he refused. He’s still alive and we’re waiting to see if he changes his mind when he gets sicker.

I used to push guillotines pretty hard and in some circumstances still do. However, I have been able to salvage some pretty gnarly legs with aggressive debridements, vacs, and biologic dressings in patients who refuse. I am surprised at some of the limbs that make it. It’s not an easy road though for sure. And takes months.

 

[LucidSplash]

I used to push guillotines pretty hard and in some circumstances still do. However, I have been able to salvage some pretty gnarly legs with aggressive debridements, vacs, and biologic dressings in patients who refuse. I am surprised at some of the limbs that make it. It’s not an easy road though for sure. And takes months.

Agreed that they are overused in a lot of places. The only ones I do here are for actively dying type folks. Even that guy with the nonsalvageable Charcot foot would actually get a formal BKA if he opts in soon enough. The infection is only in the foot and we could get clean planes. But with the creatinine of 4.5 (baseline normal) and leukocytosis 25 and pressures in the 80s the foot has to go at some point. It’s three times the size of his other foot and not doing him any good.

And agreed on taking the time with some so-called “nonsalvageable” limbs to salvage them. If the patient is willing to put the work in and be compliant, you can do a lot.

I’ve also come around to the idea that a Lisfranc or Chopart are better options for some who need more than a TMA but maybe not a BKA. It’s best if there’s a high quality prosthetist you can rely on but even still, some of my patients use it like a peg leg if they aren’t very mobile anyway and, as previously referenced, like that they don’t lose control of their bladder before getting to the bathroom at night. I was taught in residency that those kinds of amps were only for special cases in the very young patient but now I agree they have a role in vascular limb salvage too.

Of course, patient selection is key.

 

[Jolie South]

Agreed that they are overused in a lot of places. The only ones I do here are for actively dying type folks. Even that guy with the nonsalvageable Charcot foot would actually get a formal BKA if he opts in soon enough. The infection is only in the foot and we could get clean planes. But with the creatinine of 4.5 (baseline normal) and leukocytosis 25 and pressures in the 80s the foot has to go at some point. It’s three times the size of his other foot and not doing him any good.

And agreed on taking the time with some so-called “nonsalvageable” limbs to salvage them. If the patient is willing to put the work in and be compliant, you can do a lot.

I’ve also come around to the idea that a Lisfranc or Chopart are better options for some who need more than a TMA but maybe not a BKA. It’s best if there’s a high quality prosthetist you can rely on but even still, some of my patients use it like a peg leg if they aren’t very mobile anyway and, as previously referenced, like that they don’t lose control of their bladder before getting to the bathroom at night. I was taught in residency that those kinds of amps were only for special cases in the very young patient but now I agree they have a role in vascular limb salvage too.

Of course, patient selection is key.

I don’t know how much stake I have in those amps. Where I am, we have great prosthetists and the vast majority end up doing great with BKAs and prosthetics. In my experience, most people that get TMAs don’t have them for long. Not because of lack of perfusion, though that may be some of it, but the flaps and the tension are the biggest contributor.

 

[vhawk]

Wouldn't it be sockopenia?

asockosis

 

[vhawk]

I used to push guillotines pretty hard and in some circumstances still do. However, I have been able to salvage some pretty gnarly legs with aggressive debridements, vacs, and biologic dressings in patients who refuse. I am surprised at some of the limbs that make it. It’s not an easy road though for sure. And takes months.

so when doing these comparisons, do you compare the patients who go through this "not an easy road" for months, all the time and resources, and then....still just end up getting an amp, which I assume must be the majority of the patients?

 

[Jolie South]

so when doing these comparisons, do you compare the patients who go through this "not an easy road" for months, all the time and resources, and then....still just end up getting an amp, which I assume must be the majority of the patients?

I wouldn’t say it’s the majority of the patients.

A lot of times, we offer the patient the opportunity to decide long road for limb salvage or early amp. I think either is reasonable if they are not septic floridly. I mean it’s their leg. I have had patients thank me for amps after attempting limb salvage. A lot of times, the amp upfront gets people functional faster depending on the level of tissue loss and intensity of wound care we are talking about.

 

[vhawk]

I wouldn’t say it’s the majority of the patients.

A lot of times, we offer the patient the opportunity to decide long road for limb salvage or early amp. I think either is reasonable if they are not septic floridly. I mean it’s their leg. I have had patients thank me for amps after attempting limb salvage. A lot of times, the amp upfront gets people functional faster depending on the level of tissue loss and intensity of wound care we are talking about.

dont get me wrong, I basically specialize in futile, useless operations

 

[dpmd]

so when doing these comparisons, do you compare the patients who go through this "not an easy road" for months, all the time and resources, and then....still just end up getting an amp, which I assume must be the majority of the patients?

Sounds like the decision making that goes into really bad open tib fib fractures. Problem is that some get a good working leg and everyone wants to believe it will be them. Not sure how easy it is to figure out which ones will benefit.

 

[dpmd]

dont get me wrong, I basically specialize in futile, useless operations

But sometimes it works right. If we had perfect prescience then we could avoid lots of trouble. Sadly we do not.

 

[vhawk]

Sounds like the decision making that goes into really bad open tib fib fractures. Problem is that some get a good working leg and everyone wants to believe it will be them. Not sure how easy it is to figure out which ones will benefit.

And even if the AVERAGE person will be worse off, is that automatically a reason not to do it? I can certainly imagine being a patient offered that choice, where you tell me my options are

A) -80
B) On average, -90 (sometimes -300, sometimes -10)

and gleefully choosing option B due to diminishing marginal disutility or whatever

 

[dpmd]

And even if the AVERAGE person will be worse off, is that automatically a reason not to do it? I can certainly imagine being a patient offered that choice, where you tell me my options are

A) -80
B) On average, -90 (sometimes -300, sometimes -10)

and gleefully choosing option B due to diminishing marginal disutility or whatever

Yeah, much as I like to claim I would take the amp and move on with life, something tells me I might feel differently if I was actually presented with the choice (though more of my thoughts on the matter come from bad open tib fibs in young people who would do great with a prosthesis which is a little different than an old vasculopath who might not ambulate well with a prosthetic)

 

[vhawk]

Yeah, much as I like to claim I would take the amp and move on with life, something tells me I might feel differently if I was actually presented with the choice (though more of my thoughts on the matter come from bad open tib fibs in young people who would do great with a prosthesis which is a little different than an old vasculopath who might not ambulate well with a prosthetic)

this is what I say to all the cynical residents and students who see these 80 yo patients or families who want to "do everything" or get maximal chemo for their panc ca, when they say things like "ugh if that was me, I would just enjoy my time and go sit on a beach."

When that patient was 35, dont you think they would have said the same thing? Everyone has a plan until they get punched in the face.

 

[dpmd]

this is what I say to all the cynical residents and students who see these 80 yo patients or families who want to "do everything" or get maximal chemo for their panc ca, when they say things like "ugh if that was me, I would just enjoy my time and go sit on a beach."

When that patient was 35, dont you think they would have said the same thing? Everyone has a plan until they get punched in the face.

I have had to have a lot of surgery in my life and every time since the second I said never again because the pain just sucks too much. But then some **** comes up and there I am saying yes. I can understand it even as I sit there with my die drinking on the beach plan going through my head.

 

[vhawk]

I have had to have a lot of surgery in my life and every time since the second I said never again because the pain just sucks too much. But then some **** comes up and there I am saying yes. I can understand it even as I sit there with my die drinking on the beach plan going through my head.

I assume based on your pics in the Picture thread its all that cosmetic surgery you've had, let me say its been worth it

 

[dpmd]

I assume based on your pics in the Picture thread its all that cosmetic surgery you've had, let me say its been worth it

not even one. All natural baby.

 

[dpmd]

Now if I can just keep different parts of my body from being broken or growing abnormally I can avoid further surgeries (not holding out much hope though because I have already have a big ganglion on my dominant wrist that is getting symptomatic)

 

[vhawk]

Now if I can just keep different parts of my body from being broken or growing abnormally I can avoid further surgeries (not holding out much hope though because I have already have a big ganglion on my dominant wrist that is getting symptomatic)

Well I just learned in the doctors lounge today that the crippling pain I've got in my dominant elbow is called "old mans elbow" and also "tennis elbow" and is "a typical thing that happens when you get into your 40s" (I'm 35) so basically I am DNR/DNI now

 

[VA Hopeful Dr]

Well I just learned in the doctors lounge today that the crippling pain I've got in my dominant elbow is called "old mans elbow" and also "tennis elbow" and is "a typical thing that happens when you get into your 40s" (I'm 35) so basically I am DNR/DNI now

To stay on topic, when's your amputation scheduled?

 

[vhawk]

To stay on topic, when's your amputation scheduled?

I just told my family to pull the plug so currently the microwave is unplugged and we are just gonna see how long i last. Its best for everyone

 

[Psai]

To stay on topic, when's your amputation scheduled?

Whoa whoa whoa that's a little premature. He needs an angio, axilloradial bypass, transmetacarpal amputation and wrist guillotine before they start to think about the elbow.

 

[LucidSplash]

Whoa whoa whoa that's a little premature. He needs an angio, axilloradial bypass, transmetacarpal amputation and wrist guillotine before they start to think about the elbow.

Ok ok don’t be so dramatic wiseguy.

I could probably take inflow from brachial, no need to go to the ax.

 

[HighPriest]

You should just graft straight from the aorta to the radial. Have a little tubed flap between his wrist and his chest. Tell him to hold real still. No surprises. Don't do the wave at football games. Added benefit is that he can't lift his hand up high enough to smoke his cigarette or drink his mad dog.

 

[LucidSplash]

You should just graft straight from the aorta to the radial. Have a little tubed flap between his wrist and his chest. Tell him to hold real still. No surprises. Don't do the wave at football games.

We recently did an emergent SMA bypass from an existing ax-fem graft. Supraceliac aorta was heavily circumferentially calcified, celiac was chronically occluded and he had a flush chronic aorta occlusion just below the renals (hence the axbifem). We were a little afraid he would get demand gut ischemia when he walked but he did ok. We told him not to walk up any steep hills or try to run very fast. Probably no walking and eating at the same time either.

 

[HighPriest]

We recently did an emergent SMA bypass from an existing ax-fem graft. Supraceliac aorta was heavily circumferentially calcified, celiac was chronically occluded and he had a flush chronic aorta occlusion just below the renals (hence the axbifem). We were a little afraid he would get demand gut ischemia when he walked but he did ok. We told him not to walk up any steep hills or try to run very fast. Probably no walking and eating at the same time either.

Don't let anyone draw blood or your legs will fall off. Probably shouldn't cut any food at home either.

 

[OrthoTraumaMD]

Don't let anyone draw blood or your legs will fall off. Probably shouldn't cut any food at home either.

People might laugh at that.... but every year I see a black thumb because someone didn’t do an Allen test before putting in a radial artery a-line in the wrist. And if their palmar arch is incomplete, the radial artery is the only blood supply to the thumb.


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[HighPriest]

People might laugh at that.... but every year I see a black thumb because someone didn’t do an Allen test before putting in a radial artery a-line in the wrist. And if their palmar arch is incomplete, the radial artery is the only blood supply to the thumb.


Sent from my iPhone using SDN mobile

I've harvested forearm free flaps as a resident. I've NOT done them for failed Allen tests. I getchu.

 

[Psai]

People might laugh at that.... but every year I see a black thumb because someone didn’t do an Allen test before putting in a radial artery a-line in the wrist. And if their palmar arch is incomplete, the radial artery is the only blood supply to the thumb.


Sent from my iPhone using SDN mobile

No one does the allen test because the sensitivity and specificity is akin to flipping a coin.

I mean the cardiac surgeons are taking bilateral radials for cabgs nowadays.

 

[dpmd]

I thought of this thread because my nec fasc consult has a cold hand without palpable pulses. Luckily no one bothered to examine his wrist so there was no erroneous vascular consult, just my knife opening up his tense tissue and cutting out dead stuff including some dead muscle.

 

[OrthoTraumaMD]

No one does the allen test because the sensitivity and specificity is akin to flipping a coin.

I mean the cardiac surgeons are taking bilateral radials for cabgs nowadays.

I do it every single time, and I haven’t had issues with black thumbs. But I know a few surgeons who bagged the radial artery doing a distal radius and regretted it.


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[HighPriest]

No one does the allen test because the sensitivity and specificity is akin to flipping a coin.

I mean the cardiac surgeons are taking bilateral radials for cabgs nowadays.

Yeah, we only cared about the results if it was positive. I recall it being fairly specific, but having poor sensitivity. But, I haven't done one in 5-6 years. Doesn't come up much now that I don't have anything to do with free flaps.

 

[ThoracicGuy]

Well I just learned in the doctors lounge today that the crippling pain I've got in my dominant elbow is called "old mans elbow" and also "tennis elbow" and is "a typical thing that happens when you get into your 40s" (I'm 35) so basically I am DNR/DNI now

I seemingly developed this after a night's sleep this past week. It's really annoying.

 

[vhawk]

I seemingly developed this after a night's sleep this past week. It's really annoying.

Honestly hadnt really heard of it or knew of it as a problem (ive heard the phrase tennis elbow i guess but not specifics) and now that i have it its everywhere. Mine came on just randomly when i woke up one morning, but i had done a hard ergonomically challenging case the day before so thought maybe that was it, dunno. It hurts every morning when i wake up now though. Apparently one of my plastics colleagues does some minimally invasive neurectomy procedure for it

 

[dpmd]

Got a nice one today. 60 something yr old with esrd, dm, dementia. Chronic wounds to ble and lue. Biopsied but not conclusive for calciphylaxis. Ble chronic venous stasis changes with ulcerations for months but soupier recently with cellulitis worst on left. Lue dialysis fistula present with some gangrenous changes to a few digits (dry) and dorsal purulent purple mess that looks like wet gangrene. I get consulted to evaluate for necrotizing fasciitis. Distal lower extremities look like typical venous stasis ulcers plus some nonhealing wounds to the heel and tips of the toes but dopplerable pulses so likely microvascular issues. The proximal stuff is various size ulcers with necrotic wound beds with a tiny red ring but otherwise not very inflamed. Aside from one bulla I don't get why they thought nec fasc. The hand looks god awful but I don't do hands. But I don't see how anything they do to that hand is going to heal.

 

[dpmd]

Honestly hadnt really heard of it or knew of it as a problem (ive heard the phrase tennis elbow i guess but not specifics) and now that i have it its everywhere. Mine came on just randomly when i woke up one morning, but i had done a hard ergonomically challenging case the day before so thought maybe that was it, dunno. It hurts every morning when i wake up now though. Apparently one of my plastics colleagues does some minimally invasive neurectomy procedure for it

Have you tried a brace or PT?

 

[LucidSplash]

Got a nice one today. 60 something yr old with esrd, dm, dementia. Chronic wounds to ble and lue. Biopsied but not conclusive for calciphylaxis. Ble chronic venous stasis changes with ulcerations for months but soupier recently with cellulitis worst on left. Lue dialysis fistula present with some gangrenous changes to a few digits (dry) and dorsal purulent purple mesh that looks like wet gangrene. I get consulted to evaluate for necrotizing fasciitis. Distal lower extremities look like typical venous stasis ulcers plus some nonhealing wounds to the heel and tips of the toes but dopplerable pulses so likely microvascular issues. The proximal stuff is various size ulcers with necrotic wound beds with a tiny red ring but otherwise not very inflamed. Aside from one bulla I don't get why they thought nec fasc. The hand looks god awful but I don't do hands. But I don't see how anything they do to that hand is going to heal.

They need to get a fistula scan/PVRs with and without compression/maybe fistulagram. Sounds like steal. Bad enough it probably needs to be ligated and go to catheter based. Or better yet hospice.

 

[dpmd]

They need to get a fistula scan/PVRs with and without compression/maybe fistulagram. Sounds like steal. Bad enough it probably needs to be ligated and go to catheter based. Or better yet hospice.

I did mention the comfort care option. She has bacteremia too. If she had half her current issues it would be dicey enough but with all of them I don't foresee any kind of reasonable outcome aside from a whole lot of stuff done to gain her some time in a hospital or some other facility.

The sparing of the palmar aaspect of the hand intrigues me. Not enough to go look up if that means something, but just enough to say "huh, weird"

 

[VA Hopeful Dr]

Have you tried a brace or PT?

That is what I would hypothetically recommend for someone who is hypothetically suffering from epicondylitis. Or, if said hypothetical patient is a busy surgeon who would find PT hard to schedule, you can look up home exercise plans online pretty easily.

 

[ThoracicGuy]

That is what I would hypothetically recommend for someone who is hypothetically suffering from epicondylitis. Or, if said hypothetical patient is a busy surgeon who would find PT hard to schedule, you can look up home exercise plans online pretty easily.

I hypothetically ordered a brace from Amazon that will arrive tomorrow, hypothetically.

 

[HighPriest]

I hypothetically ordered a brace from Amazon that will arrive tomorrow, hypothetically.

Real amazon or hypothetical Amazon? Is it your medical opinion that I should use Amazon?

 

[ThoracicGuy]

Real amazon or hypothetical Amazon? Is it your medical opinion that I should use Amazon?

If you hypothetically have Prime, you can get it sent to you in 2 days. Real amazon would take a lot longer. Not medical advice.