CP in Private Practice

[DarksideAllstar]

Few questions...

1. How much time much time would you say you spend dealing directly with CP issues (aside from the med director-type stuff)? I'm talking about reviewing smears, coag junk, micro, etc.

2. How much of your home call is devoted to blood bank? I am certain that it depends on the size of the hospitals you cover and what types of patients that they admit. Curious because I absolutely abhor the innaneness of CP call (read: blood bank). Approving 2 units of FFP at 3AM for a patient with an INR of 1.3 isn't exactly how I envision my post-training years.

3. How do you determine what types of scenarios warrant a call from your blood bank in community practice?

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[Anna Plastic]

Curious because I absolutely abhor the innaneness of CP call (read: blood bank). Approving 2 units of FFP at 3AM for a patient with an INR of 1.3 isn't exactly how I envision my post-training years.

You should NEVER approve FFP for an INR of 1.3 without getting the story from the clinician directly. Never. Ever. You, in all likelihood, won't change their INR even if you do transfuse them. And even a squirrely neurosurgeon should be contented with an INR of 1.3 post-op.

If the definition of inane which you are using includes "lacking sense or substance", you may be right--perhaps it is inane because it doesn't make sense to you yet. Or maybe you just don't like being woken up to deal with it (a valid point too). But it doesn't lack substance--your helping to manage transfusion is one of the most directly impactful things you can do as a pathologist.

As for determining when to call the pathologist for blood bank issues: I've seen this managed in several ways (caveat emptor--I've mostly seen academic practices, but have seen some private practice models too). The more proactive will do prospective screening--establish criteria for transfusion (Hct/platelet/PT/Fgn triggers), and anytime someone requests product and doesn't have documented triggers for it gets a call. Other practices set limits (i.e. only 4 RBCs or 6 FFP per 24 hours) and the on call doc gets paged when someone exceeds the limit. Of course, any clinician needing consultation gets a call back. Also, many smaller centers are now seeing the utility of having a massive transfusion protocol with direct oversight by the pathologist of any bleeding situation. Activation of the protocol generates a call to the on call doc.

A lot will depend on the patient demographic, budget, and the level of involvement of clinicians where you practice at. If you have serious inventory issues at a smaller practice, you will probably have to do prospective audits to see if anyone is transfusing excessively/improperly. Larger centers may be too big to effectively do prospective screening, but you still need to devise systems to track product use.

Needless to say, you should be conversant with what transfusion triggers are for different products under different conditions, and when/how you can modify them in emergency situations.

 

[Anna Plastic]

Just saw your signature too, Darkside. I can only hope you are not so flip in approving product in your practice. If you approve FFP for no good reason, the wrath of the attornies will just as easily fall upon you as the ordering clinician when you patient gets TRALI, dies from volume overload, or has their airway close up from an allergic reaction.

 

[yaah]

Anna Plastic - what do you tell clinicians when they refuse to do simple procedures like pulling a central line without a platelet count of 50,000? The usual call we get is their count is 30,000 and they want platelets. We usually end up approving as long as they give it immediately beforehand (usually the request is at 10pm for a 7am procedure). All the literature I have seen suggests you can do simple procedures (like LP, BM bx, line insertion/pulling, paracentesis, etc) with a count of 20,000 or even 10,000. I mention this and even cite the papers for them but they ignore me and say "The count has to be 50,000!" or more likely they blame another service for it (Heme/onc wants 50,000 or radiology wants 50,000). I have found that "passing the responsibility on" is a strategy that clinicians use for inappropriate blood requests. Usually I make them have that person call me too to discuss, which is always fun.

 

[Anna Plastic]

Anna Plastic - what do you tell clinicians when they refuse to do simple procedures like pulling a central line without a platelet count of 50,000? The usual call we get is their count is 30,000 and they want platelets. We usually end up approving as long as they give it immediately beforehand (usually the request is at 10pm for a 7am procedure). All the literature I have seen suggests you can do simple procedures (like LP, BM bx, line insertion/pulling, paracentesis, etc) with a count of 20,000 or even 10,000. I mention this and even cite the papers for them but they ignore me and say "The count has to be 50,000!" or more likely they blame another service for it (Heme/onc wants 50,000 or radiology wants 50,000). I have found that "passing the responsibility on" is a strategy that clinicians use for inappropriate blood requests. Usually I make them have that person call me too to discuss, which is always fun.

They won't pull a central line without plt=50K? Sheesh. That is our "trigger" for bleeding surgical/trauma patients. Plt of 40-50K is sufficient to do procedures like laparotomy and liver biopsy. For lumbar puncture the count should be >20-30K, but for pulling a central line? Please.

The way this conversation plays out is very dependent on who I am talking to. I generally don't waste time with talking to residents/fellows when I run into this resistance because they are acting on orders and have little authority to change course. Usually the best way to sort this out is with an attending-to-attending conversation with the attending from the team doing the procedure (avoiding buck passing). The guys doing the procedure mostly want to know that they have an expert opinion backing them. I'm surprised if your heme/onc team is behind such a conservative transfusion approach--but I sure would buy rads. If there is a very entrenched irrational transfusion practice, a simple phone call over a patient won't take care of it. You're looking at going to transfusion committee and lecturing/education with clinicians. It still amazes me that there are so many places in the country that still use a 20K trigger for prophylactic platelet transfusions, but that just shows how much education needs to take place.

Of course, reminding the team of transfusion risks is always a good way to keep their perspective balanced.

 

[yaah]

What usually happens is that I get called by a medical resident who says radiology won't do the procedure unless it's 50,000 or more. Radiology never contacts us directly, and is hesitant to even talk to us about it. What usually happens if I get a request like this is that I tell them no, try to talk to radiology, and by that point the attending gets involved and it gets worked out somehow. Oftentimes they do agree to do really simple things like pulling lines or inserting lines if the count is under 50k, but it's amazing how often they won't. It's very passive aggressive - they force the poor medical intern who doesn't really have the knowledge to fight back into fighting their battles for them. And if the patient doesn't get the procedure done because the radiologist is irrational, who gets blamed? The intern.

And yes, there is entrenched irrationality here. It is mostly localized to pediatrics where many clinicians won't even touch the patient, it seems, if the count isn't high. I have gotten requests for platelets when the patient is at 60k (because they want it at 75k) for an upper endoscopy.

The heme-onc people are pretty good. Their threshold is usually 10k unless the patient is high risk. Of course, bear in mind that many of these pediatricians that I referred to above seem to consider every patient to be "high risk." So a lot of our calls are to the pediatric hospital.

The most bizarre iteration is outlined below (two situations)

a) Patient has a count of 30k, receives a transfusion and gets to 55k at about 10pm. Procedure is at 7am and no further transfusions will be given between 10pm and 7am. Patient is transfusion dependent and holds onto his platelets for about 6 hours maximum.

b) Patient has a count of 40k at 6am.

Most of the radiologists, I would wager, at our hospital would choose situation (a) as the patient they would most prefer to do the procedure on. Isn't that bizarre? They want to "see the number."

 

[DarksideAllstar]

You should NEVER approve FFP for an INR of 1.3 without getting the story from the clinician directly. Never. Ever. You, in all likelihood, won't change their INR even if you do transfuse them. And even a squirrely neurosurgeon should be contented with an INR of 1.3 post-op.

Nope, the g*ddamned neurosurgeons are the ones telling me that they NEED FFP at 1.3. Its just ridiculous. And when I do tell them that their numbers won't budge, they shrug it off and say they want it anyway and that their is a "slight increase in midline shift" so we need this because of increased bleeding.

If the definition of inane which you are using includes "lacking sense or substance", you may be right--perhaps it is inane because it doesn't make sense to you yet. Or maybe you just don't like being woken up to deal with it (a valid point too). But it doesn't lack substance--your helping to manage transfusion is one of the most directly impactful things you can do as a pathologist.

Your tone implies that I'm learning disabled. I'm not ******ed. I'd appreciate it if you weren't so patronizing. I have been on CP for the past several months and I understand the risks of transfusing products having written up multiple reaction reports first hand. Its inane having a goddamned conversation with someone at 3AM who has no common sense re: product usage. And these aren't just the interns. I have had these conversations with the surgery chief resident who is keenly aware of transfusion guidelines. And no, I don't like being woken up at 3AM to act as a "consultant" when I am treated by the clinical service as a "gatekeeper". Its irritating. Almost never has a call to me actually ended up in a clinician learning something about products-- maybe once. Maybe. Hell, I've argued my case for not using something, then the next day I'll get another request for the same product for the same patient, same circumstances, and the BB attending will acquiesce and say "give them what they want." Its annoying. I don't want my future professsional life to be like this.

As for determining when to call the pathologist for blood bank issues: I've seen this managed in several ways (caveat emptor--I've mostly seen academic practices, but have seen some private practice models too). The more proactive will do prospective screening--establish criteria for transfusion (Hct/platelet/PT/Fgn triggers), and anytime someone requests product and doesn't have documented triggers for it gets a call. Other practices set limits (i.e. only 4 RBCs or 6 FFP per 24 hours) and the on call doc gets paged when someone exceeds the limit. Of course, any clinician needing consultation gets a call back. Also, many smaller centers are now seeing the utility of having a massive transfusion protocol with direct oversight by the pathologist of any bleeding situation. Activation of the protocol generates a call to the on call doc.

A lot will depend on the patient demographic, budget, and the level of involvement of clinicians where you practice at. If you have serious inventory issues at a smaller practice, you will probably have to do prospective audits to see if anyone is transfusing excessively/improperly. Larger centers may be too big to effectively do prospective screening, but you still need to devise systems to track product use.

Needless to say, you should be conversant with what transfusion triggers are for different products under different conditions, and when/how you can modify them in emergency situations.

Thanks, that was about how I envisoned it (similar to what we have here).

Just saw your signature too, Darkside. I can only hope you are not so flip in approving product in your practice. If you approve FFP for no good reason, the wrath of the attornies will just as easily fall upon you as the ordering clinician when you patient gets TRALI, dies from volume overload, or has their airway close up from an allergic reaction.

No, I am not this flippant in real life. It was meant to convey a sense of the frustration that myself and many [read: all] of my co-residents experience when taking CP call. Mainly, the fact that no one has any understanding of products and when we offer advice (mainly on when to give platelets for a procedure), it goes ignored. I get the sense that this is why I have met very few residents [read: none] who enjoy CP.

As an aside, how can I be liable for the clinician's inappropriate product use if I throughly explain the risks to every product that they transfuse against my recommendations and document it? It seems similar to medicine ignoring recommendations from cards or pulm, then getting their @ss sued when things go wrong. How can I be absolutely sure that the product that they are requesting isn't clinically indicated? Most of us have no clinical experience outside of med school and are not trained to make these types of judgements as to whether a patient who has "borderline numbers" (how many times are we told not to treat numbers?) is "bleeding" and needs whatever product they are requesting.

 

[DarksideAllstar]

I should state that part of my frustration comes from the fact that simple things that should be taken care of by the techs are not. For instance, last night at 0200 I get a call for an approval for 1 unit of platelets. The patient has a platelet count of 91K. What would be your first guess given this criteria:


Neuro/Optho/ENT: Transfuse at <100K
All other bleeding or planned IR procedure: Transfuse at <50K
LP:<20K
Spontaneous: <10K

Now, this being a *trauma* center I immediately put my money on NEUROSURG PATIENT. Betting myself a cool million dollars that this is a NEUROSURG patient, I call the floor, get the covering residents phone number. I get them on the phone (sounds like they were sleeping--what a rare occasion). The FIRST thing I ask is: does this patient have a head bleed? Answer: Yes. Product approved! Man that was hard. I bet it took the tech more time to call me, wait for me to talk to resident, and wait for me to call back then it would have to just call the FING RESIDENT!

I mean, how hard is it for the tech to call the floor and speak with the nurse or resident to hear them say "brain bleed"? Some of you might say that it is our "job" to do this type of thing to which I rebut-- how do I know that the surg resident is lying about a patients "head bleed" to sneak in a unit of platelets for some other crap? Theoretically, it could happen, but is it more likely to happen if the tech calls instead of me?

Maybe I'm just bitter.

 

[DarksideAllstar]

What usually happens is that I get called by a medical resident who says radiology won't do the procedure unless it's 50,000 or more.

The best is when I call radiology to get the real story and they say, "Oh we would do it while the platelets are running, so we don't need a count, but medicine wants it at >50K." WTF? Medicine isn't doing the procedure-- you are! Calls like this make me want to put a bullet in my brain. Then maybe I could get some platelets.

 

[bellgirl]

DSA,

I feel your pain. If I have to give a schpiel to one more medicine/heme-onc/ICU intern/resident/fellow about why their hypersplenic patient doesn't need crossmatched platelets...you can shoot me in my head.

And...I'd rather be b*tchslapped by my own attending every time I have to bring out "this will have to be an attending-level decision." That would be less humiliating and painful--and perhaps more instructive--than having to listen to the argument play out...


Perhaps being a "perpetual educator" of clinical teams is not in my career cards.

 

[Anna Plastic]

Darkside, I apologize for insulting you--I can hear/see how frustrated you are, and believe me when I say I know where you are coming from. I wasn't trying to be patronizing when I said that it is OK if you hate it--I was totally serious. But even if you are frustrated, you shouldn't be encouraging inappropriate use of product; I think you agree with this, right? Hard enough to teach medicine residents without creating bad impressions on tender young pathology residents...

I'm really sorry to hear your BB attending is backing down; I hope he/she isn't making a habit of it. Neurosurgeons are like kids--you gotta set limits and be consistently firm with them . But seriously, it sucks to fight the good fight only to be undermined. Take solace in knowing you are doing the right thing, and when you are an attending you can have a lot more say in how things are run. If you are doing your job right in BB, the clinicians will listen to you at least part of the time, and you do have influence over transfusion practice. I've seen amazing BB attendings who have the respect of cardiac surgery attendings, neuro attendings--these clinicians listen to and follow the advice of a strong BB doc. But it takes years and skill to build that trust. They don't respect pathologists who they see as hands off and disinterested; and they sure don't listen to them. So don't assume that just because they don't listen to you now that they wouldn't in the future.

As an aside--was that headbleed you were talking about due to warfarin? How much FFP had that patient received that day? Does your hospital use any protocol involving PCCs?

Sometimes techs will mess up, just like doctors do. How did you handle the issue with the tech the next day?

Hate to say the obvious, but everything you do will have some component that drives you bat**** crazy. Attending in a teaching hospital selects for people who like to teach, and if this ain't for you, that really is OK--its a good thing to know now. I imagine there are private practice AP guys who would bitchslap path residents when they are asked for the 500th time the difference between a TA and HP. If you hate being woken up now with BB call, you will go postal in a few years. I've always like the middle of the night calls (I'm sick, very sick), so I'm in the right field.