Difficult Spinals coverage?

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MoMD

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Our hospital has asked us to rescue/help our EM and Medicine collegues in event they are not able to get a spinal after they attempt. We are employed so feel somewhat obligated. Do any of you do this? Is it after 1 or 2 attempts by the medicine/EM docs? Do you get a new consent form from the patient or just come in and get access for the then leave? Can we bill from our department seperately?

Thanks in advance!
 
Always evaluate and consent as if you were the first person to approach this. I remember hearing a malpractice case of this very scenario where the anesthesiologist was asked for help with an LP after repeated attempts by the ED/IM doc. Pt was on plavix and this person never looked at the chart. He was just passing by and was asked for help. There was some sort of bad outcome and he was named too.

That said, we do not. If there is some difficulty with landmark technique, IR is consulted and its added on.
 
Tell them you use the same landmark technique as medicine/EM and if it’s difficult it should go to IR. They’re very rarely urgent and more of a ‘can the ER send home’ test or it’s neurology not being in house when the delirious patient spikes a fever . I did a month at a place anesthesia was the LP team, EM didn’t even try (community hospital, they were employed, had no interest). It was painful when some younger delirium of unknown cause needed an LP at night in a community hospital. Young, usually drug/psych history, trying to get to sit still in the middle of the night in a community hospital. So much time wasted.

If you’re employed: they’re adding a new line of service. IR is not a new line of service. Let them know how much it’s going to cost them. When you’re employed you have to fight every new service with pay, let them know it’s adding on more work. Why not just be the difficult IV team as well
 
I predict that once you are available for "difficult" spinals. Most will become difficult requiring your expertise. Additionally if you go to the ER or have the patient bout to PACU/Preop to do the LP, if you are supervising another room(s) you will not be compliant, even if you perform the procedure with a CRNA. That is what our compliance consultant told us 10+ years ago when we researched the issue.
 
Be careful.

It quickly can become a way for them to dump procedures onto you. Soon they will start saying it was difficult after one attempt, or patient is too high risk for them, or they aren't comfortable and it will fall to you as the backup.

If you refuse, then you are neglecting your duties.

After a few years, it will be very difficult to extricate your group from that responsibility.

Being employed does make it tricky. But if it's 2am and you get called for this, do you have to come in?
 
I quit my last job largely because we were getting called frequently and at all hours for LPs and PIV placements. A lot of the time no attempt was made prior to calling us. Actually, several of us quit. We had a weak chief who wouldn’t push back. If you want to introduce instability in your group with frequent staff turnover, this is the way.
 
We never ever do LPs. If they can't get done by the ER doc or whoever else might be doing it, they go to IR.
 
We don’t offer this coverage. If they can’t get an LP they get an IR consult. The exception is when they are doing it under anesthesia and we are standing right there. Then some of us offer to do it. 9 times out of 10 it’s not hard. We have a lot more experience with spinals than neuro, the onco and the EM folks are usually good.
Having said that, if they take 42 passes at 3 levels, I’m not going to be #43.
 
Dr. Rude said:
I predict that once you are available for "difficult" spinals. Most will become difficult requiring your expertise. Additionally if you go to the ER or have the patient bout to PACU/Preop to do the LP, if you are supervising another room(s) you will not be compliant, even if you perform the procedure with a CRNA. That is what our compliance consultant told us 10+ years ago when we researched the issue.
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Don’t you do awake blocks while rooms are running? That was a routine practice in the adult world. How is an LP different?
(To be clear, I would be pushing back on this HARD. I’m not a procedure monkey for the other services who can’t do things, though I know someone who is, and they are also on call and they have a whole suite available 24/7. They love procedures, it’s all they do. Though I suspect they won’t be coming in to do this at 2am either.)
 
UscGhost said:
Be careful.

It quickly can become a way for them to dump procedures onto you. Soon they will start saying it was difficult after one attempt, or patient is too high risk for them, or they aren't comfortable and it will fall to you as the backup.

If you refuse, then you are neglecting your duties.

After a few years, it will be very difficult to extricate your group from that responsibility.

Being employed does make it tricky. But if it's 2am and you get called for this, do you have to come in?
Click to expand...
I don’t see a reason you’d have to provide after hours coverage. You can always just give someone antibiotics and get the LP the next day
 
IlDestriero said:
Don’t you do awake blocks while rooms are running? That was a routine practice in the adult world. How is an LP different?
(To be clear, I would be pushing back on this HARD. I’m not a procedure monkey for the other services who can’t do things, though I know someone who is, and they are also on call and they have a whole suite available 24/7. They love procedures, it’s all they do. Though I suspect they won’t be coming in to do this at 2am either.)
Click to expand...
I do awake blocks all the time in preop for surgical patients while medically directing as does everyone I know. According to our consultant it is about the CPT code for a diagnostic LP that you are performing. According to them that the rules for compliance were based on patients that you giving an anesthetic to for a surgical procedure. I pointed out that this was virtually technically identically to starting another room with a spinal anesthetic with a CRNA. They said the rules were based on the CPT. IDK if they are right, but it is what they told us at the time.
 
Radetzky said:
I don’t see a reason you’d have to provide after hours coverage. You can always just give someone antibiotics and get the LP the next day
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Ideally yes.

Never know with the ER docs. Then someone documents that anesthesia refused to come at 5am. Or nobody in the group wants to do it so it gets delayed and bounced.

Just a mess worth avoiding if at all possible.
 
jwk said:
We never ever do LPs. If they can't get done by the ER doc or whoever else might be doing it, they go to IR.
Click to expand...
This.

Doing spinals under fluoroscopy is extremely easy. I inject the die for myelograms all the time. A lot of IR docs don’t like doing these either btw because they don’t want to manage blood patches should they occur.

OP-

keep in mind that you’ll be responsible for epidural blood patches as well if they come back with a spinal headache. And if you offer to help with spinals, you’re getting invited to endless consults on “evaluate for spinal headache” along with need to obtain csf for meningitis workup etc.

At that point the ER will call you and you’ll now be doing a blood patch on a patient that had a difficult spinal where you’re not sure of anatomy.

Also you have no clue who did the original spinal and how it was done. No one accurately documents how many attempts were made.

I don’t care much about spinals technically.

They’re personally very easy for me as I always do them paramedian approach where I just isolate one side and aim from left to right. I’m right handed so for me I go left to right paramedian. That’s my natural angle.

Avoid the spinous process. Hit the lamina. Advance up or down since I have the side already isolated.

I also bend the tip of my spinal needle like a hockey stick - this allows you another axis of rotation to get off the bone to enter LF and then pierce dura. Again that’s just a modification based on my training as a pain doc.

I’m however more concerned about potential for EBP and how difficult some of those can be and you’re blindly putting a tuohy needle with an ongoing CSF leak.

Anatomically, this happens because ligamentum flavum can be variable in certain areas - more so in cervical spine vs lumbar but it can happen. Even under fluoro I never feel the loss yet I’m in the epidural space based on lateral and after injecting contrast voila I’m in the epidural space. It’s quite remarkable how often that happens actually.

Given what you’re describing, I’d just decline. Even if you agree I don’t think many of your partners would want this responsibility.

And yes of course the hospital would like to pawn off this to someone else besides ER. Because no one wants to do these procedures. ER doesn’t either. Hospital wants them done because they make facility fee. IR would be the next best and safest choice IMO.
 
my old practice got consulted for spinals. We did them happily because its such an easy procedure. Mind you, we got 5 units for each LP we did, so that may have added to the willingness to do them.

If youre employed and get no bonus out of it, then this should be discussed and a stipend should be provided. If not, I concur with the others and send them to IR. Should be no pushback from the hospital since then its technically a procedure that can bill a facility fee for.
 
I appreciate the difficult situation that you are in, especially as an employed group. That being said, I’d be very hesitant to bail out the ER- you have no idea what kind of attempts were made prior to your arriving. If there is an IR department, it should be turded to them.

Analogously, every so often, we get asked by the ER to do a blood patch on someone who had a spinal placed by a non-anesthesiologist. We respectfully decline.
 
Lecithin5 said:
I appreciate the difficult situation that you are in, especially as an employed group. That being said, I’d be very hesitant to bail out the ER- you have no idea what kind of attempts were made prior to your arriving. If there is an IR department, it should be turded to them.

Analogously, every so often, we get asked by the ER to do a blood patch on someone who had a spinal placed by a non-anesthesiologist. We respectfully decline.
Click to expand...
"turded" is right.
 
Status Sciaticus said:
my old practice got consulted for spinals. We did them happily because its such an easy procedure. Mind you, we got 5 units for each LP we did, so that may have added to the willingness to do them.

If youre employed and get no bonus out of it, then this should be discussed and a stipend should be provided. If not, I concur with the others and send them to IR. Should be no pushback from the hospital since then its technically a procedure that can bill a facility fee for.
Click to expand...
That sounds horrendous. I am busy enough already. I am not trudging down to the ER so that my day gets screwed up. Send to IR.
 
MoMD said:
Our hospital has asked us to rescue/help our EM and Medicine collegues in event they are not able to get a spinal after they attempt. We are employed so feel somewhat obligated. Do any of you do this? Is it after 1 or 2 attempts by the medicine/EM docs? Do you get a new consent form from the patient or just come in and get access for the then leave? Can we bill from our department seperately?

Thanks in advance!
Click to expand...
Don’t do it. Make it a radiology problem.
 
Mofeen said:
Once got called by an ER attending to do an LP for rule out meningitis. Attending was pregnant and refused to even try out of fear of becoming infected. Thanks, I guess.
Click to expand...
who gets to own the decision if an LP is desired by the medical team if the patient is r/o meningitis on an anticoagulant or a cancer/chemo patient who is neutropenic/thrombocytopenic?
 
Simba1711 said:
Yes I am very wary of helping ed with spinal. They have different NPO guidelines for sedation and will sedate patients who are considered full stomach. Also, I went down to help an ed doc and he was trying to get a lumbar puncture in the thoracic region. I don’t want my name anywhere on that chart.
Click to expand...
It’s interesting IR has their own guidelines for anticoagulants and doing LPs too. I never came across this until IR wanted GA for a mentally unstable person for an LP. They weren’t within the asra guidelines for one of the anticoagulants and I talked with the IR dude who was cool and he said they have their own guidelines. Kind of wowed me. I’ve seen many people come up from the ER after multiple attempts at closed reductions where they essentially had a GA with a full stomach
 
Maverikk said:
It’s interesting IR has their own guidelines for anticoagulants and doing LPs too. I never came across this until IR wanted GA for a mentally unstable person for an LP. They weren’t within the asra guidelines for one of the anticoagulants and I talked with the IR dude who was cool and he said they have their own guidelines. Kind of wowed me. I’ve seen many people come up from the ER after multiple attempts at closed reductions where they essentially had a GA with a full stomach
Click to expand...

Stick to your own society's guidelines. That's what you fall back on if there is ever an issue. I don't care what ER or radiology says about theirs.
 
Dr. Rude said:
who gets to own the decision if an LP is desired by the medical team if the patient is r/o meningitis on an anticoagulant or a cancer/chemo patient who is neutropenic/thrombocytopenic?
Click to expand...
The person doing the procedure. If I'm the intensivist wanting an LP, and I consult IR because the patient just took eliquis this morning, and they say, "cool, we'll tap him first thing tomorrow morning," that's on them.
 
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