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If you think it's SBP then you're doing the para anyway?
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Elective paracentesis
Started by Groove
There's no way in hell I'm taking out 6 liters from someone and just DC'ing without likely giving albumin, watching for significant fluid shift and everything bad than can come with it. I don't care if patient needs to board for what is an elective procedure for IR to do, that's a hospital problem not a me problem. I'm not doing elective procedures in the ED bc the rest of the hospital is dysfunctional. If the hospital is so effed that they regularly need me to do elective paras then that's a place I'm not working at anymore.
To answer OP's question, I only do diagnostic paras to r/o SBP (takes prolly 5-10 minutes with an angiocath). I guess theoretically I'd do therapeutic if there was a patient with tense ascites that looked like it was so big it was causing respiratory issues but haven't seen that in years and years.
Nobody said we don’t give albumin and watch for an hour or so. They either sit in a bed doing nothing contributing to the boarding problem, or we do it, free up beds, and see more patients. We do it in the ED or discharge for an outpatient elective tap. Whether it is a hospital problem or not, the patient still needs help and is using a bed that once done, can help someone else. It is no skin off my back to do a quick, easy procedure when it is convenient in my shift for me, watch them, and move on. Patients certainly appreciate it and like has been previously stated, if it were my family, I would want to get them home as soon as possible too. The acute encounter with the patient isn’t going to solve systemic issues. To be honest, now that I do them often enough, I don’t know why this is so often turfed to IR when it is probably one of the easiest procedures I do and gets the patient home so much faster. Plus, I love when they tell me it was less painful than when IR does it 🤣
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You are being dramatic. 6 liters isn’t a big deal. The reason you don’t want to do them is . . . You don’t want to do them. That is ok. They are a time suck in a busy ED.
I don’t want to do them, either. I can. If I’m not busy I’ll do them, but most of the time it is easier to turf it to IR during the next business hours.
-it does waste a hospital bed
-it does waste a **** ton of money
Welcome to healthcare USA. That is business as usual.
Something I was taught by one attending in residency, a 27g needle is usually sufficient for a diagnostic. The rare times I do them, that's what I use. Just an US to look for a good pocket, a quick poke, I'll admit it can take a minute or two compared to a few seconds for a bigger needle to draw enough up for lab, and then done. Lower risk of persistent leak, hitting a vessel, and I don't anesthetize at all to do it.
Not if I can help it. I've gotten to the point where I just play the dumb and incompetent card and "defer to the experts" i.e. GI/IR for any poking in those gigantic water guts.
"You know...I'll see if I can find a clear window on US to get you a sample but this may be one that needs IR." Click. Admit.
I guess I don't mind so much a simple diagnostic stick but don't ask me to set up shop in one of those rooms and fill up a bunch of jugs like I'm collecting diesel for a bunch of farm equipment. I'm not enabling these people. It's a complete abuse of the ED and curses upon any GI docs sending them to the ER for taps when they could have done it in the office.
CURSES I SAY!
Edit: Hey look....I'm 20 years!
yeah the difference between a diagnostic para--
(1) place POCUS order
(2) stand up, grab US, walk towards room while passing by suture cart.
(3) at suture cart, grab 2 syringes, 2 needs, a bottle of lidocaine, chlorhexidine and a bandage.
(4) Walk in room, slap probe on, one click save image, clean belly, numb, draw off 30mL into a syringe, place bandage on.
(5) label and place in pneumatic tube, send to lab.
I can do that in under 5 minutes every time, including anesthesia and billing it as a POCUS / procedure, and sending my own samples up. Its really very fast, I ALWAYS have time to do a diagnostic para.
AND A THERAPUTIC 6L PARA....
Is 15-30min of additional time / effort, unless you happen to have nurses/students around and willing/able to change out bottles/vacuum. Which I do not.
Along with the additional possible need for monitoring, albumin, yadayada.
Its a very significant difference. I can and occasional DO perform theraputic paracentesis, but its really uncommon. I believe I've said upthread, I've done it for dyspnea and I've done it as a bridge over an XMAS weekend because I have a heart and the patient wants to die at home, etc...
(1) place POCUS order
(2) stand up, grab US, walk towards room while passing by suture cart.
(3) at suture cart, grab 2 syringes, 2 needs, a bottle of lidocaine, chlorhexidine and a bandage.
(4) Walk in room, slap probe on, one click save image, clean belly, numb, draw off 30mL into a syringe, place bandage on.
(5) label and place in pneumatic tube, send to lab.
I can do that in under 5 minutes every time, including anesthesia and billing it as a POCUS / procedure, and sending my own samples up. Its really very fast, I ALWAYS have time to do a diagnostic para.
AND A THERAPUTIC 6L PARA....
Is 15-30min of additional time / effort, unless you happen to have nurses/students around and willing/able to change out bottles/vacuum. Which I do not.
Along with the additional possible need for monitoring, albumin, yadayada.
Its a very significant difference. I can and occasional DO perform theraputic paracentesis, but its really uncommon. I believe I've said upthread, I've done it for dyspnea and I've done it as a bridge over an XMAS weekend because I have a heart and the patient wants to die at home, etc...
CURSES!
I recall the last time I "did" a therapeutic tap. I tapped it, then called the IM admitting team, and had the resident task the intern with changing the bottles!
Ya'll make me question my life choices every day it seems like. I do para's pretty frequently. Especially when they look dyspneic. Bedside US, find the pocket, make the poke, hook up to low suction and have the nurses change the canisters. Take off no more than 4L so no albumin.
That being said I also now work at a place that procedures are reimbursed well.
That being said I also now work at a place that procedures are reimbursed well.
I thought paracentesis rvu was pretty low. Better to just go see an extra patient.
It's 2 wrvu assuming you have the ability to bill for the US use.
I figure a therapeutic para takes me at least 15 min of work. Minimum. Probably closer to 25-30.
I generated 9.6 wrvu/hr last quarter not counting PA supervision.
That means that 2 wrvu for a minimum of 15 min of effort is definitely not helping the bottom line.
Your own efficiency with therapeutic paras and your wrvu/hr might change the math for you.
That may be true at the individual patient level, but if the patient is taking up a bed that could have been used to see 2-3 more patients in the same timeframe it took to board waiting for a bed, not only do you get the two RVUs for the procedure, but the additional RVUs from 2-3 more patients. If someone doesn’t want to do them then just say that or if there is a streamlined workflow to IR then it makes sense to turf it, but unless the hospital has a bunch of empty beds there is no good argument that letting someone take up a bed for >24 hours is good patient care, efficient hospital care, or good for overall ED flow. It is also something you can train the PAs to assist with if it takes too much time for the docs.
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Vet med here just creeping on the human med side. What's y'all's primary causes for peritoneal vs pleural vs pericardial effusions in the ER?
For peritoneal effusions, 90%+ of mine/ours are hemoabs due to ruptured masses (splenic vs hepatic; 75%+ neoplastic). So it's interesting to read y'all don't generally have peritoneal effusions as emergent procedures. Granted, most of these patients are euthanized due to likely cancer and the need for emergency surgery and transfusion. For transudates, it's generally cancer, but less emergent and we don't drain these due to the albumin issue. But these are less common. We see hemoabs probs once to twice a week per doctor.
For pleural/pericardial effusions, mixed bag of transudates vs pyothorax vs hemothorax. Cause is 50% idiopathic vs neoplasia (pericardial in particular). But we definitely tap every single chest with fluid unless euthanasia is the immediate owner choice. In three years since graduation, I have probably tapped a chest a month between pleural and pericardial effusions. So again, it's interesting y'all don't have chests as emergent procedures.
Obvious caveat is my average patient with these concerns is between 25-50+kg. So not quite the same size as your human patients.
Cost overall for chest tap is about 1500-1800ish per incident if a transfusion isn't needed.
For peritoneal effusions, 90%+ of mine/ours are hemoabs due to ruptured masses (splenic vs hepatic; 75%+ neoplastic). So it's interesting to read y'all don't generally have peritoneal effusions as emergent procedures. Granted, most of these patients are euthanized due to likely cancer and the need for emergency surgery and transfusion. For transudates, it's generally cancer, but less emergent and we don't drain these due to the albumin issue. But these are less common. We see hemoabs probs once to twice a week per doctor.
For pleural/pericardial effusions, mixed bag of transudates vs pyothorax vs hemothorax. Cause is 50% idiopathic vs neoplasia (pericardial in particular). But we definitely tap every single chest with fluid unless euthanasia is the immediate owner choice. In three years since graduation, I have probably tapped a chest a month between pleural and pericardial effusions. So again, it's interesting y'all don't have chests as emergent procedures.
Obvious caveat is my average patient with these concerns is between 25-50+kg. So not quite the same size as your human patients.
Cost overall for chest tap is about 1500-1800ish per incident if a transfusion isn't needed.
Awesome, thanks for contributing. The biggest difference is that our patients leave breadcrumbs of chronic disease AND they can actually give us symptoms. 99.9% of pericardial effusions and 95% of pleural effusions are transudative from heart failure. No reasons to touch those with a needle. The rest are either exudative from an obvious pneumonia, or yes, rarely cancerous, but again with known malignancy, or something that will get caught as an outpatient weeks down the road (humans don’t tend to crump from cancer in a week like dogs/cats seem to).
As far as abdominal fluid, in this thread we are talking about the patient with a history of alcohol abuse/cirrhosis, that already has confirmed ascites, or comes in with “hey doc, my belly has been getting bigger”. If they have severe pain, that’s when you tap, but you are generally looking for infection, not blood. We would also CT the patient in severe pain.
Blood in those spaces is obvious because patients either came from a gunfight/MVC, or are in PAIN. I can honestly say I’ve never seen a ruptured spleen or liver from cancer in an human. Either way, CT scan is what we order and the radiologist can generally tell if the fluid is blood or not.
Thanks for the info. Left sided heart failure will fill up a chest, especially in a cat, too. We don't get nearly the same rate of right sided failure though.
I get why y'all don't like these procedures. But tapping 100+ mls off a heart is so satisfying 😍 Granted, I can't do the pericardial window to prevent a repeat offense (regardless of cause). Owners think we're magic so they can decide what they want to do
Well there's also the difference in "i'm sticking a needle in a dog's heart because I do it all as a vet" vs. "I'm doing a pericardiocentesis in the ER on someone's mother because they're actively dying from tamponade and cards can't get here in time." Vet med and human med are very different.
Very aware. Primarily because we will never have the same level of specialization due to cost. The number of people even willing to take their pet to an ER is pretty low. That $110 day fee catches people off guard, and suddenly the coughing can wait till tomorrow for a GP appointment
I think the specter of malpractice as well as the “business of medicine” color our actions where you can practice more pure unobstructed medicine on the animals.
It’s not the specialization alone as I am perfectly capable of tapping any of these areas.
But if anything goes wrong:
“Doctor, are you aware there is a specialty that does these procedures daily in their office?” etc $1M bam
Not to mention they will just keep grinding more out of us the more we do. So I’m likely to be brought someone coding or in resp distress etc while I’m doing one of these procedures and i am single coverage, as many are, at a place that is WAY too busy to be single coverage.
if a -centesis procedure is truly emergent I bite the malpractice and throughput bullet and do it anyway but such a thing is rare. Maybe 1-2/y.
Yes and no.
Because my patients are property, malpractice lawsuits are few and far between, and can really only be for the cost of the care and animal. At least in my state, can't be sued for the emotional distress aspect or anything like that. I carry 1 mil in malpractice cause I'm paranoid; I probably don't need to.
Likewise, I need deposits before I can practice at all. I don't do a lot of unobstructed medicine to begin with because people need to pay a deposit on the diagnostics and treatment before I do any of it. Golden retriever comes in with the pericardial effusion? I can't tap it until the owner gives me the 1500 to do it right off the cuff. I euthanize 70-80% of these patients because the owners don't have 1500 (to start) or they don't like the grave to guarded prognosis of cancer and so euthanize the patient because they won't treat the cancer regardless.
This is the most poignant post on this forum in a good week. Maybe two.
I have a friend that is a vet tech in the PNW. She's crunchy, yes. She used to be in CA. She told me, more than 20 years ago, that there was a lady that paid $20k to have a kidney transplant for her cat at UC-Davis. I said, I don't know how many cats you could rescue for 20k!
But meemaw’s a fighter!
I’m also of the opinion that our pets are non-consenting so this borders on abuse. It opens a can of worms and unanswerable ethical questions, but I would feel like I was abusing my pet if I made them undergo a kidney transplant. They can’t understand what’s happening or why it hurts so badly.
I’m not saying we don’t do forced procedures for their own good frequently (small tumor removal, dental procedures, spay/neuter, even ortho procedures), but there’s definitely a line.
I’m a crazy dog person, I’ve gotten MRI’s for my dogs before. But I’ll be damned if I’m going to turn them into a science experiment because I can’t let go.
Honestly, we need some life in this forum.
I remember being at the vet and overhead a conversation across the room. Vet told dog owner, "we need to keep him overnight, and if something happens do you consent CPR". Owner said OK.
I just could not believe what I was hearing. Sorry, I have a dog, but if they need anything invasive, let them go.
I had a patient come in (I'm family med) for severe anxiety. She was devastated because her "soul mate" (exact phrase she used) was very ill and was probably going to die soon. She had taken him to an acupuncture specialist, and herbal specialist, several other specialists and dietitians, to no avail.
I felt so bad for this poor lady, until she mentioned that her soul mate was "only 8 years old." After mentally preparing what I was going to say to DCF when I called them, I realized that the patient followed that up with, "...and all my other cats lived to be at least 20."
Yes. Her "soul mate" was her cat. And she was spending a lot of money on cat acupuncture, which I didn't know was a thing until then.
This is a huge conundrum in shelter medicine right now. Like, private owner with their own pet, whatever. Spend your money how you want as long as you get informed consent.
But when shelters spend mad money on some animals, I really question the utilization of those funds.
Yeah, agreed. I personally wouldn't recommend something this extensive. And I'm the crazy golden mom who had to tell my husband to not let me do heart surgery on our dog if an incidental tumor was found on a teaching echo at a conference. And I know the stats associated with that! 🤦🏼♀️
Most places don't do open chest CPR. And, not for nothing, CPR is heinously unsuccessful in animals. We're talking 5% or fewer who make it to discharge. I've never personally had a successful code. My recommendation to euthanize comes from the success stats and the fact most of my patients who have coded did so for obvious reasons (hit by car as a prime example) that won't be fixable even if the CPR saves them
This is common. Like. Extremely common compared to what people actually think. I've had multiple welfare checks where I euthanized a beloved pet, and the owners straight up made me concerned for their lives.
On the one hand, makes my job easier because more people are willing to do basic diagnostics like rads and blood work. On the other, it's made the expectations from clients higher in regards to what they think we should be capable of and at what price.
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My wife would tell you that veterinary medicine seems to be pushing in the direction of human healthcare, and not in a good way.
Corporatization (I say as I work for a large corp), insurance, rising cost of healthcare (relatively so), rising standards of healthcare (should a boarded surgeon being doing advanced surgeries compared to GPs or non-boarded ER docs), debt to income ratio (graduate with 300k in loans and start out at 120k/yr), etc. I don't know if I could recommend vet med (doc or tech) to a high schooler right now
The debt to income ratio is insane. There’s a good chance I’d be a vet right now if I didn’t write it off completely once I saw the numbers.
Yeah, we're starting to see more applicants seriously consider the debt ratio when choosing schools over in the pre-vet forums, which is refreshing. The AVMA keeps talking about a vet shortage and I'm like, yeah. Vets are leaving at a fast rate and more and more grads are going either non-clinical or specialist to pay the bills.
I do thoras and paras (somewhat infrequently). But I tend to work at places with limited resources and I'm often doing these as a pallative intervetion on someone with terrible disease, limited life expectancy, and significant poverty. I can do a thora, let them breath a little better and get them home to whatever they like doing before they die in a few weeks to months.
No skin in the game.
These people don't know the value of a dollar because they've never worked for a dollar.
They expect to swipe their Medicaid card and then all the magical CTs and MRIs and same dar SNF placements happen.
