Emergent EGD

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Has anyone ever had GI actually emergently scope non-variceal UGIB?

I almost tire of calling them because the conversation can be so annoying. The patient is either 'too stable' or 'too unstable' to require EGD. I take a measure of reassurance from that recent RCT showing no benefit to early vs urgent (<24 hr) EGD in UGIB, although they specifically excluded hemodynamically unstable patients.

My recent case was an obvious UGIB from a patient with known gastric telangiectasias that were cryoablated in the past week. She's got melanic diarrhea and BP 70/40. I'm spiking the second unit of RBCs and GI is all ornery about why this patient doesn't need emergent EGD and "what is the hemoglobin?" The absolute kicker was that they recommended NGT placement for diagnostic lavage in case I "wanted to know if the bleeding was active or not".

*sigh*

 

[bravotwozero]

Yeah GI and urology are going to be hands down the most difficult group of consultants to deal with.

At my hospital, the GI group would put on call docs who aren’t even privileged at that hospital!

 

[Vandalia]

At my hospital, the GI group would put on call docs who aren’t even privileged at that hospital!

Brilliant.
Evil .... but brilliant.

 

[PianoMedic]

For our hospital it is doc dependent from what I hear. My n=1 was an unstable UGI without known varices who they did come in middle of the night for. Ended up getting scoped immediately then going to IR as GI couldn’t get control of the bleeding from the GDA that had been eroded into.

 

[thegenius]

Has anyone ever had GI actually emergently scope non-variceal UGIB?

I almost tire of calling them because the conversation can be so annoying. The patient is either 'too stable' or 'too unstable' to require EGD. I take a measure of reassurance from that recent RCT showing no benefit to early vs urgent (<24 hr) EGD in UGIB, although they specifically excluded hemodynamically unstable patients.

My recent case was an obvious UGIB from a patient with known gastric telangiectasias that were cryoablated in the past week. She's got melanic diarrhea and BP 70/40. I'm spiking the second unit of RBCs and GI is all ornery about why this patient doesn't need emergent EGD and "what is the hemoglobin?" The absolute kicker was that they recommended NGT placement for diagnostic lavage in case I "wanted to know if the bleeding was active or not".

*sigh*

yup yup hear it all the time. On some level I understand that they need to sedate pt's for the procedure and giving fentanyl / versed to someone who is 70/30 isn't a good idea.

Right now I don't really care all that much. I don't mind giving more blood, calling the hospitalist and ICU and saying "GI wants pt more stable before scope." Admit.

 

[CajunMedic]

n=1 here as well. Patient had 1200cc of grossly melanotic stool and a dropping BP. They sent their NP down first, who took one look at the patient and called for the attending, and the endo crew. They did their own sedation (we usually do them). I was standing there with airway gear in case they crumped, surgery was there in case they found something that needed to go to the OR, and the ICU crew was standing by to go upstairs as soon as the scope was done.

 

[Angry Birds]

 

[Arch Guillotti]

They did their own sedation (we usually do them). I was standing there with airway gear in case they crumped, surgery was there in case they found something that needed to go to the OR, and the ICU crew was standing by to go upstairs as soon as the scope was done.

In the ED?

 

[southerndoc]

At my hospital, the GI group would put on call docs who aren’t even privileged at that hospital!

Technically an EMTALA violation to do so if there is an emergency requiring their specialty.

Luckily we do not call GI unless it's an esophageal food impaction (they will come in even in middle of night to scope, send back to ER and we discharge) or if it's a very brisk GI bleed. They may not scope, but they come in and personally evaluate the patient within an hour or so. Our GI groups are really good. Two very very large groups (>30 providers each, one has 60+ docs at multiple hospitals).

 

[CajunMedic]

In the ED?

Yep

 

[WilcoWorld]

In the ED?

Yep

GI will scope in my ED as well. They can even dose their own sedation meds. It's wonderful.

 

[sylvanthus]

Ive had them come in in the middle of the night in the icu once. Variceal bleeder. 7 bands.

 

[RoyBasch]

Has anyone ever had GI actually emergently scope non-variceal UGIB?

I almost tire of calling them because the conversation can be so annoying. The patient is either 'too stable' or 'too unstable' to require EGD. I take a measure of reassurance from that recent RCT showing no benefit to early vs urgent (<24 hr) EGD in UGIB, although they specifically excluded hemodynamically unstable patients.

My recent case was an obvious UGIB from a patient with known gastric telangiectasias that were cryoablated in the past week. She's got melanic diarrhea and BP 70/40. I'm spiking the second unit of RBCs and GI is all ornery about why this patient doesn't need emergent EGD and "what is the hemoglobin?" The absolute kicker was that they recommended NGT placement for diagnostic lavage in case I "wanted to know if the bleeding was active or not".

*sigh*

I have basically come to the conclusion in the community that "emergent EGD" for UGI bleeding basically isn't a thing. Same goldi-locks bull****, patient is too stable and doesn't need it or too sick and unstable for (minimally invasive) procedure (that could make them more stable).

95% of the time I do not call gI any more on these cases, it's not helpful.

The only time I call them is when I think the patient has a decent chance of dying. I don't call them because I think they are going to give me a useful recommendation I don't already know or come in to do a procedure. I call them as a medico-legal hedge/chart buff in a case with an anticipated bad outcome. If patient gonna die it's time to load the boat, don't carry that coffin by yourself.

 

[RoyBasch]

yup yup hear it all the time. On some level I understand that they need to sedate pt's for the procedure and giving fentanyl / versed to someone who is 70/30 isn't a good idea.

Most the patients that are this sick I have already intubated and sedated anyways. If they are really worried they can have anesthesia help manage them with bolus sedation + vasopressors to offset any pharmacologic hypotension.

I mean I hear this from other specialists too (patient too unstable for X procedure, cath, bowel resection, whatever). But the logic doesn't really make sense to me.

Like I get it's a high risk procedure. Tell the patient/family there is a risk of complication, death, etc. Document on the chart that you recognize this, whatever. It's not a typical diagnostic scope, cath, laparoscopy, etc.

BUT, the bottom line is, the UNDERLYING REASON the patient is unstable is they have a problem that needs to be fixed by the procedure, and the patient can only be made SO stable until then. I mean you are filling a bucket with a hole here.

Mind you, I'm not completely rash, your GI bleed comes in BP 50/palp and unresponsive, yeah you gotta try to resuscitate them before jamming an endoscope in: A couple units of blood, FFP, plt and an ETT tube can probably get you to a better place of meta-stability to start your procedure. Same idea as resuscitating before you intubate. But at the same time, there is probably an upper limit to HOW stable can you get until the underlying problem is addressed. I have seen GI let bleeds wallow in the ICU all night getting 20units of blood products over several hours. I mean sure start the procedure with a definitive airway and a SBP at least in the 80s, but that may be the best you can get. I don't understand the idea of giving another unit q30 minutes when the pressure invariably drifts down again as infinitum.

 

[thegenius]

Most the patients that are this sick I have already intubated and sedated anyways. If they are really worried they can have anesthesia help manage them with bolus sedation + vasopressors to offset any pharmacologic hypotension.

I mean I hear this from other specialists too (patient too unstable for X procedure, cath, bowel resection, whatever). But the logic doesn't really make sense to me.

Like I get it's a high risk procedure. Tell the patient/family there is a risk of complication, death, etc. Document on the chart that you recognize this, whatever. It's not a typical diagnostic scope, cath, laparoscopy, etc.

BUT, the bottom line is, the UNDERLYING REASON the patient is unstable is they have a problem that needs to be fixed by the procedure, and the patient can only be made SO stable until then. I mean you are filling a bucket with a hole here.

Mind you, I'm not completely rash, your GI bleed comes in BP 50/palp and unresponsive, yeah you gotta try to resuscitate them before jamming an endoscope in: A couple units of blood, FFP, plt and an ETT tube can probably get you to a better place of meta-stability to start your procedure. Same idea as resuscitating before you intubate. But at the same time, there is probably an upper limit to HOW stable can you get until the underlying problem is addressed. I have seen GI let bleeds wallow in the ICU all night getting 20units of blood products over several hours. I mean sure start the procedure with a definitive airway and a SBP at least in the 80s, but that may be the best you can get. I don't understand the idea of giving another unit q30 minutes when the pressure invariably drifts down again as infinitum.

What am I gonna say. I hear you loud and clear. I had this exact patient 1 week ago (well she was 60/30...close enough) with Hg 4.3. She received 3U pRBC, 2U FFP, Vit K, octreotide, protonix, and ceftriaxone. I placed a sterile femoral vein TLC. She was mildly confused but never needed a tube. GI scoped her about 8 hours after she arrived in the ED up in the ICU. She had a duodenal ulcer with arterial bleeding and was clipped 7 times. Never had to tube her though. Never started pressors.

What I noticed though....and I'm beginning to notice this, is that these bleeding cirrhotics tend to perk up quite nicely after receiving blood.

I don't know man. I'm beginning to care less and less about all this crap. I can't force them to come in...all I can do is chart, say I requested a consult, and that's about it.

 

[Arch Guillotti]

I would cry tears of joy if I ever saw GI scope a patient in the ED. Ours want all of them done in the endo suite.

 

[Radetzky]

We generally try convince them to do it in theatre so if endoscopy fails they can get the surgeons in.

 

[HowlPrenderghast]

Oh My God. This is so good and is actually too real.

 

[RoyBasch]

I don't know man. I'm beginning to care less and less about all this crap. I can't force them to come in...all I can do is chart, say I requested a consult, and that's about it.

I mean this is where I'm at it with it to. For the record: I agree with you entirely.


My point is their rationales for not coming in don't really make sense medically. They are what they are--rationales to justify lazy behavior, not what is in the best interests of patients.

I also resent the backpedaling that occurs when bad outcomes do happen and the aforementioned specialists/proceduralists try to throw the ER physicians (the physicians who actually SAW the patient I may add) under the bus and try to argue semantics. "Well the ER physician didn't really comprehend and explain the gravity of the situation, if they had, OF COURSE I would have come running."

Of course you can dispassionately document your concerns and suggested behaviors till you're blue in the face. Problem is you are in a disagreement with a specialist the hospital fundamentally values more than you and is more willing to accept their version of events regardless of what is documented. Milage may vary when these things come to blows regardless of what was actually said/done.

 

[thegenius]

I mean this is where I'm at it with it to. For the record: I agree with you entirely.


My point is their rationales for not coming in don't really make sense medically. They are what they are--rationales to justify lazy behavior, not what is in the best interests of patients.

I also resent the backpedaling that occurs when bad outcomes do happen and the aforementioned specialists/proceduralists try to throw the ER physicians (the physicians who actually SAW the patient I may add) under the bus and try to argue semantics. "Well the ER physician didn't really comprehend and explain the gravity of the situation, if they had, OF COURSE I would have come running."

Of course you can dispassionately document your concerns and suggested behaviors till you're blue in the face. Problem is you are in a disagreement with a specialist the hospital fundamentally values more than you and is more willing to accept their version of events regardless of what is documented. Milage may vary when these things come to blows regardless of what was actually said/done.

I agree.

 

[old_boy]

I can't force them to come in...all I can do is chart, say I requested a consult, and that's about it.

Actually, you probably can if they are part of your ED call panel. EMTALA requires on-call physicians for the ED to help stabilize emergency medical conditions when asked. When there is a discrepancy between the ED and on-call physician as to if an in-person consultation is indicated, legal precedent supports the physician caring for the patient, i.e. the ED physician. Most medical staff bi-laws also say something to this effect - i.e., when requested to consult, an on-call physician must do so within "a reasonable amount of time". If you stick to your guns and put your foot down, you can in fact force the GI consult to come in, see the patient, and write in the chart that he/she doesn't believe an emergent scope is indicated.

Obviously, this "nuclear option" is a last resort and the blowback may not be worth it depending on the case. In the short-term hospital admin will have your back if your GI consultant refuses to come in and you stick to your guns. We don't technically have GI on call in my hospital, but we've had multiple cases in the past few years in my ED that have been escalated to the CMO of other consultants refusing to consult, and in each case the ED physician has "won" and the consultant has come in. But nobody comes out looking good in these cases, and ultimately an ED physician that is unliked by consultants and hospital admin and repeatedly pulls this move for BS will be managed off the schedule.

 

[thegenius]

No no no...you don't get it. I cannot FORCE the doctor to come in. I literally cannot FORCE. I can request, I can say everything you wrote above, but GI can elect not to come in.

Of course we all know that if there is a bad outcome the GI doctor will be in trouble.

 

[southerndoc]

No no no...you don't get it. I cannot FORCE the doctor to come in. I literally cannot FORCE. I can request, I can say everything you wrote above, but GI can elect not to come in.

Of course we all know that if there is a bad outcome the GI doctor will be in trouble.

You can mention that EMTALA requires them to come see the patient. If they elect not to, then they will have a short-lived career at your hospital. The reasonable amount of time is defined by hospital bylaws. In most hospitals, it's within 6 hours. If it's 2 am, well, they're seeing them in the morning when they come round.

 

[thegenius]

You can mention that EMTALA requires them to come see the patient. If they elect not to, then they will have a short-lived career at your hospital. The reasonable amount of time is defined by hospital bylaws. In most hospitals, it's within 6 hours. If it's 2 am, well, they're seeing them in the morning when they come round.

Yea I'm aware of that.

I'm a little surprised that hospital bylaws require consults for emergency medical conditions be allowed to take up to 6 hours. Kind of defeats the purpose. Critical limb ischemia causes irreversible damages at 6 hours. A testicle can only survive with minimal to no blood flow for 6 hours.

 

[southerndoc]

Yea I'm aware of that.

I'm a little surprised that hospital bylaws require consults for emergency medical conditions be allowed to take up to 6 hours. Kind of defeats the purpose. Critical limb ischemia causes irreversible damages at 6 hours. A testicle can only survive with minimal to no blood flow for 6 hours.

Critical/unstable patients usually have a 1-2 hour response time. Most hospitals won't deviate from that globally because they don't want to shoot themselves in the foot in case a specialist is tied up in a procedure, there are communication issues, traffic, etc.