ethics q: you're an attending and...

[Winged Scapula]

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I think the benefit of this thread is not one of ethics or the fantastical scenario....

Rather, I encourage all pre-meds to actually learn what different specialties do and how the arrived at that ability. It is far too uncommon for the public (and pre-meds) to be so confused. TV programs and what-not promote such a confused message. Give you some examples:

1. President mentioned pediatricians removing tonsils...
2. A lay-person once expressed they thought "cardiologists" did heart surgery
3. lay person once expressed expectation that gastroenterologist would perform anti-reflux (Nissen) procedure.
4. all the TV shows in which someone plunges large needle in center of chest of dying patient....

list goes on and on....

You and I must have been posting the above thoughts at the same time.

It is easy to be confused. We see this every day in practice. Just two weeks ago I had a patient's friend (accompanying her for "the cancer talk") tell me that a cardiologist (although supposedly a PhD doing post-doc research on some cardiac devices per the daughter, also in the room) and Ob-Gyn made different recommendations than I had. I was firm, but polite, when I suggested that they were free to seek second opinions but that I would encourage them not to take advice from two people, physicians or not, on treatment they had never done, and possibly never seen. I would not give them advice on the best anti-hypertensive or how to manage endometriosis.

The EM forum is full of posts from excited pre-meds who want to be trauma surgeons and want to know which EM program is the best. If our dear president can't even get it right, how do we expect anyone else to?

So yes, our future colleagues: please take heed and understand who does what, so you aren't consulting the gastroenterologist to perform the colon resection or the general surgeon to manage your patient's renal stones.

 

[Winged Scapula]

How about this for a scenario. You're an intern from another hospital visiting a friend. You've done 5 Lap Appys, and a patient comes in with a ruptured appendix.

Here's the kicker. A pride of lions has come into the hospital and cornered all the surgeons. On top of that, a freak accident involving surgilube and some prostitutes has taken out the landline... and oddly enough there's no cellphone reception. Oh yeah. The ambulances have been stolen by rogue ninjas, and there's a really vicious snapping turtle guarding the only entrance accessible without trying to outrun lions.

Now THERE'S a scenario I can get behind.

Ok, ruptured appy?

I'd run the patient down to IR (since they seemed to have escaped the pride of lions and snapping turtles) and have a drain put in under CT guidance, start antibiotics and admit the patient for observation.

What? You say its 4:00 pm on Friday, IR has left and there's a massive recall on antibiotics?

Then as an intern I'm probably more comfortable doing an open appy than a lap appy and that's what I'd do as I understand the OR nurses have all come down with a terrible case of gonorrhea (something about the missing surgilube) and there is no one to hold the camera for me.

And THEN I'd start looking for another job and posting my thread in the Gen Res Forum about being terminated from residency for my cowboyish-ness. 😀

 

[Laryngophed]

How about this for a scenario. You're an intern from another hospital visiting a friend. You've done 5 Lap Appys, and a patient comes in with a ruptured appendix.

Here's the kicker. A pride of lions has come into the hospital and cornered all the surgeons. On top of that, a freak accident involving surgilube and some prostitutes has taken out the landline... and oddly enough there's no cellphone reception. Oh yeah. The ambulances have been stolen by rogue ninjas, and there's a really vicious snapping turtle guarding the only entrance accessible without trying to outrun lions.

 

[Charles_Carmichael]

How about this for a scenario. You're an intern from another hospital visiting a friend. You've done 5 Lap Appys, and a patient comes in with a ruptured appendix.

Here's the kicker. A pride of lions has come into the hospital and cornered all the surgeons. On top of that, a freak accident involving surgilube and some prostitutes has taken out the landline... and oddly enough there's no cellphone reception. Oh yeah. The ambulances have been stolen by rogue ninjas, and there's a really vicious snapping turtle guarding the only entrance accessible without trying to outrun lions.

Okay, that situation is completely unrealistic. If ninjas really stole the ambulances, you wouldn't know that they were ninjas. That's the true mark of a good ninja; they're essentially invisible. So it's more likely that the ambulances were stolen by non-ninjas, possibly pretending to be ninjas. This would make the situation more plausible.

 

[JackADeli]

How about this for a scenario. ...You're an intern from another hospital visiting... You've done 5 Lap Appys, and a patient comes in with a ruptured appendix.

...[no] surgeons. ....[no] landline... and ...there's no cellphone reception. [no] ambulances ....

This one is easy, IR perc drain.... If radiologist were taken out by "the public option".... even easier...

IV antibiotics for 9 months; it's good enough for Australia and NASA, then good enough for me.😱

JAD

 

[Compass]

How about this for a scenario. You're an intern from another hospital visiting a friend. You've done 5 Lap Appys, and a patient comes in with a ruptured appendix.

Here's the kicker. A pride of lions has come into the hospital and cornered all the surgeons. On top of that, a freak accident involving surgilube and some prostitutes has taken out the landline... and oddly enough there's no cellphone reception. Oh yeah. The ambulances have been stolen by rogue ninjas, and there's a really vicious snapping turtle guarding the only entrance accessible without trying to outrun lions.

You feed the prostitutes to the lions, and have the surgeons do the surgery. Problem solved.

 

[dienekes88]

This one is easy, IR perc drain.... If radiologist were taken out by "the public option".... even easier...

IV antibiotics for 9 months; it's good enough for Australia and NASA, then good enough for me.😱

JAD

Now THERE'S a scenario I can get behind.

Ok, ruptured appy?

I'd run the patient down to IR (since they seemed to have escaped the pride of lions and snapping turtles) and have a drain put in under CT guidance, start antibiotics and admit the patient for observation.

What? You say its 4:00 pm on Friday, IR has left and there's a massive recall on antibiotics?

Then as an intern I'm probably more comfortable doing an open appy than a lap appy and that's what I'd do as I understand the OR nurses have all come down with a terrible case of gonorrhea (something about the missing surgilube) and there is no one to hold the camera for me.

And THEN I'd start looking for another job and posting my thread in the Gen Res Forum about being terminated from residency for my cowboy-ness.

pwned! 😱

From this day forward, I will forever associate OR nurses with gonorrhea. Better start stockpiling the Ceftriaxone!

 

[Depakote]

How about this for a scenario. You're an intern from another hospital visiting a friend. You've done 5 Lap Appys, and a patient comes in with a ruptured appendix.

Here's the kicker. A pride of lions has come into the hospital and cornered all the surgeons. On top of that, a freak accident involving surgilube and some prostitutes has taken out the landline... and oddly enough there's no cellphone reception. Oh yeah. The ambulances have been stolen by rogue ninjas, and there's a really vicious snapping turtle guarding the only entrance accessible without trying to outrun lions.

how many of those lap appys were on already ruptured appendixes?


edit: wow, missed a few posts, must not a have refreshed

 

[Winged Scapula]

pwned! 😱

From this day forward, I will forever associate OR nurses with gonorrhea. Better start stockpiling the Ceftriaxone!

To be fair, JAD and I have practice with the American Board of Surgery oral examination which presents scenarios JUST as implausible as the ones painted here. We had to be ready for anything.

 

[Compass]

To be fair, JAD and I have practice with the American Board of Surgery oral examination which presents scenarios JUST as implausible as the ones painted here. We had to be ready for anything.

Oh God, we're on a plane! Someone's got a ruptured appendix! Lucky for you, there's a sterile room already set up! The only thing you need to worry about is TURBULENCE!

That was actually IN a video game I played. The first time I did it, I poked a hole in the person with the sonogram Q.Q

 

[Laryngophed]

Oh God, we're on a plane! Someone's got a ruptured appendix! Lucky for you, there's a sterile room already set up! The only thing you need to worry about is TURBULENCE!

That was actually IN a video game I played. The first time I did it, I poked a hole in the person with the sonogram Q.Q

Rough day in the simulator?

 

[JackADeli]

To be fair, JAD and I have practice with the American Board of Surgery oral examination which presents scenarios JUST as implausible as the ones painted here. We had to be ready for anything.

I didn't want to let on to early in my exam how spectacular I was... so I held back when asked what I would do if a patient had a heart attack and my arms were both in casts from my MVA while racing 500 class at laguna seca.....

After they hounded me, I took the "Chicago Hope" example.... I said, "Sir, I could lean over this table, remove your heart and put it back in your chest working better then before with only your ballpoint pen between my teeth and my hands tied behind my back...."

They nervously leaned forward, shook my hand, and said, "your the kind of go-getter we look for in this club".... they seemed to completely forget that the question was about appendicitis....

JAD

 

[Rendar5]

There are only two surgical procedures I'd ever expect an EM physician to do off the top of my head. Cross-clamping aortas and perimortem C-sections. And the times when an EM physician should even consider doing the former are extremely extremely limited (and never in my case as my program no longer train thoracotomies at my program).

The only specific scenario I've heard of where it made sense to me (and I'd be surprised if this ever happened again): rupturing AAA, pt coded and revived (with neurologic status no less) once already, in-house vascular surgeon aware of pt, EM attending experienced in thoracotomies, pt coded again.

 

[JackADeli]

There are only two surgical procedures I'd ever expect an EM physician to do off the top of my head. Cross-clamping aortas and ...And the times when an EM physician should even consider doing the former are extremely extremely limited (and never in my case as my program no longer train thoracotomies at my program).

Yep.... I have heard numerous scenario attempts in discussions in which EM physicians & residents tried to develop a justification for cross-clamping.... in the absence of a surgeon!!! They kept saying it "might" help to crossclamp before 45 minute transfer!!!! I have actually received a patient they cross-clamped at a community hospital and flown in 90 minutes so we could remove clamp and allow patient to "full arrest" (completely dead organs below diaphragm). Unfortunately, autopsy showed patient had NO intra-abdominal trauma that would warrant a cross-clamp at a level I center let alone 90 minutes away.

It was one of those shining examples of "doing the wrong thing seemed better then doing nothing". The ED physician just didn't get it. They kept trying the "I was just trying to do everything possible"...."it would be unethical if I never tried"....

 

[Rendar5]

.

 

[just one]

Practicing without insurance huh, is that even legal?

Either way, that's cruel but I understand where you're coming from. I just don't think too many of us could sit there and watch a guy bleed to death when we know exactly what we "should" be doing to help him.

Yes it is legal, scary but legal. All you have to do is notify each and every patient before treatment that you do not have malpractice insurance. An attending ER physician informed me of this, he has a relative that does this, and I was shocked.

 

[Compass]

Rough day in the simulator?

Definitely. I managed to get an S ranking on it eventually, though!

 

[greatnt249]

Yep.... I have heard numerous scenario attempts in discussions in which EM physicians & residents tried to develop a justification for cross-clamping.... in the absence of a surgeon!!! They kept saying it "might" help to crossclamp before 45 minute transfer!!!! I have actually received a patient they cross-clamped at a community hospital and flown in 90 minutes so we could remove clamp and allow patient to "full arrest" (completely dead organs below diaphragm). Unfortunately, autopsy showed patient had NO intra-abdominal trauma that would warrant a cross-clamp at a level I center let alone 90 minutes away.

It was one of those shining examples of "doing the wrong thing seemed better then doing nothing". The ED physician just didn't get it. They kept trying the "I was just trying to do everything possible"...."it would be unethical if I never tried"....