Further testing? Or proceed to OR?

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TIVA

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Right, interesting case today in our ambulatory surgicenter ...

75 y.o. male about to under GA for endoscopic sinus surgery.

Surgeon is very good and experienced. Patient not seen in our pre-op clinic. History of AAA repair, CEA, prior small MI years ago, COPD with PFT's in chart showing "severe obstructive ventilatory defect," on home oxygen at night, and diabetes. ROS positive for poor functional status (METS < 4), SOB with minimal exertion, 2 pillow orthopnea. Exam significant for poor A/E, mild end expiratory wheeze, no JVD, no ankle swelling, RRR. Airway exam looks good (MC I, edentulous). EKG shows QW in II, III, and aVF. Labs (CBC, LFT's, Coags, Chem) all normal.

If I'm not mistaken, ACC/AHA guidelines suggest that anyone with poor functional status and intermediate clinical predictors automatically buys them further cardiac workup.

We discuss our concerns with the surgeon who says, "what about doing a MAC and we'll put local in."

Pop quiz, hot shots ... what do you do ...

Do you agree to proceed to OR and do GA?

Or do you agree with the surgeon's plan and aim to do a MAC anesthetic?

Or do you refer the patient for further testing?

I'll let you guys know what we ended up doing after some discussion.
 
Give me something that requires some thinking....

Go STRAIGHT to OR....

INDUCE GA immediately.....

otherwise...your senior partners will have you on the launching pad to your next job...(one of my prior members would delay this case and order more test......result....myself or another partner would take over case....ultimate result....looking for a new job....which requires reference from old job.....how do you like that?)
 
and read the ACC/AHA guidelines one more time..and see what it says about low risk surgery.
 
MAC with local sounds ******ed; you have to be prepared to put this guy to sleep if push comes to shove. H/O MI in the past with risk factors (DM, COPD &#8211;smoker), poor functional status, signs of left heart failure. How well is this guy managed? Is he beta blocked, on an ACE-I, statin, diuretics, etc? Functional status poor due to angina? Stable or unstable? It seems this guy needs a little tune up prior to an elective sinus case. Sestamibi scan vs treadmill? Dobutamine echo? ----academic center

Screw it, prop/sux/tube. ----private sector
 
tick... tick... tick... tick... tick... tick... BOOM!
 
Identical case....pt had a similiar cardiac history, minus the COPD and home O2...post op MI, settled for 800,000 just 7 weeks ago....Another partner, not even involved in the case...nurse wrote Dr x ok'd EKG....was named for 700,000. Pt went home 8 days later, but with a sig reduced EF, and was stented.

If I'm in the room, I'd do the case, knowing that if anything goes wrong...i'm fugged....Low risk case, but high risk pt that is not appropriately worked up according to the Eagle guidelines(AHA/ACA).

Fortunately, I work for a gas group with some nuggets, and the surgeons here would never even consider bringing that case to the OR without talking to you.They know it is getting cancelled.

For most low risks patients, undergoing low risk surgery...the most stressful part of the operatoin is putting that tube throug someone's cords...The amt of stress there...you can control...I do get nervous occassionally when I have to cover a CRNA in such a setting, and I'm not around in the room that often.
 
One more time....read the guidelines again....if reading is too difficult for you ACADEMIC type worried about getting sued (you get sued whether you're right or wrong....you lose whether you're right or wrong....getting sued and losing is a fact of life in high risk medicine..)

Then here is a picture to look at....look at step 6
fig1na7.jpg
 
somebody like that would be done in our asc....even with a good surgeon under mac.
i'd be too concerned about his orthopnea (two pillows ??!!) and have the case done in our hospital, surgeons and my partners would play along.
i fully buy in the concept of keeping surgeons happy and the business rolling, but above patient is too much....
fasto
 
Perhaps it is you who should learn to read....follow your alog.....leads right to testing...idiot.....and I'm not saying that is what I would do, but if you want to be a tough guy trash talker, read yourself.

get a life as well....look at your number of posts....
 
Start in box one....the kid asked a legitimate question....I am not at an academic center......small hospital with 11000 +/- cases per year....cases like this come up everyday.....if you want to be a jack A$$ about it, you're gonna get called one......

This case could be no more clear and cut to proceed to further testing, and that is the question.....not who has big enough balls to do the cass without testing......I now remember why I haven't been on this site in a while.....
 
s204367 said:
Perhaps it is you who should learn to read....follow your alog.....leads right to testing...idiot.....and I'm not saying that is what I would do, but if you want to be a tough guy trash talker, read yourself.

get a life as well....look at your number of posts....
Click to expand...


Hey *****,

Step 6 ...the arrow on the right...or perhaps you have right sided hemianopsia?

Not talking trash.....I'm giving you the scoop on what's up and coming....you can stick with what you learned in residency....and stay there or you can move on....
 
militarymd said:
Give me something that requires some thinking....

Go STRAIGHT to OR....

INDUCE GA immediately.....

otherwise...your senior partners will have you on the launching pad to your next job...(one of my prior members would delay this case and order more test......result....myself or another partner would take over case....ultimate result....looking for a new job....which requires reference from old job.....how do you like that?)
Click to expand...

We all know how brilliant you are but do you really need to be such a hard-on? The guy is asking a legitimate question to generate some discussion. Perhaps this could be a learning experience for some of the less erudite. Nice posting of the AHA/ACC guidelines, BTW.
 
militarymd said:
Hey *****,

Step 6 ...the arrow on the right...or perhaps you have right sided hemianopsia?

Not talking trash.....I'm giving you the scoop on what's up and coming....you can stick with what you learned in residency....and stay there or you can move on....
Click to expand...

😕
ummm the case that TIVA posted clearly states the patient has poor functional capacity ( METs <4) which according to ACC/AHC guidelines requires further noninvasive testing in patients who have intermediate clinical predictors. Right there in black and white slick...
 
i see step 6, met<4 --> invasive testing
hemianopsia? not the last time i got checked
do i agree with "invasive testing" NO! since when does a coronary stenosis mean tissue hypoxia?!!
mibi scan will give you much better info 😉
 
step 6 reads like this.
if intermediate predictors exist and it is not a low risk surgery use the METS to move down the tree.

if it is a low risk surgery bypass the METS and go to OR.

does this help out?
 
Hopefully by now you have read the charts again...and maybe even again, and then maybe even read the paper. Next time, before an idiot like yourself rants on some naive guy asking a serious question, pull your head out of your A$$. You just made yourself look like a complete fool. Arguing a point you are clearly wrong on. Asking others to learn to read, when it is in fact you than can not read.

Perhaps you will be at the next ASA, and I can tell you in person what an arrogant, yet stupic fu%# you are...I'm guessing you trained in a little country off the coast of S America. Perhaps a drop out from some other field back in the day when the field of anesthesiology would take anyone with a pulse. Who knows, but clearly you are an intellectual *****, and an A$$ on top of that.

Here is the quote from page 19 of the Eagle report: perhaps you can read this.....

“In any patient with an intermediate clinical predictor, the presence of either a low functional capacity or high surgical risk should lead the consulting physician to consider noninvasive testing.”

This guy has major clinical predictors,(or do I have to pull these from the paper too), let alone intermediate predictors.

I use to tell my surgical colleagues that the guidelines are clear and easy to follow. Apparrantly not..
 
dhb said:
hemianopsia? not the last time i got checked
Click to expand...

Maybe i should check again 🙂 did miss that right sided arrow!
Anyway why does everyone agree that you can conduct your anesthesia in many way but people go crazy over pre-op testing? if it suits you and your surgeon then why not? you're screwed anyway you go if you hit a bump
 
step 6 reads like this.
if intermediate predictors exist and it is not a low risk surgery use the METS to move down the tree.

if it is a low risk surgery bypass the METS and go to OR.

does this help out?
 
s204367 said:
Hopefully by now you have read the charts again...and maybe even again, and then maybe even read the paper. Next time, before an idiot like yourself rants on some naive guy asking a serious question, pull your head out of your A$$. You just made yourself look like a complete fool. Arguing a point you are clearly wrong on. Asking others to learn to read, when it is in fact you than can not read.

Perhaps you will be at the next ASA, and I can tell you in person what an arrogant, yet stupic fu%# you are...I'm guessing you trained in a little country off the coast of S America. Perhaps a drop out from some other field back in the day when the field of anesthesiology would take anyone with a pulse. Who knows, but clearly you are an intellectual *****, and an A$$ on top of that.

Here is the quote from page 19 of the Eagle report: perhaps you can read this.....

"In any patient with an intermediate clinical predictor, the presence of either a low functional capacity or high surgical risk should lead the consulting physician to consider noninvasive testing."

This guy has major clinical predictors,(or do I have to pull these from the paper too), let alone intermediate predictors.

I use to tell my surgical colleagues that the guidelines are clear and easy to follow. Apparrantly not..
Click to expand...

Here we go again....insecure, inexperienced, medical legal minded but not MEDICALLY minded ....only in the OR anesthesiologists who confuse TESTING with THERAPY...who insist on wasting money....I'll stop with the descriptions.......calling me names because.....why? I don't know.

Once again, I implore you to read the ENTIRE document as I have done multiple times...as I have reviewed with residents multiple times when I used to train residents ( 5 years worth )..

Look at the diagrams....

and MOST importantly ....pull the references....obviously you have not done that....I guess you didn't have the luxury of being an academic for a while before moving on....so you're kind of stuck with what you only learned durning residency.

You don't work in a group with "nuggets" as you call it....you work in a group where you guys are stagnant.....ready for an AMC to come and take over.....

Testing is all good and fine IF MONEY is not an issue....unfortunately money IS an issue.....

When you order unncessary tests as you appear to insist on, all you do is waste money....

The money the government is allocating to healthcare is of a finite amount....and it just gets moved around...as with the current medicare budget....reassignments of RVU's....raising reimbursements to some ...lower others....which by the way still affects anesthesia.

Overtime, silly unncessary tests like you want to order for LOW RISK surgery will ultimately impact your bottom line....

but I guess you don't care....you know it all already....and I trained in S. American where I needed a translator to do my preops....but then I don't order any tests, so it doesn't matter.


Look at the the patient's history again....there are NO modifiable risk factors....unless you want to offer a CABG or STENT before a LOW risk procedure.....and if you actually read the GUIDELINEs (not STANDARDS...I assume you know the difference)....then you know what it says about offering a CABG or STENT to get a patient through a LOW RISK Surgery.

Go ahead and call me some more names.....I've heard them all from juniors like you.
 
In the surgery center setting, surgeon springs this pt. on ole zip at 0730 and the case will get cancelled. Our surgeons won't do this because they want to make money. The ASC preop nurse will get pt's chart about 4 days in advance and show it to me. I'll tell her get clearance from cardiologist. No clearance, pt doesn't go to surgery; written clearance and we go. We don't phuck around with that algorithm box shiit - life's too short! ---Regards --Zippy
 
The reference I have at hand is the "ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive Summary" from Anesthesia & Analgesia 2002.

This document lists "head & neck surgery" as intermediate risk, but "endoscopic procedures" as low risk.

So ... this guy's getting a FESS, which is ... low risk? Or does that broad "head & neck" label trump the endoscopic label and make it intermediate risk? Seems a bit much to call a 15 minute nasal rotorooter job anything other than low risk.

s204367 said:
This guy has major clinical predictors
Click to expand...
No, he doesn't. No acute/recent MI, no unstable or severe angina, no decompensated heart failure, no valvular disease, and no significant arrhythmias.

He does have an old MI and diabetes, which are intermediate predictors.


Intermediate clinical predictors + low risk surgery = OR

Intermediate clinical predictors + not-low risk surgery + <4 METs = noninvasive testing


So back to the surgery - is it low risk or not?
 
Perhaps "endoscopic" procedures mean EGDs and colonoscopies. Last time I checked, Fesses are done by "head and neck" surgeons. ---Zip
 
threepeas said:
step 6 reads like this.
if intermediate predictors exist and it is not a low risk surgery use the METS to move down the tree.

if it is a low risk surgery bypass the METS and go to OR.

does this help out?
Click to expand...

That's how I read it.
 
Zip brings up an interesting point: the cardiologist clearance. Who cares if the cards note says "avoid hypotension" or "keep SBP 120-130?" If this patient was "cleared" by a cardiologist and he still had an MI on the table isn't the anesthesiologist still at fault and just as prone to litigation? It's not as if the clearance is a get out of jail free card. Anyone cancelled a case on a train wreck patient even though they had "cardiac clearance?"
 
1) you commit malpractice as defined by the law...meaning you deviated from accepted STANDARD of care AND the patient suffered harm

2) You were an ass to the patient, and the patient decides to take it out on you when something bad happens....which will happen no matter how good you are.


Number 2 happens much more frequently than 1...

The reason why S2349765109's partner who got sued AND lost was most likely related to Assholish behavior that the physician had with the patient along with a bad outcome.....

Bad outcomes are unavoidable...They WILL happen no matter what test you order...

Assholish behavior towards patients.....well that's avoidable ...unless you join a group of dinguses who have "nuggets" and brags about their "nuggets" on the internet.....then it is kind of hard not to become one of them.
 
the operative (pun intended) word here being "elective" procedure. if you think there's even a remote chance that ole grandpa is going to buy the farm, it really doesn't matter how much of an a-hole you were to him afterwards - you better have at least had a nice conversation with the family before you take him to the OR. maybe you've never seen a "low risk" FESS bleed. then again, as i've said before, maybe our surgeons just suck more than the rest.

tick... tick... tick... tick... tick... tick...tick... tick... tick... BOOM! (or maybe not)
 
VolatileAgent said:
the operative (pun intended) word here being "elective" procedure. if you think there's even a remote chance that ole grandpa is going to buy the farm, it really doesn't matter how much of an a-hole you were to him afterwards - you better have at least had a nice conversation with the family before you take him to the OR. maybe you've never seen a "low risk" FESS bleed. then again, as i've said before, maybe our surgeons just suck more than the rest.

tick... tick... tick... tick... tick... tick...tick... tick... tick... BOOM! (or maybe not)
Click to expand...

In private practice, 99% of cases are elective.

There is a remote chance for the ASA1 buying the farm....and it is MUCH more important to have the conversation about "buying the farm" with the family of the ASA 1 then the ASA 4..

And yes, during residency the FESSes bleed all the time, but in PP with my ENT's.... a FESS is a 10 minute procedure which is essentially a glorified nose picking done with a LMA.

That's anothy thing that junior's will/should learn when they finish their residency.....Surgical risks include how good your surgeon is.

The ACC Guidelines are broad strokes which do not take into account your surgeon's skill.

For the same procedure, I have a surgeon who I will order NO tests...while for another guy who comes on a different day....I will order a type and cross match.

At the end of the day.....none of this matters........what matters is who gets sued.....and it's usually the dingus who gets sued...not the nice incompetent boob.
 
Furthermore, the guy gets a GETA period. I have little trust in surgeons. With a mac the surgeon may hit a bleeder and blood goin' down pharnx and pt coughs unexpectantly while surgeon has the scope near his brain. Now scope is in frontal brain-- can you say PITH. With 30 pts from 7-12 in an ASC, Zip ain't got no time to monkey around on the telephone, ordering tests and foolin' around with algorithm boxes. I need something written(not verbal) from the specialist preferably or his primary stating that he's "optimized" or "cleared" for the surgery. Juries and pts like shiit like this. I tell the pt and their families that I got ya cleared by the special expert heart doctor and the heart doctor said you're good to go. Boils down to the ASC is your stage and ya better do an academy award performance in front of your pts. Regards ---Zippy
 
Man I love these threads! Getten hot and heavy baby.

Step 6 does shunt you right into the OR for a low risk surgical procedure. Its ultimately your call however. If you feel you can do the case based on your prior experience then do it. If you feel that the case presents difficulty beyond your skills and with the current set up (non invasive monitoring ie. A-Line) then pass it along. What kind of insurance did he have? J/K

Even if the guy has METS<4 but is otherwise a functional old fella then what's the revascularization ultimately gonna do for this guy? He just needs medical management. I believe the risk of morbidity and mortality from an angio and stenting (Or, GASP, A friggen CABG) is far greater compared to an endoscopic surgery.

Somebody has been following this patient which is FAR better then the stuff that fly's at us at the university. Holy cow.

Tomorrow's case: AVR for Aortic regurg secondary to endocarditis from av fistula graft seeding. Pt has ESRD, AIDS, HEPB, AIDS wasting syndrome, Gastroparesis with a G-tube, Seizure disorder, hx of pancytopenia, among other things. I just CANT WAIT to stick him with all those needles tomorrow....

I'll take the endoscopic sinus surgery any day.
 
Hey Mil, even before I read your response I could have predicted what you would do. Hey I know you are smart and its your clinical call but could you please show some BASIC politeness in your responses? Is that so hard to do? 😡 BTW I am only a resident but I would politely disagree with proceeding to OR and inducing GA in this pt ..I read that flow chart and see your point but in my limited experience the guy gets further workup..Peace

militarymd said:
Give me something that requires some
thinking....

Go STRAIGHT to OR....

INDUCE GA immediately.....

otherwise...your senior partners will have you on the launching pad to your next job...(one of my prior members would delay this case and order more test......result....myself or another partner would take over case....ultimate result....looking for a new job....which requires reference from old job.....how do you like that?)
Click to expand...
 
You guys are looking at the first simplified chart that Military has put up...It is a good first approach...but jesus, read the paper...read the paper...read the paper......below is cut and pasted....read the paper...read the paper..can i say it again.....read the paper....

Here is only one portion.....read it, and go back and read the paper.....that means pretty much all of you here.........You can practice however you want....but if you belittle someone else, when nfact you are misrepresenting a paper......kiss off

Military...did you not read this in the paper???? OR did I cut this out of some other paper?? Hmmmm...I guess I can read..next time you tell me to read the paper....get your crap together....you are like most people that run around quoting papers with no idea what they really say.

The following is a cut and paste from the article...can you read where it says...intermediate risks, MET<4 proceed to further testing?

"The preoperative guidelines (ACC/AHA) are fairly straightforward about recommendations for patients about to undergo emergency surgery, the presence of prior cardiac revascularization, and the occurrence of major cardiac predictors. However, the majority of patients have either intermediate or minor clinical predictors of increased perioperative cardiovascular risk. Table 5A presents a shortcut approach to a large number of patients in whom the decision to recommend testing before surgery can be difficult. Basically, if two of the three listed factors are true, the guidelines suggest the use of noninvasive cardiac testing as part of the preoperative evaluation. In any patient with an intermediate clinical predictor, the presence of either a low functional capacity or high surgical risk should lead the consulting physician to consider noninvasive testing. In the absence of intermediate clinical predictors, noninvasive testing should be considered when both the surgical risk is high and the functional capacity is low. The guidelines define minor clinical predictors as advanced age, abnormal ECG, rhythm other than sinus, history of stroke, or uncontrolled systemic hypertension. These factors do not by themselves suggest the need for further testing, but when combined with low functional capacity and high-risk surgery, they should lead to consideration of preoperative testing. In making the decision to obtain noninvasive testing, there will occasionally be some practical circumstances when testing will be obtained after surgery, particularly if the results will not affect perioperative care. This test information may also be useful in predicting long-term risk of cardiac events (also see Section X). More specifically, identification of high-risk patients whose long-term outcome would be improved with medical therapy or coronary revascularization procedures is a major goal of preoperative noninvasive testing. Numerous studies using different preoperative noninvasive techniques before noncardiac surgery have demonstrated the ability to detect patients at increased risk of late cardiac events (254,261,265,267-270) (see Figure 2).

Table 5. Shortcut to Noninvasive Testing in Preoperative Patients if Any Two Factors Are Present

1. Intermediate clinical predictors are present (Canadian class 1 or 2 angina, prior MI based on history or
pathologic Q waves, compensated or prior heart failure, diabetes, or renal insufficiency)
2. Poor functional capacity (less than 4 METs)
3. High surgical risk procedure (emergency major operations*; aortic repair or peripheral vascular surgery;
prolonged surgical procedures with large fluid shifts or blood loss)

HF indicates heart failure; METs, metabolic equivalents; MI, myocardial infarction.
Modified with permission from: Leppo JA, Dahlberg ST. The question: to test or not to test in preoperative cardiac risk evaluation. J Nucl
Cardiol. 1998;5:332-42. Copyright &#169;1998 by the American Society of Nuclear Cardiology. This material may not be reproduced, stored
in a retrieval system, or transmitted in any form or by any means without the prior permission of the publisher.
*Emergency major operations may require immediately proceeding to surgery without sufficient time for noninvasive testing or preoperative
interventions.

If you read the entire paper, rather than the first chart presented..there is no argument here.....yes, military, we can argue over whether or not to do it...and on that, 90% of the time, I agree with your style of practice....but don't tell me to read the paper, the references, etc...when i noe this paper better than most........
 
Ahh. Another one of those cases where our beloved guidelines let us down, or confuse the issue further. The more I use the ACC/AHA guideline, the more I come across patients who straddle categories, or who do not fit into the nice little boxes. This is where one has to remember that the guidelines are nothing more than GUIDELINES. There is, IMHO no substitute for clinical expertise and good, sound reasoned decision making. We are all specialists here, or trainee specialists. While I'm not suggesting that we toss the guideline completely, I do think that blind reliance on a revered document is dangerous. We are, after all not "barefoot doctors".
 
I'm really curious about something. So your a PP attending, who used to be an "academic", and now you openly criticize the academic perspective. Why are you hanging around a resident forum and bashing residents?



militarymd said:
Give me something that requires some thinking....

Go STRAIGHT to OR....

INDUCE GA immediately.....

otherwise...your senior partners will have you on the launching pad to your next job...(one of my prior members would delay this case and order more test......result....myself or another partner would take over case....ultimate result....looking for a new job....which requires reference from old job.....how do you like that?)
Click to expand...
 
I wouldn't do further preop testing, but at the same time, I am not sure I would proceed with the case either. If after interviewing the patient he seems that he is 'as good as he gets' then I don't see what preop testing would do. Like someone else mentioned, you wouldn't do a preop CABG on this guy.

Anyhow, I would probably take into account the capabilities of the surgeon and the surgery center and proceed if I had confidence in their abilities as well as have a honest conversation with the patient about the risks in the procedure. (Obviously)
 
I'd do the darn case, but I'd do it in the hospital... if things go south, at least there is somewhere to put him instead of having to call an ambulance to pick him up.

Bottom line... if I dont do the case, I dont get paid.
 
GasEmDee said:
I'm really curious about something. So your a PP attending, who used to be an "academic", and now you openly criticize the academic perspective. Why are you hanging around a resident forum and bashing residents?
Click to expand...

Because the "academic perspective"....or at least what residents get out of it....when they come fresh out of residency and go straight into PP.....is causing problems for our specialty......read about post of mine.


Where am I basing residents? post my link where I bashed a resident.

First VERY "bashing" came from a junior attending who thinks he knows it all because he cited a snippet of text that I have discussed with MY residents ad nausem.....and then discussed some more after pulling at ACTUAL references and reading them.

Why do I post?

I'm an educator at heart....but the current education SYSTEM is one that I am not happy with....so I make my $ and hopefully influence some up and coming physicians here.
 
Our residency training programs don't do our specialty justice.

I'll bet s23459789 came from a program where the attendings think that patients come to the hospital to get ANESTHESIA......they probably delayed cases...make the surgeons wait...cancelled cases...because money wasn't an issue...

And now that he's finished residency....rather than additional "tempering" of his skills and knowledge...he's probably buying a fancy new car to go on ski vacations....or spending an ungodly amount of money buying diamonds for his trophy wife...

Well....all beside the point.

The guidelines are 4 years old....a revision is needed...and remember these are GUIDELINES..not STANDARDS.

If you read the guidelines and references carefully....there are inherent discrepancies...as in many other guidelines (ASA OB on NPO status).....there are things written not clarified....

just like what s23435 quoted....one snippet...read the rest of it....look at the diagrams....read the references.....

bottomline:

LOW RISK SURGERY REQUIRES NO TESTING.
 
s204367 said:
You guys are looking at the first simplified chart that Military has put up...It is a good first approach...........

If you read the entire paper, rather than the first chart presented..there is no argument here.....yes, military, we can argue over whether or not to do it...and on that, 90% of the time, I agree with your style of practice....but don't tell me to read the paper, the references, etc...when i noe this paper better than most........
Click to expand...

This is the problem when you have junior anesthesiologists reading these "guidelines".

You focus on when to TEST....when to CANCEL...when to DELAY part of the articles...

You don't read the part where it says "exercise judgment"...you don't read the part where it presents data on risk in LOW RISK SURGERY.

You don't combine the simplified diagram with the text.

That little arrow on the right side of Step 6 exists because in the discussion on surgical risk, Warner (Mayo) clinic presents data from over 10,000 patients undergoing low risk surgery and compared to a cohort not undergoing surgery....

As long as you focus on the section on testing, you will find reasons to order tests...not reasons to exercise judgement and do your job.
 
Noyac,
You are right....guy is a tool, and simply not worth replying too...was written in the haste..
 
Hey junior,

I'm here posting opinions....

You're here calling people names....and boasting about your "nuggets"....

I'm here posting about interpreting a set of guidelines..

You're here calling people names....

I'm sticking to my initial point...go to the OR...

You're here calling people names....

and most importantly...you're now changing you're tune.

Cancel first.....now you say go to the OR....

OK...you're GOD....I'm nobody....

but let's get it clear who's being an ass.
\
 
s204367 said:
This discussion was never about to do the case or not...simply, what do the guidelines suggest..Yes, only guidelines..Like I said..I do the case...like I said, the guidelnies require further testing......

.
Click to expand...

Require?????

and these "required" tests makes it "safer" for these patients????

that's right...I'm a schmuck.

Stick with fancy cars and ski vacations....stick with the expensive diamonds for your trophy wife....

Don't call people names on the internet.
 
There is nothing wrong with not agreeing with another physician's opinion, but to start calling them names is just juvenile.....

s23435.....did you starting calling your oral board examiners names when they suggested or stated something that you didn't agree with....

If you did...and you passed....then I would have to say you were very lucky.

But you probably only call people names in anonymous forums like this, and you real life you're probably much more agreeable.
 
Here is the first jackass comment that was made here........and it was by you

This is the first inflicting message on this post, placed by yourself.....let me repeat..if reading is too difficult.........

"One more time....read the guidelines again....if reading is too difficult for you ACADEMIC type worried about getting sued (you get sued whether you're right or wrong....you lose whether you're right or wrong....getting sued and losing is a fact of life in high risk medicine..)

too difficult.....

Tell you what, go back to academic medicine...you can run your mouth there all day and tell others how bright you are, as you seem to do here(>3,000 posts). Those people may actually listen to you, and give a crap about what you have to say....TO me, you sound like a complete ass on most of your posts....


Post whatever you want in reply...I've wasted too much time here already, and won't be ckecking back...Do me a favor, next year at the ASA...Columbia always has a reunion party...Come find me, it'll be easy, and we will see how anonymous I am...
 
s204367 said:
Here is the first jackass comment that was made here........and it was by you

This is the first inflicting message on this post, placed by yourself.....let me repeat..if reading is too difficult.........

"One more time....read the guidelines again....if reading is too difficult for you ACADEMIC type worried about getting sued (you get sued whether you're right or wrong....you lose whether you're right or wrong....getting sued and losing is a fact of life in high risk medicine..)
.................
Post whatever you want in reply...I've wasted too much time here already, and won't be ckecking back...Do me a favor, next year at the ASA...Columbia always has a reunion party...Come find me, it'll be easy, and we will see how anonymous I am...
Click to expand...

I can't help myself.....you have been very entertaining. My remarks maybe sarcastic and to the point, but I did not call you any names...nor did I insult you.

You obviously come from a family of wealth and influence....I'll bet you're probably Dr. s2353456365 "THE THIRD" or something like that....

Got school all paid for by daddy and drove some fancy BMW during school and residency while everyone else scrapped by with debt.

I'll even bet your daddy is disappointed with you for not being a REAL doctor like a cardiologist or surgeon....so you take it out here by calling people names when someone who doesn't agree with you give a little sarcasm.........typical rich kid behavior.

Tell us....did you do this at your orals???? and did they let you pass your orals with this behavior?

I won't post again if you don't.....

and I'll ride your ass any chance I get...because you insulted me for no reason.
 
VentdependenT said:
Even if the guy has METS<4 but is otherwise a functional old fella then what's the revascularization ultimately gonna do for this guy? He just needs medical management. I believe the risk of morbidity and mortality from an angio and stenting (Or, GASP, A friggen CABG) is far greater compared to an endoscopic surgery.

.
Click to expand...

Revascularzation just adds extra risks. Remember stents will occlude if off antiplatelet drugs. You gonna do this FESS with the pt on plavix?😱 Otherwise, you are waiting 3 months to 1 year dependingon the stent placed.

Go to the OR.
 
and clearly states how you feel about the field of anesthesiology.......WTF is the matter with you....come by that reunion....
 
First off...Military is a joke...I have read your posts here often...Your posting above is your typical BS

Second, the other guy is right...I helped edit some of that paper as a medical student...It CLEARLY states that a patient such as the first listed should be CONSIDERED for further testing. Now, in PP, most wouldn't. Hopefully this patient would not show up without proper workup. but yes, this is exactly the pt that should get worked up...It is clear in writing..and yes, in the stupid man's algorithm..that would be table 5..look it up....you obviously do not think it is necessary, nor do I, but that is NOT the point..The point is, the paper clearly states that this pt PROBABLY should get a non diagnostic test.....not a cabg, not a stent....

to s12093 whoever, don't get sucked into a fool like military duds antics..he is an insecure bitter, and proabably poor clinician liked by few surgeons, feels shorted by life, as evident from the post above about rich boy status.....

btw i trained at Columbia, but do not know s383248, and from looking at his posts think i was there a few years ahead of him.....

but jeses military...your last post...delete that thing, it is an embarrassment
You obviously come from a family of wealth and influence....I'll bet you're probably Dr. s2353456365 "THE THIRD" or something like that....


by military........
"Got school all paid for by daddy and drove some fancy BMW during school and residency while everyone else scrapped by with debt.

I'll even bet your daddy is disappointed with you for not being a REAL doctor like a cardiologist or surgeon....so you take it out here by calling people names when someone who doesn't agree with you give a little sarcasm.........typical rich kid behavior.

Tell us....did you do this at your orals???? and did they let you pass your orals with this behavior?"

military, 12/14/2006
 
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