Gastric band adjustment: within our scope of practice?

[gro2001]

Wanted to get a sense of what different people do. Suppose someone with a recent gastric band adjustment comes in and it seems they need to have some fluid taken off (supposing they recently had some fluid added, started vomiting, are now on vacation and can not get to their surgeon so they come to see you). Assuming you were pretty sure there was nothing else going on, is it something you guys would do yourself? Consult surgery for? Transfer if you don't have surgery? Never adjust in the ER?

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[dotcb]

Nope - never. Not an emergency. The patient can call a bariatric surgeon of their choice.

 

[Apollyon]

What? Seriously? Remember what they tell the surgical interns? No NG tube in bariatric patients, at pain of the attending baratrician ripping them a new one?

This is in the same area - really? Adjust a gastric band? And you're not someone the bariatrician knows - you're just joe anonymous ER doc.

Agree with colleague - call their own doc. If their doc is "on vacation", and has no one covering, then that is black-letter abandonment. With bariatric surgery patients, most of them, you will never see, ever - well adjusted, know what they're doing, pseudo-normal. However, with a very few, you will see them ALL THE TIME, and they are as bat **** crazy as anyone you've ever seen.

 

[RustedFox]

In the calm words of Sweet Brown:

...

 

[deleted109597]

It has nothing to do with time.
It's malpractice.

 

[Arcan57]

So you have a patient that's not tolerating PO and has a gastric outlet obstruction. You're cool with sending that out, knowing that it's not going to spontaneously resolve? Also, due to geography, a moderate percentage of our lap band patients had the surgery done in Mexico and the surgeon is never contactable.

If you can't get a surgeon to see the patient and you have the appropriate setup (a non-coring needle like a Huber), you can make their world significantly better by removing all the fluid from the lap band. I wouldn't screw around with trying to fine tune things, just remove it all (which a certain percentage of patients will complain about vociferously), and now they are safe for almost indefinitely delayed follow-up. I've done this multiple times and I've never had the patient's abdomen explode. If you're having difficulty cannulating the port, U/S actually works really well.

 

[deleted109597]

If you can't get a surgeon to see the patient

Uh, does not follow. They're on call. If they don't see it, then who does?


Are you routinely tapping shunts too?

 

[Arcan57]

Uh, does not follow. They're on call. If they don't see it, then who does?


Are you routinely tapping shunts too?

Several posters seemed to be alluding to just sending the patient out into the wind. We have bariatrics on call, and they won't come in to tap a shunt (or agree to admit a patient with a slipped band if removing the fluid gets rid of the obstruction). Our midlevels currently have this on their delineation of privileges, so we can't claim that it's outside of scope of practice from a hospital standpoint.

I would argue that while lap bands are binary for our purposes (either filled or empty), shunts are another beast entirely. I have tapped shunts before (n=2), but as I don't have neurosurgery at my hospital they currently all get transferred downtown.

 

[Janders]

I'm with Arcan on this one. I don't "adjust" lap bands. I will, however, remove all the fluid from a lapband which is fully obstructing a patient (i.e. everytime I swallow 1oz I immediately vomit it, I am getting visibly dehydrated, this has been going on for 2 days!).

Our bariatrics guys will come in for this, but they have trained us to do it. They prefer we do it. Sometimes they are operating at another hospital, and it would take 6+ hours for them to come to us. It is easy. It is within our scope of practice. It bills well. It is NOT a dangerous procedure.

Certainly if you feel uncomfortable, or your hospital privileges don't cover this, I'm not saying you should just be a cowboy and start stabbing people in the gut... but it CAN be done by an ED doc 🙂

 

[Apollyon]

We have bariatrics on call...but as I don't have neurosurgery at my hospital

That seems a little ersatz.

Also, I thought most of bariatrics was a cash business, and those guys are making BANK. As such, I don't know if they should be more responsive, or, alternately, they're making the hospital so much money that everyone else should kiss their asses.

 

[cyclohexanol]

I'm with Arcan on this one. I don't "adjust" lap bands. I will, however, remove all the fluid from a lapband which is fully obstructing a patient (i.e. everytime I swallow 1oz I immediately vomit it, I am getting visibly dehydrated, this has been going on for 2 days!).

Our bariatrics guys will come in for this, but they have trained us to do it. They prefer we do it. Sometimes they are operating at another hospital, and it would take 6+ hours for them to come to us. It is easy. It is within our scope of practice. It bills well. It is NOT a dangerous procedure.

Certainly if you feel uncomfortable, or your hospital privileges don't cover this, I'm not saying you should just be a cowboy and start stabbing people in the gut... but it CAN be done by an ED doc 🙂

+1. My shop has bariatrics on call and they will come in, but have also trained us to remove all the fluid from a lap band for situations mentioned above.

 

[Venko]

I have to admit when I read this I thought it was crazy to suggest that adjusting fluid in a gastric band would be part of our practice. I am thankful to have great access to both in ED consultation and outpatient follow up for patients after bariatric surgery; however, I recognize not everyone is so fortunate.

I'm not sure if others knew about the banding procedure but I only had a casual knowledge, but prompted by this discussion I youtube'd the process of fluid adjustment for the band. I have to say the procedure does look very simple and almost every video showed a PA in bariatric medicine performing the procedure.

I can't say that I've encountered the situation where a patient needs emergent care because of a band that is too tight but at least I will better understand it now. For those who havent seen the procedure done take a look on youtube, and it may soften your skepticism about other EPs doing this.

With that said, I would hate for this to become a routine part of emergent care because I feel as though we should restrict to life and death issues and a bags of saline will eliminate the "dehydration" fear for these patients.

Regardless, I now need to say thank you to the original poster for challenging my way of thinking on this issue...I still wont need to do it, but knock yourselves out so to speak for others.

TL

 

[dotcb]

Vomiting with history of bariatric surgery - at my shop you're going to get labs, a CT, and a surgery consult. I know there is variation out there, but I'd be willing to wager this'd be the norm in most ED's.

Sorry if I seemed dismissive in my prior post - not of post-surgical vomiting, but of adjusting lap bands. Just never heard of a emergency physician doing this before this thread. Not planning to give it a go so far.

 

[Arcan57]

That seems a little ersatz.

Also, I thought most of bariatrics was a cash business, and those guys are making BANK. As such, I don't know if they should be more responsive, or, alternately, they're making the hospital so much money that everyone else should kiss their asses.

They typically have privileges at multiple hospitals and so have no interest in driving in from downtown when draining the reservoir eliminates the problem 90% of the time. We are a "Bariatric Center of Excellence" which is I'm sure why we even have bariatrics on our call panel in the first place.