How much of your practice is CYA?

[SurfingDoctor]

I've known this for quite some time, but he really came to a head today. We had a kid (<10 years old) more or less dying of COVID and sepsis with significant myocardial depression (x3 vasoactives). All the services were consulted when the patient arrived the night prior. I was getting signout from the junior attending who informed me, amongst other things, that the consultant services were "weighing the idea of IVIG". Granted, I think there is a lot of voodoo in IVIG, but when it comes to myocarditis... I have seen it work (and it is the mainstay in pediatric myocarditis NOS). Anyway, I was like to the junior attending "Weighing what? How much the funeral will cost? I'm just gonna give it" and put the order in.

And then it kinda struck me, they were afraid of a lack of consensus and go ahead from the consultants who at home and weren't actively watching a child circle the drain. They were practicing straight CYA medicine, ie they were afraid to make decisions that consultants wouldn't give a stamp of approval. And then I realized, literally none of the consultants were providing any help whatsoever and their "opinion" or lack thereof was possibly detrimental to the care of the patient. Again, this wasn't an epiphany so much as watching junior attendings cower to they consultants because a democratic decision was better than good judgement.

This isn't to throw other consultants nor my colleagues under the bus so much as it has become more prevalent in my field to defer to subspecialist who when most needed are incapable of pulling the trigger on anything. But in times of crisis... sometimes you just need leadership and decisions to be made. But people are afraid to do so if they think the consultants would disagree. Anyway... kinda of a vent and maybe its specific to pediatrics, but annoying all the same.

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[Siggy]

Everyone once in a while you end up surprised. I had a 40s status asthmaticus. several weeks on the vent, on steroids, lengthy period paralyzed. He was only able to move his fingers and wrist, so I consulted neuro. I even joked around about the reason being for them to tell me that my Dx of critical illness myopathy was correct. ...then his acetylcholine receptor antibody came back positive.

The more I practice, the more I realize that a lot of "CYA medicine" is really just an appropriate workup and treatment. Sure, ordering a TSH and T4 for severely hypertensive patients or tachycardic patients may seem CYA... but every 2-3 years one of those are going to come back with thyrotoxicosis and suddenly you're a baller for a shift.


In a similar vein, at least for IM, I feel like IM has a bit of a prestige problem. I've always been struck by the amount of internists who seem to think that they aren't specialists in internal medicine... and thus can't do anything without a different specialist holding their hand. Ya'll are specialists... ya'll are experts. It's OK to use that expertise to treat patients outside of consult orders.

 

[The kitchen sink]

I've known this for quite some time, but he really came to a head today. We had a kid (<10 years old) more or less dying of COVID and sepsis with significant myocardial depression (x3 vasoactives). All the services were consulted when the patient arrived the night prior. I was getting signout from the junior attending who informed me, amongst other things, that the consultant services were "weighing the idea of IVIG". Granted, I think there is a lot of voodoo in IVIG, but when it comes to myocarditis... I have seen it work (and it is the mainstay in pediatric myocarditis NOS). Anyway, I was like to the junior attending "Weighing what? How much the funeral will cost? I'm just gonna give it" and put the order in.

And then it kinda struck me, they were afraid of a lack of consensus and go ahead from the consultants who at home and weren't actively watching a child circle the drain. They were practicing straight CYA medicine, ie they were afraid to make decisions that consultants wouldn't give a stamp of approval. And then I realized, literally none of the consultants were providing any help whatsoever and their "opinion" or lack thereof was possibly detrimental to the care of the patient. Again, this wasn't an epiphany so much as watching junior attendings cower to they consultants because a democratic decision was better than good judgement.

This isn't to throw other consultants nor my colleagues under the bus so much as it has become more prevalent in my field to defer to subspecialist who when most needed are incapable of pulling the trigger on anything. But in times of crisis... sometimes you just need leadership and decisions to be made. But people are afraid to do so if they think the consultants would disagree. Anyway... kinda of a vent and maybe its specific to pediatrics, but annoying all the same.

It’s trending towards this nowadays. Consultants are afraid to commit, or assume any ownership of the patient and it is too the detriment of patient care.

It leaves the intensivist out on an island.

And I am not sure the courts would protect us either.

 

[The kitchen sink]

Everyone once in a while you end up surprised. I had a 40s status asthmaticus. several weeks on the vent, on steroids, lengthy period paralyzed. He was only able to move his fingers and wrist, so I consulted neuro. I even joked around about the reason being for them to tell me that my Dx of critical illness myopathy was correct. ...then his acetylcholine receptor antibody came back positive.

The more I practice, the more I realize that a lot of "CYA medicine" is really just an appropriate workup and treatment. Sure, ordering a TSH and T4 for severely hypertensive patients or tachycardic patients may seem CYA... but every 2-3 years one of those are going to come back with thyrotoxicosis and suddenly you're a baller for a shift.


In a similar vein, at least for IM, I feel like IM has a bit of a prestige problem. I've always been struck by the amount of internists who seem to think that they aren't specialists in internal medicine... and thus can't do anything without a different specialist holding their hand. Ya'll are specialists... ya'll are experts. It's OK to use that expertise to treat patients outside of consult orders.

Some hospitalist in my part have difficulty making actively dying pts DNR/DNI or comfort/hospice. Usually its a stat ICU consult at 2 am during the rapid response 🤣

 

[chessknt]

I've known this for quite some time, but he really came to a head today. We had a kid (<10 years old) more or less dying of COVID and sepsis with significant myocardial depression (x3 vasoactives). All the services were consulted when the patient arrived the night prior. I was getting signout from the junior attending who informed me, amongst other things, that the consultant services were "weighing the idea of IVIG". Granted, I think there is a lot of voodoo in IVIG, but when it comes to myocarditis... I have seen it work (and it is the mainstay in pediatric myocarditis NOS). Anyway, I was like to the junior attending "Weighing what? How much the funeral will cost? I'm just gonna give it" and put the order in.

And then it kinda struck me, they were afraid of a lack of consensus and go ahead from the consultants who at home and weren't actively watching a child circle the drain. They were practicing straight CYA medicine, ie they were afraid to make decisions that consultants wouldn't give a stamp of approval. And then I realized, literally none of the consultants were providing any help whatsoever and their "opinion" or lack thereof was possibly detrimental to the care of the patient. Again, this wasn't an epiphany so much as watching junior attendings cower to they consultants because a democratic decision was better than good judgement.

This isn't to throw other consultants nor my colleagues under the bus so much as it has become more prevalent in my field to defer to subspecialist who when most needed are incapable of pulling the trigger on anything. But in times of crisis... sometimes you just need leadership and decisions to be made. But people are afraid to do so if they think the consultants would disagree. Anyway... kinda of a vent and maybe its specific to pediatrics, but annoying all the same.

I think it is a stretch to say it is a clear good decision to start throwing random unproven medicines at people who are dying. Not to say I haven’t done it in other cases but with COVID I have never seen any of these salvage therapies do literally anything. Preparing everyone for death is a better use of the energy by letting them know the standard of care has been delivered and u fortunately was not enough.

 

[SurfingDoctor]

Well, none of ended up mattering. They went on ECMO today in near arrest. Of course, IVIG didn’t make a difference and chances are they will die in the next couple days, but I stand by original position.

I’m also generally full court press for any kid who was leading a relatively normal life besides nature intervening and saying otherwise. I’ll do whatever I can and let the cards fall where they may.

Anyway…

 

[Katheudontas parateroumen]

Well, none of ended up mattering. They went on ECMO today in near arrest. Of course, IVIG didn’t make a difference and chances are they will die in the next couple days, but I stand by original position.

I’m also generally full court press for any kid who was leading a relatively normal life besides nature intervening and saying otherwise. I’ll do whatever I can and let the cards fall where they may.

Anyway…

We need more people like you.

 

[chessknt]

Well, none of ended up mattering. They went on ECMO today in near arrest. Of course, IVIG didn’t make a difference and chances are they will die in the next couple days, but I stand by original position.

I’m also generally full court press for any kid who was leading a relatively normal life besides nature intervening and saying otherwise. I’ll do whatever I can and let the cards fall where they may.

Anyway…

I don't think not offering IVIG in a septic dying COVID flogged patient is not full court press. With a 50-80% mortality rate in my intubated patients I have absolutely accepted that it is going to do what it wants with very minimal input from me. Patients and their families dont have that level of acceptance because they have seen as many people die from it as I have and part of my job is to try to help bring them there when it is looking like that will be the case. It is a viral systemic illness for which there is no therapy. Many people have died from it. Being ventilating for however many days and given a shot at survival is full court press.

 

[SurfingDoctor]

I don't think not offering IVIG in a septic dying COVID flogged patient is not full court press. With a 50-80% mortality rate in my intubated patients I have absolutely accepted that it is going to do what it wants with very minimal input from me. Patients and their families dont have that level of acceptance because they have seen as many people die from it as I have and part of my job is to try to help bring them there when it is looking like that will be the case. It is a viral systemic illness for which there is no therapy. Many people have died from it. Being ventilating for however many days and given a shot at survival is full court press.

While they have COVID, their blood culture from a port came back positive with staph epi and strep pneumoniae. They also probably a component of strep meningitis.

I didn’t know that when I had the initial conversation regarding IVIG and the hesitation from others to give it. Either way, yea generally speaking the physiology will either get better or it won’t irrespective of the “supportive care” we offer. But it’s not my kid dying in the bed either, and I’m willing to do whatever to see if I can move the needle. But if others disagree so be it…