How would you do this case?

[deleted162650]

However, strict catholic doctrine is not compatible with withdrawing care or having a real-deal goals of care discussion if literally anything and everything can be done to prolong life.

I’m sorry, but this is 100% false. I can’t tell you a damn thing about any other religion’s end-of-life teachings, but it is 100% acceptable under Catholic doctrine to withdraw care. Allowing someone to die is not the same as killing them in the eyes of the Catholic Church. I may not be the most devout guy out there, but after 9 years of Catholic school, I know what I’m talking about here. But please atheist, educate me some more on Catholic teachings.

Frequently Asked Questions About End-of-Life Care

Download PDF | Spanish Version What is the difference between a hospital and a hospice? A hospital is for patients seeking medical treatment to cure their illness or injury. A hospice is for patients who have a terminal illness, who have suspended curative efforts and who want to die in a...

www.cacatholic.org

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Members don't see this ad.

 

[vector2]

I’m sorry, but this is 100% false. I can’t tell you a damn thing about any other religion’s end-of-life teachings, but it is 100% acceptable under Catholic doctrine to withdraw care. Allowing someone to die is not the same as killing them in the eyes of the Catholic Church. I may not be the most devout guy out there, but after 9 years of Catholic school, I know what I’m talking about here. But please atheist, educate me some more on Catholic teachings.

Frequently Asked Questions About End-of-Life Care

Download PDF | Spanish Version What is the difference between a hospital and a hospice? A hospital is for patients seeking medical treatment to cure their illness or injury. A hospice is for patients who have a terminal illness, who have suspended curative efforts and who want to die in a...

www.cacatholic.org

You know what you’re talking about in regard to your narrow slice of interpretation and the one website you quoted. The funny thing about Christianity, Catholicism, and religion in general that apparently you don’t seem to get is that intepretations of doctrine are highly personal, variable, and subject to debate. There are people who got an abortion and still identity as catholic or evangelical. There are people who eat bacon cheeseburgers but still identify as Jewish. The fact that catholic doctrine (per your link) mandates a feeding tube unless the patient is essentially dying in the next 5 minutes or doesn’t have a digestive tract should inform you about the kinds of choices many Catholics make when faced with dnr vs full code or trach peg vs no trach peg decisions.

Ultimately, I really don’t give two fcks what you’re posting when the son of my patient told me to my face that withdrawing would be anathema to his and his father’s beliefs. Does that make them less catholic in your 9-years-of-catholic-school-educated opinion?

 

[nimbus]

You know what you’re talking about in regard to your narrow slice of interpretation and the one website you quoted. The funny thing about Christianity, Catholicism, and religion in general that apparently you don’t seem to get is that intepretations of doctrine are highly personal, variable, and subject to debate. There are people who got an abortion and still identity as catholic or evangelical. There are people who eat bacon cheeseburgers but still identify as Jewish.

Ultimately, I really don’t give two fcks what you’re posting when the son of my patient told me to my face that withdrawing would be anathema to his and his father’s beliefs. Does that make them less catholic in your 9-years-of-catholic-school-educated opinion?

As a reformed Catholic and product of Catholic schools myself, I think your patient’s son misunderstood Catholic teaching on withdrawal of care in end of life situations. I currently work in a Catholic hospital and while we don’t do tubal ligations, elective abortions, or administer contraceptives, we withdraw care all the time.

 

[vector2]

As a reformed Catholic and product of Catholic schools myself, I think your patient’s son misunderstood Catholic teaching on withdrawal of care in end of life situations. I currently work in a Catholic hospital and while we don’t do tubal ligations, elective abortions, or administer contraceptives, we withdraw care all the time.

Many of these folks (including my patient’s son, I think) already mostly have a preconceived notion of what they think end-of-life care should entail and then use their religious beliefs to enforce these notions. My pt’s son used to say over and over how strong his dad was and how much of a fighter he was...you can just imagine how he felt after months of his dad hanging around- having survived big surgeries, fighting off a ton of minor problems, receiving a bazillion pints of blood- that a small cough and fever was the thing that was bringing him down. He just couldn’t accept it.

That being said, perhaps the Catholic Church does accept withdrawing care in particular circumstances, but take a look at the vagueness of the following

“For instance, Catholics have a moral obligation to use "ordinary or proportionate means" of preserving their lives, if the means provides a "reasonable hope of benefit and do not entail an excessive burden, or impose excessive expense on the family or the community" (ERD 56). If the patient feels the benefits are not reasonable, or entail an excessive burden, he or she may forgo those means (ERD 57).”

Furthermore, take a look at what the US conference of catholic bishops wrote less than 10 yrs ago:

“While medically assisted nutrition and hydration are not morally obligatory in certain cases, these forms of basic care should in principle be provided to all patients who need them, including patients diagnosed as being in a “persistent vegetative state” (PVS), because even the most severely debilitated and helpless patient retains the full dignity of a human person and must receive ordinary and proportionate care.”

When you have a group of people who think that trach/peg’ing a vegetable somehow maintains human dignity, who is to say that my pt’s son was wrong to think trach/peg for his father was anything but “ordinary?” The question is not whether withdrawing care is compatible with Catholicism- it’s whether one can say that prolonging life in such a miserable fashion is expressly not compatible, which opens up a whole can of philosophical No-True-Scotsman problems . Obviously we can’t say that considering many Catholic websites and leaders have had to go out of their way to clarify and dispel myths and to say that things such as DNR and palliative care have become acceptable in the last 30 yrs even though they were unacceptable for a whole slew of Catholics for the preceding 300 yrs.

 

[deleted162650]

Ultimately, I really don’t give two fcks what you’re posting when the son of my patient told me to my face that withdrawing would be anathema to his and his father’s beliefs. Does that make them less catholic in your 9-years-of-catholic-school-educated opinion?

Relax dude. You're going all Antifa on me. I would never claim to be more Catholic than anyone, and I certainly am not trying to tell you what your patient and his family's beliefs were. I'm just pointing out that his beliefs are not the official teaching of the Roman Catholic Church as you erroneously extrapolated them to be. Just trying to enlighten you on that point. Consider yourself woke.

 

[vector2]

Relax dude. You're going all Antifa on me. I would never claim to be more Catholic than anyone, and I certainly am not trying to tell you what your patient and his family's beliefs were. I'm just pointing out that his beliefs are not the official teaching of the Roman Catholic Church as you erroneously extrapolated them to be. Just trying to enlighten you on that point. Consider yourself woke.

The pt’s son beliefs (by way of his father also when he still had decision making capacity) to keep transfusing blood for months on end, intubate, and trach/peg are literally all things that are compatible with the catechism statements about euthanasia and end of life care, especially the more mundane procedures and treatments that simply sustain basic bodily functions regardless of prognosis. In regard to coding and DNR, you make a fair enough point and what I said about life being mandated ‘at all costs’ is inaccurate considering the 50-something Catholic son could’ve changed his beliefs and made his 80-something Catholic father DNR based on the directives published less than 10 years ago. Mea culpa.

Also bro those are some hilarious “you’re a lib” burns. Very fresh. Those and the rest of your always sarcastic posts totally don’t make you look like a perpetual try-hard snarky b*tch.

 

[Mikkel]

IR is obviously a better option if the lesion is well past the duodenum/proximal jejunum. But the patient still needs an upper and lower GI for the initial screening and they very well may find angiodysplasias in the visualized colon or duodenum. Only once that's negative will they get a pill cam and/or tagged RBC scan/multiphase CT with contrast if a GI bleed is still the presumed diagnosis. Even then, identifying a tiny bleeder in the IR suite with fluoro is a huge pain.

In CCM fellowship, I had a pt s/p old AVR now with prosthetic stenosis (not eligible for ViV tavr) that was in the SICU for 9 months out of my 12. He would receive 1u of blood every 4-5 days d/t GI bleed. An area that was probably identified as the culprit on RBC scan couldnt be reached with scope or identified with fluoro. Surgery wouldnt operate and the pt's son wouldnt agree to surgery anyway. They were extremely catholic and would not deal with palliative either. So he would bleed, we would give blood, and such was life. He ended up dying of pneumonia right before I left.

As far as the case in question, I don't think slow propofol is the worst idea if this was just a screening colonoscopy. Slow propofol is a bad idea when you know the case is minimum going to be a double plus possible push plus possible multiple coags or epi injections. I honestly don't care that I might looks like a dunce if it's a quick in and out both top and bottom and I did geta for a nothing case. But its certainly going to be the safest thing for the patient if the case turns into a 1hr+ odyssey of the GI tract.

You're a CCM fellowship trained anesthesiologist but you're not aware of palliative options for Catholic patients? They're against euthanasia, but that's about it.

You've never done 2+ hour MAC cases for GI docs before? I have, just hook em up to a pump and take care of your email.

 

[MoMoGesiologist]

I don’t think @vector2 is saying Catholicism is against comfort care, just that in this instance, this family considered doing everything (trach, PEG, etc) consistent with their view of their faith. We have all had those patients. I’ve never tried to talk to a patient and correct them on how their interpretation of faith is wrong, even if it would be better for the patient to be hospice care

 

[vector2]

You're a CCM fellowship trained anesthesiologist but you're not aware of palliative options for Catholic patients? They're against euthanasia, but that's about it.

I never really ask the patients faith and usually dont know unless they voluntarily provide it. Everyone in the ICU is offered spiritual, psychological, palliative care (depending on presumed prognosis, debility, and comorbidities), and eventually a discussion with an organ procurement counselor. Whether they accept all these services is up to the pt and their families.

You've never done 2+ hour MAC cases for GI docs before? I have, just hook em up to a pump and take care of your email.
]

Are you dense or just antagonizing for kicks? Deliberately planning a 2 hr-likely-intervention-heavy propofol MAC (which as we know many times are really unprotected-airway general) for a severe AS pt in the GI suite of all places would be pretty damn stupid.

 

[Mikkel]

Are you dense or just antagonizing for kicks? Deliberately planning a 2 hr-likely-intervention-heavy propofol MAC (which as we know many times are really unprotected-airway general) for a severe AS pt in the GI suite of all places would be pretty damn stupid.

I have done plenty of 2-3 hour MAC GI cases, including interventions, including prone, including ERCP, most of whom were sick as s***, with no problems other than what you would expect.

Propofol, by itself, is extremely well tolerated.

I think it's stupid for you to assume that the way another anesthesiologist practices is by default "stupid" based only on your past experience in your bubble.

 

[Mikkel]

I don’t think @vector2 is saying Catholicism is against comfort care, just that in this instance, this family considered doing everything (trach, PEG, etc) consistent with their view of their faith. We have all had those patients. I’ve never tried to talk to a patient and correct them on how their interpretation of faith is wrong, even if it would be better for the patient to be hospice care

I've had patients of the atheist faith with their kooky beliefs and practices, who are also against palliative care, DNR status, etc.

 

[vector2]

I have done plenty of 2-3 hour MAC GI cases, including interventions, including prone, including ERCP, most of whom were sick as s***, with no problems other than what you would expect.

Propofol, by itself, is extremely well tolerated.

I think it's stupid for you to assume that the way another anesthesiologist practices is by default "stupid" based only on your past experience in your bubble.

I honestly dont think you know what you're talking about when it comes to sedating pts with severe stenotic lesions, cause they're not the same as whatever run of the mill 'sick as ****' cirrhotic or biliary obstruction you're sedating for an endo/ ERCP.

But anyway, you're free to play GI mac roulette with your patients' lives if you wish. Hell, you can even do an upper esophageal impaction without an ETT and I won't stop you. You'll probably get away with your risky plans most of the time because major events even in sick patients are still relatively rare, and thus your confirmation bias that nothing bad ever happens will continue. Me, on the other hand, I prefer (and am paid) to do the things safely, not be a cowboy or the GI docs whipping boy.

 

[Mikkel]

I honestly dont think you know what you're talking about when it comes to sedating pts with severe stenotic lesions, cause they're not the same as whatever run of the mill 'sick as ****' cirrhotic or biliary obstruction you're sedating for an endo/ ERCP.

But anyway, you're free to play GI mac roulette with your patients' lives if you wish. Hell, you can even do an upper esophageal impaction without an ETT and I won't stop you. You'll probably get away with your risky plans most of the time because major events even in sick patients are still relatively rare, and thus your confirmation bias that nothing bad ever happens will continue. Me, on the other hand, I prefer (and am paid) to do the things safely, not be a cowboy or the GI docs whipping boy.

Ok, sure, your way is the best way and the only way, all others must bow to you in your incredible wisdom.

Have you forgotten that inducing and intubating a patient involves:

1) Use of sedatives, and narcotics which can cause ICU delirium and prolonged ICU stay

2) A medical procedure which subjects the patient to unnecessary risks including failure to intubate, failure to ventilate, hypoxia, death

3) Hemodynamic changes related to positive pressure ventilation including deceased preload and decreased cardiac output

4) Airway instrumentation and alteration of the patient's pulmonary mechanics which could result in prolonged mechanical ventilation and weaning


My MAC GI patients have far fewer complications than your so-called "safe" GA GI patients, so obviously the way you do anesthesia is the wrong way.

 

[vector2]

Ok, sure, your way is the best way and the only way, all others must bow to you in your incredible wisdom.

Have you forgotten that inducing and intubating a patient involves:

1) Use of sedatives, and narcotics which can cause ICU delirium and prolonged ICU stay

2) A medical procedure which subjects the patient to unnecessary risks including failure to intubate, failure to ventilate, hypoxia, death

3) Hemodynamic changes related to positive pressure ventilation including deceased preload and decreased cardiac output

4) Airway instrumentation and alteration of the patient's pulmonary mechanics which could result in prolonged mechanical ventilation and weaning


My MAC GI patients have far fewer complications than your so-called "safe" GA GI patients, so obviously the way you do anesthesia is the wrong way.

I know your reading comprehension is poor and you like ignoring the salient points of the actual case in question, so I’ll refresh your memory again: this pt is a preop tavr, severe AS with a high risk of angiodysplasia requiring intervention who is getting a double scope and likely a push through. I could educate you about how bucking or coughing or 2 hrs of prolonged hypoventilation/hypercarbia or hypoxia could affect a pt who likely has severe LVH, diastolic dysfunction, and increased PA pressures, but I think we all know you really don’t give two sh*ts about determining an optimal way to do this case, you’re just arguing for the sake of arguing.

 

[Mikkel]

I know your reading comprehension is poor and you like ignoring the salient points of the actual case in question, so I’ll refresh your memory again: this pt is a preop tavr, severe AS with a high risk of angiodysplasia requiring intervention who is getting a double scope and likely a push through. I could educate you about how bucking or coughing or 2 hrs of prolonged hypoventilation/hypercarbia or hypoxia could affect a pt who likely has severe LVH, diastolic dysfunction, and increased PA pressures, but I think we all know you really don’t give two sh*ts about determining an optimal way to do this case, you’re just arguing for the sake of arguing.

It's not my fault the quality of your MAC GI cases is so poor that your patients are constantly "bucking" and that you have to resort to an ETT every time a prolonged GI case comes along.

 

[vector2]

It's not my fault the quality of your MAC GI cases is so poor that your patients are constantly "bucking" and that you have to resort to an ETT every time a prolonged GI case comes along.

It’s unfortunate you don’t have the know-how to safely induce GETA in severe AS nor the idea that manipulating hemdynamics is typically easier at 0.7 Mac of volatile, but anyway, your selective latching on to one word of a response and then trying to get a zinger in, all the while ignoring the totality of the point that was made isn’t fooling anyone. Try again, hoss (and maybe before you reply you can think about how high dose prop infusions - enough to tolerate a push through and abolish airway reflexes for two hours - affect ventilation, contractility, and coronary perfusion in a pt with severe AS and diastolic dysfunction. Maybe you can also think about how a neo gtt doesn’t always counteract the effects of the anesthetic in said pt)

 

[Mikkel]

It’s unfortunate you don’t have the know-how to safely induce GETA in severe AS, but anyway, your selective latching on to one word of a response and then trying to get a zinger in, all the while ignoring the totality of the point that was made isn’t fooling anyone. Try again, hoss (and maybe before you reply you can think about how high dose prop infusions - enough to tolerate a push through and abolish airway reflexes for two hours - affect ventilation, contractility, and coronary perfusion in a pt with severe AS and diastolic dysfunction. Maybe you can also think about how a neo gtt doesn’t always counteract the effects of the anesthetic in said pt)

I can do GA easily for patients with severe AS, and I will take those risks if the procedure dictates.

However, choosing to do routine GA for prolonged GI cases says more about you not being able to do a MAC worth anything, which is evidenced by the fact that you think you have to abolish airway reflexes for 2 hours even though the scope tip has already been advanced past the oropharynx and the patient is sleeping with barely any propofol being infused.

 

[deleted162650]

The pt’s son beliefs (by way of his father also when he still had decision making capacity) to keep transfusing blood for months on end, intubate, and trach/peg are literally all things that are compatible with the catechism statements about euthanasia and end of life care, especially the more mundane procedures and treatments that simply sustain basic bodily functions regardless of prognosis. In regard to coding and DNR, you make a fair enough point and what I said about life being mandated ‘at all costs’ is inaccurate considering the 50-something Catholic son could’ve changed his beliefs and made his 80-something Catholic father DNR based on the directives published less than 10 years ago. Mea culpa.

Also bro those are some hilarious “you’re a lib” burns. Very fresh. Those and the rest of your always sarcastic posts totally don’t make you look like a perpetual try-hard snarky b*tch.

SMH. First off, this stance on end-of-life issues is not new in the last 10 years. It's the same as now as it was when I was back in high school (certainly over 10 years ago), and it wasn't new at that time either. Again, please stop trying to educate me on something of which you are clearly ignorant. Perhaps your own views regarding religion are shading what you previously though were the views of the Catholic Church, when in reality, those views are not dramatically different than your own. Aside from MIVF and a dobhoff for food/water, everything else is "extraordinary" and may be withdrawn. They even accept the "double effect."

For someone who prides themselves on being progressive and open minded, you sure do have a hard time accepting being corrected and learning new information about someone else's culture/point-of-view. You started in with the language and ultimately personal attacks just because you couldn't handle being wrong. While I may come across as a

a perpetual try-hard snarky b*tch.

, you come across as a huge D-bag/spoiled little child. Grow up, act like a man, graciously admit when you're wrong, and don't attack those who would dare correct your flawed and apparently fragile world view.

PS: Thanks for the new tagline

 

[vector2]

I can do GA easily for patients with severe AS, and I will take those risks if the procedure dictates.

However, choosing to do routine GA for prolonged GI cases says more about you not being able to do a MAC worth anything, which is evidenced by the fact that you think you have to abolish airway reflexes for 2 hours even though the scope tip has already been advanced past the oropharynx and the patient is sleeping with barely any propofol being infused.

There’s nothing routine about this case, genius, hence the reason the OP made a post about it in the first place to gauge everyone’s opinion. Again, you latch on to one word about bucking and forget the rest of the point. Firstly, pts will still cough or buck even once the scope is past the esophagus unless they are very well topicalized or the prop gtt is running at at least 75-100 if not higher. If you’re not familiar with the phenomenon then maybe it’s because you’re never actually in the room and your CRNA is titrating drips and bolusing.

Secondly, even if you magically get your prop gtt down to 25-50 while still achieving acceptable procedure conditions, even if the sat is 100, the pt is still hypoventilating and becoming relatively hypercarbic, and again, think about how that affects plum HTN or bad stenotic lesions...

 

[vector2]

SMH. First off, this stance on end-of-life issues is not new in the last 10 years. It's the same as now as it was when I was back in high school (certainly over 10 years ago), and it wasn't new at that time either. Again, please stop trying to educate me on something of which you are clearly ignorant. Perhaps your own views regarding religion are shading what you previously though were the views of the Catholic Church, when in reality, those views are not dramatically different than your own. Aside from MIVF and a dobhoff for food/water, everything else is "extraordinary" and may be withdrawn. They even accept the "double effect."

I think perhaps your view of whatever you think of my views are are shading how you choose to reply. There is pretty much no knowledge I shun and I read about a variety of topics- those I believe in, those I don’t, and those I don’t know much about. I’d love to know the history of when the Catholic stance on end of life issues changed. Unfortunately, all you provided was your anecdotal personal experience and a link to a California Catholics site. In earnest, I looked up when the official catechism on euthanasia and end of life issues was published (the 90s), and when the US conference of Catholic Bishops “Ethical and Religious Directives for Catholic Health Care Services” was originally published. The USCCB is what most of these non-official Catholic sites such as the one you quoted seem to source, in addition to being what most Catholic hospitals in the US follow, and those guidelines were first published in 2009. Maybe Catholics have been following more liberal end-of-life policies for longer than that just to keep up with the rise of secularism and achieve some level of pragmatism for what most believers want, but the “official teaching of the Roman Catholic Church” in the written form is certainly not as clearcut as you make it out to be. Perhaps for the 80-something Catholic pt, it’s even less so.

For someone who prides themselves on being progressive and open minded, you sure do have a hard time accepting being corrected and learning new information about someone else's culture/point-of-view. You started in with the language and ultimately personal attacks just because you couldn't handle being wrong. While I may come across as a
, you come across as a huge D-bag/spoiled little child. Grow up, act like a man, graciously admit when you're wrong, and don't attack those who would dare correct your flawed and apparently fragile world view.

PS: Thanks for the new tagline

No offense man, but a ton of your posts are mostly sarcastic zingers passed off for a laugh. I have no problem being corrected and I admitted I was wrong, but just like anyone else I look at the source first. Sure, I was fired up at the time when I said don’t give a “f”, but I’m not sure what makes you think that calling me a woke antifa atheist is you just graciously educating me on a cultural point of view. Grace begets grace, after all. If you truly want to educate, bravo. If you’re just trying to get a rhetorical jab in as you’re sometimes wont to do, excuse me for not turning the other cheek.

Ultimately, whatever preconceptions or biases I have about religious people (or for that matter, any group) are irrelevant to me because the individual preferences are so varied. There are Muslims who will accept a porcine heart valve, and there are Jehovah’s witnesses who consent to blood as soon as you get the family out of the room. I don’t assume anything about a pt just because they say they are X, Y, and Z- I just ask them what they would like in a particular circumstance and proceed accordingly.

 

[Mikkel]

There’s nothing routine about this case, genius, hence the reason the OP made a post about it in the first place to gauge everyone’s opinion. Again, you latch on to one word about bucking and forget the rest of the point. Firstly, pts will still cough or buck even once the scope is past the esophagus unless they are very well topicalized or the prop gtt is running at at least 75-100 if not higher. If you’re not familiar with the phenomenon then maybe it’s because you’re never actually in the room and your CRNA is titrating drips and bolusing.

Secondly, even if you magically get your prop gtt down to 25-50 while still achieving acceptable procedure conditions, even if the sat is 100, the pt is still hypoventilating and becoming relatively hypercarbic, and again, think about how that affects plum HTN or bad stenotic lesions...

I do my own cases, I don't supervise.

My older, sicker patients don't "buck" in the middle of an EGD, because I find the right plane of anesthesia quickly and easily. Your patients might be "bucking" a lot, but again, that's your fault for not mastering the art of MAC, and your lack of comfort in performing it.

Topicalization of the oropharynx doesn't add much if you're in the right plane, so I don't encourage topicalization routinely, and I wouldn't in this case either.

You want to throw severe pulmonary hypertension into the picture? What's going to kill a patient faster, a recruitment maneuver with an ETT, or a patient yawning and auto-recruiting under light propofol sedation?

 

[vector2]

I do my own cases, I don't supervise.

My older, sicker patients don't "buck" in the middle of an EGD, because I find the right plane of anesthesia quickly and easily. Your patients might be "bucking" a lot, but again, that's your fault for not mastering the art of MAC, and your lack of comfort in performing it.

Topicalization of the oropharynx doesn't add much if you're in the right plane, so I don't encourage topicalization routinely, and I wouldn't in this case either.

You want to throw severe pulmonary hypertension into the picture? What's going to kill a patient faster, a recruitment maneuver with an ETT, or a patient yawning and auto-recruiting under light propofol sedation?

LOL, I'm glad you sit your own cases and run 100% flawless 2hr long true MACs on pts with severe pulmonary hypertension. I bet your pts all **** gold to thank you when the case is done, too.

But yes, I'm around for whenever you wanna discuss reality instead of whatever fantasy world you perform anesthesia in.

 

[deleted162650]

a ton of your posts are mostly sarcastic zingers passed off for a laugh

Guilty as charged. I'm the first to admit that my one-liner/off color comment to clinically relevant anesthesia comment ratio meets or exceeds 9:1.

I was just trying to educate you, and anyone else reading at the time. I didn't respond with a light hearted jab until after you started to cop an attitude.

Thank you though for now responding in a calm, professional matter. Cheers, and may the GI discussion continue.

woke antifa atheist

totally needs to be your new tagline though.

 

[Mikkel]

LOL, I'm glad you sit your own cases and run 100% flawless 2hr long true MACs on pts with severe pulmonary hypertension. I bet your pts all **** gold to thank you when the case is done, too.

But yes, I'm around for whenever you wanna discuss reality instead of whatever fantasy world you perform anesthesia in.

I'm sorry you're having a hard time coming to grips the experiences of other anesthesiologists contrary to your own limited understanding.

 

[fakin' the funk]

None of the rest of my medical care is based on Catholic doctrine, and neither should end-of-life care be.

Patients can believe or prefer whatever they want, we as physicians are only bound to provide reasonable, beneficial, nonharmful care that respects the patient's autonomy.

After all, no matter the belief system, patients come to us seeking care in OUR system which is based on medical science, ethics, and US law.

 

[Twiggidy]

Wow......this thread

 

[deleted162650]

None of the rest of my medical care is based on Catholic doctrine, and neither should end-of-life care be.

Patients can believe or prefer whatever they want, we as physicians are only bound to provide reasonable, beneficial, nonharmful care that respects the patient's autonomy.

After all, no matter the belief system, patients come to us seeking care in OUR system which is based on medical science, ethics, and US law.

I don’t think anyone was ever suggesting that the medical care we provide should be based on religious doctrine (Catholic or otherwise).

 

[deleted59964]

I don’t think anyone was ever suggesting that the medical care we provide should be based on religious doctrine (Catholic or otherwise).

hmmm

Redirect Notice

www.google.com.au

 

[deleted162650]

hmmm

Redirect Notice

www.google.com.au

Well of course the Pope is going to think religious doctrine should guide medical care. I’m not sure what point you’re trying to make.

A patient’s faith is likely to guide their own medical decisions.

As physicians, our decisions are based on a combination of patient autonomy, medical ethics, and the laws of the country we practice in. It would be wrong for me to base the medical care of my patient on my faith which of course may not be inline with that of my patient.

 

[fakin' the funk]

That being said, perhaps the Catholic Church does accept withdrawing care in particular circumstances, but take a look at the vagueness of the following

you were saying, @SaltyDog ?

 

[fakin' the funk]

My pt’s son used to say over and over how strong his dad was and how much of a fighter he was...

I LOL'd at this because it is universally stated by family members when they are proposing we do unreasonable and nonbeneficial and painful care to their loved ones.

Like "oh, YOUR dad is a fighter? That's so crazy because the 3 other people who died in the ICU this shift really just rolled over and took it"

"Being a fighter" is not a value or a goal of care

 

[deleted162650]

you were saying, @SaltyDog ?

Huh? I must be particularly dense this morning, ‘cuz I’m not sure what you’re trying to say here.

 

[deleted59964]

Well of course the Pope is going to think religious doctrine should guide medical care. I’m not sure what point you’re trying to make.

The pope is one such person that suggests that the medical care we provide should be based on religious doctrine.

 

[Noyac]

You do this? Is anyone else here pushing sedation on full stomachs? I’ve never done it but curious if others do it and how they prevent adverse events

If the GI doc is comfortable with a mostly awake pt then sure. Just don’t get them real deep.

 

[Mikkel]

If the GI doc is comfortable with a mostly awake pt then sure. Just don’t get them real deep.

General anesthesia paralyzed patients won't cough with aspirated stomach contents, but lightly sedated patients still have airway reflexes and will cough that crap out.

Drunk people puke all the time, yet there's no epidemic of aspiration pneumonia. This might surprise some people on this board who think 100% of full stomach patients need to intubated for any procedure.

 

[nimbus]

General anesthesia paralyzed patients won't cough with aspirated stomach contents, but lightly sedated patients still have airway reflexes and will cough that crap out.

Drunk people puke all the time, yet there's no epidemic of aspiration pneumonia. This might surprise some people on this board who think 100% of full stomach patients need to intubated for any procedure.

Agree. EM docs do full stomach sedation all the time, have data that it’s safe, and get away with it most of the time. It’s probably safer than most anesthesiologists think.

 

[MoMoGesiologist]

General anesthesia paralyzed patients won't cough with aspirated stomach contents, but lightly sedated patients still have airway reflexes and will cough that crap out.

Drunk people puke all the time, yet there's no epidemic of aspiration pneumonia. This might surprise some people on this board who think 100% of full stomach patients need to intubated for any procedure.

Dang... you just made a lot of sense...

 

[fakin' the funk]

Drunk people puke all the time, yet there's no epidemic of aspiration pneumonia. This might surprise some people on this board who think 100% of full stomach patients need to intubated for any procedure.

A) aspiration pneumonia is extremely common
B) host factors matter
C) pneumonia vs pneumonitis
D) this claim and/or your critique of it needs qualification

 

[Mikkel]

A) aspiration pneumonia is extremely common

If common is 1-10%, very common is 10%, then what's extremely common? 20-50%?

50% of people who've vomited while drunk end up being hospitalized with aspiration pneumonia?

I feel like I would have seen this more often while on both outpatient and inpatient medicine rotations, and in ICU rotations....

 

[DrZzZz]

General anesthesia paralyzed patients won't cough with aspirated stomach contents, but lightly sedated patients still have airway reflexes and will cough that crap out.

Drunk people puke all the time, yet there's no epidemic of aspiration pneumonia. This might surprise some people on this board who think 100% of full stomach patients need to intubated for any procedure.

If you're providing an anesthetic for virtually any procedure on a known full stomach and don't place an ETT, if they aspirate, you have zero defense. Hand over your blank check. It doesn't matter what you can get away with. You'll probably get away with it a thousand times over. But the one time you don't, you won't have anyone there to back you on the stand.

 

[deleted875186]

If common is 1-10%, very common is 10%, then what's extremely common? 20-50%?

50% of people who've vomited while drunk end up being hospitalized with aspiration pneumonia?

I feel like I would have seen this more often while on both outpatient and inpatient medicine rotations, and in ICU rotations....

Your assumption that someone intoxicated from alcohol and someone under sedation with propofol have the same preservation of reflexes is wrong.

Also, as stated above, even a rare event, if harmful enough, is not acceptable, especially when an alternative safer technique is available (GETA).

I do agree that ASA NPO guidelines are not the best. I am aware of the EM guidelines, and I also think they are not based on good evidence.

 

[MoMoGesiologist]

Your assumption that someone intoxicated from alcohol and someone under sedation with propofol have the same preservation of reflexes is wrong.

Also, as stated above, even a rare event, if harmful enough, is not acceptable, especially when an alternative safer technique is available (GETA).

I do agree that ASA NPO guidelines are not the best. I am aware of the EM guidelines, and I also think they are not based on good evidence.

Sure in a healthy person, GA can be safer than sedation if there’s an aspiration risk. But what about sicker pts (severe AS, pulm HTN, etc) where placing a tube for a ten minute scope may cause more harm than doing sedation with small titrated propofol on someone who may be a little nauseous or bad GERD or slightly increased aspiration risk? I feel like we are trained to tube anyone who may aspirate because apparently it’s absolutely not defendable in court as an anesthesiologist (but somehow ED docs can do it), but often times it’s fine and seems like it’s safer to lightly sedate some sicker people than do a GA.

 

[Mikkel]

If you're providing an anesthetic for virtually any procedure on a known full stomach and don't place an ETT, if they aspirate, you have zero defense. Hand over your blank check. It doesn't matter what you can get away with. You'll probably get away with it a thousand times over. But the one time you don't, you won't have anyone there to back you on the stand.

So you'd never do a MAC on a gastroparetic patient, since they're considered "full stomach"?

 

[DrZzZz]

... virtually any procedure on a known full stomach...

So you'd never do a MAC on a gastroparetic patient, since they're considered "full stomach"?

Notice the qualifier in my statement. Never say never. Depending on how long the patient has been npo for, what procedure is being performed, etc, I'd consider it. But there'd have to be a good reason for me to not place an ETT. A GI doc telling me it'll be a quick procedure isn't reason enough.

 

[T-burglar]

the real question is how truly severe this “severe AS” is. This is where being able to interpret images and data on a consultant level is very helpful. Not all “severe” AS lesions are the same just because they meet the AVA criteria. Severe AS can be a non issue or it can be truly scary. If you deal with these people enough to learn the difference. I’m truly severe enough cases even a touch of midazolam and fentanyl can put the systemic pressure into the red zone.

 

[dannyboy1]

Sure in a healthy person, GA can be safer than sedation if there’s an aspiration risk. But what about sicker pts (severe AS, pulm HTN, etc) where placing a tube for a ten minute scope may cause more harm than doing sedation with small titrated propofol on someone who may be a little nauseous or bad GERD or slightly increased aspiration risk? I feel like we are trained to tube anyone who may aspirate because apparently it’s absolutely not defendable in court as an anesthesiologist (but somehow ED docs can do it), but often times it’s fine and seems like it’s safer to lightly sedate some sicker people than do a GA.

Agreed. In my hospital the GI suite is populated with patients who have one foot in the grave. (LVADs, ef of 10%. severe AS on HD)If I induced and tubed every gastroparetic, acute anemia, bad GERD ect. I would be coding multiple patients a day.