I Don't Get Some People

[Noyac]

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I had an 88 yo female coming to my OR for a 2 level kyphoplasty today. She is an inpatient and has been cared for by the Inpatient Service. I start to review her chart b/4 the case and I find that she has probably just suffered an MI. Trop. 0.3 yesterday and today down to 0.11. Both Cards and IPS have cleared her for surgery. IPs got an echo w/c showed global hypokinesis with PHTN and fairly decent LV fxn. Then I see a note that the family refused any further workup (ie: cath) w/c we all know, I am OK with that. I am sick and tired of the full court press on these pts that are complete disasters and have no chance of getting better.

So I say fine I will see this pt and take her to the OR if eerything I see checks out. Well, I get to her bedside in PACU (inpts come to pacu b/4 surgery) and she can barely breath. I can hear her wheezing from across the room. She can hardly talk to me. Her son says this is normal for her but is hesitant to give any more information. I grab he surgeon and say, "What the hell is going on here?" He says she just wants to get some pain relief from her compression fx's and that she has been cleared for surgery. I said, " Not by me she hasn't".

I call the cardiologist and he confirms that she may have knocked off some myocardium but nothing big and there is nothing more to do for her. I asked him if he thought she might be teatering on CHF and he says "no". "OK, then what is all her wheezing and SOB coming from." His reply, " I wasn't told she was wheezing and SOB"

Me: Didn't you see or hear it yourself?

Cards: Well i never really saw her, I just looked at her echo.

Me: Great, thats all the info I need.

I look at the surgeon and say " your case is cancelled, have a nice evening."



I don't get it sometimes. What he hell are these people thinking?😡

This is the first case I can remember canceling in 3 years.

 

[VentdependenT]

Jesus...

 

[InGasWeTrust]

Noy,

Pent, sux, tube....

Next case!



Serioulsy....sounds like the family has been misled by our ever optimistic surgical colleugues!

 

[OldManDave]

Seriously....sounds like the family has been misled by our ever optimistic surgical colleugues!

And our cardiology buddy sure as hell screwed the pooch! Maybe I am just naive, but no way in hell I am signing a "consult" on some pt that I had not actually seen. In my estimation, that is tantamount to fraud!

In med school, we had this very elderly gentleman physician - Class of 1931 - who was a Professor Emeritus. The old guy still gave occasional lectures and they were lucid, tight & coherent. He still rounded on patients every morning, although he no admitted, he was mostly socializing since he had been an FP in this community since he graduated in 1931.

Anyhow, his lectures generally focused on the more metaphysical, doctor-patient relations, respect & professional conduct. However, one thing this guy said in every lecture - and it has really stuck with me - if you do not have a dmaned good idea what is going on after your H&P, go back & do it again because you have missed what the pt was trying to tell you. He added that all of our modern tests are fantastic, BUT, they are merely there to confirm what you already suspect and not the other way around.

I think your surgical & cardio colleagues need a lesson from this old-world doctor. Too bad he passed away just before I graduated. He was a fine old gentleman: Max Gutensohn, D.O., KCOM - Class of 1931.

 

[CremeSickle]

everytime i read this response i near die laughing! Keep em commin!

Noy,

Pent, sux, tube....

Next case!



Serioulsy....sounds like the family has been misled by our ever optimistic surgical colleugues!

 

[mille125]

why didnt the surgeon just do it under local and not involve anesthesiology if he thought that it "needed" to be done....this case can be done under local



I agree with you about cancelling the case (and probably would do it if in your position)................ however this is a case where you can play devils advocate....acute pain from a compression fracture is also not helping her myocardium....the kyphoplasty is a very quick and very succesful treatment that can "cure" her acute pain in a matter of hours......catecholamine surge from acute pain in an 88 yo is not good for the myocardium....this is an argument for doing the case.........



i am interested in hearing other opinions.....

 

[Noyac]

why didnt the surgeon just do it under local and not involve anesthesiology if he thought that it "needed" to be done....this case can be done under local



I agree with you about cancelling the case (and probably would do it if in your position)................ however this is a case where you can play devils advocate....acute pain from a compression fracture is also not helping her myocardium....the kyphoplasty is a very quick and very succesful treatment that can "cure" her acute pain in a matter of hours......catecholamine surge from acute pain in an 88 yo is not good for the myocardium....this is an argument for doing the case.........




i am interested in hearing other opinions.....

I agree totally. I used to do these in residency under local as well. I told him of that option but it was not received well. Therefore, no surgery.

I will add this, she became more and more SOB while lying flat. Right in front of my eyes. 😱 THe wheezing was also quite impressive.

Kypho is one of the procedures that can give a pt immediate relief. This is what made it such a difficult decision for me.

 

[VolatileAgent]

what did the chest xray show?

 

[mille125]

I agree totally. I used to do these in residency under local as well. I told him of that option but it was not received well. Therefore, no surgery.

I will add this, she became more and more SOB while lying flat. Right in front of my eyes. 😱 THe wheezing was also quite impressive.

Kypho is one of the procedures that can give a pt immediate relief. This is what made it such a difficult decision for me.

I think that you did an excellent job and took all factors into account. No one can really criticize you for cancelling. It is a pity that the surgeon would not consider local anesthesia. I have seen patient get great benefit from kyphoplasty in a very short amount of time.

 

[Noyac]

what did the chest xray show?

Cardiomegaly mostly. There was some cephalization as well as Kerley B lines.

This case was a no brainer.

 

[VentdependenT]

The dreaded kerly b. Who the hell was that guy anyways.

 

[huron]

why didnt the surgeon just do it under local and not involve anesthesiology if he thought that it "needed" to be done....this case can be done under local



I agree with you about cancelling the case (and probably would do it if in your position)................ however this is a case where you can play devils advocate....acute pain from a compression fracture is also not helping her myocardium....the kyphoplasty is a very quick and very succesful treatment that can "cure" her acute pain in a matter of hours......catecholamine surge from acute pain in an 88 yo is not good for the myocardium....this is an argument for doing the case.........



i am interested in hearing other opinions.....

I was on a locums gig where I was asked to do two of these kyphoplasty case in radiology on two similar very sick 90 year old train wreck patients. But the radiologist wanted them to be done with very light MAC in the prone position on the special procedures table in the radiology department. The minute the radiologist started it became clear that to him MAC meant general anesthesia and the radiologist started to complain about the patient moving when he stuck a 14 gauge needles in the patient's back with out bothering to use any local.


Yes this could be a local or MAC case but only if done gently by an experienced practitioner, all too often you will need to use general anesthesia since the case requires the patient to be prone, and may be scheduled out side the OR in the very difficult environment of the special procedures room in radiology.