ICU docs

[urge]

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Why is it they always want to know irrelevant stuff? Like cross clamp time & bypass time. Is it going to affect the way they give their epi and their seroquel? Drives me nuts. You cannot do anything about it, and the info is not changing your management.

Now important stuff, like examining their patients, they don't care about.
For example a pt with a half assed valve surgery they don't even document presence or lack of a murmur. They just send an echo 3 days later. I have seen pt where they documwnt "vad" sounds, that do not have a vad. They document normal neuro exams on pts that are all stroked out. They do all sorts of stuff like that. But they got to have the cpb and xclamp times to the second.

Rant over.

 

[Hernandez]

As opposed to extubating a pt as you push dilaudid and versed to wonder why they get retubed and then ship them to ICU for me to extubate half an hour later? Or show up with a pt in ICU w/o telling us with a pt with no blood pressure? Or calling me down to manage your pt in the PACU who's been there all of 5 minutes?

As my IM program directories to say, "I'm glad I'm perfect"........

 

[urge]

Don't get me going on the icu. Plenty more where this came from. Like the fact that you guys chart vs once an hr, they all look goos until the patient "suddenly" drops dead. Never mind that the levo wasn't running for half an hr.... That all becomea very clear when riak management gets involved.

 

[Hernandez]

So intensivists chart VS and change out bags of levo now?

I get it, you've had a bad day, you're not the only who has idiots who work in the hospital, but generalizing is going to do nothing but annoy others.

 

[urge]

Today was a nice nice easy day. I have had this brewing for a long time. Time to get it out.

 

[urge]

So intensivists chart VS and change out bags of levo now?

intensivists are the ones with no explanations of what happened. I'm not saying they did it.

 

[imfrankie]

The intensivists I know are stellar.

 

[michigangirl]

There is probably a little more homogeneity in the adult world, but in peds cardiac cases we get a lot of info from CC and bypass times when they arrive in the PICU-- if cross clamp is 2 hours and bypass is 4 hours for a difficult congenital cardiac case, I know I'm probably going to be dealing with renal failure, post-pump slump, lactates through the roof, etc. etc. I can better predict outcomes, need for prolonged mechanical ventilation/readiness for extubation, the list goes on. I'll even bug the anesthesiologist about details of the MUF. 🙂

Peds intensivists love us some cross clamp/bypass times. Bring it on.

 

[2win]

Why is it they always want to know irrelevant stuff? Like cross clamp time & bypass time. Is it going to affect the way they give their epi and their seroquel? Drives me nuts. You cannot do anything about it, and the info is not changing your management.

Now important stuff, like examining their patients, they don't care about.
For example a pt with a half assed valve surgery they don't even document presence or lack of a murmur. They just send an echo 3 days later. I have seen pt where they documwnt "vad" sounds, that do not have a vad. They document normal neuro exams on pts that are all stroked out. They do all sorts of stuff like that. But they got to have the cpb and xclamp times to the second.

Rant over.

HA! Your post is absolutely irrational.
First of all you have a condescended attitude towards a critical care specialists.
Check your literature regarding the clamp time &bypass time and the outcome.
Remember that we HAVE to know these in order to predict an outcome.
And to inform the families. And to treat the patient.
How many times did you really spoke with a family member about your patient POST surgery???
"they don't even document presence or lack of a murmur. " - Yes - true - we have echo ...
When did you last time checked EBM - auscultation vs echo??? You didn't ...
Before to start a rant like yours ...better learn and do what is better for your patient.
And I mean - give the report.
If you are ignorant - try to improve.
2win

 

[2win]

intensivists are the ones with no explanations of what happened. I'm not saying they did it.

Where do you practice???
In the neck of the woods?
You want more?
Change your practice. Oh - you gonna loose some money...I forgot.
You want the best of 2 worlds. Money and good critical care. Will not happen soon.
You see - Urge - one of the downside of practicing in a "no name" area is being in contact with physicians that are "no name". I was there and I know.
We - the critical care specialists - KNOW most of the time what happened.
2win

 

[urge]

There is probably a little more homogeneity in the adult world, but in peds cardiac cases we get a lot of info from CC and bypass times when they arrive in the PICU-- if cross clamp is 2 hours and bypass is 4 hours for a difficult congenital cardiac case, I know I'm probably going to be dealing with renal failure, post-pump slump, lactates through the roof, etc. etc. I can better predict outcomes, need for prolonged mechanical ventilation/readiness for extubation, the list goes on. I'll even bug the anesthesiologist about details of the MUF. 🙂

Peds intensivists love us some cross clamp/bypass times. Bring it on.

BS!

You don't do anything with that info. You go by the hourly blood gases & the daily bmp.

Kid is on rocket fuel: will not get extubated soon.....

What the hell you you need to know about MUF?

I bet you 1 million bucks I bring you a kid and you cannot tell whether MUF was done or not.

You should worry about examining your pt properly, not useless nonsense which you cannot control.

 

[urge]

HA! Your post is absolutely irrational.
First of all you have a condescended attitude towards a critical care specialists.
Check your literature regarding the clamp time &bypass time and the outcome.
Remember that we HAVE to know these in order to predict an outcome.
And to inform the families. And to treat the patient.
How many times did you really spoke with a family member about your patient POST surgery???
"they don't even document presence or lack of a murmur. " - Yes - true - we have echo ...
When did you last time checked EBM - auscultation vs echo??? You didn't ...
Before to start a rant like yours ...better learn and do what is better for your patient.
And I mean - give the report.
If you are ignorant - try to improve.
2win

The outcome is the outcome whether you can predict it or not. Your knowing the clamp time does not change the outcome.

Whether the clamp time was 10 min or 8 hrs is an irrelevant tidbit of information for you.

 

[Doctor4Life1769]

As opposed to extubating a pt as you push dilaudid and versed to wonder why they get retubed and then ship them to ICU for me to extubate half an hour later? Or show up with a pt in ICU w/o telling us with a pt with no blood pressure? Or calling me down to manage your pt in the PACU who's been there all of 5 minutes?

As my IM program directories to say, "I'm glad I'm perfect"........

lolwut?

i'm not looking to get involved... but this got me. i wonder what bozo would actually do that.

sure, i titrate fentanyl as long as they are breathing on their own, and on PSVpro for support, but dilaudid + versed at time of extubation?!

 

[chessknt]

Does anyone else find it strange that other attendings from other specialties are converging on this one thread?

 

[periopdoc]

i wonder what bozo would actually do that...

but dilaudid + versed at time of extubation?!

This bozo has done this on more than one occasion.

Not defending the dude in this situation, but it isn't completely unreasonable in the right patient.

I am sure I could blow some ICU minds with the amounts of fentanyl and dilaudid I have used on some cases where I extubated at the end. 15 min case 4g 4mg fentanyl and 20mg dilaudid case comes to mind. Don't get to do it as much where I live now, but back in training.

-pod

 

[Hernandez]

This bozo has done this on more than one occasion.

Not defending the dude in this situation, but it isn't completely unreasonable in the right patient.

I am sure I could blow some ICU minds with the amounts of fentanyl and dilaudid I have used on some cases where I extubated at the end. 15 min case 4g fentanyl and 20mg dilaudid case comes to mind. Don't get to do it as much where I live now, but back in training.

-pod

Bingo, 90 year old 90 pound ladies don't tend to tolerate this approach well though. But in fairness my shop's gas department is horribly pro-CRNA and I very rarely see a real doc in the PACU which can be terribly frustrating.

And Shirley you mean 4mg of fentanyl? I can't fathom 4gm. But if so, ok, I'll concede my mind is blown.

 

[Bostonredsox]

Took a bad fem-pop redo a few weeks ago. 49 y/o. Had excoriatedd her own graft (she was bat**** crazy) infected it and was in septic shock post redo. brought to me post bypass with lactate of 21 on epi/vaso. essentially mottled/pulseless leg.

Anesthesia : "we have been having a hard time ventilating her thoughout the case. Not sure whats going on, but given her septic shock I am sure shes just heading towards ARDS and a really bad outcome"

Me: "ok I will see what I can do"

Look over labs, examine pt, take a look at the vent waveforms, and then I pull up intra-op chest film anesthesia had done after they shoved a cordis into the right subclavian, which they clearly never looked at for one, and second, electively chose not to use their beautiful $20k ultrasound for the line while I do not have an US to use in the unit, and have to borrow radiologys portable one....

Long and short, 40% PTX in the right chest. Took me 10 minutes to fix. amazing how much easier to ventilate after.

We all have bad days where our collegues do stupid **** or ask for what we think is stupid information. Just remember no one is perfect....

There is enough going on in the MICU, atleast in mine, that I do not have time for useless information. If I or my attending ask for soemthing, there is a reason we want to know it.

 

[urge]

None of you have made a valid argument as to why you need to know the cpb or clamp time.if the pt needs 2 inotropes and a balloon pump, it doesn't matter if the times were 10 min or 10hrs. Assess your pts and take care of them based on your assessment.

Stop asking for irrelevant stuff.

 

[Hernandez]

http://www.ncbi.nlm.nih.gov/m/pubmed/18272383/

It is a predictor of mortality. And actually read the article before you jump on the "it doesn't predict in low EF PTs" that wasn't what the conclusion was.

Bypass time isn't as straight forward but the CC books still allude that longer times have worse splachnic perfusion and worse outcomes.

 

[Dejavu]

As opposed to extubating a pt as you push dilaudid and versed to wonder why they get retubed and then ship them to ICU for me to extubate half an hour later? Or show up with a pt in ICU w/o telling us with a pt with no blood pressure? Or calling me down to manage your pt in the PACU who's been there all of 5 minutes?

As my IM program directories to say, "I'm glad I'm perfect"........

Very interesting thread. Glad to see I am not the only person with pet peeves.

On an amusing note, and definitely not to be a grammar cop because if communication took place then language did its job, but you have to admit that the irony inherent in that last sentence is priceless.

 

[jwk]

Bingo, 90 year old 90 pound ladies don't tend to tolerate this approach well though. But in fairness my shop's gas department is horribly pro-CRNA and I very rarely see a real doc in the PACU which can be terribly frustrating.

And Shirley you mean 4mg of fentanyl? I can't fathom 4gm. But if so, ok, I'll concede my mind is blown.

And don't call me Shirley.

Let's see - 4mg of fentanyl = 4000mcg = 80cc. Hmmmmmmm.

 

[Dejavu]

And don't call me Shirley.

Let's see - 4mg of fentanyl = 4000mcg = 80cc. Hmmmmmmm.

Boy, Leslie Nielsen was an artist. May he RIP. He brought a lot of joy to the world.

 

[Hernandez]

And don't call me Shirley.

I'm glad someone appreciates the classics.

 

[periopdoc]

And Shirley you mean 4mg of fentanyl? I can't fathom 4gm. But if so, ok, I'll concede my mind is blown.

I blew my own mind with that typo. Bummed that JWK beat me to the punch line.

Yes, it was 4mg.

Lady woke up, looked around with her pinpoint pupils, and said, "I feel wonderful for the first time in years."

Needless to say, she was a lot happier about it than pharmacy.


-pod

 

[periopdoc]

And don't call me Shirley.

Let's see - 4mg of fentanyl = 4000mcg = 80cc. Hmmmmmmm.

Yep, started the case with two of the big bottles of fent and 5 sticks of dilaudid. Gave her 1000 and 4 before induction. Induced and placed LMA so she was breathing throughout. Had my buddy grab another two and five during the case. We wanted to see how much we could put in her and still have her breathing and wake up at the end of the case.

We obviously had some history to work off of and this wasn't my first time to anesthetize her.


- pod

 

[okayplayer]

Sounds like a 2AM case at the county hospital POD. Some of my favorite times in residency so far.

 

[TrustMe]

We realize we can't change the times but they are nice to know so that when the pt starts circling the drain we have a little understanding why and can better inform the family about expectations.

I always talk with the anesthesia attending when they drop off a pt in my unit. Biggest thing I want to know is what the TEE looked like before they left the room and how that compared to pre-CPB. Actually, if I have a few free minutes I go in the OR and look at it myself.

So in regards to your comment, those times are nice to know but there is a lot of other stuff they should be asking. That is one difference in caring for medical pts and post-op surgical pts. Maybe when they ask those numbers you should also offer stability going on CPB and coming off CPB and what the TEE looked like. Maybe they don't know to ask other relevant questions.

 

[okayplayer]

Had an interesting recent case on OB. Woman with hx of heroin abuse now actively managed on suboxone at 30 weeks GA with dead fetus in utero. Needs a csxn given multiple craniofacial abnormalities making vaginal delivery unsafe. Refuses spinal/CSE (doesn't want to be awake for the procedure. Reasonable under the circumstances.). We pushed hard for a preop LEP for postoperative pain relief given her suboxone hx. She refused this as well. Refused TAP block, but with the understanding that we would readdress postoperatively if she desired.

Did a literature review on suboxone and ended up giving fentanyl only for opiate, as my understanding is HM/MS do not bind avidly enough to the opiate receptor to displace the suboxone molecule. She had a total of 5000 mcg fentanyl for the csxn, in addition to ketamine (bolused 0.5 mg/kg and infusion of 8mg/h intraop/postop). Fentanyl PCA postop. She did outstanding surprisingly.

 

[Gaseous Clay]

This is a dumb thread. We have anesthesiologists ripping on intensivists and of course, the intensivists have to come and defend their mojo by telling us how stupid anesthesiologists are. These "anonymous" posts tick me off. Instead, why don't you find each other in the hospital, give them a hard shoulder bump as you pass them in the hall or doctors lounge, and settle it that way? Yes, I've had major issues with ICU docs, ER docs, OBs, surgeons, etc and I'm sure vice versa. But to come on here and rant about ONE specific experience and then claim that all anesthesiologists or intensivists are mind numbingly stupid or worthless is just plain f*ckin obnoxious.

 

[michigangirl]

This is a dumb thread. We have anesthesiologists ripping on intensivists and of course, the intensivists have to come and defend their mojo by telling us how stupid anesthesiologists are. These "anonymous" posts tick me off. Instead, why don't you find each other in the hospital, give them a hard shoulder bump as you pass them in the hall or doctors lounge, and settle it that way? Yes, I've had major issues with ICU docs, ER docs, OBs, surgeons, etc and I'm sure vice versa. But to come on here and rant about ONE specific experience and then claim that all anesthesiologists or intensivists are mind numbingly stupid or worthless is just plain f*ckin obnoxious.

You hit the nail on the head. It's easy to claim that every other speciality is stupid and you're the only one who knows what you're doing. When you do it, it screams zero perspective, IMHO.

 

[michigangirl]

BS!

You don't do anything with that info. You go by the hourly blood gases & the daily bmp.

Kid is on rocket fuel: will not get extubated soon.....

What the hell you you need to know about MUF?

I bet you 1 million bucks I bring you a kid and you cannot tell whether MUF was done or not.

You should worry about examining your pt properly, not useless nonsense which you cannot control.

Seriously? 🙄
Please bet me the 1 million bucks. Then I can pay off my house.

 

[urge]

This is a dumb thread. We have anesthesiologists ripping on intensivists and of course, the intensivists have to come and defend their mojo by telling us how stupid anesthesiologists are. These "anonymous" posts tick me off. Instead, why don't you find each other in the hospital, give them a hard shoulder bump as you pass them in the hall or doctors lounge, and settle it that way? Yes, I've had major issues with ICU docs, ER docs, OBs, surgeons, etc and I'm sure vice versa. But to come on here and rant about ONE specific experience and then claim that all anesthesiologists or intensivists are mind numbingly stupid or worthless is just plain f*ckin obnoxious.

The point of the thread is to vent, so that I can smile the next day as I report the cpb and xclamp times. When someone gives me details as to what to report for the MUF, I will do that, with a big grin on my face.

It keeps me sane.

🙂

 

[urge]

Seriously? 🙄
Please bet me the 1 million bucks. Then I can pay off my house.

Right!

🙄

 

[urge]

http://www.ncbi.nlm.nih.gov/m/pubmed/18272383/

It is a predictor of mortality. And actually read the article before you jump on the "it doesn't predict in low EF PTs" that wasn't what the conclusion was.

Bypass time isn't as straight forward but the CC books still allude that longer times have worse splachnic perfusion and worse outcomes.

So you are going to tell the family " You know, we could actually assess this patient frequently and treat him as necessary, but since the cross clamp was 8 hr and that is a predictor for mortality, I'm just going to go to bed while he dies. What is the point of me trying to save him? Clap time predicts death. Go home and make funeral arrangements."

All I'm saying is to stop focusing on "predictors" and focus on ASSESSING your pt.

It does not sit well with a lot of people in this board for some reason.

 

[chessknt]

So you are going to tell the family " You know, we could actually assess this patient frequently and treat him as necessary, but since the cross clamp was 8 hr and that is a predictor for mortality, I'm just going to go to bed while he dies. What is the point of me trying to save him? Clap time predicts death. Go home and make funeral arrangements."

All I'm saying is to stop focusing on "predictors" and focus on ASSESSING your pt.

It does not seat well with a lot of people in this board for some reason.

I don't think that is what he is trying to say--I am sure most ICU docs do continue to assess and treat their patients. However, when they are talking to the family (or pt) it is helpful to have predictor info to help set expectations and, if it comes to it, realign goals of care. You can imagine having evidence to help support your argument that someone should be placed on comfort care makes that conversation much easier.

 

[urge]

We realize we can't change the times but they are nice to know so that when the pt starts circling the drain we have a little understanding why and can better inform the family about expectations.


So in regards to your comment, those times are nice to know but there is a lot of other stuff they should be asking. That is one difference in caring for medical pts and post-op surgical pts. Maybe when they ask those numbers you should also offer stability going on CPB and coming off CPB and what the TEE looked like. Maybe they don't know to ask other relevant questions.

Times are just trivia.

Agreed pre and post cpb function being important. Also adequacy of repair, urine output, hemostasis, airway difficulty.... That always gets reported.

 

[urge]

I don't think that is what he is trying to say--I am sure most ICU docs do continue to assess and treat their patients. However, when they are talking to the family (or pt) it is helpful to have predictor info to help set expectations and, if it comes to it, realign goals of care. You can imagine having evidence to help support your argument that someone should be placed on comfort care makes that conversation much easier.

So now you are going to tell them their family member is not doing well because Dr Slow took too long?

 

[Bostonredsox]

So you are going to tell the family " You know, we could actually assess this patient frequently and treat him as necessary, but since the cross clamp was 8 hr and that is a predictor for mortality, I'm just going to go to bed while he dies. What is the point of me trying to save him? Clap time predicts death. Go home and make funeral arrangements."

All I'm saying is to stop focusing on "predictors" and focus on ASSESSING your pt.

It does not sit well with a lot of people in this board for some reason.

Mortality predictors are extremely useful in trying to explain to families that they should make their loved ones DNRs and/or de-escalate care. It also gives them an understanding of what they are up against and clamp time is one of them. I use apache scores and lactate levels all the time. There is excellent data showing linear mortality correlation in an ICU with rising lactate levels. So when the 84 year old septic shocker has a lactate of 19, thats a good time to start the DNR and de-escalation talks. I highly doubt Hernandez says "the cross clamp time was such and such so moms going to die", but more or less, '' well some of the important markers of how she did with the surgery are very concerning and frankly worrisome to me right now, she is quite sick since coming out of the operation and I am not entirely sure she will survive this catastrophic event to her heart." ..........lots of ways for us to relay extremely poor prognostic indicators to families, particualry if it will lead to a change in management.

 

[urge]

Mortality predictors are extremely useful in trying to explain to families that they should make their loved ones DNRs and/or de-escalate care. It also gives them an understanding of what they are up against and clamp time is one of them. I use apache scores and lactate levels all the time. There is excellent data showing linear mortality correlation in an ICU with rising lactate levels. So when the 84 year old septic shocker has a lactate of 19, thats a good time to start the DNR and de-escalation talks. I highly doubt Hernandez says "the cross clamp time was such and such so moms going to die", but more or less, '' well some of the important markers of how she did with the surgery are very concerning and frankly worrisome to me right now, she is quite sick since coming out of the operation and I am not entirely sure she will survive this catastrophic event to her heart." ..........lots of ways for us to relay extremely poor prognostic indicators to families, particualry if it will lead to a change in management.

So now you are telling me all you guys are looking for is to have a good excuse to make everybody DNR and roll back to bed?

No "Let's wait and see what happens in the next 2 or 3 days". Just "sign here it's not worth it"

This just keeps going down hill.

 

[michigangirl]

So you are going to tell the family " You know, we could actually assess this patient frequently and treat him as necessary, but since the cross clamp was 8 hr and that is a predictor for mortality, I'm just going to go to bed while he dies. What is the point of me trying to save him? Clap time predicts death. Go home and make funeral arrangements."

All I'm saying is to stop focusing on "predictors" and focus on ASSESSING your pt.

It does not sit well with a lot of people in this board for some reason.

If the clamp time was long, then I know that my fellow and/or myself are going to sit our butts by that bedside for most of the night-- no surprises-- just expect badness. If the clamp/bypass time is long and the function is poor 6 hours out and I'm pouring fluids and pressors into the patient, then I'm not as crazed looking for other reasons why this heart sucks right now. If the CC/bypass was nothing special and the heart is failing six hours out, I better find another explanation asap. Before you jump on this argument, we are always looking for other explanations. But you can't chalk the latter up to post-pump slump-- differential gets narrower.

If an ICU physician is only focused on predictors, then they need to take another look at their profession. But predictors are an important part of my management. Even if I can tell the family to expect a rocky course because the surgery took a million years, your 2 seconds of spouting off times was worth it. Or I don't have to get them from you-- I'll get them from the cardiac surgeons or OR staff. And I'm not just speaking from this end of the sign-out. I'm on the other side just as much, and will happily give times to all who will listen. Except my grin is genuine.

 

[Bostonredsox]

So now you are telling me all you guys are looking for is to have a good excuse to make everybody DNR and roll back to bed?

No "Let's wait and see what happens in the next 2 or 3 days". Just "sign here it's not worth it"

This just keeps going down hill.

Quite the opposite. I am constantly taking pts who are presenting with septic shock 5 months into a diagnosis of pancreatic adeno with complete SBOs and liver and brain mets all the time. Critical care in most of those patients is essentially medically futile. But if the patient and family understand what they are about to go through in terms of the ventilator, chest compressions and shocks, I proceed without any hesitation. The greater majority of what I tell pts is we are going to take this in 6 hour intervals, some really sick patients 1 hour intervals. we will reassess how they are doing clinically as well as see if they are having improvement in their creatinines, UO, pressor requirements etc. But there are plenty of patients that I know when they hit the door they are toast. If that is my father, I dont want him suffering through his last 24 hours of life. And believe me, I am the prototypical future CC fellow IM resident. the sicker they are the happier I am, in a non-sadistic way. I want the complete heart blocks that roll in and need urgent transvenous pacing, the MIs that crash and need IABPs, the tamponades that get opened up at bedside (one of the coolest things I ever saw as an intern). Every possible procedure I can do I want to do. And every bit of help I can provide a critically ill patient I want to provide.
But......I also have a conscience and took an oath to do know harm. And I know the 85 year old that was down in the field 45 minutes before EMS got to her and now has an 'epi gtt pulse", would be better off extubated and allowed to go to God peacefully. That, is where the #s can help.

 

[urge]

If the clamp time was long, then I know that my fellow and/or myself are going to sit our butts by that bedside for most of the night-- no surprises-- just expect badness. If the clamp/bypass time is long and the function is poor 6 hours out and I'm pouring fluids and pressors into the patient, then I'm not as crazed looking for other reasons why this heart sucks right now. If the CC/bypass was nothing special and the heart is failing six hours out, I better find another explanation asap. Before you jump on this argument, we are always looking for other explanations. But you can't chalk the latter up to post-pump slump-- differential gets narrower.

If an ICU physician is only focused on predictors, then they need to take another look at their profession. But predictors are an important part of my management. Even if I can tell the family to expect a rocky course because the surgery took a million years, your 2 seconds of spouting off times was worth it. Or I don't have to get them from you-- I'll get them from the cardiac surgeons or OR staff. And I'm not just speaking from this end of the sign-out. I'm on the other side just as much, and will happily give times to all who will listen. Except my grin is genuine.

So now you are saying that if the clamp time was long and the pt crumps, you are just going to blame the clamp time and not try to find an etiology.

From what you tell me, long clamp times might be a poor prognostic because the intensivist rolls over on bed and chalks up all badness to prolonged clamps times instead of looking for an etiology.

You guys keep digging a deeper hole.

 

[urge]

Quite the opposite. I am constantly taking pts who are presenting with septic shock 5 months into a diagnosis of pancreatic adeno with complete SBOs and liver and brain mets all the time. Critical care in most of those patients is essentially medically futile. But if the patient and family understand what they are about to go through in terms of the ventilator, chest compressions and shocks, I proceed without any hesitation. The greater majority of what I tell pts is we are going to take this in 6 hour intervals, some really sick patients 1 hour intervals. we will reassess how they are doing clinically as well as see if they are having improvement in their creatinines, UO, pressor requirements etc. But there are plenty of patients that I know when they hit the door they are toast. If that is my father, I dont want him suffering through his last 24 hours of life. And believe me, I am the prototypical future CC fellow IM resident. the sicker they are the happier I am, in a non-sadistic way. I want the complete heart blocks that roll in and need urgent transvenous pacing, the MIs that crash and need IABPs, the tamponades that get opened up at bedside (one of the coolest things I ever saw as an intern). Every possible procedure I can do I want to do. And every bit of help I can provide a critically ill patient I want to provide.
But......I also have a conscience and took an oath to do know harm. And I know the 85 year old that was down in the field 45 minutes before EMS got to her and now has an 'epi gtt pulse", would be better off extubated and allowed to go to God peacefully. That, is where the #s can help.

What does that have to do with cpb and clamp times?

I agree. You assess you pt trending labs, markers,..., however you want and make a medical decision. However, CPB and clamp time is not one of those things you use to make a decision.

 

[Bostonredsox]

What does that have to do with cpb and clamp times?

I agree. You assess you pt trending labs, markers,..., however you want and make a medical decision. However, CPB and clamp time is not one of those things you use to make a decision.

I dont have a ton of experience with bypass patients yet, small hospital and our CTS manage them themselves for the most part, but from what I am reading and the links, the intensivisits seem to disagree with that. And I guess my final thought on this thread would be, as they are the ones continuing all the critical care and as they will be the ones having these family discussions, if they feel these 2 pieces of information will help them, give it to them. At the end of the day is it really that much extra work to communicate 2 numbers you already know?

 

[urge]

At the end of the day is it really that much extra work to communicate 2 numbers you already know?

I don't know them because I don't care for them. They play no role in my management. Pts need inotroped based on fuction, not on clamp time.

When they ask and I guesstimate saying they were long "around 3 and 2 hrs respectively" they have a fit. They want the exact amount of minutes to write it down over and over as they copy and paste their notes.

Never mind that the pt got extubated last night, they copy and paste the note from the day before where it says they are still intubated and sedated......

 

[cchoukal]

As the accepting physician, I get to decide what I need to know. Call it "wanting to know the whole story of the patient" as a nod to the days of giants when being a doctor meant really knowing the patient, or call it "assessing risk factors for the upcoming clinical course," it is important to some of us. Suggesting that the accepting physician should only know the bare minimum, overtly actionable details to deal with the narrow scope of the patient's presenting condition seems a little short-sighted.

To me, it's akin to a surgeon asking me why I want to know details about the surgical plan, or pre-operative evaluation. Do I REALLY need to know how much of the Whipple they're doing to tailor my anesthetic plan, or do I really need to SEE the stress test report or just hear that it's "negative"? Perhaps not, but I'm the patient's doctor and I want to know the full story and it's up to me to decide what I want to know, whether I'll use that information in some specific, tangible way or not. Reducing this professional interaction to merely the most essential, demonstrable action-items degrades us both.

 

[urge]

As the accepting physician, I get to decide what I need to know. Call it "wanting to know the whole story of the patient" as a nod to the days of giants when being a doctor meant really knowing the patient, or call it "assessing risk factors for the upcoming clinical course," it is important to some of us. Suggesting that the accepting physician should only know the bare minimum, overtly actionable details to deal with the narrow scope of the patient's presenting condition seems a little short-sighted.

To me, it's akin to a surgeon asking me why I want to know details about the surgical plan, or pre-operative evaluation. Do I REALLY need to know how much of the Whipple they're doing to tailor my anesthetic plan, or do I really need to SEE the stress test report or just hear that it's "negative"? Perhaps not, but I'm the patient's doctor and I want to know the full story and it's up to me to decide what I want to know, whether I'll use that information in some specific, tangible way or not. Reducing this professional interaction to merely the most essential, demonstrable action-items degrades us both.

So you are degraded because you cannot write down the cpb and clamp times on the progress notes?

I'm uncovering some issues now.

 

[Idiopathic]

I don't know them because I don't care for them. They play no role in my management. Pts need inotroped based on fuction, not on clamp time.

When they ask and I guesstimate saying they were long "around 3 and 2 hrs respectively" they have a fit. They want the exact amount of minutes to write it down over and over as they copy and paste their notes.

Never mind that the pt got extubated last night, they copy and paste the note from the day before where it says they are still intubated and sedated......

you made your point, i think, but if your argument is that patients dont behave differently following 400 minute pump runs as opposed to 60 minute pump runs then you are completely wrong. if your argument is that knowing that CPB time was "3 hours" as opposed to 155 minutes is functionally the same, I will agree with you. But to think that you dont have to communicate these times is probably not acceptable. It is important.

 

[urge]

you made your point, i think. starting to look a little silly.

Agreed. Hopefully this thread will be a good reminder for me to have the cpb and clamp times when I give report.

Different strokes for different folks.

It was a good venting exercise. Got it off my system without pissing off the people I work with. Might have pissed off a few people here, but who cares? I don't even know you.

😛

 

[Ronin786]

you made your point, i think, but if your argument is that patients dont behave differently following 400 minute pump runs as opposed to 60 minute pump runs then you are completely wrong. if your argument is that knowing that CPB time was "3 hours" as opposed to 155 minutes is functionally the same, I will agree with you. But to think that you dont have to communicate these times is probably not acceptable. It is important.

.