Lap Chole's

[Noyac]

Who's doing them at ambulatory surgery centers?

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[militarymd]

Who's doing them at ambulatory surgery centers?

we do.

 

[nimbus]

We do them at our hospital attached ASC but decided not to at our free-standing facility. Lost some business. So what?

Who thinks it is a good idea except the bean counters (our collective bosses)?

 

[Hockeyguy]

Had a disaster too. First assist on one that had a cystic artery injury that we were unable to control. Crit 44 to 28. BP down Heart rate up. Emergently opened. Was a nightmare had to transfer patient to ICU - across street - she had an MI etc. The surgeon is on the verge of getting canned because he is such a hack. He also had a BD injury that resulted in liver lobe resection on a 22 year old, so it may have been more a question of his ability or lack of. Anyway freaked me out though because the Anesthesiologist didn't even have supplies to an art line and it put him in a very difficult position. I think any case can go bad. But lap chole may be pushing it in an outpatient surgicare. I would hate to be in that position in a few years.

Mario

 

[rn29306]

I would almost think this practice should be surgeon practitioner dependent. No hacks allowed. Look at surgeon's performance and statistics and then go from there. We had this one private practice dude in GA that would do 17-19 minute skin to skins all damned day. He would be a perfect candidate.

What I would worry about lap choles in an ASC is laceration or introduction into the major vessels during needle insertion. It happens to the best of surgeons (even due to anatomy and not technique) once in a while and is FUBAR when it does. This would be a nightmare situation for a ASC, esp a free-standing one.

Admittantly I don't have statistics to back me up...just my thoughts.

 

[VolatileAgent]

my $0.02? not a good idea.

(and, just fyi: it's "fubar")

 

[UTSouthwestern]

More and more difficult cases are being done in free standing ASC's, especially physician owned ones. There are some here in DFW that do multiple lap bands and lap Roux N Y's on an outpatient basis.

Heard of a facility doing total joints as well.

If you are going to practice with a group that has to cover one of these facilities, insist that the proper equipment and setup be available (cell saver, invasive lines, on site or reasonably close blood bank, etc.).

 

[Noyac]

Heard of a facility doing total joints as well.

We did unicondylar knees in an ASC at my previous gig. Nobody doing uni's at my present gig.

 

[militarymd]

It's just about the money....

 

[Noyac]

my $0.02? not a good idea.

(and, just fyi: it's "fubar")

So you have never seen a tonsilectomy go bad?

 

[Noyac]

It's just about the money....

Of course!

 

[VolatileAgent]

let's put it this way, noyac. i've never seen a patient die from a "tonsillectomy gone bad". can't say that about a what-should-have-been-a-routine lap chole.

 

[militarymd]

let's put it this way, noyac. i've never seen a patient die from a "tonsillectomy gone bad". can't say that about a what-should-have-been-a-routine lap chole.

That must be some residency.....2 years...and you've seen it all.

 

[VolatileAgent]

That must be some residency.....2 years...and you've seen it all.

ummm... i'm in the middle of my fourth year. and, if you tag on 4 years of med school plus a long list of life experience in the peri-medical field before that, i'd say that makes my opinion worth a bit more than the paltry two cents offered. still, i've never said i've seen it all. nor have you. however, i do believe i know more about the business world, and probably have better business sense, than you do, but that has nothing to do with this thread despite that you're trying to dredge-up that grudge here. (and, note for the record who's taken the initiative, as per usual, of being a dickhead on this forum.)

we do part of our training at an outpatient surgery center. my first of two months is coming up soon. i know the types of cases they do over there, and they are definitely not doing lap choles for the aforementioned reasons. and, yes, we have had patients die in the peri-operative period upon undergoing a lap chole, one that was a bleeder not recognized until the wee hours of the morning who crumped and died before they could get her back to the OR. i've personally never heard of such a thing happening with a tonsillectomy.

so if you don't want me to invoke the sentiment in my signature line, then speak to the facts, not to the man, mil.

 

[militarymd]

ummm... i'm in the middle of my fourth year. and, if you tag on 4 years of med school plus a long list of life experience in the medical field before that, i'd say that makes my opinion worth a bit more than the paltry two cents offered. still, i've never said i've seen it all. nor have you. however, i do believe i know more about the business world, and probably have better business sense, than you do, but that has nothing to do with this thread despite that you're trying to dredge-up that grudge here. (and, note for the record who's taken the initiative, as per usual, of being a dickhead on this forum.)

.

1) tell us about your nebulous business experience that you have been bragging about for the last 1000 threads.

2) once again....you are calling people names and insulting people.

3) after I admired how prodigious your residency training program is.

 

[VolatileAgent]

2) once again....you are calling people names and insulting people.

exactly, see what i mean, everyone?

me and my wife are going out to a friend's party tonight. i'm waiting for the babysitter to come over literally in a few minutes. right now, my beautiful wife is finishing getting ready. the kids are parked in front of the t.v. i'll be logging off after this post, and enjoying the rest of the evening.

what are you doing tonight, mil, besides sitting by your computer with a box of kleenex?

 

[militarymd]

what are you doing tonight, mil, besides sitting by your computer with a box of kleenex?

I'm having dinner with the CEO of our hospital.

 

[Steel_City]

Mil...you must be an important guy. Do you and the CEO like to ride tandem on that mo-ped. I bet both of your knees get sore when you take those corners extra tight. Will you sign my shirt?

 

[zippy2u]

Damm volatile, from where I come from, Military man done owned you. Regards, ---Zippy

 

[Noyac]

once again you two have hijacked another perfectly good thread.

 

[Noyac]

let's put it this way, noyac. i've never seen a patient die from a "tonsillectomy gone bad". can't say that about a what-should-have-been-a-routine lap chole.

http://www.meshbesher.com/news/20040729.php

http://alexanderharris.co.uk/articl...irl_who_died_following_tonsillectomy_2249.asp

Hemorrhage is the most common complication. An estimated 2-3% of patients have hemorrhage, and 1 of 40,000 patients die from bleeding.

Pressure can be applied to a bleeding tonsil fossa by using a sponge and a long clamp. Dipping the sponge in epinephrine or thrombin powder may be helpful. If this fails, the patient should be taken to the operating room. Options to stop the bleeding are electrocautery of the tonsil bed, use of further topical hemostatics, or ligation of the ipsilateral carotid artery as the last resort. Diathermy is thought to be superior to ligation because of the risk of perforating large vessels with the needle. In severe situations, a sponge may be fixed in place by using sutures. Another last resort is ligation of other large vessels, such as the external carotid artery.

Bleeding may be classified as intraoperative, primary (occurring within the first 24 hours), or secondary (occurring between 24 hours and 10 days).

Moderate to severe hemorrhage should be addressed in the operating room. Post-operative tonsillar bleeding can be immediately life-threatening with the involvement of major vessels (internal carotid, facial and lingual arteries). The patient often will require resuscitation with intravenous fluids and blood if it is available, prior to or during surgery. There is no method of hemostasis during tonsillectomy (Cockley knots, suture ligature or suction cautery) that does not have a postoperative incidence of hemorrhage. suture ligatures should be performed with caution since the needle can perforate near-by major vessels.

 

[Noyac]

http://www.meshbesher.com/news/20040729.php

http://alexanderharris.co.uk/articl...irl_who_died_following_tonsillectomy_2249.asp

Hemorrhage is the most common complication. An estimated 2-3% of patients have hemorrhage, and 1 of 40,000 patients die from bleeding.

Pressure can be applied to a bleeding tonsil fossa by using a sponge and a long clamp. Dipping the sponge in epinephrine or thrombin powder may be helpful. If this fails, the patient should be taken to the operating room. Options to stop the bleeding are electrocautery of the tonsil bed, use of further topical hemostatics, or ligation of the ipsilateral carotid artery as the last resort. Diathermy is thought to be superior to ligation because of the risk of perforating large vessels with the needle. In severe situations, a sponge may be fixed in place by using sutures. Another last resort is ligation of other large vessels, such as the external carotid artery.

Bleeding may be classified as intraoperative, primary (occurring within the first 24 hours), or secondary (occurring between 24 hours and 10 days).

Moderate to severe hemorrhage should be addressed in the operating room. Post-operative tonsillar bleeding can be immediately life-threatening with the involvement of major vessels (internal carotid, facial and lingual arteries). The patient often will require resuscitation with intravenous fluids and blood if it is available, prior to or during surgery. There is no method of hemostasis during tonsillectomy (Cockley knots, suture ligature or suction cautery) that does not have a postoperative incidence of hemorrhage. suture ligatures should be performed with caution since the needle can perforate near-by major vessels.

I'm sure that you have heard it b/4,"if you haven't seen it then you haven't done enough."

 

[militarymd]

we have had patients die in the peri-operative period upon undergoing a lap chole, one that was a bleeder not recognized until the wee hours of the morning who crumped and died before they could get her back to the OR. i've personally never heard of such a thing happening with a tonsillectomy.

I'm sure that you have heard it b/4,"if you haven't seen it then you haven't done enough."

once again you two have hijacked another perfectly good thread.

Noyac, I can't help it.

We got junior here who thinks he knows it all calling me names and insulting me left and right.....and the moderators say they can't do anything about it because gasforum is no longer a part of SDN.

Anyways....I'm just pointing out to him that Tonsils bleed too....and most tonsils go home in the real world....so the situation he pointed can happen to a tonsil also....

During my time in the Navy....I've had to bitch-slap so many junior physicians like this guy it is not funny. Many physicians in the military are former line officers who confuse age and rank with experience with being a doctor....And it was ALWAYS in THEIR best interest to bitch slap them frequently and regularly before they finish their residency so that their egoes don't go on to harm patients or obstruct the delivery of good health when they are allowed to work unsupervised.

 

[Noyac]

the moderators say they can't do anything about it because gasforum is no longer a part of SDN.

Yeah they can't b/c thats how we got into this situation. Someone didn't agree with someone else and would complain to a mod, any mod, then the mod jumped in without knowing the situation or the issues. Everyone was in an uproar. I feel that these things have a way of working their way out. Granted the tiff b/w you two has lasted long enough and is old. Until lines are crossed I don't feel the need to take sides. You guys are adults.

 

[cfdavid]

Yeah they can't b/c thats how we got into this situation. Someone didn't agree with someone else and would complain to a mod, any mod, then the mod jumped in without knowing the situation or the issues. Everyone was in an uproar. I feel that these things have a way of working their way out. Granted the tiff b/w you two has lasted long enough and is old. Until lines are crossed I don't feel the need to take sides. You guys are adults.

Dudes, in general, we all need to maintain a perspective of professionalism. Whatever happened to not burning bridges? It's fine to have differing opinions, but let's keep it above board.

Mil, nobody disputes your contributions to this board and your wealth of knowledge in the field of anesthesiology. I love reviewing many of you seasoned dudes' technical/clinical posts (even though I can only understand 0.3% of it....lol). But, Volatile has a point that I can understand as a non-trad that has entered medicine after many years in business. Though I'm a total neophyte (a 1st year! lol) in the medical world, our past experiences DO lend themselves to a solid perspective on medically related issues such as the business of medicine and business practice in general.

 

[Steel_City]

Just wanted to point out that I have a luncheon scheduled today with the CEO's CEO of our hospital.

 

[militarymd]

1) tell us about your nebulous business experience that you have been bragging about for the last 1000 threads.

2) once again....you are calling people names and insulting people.

3) after I admired how prodigious your residency training program is.

........But, Volatile has a point that I can understand as a non-trad that has entered medicine after many years in business. Though I'm a total neophyte (a 1st year! lol) in the medical world, our past experiences DO lend themselves to a solid perspective on medically related issues such as the business of medicine and business practice in general.

so...let's hear about it.

 

[swpm]

once again you two have hijacked another perfectly good thread.

Amen. The usual snide comments from militarymd, and the usual pomposity from volatileagent.

Give it a rest guys.

 

[militarymd]

Amen. The usual snide comments from militarymd, and the usual pomposity from volatileagent.

Give it a rest guys.

I know I shouldn't, but I can't help it.

I'm always the sarcastic, snide,, cut to the chase kind of guy....I don't mince words...


Volatile will be always what he will be...because he can't help it....


.....sort of like the fat medical students and doctors...who know better....but don't have the self control to change because it is just tooo hard.

 

[jetproppilot]

Until lines are crossed I don't feel the need to take sides..

And thats the way it needs to stay.

Thanks for that, Noy.

Let us homies settle our s h it gangsta style.

And if we cross the line you can Pop Your Glock.

 

[cfdavid]

so...let's hear about it.

It's a simple matter of having had similar experiences. Business is business, as I believe you already know. Not sure exactly what you're asking me, frankly.

 

[militarymd]

It's a simple matter of having had similar experiences. Business is business, as I believe you already know. Not sure exactly what you're asking me, frankly.

So what you're saying is:

manager of your local McDonald's = CEO of GM = owner of local hardware store = manager of Home Depot = owner of AMC = owner of 5 man anesthesia group ?????

when it comes to experience

 

[cfdavid]

So what you're saying is:

manager of your local McDonald's = CEO of GM = owner of local hardware store = manager of Home Depot = owner of AMC = owner of 5 man anesthesia group ?????

when it comes to experience

No, but I'd respectfully suggest that owning a 5 man anesthesia practice is not all that different from running a small business unit of a company, or managing a large sales territory, with responsibility for profit and loss. Both of which are not unreasonalbe accomplishments of many of us that have worked (post-college) in the real world prior to attending medical school.

All I was suggesting is that these experiences, from a business perspective, lend themselves very well to the business end of medicine, as they would any other industry. I'm sure you'd agree that your instincts for negotiating, leading/managing people, and handling "customer" issues (and liabilities) have become honed over the years. And those, specific, skills are obviously not unique to running an anesthesiology group.

 

[VolatileAgent]

http://www.meshbesher.com/news/20040729.php

http://alexanderharris.co.uk/articl...irl_who_died_following_tonsillectomy_2249.asp

Hemorrhage is the most common complication. An estimated 2-3% of patients have hemorrhage, and 1 of 40,000 patients die from bleeding.

Pressure can be applied to a bleeding tonsil fossa by using a sponge and a long clamp. Dipping the sponge in epinephrine or thrombin powder may be helpful. If this fails, the patient should be taken to the operating room. Options to stop the bleeding are electrocautery of the tonsil bed, use of further topical hemostatics, or ligation of the ipsilateral carotid artery as the last resort. Diathermy is thought to be superior to ligation because of the risk of perforating large vessels with the needle. In severe situations, a sponge may be fixed in place by using sutures. Another last resort is ligation of other large vessels, such as the external carotid artery.

Bleeding may be classified as intraoperative, primary (occurring within the first 24 hours), or secondary (occurring between 24 hours and 10 days).

Moderate to severe hemorrhage should be addressed in the operating room. Post-operative tonsillar bleeding can be immediately life-threatening with the involvement of major vessels (internal carotid, facial and lingual arteries). The patient often will require resuscitation with intravenous fluids and blood if it is available, prior to or during surgery. There is no method of hemostasis during tonsillectomy (Cockley knots, suture ligature or suction cautery) that does not have a postoperative incidence of hemorrhage. suture ligatures should be performed with caution since the needle can perforate near-by major vessels.

the difference is that post-operative tonsillar bleeding is immediately obvious. not so with a lap chole, as i pointed out before.

and, being "bitch slapped" by militarymd... give me a break. if i met him in person, which there's a good chance i will someday, we'd see how big of a man he really is - which isn't very, based on how he's presented himself here. the only thing he's proven to me so far is that he is a reckless egomaniac and equally dangerous anesthesiologist who gets some sort of perverse ego-boost by posting nasty, derogatory, snide comments against those he perceives to be his inferiors on a forum designed for residents and med students.

and, bottom line, all this thread has proven to me so far is that those of you who think doing an outpatient lap chole is a good idea really need more training.

 

[blotto geltaco]

We got junior here who thinks he knows it all calling me names

Boo hoo hoo

 

[joshmir]

Vol posts here quite a bit, but the newbie cats who are taking shots at Mil's posts ought to know they're not going to build much credibility round these here parts....but hell, what do i know, maybe they're CCM-certified managing-partner attendings with service experience as well...

 

[iron]

I skipped this thread when it originally appeared b/c we weren't doing lap choles at our ASC. Today is a new day and we are doing one today.

5'1" 260#. sigh.

Surgeon dependent scheduling
patient dependent?

What guidelines for selecting patients/surgeons are people using, if any?

 

[militarymd]

I skipped this thread when it originally appeared b/c we weren't doing lap choles at our ASC. Today is a new day and we are doing one today.

5'1" 260#. sigh.

Surgeon dependent scheduling
patient dependent?

What guidelines for selecting patients/surgeons are people using, if any?

The surgeons should know themselves whether or not they should be scheduling cases in free standing operative locations.....

As for anesthesia stuff....Just use the ASC's pre-existing guidelines.

 

[Noyac]

I skipped this thread when it originally appeared b/c we weren't doing lap choles at our ASC. Today is a new day and we are doing one today.

5'1" 260#. sigh.

Surgeon dependent scheduling
patient dependent?

What guidelines for selecting patients/surgeons are people using, if any?

Beware of OSA!