New case

[Planktonmd]

65 Y/O, male, 360 pounds, in surgery center for EGD and Colonoscopy.
PMH: CAD, MI 5 years ago, CABG 5 years ago, Chronic Afib on Warfarin, HTN,hyperlipedemia, snores at night and was refered to a sleep lab but left before the end of the study.(He said he will never use a CPAP so what's the point?).
He also says that his cardiologist in another state did a nuclear stress test a year ago that apparently was positive, they suggested a cardiac catheter but he moved before doing it and forgot to follow up.
He denies ches pain.
His excercise tolerance is almost non excistant, and he gets short of breath after a few steps.
He has a big head, a short very thick neck, small mouth and MP3.
His BP is 165/115.
His SPO2 is 93% on room air.
No previous records of any kind are available.
He is anxious to proceed
What would you do?

By the way this is a real case not a joke!

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[LostTommyGuns]

Sounds non-emergent and he clearly could be optimized... Seems like getting him squared away with Cardiology is the first step.

 

[fval28]

Is he bleeding or is this a screening?

If only a screening- I would tell him his GERD would be frickin cured if he lost 100 #s. If he's that concerned bout colon CA, tell him about the increased risk of it r/t a high fat diet

My big concerns would be his non-compliance with previous medical interventions (cath and sleep lab) and his uncontrolled HTN.

If he came to my small hospital- cancelled until he gets tied in with a cards guy and I get the OK. Once he gets that he comes in and gets an awake FOB in the OR.

 

[Noyac]

I wouldn't touch him with a ten foot pole, even if it came from Mil.

 

[Planktonmd]

He wasn't bleeding.
The EGD was being done for Barrett's esophagus follow up, and the Colonoscopy for routine screening.
I forgot to mention that he could not lie down flat at all

 

[zippy2u]

Not a candidate for a surgery center. Tell GI guy to do him in the hospital. Next! ---Zip

 

[fval28]

He wasn't bleeding.
The EGD was being done for Barrett's esophagus follow up, and the Colonoscopy for routine screening.
I forgot to mention that he could not lie down flat at all

Besides the cards consult- would probably consult a priest too...

 

[EV-Stentor]

This one is a no brainer to me......cancel and send pt to see a flea and cardiologist....the GI doctor should know better before scheduling such a case. Sounds like this is an elective case except if the fat guy is hemorrhaging...

65 Y/O, male, 360 pounds, in surgery center for EGD and Colonoscopy.
PMH: CAD, MI 5 years ago, CABG 5 years ago, Chronic Afib on Warfarin, HTN,hyperlipedemia, snores at night and was refered to a sleep lab but left before the end of the study.(He said he will never use a CPAP so what's the point?).
He also says that his cardiologist in another state did a nuclear stress test a year ago that apparently was positive, they suggested a cardiac catheter but he moved before doing it and forgot to follow up.
He denies ches pain.
His excercise tolerance is almost non excistant, and he gets short of breath after a few steps.
He has a big head, a short very thick neck, small mouth and MP3.
His BP is 165/115.
His SPO2 is 93% on room air.
No previous records of any kind are available.
He is anxious to proceed
What would you do?

By the way this is a real case not a joke!

 

[zippy2u]

True dat, it would be super nice if it was the only surgery center in town-- I'd verbally rip a new a$$hole in that GI flea. If the pt. was hemorrhaging, certainly not a case for the surgery center--Bigtime. ---Zip

 

[EtherMD]

65 Y/O, male, 360 pounds, in surgery center for EGD and Colonoscopy.
PMH: CAD, MI 5 years ago, CABG 5 years ago, Chronic Afib on Warfarin, HTN,hyperlipedemia, snores at night and was refered to a sleep lab but left before the end of the study.(He said he will never use a CPAP so what's the point?).
He also says that his cardiologist in another state did a nuclear stress test a year ago that apparently was positive, they suggested a cardiac catheter but he moved before doing it and forgot to follow up.
He denies ches pain.
His excercise tolerance is almost non excistant, and he gets short of breath after a few steps.
He has a big head, a short very thick neck, small mouth and MP3.
His BP is 165/115.
His SPO2 is 93% on room air.
No previous records of any kind are available.
He is anxious to proceed
What would you do?

By the way this is a real case not a joke!

The fact you are even considering giving this guy an anesthetic is hilarious. All you left out are the PVC's on EKG, occ. angina and the fact a relative of his works for the largest Civil Trial lawyer in town.

Ever heard of I.V. sedation? A true "MAC" thirty years ago meant lidocaine spray to the throat and minimal drugs. Still, I would never get involved in such a case without multiple notes of the chart documenting necessity of the procedure even in a hospital setting. Plus, you will need to observe him for 2-3 times longer than your normal GI patient secondary to sleep apnea and other medical conditions.

Clearly, you have little experience with Malpractice lawyers (that is a good thing) and the expense (time and money) involved with a case. I rec. you keep it that way.

 

[Planktonmd]

I actually cancelled the case and told the guy that I feel sorry that he had to go through the colon prep for nothing.
The GI guy thought I was being mean, and suggested to do only the upper part, I refused, and he didn't argue.
The funny thing is that this GI man is an internist, he actually sees patients pre-op and "clears" them for surgery!
Just needed to vent

 

[zippy2u]

OK, back in the cowboy days of my youth, to get this guy done it would play out like this... 3mls of 4% lidocaine, swish , gargle and swallow. Wait a couple of minutes and repeat. Place in a semi recumbent position on left side and place towel over eyes. Titrate versed 2mgs and fentanyl 100mikes. EGD can be done with no propofol as esoph is rather numb. EGD done first and make sure GI gets in and out quickly and sucks stomach contents totally out. Then do the colon with minimal amounts of propofol. Next! Regards--- Zip

 

[Planktonmd]

Zippy, I totally agree, you can do it this way, but that patient simply did not belong in the surgery center.