no further cardiac workup indicated

[nap$ter]

yours truly, medicine consult service.

so, doin my preop chart previews last night:

76yo morbidly obese female for DL c ENT, excision tracheal granulomas.

the story: fell at home 2 months ago, got dilaudid at OSH for bruised hip, went into respiratory distress, intubated, failed to wean from vent, trach/peg - sent to vent SNF. now with granuloma/stenosis above trach below the cords, ENT wants to excise/explore with the long term goal of decannulating/talking...

PMH:
-morbid obesity 360#, 5'2" - pear
-OSA on CPAP
-h/o "CHF c cor pulmonale" - no further details available
-rate-controlled afib on coumadin, dilt, amio
-hypothyroid
-albumin 2.0/poor protoplasm
-NIDDM

MEDS:
amiodarone
diltiazem
ISS
psych meds/antidepressants/xanax
coumadin (being held)
lasix
K+
nebs
vicodin

ENT sends the patient to medicine consult service (not preop clinic). the doc over there reports on exam pt is bed-bound, so weak she can scarcely lift an arm, vent-dependent, difficult to communicate with, edematous but SpO2 98% vented on rr18/TV600/peep5/FiO250%. The SNF records show attempts at diuresis limited by creatinine elevations, although current creatinine is 0.6. EKG shows afib at 96. no other historical records are available.

The medicine consult doc states "pt cleared for surgery", "no further cardiac workup necessary as pt appears optimized".

what do you guys want to do with this lady?

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[OB1🤙]

I mean.... you can work this patient up till you (and she!) are blue in the face, but at the end of the day you're gonna hook the circuit up to the trach and turn on the volatile...

 

[Planktonmd]

He is right.
No further workup needed.

 

[pd4emergence]

An echo would be nice but I do agree with the above. I would not delay the case for it. As an aside, I hate the whole "consult for clearance for surgery" deal. But, looking at it from an internist/cardiology standpoint they hate it to. When a surgeon consults them like this, they generally have no idea what we need or what we are looking for. When we as anesthesiologists consult a specialist or internist we really should communicate the reason for the consult. I know in this case the surgeon consulted them. Think about how many times this happens to you and how useful the info is when it does. Consults are only as good as your communication with the consultant.

 

[nap$ter]

normally i would just cowboy up, connect circuit to trach, and dial up volatile. BUT - i wanted to cancel this case. i did not see the utility in taking down granulomatous tissue ABOVE the stoma, below the cords. I don't think the risk/benefit ratio was in favor of that plan in this patient. the granuloma wasn't causing any problems above the trach, and this lady was no where near close to coming off the vent.

when i saw her in pre-op she was as advertised - completely vent-dependent, debilitated, unable to lift an arm off the bed, edematous, gelatinous, trying to mouth words. unclear as to whether cognitive function was there or not - couldn't understand her. morbidly obese, huge pannus. bibasilar rales, but distant breath and heart sounds, SpO2 97% on 50% peep 5. not overbreathing volume control at all. peak pressures 37. afib on the monitor at rate of 96.

surgeon walks by, mentions that she wants to do the case with an armored tube in the stoma which she may need to move in and out, during suspended laryngoscopy.

i lobbied with my attending to at least delay the case until the patient is rehabilitated to the point where decannulation might be immediately realistic.

i also argued for an echo. this was not an emergent case, and i thought it would guide management. pretty sure it would show moderate pulmonary HTN, but i wanted to rule out valvular disease and a quantification of EF. gonna get some hemodynamic changes from laryngoscopy or deep anesthesia.

i argued that the info from echo very well might change our plan ie mitral regurg vs ventricular hypertrophy vs dilated CM vs AS vs segmental hypokinesis vs vs... aline vs cuff - can't hear heart sounds very well through huge boobs. i usually argue against cardiac workup, but this lady had no functional status, no historical records, couldn't communicate, can't hear her heart, edematous, with a history of "CHF c cor pulmonale" in her chart...

my attending heard me out, agreed with you guys, and we proceeded. (this case was actually yesterday)

managed an 18g in the AC, no aline, cuff on the forearm works well, vasopressin, phenylephrine, and remi gtts in the room. off to the OR, plug trach to circuit, dial up sevo slowly...

you guys still think this was the best plan? i kinda felt like a wussy at this point..

 

[2win]

An echo would be nice but I do agree with the above. I would not delay the case for it. As an aside, I hate the whole "consult for clearance for surgery" deal. But, looking at it from an internist/cardiology standpoint they hate it to. When a surgeon consults them like this, they generally have no idea what we need or what we are looking for. When we as anesthesiologists consult a specialist or internist we really should communicate the reason for the consult. I know in this case the surgeon consulted them. Think about how many times this happens to you and how useful the info is when it does. Consults are only as good as your communication with the consultant.

The ent surgeon is dreaming...but they have to teach residents and to do something else beside tonsils and sinus surgery.
I bet that this patient didn't tolerate the CPAP...

 

[dhb]

76yo morbidly obese female for DL c ENT, excision tracheal granulomas.

the story: fell at home 2 months ago, got dilaudid at OSH for bruised hip, went into respiratory distress, intubated, failed to wean from vent, trach/peg - sent to vent SNF.

Why the F*** do you hand out opiates like candies in the US?? In Europe no one give dilaudid in the scenario.
No wonder you have so many addicts to painkillers.

 

[pd4emergence]

normally i would just cowboy up, connect circuit to trach, and dial up volatile. BUT - i wanted to cancel this case. i did not see the utility in taking down granulomatous tissue ABOVE the stoma, below the cords. I don't think the risk/benefit ratio was in favor of that plan in this patient. the granuloma wasn't causing any problems above the trach, and this lady was no where near close to coming off the vent.

when i saw her in pre-op she was as advertised - completely vent-dependent, debilitated, unable to lift an arm off the bed, edematous, gelatinous, trying to mouth words. unclear as to whether cognitive function was there or not - couldn't understand her. morbidly obese, huge pannus. bibasilar rales, but distant breath and heart sounds, SpO2 97% on 50% peep 5. not overbreathing volume control at all. peak pressures 37. afib on the monitor at rate of 96.

surgeon walks by, mentions that she wants to do the case with an armored tube in the stoma which she may need to move in and out, during suspended laryngoscopy.

i lobbied with my attending to at least delay the case until the patient is rehabilitated to the point where decannulation might be immediately realistic.

i also argued for an echo. this was not an emergent case, and i thought it would guide management. pretty sure it would show moderate pulmonary HTN, but i wanted to rule out valvular disease and a quantification of EF. gonna get some hemodynamic changes from laryngoscopy or deep anesthesia.

i argued that the info from echo very well might change our plan ie mitral regurg vs ventricular hypertrophy vs dilated CM vs AS vs segmental hypokinesis vs vs... aline vs cuff - can't hear heart sounds very well through huge boobs. i usually argue against cardiac workup, but this lady had no functional status, no historical records, couldn't communicate, can't hear her heart, edematous, with a history of "CHF c cor pulmonale" in her chart...

my attending heard me out, agreed with you guys, and we proceeded. (this case was actually yesterday)

managed an 18g in the AC, no aline, cuff on the forearm works well, vasopressin, phenylephrine, and remi gtts in the room. off to the OR, plug trach to circuit, dial up sevo slowly...

you guys still think this was the best plan? i kinda felt like a wussy at this point..

I don't disagree with you and your feeling about this case. This lady is nowhere near coming off the vent or getting her trach out. Honestly, in my opinion she will never get her trach out. She is morbidly obese with sleep apnea and deconditioned to the point that she may not ever be able to do much of anything. But I have been wrong. In residency, one of the hardest realizations for me to come to is that people actually do get better (even in the SICU).
Another thing that is hard to accept is that you are a consultant. You make surgery possible. This surgeon has scheduled this case because from his/her standpoint they feel that it is the best thing for the patient at this time. It is your job to take care of this lady with the least amount of risk possible. If you feel conflicted, and feel that the risk of an anesthetic in a patient does not outweigh the benefit, have an honest discussion with the surgeon. Alot of these types of discussions I have had in the past have shown me a different point of view and brought to light factors that I either had not or could not have thought of.
As for this lady, Does her true anesthetic risk outweigh her benefits of having the case done. My guess is if you talk to the ents, they are trying to keep her from getting severe tracheal stenosis and either a. never getting the trach out or b. having to have some big tracheal resection down the road when (and if) she gets better.

 

[nap$ter]

Why the F*** do you hand out opiates like candies in the US?? In Europe no one give dilaudid in the scenario.
No wonder you have so many addicts to painkillers.

clearly in retrospect too much opiate was given, but we weren't in the ED, didn't see the injury, don't know how much dilaudid was given etc.. without all of the details i wouldn't jump to judgment too quickly.

i agree with the attitude that this country is way too liberal with opiates, but i don't agree with your global (or rather, all of Europe) generalizations. patients in this country have a misbegotten sense of entitlement to a life completely free of discomfort, and holy mackerel, now that folks are finally starting to accept that antidepressants are no better than placebo, wtf are they gonna do?

 

[2win]

I don't disagree with you and your feeling about this case. This lady is nowhere near coming off the vent or getting her trach out. Honestly, in my opinion she will never get her trach out. She is morbidly obese with sleep apnea and deconditioned to the point that she may not ever be able to do much of anything. But I have been wrong. In residency, one of the hardest realizations for me to come to is that people actually do get better (even in the SICU).
Another thing that is hard to accept is that you are a consultant. You make surgery possible. This surgeon has scheduled this case because from his/her standpoint they feel that it is the best thing for the patient at this time. It is your job to take care of this lady with the least amount of risk possible. If you feel conflicted, and feel that the risk of an anesthetic in a patient does not outweigh the benefit, have an honest discussion with the surgeon. Alot of these types of discussions I have had in the past have shown me a different point of view and brought to light factors that I either had not or could not have thought of.
As for this lady, Does her true anesthetic risk outweigh her benefits of having the case done. My guess is if you talk to the ents, they are trying to keep her from getting severe tracheal stenosis and either a. never getting the trach out or b. having to have some big tracheal resection down the road when (and if) she gets better.

I do agree with you BUT there are few points that need clarification:
CONSULTANT :
1. (Medicine)a. a senior physician, esp a specialist, who is asked to confirm a diagnosis or treatment or to provide an opinion
b. a physician or surgeon holding the highest appointment in a particular branch of medicine or surgery in a hospital

In this particular case - we are not "consulting" - we are "providing" anesthesia. So let's say that you believe that the procedure is futile - who cares? And don't go back to the post with the private practice and entertaining surgeons in the lunch room. We wanna be consultants and I hope that we'll become but now we're far away.

 

[nap$ter]

I don't disagree with you and your feeling about this case. This lady is nowhere near coming off the vent or getting her trach out. Honestly, in my opinion she will never get her trach out. She is morbidly obese with sleep apnea and deconditioned to the point that she may not ever be able to do much of anything. But I have been wrong. In residency, one of the hardest realizations for me to come to is that people actually do get better (even in the SICU).
Another thing that is hard to accept is that you are a consultant. You make surgery possible. This surgeon has scheduled this case because from his/her standpoint they feel that it is the best thing for the patient at this time. It is your job to take care of this lady with the least amount of risk possible. If you feel conflicted, and feel that the risk of an anesthetic in a patient does not outweigh the benefit, have an honest discussion with the surgeon. Alot of these types of discussions I have had in the past have shown me a different point of view and brought to light factors that I either had not or could not have thought of.
As for this lady, Does her true anesthetic risk outweigh her benefits of having the case done. My guess is if you talk to the ents, they are trying to keep her from getting severe tracheal stenosis and either a. never getting the trach out or b. having to have some big tracheal resection down the road when (and if) she gets better.

my attending and i had this discussion with the ENT. this was her justification for the procedure - to give her the best shot in the future for decannulation. my feeling was that same as yours; that this lady had shown no improvement (actually some decline) in the SNF over the last two months, and that at 76yo her chances of ever getting the trach out were slim to none.

so, the risks and benefits were discussed. the most important point you make is that i am a consultant and that my job is to make surgery possible with the least amount of risk possible; something that i think we are not taught enough as residents (or maybe i've just been slow to realize).

i wanted an echo, but my attending and the medicine consult (and a few of you guys) felt it would be of minimal benefit - so I bowed my head and went with the flow as best I could..

so, 18g IV, no aline, plugged circuit to trach and slowly dialed in sevo. did the case on her ICU bed.

the case was painful - sevo dumped her blood pressure at even half a mac; small amounts of cisatracurium to keep her still. BP was relatively unresponsive to phenylephrine, but vasopressin worked well. when the surgeon put the laryngoscope in and suspended, her afib rate increased to 140's and BP dropped further. started remi and vasopressin gtts, HR and BP stabilized. we swapped an armored tube for the trach and ent started excising granuloma.

she had the unfortunate combo of a thick fat neck and short lil trachea so there was this tiny sweet spot positionally for the tube - too deep and we were right mainstem, and slightly too shallow and air would blow out her mouth and around her stoma. she desatted and took ages to bag back up any time we lost peep or had a pause in ventilation, which was often since the surgeon wanted to take the tube out a few times. in addition, any time she desatted or co2 went up her HR would jump an BP drop. pain in my arse.

but, at the end of it all, my attending was happy, the ent was happy, and the patient returned to her SNF after spending last night in the ICU, in the same condition she started in, minus some granuloma tissue.

still would have like that echo preop...

 

[2win]

" at the end of it all, my attending was happy, the ent was happy,"
AND we'll see IF the patient will be happy - which I doubt.
All of us got the paycheck.

 

[nap$ter]

" at the end of it all, my attending was happy, the ent was happy,"
AND we'll see IF the patient will be happy - which I doubt.
All of us got the paycheck.

if she ever recovers, she'll be happy she's getting the best shot at decannulation. she's lucky to have made it to 76 years of age at 360 pounds..

of course she's not happy to be fat, trach'd, peg'd, and bed bound, but that is an entirely different discussion having little to do with anesthesia...

 

[2win]

if she ever recovers, she'll be happy she's getting the best shot at decannulation. she's lucky to have made it to 76 years of age at 360 pounds..

of course she's not happy to be fat, trach'd, peg'd, and bed bound, but that is an entirely different discussion having little to do with anesthesia...

"having little to do with anesthesia" - this is a problem. Whenever we touch a patient - we have a contribution to the his (her) outcome. The same statement could be made by Joe the transporter - BUT we are doctors...
Don't get me wrong - I am playing the same game but sometimes I wonder...

 

[pd4emergence]

my attending and i had this discussion with the ENT. this was her justification for the procedure - to give her the best shot in the future for decannulation. my feeling was that same as yours; that this lady had shown no improvement (actually some decline) in the SNF over the last two months, and that at 76yo her chances of ever getting the trach out were slim to none.

so, the risks and benefits were discussed. the most important point you make is that i am a consultant and that my job is to make surgery possible with the least amount of risk possible; something that i think we are not taught enough as residents (or maybe i've just been slow to realize).

i wanted an echo, but my attending and the medicine consult (and a few of you guys) felt it would be of minimal benefit - so I bowed my head and went with the flow as best I could..

so, 18g IV, no aline, plugged circuit to trach and slowly dialed in sevo. did the case on her ICU bed.

the case was painful - sevo dumped her blood pressure at even half a mac; small amounts of cisatracurium to keep her still. BP was relatively unresponsive to phenylephrine, but vasopressin worked well. when the surgeon put the laryngoscope in and suspended, her afib rate increased to 140's and BP dropped further. started remi and vasopressin gtts, HR and BP stabilized. we swapped an armored tube for the trach and ent started excising granuloma.

she had the unfortunate combo of a thick fat neck and short lil trachea so there was this tiny sweet spot positionally for the tube - too deep and we were right mainstem, and slightly too shallow and air would blow out her mouth and around her stoma. she desatted and took ages to bag back up any time we lost peep or had a pause in ventilation, which was often since the surgeon wanted to take the tube out a few times. in addition, any time she desatted or co2 went up her HR would jump an BP drop. pain in my arse.

but, at the end of it all, my attending was happy, the ent was happy, and the patient returned to her SNF after spending last night in the ICU, in the same condition she started in, minus some granuloma tissue.

still would have like that echo preop...

Sounds like a miserable case. But, the patient did as well as can be expected because of your management. I know it doesn't feel like it now but later you will be thankful for all the sick as sh$t patients that you take care of in residency. You seem to be flexible, and have a good attitude. Alot of people would have argued until they were blue in the face that their way was the only way to do things and that everybody else was wrong. It's hard to teach those folks anything and even harder to work with them.

 

[nap$ter]

"having little to do with anesthesia" - this is a problem. Whenever we touch a patient - we have a contribution to the his (her) outcome. The same statement could be made by Joe the transporter - BUT we are doctors...
Don't get me wrong - I am playing the same game but sometimes I wonder...

dude - how is this a problem? it's the truth - her unhappiness with her medical problems really does have very little to do with anesthesia. sure we should be empathetic and treat her with the utmost of care - but she's only gonna be awake 5min in my care. my contribution to her care is the safest most comfortable surgery possible. i have no misconceptions about my specialty and my strengths and weaknesses - they are a good match.

i don't mind being compared to Joe the Transporter - he's a pretty nice guy, and, to be honest, he might be better at the whole empathy thing than i am - i work on it and do my best.

"BUT we are doctors" - no offense, dude, but that happy sappy arrogant horse**** is why i went into anesthesia. i'm probably misinterpreting what you mean there, so sorry if i'm off base.

 

[2win]

dude - how is this a problem? it's the truth - her unhappiness with her medical problems really does have very little to do with anesthesia. sure we should be empathetic and treat her with the utmost of care - but she's only gonna be awake 5min in my care. my contribution to her care is the safest most comfortable surgery possible. i have no misconceptions about my specialty and my strengths and weaknesses - they are a good match.

i don't mind being compared to Joe the Transporter - he's a pretty nice guy, and, to be honest, he might be better at the whole empathy thing than i am - i work on it and do my best.

"BUT we are doctors" - no offense, dude, but that happy sappy arrogant horse**** is why i went into anesthesia. i'm probably misinterpreting what you mean there, so sorry if i'm off base.

Slavin - I am not talking about empathy - wtf are you talking about???
"the intellectual identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another."

I was talking about the outcome of the procedure. the final one.

"BUT we are doctors" - no offense, dude, but that happy sappy arrogant horse**** is why i went into anesthesia"
You basically erased anesthesia as a physician specialty. Please mention in your statement if you gonna apply ever for a fellowship (CCM , pain or palliative care) this stuff and ask yourself why nobody will call you back.
Glad that I am not you. Dude.
BTW- why do you call yourself a "consultant"?
Give it a second thought. Sorry if I was rude - still learning English.

 

[Licoricestick]

Slavin, I thought 2win was suggesting that even though both Joe and anaesthesia both have nothing to do with the fact that "she's not happy to be fat, trach'd, peg'd, and bed bound", people will consider the involvement of anaesthetics to be more significant just because we're doctors, regardless of the fact that we normally don't have a say in longer term management of patients.

Is that right 2win?

 

[nap$ter]

"BUT we are doctors" - no offense, dude, but that happy sappy arrogant horse**** is why i went into anesthesia. i'm probably misinterpreting what you mean there, so sorry if i'm off base.

ah - like i said, thought there might be a misunderstanding here. also, as i said, no offense meant, 2win. the internet is a great social vehicle but some things are missed. words are innocuous, it is their consensus that gives them meaning.

i think we re actually on the same page 2win, hence my initial concern about risks vs benefits long term for surgery for this lady, and the discussion with her ENT's.

and btw, 2win, "dude" is a label i don't mean as disrespectful, it's something i call every man, woman, and child. dontcha think it might be a little hasty to say "no one is going to call you back" for a fellowship? might be a leap to make that judgment based on two internet posts?...

 

[2win]

"BUT we are doctors" - no offense, dude, but that happy sappy arrogant horse**** is why i went into anesthesia. i'm probably misinterpreting what you mean there, so sorry if i'm off base.

ah - like i said, thought there might be a misunderstanding here. also, as i said, no offense meant, 2win. the internet is a great social vehicle but some things are missed. words are innocuous, it is their consensus that gives them meaning.

i think we re actually on the same page 2win, hence my initial concern about risks vs benefits long term for surgery for this lady, and the discussion with her ENT's.

and btw, 2win, "dude" is a label i don't mean as disrespectful, it's something i call every man, woman, and child. dontcha think it might be a little hasty to say "no one is going to call you back" for a fellowship? might be a leap to make that judgment based on two internet posts?...

Slavin - I used "dude" a lot and sounds cool for me!
You gonna get a fellowship if you want one . I was just saying that in the application and during the interview you have to show that an anesthesia doc is a "physician" - whatever this one means instead of a cold technician.
catch you later - 2win

 

[amyl]

i have to agree that some doctors here are too heavy handed w the narcs but i don't think its the anesthesiologists. i recently had an accident. i was given 4mg morphine iv in the ambulance, that went okay. when i got to the ER, they stuck me in a room, didn't hook me up to the monitors and pushed a mg of dilaudid. i am narc naive so you can imagine how that went...