Private equity buys anesthesia - Dr. Glaucomflecken

[Beeftenderloin]

was it for atrial fib or flutter because then maybe the BMP is more justified but it does support the saying “if you go looking for trouble you’re more likely to find it”

Paroxysmal AFib, workup for watchman. Was in sinus the whole time I saw him.

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[secretasianman]

You probably don’t realize this, but you are a major douchebag. If this same case proceeded and there was a major complication we all know you’re the type to throw anesthesia under the bus. We can smell you from miles away. Feel free to disagree.

If patient experiences unexpected pain with a 14G Tuohy in their spine over their cord and wiggles, they can be injured. MAC not used because I do not know who I am getting and many of the CRNA, AA/PA people go light and patient not sedated, just disinhibited becoming a danger to themselves. I have done SCS case implants under local and it goes much smoother under general. If you cancelled my cases all the time at 5.5, I would file complaint through admin and work to get you fired. If normal range is 5.5 and literature says do not change anesthetic plan if K+ <6.

 

[DrOwnage]

There is a grey area in medicine. We risk stratify, follow certain guidelines, even go off anecdotal evidence. For things like electrolytes no one will actually know how much risk increases from 5.5 to 6.0 in a given patient. You can always find another person who will have a different opinion, just like how you would operate on someone given their MRI when others might not. But to insinuate anesthesiologists are just out there cancelling cases for no reason because you googled "normal potassium range" is absurd. Even you see the variation in guidelines and cutoffs. Stop stabbing your coworkers in the back. We don't get paid to cancel cases. If something goes wrong or the patient has a shockable arrythmia while you're prepped and prone without pads on, I don't think you're gonna be the one dealing with the consequences. Well maybe the legal ones.

People get too angry. We're not stealing your livelihood. The patient was within a questionable range. Let it go.

 

[lobelsteve]

You probably don’t realize this, but you are a major douchebag. If this same case proceeded and there was a major complication we all know you’re the type to throw anesthesia under the bus. We can smell you from miles away. Feel free to disagree.

So lets say the case gets started and 15 min in labs become available and K=5.7
What do you differently?

 

[IMGASMD]

So lets say the case gets started and 15 min in labs become available and K=5.7
What do you differently?

I’d be praying out loud, so my proceduralist can hear me clearly.

I’d like to know what you would do “If something goes wrong or the patient has a shockable arrythmia while you're prepped and prone without pads on….”?
Let me attempt to answer this for you,
“nothing, because I’m ‘only’ the pain guy.”
While the most of us will start treating, because it is our responsibility as well as, “we” are the one who “let” the case started. I would (have to) take this head on, because I’ve made my bed, now it’s time to lie in it.

 

[IMGASMD]

none moreso than ortho

Let me illustrate this for a case that I had over that weekend.

92 yo woman, HOH, little “forgetful” otherwise in good health. ~ 4 METs. Fell, broke her hip.

Admitted to IM by a midlevel late evening. “Based on RCRI 0, proceed without further testing….”
Okay. That’s pretty bold, but okay.

Hospitalist came on overnight, while co-signing the note, added “TTE and trop, if okay, proceed”.

Next morning, a different IM PA on. “2 sets of positive trop. Cardiology said most likely supply vs demand, can proceed without any further testing.”

Ortho. IM said there’s no risk, let’s go.

My rationale, holdup…..
You had a physician who wanted a TTE, now you have two sets of “indeterminate” trop. Cardiologist verbally told you it’s okay, but don’t want to do a formal consult…..

I am the dingus who won’t let ortho start the case?

 

[anbuitachi]

Let me illustrate this for a case that I had over that weekend.

92 yo woman, HOH, little “forgetful” otherwise in good health. ~ 4 METs. Fell, broke her hip.

Admitted to IM by a midlevel late evening. “Based on RCRI 0, proceed without further testing….”
Okay. That’s pretty bold, but okay.

Hospitalist came on overnight, while co-signing the note, added “TTE and trop, if okay, proceed”.

Next morning, a different IM PA on. “2 sets of positive trop. Cardiology said most likely supply vs demand, can proceed without any further testing.”

Ortho. IM said there’s no risk, let’s go.

My rationale, holdup…..
You had a physician who wanted a TTE, now you have two sets of “indeterminate” trop. Cardiologist verbally told you it’s okay, but don’t want to do a formal consult…..

I am the dingus who won’t let ortho start the case?

Im surprised the IM midlevel who wrote based on rcri 0, didnt also write patient is asa1

 

[Arch Guillotti]

Admitted to IM by a midlevel late evening. “Based on RCRI 0, proceed without further testing….”
Okay. That’s pretty bold, but okay.

This case is a dime a dozen. Unless there are some pretty obvious indicators, not sure what additional testing gives you.

 

[IMGASMD]

This case is a dime a dozen. Unless there are some pretty obvious indicators, not sure what additional testing gives you.

It doesn’t. I’m not convinced that it adds anything. I am however concerned with different management that was “suggested”. in this patient. Especially when I don’t really see them until they come to holding. Why did the hospitalists want TTE in the first place? He certainly didn’t write any rationale for it. Who am I to overrule a test, when I haven’t seen the patient?

I’ve worked at enough places now to know different cultures at different hospitals can hurt me. As I get more experience, more CYA I’ve become.

 

[GassYous]

This case is a dime a dozen. Unless there are some pretty obvious indicators, not sure what additional testing gives you.

If something goes wrong (very high chance) your ass is grass

 

[Arch Guillotti]

If something goes wrong (very high chance) your ass is grass

So we should just go ahead and cath the lady and then drop a TEE probe intraop just in case I guess.

 

[coffeebythelake]

If something goes wrong (very high chance) your ass is grass

This is why ASA has advocated for minimal and rationale driven testing. Because when IM or cardiology willy nilly orders a lab you are compelled to act on results.

In this case here I wouldn't say ass is grass, but I think everyone involved needs to be aware that this isn't a healthy patient with no cardiac issues going forward into the case. The patient should be made aware of their cardiac risk and it isn't a baseline risk.

 

[GassYous]

So we should just go ahead and cath the lady and then drop a TEE probe intraop just in case I guess.

If that's what the cardiologist recommended...

 

[Arch Guillotti]

this isn't a healthy patient

This particular patient sounds like a rose compared to some that roll through.

 

[Twiggidy]

It makes you curious of the story of "the fall". Did she pass out and fall or did she just trip and fall?

If she passed out and fell, I can understand the TTE. Maybe we're worried about severe aortic stenosis. Lady still needs the hip done, but at least now you know to treat this lady a smidge different then if she had a wide open AV.

If she just tripped and otherwise has no history other than age, then i'm not 100% sure of the million dollar work up.

The things consultants put in charts can present a challenge when they're doing "shotgun medicine". I had an orthopedic surgeon once who had a case that "needed cardiac anesthesia". When I reviewed the case, the lady just had some mitral regurgitation, probably moderate at most. When I asked him why a cardiac anesthesiologist was need he said, "The cardiologist recommended it in his note and if I ignore that and something goes wrong that's my butt." Maybe he's right and maybe he's wrong, but I understood where he was coming from.

 

[Arch Guillotti]

If you cancelled my cases all the time at 5.5, I would file complaint through admin and work to get you fired.

You must be a joy to work with

 

[MirrorTodd]

It makes you curious of the story of "the fall". Did she pass out and fall or did she just trip and fall?

If she passed out and fell, I can understand the TTE. Maybe we're worried about severe aortic stenosis. Lady still needs the hip done, but at least now you know to treat this lady a smidge different then if she had a wide open AV.

If she just tripped and otherwise has no history other than age, then i'm not 100% sure of the million dollar work up.

The things consultants put in charts can present a challenge when they're doing "shotgun medicine". I had an orthopedic surgeon once who had a case that "needed cardiac anesthesia". When I reviewed the case, the lady just had some mitral regurgitation, probably moderate at most. When I asked him why a cardiac anesthesiologist was need he said, "The cardiologist recommended it in his note and if I ignore that and something goes wrong that's my butt." Maybe he's right and maybe he's wrong, but I understood where he was coming from.

That's insane, but 100% believable. Gotta love the American health system.

 

[pgg]

Orthopedic surgeons are some of coolest and nicest people in the OR but man sometimes they can live up to the stereotype

I did a case a few weeks ago. Can't remember if I've already told this story here or not, but it bears repeating.

Patient had an ankle fracture. 20 days ago, had a STEMI and some DES placed. On DAT, aspirin and clopidogrel. Cardiology was consulted and wrote, in bold, that the DAT must be continued throughout the period period.

Patient shows up for surgery, didn't take her Plavix that day. Ortho told her not to. I order it and give it to her in preop. Ortho is mad. "Buuuuut I have to oooooperate! Oh fine, if it makes you feel better."

Also made the comment that missing one dose doesn't matter. I mean, it apparently matters that her ankle, distal to a tourniquet, will clot better after missing a dose, making his field less bloody. But he couldn't connect the dots between that and in-stent clots putting her pre-osseous Ancef pump at risk.

That's ortho for ya.

 

[Twiggidy]

I did a case a few weeks ago. Can't remember if I've already told this story here or not, but it bears repeating.

Patient had an ankle fracture. 20 days ago, had a STEMI and some DES placed. On DAT, aspirin and clopidogrel. Cardiology was consulted and wrote, in bold, that the DAT must be continued throughout the period period.

Patient shows up for surgery, didn't take her Plavix that day. Ortho told her not to. I order it and give it to her in preop. Ortho is mad. "Buuuuut I have to oooooperate! Oh fine, if it makes you feel better."

Also made the comment that missing one dose doesn't matter. I mean, it apparently matters that her ankle, distal to a tourniquet, will clot better after missing a dose, making his field less bloody. But he couldn't connect the dots between that and in-stent clots putting her pre-osseous Ancef pump at risk.

That's ortho for ya.

I’ll never forget one of my cardiac attendings saying “the further a surgeon gets away from the heart, the less the less they care about it”.

 

[Twiggidy]

I did a case a few weeks ago. Can't remember if I've already told this story here or not, but it bears repeating.

Patient had an ankle fracture. 20 days ago, had a STEMI and some DES placed. On DAT, aspirin and clopidogrel. Cardiology was consulted and wrote, in bold, that the DAT must be continued throughout the period period.

Patient shows up for surgery, didn't take her Plavix that day. Ortho told her not to. I order it and give it to her in preop. Ortho is mad. "Buuuuut I have to oooooperate! Oh fine, if it makes you feel better."

Also made the comment that missing one dose doesn't matter. I mean, it apparently matters that her ankle, distal to a tourniquet, will clot better after missing a dose, making his field less bloody. But he couldn't connect the dots between that and in-stent clots putting her pre-osseous Ancef pump at risk.

That's ortho for ya.

Wait......also......not taking plavix the morning of surgery means nothing from coagulation standpoint. This patient is still going to bleed. Again, ortho living up to the stereoptype.

 

[nimbus]

Wait......also......not taking plavix the morning of surgery means nothing from coagulation standpoint. This patient is still going to bleed. Again, ortho living up to the stereoptype.

So ortho is right!

 

[MirrorTodd]

Lol "Pre-osseus ancef pump" I'm so using that in the future.

 

[D P356]

So lets say the case gets started and 15 min in labs become available and K=5.7
What do you differently?

Generally if someone has a feeling that a lab needs to be drawn, it’s best to wait for the result.

Respectfully, you’re a physician capable of sedating a pt. But I’m guessing there is a reason you have an anesthesia team involved. You don’t want that responsibility all the time.

A tuohy going into the back of an anesthetized patient also has risk. Pt not able to communicate paresthesia or nerve irritation.

If you’re petty, they may cancel your next two cases as tribute

 

[Shimmy8]

Problem is once something is ordered, and **** hits the fan, our ass is on the line for ignoring/subverting a subspecialists recommondation.

Happens weekly if not daily. None of us would order echo/trops on the mechanical falls with compensated CHF, rate controlled afib, stable CAD, etc. But once cardiology weighs in before we even get noticed of the patient, our hands are tied.

 

[fakin' the funk]

Read most of this thread and have to agree/reiterate that
1) other specialties have no idea how anesthesia and the perioperative period work and thus their recommendations are usually useless or dangerous
2) surgeons and the rest have a dismaying disrespect for our specialty
3) the more face time with surgeons, consultants, and patients we spend, the better we are and the better we look
4) having written policies for things like K+ cutoffs makes things predictable and reliable

 

[fakin' the funk]

So lets say the case gets started and 15 min in labs become available and K=5.7
What do you differently?

I'm gonna treat it immediately, being the medical emergency that it is, so as to avoid it worsening during (if no other time) the expected postop respiratory acidosis. Clown

 

[2Fast2Des]

Read most of this thread and have to agree/reiterate that
1) other specialties have no idea how anesthesia and the perioperative period work and thus their recommendations are usually useless or dangerous
2) surgeons and the rest have a dismaying disrespect for our specialty
3) the more face time with surgeons, consultants, and patients we spend, the better we are and the better we look
4) having written policies for things like K+ cutoffs makes things predictable and reliable

Yeah I remember in residency had pulm evaluate a pt with severe pulm HTN for a big revision knee case, the attending wrote in their note they recommend cardiac anesthesiologist to do the case. My attending was PO'd, called up the attending and her chairman to have a chat about that because he took it as an insult that as if the rest of the anesthesiologists couldn't manage the case. In residency everyone stayed in their silos so I don't think having a cardiac guy who only does hearts come float over to Ortho land to do a case with none of the equipment that would make it worthwhile to have a cardiac guy useful lol.

Or the cardiologist that says pt with severe AS high risk for GA, recommend spinal instead 🤣

 

[IMGASMD]

Yeah I remember in residency had pulm evaluate a pt with severe pulm HTN for a big revision knee case, the attending wrote in their note they recommend cardiac anesthesiologist to do the case. My attending was PO'd, called up the attending and her chairman to have a chat about that because he took it as an insult that as if the rest of the anesthesiologists couldn't manage the case. In residency everyone stayed in their silos so I don't think having a cardiac guy who only does hearts come float over to Ortho land to do a case with none of the equipment that would make it worthwhile to have a cardiac guy useful lol.

Or the cardiologist that says pt with severe AS high risk for GA, recommend spinal instead

What happened with the case?
In residency, cardiac anesthesiologists would never step in any general cases. Gen guys have aversions to step in cardiac rooms.

 

[chessknt]

Let me illustrate this for a case that I had over that weekend.

92 yo woman, HOH, little “forgetful” otherwise in good health. ~ 4 METs. Fell, broke her hip.

Admitted to IM by a midlevel late evening. “Based on RCRI 0, proceed without further testing….”
Okay. That’s pretty bold, but okay.

Hospitalist came on overnight, while co-signing the note, added “TTE and trop, if okay, proceed”.

Next morning, a different IM PA on. “2 sets of positive trop. Cardiology said most likely supply vs demand, can proceed without any further testing.”

Ortho. IM said there’s no risk, let’s go.

My rationale, holdup…..
You had a physician who wanted a TTE, now you have two sets of “indeterminate” trop. Cardiologist verbally told you it’s okay, but don’t want to do a formal consult…..

I am the dingus who won’t let ortho start the case?

Late to the party I know but think about the risk that unfixed hip poses and whether surgery is going to be safer after a stent in an otherwise stable coronary lesion that caused some mild demand now on 2 antiplatelet agents. We all know comfort care is probably a better answer but this is America so we can't do that.

I would argue that the risk is higher sure but you don't have a good alternative for an urgent surgery.

 

[chessknt]

If something goes wrong (very high chance) your ass is grass

I think never having to deal with people in a longitudinal fashion jades you a bit. Generally people this old have families that know that they are old and that old people can die. If you tell them that they are at risk for something bad happening intraop and you'll do your best to get her through and then something bad happens they aren't going to sue anyone. They are going to go through grief stages and move on. They sue people when things are hidden, obfuscated, not explained, or you act like an dingus.

I have seen absolute malpractice happen (think asc where anesthesia couldn't get the airway and caused anoxic brain injury in a healthy person) and nobody got sued because the family was treated with respect. Does it guarantee you are safe? Absolutely not but it isn't like any time there is a slightly suboptimal configuration to care that you get dragged to court if something happens. Not everyone out there wants to rehash a death or bad outcome for money, in fact very few do.

 

[IMGASMD]

Late to the party I know but think about the risk that unfixed hip poses and whether surgery is going to be safer after a stent in an otherwise stable coronary lesion that caused some mild demand now on 2 antiplatelet agents. We all know comfort care is probably a better answer but this is America so we can't do that.

I would argue that the risk is higher sure but you don't have a good alternative for an urgent surgery.

It depends on a lot of factors. The “safest” thing to be is not necessarily the “right” thing. And the “safest” thing to me maybe different than yours.

If there are differences of management that’s played out on paper, I will let everyone have their say and put them on paper, before I proceed.

I was welling to proceed, but then found out hospitalist wants an Echo and trop. Then positive trop. Sure I can explain it away and the surgeon “can” declare it an emergency/urgency surgery, but he didn’t.

I was going to ask arch, now you. Let’s say before any of the things that you don’t believe should be done is done. Echo, cardiology consult and/or more trop is done, you decided to just go ahead. How would you document, or would you document anything in the chart?

To also respond to the comment below, if you have a good relationship with the patient, then you wouldn’t be sued. There was a post on Reddit (I am on vacation this week, so no judgment…) by a cardio thoracic surgeon about being sued by a patient that he “just” operated on. Per the story, he put the patient on ecmo a few months ago, while patient was very sick, saved his life. The patient was so grateful with the outcome, decided to come back and have cabg by him. The patient is currently in ICU after a 10 hour surgery, surgeons office just informed him that the very patient he just operated on, is in fact suing him still on vent in icu. He was venting as well as asking what to do tomorrow morning, when they actually round on the patient…. Sure the suit may be dismissed soon, but it’s still a stressor. He still needs to respond to it, with time, money and energy.

 

[GassYous]

It depends on a lot of factors. The “safest” thing to be is not necessarily the “right” thing. And the “safest” thing to me maybe different than yours.

If there are differences of management that’s played out on paper, I will let everyone have their say and put them on paper, before I proceed.

I was welling to proceed, but then found out hospitalist wants an Echo and trop. Then positive trop. Sure I can explain it away and the surgeon “can” declare it an emergency/urgency surgery, but he didn’t.

I was going to ask arch, now you. Let’s say before any of the things that you don’t believe should be done is done. Echo, cardiology consult and/or more trop is done, you decided to just go ahead. How would you document, or would you document anything in the chart?

To also respond to the comment below, if you have a good relationship with the patient, then you wouldn’t be sued. There was a post on Reddit (I am on vacation this week, so no judgment…) by a cardio thoracic surgeon about being sued by a patient that he “just” operated on. Per the story, he put the patient on ecmo a few months ago, while patient was very sick, saved his life. The patient was so grateful with the outcome, decided to come back and have cabg by him. The patient is currently in ICU after a 10 hour surgery, surgeons office just informed him that the very patient he just operated on, is in fact suing him still on vent in icu. He was venting as well as asking what to do tomorrow morning, when they actually round on the patient…. Sure the suit may be dismissed soon, but it’s still a stressor. He still needs to respond to it, with time, money and energy.

Link?

 

[chessknt]

It depends on a lot of factors. The “safest” thing to be is not necessarily the “right” thing. And the “safest” thing to me maybe different than yours.

If there are differences of management that’s played out on paper, I will let everyone have their say and put them on paper, before I proceed.

I was welling to proceed, but then found out hospitalist wants an Echo and trop. Then positive trop. Sure I can explain it away and the surgeon “can” declare it an emergency/urgency surgery, but he didn’t.

I was going to ask arch, now you. Let’s say before any of the things that you don’t believe should be done is done. Echo, cardiology consult and/or more trop is done, you decided to just go ahead. How would you document, or would you document anything in the chart?

To also respond to the comment below, if you have a good relationship with the patient, then you wouldn’t be sued. There was a post on Reddit (I am on vacation this week, so no judgment…) by a cardio thoracic surgeon about being sued by a patient that he “just” operated on. Per the story, he put the patient on ecmo a few months ago, while patient was very sick, saved his life. The patient was so grateful with the outcome, decided to come back and have cabg by him. The patient is currently in ICU after a 10 hour surgery, surgeons office just informed him that the very patient he just operated on, is in fact suing him still on vent in icu. He was venting as well as asking what to do tomorrow morning, when they actually round on the patient…. Sure the suit may be dismissed soon, but it’s still a stressor. He still needs to respond to it, with time, money and energy.

As above I would document (from the IM side) that in the risk of deconditioning, delirium, clots, femoral head AVN from an unrepaired hip fracture in a 90+ year old exceeds any increased perioperative mortality/morbidity risk from a potential unrepaired stable coronary lesion in an otherwise full code patient. Done, no need for any bull**** cardiac workup that wont change the reality that she still needs that fracture fixed.

Play it out in your mind--she has a perioperative MI and dies (worst case scenario)--what would have happened if she had to lay in bed for 1 month unable to move waiting for her BMS to be able to come off antiplatelet therapy? I pitch that to a family as we can optimize her chance to survive the surgery in exchange for her lying in bed unable to move for a month at high risk for blood clots and confusion and malnutrition or we can accept a bit of a higher periop risk and get the fracture fixed now, which do you think is best?

 

[IMGASMD]

Link?

I think it was taken down. Many posters were telling him, anything he posts can and will be used. He was pretty confident it would be fine, at least this morning.

On the other hand, it can certainly be not a true story. He did provide enough details and used all the right words to not be some elaborate prank.

 

[GassYous]

I think it was taken down. Many posters were telling him, anything he posts can and will be used. He was pretty confident it would be fine, at least this morning.

On the other hand, it can certainly be not a true story. He did provide enough details and used all the right words to not be some elaborate prank.

What subreddit do you subscribe to

I used to have medicine and residency but it was too much

 

[nimbus]

If all geriatric hip fractures need a 12-lead EKG, one could make the argument that they should all get baseline troponins, echos, and maybe BNP too. They’d be higher yield and more useful than a resting EKG in many cases. You’d proceed with the hip orif regardless of the result, but you’d be armed with some useful information. I’m always happy when the hospitalist orders an echo, and will often order them myself while I’m reviewing a chart the night before.

 

[jwk]

You must be a joy to work with

He's actually a pretty cool guy to work with. He does a few cases at one of my hospitals but does most of his work in his own center. He told me years ago I was a wimp for having my facet blocks done with IV sedation. Turns out he was right - I had one done without sedation a few months ago, and was in and out of the pain clinic in less than 10 minutes. It was a breeze!

 

[IMGASMD]

What subreddit do you subscribe to

I used to have medicine and residency but it was too much

I check medicine/anesthesiology/residency/medicalschool

There are weeks I don’t check. I am on vacation so little more free time.

 

[Hoya11]

As above I would document (from the IM side) that in the risk of deconditioning, delirium, clots, femoral head AVN from an unrepaired hip fracture in a 90+ year old exceeds any increased perioperative mortality/morbidity risk from a potential unrepaired stable coronary lesion in an otherwise full code patient. Done, no need for any bull**** cardiac workup that wont change the reality that she still needs that fracture fixed.

Play it out in your mind--she has a perioperative MI and dies (worst case scenario)--what would have happened if she had to lay in bed for 1 month unable to move waiting for her BMS to be able to come off antiplatelet therapy? I pitch that to a family as we can optimize her chance to survive the surgery in exchange for her lying in bed unable to move for a month at high risk for blood clots and confusion and malnutrition or we can accept a bit of a higher periop risk and get the fracture fixed now, which do you think is best?

I get what you are saying but I think it’s disengenious to advertise fixing this hip as this persons ticket to walking again.

They very most often never recover and die without significant mobility regardless.

So I have no problem delaying this . I don’t believe it’s going to help most patients. It’s just a ticket for discharge unfortunately

 

[chessknt]

I get what you are saying but I think it’s disengenious to advertise fixing this hip as this persons ticket to walking again.

They very most often never recover and die without significant mobility regardless.

So I have no problem delaying this . I don’t believe it’s going to help most patients. It’s just a ticket for discharge unfortunately

Have you rounded on a 90 year old who is bedbound and in pain for several weeks? If they aren't going to fix I'd recommend hospice instead. A chance to actually get out of bed and move is better than a guarantee of bedbound status with severe pain.

 

[Hoya11]

Have you rounded on a 90 year old who is bedbound and in pain for several weeks? If they aren't going to fix I'd recommend hospice instead. A chance to actually get out of bed and move is better than a guarantee of bedbound status with severe pain.

The hip pinning is not going to change that tho.. IMO . Still going to be in bed and in pain ..

 

[chessknt]

The hip pinning is not going to change that tho.. IMO . Still going to be in bed and in pain ..

Ive seen 90 year olds get up and around after the hip replacement....

To be clear your reason for delaying would be to get a LHC to treat a 70ish% coronary lesion that was causing mild demand ischemia on presentation? Or are you worried about something else?

 

[DrOwnage]

The hip pinning is not going to change that tho.. IMO . Still going to be in bed and in pain ..

Hip pinning/replacement significantly improves the pain of the patient. Kind of counterintuitive, and I used to think the same way.

 

[anbuitachi]

Hip pinning/replacement significantly improves the pain of the patient. Kind of counterintuitive, and I used to think the same way.

what about the fat incision?

 

[Hoya11]

Ive seen 90 year olds get up and around after the hip replacement....

To be clear your reason for delaying would be to get a LHC to treat a 70ish% coronary lesion that was causing mild demand ischemia on presentation? Or are you worried about something else?

well im worried about this going badly south and the liability on me if that happens..

im worried about a massive MI, a PE, an intraop stroke, extensive bleeding, this is a 90yo frail patient .. bad stuff could definitely happen.

i have had simple procedures end in death for very elderly people.

i would think a cardiac consult on this patient with a valve issue not evaluated for some time would be standard of care.

my point is that this patient will have very likely been evaluated by cardiology prior to the procedure who will determine if an echo is warranted and also read that echo..

i just think the idea of the anesthesiologist going to the bedside with an echo or doing an intraop TEE here is just unrealistic..

 

[Hork Bajir]

I’ll just add that you don’t necessarily need to wait for a formal echo- takes only a few minutes to slap a probe on the chest and take a quick look around (assuming you have a phased array probe available). For this purpose, you don’t need very high level echo (which mitral scallop is prolapsing and is the patient at risk for SAM after a repair and blah blah blah)… We’re talking checking to see if the EF is 50, or 10. Is there severe AS staring you in the face. Is there a major, dramatic WMA. With some training, acquiring the necessary images and making these very basic determinations should be within reach for any anesthesiologist who wants to put in the time

 

[nimbus]

well im worried about this going badly south and the liability on me if that happens..

im worried about a massive MI, a PE, an intraop stroke, extensive bleeding, this is a 90yo frail patient .. bad stuff could definitely happen.

i have had simple procedures end in death for very elderly people.

i would think a cardiac consult on this patient with a valve issue not evaluated for some time would be standard of care.

my point is that this patient will have very likely been evaluated by cardiology prior to the procedure who will determine if an echo is warranted and also read that echo..

i just think the idea of the anesthesiologist going to the bedside with an echo or doing an intraop TEE here is just unrealistic..

Medicolegal risk in a 90 yo patient is very low.

 

[2Fast2Des]

What happened with the case?
In residency, cardiac anesthesiologists would never step in any general cases. Gen guys have aversions to step in cardiac rooms.

Did the case with all the fun tools including TEE, with my attending (who also happened to be former cardiac guy) and she did well! Had levo, vaso, epi and flolan on hand. Did slow release of the tourniquet so her right heart didn't give out immediately, was pretty cool to see all the emboli being released on TEE.

 

[lobelsteve]

He's actually a pretty cool guy to work with. He does a few cases at one of my hospitals but does most of his work in his own center. He told me years ago I was a wimp for having my facet blocks done with IV sedation. Turns out he was right - I had one done without sedation a few months ago, and was in and out of the pain clinic in less than 10 minutes. It was a breeze!

Oh hush. I was trolling. Lady had a renal transplant a few years prior. As well as SLE. But we did have notes from all of her treating docs. Biggest issues was the fact she was delayed/cancelled 4x prior to this. Various reasons, none of them pressing medical issues. I still haven't seen the doc who cancelled me the last time. But the patient did well with surgery and is getting great relief with the SCS.
And I am a douche.