Pulmonary Procedures in Private Practice

[95beretta]

I'm about to enter my third year of P/CC fellowship and will be entering private practice after graduation. I am curious about which procedures the attendings on this forum currently perform in private practice. The main procedures I'm considering are EBUS, ENB, bronchial thermoplasty, Pleurex catheter placement and percutaneous tracheostomy. At my fellowship, we perform all 5 of these fairly regularly, but my guess is that EBUS will likely be the only "advanced" procedure that I perform after graduation. (I'm assuming that everyone fairly regularly performs general bronchoscopy and endotracheal intubation). I am interested to hear which of these or other procedures you regularly perform after fellowship - thanks!

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[jdh71]

I do EBUS and Nav's. I'm not interested in thermoplasty. No putting in pleurex catheters. I'm also not doing any perc trachs because why? I could do any of the above. The time to compensation ratio within the context of potential complications and/or follow up I dont want to deal with leaves me personally in the EBUS and Nav only camp. I get blocks of time and anesthesia runs my sedation.

 

[group_theory]

I do EBUS and Nav's. I'm not interested in thermoplasty. No putting in pleurex catheters. I'm also not doing any perc trachs because why? I could do any of the above. The time to compensation ratio within the context of potential complications and/or follow up I dont want to deal with leaves me personally in the EBUS and Nav only camp. I get blocks of time and anesthesia runs my sedation.

Same. Do EBUS and ENB (and thoras). Not interested in BT (too much initial investment $$$, and too much time). Also have multiple departments who can do tunneled pleural catheters that I can refer to. Same with trachs.

It's time-compensation ratio, plus if you do something, you're responsible for its follow-up/complications.

Keep in mind that private practice is different than academia. Specialists (whether IR, ENT, thoracic surgery, trauma, etc) make money doing procedures/getting referrals so you won't get the same push back that you would in academia when consulting for procedures. In fact, depending on hospital and culture, they may be upset if you start taking procedures away from them.

 

[Hernandez]

Same as above, ebus, waiting to get enb equipment but will do. I'll do thoras on weekends. I could do pleurex but it's easier to have IR do it so I don't have to battle getting proper equipment and finding a nurse got meds and to be present.

Thermoplasty, I don't think there are truly that many pts who'd benefit from it, the rare one who does I'll send down to the guy who does a bunch already, and perc trach, I could do but didn't do a ton in fellowship but have a partner that is very experienced and loves them so we have them do the trachs.

 

[tartesos]

I have no interest or intentions of doing perc trachs.... Personal preference.
I heard pleurex caths pay very very well from my staff don't know how well yet though. It depends on how easy you can get it set up in your shop, but it's a quick procedure( I like them) and a quick f/u visit to remove stitches and see how it's going.

Bronch, nav, ebus should be bread and butter, anything else that you know before hand that will require you to spend more than 30 mins in the bronch lab deserves to be referred to an academic center.

 

[mochief2000]

sorry to hijack your thread, but i noticed after talking to some friends at different PCCM fellowships our procedure exposure is pretty different. What would you say you have to absolutely know how to do (procedure wise) before graduating. This includes, but not limited to, Chest tubes/pigtails, intubations, art lines, central lines, LP's, perc trachs, PA caths, chest tube management). I know some of this is more like resident level, but interested in knowing how many of you still do these, if any at all. thanks -Einstein

 

[jdh71]

sorry to hijack your thread, but i noticed after talking to some friends at different PCCM fellowships our procedure exposure is pretty different. What would you say you have to absolutely know how to do (procedure wise) before graduating. This includes, but not limited to, Chest tubes/pigtails, intubations, art lines, central lines, LP's, perc trachs, PA caths, chest tube management). I know some of this is more like resident level, but interested in knowing how many of you still do these, if any at all. thanks -Einstein

As a pulmonolgist you need to know how to bronch. In fellowship you should run around like a chicken with your head cut off, a chicken that is also holding a bronch. You'll want enough transbonchial biopsies to feel comfortable doing them outside of attending supervision and hopefully this will include a case where there is a lot of bleeding and a case where you cause a pneumothorax. You want to know how to handle your own complications without having to cry like a bitch at a surgeon. I think fellowship should also teach you EBUS as it is becoming standard of care for cancer staging. I'm +/- on Nav's as I think they are easy enough to pick up after fellowship if you actually FIRST know how to bronch. The rest of "IP" is basically also just being a decent bronch driver.

On the critical care side in my opinion you should be able to put in a central line without having to sweat. You should have enough numbers and seen enough cases that you've needed to think around some corners. While most patients are going to be pretty "out of it" when you place your line you need to know what you should do as a basic outline or sketch if you need that access and you are in unique environment like awake but encephalopathic without any other access, or INR of 12, or been stuck so many times your favorite and usual spots are a "no go", etc.

I don't think you need to have a ton of art lines. They are tricky devils really no matter what, and sometimes you just can't get them anyway, and besides that, they are almost never actually necessary to drive management - minute to minute BP monitoring is nice, but almost never absolutely needed.

Forget LPs, those have long gone to IR and they can have them - you're going to treat empirically anyway if you think you "need" and LP.

Forget Swan's too - no data has ever shown their utility in the MICU - always nice to see the numbers, but as it turns out the best critical care management based off those numbers didn't actually save anyone - ever. And they tried to show it did, many, many times. There are other means to similar data and while imperfect are good enough for "government work" in the ICU setting - ie you get an "objective enough" idea to help drive management.

**** perc trachs. Seriously. I mean if you really have a strong interest do a bunch. I don't want to deal with them, their complications, or the post-trach care - if you decide to do these you really need to have the blessings of your surgeons and ENTs because they will have to clean up your mess if you make one - I don't like creating work for others.

You should know how to toss in a "pig-tail" chest tube - and if you can place a central line you can easily do one of these. I'm not convinced knowing how to put in a surgical tube the size around of your thumb is necessary to know, but if you can pick up enough numbers to feel comfortable I don't think there is anything wrong with them either. No good data supports the big tubes in almost any case. You will need to know how to manage chest tubes standing on your head because after IR or the surgical animals put them in on medical patients, they usually like to disappear and you'll be asked to manage and it's easy enough usually I don't mind - I do a lot of tPA/dornase too.

I think you should try and get as many intubations as you can in fellowship, but you need to be humble about your skills know you will still be the third best at putting in ET tubes in the hospital, so if you're nervous about an airway . . . ASK FOR HELP. However, we can usually manage most airways and I think should generally try, so you'll want enough tubes to feel good about that before leaving fellowship.

My $0.02

 

[Hernandez]

Agree 99%, I would recommend that you learn surgical chest tube placement. It may just be my karma but when an ards pt drops a lung on me, they're never skinny pts who are easy to do seldinger chest tubes and when you gotta fix that ptx right the **** now a scalpel is your friend.

 

[group_theory]

Agree 99%, I would recommend that you learn surgical chest tube placement. It may just be my karma but when an ards pt drops a lung on me, they're never skinny pts who are easy to do seldinger chest tubes and when you gotta fix that ptx right the **** now a scalpel is your friend.

There's always the trocar method ... if they're that big, then your chances of hitting the mediastinum will be lower (most of the trocar will be in the subQ tissue/fat anyway) ... besides, finger sweeping a morbidly obese chest is as much fun as putting a femoral line in a morbidly obese patient

Or try dropping your volume/peak pressure, or decrease the amplitude on the oscillator (if you're still using that on ARDS despite the OSCAR/OSCILLATE trials) so you don't have to put in a chest tube for iatrogenic ptx

*I kid, just pulling your chains

 

[mochief2000]

@jdh71 thanks man!! With the PA caths, I was thinking more along the line of pulm htn patients in the unit (i know already poor prognosis) to help guide their already F-up sterling curve. Very helpful info though

i did enough of most of the procedures in residency, but more concerned about chest tubes, ebus and navigation bronchs. I could care less about perc trachs, i just don't see myself doing that in practice.

For all of you kind enough to respond, how many chest tubes or pigtails did you do in fellowship?

 

[jdh71]

Agree 99%, I would recommend that you learn surgical chest tube placement. It may just be my karma but when an ards pt drops a lung on me, they're never skinny pts who are easy to do seldinger chest tubes and when you gotta fix that ptx right the **** now a scalpel is your friend.

I've actually seen more problems with surgical tubes and the obese than the perc tubes. Anecdote being what it is.

 

[jdh71]

@jdh71 thanks man!! With the PA caths, I was thinking more along the line of pulm htn patients in the unit (i know already poor prognosis) to help guide their already F-up sterling curve. Very helpful info though

i did enough of most of the procedures in residency, but more concerned about chest tubes, ebus and navigation bronchs. I could care less about perc trachs, i just don't see myself doing that in practice.

For all of you kind enough to respond, how many chest tubes or pigtails did you do in fellowship?

Meh. Almost all pulmonary hypertension doesn't need a PA cath. Even in the unit. After load reduce with inhaled flolan and diurese. Flog the RV of necessary. Then pray. But only if you are a believer. If not then. Just don't pray. Management is still the same.

I probably had 20 or so pigtails and two surgical tubes.

 

[sluggs]

Gotta disagree with you on a few things JDH (although I am straight ccm, not pulm):
1. LP is a good skill and if IR is backed up and you want to get cultures before abc, you should be able to do it
2. I don't think that one can say that PA catheters are "dead" or have no place, even based on those studies. It is fundamentally flawed to randomize patients to PA or no PA. This is because there are a bunch of patients in either arm who would have gotten better without Swan. But if you have a complicated resuscitation that is not going well and you know how to insert and interpret a Swan, it can be of great value in understanding and optimizing hemodynamics and giving the patient a better chance to live! I am not saying it is a good thing routinely but I do 7-8 per year and sometimes the numbers are a "surprise" and fixing fluid status and optimizing cardiac index provokes a rally!
3. Bloody effusions and other "tenacious stuff" in the chest sometimes beg for a big cx tube.
4. Intubation is tough and some places do not have anesthesia backup (I work in one-- they are not available to tube, private practice types); spend a lot of time on it!
None of this stuff will make you $ in private practice, but it will help your patient sometimes.

 

[jdh71]

Gotta disagree with you on a few things JDH (although I am straight ccm, not pulm):
1. LP is a good skill and if IR is backed up and you want to get cultures before abc, you should be able to do it
2. I don't think that one can say that PA catheters are "dead" or have no place, even based on those studies. It is fundamentally flawed to randomize patients to PA or no PA. This is because there are a bunch of patients in either arm who would have gotten better without Swan. But if you have a complicated resuscitation that is not going well and you know how to insert and interpret a Swan, it can be of great value in understanding and optimizing hemodynamics and giving the patient a better chance to live! I am not saying it is a good thing routinely but I do 7-8 per year and sometimes the numbers are a "surprise" and fixing fluid status and optimizing cardiac index provokes a rally!
3. Bloody effusions and other "tenacious stuff" in the chest sometimes beg for a big cx tube.
4. Intubation is tough and some places do not have anesthesia backup (I work in one-- they are not available to tube, private practice types); spend a lot of time on it!
None of this stuff will make you $ in private practice, but it will help your patient sometimes.

You can disagree but LP is largely non-needed procedure at the bedside. It can wait until IR isn't backed up. Treat if you think you have it. Abx should never be delayed especially in suspected meningitis even for someone to mess around at the bedside doing an LP.

Swans have never. In any study. Looking at all patient types. Of sufficient numbers. All things then being equal it matters little if a patient would have gotten better without or with. NEVER shown to improve outcomes. Your confirmation bias notwithstanding. We all have our anecdotes. Get your IRB to approve your management and compare to those who don't use it and get back to me when the statistics become significant. I'll listen then.

Small tubes have been compared to smaller tubes. Even for bloody effusions. Unless you know of new data "bigger is better" is unfounded dogma.

I didn't suggest not spending time with airway during fellowship. It's important. Though I'd never work anywhere I couldn't rely on a colleague to help out in a very serious situation. And you maybe playing with fire in your situation. But we all need to make up our own minds.

 

[sluggs]

JDH:
1. How many doses of antibiotics do you like your patient to get before sampling CSF and condemning to no de-escalation?
2. What data do you have that arterial lines, CBCs, pulse oximetry, etco2 monitors, blood gasses or physical exams save lives?
3. ?

 

[jdh71]

JDH:
1. How many doses of antibiotics do you like your patient to get before sampling CSF and condemning to no de-escalation?
2. What data do you have that arterial lines, CBCs, pulse oximetry, etco2 monitors, blood gasses or physical exams save lives?
3. ?

The csf is going to be cellular for a long time. If the fluid pristine a day or two after empiric abx I would stop them. You have plenty of time. I'm not suggesting that if *you* *want* to do an LP that you should not. Do it if you like. It simply not necessary to do at the bedside when you have IR to do them. They are also not some kind of you "have to absolutely learn" in fellowship procedure. You can pick it up later if you unfortunately sign a contract in a location where you don't have IR support. If a fellow has s chance to do one? Great. But don't run all over the hospital with a spinal tap kit trying to find the procedure.

I don't have any data that any of the things you listed above save lives. And it wasn't a claim I ever made. So. Not sure what your point is? We do those things and they have no data about survival therefore you think this justifies your swan placement? Is this the logic I'm being walked through here? I have no data that not farting in a patient's room is or is not detrimental or positive. I still don't. Swans though, we do happen to have data on. You can do what you want but I wouldn't try and pretend you are doing anyone any favors until you can demonstrate it objectively. Show me the p < 0.05 and we can talk more about them.

 

[NewYorkDoctors]

Bump. To ask the question a different way.

What procedures would a pure outpatient pulmonologist need to know and do? It probably varies per private group. But for the sake of argument let's say a startup of pulmonary physicians who do not do MICU (closed MICU academic group in hospital for example) but does consult in the hospital for non-MICU consults and floor consults?

I would imagine:
Bronch, EBUS, TBNA
Lung U/S in the office (there is a CPT code for this)
PFT , CPET interpretation

Also, perhaps a group of private pulmonologists can hire one IP guy to do everything involved with a bronchoscope? Is that a common business model?

 

[HuskyMD Emeritus]

Bronchoscopy and associated procedures such as EBUS, thoracentesis, PleurX catheter placement, PFTs, CPET (although these aren't done that often, you can determine the cause of shortness of breath and pre-op a patient almost always without CPET, but the physiology is fun to play with. CPx equipment is over $100K).
Lung ultrasound have little use, other than for localizing pleural effusions for thoracentesis.
If you spent an extra year doing sleep, then of course sleep studies.
If you have time, staff and facilities, a pulmonary rehab program.
For IP, best to refer to center of excellence. Not that many cases to keep one person busy to justify it.

 

[QualityProcess]

You can disagree but LP is largely non-needed procedure at the bedside. It can wait until IR isn't backed up. Treat if you think you have it. Abx should never be delayed especially in suspected meningitis even for someone to mess around at the bedside doing an LP.

My ID attending would literally have a stroke if he heard this

 

[jdh71]

My ID attending would literally have a stroke if he heard this

Those guys always want *someone else* to do a procedure.

They are welcome to step up to the plate any day of the week.

No one is making bass boat payments doing LPs and all of us would gladly hand them off to the ID service.

 

[Vigileo]

Those guys always want *someone else* to do a procedure.

They are welcome to step up to the plate any day of the week.

No one is making bass boat payments doing LPs and all of us would gladly hand them off to the ID service.

I’ve offered to teach the ID fellows how to do a BAL. None take me up on it though...


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[jdh71]

I’ve offered to teach the ID fellows how to do a BAL. None take me up on it though...


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The service that should learn to bronch is the bone marrow transplant service.

 

[gutonc]

The service that should learn to bronch is the bone marrow transplant service.

They should probably also learn to do colonoscopies too.