Q waves, no symptoms

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
C

caligas

Full Member
Verified Member
10+ Year Member
Joined
Aug 17, 2012
Messages
2,237
Reaction score
2,834
Members do not see this ad.
60 y.o. female with BMI 34, otherwise healthy. Presents for Davinci Hysterectomy. No cardiac symptoms. Not particularly active but states she can climb one flight of stairs without chest pain. EKG reveals significant size q waves in leads 2 and aVF.

Proceed?

Bear in mind that on one hand Q waves are fairly specific to coronary disease but on the other hand the ACC/AHA guidlines (which don't seem to factor in Q waves) would indicate proceeding with surgery based on adequate excercise tolerance and absense of "clinical predictors"

http://www.aafp.org/afp/2008/0615/p1748.html
 
What about lead III? Were there no q wave there? I think having q waves in 2 of the 3, I would say it doesn't mean anything, probably due to lead placement, especially with a noncontributory history.
 
easy - cancel - there is risk of decreased perfusion of the vuhjj.

no excuse to keep the gynie girls away from the robot should be wasted.
 
If you're gonna get a test that isn't indicated by current guidelines, you're kinda married to working up an abnormal result, no?

If your reaction to an abnormal result isn't to delay for further workup, then the test shouldn't have been ordered.

Assuming "otherwise healthy"means no diabetes, that is.
 
Hawaiian Bruin said:
If you're gonna get a test that isn't indicated by current guidelines, you're kinda married to working up an abnormal result, no?

If your reaction to an abnormal result isn't to delay for further workup, then the test shouldn't have been ordered.

Assuming "otherwise healthy"means no diabetes, that is.
Click to expand...

What guidelines discourage ekg in this situation?
 
caligas said:
What guidelines discourage ekg in this situation?
Click to expand...

According to 2007 ACC/AHA guidelines for preop evaluation...


5.2.1. The 12-Lead ECG

Recommendations for Preoperative Resting 12-Lead ECG

Class I

Preoperative resting 12-lead ECG is recommended for patients with at least 1 clinical risk factor# who are undergoing vascular surgical procedures. (Level of Evidence: B)

Preoperative resting 12-lead ECG is recommended for patients with known CHD, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures. ( Level of Evidence: C )

Class IIa

Preoperative resting 12-lead ECG is reasonable in persons with no clinical risk factors who are undergoing vascular surgical procedures. ( Level of Evidence: B )

Class IIb

Preoperative resting 12-lead ECG may be reasonable in patients with at least 1 clinical risk factor who are undergoing intermediate-risk operative procedures. ( Level of Evidence: B )

Class III

Preoperative and postoperative resting 12-lead ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures. ( Level of Evidence: B )
 
Hawaiian Bruin said:
If you're gonna get a test that isn't indicated by current guidelines, you're kinda married to working up an abnormal result, no?

If your reaction to an abnormal result isn't to delay for further workup, then the test shouldn't have been ordered.

Assuming "otherwise healthy"means no diabetes, that is.
Click to expand...

I humbly disagree, if your post implies the further workup should mean canceling the case.

Without any symptoms and no ST segment/T wave abnormalities, the likelihood of Myocardium At Risk is pretty low. Assuming the Q waves are significant (which I doubt) someone with an (old) infarct that significantly affects cardiac function to the point where one would consider canceling the case would CERTAINLY have some kinda signs/symptoms.

In my humble opinion, this is one of the arenas that we get paid to be a

DOCTOR

and use your clinical judgement.

Keep in mind

we put people to sleep with KNOWN severe cardiac disease/dysfunction every day for heart surgery and it is rare that a catastrophic event occurs before myocardial revascularization. We also put people to sleep every day with previous MIs very safely.

Don't become a

CASE CANCEL KING

based solely on an aberrant lab value, whatever it is.

I'm not suggesting you do this case, nor am I suggesting you cancel it.

I'm suggesting that you gain experience in the trenches, trust your intuition, and

learn when you really have to cancel and when you don't.

There's alotta

GRAY.

That's why we get paid a

6th round NFL draft salary.😀

For the record,

I'd do the case.
 
If we are going to follow ACC/AHA guidelines, there are not a great number of situations that need cardiac w/u (often including an EKG, even though everybody gets this)

how many obese, smoker, HTN, high cholesterol types do we see with minor abnormalities on EKG (none of which are actual risk factors as per guidelines)

Its all about functional capacity for most of our non major vascular cases...
 
Why are we afraid of a few random q waves? Pt denies Hx of mi and states she has good exercise tolerance. Has no other risk factors for mi (HTn, smoking, dm). Case should be minimal ebl done in 3 hrs w/minimal fluid shifts of your gynes are any good. I'd be more concerned w/a bmi of 34 and steep t berg then the q waves on the EKG.

Treat the pt not the labs. If this pt had an old mi what would cards do about it? If the stress was normal (most likely scenario based on clinical picture) she's not getting a cath and you proceed. If I recall correctly the benefit to invasive testing was pts at higher risk going for high risk procedures(aaa and carotids). This is an intermediate risk procedure at most and she's a pretty low risk pt based on the rest of the clinical picture. Case proceeds IMO
 
Jet,

Of course the right answer is to do the case. My point was that the history gives you everything you need to proceed, and obtaining an EKG was an expensive exercise in futility, since the right answer having obtained an abnormal result is to proceed with the case anyway.

That said, if this lady came to me and I found it necessary for some reason to go against the ACC/AHA guidelines and go out of my way to order an EKG specifically to look for abnormalities, it would then seem strange to ignore the things I set out to look for.

I'm proud that thus far in my 7 month career, I've cancelled exactly one case (K+ of 6.8).

Healthcare costs a lot, and useless testing is one preventable contributor. Let's do our part and not add to it by ordering unnecessary tests, which open the Pandora's box of what to do when faced with an abnormal result.
 
Are those guidelines for real? Is anyone following them? My hospital gets EKGs for all men >40 and women >50, but is that really outdated? Id love to get rid of automatic EKGs, as the only abnormality that would cancel a case in the absence of symptoms would be an undiagnosed atrial fib.
 
Oggg said:
Are those guidelines for real? Is anyone following them? My hospital gets EKGs for all men >40 and women >50, but is that really outdated? Id love to get rid of automatic EKGs, as the only abnormality that would cancel a case in the absence of symptoms would be an undiagnosed atrial fib.
Click to expand...

are you asking if the ACC/AHA preoperative evaluation guidelines are for real? Umm, yes. Kind of a big deal in the anesthesia and cardiac world. 2002 was the initial one (I think) and the 2007 was an update.

You must have seen this before. It's basically the gospel of preop cardiac testing and what is indicated and what isn't and it is what every cardiology consult you ever see will reference.

Automatic EKGs are a complete waste of time and should never be done that way. The fundamental problem with preop testing is that a surgeon's goal in ordering preop tests is to make sure every box is checked so that on the day of surgery somebody can't say you should've ordered something so I'm cancelling the case. They just don't want the case cancelled. They don't care that they are ordering way too many tests.
 
Hawaiian Bruin said:
Jet,

That said, if this lady came to me and I found it necessary for some reason to go against the ACC/AHA guidelines and go out of my way to order an EKG specifically to look for abnormalities, it would then seem strange to ignore the things I set out to look for.

.
Click to expand...

You're not ignoring them, my friend.

As you progress in your career you will be continually be confronted with labs that give you abnormalities.

What you set out to look for as you know are

acute changes or

s h it so OUTTA WACK (like your case with a potassium of 6.8)

that you have no choice.

My point is as I said in my initial post...there are anesthesiologists out there that

DISSECT LABS

and cancel cases needlessly.

Don't be one of those dudes.

ALWAYS BE A DOCTOR.

A REAL DOCTOR.

With clinical intuition and judgment that you use on a daily basis to make the right choices.
 
Significant Q waves in 2 contiguous leads in this patient might be nothing. It probably is nothing based on the history. But it's not necessarily a benign finding. In this medicolegal climate, having obtained this particular result, I would repeat the EKG to confirm it, and talk to a cardiologist.

It's nothing. I know that. You know that. But big Q waves in contiguous leads?

Why are EKGs ordered? To look for active, silent ischemia? No. Do they correlate with risk of developing ischemia? I think not. To simply establish a baseline in case something happens? Some order them for this reason, which I think is weak. To evaluate for previously undiagnosed coronary disease? Yes. This is why preop EKGs have traditionally been ordered.

So you get one, and it shows possible evidence of a previous MI. If that wasn't the point of getting the test, what was? To see if she was actively infarcting without chest pain?

My point is that an important part of being a real doctor is not ordering tests when the pretest probability of the disease you're testing for is extremely low, as in this case.
 
Anectode of the day: 50something y/o guy needs his knee replaced. Good functional capacity, no cardiac symptoms. A preop EKG is knee-jerk ordered based on age, and some nonspecific abnormality is seen.

The patient is seen by a cardiologist and gets a stress test, which comes back with an abnormality, possibly artifact possibly not.

So he gets scheduled for a cath. He schedules it a few days before a cruise with his wife and kids. The cath shows no significant coronary disease. However, the catheter causes a left main dissection, and the patient crashes. He is coded for 45 minutes and attempts are made to get the pt to the OR for emergent CABG but he dies before it can happen.

This was a case from my intern year.

The cost of unnecessary testing isn't just financial.
 
Hawaiian Bruin said:
Significant Q waves in 2 contiguous leads in this patient might be nothing. It probably is nothing based on the history. But it's not necessarily a benign finding. In this medicolegal climate, having obtained this particular result, I would repeat the EKG to confirm it, and talk to a cardiologist.

It's nothing. I know that. You know that. But big Q waves in contiguous leads?

Why are EKGs ordered? To look for active, silent ischemia? No. Do they correlate with risk of developing ischemia? I think not. To simply establish a baseline in case something happens? Some order them for this reason, which I think is weak. To evaluate for previously undiagnosed coronary disease? Yes. This is why preop EKGs have traditionally been ordered.

So you get one, and it shows possible evidence of a previous MI. If that wasn't the point of getting the test, what was? To see if she was actively infarcting without chest pain?

My point is that an important part of being a real doctor is not ordering tests when the pretest probability of the disease you're testing for is extremely low, as in this case.
Click to expand...

Significant Q waves in two contiguous leads, without significant ST segment abnormalities, without significant T wave abnormalities,

IN A PATIENT WITH NO SYMPTOMS WHO,

more importantly, appears healthy to

YOU, THE DOCTOR,


S H IT.

We could go

ROUND AND ROUND WITH THIS S H I T, man.

You are a YOUNG, BRIGHT, DEVELOPING ANESTHESIOLOGIST STUD, HAWAII SURF DUDE.

I hear your JUSTIFICATION.

I don't necessarily agree with it, but I hear you.

I'll again refer back to my initial post.

Your job as an ANESTHESIOLOGIST is to get cases done in the safest and quickest way possible.

SAFEST and QUICKEST

have conflict sometimes.

Again, like in my initial post, I'll say there exists

ALOTTA GRAY

We like

BLACK AND WHITE.

Dude,

we live with alotta gray and less than we wish of the black and white.

You're well trained, right?

You're a doctor, right?

Very well.

NUT UP.

Don't be intimidated.

MAKE THE RIGHT CLINICAL CALL.

As you see it. As a

DOCTOR.

Jesus Christ, many doctors live by the MEDICAL-LEGAL SCENE

Yeah, I get that but in the end I am ALWAYS IN MY MIND MAKING THE RIGHT DECISIONS FOR THE PATIENT AND I'M PRETTY GOOD AT THIS ANESTHESIOLOGY GIG.

I've written this before, and it is not mainstream.

That's ok with me since I made a decision a long time ago that

I PRACTICE MEDICINE MAN.

I make decisions DAY IN AND DAY OUT with major impact on patient care.

I'VE CHOSEN TO NOT

be affected by LEGAL PRESSURE.

I'M GONNA PRACTICE MEDICINE AS I SEE FIT. I'M GONNA PRACTICE MEDICINE LIKE I WAS TAUGHT.



I'M GONNA MAKE CALLS LIKE I SEE IT.

Patient dude doesn't look good on pre-op? Chronic asthma with acute exacerbation, history of CHF who is tachypneic; diabetic with a 400 SUGGA, etc etc

BRAKES ON MAN I'M CANCELING

IF I DON'T SEE SOME BIG 'BRAKES ON MAN" S H IT,

I'M DOING THE CASE.

SAFELY.

Point:

Those above cancelations are

RARE RARE RARE

When they present themselves, DEAL WITH IT. MAKE AN ATTEMPT TO OPTIMIZE THE PATIENT FOR SURGERY.

Got a THREE HUNDRED BLOOD SUGAR AND THE PATIENT IS HERE 2 HOURS EARLY?

TAKE IT DOWN TO THE WIRE. START AN IV AND TREAT THEM LIKE YOU WERE AN ER DOCTOR.

(Back in the day when I moonlighted as an ER doctor when I was an anesthesia resident, I'd be presented with DKA patients who were ACIDOTIC AS S H I T with sugars in the 600s....700s....WHAT DID I DO? Insulin BOLUS followed by Insulin INFUSION followed by ALOTTA FLUIDS and other stuff that's not significant here)

You guys are all YOUNG STUDS out there.

I encourage you to be

PROACTIVE WITH THE END RESULT BEING

YOU DO THE CASE.

In other words,

Fight hard to do the case.

Use your

DOCTOR S H I T

to

OPTIMIZE THE PATIENT AND WORK AT BECOMING DEFT AT TREADING THRU MEANINGLESS ABERRANT LAB RESULTS.

Sometimes you will fail. If you become a real doctor,

RARELY YOU WILL FAIL AND MOST TIMES YOU WILL DO THE CASE.

As a caveat, in the above post I use the word FAIL kinda carelessly.

It is intentional, since I believe most residency programs, to this day,

STILL TEACH WHAT TO LOOK FOR TO CANCEL A CASE, RATHER THAN LOOKING FOR WAYS TO

DO A CASE.

That's not what's going on out here in the non-academic

REAL WORLD OF PRIVATE PRACTICE,

ladies and gentlemen.

OUR PATIENTS ARE SAFE AND HIGHLY SATISFIED.

Even the one's a compulsive academic dude WOULD'VE CANCELED.

THE TRUTH HURTS SOMETIMES.
 
Last edited:
jetproppilot said:
Got a THREE HUNDRED BLOOD SUGAR AND THE PATIENT IS HERE 2 HOURS EARLY?

TAKE IT DOWN TO THE WIRE. START AN IV AND TREAT THEM LIKE YOU WERE AN ER DOCTOR.
Click to expand...

Love it. 😍

Next time I'm in a jam in the ER I'm going to remember this post. I'm going to

TAKE IT DOWN TO THE WIRE. START AN IV AND TREAT THEM LIKE I WAS AN ANESTHESIOLOGIST.
 
We're talking past each other a little here. So here's my real life, private practice answer.

Someone else has ordered this EKG, not me. I walk it 50 feet down the hall to one of my cardiology buddies, and say "this lady is completely asymptomatic. You worried at all about these q waves?"

When they say no, I walk 50 feet back down the hall and do the case, having burned three minutes of time.

I do not postpone the case for a formal cardiology consult.

If it's a night or weekend and they're not there, I do the case. On Monday I find whoever did order it and educate them that it put me in a bad spot.

But I would never have been in this position, because I wouldn't have ordered the EKG.

Would you have ordered a preop EKG on this patient? I think not.

Because it wasn't necessary.

That was my point.
 
Also, all the stuff you said about doing real doctor shit in order to make cases happen is true and awesome.
 
Hawaiian Bruin said:
We're talking past each other a little here. So here's my real life, private practice answer.

Someone else has ordered this EKG, not me. I walk it 50 feet down the hall to one of my cardiology buddies, and say "this lady is completely asymptomatic. You worried at all about these q waves?"

When they say no, I walk 50 feet back down the hall and do the case, having burned three minutes of time.

I do not postpone the case for a formal cardiology consult.

If it's a night or weekend and they're not there, I do the case. On Monday I find whoever did order it and educate them that it put me in a bad spot.

But I would never have been in this position, because I wouldn't have ordered the EKG.

Would you have ordered a preop EKG on this patient? I think not.

Because it wasn't necessary.

That was my point.
Click to expand...

NO MY FRIEND.

WE ARE

NOT



talking past each other.

Dear young, great anesthesiologist,

You are a consultant doctor. Sometimes tests will be ordered by the surgeons that you work with. YOU HAVE NO CONTROL OVER THIS

and it's ok.

Your goal is to learn how to deal with and INTERPRET labs/EKGs....EVEN if you didn't order them.

YOU DON'T HAVE TO BE A SPECIALIST EXPERT.

You DO have to be able to identify MAJOR ABERRANCY. Which isn't hard.

My MOM could do it if I trained her for thirty minutes.

My MOM works in a cafeteria (no really she does. She's retired. Needs to be active. Took the cafeteria gig.)

Your whens and whys about lab tests are

RHETORICAL MAN.

Other people (surgeons) may order EKGs/lab tests that you think is not necessary, and

YOU'RE RIGHT, BEE-LEEEEEEVE ME YOU ARE SOOOO RIGHT,

but,

like LINKIN PARK SAID,

IN THE END,

IT DOESN'T REALLY MATERRRRRRRRRRR

So

In the ENNNNNNNNNNNNNND, (linkin park like)

DEAL WITH IT LIKE A CLINICIAN. MAKE THE RIGHT CHOICE BASED ON HOW YOU FEEL AS A DOCTOR. DON'T BASE THE WAY YOU PRACTICE ON LAB VALUES. IF I SEE A SIXTY YEAR OLD ACTING LIKE A CHEERLEADER SCHEDULED FOR A HYSTERECTOMY, I DON'T GIVE A ******* WHAT HER "PRE OP STUFF" SAYS, I'M DOING THE CASE.

caveat: as long as she is not taking Plavix or Coumadin et al that hasn't been stopped
 
Last edited:
glorfindel said:
Love it. 😍

Next time I'm in a jam in the ER I'm going to remember this post. I'm going to

TAKE IT DOWN TO THE WIRE. START AN IV AND TREAT THEM LIKE I WAS AN ANESTHESIOLOGIST.
Click to expand...

I wasn't being satirical, as it sounds you are being.
I've been in the ER as an ER Doctor, treating hyperglycemia.
I was promoting how ER doctors are PROACTIVE.
You missed it.
Your loss.
 
Hawaiian Bruin said:
Hopefully this was a useful discussion for the students and residents out there.



Reminds me, time to change my avatar...
Click to expand...

It was helpful, so thank you!

One thing I had committed to memory about asymptomatic Q's was that they do matter in patients with early repolarization - do you remember whether her STs were isoelectric? I assume you would have mentioned J waves or ST elevation.
 
Hawaiian Bruin said:
Reminds me, time to change my avatar...
Click to expand...

NO MAN!!!!!

You say that like your name and your avatar is negative somehow.

WTF?

Dude I grew up on the beach in Florida.

I could cast a cast net before I could ride a bike.

DUDE I SURFED ENDLESSLY AS A TEENAGER...

...when I was 13 I had TWO SURFBOARDS....

...one tight...FIVE ELEVEN...DOUBLE SKEG...

and

.....one LONG....for slow daysand low waves

DUDE....

KEEP THE AVATAR

IT IS MEANINGFUL....

Reminds me of my youth

RIDING THE CURL

That was the most awesome man...

When you could

TIME THE BREAK OF THE WAVE SO YOU WERE

INSIDE

Hard to do.

Everyone watches it on YouTube like it's really easy.

NO MAN.

TIMING THE BREAK TAKES SKILL.

LOLLLL!!!!

I'm sitting here in my living room thinking about how I

TIMED THE BREAK

as a 13 year old surfer

and how much that

PARALLELS MY CURRENT DAY LIFE

in other words,

You've gotta have a Skill Set but

TIMING IS EVERYTHING MAN.
 
Homey, I just changed to this avatar. Walter White was getting old.

Nothing like getting off work early and getting a session in, taking a break from the real world for a couple hours. Glad I have my ocean back after all these years away.
 
PonyUp said:
It was helpful, so thank you!

One thing I had committed to memory about asymptomatic Q's was that they do matter in patients with early repolarization - do you remember whether her STs were isoelectric? I assume you would have mentioned J waves or ST elevation.
Click to expand...

Normal st segments.

I did the case. Patient arrested on induction. Kidding. No problems.
 
jetproppilot said:
I wasn't being satirical, as it sounds you are being....
You missed it.
Your loss.
Click to expand...

My post wasn't quite complementary enough, it seems.

No cynicism at all was intended.

Pure complement, all the way.

👍👍👍
 
Hawaiian Bruin said:
Homey, I just changed to this avatar. Walter White was getting old.

Nothing like getting off work early and getting a session in, taking a break from the real world for a couple hours. Glad I have my ocean back after all these years away.
Click to expand...

Dude, your avatar

BRINGS BACK

ACTUAL VISUALS I STILL HAVE IN MY BRAIN FROM RIDING WAVES YET

THOSE NEURONS HAVEN"T BEEN FIRED ON IN QUITE SOME TIME.

Your avatar FIRED THOSE NEURONS.

I see it again, from the same perspective of your avatar.

THANKS, DUDE.

Right now because of this interaction I can smell the Mr. Zogs Sex Wax...the wax I used on my board... I liked the coconut...
 
scudrunner said:
Interesting it is not in lead 3. Check lead placement.
Click to expand...

1) You cannot "check lead placement" unless you happen to have your EKG tech, who happens to have a photographic memory, on hand. You can, however, repeat the ECG.

2) I'm curious to know how these Q's are explained electrophysiologically by lead misplacement. Please, be my guest.
 
Hawaiian Bruin said:
Healthcare costs a lot, and useless testing is one preventable contributor. Let's do our part and not add to it by ordering unnecessary tests, which open the Pandora's box of what to do when faced with an abnormal result.
Click to expand...

This is more valuable than pages and pages of bolded and big-fonted text. Well said.
 
caligas said:
60 y.o. female with BMI 34, otherwise healthy. Presents for Davinci Hysterectomy. No cardiac symptoms. Not particularly active but states she can climb one flight of stairs without chest pain. EKG reveals significant size q waves in leads 2 and aVF.

Proceed?
Click to expand...

Here's another situation. Same asymptomatic patient, same case, only someone skipped the EKG and ordered a TTE instead. Entire inferior wall is akinetic. Proceed?

Again you're in guidelines-undefined territory. Think about physiology. Worst case scenario is you have previously undiagnosed asymptomatic CAD, a preserved EF by history of functional status, and someone who can still do 4ish METs. Of course you proceed, and do all the things appropriate for a patient with CAD. Maybe you put in an A-line. Most wouldn't, I would think.

Forget what the guidelines say about Q waves and think about what those Q waves mean in your patient's beating heart.

This is of course in addition to HB's outstanding points on test ordering and interpretation above.
 
OffPiste said:
If we are going to follow ACC/AHA guidelines, there are not a great number of situations that need cardiac w/u (often including an EKG, even though everybody gets this)

how many obese, smoker, HTN, high cholesterol types do we see with minor abnormalities on EKG (none of which are actual risk factors as per guidelines)

Its all about functional capacity for most of our non major vascular cases...
Click to expand...

Agreed. Functional capacity is what I go by as well, moreso than EKG. I remember being an intern on surgery and they always got "preop workup" i.e. labs, EKG, CXR. any dude who was > 45 and any dudette > 55. such a waste. but it happens as others have stated above.

I'd consider re-checking an EKG, but most likely, I'd say continue on with the case if the patient has good functional capacity and denies having angina, hx of recent MI, PVD, and not on anticoagulants that were recently stopped, etc.

-- side note --

JPP is right about all sorts of cases happening out in private practice land. I've had attendings who started out in PP before going into academia tell me of all sorts of sick patients they provided safe anesthesia for while out in PP.

I've only requested my attending to cancel one case thus far in my short career. first case of the day. the patient looked kinda out of it and had strep throat, and it was a purely elective case for an ACDF.
 
fakin' the funk said:
Here's another situation. Same asymptomatic patient, same case, only someone skipped the EKG and ordered a TTE instead. Entire inferior wall is akinetic. Proceed?

Again you're in guidelines-undefined territory. Think about physiology. Worst case scenario is you have previously undiagnosed asymptomatic CAD, a preserved EF by history of functional status, and someone who can still do 4ish METs. Of course you proceed, and do all the things appropriate for a patient with CAD. Maybe you put in an A-line. Most wouldn't, I would think.

Forget what the guidelines say about Q waves and think about what those Q waves mean in your patient's beating heart.

This is of course in addition to HB's outstanding points on test ordering and interpretation above.
Click to expand...

Not seen this scenario but very invaluable. Thanks for sharing. I agree with this, as I imagine there are quite a few out there with undiagnosed asymptomatic CAD.
 
jetproppilot said:
Significant Q waves in two contiguous leads, without significant ST segment abnormalities, without significant T wave abnormalities,

IN A PATIENT WITH NO SYMPTOMS WHO,

more importantly, appears healthy to

YOU, THE DOCTOR,


S H IT.

We could go

ROUND AND ROUND WITH THIS S H I T, man.

You are a YOUNG, BRIGHT, DEVELOPING ANESTHESIOLOGIST STUD, HAWAII SURF DUDE.

I hear your JUSTIFICATION.

I don't necessarily agree with it, but I hear you.

I'll again refer back to my initial post.

Your job as an ANESTHESIOLOGIST is to get cases done in the safest and quickest way possible.

SAFEST and QUICKEST

have conflict sometimes.

Again, like in my initial post, I'll say there exists

ALOTTA GRAY

We like

BLACK AND WHITE.

Dude,

we live with alotta gray and less than we wish of the black and white.

You're well trained, right?

You're a doctor, right?

Very well.

NUT UP.

Don't be intimidated.

MAKE THE RIGHT CLINICAL CALL.

As you see it. As a

DOCTOR.

Jesus Christ, many doctors live by the MEDICAL-LEGAL SCENE

Yeah, I get that but in the end I am ALWAYS IN MY MIND MAKING THE RIGHT DECISIONS FOR THE PATIENT AND I'M PRETTY GOOD AT THIS ANESTHESIOLOGY GIG.

I've written this before, and it is not mainstream.

That's ok with me since I made a decision a long time ago that

I PRACTICE MEDICINE MAN.

I make decisions DAY IN AND DAY OUT with major impact on patient care.

I'VE CHOSEN TO NOT

be affected by LEGAL PRESSURE.

I'M GONNA PRACTICE MEDICINE AS I SEE FIT. I'M GONNA PRACTICE MEDICINE LIKE I WAS TAUGHT.



I'M GONNA MAKE CALLS LIKE I SEE IT.

Patient dude doesn't look good on pre-op? Chronic asthma with acute exacerbation, history of CHF who is tachypneic; diabetic with a 400 SUGGA, etc etc

BRAKES ON MAN I'M CANCELING

IF I DON'T SEE SOME BIG 'BRAKES ON MAN" S H IT,

I'M DOING THE CASE.

SAFELY.

Point:

Those above cancelations are

RARE RARE RARE

When they present themselves, DEAL WITH IT. MAKE AN ATTEMPT TO OPTIMIZE THE PATIENT FOR SURGERY.

Got a THREE HUNDRED BLOOD SUGAR AND THE PATIENT IS HERE 2 HOURS EARLY?

TAKE IT DOWN TO THE WIRE. START AN IV AND TREAT THEM LIKE YOU WERE AN ER DOCTOR.

(Back in the day when I moonlighted as an ER doctor when I was an anesthesia resident, I'd be presented with DKA patients who were ACIDOTIC AS S H I T with sugars in the 600s....700s....WHAT DID I DO? Insulin BOLUS followed by Insulin INFUSION followed by ALOTTA FLUIDS and other stuff that's not significant here)

You guys are all YOUNG STUDS out there.

I encourage you to be

PROACTIVE WITH THE END RESULT BEING

YOU DO THE CASE.

In other words,

Fight hard to do the case.

Use your

DOCTOR S H I T

to

OPTIMIZE THE PATIENT AND WORK AT BECOMING DEFT AT TREADING THRU MEANINGLESS ABERRANT LAB RESULTS.

Sometimes you will fail. If you become a real doctor,

RARELY YOU WILL FAIL AND MOST TIMES YOU WILL DO THE CASE.

As a caveat, in the above post I use the word FAIL kinda carelessly.

It is intentional, since I believe most residency programs, to this day,

STILL TEACH WHAT TO LOOK FOR TO CANCEL A CASE, RATHER THAN LOOKING FOR WAYS TO

DO A CASE.

That's not what's going on out here in the non-academic

REAL WORLD OF PRIVATE PRACTICE,

ladies and gentlemen.

OUR PATIENTS ARE SAFE AND HIGHLY SATISFIED.

Even the one's a compulsive academic dude WOULD'VE CANCELED.

THE TRUTH HURTS SOMETIMES.
Click to expand...

It'd be awesome to have you as an attending. I have a few rockstar attendings who transferred into academia from PP and their application of medicine and knowledge they provide are pure liquid gold.
 
I think the crux here is symptoms (or lack thereof). If there are no symptoms than further cardiac workup should not effect management because the patient is not a candidate for revasculization without symptoms.
 
jetproppilot said:
Dude, your avatar

BRINGS BACK

ACTUAL VISUALS I STILL HAVE IN MY BRAIN FROM RIDING WAVES YET

THOSE NEURONS HAVEN"T BEEN FIRED ON IN QUITE SOME TIME.

Your avatar FIRED THOSE NEURONS.

I see it again, from the same perspective of your avatar.

THANKS, DUDE.

Right now because of this interaction I can smell the Mr. Zogs Sex Wax...the wax I used on my board... I liked the coconut...
Click to expand...

Check out http://www.clarklittlephotography.com/gallery/ for more- Clark Little is a frigging amazing photographer and shorebreak hellman. I can stare at his shots for hours.
 
You must log in or register to reply here.

Similar threads

S
Partnership Track with no buy-ins?
Replies
10
Views
2K
james775
J
NumTacos
There Was No Golden Age of Medicine
2 3
Replies
103
Views
9K
kidthor
kidthor
GravelRider
No competition allowed here! Non-competes are back, baby!
2
Replies
71
Views
8K
deleted87051
D
O
Jobs with no salary listed on Gaswork
Replies
27
Views
5K
vm26
vm26
B
Question for DO students who applied with Step 2 score only, No Step 1
Replies
1
Views
886
Anesthesia_Guy
A
Top