Stopping Elective Cases

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GassYous said:
Pain is never an emergency and most of your other points are not valid
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Never said it was an emergency, said it was urgent or should be prioritized. I don’t think it’s in the same league as end stage OA for someone who’s had knee pain for 20 years and getting a TKA, that patient is elective.

saying acute discs can wait is cruel. I would say the same thing about cystos for big stones, or epidurals for labor, or tooth extraction or something for dental pain. If you were a patient would you really want to be told sorry, go sit at home and do some stretches, take some NSAID because no one will prescribe you opioids, if it gets to the point of foot drop come in and the surgeon will do emergency surgery.
 
dipriMAN said:
Never said it was an emergency, said it was urgent or should be prioritized. I don’t think it’s in the same league as end stage OA for someone who’s had knee pain for 20 years and getting a TKA, that patient is elective.

saying acute discs can wait is cruel. I would say the same thing about cystos for big stones, or epidurals for labor, or tooth extraction or something for dental pain. If you were a patient would you really want to be told sorry, go sit at home and do some stretches, take some NSAID because no one will prescribe you opioids, if it gets to the point of foot drop come in and the surgeon will do emergency surgery.
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We can debate among ourselves all these things.. but Don't worry there are plenty of other truly elective cases that will be cut before these ones.
 
dipriMAN said:
saying acute discs can wait is cruel.
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Why is it cruel? Lesi dont work long term? Is it cruel to deny something that doesnt work in the first place? Or is there actually evidence for them?


dipriMAN said:
I would say the same thing about cystos for big stones, or epidurals for labor, or tooth extraction or something for dental pain. If you were a patient would you really want to be told sorry, go sit at home and do some stretches, take some NSAID because no one will prescribe you opioids, if it gets to the point of foot drop come in and the surgeon will do emergency surgery.
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None of these things have a better alternative really. Big stones dont pass? Sore teeth are often infected plus the dentist does that in his clinic 95% of the time so irrelevant to hospital procedures. Moms are already in hospital
 
Newtwo said:
None of these things have a better alternative really. Big stones dont pass? Sore teeth are often infected plus the dentist does that in his clinic 95% of the time so irrelevant to hospital procedures. Moms are already in hospital
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Serious question - what's the point of arguing about a big kidney stone?
 
i actually dont care about of those cases at all annd only reallyresponded to them as they were presented. im only interested in finding out if there much evidence for acute interventions for chronic pain? Can anyone tell me?
 
Newtwo said:
i actually dont care about of those cases at all annd only reallyresponded to them as they were presented. im only interested in finding out if there much evidence for acute interventions for chronic pain? Can anyone tell me?
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There is good evidence a LESI helps with acute pain, especially for acute discs. Obviously long term outcomes won’t show a difference, your not fixing the disc. There’s essentially no other medication or non surgical intervention that’s actually been studied and proven helpful for acute discs.
 
Newtwo said:
i actually dont care about of those cases at all annd only reallyresponded to them as they were presented. im only interested in finding out if there much evidence for acute interventions for chronic pain? Can anyone tell me?
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IMO your right. There is not much evidence for any of that stuff. But even those skeptical of the field (like me) can not deny that some patients do get real benefit out of the procedures, at least for a little while.

In fellowship the thinking was this: "Yes its going to go away on its own in 2-3 months, but why suffer for that time period?, get the LESI and feel better." Im sure for some of these patients, a timely intervention does indeed save ER visits
 
Hoya11 said:
IMO your right. There is not much evidence for any of that stuff. But even those skeptical of the field (like me) can not deny that some patients do get real benefit out of the procedures, at least for a little while.

In fellowship the thinking was this: "Yes its going to go away on its own in 2-3 months, but why suffer for that time period?, get the LESI and feel better." Im sure for some of these patients, a timely intervention does indeed save ER visits
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Everyone likes to say LESIs don’t change long term outcomes as if every intervention we do in medicine has been shown to have long term benefit.

whenever a colleague, family member, etc, gets an acute radic, they get in quickly to the clinic to get an LESI.
 
Sarcasm aside, there are only 3 places I’ve ever seen bleed more than 15L intra-op: portal vein injury with HPB surgery, aorta during AAA or TAAA, and pulmonary vein injury during VATS. I think each of these locations has anatomic factors which render surgical control of hemorrhage difficult. (This is excluding cardiac surgery with RV injuries during redo sternotomy, etc- it feels a bit different when you’re hemorrhaging but you can go on sucker bypass). I guess the other way to lose that much blood would be bleeding from raw surfaces or bone marrow: liver txp, major craniofacial synostosis type stuff, multi level redo scoliosis, etc. Probably need to include C-section gone wrong —> embo —> salvage hysterectomy on that list, too.

edit: forgot to add retrohepatic IVC injury to the list… I still get nightmares thinking about that one case…
 
fakin' the funk said:
A) applies to literally all insurance
B) still gotta do a minimum amount of service to keep folks on that insurance plan
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No it doesn’t “apply to all insurance” Kaiser is both a provider and an insurer which is uniquely different from the rest so they are in a particularly exploitative position
 
Unknown-1.jpeg
After being "evened out" mascot
 
chocomorsel said:
Did they survive?
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The case I was referring to, after being taken back to the OR for the fifth time for life threatening hemorrhage in the ICU, the surgeon ended up completely lighting the IVC. I had not previously ever considered that doing so was compatible with life… but that guy walked out of the hospital about five months later.There aren’t that many truly miraculous “saves” in medicine, but that case was one of them
 
Hork Bajir said:
Sarcasm aside, there are only 3 places I’ve ever seen bleed more than 15L intra-op: portal vein injury with HPB surgery, aorta during AAA or TAAA, and pulmonary vein injury during VATS. I think each of these locations has anatomic factors which render surgical control of hemorrhage difficult. (This is excluding cardiac surgery with RV injuries during redo sternotomy, etc- it feels a bit different when you’re hemorrhaging but you can go on sucker bypass). I guess the other way to lose that much blood would be bleeding from raw surfaces or bone marrow: liver txp, major craniofacial synostosis type stuff, multi level redo scoliosis, etc. Probably need to include C-section gone wrong —> embo —> salvage hysterectomy on that list, too.

edit: forgot to add retrohepatic IVC injury to the list… I still get nightmares thinking about that one case…
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Hemipelvectomy and sacrectomy was the combo most dreaded by us folks in the blood bank. I don’t know why anyone would subject themselves to that.
 
wholeheartedly said:
Hemipelvectomy and sacrectomy was the combo most dreaded by us folks in the blood bank. I don’t know why anyone would subject themselves to that.
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You’re not kidding. Had to do a hind quarter amputation amongst urethral, bladder and GI injuries on a young adult during a trauma. Lot’s of resources. Month’s in the ICU, sepsis, etc.
Terrible quality of life is the best case scenario.
 
out of curiosity, why would all elective cases be cancelled anywhere? I mean I can understand cancelling surgeries that require inpatient admission if your hospital is full, but outpatient surgeries should be able to continue uninterrupted. It isn't like back in April last year when there were uncertain supplies of PPE.
 
Mman said:
out of curiosity, why would all elective cases be cancelled anywhere? I mean I can understand cancelling surgeries that require inpatient admission if your hospital is full, but outpatient surgeries should be able to continue uninterrupted. It isn't like back in April last year when there were uncertain supplies of PPE.
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It makes no sense to me either. Cancel ridiculous big spine surgeries or whatever that require 5 day admissions if necessary (although surgeons will find a way around it). Unexpected admission to the ICU? - board them in the pacu as far as I am concerned.
 
Arch Guillotti said:
It makes no sense to me either. Cancel ridiculous big spine surgeries or whatever that require 5 day admissions if necessary (although surgeons will find a way around it). Unexpected admission to the ICU? - board them in the pacu as far as I am concerned.
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Speculation: Staff shortage and reassigning OR, Preop, PACU and other Personnel to areas of the hospitals that are facing staffing issues. Our system is short huge numbers of Nursing and other personnel.
 
dr doze said:
Speculation: Staff shortage and reassigning OR, Preop, PACU and other Personnel to areas of the hospitals that are facing staffing issues. Our system is short huge numbers of Nursing and other personnel.
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since the OR brings in the money that pays everyone else's salary, seems financial suicide to cut off elective outpatient surgeries, especially in insured patients
 
If ICU and inpatient units are overflowing and staff are overwhelmed and at crisis levels, it might be a reasonable choice-at least for a short term. Again, just speculation on my part depending on local situation.
 
Mman said:
out of curiosity, why would all elective cases be cancelled anywhere? I mean I can understand cancelling surgeries that require inpatient admission if your hospital is full, but outpatient surgeries should be able to continue uninterrupted. It isn't like back in April last year when there were uncertain supplies of PPE.
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We have a large number of employees that are out on top of the fact we were already short nurses before this. And the ICUs and floors were already filling up before the delta surge. There's too many ICU boarders in the PACU and too few staff to even run elective outpt cases at the moment.
 
Arch Guillotti said:
It makes no sense to me either. Cancel ridiculous big spine surgeries or whatever that require 5 day admissions if necessary (although surgeons will find a way around it). Unexpected admission to the ICU? - board them in the pacu as far as I am concerned.
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Trying to manage someone actually sick in pacu is extremely dangerous. They are usually unfamiliar with who to call, depending on layout can be far from the icu, tend to lack typical icu resources/drips, RT isn’t around to help with vent issues if they arise and the rn can’t fix it etc etc. I would board people in er long before pacu.
 
chessknt said:
Trying to manage someone actually sick in pacu is extremely dangerous. They are usually unfamiliar with who to call, depending on layout can be far from the icu, tend to lack typical icu resources/drips, RT isn’t around to help with vent issues if they arise and the rn can’t fix it etc etc. I would board people in er long before pacu.
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This is really dependent on the hospital and culture. PACU can be extremely resource rich especially if anesthesia has a strong presence or even runs the ICU with the ability to triage patients or flex ICU nurses if necessary… although where I trained is likely an anomaly and certainly not the standard
 
SnapperRocks said:
This is really dependent on the hospital and culture. PACU can be extremely resource rich especially if anesthesia has a strong presence or even runs the ICU with the ability to triage patients or flex ICU nurses if necessary… although where I trained is likely an anomaly and certainly not the standard
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Not all, but some of our PACU nurses freak out if you bring a patient on a phenylephrine infusion. Our ICU nurses are a different breed from our PACU nurses.
 
SnapperRocks said:
This is really dependent on the hospital and culture. PACU can be extremely resource rich especially if anesthesia has a strong presence or even runs the ICU with the ability to triage patients or flex ICU nurses if necessary… although where I trained is likely an anomaly and certainly not the standard
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If the hospital is so strained that PACU is overflowing there arent going to be ICU nurses in the PACU, they are going to be in the ICU. They are used to calling anesthesia/surgeons for issues, knowing who is covering the ICU at different times of the day is usually not something they are familiar with. Maybe in the rare scenario where they are adjacent to an ICU or interact with the ICU on a very frequent basis there wont be too much of a disconnect but I would think the majority of non-academic PACUs are poorly equipped for boarding ICU patients for more than a few hours, let alone days.
 
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