What’s one thing you wish your IR guys/gal know?

[deleted950463]

I dont think you know what standard of care means. And if you do, you are pretty loose with it.

so you think it’s better to NOT have a PE response team than having one? You think it’s better to not have multi-disciplinary based decision making for a relatively unproven modality that’s PE lysis? Or am I just reading you wrong?

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[67552931811]

I dont think you know what standard of care means. And if you do, you are pretty loose with it.

He probably doesn’t as he’s a second year med student

Hello forum! Long time lurker but first post. I am from the NYC area and started a year ago.

One of my childhood dream would be to work at NYPresbyterian hospital as an attending and teach residents. I decided to look at their staff directory today, just typed in the letter A as last name. I cannot post the link yet, but this is the first google result if you search “nyp staff directory find a doctor”

Out of the 211 physicians on that list there are only TWO DOs! There are far more MBBS and even more PsychD listed there. Both of those DOs are in pediatrics, and right now I am thinking about diagnostic radiology or anesthesia.

Shock to find that DO BIAS is still alive and well! Will this get better with the residency merger?

I am doing fine, thank you for asking, consistently scoring above 90 percentile of my class in tests I’ve taken so far while I am already trying to study board relevant materials our classes are hitting. I have always been good at getting good grades and good exam scores.

 

[deleted950463]

He probably doesn’t as he’s a second year med student

You’ll be surprised about what a medical student know.

I am still baffled by the comment. I am not saying PE lysis is the standard of care. It’s far from being so and based on SIR position statement it’s an investigative therapy especially in submassive PE. PERT team involve multiple disciplines and allow a team based approach to this new modality rather than having one or two docs try to drive it.
How is shared decision making “loose” again?

 

[deleted547339]

so you think it’s better to NOT have a PE response team than having one? You think it’s better to not have multi-disciplinary based decision making for a relatively unproven modality that’s PE lysis? Or am I just reading you wrong?

Thank you for proving my point. You just moved the goalposts by a mile. I didn’t say I didn’t think it’s better (although I don’t), I said it isn’t standard of care. You clearly have no concept of what that means.

You said you think that it’s standard of care or should be standard of care to have a PERT team. You think podunk community hospital can have a cardiologist, potentially interventionalist, an intensivist, pulmonologist, cardiac/vascular surgeon on call for every submissive PE? There is approximately a snowballs chance in hell of that happening. If you’re saying it’s standard of care (or should be), you are saying every hospital in the country except for maybe 50-200 are committing gross malpractice each and every day. Go ahead and start shutting down hospitals because they can’t treat PEs, can’t justify their care to insurers and might as well start writing lawyers checks because they’re not meeting standard of care.

A PERT is not standard of care. It will never be standard of care. It is too resource intense to be possible anywhere except the highest level centers. Is it good for patients? No one knows (although probably not). There is no patient centered outcome that has been demonstrated to be improved beyond heparinization and close monitoring. Frankly, I think they are resource wasters - people end up getting more interventions (at my shop) without data to suggest they help people and more times some jack-wad cardiologist recommends icu admission is someone who is fine for the floor but they have no understanding of who does and doesn’t need an icu. More data and more consults does not better care make. There is a reason a lot of icus are closed.

Words have meaning. Don’t go around using those words when you don’t know what they mean. Without having any idea of what you said, you said that essentially every ER, ICU doc and hospitalist are committing malpractice.

 

[deleted950463]

Thank you for proving my point. You just moved the goalposts by a mile. I didn’t say I didn’t think it’s better (although I don’t), I said it isn’t standard of care. You clearly have no concept of what that means.

You said you think that it’s standard of care or should becomestandard of care to have a PERT team. You think podunk community hospital can have a cardiologist, potentially interventionalist, an intensivist, pulmonologist, cardiac/vascular surgeon on call for every submissive PE? There is approximately a snowballs chance in hell of that happening. If you’re saying it’s standard of care (or should be), you are saying every hospital in the country except for maybe 50-200 are committing gross malpractice each and every day. Go ahead and start shutting down hospitals because they can’t treat PEs, can’t justify their care to insurers and might as well start writing lawyers checks because they’re not meeting standard of care.

A PERT is not standard of care. It will never be standard of care. It is too resource intense to be possible anywhere except the highest level centers. Is it good for patients? No one knows (although probably not). There is no patient centered outcome that has been demonstrated to be improved beyond heparinization and close monitoring. Frankly, I think they are resource wasters - people end up getting more interventions (at my shop) without data to suggest they help people and more times some jack-wad cardiologist recommends icu admission is someone who is fine for the floor but they have no understanding of who does and doesn’t need an icu. More data and more consults does not better care make. There is a reason a lot of icus are closed.

Words have meaning. Don’t go around using those words when you don’t know what they mean. Without having any idea of what you said, you said that essentially every ER, ICU doc and hospitalist are committing malpractice.

It’s regrettable that you chose to speak to a student this way on a student forum. Not need to be rude or personal.

not sure if my goal post was ever moved. I stand by the fact that PERT should become standard of care and the decision for PE intervention should not rest on a single person/specialty.

Not every hospital/ED need a PERT. Perhaps a small center do not have IR capable of doing PE lysis. Then maybe patient should be transfered?

again, you don’t need a million different people to have a PERT. Every PERT can look different and involve different people.

If you go back and read my post, I am not talking about needing a PERT for management of PE or every PE case. I am talking about needing a PERT to aid in decision making of PE thrombolysis.

I am actually involved in making of one of our hospital’s PERT so I am fairly familiar with the subject. Either way, judge me not by my title, but the content.

 

[deleted547339]

It’s regrettable that you chose to speak to a student this way on a student forum. Not need to be rude or personal.

not sure if my goal post was ever moved. I stand by the fact that PERT should become standard of care and the decision for PE intervention should not rest on a single person/specialty.

Not every hospital/ED need a PERT. Perhaps a small center do not have IR capable of doing PE lysis. Then maybe patient should be transfered?

again, you don’t need a million different people to have a PERT. Every PERT can look different and involve different people.

If you go back and read my post, I am not talking about needing a PERT for management of PE or every PE case. I am talking about needing a PERT to aid in decision making of PE thrombolysis.

I am actually involved in making of one of our hospital’s PERT so I am fairly familiar with the subject. Either way, judge me not by my title, but the content.

I am judging you by your content and your content is exceedingly poor. Do you know the concept of the known known, the known unknown and the unknown unknown? You’re clearly in the unknown unknown. You are a novice but think you know what you’re talking about. I’m sorry you are so fragile that you view it as rude. Again, you are speaking out of turn. Standard of care is the minimum measure by which a physician is measured. Failing to meet standard of care is one component of malpractice. You are saying that 90%+ of physicians treating PEs are committing malpractice. Have you ever heard that if you can’t pick the sucker at a poker table out, you’re it? It’s unlikely that essentially every doctor in the US is committing malpractice and your utopian view of medicine is right.

And no, I don't need a team to tell me what to do with PEs - my board certification in emergency medicine and critical care do that. Having an ecmo capable center evaluate a submissive PE because the interventionalist likes billing catheter directed lytics without patient centered outcome data is not, should not and will never be standard of care.

 

[deleted950463]

I am judging you by your content and your content is exceedingly poor. Do you know the concept of the known known, the known unknown and the unknown unknown? You’re clearly in the unknown unknown. You are a novice but think you know what you’re talking about. I’m sorry you are so fragile that you view it as rude. Again, you are speaking out of turn. Standard of care is the minimum measure by which a physician is measured. Failing to meet standard of care is one component of malpractice. You are saying that 90%+ of physicians treating PEs are committing malpractice. Have you ever heard that if you can’t pick the sucker at a poker table out, you’re it? It’s unlikely that essentially every doctor in the US is committing malpractice and your utopian view of medicine is right.

And no, I don't need a team to tell me what to do with PEs - my board certification in emergency medicine and critical care do that. Having an ecmo capable center evaluate a submissive PE because the interventionalist likes billing catheter directed lytics without patient centered outcome data is not, should not and will never be standard of care.

I think we’ll just have to agree to disagree. I am glad that your expert board certification tells you exactly what to do in PE.

 

[deleted547339]

I think we’ll just have to agree to disagree. I am glad that your expert board certification tells you exactly what to do in PE.

The fact that an MS2 is being condescending to an attending is comical.

 

[MoMoGesiologist]

I think we’ll just have to agree to disagree. I am glad that your expert board certification tells you exactly what to do in PE.

No where was he rude to you.

His board certifications (EM and CCM) make him expertly qualified to decide how to treat PE...

Why do you think PE management needs a PERT team to be standard of care? Does every sepsis diagnosis need a “sepsis team” made up of ICU, ID, cards, etc? Does every tachycardic pt need a cards consult? PE really isn’t that special...

 

[Radetzky]

This has been the most entertaining 15 minutes of thread reading for a while.

Although I’m confused by why a medical student was posing as an interventional radiologist, my answer to the original question is as follows.

When I’m calling in the middle of the night to get a collection drained in a septic patient, please don’t ask me if I’ve talked to ID about making sure the pt is on the right antibiotics.

 

[vector2]

It’s regrettable that you chose to speak to a student this way on a student forum. Not need to be rude or personal.

Mmm, what's going to be regrettable is you wanting to train or work at NYPresby if a little spat like this ruffles your feathers about what's rude or personal

 

[deleted950463]

This has been the most entertaining 15 minutes of thread reading for a while.

Although I’m confused by why a medical student was posing as an interventional radiologist, my answer to the original question is as follows.

When I’m calling in the middle of the night to get a collection drained in a septic patient, please don’t ask me if I’ve talked to ID about making sure the pt is on the right antibiotics.

I am also confused that a bunch of attendings failed to see my statement pertain to use of decision making for PE lysis rather than routine treatment of PE....Of course many physicians are experts at treating PE. The issue is when you have to use an unproven modality like PE lysis.

 

[jdh71]

I don’t know about “standard of care” but PERTs are like tumor boards. Good ideas for combining a few minds quickly to try and get at the best plan. Where I work it’s not a big involved process and probably takes all of five minutes. If a PE is seen on the CT and the radiologist has measurements for RVS then the radiologist, EP, and Intensivist have a quick talk to decide if the patient should come to the ICU or if they seem fine enough for the floor. Also since I work in a system with smaller hospitals feeding a tertiary center, we will also discuss transfer or not.

 

[deleted950463]

I don’t know about “standard of care” but PERTs are like tumor boards. Good ideas for combining a few minds quickly to try and get at the best plan. Where I work it’s not a big involved process and probably takes all of five minutes. If a PE is seen on the CT and the radiologist has measurements for RVS then the radiologist, EP, and Intensivist have a quick talk to decide if the patient should come to the ICU or if they seem fine enough for the floor. Also since I work in a system with smaller hospitals feeding a tertiary center, we will also discuss transfer or not.

That’s an excellent comparison. Is tumor board standard of care? Or maybe the surgical oncologists are board certified so they don’t need to talk to heme onc or radonc at all?

 

[jdh71]

That’s an excellent comparison. Is tumor board standard of care? Or maybe the surgical oncologists are board certified so they don’t need to talk to heme onc or radonc at all?

I wouldn’t call tumor board “standard of care”.

You just got tripped up in a definition conflict based on your understandable inexperience and naïveté in working as a physician. What you meant was that PERT should be a reasonable thing we should try to do in most situations if we can. But you didn’t understand that standard or care colloquially means “if you don’t do this thing you are a bad doctor, like should be sued as a bad doctor doctor,”. The folks coming out of emergency medicine are especially sensitive to the topic.

 

[deleted547339]

I can’t believe I got baited into arguing with a troll....

 

[deleted950463]

I can’t believe I got baited into arguing with a troll....

Ah, more name calling and judging people by their credentials rather than contents of their post..

Regretable indeed. Shall we get back onto topic?

I can talk about some of my pet peeves about other clinician’s misconception about IR.

1. Please don’t make pts NPO for any procedures that isn’t gonna require sedation. Para/thora typically do not. Even port placement do not necessarily need sedation for motivated pts.

2. Arm picc request in pt with chronic renal disease. Just read the kdoqi guidelines.

3. Double/triple lumen central lines: the more lumen there is the smaller each lumen is.

 

[deleted547339]

Ah, more name calling and judging people by their credentials rather than contents of their post..

Regretable indeed. Shall we get back onto topic?

I can talk about some of my pet peeves about other clinician’s misconception about IR.

1. Please don’t make pts NPO for any procedures that isn’t gonna require sedation. Para/thora typically do not. Even port placement do not necessarily need sedation for motivated pts.

2. Arm picc request in pt with chronic renal disease. Just read the kdoqi guidelines.

3. Double/triple lumen central lines: the more lumen there is the smaller each lumen is.

Contents of your post? You are an MS2 posing as an IR attending. I’m just sorry I didn’t realize you were a troll earlier.

I’m out.

 

[deleted950463]

Contents of your post? You are an MS2 posing as an IR attending. I’m just sorry I didn’t realize you were a troll earlier.

I’m out.

Just your average MS2 who’s all about making the sweet RVU, MOC, MDC and PERT and “posing as an IR attending“. Let’s just say I am more familiar with radiology and inpatient work flow as staff than your average MS2.

 

[vector2]

1. Please don’t make pts NPO for any procedures that isn’t gonna require sedation. Para/thora typically do not. Even port placement do not necessarily need sedation for motivated pts.

This is really dumb advice. Notice how you used the words "necessarily" and "typically," but not "definitely"? Even patients who have had procedures before with no sedation can be unpredictable when a different procedure is required... or if they're just having a particularly bad day during their hospital stay. I don't like holding nutrition unnecessarily anymore than any other CC physician, but the vast majority of the time making sure there are absolutely no holdups to getting the procedure done outweighs the temporary caloric deficit.

 

[deleted950463]

This is really dumb advice. Notice how you used the words "necessarily" and "typically," but not "definitely"? Even patients who have had procedures before with no sedation can be unpredictable when a different procedure is required... or if they're just having a particularly bad day during their hospital stay. I don't like holding nutrition unnecessarily anymore than any other CC physician, but the vast majority of the time making sure there are absolutely no holdups to getting the procedure done outweighs the temporary caloric deficit.

Except what’s far more often is patients become NPO for days because clinicians automatically NPO them for paracentesis and due to department scheduling reasons they get bumped over and over as they are the least emergent cases.

I’ve had someone who didn’t eat for 3 days because they were waiting for paracentesis before. They had 30 paras before, never needed sedation.

The least you could do is give your proceduralist a call before NPO. Because guess which doctor they are going to mad at? The proceduralist because “we delayed their care”.

Same vein extends to usage of blood product. No, I don’t need FFP to fix an INR of 1.6 to do a paracentesis. First there’s the new anticoagulation guideline last year putting acceptable INR for low risk procedure much higher in the 2s and 3s, and FFP’s INR is 1.7 itself so how is FFP going to make INR below 1.6 emergently?

The hilarity also happens when we told the team “no, cant do it today due to scheduling and INR” and then they decide to give product without asking us. No, giving products today won’t change our scheduling, which often is due to techs/nurses rather than doc availablity, and also it’s a huge waste of products because will again need FFP the next day.

Don’t even get me started when the unit ask me if I want kcentra before a paracentesis....

 

[Radetzky]

While I agree that FFP for mild INR elevations is a waste of time, it is a pet peeve when people quote the reason as being “the INR of FFP is only 1.5”

The INR of a separated blood component is a meaningless concept.

 

[IMGASMD]

Op, I just hope you’re as good as you think you are. Takes boaolls to go against attendings, board certified, in CCM nonetheless. (It’s the interweb, maybe just being a keyboard warrior isn’t as hard?).

You may have the book knowledge, but when you answer some of the comments by using “we”, I find it very disingenuous. If “you” (singular) are making any of these clinical decisions, I want to know where you’re going to school or being a “team” at. Because I simply would not accept the care that you think you’re giving.

Just as some of my nurse anesthetist, you only see one side of clinical practice. They see the practical side, “I can do what you’re doing and I know how to do it.” Therefore, I am as good. For you, “I have the knowledge and read paperS, I’ve even sat in some of these discussions.” Therefore I am as good.

There is a reason why medical school is four years and shortest residency is three years. But you keep doing you.

Good luck.

 

[deleted950463]

Op, I just hope you’re as good as you think you are. Takes boaolls to go against attendings, board certified, in CCM nonetheless. (It’s the interweb, maybe just being a keyboard warrior isn’t as hard?).

You may have the book knowledge, but when you answer some of the comments by using “we”, I find it very disingenuous. If “you” (singular) are making any of these clinical decisions, I want to know where you’re going to school or being a “team” at. Because I simply would not accept the care that you think you’re giving.

Just as some of my nurse anesthetist, you only see one side of clinical practice. They see the practical side, “I can do what you’re doing and I know how to do it.” Therefore, I am as good. For you, “I have the knowledge and read paperS, I’ve even sat in some of these discussions.” Therefore I am as good.

There is a reason why medical school is four years and shortest residency is three years. But you keep doing you.

Good luck.

Oh I completely agree with you that book knowledge without clinical experiences are meaningless. I have a very close family member who’s an IR attending so I learn stuff straight from the horse’s mouth per say, but I 100% agree that there’s a reason why IR training is 6-7 years after med school. If anything there needs to be far more critical care component enfolded in that training as our pts are often in extremis.

 

[dpmd]

Except what’s far more often is patients become NPO for days because clinicians automatically NPO them for paracentesis and due to department scheduling reasons they get bumped over and over as they are the least emergent cases.

I’ve had someone who didn’t eat for 3 days because they were waiting for paracentesis before. They had 30 paras before, never needed sedation.

The least you could do is give your proceduralist a call before NPO. Because guess which doctor they are going to mad at? The proceduralist because “we delayed their care”.

Same vein extends to usage of blood product. No, I don’t need FFP to fix an INR of 1.6 to do a paracentesis. First there’s the new anticoagulation guideline last year putting acceptable INR for low risk procedure much higher in the 2s and 3s, and FFP’s INR is 1.7 itself so how is FFP going to make INR below 1.6 emergently?

The hilarity also happens when we told the team “no, cant do it today due to scheduling and INR” and then they decide to give product without asking us. No, giving products today won’t change our scheduling, which often is due to techs/nurses rather than doc availablity, and also it’s a huge waste of products because will again need FFP the next day.

Don’t even get me started when the unit ask me if I want kcentra before a paracentesis....

Well to be fair, the person who chose not to do a case for days without feeding the patient is the person the patient should be mad at. As a surgeon getting consulted to address a problem I appreciate if the requesting doc covers all the bases to allow me full options (npo, anticoagulants held, etc) and then I can make adjustments based on when and how I wish to intervene. If I can't get to a case for days I let the requesting provider know (and often let the patient know) and will take the responsibility for diet and other appropriate orders if I can't give a definite date for when I will do it. Because as it turns out they can't just read my mind and it isn't their responsibility to keep track of my schedule. As for the questions you might consider stupid. Most of the time they are being asked because one of your colleagues has demanded that previously. So maybe instead of judging the person asking you can judge your colleagues who won't do a procedure because the cirrhotic has an inr of 1.4 or similar (my favorite is when IR states it is too high risk and consult surgery for it instead like me with my knives is going to cause less bleeding than their image guided needle)

 

[deleted950463]

Well to be fair, the person who chose not to do a case for days without feeding the patient is the person the patient should be mad at. As a surgeon getting consulted to address a problem I appreciate if the requesting doc covers all the bases to allow me full options (npo, anticoagulants held, etc) and then I can make adjustments based on when and how I wish to intervene. If I can't get to a case for days I let the requesting provider know (and often let the patient know) and will take the responsibility for diet and other appropriate orders if I can't give a definite date for when I will do it. Because as it turns out they can't just read my mind and it isn't their responsibility to keep track of my schedule. As for the questions you might consider stupid. Most of the time they are being asked because one of your colleagues has demanded that previously. So maybe instead of judging the person asking you can judge your colleagues who won't do a procedure because the cirrhotic has an inr of 1.4 or similar (my favorite is when IR states it is too high risk and consult surgery for it instead like me with my knives is going to cause less bleeding than their image guided needle)

Sorry you got IRs who somehow think that their procedure will cause more bleeding than your knife.

Some IRs are not aware of the latest up to date algorithm regarding anticoagulation guideline.

One caveat though, there are certain procedures that are probably more high risk for us than for surgery because we don’t have an option to stop internal venous bleeding most of the time and we don’t have the field and bleeder exposed. We can’t tie or use electrocautery in general for deep vessels, so it’s really situationally dependent.

Take percutaneous gastrostomy tube for example. You can try to approach the stomach in an location away from the gastroepiploic arteries but those procedures involve more or less blind sticks. It’s not usually possible to image the needle path and exclude vessel in the way for us and if we stick a vessel we can’t even compress upon it because it’s stomach...

 

[Radetzky]

When I first got my driving permit I thought I knew a lot about the road. Then I nearly crashed.

It’s impossible to explain to you how limited your view is because you can’t see what’s not in your sight.

You come onto this forum and proceed to try drop some inane lectures onto CCM attendings like ‘oh there’s less space for 3 lumens than 2.’

When your limitations are pointed out to you, you don’t stop to listen and consider that you might in fact be wrong.

Nobody cares how many family members you have who are IR attendings. Or that you may have worked at an IR practice before. None of it justifies the amount of misplaced confidence present in opinions on clinical matters.

I say all this in the nicest way possible. If there’s one thing I’m reminded of everyday in my job, it’s the importance of humility.

 

[deleted950463]

When I first got my driving permit I thought I knew a lot about the road. Then I nearly crashed.

It’s impossible to explain to you how limited your view is because you can’t see what’s not in your sight.

You come onto this forum and proceed to try drop some inane lectures onto CCM attendings like ‘oh there’s less space for 3 lumens than 2.’

When your limitations are pointed out to you, you don’t stop to listen and consider that you might in fact be wrong.

Nobody cares how many family members you have who are IR attendings. Or that you may have worked at an IR practice before. None of it justifies the amount of misplaced confidence present in opinions on clinical matters.

I say all this in the nicest way possible. If there’s one thing I’m reminded of everyday in my job, it’s the importance of humility.

I completely agree with you. The practice of medicine requires the highest amount of humility. Every patient we interact could be the one that have a devastating outcome.

But then another thing that I got reminded everyday is to not judge people by their titles or perceived experience level. I see tech routinely offer ideas to residents and yes, even attending and things work.

So yes, discuss on merit rather than blatantly ignore someone’s comment because who they are.

By the way, triple lumen catheters (the small ones, not the trifusion or trialysis ones) absolutely suck.

 

[vector2]

Yea I also remember when I was preclinical that because my dad was an oncologist and I had a shadowed him, I felt perfectly comfortable going around telling pancreatic ca pts that WE recommend FOLFIRINOX over abraxane/nab-paclitaxel. They would look at me funny and I'd be like "bro, judge the recommendation on the merits"

 

[deleted950463]

Yea I also remember when I was preclinical that because my dad was an oncologist and I had a shadowed him, I felt perfectly comfortable going around telling pancreatic ca pts that WE recommend FOLFIRINOX over abraxane/nab-paclitaxel. They would look at me funny and I'd be like "bro, judge the recommendation on the merits"

So what do you know now that you didn’t back then?

 

[vector2]

So what do you know now that you didn’t back then?

I was being sarcastic, sherlock. Your lack of self-awareness and your lip service to humility (while continuing to be arrogant about what you think you know about IR) are not going to serve you well as your medical career progresses.

 

[deleted950463]

I was being sarcastic, sherlock. Your lack of self-awareness and your lip service to humility (while continuing to be arrogant about what you think you know about IR) are not going to serve you well as your medical career progresses.

Ah, more personal insults. My career is going just fine, thanks. It’s certainly harder as a DO but I’ve met a lot of mentors who are incredibly helpful.

 

[deleted547339]

Seriously, mods - this thread serves no purpose. You have a Med student posing as an IR attending to ask what IR should know from CCM attendings. No one in IR will be reading this thread, much less learning anything from it and the OP is, at best, obstinate and doesn’t want to learn from the people who he supposedly is asking opinions (and that’s giving him the benefit of the doubt that he’s not a troll).

 

[deleted950463]

Seriously, mods - this thread serves no purpose. You have a Med student posing as an IR attending to ask what IR should know from CCM attendings. No one in IR will be reading this thread, much less learning anything from it and the OP is, at best, obstinate and doesn’t want to learn from the people who he supposedly is asking opinions (and that’s giving him the benefit of the doubt that he’s not a troll).

There is most definitively IR attending(s) reading this thread.

And honestly the discussions have been valid and eye opening until trolls came in and sidetracked things from actual clinical discussion.

Perhaps this thread did run its course.

 

[group_theory]

Thread has run its course. Closed.