What's your 'The bone is broken; I need to fix it story'?

[Iso4ane]

Not to bash on surgeons or anything, but it is clear they have different priorities from us. Just the other day one of ortho sureobs wanted to take back a 90+yo male back for hemi-hip after hours. The patient had a critical aortic stenosis and stent placed less than a month ago for ostial LAD lesion (among other things), and the surgeon was getting huffy about why anesthesia was so worried about taking this patient back.

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[nimbus]

Not to bash on surgeons or anything, but it is clear they have different priorities from us. Just the other day one of ortho sureobs wanted to take back a 90+yo male back for hemi-hip after hours. The patient had a critical aortic stenosis and stent placed less than a month ago for ostial LAD lesion (among other things), and the surgeon was getting huffy about why anesthesia was so worried about taking this patient back.

Makes you wonder why they didn’t TAVR a month ago. Seems like the AS is at least as problematic as the CAD. And he’s only 90.

At 90 with critical AS, this patient has a very short life expectancy. Now the guy has a hip fracture. The options are to fix it or not fix it. If they don’t fix it, what is the likely outcome? Anything you do at this point is palliative, to ease his remaining days.

 

[caligas]

75-year-old for hemi arthroplasty. Platelet count 22,000. Brought to pre op, was cleared by medicine. No discussion of platelets. I asked heme to see her while doing previous case, Somehow the guy came and saw her in like 5 minutes. ITP. Heme dude was cool, explained everything to me and showed me the smear etc. Came back another day after steroid course and did fine.

 

[facted]

Broken hip. 95 year old bed bound dementia. Surgeon refused to wait for tee. Got admin involved, etc... In the midst of that, echo comes back:

5% EF. Critical AS. Severe RV failure with PHTN. Cards said it was the worst echo he'd ever read.

All discussed with family, family chose comfort care.

 

[Robotic Wis-Hipple]

Broken hip. 95 year old bed bound dementia. Surgeon refused to wait for tee. Got admin involved, etc... In the midst of that, echo comes back:

5% EF. Critical AS. Severe RV failure with PHTN. Cards said it was the worst echo he'd ever read.

All discussed with family, family chose comfort care.

Orthopod had actually borrowed a nurses stethoscope, there was no murmur.

 

[WholeLottaGame7]

Orthopod had actually borrowed a nurses stethoscope, there was no murmur.

Lol, to be fair, with an EF of 5%, there might not have been a murmur. You probably have to have some forward flow to create noise.

 

[DrOwnage]

Cards said it was the worst echo he'd ever read.

Please tell me you proceeded to do this:

 

[Mman]

5% EF. Critical AS. Severe RV failure with PHTN. Cards said it was the worst echo he'd ever read.

So was there like 1 red cell getting through the aortic valve with each heart beat? Of course there is PHTN and RV failure. I mean there isn't any blood moving forward so it all just kinda sits there. I mean 5%? I don't think the math to calculate even works at that low of a value. For an EF of 5%, you are looking at a stroke volume of like 5-10 mls. Be generous and give them a HR of 100 and you have a CO of 0.5-1.0 L/min.

 

[facted]

So was there like 1 red cell getting through the aortic valve with each heart beat? Of course there is PHTN and RV failure. I mean there isn't any blood moving forward so it all just kinda sits there. I mean 5%? I don't think the math to calculate even works at that low of a value. For an EF of 5%, you are looking at a stroke volume of like 5-10 mls. Be generous and give them a HR of 100 and you have a CO of 0.5-1.0 L/min.

Haha, true. All I know is his heart was done.

 

[Robotic Wis-Hipple]

Lol, to be fair, with an EF of 5%, there might not have been a murmur. You probably have to have some forward flow to create noise.

That was the joke!

 

[Monty Python]

Broken hip. 95 year old bed bound dementia. Surgeon refused to wait for tee. Got admin involved, etc... In the midst of that, echo comes back:

5% EF. Critical AS. Severe RV failure with PHTN. Cards said it was the worst echo he'd ever read.

All discussed with family, family chose comfort care.

Surprised ortho didn't just order a gram of Ancef to manage it.

 

[nimbus]

Broken hip. 95 year old bed bound dementia. Surgeon refused to wait for tee. Got admin involved, etc... In the midst of that, echo comes back:

5% EF. Critical AS. Severe RV failure with PHTN. Cards said it was the worst echo he'd ever read.

All discussed with family, family chose comfort care.

I want to know what he got for the TEE.

 

[Iso4ane]

I want to know what he got for the TEE.

Probably agitated and tried to stand up and the promptly passed out. I wonder if his dementia and agitation were exacerbated due to hypoperfusion of the brain.

 

[Robotic Wis-Hipple]

I want to know what he got for the TEE.

A TTE

 

[PainDrain]

I had a 65 year old with severe pulmHTN on remodulin and sildenifil, multiple admissions over the past year and recently transitioned to home hospice who syncopized and broke her hip. She and her family had a meeting while in the ED and decided on CMO status. Get a call from this ortho resident saying his attending wanted to book this lady for a hemi. I thought to myself “how desperate for billing do you have to be”? We refused and patient got a morphine drip for comfort.

 

[facted]

I want to know what he got for the TEE.

Ah, sorry. Typo...tte.

 

[Twiggidy]

“Orthopedic Surgery........we make smart students into dumb doctors”

 

[anbuitachi]

sometimes i can't tell if they get dumified and actually dont see it, or they really only just care about their bottom line

 

[MetaPhysicianBlog]

75-year-old for hemi arthroplasty. Platelet count 22,000. Brought to pre op, was cleared by medicine. No discussion of platelets. I asked heme to see her while doing previous case, Somehow the guy came in like 5 minutes. ITP. Heme dude was cool, explained everything to me and showed me the smear etc. Came back another day after steroid course and did fine.

Interesting. How did medicine explain the thrombocytopenia on the first evaluation?

 

[MetaPhysicianBlog]

Lol, to be fair, with an EF of 5%, there might not have been a murmur. You probably have to have some forward flow to create noise.

I tried to explain this to a nurse the other day. Basically told her I could make the BP any number she wanted. But it was about the flow. You know the whole thing about the purpose of the heart to deliver oxygen to organs?

She then asked me what medicine I was going to use to change the blood pressure.

 

[Twiggidy]

sometimes i can't tell if they get dumified and actually dont see it, or they really only just care about their bottom line

To be fair it’s not just ortho...many only care about their bottom line. The problem is there are so many ways to monitor a patient and so many medications for all critical situations they assume we can get anyone through an anesthetic, and 99% of the time we can, its just that most of us ar concerned about that 1%.

Disclosure: All those percentages are made up.

 

[coffeebythelake]

Ah, sorry. Typo...tte.

Was about to say... pt could have easily died just getting the TEE

 

[coffeebythelake]

I tried to explain this to a nurse the other day. Basically told her I could make the BP any number she wanted. But it was about the flow. You know the whole thing about the purpose of the heart to deliver oxygen to organs?

She then asked me what medicine I was going to use to change the blood pressure.

Exactly

 

[coffeebythelake]

“Orthopedic Surgery........we make smart students into dumb doctors”

Smart students??? Hahahhahahaha

 

[deleted162650]

So was there like 1 red cell getting through the aortic valve with each heart beat? Of course there is PHTN and RV failure. I mean there isn't any blood moving forward so it all just kinda sits there. I mean 5%? I don't think the math to calculate even works at that low of a value. For an EF of 5%, you are looking at a stroke volume of like 5-10 mls. Be generous and give them a HR of 100 and you have a CO of 0.5-1.0 L/min.

At least you know the EBL will be minimal.

 

[Foodie]

Not my case but my poor partners participated in this pt's care. OSA, obese, CAD s/p CABG several yrs prior then a DES to LAD in cold NY winter. Discharged home after the stent and on his way out of the car, he slipped and fell on his icy driveway and broke his hip. The poor lad developed phlebitis at an IV site and first underwent upper extremity I&D, which he tolerated okay with LMA. Then ortho pushed for hip ORIF and got their wish. My anes colleague said yes to proceed (to this day I don't know why), done under GETA. They even stopped antiplatelet therapy for the surgery. Intraop STEMI at the end of surgery and was never extubated. EF was 10% postop. On POD 3 coded multiple times in ICU before family finally agreed to stop. The last progress note from ortho was "Pt stable. OOB to chair, physical therapy when pt able to participate."

Death is stable. Is that what he meant?

 

[coffeebythelake]

Not my case but my poor partners participated in this pt's care. OSA, obese, CAD s/p CABG several yrs prior then a DES to LAD in cold NY winter. Discharged home after the stent and on his way out of the car, he slipped and fell on his icy driveway and broke his hip. The poor lad developed phlebitis at an IV site and first underwent upper extremity I&D, which he tolerated okay with LMA. Then ortho pushed for hip ORIF and got their wish. My anes colleague said yes to proceed (to this day I don't know why), done under GETA. They even stopped antiplatelet therapy for the surgery. Intraop STEMI at the end of surgery and was never extubated. EF was 10% postop. On POD 3 coded multiple times in ICU before family finally agreed to stop. The last progress note from ortho was "Pt stable. OOB to chair, physical therapy when pt able to participate."

Death is stable. Is that what he meant?

Jeezus, if family sues that ortho note would make them look like a bunch of *****s. Obviously super high risk procedure, but not really elective if pt has broken hip u going to let him sit for 6 months before surgery? Stopping dapt sounds bad, not sure if risk of bleeding would exceed risks of stopping AC, hopefully cards had some input. Hopefully pt and fam understood the risks and it was laid out clearly to them.

I would have done the case.

 

[jwk]

ASA IV pt, 80's, having a hip arthroplasty. Arrested at induction, resuscitated, surgery aborted, sent to ICU, vent, swan, etc. 3 days later cards clears her (???) and removes her swan (?????). Case fairly uneventful (lateral position back in those days), until the surgeon starts hammering in the implant. Pt arrests again. Me to surgeon "Hey doc, your patient just arrested - we need to turn her supine now so we can start CPR". Surgeon keeps hammering and tells me "just a minute, I almost have this implant in place". Pt did not survive surgery.

 

[coffeebythelake]

ASA IV pt, 80's, having a hip arthroplasty. Arrested at induction, resuscitated, surgery aborted, sent to ICU, vent, swan, etc. 3 days later cards clears her (???) and removes her swan (?????). Case fairly uneventful (lateral position back in those days), until the surgeon starts hammering in the implant. Pt arrests again. Me to surgeon "Hey doc, your patient just arrested - we need to turn her supine now so we can start CPR". Surgeon keeps hammering and tells me "just a minute, I almost have this implant in place". Pt did not survive surgery.

Idiot surgeon

 

[neutro]

Not to bash on surgeons or anything, but it is clear they have different priorities from us. Just the other day one of ortho sureobs wanted to take back a 90+yo male back for hemi-hip after hours. The patient had a critical aortic stenosis and stent placed less than a month ago for ostial LAD lesion (among other things), and the surgeon was getting huffy about why anesthesia was so worried about taking this patient back.

seems like a bunch of complaining.

help the patient. get it done.

 

[neutro]

ASA IV pt, 80's, having a hip arthroplasty. Arrested at induction, resuscitated, surgery aborted, sent to ICU, vent, swan, etc. 3 days later cards clears her (???) and removes her swan (?????). Case fairly uneventful (lateral position back in those days), until the surgeon starts hammering in the implant. Pt arrests again. Me to surgeon "Hey doc, your patient just arrested - we need to turn her supine now so we can start CPR". Surgeon keeps hammering and tells me "just a minute, I almost have this implant in place". Pt did not survive surgery.

thats terrible and hard to believe.

was this case brought up and discussed in M/M, or quality improvement meetings?

 

[Psai]

thats terrible and hard to believe.

was this case brought up and discussed in M/M, or quality improvement meetings?

It doesn't sound hard to believe at all. Asa 4s and 5s going for hip surgery is a dime a dozen.

 

[nimbus]

It doesn't sound hard to believe at all. Asa 4s and 5s going for hip surgery is a dime a dozen.

Hip fractures yes. Elective hip replacements no.

 

[neutro]

It doesn't sound hard to believe at all. Asa 4s and 5s going for hip surgery is a dime a dozen.

I was amazed that despite cardiac arrest the surgeon decided to continue the procedure

 

[ChiDO]

It's broke, we fix. I guess my biggest pet peeve is boarding the case at 5 am to follow my day as an addon at 5 pm. No one from anesthesia bothers to see the patient until 6 pm when the case was supposed to start an hour ago and now we want an echo, more labs, etc.

The other day, had an addon, get to the hospital an hour early. Three hours later, and hour after start time, we decide to cancel due to abnormal additional tests. I'm OK with patient safety, but I just wasted three hours of my life because no one ordered any tests until in preop.

 

[nimbus]

It's broke, we fix. I guess my biggest pet peeve is boarding the case at 5 am to follow my day as an addon at 5 pm. No one from anesthesia bothers to see the patient until 6 pm when the case was supposed to start an hour ago and now we want an echo, more labs, etc.

The other day, had an addon, get to the hospital an hour early. Three hours later, and hour after start time, we decide to cancel due to abnormal additional tests. I'm OK with patient safety, but I just wasted three hours of my life because no one ordered any tests until in preop.

Nobody likes surprises. How about giving your anesthesiologist or the board runner a heads up during your first case. “Hey nimbus, I added a hip at the end of my lineup. Mr X is in bed 809 and he’s pretty sick. Will you have a look at him after this case and let me know what you think?” Many of our surgeons actually do this. We can get the wheels rolling early. Maybe it’s a private practice thing. We are a team.

It can save you a lot of grief. Just a suggestion.

 

[Psai]

It's broke, we fix. I guess my biggest pet peeve is boarding the case at 5 am to follow my day as an addon at 5 pm. No one from anesthesia bothers to see the patient until 6 pm when the case was supposed to start an hour ago and now we want an echo, more labs, etc.

The other day, had an addon, get to the hospital an hour early. Three hours later, and hour after start time, we decide to cancel due to abnormal additional tests. I'm OK with patient safety, but I just wasted three hours of my life because no one ordered any tests until in preop.

Is it hard to predict who would need more tests and imaging? Do you think that we wouldn't want a workup on an 80 year old cad w stents, htn, dm, hld, pvd including cardiology evaluation? We're cranking through cases in the OR, not going around to see if the addon for later is sick as sht and hasn't been seen by the internal medicine physician yet.

 

[caligas]

Interesting. How did medicine explain the thrombocytopenia on the first evaluation?

They missed it. LOL

 

[dannyboy1]

Not my case but my poor partners participated in this pt's care. OSA, obese, CAD s/p CABG several yrs prior then a DES to LAD in cold NY winter. Discharged home after the stent and on his way out of the car, he slipped and fell on his icy driveway and broke his hip. The poor lad developed phlebitis at an IV site and first underwent upper extremity I&D, which he tolerated okay with LMA. Then ortho pushed for hip ORIF and got their wish. My anes colleague said yes to proceed (to this day I don't know why), done under GETA. They even stopped antiplatelet therapy for the surgery. Intraop STEMI at the end of surgery and was never extubated. EF was 10% postop. On POD 3 coded multiple times in ICU before family finally agreed to stop. The last progress note from ortho was "Pt stable. OOB to chair, physical therapy when pt able to participate."

Death is stable. Is that what he meant?

Not sure what you would have done differently. This case needs to go, it’s a previously ambulatory patient with a hip fracture. Maybe would have a discussion with the surgeon about continuing DAPT. Otherwise ASA 4, proceed with high risk...

 

[anbuitachi]

Not sure what you would have done differently. This case needs to go, it’s a previously ambulatory patient with a hip fracture. Maybe would have a discussion with the surgeon about continuing DAPT. Otherwise ASA 4, proceed with high risk...

Both plavix and aspirin were stopped????

 

[coffeebythelake]

Both plavix and aspirin were stopped????

Its ****ing crazy. Pt didn't bleed a lot but died from a massive STEMI instent thrombosis. But ortho can say blood loss minimal

 

[dannyboy1]

Both plavix and aspirin were stopped????

I would hope not. By DAPT i meant continuing plavix.

 

[vector2]

It's crazy to me that in this age of various bipolars, ultrasonic coagulators, and argon lasers that a liver transplant can be done on profoundly coagulopathic pts but ortho can't fix a bone on ASA and plavix. Hell, our worst surgeon takes about 5 hrs and loses a median of 1000cc on his healthy hips.

 

[coffeebythelake]

It's crazy to me that in this age of various bipolars, ultrasonic coagulators, and argon lasers that a liver transplant can be done on profoundly coagulopathic pts but ortho can't fix a bone on ASA and plavix. Hell, our worst surgeon takes about 5 hrs and loses a median of 1000cc on his healthy hips.

Bone fix. Bleeding bad.

 

[facted]

Not my case but my poor partners participated in this pt's care. OSA, obese, CAD s/p CABG several yrs prior then a DES to LAD in cold NY winter. Discharged home after the stent and on his way out of the car, he slipped and fell on his icy driveway and broke his hip. The poor lad developed phlebitis at an IV site and first underwent upper extremity I&D, which he tolerated okay with LMA. Then ortho pushed for hip ORIF and got their wish. My anes colleague said yes to proceed (to this day I don't know why), done under GETA. They even stopped antiplatelet therapy for the surgery. Intraop STEMI at the end of surgery and was never extubated. EF was 10% postop. On POD 3 coded multiple times in ICU before family finally agreed to stop. The last progress note from ortho was "Pt stable. OOB to chair, physical therapy when pt able to participate."

Death is stable. Is that what he meant?

As others said, you do the case without question. While it's not an emergency that can't wait a few hours, it's def something that needs to be done sooner rather than later (within 48 hr of fx ideally). The mistake is stopping A/C. That's a hard a stop no. The cardiologist cleared them to stop A/C? Your attending was ok with that? Was a discussion had with the surgeon about whether it was ok to continue the A/C?

 

[Twiggidy]

It's broke, we fix. I guess my biggest pet peeve is boarding the case at 5 am to follow my day as an addon at 5 pm. No one from anesthesia bothers to see the patient until 6 pm when the case was supposed to start an hour ago and now we want an echo, more labs, etc.

The other day, had an addon, get to the hospital an hour early. Three hours later, and hour after start time, we decide to cancel due to abnormal additional tests. I'm OK with patient safety, but I just wasted three hours of my life because no one ordered any tests until in preop.

Next you'll say "Anesthesia is slowing down my day because they're wasting time between my cases evaluating add-ons". How about pick up the tele in the morning and have a medicine doc see the patient and get them tuned up. At least then, you'll know the case will need to be cancelled by noon instead of one hour past the start.

Also, when things go over time, it's not just YOUR life that wasted. Be better tomorrow......

 

[dchz]

Not my case but my poor partners participated in this pt's care. OSA, obese, CAD s/p CABG several yrs prior then a DES to LAD in cold NY winter. Discharged home after the stent and on his way out of the car, he slipped and fell on his icy driveway and broke his hip. The poor lad developed phlebitis at an IV site and first underwent upper extremity I&D, which he tolerated okay with LMA. Then ortho pushed for hip ORIF and got their wish. My anes colleague said yes to proceed (to this day I don't know why), done under GETA. They even stopped antiplatelet therapy for the surgery. Intraop STEMI at the end of surgery and was never extubated. EF was 10% postop. On POD 3 coded multiple times in ICU before family finally agreed to stop. The last progress note from ortho was "Pt stable. OOB to chair, physical therapy when pt able to participate."

Death is stable. Is that what he meant?

Initially quoted this to say what everyone else said about not stopping the DAPT, emergent and needs to go, etc. Glad i wasn't the only one.

I do want to ask, once we're post op and crossed the bridge and burned the stent, any talks of ECMO and re-stent?

 

[pgg]

It's broke, we fix. I guess my biggest pet peeve is boarding the case at 5 am to follow my day as an addon at 5 pm. No one from anesthesia bothers to see the patient until 6 pm when the case was supposed to start an hour ago and now we want an echo, more labs, etc.

The other day, had an addon, get to the hospital an hour early. Three hours later, and hour after start time, we decide to cancel due to abnormal additional tests. I'm OK with patient safety, but I just wasted three hours of my life because no one ordered any tests until in preop.

When you "board" a case, does that include a de facto consult to the anesthesiology department? Are you speaking directly to an anesthesiologist or just typing a case into the computer?

It's just odd, because every other surgical specialty can manage to do a reasonable workup themselves or consult someone to do it for their same day add ons. It's alway ortho that we're having this discussion with. Always. There's a patient ownership gap between ortho and other surgical specialties.

We joke about you guys being Ancef-slinging hammer swingers but there's some truth to it. Ortho is just uninvolved in a way other surgeons aren't. Maybe that gap extends to what you expect other people to do when you post a case, and what they expect you to have done yourself.


Also, welcome to the forum.

 

[Robotic Wis-Hipple]

The problem is the rest of the hospital revolves around ortho and they get used to it then wonder why it’s always Anesthesia that doesn’t just ask how high to jump. The ortho guys haven’t managed anything that resembles Medicine in years, they admit, a Medicine doc works em up and follows for all things not bone/joint related, and on the floor side it’s all very much preferred that way. The IM groups love the ortho consults, admin loves orthopedic surgeries, the 5 device reps love to sell screws, implants, new tools, new navigational systems, etc.

But it also blows my mind that you guys haven’t figured out that the same Pt population that gets THAs or ends up with hip fractures also has an old heart with valvulopathy, coronary stents, arrhythmias, and the concomitant anticoagulants/antiplatelet agents.

 

[deleted162650]

It’s just part of the culture in Ortho. Here’s an interaction from my intern year:

Ortho senior resident: “This guy has HTN. Get a medicine consult.”
Ortho junior resident that just completed a surgery internship: “I’ll just start some Lopressor, it isn’t that difficult.”
Senior: “No, no, no. Consult medicine. They love that ****.”