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

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nimbus said:
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.
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This x1000!
 
How does Ortho remain a physician specialty? It seems a carpenter\ handyman\PA\NP well versed in anatomy could do the same job, it's pretty much all technical really if using ANY medical knowledge isn't required.
 
SaltyDog said:
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 ****.”
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lol, to the senior's credit lopressor isnt even the 2nd line let alone 1st line tx for essential HTN
 
2Fast2Des said:
How does Ortho remain a physician specialty? It seems a carpenter\ handyman\PA\NP well versed in anatomy could do the same job, it's pretty much all technical really if using ANY medical knowledge isn't required.
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I'm sure they say the same about us. It usually sounds something like, "Just put 'em to sleep."
 
vector2 said:
lol, to the senior's credit lopressor isnt even the 2nd line let alone 1st line tx for essential HTN
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What killed me in residency was our EMR had a button that literally said "Continue all home meds", but instead of pushing it we got consulted for pressures of 120/80 on home meds and A1c of 6 on home meds.
 
ChiDO said:
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.
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Bro, do you even doctor? You can't tell me that you're shocked that the 89yo SNF patient on 3L O2 and 4+ pitting edema needs a cards eval before taking to surgery. It's not like all these are hip fractures are in 20y college track athletes. You paid >$200K in medical school tuition, hopefully you can at least tell "sick" from "not sick." Hell, their family members with zero medical training know grandma ain't doing so hot.

I think the saying "a failure to plan on your part does not constitute an emergency on my part" applies here.
 
WholeLottaGame7 said:
Bro, do you even doctor? You can't tell me that you're shocked that the 89yo SNF patient on 3L O2 and 4+ pitting edema needs a cards eval before taking to surgery. It's not like all these are hip fractures are in 20y college track athletes. You paid >$200K in medical school tuition, hopefully you can at least tell "sick" from "not sick." Hell, their family members with zero medical training know grandma ain't doing so hot.

I think the saying "a failure to plan on your part does not constitute an emergency on my part" applies here.
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WholeLottaGame7 said:
Bro, do you even doctor? You can't tell me that you're shocked that the 89yo SNF patient on 3L O2 and 4+ pitting edema needs a cards eval before taking to surgery. It's not like all these are hip fractures are in 20y college track athletes. You paid >$200K in medical school tuition, hopefully you can at least tell "sick" from "not sick." Hell, their family members with zero medical training know grandma ain't doing so hot.

I think the saying "a failure to plan on your part does not constitute an emergency on my part" applies here.
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All fractures get admitted by medicine.ans cleared for surgery. If medicine feels the need for additional work up from cards, pulm, etc, they order it.

So no, I don't order pulm, heme, cards consults because they are not admitted to me. But when med clears the patient, then anesthesia wants more workup in holding, that's when it's annoying as they've been I the hospital for 15+ hours.

Also, each addon is phoned into the main or desk where a nurse takes down the info and anesthesia is informed. I don't speak directly to anes unless it's emergent and we may need to bump people.
 
jwk said:
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.
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No way, this can’t be true
 
ChiDO said:
All fractures get admitted by medicine.ans cleared for surgery. If medicine feels the need for additional work up from cards, pulm, etc, they order it.

So no, I don't order pulm, heme, cards consults because they are not admitted to me. But when med clears the patient, then anesthesia wants more workup in holding, that's when it's annoying as they've been I the hospital for 15+ hours.

Also, each addon is phoned into the main or desk where a nurse takes down the info and anesthesia is informed. I don't speak directly to anes unless it's emergent and we may need to bump people.
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Contrary to popular belief, medicine does not ultimately "clear" patients for surgery, and I'm relatively certain that if anesthesia wanted more tests it's because medicine many times does not know what they're doing or what they're looking for in regard to stratification.

Assuming you're in a place where inpatients don't get seen quickly by anesthesia for whatever reason, I'll give you an idea of the patients where you should pick up the phone to let us know as soon as you book the case:

Anyone with chest pain, recent MI/CVA/heart surgery/stents/pacemakers, SBP >180 / DBP > 110, hypotension, heart failure, severe valvular abnls or arrhythmias, SOB/respiratory distress, new oxygen requirement, sepsis, or very abnl laboratory values (K+, Hgb, BG > 250 etc)

If you can spend 5 minutes actually reviewing the patient's medical history and then calling us directly when you (or your medicine team) encounter one of these things you'd probably avoid 99% of your unexpected, last minute cancellations.
 
2Fast2Des said:
How does Ortho remain a physician specialty? It seems a carpenter\ handyman\PA\NP well versed in anatomy could do the same job, it's pretty much all technical really if using ANY medical knowledge isn't required.
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It just seems like that to us because we are ignorant. I've actually looked at orthobullets and talked to the surgeons and the amount of Ortho specific knowledge they have is incredible. We just don't know anything about their world.

You can say the same thing about anyone. Derm is just steroids and acne cream. Anesthesia is just tube and coffee. But we all have expert knowledge in our fields and should recognize each other for that.
 
ChiDO said:
All fractures get admitted by medicine.ans cleared for surgery. If medicine feels the need for additional work up from cards, pulm, etc, they order it.
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I guess the fundamental problem is that those medicine doctors are clueless about surgery and anesthesia. I've seen cardiology consults that recommend an anesthetic technique that would kill a patient. Not knowing anything about your hospital, I'd kinda suggest if you have somebody extremely ill you might want to have a 30 second conversation with one of the anesthesiologists about them in advance so they can eyeball them and see if they need anything else done. A case being posted doesn't really contain medical information about the patient and their condition.

30 seconds of your time early on can save you those hours later.
 
vector2 said:
Contrary to popular belief, medicine does not ultimately "clear" patients for surgery, and I'm relatively certain that if anesthesia wanted more tests it's because medicine many times does not know what they're doing or what they're looking for in regard to stratification.

Assuming you're in a place where inpatients don't get seen quickly by anesthesia for whatever reason, I'll give you an idea of the patients where you should pick up the phone to let us know as soon as you book the case:

Anyone with chest pain, recent MI/CVA/heart surgery/stents/pacemakers, SBP >180 / DBP > 110, hypotension, heart failure, severe valvular abnls or arrhythmias, SOB/respiratory distress, new oxygen requirement, sepsis, or very abnl laboratory values (K+, Hgb, BG > 250 etc)

If you can spend 5 minutes actually reviewing the patient's medical history and then calling us directly when you (or your medicine team) encounter one of these things you'd probably avoid 99% of your unexpected, last minute cancellations.
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When I was a medicine intern we used to admit all the hip fractures. Standard admission orders were ECHO and Pre op cardiac evaluation. We actually had echo techs late at night with the portable machine doing TTE’s. Seemed to solve a lot of problems. .....
 
dchz said:
Don't we assume the low EF is caused by the stent going down?
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The timeframe described sounded like we were dealing with a completed infarction in which case there is no functional myocardium to salvage by restenting. I guess if you got in within a timeframe where you still have 'stunned myocardium' then it's a different story.
 
ChiDO said:
All fractures get admitted by medicine.ans cleared for surgery. If medicine feels the need for additional work up from cards, pulm, etc, they order it.

So no, I don't order pulm, heme, cards consults because they are not admitted to me. But when med clears the patient, then anesthesia wants more workup in holding, that's when it's annoying as they've been I the hospital for 15+ hours.

Also, each addon is phoned into the main or desk where a nurse takes down the info and anesthesia is informed. I don't speak directly to anes unless it's emergent and we may need to bump people.
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I think that the main issue for you leading to your frustration is a lack of communication to the anesthesiology team. You need to speak directly to the anesthesiologist taking care of that patient but from your post you aren't doing that. None of what we are telling you will change your practice but I hope that it does. If you don't want to be delayed or have a patient laying on the floor for 15hrs due to needing more workup than it falls on you to take that initiative. At the end of the day, all of us want the patient to see their family after surgery and we go home to our family knowing we did some good.
 
ChiDO said:
Also, each addon is phoned into the main or desk where a nurse takes down the info and anesthesia is informed.
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welltheresyourproblem.jpg

Put down the wrench and speak to us like you're a doctor who needs help from another doctor.
 
Literally all it takes is, “Hey, just added on a new case this AM to follow this PM looks kinda sick, just FYI.” Even if the anesthesia attending isn’t in the room at the time, the message will get delivered if the resident is any good.
 
Not an unhealthy patient, or a forced ortho case, but last week I took care of a 70-something year old lady who was otherwise healthy who slipped, fell and broke her hip while helping her husband who had just had hip surgery the prior week...
 
sigrhoillusion said:
Not an unhealthy patient, or a forced ortho case, but last week I took care of a 70-something year old lady who was otherwise healthy who slipped, fell and broke her hip while helping her husband who had just had hip surgery the prior week...
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It's just turtles all the way down
 
I've spoken to many hospitalists who've admitted that they wish they had gotten more exposure to the surgical side of things in residency and managing perioperative patients. They really are pretty clueless about this stuff. And they trained at some of the best programs in the country.
 
Ezekiel2517 said:
I've spoken to many hospitalists who've admitted that they wish they had gotten more exposure to the surgical side of things in residency and managing perioperative patients. They really are pretty clueless about this stuff. And they trained at some of the best programs in the country.
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yeah and 70% of that time was spent copying yesterday's note LMAO
 
0kazak1 said:
Literally all it takes is, “Hey, just added on a new case this AM to follow this PM looks kinda sick, just FYI.” Even if the anesthesia attending isn’t in the room at the time, the message will get delivered if the resident is any good.
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The problem is he, like so many orthopedists, have probably NEVER seen or met the patient prior to seeing them in the pre-op area. Like ChiDO, they want someone else to be responsible for every other aspect of the patient's care except for the "there is fracture - I must fix it" part. And of course they complain that the patient's not worked up properly, even though they have literally never laid eyes on that patient. Anesthesiology is NOT the patient's admitting physician.
 
ChiDO said:
each addon is phoned into the main or desk where a nurse takes down the info and anesthesia is informed
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I can guarantee the bolded is not true if you're getting that many delays.

Even if you don't like to speak to the ancef pushers, all you have to do is incentivize that nurse to inform them. In private practice, they incentivize with great results in turnovers and how the OR is runned. I believe you can easily fix the problem if you want it solved. Frankly i don't even know why you need someone with an nursing degree to do this, this is purely secretarial work.

The reason that i know there is a break down in communication is that anes and ortho's goals and incentives are aligned. we are not adversaries to each other, if we somehow get informed, our goals are the same as yours, get the patient safely through the surgery asap.
 
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I know it's hard because we can all think of that time when that Orthopod...But as much as it might be fun to tell someone off, it can be quite off putting and is the least likely to make a long term positive impact on behavior. When I have medical students and residents rotate with me I go out of my way to try and figure out learning objectives that are meaningful to where they are trying to go and when it's someone of a surgical bent I always find the time to talk about how to communicate with anesthesiologists. ChiDO doesn't want to stay late and find out that the add-on case was cancelled, like that dchz said our goals our aligned; it might be helpful to point out that we don't want to stay late, only to find that a patient who has been here all day isn't appropriately worked up and we didn't know, and then after working them up have to cancel the case. Running an efficient OR is a team sport and one that is facilitated by good communication on all sides.
 
Psai said:
It just seems like that to us because we are ignorant. I've actually looked at orthobullets and talked to the surgeons and the amount of Ortho specific knowledge they have is incredible. We just don't know anything about their world.

You can say the same thing about anyone. Derm is just steroids and acne cream. Anesthesia is just tube and coffee. But we all have expert knowledge in our fields and should recognize each other for that.
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not sure if that is what the above post meant. i understood it as ortho is so far from 'medicine' that its like carpentry. it's not saying orthos dont need much knowledge just like how car mechanics know a lot about car mechanics but not medicine. orthos do so much hammering and stuff they no longer do other aspects of medicine. The only difference between dermatology and ortho is derm stays out of the OR and we dont interact with them.

And to ChiDO, there aren't always concrete guidelines to workups that needs to be done. you will always see difference in opinions and obviously the anesthesiologist will triumph over the IM doc because the anes is the one doing the anesthesia. Also IM docs do not know as much regarding the issue and that is why here the anesthesiologist works with the IM doc in pre op clinic, where the anesthesiologist has to see anyone ASA3 or above.
 
pgg said:
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. 🙂
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I am just catching up after a long week. But I am glad someone else posted my exact same thoughts.
Like what, aren’t you a doctor too? Can’t you order labs and EKG and Echo if you know the patient is sick. Or do you even read the chart at all? We all know the answer to that part.
 
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ChiDO said:
All fractures get admitted by medicine.ans cleared for surgery. If medicine feels the need for additional work up from cards, pulm, etc, they order it.

So no, I don't order pulm, heme, cards consults because they are not admitted to me. But when med clears the patient, then anesthesia wants more workup in holding, that's when it's annoying as they've been I the hospital for 15+ hours.

Also, each addon is phoned into the main or desk where a nurse takes down the info and anesthesia is informed. I don't speak directly to anes unless it's emergent and we may need to bump people.
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Wow. Are you for real? I can’t tell.

You are taking the patient to the OR and you don’t think you need to order anything for them because they are not on “YOUR” service but on Medicine’s service? Is medicine the one who’s taking them to the OR? Did they come to the hospital for a fracture or to see an IM doc?

And how the hell does Medicine clear patients anyway? Have never really understood that. Surgeons for some reason loves it when Cards or Medicine clears the patient but have no friggin' idea about how anesthetics alter physiology. Anesthesiologists clear patients. Not medicine docs.

And the kicker of it, is "I don't speak directly to anesthesia unless it's emergent". Wow. Is it so damn difficult to give the doc doing your anesthetic a heads up about a patient? Or do you feel that's not part of your job either? Like someone else "the OR desk nurse" can speak to the anesthesiologists. Are you too good to speak to us directly?

You seem to carry an air of arrogance, and a complete lack of ownership in a patient you are taking for a potentially life threatening procedure. Whether or not they are admitted to medicine because you can't manage essential HTN is irrelevant. This is YOUR patient, and they came to the hospital to have their fracture/arthritis fixed by YOU and you should be thankful that you have anesthesiologists and medicine docs willing to help you take care of YOUR patient. When we take a patient to the OR, we claim ownership of that patient even though we know the patient did not come to the hospital to have anesthesia alone.

Someone like you needs to get their cases cancelled frequently till you learn to communicate with your colleagues a little better and not expect everyone else to do your job for you.
 
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vector2 said:
Contrary to popular belief, medicine does not ultimately "clear" patients for surgery, and I'm relatively certain that if anesthesia wanted more tests it's because medicine many times does not know what they're doing or what they're looking for in regard to stratification.

Assuming you're in a place where inpatients don't get seen quickly by anesthesia for whatever reason, I'll give you an idea of the patients where you should pick up the phone to let us know as soon as you book the case:

Anyone with chest pain, recent MI/CVA/heart surgery/stents/pacemakers, SBP >180 / DBP > 110, hypotension, heart failure, severe valvular abnls or arrhythmias, SOB/respiratory distress, new oxygen requirement, sepsis, or very abnl laboratory values (K+, Hgb, BG > 250 etc)

If you can spend 5 minutes actually reviewing the patient's medical history and then calling us directly when you (or your medicine team) encounter one of these things you'd probably avoid 99% of your unexpected, last minute cancellations.
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Yea, really. Asking he/she to read the chart. Hilarious. He/she didn't go to ortho residency to waste time doing that non sense.
 
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SaltyDog said:
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 ****.”
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Blind leading the blind on this one.
 
Some of you need to take it easy. Ortho asks for help from medicine because medicine will most often be caring for the patient with the hip fracture post-op. I’m not against asking ortho to step up every now and then but their training isn’t like general surgery. Nowhere close. They get literally no medicine/ICU training in that their attendings universally tell the residents to consult for everything. Expecting anything different when they finish training isn’t realistic. And there’s nothing other than your own motivation preventing you from managing these patients pre and post. Now please, carry on....
 
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chocomorsel said:
Wow. Are you for real? I can’t tell.

You are taking the patient to the OR and you don’t think you need to order anything for them because they are not on “YOUR” service but on Medicine’s service? Is medicine the one who’s taking them to the OR? Did they come to the hospital for a fracture or to see an IM doc?

And how the hell does Medicine clear patients anyway? Have never really understood that. Surgeons for some reason loves it when Cards or Medicine clears the patient but have no friggin' idea about how anesthetics alter physiology. Anesthesiologists clear patients. Not medicine docs.

And the kicker of it, is "I don't speak directly to anesthesia unless it's emergent". Wow. Is it so damn difficult to give the doc doing your anesthetic a heads up about a patient? Or do you feel that's not part of your job either? Like someone else "the OR desk nurse" can speak to the anesthesiologists. Are you too good to speak to us directly?

You seem to carry an air of arrogance, and a complete lack of ownership in a patient you are taking for a potentially life threatening procedure. Whether or not they are admitted to medicine because you can't manage essential HTN is irrelevant. This is YOUR patient, and they came to the hospital to have their fracture/arthritis fixed by YOU and you should be thankful that you have anesthesiologists and medicine docs willing to help you take care of YOUR patient. When we take a patient to the OR, we claim ownership of that patient even though we know the patient did not come to the hospital to have anesthesia alone.

Someone like you needs to get their cases cancelled frequently till you learn to communicate with your colleagues a little better and not expect everyone else to do your job for you.
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Good advice.

Had the OR nurse supervisor go on a long tirade when I told her that we clear the patients for surgery. ‘I’ve been here for 10 years and not once has anesthesia cleared a patient for surgery, not once. Medicine does that.’

We saw all the in house patients the day before surgery and communicated with primary if we needed something specific.

The medicine notes nearly always cleared the patient and listed mace was <1%. I’m like no, your template notes do not apply to geriatric ASA3-4s. Written by interns and signed off by busy internists covering 20-30 patients. Some didn’t even bother doing the actual risk stratification or calculations. If things fell through the cracks like the call guys working all night and preops not finished, they show up to holding, ortho/gen surgeon sees them and points to the note saying they are cleared and the patient is wheezing up a storm and sating in the low 80s on room air. No go.
 
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WholeLottaGame7 said:
Bro, do you even doctor? You can't tell me that you're shocked that the 89yo SNF patient on 3L O2 and 4+ pitting edema needs a cards eval before taking to surgery. It's not like all these are hip fractures are in 20y college track athletes. You paid >$200K in medical school tuition, hopefully you can at least tell "sick" from "not sick." Hell, their family members with zero medical training know grandma ain't doing so hot.

I think the saying "a failure to plan on your part does not constitute an emergency on my part" applies here.
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Best line I’ve read in a while.
 
0kazak1 said:
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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ortho makes a lot of money for the hospital/reps/ascs due to the financial set up of our healthcare system
that leads to everyone catering to them in every possible way
that leads to ortho docs becoming detached from reality/entitled as we are talking about

think any of the surgeons feel bad or god any flack from the hospital about the bad judgement scenarios you've reported? no.

i once had an ortho surgeon poke his head into a trauma room in the ER when a GSW to the head came in and the trauma code was going on, because he didnt understand why he had to wait for his case to be started at 8pm because the anesthesiologist was busy..
 
jwk said:
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.
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Am I mistaken to think that the patient is yours and not theirs? Why are you asking them? I feel like you immediately turn her and begin resuscitation.
 
I got asked to consent a medical inpatient for an elective endoscopy/colonoscopy. Not as an emergency case, just that he had his own booking in a few months time and "while he's here we may as well add him to tomorrow's cancellation slot."

70+ year old male. ASA4. 31kg. End-stage everything. Inpatient >1 month for fulminant liver failure amongst other issues. I think the indication for the procedure was to confirm cessation of life.

I asked them to shave his beard that probably accounted for half his weight and have a real deep think about what this procedure would achieve and clarify advanced care directives before I came back to reassess with a consultant the next day. The patient mumbled he was wanting his beard shaved "for over a year," but didn't have the strength to do it himself and never asked anyone. 😱

Shortly after his haircut he slipped into a coma and died promptly the next day.

Literally not fit enough for a haircut/shave.
 
As a resident got consulted by ortho for consideration of a femoral nerve block about 45 minutes after the patient had been declared dead.
 
To be fair to orthopods every where, I think most of them care about the patients. The ones I work with, if you bring up concerns they will more than likely listen. They don't want to do anything that will ultimately harm their patient. None of them want bad outcomes. I think the disconnect comes from how they are trained and how a lot of systems are set up. I think they just assume that if a patient makes it to the holding area, then they had all the boxes checked off. They assume medicine/cardiology/pulmonary has cleared them (consulted by the interns) and are ready to cut them up. Believe me, you don't want these guys managing the patients on the floor when it comes to medicine...
 
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