Who does epidural blood patches

[aneftp]

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Always a battle especially when it’s not an anesthesia complication.

Either the pain docs outpatients come into er. Or er or neurologist wet tap causing the headaches

There is no ob service. And I’m getting harassed by admin to do it it all morning. Told them to call IR. iR doesn’t want to it either.

Admin threatening to transfer patient (fine with me). I told them I’d do it as soon as they put it in policy the order of who’s responsible for the blood patches. They give me the sob story it’s one time. Blah blah blah. Telling me sister hospital anesthesia does them all the time down the road (sister hospital has hospital w2 employed plus 24 hr ob).

Place I have is anesthesia 3rd party contracted out. Not hospital employee.

So who has written policy for epidural blood patches? For non anesthesia wet taps?

I know full well they don’t want to put anything into policy cause the ir docs are independent as well. And won’t agree to it either.

 

[deleted87051]

That’s our wheelhouse. I’ve never seen a place where it is not anesthesia.

 

[aneftp]

That’s our wheelhouse. I’ve never seen a place where it is not anesthesia.

So u guys are responsible for it 24/7? With no in house ob either?

 

[deleted87051]

So u guys are responsible for it 24/7? With no in house ob either?

We have 2 anesthesiologists inhouse 24/7. OB and trauma. If they’re both busy, we get to it when we get to it.

 

[aneftp]

We have 2 anesthesiologists inhouse 24/7. OB and trauma. If they’re both busy, we get to it when we get to it.

Well thats more practical.

We have no in house anesthesia and no ob service at one place I cover.

 

[CopaceticOne]

Always a battle especially when it’s not an anesthesia complication.

Either the pain docs outpatients come into er. Or er or neurologist wet tap causing the headaches

There is no ob service. And I’m getting harassed by admin to do it it all morning. Told them to call IR. iR doesn’t want to it either.

Admin threatening to transfer patient (fine with me). I told them I’d do it as soon as they put it in policy the order of who’s responsible for the blood patches. They give me the sob story it’s one time. Blah blah blah. Telling me sister hospital anesthesia does them all the time down the road (sister hospital has hospital w2 employed plus 24 hr ob).

Place I have is anesthesia 3rd party contracted out. Not hospital employee.

So who has written policy for epidural blood patches? For non anesthesia wet taps?

I know full well they don’t want to put anything into policy cause the ir docs are independent as well. And won’t agree to it either.

Sounds like they’re transferring the patient to their sister hospital.

 

[agolden1]

Level 1 academic-ish center with two in house anesthesiologists and residents. One attending covers OB, the other general cases. Anesthesia is responsible for doing all of them no matter who caused the issue.

If it comes in overnight, will often defer to daytime to get it done.

 

[Lecithin5]

We have in-house 24 -7 anesthesia coverage at one of the busiest OB centers in the country. And we do not touch any spinal headache that is not caused by us anesthesiologists. We ask that they are referred to IR for evaluation and possible patching.

 

[sevo00]

We only do it if we caused it. Otherwise goes to the pain clinic

 

[S0lid]

We only do anesthesia related blood patch - all others to IR.

 

[DrOwnage]

Only anesthesia related blood patches, or PDPHs that your group caused directly. A lot of the reasons neuro is doing these spinal taps is to get answers to nonspecific questions/diagnoses. Some of these people have serious problems/systemic diseases, some of which shooting 20ccs of blood into can muddy the situation. People on here saying they would do the blood patches regardless of who caused it are crazy, or must have great malpractice insurance.

 

[DocVapor]

We do blood patches on PDPH's we caused. Everything else we won't touch for the same reason @DrOwnage above stated.

We've been asked to before but never got pushback from anyone on it. We are a contracted private practice group at a community hospital without lots of full time in-house consultants.

 

[Mman]

If it comes in overnight, will often defer to daytime to get it done.

the wonderful part about PDPH is it should not bother someone at night. They can lay flat and be just fine.

We do them during daylight hours when not otherwise busy.

 

[Dawkter]

There is no reason to call an anesthesiologist in the middle of the night to do this procedure.

Fiorcet 1 tab Q4H PRN and pain clinic referral ASAP for fluoro guided blood patch.

 

[triggermaster]

There is no reason to call an anesthesiologist in the middle of the night to do this procedure.

Fiorcet 1 tab Q4H PRN and pain clinic referral ASAP for fluoro guided blood patch.

I guess IR might make the same argument but recommend referral ASAP for conventional blood patch.
One advantage is we can grab a kit and go do it in the ER in 15 minutes (unless getting blood takes forever). It’s probably cheaper and equally effective.

 

[deleted87051]

Only anesthesia related blood patches, or PDPHs that your group caused directly. A lot of the reasons neuro is doing these spinal taps is to get answers to nonspecific questions/diagnoses. Some of these people have serious problems/systemic diseases, some of which shooting 20ccs of blood into can muddy the situation. People on here saying they would do the blood patches regardless of who caused it are crazy, or must have great malpractice insurance.

Doesn’t IR face the same issue? Neurologists and ER docs don’t do blood patches.

 

[aneftp]

Well IR docs won’t do it. No one gonna to touch this patient. I certainly am not going to do something that isn’t in written policy.

 

[CopaceticOne]

Well IR docs won’t do it. No one gonna to touch this patient. I certainly am not going to do something that isn’t in written policy.

Out of curiousity, is there something unique about the patient (aka cray-cray)?

 

[aneftp]

Out of curiousity, is there something unique about the patient (aka cray-cray)?

Usual negative spinal tap. The typical neurologist checking the boxes ordering every test known to man. Yes patient has fibromyalgia, migraines etc.

It’s more on principal than anything. This place I’ve been covering locums for 4 plus years. It’s a mess

 

[kidthor]

I hate doing epidural blood patches. It's odd to be the go to team to manage PDPH because we don't have the scope to engage in expansive differential diagnosis (really this should be neurology or maybe pain) or fully manage the issue. I personally think these should all go to IR (or maybe pain), perhaps with the exception that we could do it if we caused the dural puncture. I've seen IR do a lot of blood patches and a lot of times their imaging shows dural holes entirely away from where the patient even had a known dural puncture, and they also have the ability to place fibrin glue rather than blood (which has its own sterility issue). Additionally they they have the imaging ability to prevent a repeat dural puncture.

 

[deleted87051]

I hate doing epidural blood patches. It's odd to be the go to team to manage PDPH because we don't have the scope to engage in expansive differential diagnosis (really this should be neurology or maybe pain) or fully manage the issue. I personally think these should all go to IR (or maybe pain), perhaps with the exception that we could do it if we caused the dural puncture. I've seen IR do a lot of blood patches and a lot of times their imaging shows dural holes entirely away from where the patient even had a known dural puncture, and they also have the ability to place fibrin glue rather than blood (which has its own sterility issue). Additionally they they have the imaging ability to prevent a repeat dural puncture.

So should IR be patching our L&D wet tap PDPHAs for the reasons you listed?

 

[aneftp]

So should IR be patching our L&D wet tap PDPHAs for the reasons you listed?

The answer is not always as routine as we think

As pdha alternative is it eventually resolves on its own in 7 days.

And we are asked to to a purely elective procedure for someone else’s known complication.

So assume all the risks and liability and very little reward

Risks and benefits.

The risks outweigh the benefits (for us) in this case.

Especially at non 24/7 hospitals where anesthesia doesn’t even cover ob.

 

[Hoya11]

The answer is not always as routine as we think

As pdha alternative is it eventually resolves on its own in 7 days.

And we are asked to to a purely elective procedure for someone else’s known complication.

So assume all the risks and liability and very little reward

Risks and benefits.

The risks outweigh the benefits (for us) in this case.

Especially at non 24/7 hospitals where anesthesia doesn’t even cover ob.

im honestly surprised at the level of resistance to doing EBPs

would i come in from home to do it? no way

but if i am in house and nothing going on, patient is in the ER, I can go and interview the patient and find out details and history in order to make a judgement as to whether or not to proceed.

sure if its a muddy situation with possible infection and neuro workup ongoing and you dont have their blessing, forget it

but many times ive had a totally healthy woman who is a few days out of CS or epidural or ridiculous ER LP for very unlikely infection, and the person is absolutely miserable and cant stand up. what is the feared complication you are so worried about? very high likelihood of you helping this person and them walking out

 

[GassYous]

I also used to do it in the ED. It has decent units, patients are very grateful and it's a fun quick procedure. It's pleasant to do something and have someone feel way better before you're even done with the charting.

 

[gunnershow]

The answer is not always as routine as we think

As pdha alternative is it eventually resolves on its own in 7 days.

And we are asked to to a purely elective procedure for someone else’s known complication.

So assume all the risks and liability and very little reward

Risks and benefits.

The risks outweigh the benefits (for us) in this case.

Especially at non 24/7 hospitals where anesthesia doesn’t even cover ob.

I've seen subdural hemorrhages and consequent ICU admits from untreated PDPH. Also some proportion of these headaches become chronic, though I'm not sure if EBP treatment prevents that. In the OB population, I consider it standard to offer an EBP for a severe PDPH.

 

[aneftp]

I've seen subdural hemorrhages and consequent ICU admits from untreated PDPH. Also some proportion of these headaches become chronic, though I'm not sure if EBP treatment prevents that. In the OB population, I consider it standard to offer an EBP for a severe PDPH.

Correct. More risks than rewards.

Why should I patch any dural leak from non ob epidural or spinal from someone else’s complication

Once I assume any care. I’m up the creek and liable.

And to add. This is not a 24/7 hospital. Seems very few people like those doing courtesy non ob blood patches in non in house anesthesia working hours

 

[deleted87051]

Correct. More risks than rewards.

Why should I patch any dural leak from non ob epidural or spinal from someone else’s complication

Once I assume any care. I’m up the creek and liable.

And to add. This is not a 24/7 hospital. Seems very few people like those doing courtesy non ob blood patches in non in house anesthesia working hours

Why should IR ever do an EBP?

You can do the patch between cases.

 

[aneftp]

Why should IR ever do an EBP?

You can do the patch between cases.

Well this hospital IR is refusing to do it also. Independent contractors.

I don’t get paid extra either

It really depends on the agreement between the hospital and the other services

 

[deleted87051]

Well this hospital IR is refusing to do it also. Independent contractors.

I don’t get paid extra either

It really depends on the agreement between the hospital and the other services

So did they ship her out or refer her to a pain clinic? If your contract states you are only there to provide OR anesthesia and you don’t get paid for blood patches, it makes sense to refuse. I wouldn’t do it for free either. But it’s something we do in our practice and it pays very well for 15min of work.

 

[aneftp]

So did they ship her out or refer her to a pain clinic?

Nope. It was inpatient. No one touching her. They don’t want to get dinged for transferring to sister hospital

All part of the game administration plays folks. They play doctors against each other.

Realize who is playing who these days.

They tried to give me the sob story about patient care blah blah blah. U really think I can’t see right through them. All admin needs to do is put it in writing in their policy book who is responsible for doing them. That’s put the ball back on them. Not me.

 

[deleted87051]

Nope. It was inpatient. No one touching her. They don’t want to get dinged for transferring to sister hospital

All part of the game administration plays folks. They play doctors against each other.

Realize who is playing who these days.

They tried to give me the sob story about patient care blah blah blah. U really think I can’t see right through them. All admin needs to do is put it in writing in their policy book who is responsible for doing them. That’s put the ball back on them. Not me.

That’s a shame. It’s a service that I thought all hospitals provide.

 

[ScarfTheVerb]

You guys are crazy. There’s someone miserable in the ER and you can fix it in 5 mins. Just go knock out the blood patch—you’re not going to get sued.

 

[pgg]

You guys are crazy. There’s someone miserable in the ER and you can fix it in 5 mins. Just go knock out the blood patch—you’re not going to get sued.

When a ward nurse can't get an IV in, and the patient is miserable after being stuck 6 times, and you can fix it in 5 minutes, are you going to go do that too?


We do consults to consider EBPs for all comers, no matter who put the hole on the dura.

Not infrequently, we learn, as part of doing that consult, that the patient may have something else going on that tilts the r/b away from doing a blood patch. Obviously we need to do our own due diligence, and evaluate the patient referred to us before offering a procedure.

It has even happened that OB sent a patient to the ER for a blood patch to be demanded from us, for a postpartum patient who didn't get a spinal or epidural for delivery.

These consults are are done in daytime, at our convenience. We make them bring the patient to us. I will sometimes go to see the patient elsewhere, if I'm free, but the patient gets moved to our preop area if we're going to do one.

 

[VA Hopeful Dr]

When a ward nurse can't get an IV in, and the patient is miserable after being stuck 6 times, and you can fix it in 5 minutes, are you going to go do that too?


We do consults to consider EBPs for all comers, no matter who put the hole on the dura.

Not infrequently, we learn, as part of doing that consult, that the patient may have something else going on that tilts the r/b away from doing a blood patch. Obviously we need to do our own due diligence, and evaluate the patient referred to us before offering a procedure.

It has even happened that OB sent a patient to the ER for a blood patch to be demanded from us, for a postpartum patient who didn't get a spinal or epidural for delivery.

These consults are are done in daytime, at our convenience. We make them bring the patient to us. I will sometimes go to see the patient elsewhere, if I'm free, but the patient gets moved to our preop area if we're going to do one.

So how did her eclamptic seizure go?

 

[Shimmy8]

We don’t have OB and we don’t do them at all.

IR does them all.

 

[Lecithin5]

Why should IR ever do an EBP?

You can do the patch between cases.

I think you can make an argument for both sides. My philosophy is that in a case is where we did not cause the dural leak, neurology (or IR if they’re comfortable) can do the evaluation- if it is deemed that the blood patch is the appropriate treatment, then IR can do it, given that they have the advantage of fluoro. Plus, it is essentially a purely interventional specialty-they’re used to this and it’s all they do- they get referrals to do procedures, and they more often than not just do them.

I mean, yes, at the end of the day, probably not a big deal if we ourselves patch non- Anesthesia caused leaks. We have the ability to evaluate, make reasonable judgments, and are fairly adept at performing them. I just think in principal, it makes more sense for us to stick with the leaks that we cause.

 

[deleted87051]

When a ward nurse can't get an IV in, and the patient is miserable after being stuck 6 times, and you can fix it in 5 minutes, are you going to go do that too?


We do consults to consider EBPs for all comers, no matter who put the hole on the dura.

Not infrequently, we learn, as part of doing that consult, that the patient may have something else going on that tilts the r/b away from doing a blood patch. Obviously we need to do our own due diligence, and evaluate the patient referred to us before offering a procedure.

It has even happened that OB sent a patient to the ER for a blood patch to be demanded from us, for a postpartum patient who didn't get a spinal or epidural for delivery.

These consults are are done in daytime, at our convenience. We make them bring the patient to us. I will sometimes go to see the patient elsewhere, if I'm free, but the patient gets moved to our preop area if we're going to do one.

We see the patients and do the patch in our preop/pacu area too.

 

[sevo00]

You guys are crazy. There’s someone miserable in the ER and you can fix it in 5 mins. Just go knock out the blood patch—you’re not going to get sued.

You think we are just free just chilling in preop? I’m not going to the ER to do a blood patch when I have to see my next patient and get the room ready in between cases

 

[aneftp]

We don’t have OB and we don’t do them at all.

IR does them all.

correct.

I’m trying to put things in perspective p

When a ward nurse can't get an IV in, and the patient is miserable after being stuck 6 times, and you can fix it in 5 minutes, are you going to go do that too?


We do consults to consider EBPs for all comers, no matter who put the hole on the dura.

Not infrequently, we learn, as part of doing that consult, that the patient may have something else going on that tilts the r/b away from doing a blood patch. Obviously we need to do our own due diligence, and evaluate the patient referred to us before offering a procedure.

It has even happened that OB sent a patient to the ER for a blood patch to be demanded from us, for a postpartum patient who didn't get a spinal or epidural for delivery.

These consults are are done in daytime, at our convenience. We make them bring the patient to us. I will sometimes go to see the patient elsewhere, if I'm free, but the patient gets moved to our preop area if we're going to do one.

ar my ob hospital I do blood patches but only for our own patients.

The real question is at non ob hospitals/non 24 hr coverage (aka beeper usually after 7p)

do you guys do epidurals blood patches on non ob patients (neurology/ED caused spinal taps dural leaks)?

Seems the only people doing blood patches are already 24/7 in house anyways with 24/7 ob/trauma services

 

[Gaseous Clay]

I assume you are board certified and qualified to be a consultant and also competent at doing a blood patch. If so, then evaluate the patient and if you see no contraindications, then do the procedure. If this were you being shuttled all around town because the anesthesiologist doesn't want to "touch you" since this is someone else's complication, how would you like that? If this was your spouse sitting in the ED since last night and then day time team shows up and tells you to go elsewhere, would you be pretty satisfied and understanding?

Some people do a great job and get **** done, others like to find a reason not to do something we are perfectly qualified to do.

 

[dA pilot]

Correct. More risks than rewards.

Why should I patch any dural leak from non ob epidural or spinal from someone else’s complication

Once I assume any care. I’m up the creek and liable.

And to add. This is not a 24/7 hospital. Seems very few people like those doing courtesy non ob blood patches in non in house anesthesia working hours

I am unsure about your position regarding managing someone else's complication. If you practice long enough, you will be in a position where you will need to call another specialty to help manage your complication. Anesthesiologists are typically the ones with the most expertise in doing these.

I do take home call and are at times asked to help manage these patients. They are not emergent cases. The emergency room will call us during normal hours and we try to fit them in during a break in the day.

 

[GassYous]

I mean if I need to call vascular for help with a line complication, I would be pretty peeved if they said "well I didn't put the line it's not my complication so not my problem".

 

[deleted643396]

What a weird thread. I’ve never worked at a hospital where anesthesia was not the first in line to be consulted for an epidural blood patch. Sometimes we say no for whatever reason or refer them to IR or pain, but most of the time it’s a quick, safe procedure that patients really appreciate because the relief they get is instantaneous.

 

[pgg]

do you guys do epidurals blood patches on non ob patients (neurology/ED caused spinal taps dural leaks)?

Absolutely yes.


I sometimes to tell people that 90% of the headaches in the hospital are caused by nurses, and the other 10% by LPs in the ER.

 

[secretasianman]

Admin will always push you to provide as many services for free while morally guilting you. If it’s not worth them paying then why do it? If it’s worth preventing extra days of prolonged admission then why is there no value to them? I understand where you guys are coming from but in this era everything should be transactional or it’s a slippery slope. It’s just business, not charity.

 

[TeslaCoil]

Always a battle especially when it’s not an anesthesia complication.

Either the pain docs outpatients come into er. Or er or neurologist wet tap causing the headaches

There is no ob service. And I’m getting harassed by admin to do it it all morning. Told them to call IR. iR doesn’t want to it either.

Admin threatening to transfer patient (fine with me). I told them I’d do it as soon as they put it in policy the order of who’s responsible for the blood patches. They give me the sob story it’s one time. Blah blah blah. Telling me sister hospital anesthesia does them all the time down the road (sister hospital has hospital w2 employed plus 24 hr ob).

Place I have is anesthesia 3rd party contracted out. Not hospital employee.

So who has written policy for epidural blood patches? For non anesthesia wet taps?

I know full well they don’t want to put anything into policy cause the ir docs are independent as well. And won’t agree to it either.

For the record, I am a pain doc and not only do I do my own blood patches which Ive only needed to do twice, I also do blood patches for the hospital next door’s neurologists and pain docs.

Whats the big deal? They’re so easy and effective. 🤷🏻‍♂️

 

[ScarfTheVerb]

You think we are just free just chilling in preop? I’m not going to the ER to do a blood patch when I have to see my next patient and get the room ready in between cases

Obviously you don’t delay an OR case, but get it done as able. If you dilate a carotid do you think the vascular surgeon should punt the repair because it wasn’t their complication?

Also, we can bill for these….it’s not charity.

That said, I wish neurologists would stop using 22ga needles in young females for their LPs.

 

[aneftp]

Admin will always push you to provide as many services for free while morally guilting you. If it’s not worth them paying then why do it? If it’s worth preventing extra days of prolonged admission then why is there no value to them? I understand where you guys are coming from but in this era everything should be transactional or it’s a slippery slope. It’s just business, not charity.

I’m just at a point in my career where I say no and it doesn’t both my conscience.

 

[aneftp]

For the record, I am a pain doc and not only do I do my own blood patches which Ive only needed to do twice, I also do blood parches for the hospital next door’s neurologists and pain docs.

Whats the big deal? They’re so easy and effective. 🤷🏻‍♂️

Depends if u are billing for it.

I’m not. And also
90% of them are Medicaid patients.

 

[Shimmy8]

I think it's two discussions.

One middle of the day on a weekday when you're around and can finagle it somehow between/after cases.

The other is at night and weekends for a home call position.