Would you postpone this case?

[pgg]

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Had this posed to me as part of a mock oral recently.

Craniotomy for tumor resection. Patient basically healthy, takes HCTZ for hypertension. Preop K is 2.9. No evidence of elevated ICP. Not an emergent or urgent case.

My answer was that I wouldn't delay the case for the K of 2.9, provided it had not changed recently, while recognizing that I would have to be more cautious about hyperventilating the patient given the risk of dropping her K further via a respiratory alkalosis.

In retrospect I suppose the safest oral board answer would be to delay this non-urgent case to allow for some gradual repletion of her potassium.

Just curious what you all would do in real life, and what you would say for the board.

 

[jetproppilot]

Had this posed to me as part of a mock oral recently.

Craniotomy for tumor resection. Patient basically healthy, takes HCTZ for hypertension. Preop K is 2.9. No evidence of elevated ICP. Not an emergent or urgent case.

My answer was that I wouldn't delay the case for the K of 2.9, provided it had not changed recently, while recognizing that I would have to be more cautious about hyperventilating the patient given the risk of dropping her K further via a respiratory alkalosis.

In retrospect I suppose the safest oral board answer would be to delay this non-urgent case to allow for some gradual repletion of her potassium.

Just curious what you all would do in real life, and what you would say for the board.

Despite widespread cancelling of cases for mild-to-moderate hypokalemia, there are no overwhelming literature conclusions showing deleterious outcome by proceeding. In other words, there is little danger to the patient by proceeding.

I would proceed with the case, and may elect to begin-to-address the problem intraoperatively. I say it like that because as you know its gonna take alotta 20mEq K+ runs to remedy the problem.

Your question of how to answer The Board is a trickier question than my real-life concerns.

I would be careful to not portray a "cowboy" attitude.

I would express recognition of the lab abnormality.....and also the knowledge of lack-of-literature-support-for-delay.

I would say that if the patient were a family member I would want the tumor resected as quickly as possible. Cancer is not an issue to cancel resection needlessly.

Surveillant preoperative workup reveals something that needs to be investigated before resection due to concern of complication?

Great.

But a K+ of 2.9 is not one of them.

VERY SALIENT QUESTION that is useful to resident colleagues, BTW.

Thanks for posting.

Now on with more opinions...

 

[coprolalia]

What does the EKG show?

-copro

 

[pgg]

What does the EKG show?

Nothing. NSR, no U waves.

 

[Planktonmd]

Agree with Jet on this one.
Most likely this patient is on steroids and that is causing his hypokalemia.
I would initiate the Potassium replacement, give some Magnesium and proceed.

 

[coprolalia]

Agree with Jet on this one.
Most likely this patient is on steroids and that is causing his hypokalemia.
I would initiate the Potassium replacement, give some Magnesium and proceed.

Agree with Plank and Jet. If patient is otherwise healthy, I would proceed but also stay away from drugs (like insulin and beta-agonists) that would further shift K+ and drop the levels further. I think that they wanted you to think about the underlying mechanism of the low K+, like some sort of endocrine-related tumor in the pituitary gland (etc.) and what you might do to come up with a treatment plan that addressed that both intraoperatively and post-operatively.

-copro

 

[numbmd]

I would have to disagree w/Jet. I think that it's actually a no-brainer. The potassium is low and with a good reason. This is not an emergent nor even an urgent case. I see no problem with delaying this case for 24 hours to bring up the potassium. Do you know how much you will need to bring down the co2? 2.9 is significantly low, it's clear that the patient is not in the best condition that they can be in. A day is not too long to wait.

 

[coprolalia]

2.9 is significantly low

Not if it is a kid. In a kid, 2.5 is considered low "normal".

-copro

 

[pgg]

I would have to disagree w/Jet. I think that it's actually a no-brainer. The potassium is low and with a good reason. This is not an emergent nor even an urgent case. I see no problem with delaying this case for 24 hours to bring up the potassium. Do you know how much you will need to bring down the co2? 2.9 is significantly low, it's clear that the patient is not in the best condition that they can be in. A day is not too long to wait.

If she's hypokalemic because of longstanding diuretic use or tumor effect, her total body K is probably so low that 24 hours of repletion isn't going to fix her. And if you're going to hold off because of hypokalemia, I think you're obligated to actually treat it, and that's going to take days/weeks. So then the question is, how long do you delay the case? How much extra risk are we taking by giving the tumor another week to grow?


I typically don't aim for an end tidal CO2 any lower than 25-30. The party line around here is that if you go below 22 or so, you start to risk ischemia. Once the dura is open and the surgeon's happy with conditions, I'll usually let the patient drift back toward normocarbia.

The paradox is that if you really need to drop her CO2, it's probably because she has elevated ICP and the case is urgent. So of course you won't cancel because her K is 2.9 ... whereas you're far less likely to really need the power of hypocarbia in an elective crani.

 

[cubs3canes]

Mg, K+, there is also 5mEq per bag of normosol. I would probably have a 5 lead EKG instead of a 3 lead for sensitivity purposes (even though the data on the differences between 3 and 5 lead sucks).

This would take weeks to correct after the prolonged diuretic use.

This brings me back to a case I was involved with this week. Pt for Heart Transplant..who cares about the details she is getting a heart transplant..so crappy heart. K comes back 3.4. Cardiologist orders 80mEq of ORAL potassium. The pills are the size of my black labs dog crap. She would need a L of H2O to swallow the pills. I know the absoprtion is better orally, but think about it. Thankfully the nurse called us and we stopped the order.

First iStat, K is 3.5, end of case K is 4.0. The ECT dude corrected the ****.

Dom

 

[Planktonmd]

Mg, K+, there is also 5mEq per bag of normosol. I would probably have a 5 lead EKG instead of a 3 lead for sensitivity purposes (even though the data on the differences between 3 and 5 lead sucks).

This would take weeks to correct after the prolonged diuretic use.

This brings me back to a case I was involved with this week. Pt for Heart Transplant..who cares about the details she is getting a heart transplant..so crappy heart. K comes back 3.4. Cardiologist orders 80mEq of ORAL potassium. The pills are the size of my black labs dog crap. She would need a L of H2O to swallow the pills. I know the absoprtion is better orally, but think about it. Thankfully the nurse called us and we stopped the order.

First iStat, K is 3.5, end of case K is 4.0. The ECT dude corrected the ****.

Dom

Trying to fix mild hypokalemia in a patient who is going on bypass shortly is a very ******ed thing to do.

 

[militarymd]

Acute corrections (over 24 hours) of potassium levels in otherwise asymptomatic patients is probably more dangersous than putting them to sleep.

Obviously no studies comparing the two options.

I would have to disagree w/Jet. I think that it's actually a no-brainer. The potassium is low and with a good reason. This is not an emergent nor even an urgent case. I see no problem with delaying this case for 24 hours to bring up the potassium. Do you know how much you will need to bring down the co2? 2.9 is significantly low, it's clear that the patient is not in the best condition that they can be in. A day is not too long to wait.

 

[joshmir]

the examiners may also want you to think about the effects of what would happen to the K if the surgeon asks you to give mannitol and lasix during the case for a tight dura

 

[militarymd]

70 year old fat hypertensive/diabetic with creatine of 2 and potassium of 6.0 meq/liter....who, when you take a history from him......."ain't got nuthin wrong with me".....

denies having diabetes or kidney problems ....just some "high blood".

ready for his lum/lam.....WANTS his surgery...doesn't want to hear about risks.

ECG is normal.

meds...metformin/lisinopril/hctz

no limitations on physical activity.

serum bicarb... 27 (ie no RTA for those of you wondering why I post it)


CRNA was reluctant ...I said "damn the potassium...full speed ahead"

I wanted to use sux cause his a/w was marginal, but CRNA was insisted on vec...I yielded....

He did fine....things I did on him that I otherwise wouldn't have...

1) 30 meq of bicarb and one liter of LR before induction
2) foley for the case
3) diuresis with 10 mg of lasix during cases with additional fluid
4) hospitalist to see him post op

I'm sure there are no studies addressing cases like this, and I'm sure there are many of you who are aghast at me doing the case...but you know what...you can't shine sh it.....you can only deal with it.....or not.

 

[militarymd]

educated elderly patient who has cancer and non operable AS....told to be "bad" but not quantified...to under go what turned out to be a major blood loss lumbar fusion...

pmhx...cad with cabg...carotid disease with cea...

nothing on chart in preop...not even a ECG....did have a cbc

 

[militarymd]

fat lady with a MAJOR nose bleed coming to the OR from the ER....has a 20ga IV connected......drum roll please......a heplock!!!!

So after fixing the IV....would you RSI or LMA???

 

[VentdependenT]

fat lady with a MAJOR nose bleed coming to the OR from the ER....has a 20ga IV connected......drum roll please......a heplock!!!!

So after fixing the IV....would you RSI or LMA???

TUbage.
edit: Have a proseal on standby (as in: open n' lubed next to your larnygoscope)

A K of 6 would stop me if I expect large blood losses during the case. If that fooker is on dialysis, I'm gonna send him for dialysis prior to any non-ditzelish surgery.

No dialysis then check if K been elevated on prior labs =if yes then no problem. If new onset why (kidneys, gut, acidotic, s/p transfusion?)? If non major blood loss case then to OR with 20-40 of lasix goin in after induction.

If major blood loss expected then sorry bud, you gonna poo that K out on the floors for the day.

 

[Planktonmd]

potassium of 6.0 meq/liter
I wanted to use sux cause his a/w was marginal, but CRNA was insisted on vec...I yielded....

I am curious,
Why would you use Sux if the Potassium is 6 ?

 

[militarymd]

I am curious,
Why would you use Sux if the Potassium is 6 ?

like I said, the a/w was marginal

 

[Planktonmd]

like I said, the a/w was marginal

Ok,
I had a patient who had a hyperkalemic cardiac arrest in a very similar situation.

 

[militarymd]

Ok,
I had a patient who had a hyperkalemic cardiac arrest in a very similar situation.

then why did you use sux?

 

[Planktonmd]

then why did you use sux?

I didn't, someone else did.

 

[militarymd]

Ok,
I had a patient who had a hyperkalemic cardiac arrest in a very similar situation.

I didn't, someone else did.

When you use the word "I"....it usually means that YOU did it.

So....you know of a patient who had diabetes and HTN who came/drove from home to the hospital to have a minimally invasive surgery who you would otherwise NOT order ANY tests ..and who was planning on going home later in the day......ARREST during induction because of succinycholine induced hyperkalemia?????

I say BS.

 

[Planktonmd]

When you use the word "I"....it usually means that YOU did it.

So....you know of a patient who had diabetes and HTN who came/drove from home to the hospital to have a minimally invasive surgery who you would otherwise NOT order ANY tests ..and who was planning on going home later in the day......ARREST during induction because of succinycholine induced hyperkalemia?????

I say BS.

I Was the one who did CPR on this patient for 45 minutes and It wasn't a very pleasant thing to do.
But since it is obvious where this exchange is heading, all I am going to say to you:
Yes it is B.S. or whatever makes you happy.
I just can't let you tell people to use Sux on a patient with potassium of 6 without commenting.

 

[militarymd]

I Was the one who did CPR on this patient for 45 minutes and It wasn't a very pleasant thing to do.
But since it is obvious where this exchange is heading, all I am going to say to you:
Yes it is B.S. or whatever makes you happy.
I just can't let you tell people to use Sux on a patient with potassium of 6 without commenting.

I''m willing to bet that I've coded MORE patients who arrested from sux than you.....

and I'm also willing to bet that the patient you provided chest compression for did not fit the profile of my patient that I wanted to give sux to...

a single potassium value is not a contraindication to sux.

 

[Planktonmd]

a single potassium value is not a contraindication to sux.

Do you mean that you rechecked the potassium value and it came back different?

 

[militarymd]

No...I mean when you EVALUATE a patient...or at least when I assess a patient.....

Why bother rechecking it? what if it came back 8....or 9...or 10....it doesn't matter.

The guy WALKED into the hospital...I took a history...and I did a physical examination.......I would not have checked his lab...some nitwit ordered it.

Do you mean that you rechecked the potassium value and it came back different?

 

[Planktonmd]

No...I mean when you EVALUATE a patient...or at least when I assess a patient.....

Why bother rechecking it? what if it came back 8....or 9...or 10....it doesn't matter.

The guy WALKED into the hospital...I took a history...and I did a physical examination.......I would not have checked his lab...some nitwit ordered it.

I am not sure how WALKING into the hospital or the presence or absence of any finding on the physical exam would allow you to give Sux to a patient with hyperkalemia.
If you think the lab result is wrong then you need to re check it.
Even if you think that there was no indication to order the lab, it has been done, you can't ignore it.

 

[militarymd]

I am not sure how WALKING into the hospital or the presence or absence of any finding on the physical exam would allow you to give Sux to a patient with hyperkalemia.
If you think the lab result is wrong then you need to re check it.
Even if you think that there was no indication to order the lab, it has been done, you can't ignore it.

I can...and I did.

 

[jetproppilot]

 

[Planktonmd]

I can...and I did.

Ok,
Good for you!

 

[Planktonmd]

Say something 🙂

 

[militarymd]

I'm still waiting to hear the details if your sux induced arrest.

I'm still waiting for you to say the guy had NO RISK factors other than a elevated K that he's been walking around with for probably months.

I know why you're not saying anything....and that's because your patient who arrested DID have risk factors that YOU proabably should have known about from the history and physical.....and it did NOT matter WHAT the K was....because the typical sux arrests START with normal levels of K...

which goes up in an exaggerated manner from sux because of RISK factors.

 

[Planktonmd]

I'm still waiting to hear the details if your sux induced arrest.

I'm still waiting for you to say the guy had NO RISK factors other than a elevated K that he's been walking around with for probably months.

I know why you're not saying anything....and that's because your patient who arrested DID have risk factors that YOU proabably should have known about from the history and physical.....and it did NOT matter WHAT the K was....because the typical sux arrests START with normal levels of K...

which goes up in an exaggerated manner from sux because of RISK factors.

Patient was 50 Y/O for Fem pop, border line renal function and initial potassium 5.8 or 5.9.
The anesthesiologist decided to proceed since there was no other issues and the plan was GA with ETT because of a significant history of GERD.
Somehow people forgot about the potassium and gave Sux for intubation.
The events that followed where typical:
Bradycardia that progressed to huge T waves then really wide QRS then flat line despite Calcium, Bicarb....
The Code was complicated and took a long time but we got him back.
I am not saying it happens always, but it does happen.

 

[militarymd]

Why don't you be honest and give the rest of the history....Like..

he'd been in the hospital for a couple of weeks....lying in bed immobile for that time period because of the non-healing diabetic foot ulcer that necessitated the fem-pop...

Patient was 50 Y/O for Fem pop, border line renal function and initial potassium 5.8 or 5.9.
The anesthesiologist decided to proceed since there was no other issues and the plan was GA with ETT because of a significant history of GERD.
Somehow people forgot about the potassium and gave Sux for intubation.
The events that followed where typical:
Bradycardia that progressed to huge T waves then really wide QRS then flat line despite Calcium, Bicarb....
The Code was complicated and took a long time but we got him back.
I am not saying it happens always, but it does happen.

 

[Planktonmd]

Why don't you be honest and give the rest of the history....Like..

he'd been in the hospital for a couple of weeks....lying in bed immobile for that time period because of the non-healing diabetic foot ulcer that necessitated the fem-pop...

I wish I could help you here but I really don't think there was any other factors that could have contributed to his reaction to sux, although there was ongoing ischemia of his leg but we have patients like this all the time and they get Sux and nothing happens.
Your patient on the other hand could have misuse of his legs and muscle atrophy because of spinal stenosis, did you take that into consideration? 😎

 

[militarymd]

You said yourself it wasn't your patient....obviously you know nothing about him.

5.8 >>>> 6.3 ain't gonna have a patient do what you described...just doesn't work that way...

5.8 >>>>>> 9.0 ...yes...and for that to happen...there are risk factors.....

BE HONEST.....there was something else.....or you could lie...and pretend that there wasn't anything else.

I wish I could help you here but I really don't think there was any other factors that could have contributed to his reaction to sux, although there was ongoing ischemia of his leg but we have patients like this all the time and they get Sux and nothing happens.
Your patient on the other hand could have misuse of his legs and muscle atrophy because of spinal stenosis, did you take that into consideration? 😎

 

[Planktonmd]

You said yourself it wasn't your patient....obviously you know nothing about him.

5.8 >>>> 6.3 ain't gonna have a patient do what you described...just doesn't work that way...

5.8 >>>>>> 9.0 ...yes...and for that to happen...there are risk factors.....

BE HONEST.....there was something else.....or you could lie...and pretend that there wasn't anything else.

This case was discussed extensively and to the best of my knowledge there was no other problems: No known neuromuscular disease, no history of burn no prolonged immobility.... nothing!
Could there have been something that we missed? sure, but that could be the case with any patient couldn't it?

 

[militarymd]

If what you say is true....and I doubt it...then you should publish it as a case report.....because I'm not aware of any case reports describing what you claimed happened.

This case was discussed extensively and to the best of my knowledge there was no other problems: No known neuromuscular disease, no history of burn no prolonged immobility.... nothing!
Could there have been something that we missed? sure, but that could be the case with any patient couldn't it?

 

[Planktonmd]

If what you say is true....and I doubt it...then you should publish it as a case report.....because I'm not aware of any case reports describing what you claimed happened.

I really couldn't care less about what you believe or what you don't.
You do know that don't you?

 

[pd4emergence]

70 year old fat hypertensive/diabetic with creatine of 2 and potassium of 6.0 meq/liter....who, when you take a history from him......."ain't got nuthin wrong with me".....

denies having diabetes or kidney problems ....just some "high blood".

ready for his lum/lam.....WANTS his surgery...doesn't want to hear about risks.

ECG is normal.

meds...metformin/lisinopril/hctz

no limitations on physical activity.

serum bicarb... 27 (ie no RTA for those of you wondering why I post it)


CRNA was reluctant ...I said "damn the potassium...full speed ahead"

I wanted to use sux cause his a/w was marginal, but CRNA was insisted on vec...I yielded....

He did fine....things I did on him that I otherwise wouldn't have...

1) 30 meq of bicarb and one liter of LR before induction
2) foley for the case
3) diuresis with 10 mg of lasix during cases with additional fluid
4) hospitalist to see him post op

I'm sure there are no studies addressing cases like this, and I'm sure there are many of you who are aghast at me doing the case...but you know what...you can't shine sh it.....you can only deal with it.....or not.

I would not do an elective case with a K of 6 and previously undiagnosed renal failure/renal insuffiency. I'd make sure the value is correct but if it was truly 6 I would not do him. Admit him, let the nephologists/medicine doctors do their magic. Let them tell him before his surgery how bad his kidneys really are. That way after his surgery, if he ends up on dialysis he doesn't blame you. I think by proceeding, I would be placing him in at undue risk without a renal eval. I don't feel there is any margin for error in regards to blood administration, CO2 levels, or BP management if you proceed. I think at this point you have really no idea what his kidneys are doing and for an elective case I would find out.

 

[toughlife]

70 year old fat hypertensive/diabetic with creatine of 2 and potassium of 6.0 meq/liter....who, when you take a history from him......."ain't got nuthin wrong with me".....

denies having diabetes or kidney problems ....just some "high blood".

ready for his lum/lam.....WANTS his surgery...doesn't want to hear about risks.

ECG is normal.

meds...metformin/lisinopril/hctz

no limitations on physical activity.

serum bicarb... 27 (ie no RTA for those of you wondering why I post it)


CRNA was reluctant ...I said "damn the potassium...full speed ahead"

I wanted to use sux cause his a/w was marginal, but CRNA was insisted on vec...I yielded....

He did fine....things I did on him that I otherwise wouldn't have...

1) 30 meq of bicarb and one liter of LR before induction
2) foley for the case
3) diuresis with 10 mg of lasix during cases with additional fluid
4) hospitalist to see him post op

I'm sure there are no studies addressing cases like this, and I'm sure there are many of you who are aghast at me doing the case...but you know what...you can't shine sh it.....you can only deal with it.....or not.

Why would you want to give LRs to an already hyperkalemic patient? This is assuming the K of 6 is a true value and not falsely elevated.

 

[militarymd]

oh ...yes you do....otherwise you wouldn't answer my posts......and I KNOW that you care what one of my partners think about you.

I really couldn't care less about what you believe or what you don't.
You do know that don't you?

 

[militarymd]

Do you know how many meq of potassium the average American consumes on a daily basis?

How many patients do you know get put on a potassium restricted diet?

Yup...I knew you didn't know...

and btw....4 meq of potassium is equivalent to eating 1/3 to 1/2 of a banana.....

Why would you want to give LRs to an already hyperkalemic patient? This is assuming the K of 6 is a true value and not falsely elevated.

 

[militarymd]

I disagree......and what kind of "magic" do REAL doctors have that anesthesiologists don't have?????

We're not talking about a AAA here....we're talking about a lum /lam....a no blood loss...20 minute procedure ...with no deliberate or otherwise hypotension .

I would not do an elective case with a K of 6 and previously undiagnosed renal failure/renal insuffiency. I'd make sure the value is correct but if it was truly 6 I would not do him. Admit him, let the nephologists/medicine doctors do their magic. Let them tell him before his surgery how bad his kidneys really are. That way after his surgery, if he ends up on dialysis he doesn't blame you. I think by proceeding, I would be placing him in at undue risk without a renal eval. I don't feel there is any margin for error in regards to blood administration, CO2 levels, or BP management if you proceed. I think at this point you have really no idea what his kidneys are doing and for an elective case I would find out.

 

[toughlife]

Do you know how many meq of potassium the average American consumes on a daily basis?

How many patients do you know get put on a potassium restricted diet?

Yup...I knew you didn't know...

and btw....4 meq of potassium is equivalent to eating 1/3 to 1/2 of a banana.....

When I did my nephro rotation at the VA the nephrologist I worked with had some dialysis patients on a potassium restricted diet. Granted this situation is different.


Let me rephrase the question.. how would you explain it in court if you had to?

 

[ucsfgaspain]

First post here so not meant to offend.

Militarymd, I'm trying to figure out what your practice philosophy is. It seems to me that you are pushing the envelope in terms of anesthetics.

Pt. with a K of 6 and asymptomatic. I'd say most anesthesiologists would be concerned about raising the K any higher. So I'm going to give succ, I'm gowing to give LR? Why?

(We all know that succ elevates K by only 0.5 meq and K in LR is negligibe. But why even go there, when you can give a non depolarizer and NS)

Why not do everything that you can to keep the K low? Why not use a non depolarizer? You stated that the airway was marginal? If it was marginal, why induce? Why not go fiber?

If it was the "marginal" but not scareway...then why not prove mask ventilation, then give a non depolarizer? Or go with an intubating LMA?

In addition, if you were not concerned about the K? Why would give bicarb, give lasix? It seems like you say one thing but also hedge. BTW why wouldn't you give calcium since it is probably the most important thing to give to stabilize the cardiac membrane ?

I'm confused about your practice philosophy. Is it to push the limits of a "safe" anesthetic so that you can prove that you can live on the razor's edge? Is it not your patient's health that you are gambling with not your own?

I've had the honor of training with some of the greats of anesthesia. Eger, Gregory, Rosen. And the one thing that I've learned from all of them is that anesthesiology is about managing risk. Do everything to reduce risk cuz you can't eliminate it.

 

[jetproppilot]

First post here so not meant to offend.

Militarymd, I'm trying to figure out what your practice philosophy is. It seems to me that you are pushing the envelope in terms of anesthetics.

Pt. with a K of 6 and asymptomatic. I'd say most anesthesiologists would be concerned about raising the K any higher. So I'm going to give succ, I'm gowing to give LR? Why?

(We all know that succ elevates K by only 0.5 meq and K in LR is negligibe. But why even go there, when you can give a non depolarizer and NS)

Why not do everything that you can to keep the K low? Why not use a non depolarizer? You stated that the airway was marginal? If it was marginal, why induce? Why not go fiber?

If it was the "marginal" but not scareway...then why not prove mask ventilation, then give a non depolarizer? Or go with an intubating LMA?

In addition, if you were not concerned about the K? Why would give bicarb, give lasix? It seems like you say one thing but also hedge. BTW why wouldn't you give calcium since it is probably the most important thing to give to stabilize the cardiac membrane ?

I'm confused about your practice philosophy. Is it to push the limits of a "safe" anesthetic so that you can prove that you can live on the razor's edge? Is it not your patient's health that you are gambling with not your own?

I've had the honor of training with some of the greats of anesthesia. Eger, Gregory, Rosen. And the one thing that I've learned from all of them is that anesthesiology is about managing risk. Do everything to reduce risk cuz you can't eliminate it.

YOU'RE A TROLL, OBVIOUSLY.

Save your "no meaning to offend" crap, think up another catchy screenname, and go troll somewhere else.

Your IP address is on the watch screen as of now.

 

[ucsfgaspain]

I don't see how this is being a troll? How are the questions I asked offensive? UCSF gas pain is where I trained for both residency and fellowship. Interesting that you would ban me for asking, I think very pertinent questions.

 

[Idiopathic]

Pretty scary case, when you think about it. 90% of M+M conferences start with "Just a Saturday morning cysto" or "Simple lum/lam"

Definitely agree with you that its okay to do the case, but wouldnt use sux, if only because of how stupid it would look when the guy arrested.