- Joined
- Sep 30, 2011
- Messages
- 1,102
- Reaction score
- 2,849
My mortality rate is 60%. :\ It is what it is I guess.I'm an ENT and I've only done three. Good /bad for you, I suppose.
My mortality rate is 60%. :\ It is what it is I guess.I'm an ENT and I've only done three. Good /bad for you, I suppose.
The very first one I did as a second year resident about 6 months in I did a technically flawless performance and the patient lived without any complications. Then a few months later he killed his wife and mother in law in front of their children. I kinda wished I had ****ed up and given him brain damage or killed him.My mortality rate is 60%. :\ It is what it is I guess.
As others said, I don't hesitate to come and help if someone calls for it. I helped MIS out at 2AM with a similar case that was about a week out from a lap fundoplication and HH repair. Elderly lady who was vomiting at home and had the repair fail, leading to gastric incarceration and perforation into both pleural spaces. I did a thoracotomy with the MIS attending, repaired the perf and hiatus, then washed her out well. MIS then did a lap gastropexy.I basically did this case except there was no chest tube present and no one ever considered asking thoracic to do it. I did call thoracic when I could not for the life of me reduce the stomach out of the chest but they were reluctant to get involved. I ended up making the gastric perforation bigger within the chest (from below of course because I wasn't about to open the chest) so I could empty the stomach out at which point I finally got it to fit through the opening in the diaphragm but was left with a question of what to do with the chest that had all that vegetative gastric contents evacuated into it. I washed out from below as best as I could but she ended up needing a VATS later to clean it out some more. Not sure that would have been avoided had they done something at my surgery though.
What might work really well for that is divide the crus with a reinforced staple load and then you can use the seamguard reinforcement to hold stitches instead of pledgets. I do that for the SCM in the neck when I need to get much larger exposure. Doesn't shred the muscle.As others said, I don't hesitate to come and help if someone calls for it. I helped MIS out at 2AM with a similar case that was about a week out from a lap fundoplication and HH repair. Elderly lady who was vomiting at home and had the repair fail, leading to gastric incarceration and perforation into both pleural spaces. I did a thoracotomy with the MIS attending, repaired the perf and hiatus, then washed her out well. MIS then did a lap gastropexy.
I did two more cases like this in the last two months. I'm becoming the regional expert on perforated intra-thoracic fundoplications.
In your case dpmd, did you consider dividing the left crus to help reduce the stomach? I know it can sometimes be a tight space to work in with incarcerated viscera, but that's what I would've tried if I wasn't making any headway. It's easy to repair and is unlikely to impact diaphragm function. Gastric decompression is a good last resort measure if all else fails.
If you didn't feel like you'd washed out the pleural space well enough either, thoracic could've at least helped ensure adequate chest drainage or even done a quick look with a scope. Better than coming back for her decort a week or two later.
I opened the prior repair which let me get my hand up into the chest but was reluctant to make the opening any bigger. However this sounds like when I had a rectally inserted foreign body that I couldn't get out from below and also couldn't move it proximal to remove through sigmoid and I phoned a friend who had me divide the rectovesical fascia and then was able to move it. Once you learn it the trick sounds easy but if you don't know about it you don't think of it.As others said, I don't hesitate to come and help if someone calls for it. I helped MIS out at 2AM with a similar case that was about a week out from a lap fundoplication and HH repair. Elderly lady who was vomiting at home and had the repair fail, leading to gastric incarceration and perforation into both pleural spaces. I did a thoracotomy with the MIS attending, repaired the perf and hiatus, then washed her out well. MIS then did a lap gastropexy.
I did two more cases like this in the last two months. I'm becoming the regional expert on perforated intra-thoracic fundoplications.
In your case dpmd, did you consider dividing the left crus to help reduce the stomach? I know it can sometimes be a tight space to work in with incarcerated viscera, but that's what I would've tried if I wasn't making any headway. It's easy to repair and is unlikely to impact diaphragm function. Gastric decompression is a good last resort measure if all else fails.
If you didn't feel like you'd washed out the pleural space well enough either, thoracic could've at least helped ensure adequate chest drainage or even done a quick look with a scope. Better than coming back for her decort a week or two later.
I had no idea that existed but I could see where it would come in handy especially in a narrow male pelvisWhat might work really well for that is divide the crus with a reinforced staple load and then you can use the seamguard reinforcement to hold stitches really well instead of pledgets. I do that for the SCM in the neck when I need to get much larger exposure. Doesn't shred the muscle.
Also googled the staple load because I couldn't remember the word seamguard from a TIA but when I did I found this little beast. Didn't even know this thing existed. What a weird stapler. Endo GIA™ Radial Reload with Tri-Staple™ Technology | Medtronic
Has anyone used this thing?
I was thinking it might be nice through a gelport to divide the distal esophagus on a total gastrectomy.I had no idea that existed but I could see where it would come in handy especially in a narrow male pelvis
I don't do those but yeahI was thinking it might be nice through a gelport to divide the distal esophagus on a total gastrectomy.
I was thinking it might be nice through a gelport to divide the distal esophagus on a total gastrectomy.
This is what I've used them for, as well as the pelvis. That being said, I've mostly done hand-assist LARs where the Echelon Contour works just as well.
Don't quote me on it, but I thought some of the thoracic guys would use them on VATS lung resections.
Same. Never used it and I'm not sure we even stock it since we mostly use Covidien staplers.It is generally marketed for that. I've never actually used that load before, though.
Heads up call should be a fireable offense. Don't do that **** to your colleagues!ED at 0300: “So I wanted to give you a heads up on this guy. I think he has a type B or maybe a rupture or something. I think you’ll have to take him to the OR. He looks really sick.”
Me: “What’s going on?”
ED: “He’s having pain and just looks sick. He’s on his way to the scanner. Labs are pending. But he has abdominal pain.”
Me: “What are his vitals? Pulses? Exam?”
ED: “BP 150s, HR 70s. I didn’t get a chance to check pulses. But he’s had prior vascular stents, and with all this pain he’s having, I think it could be something big, maybe his aorta. He’s grey and sweaty.”
Me: “Ok......”
ED: “You don’t have to see him yet! I’m not putting in for a consult now; he’ll be done with the scan in a sec. This is just a heads up call in case the CT scan does show something.”
Me: .....”Ok. Please call me when he’s back.”
.....CT and labs were stone cold normal. He normal pulses. Acute case of dilaulipenia.
ED at 0300: “So I wanted to give you a heads up on this guy. I think he has a type B or maybe a rupture or something. I think you’ll have to take him to the OR. He looks really sick.”
Me: “What’s going on?”
ED: “He’s having pain and just looks sick. He’s on his way to the scanner. Labs are pending. But he has abdominal pain.”
Me: “What are his vitals? Pulses? Exam?”
ED: “BP 150s, HR 70s. I didn’t get a chance to check pulses. But he’s had prior vascular stents, and with all this pain he’s having, I think it could be something big, maybe his aorta. He’s grey and sweaty.”
Me: “Ok......”
ED: “You don’t have to see him yet! I’m not putting in for a consult now; he’ll be done with the scan in a sec. This is just a heads up call in case the CT scan does show something.”
Me: .....”Ok. Please call me when he’s back.”
.....CT and labs were stone cold normal. He normal pulses. Acute case of dilaulipenia.
HahhahahahaGot a call for epiglottitis. 22 year old. The ED doc is “really worried about her.” She has a “hot potato voice and everything.” He had a plain film. Looked normal to me, but the radiologist thinks maybe the epiglottis looks a little bigger than it should. So I came in. At night. Patient is 22, 350 lbs. she’s laying supine, texting on her phone, laughing at something her mother said. She’s not even on pulse oximetry. She’s not short of air, she’s not in a sniffer position, she’s tolerating her secretions. She’s had a sore throat for three days. I asked her if her voice sounded different and both she and her Mom said it did not.
Normal exam. Normal NP scope.
Told the ER doc it isn’t epiglottitis because she has none of the clinical symptoms of epiglottitis. He asked about her voice and I told him that isn’t a hot potato voice. She’s just fat.
I have been called into the"...I can’t swear I wouldn’t still get called into the PD’s office for it."
This hits me right in the feels as a former CT surg fellow. I'm usually pretty quiet and reserved, but fellowship really tried my patience some days. The OR staff couldn't wait to hear my next rant whenever my pager went off with the newest disaster.Man oh man, those PGY-2 & 3 years took me to some really dark places. I'm a socially adaptable curmudgeon, but the crucible of junior residency just cranked my baseline levels of snark to an 11.
A resident in our program was off service on gen surg trauma first thing intern year: I can't remember the exact details, but at one point just a week or two into July he was dealing with simultaneous traumas and this notoriously bad ED attending was causing flak while he was trying to take care of the patients. Eventually they got into a spat and he told the ED attending she "wasn't a real doctor."I have been called into theprincipal'sProgram Director's office 3 times as a general surgery resident and told, "TAD, you can't call people stupid." This is actually a direct quote and even as I write this, I can see his face and hear his voice. My reply was usually, "But Dr. PD, I didn't tell the EM Resident/Attending that they were stupid, I just said that their plan was stupid." Man oh man, those PGY-2 & 3 years took me to some really dark places. I'm a socially adaptable curmudgeon, but the crucible of junior residency just cranked my baseline levels of snark to an 11.
At our facility there is a group of trauma NPs that cover trauma patients that don’t require SICU level of care. They are notorious for pan-scanning people once they hit the floor and blasting out consults for every incidental finding. This week alone I got a consult for “incidental SMA stenosis, please provide recs” (40% stenosis and completely asymptomatic) and on Friday at about 5:45 PM got this little number.
NP: so we got this guy up here with a GSW to the leg. We want you to come take a look at him.
Me, thinking it’s for vascular compromise of the leg: oh dang ok I’ll grab my chief and we’ll be right up. What’s his NV exam like?
NP: oh it’s normal, he’s been up here for a few days and he’s fine, probably will be discharged soon. We want you to come evaluate his aorta though.
Me: oh ok, what’s going on?
NP: well we were reading the report of the CTA we did when he got here and they comment that he has an AAA. We just noticed it now. They say his aorta is dilated to 26 mm, can you come evaluate?
me: ……….
My chief was thrilled when I called to inform her we had one more patient to see before we could sign out.
Well, to be fair, if your metric for care is that the patient has his medical concerns addressed, then it’s equal. Because they’re just going to call you down for every medical concern, and then let you manage it on their behalf.EqUaL oR bEtTeR cARe
Don’t give them any ideas for a new study.Well, to be fair, if your metric for care is that the patient has his medical concerns addressed, then it’s equal. Because they’re just going to call you down for every medical concern, and then let you manage it on their behalf.
$&@t, that’s half my referrals. I had a patient come in the other day for a 2 year cough. PCP had done literally nothing. No CxR, no abx, no steroids, not even an inhaler. I asked her what her PCP had done for her, and her response was matter-of-fact: “Oh, nothing. She doesn’t do anything. She just refers me places.”Started a new job this month. Really loving it so far but noticed a number of referrals from corporate satellite urgent cares, some same day, for abscess I&D’s. These aren’t brain busters, I’m talking throw a dart from the other side of the room drainage. Now this is fine with me. Easy money. But I can’t help but feel like the Bob’s looking at these urgent care docs’ charts wondering, “What would you say you do here.”
From the primary care side, ENT referrals are the most frustrating. Yesterday I had a patient call demanding an ENT referral for a hoarse voice. She has never seen me about this before and its only been going on for about 2-3 weeks. Offered her an appointment which she refused and said if I didn't place the referral she'd find a doctor who would. I think you can guess what I did.$&@t, that’s half my referrals. I had a patient come in the other day for a 2 year cough. PCP had done literally nothing. No CxR, no abx, no steroids, not even an inhaler. I asked her what her PCP had done for her, and her response was matter-of-fact: “Oh, nothing. She doesn’t do anything. She just refers me places.”
So…why not just have, like, a vending machine for referrals?
Like in Japan, you can order Ramen some places by just clicking buttons to indicate what you want in it, you hit enter, you pay, and it provides you a receipt to go get your Ramen.
Why not just have primary/urgent care replaced by these? You enter you symptoms, pay, hit enter, and it spits out a referral and a z-pack. Why pay people to do this?
I realize this happens. I see it mentioned in notes (patient demanded referral). I don’t blame PCPs for this. I also know it doesn’t account for every completely unworked up patient that I see.From the primary care side, ENT referrals are the most frustrating. Yesterday I had a patient call demanding an ENT referral for a hoarse voice. She has never seen me about this before and its only been going on for about 2-3 weeks. Offered her an appointment which she refused and said if I didn't place the referral she'd find a doctor who would. I think you can guess what I did.
I wish I had a way to pre-warn our ENTs about patients like this as this is not a rare occurrence and I'd rather not be thought of as either lazy or incompetent.
Urgent Care Provider: Well look I already told you! I deal with the gosh darn patients so that the ER doesn't have to. I have people skills! I am good at dealing with patients! Can't you understand that?!?! WHAT THE HELL IS WRONG WITH YOU PEOPLE?!?!But I can’t help but feel like the Bob’s looking at these urgent care docs’ charts wondering, “What would you say you do here.”
$&@t, that’s half my referrals. I had a patient come in the other day for a 2 year cough. PCP had done literally nothing. No CxR, no abx, no steroids, not even an inhaler. I asked her what her PCP had done for her, and her response was matter-of-fact: “Oh, nothing. She doesn’t do anything. She just refers me places.”
So…why not just have, like, a vending machine for referrals?
Like in Japan, you can order Ramen some places by just clicking buttons to indicate what you want in it, you hit enter, you pay, and it provides you a receipt to go get your Ramen.
Why not just have primary/urgent care replaced by these? You enter you symptoms, pay, hit enter, and it spits out a referral and a z-pack. Why pay people to do this?
From the primary care side, ENT referrals are the most frustrating. Yesterday I had a patient call demanding an ENT referral for a hoarse voice. She has never seen me about this before and its only been going on for about 2-3 weeks. Offered her an appointment which she refused and said if I didn't place the referral she'd find a doctor who would. I think you can guess what I did.
I wish I had a way to pre-warn our ENTs about patients like this as this is not a rare occurrence and I'd rather not be thought of as either lazy or incompetent.
Can I be a decent PCP but still have dog**** notes?I have the same experience and find it bewildering. And with the rise in telemedicine it's gotten even worse. PCPs will see people with ear pain and refer. "cannot assess will refer to ENT" like you're too good to see the ****ing patient in person but I can? It's such a waste of everyone's time and money.
I think we all know that these patients come through your offices and they're pretty obvious when we see them. I doubt any ENT would blame a referral doctor for those. I think there's a clear delineation of PCPs - I see half that have thoughtful notes and attempted treatments (this is how I picked out my PCP actually) and half that clearly put zero thought and are referral machines with dog**** notes. And i wish I could blame it on NPs/PAs but the worst offenders are a select few MDs.
Can I be a decent PCP but still have dog**** notes?
Can I be a decent PCP but still have dog**** notes?
Yes but it is difficult to determine that from a specialist standpoint if it is difficult to tell why you have referred a patient to me, especially when the patient themself isn’t sure. I get a ton of referrals for “PVD” and it can be miserable trying to suss out from the patient what the concern is.
Some of the notes I get say almost nothing in the HPI and I just see a one line in the assessment/plan section that says something like PVD and there is nothing elsewhere to suggest what is going on. It's really annoying to see that. Sometimes its something, sometimes its ridiculous.
Drives me nuts. I've noticed that a lot of referral notes recently are literally just the diagnosis codes with "referral to CT surgery" underneath. No HPI, no impression of what might be going on. If I'm lucky, there will be a radiology report along with it. And maybe, just maybe, the actual imaging.Some of the notes I get say almost nothing in the HPI and I just see a one line in the assessment/plan section that says something like PVD and there is nothing elsewhere to suggest what is going on. It's really annoying to see that. Sometimes its something, sometimes its ridiculous.
I’m curious - what kind of PCP referrals are you getting in CT surg without imaging being done or sent over? (In GS residency, I didn’t see a ton of CT clinic but enjoyed what I saw; it seemed much less vague not worked up stuff than GS. The cardiac stuff come from the cardiologists pretty much wrapped up w/ cath+ echo at minimum; the thoracic was usually an oncology referral already discussed at tumor board except for the random annoying decort type consult or rare TOS/thymoma/sympathectomy.)Drives me nuts. I've noticed that a lot of referral notes recently are literally just the diagnosis codes with "referral to CT surgery" underneath. No HPI, no impression of what might be going on. If I'm lucky, there will be a radiology report along with it. And maybe, just maybe, the actual imaging.
The icing on the cake is when the patient isn't quite sure either why they're seeing me and we have to play 20 questions to suss this mystery out together. Wastes so much time.
These are referrals that come outside our system and the pattern seems to be chest wall lesions/injuries. Just yesterday, I saw a referral in clinic that was literally what I described: referral from family practice for rib fractures, brief HPI, A/P listed CPT code for rib fractures and "referral to CT surgery". No report or outside images. Fortunately, the patient brought the disc. But it was just a CXR with limited views. Symptomatic non-union 8 weeks after a fall. Getting a CT for operative planning.I’m curious - what kind of PCP referrals are you getting in CT surg without imaging being done or sent over? (In GS residency, I didn’t see a ton of CT clinic but enjoyed what I saw; it seemed much less vague not worked up stuff than GS. The cardiac stuff come from the cardiologists pretty much wrapped up w/ cath+ echo at minimum; the thoracic was usually an oncology referral already discussed at tumor board except for the random annoying decort type consult or rare TOS/thymoma/sympathectomy.)
Oh yeah. Or you get no images, but a report that is highly dubious in the extent of it vagueness.I always look ahead to see what's coming up and tell my office to get the images beforehand so we don't waste time. But there's always some excuse about incompatibility, the patient has the disc, or it's the wrong study I'd want. Happens at least once a week.
I recently got a new clinic manager and told him that I've been eating a lot of ass recently with some really bullsh*t referrals. To help sift through the enormous amounts of **** I have been requesting an ABI/PVR because the PCP's note will only say "leg pain" or "leg swelling."
His reply was, "Why is it important to have this testing prior to seeing you? You can see them, then order the test, then see them again and bill for two clinic notes." My reply was something like, "Because that is wildly inefficient, I don't want to listen to sob stories if they have normal perfusion, some of these people drive from a long distance away, and my time is more valuable than billing peanuts for second clinic visit."
It's actually quite gratifying when I have ABI/PVRs that are stone cold normal and I can palpate pulses, because it allows me to shift the entire conversation. It's like having an UNO Reverse card.
Exactly. When I get outside reads from East Jesus Hospital that describe a vague lesion I can't see, the first thing I do is have our radiologists review the films. They're usual response is, "I wouldn't have called that". I all also bug my ortho onc colleagues to look at the bones just to affirm I'm not crazy and missing something.Oh yeah. Or you get no images, but a report that is highly dubious in the extent of it vagueness.
In vascular clinic this week I saw two referrals from the same PCP office come for “leg pain with walking.” Pulses easily palpable and the first thing they did when I asked them about it was start grabbing their knee and talking about how hard it is to walk on their knee that “feels like it’s grinding.”I recently got a new clinic manager and told him that I've been eating a lot of ass recently with some really bullsh*t referrals. To help sift through the enormous amounts of **** I have been requesting an ABI/PVR because the PCP's note will only say "leg pain" or "leg swelling."
His reply was, "Why is it important to have this testing prior to seeing you? You can see them, then order the test, then see them again and bill for two clinic notes." My reply was something like, "Because that is wildly inefficient, I don't want to listen to sob stories if they have normal perfusion, some of these people drive from a long distance away, and my time is more valuable than billing peanuts for second clinic visit."
It's actually quite gratifying when I have ABI/PVRs that are stone cold normal and I can palpate pulses, because it allows me to shift the entire conversation. It's like having an UNO Reverse card.
Our local vascular surgeons require ABIs at minimum as well. That's not unreasonable to my mind.I recently got a new clinic manager and told him that I've been eating a lot of ass recently with some really bullsh*t referrals. To help sift through the enormous amounts of **** I have been requesting an ABI/PVR because the PCP's note will only say "leg pain" or "leg swelling."
His reply was, "Why is it important to have this testing prior to seeing you? You can see them, then order the test, then see them again and bill for two clinic notes." My reply was something like, "Because that is wildly inefficient, I don't want to listen to sob stories if they have normal perfusion, some of these people drive from a long distance away, and my time is more valuable than billing peanuts for second clinic visit."
It's actually quite gratifying when I have ABI/PVRs that are stone cold normal and I can palpate pulses, because it allows me to shift the entire conversation. It's like having an UNO Reverse card.