L****n
发帖数: 12932 | 1 First congratulate to the new board. sorry to rant here as my first post,
but i am about to explode...and this is what a physician board is for, right?
a lady had a MVA yesterday and the orthopod want to take her to OR for femur
fx ORIF. She also have intracranial bleeding shown on CT. obviously i was
concerned about putting her to sleep. My suggestion is spinal anesthesia-
which also carries significant risk. One of the neuro surgeon - a MEAN 50yo
white bitch, was the neuro attending. She told the orthopod to only proceed
with Epidural anesthesia, which by it self is an acceptable way of
anesthesia. Epidural is done with a 18Ga needle and has 2-3% chance of wet
tap. Spinal, however is done with a much smaller 25Ga. needle - the spinal
fluid leak is, theoretically, minimal. Both risk profile is truly debatable.
However, when i called her to discuss this patient, the way she speaks is
what gets me aggravated... She said:" i'm very busy, let me tell you my
opinion, IN PERFECT ENGLISH, i am not going to be liable to any complication
if you choose to proceed with spinal...."
I felt like to slam the phone on the face...At the end, i told the orthopod
(who is a very nice young guy, also white) i am not going to do the case.
another anesthesiologist eventually did the case, with epidural, without
complication.
Would you feel been insulted, or am i too sensitive...how would you handle
that if this happens to you? |
x******i
发帖数: 14369 | |
A*******s
发帖数: 9638 | 3 Patpat.
I think she preferred general anesthesia rather than epidual due to the risk
of CSF leakage(2-3%). This could cause uncal herniation if it does happen.
(ICH)
You may explain to her that the risk for general anesthesia is higher than
the chance of CSF leakage. The NSG just tried to protect herself. I would
not take it as an insult. |
L****n
发帖数: 12932 | 4 no, it's a no no for general, she knows that. If the patient fail to wake up
after GA, it'll be big mess. She, as a neuro, want to dictate how
anesthesia is done for a ortho case, while refuse to take any responsibility
, and talk in a way that indeed make me feel being discriminated.
risk
happen.
【在 A*******s 的大作中提到】
: Patpat.
: I think she preferred general anesthesia rather than epidual due to the risk
: of CSF leakage(2-3%). This could cause uncal herniation if it does happen.
: (ICH)
: You may explain to her that the risk for general anesthesia is higher than
: the chance of CSF leakage. The NSG just tried to protect herself. I would
: not take it as an insult.
|
A*******s
发帖数: 9638 | 5 May I ask why you choose not to put her in sleep? |
A*******s
发帖数: 9638 | 6 Neuros are all like that. They are just BS. lol.
If the patient has ICH, fail to wake up is not unusual. Well, whatever the
decision was, she should respect your professional judgement. I am with you.
But I would not take it too serious.
up
responsibility
【在 L****n 的大作中提到】
: no, it's a no no for general, she knows that. If the patient fail to wake up
: after GA, it'll be big mess. She, as a neuro, want to dictate how
: anesthesia is done for a ortho case, while refuse to take any responsibility
: , and talk in a way that indeed make me feel being discriminated.
:
: risk
: happen.
|
L****n
发帖数: 12932 | 7 well, with unstable intra-cranial bleeding, any spiking in blood pressure
could have grave consequence. Induction/emergence of GA would both present a
big challenge. In short, you don't want any this thing that could cause
mental status change in this patient. Neuro team is monitoring this to
decide if they need to take her for craniotomy to evacuate the hematoma. |
A*******s
发帖数: 9638 | 8 Would the craniotomy require GA?
a
【在 L****n 的大作中提到】
: well, with unstable intra-cranial bleeding, any spiking in blood pressure
: could have grave consequence. Induction/emergence of GA would both present a
: big challenge. In short, you don't want any this thing that could cause
: mental status change in this patient. Neuro team is monitoring this to
: decide if they need to take her for craniotomy to evacuate the hematoma.
|
L****n
发帖数: 12932 | 9 yes, but it is for the bleeding, and there is no alternative. so if you HAVE
TO take the risk, you have to take the risk.
【在 A*******s 的大作中提到】
: Would the craniotomy require GA?
:
: a
|
A*******s
发帖数: 9638 | 10 I C.
The neuro tried to avoid the craniotomy. And a wet tap would unfortunately
guarantee it.
a
【在 L****n 的大作中提到】
: well, with unstable intra-cranial bleeding, any spiking in blood pressure
: could have grave consequence. Induction/emergence of GA would both present a
: big challenge. In short, you don't want any this thing that could cause
: mental status change in this patient. Neuro team is monitoring this to
: decide if they need to take her for craniotomy to evacuate the hematoma.
|
|
|
L****n
发帖数: 12932 | 11 not necessarily guarantee it, but increase the likelihood a lot. with spinal
, there will be a small hole, with epidural, there most likely will be no
leak, if it's done right. but if wet tap happens, there will be a BIG hole.
the patient have femur fx, positioning will be a big issue, there fore
chance of getting a wet tap is higher (normally 2-3% in ideal situation). i'
m just not comfortable.
unfortunately
【在 A*******s 的大作中提到】
: I C.
: The neuro tried to avoid the craniotomy. And a wet tap would unfortunately
: guarantee it.
:
: a
|
A*******s
发帖数: 9638 | 12 So both GA and epidual are high risk, right?
With an increased ICP in presence of the ICH, the chance of herniation would be high if a
wet tap happens. My understanding is just a matter of time.
Well, you are the man who does the procedure, right?
Maybe she just had a bad day.
spinal
.
i'
【在 L****n 的大作中提到】
: not necessarily guarantee it, but increase the likelihood a lot. with spinal
: , there will be a small hole, with epidural, there most likely will be no
: leak, if it's done right. but if wet tap happens, there will be a BIG hole.
: the patient have femur fx, positioning will be a big issue, there fore
: chance of getting a wet tap is higher (normally 2-3% in ideal situation). i'
: m just not comfortable.
:
: unfortunately
|
N*******r
发帖数: 118 | 13 It's all depends.
If your question is "Would ALL crani require GA?", then the answer is NO.
Awake craniotomy with local and IV sedation is a common surgery for some
brain tumor.
For certain ICH, Burr Holes (or Burr-hole craniotomy) are usually done under
local anesthesia.
【在 A*******s 的大作中提到】
: Would the craniotomy require GA?
:
: a
|
V**y
发帖数: 788 | 14 人可能更年期到了原谅这个荸荠吧、
right?
femur
50yo
proceed
【在 L****n 的大作中提到】
: First congratulate to the new board. sorry to rant here as my first post,
: but i am about to explode...and this is what a physician board is for, right?
: a lady had a MVA yesterday and the orthopod want to take her to OR for femur
: fx ORIF. She also have intracranial bleeding shown on CT. obviously i was
: concerned about putting her to sleep. My suggestion is spinal anesthesia-
: which also carries significant risk. One of the neuro surgeon - a MEAN 50yo
: white bitch, was the neuro attending. She told the orthopod to only proceed
: with Epidural anesthesia, which by it self is an acceptable way of
: anesthesia. Epidural is done with a 18Ga needle and has 2-3% chance of wet
: tap. Spinal, however is done with a much smaller 25Ga. needle - the spinal
|
L****n
发帖数: 12932 | 15 yes i do think menopause has something to do with her been so bitchy. She is
one of the most "hated" asshole in the OR. pretty much complaint of anyone
and everyone that is ever in touch with her - I have heard more evil words
from her mouth than anybody else combine.
【在 V**y 的大作中提到】
: 人可能更年期到了原谅这个荸荠吧、
:
: right?
: femur
: 50yo
: proceed
|
N*******r
发帖数: 118 | 16 Just for the discussion of the anesthetic options for that patient, I agree
with that neurosurgeon. It's all about the risk and benefit.
For the patient with possible increased ICP, sudden drop of the ICP from
losing CSF can cause intracranial herniation and death. That's a well
documented risk, and we all know it. I know the spinal needle is small, but
the risk of CSF leak is still there.
right?
femur
50yo
proceed
【在 L****n 的大作中提到】
: First congratulate to the new board. sorry to rant here as my first post,
: but i am about to explode...and this is what a physician board is for, right?
: a lady had a MVA yesterday and the orthopod want to take her to OR for femur
: fx ORIF. She also have intracranial bleeding shown on CT. obviously i was
: concerned about putting her to sleep. My suggestion is spinal anesthesia-
: which also carries significant risk. One of the neuro surgeon - a MEAN 50yo
: white bitch, was the neuro attending. She told the orthopod to only proceed
: with Epidural anesthesia, which by it self is an acceptable way of
: anesthesia. Epidural is done with a 18Ga needle and has 2-3% chance of wet
: tap. Spinal, however is done with a much smaller 25Ga. needle - the spinal
|
L****n
发帖数: 12932 | 17 i think it's debatable. it's about "sudden". a 25Ga. non cutting needle
like sprott is NOT gonna give a sudden drop in pressure - leak maybe, but
not pouring, however, if a 18Ga needle hole is there, it'll be like pouring.
agree
but
【在 N*******r 的大作中提到】
: Just for the discussion of the anesthetic options for that patient, I agree
: with that neurosurgeon. It's all about the risk and benefit.
: For the patient with possible increased ICP, sudden drop of the ICP from
: losing CSF can cause intracranial herniation and death. That's a well
: documented risk, and we all know it. I know the spinal needle is small, but
: the risk of CSF leak is still there.
:
: right?
: femur
: 50yo
|
A*******s
发帖数: 9638 | 18 Thanks for the input.
under
【在 N*******r 的大作中提到】
: It's all depends.
: If your question is "Would ALL crani require GA?", then the answer is NO.
: Awake craniotomy with local and IV sedation is a common surgery for some
: brain tumor.
: For certain ICH, Burr Holes (or Burr-hole craniotomy) are usually done under
: local anesthesia.
|
A*******s
发帖数: 9638 | 19 Yes, 25 Ga is very tiny. The problem also depends on how high the ICP is.
Well, at least the Neuro should discuss with you instead of threatening.
pouring.
【在 L****n 的大作中提到】
: i think it's debatable. it's about "sudden". a 25Ga. non cutting needle
: like sprott is NOT gonna give a sudden drop in pressure - leak maybe, but
: not pouring, however, if a 18Ga needle hole is there, it'll be like pouring.
:
: agree
: but
|
p***0
发帖数: 22 | 20 没办法，你只能给ya俩儿中指。这种a-hole太多了，你不是还得靠ta吃饭吗？ |
|
|
f******w
发帖数: 10267 | 21 You are not too sensitive. 我以前经常拍电话。有一次一个女的跟我喊，我站起来
就出了房间。当然，大家别学我。 |
h****o
发帖数: 1 | 22 so basically you do no thing to the ICM, just observe?
why you put the fx top priority, just to prevent the DVT?
just for curiosity, if this case is in china, we probably do not deal with
the fracture first. can any senior doctor tell me why? |
L****n
发帖数: 12932 | 23 what i understand is certain kind of fracture need to be fixed with time
urgency. ICH can be observed if condition seems to stabilized.
【在 h****o 的大作中提到】
: so basically you do no thing to the ICM, just observe?
: why you put the fx top priority, just to prevent the DVT?
: just for curiosity, if this case is in china, we probably do not deal with
: the fracture first. can any senior doctor tell me why?
|
A*******s
发帖数: 9638 | 24 I agree. Most ICHs need no surgery as long as it is stable.
【在 L****n 的大作中提到】
: what i understand is certain kind of fracture need to be fixed with time
: urgency. ICH can be observed if condition seems to stabilized.
|
s*******1
发帖数: 428 | 25 I would have the same feeling as you have.
Don't know how to handle it. But one thing I know for sure, she will make
more and more enemies, and eventually it will backfire and affect her career.
patpat.
but i am about to explode...
【在 L****n 的大作中提到】
: First congratulate to the new board. sorry to rant here as my first post,
: but i am about to explode...and this is what a physician board is for, right?
: a lady had a MVA yesterday and the orthopod want to take her to OR for femur
: fx ORIF. She also have intracranial bleeding shown on CT. obviously i was
: concerned about putting her to sleep. My suggestion is spinal anesthesia-
: which also carries significant risk. One of the neuro surgeon - a MEAN 50yo
: white bitch, was the neuro attending. She told the orthopod to only proceed
: with Epidural anesthesia, which by it self is an acceptable way of
: anesthesia. Epidural is done with a 18Ga needle and has 2-3% chance of wet
: tap. Spinal, however is done with a much smaller 25Ga. needle - the spinal
|
t*****l
发帖数: 5477 | 26 下次你可以见到他的时候开玩笑说，你们美国人的英语真地道哈哈哈哈……
right?
femur
50yo
proceed
【在 L****n 的大作中提到】
: First congratulate to the new board. sorry to rant here as my first post,
: but i am about to explode...and this is what a physician board is for, right?
: a lady had a MVA yesterday and the orthopod want to take her to OR for femur
: fx ORIF. She also have intracranial bleeding shown on CT. obviously i was
: concerned about putting her to sleep. My suggestion is spinal anesthesia-
: which also carries significant risk. One of the neuro surgeon - a MEAN 50yo
: white bitch, was the neuro attending. She told the orthopod to only proceed
: with Epidural anesthesia, which by it self is an acceptable way of
: anesthesia. Epidural is done with a 18Ga needle and has 2-3% chance of wet
: tap. Spinal, however is done with a much smaller 25Ga. needle - the spinal
|
L****n
发帖数: 12932 | 27 THAT IT! THANK YOU!
Next time she start yapping her perfect English, i'd cut her off and say :"
you mean your PERFECT American English?"
【在 t*****l 的大作中提到】
: 下次你可以见到他的时候开玩笑说，你们美国人的英语真地道哈哈哈哈……
:
: right?
: femur
: 50yo
: proceed
|
N*******r
发帖数: 118 | 28 That patient must be a stable ICH patient, otherwise the first surgery
should be an emergent Burr hole evacuation and drainage of the ICH.
The current AAOM guideline for the hip fractures, as I know, recommends all
hip fracture should be reduced and fixed within 72 hours to reduce the risk
of the life-threatening complications.
【在 A*******s 的大作中提到】
: I agree. Most ICHs need no surgery as long as it is stable.
|
D****r
发帖数: 162 | 29 You dont really win anything by talking down others. Think of some win-win
approaches to this sticky situation.
Btw, I dont think she meant ill by "perfect English". To my understanding,
it simply means she wants to make it simple, plain, straightforward. It is
like saying 'English please' to someone who is confusing others by using a
lot of jargon. It has nothing to do with your race, your English level.
【在 L****n 的大作中提到】
: THAT IT! THANK YOU!
: Next time she start yapping her perfect English, i'd cut her off and say :"
: you mean your PERFECT American English?"
|
D****r
发帖数: 162 | 30 A true story of mine:
My mentor said to me 'it is ancient history.' I was like 'Asian history is
so bad?'. Thanks goodness. I kept mum about this.
right?
femur
50yo
proceed
【在 L****n 的大作中提到】
: First congratulate to the new board. sorry to rant here as my first post,
: but i am about to explode...and this is what a physician board is for, right?
: a lady had a MVA yesterday and the orthopod want to take her to OR for femur
: fx ORIF. She also have intracranial bleeding shown on CT. obviously i was
: concerned about putting her to sleep. My suggestion is spinal anesthesia-
: which also carries significant risk. One of the neuro surgeon - a MEAN 50yo
: white bitch, was the neuro attending. She told the orthopod to only proceed
: with Epidural anesthesia, which by it self is an acceptable way of
: anesthesia. Epidural is done with a 18Ga needle and has 2-3% chance of wet
: tap. Spinal, however is done with a much smaller 25Ga. needle - the spinal
|
|
|
s*********t
发帖数: 4253 | 31 中国人对中国人干嘛以洋文书写。 有没见过 洋人对洋人 用CHINESE交流？ |
A*******s
发帖数: 9638 | 32 Very well said.
Win-win is what we want.
win
,
is
【在 D****r 的大作中提到】
: You dont really win anything by talking down others. Think of some win-win
: approaches to this sticky situation.
: Btw, I dont think she meant ill by "perfect English". To my understanding,
: it simply means she wants to make it simple, plain, straightforward. It is
: like saying 'English please' to someone who is confusing others by using a
: lot of jargon. It has nothing to do with your race, your English level.
|
A*******s
发帖数: 9638 | 33 用什么语言是个人的选择和自由，不管什么人都得尊重别人， 是不是？
【在 s*********t 的大作中提到】
: 中国人对中国人干嘛以洋文书写。 有没见过 洋人对洋人 用CHINESE交流？
|
L****n
发帖数: 12932 | 34 oh, because it's a question about HOW TO SAY SOMETHING IN ENGLISH.
【在 s*********t 的大作中提到】
: 中国人对中国人干嘛以洋文书写。 有没见过 洋人对洋人 用CHINESE交流？
|
D****r
发帖数: 162 | 35 True story. I swear on my ancestor's tombs I am not making this up. 3
Americans with 1 Chinese spoke Chinese at the next table the whole
time.....
【在 s*********t 的大作中提到】
: 中国人对中国人干嘛以洋文书写。 有没见过 洋人对洋人 用CHINESE交流？
|
