As long as we're...

I was signing out my patients today and I told the on call resident that my patient had a case of the "As long as we're"s. I realize that no one else uses my jargon. My bad. But you all know what I mean. The classic example is cardiac. As long as we're doing a valve replacement, let's do a CABG. And as long as we're doing a CABG, let's do a carotid endarterectomy too.

However, CT surgery isn't the only offender. Too often, it's used to justify lines and other bedside procedures. As long as he's in the unit, let's get an a-line to monitor pressures while on pressors. As long as we're giving pressors, let's get a central line for access. As long as we're doing a central line, let's do an IJ because it's more sterile. As long as we're doing an IJ, let's do a Swann.

The truth about the hospital is that it's all about inertia. You have to surpass the threshold for activity, and once you have, then it's in for a penny, in for a pound. It scares me to think that so much of what I do is governed by the simple fact that I have to be in the hospital. Well, as long as I'm here...

6 comments:

the evil intern said...

heh, maybe it's because I'm in California and they're gearing us to self-examine our practice the way an HMO administrator would, but we definitely don't do "as long as we're's." or, in reality, we do, but we have to employ sophistry and find creative ways to justify it. for example, the last time we were going to float a swan, the cardiology fellow, while intent on teaching the procedure, asked these key questions: "is it going to change our management? what are we going to with the information?" since the answers were "no," and "if the wedge is high, we'll diurese, and if the wedge is low, we'll diurese," we opted not to do the swan just then. when, however, it came time to pull the cordis, we floated a swan first to get some numbers "so we can gage how well our diuresis went" since we wouldn't have numbers afterwards. I admit, we were doing it just because we could, but in the chart, it looks like we were doing it for a real reason.

the evil intern said...

oh, and random data point, but did you know that doing a mitral valve replacement AND a CABG at the same time has almost a 20% perioperative mortality risk? I seriously had a patient sign out AMA right after being presented with the consent by the CT surgeons. It's worse odds than playing Russian roulette!

incidental findings said...

Sorry, pet peeve. Russian Roulette has 50/50 odds, because you play against another person until someone dies.

And as far as justification, we do justify things, so it's not without reason, but it's one of those things where once you start doing things, it snowballs.

Anonymous said...

But shouldn't someone have an arterial line if they're on pressors anyways? And then shouldn't they have central access to give pressors unless you anticipate short term dopamine through a peripheral IV. Those make sense for someone in the MICU on pressors.

I don't know about your hospital, but Swans are rarely used here -- like Evil Intern said, "is it going to change our management" always comes up before we float a swan. I've seen 2 horrible complications from Swans to definitely make me think twice.

But in any case, teaching hospitals are probably the least guilty of the "snowballing" of procedures/imaging because there's no financial incentive. I see a lot more unnecessary shit go on in private hospitals.

the evil intern said...

heh, yeah, re: odds, I wasn't looking at the big picture. I was thinking more of "number needed to harm" (for some sick reason, I really like that phrase.) with every pull of the trigger, there is a 1 out of 6 chance that someone is going to blow their head off, which is slightly better than the 1 out of 5 chance that every time you open someone's chest and decide to replace the mitral valve AND graft some saphenous veins, that someone is going to go to the eternal care facility in the sky. hell, I'm not sure I would consent to having a MVR+CABG done on me.

incidental findings said...

I'd just like to make clear, we're not doing unjustified procedures. It's more like, if I told you that I was going to give your uncle some medicine to get his blood pressure up, that means nothing more than some strange colored fluid in an IV line. To us, it's a central line, an art line, and maybe even a Swann if they're in shock.

My problem with the "as long as we're" justification is that you can never just do one thing. You can't just give a pressor,. You can't just do a valve repair. You can't take one step, you've got to take 15.

And as far as MVR + CABG mortality, it sucks big time, and as I'm fond of telling my friends, is 27 too young to be made DNR?