- Joined
- Nov 2, 2004
- Messages
- 4,461
- Reaction score
- 5,245
THISThe problem with medicine however, is the consumer of products and services are not the payors.
This is why applying principles of market-based capitalism to healthcare doesn't work.
THISThe problem with medicine however, is the consumer of products and services are not the payors.
Most abscesses in the ED are empirically drained. Occasional bedside US, but otherwise rarely formal imaging.When I did PCP, if I did an InD in the office and missed a loculated abscess because I don't have any imaging and then patient goes into septic shock, then the pt suffers the most and potentially can die. Sending them to the ED and potentially getting imaging is the best for everyone imo.
This is so low on my list of medicolegal concerns.If someone did an InD and missed a loculation and they ended up in the ICU with septic shock, you know that pt's lawyer is going to rake the docs over the coals.
Why would you ever want to catch it?Most of the PCP offices (both community and academic) that I rotated through wouldn't even have a bin to catch all of the purulent d/c.
Abscesses essentially never have that much pus.Not all offices even have gauze. I would have to use paper towels to catch the d/c, which would be hard to do if there was >500 cc.
Yeah, we drain more abscess in the ED than almost anyone else. We know abscesses. You sound early on the curve.We just see different things as we function in different roles in the hospital. We can agree to disagree. You think you're right. I know I am right because I treated it in real life.
Looks like he/shes a fellow.
This!The worst for me are the non-emergent "My widget is malfunctioning". 90% of the time it's not an emergency, and I don't have IR in house to fix their dialysis catheter, nephrostomy tube, suprapubic catheter, pain pump, etc.
This!
Plus in the end, if we can fix their problem, patients are often unsatisfied because the result isn’t what they expected. “This G tube doesn’t look like my old one”. Sorry?
Fair enough, but, what are the chances of an aberrant artery that you might cut while doing your I&D? I mean, I remember once in residency when there was an abscess directly over the femoral artery. I thought it was manageable, but, my attending was losing her sht. So, we punted and called surgery.I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
I do kyphoplasties, spinal cord stimulators and epidural steroid injections in an outpatient office I share with PCPs, and I'm not having any catastrophic outcomes. How come you're having them with simple I&Ds?I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
Dentists use lidocaine all the time, have a risk of hitting a pretty large artery, and have less training at dealing with emergencies than FP's do.I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
Fellow in what?Again, not all offices have the equipment to do it. Not all offices even have gauze. I would have to use paper towels to catch the d/c, which would be hard to do if there was >500 cc. Let's not even talking about hemostats and forceps, let alone POC US.
Fellow.
I have personally treated this in the ICU. They went and got an InD. Not all of it was drained. Then they don't f/u with anyone and just don't take care of themselves. They ignored all signs. Then they are brought in by family when they are in shock. I'll admit that this rare and unlikely, but it is possible. And to that pt, it isn't a rare occurance.
Heck, I had a pt go into shock after removing a small 2mm skin lesion. It got infected and they presented a few weeks later in shock. They were on my service and on pressors for weeks. True story. Now that I think about it, I should have published that case report because it was so unbelievable.
We just see different things as we function in different roles in the hospital. We can agree to disagree. You think you're right. I know I am right because I treated it in real life. There isn't much fruitful discussion that I can contribute on this topic as we are on an impasse. I won't be posting on this thread anymore. Thank you.
Dentists use lidocaine all the time, have a risk of hitting a pretty large artery, and have less training at dealing with emergencies than FP's do.
The only reason FP's don't have the equipment is because they didn't order it. My FP does I&D's. I know because he knows I'm an ER doc and he was talking about a pilonidal abscess he did earlier in the day and was regretting not having any suction equipment available.
Fellow in what?
I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
I would never want a physician to do something/a procedure they are not comfortable with, but what you're saying just sounds...I don't now how to say it without sounding like a jerk....crazy. I'm not trying to be a jerk I swear.I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
I think the OPs post is a great example of what happens in someone’s training when their quotes adverse events to use them as an excuse for not doing something, and the trainee never questions the probability of that happening and their ability to deal with the complications.I would never want a physician to do something/a procedure they are not comfortable with, but what you're saying just sounds...I don't now how to say it without sounding like a jerk....crazy. I'm not trying to be a jerk I swear.
Disclaimer: I'm a dermatologist, not FP or EP.
Lido overdose:
Follow that and document amounts. Could a rare untoward thing happen? Sure, but we are physicians. Part of our every day jobs include some amount of risk taking. I have been practicing for 5 years (with about 20 colleagues) and have never heard of a lido overdose happen...and we're sticking lidocaine in probably 10 or so people a day each sometimes.
Anaphylaxis? I suppose, but again, see above about some amount of risk taking. When you weigh the scales it is so much more cost effective for one to just drain an abscess in office than to send to an ED. Could an anaphylaxis happen? I guess. I think every good office should either have a crash cart of some sort if they are not close to an ED. Just know how to recognize Vasovagal and now how it's different than anaphylaxis. If you do any procedures in your office you WILL have people vasovagal. The first time it happens, it's like the end of the world...after that it's like, ok, this is a little blip in my day..no worries...nurse, can you get this pt in trendelenberg, get them some water/juice, and sit with them for 15 or 20 mins?
Major bleeding? from what? if you have an abscess on an abdomen or forearm, or back I'm not sure how that would happen with a simple I and D. I think out of 5 years I have heard of one our patients having to go to the ED for bleeding (someone tagged an artery...maybe peroneal? from doing a DEEP biopsy (not a simple I and D). If you have a hyfrecator in your office and some hands to hold pressure, you should be good in almost all instances.
Again, I'm not at all advocating for people to do any procedures they are uncomfortable with doing. However, the risks you list are so rare to happen. We as non ED clinicians should really be taking those risks (SUPER DUPER UPER low risks) so we can keep these pts out of the ED and let the ED docs take care of more acute issues.
I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
“Healthcare”Fellow in what
I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
I think the logic is more about petting burning dogs. It’s not that I’m worried about bleeding or iatrogenic septic arthritis so much as I am having the ER turn into the procedure suite of choice for literally everybody. Once people start treating the ED as an IR suite you don’t have to schedule or get pre authorized you start having a lot of nonsense that requires an inordinate amount of physician time.I had a visceral reaction to this and was going to jump on the train denigrating you, but then I realized that this is the same sort of logic employed by ED docs all the time to defer low risk, in-scope procedures to other specialists. Things like paras, small joint taps, etc.
“Healthcare”
I think the logic is more about petting burning dogs. It’s not that I’m worried about bleeding or iatrogenic septic arthritis so much as I am having the ER turn into the procedure suite of choice for literally everybody. Once people start treating the ED as an IR suite you don’t have to schedule or get pre authorized you start having a lot of nonsense that requires an inordinate amount of physician time.
I think the logic is more about petting burning dogs. It’s not that I’m worried about bleeding or iatrogenic septic arthritis so much as I am having the ER turn into the procedure suite of choice for literally everybody. Once people start treating the ED as an IR suite you don’t have to schedule or get pre authorized you start having a lot of nonsense that requires an inordinate amount of physician time.
Forget that stuff, the ER is already exactly that for nursing home patients, those with a broken widget, and those who want *whatEVer* at all hours.
This is why I laugh when people say we can't do primary care. Yes we wouldn't be super good at it at first but the nature of the ED we deal will a lot of stuff like HTN, widgets, psych, calling and dealing with multiple specialists in real time and so on.
I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
This is why I admit all simple I & Ds to the surgeon so they can drain them in the OR. The patient might require the anesthesia team.I'm a family medicine resident. I'd love to do simple I and Ds. The problem is no office has the equipment and capabilities to deal with complications. Lidocaine overdose, anaphylaxis, major bleeding. The ED is a space ship compared the PCP office. Can you imagine the outcry when something goes wrong and the PCP doctor can't manage it. Why start a procedure when you know you won't be able to manage the complications.
Come on, seriously!?
If these are your reasons for not managing something then by that logic you shouldn't be managing hypertension, diabetes, repairing lacs, or pretty much doing any medicine at all because most procedures use some form of anesthesia and most medications can cause anaphylaxis!
These are unnecessarily harsh, even if in jest.This is why I admit all simple I & Ds to the surgeon so they can drain them in the OR. The patient might require the anesthesia team.
but the surgeon usually just wants me to call life flight and have the patient choppered out to a tertiary care center since we don’t have a SICU here.
Not really.These are unnecessarily harsh, even if in jest.
Lol, I think everyone’s made their point quite clear.
I am just a pharmacist so I can't comment on much of this other than the risk of lidocaine OD - there is a simple calculation you can do prior to administering it - I get asked to do it on occasion for our docs/PA - you have to use a quite a bit before it becomes a problem (I have never seen someone need anywhere near the max for an abscess thou).
I have seen one sad case of a rxn to a local anesthetic (marcaine I think) from an OB office when they were placing an IUD - they said anaphlyaxis vs inter-arterial injection (I don't know the anatomy there if that is possible or not) that lead to cardiac arrest.
But I did grow up on farm and my dad often would drain an abscess on one our pigs using a pocket knife that he dipped in alcohol and then sprayed the wound with iodine. It was actually quite satisfying to see the amount of puss you could get out of one. He barely graduated high school and rarely had any complications, and good thing is the pigs wouldn't sue if something bad happened.
Your excellent EM training.4mg/kg without epi.
7mg/kg with epi.
How do I remember these things?
4mg/kg without epi.
7mg/kg with epi.
How do I remember these things?
Had an FM PGY3 in the peds ER doing an big thigh lac. Poked my head in and see TWO 10 mL vials of lido w/o epi drained on the table. Said he’d used all of it. You should probably let boss man know about that one dude, that’s a lot of lido.Your excellent EM training.
That violates the golden rule of medication administration. If you’re needing to grab a second vial/bottle, stop and ask yourself if you’ve ****ed up some calculation.Had an FM PGY3 in the peds ER doing an big thigh lac. Poked my head in and see TWO 10 mL vials of lido w/o epi drained on the table. Said he’d used all of it. You should probably let boss man know about that one dude, that’s a lot of lido.
Dude was completely unaware there even was a max dose for lidocaine. We went to med school at the same place, and I’m sure this was covered at least a few times.
200 mg of lidocaine, into a 15kg child… 13 mg/kg.
Kid was fine, said their tongue felt fuzzy, but fine. Attending called poison and admitted the kid for obs.
Thanks.Your excellent EM training.
Large superficial laceration running vertically down the thigh. Very long but not very deep, just deep enough for sutures for cosmetics. Could have been done with far, far less lido.That violates the golden rule of medication administration. If you’re needing to grab a second vial/bottle, stop and ask yourself if you’ve ****ed up some calculation.
As an aside, 20ml into a 15kg kid? Did he have to sew the kids leg back on or something?
I am just a pharmacist so I can't comment on much of this other than the risk of lidocaine OD - there is a simple calculation you can do prior to administering it - I get asked to do it on occasion for our docs/PA - you have to use a quite a bit before it becomes a problem (I have never seen someone need anywhere near the max for an abscess thou).
I have seen one sad case of a rxn to a local anesthetic (marcaine I think) from an OB office when they were placing an IUD - they said anaphlyaxis vs inter-arterial injection (I don't know the anatomy there if that is possible or not) that lead to cardiac arrest.
But I did grow up on farm and my dad often would drain an abscess on one our pigs using a pocket knife that he dipped in alcohol and then sprayed the wound with iodine. It was actually quite satisfying to see the amount of puss you could get out of one. He barely graduated high school and rarely had any complications, and good thing is the pigs wouldn't sue if something bad happened.
4mg/kg without epi.
7mg/kg with epi.
How do I remember these things?
Had an FM PGY3 in the peds ER doing an big thigh lac. Poked my head in and see TWO 10 mL vials of lido w/o epi drained on the table. Said he’d used all of it. You should probably let boss man know about that one dude, that’s a lot of lido.
Dude was completely unaware there even was a max dose for lidocaine. We went to med school at the same place, and I’m sure this was covered at least a few times.
200 mg of lidocaine, into a 15kg child… 13 mg/kg.
Kid was fine, said their tongue felt fuzzy, but fine. Attending called poison and admitted the kid for obs.
You are SUCH a buzz kill!At one of my ER's, the ED / ENT was numbing a guys throat to do a PTA or direct laryngoscopy or something. I can't remember the procedure. They gave nebulized 4% lidocaine and put lido directly on the tongue. Maybe they even numbed the back of the throat with a needle. I don't recall the specifics but I do recall the pt developing uncontrollable seizures, needing intubation and ICU admission.