Pigtail WTF moment

[epsilonprodigy]

I went to pull a pigtail the other day, and for the life of me, I could not find the damn thread to cut before pulling it. I ended up calling IR. They were very irritated and ended up sending someone up to pull the damn thing, who claimed the thread was "where it had always been." WTF? are there different places the end can be? I have heard that for some, you don't have a visible end hanging out and have to cut the distal catheter itself, but have never had to do that. Any pictures/ explanations would be great.


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[vhawk]

You can always just cut the catheter just don't cut it right at the akin. I've never personally had the issue you are talking about but I've heard of it happening to other people or at least I've heard of other people screwing it up haha, enough so that it is a well known dummy proof approach to just cut the whole thing a few inches from skin and pull.

Then again nothing is dummy proof and ive ALSO heard of people doing this and cutting it right at the skin such that it retracted back and had to be retrieved. Don't do that.

 

[TraumaLlamaMD]

There are different brands, and often they do hide the string from you, as so:



That said, from what I've seen, it's not unusual for IR to remove their own drains.

 

[Jolie South]

IR removing their own drains? Hahahahahahaha. We get called all day to manage their tubes/lines/drains.

I always just cut the tube itself several cm from the entry point. Saves time and frustration.

 

[DrBowtie]

I went to pull a pigtail the other day, and for the life of me, I could not find the damn thread to cut before pulling it. I ended up calling IR. They were very irritated and ended up sending someone up to pull the damn thing, who claimed the thread was "where it had always been." WTF? are there different places the end can be? I have heard that for some, you don't have a visible end hanging out and have to cut the distal catheter itself, but have never had to do that. Any pictures/ explanations would be great.


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Some that we use have an internal string and once the locking mechanism is engaged, you can't "unlock" it.

What I do is first cut the skin sutures to "mobilize" the drain. You may need to retract enough of the drain to get decent distance between the hub and skin.

You can then either hold the catheter at the skin or clamp some hemostats to prevent it from retracting deep to the skin.

Cut the tubing below the hub which also cuts the tension string. Slowly pull out the catheter and bandage.

I agree they are not very intuitive if you've never seen that type before.

 

[Winged Scapula]

There are different brands, and often they do hide the string from you, as so:



That said, from what I've seen, it's not unusual for IR to remove their own drains.

Thanks!
My staff has on occasion been flummoxed by these and its nice to have a video to show them what I mean.

 

[dpmd]

I went to pull a pigtail the other day, and for the life of me, I could not find the damn thread to cut before pulling it. I ended up calling IR. They were very irritated and ended up sending someone up to pull the damn thing, who claimed the thread was "where it had always been." WTF? are there different places the end can be? I have heard that for some, you don't have a visible end hanging out and have to cut the distal catheter itself, but have never had to do that. Any pictures/ explanations would be great.


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Yes there are different places it can be. At my current hospital system the ones they use confused me and I wasn't sure if I was unlocking it or not (my previous place you just turned something and it internally cut the stitch but I got shown so knew it was right). So I decided to just cut the catheter. Luckily they always leave a decent amount of catheter outside the skin so very little risk of losing it after you cut, but I never let go of the thing while I cut and then pull so even less chance of a mishap.

 

[dpmd]

I also know someone who maintains that if you pull hard enough all of them will eventually unlock, but seems rude to the patient (have seen it done like that on accident and they definitely feel it more).

 

[vhawk]

I can certainly verify that any old MS4 can, with enough elbow grease, get any drain out of any person regardless of any unlocking or cutting of suture

 

[bannie22]

I also know someone who maintains that if you pull hard enough all of them will eventually unlock, but seems rude to the patient (have seen it done like that on accident and they definitely feel it more).

hahahahahah

 

[Winged Scapula]

I can certainly verify that any old MS4 can, with enough elbow grease, get any drain out of any person regardless of any unlocking or cutting of suture

I can also personally verify the same .

I may or may not have been such an MS4.

 

[vhawk]

one exception being if you sew the drain into the fascial closure with a #1 PDS....

 

[Pir8DeacDoc]

Tell IR to manage their own $hi!

 

[dpmd]

one exception being if you sew the drain into the fascial closure with a #1 PDS....

Doh!

 

[dpmd]

Tell IR to manage their own $hi!

There have been a few times I was no longer seeing a patient that IR had put a drain in and the patient was ready to go home otherwise but I was not around. I advised the hospitalist to send the pt to IR to get the drain pulled. Each time was successful but sometimes took a day to arrange. I also think they re-imaged. All in all if it is a patient I am actively seeing it is less trouble to just remove it when I want. Also if they are outpatient with the drain I don't know how I would get the patient back to IR for removal whereas a clinic appointment with me is easy.

 

[deleted547339]

Tell IR to manage their own $hi!

lolz.

 

[Pir8DeacDoc]

They provide a valuable service to patients. But they seem to have little interest in "finishing" the job..we had a lot of our head and neck cancer patients in training get g tubes through IR. We complained about the lack of follow up and they hired a PA to take care of their stuff afterwards. Worked very well

 

[Apollyon]

Each time was successful but sometimes took a day to arrange. I also think they re-imaged.

"If all you have is a hammer, everything looks like..."

Or, alternately, "we let the shark go, because it does what a shark does".

 

[DrBowtie]

"If all you have is a hammer, everything looks like..."

Or, alternately, "we let the shark go, because it does what a shark does".

To be fair in the case of an abscess drain with output meeting clinical criteria for removal, a limited CT of the area to confirm resolution of the collection prior to removal is done because repositioning or replacing the drain over a wire is much easier than pulling it and having to place a second de novo drain when the patient bounces back.

 

[dpmd]

To be fair in the case of an abscess drain with output meeting clinical criteria for removal, a limited CT of the area to confirm resolution of the collection prior to removal is done because repositioning or replacing the drain over a wire is much easier than pulling it and having to place a second de novo drain when the patient bounces back.

Yeah,but how often are people actually bouncing back? I take care of a lot of people who get IR drains of abscesses and the times a drain has had to be put back in are rare enough to be memorable even though I don't do any imaging before I pull it.

 

[DrBowtie]

Yeah,but how often are people actually bouncing back? I take care of a lot of people who get IR drains of abscesses and the times a drain has had to be put back in are rare enough to be memorable even though I don't do any imaging before I pull it.

I've seen it quite frequently but obviously due to sample bias. We don't ever see the people who do well again since they don't re-present to the ER or for outpt imaging.

Those that do with known prior abscess comes to ER, gets a CT which shows any residual drainable collection is seemingly an automatic diagnostic aspiration or repeat drain placement.

I think checking with a limited CT is reasonable. It confirms that the lack of output is from resolution and not migration or secondary loculation and getting an "after" picture establishes a new baseline should they come back.

Guidelines say you can judge clinically or image. I tend to err on the side of knowing for certain with imaging but my exam and clinical skills are certainly more limited than surgeons.

 

[vhawk]

And on the flip side, there is almost no drain that an MS3 can pull without calling for help/backup...

Feel like there is some sort of maxim in this, something like

"No task so basic that an MS3 doesn't need their hand held
No task so advanced that an MS4 doesn't cavalierly think he can handle on his own."

Someone with a more poetic bent improve on that so that I can steal it and name it after myself

 

[badasshairday]

I put so many drains in that if i rounded on every single one i literally would not have time to do any more of the drain placements that surgery wants me to do. I follow the drains related to my procedures (ie. Post lung biopsy ptx chest tube or post renal mass ablation violating diaphragm chest tube) or those that are on hospitalist or other nonsurgical service.

Pro tip. Cut the catheter then pull. Cutting the catherer will unlock the pig tail.

 

[vhawk]

I put so many drains in that if i rounded on every single one i literally would not have time to do any more of the drain placements that surgery wants me to do. I follow the drains related to my procedures (ie. Post lung biopsy ptx chest tube or post renal mass ablation violating diaphragm chest tube) or those that are on hospitalist or other nonsurgical service.

Pro tip. Cut the catheter then pull. Cutting the catherer will unlock the pig tail.

Like SouthernSurgeon says....LOL at this. You doing 50 a day huh?

 

[irwarrior]

I personally try to follow all of my own IR placed tubes and drains , biliary drains, chest tubes, gastrostomy tubes, nephrostomy tubes etc. I agree that the poor follow up of IR for these patients can have potentially negative impact on the outcome of these patients. By following these drain patients we developed some consensus on how to manage these patients and learned to manage common problems. We also gathered considerable data. There were many unfortunate things that can occur including patient's not getting home health scheduled, having inadequate supplies to change the drain sponges, leaving biliary drains uncapped and becoming dehydrated. Many of these issues should not have happened and can be blamed on poor IR follow up.

If you have the time to place the drain or tube, you should find the time or get support staff to help you follow the drains. With time after following my own drains, we were able to ultimately get a physician extender to help with the tube and drain management. This still enables the IR service to irrigate and aspirate drains, do sinograms, order repeat CT imaging, look for fistulas, determine duration of antibiotics and when appropriate to remove drains. It also educated us on which patients were likely to get recurrence as we would follow these patients in the outpatient clinic even after drain removal.

Ultimately, it has enabled our IR service to learn a great deal about the management of the conditions that these patients have. Unfortunately many IR divisions do a very poor job on drain management and leave the poor patients in limbo with no one taking ownership for the patient's care. I have had my own patients who have gone to outside hospitals and needed IR services and with no follow up and poor education on how to manage their condition. Hopefully this will continue to change as more and more IR physicians understand their shortcomings and overcome this by providing better longitudinal care.

 

[vhawk]

I personally try to follow all of my own IR placed tubes and drains , biliary drains, chest tubes, gastrostomy tubes, nephrostomy tubes etc. I agree that the poor follow up of IR for these patients can have potentially negative impact on the outcome of these patients. By following these drain patients we developed some consensus on how to manage these patients and learned to manage common problems. We also gathered considerable data. There were many unfortunate things that can occur including patient's not getting home health scheduled, having inadequate supplies to change the drain sponges, leaving biliary drains uncapped and becoming dehydrated. Many of these issues should not have happened and can be blamed on poor IR follow up.

If you have the time to place the drain or tube, you should find the time or get support staff to help you follow the drains. With time after following my own drains, we were able to ultimately get a physician extender to help with the tube and drain management. This still enables the IR service to irrigate and aspirate drains, do sinograms, order repeat CT imaging, look for fistulas, determine duration of antibiotics and when appropriate to remove drains. It also educated us on which patients were likely to get recurrence as we would follow these patients in the outpatient clinic even after drain removal.

Ultimately, it has enabled our IR service to learn a great deal about the management of the conditions that these patients have. Unfortunately many IR divisions do a very poor job on drain management and leave the poor patients in limbo with no one taking ownership for the patient's care. I have had my own patients who have gone to outside hospitals and needed IR services and with no follow up and poor education on how to manage their condition. Hopefully this will continue to change as more and more IR physicians understand their shortcomings and overcome this by providing better longitudinal care.

Nice post. It really just goes to show you how powerful a concept "anchoring" is. If your baseline expectation is that you will not follow up these patients, then you cant even imagine how you would ever have time following up all these patients. But if you are used to doing it, it seems standard and you can easily make time. The surgeons were mocking a bit, but if they had been trained or practiced for a few years in environments where they didnt do any follow ups, they'd probably feel the same way about it.

 

[badasshairday]

Like SouthernSurgeon says....LOL at this. You doing 50 a day huh?

Lol indeed. But when a thoracic surgeon asks us to do a chest tube stat, I'm pretty sure they can follow that up since they are already seeing the patient daily.

But irwarrior is right. It is institutuon dependent and many IR departments have "drain rounds " and literraly follow up every single drain they place daily.

 

[badasshairday]

If all the patients we operated on required postop care we wouldn't have time to operate...oh wait...

It is a bit different. You see, interventional radiology is going through growing pains right now as a specialty. Now becoming a primary residency. But fellowships for IR right now do not have interns and scant resident (usually those who are in radiology purely for diagnostics and have no care and little knowledge for interventional other than doing some consents and orders for sedation meds). We are expected to learn the gamut of procedures, consults, clinic, inpatient rounds almost entirely on our own with minimal to no junior resident, midlevel, or intern help. On the contrary the fellows in the surgical division have a significant amount of help for non procedural work as this is how surgery has been set up since the beginning. Things are changing in IR with the new residency and incorporation or midlevel providers and a primary IR residency to help with grunt work. At my institution i work more hours than the vascular surgery fellows to give you an idea.

Regardless. @irwarrior is right. We should follow up all our drains which many IR departments are doing now. In fact we are starting this transition to this now but aren't quite there yet as i indicated above.

 

[badasshairday]

Like SouthernSurgeon says....LOL at this. You doing 50 a day huh?

Feels like it sometimes . I do have to follow up our oncologic tumor embo / ablation cases, stroke intervention caaes, peripheral vascular cases, gi bleeder cases, post thrombolysis cases, fibroid embo cases, etc. Then the drains which are lower priority since these are usually requested by surgical services which can easily manage those. Or at least I thought don't mind manging them. Maybe i thought wrong?

I almost never follow up with percutaneous urologic procedures like nephrostomy creations as these are always done at the request of our urology collegues for stone access or urgent decompression of Obstructive nephropathy. They don't mind following up on them.

 

[badasshairday]

Interesting discussion. Would like to hear more input from my surgical brethren.

 

[badasshairday]

I mean, the reality is you don't do it because as a specialty of proceduralists and not patient care providers, you've allowed that culture to develop. And then you developed excuses as to why it is (the aforementioned "If I had to round on all my drains..." line, and then this post). It's similar to the whole ortho/medical-care stereotypes.

We actually had an IR fellow try to turf a procedure related complication to the on call vascular fellow a couple of years ago. When the vascular fellow called the IR guy, he literally said something to the effect of "I don't have the team of people to deal with this stuff like you do". The vascular fellow was like - what team? It's 2am and this means I have to come in from home to fix your mistake.

It's admirable that there are efforts to try and change the culture. But I'd encourage you to avoid making excuses for why you don't do it now, especially ones that imply you've got so much more on your plate than anyone else; we are all busy and have a ton of things to cover - all while we are trying to learn too.

Didn't mean to imply that i have more on my plate. We are all busy. It is a culture thing. Truly. But this is changing with the new IR residency. In fact today, I saw my post peripheral vascular intervention patient alone while I saw vascular surgery fellow rounding with vasc team which including 2 radiology trainees. One was our first ever IR residency matched intern starting his categorical internship. The other was a new senior rad resident who matched IR.

 

[DrfluffyMD]

I plan to follow all my procedures next year and write notes on them daily. How am I going to convince people that we are real doctors or take back / maintain turfs if we aren't acting like real doctors?

 

[vhawk]

Have you considered wearing a stethoscope draped around your neck?

 

[badasshairday]

Have you considered wearing a stethoscope draped around your neck?

Nah bro. That is going too far. I carry it crunched in my hand and use it on rare occasions. I do the ortho magic auscultation spot right at the xyphoid process to hear lungs, heart, and bowl all at the same time.