Monday, March 16, 2015

The LP

When I was a medical student on my neurology rotation, I was sent down to radiology because the radiology attending who was doing an LP didn't want to take more than 6 cc out of the patient's spine, because he was worried the patient would get a headache. So in order to absolve himself of responsibility, he said that if neuro wanted more than 6 cc, we physically had to go down and take out the rest of the fluid ourselves. Specifically, I had to go down there and hold a test tube to catch the fluid (over 6 cc) dripping out of the patient's spine.

As soon as I got down there, the rad attending was acting like an asshole. After much ado and my having to page my attending, he agreed to let us take out 25 cc total, as long as I was the one taking it out.

So the radiology resident got the tube in his spine and got out the first 6 cc. He hands me the test tube and the attending said to me, "OK, we're all leaving now."

I looked at him with sheer panic and I was like, "Wait!" I didn't know what could possibly go wrong with the patient during this procedure, but considering I knew very little, and the attending felt it was dangerous enough that he didn't want to be there, I didn't want to be alone.

The resident was sympathetic and asked the attending if he could stay with me. But the attending was insistent that nobody be in the room with me. I said, "What if something goes wrong? How do I get it out?" The answer to that question was that they would be a few doors down and the patient's son could go get them. Finally, the resident told me quietly that he'd come back before I was done and remove the tube from the spine.

It baffles me that an attending could act that way. I was shocked and I felt awful for the patient who had to hear this exchange.

25 comments:

  1. That is a living nightmare. Hope all went well.

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  2. I suppose this "compassionate humanitarian" is still a doctor. Let me know where so I never go there.

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    1. Agreed! I consider it a violation, Dr. Fizzy. Whenever a person takes advantage of their position to cause harm to another person, they
      are violating them. You were terrified and rightfully so. I'm sorry you
      had to have that experience. Shame on them!
      On a more positive note, how is your knee doing Jono?
      - Paul

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  3. Correction: Shame on the attending! The resident tried to do the right thing.
    - Paul

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  4. They wanted to leave you alone to do a procedure as a med student?? How many times had you done the procedure before?

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  5. So I am new to all this - is there any place for "I am uncomfortable with this plan given my lack of experience, I would like to talk this over with my attending and see if he/she can think of some other options?" … In hindsight would you do anything different? Also, it sounds like this attending had a very wrongheaded idea about how malpractice suits go. … I suspect he would be just as responsible whether or not he is IN the room if he is the attending overseeing the procedure.

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    1. I think it depends on your program. Where I went to medical school, a med student saying that would most likely be met with blank stares and the directions would be repeated. If you refused, there is probably a 50/50 chance you would fail the rotation, limiting your residency/career options and requiring that you do another month of that specialty.
      You are always free to do what you want, but there can be huge consequences as a third year med student.

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  6. And perhaps not being IN the room leaves him open to worse types of malpractice issues - like the negligence he was clearly showing.

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  7. Agree that the radiologist was extremely out of line. We should also take a moment to feel contempt for the neurologists who sent a medical student into the middle of that changed situation in which they are already in open conflict with rads.

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    1. Agreed. What on earth was your neurology attending doing that was so important that he couldn't personally walk down and supervise this procedure? He was paged, so it's not like he didn't know this was all going on. It sounds like they were both being stubborn, refusing to do it themselves, and ultimately the poor third year med student ended up being the only one who couldn't say "no."

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  8. I have n idea what the attending was thinking. Other than it being unprofessional, he absolutely WOULD be held responsible, had there been some sort of complication, for leaving a med student alone during an advanced procedure. The patient could have made a complaint based on the exchange itself.

    And, no, this is not typical physician behaviour. I can't think of a single radiologist - or any consultant - at my hospital who would have behaved that way. Can they be ornery and unpleasant sometimes? yes. But ultimately, they do what's appropriate.

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  9. I didn't think of it at the time, but in retrospect, I'm a little peeved at my neurology attending for putting me in that position. He was a nice guy though.

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  10. You have to be kidding me. It takes a Radiologist to do an LP ? Why can't a Neurologist do an LP ? Talk about over-specialisation. I'm a GP, and I do LPs all the time, for heaven's sake...

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    1. I think there was some special circumstance or reason why it needed to be done in radiology.

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    2. It happens all the time. You're using the expression "GP" so I have to assume you're not practicing in the US. Therefore I challenge you to do an LP on a person with a BMI of 50.

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    3. Never make assumptions. It would be my pleasure :-) Interventional Radiology has a definite role (embolisations etc.), but it's become the easy opt out for chest pig-tail catheters / LPs, yada yada, and is a big city phenomenon. I'm a rural GP, and I've made sure I'm U/S trained and competent - I'll happily find the intervertebral space in a BMI of 50. I do U/S guided central line placement, FAST, IUP confirmation, U/S guided regional blocks, yada yada. U/S training is now becoming as ubiquitous as a stethescope at undergrad level - for good reason.

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    4. Anon, you're making all kinds of assumptions about this patient you haven't evaluated and this neurologist you've never met, so you may want to plot an easy route of descent from your high horse here.

      Back when EM was embarking on the road to become the last major specialty recognized as a thing, the major reason strong opposition never developed was that the legacy docs were sick and tired of getting out of bed or rushing out of their clinics every time their patients had an emergency. Yet there are very few people who would argue we should go back to the old way.

      I see a lot of similarities in the growth of IR. A lot of things are safer and better under IR guidance, but it's also a dead easy way of getting a time-consuming procedure off your to-do list. I myself have been guilty of sending therapeutic peritoneal taps to IR, because on single coverage I don't have an hour to stand there filling bottles. In moderation, this is just an effective way of using your resources to get the job done.

      We don't all have the leisurely pace of life of a rural GP.

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    5. Wow - talk about making assumptions! I have worked in both rural and urban areas, as well a large teaching centres, and I can tell you there is NOTHING leisurely about being a rural MD. You often have to be a jack of all trades, and care for a very large population with very little time away, given the low density of physicians in the area. Also, the lack of easy access to tertiary care services means that you have to make some really tough decisions, instead of just calling whatever on-call resident is available to take the patient off your hands.

      Rural medicine is much more challenging, and rural GPs are to be respected for the breadth and depth of their skills.

      different anon from above, who now works in a large urban centre

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  11. a radiologist doing a LP??? why?

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  12. You should have had me as the patient. I would have reported his tail so fast, and put it in writing.

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  13. Two points:

    1. Post-LP headaches have much more to do with the type and size of needle than with the volume of fluid drawn, so the radiologist was freaking out over nothing.

    2. Some LPs must be done via interventional radiology. Some people have poor bony spinal anatomy or are... frankly, too fat to have it done easily at the bedside by a neurologist. With IR, they use fluoroscopy so they can actually *see* where the needle is going, so the fail rate is vanishingly small

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  14. What NeuroTrumpet said. And, based on personal experience working in a program where Interventional Radiology is not always helpful, the perspective of neurology went something like this: "those pansy excuses for physicians down in IR wont obtain the necessary sample? Why not? No good reason? I will show them, I will send a medical student down to do their job for them!" We (general surgery) almost did this exact thing when IR refused to suture in a G-J tube, although we were planning to send an extremely competent sub-I. We intended it primarily as a way to get the tube secured without one of us being removed from patient care for half an hour while the patient was positioned, the tube placed, etc, etc, and secondarily as a passive aggressive insult to the IR attending who had refused to secure the previously placed tube (which then promptly fell out).

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  15. After hearing/experiencing that spat of unprofessionalism, it seems the radiologist ensured the patient got a headache anyway.

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  16. From wikipedia "Hence the choroid plexus must produce about 500 milliliters of CSF daily (or 21 mL per hour)."
    Convert cc to mL 1 to 1.

    Everything is fine unless a tumor is involved "certain situations such as a tumour, because it can lead to brain herniation and ultimately death."

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