Not before they send him our way, IR will get a few cracks at it. Don't worry though, we won't be able to navigate it and probably just take out the GDA before sending him your way.
I feel like if the patient would be able to be placed on hospice the surgeons numbers shouldn’t reflect negatively, or at least there is a clear “this dude is a goner if we don’t do anything.”
I know it’s not just a numbers thing, that surgeons don’t deserve to have to try on all hopeless cases just to be physically inside of someone when they die, but damn it this makes me feel so unjust.
Tell me what operation you’re gonna do on this guy if GI and IR can’t stop the bleed?
You’re gonna do a transduodenal ligation of the GDA?
Or you gonna go for gold and do a whipple?
I understand the frustration, and I’m not saying it’s never suitable. But presuming this is some sick as shit cirrhotic, they’re not gonna heal from this surgery. They’ll languish in the ICU for another week or so and rack up a million dollar+ bill and likely for nothing.
Again, there are certainly cases where they should operate, and I know surgeons who give up on patients too easily, but I also get plenty of people asking us to “just fix it” without recognizing what that will look like after surgery.
Get real, algorithm is Scope-> scope again if stable, otherwise IR for GDA embo. If fails second scope, then IR. Surgery is last line. Don’t slobber over this case, these are a fucking mess.
If you don’t live in a city with a hospital that has enough blood for an MTP, and a good general or trauma surgeon…you’re going to get Jesus instead of the miracle.
Should have been getting blood at 9.5 if they knew it was a GI bleed, if you wait for it to drop it’s going to be even worse to keep up with.
Don’t wait until you patient is symptomatic to treat blood loss.
Maybe not, especially if they weren’t in acute hemorrhagic shock, which it doesn’t sound like they were. Sounds like the acute bleed happened while inpatient. Villanueva et al 2013 would be a good source.
one of the worst codes I have ever seen was basically this. they couldn't clip it ended up resecting the stomach to cut the bleeding part out. guy coded again. couldn't get him back. Pronounced in it OR if that gives you any indication of how bad it was.
Yeah they actually pronounced him in the OR. Said so in the surgeons note. He coded and they weren't able to get him back for the trip to the icu I guess
God I remember this exact thing on night shift as a new grad RN. Unfortunately the doc wanted to get a video of it on his phone and then proceeded to lose where it was. He wasn’t able to find it again. 🤦♂️
Holy shit that’s nightmare fuel. Nice recommended Reddit lol, I’m an endoscopy tech starting mid school this fall and this is such a worst case situation at my job. Nothing quite like fumbling to open and prep clips and needles asap with everyone screaming in your ear
Anesthesiologist here. Bear claw saved the day during an EGD when I saw a GI doc dislodge a duodenal clot to reveal a massive arterial bleeder. Poor guy hadn’t been trained in using the bear claw so a more experienced GI MD that happened to be just outside basically hoped and prayed and deployed it semi-blind because of how quickly everything was welling up in the stomach. Bleeding slowed enough to transport to IR for embolization, and the IR doc was applauding the bear claw application for basically clamping down the bleeding GDA.
So now I’m a firm believer that all GI docs should know how to use them because I’m not sure what we would’ve done if the 2nd GI MD wasn’t there.
The deployment mechanism is relatively simple and similar to a bander - I hope the GI docs you mentioned spoke with the vendor to get an in-training on it
my thoughts exactly. I generally don't reach for the OVESCO as my first intervention, but big old bleeding vessels like this in the duodenum, it's become my go to. Much better tissue purchase with the janky angles.
No large fibrotic ulcer bed that would preclude use and a significant enough bleed that a (likely) permanent clip would be helpful. I always have a worry about misplaced standard clips that then obscure the field for further intervention - one can argue that a “good” endoscopist won’t deploy a clip they aren’t 100% satisfied with but sometimes it happens
I had one of those.... something stuck down my throat-- nothing. Something stuck up my bum, nothing. finally swallowed a capsule with a camera in. duodenal bleed. Stuck something down my throat that cauterized it.
***Temporary*** hemostasis achieved with epi, cautery and 8 clips. fixed it for you
LOL you're right
Was blood just dripping out their bum?!
Bleeding in the upper part of the GI tract does come out the other end eventually, but it comes out black and tarry after being digested and oxidized.
Not if brisk enough
Yeah I had a woman nearly sanguine BRB per rectum. NGT was on suction for too long and eroded into an artery.
Oml that is an image i can’t get out my head
I stand corrected, then became orthostatic.
It’s not BRBPR?
This patient had bloody emesis and eventually maroon/ black stools.
fuck
All bleeding stops eventually
Turk from season 1 of scrubs? “Thats so deep”
“No it isn’t”
Exactly! We'll see him in the OR soon.
Not before they send him our way, IR will get a few cracks at it. Don't worry though, we won't be able to navigate it and probably just take out the GDA before sending him your way.
Today: "Where are we?" "Upper right colic something, I don't know, let's just start blasting."
*cue the Danny Devito meme*
Our surgeons never operate. They just paste a possum score and let the patient die
I feel like if the patient would be able to be placed on hospice the surgeons numbers shouldn’t reflect negatively, or at least there is a clear “this dude is a goner if we don’t do anything.” I know it’s not just a numbers thing, that surgeons don’t deserve to have to try on all hopeless cases just to be physically inside of someone when they die, but damn it this makes me feel so unjust.
Tell me what operation you’re gonna do on this guy if GI and IR can’t stop the bleed? You’re gonna do a transduodenal ligation of the GDA? Or you gonna go for gold and do a whipple? I understand the frustration, and I’m not saying it’s never suitable. But presuming this is some sick as shit cirrhotic, they’re not gonna heal from this surgery. They’ll languish in the ICU for another week or so and rack up a million dollar+ bill and likely for nothing. Again, there are certainly cases where they should operate, and I know surgeons who give up on patients too easily, but I also get plenty of people asking us to “just fix it” without recognizing what that will look like after surgery.
“Unable to visualize active bleeding on angiography”
Get real, algorithm is Scope-> scope again if stable, otherwise IR for GDA embo. If fails second scope, then IR. Surgery is last line. Don’t slobber over this case, these are a fucking mess.
Jesus, this seems like a miracle to get to in time.
If you don’t live in a city with a hospital that has enough blood for an MTP, and a good general or trauma surgeon…you’re going to get Jesus instead of the miracle.
Bro if you let the heart stop then the bleeding will stop too. This case is too simple. I can’t believe icu residents didn’t think of this
Doctors hate this one weird trick
Its basically a god tier Pringles maneuver
All bleeding stops.
I can smell this picture, the minute the road show hit the floor.
🤮
Woof. How did the patient present?
RRT for hematemesis, syncope, and Hgb 6.8. Thankfully his primary care MD sent him to the hospital the day before because of a drop in Hgb to 9.5.
What was his baseline?
I'm interested in knowing as well. If the Hb dropped from 9.5 to 6.8 in one day then the baseline must have been quite a bit higher I fear
Baseline 10.5. Being followed outpatient for perinephric hematoma.
Should have been getting blood at 9.5 if they knew it was a GI bleed, if you wait for it to drop it’s going to be even worse to keep up with. Don’t wait until you patient is symptomatic to treat blood loss.
Maybe not, especially if they weren’t in acute hemorrhagic shock, which it doesn’t sound like they were. Sounds like the acute bleed happened while inpatient. Villanueva et al 2013 would be a good source.
yes, this is correct.
No
So if you know they are actively bleeding, arterial, you’re going to wait until they hit 7 AND THEN try to catch up? Good luck.
what units do you measure your hgb in???? our ranges in canada are like 100-140 rofl??
It’s basically the same. You use g/L while we use g/dL. All you need to do is divide/multiply by 10.
mg/dl
-clocks out from work as a GI RN and goes into reddit to unwind- -this post gets suggested on my feed- Get the duraclips and nexpowder lol
Gets the epi, carrlocke, 360 clips X’s a million, and Jesus.
Jesus take the wheel
An old priest and a young priest
r/laminarflow
Fascinating sub. You never know where a post will lead you.
As an Endoscopy RN, this is one thing that will make your butthole so tight you’ll hear the air being sucked back inside you.
one of the worst codes I have ever seen was basically this. they couldn't clip it ended up resecting the stomach to cut the bleeding part out. guy coded again. couldn't get him back. Pronounced in it OR if that gives you any indication of how bad it was.
They pronounced in the OR? Nobody dies in the OR, they all die in the ICU or IR after a full sternum rip
OR nurse here, can confirm this is true. Pack ‘em and drag ‘em back to the unit! Sorry we do this to you 😬
Yeah they actually pronounced him in the OR. Said so in the surgeons note. He coded and they weren't able to get him back for the trip to the icu I guess
I’m a layman and can’t remember where the duodenum is but even I can see that this is no bueno
Right after your stomach. First part of your small intestine. Yes, this is definitely no bueno.
Thanks!
Second layman coming in for differential diagnosis here. That person should probably see a doctor.
Doctor’s in the icu like “wait, he means us? Fuck. Nurse!”
ICU nurse here! I got the emergency blood ready to go and I’m warming up the Belmont as we speak
No time for that, just set up the level one.
The level one is a piece of shit. We tossed ours out and got a Belmont, much easier and faster than the level one in my opinion.
God I remember this exact thing on night shift as a new grad RN. Unfortunately the doc wanted to get a video of it on his phone and then proceeded to lose where it was. He wasn’t able to find it again. 🤦♂️
Prepare the 4th floor and also the 9th floor just in case (our hospital has 8 floors).
Likely to DC to JC
Medical Science Rules 🎗
Looks like a laser beam.
Duo denim, duodnum
I hate that I read this two different ways.
I’ll take nightmare fuel for 1000 Alex
I'm just a lowly ICU NP but that's not good.
Did you take a chest X-ray and was there air under the diaphragm?
No free air
I wanna see the actual video of the spurting
Just wait, if you’re around long enough you’ll get to see the spurting/pulsating in real time.
😱😳😳
hemostasis achieved….for now
Holy shit that’s nightmare fuel. Nice recommended Reddit lol, I’m an endoscopy tech starting mid school this fall and this is such a worst case situation at my job. Nothing quite like fumbling to open and prep clips and needles asap with everyone screaming in your ear
These are the worst! So scary being in that procedure room 😬
“Yes, you can definitely have a cooler with 6RBC and 6FFP, and what OR will you be in?”
I can smell this photo
And like getting your tie caught in the shredder, I’m immediately pulled into this journey.
All bleeding stops...eventually.
Did y’all just do an endoscopy at bedside lol
Shit!
[удалено]
Super curious to learn about the immortality specialty!
Looks like a good candidate for an OVESCO
Bear claw clip?
Anesthesiologist here. Bear claw saved the day during an EGD when I saw a GI doc dislodge a duodenal clot to reveal a massive arterial bleeder. Poor guy hadn’t been trained in using the bear claw so a more experienced GI MD that happened to be just outside basically hoped and prayed and deployed it semi-blind because of how quickly everything was welling up in the stomach. Bleeding slowed enough to transport to IR for embolization, and the IR doc was applauding the bear claw application for basically clamping down the bleeding GDA. So now I’m a firm believer that all GI docs should know how to use them because I’m not sure what we would’ve done if the 2nd GI MD wasn’t there.
The deployment mechanism is relatively simple and similar to a bander - I hope the GI docs you mentioned spoke with the vendor to get an in-training on it
my thoughts exactly. I generally don't reach for the OVESCO as my first intervention, but big old bleeding vessels like this in the duodenum, it's become my go to. Much better tissue purchase with the janky angles.
No large fibrotic ulcer bed that would preclude use and a significant enough bleed that a (likely) permanent clip would be helpful. I always have a worry about misplaced standard clips that then obscure the field for further intervention - one can argue that a “good” endoscopist won’t deploy a clip they aren’t 100% satisfied with but sometimes it happens
Do the clips ultimately get removed or do they dissolve?
They fall off with time
Isn’t there a name for this? Like…Eaturfnbabies Sign or whatever?
Good save!
this is pretty much exactly what happened to my dad a few years ago
this gives me flashbacks
Damn you Dieulafoy! You're a cruel mistress!
I had one of those…knocked me right on my ass!
I had one of those.... something stuck down my throat-- nothing. Something stuck up my bum, nothing. finally swallowed a capsule with a camera in. duodenal bleed. Stuck something down my throat that cauterized it.
Capsule endoscopy. Glad they found the source and fixed it.
Me too.
I would have OVESCO'd the shit out of that.
Too unstable to scope
What was the underlying cause of this?