[HSF] SBE and the Indications for Surgery

Tea Acuff tacuff at swbell.net
Wed Feb 7 20:42:37 EST 2007 

I may have told this story about when I asked my father, a general surgeon, what was the main difference between private and academic practice, when I was a resident.

His reply: "In academic practice you tell the referring physican that he nearly killed the patient, and to next time send him earlier and not act like an idiot. In private practice you thank the referring physician for the very interesting case!"
tea


----- Original Message ----
From: "hgrmd at aol.com" <hgrmd at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Wednesday, February 7, 2007 5:05:55 PM
Subject: Re: [HSF] SBE and the Indications for Surgery


Dear Ben,
  I'm glad you realize the dynamics under which I exist in private practice.  Now that you mention it, that particular ID doc's group also has a large number of patients since they also do a fair amount of primary care.  Publicly taking this doc to task would definitely not be in my best interest.  In addition, he's actually a reasonable guy and usually a good clinician.  If I thought he was an ongoing problem, then I would do what I had to do to protect the public.  However, I think he made an honest, isolated mistake.  
Hal


-----Original Message-----
From: benjamin.bidstrup at bigpond.com
To: OpenHeart-L at lists.hsforum.com
Sent: Wed, 7 Feb 2007 11:07 AM
Subject: Re: [HSF] SBE and the Indications for Surgery


Hal, 
You have called this SBE. If one goes back to the older definitions of endocarditis (and it should be called IE) Staph infection was part of the entity known as acute endocarditis. This is because even in the early days the propensity to embolize and especially for cardiac skeletal destruction was much greater than say with S viridans. The name of acute endocarditis I believe also indicates the degree of urgency with which surgery should be approached. 
In private practice as you are, you cannot p... off your referrers and dissent is a good way of doing that. (Don't really need me to tell you that) Esp when the family were told what they probably wanted to hear at the time - no operation. 

>Dear Ani, 
> The cardiologist and I both advised surgery. The day before >surgery, the ID doctor wrote an emphatic note on the chart saying >there was no indication for surgery. He also told that to the >patient and her son. I was told this by one of my partners who was >rounding at that hospital that day. The cardiologist called me and >said that we should back off since the ID doc had already convinced >the family that surgery wasn't indicated. This ID doc had always >been a reasonable and well respected consultant for many years on >many cases. The cardiologist and I were reluctant to go against his >and the family's wishes. We backed off. Simple as that. > 
>Hal 
> 
>-----Original Message----- 
>From: anianyanwu at hotmail.com 
>To: OpenHeart-L at lists.hsforum.com 
>Sent: Wed, 7 Feb 2007 7:08 AM 
>Subject: Re: [HSF] SBE and the Indications for Surgery 
> 
> 
>Dr`Frater 
> 
>Is the decision to proceed with surgery not one that can only be taken by the 
>surgeon and the patient? I am not sure how the situation could arise >that an ID 
>doctor is the one who decides if surgery is appropriate - is that not the role 
>of a surgeon? There are numerous patients - indeed the majority - >with SBE that 
>we never hear about treated with antibiotics. The fact that Hal >heard about this 
>case meant that the primary doctors were at least contemplating a role for 
>surgery. May Hal could elaborate on the referral/consultation process and who 
>made the decision not to proceed with surgery. If it was the patient >(regardless 
>of whose advice they followed) then I am not sure we can criticize it. Also if 
>it was a group decision (of which the surgeon is a part of) then the >surgeon is 
>as responsible for the decision as much as the rest of the group, even if he 
>made a minority opinion strongly known. If a surgical opinion was not sought 
>then it is bad practice, but if one was sought then a >multidiscplinary decision 
>was made and hopefully the patient was well informed. 
> 
>With a patient so old frail with what is a potentially fatal disease there may 
>not always be clear cut answers for the doctors and families. All we can do as 
>surgeons is advice on surgery and tell them the risks but the patient has to 
>decide. If we had operated and the patient died (as they not infrequently do) 
>the case would probably be on an ID discussion board saying how surgeons 
>operated against their advice and the patient died. 
> 
>Another thing not raised is the timing of surgery - were the ID doctors hoping 
>for interval surgery or was surgery excluded entirely? We had a >similar case 12 
>months ago in a 27 year old. She wanted to go spend the holidays >with family and 
>comeback for surgery in a month. The ID doctor told her there were no clear 
>indications for immediate surgery. We said we would operate now or >when she came 
>back. She went on holidays to CA and a week later embolized to the worst of 
>places and is now blind in one eye. 
> 
>A Anyanwu 
> ----- Original Message ----- 
> From: Rwmfglycar at aol.com<mailto:Rwmfglycar at aol.com> 
> To: OpenHeart-L at lists.hsforum.com<mailto:OpenHeart-L at lists.hsforum.com> 
> Sent: Wednesday, February 07, 2007 6:45 AM 
> Subject: Re: [HSF] SBE and the Indications for Surgery 
> 
> 
> Dear Hal, 
> Lord Almighty! I cannot believe that any ID person could be so wilfully > stupid. It is years since a relationship between vegetation size and SBE 
>outcome > was recognised. 
> Joel Strom and I presented this at the AHA in 1982!!! See Circulation v66, > Supp II: II-103 1982. 
> Another publication was Am J Med 80(2) 165-171 Feb 1986. 
> Note that we published in medical not surgical journals. 
> Vegetations more than 1cm in diameter were associated with more >emboli, more 
> valve disruption and more antibiotic treatment failure. Your colleague > ignored a definite indication for surgery. He needs censure and education. 
> Bob 
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-- Ben Bidstrup FRACS FRCSEd FEBCTS 
Consultant Cardiothoracic Surgeon 
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