Date: August 23,1995
From: Sid Holec, med dir venice hospital vasc lab
Address: [log in to unmask]

Dear MAR:
I have long enjoyed, admired and shared many of your opinions but I strongly
disagree with your response to the hypothetical situation you pose (aka the
"mother" test).
I love my mother and I would send her to the VHVL 0730 the next morning
because I know there is no scientific evidence to support "stat" venous nis
in this setting. Furthermore, I practice what I preach as this is also the
practice of our vascular lab. I have taken (and continue to take) substantial
heat for this position but until there is a study that shows it makes a
difference, the decsion stands.
As long as I have the floor, let me also say that there are also few vascular
surgical "arterial" emergencies after hours that require a nis instead of
direct surgical attack and/or direct angiography. When I personally think
that rare case needs the afterhours nis, ie, arterial test, I usually roll
the machine down to the er and do it myself! More often than not, I do what I
expect my fellow clinicians to do--I make the best clinical decision without
the nis.
Let's "talk" more as I suspect my rigid stance could use some modification as
could yours. 
By the way, I'll be at the Einstein vascular meeting in NYC this November.
Perhaps we could meet and talk then.

I remain a big fan of yours,
Sid Holec
Venice, FL



From:  [log in to unmask]
X-From: [log in to unmask] (Michael A. Ricci)
Sender: [log in to unmask]
Reply-to: [log in to unmask]
To: [log in to unmask]


Let me pose a question, from someone who does not order unnecessary tests:

YOUR mother has a swollen leg for two days. She has a history of 
diverticulosis and had a DVT years ago.  She was up alot the last few 
days preparing for the Church bake sale.  But her leg aches a bit now.  
She tells you this at 9 pm when you call her after just returning from 
the ER doing a DVT study for cellulitis. You tell her she better call her 
Doctor who sends her to the ER.

Now, the appropriate response is:

1) admit her to the hospital, put her on heparin

 Then, an US the next day shows a DVT

  OR

 It shows a normal study and after a night of bedrest her leg is 
 not swollen and feels better

2) US her in ER and follow one of the two outcomes above based on US.


The reality of the situation is that it simply is not good patient care 
to put people on drugs that are potentially life threatening (not to 
mention subjecting them to all the pain involved with IVs etc) because it 
is inconvient to do an US.

It is clearly not cost effective.

Just wanted to supply my perspective...

MAR