Sid,

Thanks for the testimonial...

> 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. 

I agree there is no evidence in that setting.  It's not something I would 
care to study.  Nobody knows what the real threat of DVT is, after all 
these years of study (Seavitt and Gallagher autopsy studies are still the 
classics...but seriously limited in a clinical sense.)  Leaving out the 
arguement about legal liability (which apparently is a "false" issue that 
leads to many ER Docs getting Duplexes for cellulitis!), if someone come 
to the ER with a good history for DVT, they should be diagnosed and 
treated, regardless of the inconvience.  (The old appraoch used to be 
admit and treat with heparin and get a study in the morning...a 
particularly reprehensible concept to me.)

> 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.

I imagine you have, but I understand your point.


But what I am hearing from the techs is not so much a complaint about 
work (although I can't believe a lab that is open 7 days a week still 
wants people to take call at 1.75$ an hour!), but complaints over 
unnecessary tests!  I find it horrible that cellulitis gets Duplex 
scans!  I can see their frustration!  (One Doc in our ER gets an 
ultrasound of the abdomen on every abd pain--r/o AAA, R/o 
appendicitis---take a god-damn history and do a physical exam!!!)

Here, we have just merged our hospitals and physician group.  
Accountability has been bantered about.  I hope that this setting will 
really provide a mechanism to point out the errors in patient management, 
from a cost basis if that will get there attention (ie, it cost more for 
you to work up cellulitis than everybody else so you change or get paid 
less!).  education apparently hasn't worked for many of our colleagues.  
Unfortunately, what happens in most systems is the Doc orders the 
unnecessary test, it gets done, and the insurance company doesn't PAY the 
LAB (who's people had to get out of bed and drive in to do the study!)  
That's crazy!!  The Doc gets off and, in fact, his behavior is "enabled" 
sincethe patient didn't have a DVT and they'll never see the patient 
again to hear the complaints about the insurance not paying.  Although I 
won't be e-mailing this to my Senators, I think, that the system as 
outlined may lead to change.  (I think it is better that Docs make these 
changes and behavior modifications rather than insurance companies...)

> 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. 

I agree for the most part.  Except I see an emerging role for Duplex in 
trauma, particularly carotids, which may avoid an angio (in our place a 
carotid angio costs $ 6,000!).  I think that we are close to eaqually the 
information gained (or exceeding it since we get physiology) from 
arteriography, a position not popular with our Radiologists.  (carotid 
surgery is the best example!)

> 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! 

I agree and all our residents can do that. (We particularly like Kaj 
Johansen's study regarding peripheral trauma and ABI's!)  I also see us 
integrating our residents into ultrasound training, especially for more 
general surgical--imaging only--problems, but that's another story. (we 
currently use US for blunt trauma to the abd, performed by the trauma 
Docs and ER staff)

> By the way, I'll be at the Einstein vascular meeting in NYC this November.
> Perhaps we could meet and talk then.

Nope.  But feel free to visit us up here in God's country anytime!
BTW, are things a little wet where you are?

MAR

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Michael A. Ricci, MD			
Assistant Professor of Surgery			Phone:  (802) 656-8455
Vascular and Transplant Surgery			FAX:    (802) 893-0305
University of Vermont College of Medicine

Office: FAHC-University Health Center Campus
	One South Prospect Street
	Burlington, VT  05401
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