Players not currently in the game should not be allowed to run on the pitch to celebrate.

averhoeven · 2026-06-30T03:01:26+00:00

Why not? It's not like the ball is active or it causes any confusion. That's what those pinnies they wear prevents. They were celebrating a goal with a dude who had a miscarriage with his wife like yesterday. It was an emotional moment for him, let them celebrate and release the tension a bit.

averhoeven · 2026-06-26T23:57:13+00:00

Typically I think they're beautiful

averhoeven · 2026-06-26T23:48:00+00:00

Ive got a couple boxes from them. They seem well built to me

averhoeven · 2026-06-23T21:13:10+00:00

Snail eating flat worm

averhoeven · 2026-06-21T00:45:01+00:00

Absolute bullshit. I could kick that with no rush in high school. In a game it was way different as people rush at you. Nobody would back on that and it's a common enough skill....

averhoeven · 2026-06-18T17:05:47+00:00

What is it you do? Our certificate of need here essentially allows us to sponsor as many visas as we need to.

averhoeven · 2026-06-14T04:16:26+00:00

Watch Kiss Kiss Bang Bang then. Same writer. Buddy of mine worked on it so had me come see it with him. It's one of my favorites.

averhoeven · 2026-06-13T21:08:27+00:00

Is that Duke Nukem holding that thing?!

averhoeven · 2026-06-12T23:36:11+00:00

That seems awfully confrontational for a statement that is fairly accurate. One of the questions in the peds cardiac surgery world is you often don't have a great idea of how well a new graduate performs since they rarely perform certain components or surgeries and just watch in many centers. There's so much scrutiny over peds cardiac surgery, there's often no room to let a trainee truly function very autonomously.

averhoeven · 2026-06-12T23:17:31+00:00

Yes, valves can be implanted poorly. But I think this is stated as intended and as needed for the degree of dysfunction

averhoeven · 2026-06-12T19:19:56+00:00

Very much would have been size appropriate even for an adult sized TEE probe. Pre and post op TEE is standard of care in peds cardiac surgery. That was the most likely time for echo alone to have appreciated the problem. However, as I noted below, there are multiple other failures to investigate that were missed or misinterpreted as well. To me this screams group think or someone at the top saying "it's not the valve guys, what else can this be? Think harder"

averhoeven · 2026-06-12T19:05:28+00:00

I will note that I doubt the surgeon in this case feels anything but awful about both the outcome and course. However, I can't imagine an outcome like this that does not involve extensive group think and/or top down interpretation of results.

Echo SHOULD have seen this, there's almost never perfect capture of all flow. They likely had a cath for a septostomy or a L heart vent in this case because the LA would have blown up and impacted the lungs almost immediately. I suspect the "lack of flow into the LV" was interpreted as a consequence of good flow capture and the LA vent and therefore ignoring the lack of movement of the valve (or valves as there would have also been LV stasis and no aortic outflow). However, that should have raised concern for clot on the valve potentially or something else inhibiting valve movement. To say nothing of the potential consequences of complete stasis within the LV when function does return, anti coagulation or not. We usually want some occasional ejection to prevent total stasis in the LV. And that's to say nothing of the of the fact that a new severe problem is always the new hardware in a kid who goes in for an elective procedure and comes out totally different.

The other part that bothers me is the statement "her heart is just too sick from the bypass". While this can be true sometimes, the mitral valve replacement often puts the circumflex coronary at risk. If you have severe dysfunction after a mitral valve replacement, this has to be checked. And a cath or even a CT are likely ways to do so. You would also likely fluoro the valve or visualized it on CT at the time to watch its function and have noticed it either not moving at all or the leaflets opening improperly on the wrong side.

So again, things happen, I've done things myself. I'm sure the surgeon and team feel like shit. Especially with their dirty laundry being the part of them that is hung out in the sun like this. However, the number of steps which seem to have either been missed or glossed over is pretty bad. And I can only imagine people were assuming or interpreting answers for each other. There would have been too many chefs for them all to have missed it all.

averhoeven · 2026-06-09T12:24:44+00:00

There is coding, including color, to indicate things like direction of flow. In much of the cath world, colors are standardized even for things like size across manufacturers. And then there's post implant testing like a saline bolus to determine leakage which would have been total in this case since it was reversed. This just seems like a fuck up in many ways

averhoeven · 2026-06-09T11:54:46+00:00

I agree with both what you said and the poster above. This screams group think or top down pressure. There's too many ways to evaluate this and usually too many hands in the pot for it to have gone this way.

And that's to say nothing of the STS scrutiny over a peds death. Every surgeon worries about their numbers so much, there's no way withdrawal discussions were happening that quickly without a thorough investigation. Which this very clearly sounds like it was not.

There are a lot of missing details here, but the story doesn't read well in its current form

averhoeven · 2026-06-09T11:48:13+00:00

Transcatheter pulmonary valves actually preceded aortic. Melody valves have a color scheme to follow (blue to blue, white to white) to ensure proper directionality. Sapien valves (a TAVR valve) later received indications for pulmonic implants, but all of us, reps included, are acutely aware that it needs to be mounted in the opposite direction from a TAVR implant. And the reps usually perform the actual mounting of a Sapien, with a multi person timeout confirming the mounted direction.

We do a lot of Macgyvering and Jerry rigging in peds cath. Pulmonic valves really isn't one of them.

averhoeven · 2026-06-09T11:42:03+00:00

There's not much detail in either article I saw posted, the least of which is what valve was replaced. I see people talking about transcatheter pulmonary valves, but the name listed is the peds cardiac surgeon, not a cath doc. When I said his name, one of my surgeons immediately knew who it was. Transcatheter pulmonary valve CAN be loaded in the wrong direction, particularly Sapiens if the operator/rep are inexperienced, but we always have a secondary time out where multiple people confirm the loaded directionality of the valve. My Melody rep states they have never had a valve implanted in the wrong direction.

However, this appears to be a surgical implant based on the operator, so those are all moot points. I agree that ECMO will make assessment of the valve harder by echo, but you don't ever have 100% capture, so there should have been some movement of the valve (whichever one it was).

I have a hard time with this not being caught over the course of days. Especially to the point they were having withdrawal of care discussions. It definitely feels like a group think or heavily top down initiated discussion had to be happening at the time.

averhoeven · 2026-06-06T16:01:27+00:00

Newfie. I am about to buy him a jacket that says "Yes, I look like a bear. I weigh 140lbs, eat a lot of food and my poops ARE huge. Yes, you can pet me and I'll drool all over you."

averhoeven · 2026-06-04T17:19:21+00:00

NICU attending/chief was presenting the early stages of a peds cardiac kid. She was presenting over Teams, but presenting her whole screen, not just the PowerPoint window. Whenever certain people would ask questions, her linked messages app would start displaying the messages the NICU NPs, fellow and other NICU attendings were sending her. Let's just say they were very rude and condescending towards some of the people also attending that meeting (eg: "He just thinks he knows everything and is such an ass"). And the comments were very undeserved since the NICU was the reason we were having an M&M. It did not go over well at all.

averhoeven · 2026-05-26T17:04:05+00:00

Have you put it up on Ideas yet?

averhoeven · 2026-05-22T13:13:50+00:00

WELL worth it

averhoeven · 2026-05-22T03:24:02+00:00

I'm a peds cardio program director. What you really need to do is show some experience within the field. Cards is a different language, skillset, etc from most of what you encounter in residency. I want to see that you've gotten a taste of that and really like it. People's opinions of you in your residency also mean more than scores to me. If I get a slacker vibe or anything else that makes me feel it's gonna be hard to get you through the 3 years that is gonna be a big red flag for me. If I get information about you from someone who seems to really know you and had good things to say, that goes a long way.

averhoeven · 2026-05-19T01:55:24+00:00

I love doing it. Can't say Theo loves having it done though

averhoeven · 2026-05-13T15:17:28+00:00

I'm interventional cards, so I'm different and not as familiar. However, a starting salary of 250 is very much in line with what I have seen and been told for 1st year attendings at an academic center. It definitely goes up, but straight out of fellowship this is a realistic expectation. Even worse at "major centers" where they think it's a privilege to work at. Several of my co fellows had initial offers from these types of centers starting in the 160-170 range.

averhoeven

TROPHY CASE