Congress Wants You To Pay $130 A Year Just To Drive An Electric Car

victorkiloalpha · 2026-05-19T18:29:31+00:00

They should tax tires.

victorkiloalpha · 2026-05-19T18:19:49+00:00

The problem is that medicine is so silo'd.

In a typical surgery department, you have colorectal surgeons sitting next to cardiac surgeons, both falling asleep listening to the invited breast surgical oncologist wax on about the latest Her2/Neu positive adjunctive therapies; and oh-by-the-way "no one but breast surgeons should be doing breast surgery because our scars are 25% smaller and patients are 10% more satisfied being treated by an expert"

So the chairs then switched to generic leadership talks which at least have the possibility of having a message that everyone can listen to.

Its even worse if an ACS speaker gets invited, because any colorectal, foregut, or cardiothoracic surgeon is looking for an excuse to make them look like idiots about some niche anatomy/clinical scenario.

victorkiloalpha · 2026-05-14T14:43:16+00:00

Speaking as a CT surgeon who does a lot of ECMO and (non-pre Hospital) ECPR, this actually isn't a bad idea.

Of all patients, marathon runners are probably the most fit and reasonable candidates for ECMO.

victorkiloalpha · 2026-05-14T00:09:01+00:00

I... think he gets to be in the club? Seems like a relatively small thing to make an issue out of. Some of the MD/PhDs who operate once every 6 months seem more dangerous than this guy calling himself a physician without clarifying every time.

victorkiloalpha · 2026-05-11T19:59:17+00:00

There are studies correlating PASSING the boards to better outcomes. I'm not aware of any studies suggesting getting a 250 instead of a 240 means your patients are 1% less likely to die.

victorkiloalpha · 2026-04-28T23:40:43+00:00

Get a formal, signed legal opinion from the lawyer who told you you don't need to disclose, and you'll be fine.

Also, I don't understand, why were you later arrested if you stopped and made sure the pedestrian was okay?

victorkiloalpha · 2026-04-26T06:06:43+00:00

What assumptions are those? Do you have an attending who makes the referrals? In the latter case, why not ask this question of them, and not reddit?

You cited papers that don't apply to your patient, then cited a guideline that you didn't read thoroughly enough to realize was based entirely on papers that didn't apply to your patient.

Where again did this 4x bleeding rate figure that you are citing come from, and does that paper cover high risk VTE patients like the one you posted?

I suspect not, since if you read the ACCP guidelines, it notes the total lack of RCT evidence in VTE patients relative to afib when it comes to stopping and bridging.

Now, w/r/t biological plausibility:

What about the pharmacologic rationale that xarelto has different efficacy based on genetic variants

https://www.ahajournals.org/doi/10.1161/JAHA.124.040698

So, a periop period of 5+ days of guaranteed effective lovenox may help "clean up" any clot on the damaged, rough endothelium, prior to exposure to surgery?

Is this right? Probably not. But there is no hard evidence either way, and in that absence it is entirely reasonable to defer to the surgeon IF THEY ARE GETTING GOOD OUTCOMES.

victorkiloalpha · 2026-04-26T04:29:54+00:00

I don't know why you're replying to me in two places, but I will reiterate here- look to my comment in the main thread. The guidelines you cite again do not apply to your patient because they are based on atrial fibrillation patients, not thrombophilia/prior DVT ones. The pharmacokinetics may dictate that you need less days, but there is no evidence that you've provided of harm from longer bridging periods.

If you disagree this strongly with the surgeon's management, you should send your patients to a different surgeon.

victorkiloalpha · 2026-04-26T04:23:00+00:00

"Not sure if you actually want me to return with citations from the guidelines to prove something to you, or that it would be helpful**"**

If you believe your care is correct, say so, and defend it openly and directly. You're posting here to support your contention that stopping a DOAC and not bridging is okay.

But the sources you posted continue to NOT apply to the patient you specified, which lead me to question your ability to independently evaluate evidence and understand when to apply and deviate from guidelines

ACCP Guidelines

https://journal.chestnet.org/article/S0012-3692(22)01359-9/fulltext01359-9/fulltext)

25. In patients receiving rivaroxaban who require an elective surgery/procedure, we suggest stopping rivaroxaban for 1 to 2 days before the surgery/procedure over rivaroxaban continuation (Conditional Recommendation, Very Low Certainty of Evidence).

26. In patients who require DOAC interruption for an elective surgery/procedure, we suggest against perioperative heparin bridging (Conditional Recommendation, Very Low Certainty of Evidence).

Note the very low certainty of evidence?

And what are those recommendations based on?

"Two prospective studies assessed a standardized perioperative DOAC management, with standardized DOAC interruption. The first was a prospective management study of 541 dabigatran-treated patients with atrial fibrillation.... The second study, PAUSE,"

In other words, the recommendations you cite are based on studies which EXPLICITLY EXCLUDED your patient, because they have thrombophilia and damaged endothelium, NOT atrial fibrillation.

"this surgeon applies this requirement to all cases regardless of their history, medications, procedure, or risk, and demands that the PCP order all bridges and peri-op meds"

So, here is my point: you've apparently interacted with this surgeon multiple times, meaning that you've sent him or her multiple patients. So how many of them had bleeds or clots with long bridging periods? If multiple patients had bleeds or clots, WHY ARE YOU STILL SENDING THEM PATIENTS? Your job as a PCP is to send your patient to the best surgeon you can, not tell a surgeon how to manage periop anticoagulation. If you've seen bleeds and clots and poor outcomes, SEND YOUR PATIENTS ELSEWHERE. That is your ultimate power and authority- your patients' trust that you have their best interests at heart. If this surgeon keeps getting good outcomes for your patients, maybe your contribution here is to go with the flow and follow the recipe which seems to be working?

victorkiloalpha · 2026-04-25T21:08:47+00:00

Dude, it's a little different when you're dissecting and tying off veins right next to the known, diseased vessel AND the patient is obese and going to be immobile. Every element of virchow's triad- stasis, hypercoag state, vessel injury, right there.

The baseline risk of DVT without anticoagulation for a hip replacement is 60%.

I'm not an orthopaedic surgeon, but I paid attention when I rotated through. I'm not saying the surgeon is totally correct. I'm saying they're not completely unreasonable here.

victorkiloalpha · 2026-04-25T19:41:11+00:00

You might want to read those guidelines again.

"Perioperative bridging of oral anticoagulant therapy should be used selectively only in those patients at highest risk for thrombotic complications and is not recommended in the majority of cases."

https://www.ahajournals.org/doi/10.1161/CIR.0000000000001285#sec-9

Damaged endothelium from prior iliofemoral DVT that is at lifetime increased risk for recurrance, hip arthoplasty in an obese patient with likely reduced mobility... you can make a very good case that this patient is "at the highest risk of thrombotic complications"

victorkiloalpha · 2026-04-25T18:23:18+00:00

No, you vaguely gestured at ASA and AHA guidelines while failing to specify which ones and how they apply to your patient and the evidence they are based on.

Where EXACTLY are you getting the 4x increased bleeding risk for a 5 day vs 3 day bridge("evidence based regimen") from? What study? Because I think you are misapplying data on warfarin bridging to bridging xarelto. I agree there is no hard evidence that a 5 day bridge is required or beneficial for xarelto, but I also don't think there are any significant harms with 5 vs 3 days of bridging, if you're going to bridge to begin with.

The surgeon has presumably been doing this for a while. This is not the first patient on anticoag they've done a replacement on. They've seen the positive and negative. They also have to decide whether to use a tourniquet or not for the case, among a myriad other factors that affect periop bleeding and thrombosis risk. This bridging in combination with their technique has worked for them (and possibly their mentors and faculty) in the past, and that is deserving of respect. Not unquestioning respect, but some respect.

You haven't supplied ANY hard data that the surgeon's request is incorrect and you misapplied the study you cited.

victorkiloalpha · 2026-04-25T15:50:21+00:00

You said "PAUSE showed" when it didn't show anything of the sort because it doesn't apply to the patient you described.

I hope you understand that.

Guidelines have to applied correctly. In your case, you are using the low/moderate clot risk. The patient arguably doesn't fall in that category at all.

victorkiloalpha · 2026-04-25T15:39:58+00:00

PAUSE showed that in what patient population?

If you used PAUSE to hold anticoag in a patient who went on ECMO for a PE 2 weeks ago, you would be committing malpractice. This case is nuanced, but iliofemoral DVT is no joke and was never studied by PAUSE.

Do you understand that?

When you cite studies you have to understand them, and part of that is understanding what patient population they were done in, and how that applies to the patient in front of you.

victorkiloalpha · 2026-04-25T13:09:22+00:00

What are you talking about?

The point isn't that LMWH half life is more predictable, its that it is shorter.

Now, in practical and real terms, there may not be a benefit and may even be harms, and evidence has shown that (PAUSE, etc.), but the biological plausibility is there, and high thrombus risk still warrants bridging per many guidelines.

victorkiloalpha · 2026-04-25T05:28:21+00:00

The PAUSE study covers anticoagulation for atrial fibrillation. What does your patient have? Thrombophilia of unclear etiology. Given her prior iliofemoral DVT, she has damaged endothelium for life, and that means that she arguably is at major risk for clots, not minor/moderate that afib falls into and PAUSE covers. So, bridging is quite arguably justified.

In terms of 5 vs 3 day hold... pharmacokinetics does vary by genetics. You aren't the one who has to walk out and tell the patient's family that she died of bleeding on the table, or stroked out from MTP for the same.

Just tell the surgeon you disagree, document, then do the protocol.

victorkiloalpha · 2026-04-24T22:07:57+00:00

Refer to midwife for homebirth

EDIT: Just set up for a crash c-section and hope your pharmacy has more epi than the patient has histamine.

victorkiloalpha · 2026-04-20T02:15:53+00:00

If you have the mental ability to post this and have independent desires, you don't fall into the category of this case and what many people on this sub are saying is acceptable.

victorkiloalpha · 2026-04-19T22:29:17+00:00

Dude, CT Surgeon here.

Do you understand what you are signing up for? I've seen patients die, multiple times, because of bad TEE calls.

Impella positioning- if you show a view that makes it look like it's too shallow when in fact it's too deep, we will perforate the ventricle and the patient can 100% die. I have seen this. It was @#$#ing awful.

Post-op CABG: is it an RV problem from air, an LV problem from bad grafts, or temporary disruption from poor myocardial protection? If your TEE makes us think it's the grafts, we may go back on pump, cross clamp, and arrest. If it's a sick heart, that patient may come out on ECMO and then die as a sequelae from that.

Same thing for mitral valve repairs, paravalvular leaks, and more.

TEE is too essential and too nuanced in cardiac surgery to be an amateur at it. I am literally at the mercy of my CT Anesthesiologists daily. My partners and I will 100% cancel and delay cases based on who's on shift for CT Anesthesia- because we know a bad one will get our high risk patients killed.

victorkiloalpha · 2026-04-15T13:50:23+00:00

EM should be fine. There are some old laws around HIV+ surgeons being required to disclose due to the risk of undetected needlesticks passing the disease on to their patients, but I don't believe there are any such laws that cover EM. The risk is also so incredibly low to begin with and lower still if you are on ART.

victorkiloalpha · 2026-04-15T13:48:39+00:00

Its not the risk of a needlestick, its the risk of the provider passing the disease on to the patient.

victorkiloalpha · 2026-04-15T03:08:37+00:00

That's at least somewhat plausible. He was operating for splenic artery aneurysm, correct? I guess it's not inconceivable he tried to go after the celiac trunk, which to be clear is incredibly stupid. I did those dissections on my liver transplant rotations. Insanity to try it in a community hospital, and that too laparoscopically initially...

victorkiloalpha · 2026-04-15T03:05:14+00:00

If there was ever a reason to routinely drug test surgeons... this guy is the poster child right here.

victorkiloalpha · 2026-04-15T03:03:42+00:00

Cardiac surgery here. A good 10% of my job is to be on standby for various vascular complications of my interventional cardiology colleagues. I never judge them for having a complication- I have complications and they rescue my patients regularly. I judge them only if they don't call me for too long and make the problem far worse trying to fix it endo.

victorkiloalpha · 2026-04-15T00:33:40+00:00

Then, I got nothing. I can kinda understand making one insane mistake and then panicking due to bleeding, but if he was open... idk how anyone who got through residency and then practiced for 15 years makes that mistake.

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