I'm sitting in the back again. All right, so this next talk is called the On-Call Call. And it's basically advice for what to do when you're on-call, all right? All right, it sounds like a pager. That phone does not sound like that. You guys have never used a phone that looks like this. You guys are way too young for that. All right, but this is my disclosures. I'm a consultant for Boston Scientific. All right, so first question, are you a black cloud? So choices are A, have you not been on-call yet? B, was on-call and got the best sleep ever. C, was on-call, got some calls, but didn't have to go in. Or D, was on-call, and you're still having PTSD from that night. Go. Oh, what's going on here? There's only like 30 of you guys in here? I think we've lost a bunch. All right, well, I'm moving on. Let's see. All right, so more than half of you guys have not been on call yet. That's pretty good. Most of our fellows have been on call with the exception of one, but we start them like right in there first day. Okay, looks like a quarter of you guys were on call, but didn't have to go in, that's good. And then unfortunately, 20% of you have already had a terrible call and you have three more years left, or like two years and 11 months left of fellowship. Hopefully it gets better. All right, now we've moved on to a flip phone, which you guys have still not used before. All right, so case one. It's your first night on call as a first-year GI fellow. At 6.05 p.m., your pager starts beeping. Is it a bleeder? Is it a food infection? Nope, it's a patient with a PrEP question. So many of you guys will be covering outpatients in addition to inpatients, all right? Everyone's fellowship's a little bit different, but if you cover outpatients, you're gonna get calls like this, okay? So the question is, doc, my colonoscopy is scheduled for tomorrow morning and I lost my PrEP instructions. What do I do? And so you obviously wanna be professional when you answer these calls. Core principles of great customer service, speed, accuracy, transparency, accessibility, patient-centeredness. And just remember in your words and your actions, you represent yourself as well as your attending and your institution. Another way of thinking about this, people talk about the three A's of being a consultant, right, availability, affability, ability. Different ways of looking at it, but the idea being you wanna be professional as a consultant. And we'll go through some of these characteristics. So the first one's speed, right? This is a simple graph that shows customer satisfaction versus resolution time. And the longer you have to wait, the more unhappy you are, right? So think about when you're on the phone, on hold with like the airline or your internet provider, the longer you wait, the more angry you get to the point where when a person picks up like 20 minutes later, you're already furious, right? If they picked up right away, you wouldn't be so angry, but because you waited so long, you're even more pissed. So just think about that when you're answering your pages and replying back. Obviously you guys will be busy, you might be in a procedure, you can't reply right away. But the longer you take to respond, the patients or your medicine teams might be getting more and more upset. In terms of accuracy, your answer should be correct. If you don't know, tell the patient, you'll get back to them and then make sure you do. So for example, doc McClennan asked me this tomorrow, I lost my prep, what do I do? You wanna know your preps and you wanna know what your home institution is using. Okay, so there's lots of preps in the market now. If you start giving instructions on one prep, it might not be relevant to the patient because they may be using a different prep. Even at your home institution may be difficult, right? Because even at UCLA, I know that our group uses Miralax and Gatorade. Other practices, even within UCLA, use Miralax or use GoLightly. So it's all different depending on the clinic. There are also patients who are very, like this is like third or fourth colonoscopy, they know it works for them. You may say, well, you're using Miralax, Gatorade. No, no, no, I'm using Suprep, right? And you may not know what that is or may not be familiar with what that is. So the idea being you should know what the home institution uses because that may be what most of your patients use, but then also be familiar with what your general prep instructions are for many of these other types. I'd also encourage all you guys at some point to try a complete bowel prep, okay? Sounds crazy, but I think you have a lot more empathy for your patients if you try drinking four liters of GoLightly, okay? It is salty, it is a lot of volume to drink in a short period of time. I tried it when I was a fellow. It made me nauseous because it's a lot of volume to drink, okay? And then currently next day, you have a lot of diarrhea too. So you gotta be sympathetic to that as well. My only caveat to that is if you're gonna do one, maybe just try the Miralax Gatorade prep, okay? Because I tried Suprep and GoLightly. And then years later, when I went to get life insurance, the life insurance company said, why did you have to take Suprep? Why would you prescribe Suprep and GoLightly at some point in your life? And I had to like explain to them what I was doing because life insurance will go back and look at all your prescriptions and any clinic that you have with the doctor before they give you life insurance. So they probably thought I had some sort of GI condition that was gonna be a serious issue for me moving forward. So if you're gonna get a prescription, be careful. Otherwise, Miralax and Gatorade are both over the counter and you can try doing the prep that way. But I would encourage you to try a bowel prep or at least taste some of these things because they're not great. Okay, none of them taste good. In terms of colonoscopy preps, there's split dose prepping versus evening before dosing. Again, check with your institution. I'd say split dose prep has become the standard. People drink half the solution or half the prep the night before and they drink the other half six to eight hours before their procedure. So that depends what time their procedure is, right? So if they're at 8 a.m. procedure, they're gonna be drinking their prep at two in the morning, right? If they are a 4 p.m. procedure, then they'd be drinking their prep at 10 a.m. around that time, right? So the time may vary depending on when your procedure is. I suppose the evening before, this is like the old school way where you drank four liters or go lightly the night before, right? Doesn't tend to work as well, but again, it really depends on what your home institution is doing. Sometimes you supplement the preps with bisacrylidol and then there's diet instructions, low residue diet for two days, clear liquid diet for one day. The question always becomes, what's a clear liquid diet, right? So the question is, Doc, is it okay if I have a sandwich with my prep? How about a kombucha? Enter is no, of course, right? So clear liquid diet, water, clear juice, soda, Gatorade tea, coffee is considered a clear liquid. Coffee is obviously not clear, all right? But it's mostly water, right? If they add cream, there's no longer a clear liquid, okay? So if they're drinking black coffee, it's okay. If they're drinking tea, it's okay. Otherwise you can tell them, you have to be able to read through the cup of whatever solution you're drinking, right? So you can read the newspaper on the other side of a cup, it's clear, except tea and coffee, which obviously are a little bit darker. And you can also have clear broth, jello, Popsicles and hard candy, but you can't have any red or purple drinks because that can look like blood. Alcohol, while it is clear, you don't wanna have inebriated patients coming into the hospital and then obviously nothing solid, okay? All right, so now the patient calls back and says, oh yeah, I'm diabetic too. What do I do about my diabetes and blood pressure medications? All right, so which should patients generally take on the morning of their, say, colonoscopy? A, glimepiride, I don't know what that is. Lisinopril, Prosegryl, fish oil. That's how long ago I did internal medicine. All right, go ahead and vote. Glimepiride, Lisinopril, Prosegryl, fish oil. And you guys are laughing now, but wait till 10 years from now, you guys are not gonna have any diabetes medications. All right. What do we got here? All right. So 83% of you said lisinopril. One person picked glinepiride. One person picked prosegryl. You guys can keep yourselves quiet. All right. The answer is lisinopril, okay? So in terms of medications, take all essential medications such as blood pressure medications, antiarrhythmics, and anti-seizure medications the morning of the procedure, okay? You can take with a small sip of water. That's totally okay. You encourage them to take these essential medications. But hold oral diabetes medications, morning regular insulin, and take half dose of long-acting insulin, okay? So no short-acting insulin the day of the exam, and that's because patients come in NPO, the patient's procedure gets delayed by a few hours, and they've been NPO for a long time. You don't want their blood sugars to drop. And so just hold the oral meds or any regular insulin in the morning on the day of the procedure, and again, take half the long-acting dose. Antithrombotic agents should usually be held, right? Aspirin does not need to be held, okay? This comes up all the time. Patients ask, aspirin never needs to be held. They can take it the day before, the day of, the day after, but you don't hold aspirin for anything. The AST recommendations you should look at and know these guidelines on the management of antithrombotics, antipylotic agents, and aspirin does not need to be held. It doesn't matter what we're doing, serine therotomy, dilation, EMR, but the other medications should be held for high-risk procedures, okay? All right, the patient calls back again. It's me again, doc. I just puked up some of this nasty stuff. Should I cancel my procedure? And again, core principles here. So patient vomiting prep. So again, if you try drinking a bowel prep yourself, you'll realize how much volume it is and how difficult it can be to drink all that volume, and you guys are like young, healthy people, right? So imagine being 70 years old, trying to prep for a colonoscopy. So one idea is to stop, give it 30, 45 minutes, allow some of the prep to go down, resume at a slower pace. You can try chilling the bowel prep. I don't know if it makes it taste any better, but maybe a little more tolerable. You can drink it through a straw, again, to bypass the tongue so you don't taste this salty solution. You try flavoring it with crystal light. These are just some ideas, suggestions you can make to the patient. You can also have them ambulate, again, trying to get some of this bowel prep moving through peristalsis. You can try taking prokinetics or prescribe some antiemetics to help them get through it. And maybe for the next time, have them change to another prep, all right, just a suggestion because there are less volume preps out there. There are ones that are more pill-based as opposed to volume-based. But these are suggests kind of for the next colonoscopy. All right, said, got it, thanks, Doc. And hopefully he made it to his next colonoscopy in the morning. All right. Case two. This flip phone goes off again. 10 p.m., you get a page from the ICU resident. Is this the GI fellow? Thank God. I have a patient with a GI bleed and my senior wants you to scope him now. This guy is having more problems than GI bleeding, but... All right, so you have to know the difference between emergent versus urgent endoscopy. So emergent is going in tonight. It's an emergency. Scoping as soon as the patient is stabilized. And then there's urgent, which is, here are my recommendations. I'll see you first thing in the morning. And then you can scope them 12 to 24 hours from now, okay? All right. So which does not require emergent endoscopy? A, a 35-year-old man with chest pressure and spitting up saliva after eating steak. B, a 63-year-old woman with ascites and vomiting blood. C, a 70-year-old man on Warfarin with red blood and blood clots per rectum with stable vital signs. Or D, an 85-year-old woman with distension and coffee bean-shaped loop of colon on KUB. Which does not require emergent endoscopy. All right. 30 responses. Great. I'm going to have to change your answers. All right. So a 70-year-old man on Warframe with red blood and blood clots per rectum with stable vital signs. Right? So patient's stable. Probably does not need an emergent procedure. All right, so here are some indications for emergent scope or emergent endoscopy. Overt major GI bleeding. And variceal bleeding, so there's a varix with the active bleed there. Bleeding post high-risk intervention, so a patient who's had an EMR or a sphincterotomy say a day or two ago. Food impaction or a foreign body, so here's a piece of chicken or a meat or something in the esophagus. And then a colonic volvulus. Right? So these are indications for emergent scoping or at least emergent evaluation. So if you get a call about one of these types of patients, you want to go in, evaluate the figure out what's going on, and let your attending know. So this is July, okay? Don't assume the resident has knowledge of basic GI bleeding management. This is also including the intern who's just started, right? So they may call you frantically because they saw blood, they don't know where the blood's coming from, but they saw blood, the nurse saw blood, someone saw blood, they're calling you, okay? That's typically how it works in the hospital. They may not recognize massive GI bleeding. So I would say early in the year, I felt very low threshold to evaluate the patient, okay? I can't really trust the intern or resident necessarily. When I was a resident, I thought I was a great resident, right? And then I became a GI fellow, and I'm like, these residents don't know anything, all right? I don't think I changed them. I was probably the same resident who thought I knew everything, it was probably, you know, the same GI fellow probably thought the same of me when I was a resident. So it's just different being on the procedural side of things and being a consultant than being on the internal medicine side, you know, in the hospital taking care of the patients. You may want to help them identify the source of bleeding, the history of NSAIDs, anticoagulants, any signs of cirrhosis, do you need to do an NG tube lavage? They're just kind of pointers to help figure out, you know, what needs to be done, where the bleeding could be coming from. So when you're talking to the resident or intern, you may want to ask specific questions, call me back with, say, some information or call me back if something happens, give some specific directions, what to do in what order. You'll quickly find out, for those of you guys who have not been on call, that GI bleeding becomes, like, you'll get this down, right? It'll become the same thing every single time to the point where...but in the first-year fellowship, there's like five consults you'll do over and over again. It's like upper GI bleeding, lower GI bleeding, food impaction, you know, the patient with, like, severe constipation, it's the same stuff over and over again, right? So, like, at some point, you'll get this down and you'll know what instructions to give the house staff, depending on the scenario. Trust but verify, if any doubts, assess the patient yourself. So for example, this is a patient with cirrhosis who started vomiting blood, is hypotensive, what should we do? So obviously, you may want to ask some questions. Where is the patient located in the hospital, do you think the patient should be in the ICU, are they appropriately monitored, are they having abdominal pain, is there a worry for perforation ischemia, free or unimaging, do we need to call any other services to help out managing the patient? So can the patient tolerate endoscopy? And I'd say there's so many things where until you guys do these procedures, right, and have understanding of what it takes or what it involves, it can sometimes be hard to figure out when's the appropriate time. You guys may be thinking, oh, yeah, I'm the GI consultant, I'm going to go in there and scope the patient and save the day, right? That's great. Like, you could think like the knight in shining armor is going to show up and save everyone. But the reality is you have to have things in place before you can do that, okay? So has the patient been resuscitated, right? They need IV access, they need to get blood, they need to get fluids. This may seem simple, straightforward, but they need to be resuscitated before you go in there, right? They're hypotensive on three processors before you go in, by the time you sedate the patient, they will tank, right? You cannot go in there until they've been resuscitated adequately for you to do your endoscopy. Do you have any cardiac disease, your ponens, EKG changes, does the patient need to be intubated, right? And again, it's not something we think about a lot in internal medicine, but once you become the physician doing the procedure, these patients can be really sick. If there's any concern for respiratory compromise, are they encephalopathic, altered mental status in the setting of their hypotension, then they may need to be intubated, right? Which means they need to have to be moved to the ICU, the ICU team or anesthesia needs to be called to intubate the patient. All that needs to be done before you go in and scope the patient, right? So as an attending, I would ask, try to get all that stuff done before I show up to the hospital, right? Like I don't show up to the hospital and be like, hey, Brandon, nice to see you. And now we're waiting together from 10pm to 1am in the morning for the patient to move to the ICU to get resuscitated, to get intubated, right? Try to get all that stuff tied up ahead of time so when I'm coming in, we can do the procedure to try to stop the bleeding, right? And also consider situations where the surgery or IR need to be contacted. Again, we think we can stop everything, all GI bleeding, but the patient not having severe hematochysia, right, if you guys put a scope and a patient's bleeding, you can't see anything, right? You guys have seen now the scopes, you know, tighten the lenses in that end of the scope. You put a patient just bleeding out, hasn't been prepped yet, you put the scope in, it's completely black on the screen, okay, you can't see anything, right? Forget washing, cleaning, you're never going to get anywhere. So that patient needs to be prepped in order to have a colonoscopy. If they can't get prepped because they're too unstable, then maybe they need to go to IR, right? Maybe they need an angio, not a colonoscopy, okay, despite the fact that they're GI bleeding and your first instinct is, oh my god, this patient needs to be scoped, right? So just some things to think about. And again, you'll get better and better at this because you'll see this over and over and over again over the course of your fellowship. All right, so here are some things. So you know what to do. You ask the ICU to intubate the patient, start large bore IVs, check labs, transfuse blood, start IV actreotide, IV PPI, IV antibiotics, like you got this thing down, you tell the medicine team, do all these things, I'll come and assess the patient, we'll go from there. Finally, they get all that done, you notify your attending, the GI staff comes in, you do the EGD, and you save the day by banding these esophageal apparatuses, okay? But I'd say endoscopy and GI bleeding, it's one of these things where like, if they're bleeding too much, you can't do anything, they're not bleeding at all, like they can probably wait. It's like this fine line in between bleeding and not bleeding, okay? Gotta like, gotta get in there like in between those two situations. Okay, so meanwhile, while you're managing this patient, you receive four more calls. Which is an emergent or urgent indication for ERCP? A, cholangitis without sepsis, B, a bile leak after a liver transplant, C, malignant biliary obstruction, or D, gallstone pancreatitis. Dude, where's the 30th fellow? One of you guys didn't answer the question. Okay, so we're kind of all over the place here. We got cholangitis without sepsis, bile leak after liver transplant, and then this gallstone pancreatitis. Okay. All right, so the answer is bile leak after liver transplant. Okay, in terms of urgent emergent ERCPs, when do you contact the ERCP team? So, in many hospitals, the ERCP team is different than the general GI team. It's a different tech who has skills in doing ERCP, not the general GI team that comes and do all the bleeders and the food impactions and the volvulus, okay? So obviously, you gotta make sure your attending says, okay, call the ERCP team in. But the two scenarios are cholangitis with sepsis. Okay, and you guys think cholangitis, this is bad, it needs to be emergent, but there are many times where patients have cholangitis or suspected cholangitis, they get antibiotics, and they get the procedure done the next day, okay? Say once a year or so, we get a patient who's got cholangitis with a white count of 30, 35,000, they're hypotensive, maybe they're on a presser in the ICU, like those patients, that patient needs to be done emergently. But for the most part, most patients who come in cholangitis can be done the next day safely, okay? As long as they're on antibiotics. And then the bile leak post-surgery, like most surgeons don't like having complications. We don't like having complications. We can fix their complication pretty easily with a stent. In this situation, this question was more about the bile leak in this liver transplant patient. Liver transplant surgeons are pretty demanding. You know, they don't like to have their transplant liver get affected or injured in any way. And so if there's a leak after a liver transplant, they often want us to go in and do something pretty quickly. And you wanna, you know, keep good relationships with your transplant surgeons, all right? Okay, any questions so far? GI bleedings, urgent ERCP indications. Okay, case three, 12.30 a.m., rough night. You're home and getting ready for bed. You get another patient call. I had a colonoscopy this afternoon. I'm having a lot of pain. Is this normal? Oh my God, it's still beeping. Okay, so think about this. Okay, so think about when was the procedure done, who performed the procedure, and make sure that the attending who did the procedure is notified either that day or the next day about this potential complication. You wanna look at the procedure report. What was done during the procedure? Was there a polypectomy, hemostasis, dilation, right? Things that are higher risk for complications. What's the coagulation status of the patient? And are there any alarm symptoms? And so here are reasons to send the patient to the ER, including but not limited to severe worsening or persistent pain, fevers, hematokizia, dizziness or fainting, altered mental status. The bottom line is when in doubt, send to the ER, okay? No one will ever fault you for sending someone to the ER. If you don't and they have a complication at home and they're getting worse, and you told them to stay at home, that can be pretty bad, okay? Look, none of us wanna have complications. We will have complications, unfortunately. It's the nature of what we do. It's an invasive procedure that we perform. You guys will have complications as well. But when you're a fellow, we are counting on the fellows to manage the patients, right? You guys are our front lines. You guys wanna get the page. We are expecting you guys to triage the patients appropriately and hopefully let us know in a timely fashion about our potential complications, okay? And then when you guys become faculty members and you guys have fellows, you expect the same from your fellows, okay? It's kind of the circle of life. But you can't triage over the phone very well, okay? Just in general, not like you guys. Like, patients are in pain, you're not sure what's happening, just send them to the ER so they can get worked up, okay? Just have a very low threshold. If they've had a procedure and have some sort of complication, bleeding, pain, just tell them to go to the hospital. All right, question. Significant discomfort is not expected after which intervention? PEG placement, that was your last talk. Variceal banding, esophageal stent placement, or biliary strength automy? 30, yeah, we hit 30 this time. All right. Well, biliary scinthorotomy, 50%, that's good. 30 guys said variceal banding. All right, that's good. That's better than the last group. The last group had, most people picked variceal banding. And the answer is biliary scinthorotomy, okay? People can definitely have pain after a PEG placement, okay? The PEG, you're creating a hole in your skin, okay? So I take a knife, a scalpel, and I poke you in the abdomen, that's gonna hurt, okay? So just because you got a little bit of lidocaine does not mean it's not gonna hurt when you wake up, okay? Just be realistic about this. Variceal banding, a patient will complain of pain after they get banded, because you're from kind of pulling the esophageal mucosa real tight. Esophageal stents can cause a lot of pain. There are patients who can't tolerate it and want it taken out because it's so bad. But biliary scinthorotomy should not cause a lot of pain. Obviously, if they have a lot of pain after ERCP, you should be worried about another complication, which we'll talk about. But scinthorotomy itself should not cause a lot of pain, okay? All right, so review the patient's colonoscopy report. There's one large 10-millimeter ascending colon pulp, which was removed with hot snare cautery. So post-colonoscopy pain, the differential diagnosis includes stretch pain from luminal distension. That's just from the air that was put in during the procedure. Perforation, right, that's the dreaded P word. One in 10,000, okay, it's pretty low risk. Colonoscopy is pretty safe, even with first-year fellows doing the procedure, okay? It's really hard, I don't wanna say really hard, but it's pretty hard to perforate, okay? You have to really try to perforate. It's just not that common. And hopefully it doesn't happen to you guys in your first year, okay? But it's not that common. There's post-polypectomy syndrome, which this patient likely has, which we'll get to. And then there's these rare complications, mesenteric tears or splenic ruptures, very uncommon, but you may see them actually during your training, but they're not that rare. Send the patient to the ER, the CT scan shows no perforation. So the patient is treated for post-polypectomy syndrome with liquid diet and antibiotics, right? So post-polypectomy syndrome, basically using a lot of cautery during the procedure. That cautery can cause a transmural burn through the colon wall, and for you and for the patient, it looks like a perforation. They have peritonitis, they have severe pain, is after a colonoscopy with a polypectomy, your concern is perforation, perforation, perforation. And when you see that there's no free air, you can kind of take a deep breath and say, oh, this is just post-polypectomy syndrome. You can pretty much treat them conservatively and get away with it, okay? All right, you get one last call from a patient who had an ERCP earlier. Which of these, which of these are the correct rates of post-ERCP complications? A, pancreatitis, 5%, perforation, 3%, post-anthrotomy bleeding, 8%, or bile leak, 1%. Which of these are correct rates of post-ERCP complications? All right, let's check. Pancreatitis, good. So pancreatitis, 5%. No one picked perforation. Good job, guys. OK, if perforation rate was 3%, I would retire from doing ERCP. So pancreatitis rates, 5%. So these are complication rates of ERCP. Obviously, you get pain from luminal distension. Pancreatitis rates usually less than 7%. That depends on the patient population, right? So if you have a young, healthy woman, syncthovotid dysfunction, the rates are about 15% to 20%, right? But for all comers, somewhere around the 5% range. Post-synchthorotomy bleeding rates are pretty low, 1% to 2%. Here's a picture of a post-synchthorotomy bleeding. And then perforation, less than 1%, right? It's pretty low. OK, so general principles. Assume there has been a complication until proven otherwise. OK? Communication with the attending are appropriate and essential when a complication is suspected. Then make sure you notify other specialties early in the process when indicating, including surgery and your IR colleagues. OK? And by 3 a.m., you get to go to bed. All right? And he's falling asleep now. Any questions about the talk? No questions? All right, fill out this question, and then when I get to 30 responses, I'm going to take a look. Just kidding. All right, that's it, guys. Thank you.

on-call management

patient triage

emergency handling

GI bleeds

ERCP complications

post-procedure complications

gastroenterology practice