Cardiac Stent + Elective Case

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Planktonmd said:
So, let's say you work at a surgery center and you do a lot of plastic and cosmetic surgery, would you refuse to provide anesthesia to these patients unless their surgery had a medical indication and no serious side effects?
and if you do, how long you think you are going to remain employed?
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Plastic surgery isn't outside the standard of care.

Really, you're overthinking this.
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pgg said:
Plastic surgery isn't outside the standard of care.

Really, you're overthinking this.
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So, it's OK to provide anesthesia to an old patient with multiple comorbidities for her vaginal rejuvenation or her 7th face lift , but it's not OK to do medically indicated knee surgery on a patient with a DES although both patients understand the risks and consent for the surgery?
 
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Planktonmd said:
Patients have the right to make decisions regarding their health care and your role is to provide them with the information necessary to make these decisions in an educated way.
For example if a patient decides to be DNR and you find yourself in a situation where you know that intubating that patient would save his life you wouldn't violate his wishes and intubate him would you?
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Exactly! Once a patient is presented with a detailed discussion of all the risks vs benefits of the various options s/he has, the consequences of any decision s/he takes should be his/her own fault. As long as the consent was truly informed, and there was no egregious error on the part of the physician, there should be no repercussions, not even the possibility of being named in a malpractice suit. That's how it is in any normal society.

We have to make up our mind: are American patients independent adults, or do they need tutelage? Because if it's the latter, maybe they shouldn't be allowed to vote either, not to speak about being part of a malpractice jury (which uses exactly the same intellectual skills as an informed consent).
 
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I've done my fair share of what I think are basically pointless cases on healthy patients or otherwise.

However there aren't guidelines/recommendations/standards of care etc. that dictate what is or isn't a useless procedure on an "old person with co-morbidities". On the other hand there are recommendations and data to support waiting a certain period of time before doing an elective case after a cardiac stent.
 
Planktonmd said:
So, it's OK to provide anesthesia to an old patient with multiple comorbidities for her vaginal rejuvenation or her 7th face lift , but it's not OK to do medically indicated knee surgery on a patient with a DES although both patients understand the risks and consent for the surgery?
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The old crone won't be substantially medically optimized a few months later.

The guy with a sore knee WILL be lower risk a few months later.

Next question.
 
That wasn't his point, I think.

We see so many useless plastic surgeries, it's bordering shamanism. Tummy tucks on BMI 18 patients, face implants at age 30 etc. Not to speak about all the worthless back surgeries, with proven negative outcomes (same **** as physical therapy after 1 year). There is nothing more ethical about these than letting a competent adult decide that he'd rather risk a heart attack than wait another 3-9 months in excruciating pain.
 
Let's back up and maybe put a couple bags of concrete around the goalposts so they quit moving so much ...

Weren't we talking about risk management and the timing of an elective case?

The question of whether or not a person with some flavor of body dysmorphic disorder should have elective plastic surgery AT ALL is entirely different than the question of WHEN to do elective surgery in a patient who has a fresh stent that will be at markedly lower risk of rethrombosis in just a few months.
 
Except that the former does not need surgery at all, while the latter has the IQ to compare risks vs benefits.

I don't see why the first is acceptable and the second is malpractice at the same time. I must have eaten too much seafood. :)
 
It's never our decision IF a patient needs surgery or not. 30 yo with occasional upper extremity numbness who hasn't tried ESI... Do they NEED an ACDF? Doubt it but I don't know. I'm not a neurosurgeon. 90 yo who's stroked out living in nursing home with colon CA.... Do they NEED a colectomy? Doubt it but I don't know. I'm not a surgical oncologist. Does a kid who swallowed a coin NEED rigid esophagoscopy at 3 am or could you give it a few hours to see if it moves along? Doubt we need to go to OR right now but I don't know. I'm not a pediatric surgeon.

What I do know is that agreeing to perform an anesthetic on anyone for any elective procedure when there are clear recommendations about what to do when a patient has a cardiac stent and you violate those well documented recommendations you are asking for trouble.
 
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IveGotTwins said:
It's never our decision IF a patient needs surgery or not. 30 yo with occasional upper extremity numbness who hasn't tried ESI... Do they NEED an ACDF? Doubt it but I don't know. I'm not a neurosurgeon. 90 yo who's stroked out living in nursing home with colon CA.... Do they NEED a colectomy? Doubt it but I don't know. I'm not a surgical oncologist. Does a kid who swallowed a coin NEED rigid esophagoscopy at 3 am or could you give it a few hours to see if it moves along? Doubt we need to go to OR right now but I don't know. I'm not a pediatric surgeon.

What I do know is that agreeing to perform an anesthetic on anyone for any elective procedure when there are clear recommendations about what to do when a patient has a cardiac stent and you violate those well documented recommendations you are asking for trouble.
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But an expert cardiologist told you it's OK to do it... and you are not a cardiologist!
 
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pgg said:
The old crone won't be substantially medically optimized a few months later.

The guy with a sore knee WILL be lower risk a few months later.

Next question.
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pgg said:
Let's back up and maybe put a couple bags of concrete around the goalposts so they quit moving so much ...

Weren't we talking about risk management and the timing of an elective case?

The question of whether or not a person with some flavor of body dysmorphic disorder should have elective plastic surgery AT ALL is entirely different than the question of WHEN to do elective surgery in a patient who has a fresh stent that will be at markedly lower risk of rethrombosis in just a few months.
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Obviously you feel that the patient's educated choice and the opinion of the consultant cardiologist are not a factor in you decision... in the real world of private practice this is not how things usually work.
 
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Oh, I would consider their opinions, and then politely dismiss them, because they're wrong and I'd be the expert who's, you know, actually responsible here.

I am of course an advocate for patient autonomy and will bend over backwards to accommodate reasonable and safe requests and preferences, but doing major elective surgery on a patient with a new DES who stopped his DAT isn't reasonable IMO.
 
I did a case as a resident where patient was about 4 months pose DES placement. He had stopped ASA and plavix for the case, and it was elective but necessary for him to continue working. Kicker was patient was himself a cardiologist. Following lengthy discussion, case proceeded following 325mg of aspirin.
 
Planktonmd said:
But an expert cardiologist told you it's OK to do it... and you are not a cardiologist!
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My examples were illustrating surgeons deciding to perform surgery in cases which are suspect or questionable. As an anesthesiologist I'm not in a place to decide when and if someone needs to have a particular procedure.

In your above example you're suggesting that a cardiologist can decide if it's ok to have surgery/general anesthesia? The risk of which he/she is not incurring.

Apples/oranges.
 
IveGotTwins said:
My examples were illustrating surgeons deciding to perform surgery in cases which are suspect or questionable. As an anesthesiologist I'm not in a place to decide when and if someone needs to have a particular procedure.

In your above example you're suggesting that a cardiologist can decide if it's ok to have surgery/general anesthesia? The risk of which he/she is not incurring.

Apples/oranges.
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The surgeon also wanted to do the surgery, didn't he? and you are not a surgeon are you?
 
Planktonmd said:
So, it's OK to provide anesthesia to an old patient with multiple comorbidities for her vaginal rejuvenation or her 7th face lift , but it's not OK to do medically indicated knee surgery on a patient with a DES although both patients understand the risks and consent for the surgery?
Click to expand...

I agree its not apple and oranges. The surgical reasons a surgeon wants to perform a surgery is between him and his patient. The medical reasons an anesthesiologist permits a surgery is between the anesthesiologist and his patient.

I think a better question would be:

Is it ok for an 80 yo pt with multiple comorbities to do a TKA? How about a vaginal rejuvenation?
If optimized, Yes and Yes

Is it ok to do a TKA on a pt that is 3 months s/p DES cardiac stents? How about for a vaginal rejuvenation?
If they are both purely elective: No and No.
The level of nastiness of her vagina should not influence your decision.
 
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NOsaintsfan said:
Is this the type of fellowship you guys are talking about?

www.tulaneanesthesiology.com/web/default.asp?id=fellowships
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What a joke. People can learn all of that with private practice experience and maybe a couple of weekend classes (even the ASA offers some). Not to mention the lost income from another year unemployed.

The biggest joke:
"On clinical days, the fellow is expected to staff the operating room, supervising both CRNAs and residents."
Basically saying were gonna give you 10 dollars an hour to do something you should already know how to do for 200/hr.
 
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RxBoy said:
I agree its not apple and oranges. The surgical reasons a surgeon wants to perform a surgery is between him and his patient. The medical reasons an anesthesiologist permits a surgery is between the anesthesiologist and his patient.

I think a better question would be:

Is it ok for an 80 yo pt with multiple comorbities to do a TKA? How about a vaginal rejuvenation?
If optimized, Yes and Yes

Is it ok to do a TKA on a pt that is 3 months s/p DES cardiac stents? How about for a vaginal rejuvenation?
If they are both purely elective: No and No.
The level of nastiness of her vagina should not influence your decision.
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You and I agree. My point was that indications for surgery are not our purview. Determining a patients fitness for surgery is our decision. This was the apples/oranges comparison I was making.

We can choose to agree or disagree with a cardiologist who "clears" a patient for surgery. It is not their decision if a patients is fit for surgery. (Plus they aren't incurring the risk)
So based on current recommendations I do not think a patient who presents for ANY elective procedure and is less than six months post DES on DAT is fit for surgery.

The surgeon's decision to post the case may or may not be based on sound judgement and reasonable indications; it doesn't matter if the patient is less than 6 months post DES.
 
The discussion was about the ethical problem of letting a patient assume risks for herself. I am a libertarian by nature, so my vote goes to yes. Self-determination means that, if given all data, any adult should be allowed to decide the amount of risk s/he wants to take.

When we let people jump out of airplanes with parachutes "for fun", we ask that they sign a waiver, and that's it, although they could DIE! Why can't this happen in medicine: "I have been informed that I could have a heart attack and even die on the table, if I undergo this surgery just 3 months after my stent placement, but I still want it now. Signed: Patient John Doe"? What's the big philosophy here? Why doesn't a document like this waive any rights to sue for malpractice, in case of complications (such as death), except for egregious incompetence? Because that's how it would happen in 90+% of the countries in this world. Just sayin'...

(The answer to my rhetorical question is that the US is the only country I know about where one cannot waive one's rights to sue for malpractice, not even in exchange for free care.)
 
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FFP said:
The discussion was about the ethical problem of letting a patient assume risks for herself. I am a libertarian by nature, so my vote goes to yes. Self-determination means that, if given all data, any adult should be allowed to decide the amount of risk s/he wants to take.

When we let people jump out of airplanes with parachutes "for fun", we ask that they sign a waiver, and that's it, although they could DIE! Why can't this happen in medicine: "I accept I could have a heart attack and even die on the table, if I undergo this surgery just 3 months after my stent placement. Signed: Patient John Doe"? What's the big philosophy here? Why doesn't a document like this waive any rights to sue for malpractice, in case of complications (such as death), except for egregious incompetence? Because that's how it would happen in 90+% of the countries in this world. Just sayin'...
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I think understanding the risk of gravity plus high altitude is far easier to grasp versus deciding to undergo surgery unoptimized. No matter how extensive the discussion in pre-op holding it isn't enough.

If I actually thought the consent for anesthesia would protect us from retribution in the theoretical scenario I would be more inclined to move forward.
 
IveGotTwins said:
If I actually thought the consent for anesthesia would protect us from retribution in the theoretical scenario I would be more inclined to move forward.
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It doesn't. And that's the real reason no American anesthesiologist in her right mind would go ahead with this.

In this country, one cannot waive one's right to sue for medical malpractice, not even in exchange for free care.
 
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