Note says "cleared for surgery" (gasp)

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jetproppilot

jetproppilot

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Med student/resident colleagues out there in virtual land,

THIS IS A TRUE STORY.

From a private practice dude.

Starts pretty easily.

Dr. Periosteum, a.k.a. ORTHO STUD, has an add-on hip fracture.

Patient is in the ICU.

Ortho stud has five cases and wants to follow with this "add on".

No big deal.

This s hit happens every day. Part of our routine.

So I mosey over to the ICU to pre-op the dude....something we all do routinely during a normal work day....pre-op add-ons....usually very routine...usually you're documenting stuff thats important for the surgery that you know is gonna happen since.....uhhhhh....

I'M JET.

I don't cancel cases needlessly.

And, uhhhh, colleague residents, theres alotta "NEEDLESSLY" you're learning right now during your training that really doesnt need to be cancelled.

I walk into the ICU and find the dude.

When I do a pre-op, I like to try and make myself unbiased, so I SEE THE PATIENT FIRST, WITHOUT LOOKING AT THE CHART.geez thats another great subject but its not for here...

I try and talk with the dude but its useless.

Patient is an 82 y/o gentlemen who is not responsive to person, place, or time.

Lost to medical surveillance years ago, when he had a history of hypertension, and COPD from THOSE BAD A SS MARLBORO REDS INNA BOX....

SO JET WALKS INTO THE ICU, FINDS DUDE, TRIES TO TALK WITH HIM, DOESNT WORK, JET REVERTS TO OBJECTIVE DATA AND HERES WHAT HE FINDS:

82 YEAR OLD DUDE, S/P FALL.

Hip fracture which is, uhhhhh, why I'm in the ICU right now.

I start sifting thru the workup......

HOLY COW....this is why we do pre-ops....

I sift thru the chart....in the consults section I see a note from the cardiologist that says CLEARED FOR SURGERY.

Thats all it says.

CLEARED FOR SURGERY.

Followed by a signature.

🙂lol🙂

RESIDENT COLLEAGUES, PLEASE "CLEAR" YOUR OWN PATIENTS.

I am quoting Mil when I say anesthesiologists "clear" patients. Noone else.

We all see the "clearances."

So, uhhhhh, I'm in private practice where most clearances are helpful.

BUTCHA NEVER KNOW.....HENCE THE RULE OF THE "PRE-OP" THAT WE ALL KINDA HATE....BUT IS SOOOOOOO NECESSARY.......

LEMME LIST THE OBJECTIVE DATA FOR YOU COLLEAGUES FOR THIS ORIF-HIP-ADD ON THAT I FOUND:

1)Intracranial hemorrhage, albeit stable, S/P his fall
2)Intracerebral metastasis lesions, from a primary of unknown etiology.
3)INR=2.0 for some unknown reason. No anticoagulants on board.
4)Perihilar mass on the right. Noone knows what it is.
5)ELECTROLYTE- ABNORMALITIES.... Na=159 HCO3=18
6) Cr=2.4

THATS SIX THINGS THAT THE CARDIOLOGIST WHO WROTE "CLEARED FOR SURGERY" ON HIS CONSULT SHEET APPARENTLY, UHHHHHH, DIDNT CONSIDER.

WHERE DOES THAT LEAVE US?

That leaves us where Mil left off with his point that anesthesiologists clear patients for surgery.

Not medicine doctors.

I had a medicine doctor "clearance" on the chart for this case.....

and there was NO WAY this case was gonna happen.

I meander into the ortho studs OR and communicate with him why his add on shouldnt happen.

Then I call the cardiologist who "cleared" this dude for surgery:

"Doctor X? Hey its Jet, wanna the anesthesiologists here. Yeah, I read your consult. Unfortunately I humbly disagree with the clearance.....eighties-plus-dude, intracranial hemorrhage, intracerebral metastatic sites revealed on CT, some kinda perihilar mass on the heart border, ALL OF HIS ELECTROLYTES ARE ABNORMAL, his INR is high, his creatinine is high.....

"Guess what I'm saying is the risk of the surgery ABSOLUTELY outweighs the benefits, Dude."

next prose is absolutely the truth....

Cardiologist: "I'm just the cardiologist. I cleared his heart. Maybe you need to call his internist."

😱

HUH?

UHHHHHHH......WAITAMINUTE........

Heres an internist-like-dude who wrote, clearly I may add, on his consult sheet,

"CLEARED FOR SURGERY"

and yet when I call you on the phone, kinda face-to-face, you're gonna plead that, uhhhhh, I'M JUST THE CARDIOLOGIST SO I'M JUST CLEARING THE PATIENT'S HEART?

HAHAHAHAHAHAHAHAHAHAHAHAHA

I wish I was making this stuff up.

But thats what the dude said....

"I'm the cardiologist. I cleared his heart, and thats it. You may wanna contact his internist...."

So after that conversation I regressed back to the

response to "patient clearances."

The cardiologist "cleared" this dude for an operation.

The ortho stud read the chart and is ready to operate and...uhhhhh.....doesnt know any better.....

SO I'M THE BAD GUY.

Cancelling the case.

And, uhhhhhhhh,

I DONT CANCEL CASES.

But I cancelled this one.

WHAT A FRIKKKIN JOKE.

That I have to intervene on this TRAINWRECK to do whats right for the patient.

It doesnt happen often, out here in private practice wonderland.

But it DOES happen.

Sometimes.😏😏
 
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You shoulda told him to come back and fix his consult note so it said only the patients heart was cleared for surgery.
 
Agree that this is poor communication. The note on the chart is clearly not correct. If the cardiologists don't want to consider all the patient's comorbidities then they need to make it clear all they do is clear patient's "hearts" and make it known another consult is needed.
 
This is the same kind of crap we get all the time at our place as well. We're trying to change the culture from "cleared" to "pre op medical evaluation." They can't clear, they have no idea. Unless they want to start pushing the white stuff, they can't clear for surgery.

Wait a minute! if you ever talk to a GI F**KER, they think they can do the white stuff too. Tools.

Most medical consults aren't worth the paper they are written on.

Worst is the prescription note with "Cleared for Surgery" and a signature.

Can't even wipe your ass with it. You'll get s**t on your fingers.

Fleas.
 
Excellent story telling skills "dude". Loved it
 
I would expect the note to be a little more detailed... like saying something like.. avoid hypoxia, hypercarbia, hypotension, and tachycardia....

Gee thanks Mr. Medical Doctor... that quite wasnt obvious to me..
 
numbmd said:
This is the same kind of crap we get all the time at our place as well. We're trying to change the culture from "cleared" to "pre op medical evaluation." They can't clear, they have no idea. Unless they want to start pushing the white stuff, they can't clear for surgery.

Wait a minute! if you ever talk to a GI F**KER, they think they can do the white stuff too. Tools.

Most medical consults aren't worth the paper they are written on.

Worst is the prescription note with "Cleared for Surgery" and a signature.

Can't even wipe your ass with it. You'll get s**t on your fingers.

Fleas.
Click to expand...

In their defense, they are seeing about 50 patients a day and get endless b.s. consults and crap dumped from other services.
 
radslooking said:
In their defense, they are seeing about 50 patients a day and get endless b.s. consults and crap dumped from other services.
Click to expand...

And your point is....?

Everyone is busy but it's your job to get sh it done in a proper way.

Since I have so many patients, I will just skip this one patient and scribble some DUMB SH IT on a paper that makes no sense and send him back where he came from...Hopefully, sh it won't hit the fan and all will go well as anesthesia will pick up what's wrong (*internist crosses his fingers, says a prayer and writes cleared for surgery*)

This type of lame "I am too busy" attitude is running rampant now-a-days. 👎
 
GuP said:
And your point is....?

Everyone is busy but it's your job to get sh it done in a proper way.

Since I have so many patients, I will just skip this one patient and scribble some DUMB SH IT on a paper that makes no sense and send him back where he came from...Hopefully, sh it won't hit the fan and all will go well as anesthesia will pick up what's wrong (*internist crosses his fingers, says a prayer and writes cleared for surgery*)

This type of lame "I am too busy" attitude is running rampant now-a-days. 👎
Click to expand...

Well, all I can say is that you should be in that position before you criticize. I think you'd see it differently. I am not defending the cardiologist, because he's obviously a bonehead. Neither do I defend a ***** who blindly writes "cleared for surgery" without barely looking at the chart. The fact of the matter is that you need to incentivize people to do the right thing. Since internists are looking at the patient once and aren't ever responsible again, it would be preferable for anesthesiologists to do the pre-ops as they have a better idea of the anesthetics involved and will be ultimately responsible. Internists don't really have the training involved to assess surgical risk since they are never involved in surgeries, in any capacity. But nobody else wants to do the work (i.e. sh it work) so they dump it on them.
 
If we don't want internists to say "cleared for surgery" then why are they being consulted in the first place? So they can say "chronic medical problems optimized prior to surgery?"

Why doesn't the preoperative consult go to an anesthesiologist? (I assume the answer is $$$) Why do guidelines on perioperative risk come from the cardiologists, not anesthesiologists? If we want to be "perioperative physicians" then why are we listening to non-surgically-related docs tell us what to do in the perioperative period?

Isn't it the anesthesiologist who ultimately "clears" a patient for surgery, meaning, OK's the surgery to go ahead?
 
The function of consulting an internist or cardiologist preop is for them to recognize any way in which the pt is not optimized (uncontrolled HTN, DM, CHF, etc) and fix it. The idea being that they don't show up on the day of surgery with BP 220/110, BG 450, and 3+ pitting to the thighs, since the surgerizer isn't always gonna notice those kinds of things or do anything to fix them.

The only two things internists' "clearance" notes should end with:

"This pt is medically optimized." Whatever their comorbidities are, they're as good as they're gonna get. "This is a low/medium/high risk pt for a low/medium/high risk procedure." They've applied the ACC/AHA guidelines to the pt and have stated their assessment of the applicable risk.

The only thing a cardiac "clearance" note should end with:

"This pt's cardiac condition has been optimized, and no further diagnostic testing is warranted. This is a low/medium/high risk pt for a low/medium/high risk procedure. This is an acceptable risk for the planned procedure."

One of the good things about the VA where I did internship was that these kinds of notes had been made standard throughout the system. I had never seen the whole "pt is cleared for surgery" on a prescription pad thing until this year, and it made me laugh the first time I saw it.

There is no such thing as far as I'm concerned as "clearance" from an internist or cardiologist. I just want confirmation that they're optimized, and that they've thought about this particular pt's comorbidities in the context of this particular elective procedure.

Then I'll do the "clearing," thank you very much.
 
Hawaiian Bruin said:
The function of consulting an internist or cardiologist preop is for them to recognize any way in which the pt is not optimized (uncontrolled HTN, DM, CHF, etc) and fix it. The idea being that they don't show up on the day of surgery with BP 220/110, BG 450, and 3+ pitting to the thighs, since the surgerizer isn't always gonna notice those kinds of things or do anything to fix them.

The only two things internists' "clearance" notes should end with:

"This pt is medically optimized." Whatever their comorbidities are, they're as good as they're gonna get. "This is a low/medium/high risk pt for a low/medium/high risk procedure." They've applied the ACC/AHA guidelines to the pt and have stated their assessment of the applicable risk.

The only thing a cardiac "clearance" note should end with:

"This pt's cardiac condition has been optimized, and no further diagnostic testing is warranted. This is a low/medium/high risk pt for a low/medium/high risk procedure. This is an acceptable risk for the planned procedure."

One of the good things about the VA where I did internship was that these kinds of notes had been made standard throughout the system. I had never seen the whole "pt is cleared for surgery" on a prescription pad thing until this year, and it made me laugh the first time I saw it.

There is no such thing as far as I'm concerned as "clearance" from an internist or cardiologist. I just want confirmation that they're optimized, and that they've thought about this particular pt's comorbidities in the context of this particular elective procedure.

Then I'll do the "clearing," thank you very much.
Click to expand...

Excellent response.

Just like "when you say Budweiser, YOU'VE SAID IT ALL
 
fakin' the funk said:
If we don't want internists to say "cleared for surgery" then why are they being consulted in the first place? So they can say "chronic medical problems optimized prior to surgery?"

Why doesn't the preoperative consult go to an anesthesiologist? (I assume the answer is $$$) Why do guidelines on perioperative risk come from the cardiologists, not anesthesiologists? If we want to be "perioperative physicians" then why are we listening to non-surgically-related docs tell us what to do in the perioperative period?

Isn't it the anesthesiologist who ultimately "clears" a patient for surgery, meaning, OK's the surgery to go ahead?
Click to expand...

The reason why other specialists "clear" the patients for surgery is because the system does not recognize us as perioperative physicians and because we are seen by the majority of our colleagues as service providers who hide in the OR and put patients to sleep for other real doctors to do procedures on them .
Many other specialists (the majority) think of us as something equivalent to pathologists or radiologists, we don't practice medicine we just give anesthesia.
The fact the they increasingly see nurses administering the anesthetic actually enforces that perception.
It is frustrating to deal with colleagues that have no understanding about our specialty but you can't change the world, you just learn to accept it and move on.
I rarely read notes from internists and I can't even remember the last time I asked for a consult from anyone.
 
I don't think these notes, even properly stated, are worth the paper they are written on. You might think, "Well, if the patient dies during surgery, I've got something in writing from another doctor saying it was okay to take him. The blame won't be on me." Not so.

I don't know how we get this through people's heads out there that we make the the determination that someone is "cleared" for surgery. Every case I've ever done requires an anesthesia consult prior to going to the OR. So, while I might see such a note in the chart, it basically doesn't mean anything. If I find a problem, I address it whether or not they were cleared.

We used to have this problem. It always generated a call back to the physician generating the note. It ranged from internist to cardiologists to even - perish the thought - FP docs writing "cleared for surgery". Trust me, when they get a call asking, "Well, Mr. Jones has been on fondaparinux for the past 8 days. Are you sure he's still cleared for surgery?"... or... "Mrs. Smith aortic valve is only 0.2 cm2 and the induction might kill her. Are you sure she's still cleared for surgery?"... they eventually stop writing stupid **** in the chart and just let you handle it.

It's amazing what a phone call can do.

-copro
 
But the absolute worst is the cocky cardiologist who won't tell you squat. i had this guy who wrote of the square of toilet paper "cleared for surgery." and the patient had a significant coronary issue, including a past infarct of unknown age. I called this c*cksucker up (he liked roosters), and asked him to relate the extent of the patients disease. His response? "Well if you are uncomfortable, then cancel the case." Wouldn't even look in the patient's chart. I tried to explain that it might affect my anesthetic plan, and he just repeated, "Well if you are scared then don't do the case, send her over to our hospital."

I explained to the patient's family that because her cardiologist was basically refusing to talk to me that I had to give her an anesthetic that might require her to be on the ventilator for a few hours after the surgery. I also told her that her cardiologist was an awful doctor and that she should go to another cardiologist. I also gave her the names (with numbers) of a few good cardiologists on staff, and recommended that she should go to them instead.

Gives the good guys a bad name.
 
jetproppilot said:
Then I call the cardiologist who "cleared" this dude for surgery:

"Doctor X? Hey its Jet, wanna the anesthesiologists here. Yeah, I read your consult. Unfortunately I humbly disagree with the clearance.....eighties-plus-dude, intracranial hemorrhage, intracerebral metastatic sites revealed on CT, some kinda perihilar mass on the heart border, ALL OF HIS ELECTROLYTES ARE ABNORMAL, his INR is high, his creatinine is high.....
"Guess what I'm saying is the risk of the surgery ABSOLUTELY outweighs the benefits, Dude."

next prose is absolutely the truth....
Cardiologist: "I'm just the cardiologist. I cleared his heart. Maybe you need to call his internist."
😱
Click to expand...

Jet - you shoulda sent this mofo a bill, charging him what his lawyer's retainer is, 'cause you just kept him outta court. 👍

dc
 
Very nice Jet... way to STEP UP TO THE MIKE WITH MICATIN!

(Sorry, had to be said!) 😀
 
Hawaiian Bruin said:
The only two things internists' "clearance" notes should end with:

"This pt is medically optimized." Whatever their comorbidities are, they're as good as they're gonna get. "This is a low/medium/high risk pt for a low/medium/high risk procedure." They've applied the ACC/AHA guidelines to the pt and have stated their assessment of the applicable risk.
Click to expand...

And that's almost exactly the way mine read. I've never written "cleared for surgery" in my life. That's not my job.

numbmd said:
But the absolute worst is the cocky cardiologist who won't tell you squat. ...I also told her that her cardiologist was an awful doctor and that she should go to another cardiologist.
Click to expand...

Feel better? 🙄

Slamming a colleague is never the right answer. Think it, but don't say it. And never write it in the chart.
 
Slam a colleague? Colleagues are supposed to discuss, not berate each other. This tool was not incompetent, he was an obstructionist in the care of his own patient. His attitude could have potentially affected the patient n an adverse way. The patient and the family was mortified before I even got to try to explain. Absolutely no excuse for that kind of behavior.

When the patient is asking you what should they do, should you just be silent? I disagree. With such a blatant disregard for his patients, I hope that guy is out of work. Nobody should go to him.
 
numbmd said:
When the patient is asking you what should they do, should you just be silent? I disagree.
Click to expand...

You don't have to "be silent," but you should be diplomatic and nonjudgemental in front of patients. You can always steer them in the right direction without badmouthing anyone.

Remember, what goes around comes around.
 
I've always wondered about this same thing. Ortho many times will have medicine come "clear" the patient for surgery before calling us to tell us about the patient. Then we get a call from them that there is an add on and medicine has cleared them like that is the magical key to getting a patient to the OR. I'm always like, "thats great but, medicine doesn't decide if my patient is cleared. Only I do that". I've never cancelled a case. We have postponed a middle of the night hip to get an echo on a patient with known heart disease who was never worked up but, I've never seen a case flat out cancelled.

One of my colleagues said it well when we were discussing this same issue one day. Medicine risk stratifies, anesthesia clears. Even better I love when the medicine consult says ... consider regional anesthesia. Oh, OK like we wouldn't think of that. Thanks. Once I asked the medicine resident what kind of regional anesthesia they think the patient should consider and they looked at me like I had two heads. Nice.
 
I have had internists and cardiologists "clear" patients for spinal anesthesia only or MAC only several times, this is one of the reasons why I rarely read these silly notes.
The chances of me canceling a case are almost non existent anyway and the cases I might cancel are usually "cleared" by internists (it happens like once every 2 years that I cancel a case), so why should I read their notes?
 
Blue Dog
I stand corrected. I did not explain myself adequately as to why I gave the patient the other specialists numbers, I was asked. However it was also incorrect to post about it as if it was a proper thing to do. I agree that usually it is wrong to slam others when they aren't there. It reflects poorly upon yourself.

Even if they ARE lazy d!cks.
 
To be fair, I have to give props to the Internal Medicine docs at University of Washington. They know their s*** and their limits. They do not write BS in the charts about avoid blah blah blah and they do not "clear" patients for surgery. They risk stratify them and they medically optimize them and that is how they document it in the chart.

Of course at our other institution, the SURGEONS "clear" them which can lead to a whole other set of interesting interactions.

pod
 
jetproppilot said:
WOW.

You need to give virtually the rest of american internists/cardiologists a class.👍
Click to expand...

it's misleading however. Whenever a surgeon or ortho says they need a consult, they ALWAYS say "he needs to be CLEARED for surgery". every time. that is the verbeage that is used.
 
radslooking said:
it's misleading however. Whenever a surgeon or ortho says they need a consult, they ALWAYS say "he needs to be CLEARED for surgery". every time. that is the verbeage that is used.
Click to expand...

In surgeon speak, that means "he needs whatever the hell medicine-ey thing it is you people do so I can get him on the operating table without being canceled at the last minute."

It's much easier for them to say "cleared" than it is to say "optimized and risk-stratified."
 
I very much like the phrase, "Patient is at high/medium/low risk per AHA guidelines for the planned procedure." The longer I do this, the more I start to sound like a radiologist.
 
I hate the term "medical optimized"...

How many patients have you EVER seen have their medical problems "optimized".

Do people even know what that term means?

If you have hypertension under treatment....your BP should be less than 120/80 after 5 minutes of rest and measured with the patient in the seated position with their arm at their side (according the JNC)

How many hypertensive patients meet that criteria....practically none...meaning they are NOT "optimized".

How many DM patients have their HbA1c normalized before you take them to the OR....

This list goes on and on and on and on.

And yet we continue and persist with the term "optimized".

The internists don't bother with anything other than "cleared" because they runs into to many damn fool anesthesiologists who don't know what "optimized" means.

"medically acceptable" or "medically treated" are better phrases.
 
Planktonmd said:
The reason why other specialists "clear" the patients for surgery is because the system does not recognize us as perioperative physicians and because we are seen by the majority of our colleagues as service providers who hide in the OR and put patients to sleep for other real doctors to do procedures on them .
Many other specialists (the majority) think of us as something equivalent to pathologists or radiologists, we don't practice medicine we just give anesthesia.
The fact the they increasingly see nurses administering the anesthetic actually enforces that perception.
It is frustrating to deal with colleagues that have no understanding about our specialty but you can't change the world, you just learn to accept it and move on.
I rarely read notes from internists and I can't even remember the last time I asked for a consult from anyone.
Click to expand...

Well, you can always point out how the NP runs around and actually writes the note and orders stuff, even on private cardiology services. The cards guy is only called when something really goes crazy abruptly or for rounds.

Nurses give anesthesia but its kind of funny when they have to think outside of a typical GA or MAC. Guys breathing fast. Should I extubate? Well... That's the technician part. Can't think of possible ideas when things don't go as programmed.

As ANESTHESIOLOGISTS, we NEED to push for legislation that LEGITIMIZES PREOPERATIVE CLINICS and PREOPERATIVE CONSULTS. They are consults. Do surgeons get paid a fee for a consult and then op + post op?
 
In response to mil-

As I said earlier in this thread, I define optimized by "Whatever their comorbidities are, they're as good as they're gonna get."

Fact is, it isn't my role to figure out the best reasonably attainable blood pressure for a guy who shows up in the holding area with a BP of 220/110. Do I need him to be at 120/80? Of course not. But there's plenty of room for improvement. Maybe 150/90 is as good as it'll get. Fine. I don't have time, nor is it my role, to figure that out. But his internist should, and should document it.

It also isn't my role to have determined the best medical regimen for the guy walking around with a BG of 450 and A1C of 13.

It also isn't my role to diurese, digitalize, and afterload reduce the guy with an EF of 20% in the days/weeks before surgery.

It's the internists'/cardiologists' role to do these things preoperatively. As such, they should put a note in the chart saying they've executed that responsibility to the best of their ability. Optimized.

I think "medically acceptable" means even less than "optimized."

"Medically treated" is OK, but you can give the 220/110 guy 12.5 mg HCTZ QDay and say you're treating his hypertension. You might not be treating it optimally, but hey, you're doing something.

My 2 cents.
 
Hawaiian Bruin said:
In response to mil-

As I said earlier in this thread, I define optimized by "Whatever their comorbidities are, they're as good as they're gonna get."

Fact is, it isn't my role to figure out the best reasonably attainable blood pressure for a guy who shows up in the holding area with a BP of 220/110. Do I need him to be at 120/80? Of course not. But there's plenty of room for improvement. Maybe 150/90 is as good as it'll get. Fine. I don't have time, nor is it my role, to figure that out. But his internist should, and should document it.

It also isn't my role to have determined the best medical regimen for the guy walking around with a BG of 450 and A1C of 13.

It also isn't my role to diurese, digitalize, and afterload reduce the guy with an EF of 20% in the days/weeks before surgery.

It's the internists'/cardiologists' role to do these things preoperatively. As such, they should put a note in the chart saying they've executed that responsibility to the best of their ability. Optimized.

I think "medically acceptable" means even less than "optimized."

"Medically treated" is OK, but you can give the 220/110 guy 12.5 mg HCTZ QDay and say you're treating his hypertension. You might not be treating it optimally, but hey, you're doing something.

My 2 cents.
Click to expand...


Are you not a doctor?

The difference between the cardiologists and internists lies in the length of follow up. It doesn't relieve you of knowing what's best for the patient.....otherwise a CRNA can do OUR job, because they can push the propofol and put the tube just as well/or better than you can.

All you're saying is that you want to spread the responsibility/liability around to cover your as s.
 
I dunno mil. I can treat HTN, DM, whatever also. However, do I know this patient as well as the doctor that has been treating him for X amount of years? Of course not. I can control the parameters as best as I can in the perioperative period and make recommendations as far as optimizing the patient for surgery, but it is out of my scope of practice to recommend what the long term care for this patient should be. Im not the doctor who will have to be following up with this patient post op and further when he will continue to have these medical issues. I think Bruin was just commenting on the fact that this patient is best served by being optimized by his primary physician first prior to coming to surgery. If they are unsure about how to adjust medical regimens preop, then most places have a preop clinic of some sort where an anesthesiologist can evaluate the patient and make recommendations (which I do at my current job and am more than happy to do).
 
huktonfonix said:
I dunno mil. I can treat HTN, DM, whatever also. However, do I know this patient as well as the doctor that has been treating him for X amount of years? Of course not. I can control the parameters as best as I can in the perioperative period and make recommendations as far as optimizing the patient for surgery, but it is out of my scope of practice to recommend what the long term care for this patient should be. Im not the doctor who will have to be following up with this patient post op and further when he will continue to have these medical issues. I think Bruin was just commenting on the fact that this patient is best served by being optimized by his primary physician first prior to coming to surgery. If they are unsure about how to adjust medical regimens preop, then most places have a preop clinic of some sort where an anesthesiologist can evaluate the patient and make recommendations (which I do at my current job and am more than happy to do).
Click to expand...

then why bother with a consult? other than to spread the blame around...

and as I pointed out....almost NEVER are patients "optimized".
 
no argument there. I agree most consults dont help me at all. Most of the time the consults are helpful in that they expedite the process for the patient obtaining any necessary additional studies (echo, cath, PFT). Could these studies be obtained by a preop clinic? Sure, but the cardiologist is probably more familiar with the process and will be needed to read the test anyway. In some cases (hyperthyroid for example) an endocrinologist would definitely be useful in treatment since I dont regularly treat this.
 
militarymd said:
Are you not a doctor?

The difference between the cardiologists and internists lies in the length of follow up. It doesn't relieve you of knowing what's best for the patient.....otherwise a CRNA can do OUR job, because they can push the propofol and put the tube just as well/or better than you can.
Click to expand...

He didn't say he didn't know how to do it. He said it wasn't his role to do it. I don't know of many anesthesiologists who run pre-op internal medicine clinics with multiple preop follow-up visits in their spare time...
 
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Epidural for cosmetic surgery
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