Call To Attendings: Canceling Cases

[Coastie]

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Can we have a discussion on when to cancel cases...and when not to, including clinical examples from your practice? It seems academia does not do a good job preparing us for private practice where canceling a case has far greater consequences than the ivory towers of the university hospitals.

 

[pmichaelmd]

First, many surgeons don't care about the physiologic status of the patient. They just want to know if they can cut. That said, none of them want a patient to die on their table either as that affects their stats. You'll find that you'll just have to use your "better judgment" as to when to let a case go.

Second, you will never "cancel" a case. You may postpone it until medically appropriate, but never cancel. Seems like silly semantics, but sometimes that matters.

We are forever getting add-on hips that are 80-90 years old. Many of them have cardiac issues. The orthopod may not have consulted IM or looked the medical history over and want to go straight to the OR. Example: 85-year old male fell and sustained a hip fx. Orthopod wants to go do a bipolar. He didn't think to ask "why did said 85-year old fall?" Oh, it was due to his MI! Whether or not cardiology would actually make an intervention is a question for another discussion, but I wouldn't proceed unless absolutely necessary in this case.

PMMD

 

[BLADEMDA]

First, many surgeons don't care about the physiologic status of the patient. They just want to know if they can cut. That said, none of them want a patient to die on their table either as that affects their stats. You'll find that you'll just have to use your "better judgment" as to when to let a case go.

Second, you will never "cancel" a case. You may postpone it until medically appropriate, but never cancel. Seems like silly semantics, but sometimes that matters.

We are forever getting add-on hips that are 80-90 years old. Many of them have cardiac issues. The orthopod may not have consulted IM or looked the medical history over and want to go straight to the OR. Example: 85-year old male fell and sustained a hip fx. Orthopod wants to go do a bipolar. He didn't think to ask "why did said 85-year old fall?" Oh, it was due to his MI! Whether or not cardiology would actually make an intervention is a question for another discussion, but I wouldn't proceed unless absolutely necessary in this case.

PMMD

Good Answer. Here is my approach:

Try to develop a relationship with the surgeon. Once he/she knows you want to do cases and not delay them it is much easier to "cancel" a case.

This takes time so try to involve a senior colleague when in doubt. Your cancellation rate should be low as most cases can safely be done in a timely manner. For example, I had a 90 year old Nursing home patient with history of cardiomyopathy but no echo in the past 5 years. I did my own stat echo exam in the holding area. It "delayed" the case only 15 minutes. As perioperative physicians we are there for safety and efficiency. Our skill set and knowledge can move cases along.

 

[Planktonmd]

This is a very important question and I don't think there is a simple answer.
When you finish residency you are loaded with dogma that is incompatible with private practice but usually you find out quickly that you need to unlearn many things and you start developing your own rules and limits to what is acceptable and what is not.
You eventually realize that cancelling a case is actually rarelly necessary and the number of times that you do that decreases with your level of exerience and comfort.
But, every practice is different and every Anesthesiologist is different so there is really no simple answer.

 

[jetproppilot]

This is a very important question and I don't think there is a simple answer.
When you finish residency you are loaded with dogma that is incompatible with private practice but usually you find out quickly that you need to unlearn many things and you start developing your own rules and limits to what is acceptable and what is not.
You eventually realize that cancelling a case is actually rarelly necessary and the number of times that you do that decreases with your level of exerience and comfort.
But, every practice is different and every Anesthesiologist is different so there is really no simple answer.

WOW.

Someone needs to take the s hit posted by Plank above and PUT IT INTO THE BIBLE. NEXT TO PSALMS 3:13.13722566252 (or whatever)

Cuz thats some TRUE s hit.

No.....its not just that.....its the ULTIMATE TRUTH.

Plank, if I ever doubted you,

I apologize.

Its now obvious to me you wield THE FORCE.

Again, I apologize for any previous misgivings on my part.

 

[Planktonmd]

WOW.

Someone needs to take the s hit posted by Plank above and PUT IT INTO THE BIBLE. NEXT TO PSALMS 3:13.13722566252 (or whatever)

Cuz thats some TRUE s hit.

No.....its not just that.....its the ULTIMATE TRUTH.

Plank, if I ever doubted you,


I apologize.

Its now obvious to me you wield THE FORCE.

Again, I apologize for any previous misgivings on my part.

I am actually thankful to SDN for giving me the opportunity to meet some exceptional physicians and wonderful people that I wouldn't have met in real life.
You my friend are one of these great people that I feel privileged to know.

 

[ncdoc1974]

I find there are only a few reasons I will cancel/"postpone" an elective case, it is usually one of the following:
1. NPO status
2. extreme & unexplained electrolyte abnormalities or blood/coag abn
3. cocaine use in the parking lot preop
4. unaddressed unstable angina
IF a surgeon ever even TRIES to give me crap, I tell him/her that I am trying to keep them out of court...they usually get real quiet real quick...Also I always tell the surgeon exactly what they need to do to get the patient back on schedule (i.e. "you need to consult cardiology to have this patients symptoms of unstable angina evaluated"...or "please tell your patients not to do cocaine in the parking lot and ideally tell them to lay off the sauce for a few weeks before surgery so they dont code on induction" Finally, ALWAYS tell the surgeon you are already getting the next case ready to roll back to the OR ASAP...They become less frustrated when they know they will soon have a knife in their hand.

 

[Dinkyconductor]

I find there are only a few reasons I will cancel/"postpone" an elective case, it is usually one of the following:
1. NPO status
2. extreme & unexplained electrolyte abnormalities or blood/coag abn
3. cocaine use in the parking lot preop
4. unaddressed unstable angina
IF a surgeon ever even TRIES to give me crap, I tell him/her that I am trying to keep them out of court...they usually get real quiet real quick...Also I always tell the surgeon exactly what they need to do to get the patient back on schedule (i.e. "you need to consult cardiology to have this patients symptoms of unstable angina evaluated"...or "please tell your patients not to do cocaine in the parking lot and ideally tell them to lay off the sauce for a few weeks before surgery so they dont code on induction" Finally, ALWAYS tell the surgeon you are already getting the next case ready to roll back to the OR ASAP...They become less frustrated when they know they will soon have a knife in their hand.

Good advice, agreed on all points.

One question about NPO status I have yet to resolve...do you guys ever bend the NPO rules at all?

For example, (this comes up all the time) a cataract who had toast two hours ago. I was planning on giving 2cc versed and 1cc fentanyl as the entire anesthetic. Sometimes 3cc versed. Why do I need to cancel this guy? If giving a little versed and fentanyl puts the patient at unacceptable risk of aspiration, then I guess I should never give any versed in the holding area for, say, an appy or an emergent D&C.

I freely admit I've been canceling these purely for medicolegal reasons (if something weird -were- to happen, the fact that I brazenly defied the official recommendations would be indefensible).

Along similar lines, my group seems to have no coherent policy regarding NPO status in C-sections. For example, repeat c-section arrives in labor, I always proceed ASAP with the reasoning that a term parturient is always considered a full stomach anyway. Still, others seem to insist on waiting eight hours.

 

[proman]

Why give anything for a cataract? It is possible to do peribulbar blocks without sedation. Avoid the problem entirely.

 

[Planktonmd]

NPO status in the "real world" is a very relative parameter.
There are so many factors involved which makes it a thing that you decide on a case by case basis.
In OB: the only time I ask about NPO status is when we are doing an elective C Section, in all other instances I simply don't care when they last ate.
In other surgeries: Each patient, each surgeon, and each indication is different so I would take the ASA recommendations into consideration but ultimately I will use my experience and my clinical judgment to decide when it is safe to proceed for each patient.
I hope this helps. 🙂

 

[Danbo1957]

First, many surgeons don't care about the physiologic status of the patient. They just want to know if they can cut. That said, none of them want a patient to die on their table either as that affects their stats.
PMMD

Feel free to post this over in the surgery forums...

 

[dA pilot]

Why give anything for a cataract? It is possible to do peribulbar blocks without sedation. Avoid the problem entirely.

A peribulbar block is still a needle stick into your eye that is painful, i would prefer a little bit of sedation for the block. Topical drops are much better tolerated without sedation.

I do take npo status on a case by case basis, but how defensible is it if you are doing a cataract under straight bulbar block with no sedation and a complication arises, such as intravascular injection and then patient seizes and aspirates toast.