Can Anesthesiologists refuse to work a case for any reason?

[deleted697127]

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I think I agree with both sides of this argument. Punting sucks but not everything is punting. It is not infrequent that members of my group volunteer to do difficult cases that come up to help each other out. In fact, where i did residency, if there was legitimate concern for accreta, this case would be identified and staffed far in advance. No one wants to see someone die but providing excellent care with an established plan coordinated between OB, IR, Gen surg, anesthesia, and nursing used to at least ease everyones minds. And yes, people did volunteer to be involved with cases like this much like residents want to do lines, blocks, hearts, livers, double lumen tubes, and awake intubations.

 

[fakin' the funk]

Just regular obese people, all three with HTN and two also with DMII. No other serious PMH

Pretty typical for this disease at ICU level severity. Lots of peri-healthy people (*note - not actually healthy) in their 40s and 50s and 60s, but normal lives, severe ARDS from COVID and either die in the near term (5-10 days after intubation from MSOF) or make it to 30-40+ days to be trached and vented and who knows what. Dodge the PE and renal failure and you've got a shot. Deeply sedated (GA +/- paralytics) for weeks. Pretty terrible.

 

[dhb]

I'm really surprised about the attacks on @Angus Avagadro a lot of his situation boils down to group dynamic and how cases are shared with the group. If you have a good relation with your partners and you can discuss the case and get it done i don't see the problem.

 

[MirrorTodd]

I'm really surprised about the attacks on @Angus Avagadro a lot of his situation boils down to group dynamic and how cases are shared with the group. If you have a good relation with your partners and you can discuss the case and get it done i don't see the problem.

I think it was the wording of the original post that set most people against him. It read a little bit callous/selfish. I do agree with him about his choice to do the case versus see if a partner would do it. I'm young in my career so I'd be game but maybe thirty years down the road I'll be doing the same thing. Right now I feel like, the baby is coming out one way or the other....I don't think it's better to wait until she's in labor and it's an emergency before you accept a JW pt for a cesarean. In my mind, a planned cesarean is safer than a non planned one.

 

[Neopolymath]

There seems to be one.
And there are like 20 or so of us regulars on this board. I highly doubt we represent the thousands of docs out there who don’t partake in this board.

Please notice how I said I don't care if that person dies not that I actively want to go be involved in it. No one actively wants to do something like that even if my principles say it's completely fine and I could sleep at night.

A great example would be abortion. People that are pro choice don't love abortion and they don't actively want to be involved in a bunch of abortions. They would ideally want zero abortions just like anyone else in a perfect world. Similarly, I wouldn't want to be involved in any JW situations like that but it's not keeping me up at night because if they are adults then they know the outcomes. Play stupid games, win stupid prizes as they say.

 

[pjl]

To broaden the topic again, what types of cases/reasons do you guys feel would warrant deciding to be uninvolved (obviously while providing an alternative)?

So far we have mentioned:
-Organ harvest
-DNR status
-JW
-Abortion
-Futile Care
-Surgeon slept with your wife
-Certain Social relationships with patient
-Bad insurance

Any others?
Who in your group do you pawn these cases off on? Senior/junior guys?

 

[deleted126335]

To broaden the topic again, what types of cases/reasons do you guys feel would warrant deciding to be uninvolved (obviously while providing an alternative)?

So far we have mentioned:
-Organ harvest
-DNR status
-JW
-Abortion
-Futile Care
-Surgeon slept with your wife
-Certain Social relationships with patient
-Bad insurance

Any others?
Who in your group do you pawn these cases off on? Senior/junior guys?

-Incompetent surgeon.
-Unethical surgeon doing medically questionable surgeries.

 

[DrZzZz]

Who in your group do you pawn these cases off on? Senior/junior guys?

No one. I don't think anyone in my group would pawn any of these off (aside from preexisting relationship with the patient, in which case, it can be swapped with anyone else working that day). The only things we swap around for is if a patient/case gets moved into your room that would be better served by another doc. And most often at our practice, it's the rare NICU baby that a subset of our group is more comfortable taking care of. That's about it.

 

[Angus Avagadro]

To broaden the topic again, what types of cases/reasons do you guys feel would warrant deciding to be uninvolved (obviously while providing an alternative)?

So far we have mentioned:
-Organ harvest
-DNR status
-JW
-Abortion
-Futile Care
-Surgeon slept with your wife
-Certain Social relationships with patient
-Bad insurance

Any others?
Who in your group do you pawn these cases off on? Senior/junior guys?

Probably the social relationships probably would do it for me if I thought someone else might be more objective. How about a med mal lawyer? I never had an issue with them, but a couple surgeons and a few of my partners did.

 

[IMGASMD]

To broaden the topic again, what types of cases/reasons do you guys feel would warrant deciding to be uninvolved (obviously while providing an alternative)?

So far we have mentioned:
-Organ harvest
-DNR status
-JW
-Abortion
-Futile Care
-Surgeon slept with your wife
-Certain Social relationships with patient
-Bad insurance

Any others?
Who in your group do you pawn these cases off on? Senior/junior guys?

Bad insurance? If you’re eat what you kill.... don’t have many of those around here. Everyone at least blend their units. I do know some people will start a case then dump the case to junior guys or on all people.

Of course pawn them to the junior guys.... 😉

I’ve heard about mal practice lawyers too. Haven’t encountered any yet. Or they just don’t tell me.....

 

[MikeMerk-MtS]

Two questions:

1. What is your cutoff for hyper and hypo K that you will delay/cancel a case?

2. Pt with severe cardiac history (several MIs, CAD s/p CABG, A-fib... you know, the usual) comes in for acute chole (normal WBC, afebrile, stable, overall feels well) without a cardiac note in chart or echo... do you delay for cardiac workup and/or a bedside TTE?

 

[IMGASMD]

Two questions:

1. What is your cutoff for hyper and hypo K that you will delay/cancel a case?

2. Pt with severe cardiac history (several MIs, CAD s/p CABG, A-fib... you know, the usual) comes in for acute chole (normal WBC, afebrile, stable, overall feels well) without a cardiac note in chart or echo... do you delay for cardiac workup and/or a bedside TTE?

1. Depends on urgency. but if it’s elective case, less than 3 or over 5. If ESRD, I may let it slide up little higher.

2. Activity status? Call cardiologist for the last set of numbers?

 

[GassYous]

I'd like my K above 3 and below 5.5 ideally. I'm not sure I'd cancel but I would ask to reshuffle the schedule until they are fixed.

Mets >4, proceed to OR. The chole can wait for cardiologist to come by for medicolegal reasons but I'd do the case. Unless the pt has a blocked left main, prox LAD, severe AS, I'm not sure that it's helpful. Literature is not very supportive of cardiac evaluation/intervention prior to procedures.

 

[MikeMerk-MtS]

1. Depends on urgency. but if it’s elective case, less than 3 or over 5. If ESRD, I may let it slide up little higher.

2. Activity status? Call cardiologist for the last set of numbers?

Pt is 85 years old with b/l knee OA and states he doesn't walk much because of the pain but "thinks" he could walk up 2 flights with just minimal SOB (but hasn't attempted in a while). Proceed or delay for bedside echo and cardiology consult?

 

[MikeMerk-MtS]

I'd like my K above 3 and below 5.5 ideally. I'm not sure I'd cancel but I would ask to reshuffle the schedule until they are fixed.

Mets >4, proceed to OR. The chole can wait for cardiologist to come by for medicolegal reasons but I'd do the case. Unless the pt has a blocked left main, prox LAD, severe AS, I'm not sure that it's helpful. Literature is not very supportive of cardiac evaluation/intervention prior to procedures.

Those are the numbers I generally use, as well.

I was unable to assess METs as he has severe b/l knee OA and doesn't ambulate much. I agree that cardiac eval may not add much and I could just proceed with caution and assume his heart is ****ty but god forbid we had a poor outcome I would've been SOOL.

 

[Angus Avagadro]

Pt would probably have been admitted to an observation bed at my hospital. ER would have gotten Troponin, EKG, etc., and ruled out anything acute. We had a very busy cath lab and our cardiologists were very responsive. Getting a cardiac consult for a patient like this was really easy.The cardiologist probably would see this patient first thing in am, then we would proceed. If the cardiologist wasn't available and EF on old records was half decent say 35%, and pt didnt complain of cardiac symptoms, I would also be inclined to proceed. The surgeon was usually the one reluctant to go forward without the patient being blessed by cardiology. We had a lot of cardiac patients for non cardiac surgery.
I'm in agreement with the K numbers above.

 

[surgndoc]

1 - no hard cutoffs but if there are no peaked T waves or U waves on EKG I would proceed

2- if functional status is OK I’d go ahead without a TTE or cardiac workup

 

[Arch Guillotti]

To broaden the topic again, what types of cases/reasons do you guys feel would warrant deciding to be uninvolved (obviously while providing an alternative)?

So far we have mentioned:
-Organ harvest - No, never even thought about it
-DNR status - No, never even thought about it
-JW - No, never even thought about it
-Abortion - Never been involved with one, but no
-Futile Care - Futility can mean a lot of things
-Surgeon slept with your wife - That's weird
-Certain Social relationships with patient - Wouldn't have a problem unless it was something weird
-Bad insurance - No, never even thought about it

If you can't handle these cases just go do some cataracts somewhere😕

 

[Arch Guillotti]

Who in your group do you pawn these cases off on? Senior/junior guys?

Anybody I can?

In all seriousness I would not want to be part of a practice where cases are pawned off just because you don't want to do them. Tough cases are a regular part of the job.

 

[GassYous]

Pt is 85 years old with b/l knee OA and states he doesn't walk much because of the pain but "thinks" he could walk up 2 flights with just minimal SOB (but hasn't attempted in a while). Proceed or delay for bedside echo and cardiology consult?

If it's gonna be mine, right to OR right away! No trial no nothing. Otherwise find someone to dump it on 😉

 

[Arch Guillotti]

2. Pt with severe cardiac history (several MIs, CAD s/p CABG, A-fib... you know, the usual) comes in for acute chole (normal WBC, afebrile, stable, overall feels well) without a cardiac note in chart or echo... do you delay for cardiac workup and/or a bedside TTE?

No.

 

[deleted697127]

Pt is 85 years old with b/l knee OA and states he doesn't walk much because of the pain but "thinks" he could walk up 2 flights with just minimal SOB (but hasn't attempted in a while). Proceed or delay for bedside echo and cardiology consult?

Do you have a previous echo to compare it to? What do you do when it says EF 45-50 with mild RWMA? What can he do? Can he walk his dog or get his own groceries? Does he look like he’s falling apart? If he’s able to take care of himself without limitation from CP or sob, I would proceed. If his functional status was questionable, I would call cardiology and if no changes in baseline low functional status and they had not previously planned for further workup, i would proceed.

 

[deleted126335]

If you can't handle these cases just go do some cataracts somewhere😕

You mean the high volume cataract center where the ophtos just go around doing fundoscopic exams on demented, incontinent patients looking for cataract surgery "candidates". Because their only pleasure is watching TV or seeing the faces of their family members?

 

[pjl]

If you can't handle these cases just go do some cataracts somewhere😕

To be clear, I do all these except the social ones. My line for social ones are almost exclusively teenage girls who will have breasts or vagina exposed where I will be seeing them playing with my kids around my house or at church. Not because it bugs me, but because my daughter has told me so-and-so was mortified when I came in for an appy. I figure I’ll save them those feelings.

I just wanted us to stop bleeding the JW thing to death.

 

[Arch Guillotti]

You mean the high volume cataract center where the ophtos just go around doing fundoscopic exams on demented, incontinent patients looking for cataract surgery "candidates". Because their only pleasure is watching TV or seeing the faces of their family members?

Yes, the one where they put all the gomers to sleep because they can't hold still for the cataract!

 

[Arch Guillotti]

To be clear, I do all these except the social ones. My line for social ones are almost exclusively teenage girls who will have breasts or vagina exposed where I will be seeing them playing with my kids around my house or at church. Not because it bugs me, but because my daughter has told me so-and-so was mortified when I came in for an appy. I figure I’ll save them those feelings.

I just wanted us to stop bleeding the JW thing to death.

Yeah I get it and I agree. Beat that JW one to pieces because I feel so strongly about it. Once I worked with a partner who “dumped” cases on others under some ridiculous pretenses. I became very averse to picking up something tough just because somebody did’t want to deal with it or just flatout ignored it.

 

[GassYous]

You mean the high volume cataract center where the ophtos just go around doing fundoscopic exams on demented, incontinent patients looking for cataract surgery "candidates". Because their only pleasure is watching TV or seeing the faces of their family members?

I don't care how gomer they are as long as I'm getting those sweet startup units

 

[MikeMerk-MtS]

Do you have a previous echo to compare it to? What do you do when it says EF 45-50 with mild RWMA? What can he do? Can he walk his dog or get his own groceries? Does he look like he’s falling apart? If he’s able to take care of himself without limitation from CP or sob, I would proceed. If his functional status was questionable, I would call cardiology and if no changes in baseline low functional status and they had not previously planned for further workup, i would proceed.

No previous echo available and unknown functional status because of severe b/l knee pain from OA. So no info on his heart whatsoever (except him telling me he had multiple MIs, CAD s/p CABG and Afib). I decided to wait for cardiology and bedside echo (took a total of 1 hour) and then proceeded. Case went fine. But of course had I not gotten it...

 

[coffeebythelake]

Would be an interesting court case... Where the surviving person with a good outcome sues the doctor for saving their life when they could have been left for dead haha

I'm sure it has happened before.

 

[pjl]

I don't care how gomer they are as long as I'm getting those sweet startup units

Wrong, you want the 64 year old “early” cataracts right before they retire.