Case Cancelled!

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sublimaze

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Working at the big house, we see all kinds of craziness.
The best reasons I've seen/heard of so far:

- Pt arrested for unpaid parking tickets en route to day surgery
- Pt drank Tang at 1100 (Unaware they still make/sell this stuff.)
- Pt swallowed chewing tobacco at 0700 in day surgery
- Pt eating tater-tots in day surgery (not a pedi pt, "normal intelligence adult"...)
- MRI scanner too narrow for pt (Fairly certain the pt was too wide for scanner...)
- Pt smoked THC prior to arrival in day surgery (was nervous about upcoming surgery), another one admitted to EtOH & cocaine at 0300 prior to arrival
- Surgeon unaware of pt/surgery
- Pt refused to have labs drawn/IV placed
- The always-good "Surprise, you're pregnant!"
 
sublimaze said:
Working at the big house, we see all kinds of craziness.
The best reasons I've seen/heard of so far:

- Pt arrested for unpaid parking tickets en route to day surgery
- Pt drank Tang at 1100 (Unaware they still make/sell this stuff.)
- Pt swallowed chewing tobacco at 0700 in day surgery
- Pt eating tater-tots in day surgery (not a pedi pt, "normal intelligence adult"...)
- MRI scanner too narrow for pt (Fairly certain the pt was too wide for scanner...)
- Pt smoked THC prior to arrival in day surgery (was nervous about upcoming surgery), another one admitted to EtOH & cocaine at 0300 prior to arrival
- Surgeon unaware of pt/surgery
- Pt refused to have labs drawn/IV placed
- The always-good "Surprise, you're pregnant!"
Click to expand...
You guys are obviously too picky!
 
Recently had a cancellation/back on.
The old "surprise, your pregnant" followed by "whoops, lab error".
Thank god all this transpired before I had the pleasure of meeting the patient!
 
I'm all for patients doing well, satisfaction is a distant second, I feel like there should be a pamphlet that states something along the lines, "6-8 hours before surgery? Before you you take a bite out of that, is that what you want to choke on and potentially die from? Do you want to be known as 'The Muffin Man'?"
 
ZzzPlz said:
Caught a patient eating a snickers in preop slot.
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He needs to have that added in the electronic medical record, under Difficult Airway. I always document when I catch a patient lying or doing something stupid; they might do that to a different doctor (or to me, about other details).

This is a level of stupidity that goes to character. The record of what he did should follow him. Someday it might save his life.
 
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I had a patient admit to smoking a joint to "calm their nerves" an hour pre op.

Had another guy get to the OR and transferred to the table. I noticed frosting all over his lips. I asked him what that blue stuff was and he told me it was from the cake on his meal tray. He also had a burger. The NPO order was apparently never put in.

It didn't happen to me but I knew of a case canceled due to pregnancy. The woman was 50 and was told in front of her adult daughter.
 
Patient drank coffee in preop stating "surgeons are always late, so I wasn't going to sit here and miss my morning coffee"
 
I had a patient smoke a joint on his way to the hospital, too. I promptly cancelled his surgery on account of inability to consent.

I have also had patients finding out they were pregnant on the day of surgery.
 
FFP said:
I had a patient smoke a joint on his way to the hospital, too. I promptly cancelled his surgery on account of inability to consent.

I have also had patients finding out they were pregnant on the day of surgery.
Click to expand...

Are they really unable to consent? What if they're "prescribed" marijuana for pain or something.

Besides possible consent issues, is there any iimplication in anesthetic safety? Cholinergic crisis??
 
You guys cancel for smoking weed? I've questioned some of my attendings about it but they view it as someone who's on chronic opiates. Its legal here for "medical" use so a decent number of our patients have a card and use regularly including on their way to the hospital. Once we had a dude that came in stoned and was feaking out over the IV placement. He wanted a nerve block for his fracture but was too scared of needles. Ortho really wanted a block because they knew he was going to be a PITA postop. My attending eventually agreed to do the block under GA.

Edit: ironically the fracture was from a MVA while working in some sort of delivery/driver job, probably while smoking a blunt since he admitted to heavy use all day everyday.
 
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We have an attending who is notorious for cancelling case . The other day he called up the preop clinic and balled them out for not ordering an EKG on an otherwise healthy, asymptomatic/decent exercise tolerance, 50F with controlled HTN scheduled for breast Bx. He ordered one the morning of which showed some sort of nonspecific abnormality so he cancelled the case and made her get a cardiology consult.

One case that I was glad to have cancelled was a pt scheduked for either MVR or AVR. Under GA, the CT attending didn't notice any valvular abnormalities whatsoever. CT surgeon insisits pt has the lesion. Anesthesiologist proceeds to give a slug of epi, still no abnormalities on echo. CT surgeon says, well, he's likely going to need the valve replaced eventually so we might as well do it now. Anesthesiologist decides to order some labs and notices a potassium slightly low at ~3.2 so he told the surgeon he was cancelling the case for hypokalemia. They woke the patient up and told him to run like hell and never let that surgeon touch his chest.
 
I've had a lady come in for knee scope. looks pregnant to the nursing staff, so I ask her about it. she says she had a C/S 2 mths prior. I look at her scar, and it looks very old. I look at the old records. the c/s was several yrs ago, and guess what there's a transvag u/s from 1.5 mth ago that shows a pregnancy. she knew she was pregnant, lied about it, then ran out AMA when confronted about it...case canceled!
this is why I almost never accept a pregnancy waiver
 
gasdoc77 said:
Recently had a cancellation/back on.
The old "surprise, your pregnant" followed by "whoops, lab error".
Thank god all this transpired before I had the pleasure of meeting the patient!
Click to expand...

We had this, with patient for hysterectomy, with husband in room, after being active duty for months. She had delayed surgery till he got back for help caring for other kids. Had to leave a nurse in the room to "supervise" until we got the blood confirmation back, which thankfully was negative. Talk about tension in a room you could cut with a knife...
 
kazuma said:
You guys cancel for smoking weed? I've questioned some of my attendings about it but they view it as someone who's on chronic opiates. Its legal here for "medical" use so a decent number of our patients have a card and use regularly including on their way to the hospital. Once we had a dude that came in stoned and was feaking out over the IV placement. He wanted a nerve block for his fracture but was too scared of needles. Ortho really wanted a block because they knew he was going to be a PITA postop. My attending eventually agreed to do the block under GA.

Edit: ironically the fracture was from a MVA while working in some sort of delivery/driver job, probably while smoking a blunt since he admitted to heavy use all day everyday.
Click to expand...
Block in adults under GA? Recipe for malpractice. If the patient wakes up with nerve injury from the surgery itself, the orthopod will blame it on your block.

Same goes for consenting a potentially intoxicated patient. Once the nurses wrote in their note that the patient had admitted to recent marijuana use and that he seemed slightly high, my hands were tied.
 
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anes said:
Are they really unable to consent? What if they're "prescribed" marijuana for pain or something.

Besides possible consent issues, is there any iimplication in anesthetic safety? Cholinergic crisis??
Click to expand...
With marijuana there shouldn't be any real anesthetic implications. With some stronger drugs, withdrawal is an issue. The drug one should be really afraid of is cocaine, because it exposes the body chronically to toxic levels of catecholamines (patients can behave intraop like severe hypertensives). It also interferes with a bunch of drugs. Although it's been reported that elective surgery with non-toxic levels is safe.
 
FFP said:
With marijuana there shouldn't be any real anesthetic implications. With some stronger drugs, withdrawal is an issue. The drug one should be really afraid of is cocaine, because it exposes the body chronically to toxic levels of catecholamines (patients can behave intraop like severe hypertensives). It also interferes with a bunch of drugs. Although it's been reported that elective surgery with non-toxic levels is safe.
Click to expand...
FFP,
I read recently read an EBM article of cocaine and anesthetic implications. Acute users of Cocaine are the ones to usually manifest cardiac complications. Chronic users whom have had a history of cocaine use with a negative 12 lead EKG(no T wave, or ST changes) are lower risk then previously thought for cardiac complications. For elective procedures and history of cocaine use in the last 48 hrs I would do the case with a negative 12 lead EKG. With a positive EKG I would hold for cardiac evaluation. However most large hospitals have blanket policies of cancelling cases due to a positive cocaine test on drug screen/ or during your preopeval.
 
Kazuma, that is a terrible story if true from the CT surgeon. Was he serious? Gonna do one of the most dangerous surgeries one can do on a person because he
"would eventually need it"? Talk about maleficence. What if something happened during the case or post-operatively to the patient? A myriad of complications I could think of from open heart surgery including the patient uhh, dying!!!! Really?

And the fact that the anesthesiologist didn't just straight cancel the case instead of coming up with a weak ass "hypokalemia" reason to do so blows my mind. What if his labs were all normal? Then what? He would have let the surgeon go to town replacing a totally normal valve? How would you have felt about that as the resident? Would you have removed yourself from the case or done is since you have little power: He/she is a CT anesthesiologist for crying out loud so I would expect confidence and balls to stand up to a rogue surgeon.

That is some messed up ****. I hope someone reported him to his superiors.
 
Totally agree about the block under GA. I told the dude we weren't going to do it.


About the CT surgeon, no the anesthesiologist wasn't going to let that case go even if normal labs were present. The mild hypokalemia was an easy out though. that surgeon was subsequently fired for similar unethical activities.

I also agree about consenting drunk patients. Recently I had an attending make me bring a drunk with multiple facial lacerations to the o.r with the assumption we would be fine as long as we only gave him dilaudid in Fentanyl. the guy was screaming and yelling in pain and the surgeon kept asking me if I could give him some propofol because he had this assumption that bringing this facial laceration to the o.r. would make the patient more comfortable. I refused. he then asked if I could keep giving him more dilaudid. I had to remind him that despite the intermittent screaming, the patient was drunk and barely breathing with several mg of dilaudid on board. I was so pissed that my attending made me take this case to the o.r. Complete waste of resources and could have been sutured in the ER by residents and medical students.
 
FFP said:
With marijuana there shouldn't be any real anesthetic implications. With some stronger drugs, withdrawal is an issue. The drug one should be really afraid of is cocaine, because it exposes the body chronically to toxic levels of catecholamines (patients can behave intraop like severe hypertensives). It also interferes with a bunch of drugs. Although it's been reported that elective surgery with non-toxic levels is safe.
Click to expand...


Agreed. I'm just saying if I had a patient who chronically smoked marijuana, I don't know if I'd necessarily cancel the case. I don't think consent would be an issue in the vast majority of chronic marijuana users.
 
FFP said:
With marijuana there shouldn't be any real anesthetic implications.
Click to expand...

I've seen some longtime heavy users need substantially higher than average dosing on their propofol infusions. Definitely less worrisome intraop than cocaine, though.
 
If you are OK giving anesthesia to people who smoke cigarettes I don't see why smoking Marijuana would be a problem.
Nicotine and the other chemicals they put in cigarettes are far more toxic than cannabis, so you need to ask yourself this question:
If a patient told me he smoked a cigarette on the way to surgery am I going to cancel the surgery?
If the answer is no... then you need to move on and stop worrying about Marijuana!
 
I got one...
We do a lot dental work for mentally delayed cases. Most of the patients will cooperate and occasionally we will have a few that need to be "darted" with IM ketamine. We had a new attending start and we explained to him that for "darting" we tend to over dose slightly because we rather have a calm lethargic patient.

However our new colleague decided to severely under dose the patient. Btw this patient was over six feet and easy 250lbs. Well things didn't go as planned. The patient literally jumped out of the gurney screaming and howling and ran right for the exit (orderlies holding him down didn't have a glint of hope). He ran down the main hospital hallway with the needle still stuck in his arm and no one in sight to stop him. He eventually made it to the parking lot (hallway leads directly to parking lot) and jumped into the first car he saw driving by (door was unlocked). The person driving the car stopped and jumped right out leaving the patient in the car in the middle of the lot. Patient was smart enough to lock the door and off course the keys were in the car.

We had to call the police the firemen down the street also came and eventually got the patient out. Our new colleague after that refused to work with these patients. Yes we still laugh about it...he does not find it funny...little to say case and the day was cancelled!
 
Actually had a mommy in labor actively tweaking - decided labor pains warranted smoking some meth. She actually blamed my epidural for her wrist pain -- not the writhing tweak she did for hours --- and actually gave me **** saying my epidural wasn't as good as the meth for her labor pain. Smh.... Call dcfs.
 
amyl said:
Actually had a mommy in labor actively tweaking - decided labor pains warranted smoking some meth. She actually blamed my epidural for her wrist pain -- not the writhing tweak she did for hours --- and actually gave me **** saying my epidural wasn't as good as the meth for her labor pain. Smh.... Call dcfs.
Click to expand...
Some one needs to do a study to confirm her observation about the superiority of methamphetamine to epidural analgesia for labor pain... she might be on to something big here
 
Patients who state, "I hope I die" are going to be cancelled and sent to the ER.

Chronic esophageal stricture patient with bad heartburn and complains of chest and shoulder pain for 3 months scheduled for EGD. She had been to the ER multiple times. Cardiac work-up had been negative or non-specific. ER, hospitalist and cards docs all state it is likely heartburn and to proceed with EGD. 10 minutes before the procedure I gave her bicitra and her standard heartburn pains go away, but the shoulder pains remains. At this moment the second troponin comes back at slightly elevated, 0.5. Combination of this and the pains that don't go away with antacid lead me to cancel the case and have cardiology look at her again. Further work-up by cards doctor shows a drop in EF from 70% a few months ago down to 35% now. She ended up getting a 4 vessel CABG a couple of days later. Doing very well now.

Bad cancellation:
My slightly overweight brother who jogs a couple times a week was scheduled for an EGD at an outpatient GI center. Upon arrival he was nervous and his blood pressure was 145. They cancelled the case. I couldn't believe it.
 
Impromptu said:
Patients who state, "I hope I die" are going to be cancelled and sent to the ER.

Chronic esophageal stricture patient with bad heartburn and complains of chest and shoulder pain for 3 months scheduled for EGD. She had been to the ER multiple times. Cardiac work-up had been negative or non-specific. ER, hospitalist and cards docs all state it is likely heartburn and to proceed with EGD. 10 minutes before the procedure I gave her bicitra and her standard heartburn pains go away, but the shoulder pains remains. At this moment the second troponin comes back at slightly elevated, 0.5. Combination of this and the pains that don't go away with antacid lead me to cancel the case and have cardiology look at her again. Further work-up by cards doctor shows a drop in EF from 70% a few months ago down to 35% now. She ended up getting a 4 vessel CABG a couple of days later. Doing very well now.

Bad cancellation:
My slightly overweight brother who jogs a couple times a week was scheduled for an EGD at an outpatient GI center. Upon arrival he was nervous and his blood pressure was 145. They cancelled the case. I couldn't believe it.
Click to expand...

Cancelled for a blood pressure of 145? Jesus, do they do any cases at that GI center? Poor form.
 
I wouldn't cancel for recent marijuana use, provided the patient wasn't presently intoxicated. The appy from the ER who got 2 mg of Dilaudid is more "impaired" ...

In terms of anesthetic implications of illicit drug use, I care about meth and cocaine and not much else.


I've done quite a few u/s guided blocks and epidurals in adults under anesthesia. It's safe. Great results. But I did that in Afghanistan where I was absolutely un-sue-able. I wouldn't do it here in the US.
 
pgg said:
I've done quite a few u/s guided blocks and epidurals in adults under anesthesia. It's safe. Great results. But I did that in Afghanistan where I was absolutely un-sue-able. I wouldn't do it here in the US.
Click to expand...
My program rotates through an ortho heavy hospital where every single postop block/catheter for lower extremity cases are done under GA. We also routinely place epidurals/paravertebrals for intubated rib fx patients essentially under GA in the ICU. I'm not trying to comment on whether or not this is the correct practice or not, just stating what happens here.
 
The problem is not that anyone really believes that there is increased risk if these blocks are done under anesthesia, the problem is that there will be plenty of fellow anesthesiologists who will be eager to testify against you if you do it and you have a nerve injury.
 
Wish someone would do that study already to prove no more complications under ga. I'd want mine after induction thank you very much
 
amyl said:
Wish someone would do that study already to prove no more complications under ga. I'd want mine after induction thank you very much
Click to expand...
The problem is that the patient cannot waive her rights to sue for malpractice (so that the anesthesiologist can feel safe to do the block under GA). Hence no smart anesthesiologist will risk it, regardless of what the patient wants.
 
FFP said:
The problem is that the patient cannot waive her rights to sue for malpractice (so that the anesthesiologist can feel safe to do the block under GA). Hence no smart anesthesiologist will risk it, regardless of what the patient wants.
Click to expand...

For two years I have been doing blocks under GA, now you guys have me worried. I am not so much worried having an awake patient will make a difference, I am more concerned that some lawyer will convince a jury blocks are truly safer in an awake patient.
 
FFP said:
The problem is that the patient cannot waive her rights to sue for malpractice (so that the anesthesiologist can feel safe to do the block under GA). Hence no smart anesthesiologist will risk it, regardless of what the patient wants.
Click to expand...
What if the cardiologist says it's OK? 🙂
 
PainDrain said:
For two years I have been doing blocks under GA, now you guys have me worried. I am not so much worried having an awake patient will make a difference, I am more concerned that some lawyer will convince a jury blocks are truly safer in an awake patient.
Click to expand...
It won't take a lot of convincing. It's very easy to find an expert to say that's the standard of care.

It's the same as lap chole's with LMAs. If the patient aspirates... not defensible in this country.

I would document the hell out of the fact that I explained the patient the much increased risk for nerve damage under GA, compared to an awake block, and that the patient refused the awake block. Even that might not be a good enough defense (this is an elective procedure with much safer alternatives, plus the patient does not get to choose an unsafe method in this country, period). But, if you didn't even offer an awake block or didn't explain the increased risk for intraneural injection, you would clearly be liable in case of any neurological complication IMO.
 
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There are two huge databases of peds blocks which show actually a lower rate of complications in blocks done under GA vs the existing adult databases of blocks done awake.
 
drrosenrosen said:
But is their peripheral neurophysiology substantively different?
Click to expand...
At least 3 things are significantly different:
- Their huge potential for tissue repair. So even if there is nerve damage I wouldn't be surprised if they grow it out.
- Their low tolerance for awake procedures, which actually makes an awake procedure more dangerous, since they can move at any time. One cannot rely on their feedback, so one can as well do the procedure with them asleep.
- Most of them have normal BMI, hence the blocks are easy.
 
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FFP said:
I would document the hell out of the fact that I explained the patient the much increased risk for nerve damage under GA, compared to an awake block, and that the patient refused the awake block.
Click to expand...

Has this ever been shown? In my first 8 years of practice I did literally hundreds, maybe into the thousands, of femoral nerve blocks under spinal anesthesia. Never had a problem except the rare block that lasted a little longer than anticipated. But I still get that with awake patients. I stopped because the practice was becoming outside the standard of care and thus medicolegally indefensible. Still, I remain unconvinced that it is actually safer to do an awake block. My only serious nerve injury which took months to recover was on an awake patient, US guided with textbook images. Is the incidence of nerve injury much higher or even slightly higher in pediatric patient? The denominator is greater now but it seems as if the incidence of nerve injury and other block complications has gone up, not down.

We really don't know what causes most cases of clinically significant nerve injury so it makes no sense to say we know how to prevent it.
 
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The incidence of nerve injury is actually lower in the pediatric patient.

Ecoffey C, Lacroix F, Giaufré E, Orliaguet G, Courrèges P; Association des
Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF).
Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year
prospective survey of the French-Language Society of Paediatric Anaesthesiologists
(ADARPEF). Paediatr Anaesth 2010 Dec; 20(12): 1061-9.
 
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