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- Mar 17, 2006
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Newbie here on anesthesia rotation... starting CA1 in a couple months. I saw a case today that was not all that interesting, but the decision making was. 60 y/o M in for an elective b/l mastectomy for "idiopathic" gynecomastia. PMH of DM, Etoh abuse (still drinks a 12 pack/day), HTN, CAD and chronic renal failure. No DOCUMENTED hx of hep C, cirrhosis, or liver problems. His only labs are a BMP showing BUN 66, Cr 3.4 and a normal H&H. No coags, LFTs, no platelet count. When asked if he's had any bleeding problems in the past, he said that he did back in December when a dialysis cath was placed and he needed a "bunch" of blood transfusions. CRNA calls surgeon to ask if pt/INR is needed. Surgeon says no and they will proceed as scheduled. 😱 I ask the attending anesthesiologist what should be done, and he informs me that as long as the surgeon was informed of things, then you are safe. To make things more complicated, we are at the VA where STAT lab means sometime before next month.
Now I know that there are several questionable things going on here. Obviously the INR doesn't mean jack since he's not on coumadin and they need a pt/ptt. They also need to get a platelet count. This guy has gynecomastia/alcoholism/previous bleeding problems and it appears that no one has even considered that he has some liver failure going on. You can't only blame the CRNA for not putting the gynecomastia and etoh use together with the probability that this guy has serious liver dz and will bleed like a stuck pig... because the surgeon did not either! My question is what I should do in the future as a resident in a situation like that. How about as an attending? Can I completely refuse to do the ELECTIVE case? From a legal standpoint, I was told that I would be safe since the surgeon was informed. But I would think that it would be my responsibility to protect the patient from stupid decisions regardless of who is legally responsible. I don't want my name ending up on a lawsuit even if it gets dropped. More importantly, I don't want a patient bleeding out on the table. Any thoughts??
Now I know that there are several questionable things going on here. Obviously the INR doesn't mean jack since he's not on coumadin and they need a pt/ptt. They also need to get a platelet count. This guy has gynecomastia/alcoholism/previous bleeding problems and it appears that no one has even considered that he has some liver failure going on. You can't only blame the CRNA for not putting the gynecomastia and etoh use together with the probability that this guy has serious liver dz and will bleed like a stuck pig... because the surgeon did not either! My question is what I should do in the future as a resident in a situation like that. How about as an attending? Can I completely refuse to do the ELECTIVE case? From a legal standpoint, I was told that I would be safe since the surgeon was informed. But I would think that it would be my responsibility to protect the patient from stupid decisions regardless of who is legally responsible. I don't want my name ending up on a lawsuit even if it gets dropped. More importantly, I don't want a patient bleeding out on the table. Any thoughts??