Reading Toughlife's thread about what to do with some poor dudette with metastatic disease everywhere and alotta heart issues, and you are consulted for sedation for a diagnostic, not therapeutic procedure brought out some thoughts of mine. (BTW Toughie used some abbreviations I didnt understand either......hey Tough, what the f u k?) "UH, Yeah, Tough here, gotta case, 78 year old lady, HYG, GHB, FFGN, HNG, she's got metastasis with GRFD, FGBV, so we contacted the FGWQ for a DCF and the result was SDFC. SO WHADDYA ALL THINK? Anyway, back to my thoughts. I don't know what the right answer is for Toughy's case. But it reminded me of justa few cases I've had in the past eleven years where I was adamant about not going forward. Going against the grain. Yes, Mil, Noy, me, Plank, Zippy et al preach day in and day out how too many cases are cancelled needlessly. And thats true. Doesnt mean cancellations are nonexistent. Went to preop an AAA for the following day at my previous goldmine gig....elective case...well....as elective as an AAA can be.... dudes pulmonary status sucked. I knew it as soon as I walked in the room. which brings out a tangential thought, resident colleagues....you don't need PFTs, ABG, etc to determine whether someone has pulmonary dysfunction....your eyes are alot more useful. Dude was obviously short winded, talking in broken sentences....listened to his lungs which sounded like a flute at Carnegie Hall... Soon as I could break away I went to the nurses station and called the thoracic surgeon Gary Jones.....Trin, remember him? great dude... "Gary! Hey, its Bill. Dude, you don't wanna operate on this guy tomorrow...." Filled him in. Know what he said? "Thanks, William." dude always called me William ITS OK TO SAY NO SOMETIMES. Another one was with an aggressive ortho dude named Mark (hey Trin, remember him?)...not aggressive personally, actually a great guy....but dude would operate on anybody....we had a great relationship....friends.... so I go up to see an add on hip ORIF in the ICU he had posted....patient was in early stages of pulmonary edema..... as a group of physicians, anesthesiologists arent scared of much out here in practice....but one thing that raises your concern level is preoperative pulmonary edema. I don't cancel many cases. But I cancel the ones that need to be cancelled. And this was one of them. I go tell my ortho buddy Mark sorry Dude we aint doin that add on today.....patient can be optimized in a relatively short period of time.... Mark gotta little heated. But he didnt question the decision. Resident colleagues, Tough's post about how to handle his case brought up something I want you to keep in the back of your head. And yeah, it doesnt happen often. I'd go-so-far to say its rare. And because of the rareness, surgeons will not second-guess you when it arises. And it will arise. Every once in a while, and stick to your decision in the rare event you make it, ITS OK TO SAY NO.