Garbage clearances

[TheLoneWolf]

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Ironically when you actually want their input for something acute they write stuff like "it's just demand ischemia" or "there's no need to trend troponins" or "they should get a stress test after surgery" and such.

GI and NPs call it trop leak. Cardiologist and EKG machine call it an NSEMI. Guess who's word I take?

 

[PpfSuxTube]

Recently got pushback for a femur fx because cardiology “cleared” a pt with known history of CAD, CHF, and moderate AS. Note said low to moderate risk.

The kicker was than nothing had resulted. TTE was ordered but hadn’t been done. Didn’t even have basic labs back. There was literally nothing in the chart other than EM, ortho, and cardiology notes. Seemed pretty obvious that they just threw a generic note in and planned to add end it after the echo was done.

You're not going to like this but you may be wrong.

Waiting for an echo is just increasing this patients mortality risk. There is evidence for this. Look it up. Regular labs take 30 mins.

Doesnt matter what the note says about risk. Thats useless.

Assume the patient has sever AS and do the case. Or palliate them. You have 48 hours max to optimize a hip fracture then their morbidity sky rockets. Probably the newest evidence will actually drop that window drop 48 hrs to 24 hours.

The tte might make you feel you have done a service to the patient but you probably havent

 

[Maz777]

You're not going to like this but you may be wrong.

Waiting for an echo is just increasing this patients mortality risk. There is evidence for this. Look it up. Regular labs take 30 mins.

Doesnt matter what the note says about risk. Thats useless.

Assume the patient has sever AS and do the case. Or palliate them. You have 48 hours max to optimize a hip fracture then their morbidity sky rockets. Probably the newest evidence will actually drop that window drop 48 hrs to 24 hours.

The tte might make you feel you have done a service to the patient but you probably havent

All hip fractures should be emergent level 1 cases. Every orthopedic surgeon would love you. It's a level 1. Let's bump this elective Whipple and get this femur nailed ASAP otherwise granny will be dead and you'll have blood on your hands.

There is no way there is an actual mortality difference between fixing a hip between 0-24 hours and 24-48 hours. Any retrospective study saying so is completely flawed because of "healthier"/younger hips are going to be approved to go earlier than the 98 year-old that can't ambulate at baseline and might need some medical optimization. You can try to adjust all you want for that retrospectively with your fancy multivariate logistic regression/stratification but it's just basic common sense.

You are absolutely not increasing the mortality risk by waiting a bit to get a TTE. Granted, most TTEs in these patients don't actually change perioperative management and are a waste of time. But no one is increasing their mortality by doing so. Foolish to say otherwise.

 

[aafisahar]

There are only a few things that matter from a cardiology perspective re: cardiac risk.

1. Heart failure especially if they are decompensated. Getting them on good meds as well.

2. Acute MI within 6 weeks. Highest risk for arrhythmia. Need to know if can do surgery on DAPT.

3. Active VT eg did they just get shocked recently. Are they on good meds?

4. Severe valvular disease especially aortic stenosis.

5. Mechanical valve and timing of AC. If this goes south it can go south real bad.

Ischemia matters a lot less than we fret about. A positive stress with stable symptoms and an otherwise reassuring TTE? Go on without a stent. Fixing ischemia doesn't reduce perioperative outcomes in the highest risk patients (see CARP 2008 Nejm), it'll be fine for the same day chole. A lot of gestalt is obviously involved but nearly all patients will get through nearly all surgeries without much issue.

 

[TheLoneWolf]

A couple more

Morbidly obese physician comes in for a hysterectomy for anemia from heavy menses. Hb 11ish. Preop, the surgeon ordered a TSH (they are repro endo). Comes back near a hundred. I offered to repeat labs and a T4 to buy time. TSH in 30s but T4 undetectable. The physician patient quickly understood the risk of myxedema coma and I canceled. Surgeon kept pushing to do it citing it would "take months to correct her thyroid issue".

75 year old comes ot the ASC for an elective hip replacement. Comes with 2 cardiac clearances from the same practice. The first noted his ekg showing Mobitz 2 and said he is not cleared pending further workup. The second a few days later, he sees a partner of the cardiologist who clears the guy and clearance note said "he had Mobitz 2 on ekg recently but ekg today is normal, ok to proceed." No guidance on what to do if he goes into that rhythm intraop or weather we should delay so the guy can get a pacemaker. I called the cardiology office and the initial cardiologist who did not clear the guy was on call. He said do not proceed. I put my foot down and say a hard no. Family and orthopod throw a fit. I explain to them we have no cardiac capability outside of maybe transcutaneous pacing and that the guy needs a pacer. Surgeon puts up a huge stink saying a cavalier partner reviewed the chart and cleared for surgery a few days back. I told him he can have that partner do the case if he disagrees with my assessment. They regularly shop this ridiculousness at the ASC. End of story, other anesthesiologist walks into the patient room and loudly says " hey 10% chance you die on the table, do you want to proceed?" Patient and his family say they are good with it. I stare in awe as they proceed against my and the cardiologist recommendations. Same orthopod likes to remind me how everything went well with that case despite my concerns.

I can't believe someone like this can maintain board certification in our field. Just throw all guidelines out the window.

 

[kidthor]

A couple more

Morbidly obese physician comes in for a hysterectomy for anemia from heavy menses. Hb 11ish. Preop, the surgeon ordered a TSH (they are repro endo). Comes back near a hundred. I offered to repeat labs and a T4 to buy time. TSH in 30s but T4 undetectable. The physician patient quickly understood the risk of myxedema coma and I canceled. Surgeon kept pushing to do it citing it would "take months to correct her thyroid issue".

75 year old comes ot the ASC for an elective hip replacement. Comes with 2 cardiac clearances from the same practice. The first noted his ekg showing Mobitz 2 and said he is not cleared pending further workup. The second a few days later, he sees a partner of the cardiologist who clears the guy and clearance note said "he had Mobitz 2 on ekg recently but ekg today is normal, ok to proceed." No guidance on what to do if he goes into that rhythm intraop or weather we should delay so the guy can get a pacemaker. I called the cardiology office and the initial cardiologist who did not clear the guy was on call. He said do not proceed. I put my foot down and say a hard no. Family and orthopod throw a fit. I explain to them we have no cardiac capability outside of maybe transcutaneous pacing and that the guy needs a pacer. Surgeon puts up a huge stink saying a cavalier partner reviewed the chart and cleared for surgery.l a few days back. I told him he can have that partner do the case if he disagrees with my assessment. They regularly shop this ridiculousness at the ASC. End of story, other anesthesiologist walks into the patient room and loudly says " hey 10% chance you die on the table, do you want to proceed?" Patient and his family say they are good with it. I stare in awe as they proceed against my and the cardiologist recommendations. Same orthopod likes to remind me how everything went well with that case despite my concerns.

I can't believe someone like this can maintain board certification in our field. Just throw all guidelines out the window.

Uh why didn’t your partner refuse to do the case also? He/she’s part of the problem…

 

[Maz777]

A couple more

Morbidly obese physician comes in for a hysterectomy for anemia from heavy menses. Hb 11ish. Preop, the surgeon ordered a TSH (they are repro endo). Comes back near a hundred. I offered to repeat labs and a T4 to buy time. TSH in 30s but T4 undetectable. The physician patient quickly understood the risk of myxedema coma and I canceled. Surgeon kept pushing to do it citing it would "take months to correct her thyroid issue".

75 year old comes ot the ASC for an elective hip replacement. Comes with 2 cardiac clearances from the same practice. The first noted his ekg showing Mobitz 2 and said he is not cleared pending further workup. The second a few days later, he sees a partner of the cardiologist who clears the guy and clearance note said "he had Mobitz 2 on ekg recently but ekg today is normal, ok to proceed." No guidance on what to do if he goes into that rhythm intraop or weather we should delay so the guy can get a pacemaker. I called the cardiology office and the initial cardiologist who did not clear the guy was on call. He said do not proceed. I put my foot down and say a hard no. Family and orthopod throw a fit. I explain to them we have no cardiac capability outside of maybe transcutaneous pacing and that the guy needs a pacer. Surgeon puts up a huge stink saying a cavalier partner reviewed the chart and cleared for surgery.l a few days back. I told him he can have that partner do the case if he disagrees with my assessment. They regularly shop this ridiculousness at the ASC. End of story, other anesthesiologist walks into the patient room and loudly says " hey 10% chance you die on the table, do you want to proceed?" Patient and his family say they are good with it. I stare in awe as they proceed against my and the cardiologist recommendations. Same orthopod likes to remind me how everything went well with that case despite my concerns.

I can't believe someone like this can maintain board certification in our field. Just throw all guidelines out the window.

You have some sketchy partners. I wouldn't fathom doing a case the same day that a colleague cancelled/postponed. Optics are terrible.

Did you document your discussion in the chart?

 

[pgg]

A couple more

Morbidly obese physician comes in for a hysterectomy for anemia from heavy menses. Hb 11ish. Preop, the surgeon ordered a TSH (they are repro endo). Comes back near a hundred. I offered to repeat labs and a T4 to buy time. TSH in 30s but T4 undetectable. The physician patient quickly understood the risk of myxedema coma and I canceled. Surgeon kept pushing to do it citing it would "take months to correct her thyroid issue".

75 year old comes ot the ASC for an elective hip replacement. Comes with 2 cardiac clearances from the same practice. The first noted his ekg showing Mobitz 2 and said he is not cleared pending further workup. The second a few days later, he sees a partner of the cardiologist who clears the guy and clearance note said "he had Mobitz 2 on ekg recently but ekg today is normal, ok to proceed." No guidance on what to do if he goes into that rhythm intraop or weather we should delay so the guy can get a pacemaker. I called the cardiology office and the initial cardiologist who did not clear the guy was on call. He said do not proceed. I put my foot down and say a hard no. Family and orthopod throw a fit. I explain to them we have no cardiac capability outside of maybe transcutaneous pacing and that the guy needs a pacer. Surgeon puts up a huge stink saying a cavalier partner reviewed the chart and cleared for surgery.l a few days back. I told him he can have that partner do the case if he disagrees with my assessment. They regularly shop this ridiculousness at the ASC. End of story, other anesthesiologist walks into the patient room and loudly says " hey 10% chance you die on the table, do you want to proceed?" Patient and his family say they are good with it. I stare in awe as they proceed against my and the cardiologist recommendations. Same orthopod likes to remind me how everything went well with that case despite my concerns.

I can't believe someone like this can maintain board certification in our field. Just throw all guidelines out the window.

I think you should quit and find a better job.

You'll find an idiot surgeon or two everywhere, but life's too short to put up with ****ty partners like that.

If you're anchored to this practice for family reasons, my condolences. Hope they at least pay you well.

 

[TheLoneWolf]

Uh why didn’t your partner refuse to do the case also? He/she’s part of the problem…

Surgeon reminded him he cleared that case a couple days previously. He didn't want to go back on his word. My guess is that he either didn't review or didn't review the chart with more than a cursory look.

 

[TheLoneWolf]

You have some sketchy partners. I wouldn't fathom doing a case the same day that a colleague cancelled/postponed. Optics are terrible.

Did you document your discussion in the chart?

Of course, if don't, orthopod can turn it around and get me into trouble for obstructing his cases with admin. I mean just look, "there's a cardiac clearance what more do you want?" With a straight face while also seeing the other clearance that says don't proceed. The irony is palpable.

 

[deleted1130227]

A couple more

Morbidly obese physician comes in for a hysterectomy for anemia from heavy menses. Hb 11ish. Preop, the surgeon ordered a TSH (they are repro endo). Comes back near a hundred. I offered to repeat labs and a T4 to buy time. TSH in 30s but T4 undetectable. The physician patient quickly understood the risk of myxedema coma and I canceled. Surgeon kept pushing to do it citing it would "take months to correct her thyroid issue".

75 year old comes ot the ASC for an elective hip replacement. Comes with 2 cardiac clearances from the same practice. The first noted his ekg showing Mobitz 2 and said he is not cleared pending further workup. The second a few days later, he sees a partner of the cardiologist who clears the guy and clearance note said "he had Mobitz 2 on ekg recently but ekg today is normal, ok to proceed." No guidance on what to do if he goes into that rhythm intraop or weather we should delay so the guy can get a pacemaker. I called the cardiology office and the initial cardiologist who did not clear the guy was on call. He said do not proceed. I put my foot down and say a hard no. Family and orthopod throw a fit. I explain to them we have no cardiac capability outside of maybe transcutaneous pacing and that the guy needs a pacer. Surgeon puts up a huge stink saying a cavalier partner reviewed the chart and cleared for surgery a few days back. I told him he can have that partner do the case if he disagrees with my assessment. They regularly shop this ridiculousness at the ASC. End of story, other anesthesiologist walks into the patient room and loudly says " hey 10% chance you die on the table, do you want to proceed?" Patient and his family say they are good with it. I stare in awe as they proceed against my and the cardiologist recommendations. Same orthopod likes to remind me how everything went well with that case despite my concerns.

I can't believe someone like this can maintain board certification in our field. Just throw all guidelines out the window.

My response would be "just because you didn't lose at Russian Roulette doesn't mean that it was a good idea".

 

[medicine2wallstreet]

Had one of these tight aortic valves for TKR and the cardiologist said "Cleared for Spinal" on the chart. When the patient got to the OR, I had the Pre Op nurse page the cardiologist and tell him the patient was here and we were waiting for him to come do the spinal. Having made my point, we did GA.

Honestly man that's just being an a$$hole.

 

[medicine2wallstreet]

We get cardiac or pulmonary (or whatever) consultations, which hopefully contain actual useful information, some risk stratification and or statements along the lines of "pt is optimized" or "pt is as good as they're going to get". Unfortunately we get some of those from NPs/PAs but we have no problem going straight to their boss. None of those people get to clear anyone for surgery. That's the job for the physician anesthesiologist who actually evaluates the patient pre-operatively.

Physician anesthesiologist.....just say anesthesiologist.

 

[medicine2wallstreet]

Honestly, we need to abandon the term cardiology clearance. It’s misleading to patients (and some clueless surgeons). Maybe we should start calling it cardiac advisory or something like that.

Well the term cardiology clearance is a misnomer and that has been used by anesthesiologists. The correct term is cardiac risk assessment. Technically the phrase is supposed to be the patient is at an acceptable level of cardiac risk for the surgery. But low brain anesthesiologists request "cardiac clearance". Cardiologists understand that they are assessing the cardiac risk and that they cannot clear anyone for surgery but anesthesiologists have pinned cardiologists down to divert medical legal blame and thus we have cardiac clearance.

 

[vector2]

... but anesthesiologists surgeons and proceduralists have pinned cardiologists down to divert medical legal blame and thus we have cardiac clearance.

Ftfy

 

[The Duck Knows]

You're not going to like this but you may be wrong.

Waiting for an echo is just increasing this patients mortality risk. There is evidence for this. Look it up. Regular labs take 30 mins.

Doesnt matter what the note says about risk. Thats useless.

Assume the patient has sever AS and do the case. Or palliate them. You have 48 hours max to optimize a hip fracture then their morbidity sky rockets. Probably the newest evidence will actually drop that window drop 48 hrs to 24 hours.

The tte might make you feel you have done a service to the patient but you probably havent

I wasn’t asking for 3 days of workup. The guy had been in the ED for 30 minutes and was stable. He didn’t even have CBC or CMP. I’m not one to waste time with unnecessary workup for emergent cases. I am against cards and ortho saying he needs an echo out of one side of their mouth, then saying he’s “low risk” with absolutely zero evidence to support that claim. If anything happened in the OR you know they would have flipped and asked why I proceeded without the echo being finalized.

 

[coffeebythelake]

Well the term cardiology clearance is a misnomer and that has been used by anesthesiologists. The correct term is cardiac risk assessment. Technically the phrase is supposed to be the patient is at an acceptable level of cardiac risk for the surgery. But low brain anesthesiologists request "cardiac clearance". Cardiologists understand that they are assessing the cardiac risk and that they cannot clear anyone for surgery but anesthesiologists have pinned cardiologists down to divert medical legal blame and thus we have cardiac clearance.

It is a risk assessment. I dont know of any anesthesiologists who use it as gospel and proclaim the patient to be low risk for complications if they have "cardiac clearance"... Some surgeons unfortunately do.

 

[dannyboy1]

It is a risk assessment. I dont know of any anesthesiologists who use it as gospel and proclaim the patient to be low risk for complications if they have "cardiac clearance"... Some surgeons unfortunately do.

I look at it as a legal defense in case the patient has a post op MI. if something happens intra-op you will be blamed anyways. Echo is helpful to assess function and guide management. Don’t really care about coronaries unless something acute going on. I just avoid hypoxia and hypotension 😊

 

[ucladoc2b]

It is a risk assessment. I dont know of any anesthesiologists who use it as gospel and proclaim the patient to be low risk for complications if they have "cardiac clearance"... Some surgeons unfortunately do.

That’s how I treat it and the good cardiologists treat it (I hate when they say “clear for surgery” in the note). My personal frustration stems from how this comes off to the patient/family and how certain surgeons misuse it.

 

[VA Hopeful Dr]

That’s how I treat it and the good cardiologists treat it (I hate when they say “clear for surgery” in the note). My personal frustration stems from how this comes off to the patient/family and how certain surgeons misuse it.

FP here. The surgeons force us to write "cleared for surgery" in our note.

The form they send with what tests they want us to run says so in large bold letters.

 

[abolt18]

FP here. The surgeons force us to write "cleared for surgery" in our note.

The form they send with what tests they want us to run says so in large bold letters.

Seems everyone's getting handcuffed by the surgeon I guess. Really the only question I have of the cardiologist or FP is "Does the patient have any modifiable risk factors?" AKA, is the HTN, asthma, COPD, heart failure, pulmonary hypertension, etc. optimized to its very best we can get it to?

If so, then I'll have a good discussion with the patient about their risks and proceed if they are willing. If those things are not optimized, and have potential to significantly affect their safety in the perioperative period before an elective surgery, then we're not proceeding regardless of "clearance".

 

[coffeebythelake]

FP here. The surgeons force us to write "cleared for surgery" in our note.

The form they send with what tests they want us to run says so in large bold letters.

I don't quite understand. What do you mean the surgeons "force you"? You can always refuse. Or you can write a disclaimer for what your evaluation involves.

 

[VA Hopeful Dr]

I don't quite understand. What do you mean the surgeons "force you"? You can always refuse. Or you can write a disclaimer for what your evaluation involves.

That's true, I could refuse to do that. Then the patient is pissed off and will both find another doctor and leave a bad review, both of which is result in me getting called to the principal's office and taking a hit to my pay.

Do it enough and the surgeons will start steering patients to other doctors for the pre-op visit.

My hospital is the most primary-care focused place I've ever worked at and even then they will choose the surgeons over me for a matter of what, to them, is semantics.

So yes, I could refuse but it would go very badly for me. Same way you could cancel whatever cases you want, but eventually it would come back to bite you.

 

[coffeebythelake]

That's true, I could refuse to do that. Then the patient is pissed off and will both find another doctor and leave a bad review, both of which is result in me getting called to the principal's office and taking a hit to my pay.

Do it enough and the surgeons will start steering patients to other doctors for the pre-op visit.

My hospital is the most primary-care focused place I've ever worked at and even then they will choose the surgeons over me for a matter of what, to them, is semantics.

So yes, I could refuse but it would go very badly for me. Same way you could cancel whatever cases you want, but eventually it would come back to bite you.

You aren't just rubber stamping your cases.. Are you addressing medical issues to optimize the patient? I mean that's the point of the "clearance".

And when you have days/weeks even months in advance of surgery there is a lot of optimization that can take place.

The clearance ultimately isn't a ticket to ride. But it seems like your surgeons purposefully and perhaps maliciously want to confuse the patients by forcing you to say that.

I rarely cancel a case, and when I do it more like convincing the surgeon and having them cancel it for me.

 

[VA Hopeful Dr]

You aren't just rubber stamping your cases.. Are you addressing medical issues to optimize the patient? I mean that's the point of the "clearance".

And when you have days/weeks even months in advance of surgery there is a lot of optimization that can take place.

The clearance ultimately isn't a ticket to ride. But it seems like your surgeons purposefully and perhaps maliciously want to confuse the patients by forcing you to say that.

I rarely cancel a case, and when I do it more like convincing the surgeon and having them cancel it for me.

Of course I'm not, and I will absolutely delay cases if the patient isn't optimized.

 

[greatnt249]

And when you have days/weeks even months in advance of surgery there is a lot of optimization that can take place.

In my case, it's more like "2 days" to address an EKG that was ordered several weeks prior but just now being followed up on.

 

[coffeebythelake]

In my case, it's more like "2 days" to address an EKG that was ordered several weeks prior but just now being followed up on.

Sounds terrible. Seems like someone dropped the ball.. Why was the ekg even ordered? Don't tell me "routine presurgical"

 

[greatnt249]

Sounds terrible. Seems like someone dropped the ball.. Why was the ekg even ordered? Don't tell me "routine presurgical"

Yes, yes, and yes. I might be an outlier, but it happens fairly often in my neck of the woods. The patient usually shows up saying "I'm not sure why I'm here right now, I had that EKG done a month ago." Problem is, usually it's some variety of over-call on the EKG that forces my hand to have to do "something" to clear the air and not be the bad guy who cancels the surgery they've usually been waiting a while for at the last second. Usually it works itself out; would just be nice to have more than a couple-day buffer to be able to plan some things in advance if I need to.

 

[Maz777]

That's true, I could refuse to do that. Then the patient is pissed off and will both find another doctor and leave a bad review, both of which is result in me getting called to the principal's office and taking a hit to my pay.

Do it enough and the surgeons will start steering patients to other doctors for the pre-op visit.

My hospital is the most primary-care focused place I've ever worked at and even then they will choose the surgeons over me for a matter of what, to them, is semantics.

So yes, I could refuse but it would go very badly for me. Same way you could cancel whatever cases you want, but eventually it would come back to bite you.

Doing whatever a surgeon wants is just wrong. Providing the opposite of appropriate care is downright soul-crushing. That's what writing "cleared for surgery" amounts to. That word is meaningless coming from a PCP. Only an anesthesiologist can "clear" a patient for surgery. No one can force you to do anything. You aren't a mid-level.

These "clearance" visits are usually hated by most PCPs, and they would be glad to get them off their overbooked schedule. Sucks that you need that volume apparently. PCPs are always complaining of these visits on other sites.

You need a new job. Sounds awful. Ironic that your handle is VA Hopeful Dr. This would absolutely never happen at our local VA. In fact, the exact opposite usually happens. Whenever I am ambivalent about proceeding with a case day of (gray zone), most of our surgeons won't want to proceed for fear of an untoward outcome leading to a Peer Review.

 

[coffeebythelake]

I echo Mazz's sentiments. Is doing preop evaluations so profitable? It seems to me the pcps out here are so damn busy with other patient care responsibilities that they don't like to do them much.

 

[ucladoc2b]

I echo Mazz's sentiments. Is doing preop evaluations so profitable? It seems to me the pcps out here are so damn busy with other patient care responsibilities that they don't like to do them much.

I’m kind of surprised the surgeons control this. You would figure the PCP referral to the surgeon would make them be a little more appreciative.

 

[coffeebythelake]

I’m kind of surprised the surgeons control this. You would figure the PCP referral to the surgeon would make them be a little more appreciative.

Well this isn't the PCP patient being referred to surgery. This is surgeon directing patient to PCP for the preop evaluation.. unclear if there is a strong preexisting relationship with the patient. "Whose patient" it is defines the interaction and dynamics between PCP and surgeon.

 

[ucladoc2b]

Well this isn't the PCP patient being referred to surgery. This is surgeon directing patient to PCP for the preop evaluation.. unclear if there is a strong preexisting relationship with the patient. "Whose patient" it is defines the interaction and dynamics between PCP and surgeon.

Makes sense. It seems, at least here, that most patients go to their own PCP or cardiologist.

This doesn’t stop the blindly “cleared for surgery.”

 

[Maz777]

I’m kind of surprised the surgeons control this. You would figure the PCP referral to the surgeon would make them be a little more appreciative.

That's the normal referral dynamic. Surgeons buttering up PCPs to get those referrals/cases. This PCP's health system sounds completely backwards. Never heard of a PCP groveling for surgical "clearance" visits.

 

[Beeftenderloin]

That's true, I could refuse to do that. Then the patient is pissed off and will both find another doctor and leave a bad review, both of which is result in me getting called to the principal's office and taking a hit to my pay.

Do it enough and the surgeons will start steering patients to other doctors for the pre-op visit.

My hospital is the most primary-care focused place I've ever worked at and even then they will choose the surgeons over me for a matter of what, to them, is semantics.

So yes, I could refuse but it would go very badly for me. Same way you could cancel whatever cases you want, but eventually it would come back to bite you.

Tell them you’ll write whatever you think is medically appropriate in your pre-op visit note and you’ll make sure to send your ample supply of patients with hernias and cholelithiasis to a different surgeon if that’s going to be a problem.

 

[VA Hopeful Dr]

Man, this really blew up...

First, it's only Ortho that does this. General surgeons clear their own patients. Will occasionally get them from plastics but it's like 2 lines long: do whatever you feel is best to make sure patient will be optimized for surgery.

Second, Ortho sends a form saying "order the following tests and when everything is OK, write Cleared for Surgery and fax back to us. Every single orthopod within a 60 miles radius does this. Every single one.

Third, I don't work at the VA. Username is from when I was an undergrad in Virginia.

Fourth, I love these visits. 90+% of the time everything goes smoothly and I get to bill a fairly high office charge and an ECK interpretation.

Fifth, I'm very busy (new patients booked out 3 months) but my schedule is such that I'm at best 50% booked for established patients at 1 week out. Honestly anything less is bad doctoring because it means patients can't get in to see you when they need to.

Sixth, outside of trauma every local Ortho office is booked out 1+ months. They wouldn't even notice if I stopped sending them patients. Plus, as mentioned above: where would I send them.

Seventh, everyone else (100+ PCPs in the network) just go along with it. I'm sure it would go great for me if I was the one exception about this.

Eighth, and most importantly, it's pure semantics. The local anesthesia group knows what the score is here and they practice appropriately.

 

[Southpaw]

leave a practice over pre op clearances? Well that escalated quickly.

 

[vector2]

Second, Ortho sends a form saying "order the following tests and when everything is OK, write Cleared for Surgery and fax back to us. Every single orthopod within a 60 miles radius does this. Every single one.

Lol this is some bush league horse sht

Third, I don't work at the VA. Username is from when I was an undergrad in Virginia.

Also, for years (decades???) I've thought your handle unironically meant you wanted to work for a Department of Veterans Affairs hospital.

 

[VA Hopeful Dr]

Lol this is some bush league horse sht



Also, for years (decades???) I've thought your handle unironically meant you wanted to work for a Department of Veterans Affairs hospital.

Ha, you and everyone else.

In the list of things that tick me off on a regular basis, these Ortho forms don't even break top 10.

 

[greatnt249]

In the list of things that tick me off on a regular basis, these Ortho forms don't even break top 10.

Right, it's not the evaluation itself that's annoying, it's the last minute dump into my schedule that irritates me (especially when the thing I'm being asked to comment on was known about well before the referral was ever placed). I could think of plenty of other things that irritate me more on a daily basis than doing a preoperative evaluation.

 

[coffeebythelake]

WHY AM I NOT SURPRISED IT IS ORTHO!!!

 

[Dantrolene FC]

The funny thing is, when they consult me (anesthesia resident), I refuse to “clear them for surgery”. They ask if I’ll drop a note saying they’re cleared for surgery for the next day. I always say no. “I can write a note with recommendations for further workup if I see any, but the only person that can clear them for surgery is the anesthesiologist the day of surgery.” Then I call them back at 2 am with recommendations to continue beta blockers, hold ACE/ARB unless they’re BP is uncontrolled, and to keep the patient NPO.

 

[Simba1711]

Yeah clearances are stupid. We had them at our old hospital which were mostly for billing. The surgeons would have the hospitalist or cardiologist “clear” the patient. They would never write clear on the chart so I’m not sure what it was for. Usually just list the cardiac conditions and test results. It would also include useless advice like avoid benzodiazepines and narcotics due to dementia risk and patient age. It was annoying because the older anesthesiologists would refuse to do a case until they had a clearance note and the surgeons would shop around doctors for the clearance note.

We have a Poma now at a Major hospital system for elective cases. The internal medicine doctor orders tests if indicated. They also write their risk and whether they are optimized for the procedure. This is much more helpful imo. If we have an urgent case and have time before the case proceeds the surgeons are good about having one of their pas or residents contact the attending on call to see what tests or labs if any we would like to have.

 

[TheLoneWolf]

I worked at a place where you had to manually clear your upcoming cases for the month. Pick up a stack of paperwork in your mailbox and review intraop or on off time where you review med history, order labs and meds then sign off on clearing the patient. Could contact patient for clarifications or send to anesthesia clinic if had concerns. Rarely had to cancel cases but the added workload wouldn't work for everyone

 

[gunnershow]

I worked at a place where you had to manually clear your upcoming cases for the month. Pick up a stack of paperwork in your mailbox and review intraop or on off time where you review med history, order labs and meds then sign off on clearing the patient. Could contact patient for clarifications or send to anesthesia clinic if had concerns. Rarely had to cancel cases but the added workload wouldn't work for everyone

I wouldn't mind this. I basically do this except the day before surgery when I find out my assignment, which leaves me scrambling last minute to find out information and tee up borderline patients.

 

[FiO2@21]

To be fair what are you going to do about the occluded RCA. By definition if he is alive he’s got collateral flow. You’d be hard pressed to find someone whose going to try try bore open a CTO preoperatively.

In general we chase coronary workups too much. Revascularising stable disease doesn’t prevent perioperative cardiac events. Preop TTE on the other hand is worth it’s weight in gold imo

Like you alluded to that infarct likely completed but if there was optimizing of the ischemic CM to be done (diuresis, GDMT, etc), that should be done before an elective knee.

When I was a resident I'd see some physicians or CRNAs say stuff like "oh we take back patients sicker than that all the time"...

I was on a practice management rotation where you pretended to be the care team attending. Had this woman come in w/ COVID 1-2 months ago with progressively worsening DOE since then. Almost collapsed in the lobby and needed a wheelchair to get into pre-op. I pushed for an admission and workup for ischemia, PE, new HF, etc. The anesthetist (who's excellent) said the above to me. The workup ended up being negative for anything that'd kill the pt on induction and they proceeded uneventfully the next day.

But I was grateful people weren't stamping their feet when I advocated for delaying.

 

[coffeebythelake]

Like you alluded to that infarct likely completed but if there was optimizing of the ischemic CM to be done (diuresis, GDMT, etc), that should be done before an elective knee.

When I was a resident I'd see some physicians or CRNAs say stuff like "oh we take back patients sicker than that all the time"...

That's true, but there is a distinction between a stable sick patient, optimized, with bad DOE vs. the example you provided
Optimization is what we aim for. We aren't going to make a 100 pack year smoker with COPD breathe like a 20 year old athlete.

 

[pgg]

Like you alluded to that infarct likely completed but if there was optimizing of the ischemic CM to be done (diuresis, GDMT, etc), that should be done before an elective knee.

When I was a resident I'd see some physicians or CRNAs say stuff like "oh we take back patients sicker than that all the time"...

I was on a practice management rotation where you pretended to be the care team attending. Had this woman come in w/ COVID 1-2 months ago with progressively worsening DOE since then. Almost collapsed in the lobby and needed a wheelchair to get into pre-op. I pushed for an admission and workup for ischemia, PE, new HF, etc. The anesthetist (who's excellent) said the above to me. The workup ended up being negative for anything that'd kill the pt on induction and they proceeded uneventfully the next day.

But I was grateful people weren't stamping their feet when I advocated for delaying.

We're in the business of understanding, reducing, and accepting risk.

Accepting risk when you have an appropriate understanding of the risk is different than accepting risk because you think everything is risky and you rationalize proceeding by assuming the worst.

One approach is OK, and one is characteristic of excellent physicians who inevitably come up short one day and are revealed to be not quite as excellent as inexperienced observers think they are.

 

[kidthor]

We're in the business of understanding, reducing, and accepting risk.

Accepting risk when you have an appropriate understanding of the risk is different than accepting risk because you think everything is risky and you rationalize proceeding by assuming the worst.

One approach is OK, and one is characteristic of excellent physicians who inevitably come up short one day and are revealed to be not quite as excellent as inexperienced observers think they are.

Very well put…

I am often frustrated by the “all the patients are just really sick” crowd because they are poor risk mitigators. IMO it’s an ethical requirement to ensure patients are as optimized as possible and that they understand the risks/benefits of surgery and anesthesia. Plus we can get almost all patients through surgery, but plenty of those poorly optimized patients are then set up for post op complications.

 

[hiyaman]

I'm always surprised when I see a PCP write a decent pre-op risk assessment/stratification note. Most of what I get are rcri number and then something saying low risk ok to proceed.