HEY NOYAC: Quick question...

[BuzzPhreed]

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Any issues with the 25 y.o. lap appy showing up in the ED stoned? Now that you have those wacky-tabacky laws out there in skier's paradise, are you having any co-requisite "informed consent" (or other issues)? I would imagine that you'd proceed under the guise of "implied consent" in an emergency, but what about the gray areas? Or, other issues with the weed (e.g. the chronic chronic-user wanting to step outside for a bong hit as part of his "pain management" post-op plan, etc.).

Just curious.

 

[Hockeyguy]

Prop-sux-tube.

 

[pgg]

Would it be any different in a state where it's illegal? If someone's impaired and can't consent, they can't consent. But not everyone who has recently partaken in a mind altering substance, whether THC in the car or Dilaudid in the ER, is unconsentable.

As far as affecting anesthesia risk, the only drugs I really care about are cocaine and amphetamines.

I wouldn't ever cancel a case because a patient smoked marijuana on the way to the hospital, no matter what state I was in.

 

[Planktonmd]

I wouldn't hesitate to proceed..

 

[BuzzPhreed]

I have a different take not directly related to anesthesia risk (which I think marijuana is either low or non-existent).

If they are impaired and can't make a decision, then that could constitute battery. I'm more interested in elective cases where it may not be as obvious someone is stoned. You know, they wake-and-bake the morning of their hernia repair. Something goes wrong, and later they claim they were stoned and sue you for informed consent issues.

The ASA Closed Claims Project2 has indicated that less than 1 percent of all anesthesia lawsuits are due to a lack of informed consent. So why even be concerned? However, what has been frequently ignored in the Closed Claims study is that within the lawsuits evaluated, 22 percent were found to be inadequate in regard to anesthesia informed consent. While this may not directly enter into a jury verdict, a poorly documented informed consent is often used as a ploy by attorneys to influence a jury as a demonstration of inadequate care, a lack of compassion and substandard professionalism.3 A well-documented informed consent process serves to immediately remove this area of attack by the plaintiff attorney, requiring that the focus be keep on the salient medical issues.

https://www.asahq.org/sitecore/cont...icleID={CEA9E9D2-DE61-4164-B89C-22D89323CD41}

 

[deleted171991]

I had exactly this problem today. Nice elderly lady, living with her "drug-addicted" son (her words), could not help but have a hit or two last night and this morning. Elective procedure under MAC.

Would have loved to help her but, if anything bad happened, with the chart screaming that she had marijuana this AM, I would have had to prove that she was competent when she consented. Case "postponed".

 

[BuzzPhreed]

What's interesting is that it is legal in Washington and Colorado. If you show up drunk you're invariably cancelled (unless it's an emergency). But it can be a lot harder to tell if someone is stoned.

I mean, they can lie to you when you ask them about "illicit" substances and alcohol use. But the kronik is no longer illicit in those states.

I'm just curious if those of you who practice in a state where toking up is legal now have come across this, and what you're doing about it (if anything). For example has anyone amended their language in their informed consent to include info about failure to disclose drug use? This can happen to anyone anywhere, but I'd suspect it will occur more frequently in places where you can now easily (and legally) get marijuana. Stoners don't see themselves as necessarily "impaired" either. I knew more than a few dudes in college who'd bake it up 3-4 times a day... everyday... went to class... took tests. All high.

Where's zippy2u when you need him?

 

[Mman]

What's interesting is that it is legal in Washington and Colorado. If you show up drunk you're invariably cancelled (unless it's an emergency). But it can be a lot harder to tell if someone is stoned.

I mean, they can lie to you when you ask them about "illicit" substances and alcohol use. But the kronik is no longer illicit in those states.

The only problem I see is that we don't have a reliable test for measuring how impaired somebody is from marijuana. But we can urine drug screen them. So it might be legal in some states just like alcohol is legal in every state, and if you appear under the influence we can test you to see if it is present in your system. If you smoke it the morning of surgery and don't tell anybody and do not appear to be under the influence, well then good for you for sneaking it by us. But if somebody is suspicious and they check your urine and it's positive, well then I'm cancelling any non emergent procedure for failure to consent.

Now I understand it's possible to have smoked it 2 or 3 days ago and not be impaired and still urine test positive. But I don't care. If you clinically seem impaired and it's a positive test than that's enough proof for me to cancel elective cases.

 

[Noyac]

Sorry but I just got around to checking this site.
A couple observations since the "legalization" of the whacky weed here:
1) I'm using a lot less anesthetic these days. 1/2 MAC SEEMS TO WORK JUST FINE.
2) people seem to be more open with their usage since, you know, "it's legal man".

I haven't changed my consent and I don't plan to at this point or any time soon. People are frequent
Y under the influence of many things. We can't address them all and I don't even care to. This. At be the wrong approach but in the current medical environment, I just don't have the energy to address every single little things hat "might" be an issue. I talk about the big ones but then ask a very general question like, "do you want to go through all the various risks involved in your case?" They always say, "no". It may not protect me legally but I can't possibly cover everything and therefore, I choose to do this.

So far >10 yrs without an issue. But it only takes one, right?

 

[BuzzPhreed]

So far >10 yrs without an issue. But it only takes one, right?

I don't know. I would hope that anyone who shows up to court with the cornerstone of their plaintiff's case being "I was high, didn't tell my doctor, and therefore didn't really know what he/she was doing" would get an immediate summary judgment and be dismissed. But you never know what a judge or jury will think.

I was just trying to get a sense if you've seen an increase in burners. If you're running a 1/2 MAC, and it's not the altitude, then maybe yes is the answer to that.

 

[Noyac]

I was just trying to get a sense if you've seen an increase in burners. If you're running a 1/2 MAC, and it's not the altitude, then maybe yes is the answer to that.

The more I think about your question the more I begin to believe that we are seeing more "burners". In the past it was sort of kept secret and therefore they wouldn't disclose it and if they had partaken in such "medicine" they wouldn't come to us completely stoned. Fast forward to today, my ortho pod just cancelled a 16 yo a coup,e weeks ago because he was so baked. The funnier part of this is that his partners were there with him in pre-op and they thought it was ok for him to be stoned since "it's legal now". Like that miraculously makes any anesthetic issues disappear.
So more to your question, yes people are coming to us more stoned than I recall before legalization. Is it an issue? Well not so much yet but it could be I guess.

 

[pgg]

Marijuana is an anxiolytic, antiemetic, and antisialogogue. Maybe we should be encouraging its preop use. Then again, the munchies might predispose patients toward violating NPO instructions.

 

[deleted171991]

Alcohol is legal, too, but most of us wouldn't anesthetize a patient if we smell alcohol in his breath. Why is MJ different?

 

[Noyac]

Alcohol is legal, too, but most of us wouldn't anesthetize a patient if we smell alcohol in his breath. Why is MJ different?

This is a different bred of people.

 

[deleted171991]

What's the difference between a person who cannot abstain from drinking before surgery, and one who cannot skip having a joint? In my eyes, they are both addicted, and both impaired (for informed consent purposes). I care mostly about the latter, not the former.

 

[Noyac]

NPO status?

 

[pgg]

What's the difference between a person who cannot abstain from drinking before surgery, and one who cannot skip having a joint? In my eyes, they are both addicted, and both impaired (for informed consent purposes). I care mostly about the latter, not the former.

There's a line somewhere between recent use and acute intoxication. Individual discretion has to be involved in deciding where to draw that line.

Alcohol adds other issues, namely NPO status and withdrawal considerations. The guy who quits smoking pot isn't at risk for DTs 48 hours later.

I am not AT ALL concerned with THC's effect on my anesthetic, provided the patient isn't so intoxicated that I can't reasonably consent him. 2 mg of hydromorphone in the ER or the PO Valium the surgeon gave an anxious patient to take preop are more significant (though still not a big deal either). Much ado about nothing.

A tox screen + for meth or cocaine is another issue.

 

[kazuma]

But doc, the pre-op clinic said I could have unlimited clear liquids up to 2 hrs before surgery...

 

[BuzzPhreed]

Ha ha. Love it.

 

[deleted171991]

But doc, the pre-op clinic said I could have unlimited clear liquids up to 2 hrs before surgery...

My thoughts exactly.

Make it 4-6 hours, and one cannot argue that alcohol is an NPO issue. Not even a withdrawal issue, especially if the patient had some in the AM.

It's a consent and legal issue, exactly like marijuana. The guy who admits to smoking pot on the day of surgery opens one to informed consent issues, which are the new darlings of the malpractice industry.