How much do we really need to know about our pts?

[Noyac]

I sometimes wonder what my pts tell me and what they decide to keep from me. I'm sure they keep many things to themselves, like the fact that they got high on the way to the hospital. Or that they actually ate something before surgery. Just a few of the things I believe they never tells us. But all this makes me wonder something else. How much do we really need to know? Sure, I'd like to know everything but I can still do my job with very little information usually.

Some things I really want to know:
Aortic stenosis
NPO status
Allergies
Meds and or drugs taken
Ischemic threshold

These are a few.

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[Planktonmd]

We never know everything we want to know but we can always provide a safe anesthetic based on what they tell us combined with our clinical judgement and experience.

 

[Gimlet]

Noy, when I was in residency I used to pride myself on knowing my patients' medical/social history better than pretty much anyone in the hospital. I bet I knew their story better than their PCP and definitely better than their surgeon. Toward the end of residency and fellowship I realized this was probably overkill and a waste of my time as most things won't significantly change my management. Now that I am in a care team practice it's simply not possible to keep all the minutiae straight between patients, anyway.

I still do a comprehensive review of everybody's EMR, and I cover the basics with everybody for pertinent positives/negatives of the things I REALLY care about in about a 30 second conversation before I start my informed consent spiel to tell them about my plan for their anesthesia. But I care much less about remembering the exact details of when they last took their synthroid or how badly their fibromyalgia has been acting up with the recent weather, for example.

 

[B-Bone]

We never know everything we want to know but we can always provide a safe anesthetic based on what they tell us combined with our clinical judgement and experience.

We usually know too much, like when a two year old boy's last period was, or the religious preferences of the unconscious GSW victim rushed in from the ED. Those types of things never get missed by some nurse with a clipboard, but nobody can tell me how a demented old guy got that zipper down the front of his chest or why the exsanguinating parturient has a five page birth plan but no type-and-screen.

Gotta love modern medicine.

 

[dhb]

We never know everything we want to know but we can always provide a safe anesthetic based on what they tell us combined with our clinical judgement and experience.

My partner had a case last month; the patient denied on the form they fill any medical issue, went in for a THP and suffered an extensive MI on POD 1 with subsequent death a couple of hours later in the ICU.
When he spoke with the family they said he actually did have symptoms in the past couple of months...

 

[Planktonmd]

My partner had a case last month; the patient denied on the form they fill any medical issue, went in for a THP and suffered an extensive MI on POD 1 with subsequent death a couple of hours later in the ICU.
When he spoke with the family they said he actually did have symptoms in the past couple of months...

was the patient mentally competent? and did he also deny symptoms when interviewed by the anesthesiologist or was the written form all that you guys had?

 

[Promethean]

Disclaimer, I'm an OR nurse, not an anesthesiologist or even a CRNA. But, I have seen a few cases where a seemingly insignificant detail was the key to preventing a catastrophic outcome.

I've also gotten a lot of reports that tell me that my 17 year old patient is an ex-36 week premie who had an umbilical hernia repair, ear tubes, T&A at 7, etc. No mention of his congenital cardiac history until I see the sternal scar.

There is so much information to sift through to find the points that matter. When the person doing the pre-op H&P is concerned with checking boxes rather than critically evaluating the patient, the minutia will tend to drown out the relevant, every time. You can't ever assume that you know everything that you need, that no new information will be pertinent. Gotta keep your own eyes and ears open, and communicate effectively with the other members of the team about what you find out. For me, that means hoping that my observations aren't dismissed as being from "just a nurse with a clipboard."

 

[Planktonmd]

What really matters the most is the current state of health and the ability to tolerate exercise or surgical stress.
An experienced anesthesiologist conducting a focused history and physical exam should be able to detect red flags relevant to the anesthetic, that's why anesthesiologists are paid the big bucks

 

[BuzzPhreed]

I definitely want to know if they are on suboxone. I got burned really badly one time because the patient didn't tell me that (afraid to admit it in front of their spouse after recovering from a prescription med addiction).

Besides that the basic questions I ask usually get to the bottom of what's important. And everything Noyac said.

 

[dhb]

What really matters the most is the current state of health and the ability to tolerate exercise or surgical stress.
An experienced anesthesiologist conducting a focused history and physical exam should be able to detect red flags relevant to the anesthetic, that's why anesthesiologists are paid the big bucks

I don't have all the details.
Do you investigate every (self-declared) ASA1 patient for cardiac symptoms?

 

[Planktonmd]

I don't have all the details.
Do you investigate every (self-declared) ASA1 patient for cardiac symptoms?

I always ask people about their exercise tolerance and about chest pain or shortness of breath... if they say that they can walk a mile, climb 2 flights of stairs without symptoms I usually believe therm unless they are demented or crazy

 

[sevoflurane]

NPO... for sure. Had a lap chole pucking up hamburger meat post op not too long ago. Pissed me off and I called out the patient on it (and admitted to biscuits and gravy at 6:45am).

Certain must knows for certain cases. ie. pneumonectomy with and FEV1 of 600ml. Or... need for a RUQ verrus needle because of anatomy/colostomy bag that's hidden under the patients gown. Exercise tolerance is always a good one to know as are other documented disease states such as a large AAA than needs tight BP control intraop.... or an occluded LCC.

Healthy 15 y/o for lap appy? I'd like to know what the best FPS game that is available for the xbox.

 

[sevoflurane]

After a while in a particular community, one can make pretty good guesses as to who may be shaddy and who may not be. There are always those who lie outside of the bell curve. So you use your clinical judgement... always.

 

[k12balla]

Maybe this is more relevant to pet peeves, but a not too infrequent conversation I have with patients:
Me: Do you have any medical problems that you know about?
Pt: nope
Me: Have you ever had a heart attack or a stroke?
Pt: Yes, I had two stents placed, 3v cabg, and am on asa/plavix which I stopped last week..


Usually a thorough med review and exercise tolerance tells me most of what I need to know.

 

[k12balla]

Maybe this is more relevant to pet peeves, but a not too infrequent conversation I have with patients:
Me: Do you have any medical problems that you know about?
Pt: nope
Me: Have you ever had a heart attack or a stroke?
Pt: Yes, I've had two stents placed, a 3v cabg, and am on asa/plavix which I stopped last week..


Usually a thorough med review and exercise tolerance tells me most of what I need to know.

 

[Mman]

What I really want to know?

Cardiac function (EF, valves, etc) if possible
Any known coronary disease or signs of ischemia
Diabetes/HTN and usual state of control for each
If they take blood thinners beyond ASA

Anything else probably depends on the particulars of the surgery.

 

[Triple AAA]

Our clinical decision making is based on our H + P, along with the premise that the patient is telling us the truth. If a bad outcome occurs because a patient is dishonest, and there is no information in the chart to prove otherwise, can we really be held liable? If so, on what grounds? What else could we have done to prevent such outcomes? Should we assume that everyone lies about everything? What should we believe?

 

[Noyac]

I definitely want to know if they are on suboxone. I got burned really badly one time because the patient didn't tell me that (afraid to admit it in front of their spouse after recovering from a prescription med addiction).

Besides that the basic questions I ask usually get to the bottom of what's important. And everything Noyac said.

Yes, I will add suboxone to that list. Had the exact thing happen.

 

[RxBoy]

What really matters the most is the current state of health and the ability to tolerate exercise or surgical stress.

Single most important information you could illicit from a pt.

The most basic questions:
NPO status
Allergies
Hx of anesthetic complications
Exercise tolerance

If all I knew was that a pt is NPO, NKDA, no hx of anesthetic complications and has good exercise tolerance... I think I could administer a safe anesthetic 99/100 times. Wouldn't be pretty, but would get them through.

If I considered a spinal... Also would want to know
AS/MS
Bleeding disorders
Blood thinners

 

[RxBoy]

Forgot to mention brief airway exam as well.

 

[risnwb]

I sometimes wonder what my pts tell me and what they decide to keep from me. I'm sure they keep many things to themselves, like the fact that they got high on the way to the hospital. Or that they actually ate something before surgery. Just a few of the things I believe they never tells us. But all this makes me wonder something else. How much do we really need to know? Sure, I'd like to know everything but I can still do my job with very little information usually.

Some things I really want to know:
Aortic stenosis
NPO status
Allergies
Meds and or drugs taken
Ischemic threshold

These are a few.

Id add pulmonary HTN to those things i really wanna know. This definitely changes my management in that it significantly lowers my threshold for allowing hypercapnea/hypoxia... And I guess along with this I wanna know rv fcn if phtn is present...


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[Noyac]

Id add pulmonary HTN to those things i really wanna know. This definitely changes my management in that it significantly lowers my threshold for allowing hypercapnea/hypoxia... And I guess along with this I wanna know rv fcn if phtn is present...


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Well, I practice at altitude so I assume PHTN in everyone. Just today I had a basic spine case with PAP 75/40. No problem.

 

[Noyac]

So here is what trauma is like ( I know everyone does trauma and knows this already but indulge me). An obese 70 yo male comes to the OR emergently after an MVA. He is in obviously pain, confused, has blood in the abdomen, and extremely poor dentition. VS are borderline but manageable. Family expired in the accident so nobody to give a history. Pt is a from out of town so no EHR. We do these cases all the time knowing absolutely nothing and we get by, sometimes we even get by as if we knew the PMH in and out. If this guy had a zipper on his chest I'd be pleased. At least I know he has been fixed at some point and probably sees a cardiologist enough to be ready for surgery.
Anybody care to speculate why I said "extremely poor dentition"?
I love these cases clinically, not so much personally though.

 

[risnwb]

So here is what trauma is like ( I know everyone does trauma and knows this already but indulge me). An obese 70 yo male comes to the OR emergently after an MVA. He is in obviously pain, confused, has blood in the abdomen, and extremely poor dentition. VS are borderline but manageable. Family expired in the accident so nobody to give a history. Pt is a from out of town so no EHR. We do these cases all the time knowing absolutely nothing and we get by, sometimes we even get by as if we knew the PMH in and out. If this guy had a zipper on his chest I'd be pleased. At least I know he has been fixed at some point and probably sees a cardiologist enough to be ready for surgery.
Anybody care to speculate why I said "extremely poor dentition"?
I love these cases clinically, not so much personally though.

Bad teeth generally = poor/non-existent medical care?
That or he has been smoking the crystal meth...


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[GhostTree]

Bad teeth generally = poor/non-existent medical care?
That or he has been smoking the crystal meth...


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Bad teeth usually make intubation easier: unless one gets knocked out and ends up in the lung....

 

[RxBoy]

So here is what trauma is like ( I know everyone does trauma and knows this already but indulge me). An obese 70 yo male comes to the OR emergently after an MVA. He is in obviously pain, confused, has blood in the abdomen, and extremely poor dentition. VS are borderline but manageable. Family expired in the accident so nobody to give a history. Pt is a from out of town so no EHR. We do these cases all the time knowing absolutely nothing and we get by, sometimes we even get by as if we knew the PMH in and out. If this guy had a zipper on his chest I'd be pleased. At least I know he has been fixed at some point and probably sees a cardiologist enough to be ready for surgery.
Anybody care to speculate why I said "extremely poor dentition"?
I love these cases clinically, not so much personally though.

To lazy to write my own reply:

Oral health - general health
The interrelationship between oral and general health is proven by evidence. Severe periodontal disease, for example, is associated with diabetes The strong correlation between several oral diseases and noncommunicable chronic diseases is primarily a result of the common risk factors. Many general disease conditions also have oral manifestations that increase the risk of oral disease which, in turn, is a risk factor for a number of general health conditions. This wider meaning of oral health does not diminish the relevance of the two globally leading oral afflictions - dental caries and periodontal diseases. Both can be effectively prevented and controlled through a combination of community, professional and individual action.

 

[pgg]

I'll add HCG to the short lists of things above that I really care about.

Anybody care to speculate why I said "extremely poor dentition"?

Only tooth I've ever broken on DL was in a meth user. Meth and cocaine are the two main illicit drugs I care about, but patients probably lie about it more often than not. I sometimes wonder, when a patient's hemodynamics are unusually labile, if it's because they used on the way to the hospital that morning ...

 

[Hoya11]

I definitely want to know if they are on suboxone. I got burned really badly one time because the patient didn't tell me that (afraid to admit it in front of their spouse after recovering from a prescription med addiction).

Besides that the basic questions I ask usually get to the bottom of what's important. And everything Noyac said.

why do we need to know about suboxone so badly? the "ceiling effect" is mostly theoretical. In practice these patients will respond to IV fentanyl, morphine, dilaudid like everyone else, just at higher doses. So, in my opinion, you DONT need to know. you get in the room, you give the usual narcotics, they demonstrate tolerance, you give more until effect like any other patient abusing any other opiate. and then you say, wow this guy must be using opiates of some kind. I guess it would throw you into thinking the hypertension/tachy were something other than pain related prior to increasing dose, but really in the real world suboxone is just like any other narcotic and this "ceiling" business can be overcome by higher doses of fent and dilaudid, they WILL respond eventually. bup/naloxone does not bind every opiate receptor in the body irreversibly.

 

[Consigliere]

As soon as patients start talking about non-medical issues that aren't directly related to what I am asking them, a switch in my brain flips to "off."

 

[shopsteward]

Anybody care to speculate why I said "extremely poor dentition"?

Link between gum disease and heart disease/stroke risk?

 

[oldguy55]

I think I get a more complete "gestalt" picture of my patient's medical conditions in my <5 minute interview than any surgeon does during his so-called H&P. Medication list, previous surgery, exercise tolerance, body habitus, smoking/drinking history. These things tell me most of what I need to know, or at least guide me toward further questions.

Yesterday, the sweet 86 yr old GI bleeder corrected me when I asked when her heart bypass was done. She said "I didn't have a bypass, I had the aortic valve replaced." One hospitalist had misinterpreted the mid-sternal scar and every subsequent physician had repeated (copied and pasted) the error. Laziness, pure and simple.

Our QI folks periodically fuss about poor quality, incomplete surgical H&Ps. I just tell them I really don't care because I don't believe what the surgeon, or his nurse, or medical assistant has written.

 

[Noyac]

I'll add HCG to the short lists of things above that I really care about.

I'm just wondering how many pts I've put to sleep without knowing that they were preggo. I'm sure it's more than a few.

 

[risnwb]

why do we need to know about suboxone so badly? the "ceiling effect" is mostly theoretical. In practice these patients will respond to IV fentanyl, morphine, dilaudid like everyone else, just at higher doses. So, in my opinion, you DONT need to know. you get in the room, you give the usual narcotics, they demonstrate tolerance, you give more until effect like any other patient abusing any other opiate. and then you say, wow this guy must be using opiates of some kind. I guess it would throw you into thinking the hypertension/tachy were something other than pain related prior to increasing dose, but really in the real world suboxone is just like any other narcotic and this "ceiling" business can be overcome by higher doses of fent and dilaudid, they WILL respond eventually. bup/naloxone does not bind every opiate receptor in the body irreversibly.

I think this really depends on the dose. The little old lady taking 4 mg a day for her chronic back pain is probably not going too be a problem, but the recovering addict taking 20 mg a day has a lot more receptors bound, and severe pain is going to be nearly impossible to control. I'd like to know about the latter pre-op.



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[Numbex]

I think I get a more complete "gestalt" picture of my patient's medical conditions in my <5 minute interview than any surgeon does during his so-called H&P.

If you work in an institution with Epic, the surgeon's H&P is likely to be mostly superfluous, consisting of data populated from
a template, data you already have in your preop navigator. So it's worth maybe a five second glance unless you're curious about what the surgeon says about the surgical diagnosis. Otherwise, the surgeon almost certainly hasn't put any thought into what Epic thinks is his/her PMH.

 

[sevoflurane]

If you work in an institution with Epic, the surgeon's H&P is likely to be mostly superfluous, consisting of data populated from
a template, data you already have in your preop navigator. So it's worth maybe a five second glance unless you're curious about what the surgeon says about the surgical diagnosis. Otherwise, the surgeon almost certainly hasn't put any thought into what Epic thinks is his/her PMH.

Funny how the most cumbersome parts of an electronic medical record (data entry) can be absolutely worthless and very time comsuming.

Our surgeons wen't to a different electronic medical record a couple years ago. They ALL hate it (forced in by administration).

Now instead of seeing 40-60 patients in the ortho clinic... they are down to 20-30 due to the "new" electronic data entry.

 

[Spinach Dip]

As a patient, one question I really appreciated being asked was "Do you want some versed now? Or after we get to the OR?"

It's simple things like that which let the patients feel they have some sort of control and/or consideration regarding their care.

 

[Spinach Dip]

As a patient, one question I really appreciated being asked was "Do you want some versed now? Or after we get to the OR?"

It's simple things like that which let the patients feel they have some sort of control and/or consideration regarding their care.

DISCLAIMER:

And yes, I realize I am not an attending (and if I were, this would be far from the first concern on my mind), but I believe it is possible to provide a safe anesthetic while making the patient feel like their input is actually valued.

 

[Noyac]

As a patient, one question I really appreciated being asked was "Do you want some versed now? Or after we get to the OR?"

It's simple things like that which let the patients feel they have some sort of control and/or consideration regarding their care.

That is a comforting question as far as the pt is concerned. But versed once the pt enters the room is a waste of time, money and usually only a practice seen by crna's. The reason being, what is versed going to do for you or the pt when given just before induction? Spinals excluded of course.

 

[Spinach Dip]

But versed once the pt enters the room is a waste of time, money and usually only a practice seen by crna's.

I agree with you 100%, but this is what an attending told me when I observed a resident give versed "pre-med" 10 seconds before pushing propofol:

"Some hospitals consider "giving pre-med" to be a measure of quality assurance. So every resident better be sure to give pre-meds before induction (exceptions allowed are: allergy, no IV line (peds) and emergencies). Even if the patient refuses pre-meds in the pre-op area, they must still be given before the induction agent is pushed. Otherwise, administration will have something to say to you."

And before you say anything...YES, it's absurd.

 

[pgg]

I agree with you 100%, but this is what an attending told me when I observed a resident give versed "pre-med" 10 seconds before pushing propofol:

"Some hospitals consider "giving pre-med" to be a measure of quality assurance. So every resident better be sure to give pre-meds before induction (exceptions allowed are: allergy, no IV line (peds) and emergencies). Even if the patient refuses pre-meds in the pre-op area, they must still be given before the induction agent is pushed. Otherwise, administration will have something to say to you."

Oh my god that's almost as ******ed as giving 1 mL of esmolol to not run afoul of the stupid beta blocker SCIP measure.

I would start documenting "lidocaine 60 mg IV" or perhaps even "rocuronium 5 mg IV" as my "premed" ...

 

[pgg]

The reason being, what is versed going to do for you or the pt when given just before induction?

I posed that question to an at-induction-Versed'er once and was told, and I am not making this up, that it would guarantee amnesia in case something went wrong with induction.