How to deal with an irate surgeon...

[Voodoo]

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Specific question for y'all folks who've been there and done that about how to maintain a positive relationship after a negative incident.

About me: 3 years in an MD only private practice of 40.

We have one anesthesiologist float on a daily basis - run the board, put in all blocks feasible, answer codes, etc...

I was the float guy last week and a high volume orthopedist (6-7 total joints twice a week plus lotsa scopes in an ortho ambulatory center) calls me up at 10 am Friday telling me that he has an infected hip that he wants to wash out. She ate breakfast at 7:30 and the OR schedule can accomadate any time. He says he has room at 2:30 pm. I was putting in a block and had him on speaker phone so I said sure (7 h NPO).

At 2:00 pm the preop nurse informs me that said patient has arrived but has eaten something equivalent to the golden corral mega breakfast (sausage, ham, yogurt, eggs, etc.) and to boot, she's a big diabetic lady. I talk to the guy who's gonna sit the case and we decide that we should wait the 8 hours.

I call the surgeon a minute later to tell him the delay, and he proceeds to chew my rear end up and down dropping every profanity (e.g. "I specifically asked you about this and you *(#(*! %(#)#$ it up, what the *#&% is wrong with you?") He then tries to barter a 3 pm deal and I tell him no unless he's willing to document it as an emergency, so he cancels the case and puts it on for MONDAY at 6 pm. The back story is that he wanted to watch his kid play in some [insert random peewee sport] tournament at 5 pm that day.

While I commend his priorities to family life, I don't necessarily agree with his demeanor. Additionally, I heard from my partner who did his cases on Monday that he was smearing me up and down.

To those of you who have weathered these storms time and time again, what is the best approach to the guy?

 

[error404]

The same way I deal with my mother-in-law.

Smile, nod, wait it out and only scream on the inside.

Seriously, just try to take some deep breaths and "bigger man" it by realizing the dude was under a lot of stress. Douchebaggery happens. And you know you're right. 🙂

I feel like residency has prepared me to take a lot of crap with a smile on my face.

 

[2win]

Specific question for y'all folks who've been there and done that about how to maintain a positive relationship after a negative incident.

About me: 3 years in an MD only private practice of 40.

We have one anesthesiologist float on a daily basis - run the board, put in all blocks feasible, answer codes, etc...

I was the float guy last week and a high volume orthopedist (6-7 total joints twice a week plus lotsa scopes in an ortho ambulatory center) calls me up at 10 am Friday telling me that he has an infected hip that he wants to wash out. She ate breakfast at 7:30 and the OR schedule can accomadate any time. He says he has room at 2:30 pm. I was putting in a block and had him on speaker phone so I said sure (7 h NPO).

At 2:00 pm the preop nurse informs me that said patient has arrived but has eaten something equivalent to the golden corral mega breakfast (sausage, ham, yogurt, eggs, etc.) and to boot, she's a big diabetic lady. I talk to the guy who's gonna sit the case and we decide that we should wait the 8 hours.

I call the surgeon a minute later to tell him the delay, and he proceeds to chew my rear end up and down dropping every profanity (e.g. "I specifically asked you about this and you *(#(*! %(#)#$ it up, what the *#&% is wrong with you?") He then tries to barter a 3 pm deal and I tell him no unless he's willing to document it as an emergency, so he cancels the case and puts it on for MONDAY at 6 pm. The back story is that he wanted to watch his kid play in some [insert random peewee sport] tournament at 5 pm that day.

While I commend his priorities to family life, I don't necessarily agree with his demeanor. Additionally, I heard from my partner who did his cases on Monday that he was smearing me up and down.

To those of you who have weathered these storms time and time again, what is the best approach to the guy?

Happens all the time for all of us...
Now - if you have a group policy regarding the NPO status - I would respect it.
If other partners step out of the policy I would use my judgment -
1) friend and supportive surgeon - without to mess up with my schedule, , good guy , fast, knows when to ask for an "emergency" or not, spinal agreed by the patient or otherwise easy intubation - I would say YES - bring me the baby...
2) as***hole - demanding, asking q 5 min to bring the table up (or down ), making his schedule ( office hours) MINE, 12 am hips, and READING EKG-s - I would say NO

Sometimes - sooner or later - you have to make your own calls. Even against the group if you believe so.
I think that you took the right path here.
Anyway - keep in touch - it will take me 1 (UNO, ONE, EINS) year to open my private gig (if Mobama doesn't kill US).
And I want there people like you.
2win

 

[drccw]

I can't give you advice on how to maintain a positive relationship. Of course you have to apologize to the surgeon. You dropped the ball here.

You told him 7 hours was fine, 230 PM was ok. He very well might have re-arranged his schedule. If you aren't willing to standby what you said then he has every right to be mad at you....

Here's probably what should have happened; here's what I do:

I tell the surgeon NPO guidelines are 8 hours.. Especially if I am busy and don't have time to look up the patient, etc. i stick hard and fast at 8 hours. However, if when I was done with the block, I find out that this is a young healthy gal (of course not because they need a hip washed out) who had maybe some yogurt or whatever; then I call the surgeon back and say

"hey doc, we might be able to go earlier. you mentioned 1430 beforehand, can you still do that?"

Half the game is politics... underpromise and over deliver is what I think is the best. He's pissed at you because you promised something and didn't deliver. Simple as that....

drccw

 

[urge]

She ate breakfast at 7:30 and the OR schedule can accomadate any time. He says he has room at 2:30 pm. I was putting in a block and had him on speaker phone so I said sure (7 h NPO).

Know yourself and know your partners. You f-up. Should have pushed for 8 hrs since the beginning if you wanted to follow the guidelines. Especially if you are not sitting the case. You opened your mouth and didn't follow through.

 

[IlDestriero]

As the others have said, don't vary from the norm/guidelines/routine when you're making promises for someone else. When you see him again apologise, if he pushes you, fall back on the "well I didn't know her breakfast was pulling up a chair to the all you can eat bar at Denny's" and apologise again. It could have been worse if they were all ready to go at 1430 and your partner found out the details and cancelled the case.
Don't worry too much, I you're doing a good job the orthopod knows it. He'll get over it. If you're weak, expect endless abuse.

 

[Sergio99]

Hello,

I don't find any fault with what you did. I would have probably told him 8 hours from the beginning, but what you did was not wrong either. You tried to give him the benefit of the doubt and it didn't work out. What can you do? If he is going to crucify you because you tried to expedite things for him, he is a jerk.

The other side of the coin is, this is not the first time it happens in the world, and is not going to be the last. We cannot be always perfect. So we have to deal with the fact that whenever we miscalculate something, we have to be willing to correct it and put ourselves in uncomfortable positions rather than put the patient at risk.

Backpedaling because the situation is not what you initially thought it was, is never wrong. Every time this happens it makes you look bad, but if you persist in your initial plan after realizing that you should have changed it, it may end up being infinitely worse.

Develop a little thicker skin and don't worry for things that you know you did right, even if other people didn't like them. If the appropriate chance opens, if you get a good opportunity to explain it to the surgeon, explain it, but if not, don't force it. He may never be your best friend again, but don't worry; you don't have to be best friends with everybody. This also will pass.

Greetings

 

[Intensivist]

l am a bit cought by surprise by general opinion that he should give slack to surgeons yelling... what l would do, l would bugg off motherf.uck.er maybe in some more polite way, but certainly wouldn't hold back after he has shook off his garbage at me. if a surgeon acts as a jerk, he wouldn't walk away with debt from my side.

 

[Hockeyguy]

I love the one hour difference argument we got going. 7 vs 8 hours. does anyone really think this will make a difference - really? RSI OG tube slap eachother on the back on the way to the parking garage and drop your billing sheet of to the secratary.

 

[Sergio99]

I love the one hour difference argument we got going. 7 vs 8 hours. does anyone really think this will make a difference - really? RSI OG tube slap eachother on the back on the way to the parking garage and drop your billing sheet of to the secratary.

Hello,

With such a big breakfast it will not make any difference, but legally you are bound to it because the published guidelines say so. Even if you do RSI or OG tube or anything you want, it will not give you a guarantee that the patient won't vomit. With such a background, you are wiser to follow the guidelines.

Greetings.

 

[IlDestriero]

I love the one hour difference argument we got going. 7 vs 8 hours. does anyone really think this will make a difference - really? RSI OG tube slap eachother on the back on the way to the parking garage and drop your billing sheet of to the secratary.

Playing fast and loose with published and accepted guidelines for elective cases is asking for a large settlement after a bad outcome. The jury will side with the plantiff's expert's explanation of the black and white guidelines, and how you didn't follow them. You don't have to follow ANY guidelines, but you do so at your own risk. The surgeon will also not appreciate the increased exposure, no matter what they say at the time. At trial, they will claim ignorance and the blame will land at your feet. I'm not sure I would want you as my partner if this is your attitude, really.

 

[Arch Guillotti]

l am a bit cought by surprise by general opinion that he should give slack to surgeons yelling... what l would do, l would bugg off motherf.uck.er maybe in some more polite way, but certainly wouldn't hold back after he has shook off his garbage at me. if a surgeon acts as a jerk, he wouldn't walk away with debt from my side.

why stop there, just shove your foot up his ass...

 

[dhb]

do a spinal and get the case done

 

[Sergio99]

do a spinal and get the case done

Are you kidding?

You do a spinal, get a sympathetic block, hypotension, nausea, vomiting, the patient cannot turn to the side because of the paralysis, aspirates and dies.

Besides, have you heard of high spinals and total spinals? And what is worse than that? Answer: A high or total spinal with full stomach.

You may say that you are careful and will not let it go high... if that were possible, that is. But there is also such thing as a low spinal, that does not reach the level you wanted, and then, in the middle of the procedure you have to convert it to a general anesthetic.

A spinal is no substitute for doing the right thing.

Greetings

 

[IlDestriero]

do a spinal and get the case done

Congrats, you just failed your oral boards, see you and your $2000 again next year!👍

 

[pgg]

Sorry I have to pile on too, NPO guidelines are for regional anesthetics too ... and not just for the boards.

 

[Voodoo]

I appreciate all of the responses, and have the following comments:

#1 - I know I F'd up - to those people who simply chimed in to say, "dude you f'd up" -- thanks. That was not what I was asking. I was asking for how to deal with an unprofessional surgeon to keep from alienating him - I have years ahead of me and don't really want to be "that guy."

#2 - I do appreciate all input, but having residents who have no clue about how fragile relationships can become in the real world, things aren't necessarily black and white. Having a "keep your chin up" attitude is a given - and if you don't possess such attributes, you will cry yourself to sleep every night. Again, I didn't want a pat on the back or a hug, just advice on how to maintain future interactions.

Thanks to everyone for your time, especially those with insightful answers.

 

[Arch Guillotti]

l am a bit cought by surprise by general opinion that he should give slack to surgeons yelling... what l would do, l would bugg off motherf.uck.er maybe in some more polite way, but certainly wouldn't hold back after he has shook off his garbage at me. if a surgeon acts as a jerk, he wouldn't walk away with debt from my side.

A little bit more serious answer - the OP is a fairly new member of the group and the surgeon brings in volume, this is a minor battle and you don't wan't to say something in the heat of the moment that you may regret later.

With that being said there is no reason for the orthopod to be such a jerk. Very calmly ask him why he is yelling at you and explain your position to him. Who knows, he may realize that he is being as ass (maybe) and who knows he may come to his senses (maybe).

I also think that the distinction between 7-8 hours is sort of arbitrary in an obese diabetic. Everyone who is put in the decison of whether or not to do a case has been a victim of medicolegal type of fears. I think a lot of our fears are unfounded but unfortunately I let these fears control my decisions sometimes too.

 

[Noyac]

Just let it go. Eventually the two of you will probably have a good laugh about it.



BTW, you f'd up.

 

[notinkansas]

Long time ago, I remember reading somewhere about a resident who dealt with attending tirades like this by simply standing there calmly. When the tirade was finished, the resident would simply ask "are you finished?" and if the attending replied "yes", the resident would say "OK" and go back to work. This may not be as effective on the phone.

Does this hospital have a policy about disruptive behavior? If so, and if this surgeon keeps behaving this way (my guess it wasn't the first time and won't be the last) he is liable to get himself in trouble with that policy at some point. It seems that nurses are becoming more aggressive in filing such complaints. You might just want to document for your own files any troublesome incidents.

I think it is wise to consider apologizing, if you think it will make a difference. Are your partners (who know the guy better) giving you any advice? Is he a jerk to everyone, only sometimes, or was this out of norm for him? Your partners may be able to advise you if it's better to apologize or just continue to be pleasant as if nothing had happened. Other than that I'm not seeing much else you can do, other than learn from the incident as it appears you have.

 

[Sergio99]

Hello again,

With all these opinions being expressed, I feel the obligation, the civic duty, the imperative, to repeat what I said earlier and clarify it a little better: You did not do anything wrong: It was perfectly OK.

That is why in my earlier post I used the word "explain" and not "apologize," as in explain something in order to teach, not explain yourself to say you are sorry. You should not be sorry for this. You should be proud that you acted in the best possible way and in the best interest of the patient, and that is the message you want to convey when you explain it to others, not that you are sorry for having done it. Remember that, if this patient had been his mother, the surgeon would have wanted you to do what you just did for this patient.

Greetings

 

[orangele]

My standard answer to when a NON NPO patient can have surgery is, "I don't know, let me evaluate the patient." Then when possible I go evaluate the patient.

If this scenario happened to me, I would apologize to the surgeon saying that in an effort to get this case done ASAP I gave you a time prior to having an opportunity to evaluate the patient. I should have evaluated the patient prior to giving you a time.

With this answer, hopefully in the future you will not feel pressured to give a time without all the facts.

 

[dhb]

Are you kidding?

You do a spinal, get a sympathetic block, hypotension, nausea, vomiting, the patient cannot turn to the side because of the paralysis, aspirates and dies.

Besides, have you heard of high spinals and total spinals? And what is worse than that? Answer: A high or total spinal with full stomach.

You may say that you are careful and will not let it go high... if that were possible, that is. But there is also such thing as a low spinal, that does not reach the level you wanted, and then, in the middle of the procedure you have to convert it to a general anesthetic.

A spinal is no substitute for doing the right thing.

Greetings

Are you really an attending?

Btw passed my boards last month 😎

 

[IlDestriero]

Are you really an attending?

Btw passed my boards last month 😎

Not sure what board you passed, but you won't pass the ABA oral board with that answer.😉

 

[dhb]

Not sure what board you passed, but you won't pass the ABA oral board with that answer.😉

How about being paralysed and not being capable of turning your head? 😱
Does that give you a pass?

 

[IlDestriero]

How about being paralysed and not being capable of turning your head? 😱
Does that give you a pass?

😕

 

[orangele]

I am with Sergio99 that any case you do, you should be prepared to (and defend potential complications (aspiration) convert to a general anesthetic.

Most in practice for more than several years has been in a small case with an anticipated less than an hour duration that turned into a marathon (requiring a general anesthetic) due to circumstances beyond your control.

 

[dhb]

Are you kidding?

You do a spinal, get a sympathetic block, hypotension, nausea, vomiting, the patient cannot turn to the side because of the paralysis, aspirates and dies.

I was refering to this piece of art.

What are you going to do after 8h LMA? tube? spinal?
What's the difference between 7 and a half hours and 8? the stomach magically empties?
Pick up your balls and do what you have to do.

 

[IlDestriero]

I was refering to this piece of art.

What are you going to do after 8h LMA? tube? spinal?
What's the difference between 7 and a half hours and 8? the stomach magically empties?
Pick up your balls and do what you have to do.

You don't HAVE to do anything, the case is not even urgent. The surgeon waited 3 days to wash it out. That sounds questionable as well, but I don't know what the standards of care are for infected joints.
Follow the accepted, black and white, guidelines or risk unnecessary malpractice exposure after an unexpected bad outcome, like aspiration.
The OP's partner didn't want to do the case at 7 hours, not because he's a wimp, but because he wants to keep his job and his Benz. Light meal 6 hours, heavy 8. The only "magic" that happens in waiting the extra hour is that if the pt aspirates on induction there will not be a long line of Board Certified Anesthesiologists waiting to testify for the plaintiff, since you followed the guidelines. There may be a departmental policy in place for elective surgery as well. If you violate standards and policies, you also risk being terminated immediately for cause. That usually means that you're f*cked, BTW. No benefits, no tail coverage, no unemployment, no letters of rec for the new job, possible increased malpractice premiums, etc. That termination will follow you around forever.
Enjoy your new career supervising militant CRNAs 😍 in backwoods Montana, or one of the "bad" VA hospitals.👍
Standards may be different overseas, but they are pretty clear here.

 

[Jay K]

Sorry I have to pile on too, NPO guidelines are for regional anesthetics too ... and not just for the boards.

For further clarification, NPO guidelines by the ASA actually include general, regional and SEDATION/ANALGESIA (MAC) mentioned on multiple pages under the recommendations for 2hr, 4hr, 6hr NPO status. I.D. and pgg are spot on. If you're going to follow the guidelines to a T - that's what they "recommend." The NPO guidelines from ASA are available online and for download.

 

[dhb]

Well if it's not urgent then the jury will say you should have waited longer than 8h because the patient was diabetic etc etc...
I still don't how you risk aspiration in this case. A high spinal is as probable as being hit by an asteroid. If you want to go all academic on this case fine but don't come up with horses!!t excuses.

 

[urge]

I appreciate all of the responses, and have the following comments:

#1 - I know I F'd up - to those people who simply chimed in to say, "dude you f'd up" -- thanks. That was not what I was asking. I was asking for how to deal with an unprofessional surgeon to keep from alienating him - I have years ahead of me and don't really want to be "that guy."

How to deal with irate surgeons?

#1 don't f up. DON'T F UP. DON'T F UP.
#2 Say "I understand your point of view but I don't appreciate your tone. We can work out differences in a more civilized manner." Maker sure you say that aloud with a bunch of OR nurses, MD's, and even janitors to hear you. I used that line with an abusive heart surgeon in front of 8 people or so during a cardiac case. He was my bish afterward. I'm sure he felt 1 inch tall while I was talking. He f-ing loved(feared?) me ever since. I only heard good things from him after that.

 

[Sergio99]

Are you really an attending?

Btw passed my boards last month 😎

A high spinal is as probable as being hit by an asteroid.

Hello,

Congratulations for passing the boards.

I have done many spinals, both for OB and for general surgery, and have not had a total spinal yet in 35 years, and patients have not aspirated, but I have heard and read that it happens and that it is still a problem, and is more frequent than being hit by an asteroid.

Greetings

 

[dhb]

Hello,

Congratulations for passing the boards.
Greetings

I have done many spinals, both for OB and for general surgery, and have not had a total spinal yet in 35 years, and patients have not aspirated, but I have heard and read that it happens and that it is still a problem, and is more frequent than being hit by an asteroid.
Greetings

Thanks and thanks for confirming what i've been saying: high spinals come from missed epidurals, paravertebrals or lumbar plexus blocks not by putting 2cc of local anesthetic in the sub-dural space.

 

[Voodoo]

Thanks all for the insightful answers guys. I did tell the guy on the phone that the scheduling issue was my fault but that's neither here nor there - I think the general consensus is that my management was not out of line.

My partners agreed with me - the guy can suck it cuz he's a greedy douche nozzle.

To DHB - I appreciate your input as well, and I cerntainly understand that an anonymous message board probably does add to bravado, but no one likes an arrogant partner who's been in practice for < a year for 2 reasons: 1) you are most likely on a group malpractice program and cavalier acts open your partners up to liability, and 2) cocky people are a pain in the ass.

I'm certainly not calling you cocky or arrogant because (as I mentioned before) I don't know you. It's all fun and games to throw back a beer and talk about the 6 foot long pike you caught, the 2 hole-in-ones you shot on the back nine, or the 300 pound biker you made cry like a sissy, but it's wise not to come off as brash to your partners who will undoubtedly be watching you with a careful eye for the first few years you work.

 

[dhb]

If you've been there for three years you're hardly the new guy.
I approached the case on a clinical base not on a group dynamic pov.
Now the patient was NPO for 7h which is plenty although not the recommended 8. I would like to hear about how the patient was managed after he met your criteria?
I don't see it as being arrogant some people let lawyers dictate their practice I don't.

 

[Voodoo]

If you've been there for three years you're hardly the new guy.
I approached the case on a clinical base not on a group dynamic pov.
Now the patient was NPO for 7h which is plenty although not the recommended 8. I would like to hear about how the patient was managed after he met your criteria?
I don't see it as being arrogant some people let lawyers dictate their practice I don't.

IV antibiotics all weekend since said douche nozzle didn't want one of his partners (or possibly LACK OF help from his partners because of his inability to play in the sandbox) until monday, standard 8 hours NPO (I think the surgeon made her NPO p MN the am of for an 18:00 case), then GA. I didn't sit the case so unaware of the specifics.

If you're planning on bagging on me about the difference between 7 and 8 hours don't waste your time. I'm not aware of any literature to support the 8 hours, but as other members posted, it is a "medicolegal" (or whatever the trendy term is to denote pseudosophistication substituting for education) issue. The original question was about management of interdepartmental relations.

I totally hear where you're coming from, for what it's worth. There are a few headstrong people in my group who insist it's my way or the highway. These people quickly become marginalized and are not given any leadership responsibilities, etc.

I am curious, however, why you would knowingly place yourself at risk with a SAB in a patient who does not meet ASA guidelines for NPO status. Have you never had a failed spinal? Remember, if that happens and the patient starts puking on induction (mind you, no more or less than an hour or half an hour later if you waited the 8 hours) and you do decide for whatever reason to induce the patient and something bad happens, that surgeon who was all chummy with you will turn around and point the finger at you in a heartbeat. And the whole while probably saying, "I didn't mind waiting, but that board certified anesthesiologist said it was ok, and I defer to his judgment. Actually, even more so because he JUST GOT BOARD CERTIFIED A MONTH AGO, so he must know the latest stuff..."

 

[IlDestriero]

IV antibiotics all weekend since said douche nozzle didn't want one of his partners (or possibly LACK OF help from his partners because of his inability to play in the sandbox) until monday, standard 8 hours NPO (I think the surgeon made her NPO p MN the am of for an 18:00 case), then GA. I didn't sit the case so unaware of the specifics.

If you're planning on bagging on me about the difference between 7 and 8 hours don't waste your time. I'm not aware of any literature to support the 8 hours, but as other members posted, it is a "medicolegal" (or whatever the trendy term is to denote pseudosophistication substituting for education) issue. The original question was about management of interdepartmental relations.

I totally hear where you're coming from, for what it's worth. There are a few headstrong people in my group who insist it's my way or the highway. These people quickly become marginalized and are not given any leadership responsibilities, etc.

I am curious, however, why you would knowingly place yourself at risk with a SAB in a patient who does not meet ASA guidelines for NPO status. Have you never had a failed spinal? Remember, if that happens and the patient starts puking on induction (mind you, no more or less than an hour or half an hour later if you waited the 8 hours) and you do decide for whatever reason to induce the patient and something bad happens, that surgeon who was all chummy with you will turn around and point the finger at you in a heartbeat. And the whole while probably saying, "I didn't mind waiting, but that board certified anesthesiologist said it was ok, and I defer to his judgment. Actually, even more so because he JUST GOT BOARD CERTIFIED A MONTH AGO, so he must know the latest stuff..."

Looking at his old posts, he doesn't practice in the US, and his profile also has him as a resident. Hence my board certified in what?
It's easy to bluster with nothing at risk. I'll follow the Standards, guidelines and policies, evidence based or not, that's what they are. I'll also not risk my job and my house so some dunce dbag orthopod can make his kids 2nd string pee wee football game.
There's a medicolegal term, which he may learn sooner rather than later, for choosing to ignore standards of practice. It's called malpractice.

 

[Mman]

Specific question for y'all folks who've been there and done that about how to maintain a positive relationship after a negative incident.

About me: 3 years in an MD only private practice of 40.

We have one anesthesiologist float on a daily basis - run the board, put in all blocks feasible, answer codes, etc...

I was the float guy last week and a high volume orthopedist (6-7 total joints twice a week plus lotsa scopes in an ortho ambulatory center) calls me up at 10 am Friday telling me that he has an infected hip that he wants to wash out. She ate breakfast at 7:30 and the OR schedule can accomadate any time. He says he has room at 2:30 pm. I was putting in a block and had him on speaker phone so I said sure (7 h NPO).

At 2:00 pm the preop nurse informs me that said patient has arrived but has eaten something equivalent to the golden corral mega breakfast (sausage, ham, yogurt, eggs, etc.) and to boot, she's a big diabetic lady. I talk to the guy who's gonna sit the case and we decide that we should wait the 8 hours.

I call the surgeon a minute later to tell him the delay, and he proceeds to chew my rear end up and down dropping every profanity (e.g. "I specifically asked you about this and you *(#(*! %(#)#$ it up, what the *#&% is wrong with you?") He then tries to barter a 3 pm deal and I tell him no unless he's willing to document it as an emergency, so he cancels the case and puts it on for MONDAY at 6 pm. The back story is that he wanted to watch his kid play in some [insert random peewee sport] tournament at 5 pm that day.

While I commend his priorities to family life, I don't necessarily agree with his demeanor. Additionally, I heard from my partner who did his cases on Monday that he was smearing me up and down.

To those of you who have weathered these storms time and time again, what is the best approach to the guy?

I believe I had this exact same situation, except for a I/D of an ankle about 6 months ago.

Orthopod scheduled it at 1:30 PM and allowed pt to be served breakfast in AM (done eating by 7 AM). Problem was they gave the patient everything under the sun. Bacon, biscuit, eggs, etc. I said, that's 8 hours not 6 for that kind of meal. Surgeon said can't you just do spinal? No. MAC? No. Was told they'd do it under local with out us. I said that is fine by me. They cancelled the case 20 mins later because surgeon had somewhere to be.

Haven't noticed any hard feelings since.

 

[dhb]

This forum is full of great clinical cases that don't follow the guidelines. Now if you abide by them for every case every day fine , you must be a great academic attending.

 

[Voodoo]

Don't get your panties in a bunch dhb, just telling you the way it is. I'm not in an academic center. I sit my own cases and clearly am good enough to survive in this setting, so stuff your judgments. Maybe if pretty much everyone disagrees with you, everyone isn't wrong?

 

[Noyac]

Let's keep it civil guys. DHB is an honest and very informed poster that has had more than his share of quality posts especially for a resident.

Voodoo, you are an attending and also have very good comments for this forum. And it is fine to disagree.

Let's just not let this get out of hand here.

 

[sevoflurane]

Let's keep it civil guys. DHB is an honest and very informed poster that has had more than his share of quality posts especially for a resident.

Voodoo, you are an attending and also have very good comments for this forum. And it is fine to disagree.

Let's just not let this get out of hand here.

👍

 

[ssmallz]

WWMMDD? (what would mil do) I think we all know the answer

 

[Sergio99]

Thanks and thanks for confirming what i've been saying: high spinals come from missed epidurals, paravertebrals or lumbar plexus blocks not by putting 2cc of local anesthetic in the sub-dural space.

Hello, dhb,

My experience confirms what you say. As I said above, I never had a total spinal myself in 35 years of anesthesia practice, but one of my junior residents in 1977 had one as a result of a misplaced epidural, and another resident while I was in fellowship in 1979 had a very high spinal, but not a total, from a stellate ganglion block.

However, since my experience does not comprise all the cases in the world, I tend to believe and repeat what trusted textbooks say. I just checked Barash and Miller, the textbooks in vogue today, and both say that a spinal can also cause high and total spinals. I have no way of refuting them.

Greetings

 

[Hockeyguy]

The jury will side with the plantiff's expert's explanation of the black and white guidelines, and how you didn't follow them. I'm not sure I would want you as my partner if this is your attitude, really.

What black and white guidelines are you referring to?

Recommendations: It is appropriate to fast from intake
of a light meal or non-human milk far 6 or more
hours befort: elective procedures requiring general anesthesia,
regional anesthesia, or sedation/analgesia (i.e.,
monitored anesthesia care) /Table I]. The Task Eorce
notes that intake of fried or fatty foods or meat may
prolong gastric emptying time. Both the amount and
type of foods ingested must be considered when determining
an appropriate fasting period. Since non-human
milk is similar to solids in gastric emptying time, the
amount ingested must be considered when determining
an appropriate fasting period.

http://www.asahq.org/publicationsAndServices/NPO.pdf

I personally know a member of said task force that wrote the guidelines. He is also an oral board examiner. Did a dissecting aneurysm with him on Sunday night. I asked him about this about this. They didn't put 8 hrs into their recommendation there so the individual could make his or her own judgment and wouldn't be "bound" (his term) by the 8 hours. Even though some members of the teask force supported an 8 hour fast it is not in the recommendations because has been stated multiple times there is no evidence that the stomach magically empties at 8 hours and no one voted in favor of reccomending an 8 hour fast. So in fact no one could parade anything in front of jury because there is no such recommendation let alone a "black and white guideline" exists. In fact if you have this question in an oral board, according to a real life oral board examiner, and answered I would wait eight hours his response would be "based on what". When you said published recs he would say "what published recs". When you finally moved on from that and induced he said they would likely have the patient aspirate. I'm not trying to be a dick I'm just relaying information I obtained from a real life oral board examiner who was also a member of the task force that published the guidelines you keep incorrectly citing.

As far as the you wouldn't want me as a partner thing - that's cool I don't want to practice with a jackass who uses fear of litigation as a factor in his medical decision making. Which is really all your doing when you say I would do this at 8 hours but not at 7hrs and 30 minutes. In my experience the physicians that do that are usually pretty lousy docs - just an observation though, really.

 

[IlDestriero]

Hmmm? I actually know what these guidelines say. I used them to update our NPO policy for elective surgery several years ago at my old gig. Are you sure the magic "8 hours" is not there? Anywhere? 😕

V. Preoperative Fasting Status (Solids and
Non-human Milk)
There is insufficient published evidence to address the
safety of any preoperative fasting period for solids or
non-human milk. For patients of all ages, the Consultants
and Task Force support a fasting period for a light meal
(e.g., toast and a clear liquid) of 6 hours before elective
procedures requiring general anesthesia, regional anesthesia,
or sedation/analgesia (i.e., monitored anesthesia
care). They also support a fasting period for a meal that
includes fried or fatty foods or meat of 8 or more hours
before elective procedures.

I don't make this stuff up. The "8 hours" is right there in the practice guideline. Leaving it out of the "recommendations" yet putting that in the text is classic waffling. There was no clear agreement, so this is how they got around the issue. Yet they left that sentence there. They could have taken out the 8 hours and said something like, "Large meals containing fried or fatty foods or meat may further delay gastric emptying." That would have probably been too vague though, and caused other problems.
This is where most hospitals/groups generate their policies on preoperative fasting for elective cases. Does your hospital really not have a policy on preoperative fasting for elective surgery? A clear policy solves a lot of potential problems with aggressive surgeons that want to push the envelope and make their tee time, or their daughter's dance recital.🙄

Here's an example I found for you online. It's from the Cleveland Clinic. Our policy is similar.

Appendix A
Fasting Recommendations to
Reduce the Risk of Pulmonary Aspiration
1 These recommendations apply to healthy patients who are undergoing elective procedures. They are not intended for women in labor. Following the guidelines does not guarantee that complete gastric emptying has occurred. Causes of delayed gastric emptying include: diabetes, narcotic use, presence of ascites or other intra-abdominal processes which may make the stomach smaller than normal, significant uremia, chronic significant neurological disease, etc.
2 The fasting periods noted below apply to all ages.
3 Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee.
4 Since non-human milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period.
5 A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining an appropriate fasting period.
Ingested Material Minimum Fasting Period
Clear liquids 2h
Breast milk 4h
Infant formula 6h
Non-human milk 6h
Light meal 6h
Regular meal 8h

Living where I live, healthy respect for litigation is what spares physicians from a $10M judgment. No tort reform here. The lack of tort reform makes you conservative. It's not fear, it's a survival instinct. That's life in the real world. You're free to practice any way you wish. You may choose to interpret the above differently, but if you have a fasting policy that you choose to ignore, you've just opened the door to potential disaster. But what do I know, I'm a pretty lousy doc (with years of experience in the military, PP and academia).
BTW you're not being a dick, and if you actually think about things enough to post here, you're better than most.👍 I just interpret their "support" of 8 hours very differently. Every facility I have ever worked in has had essentially the same policy. If you think I'm overly conservative you should see some of the jokers that I have the pleasure to work with. They think I'm a cowboy.

 

[Hockeyguy]

Hmmm? I actually know what these guidelines say. I used them to update our NPO policy for elective surgery several years ago at my old gig. Are you sure the magic "8 hours" is not there? Anywhere? 😕

V. Preoperative Fasting Status (Solids and
Non-human Milk)
There is insufficient published evidence to address the
safety of any preoperative fasting period for solids or
non-human milk. For patients of all ages, the Consultants
and Task Force support a fasting period for a light meal
(e.g., toast and a clear liquid) of 6 hours before elective
procedures requiring general anesthesia, regional anesthesia,
or sedation/analgesia (i.e., monitored anesthesia
care). They also support a fasting period for a meal that
includes fried or fatty foods or meat of 8 or more hours
before elective procedures.

I don't make this stuff up. The "8 hours" is right there in the practice guideline. Leaving it out of the "recommendations" yet putting that in the text is classic waffling. There was no clear agreement, so this is how they got around the issue. Yet they left that sentence there. They could have taken out the 8 hours and said something like, "Large meals containing fried or fatty foods or meat may further delay gastric emptying." That would have probably been too vague though, and caused other problems.
This is where most hospitals/groups generate their policies on preoperative fasting for elective cases. Does your hospital really not have a policy on preoperative fasting for elective surgery? A clear policy solves a lot of potential problems with aggressive surgeons that want to push the envelope and make their tee time, or their daughter's dance recital.🙄

Here's an example I found for you online. It's from the Cleveland Clinic. Our policy is similar.

Appendix A
Fasting Recommendations to
Reduce the Risk of Pulmonary Aspiration
1 These recommendations apply to healthy patients who are undergoing elective procedures. They are not intended for women in labor. Following the guidelines does not guarantee that complete gastric emptying has occurred. Causes of delayed gastric emptying include: diabetes, narcotic use, presence of ascites or other intra-abdominal processes which may make the stomach smaller than normal, significant uremia, chronic significant neurological disease, etc.
2 The fasting periods noted below apply to all ages.
3 Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee.
4 Since non-human milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period.
5 A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining an appropriate fasting period.
Ingested Material Minimum Fasting Period
Clear liquids 2h
Breast milk 4h
Infant formula 6h
Non-human milk 6h
Light meal 6h
Regular meal 8h

Living where I live, healthy respect for litigation is what spares physicians from a $10M judgment. No tort reform here. The lack of tort reform makes you conservative. It's not fear, it's a survival instinct. That's life in the real world. You're free to practice any way you wish. You may choose to interpret the above differently, but if you have a fasting policy that you choose to ignore, you've just opened the door to potential disaster. But what do I know, I'm a pretty lousy doc (with years of experience in the military, PP and academia).
BTW you're not being a dick, and if you actually think about things enough to post here, you're better than most.👍 I just interpret their "support" of 8 hours very differently. Every facility I have ever worked in has had essentially the same policy. If you think I'm overly conservative you should see some of the jokers that I have the pleasure to work with. They think I'm a cowboy.

Dude were splitting hairs and both want to do, I hope, what's best for the patient. But be clear there is NO ASA RECOMMENDATION THAT ADVISES SPECIFICALLY AN 8 HOUR FAST. If I am missing a SPECIFIC 8 HOUR RECOMMENDATION let me know. But 7 vs. 8 hours - come on dude honestly? Don't say I am flying in the face of "black and white" guidelines by ignoring some arbitrary 8 hour rule and being a shi tty doc cause it doesn't exist.. The whole were all going to get sued to hell argument because there are "black and white" guidelines is false. You're talking out your ass. I'm telling you from the horses mouth and showing the actual recommendations what it says. I'm not really sure how you could argue that but in true SDN crazy fashion you try. I would do this case in a millisecond and if this patient yuked and died and sued (prob 1:10,000.000) I would say to whatever butt fuc k fly-by-night expert witness the prosecution paraded around to show me a specific recommendation that said eight hours. In this case I know I would have at least one expert witness on my side (the f'ing guy who wrote the recs) to say 7 vs 8 hours makes no difference. You can show me whatever institution recs you want at Wash U/BJH we did greater than 80k+ anesthetics last year and on the ground we employ a six hour solid NPO rule and I know 100% for sure we haven't had an aspiration suit in 10 years. I did a project looking at our suits/closed claims. I'd be happy to talk about that if you'd like but I promise you NPO/aspiration wasn't even on the radar as a problem

 

[dhb]

Maybe if pretty much everyone disagrees with you, everyone isn't wrong?

Looks like not everyone disagrees with me 😉

 

[IlDestriero]

That's the source of the 8 hour policy for full or fatty meals that has been used to generate the 8 hour guideline for preoperative fasting for elective surgery at virtually every ASC and hospital I have worked at since around 2000. You've probably heard of some of them. Thanks for saving me the trouble of linking the practice guideline. You waste a lot of words to say, "We have a 6 hour policy here."
You should ask your attending why they would include the 8 hour statement there in the guidelines if there was really no evidence to support it being a "recommendation".
The Cleveland clinic policy was just an example of a fasting policy I found online for someone without one in place. It does not constitute evidence of anything.
PS You know that the utility of closed claims data is quite limited.