Well what actually happened was this:
I was pushing hard for my attending to postpone the case and actually work her up (other attendings passing by suggested the same), but he didn’t want to.
So we did a interescalene block (which I suggested was a bad idea) plus precedex.
The patient actually did well, her spo2 stayed around 85 all surgery. Still the whole thing left me kind of angry, the fact that everything went well doesn’t mean it was the right call and I didn’t like the attitude of my attending (kinda simping to orthobros).
I would agree with your attending to proceed with the case and get the surgery done.
This is not an uncommon scenario in many rural and community hospitals by the way - if you wait for consults it would take 3 days to get the work up done and you’d still proceed with optimization. Consults and labs are nice to have but they shouldn’t obstruct in providing timely care.
Yeah shoulder surgery is not “urgent” but the patient cannot really function and may have to take pain meds for extended period of times - many times opioids. A fast surgeon and appropriate anesthetic is often sufficient to get the job done.
At the end of the day, it’s the anesthesiologist who’s responsible for the patient. Not the Pulm or cardiologist. They tend to comment on matters that they often have little knowledge on - for instance “avoid general anesthesia for this surgery”. I find it annoying actually. We both know that we often proceed with our plan without taking their recs into consideration.
So many anesthesiologists optimize as best as they can given the resources at hand and proceed. This is common in many community hospitals.
Let’s say this patient sees a pulmonologist and cardiologist and medicine. What will they do? Labs? Echo? CTA. Will they do cath? I mean are you concerned about cardiac ischemia? Heart failure? Even if she has a mediastinal mass - are you going to delay surgery for fracture and call cardio-thoracic surgery first to intervene? Are they going to operate? Assume she has an EF less than 20%…what are you going to do differently? What if she has pulmonary hypertension?
You see what I mean? It won’t change much as to how you do your anesthetic.
The purpose of diagnostic tests and consults is to help guide changes in treatment. You already know you’re going to do a block and avoid a heavy anesthetic on this patient and ideally keep the patient spontaneous.
You’ll of-course give her a breathing treatment, etc…make sure she stays within 20% of her hemodynamic range. Maybe you’ll do an art line and keep glide-scope in room…but are you really going to be able to fix her sats of 80-85% from chronic smoke exposure?
This lady was in routine health prior to coming to the hospital wasn’t she? Did she acutely decompensate?
Maybe your attending is experienced and upon his pre-op evaluation, although the patient may have appeared to disastrous on paper/labs/chart, but was close to her baseline and he felt that an expensive work up would just delay surgery and would not add anything of use. I’m suspecting that’s what happened.
If that’s the case - he did the right thing.
A good block and assessment of complete block before going to the OR with sedation would be my choice also in this situation if I was happy with my pre op interview about her general health.
But i would need to make sure that patient is at her baseline based on history and asking her and her family questions and essentially risk stratify.
I would definitely get a good and detailed consent. But if I think she’s close to her baseline, I would just proceed to avoid delay. It is what it is. We cannot fix chronic problems acutely.