Interesting case

[Radetzky]

Neither do you though. The difference is you’re assuming the worst and have already made up your mind that this is poor care.

You will find out your answers you posted above if you talk to the patient. You know, do your job as a physician. Your questions in your post will be answered by a pre op HP as ASA and most experienced anesthesiologists recommend.

Then get labs. Get a lot of them. Get consults.

Don’t blindly order workups if on your clinical evaluation and what you’re planning to do as an anesthesiologist it’s not going to change management

Yes, and having established the most likely cause I would give time for the appropriate therapy to work. There is nothing I could find on my preop evaluation that would make me want to proceed (unless there was some vascular compromise or other surgical urgency)

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[neutro]

This is an interesting perspective.

I have some questions for you (remembering this surgery is non-urgent and as some have pointed out, not even required, and also as presented, we have no idea what underlying pathology is responsible for current abnormalities.)

If this baseline PulseOx doesn’t bother you; what baseline would?

If this deviated trachea of unknown cause doesn’t bother you, can you give me some examples of some airway pathology or lung disease that would bother you? If this degree of deviation is non-concerning, what degree of deviation would make you question your decision to proceed or not?

You aren’t worried about loss of diaphragm function in this patient. What scenario would you be worried about it?

I would first and foremost start by asking the patient how have they been for the past 6 months. Then 3 months. Then last month. Then two weeks. Then last week. Then what brought them to he hospital.

I do this for every single one of my patients that requires answering complex situations such as these.

The pattern, chronicity, changes in health are cause of decline is vvip.

Sats of 85% sure. Has she always had low sats? Has this been diagnosed? Does she see a pulmonologist outpatient? Is she on steroids, oxygen, inhalers? Or all three? Bipap or cpap? Compliant? Ask and find out. Get last Pulm notes. Call the guy if you have to. Find out what’s normal for her.
Is this ILD?
Again I haven’t ordered anything yet.

Similar approach for everything else.
Deviated trachea. Have her symptoms gotten worse? Is she able to lay flat? What’s the deviated trachea from?

Now I would ask the same questions about difficulty swallowing. That can mean many things.

Is she hypertensive? Is she on meds?

Echo would be useful.

I would like to know if there is pulmonary HTN. Have they done a right heart cath in the past to obtain right sided pressures? If not then maybe get a cardiology consult. Have they had one in the past? Then look at it and maybe get one- bust assume Pulm htn and avoid hypoxia.

I would ask her activity tolerance. Ability to do chores - what can she do. What she cannot do.

Does she have dyspnea at rest? Is that cardiac or pulmonary or both?

What’s her meds list? What does her pcp say?

Again I have gotten a sense of her health based on that already without blindly ordering consults.

And if I’ve ordered consults, they’re directed.

I already know I would do a block plus sedation for her as my primary plan. I would ensure that the block works before I go to OR.

Precedex is a good choice for sedation.

If for some odd reason I have to convert to geta- low threshold for echo, and art line. Glidescope in room ofcourse. The chance of this happening is low but can happen - but please tell me how would it be different at any other tertiary care center?

I would consent all that and discuss risks.

I just don’t think that this plan would change two weeks down the road even if the patient gets all the work up.

 

[PpfSuxTube]

This is not the patients “baseline”.

Finally someone mentions this.. 100%.

I started reading this 'interesting case' to pass the time but now if i actually cared enough, i would be shocked at how genuinely poor some people's practice is... cowboy stuff, and bravado might be fine in hicksville but unfortunately isnt an option where everywhere. I wish it was sometimes. Job would be so much easier.

Now This may actually be her baseline but that would require some degree of workup, treatments of acute pathologies, following for some degree of time.

Im just glad i dont live or practice near some of poster's on here, and glad some of you dont make actual end of life decisions or conversations often for your own and your patients sakes...

 

[PpfSuxTube]

^ ok. Sure.

I will counter with a very basic argument - it’s not really upto anesthesia to decide who “needs” surgery or not and “when” (at least most of the time).

That’s upto the surgeon.

Hmm not really...
Glaucomflecken got this one spot on. Surgeons just want to operate. The majority dont care about the rest. Thats what we're there for...

Gotta respectfully disagree with you, i would be postponing this case for a few days, for reasonable optimization and some hard conversations

 

[pgg]

^ I am being realistic. Me commenting on this case is no different than your comment. It’s just a matter of perspective. We are presented with information by a resident. Neither you or I actually evaluated the patient clinically.

What, do you think the OP is lying? Even if he is, there's no point discussing any case at all if we don't all agree that the words in the case presentation mean what they say.

The sats are eighty to eighty-****ing-three at best and she has a week-old fracture. What's the rush?

Lots of thing that cause hypoxia can be dramatically improved over the course of 24-48 hours, if you take the time to care.

 

[neutro]

What, do you think the OP is lying? Even if he is, there's no point discussing any case at all if we don't all agree that the words in the case presentation mean what they say.

The sats are eighty to eighty-****ing-three at best and she has a week-old fracture. What's the rush?

Lots of thing that cause hypoxia can be dramatically improved over the course of 24-48 hours, if you take the time to care.

Im not saying anything.
But every one is assuming that substandard care was provided based on his presentation.
There’s a disconnect between presentation and what actually transpired.

Knowing trainees/residents/CRNAs, I wouldn’t be surprised.

Call me cynical. Sure.

 

[neutro]

Hmm not really...
Glaucomflecken got this one spot on. Surgeons just want to operate. The majority dont care about the rest. Thats what we're there for...

Gotta respectfully disagree with you, i would be postponing this case for a few days, for reasonable optimization and some hard conversations

Ok now it’s few days and not two weeks or whatever. That works. I’ll take that.
Sure ok to disagree.
We all have our own thresholds for risk.

 

[neutro]

Finally someone mentions this.. 100%.

I started reading this 'interesting case' to pass the time but now if i actually cared enough, i would be shocked at how genuinely poor some people's practice is... cowboy stuff, and bravado might be fine in hicksville but unfortunately isnt an option where everywhere. I wish it was sometimes. Job would be so much easier.

Now This may actually be her baseline but that would require some degree of workup, treatments of acute pathologies, following for some degree of time.

Im just glad i dont live or practice near some of poster's on here, and glad some of you dont make actual end of life decisions or conversations often for your own and your patients sakes...

Cool you practice your way and let others be responsible for the way they practice.

They’ll answer to their own peer review committees, credential committee, malpractice carriers etc.

Please lets stay in our own lane and try to understand anesthetic technique rather than blast an experienced anesthesiologist based on a trainees perspective. Lmao 🤣

At this time we don’t have knowledge of his assessment. It’s conjecture and in typical sdn way - if the peanut gallery doesn’t agree, let’s bully him.

 

[deleted875186]

I would first and foremost start by asking the patient how have they been for the past 6 months. Then 3 months. Then last month. Then two weeks. Then last week. Then what brought them to he hospital.

I do this for every single one of my patients that requires answering complex situations such as these.

The pattern, chronicity, changes in health are cause of decline is vvip.

Sats of 85% sure. Has she always had low sats? Has this been diagnosed? Does she see a pulmonologist outpatient? Is she on steroids, oxygen, inhalers? Or all three? Bipap or cpap? Compliant? Ask and find out. Get last Pulm notes. Call the guy if you have to. Find out what’s normal for her.
Is this ILD?
Again I haven’t ordered anything yet.

Similar approach for everything else.
Deviated trachea. Have her symptoms gotten worse? Is she able to lay flat? What’s the deviated trachea from?

Now I would ask the same questions about difficulty swallowing. That can mean many things.

Is she hypertensive? Is she on meds?

Echo would be useful.

I would like to know if there is pulmonary HTN. Have they done a right heart cath in the past to obtain right sided pressures? If not then maybe get a cardiology consult. Have they had one in the past? Then look at it and maybe get one- bust assume Pulm htn and avoid hypoxia.

I would ask her activity tolerance. Ability to do chores - what can she do. What she cannot do.

Does she have dyspnea at rest? Is that cardiac or pulmonary or both?

What’s her meds list? What does her pcp say?

Again I have gotten a sense of her health based on that already without blindly ordering consults.

And if I’ve ordered consults, they’re directed.

I already know I would do a block plus sedation for her as my primary plan. I would ensure that the block works before I go to OR.

Precedex is a good choice for sedation.

If for some odd reason I have to convert to geta- low threshold for echo, and art line. Glidescope in room ofcourse. The chance of this happening is low but can happen - but please tell me how would it be different at any other tertiary care center?

I would consent all that and discuss risks.

I just don’t think that this plan would change two weeks down the road even if the patient gets all the work up.

I appreciate the thorough history youre describing. Again if we have an etiooogy for the patients presentation and some more info than maybe someone can argue proceeding, but I honestly don’t want my anesthesiologist taking a best guess at why my sat is 83% and proceeding with a block and precedex sedation. Anyone can survive a block and precedex. But I think we can all agree that at the very least an echo and a chest CT are a minimum workup here. Internal medicine needs to take over. We just don’t have enough info.

 

[DrOwnage]

I’ve had some sketchy cases like this where I’ve done some, delayed some. In the ones I’ve delayed, I’ve described them to colleagues and there’s some people who honestly just don’t care. They don’t have much input into it. They go with their gut. They’ve become accustomed to just putting people to sleep and dealing with it when **** hits the fan. When something goes wrong they go “oh well the patient needed the surgery.” It’s two different outlooks on the practice and it’s very hard to make them see it differently.

 

[IlDestriero]

God damn that was stupidly ballsy.

Just stupid, not ballsy.

 

[IlDestriero]

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.

I disagree with this as well.
1. This isn’t urgent. Percocet and a sling will get you time for an evaluation.
2. They may not be able to optimize anything in this patient at all, and nothing will change, EXCEPT you’ll know WTF is going on and can optimize your anesthesia plan accordingly. Maybe your answer is a kiss of precedex and a block either way, but the block isn’t always 100% effective and you need a well considered plan B.
3. Maybe after an understanding of her condition, whatever it is, and the risks of an anesthetic, she would elect to not have the operation. Maybe the surgeon wouldn't want to take the risk either and just a cast is looking better now.

I had a somewhat similar conversation recently with a usually reasonable surgeon about at 100% elective case at an ASC who had a significant and obvious undiagnosed delays that were documented by their NP and ignored, and some dysmorphic features as well. He couldn’t understand why I wanted the patient to have a work up before surgery. “What would it change?” He was pushing back so hard I actually asked him if he was f’ing with me. It was a twilight zone moment. I told him the same thing I told the mom when I postponed the surgery, though way more condescendingly. “Some times kids with these kinds of delays have problems that can have profound anesthetic implications and to just go in guns blazing with anesthesia for x 101, is dangerous and can pose a significant and avoidable risk of life threatening complications. I can’t optimize an anesthesia plan for every possible diagnosis simultaneously.” I also added that the NP that’s been following the patient for the last 18 months is brain damaged as they think all this kids documented worsening problems/delays were related to needing this 1000% non urgent surgery that is not related to the kids obvious delays in any way that I’m aware of, and if he’s comforted that this is the kids baseline and they’re good to go he’s very mistaken. The surgeon went on to complain to the medical director of the site because the patient and their crack pot NP complained to him for delaying the case and they didn’t think he needed a work up. The inmates are running the asylum apparently. He lost all my respect after that. You’re paying me for 20+ years of experience and an understanding of the risks of anesthesia, not to mask down whoever rolls in the room. They made a Propofol robot for that.

 

[woopedazz]

Whole debate can be boiled down to: If it were a #NOF @neutro would be preaching to the choir.

 

[abolt18]

Whole debate can be boiled down to: If it were a #NOF @neutro would be preaching to the choir.

Forgetting, what is NOF?

 

[woopedazz]

Forgetting, what is NOF?

Sorry, neck of femur.