Listen to this BS

[B-Bone]

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Last week, I was scheduled to do a flex-nail of radial/ulnar fracture on a healthy two year old (first case of the day). Pt shows up to hospital 90 minutes late (i.e. 10 minutes after scheduled start time), and surgeon considers cancelling because he has clinic. He decides to do the case, and after the 35 MINUTES it took to admit a 2 year old to the hospital (you know, to ask about her religious preferences and if she has asbestos in her home, etc) we bring her back to the OR. Surgeon is pissed at this time. At that point, we mask her down and I go to start IV. 30 minutes (and >12 pokes by me and a partner) later (nothing to see, no luck with blind saphenous, IR vein-finder, etc), we still don't have an IV. Surgeon decides to go talk to pts dad. As soon as he walks out, we get a 22 in the EJ. He walks back in and says he's cancelling case to go to clinic. I let him know we're ready to go and recommend he be late to clinic. He refuses and decides to send her home to do later in the day. I inform him that I won't send her home with a neck IV and she is unlikely to be an easier stick later in the day (more NPO, etc). He says wake her up and get her out of here. I run in 500 cc IVF to try to hydrate her a little, wake her up and pull the IV.

Long story short, she comes back in 4 hours, and I pop in an AC under US with a single stick. Case done, no further complications. Basically, the kid got an unnecessary anesthetic because the surgeon didn't want to be late for clinic. Probably no big deal in the grand scheme of things, but man was I pissed. Thoughts?

 

[Hernandez]

but man was I pissed. Thoughts?

be mad at the parents, **** happens but clinic still has to be done, you can't just cancel those appts due to someone else's tardiness....

work on getting your admit nurses to move ther paperwork along a little quicker next time too...

 

[B-Bone]

be mad at the parents, **** happens but clinic still has to be done, you can't just cancel those appts due to someone else's tardiness....

work on getting your admit nurses to move ther paperwork along a little quicker next time too...

I guess I was pissed because I think you shouldn't cancel a case after the patient is asleep, unless you're doing it for a medical reason. Especially in a two year old. There are some recent studies out there showing long term cognitive delay/deficits in kids who receive more anesthetics:

Early exposure to anesthesia and learning disabilities in a population-based birth cohort.

Wilder RT, Flick RP, Sprung J, Katusic SK, Barbaresi WJ, Mickelson C, Gleich SJ, Schroeder DR, Weaver AL, Warner DO.

Anesthesiology. 2009 Apr;110(4):796-804.

 

[IN2B8R]

Last week, I was scheduled to do a flex-nail of radial/ulnar fracture on a healthy two year old (first case of the day). Pt shows up to hospital 90 minutes late (i.e. 10 minutes after scheduled start time), and surgeon considers cancelling because he has clinic. He decides to do the case, and after the 35 MINUTES it took to admit a 2 year old to the hospital (you know, to ask about her religious preferences and if she has asbestos in her home, etc) we bring her back to the OR. Surgeon is pissed at this time. At that point, we mask her down and I go to start IV. 30 minutes (and >12 pokes by me and a partner) later (nothing to see, no luck with blind saphenous, IR vein-finder, etc), we still don't have an IV. Surgeon decides to go talk to pts dad. As soon as he walks out, we get a 22 in the EJ. He walks back in and says he's cancelling case to go to clinic. I let him know we're ready to go and recommend he be late to clinic. He refuses and decides to send her home to do later in the day. I inform him that I won't send her home with a neck IV and she is unlikely to be an easier stick later in the day (more NPO, etc). He says wake her up and get her out of here. I run in 500 cc IVF to try to hydrate her a little, wake her up and pull the IV.

Long story short, she comes back in 4 hours, and I pop in an AC under US with a single stick. Case done, no further complications. Basically, the kid got an unnecessary anesthetic because the surgeon didn't want to be late for clinic. Probably no big deal in the grand scheme of things, but man was I pissed. Thoughts?

If the kid was that dehydrated and you could not get a peripheral IV, maybe you should have canceled the case yourself? Or, perhaps, just put in a neck line if you are strugling that bad (prolly not worth it for a five minutes case, though)....

 

[michigangirl]

He should have cancelled the case from the get go when the family was 90 minutes late. Once he committed and let you put the kid to sleep, it's his obligation to do the case unless you feel that it needs to be cancelled for anesthetic safety reasons. It's dumb that she had to come back and go to sleep again. Grr.

 

[gaspasser2004]

I agree with the previous posters. Ideally, the surgeon should have either canceled the case or gone through with it, even if he was late to clinic and inconvenienced other patients. I think it is unacceptable to put a two year old to sleep, struggle with IV access, finally get IV access, not do the case because of surgeon schedule preference and then have the kid come back.

Two year olds obviously have no control over when they are going to show up to the hospital, so you can't blame the patient. Even blaming the parents may be presumptive - OR schedulers/day surgery nurses mess up appointment times frequently (depending on where you work).

The unfortunate thing about some private practice gigs is that when the rubber meets the road, you are sometimes doing things that you don't feel comfortable with. Waking this kid up, pulling out the IV you worked so hard for, and then having the kid come back on the same day? Give me a break. However, in the "real world" you have to placate the surgeons who feed you.

 

[pgg]

"Surgery cancelled after induction of anesthesia" is a mandatory reportable event that gets reviewed by our hospital risk management people.

 

[jwk]

"Surgery cancelled after induction of anesthesia" is a mandatory reportable event that gets reviewed by our hospital risk management people.

As it should be. Huge red flag at my place.

Surgeons are late ALL THE FRIGGIN TIME! Do they apologize? Not usually. Do they call and say they'll be late? Not usually.

 

[sevoflurane]

Last week, I was scheduled to do a flex-nail of radial/ulnar fracture on a healthy two year old (first case of the day). Pt shows up to hospital 90 minutes late (i.e. 10 minutes after scheduled start time), and surgeon considers cancelling because he has clinic. He decides to do the case, and after the 35 MINUTES it took to admit a 2 year old to the hospital (you know, to ask about her religious preferences and if she has asbestos in her home, etc) we bring her back to the OR. Surgeon is pissed at this time. At that point, we mask her down and I go to start IV. 30 minutes (and >12 pokes by me and a partner) later (nothing to see, no luck with blind saphenous, IR vein-finder, etc), we still don't have an IV. Surgeon decides to go talk to pts dad. As soon as he walks out, we get a 22 in the EJ. He walks back in and says he's cancelling case to go to clinic. I let him know we're ready to go and recommend he be late to clinic. He refuses and decides to send her home to do later in the day. I inform him that I won't send her home with a neck IV and she is unlikely to be an easier stick later in the day (more NPO, etc). He says wake her up and get her out of here. I run in 500 cc IVF to try to hydrate her a little, wake her up and pull the IV.

Long story short, she comes back in 4 hours, and I pop in an AC under US with a single stick. Case done, no further complications. Basically, the kid got an unnecessary anesthetic because the surgeon didn't want to be late for clinic. Probably no big deal in the grand scheme of things, but man was I pissed. Thoughts?

*****hole surgeon. This would drive me mad. He said to proceed with the case right?????? I don't care 'bout his clinic. It can run late. What I care about is a 2 y/o child being stuck so many times... then finally getting an IV and the surgeon cancelling the case.

Poor form and the child comes back for another GA 4 hrs. later. What if the AC's were tapped out?

Ridiculous.

I would also be pissed and have a sit down with said surgeon.... saying something to the tune of:

"You either do the case or you don't."

Remember that it is your license on the line my friend...

Sounds like this surgeon could care less about it.

 

[Mac4]

So, the surgeon did the case later the day. If you think about it, the cancellation actually made his/her day longer because the kid had to be anesthetized again and the OR had to be set up again. I can not image what was so important in clinic that he could not be later for 15 mins.

The whole ordeal is bad for the pt, anesthesiologist, OR staff, billing and even the surgeon himself. Why did he do this? I really think it was about the surgeon's ego...you know "I can cancel the damn case because I am pissed".....&*^%hole!

 

[CrazyJake]

As above, the case should have just been cancelled from the start b/c of the parents being late - no rushing, no skipping steps, pt safety 1st...surgeon operating not fuming mad. There are plenty of risk for every GA, especially with kids.

I wonder if this happened agan, if 1 could issue a stat ethics consult with the hospital ethics team. At my hospital, they're available 24/7 for emergency decision making in the ER, OR's, ICU's, etc.

At the very least, you probably should file a report (safety committee, patients advocate group - whoever handles this at your hospital) on this b/c at many hospitals this is highly frowned upon. As a resident, I would file it...have to from an ethical/legal standpoint, IMHO.

CJ

 

[urge]

At the very least, you probably should file a report (safety committee, patients advocate group - whoever handles this at your hospital) on this b/c at many hospitals this is highly frowned upon. As a resident, I would file it...have to from an ethical/legal standpoint, IMHO.

This.

 

[IlDestriero]

If you pulled that where I work it would be a monumental F up and almost certainly career ending. (here). He would get incident reports from me and the OR nurse, and the pre op and post op nurses. Risk management, chief of surgery, patient safety officer, the front office brass- all would hear about it and want his head.
Patient safety is job 1, 2, and 3. There's nothing safe about forcing a 2nd anesthetic electively because you're late for clinic and chose to proceed anyway, or making an NPO kid wait several more hours for his necessary procedure.
Pretty shocking behavior if you ask me and very unprofessional.
That would never happen here, and shouldn't happen anywhere.