Medical Clearance question

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Dream Weaver

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Hypothetical elective oupatient surgery Total Knee Replacement Cardiac stent 7 years ago, diabetic, HTN couple of outpatient surgeries in the past prior to stent placement. No known cardiac problems per patient since stents placed. Preop clearance by Family Practice or Internal med no cardiology consult. EKG- normal, Labs normal, no cardiology workup since stents. Here is my question. At what point is the anesthesiologist responsible for this patient as far as work-ups prior to surgery. If something happened during surgery cardiac wise is the anesthesiologist responsible for this patient because an echo wasn't ordered on this patient by the clearing physician? Or is this go back on the physician that cleared the patient (or medically optimized) this patient to begin with? If you didn't know about the pulmonary hyperstension or the aortic stenosis prior to surgery are you then responisble for the bad outcome if something untoward happens? Do you find yourself having to play defensive medicine at times because of the "lack of specialist training" of the family practice physicians? I don't want to sound like I'm bashing family practice docs they seem like they have a lot of knowledge but not a great depth of knowledge. I know in a sue happy society everyne would get named initially in a lawsuit but are you responisble for ensuring that this patient was properly cleared?

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You are the anesthesiologist. That makes you the doctor ultimately in charge of "clearing" a patient for an elective surgical procedure....emergency cases are a beast their own.

But for elective cases, it's you decision whether to proceed or not. As a general rule, I usually refer to the ACC guidelines for elective non-cardiac surgeries.

You, as the anesthesiologist need to perform a targeted history and physical when evaluating the patient. While I do rely on my cardiology colleagues to give me guidance, remember you are the doctor also. You need to make the ultimate decision.

I've canceled cases for elective outpatient procedures even with cardiac clearance. The cardiologist is never asked if a patient is cleared for standalone outpatient procedures. They are just asked if they are cleared. Lots of varying factors. While it was a simple hernia case, the patient was morbidly obese, sleep apnea, CAD, DM, everything. He was "stable" from a cardiac viewpoint. However, I told the surgeon, this guy's got severe Aortic Stenosis that's not going to operated on. I told him to boot the case back to the main hospital where there's more monitoring equipment available.

So if something happens during/short after the case, who's responsible? There where a well documented H and P comes into play. Document everything. Think like a lawyer. Close every angle that they made attack you on. Never just write "cardiac clearance in chart". Write, "exercise status at baseline, no symptoms, no changes in medical status etc". Unfortunately you have to write all these things down when pre-oping a patient. Take your time. Never rush. You can do things efficiently while not rushing.
 
This is an odd question for a first post. Kinda lawyerly. But benefit of the doubt ...

The short answer is that angry people and their oily reptilian lawyer minions can sue anybody for anything, justified or not, and it's silly to think that an 'OK for surgery' note scrawled in the chart by a consultant will either absorb a quantifiable amount of the anesthesiologist's liability or prevent a jury from being maipulated by a plaintiff's attorney.

That's not to say preop consults are worthless. While I value the data a consultant can provide I place less weight upon their opinions. For example, I'm a lot more interested in the echo report sent by the cardiologist than I am his overall "clearance" - there are many, many factors related to the procedure, its urgency, non-cardiac comorbidities, postop care, the utility or futility of delays for optimization of cardiac vs other problems, the patient's wishes and informed risk tolerance, etc, that the cardiologist may not be aware of - or qualified to evaluate in our perioperative anesthesia world.

Data provided by a consultant, +/- their input on how some of that data might be interpreted, is helpful as I make the go/no-go decision and plan the anesthetic. The mere fact that they OK a patient for surgery has minimal influence on whether or not I OK that patient for surgery.


Dream Weaver said:
If something happened during surgery cardiac wise is the anesthesiologist responsible for this patient because an echo wasn't ordered on this patient by the clearing physician?

This is a dangerous line of thought. A bad outcome doesn't prove or even imply a poor decision pre- or intra-op.

The AHA/ACC guidelines are just that, guidelines, to assist the anesthesiologist in determining which (if any) cardiac tests may be helpful. The great majority of patients, even those with known cardiac disease, do not need pre-op cardiac workups to include echos, stress tests, caths, or anything else.

The anesthesiologist is obviously responsible for the patient. But a bad outcome + responsibility doesn't automatically (or even usually) equal malpractice.
 
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I would erase the term "medical clearance" from your vocabulary. It implies "I don't have to think about the medical issues because I have a note from a doctor." No one understands OR medicine better than an anesthesiologist, so the only "clearance" that matters comes from you. A better term to substitute would be "medical optimization". A cardiologist may not be able to guarantee what will or will not happen under anesthesia in the OR, but he can tell you if everything that's fixable is tip top. That and his data are the best you're gonna get.


Hypothetical elective oupatient surgery Total Knee Replacement Cardiac stent 7 years ago, diabetic, HTN couple of outpatient surgeries in the past prior to stent placement. No known cardiac problems per patient since stents placed. Preop clearance by Family Practice or Internal med no cardiology consult. EKG- normal, Labs normal, no cardiology workup since stents. Here is my question. At what point is the anesthesiologist responsible for this patient as far as work-ups prior to surgery. If something happened during surgery cardiac wise is the anesthesiologist responsible for this patient because an echo wasn't ordered on this patient by the clearing physician? Or is this go back on the physician that cleared the patient (or medically optimized) this patient to begin with? If you didn't know about the pulmonary hyperstension or the aortic stenosis prior to surgery are you then responisble for the bad outcome if something untoward happens? Do you find yourself having to play defensive medicine at times because of the "lack of specialist training" of the family practice physicians? I don't want to sound like I'm bashing family practice docs they seem like they have a lot of knowledge but not a great depth of knowledge. I know in a sue happy society everyne would get named initially in a lawsuit but are you responisble for ensuring that this patient was properly cleared?
 
Thanks for the replies. Here is why I posed the question. I completed my premed last December and was thinking of applying next year for medical school. My brother is a family practice physician in a semi rural area of Iowa. He let me "shadow" him and the chief of staff (another FP physician). In addition I got to spend some time down in the anesthesia department with the anesthetists(RN's) and also with the radiologist. The chief family pratice physician had cleared a patient for a surgery but the anesthetist wanted to have cardiology see the patient prior to surgery. The point I got from the family practice physician when I was following him was basiclly once I clear a patient for surgery they are cleared. Now my brother on the other hand will say I'm not a cardiologist, pulmonigist, etc. and I think this patient needs a referral (not this specific patient) so he seems to know his limitations which I look at as a good thing. The chief seems more like someone with a big ego (just my opinion). So the surgery gets delayed and the surgeon is upset because she just wants to operate and can't understand why her case gets cancelled. So basically the anesthetist gets grief from the surgeon and grief from the family practice physicians who complain to administration and then she gets grief from them as well. So I'm thinking if this is what you have to put up with all the time as an anesthesiologist then being a radiologist looks kind of attractive. My brother did tell me that "once you stop doing right by the patient then it is time to find a new line of work". Do you have to put up with a lot of crap like this or can you just go and do your job everyday in the operating room and go home?
 
I got to spend some time down in the anesthesia department with the anesthetists(RN's)

The chief family pratice physician had cleared a patient for a surgery but the anesthetist wanted to have cardiology see the patient prior to surgery.

So the surgery gets delayed and the surgeon is upset because she just wants to operate and can't understand why her case gets cancelled. So basically the anesthetist gets grief from the surgeon and grief from the family practice physicians who complain to administration and then she gets grief from them as well.

It's impossible for us to know if the case was appropriately delayed by the CRNA (RN anesthetist), or if the surgeon was justified in his irritation.

Do you have to put up with a lot of crap like this or can you just go and do your job everyday in the operating room and go home?

In a sense, you're asking the wrong question if you're bound for medicine and considering anesthesia - you, as a physician anesthesiologist, will have the medical background, training, perspective, and duty to "clear" patients for surgery. The same can not be said for CRNAs, even the ones with genuine independent practice.

What apparently happened in your scenario was that a physician "cleared" the patient (granted it was a FP), and then a nurse (anesthetist) "uncleared" the patient. The surgeon may or may not be justified in objecting to the delay, but it's certainly easy to understand his frustration.

This is just one more reason why CRNAs belong in an ACT practice where there are physician anesthesiologists to
- consistently make correct (or at least defensible) preop decisions
- face down the surgeon from level physican-physician footing, if necessary

As for your question - no, I never have to put up with crap like that because I'm not a CRNA, and when I delay a case I can articulate a compelling reason why to the surgeon and family.
 
It seems to me that you are describing a situation where an unsupervised nurse anesthetist decided to delay a surgical case to get a cardiology consult.
In general it is very difficult for nurses to understand the whole clinical picture and decide when a consultant is actually needed.They are also likely to request inappropriate or unnecessary consults, which would cause many people to be unhappy (patient, surgeon, administration, consultants...)
An anesthesiologist is a consultant physician who can evaluate the patient objectively and if an anesthesiologist requests input from a consultant it is usually clearly indicated and as a result does not cause the kind of unhappiness you witnessed.
 
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