Only Surgeons should be cancelling (or transferring) cases

[Mr.Golf]

I don't know if the discussion got moved to the private forum, or deleted. But there was a thread about a huge pediatric liver resection that had absolutely no business being done anywhere but a tertiary medical center.

I can find no fault in how the anesthesiologists handled the case. As a department, it sounded like they did their best to convince the surgeon to refer the case to Stanford.

For anybody coming to the forum looking for evidence that the anesthesiologists were to blame (or somehow violated the standard of care), I'm here to say it bluntly: ANESTHESIOLOGISTS HAVE NO POWER TO CANCEL OR TRANSFER CASES. None. The most we can do is delay for further workup or optimization. That's it. If the surgeon insists on doing the case, it's our job to do it as safely as possible.

It is possible that some anesthesiologists work in ambulatory centers as medical directors. True, in that capacity--AS MEDICAL DIRECTORS--we can send cases to the associated hospital. But, even then, it's only for cut and dry reasons like BMI, or strict age criteria.

I feel terrible for the anesthesiologists in the case. Working with surgeons who have an inflated sense of their own capabilities is, for me, the worst part of the job.

I have been in a position to deal with new hires (almost without exception recent graduates) who think that they can allow insured cases to be transferred elsewhere. It always--ALWAYS--ends poorly for the anesthesiologist.

If you don't feel comfortable doing the case, either find a partner who will do it for you, or find a lab abnormality that can be addressed--and hope the scheduling lightning doesn't strike you twice.

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[Dr. Rude]

I don't know if the discussion got moved to the private forum, or deleted. But there was a thread about a huge pediatric liver resection that had absolutely no business being done anywhere but a tertiary medical center.

I can find no fault in how the anesthesiologists handled the case. As a department, it sounded like they did their best to convince the surgeon to refer the case to Stanford.

For anybody coming to the forum looking for evidence that the anesthesiologists were to blame (or somehow violated the standard of care), I'm here to say it bluntly: ANESTHESIOLOGISTS HAVE NO POWER TO CANCEL OR TRANSFER CASES. None. The most we can do is delay for further workup or optimization. That's it. If the surgeon insists on doing the case, it's our job to do it as safely as possible.

It is possible that some anesthesiologists work in ambulatory centers as medical directors. True, in that capacity--AS MEDICAL DIRECTORS--we can send cases to the associated hospital. But, even then, it's only for cut and dry reasons like BMI, or strict age criteria.

I feel terrible for the anesthesiologists in the case. Working with surgeons who have an inflated sense of their own capabilities is, for me, the worst part of the job.

I have been in a position to deal with new hires (almost without exception recent graduates) who think that they can allow insured cases to be transferred elsewhere. It always--ALWAYS--ends poorly for the anesthesiologist.

If you don't feel comfortable doing the case, either find a partner who will do it for you, or find a lab abnormality that can be addressed--and hope the scheduling lightning doesn't strike you twice.

Except that we have a duty to say "NO" in certain situations. Even if it may cost you you job.

 

[dabears505]

If it needs to be canceled, cancel it. You can always get a different job, the lawsuit is forever. And at which point you might not be able to get a different job.

 

[pgg]

or find a lab abnormality that can be addressed--and hope the scheduling lightning doesn't strike you twice.

This is ridiculous and I would hate having a colleague who did this. It's beyond weak and unprofessional.

 

[Beeftenderloin]

ANESTHESIOLOGISTS HAVE NO POWER TO CANCEL OR TRANSFER CASES.

Sounds like you work for a group that has zero clout and receives zero respect for your expertise (?) as peri-op consultants. This is 100% part of the job description as an anesthesiologist, if indicated. So much so that they now literally test your ability to sit across from a surgeon and do exactly that on the OSCE portion of boards. This may be the reality at your shop because of the situation you’re group has allowed itself to be cornered into, but it is absolutely not the case everywhere and certainly shouldn’t be.

Everyone wants to puff their chest out and say anesthesiologists are providing higher level care than nurses, but what your describing ain’t that. It’s weak, and it has the potential to cause serious harm, as evidenced by the thread you mentioned.

Edit: I get it, production pressure, contract negotiations, AMCs, blah, blah… you gotta do what you gotta do to keep your job. If that’s the reality of your group, whatever, PM where it’s at so I can steer clear. Just don’t go around telling the world that’s the way it is everywhere because you’re flat out wrong.

 

[Volatile]

I’ve canceled a few cases where a lab abnormality or optimization wasn’t going to improve anything. They were all train wrecks that ended up on palliative/hospice care. I’ve never been threatened with my job.

 

[NICMAN]

Um, I am a medical director but regardless, read the medical staff bylaws and there almost always is a provision that states that no medical staff shall be forced to provide a medical service which is against their medical or ethical judgement.

Now, it isn’t absolute and will get scrutinized but to say anesthesiologist must perform cases they deem medically or ethically wrong is not correct in my experience.

 

[NICMAN]

I have been in a position to deal with new hires (almost without exception recent graduates) who think that they can allow insured cases to be transferred elsewhere. It always--ALWAYS--ends poorly for the anesthesiologist.

If you don't feel comfortable doing the case, either find a partner who will do it for you, or find a lab abnormality that can be addressed--and hope the scheduling lightning doesn't strike you twice.

Wow, what a way to back up your young partners! Force them into nightmare scenarios where they are exposed to risk, and then what? You probably feed them to the lawyer wolves to save your own skin.

The last statement is such a weasel move. I really hope you grow a pair of integrity and courage at some point in your career.

 

[IMGASMD]

I’ve been out for less than five years. Worked a few jobs. It really depends on the job and the group culture.
Throughout the years,
I’ve seen attendings trying to manage BP>220 on elective cases in preop, just so they don’t have to cancel the case.
I’ve seen CRNAs refused to do a case, because patient didn’t have a cardiac “clearance”.
I’ve seen case canceled for K of 3.3.
I’ve seen patient who was trached 20 years ago being done at a surgical center.
I’ve personally done some iffy cases at surgicenters, after consulting my senior partners.

I don’t complete agree with OP, but at the same time I also understand there’s certain production/make nice nice pressure with the surgeons and administrators. IIRC, even within that thread there are a few people who think the case can or even should be done at Walnut Creek.

Edit: typos and clarifications.

 

[The Duck Knows]

I always figured we just canceled the anesthetic. If they want to do their first liver transplant under local, that’s their decision.

But as a trainee, this makes me want to find a group where we back each other up in situations like this. If you have a crazy surgeon doing dangerous and unethical cases, I have no power if I know my colleagues will just turn a blind eye and proceed with the case. But if we all refuse to do that rare case that is just insane, our collective refusal has some strength behind it. It almost makes me wonder if the surgeons pushing the medical board to block Dr Death couldn’t have been better served by also spreading the word to anesthesia groups in the area.

 

[Beeftenderloin]

I always figured we just canceled the anesthetic. If they want to do their first liver transplant under local, that’s their decision.

One of my favorite quotes from one of my favorite attendings in training: “I’m not telling you that you can’t operate, I’m just letting you know we won’t be providing anesthesia”

 

[Mman]

so the thing with that peds liver case is that something that is decided way ahead of time before they show up in preop holding. This isn't a broken hip that shows up with a loud systolic murmur that you want to wait and get an echo before putting a spinal in. It was a patient that was optimized for the surgery they were going to have done. You can't cancel that on the morning of surgery. If it needed to be cancelled, it needed to be done ahead of time.

 

[Hoya11]

so the thing with that peds liver case is that something that is decided way ahead of time before they show up in preop holding. This isn't a broken hip that shows up with a loud systolic murmur that you want to wait and get an echo before putting a spinal in. It was a patient that was optimized for the surgery they were going to have done. You can't cancel that on the morning of surgery. If it needed to be cancelled, it needed to be done ahead of time.

Most hospitals that aren't huge academic centers have limits. For example, we did not do lung transplants or heart transplants at my local 400 bed medium sized community hospital. If there was interest in starting to do them, anesthesia chairman gets a say in the feasibility of doing that. Now yes they can always replace the anesthesia chairman or group until you find someone who agrees. But Im sure the anesthesia department involved in this liver case was consulted and said they agree to start doing them at this new institution. Its not like you show up and oh its a liver transplant today who knew..

 

[Mman]

Most hospitals that aren't huge academic centers have limits. For example, we did not do lung transplants or heart transplants at my local 400 bed medium sized community hospital. If there was interest in starting to do them, anesthesia chairman gets a say in the feasibility of doing that. Now yes they can always replace the anesthesia chairman or group until you find someone who agrees. But Im sure the anesthesia department involved in this liver case was consulted and said they agree to start doing them at this new institution. Its not like you show up and oh its a liver transplant today who knew..

yep, if you don't think your hospital should be doing whatever procedure then don't be on the team that does them.

 

[Hoya11]

I don't know if the discussion got moved to the private forum, or deleted. But there was a thread about a huge pediatric liver resection that had absolutely no business being done anywhere but a tertiary medical center.

I can find no fault in how the anesthesiologists handled the case. As a department, it sounded like they did their best to convince the surgeon to refer the case to Stanford.

For anybody coming to the forum looking for evidence that the anesthesiologists were to blame (or somehow violated the standard of care), I'm here to say it bluntly: ANESTHESIOLOGISTS HAVE NO POWER TO CANCEL OR TRANSFER CASES. None. The most we can do is delay for further workup or optimization. That's it. If the surgeon insists on doing the case, it's our job to do it as safely as possible.

It is possible that some anesthesiologists work in ambulatory centers as medical directors. True, in that capacity--AS MEDICAL DIRECTORS--we can send cases to the associated hospital. But, even then, it's only for cut and dry reasons like BMI, or strict age criteria.

I feel terrible for the anesthesiologists in the case. Working with surgeons who have an inflated sense of their own capabilities is, for me, the worst part of the job.

I have been in a position to deal with new hires (almost without exception recent graduates) who think that they can allow insured cases to be transferred elsewhere. It always--ALWAYS--ends poorly for the anesthesiologist.

If you don't feel comfortable doing the case, either find a partner who will do it for you, or find a lab abnormality that can be addressed--and hope the scheduling lightning doesn't strike you twice.

one time i had a 9 year old kid shot in the stomach and face come in emergently. We intubate and surgeons open, picking french fries out of the abdominal cavity. Stomach contents completely spilled out. The surgery goes on for about 3 hours and despite fluids pressure starting to get a little soft. Surgeons wanted me to extubate at the end of the case so they can keep the kid at our hospital. We have a policy against intubated kids under 12. I refused to extubate and they called the helicopter and i helped load him in...

 

[Bryan O’Blivion]

I don't know if the discussion got moved to the private forum, or deleted. But there was a thread about a huge pediatric liver resection that had absolutely no business being done anywhere but a tertiary medical center.

I can find no fault in how the anesthesiologists handled the case. As a department, it sounded like they did their best to convince the surgeon to refer the case to Stanford.

For anybody coming to the forum looking for evidence that the anesthesiologists were to blame (or somehow violated the standard of care), I'm here to say it bluntly: ANESTHESIOLOGISTS HAVE NO POWER TO CANCEL OR TRANSFER CASES. None. The most we can do is delay for further workup or optimization. That's it. If the surgeon insists on doing the case, it's our job to do it as safely as possible.

It is possible that some anesthesiologists work in ambulatory centers as medical directors. True, in that capacity--AS MEDICAL DIRECTORS--we can send cases to the associated hospital. But, even then, it's only for cut and dry reasons like BMI, or strict age criteria.

I feel terrible for the anesthesiologists in the case. Working with surgeons who have an inflated sense of their own capabilities is, for me, the worst part of the job.

I have been in a position to deal with new hires (almost without exception recent graduates) who think that they can allow insured cases to be transferred elsewhere. It always--ALWAYS--ends poorly for the anesthesiologist.

If you don't feel comfortable doing the case, either find a partner who will do it for you, or find a lab abnormality that can be addressed--and hope the scheduling lightning doesn't strike you twice.

I’ve canceled cases. Everything went just fine. If you work somewhere where you can’t exercise your medical judgment, or if it always ends poorly for you if you do, you should consider looking around. That sounds kinda terrible.

 

[markneil]

I don't know if the discussion got moved to the private forum, or deleted. But there was a thread about a huge pediatric liver resection that had absolutely no business being done anywhere but a tertiary medical center.

I can find no fault in how the anesthesiologists handled the case. As a department, it sounded like they did their best to convince the surgeon to refer the case to Stanford.

For anybody coming to the forum looking for evidence that the anesthesiologists were to blame (or somehow violated the standard of care), I'm here to say it bluntly: ANESTHESIOLOGISTS HAVE NO POWER TO CANCEL OR TRANSFER CASES. None. The most we can do is delay for further workup or optimization. That's it. If the surgeon insists on doing the case, it's our job to do it as safely as possible.

It is possible that some anesthesiologists work in ambulatory centers as medical directors. True, in that capacity--AS MEDICAL DIRECTORS--we can send cases to the associated hospital. But, even then, it's only for cut and dry reasons like BMI, or strict age criteria.

I feel terrible for the anesthesiologists in the case. Working with surgeons who have an inflated sense of their own capabilities is, for me, the worst part of the job.

I have been in a position to deal with new hires (almost without exception recent graduates) who think that they can allow insured cases to be transferred elsewhere. It always--ALWAYS--ends poorly for the anesthesiologist.

If you don't feel comfortable doing the case, either find a partner who will do it for you, or find a lab abnormality that can be addressed--and hope the scheduling lightning doesn't strike you twice.

We have the ability and the power to cancel cases and suggest transfer to a higher level of care if necessary. You and your surgeons should be on the same page most of the time and luckily where I work we are.

 

[coffeebythelake]

We have the ability and the power to cancel cases and suggest transfer to a higher level of care if necessary. You and your surgeons should be on the same page most of the time and luckily where I work we are.

It would be hard to do so in this particular case for the reason mman said. This was planned well beforehand, otherwise medically optimized, and was given the go-ahead by the head anesthesiologist who then proceeds to unattach himself to the case because of a "schedule conflict", hence forcing the case on some other anesthesiologist. What a ****ing snake.

 

[nofliesonme]

Surgeon here.....if the patients anesthesiologist wants to cancel the cancel.....the case is cancelled.

 

[coffeebythelake]

Surgeon here.....if the patients anesthesiologist wants to cancel the cancel.....the case is cancelled.

You would be the most laid back surgeon ever. If the case was planned for weeks, optimized, given the go ahead by the anesthesia department, and then on the day of surgery told case cancelled because the anesthesiologist didn't feel comfortable I think you and everyone else would be very upset.

 

[aneftp]

I’ve done lots of risk management courses to reduce my malpractice (which I paid myself). Having covered stand a lone ASC who push the limit (lap choly outpatient in BMI 45 with obvious severe sleep apnea but never tested).

Malpractice lawyers say as long as the same standard available equipment is available at the ASC (fiber optic/glidescope) ventilators normally available at any hospital setting. It’s safe

So the peds anesthesia doc in that hospital liver case. If the hospital has the same resources within that hospital. Blood blank , (Picu staffing etc)Than lawyers will say it’s safe to do at that community hospital

 

[OptionOffense]

This is ridiculous and I would hate having a colleague who did this. It's beyond weak and unprofessional.

save him from a lawsuit tho

 

[OptionOffense]

I. What a ****ing snake.

This is how all chairman operate without exception.

 

[anbuitachi]

You would be the most laid back surgeon ever. If the case was planned for weeks, optimized, given the go ahead by the anesthesia department, and then on the day of surgery told case cancelled because the anesthesiologist didn't feel comfortable I think you and everyone else would be very upset.

i mean thats all historical. patients do acutely change. ive cancelled my fair share of patients. patients who were 'cleared' then showed up with covid for elective cases, or clearly sick.

or patients who did all the paperworks pre op, then on day of surgery, clearly have obvious ekg changes, mobitz blocks, etc.

anestthesiologists also dont want to cancel patients for no reason. we can imagine ourselves as patients, taking time off, doing all the stuff, only to be cancelled day of, is a huge pain.

though i'd say surgeons cancel a lot more in my hospital than anesthesiologists. usually because one of their cases ran really over time, and they dont want to stay for the next case, because its late or they have plans. other times, they get bumped by some emergency, and that makes late, and they no longer wants to stay. etc. that's probably a top reason for cancellation here

 

[anbuitachi]

but i do not agree that anesthesiologists cant cancel cases.

one of our ortho surgeons want to replace a hip after patient fell out of bed. patient is demented, bedbound, doesnt move. TTE shows significant CHF and also with a large pericardial effusion that cardiology says they cannot drain due to positioning. our department told the surgeon we arent doing the case here, and the decision was made to transfer the patient to bigger hospital with more resources.

the procedure never ended up going even in the other hospital. she was deemed not to be candidate for surgery and anesthesia at the other hospital

 

[anbuitachi]

and like above poster. anesthesiologist can always REFUSE to provide anesthesia for the case. the surgeon can decide if the case is cancelled, or will proceed without anesthesia.

so i guess in a way, the surgeon cancels the SURGERY. but anesthesiologist cancels the anesthesia

 

[UscGhost]

I don't know if the discussion got moved to the private forum, or deleted. But there was a thread about a huge pediatric liver resection that had absolutely no business being done anywhere but a tertiary medical center.

I can find no fault in how the anesthesiologists handled the case. As a department, it sounded like they did their best to convince the surgeon to refer the case to Stanford.

For anybody coming to the forum looking for evidence that the anesthesiologists were to blame (or somehow violated the standard of care), I'm here to say it bluntly: ANESTHESIOLOGISTS HAVE NO POWER TO CANCEL OR TRANSFER CASES. None. The most we can do is delay for further workup or optimization. That's it. If the surgeon insists on doing the case, it's our job to do it as safely as possible.

It is possible that some anesthesiologists work in ambulatory centers as medical directors. True, in that capacity--AS MEDICAL DIRECTORS--we can send cases to the associated hospital. But, even then, it's only for cut and dry reasons like BMI, or strict age criteria.

I feel terrible for the anesthesiologists in the case. Working with surgeons who have an inflated sense of their own capabilities is, for me, the worst part of the job.

I have been in a position to deal with new hires (almost without exception recent graduates) who think that they can allow insured cases to be transferred elsewhere. It always--ALWAYS--ends poorly for the anesthesiologist.

If you don't feel comfortable doing the case, either find a partner who will do it for you, or find a lab abnormality that can be addressed--and hope the scheduling lightning doesn't strike you twice.

We cancel cases all the time.

If patient needs further optimization, npo issues, lab abnormalities or if the case isn't suitable for the OR.

Just try to have a legitimate reason

 

[coffeebythelake]

i mean thats all historical. patients do acutely change. ive cancelled my fair share of patients. patients who were 'cleared' then showed up with covid for elective cases, or clearly sick.

or patients who did all the paperworks pre op, then on day of surgery, clearly have obvious ekg changes, mobitz blocks, etc.

anestthesiologists also dont want to cancel patients for no reason. we can imagine ourselves as patients, taking time off, doing all the stuff, only to be cancelled day of, is a huge pain.

though i'd say surgeons cancel a lot more in my hospital than anesthesiologists. usually because one of their cases ran really over time, and they dont want to stay for the next case, because its late or they have plans. other times, they get bumped by some emergency, and that makes late, and they no longer wants to stay. etc. that's probably a top reason for cancellation here

Yes things can change, but jf the only change is the anesthesiologist and nothing about the pts clinical status has changed, that's a tough sell to cancel. This is an issue of institutional appropriateness, and it requires a higher level decision to send out to the flagship hospital, which unfortunately thr leadership in anesthesia department had already deemed unnecessary. So the pt is just going to show up another day back in the same OR, and maybe with someone else you pass the buck to. Sure it might save you from doing the case but the patient outcome remains unchanged and your colleagues might despise you

 

[anbuitachi]

Yes things can change, but jf the only change is the anesthesiologist and nothing about the pts clinical status has changed, that's a tough sell to cancel. This is an issue of institutional appropriateness, and it requires a higher level decision to send out to the flagship hospital, which unfortunately thr leadership in anesthesia department had already deemed unnecessary. So the pt is just going to show up another day back in the same OR, and maybe with someone else you pass the buck to. Sure it might save you from doing the case but the patient outcome remains unchanged and your colleagues might despise you

yea there is definitely a lot of variability because there may not be always a lack of guidance. kind of like oral boards. as long as you can justify the reason. but different people will have different answers. i remember those popular questions on the boards, what is your cutoff for hypokalemia to cancelling? hyperkalemia? for somewhat elective cases? everyone says different things

 

[RemyMcswain]

I don't know if the discussion got moved to the private forum, or deleted. But there was a thread about a huge pediatric liver resection that had absolutely no business being done anywhere but a tertiary medical center.

I can find no fault in how the anesthesiologists handled the case. As a department, it sounded like they did their best to convince the surgeon to refer the case to Stanford.

For anybody coming to the forum looking for evidence that the anesthesiologists were to blame (or somehow violated the standard of care), I'm here to say it bluntly: ANESTHESIOLOGISTS HAVE NO POWER TO CANCEL OR TRANSFER CASES. None. The most we can do is delay for further workup or optimization. That's it. If the surgeon insists on doing the case, it's our job to do it as safely as possible.

It is possible that some anesthesiologists work in ambulatory centers as medical directors. True, in that capacity--AS MEDICAL DIRECTORS--we can send cases to the associated hospital. But, even then, it's only for cut and dry reasons like BMI, or strict age criteria.

I feel terrible for the anesthesiologists in the case. Working with surgeons who have an inflated sense of their own capabilities is, for me, the worst part of the job.

I have been in a position to deal with new hires (almost without exception recent graduates) who think that they can allow insured cases to be transferred elsewhere. It always--ALWAYS--ends poorly for the anesthesiologist.

If you don't feel comfortable doing the case, either find a partner who will do it for you, or find a lab abnormality that can be addressed--and hope the scheduling lightning doesn't strike you twice.

I disagree. Pretty vehemently. If it is unsafe, it’s unsafe. You absolutely can say no. Then another partner can say no, and so on. We don’t just wing-it because the surgeon booked a case. Would you do a liver transplant if your blood bank had 4u PRBC on hand? Would you do a craniotomy if there wasn’t appropriate post op icu care? I’m surprised you feel this way

 

[Onefellswoop87]

OP makes inflammatory post as his/her first and only post. Doesn’t return yet. I’d be very surprised if ever does.

0/10 - try harder next time.

 

[AnesRunner]

So much wrong with the OP's opinion. We have a duty to do what's best for the patient. We do not have a duty to do whatever the surgeon wants. This case is a perfect example of why it is important doing what is best for the patient. Otherwise, you will be blamed as well. Remind everyone never to join your feeble/spineless group. You're essentially operating at the level of a CRNA.

 

[turnupthegas]

I cancel the anesthesia not the case. The surgeon can do whatever the hell they want.

 

[Mr.Golf]

I'm not saying that anytime a surgeon boards a case, it has to be done without regard to safety.

Of course, the best course of action is direct conversation with the surgeon. Mostly, if we are concerned, they are concerned. But it's their patient and their primary responsibility. Plus, they can always say the case is an emergency and then we simply have to do the best we can.

Though everybody has acted like they will never be pushed around by surgeons, nobody has really attacked my point head on: Anesthesiologists can delay cases for further workup or optimization. anesthesiologists might also RECOMMEND transfer to a higher level of care, or even SUGGEST that a proposed avenue of surgical intervention offers risks that have not yet been minimized. But the ultimate decision to operate (or not) belongs to the surgeon. And ONLY to the surgeon.

Let me paint a bit of an exaggerated picture.

Let's say a surgeon is caring for a patient who is going to need considerable post-op care (wound care, physical therapy, PICC line care, nutrition visits, getting on disability, who knows??). For our example, we can pretend the patient is either in a county hospital or even the VA. The social worker finds out that the patient is fabulously wealthy, privately insured, and is already plugged in to the most luxurious healthcare network in the community. In other words, the patient does not need the social worker's expertise.

Should the social worker then take it upon him/herself to transfer the patient to the opulent private hospital up the street? Of course not. Why not? Well, because it's the surgeon's patient, and the surgeon has merely asked for a professional consultation from the social worker. The social worker has decided that he or she can't offer precisely what the surgeon was hoping for. But that doesn't mean that the surgeon no longer has a patient to care for. The surgeon now has to formulate plan B. "Plan B" might even involve clarifying something in the chart (not necessarily a lab value, but maybe an insurance status), then re-connecting with the same social worker (or a colleague) later. But to suggest that the social worker should transfer the patient out of the hospital or suggest that because one consultant didn't have anything to offer, that the patient will receive no additional care is nuts.

If you don't like the social worker angle, go ahead and substitute any other consultant service: interventional radiology, PT, OT, BT, nutrition, dialysis, EGD, colonoscopy, bronchoscopy... Just because the consultant decides that the patient is not presently optimized for the surgeon's requested intervention does not give the consultant the power (or the obligation) to transfer the patient to another hospital, or to imply that surgeon won't still have to manage the patient.

Closer to home, what if a surgeon wants a spinal for a hip fracture on a patient on blood thinners? Of course, the anesthesiologist can "cancel" the spinal--but he can't cancel the hip repair. He can ask to delay, or he can come up with a safer plan. But nobody would expect him to go out and tell the patient the surgeon doesn't know what he's talking about, so the best course of action is to transfer the case to the university where they might see fit to do a general.

Sure, to a person whose only tool is a hammer, every problem looks like a nail. Surgeons get paid to perform surgery. Anesthesiologists get paid to anesthetize. But it is not the anesthesiologist's job, moral obligation, or expertise to be prescribing courses of surgery. Anesthesiologists can prescribe, amend, or cancel anesthetics. The best anesthesiologists in the best jobs have a relationship with the surgeons where everybody is acting in the patient's best interests. But lots of us work in places where surgeons want to do big cases, employ new toys, or prove that they have the machismo to take cases that others won't. It sucks, but it's not the anesthesiologists job to rein those surgeons in. It simply isn't.

 

[Mr.Golf]

Regarding the case at Walnut Creek, are those of you who are puffing out your chests to imply that "I'll never be pushed around by administration or a surgeon" also suggesting that the two anesthesiologists who showed up the morning to do the case that had been given administrative, nursing, surgical, and anesthetic approval had any choice whatsoever??

I'm here to say it bluntly: the two anesthesiologists did as best they could. They were prepared as well as they could be.

The patient did not die because of an anesthetic complication. The patient had a bad outcome from a series of SURGICAL missteps, starting with boarding the case in a non-tertiary hospital and, more importantly, then creating a hole in the inferior vena cava.

There seem to be lots of bad guys in Walnut Creek. But the two anesthesiologists who did the case are absolutely blameless.

 

[anbuitachi]

I'm not saying that anytime a surgeon boards a case, it has to be done without regard to safety.

Of course, the best course of action is direct conversation with the surgeon. Mostly, if we are concerned, they are concerned. But it's their patient and their primary responsibility. Plus, they can always say the case is an emergency and then we simply have to do the best we can.

Though everybody has acted like they will never be pushed around by surgeons, nobody has really attacked my point head on: Anesthesiologists can delay cases for further workup or optimization. anesthesiologists might also RECOMMEND transfer to a higher level of care, or even SUGGEST that a proposed avenue of surgical intervention offers risks that have not yet been minimized. But the ultimate decision to operate (or not) belongs to the surgeon. And ONLY to the surgeon.

Let me paint a bit of an exaggerated picture.

Let's say a surgeon is caring for a patient who is going to need considerable post-op care (wound care, physical therapy, PICC line care, nutrition visits, getting on disability, who knows??). For our example, we can pretend the patient is either in a county hospital or even the VA. The social worker finds out that the patient is fabulously wealthy, privately insured, and is already plugged in to the most luxurious healthcare network in the community. In other words, the patient does not need the social worker's expertise.

Should the social worker then take it upon him/herself to transfer the patient to the opulent private hospital up the street? Of course not. Why not? Well, because it's the surgeon's patient, and the surgeon has merely asked for a professional consultation from the social worker. The social worker has decided that he or she can't offer precisely what the surgeon was hoping for. But that doesn't mean that the surgeon no longer has a patient to care for. The surgeon now has to formulate plan B. "Plan B" might even involve clarifying something in the chart (not necessarily a lab value, but maybe an insurance status), then re-connecting with the same social worker (or a colleague) later. But to suggest that the social worker should transfer the patient out of the hospital or suggest that because one consultant didn't have anything to offer, that the patient will receive no additional care is nuts.

If you don't like the social worker angle, go ahead and substitute any other consultant service: interventional radiology, PT, OT, BT, nutrition, dialysis, EGD, colonoscopy, bronchoscopy... Just because the consultant decides that the patient is not presently optimized for the surgeon's requested intervention does not give the consultant the power (or the obligation) to transfer the patient to another hospital, or to imply that surgeon won't still have to manage the patient.

Closer to home, what if a surgeon wants a spinal for a hip fracture on a patient on blood thinners? Of course, the anesthesiologist can "cancel" the spinal--but he can't cancel the hip repair. He can ask to delay, or he can come up with a safer plan. But nobody would expect him to go out and tell the patient the surgeon doesn't know what he's talking about, so the best course of action is to transfer the case to the university where they might see fit to do a general.

Sure, to a person whose only tool is a hammer, every problem looks like a nail. Surgeons get paid to perform surgery. Anesthesiologists get paid to anesthetize. But it is not the anesthesiologist's job, moral obligation, or expertise to be prescribing courses of surgery. Anesthesiologists can prescribe, amend, or cancel anesthetics. The best anesthesiologists in the best jobs have a relationship with the surgeons where everybody is acting in the patient's best interests. But lots of us work in places where surgeons want to do big cases, employ new toys, or prove that they have the machismo to take cases that others won't. It sucks, but it's not the anesthesiologists job to rein those surgeons in. It simply isn't.

in the end its still the same as what most people said. surgeons deal with surgery. anesthesiologist deal with anesthesia. we can cancel the anesthesia, but if they want to do the hip fracture under local, go ahead. if the surgeon wants to place the local in the intrathecal space... go ahead. not my problem

 

[Teillard]

in the end its still the same as what most people said. surgeons deal with surgery. anesthesiologist deal with anesthesia. we can cancel the anesthesia, but if they want to do the hip fracture under local, go ahead. if the surgeon wants to place the local in the intrathecal space... go ahead. not my problem

What if it's a female surgeon? It's just that kind of attitude that gets dudes into trouble...

 

[nimbus]

If you don't feel comfortable doing the case, either find a partner who will do it for you, or find a lab abnormality that can be addressed--and hope the scheduling lightning doesn't strike you twice.

Or talk to your senior partner/medical director who greenlighted the case.

It sounds like that case was discussed as nauseum before being scheduled. Another anesthesiologist raised red flags.

 

[Mehd School]

One of my attendings in residency had a similar stance on this as OP. We told the surgeon it probably wasn't a good idea to do an elective shoulder replacement in beach chair in the sweet 70's year old woman with symptomatic cervical myelopathy that hadn't been investigated and baseline blood pressure of 210's/120's. Surgeon told my attending too bad, we're doing it. Lady woke up paralyzed from the collarbones down, but hey, her shoulder pain is gone.

 

[Arch Guillotti]

One of my attendings in residency had a similar stance on this as OP. We told the surgeon it probably wasn't a good idea to do an elective shoulder replacement in beach chair in the sweet 70's year old woman with symptomatic cervical myelopathy that hadn't been investigated and baseline blood pressure of 210's/120's. Surgeon told my attending too bad, we're doing it. Lady woke up paralyzed from the collarbones down, but hey, her shoulder pain is gone.

Did the attending discuss it with the patient? Laying it on the line with the patient can tesult in the payient just cancelling themselves.

 

[Mman]

Did the attending discuss it with the patient? Laying it on the line with the patient can tesult in the payient just cancelling themselves.

that's my approach. I just give honest opinion of risks to surgeon and to patient/family. One of them always decides it is best not to proceed, and I don't particularly care which one it is.

 

[pgg]

Anesthesiologists can prescribe, amend, or cancel anesthetics.

Did you really start this thread to split semantic hairs about how we don't cancel surgery, just the anesthesia? And that we shouldn't even do that, if the patient is "optimized"?

It sounds like you actually think anesthesiologists are somehow obligated to be accessories to whatever homicidal plan Dr. Surgeon comes up with, so long as the patient is optimized. You must live and work in a very strange world.

To give you an example only slightly less ridiculous than your bizarre non-physician social worker (or nutrionist, occ therapist, Red Cross volunteer, hospital HVAC technician, etc) analogy, if a surgeon brought in an "optimized" patient to do a off pump CABG at a community hospital that doesn't usually do hearts, you'd just do it, right?

Oh, wait. You'd find a lab value you didn't like, delay the case, flee the premises, and hope the scheduling lightning didn't get you twice.

 

[Arch Guillotti]

Closer to home, what if a surgeon wants a spinal for a hip fracture on a patient on blood thinners?

I tell them no. What's the big deal?

 

[Arch Guillotti]

One of my attendings in residency had a similar stance on this as OP. We told the surgeon it probably wasn't a good idea to do an elective shoulder replacement in beach chair in the sweet 70's year old woman with symptomatic cervical myelopathy that hadn't been investigated and baseline blood pressure of 210's/120's. Surgeon told my attending too bad, we're doing it. Lady woke up paralyzed from the collarbones down, but hey, her shoulder pain is gone.

No offense but your attending sounds like an idiot.

 

[eagle0990]

One of my attendings in residency had a similar stance on this as OP. We told the surgeon it probably wasn't a good idea to do an elective shoulder replacement in beach chair in the sweet 70's year old woman with symptomatic cervical myelopathy that hadn't been investigated and baseline blood pressure of 210's/120's. Surgeon told my attending too bad, we're doing it. Lady woke up paralyzed from the collarbones down, but hey, her shoulder pain is gone.

This is malpractice. This patient’s quadriplegic future is 100% on that physician.

 

[dabears505]

Things that have guidelines written are really dumb to not cancel for. Like he just took his Plavix this morning, don't expect to win any sort of lawsuit for complications for the spinal. And don't think the surgeon will come to the courthouse and back you up.

 

[Mr.Golf]

To give you an example only slightly less ridiculous than your bizarre non-physician social worker (or nutrionist, occ therapist, Red Cross volunteer, hospital HVAC technician, etc) analogy, if a surgeon brought in an "optimized" patient to do a off pump CABG at a community hospital that doesn't usually do hearts, you'd just do it, right?

Listen, every program had to do a "first such and such" case once upon a time. Providing administration, nursing, S-ICU, bloodbank, cardiology, and vascular surgery backup/perfusionist backup had been arranged for, no, I don't think the anesthesiologist should, on the day of surgery, cancel the case because he or she gets cold feet.

Half of the hospitals in the country are below average. Are you suggesting that every anesthesiologist working in a below-average hospital has a moral obligation to transfer surgical cases to a better hospital?? If you aren't suggesting it, why not? Are you a patient advocate, or aren't you? Shouldn't safety be your only concern?

Unfair comparison. Maybe. But by the same logic, half the surgeons are below average...even at average or even above average hospitals. Should anesthesiologists be cancelling surgical cases and referring the patients to better surgeons?

Half of all anesthesiologists are below average. Should the dolts among us refuse to do anything but cataracts and lumps and bumps in a cushy ASC?

 

[pgg]

Listen, every program had to do a "first such and such" case once upon a time. Providing administration, nursing, S-ICU, bloodbank, cardiology, and vascular surgery backup/perfusionist backup had been arranged for, no, I don't think the anesthesiologist should, on the day of surgery, cancel the case because he or she gets cold feet.

Half of the hospitals in the country are below average. Are you suggesting that every anesthesiologist working in a below-average hospital has a moral obligation to transfer surgical cases to a better hospital?? If you aren't suggesting it, why not? Are you a patient advocate, or aren't you? Shouldn't safety be your only concern?

Unfair comparison. Maybe. But by the same logic, half the surgeons are below average...even at average or even above average hospitals. Should anesthesiologists be cancelling surgical cases and referring the patients to better surgeons?

Half of all anesthesiologists are below average. Should the dolts among us refuse to do anything but cataracts and lumps and bumps in a cushy ASC?

Are you high?

I didn't say anything about the Walnut Creek peds liver case. There was plenty wrong with that process.

I've been talking about your absolutely bonkers absurd ridiculous assertions that we do the cases that the surgeons book, unless we can conjure a lab abnormality and dump it on a colleague.

Now you're off on some stream-of-consciousness rant about "half of everyone and everyplace are below average"?

What non sequitur is next on your list?

 

[Gator7]

What are you talking about I cancel surgeries all the time. Even inappropriately booked “emergencies.”

Example: cancelled an elective radical neck due to patient having symptomatic severe AS. Surgeon tried to be slick and booked the case as an “emergency” the following Saturday. Guess who was on call? It was real awkward for the surgeon when I cancelled it again.

Once the patient eventually had their valve repaired we did the case. Patient did fine.

You don’t have to be a surgeon to understand when something is an actual emergency or not. My job is to care for the patient not please the surgeon.

 

[Mman]

Example: cancelled an elective radical neck due to patient having symptomatic severe AS. Surgeon tried to be slick and booked the case as an “emergency” the following Saturday. Guess who was on call? It was real awkward for the surgeon when I cancelled it again.

on average, I find about one person per year that needs TAVR prior to whatever surgery they were booked for