Ophthalmologist requiring medical clearance for cataract patients, aargh...

[pastafan]

Patient is 93 y.o. undergoing planned cataract extraction. Ophthalmologist ordered medical clearance. We have known for over 40 years that cataract surgery is so low risk that medical conditions that don't involve an inability to lie still don't affect anesthetic risk.

How much money is wasted yearly by Medicare for this nonsense? I believe that there should be a push to have this expense come from the surgeon's global fee. That would end the practice in a heartbeat. End of rant.

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[nimbus]

Somebody probably cancelled one of his cataracts 15 years ago so that’s what we get. I agree the risk is no higher than teeth cleaning.

 

[UscGhost]

Patient is 93 y.o. undergoing planned cataract extraction. Ophthalmologist ordered medical clearance. We have known for over 40 years that cataract surgery is so low risk that medical conditions that don't involve an inability to lie still don't affect anesthetic risk.

How much money is wasted yearly by Medicare for this nonsense? I believe that there should be a push to have this expense come from the surgeon's global fee. That would end the practice in a heartbeat. End of rant.

Just curious...is there a particular reason you care on this instance?

 

[thinkorswim]

Just curious...is there a particular reason you care on this instance?

The internist probably recommended a cardiac anesthesiologist do the case.

 

[pastafan]

Just curious...is there a particular reason you care on this instance?

The patient is my father.

 

[aneftp]

Patient is 93 y.o. undergoing planned cataract extraction. Ophthalmologist ordered medical clearance. We have known for over 40 years that cataract surgery is so low risk that medical conditions that don't involve an inability to lie still don't affect anesthetic risk.

How much money is wasted yearly by Medicare for this nonsense? I believe that there should be a push to have this expense come from the surgeon's global fee. That would end the practice in a heartbeat. End of rant.

Apparently you have never worked at a place (and they do exist) where they still want to do Asa 4 85 year old terminal stage cancer Mets to the bone wanting do elective cataracts under general anesthesia cause patient cannot tolerate laying relatively flat. Usual vascular path train wreck as well.

So there are Cataracts cases where medical evaluation is warranted.

 

[DocMcCoy]

99% of these people don’t need anything but topical and a calm voice.

The other 1% have bigger problems than their cataract. Or a shty surgeon.

 

[coffeebythelake]

99% of these people don’t need anything but topical and a calm voice.

The other 1% have bigger problems than their cataract. Or a shty surgeon.

99% of my cataract patients would freak the **** out without versed

 

[HemeOncHopeful19]

I had a form last week in my Onc office wanting me to check a box to clear a patient for anesthetics for a “deep teeth cleaning.”

I just wrote “Oncologists don’t do that” and handed it to the patient.

 

[Iso4ane]

99% of my cataract patients would freak the **** out without versed

As one attending I once knew would say, ‘those patients need to grow the **** up’.

 

[Hoya11]

Patient is 93 y.o. undergoing planned cataract extraction. Ophthalmologist ordered medical clearance. We have known for over 40 years that cataract surgery is so low risk that medical conditions that don't involve an inability to lie still don't affect anesthetic risk.

How much money is wasted yearly by Medicare for this nonsense? I believe that there should be a push to have this expense come from the surgeon's global fee. That would end the practice in a heartbeat. End of rant.

many of these people havent been to the doctor in years and this is the way to get them plugged in, when they actually need something done they will do what they have been putting off.. thats the idea anyway

 

[UscGhost]

The patient is my father.

Gotcha. Yea waste of a trip. But not uncommon

 

[nimbus]

many of these people havent been to the doctor in years and this is the way to get them plugged in, when they actually need something done they will do what they have been putting off.. thats the idea anyway

Interesting

 

[DocMcCoy]

99% of these people don’t need anything but topical and a calm voice.

The other 1% have bigger problems than their f’n cataract. Or a shty surgeon.

99% of my cataract patients would freak the **** out without versed

PO Valium. Preop per optho. If it’s good enough for lasik it’s good enough for simple cataract.


If 99% of your patients are complex dense cataracts that’s another story and I’m glad when they show up with preop “clearance”

 

[patriot6]

Not to derail this thread too much, but with all this talk about "clearance", I just wanted to say f*** clearance. I'm so tired of pre-op nurses and surgeons treating the **** clearance note from some NP/PA as the golden ticket to the OR. I recently canceled a case in GI -- inpatient EGD for anemia w/u. Hct was stable, vitals were fine. But the patient was in acute heart failure, 4L oxygen (2L at baseline), can't finish a sentence, extremities like soggy marshmallows. Ofc the clearance note says "moderate to high risk / okay to proceed". Lmao, hard stop.

 

[pastafan]

This should be mandatory for anesthesiology residency training:

 

[deleted1147063]

99% of my cataract patients would freak the **** out without versed

99% of my cataract patients don't get Versed, just my charming personality disorder. 🙂

 

[deleted1147063]

Not to derail this thread too much, but with all this talk about "clearance", I just wanted to say f*** clearance. I'm so tired of pre-op nurses and surgeons treating the **** clearance note from some NP/PA as the golden ticket to the OR. I recently canceled a case in GI -- inpatient EGD for anemia w/u. Hct was stable, vitals were fine. But the patient was in acute heart failure, 4L oxygen (2L at baseline), can't finish a sentence, extremities like soggy marshmallows. Ofc the clearance note says "moderate to high risk / okay to proceed". Lmao, hard stop.

A little peripheral and interstitial edema has never stopped me from a 10-minute low risk procedure that could change outcomes. And an extra 2L/min of O2 over baseline is practically baseline.

Many cardiac patients are poorly managed fluid-wise, for the simple reason that many cardiologists and PCPs suck at the task. What they call dry weight is usually a joke. Half of my so-called ARDS or acute HF patients suffer from bad doctoritis.

The anemia may have also been the cause of the acute heart failure.

 

[woopedazz]

I'm more concerned about the drugs that have nothing to do with me. i.e. the eye drops.

 

[patriot6]

A little peripheral and interstitial edema has never stopped me from a 10-minute low risk procedure that could change outcomes. And an extra 2L/min of O2 over baseline is practically baseline.

Many cardiac patients are poorly managed fluid-wise, for the simple reason that many cardiologists and PCPs suck at the task. What they call dry weight is usually a joke. Half of my so-called ARDS or acute HF patients suffer from bad doctoritis.

The anemia may have also been the cause of the acute heart failure.

I appreciate the thoughts FFP, but this was a guy that absolutely did not pass the eyeball test. I failed to mention that his SpO2 on 4L was sub 88%, very dyspneic, could not lie flat at all. His anemia was not significant. No one may die without passing through the GI lab.

 

[D P356]

No one may die without passing through the GI lab.

That’s actually a pretty good quote. I may have to use it.

 

[pastafan]

I appreciate the thoughts FFP, but this was a guy that absolutely did not pass the eyeball test. I failed to mention that his SpO2 on 4L was sub 88%, very dyspneic, could not lie flat at all. His anemia was not significant. No one may die without passing through the GI lab.

If you have an opening they have an opening...

 

[Royster33]

I had a form last week in my Onc office wanting me to check a box to clear a patient for anesthetics for a “deep teeth cleaning.”

I just wrote “Oncologists don’t do that” and handed it to the patient.

I referred a patient for dental clearance prior to starting Xgeva. I got a letter in return from the dentist on the same patient asking for clearance for tooth extraction..... 😒

 

[Angus Avagadro]

This should be mandatory for anesthesiology residency training:

A Classic!!! Never gets old.

 

[Angus Avagadro]

The earlier version is funnier. A ..SIS...TOLIE

 

[IMGASMD]

The earlier version is funnier. A ..SIS...TOLIE

I didn’t even know a different version was posted.
This is the version I grew up with.

 

[nimbus]

The earlier version is funnier. A ..SIS...TOLIE

What is that?

 

[Angus Avagadro]

What is that?

It's a funny little Meme about an ortho resident trying to schedule a case.

 

[nimbus]

It's a funny little Meme about an ortho resident trying to schedule a case.

I was asking about A…SIS….TOLIE. Lol

 

[deleted1147063]

I appreciate the thoughts FFP, but this was a guy that absolutely did not pass the eyeball test. I failed to mention that his SpO2 on 4L was sub 88%, very dyspneic, could not lie flat at all. His anemia was not significant. No one may die without passing through the GI lab.

Ouch!

I put my foot in my mouth again. Sorry! 😳

 

[Angus Avagadro]

I was asking about A…SIS….TOLIE. Lol

Listen to the Meme and you will see. A..sys..tole.
Lol. My earlier spelling was the orthopaedic version

 

[chocomorsel]

Patient is 93 y.o. undergoing planned cataract extraction. Ophthalmologist ordered medical clearance. We have known for over 40 years that cataract surgery is so low risk that medical conditions that don't involve an inability to lie still don't affect anesthetic risk.

How much money is wasted yearly by Medicare for this nonsense? I believe that there should be a push to have this expense come from the surgeon's global fee. That would end the practice in a heartbeat. End of rant.

Great, well needed rant. I love it!!

 

[chocomorsel]

I appreciate the thoughts FFP, but this was a guy that absolutely did not pass the eyeball test. I failed to mention that his SpO2 on 4L was sub 88%, very dyspneic, could not lie flat at all. His anemia was not significant. No one may die without passing through the GI lab.

You do you, he does he. Y’all are different and you have your reasons and training and he has his. No need to explain. Some people like to play cowboy, some like to be safer than sorry.

 

[epidural man]

My office mate last week did an A-line and GA with airway for a cataract last week.

I thought it was crazy - but no real alternative. Patient had horrific back pain and couldn’t tolerate lying down and had horrible aortic stenosis among other things.

 

[PainDrain]

Apparently you have never worked at a place (and they do exist) where they still want to do Asa 4 85 year old terminal stage cancer Mets to the bone wanting do elective cataracts under general anesthesia cause patient cannot tolerate laying relatively flat. Usual vascular path train wreck as well.

So there are Cataracts cases where medical evaluation is warranted.

I have canceled two cataracts. First one: 78 yo M w/ hx of recent MI /Des in the last 6 months, CHF, hemorrhagic stroke with trach/PEG four years prior, decanulated but with tracheal stenosis per wife (told intubation would be difficult), multiple bouts of aspiration PNA, PEG tube dependent for feeds and couldn’t lay flat per surgeon so would require GA. I just wasn’t going to do this at an outpatient center with no advanced airway equipment and potential for aspiration under LMA.

The other case I canceled was a spastic quad with no IV access. I tried everything to get an IV. I even placed an 18g EJ but it infiltrated. I wasn’t about to do a central line for a cataract.

 

[BobLoblaw78]

99% of these people don’t need anything but topical and a calm voice.

The other 1% have bigger problems than their cataract. Or a shty surgeon.

Routinely have to tell the surgeon that yes he can do this surgery under local. He requests about 10% of these cataracts under general and would if we allowed it. There is still way too many that get general.

 

[pastafan]

I

Routinely have to tell the surgeon that yes he can do this surgery under local. He requests about 10% of these cataracts under general and would if we allowed it. There is still way too many that get general.

WTF? Before topical cataracts done under retrobulbar block with propofol for the block only. GA for cataracts??

 

[UscGhost]

Given that patients are often terrible historians... A preop clearance from a PCP or cardiologist who actually knows the patients history is definitely useful in speeding things up.

Does it chance management? Rarely.

 

[patriot6]

Given that patients are often terrible historians... A preop clearance from a PCP or cardiologist who actually knows the patients history is definitely useful in speeding things up.

Does it chance management? Rarely.

I also appreciate a detailed pre-op note from the patient's cardiologist.
What I don't appreciate is it being viewed as a ticket to ride to the OR.
Cardiology can modify my patient's risks; they can't perform my anesthetic.

 

[BobLoblaw78]

I also appreciate a detailed pre-op note from the patient's cardiologist.
What I don't appreciate is it being viewed as a ticket to ride to the OR.
Cardiology can modify my patient's risks; they can't perform my anesthetic.

I welcome all cardiac and IM "clearances." I have no problem disagreeing when they are wrong and thankfully I have the trump card.

My biggest issue has been the pulmonologists who say that the patient needs mechanical ventilation after surgery, deep sedation instead of general anesthesia, etc. That situation sets up a physician note that is incriminating if the slightest thing goes wrong. It makes you look negligent if you don't do it and it goes sideways. And I find their understanding of anesthesia lacking (at least with the ones I work with) and not improved with discussion.

 

[BobLoblaw78]

WTF? Before topical cataracts done under retrobulbar block with propofol for the block only. GA for cataracts??

Yep. So on many I take the stance that it can be done with local and sedation- no GA. And then I will have cases that I wish I'd done GA (and it isn't bc of the patient)

 

[pastafan]

I welcome all cardiac and IM "clearances." I have no problem disagreeing when they are wrong and thankfully I have the trump card.

My biggest issue has been the pulmonologists who say that the patient needs mechanical ventilation after surgery, deep sedation instead of general anesthesia, etc. That situation sets up a physician note that is incriminating if the slightest thing goes wrong. It makes you look negligent if you don't do it and it goes sideways. And I find their understanding of anesthesia lacking (at least with the ones I work with) and not improved with discussion.

I remember a pulmonologist recommending a thoracotomy be performed under MAC!

 

[PainDrain]

I remember a pulmonologist recommending a thoracotomy be performed under MAC!

VATS can be done under MAC. Probably not a thoracotomy.

 

[GassYous]

VATS can be done under MAC. Probably not a thoracotomy.

Maybe epidural only

 

[nimbus]

VATS can be done under MAC. Probably not a thoracotomy.

We used to do them in residency with a French trained “interventional pulmonologist”. Minor procedures like talc pleurodesis and biopsies. They were not fun. GA all the way.