Preanesthetic interview

[Noyac]

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What's your approach? Do you need a stethoscope? Do you have the gift of gab or are you all business? How long does it take you to assess a moderately sick (htn DM and obese) pt for a moderately big case (colon resection)?

 

[nimbus]

5 minutes unless I find issue that needs to be addressed. They fill out a good questionnaire. Only use stethoscope once or twice a month.

Otoh....one of my partners loves to talk. "What kind of cheese was on the sandwich you had for lunch yesterday?"....haha

 

[gasdoc77]

Ask yourself "how specifically will their answer effect my management?" You can then pare your questions down to about 6-7. Anything additional is simply lip service and creating a sense of kinship.

 

[Consigliere]

We have a pre-op clinic and an anesthesiologist or CRNA interviews almost every pt coming in for surgery (not cataracts, etc.). All the testing and appropriate consultations are ordered at this time. The day of surgery is a brief review of the anesthetic record (an anesthesiologist will have been informed of any lab or EKG abnormalities and have intervened accordingly) and a quick "hey, how ya' doin' any questions about your anesthesia? No. Great. Bye." Almost 0% DOS cancellations. Inpatient add-ons are seen by a CRNA and reviewed with the anesthesiologist on-call.

 

[sevoflurane]

What's your approach? Do you need a stethoscope?

This is funny....what's a stethoscope...? Remember that one?

 

[sevoflurane]

My approach goes through metamorphosis depending on the patient and severity of disease. I do like to ask about stents and blood thinners. Especially if regional is part of the plan or they've had the stent placed w/ in the last year. I've caught a couple of surgeons taking patients off anticoagulants prematurely.

I do enjoy getting to know my patients (outside of medicine)... so long as I'm not in there for more than 5 minutes. You tend to ease their anxiety when you get to know them a little.

 

[urge]

Depends on how good their paperwork is. After 5 min I cannot get any extra information, even if I talked an hour with them. It's just a matter of whether their caths, echos, ekgs,... are on the chart or not.

So, talking to the pt less than 5 min. Doing a proper evaluation might even take days depending on how hard old documents are to find

 

[Noyac]

Good posts but you guys are attendings. How about the residents out there?

 

[WholeLottaGame7]

http://www.gomerblog.com/2013/06/398/

 

[Depakote]

Good posts but you guys are attendings. How about the residents out there?

CA-2 here, I'd say he majority of my pre-anesthetic eval comes from reviewing the patient's chart. Following a thorough review of that, existing studies and diagnoses, I am usually able to get through a pre-op interview in a couple minutes just clarifying information I need and hitting a few points that might not be in there. Plus, the attendings usually rely on the residents for a complete chart, so I have to make sure all the boxes are addressed.

I do usually slap a stethoscope on the patient. I'm not going for anything huge, but I would like to know if my patient is wheezing or has some crazy murmur that hasn't been documented in the past.

On top of that, it's a little chatting (building a rapport) and explaining the anesthetic plan to the patient.

 

[Planktonmd]

I like talking to patients beyond the usual clinical questions and I actually enjoy it!
I also think that it makes them much more relaxed and comfortable if the anesthesiologist is pleasant, smiling and has a positive attitude.
I could go as far as saying that the pre-op conversation with patients is an integral part of a smooth and successful anesthetic and it could be all that the patient would remember about us.

 

[Noyac]

I agree with everyone here. The interview should be brief. The interview as I see it is my time to meet the pt and to instill in that pt, confidence in myself and the procedure at hand. Most of the time I find myself having a general conversation with the pt and family and frequently there is a bit of humor involved if I get a feel that I can break the tension. Not everyone has the bedside skills that can put a pt at ease within a couple minutes but those that do are a great asset to a group. Some here like to throw all their beliefs into studies and outcomes. But we all know that it is very difficult to study differences in outcomes because we tend to measure the usual end points, complications. I am here to tell you, there are differences that are obvious if you pay attention but are too difficult to measure. Some may then say that they are unimportant then and that's fine, they can believe that and therefore remain mediocre. But pts will show you a difference if you pay attention. Just as when a nurse maintains the majority of the case with physician supervision vs when a physician does the case personally, there should be a difference. Difficult to measure but still a difference.

So IMO, the chart should have all that you need to do the case safely. The interview is your chance to "meet" your pt and address their fears and concerns. And to make a difference.

 

[CaliGasDoc]

CA-2 resident. Agree with above. Thorough review of the chart and a quick interview to build rapport or make sure there are no recent health changes or sickness. Stethoscope for peds, not for 24 y/o ASA 1 for CTR. Otherwise I touch the patient on a case by case basis.

 

[periopdoc]

Depends on the surgeon. There are 1 or 2 here who can't be trusted to obtain a proper history. Think ASA 4 patient who's PMH on the surgeons H&P says nothing about the co-morbidities etc. This can result in the pre-anesthesia clinic assigning them to a lower level of review than necessary.

For the patients of this surgeon I spend more time asking about potential red flags in their history. Otherwise, it is just a quick once over of the workup that is already done, then a chance to chat with the patient for a few minutes. Sometimes we find a common interest and chat, sometimes I just go through risks/benefits.

- pod

 

[Planktonmd]

I found that the best way to learn how to talk to patient is to try to imagine yourself in their position... ask yourself: If I was in this dude's shoes what would I want my anesthesiologist to say? and how would I want him to behave?
The rest should come natural provided you are a semi normal human being with only minimal sociopathic tendencies!

 

[chocomorsel]

I go thru a whole ROS. And a CV and lung exam. And the plan or options. Yeah it takes me a little while. 10-12 minutes.

 

[Colba55o]

I'm an attending and I always do 3-5 minute history followed by an airway exam, heart lung auscultation and explanation of consent. Efficiency is important but bragging that you don't even place a stethoscope on the patient and do a drive-by H&P is sad. Especially when half the threads on this forum are complaints about not being considered real doctors by other healthcare staff and patients.

If we don't act like real doctors, people wont look at us that way.

 

[BuzzPhreed]

I'm an attending and I always do 3-5 minute history followed by an airway exam, heart lung auscultation and explanation of consent. Efficiency is important but bragging that you don't even place a stethoscope on the patient and do a drive-by H&P is sad. Especially when half the threads on this forum are complaints about not being considered real doctors by other healthcare staff and patients.

If we don't act like real doctors, people wont look at us that way.

In my last recent job there was no time for anything except "drive by" H&Ps. That was part of the problem and part of the reason why I abruptly left. There was no plan except that everyone basically got the same cookie-cutter anesthetic. You have 4 rooms and the patients you have to see don't show up and even begin to get interviewed by the intake nurse until 6:30-6:45 AM with no staggered starts and the expectation you'll launch all ships at 7:30 AM sharp. See how much actual time you get to spend with the patients before consenting them, answering questions, and heaven forbid having to deal with a more complex than normal patient.

The solution? Don't take crap jobs that put you in the position of not being a doctor. I'd love to see one - just one - of these holier-than-thou-I'm-your-equal CRNAs try to manage and supervise four rooms for a solid week with all the legal responsibility, pre-ops, PACU sign-outs, and chart reviews in the preadmissions clinic and all the other scutwork that goes on. They'd be begging to be back in a room with their "one patient at a time and I'm as good as you", or they'd be looking for a new job. That's my bet.

 

[BuzzPhreed]

And...

One of the jackasses at the job I just left had the nerve to brag how "efficient" they were at getting the work done. They are a goddamn accident waiting to happen and one multimillion dollar lawsuit is gonna fix that attitude quickly.

 

[Noyac]

I'm an attending and I always do 3-5 minute history followed by an airway exam, heart lung auscultation and explanation of consent. Efficiency is important but bragging that you don't even place a stethoscope on the patient and do a drive-by H&P is sad. Especially when half the threads on this forum are complaints about not being considered real doctors by other healthcare staff and patients.

If we don't act like real doctors, people wont look at us that way.

As we evolve through our practice we tend to become more efficient at evaluating the pt and their comorbidities. As a resident I would go into a litany of questions regarding the pts health. These days, every interview is slightly different depending on the pt and the case. Placing a stethoscope on every pt will rarely if ever discover anything if the pt is symptom free. If the pt has a history of severe asthma then sure, take a listen.
I actually listened to a pt's heart the other day. She was only 14 yo and healthy. But parents reported a murmur in the past but thought it was gone now. They were wrong.
The point is, we don't need to go through the entire medical history and do an extensive PE on every pt. As you grow in your practice you will undoubtedly develop your style in the anesth pre-operative interview.

 

[OB1🤙]

I use the interview as an extension of the anesthetic, if needed. That is, the preop is the premed. Some patients don't want to hear any of it and just want to get it over with, in which case I cut to the chase, do a cursory airway exam if the chin looks a little short or the neck a little fluffy, and be on my way. Risk discussion depending on procedure.

For those who are clearly scared shiteless, I spend a few extra minutes going over any concerns and reassuring them. Some people have a bazillion questions, and I feel it's fine to slow things down for them so that they feel they've been heard out.

I haven't put a stethoscope on a chest in quite some time. But we have a VScan, so if I'm at all concerned about the heart, or the patient is sick and hasn't been out of bed in months, I slap that on as my stethoscope if there's no recent echo. If anything is truly concerning, there is a real echo machine down the hall and I'll do a more formal echo myself including Doppler of the aortic valve, TR looking at PA pressures, etc. Also get to see the volume status before going in. Takes 5 minutes at most, and no need to cancel cases for cards workups just because someone heard a murmur. Show me a CRNA that can do that.

 

[pjl]

I do a deep review of the chart on our ever more complete EMR, then talk to the patient. I start with addressing the known health concerns they have, which I feel gives them confidence that I know what I am doing and that I know them. Then I hit the important systems which are allegedly negative. I never trust them to answer these questions truthfully, but still ask, as at least I feel I have done my due diligence if something were to happen related to those systems. Rarely I find something that will change my plan, but I still ask. Then every single patient gets a airway and heart/lung exam, placing my other hand gently on their shoulder. I virtually never find anything on that exam which changes management, however I was taught and believe that this "laying on of hands" adds to the level of comfort the patient has, it creates a physical bond. I then make at least one stupid joke that they laugh at and describe the anesthetic, potential complications etc.
ASA 1 patient for simple case ~1 min chart review (45 seconds of which is logging in), 3-5 min talking and filling out EMR. ASA 4 patient gets as long as it takes. Most of the time visits are under 10 minutes, but if they need to go longer, I work in a good team atmosphere and one of my partners will pick up the other waiting patients, as I would do for them.