preop stent case

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
C

cleansocks

Junior Member
15+ Year Member
Joined
Apr 16, 2005
Messages
255
Reaction score
44
Members don't see this ad.
Had this one the other day:

55yoM presents to ambulatory surgery center for shoulder repair which was scheduled a few weeks ago. He is at the end of a "surgical window period" following his acute shoulder injury after which time the shoulder (biceps tendon I believe) cannot be reliably repaired. He will likely fall outside of the window period if not repaired today. Shortly after scheduling this surgery he had a drug eluting stent placed. This was 3 weeks ago. He did not follow up with the cardiologist, somehow slipped through the preoperative assessment cracks, and stopped his plavix/ASA 5 days prior to the surgery. Pt is understandably very upset and feels this case qualifies as an emergency because if he doesn't get his shoulder fixed soon he may not be able to return to work. The orthopod agrees the shoulder needs to be fixed ASAP but also is reasonable and understands our perspective so he is relying on us to help make the call. What would you do?
 
Location of the DES? Obtuse marginal? Left Main?

That is really besides the point though... He's 3 weeks out? Usually heart wins over shoulder... but the patient certianly has a say in all of this. How active is she?

"Surgical window period" sounds like BS. It has to be done "today"... means the orthopod could've done it yesterday. I hope he doesn't present it to the patient that way.

No dual therapy + prothrombotic state via his shoulder surgery = potential badness. Hence the question: Where is this stent located?

When I hear "surgical window period ends today" I'm generally--> :eyebrow:... with a slice of :sour:.

Now... if it's an emergency... then that is a different story. What are the long term implications if the surgery is delayed?

We are doing this at an ASC with a recent stent that hasn't endothilialized? :nono:

Lawyers would love this case to go bad.
 
If he's a NFL quarterback and needs that tendon fixed perfect rightnow so he can collect a $7 million roster bonus in 2 months, which he'll cut me in on, we can talk. Otherwise ... no.

Seriously, he's 3 weeks out of a stent and it's his shoulder. Even an orthopod should know better.
 
pgg said:
If he's a NFL quarterback and needs that tendon fixed perfect rightnow so he can collect a $7 million roster bonus in 2 months, which he'll cut me in on, we can talk. Otherwise ... no.

Seriously, he's 3 weeks out of a stent and it's his shoulder. Even an orthopod should know better.
Click to expand...


but... it's the "surgical window period ".... :nailbiting:
 
cleansocks said:
Had this one the other day:

55yoM presents to ambulatory surgery center for shoulder repair which was scheduled a few weeks ago. He is at the end of a "surgical window period" following his acute shoulder injury after which time the shoulder (biceps tendon I believe) cannot be reliably repaired. He will likely fall outside of the window period if not repaired today. Shortly after scheduling this surgery he had a drug eluting stent placed. This was 3 weeks ago. He did not follow up with the cardiologist, somehow slipped through the preoperative assessment cracks, and stopped his plavix/ASA 5 days prior to the surgery. Pt is understandably very upset and feels this case qualifies as an emergency because if he doesn't get his shoulder fixed soon he may not be able to return to work. The orthopod agrees the shoulder needs to be fixed ASAP but also is reasonable and understands our perspective so he is relying on us to help make the call. What would you do?
Click to expand...

the patient stopped his own plavix/asa? sounds like the orthopod had a hand in that - he is therefore not "reasonable" and should be taken to task. i am absolutely certain that your orthopod did not schedule this surgery "a few weeks ago" for the last day in the "surgical window".

this is the easiest question i've heard in a while. i would be pissed the orthopod wasted my time putting this guy on the schedule.

hope you didn't do the case...
 
This is total BS. Surgical window my arse.

This surgeon just doesn't want to be the bad guy and therefore, is making you be that person.
 
Yeah, sounds like the orthopod is trying to enlist the patient's help to push the surgery through.

You know what else will keep the patient from returning to work besides a bum shoulder? A massive MI.
 
Was a DES to PDA I believe. I should also mention this was a colleague's case. I would've canceled even if the patient had maintained plavix\ASA for a reason nobody has mentioned yet.

Hmmm well to respond to one post, I certainly dont think this case is easy. There are 3 aspects to a medically difficult decision: clinical, political, and medico legal. None in this case are extremely straightforward on the face of it.

Clinically is there anything that can be done to mitigate the cardiac risk acutely? Is a call to the patients cardiologist useful?

Medicolegally what is the risk of being sued for delaying the case and being blamed for permanent disability vs the risk of MI? It was our Preop team that for some reason failed to tell the patient to continue the plavix and aspirin after all.

Politically its less of an issue for the following reason: a few of you are making wrong assumptions about the surgeon. The patient came to us with the notion that he was at the end of this window period. The surgeon did not bring it up because of the threat of cancelation. The surgeon actually said he was fine with canceling but the patient demanded to talk with him and asked him to go over the risks to his shoulder which he did truthfully. He is a busy popular surgeon and thus scheduled the patient the way he did near the end of this window period. In any case, politically we would not be burning bridges with the surgeon by canceling.

I'll let u all conjecture a little more b4 letting you know what went down.
 
This is coming from a soon to be grad. Can't wait to deal with this stuff.

I don't see what there is to conjecture here. He has a recent DES in his PDA. He is a no go for at least 6 months. Additional questions I have are was this placed for an MI? If no, then what symptoms was he having and how did that lead up to the stent placement. Is it really 1 stent, overlapping, fully deployed, bifurcation anywhere? Any hit to the EF? Beta blocker, ACEI, statin? Is he left or right dominant?

He somehow survived ASA withdrawal, but dude needs some DAPT. If for some crazy reason this guy gets a surgery, not at an ambulatory center. He gets done where there is a Cath lab, so when his stent thromboses, we have a 50% chance of keeping him alive.

Integrellin has been used for recent stent patients. Short half life. But if it were me, I would let my stent chill for a while before inducing a prothrombotic by having a surgery.
 
cheap_day_surgery_assessment.jpg
 
cleansocks said:
Was a DES to PDA I believe. I should also mention this was a colleague's case. I would've canceled even if the patient had maintained plavix\ASA for a reason nobody has mentioned yet.

Hmmm well to respond to one post, I certainly dont think this case is easy. There are 3 aspects to a medically difficult decision: clinical, political, and medico legal. None in this case are extremely straightforward on the face of it.

Clinically is there anything that can be done to mitigate the cardiac risk acutely? Is a call to the patients cardiologist useful?

Medicolegally what is the risk of being sued for delaying the case and being blamed for permanent disability vs the risk of MI? It was our Preop team that for some reason failed to tell the patient to continue the plavix and aspirin after all.

Politically its less of an issue for the following reason: a few of you are making wrong assumptions about the surgeon. The patient came to us with the notion that he was at the end of this window period. The surgeon did not bring it up because of the threat of cancelation. The surgeon actually said he was fine with canceling but the patient demanded to talk with him and asked him to go over the risks to his shoulder which he did truthfully. He is a busy popular surgeon and thus scheduled the patient the way he did near the end of this window period. In any case, politically we would not be burning bridges with the surgeon by canceling.

I'll let u all conjecture a little more b4 letting you know what went down.
Click to expand...

i think it is easy. cancel today. those three aspects are too much to consider in the 5 minutes usually available in an ASC for a preop check.

the decision whether to proceed before 6 months have elapsed is too complicated to make today in your ambulatory surgery center (and the case should probably be done as an inpatient if at all anyhow). your preop clinic dropped the ball big time. stopping the asa/plavix 3 weeks out is a potential clean kill shot, and someone lucked out. sounds like your surgeon isn't responsible as he probably didn't know about the stent/asa/plavix. regardless the pt needs to see his cardiologist, get back on plavix/asa, then back to preop clinic to facilitate agreement between your anesthesia group, the cardiologist, and orthopedic surgeon.

you are weighing a significant risk of rethrombosis and death or at least major adverse cardiac outcome against a putative increased chance of a less than perfect shoulder repair. your orthopedic surgeon is going to have to document a pretty huge risk for disability for me to do this case before 6 months are gone - i don't think he can justify it. the aha hasn't revised their guidelines since 2007 regarding timing of noncardiac surgery after stenting, and there is a metanalysis/review paper in the 2013 (i think) JAMA questioning the need for the periop continuation of antiplatelet tx, but even those authors don't question the 6 month delay. the real question is how urgent is this surgery (and i think the heart is always gonna trump a shoulder).

if the patient is pissed and rejects my recommendation to wait 6 months, i can avoid the risk of liability by referring him to another colleague ie a partner or another group (this is putatively urgent, not emergent).

i've never had to refer a patient to another provider - usually patients can be steered in the right direction. curious about what happened here.
 
Sorry sir, you are at a high risk of dropping dead if we do surgery on you. Furthermore you shouldn't have dared stop your dual antiplatelet therapy so here's a dose and you might want to chew the aspirin first. Please head straight to your cardiologist's office.

A nonfunctional shoulder is not a concern of a dead man. And while that is a medico-legal response to this case, it's also my real world caring about the patient and listening to his concerns response.
 
No medico legal risk to cancelling surgery. Not an emergency. You used sound medical judgement and followed published national guidelines. You were never his doctor.
 
nimbus said:
No medico legal risk to cancelling surgery. Not an emergency. You used sound medical judgement and followed published national guidelines. You were never his doctor.
Click to expand...

What does the independent CRNA at the ASC do? Does he have the medical knowledge to understand the risks of proceeding with the surgery given the recent DES placement? Will he understand that the case needs to be postponed? Will he be more likely to given into pressure from the surgeon and not do what's in the patient's best interest?
 
Mortality from stent thrombosis is around 10-25%. Thought it was higher actually. Nonetheless, no way that's happening on my watch.
 
srleslie said:
What does the independent CRNA at the ASC do? Does he have the medical knowledge to understand the risks of proceeding with the surgery given the recent DES placement? Will he understand that the case needs to be postponed? Will he be more likely to given into pressure from the surgeon and not do what's in the patient's best interest?
Click to expand...
Like the the other people responding so far, I don't think there is a gray area here. There are well-established guidelines. Anyone can follow guidelines blindly for things like this - CRNAs included.
 
They ended up getting the cardiologist on the phone and had a conference call in the Preop cubical with the patient, pt family, surgeon, anesthesiologist, and cardiologist. It would've been interesting to hear the dynamics of the conversation but the end result was the cardiologist documented the surgery would be of minimal risk if the patient were to be plavix loaded and aspirin loaded prior to proceeding. Thus the case went forward (!) after these loads and a dense interscalene block (!). What do you think of this plan? Will the load likely work? When do periop MIs usually happen - intraop, post op, etc? Is an interscalene enough to cover a biceps repair under Mac?

Like a couple of you mentioned I wouldn't do it even if the patient had continued his antiplatelets without the ability to have a STEMI to needle time of 30 minutes. Do you all even allow patients with a history of CAD to come to an ASC? What is your line in the sand for telling a surgeon "no this patients CAD is too bad for outpatient surgery"?
 
I'm amazed this went through. Seems crazy to me. Maybe I am just a conservative soon to be grad but man. You may get by with an interscalene for this case, may not. Either way you still induce a prothrombotic state, with a nonendothelialized stent. I also find it crazy that this wasn't done somewhere with a Cath lab.

If the patient has CAD, prior MI, stents, I would want to know what meds the patient takes, any symptoms of angina, is it stable, any recent echo. Make my decision based off that.
 
If there was an adverse event, that decision would be indefensible. Cardiologist, surgeon and anesthesiologist would all be writing fat checks.
 
cleansocks said:
They ended up getting the cardiologist on the phone and had a conference call in the Preop cubical with the patient, pt family, surgeon, anesthesiologist, and cardiologist. It would've been interesting to hear the dynamics of the conversation but the end result was the cardiologist documented the surgery would be of minimal risk if the patient were to be plavix loaded and aspirin loaded prior to proceeding. Thus the case went forward (!) after these loads and a dense interscalene block (!). What do you think of this plan? Will the load likely work? When do periop MIs usually happen - intraop, post op, etc? Is an interscalene enough to cover a biceps repair under Mac?
Click to expand...

Wait, so the aspirin and plavix load would not make the ISB contraindicated from a bleeding standpoint but would still be effective for protecting from coronary artery stent thrombosis in the OR?
 
Impressive.

Still in training, but I'd be hard pressed to defend proceeding with such a recently placed stent in a patient off their anti-platelet agents for way too long. Loading them would be helpful (if not mandatory) for working on fixing the fact he's been off his therapy for 5 days, but I can't justify proceeding with surgery.

As for Block+MAC v. General. Does anyone have any data or even anecdotes that a block/MAC is any safer than a general in this situation? I fail to see any advantage.
 
Doing the case at an ASC is indefensible.

If the orthopod is adamant about the need of surgery, he can reschedule the case as an emergency at a good hospital, one with cardiac bypass surgery available in-house for when the stent thromboses intraop/postop. In the meanwhile, he can confer with the patient's cardiologist about the plavix.
 
cleansocks said:
Thus the case went forward (!) after these loads and a dense interscalene block (!). What do you think of this plan?
Click to expand...

I think it's so ******ed it should be wearing a helmet.


Two things to add -

Concerning anticoagulation, the current ASRA guidelines don't view peripheral nerve blocks any different than neuraxial blocks. In essence, they don't recommend PNBs in patients who've taken clopidogrel within the last 7 days. I don't fully agree with that, but were something to go wrong there'd be a line of expert witnesses there to say an ISB shouldn't have been done.

There's an article on NYSORA that discusses Plavix loads:
The maximal inhibition of ADP-induced platelet aggregation with clopidogrel occurs 3 to 5 days after the initiation of a standard dose (75 mg), but within 4 to 6 hours after the administration of a large loading dose of 300 to 600 mg.
Click to expand...


There's a lot wrong with this case.
 
I had a similar case last week want to see what you people think
70 y/f had recent DES to LAD 4weeks back and was put on dual antiplatelet meds, Patient developed severe anemia and hematurea and cystoscopy was performed ( with anti platelet coverage). Patient was found to have bladder tumor so needed to have TURBT. Surgeon stopped patients antiplatelet meds for 7 days after consulting with patients cardiologist and patient is now in preop area for TURBT with her antiplatelets off for 7 days
what would you do?
 
pgg said:
I think it's so ******ed it should be wearing a helmet.


Two things to add -

Concerning anticoagulation, the current ASRA guidelines don't view peripheral nerve blocks any different than neuraxial blocks. In essence, they don't recommend PNBs in patients who've taken clopidogrel within the last 7 days. I don't fully agree with that, but were something to go wrong there'd be a line of expert witnesses there to say an ISB shouldn't have been done.

There's an article on NYSORA that discusses Plavix loads:



There's a lot wrong with this case.
Click to expand...


Haha I'm gonna have to plagiarize that line.

Nice data about plavix peak effect times! Wonder if there's something out there about aspirin load.

Personally I believe ASRA guidelines shouldn't be applied to peripheral nerve blocks period. There is no evidence for extending them beyond their intended target (neuraxiom). The evidence they site in their giant document is weak with no external validity for PNB's. Unfortunately even as guidelines they're written as if failing to follow the recommendations is tantamount to malpractice in many people's eyes. Withholding nerve blocks as a result is a disservice to many patients. I'm very confident with regional so that might bias me but with a single shot interscalene block in my hands the least of my concerns is hematoma especially when a surgeon is comfortable slicing open a joint capsule and then suturing it back together. I'd be more weary of a catheter in this region as there is a case report citing a hematoma and even subsequent sepsis associated with interscalene catheter. I can imagine a situation where the catheter migrates to poke through the vertebral artery, subclavian, or carotid.

There are some people (esp where I did some training which speaks to my bias as well) trying to publish evidence to oppose the guidelines but unfortunately there's a long way to go. for example: http://www.asra.com/display_spring_2011.php?id=129
This was published in a journal recently as well.

For a biceps repair you may need cutaneous coverage of the T2, C2-4, and medial brachial so I'd consider supplementing with appropriate blocks.

There is pretty convincing and I believe accepted evidence that regional in major joint surgery reduces the incidence of DVT. However, since the mechanisms of clot formation with DVT and coronary thrombosis are very different I don't think current literature adequately supports the idea that regional is better than general for CAD. However, it does pass the sniff test in my mind. Maybe there'll be data someday.

Anyone ever have to help create ASC guidelines regarding CAD patients?
 
Our ASC is pretty aggressive with the patient population; we do lots of big patients (cutoff is technically BMI 50 but they've snuck some bigger ones in), sick patients (CAD, low EF, vascular), etc, and we'll regionalize almost anyone, but I don't think this patient would have made the cut.
 
napman said:
I had a similar case last week want to see what you people think
70 y/f had recent DES to LAD 4weeks back and was put on dual antiplatelet meds, Patient developed severe anemia and hematurea and cystoscopy was performed ( with anti platelet coverage). Patient was found to have bladder tumor so needed to have TURBT. Surgeon stopped patients antiplatelet meds for 7 days after consulting with patients cardiologist and patient is now in preop area for TURBT with her antiplatelets off for 7 days
what would you do?
Click to expand...

do it - cardiologist was consulted, and this is an urgent case. the risk of ischemia from anemia is significant in this pt.

the OP's case was a completely different story. that was malpractice, imho.
 
Sorry have off tomorrow thanks to the holiday and looking at old threads to enhance my Jedi knowledge.

Stumbled upon this beauty.

I feel like I need that helmet... 😱

Arch, please tell me that when you said you'd do the case, you were referring to the TURBT and not the semi-emergent shoulder.

And since we're talking about stents, what do the new guidelines set about the original case. pretty sure it's still a postponement.
 
No will not do the case in the small rural hospital. Steer the patient to a bigger center with cath facility.
 
This guy got past the preop evaluation, he also got a stent without anybody telling him or asking him about upcoming surgeries. He should be equally pissed at the cardiologist, who should have asked him about surgeries and put in a BMS.
 
It is not an ASC case. Should have been cancelled. The antiplatelet load although sensible does not have any data or guideline behind it.

I would do it in the big house with the understanding that he might have an MI post op needing another trip to the cath lab.
 
I agree with the above statement in regards to the first case. Second case is not as bad to go forward and put patient to sleep. In regards to regional I agree with cleansocks. The guidelines should be changed for PNB's. I have done blocks with patients on/off plavix for variable timelimits <7 days. With a small single pass needle under ultrasound guidance you can be very careful and still be safe. Remember these guidelines are written by the academic guys who would probably think twice about a resident doing a block with anticoaged patient vs a full-time attn :0
 
I can't go into too much details but there has been at least one death at the ASC that I bring my cases to as a pain doctor. I would say the anesthesiologists there are pretty good at sniffing out the no-goes and since I'm only peripherally aware of the case I can't assign blame, but once something like that happens the cavalier attitude towards "maybe the patient will fly" goes out the window. I'm wondering if your ASC hasn't experienced any bad outcomes yet and so they're more focused on keeping the patient and surgeon happy?

How much do you want to bet the case would have been canceled if it was a patient on Medicare...
 
How can we perform without fear or favor and perform dispassionately? As "medical corpse" quotes that anesthesiology is inherently disruptive. How do we do the job without upsetting surgical schedule. Keep admin on a tight leash?

Where does our liability end and total blame on whoever does reckless medicine begin.
 
inquisitiveanes said:
How can we perform without fear or favor and perform dispassionately? As "medical corpse" quotes that anesthesiology is inherently disruptive. How do we do the job without upsetting surgical schedule. Keep admin on a tight leash?

Where does our liability end and total blame on whoever does reckless medicine begin.
Click to expand...
Using the Swiss Cheese theory, this case has gone through so many holes already that disrupting the surgical schedule is irrelevant. This requires salvage mode, not pleasing mode.

It's a matter of local culture. You let these cases go ahead a few times and it becomes the norm. You stop them a few times and the surgeons will learn.

In the end it is your license and your assets that are on the line. I think administration can beat it.
 
urge said:
Using the Swiss Cheese theory, this case has gone through so many holes already that disrupting the surgical schedule is irrelevant. This requires salvage mode, not pleasing mode.

It's a matter of local culture. You let these cases go ahead a few times and it becomes the norm. You stop them a few times and the surgeons will learn.

In the end it is your license and your assets that are on the line. I think administration can beat it.
Click to expand...
The problem is, and I have seen this happen, that somebody refuses a case (pertinently) and then somebody else does it instead (usually a manager or a partner). Now, suddenly, one becomes incompetent both in the eyes of the surgeon (and surgeons do talk among themselves) and the administration, just for doing the right thing for the patient (who many times is dumb and doesn't get that you're doing him/her a service).

I remember interviewing in a place where there was no policy for fasting blood sugar, no policy for preop BP, not even something like 250/120. I actually witnessed a patient with a sugar of almost 500 get treated and the elective surgery proceed. These practices are out there, and they are less and less the exception, as the market goes south. And if you do your job, and try to postpone a case, you are labeled an obstructionist. Also, don't forget, these bosses will be your references for future jobs. What do you think they will say, especially if they don't practice much anymore? "This guy does everything by the book, and I would love to have him as my anesthesiologist", or "this guy is an incompetent who is not able to deal with complicated cases"?

Also, what urge pointed out: even if the patient gives the most informed and well-documented consent, that will not save me and my assets if something goes wrong, because this is the land of malpractice attorneys, not of free consenting adults (who bear the consequences of their risk-taking because they didn't want to come back on a different day).
 
Last edited by a moderator:
similar case earlier in my residency where a patient had DES one month earlier, stopped his ASA, Plavix ( patient claims that cardiologist told him to stop) and is presenting for cataract. the case proceeded, with the rationale being that a cataract surgery does not induce hypercoagulable state and the patient got ASA, plavix in PACU. thoughts? and will this rationale protect you in court ?
 
dannyboy1 said:
similar case earlier in my residency where a patient had DES one month earlier, stopped his ASA, Plavix ( patient claims that cardiologist told him to stop) and is presenting for cataract. the case proceeded, with the rationale being that a cataract surgery does not induce hypercoagulable state and the patient got ASA, plavix in PACU. thoughts? and will this rationale protect you in court ?
Click to expand...
No rationale will protect one in court, in case of a bad outcome. They will find 10 textbooks/guidelines saying that the patient shouldn't have had elective surgery, and 3 of their fancy-shmancy authors to testify. It's pure Russian roulette, a game of probabilities and of Fortuna's love.

As the market goes now, if you get sued, your career is almost over; nobody will hire you for a good job, when they have three other squeaky clean guys to choose from. And it's not like you can just go and open your own independent practice, as in other specialties.
 
Last edited by a moderator:
urge said:
It's a matter of local culture. You let these cases go ahead a few times and it becomes the norm. You stop them a few times and the surgeons will learn.
Click to expand...

The solution to keeping everyone happy is to get involved in the process of preop workup and approval for the case to be done at an outpatient center so you can turf them to a hospital when the case is scheduled originally and not just cancel on the day of surgery. Same day cancellations are massive pains in the butt for patient, surgeon, and administration. They also cost the system money. If you can intervene 2 weeks prior and get the cardiology input and location for case better determined, the whole process is more efficient and everybody is happier.
 
Mman said:
The solution to keeping everyone happy is to get involved in the process of preop workup and approval for the case to be done at an outpatient center so you can turf them to a hospital when the case is scheduled originally and not just cancel on the day of surgery. Same day cancellations are massive pains in the butt for patient, surgeon, and administration. They also cost the system money. If you can intervene 2 weeks prior and get the cardiology input and location for case better determined, the whole process is more efficient and everybody is happier.
Click to expand...
If the patient shows up with a (probably chronic) sugar of 500 on the day of elective surgery, it doesn't matter whether the surgery is in a hospital or not, it just shouldn't happen. But it does. That's what I am talking about. More and more bean counters try to get any elective case done, just because "this is a hospital".
 
FFP said:
If the patient shows up with a (probably chronic) sugar of 500 on the day of elective surgery, it doesn't matter whether the surgery is in a hospital or not, it just shouldn't happen. But it does. That's what I am talking about. More and more bean counters try to get any elective case done, just because "this is a hospital".
Click to expand...

I agree. But I'm talking about being part of the process long before the patient sets foot in the hospital. A patient like that should have an A1C checked 2 weeks preop. If that is 13, then they probably shouldn't be done at the outpatient center because you know it's going to be out of control. If their A1c is 5.7, well you already know their glucose won't be 500 on the day of surgery.

Be a part of the solution and then you won't just be seen as the obstructionist cancelling cases on the day of surgery.
 
Mman said:
I agree. But I'm talking about being part of the process long before the patient sets foot in the hospital. A patient like that should have an A1C checked 2 weeks preop. If that is 13, then they probably shouldn't be done at the outpatient center because you know it's going to be out of control. If their A1c is 5.7, well you already know their glucose won't be 500 on the day of surgery.

Be a part of the solution and then you won't just be seen as the obstructionist cancelling cases on the day of surgery.
Click to expand...
If their A1c is 13, they shouldn't have elective surgery, period. It's recipe for complications/malpractice, except it's not the manager's/employer's, so they don't care. Neither does the surgeon (who's probably dumb/greedy enough if he didn't pick up the problem when first seeing the patient). They want the case done, with the patient sent home postop ("it's just a simple surgery", "just give him some insulin" etc.). That's the coming future.

There are more and more situations like this, where the only decent solution should be to postpone the case for 2-3 months (and optimize the patient), and where the anesthesiologist is bullied instead. It's usually because the group is afraid to lose the contract to an AMC, or exactly because it's an AMC.
 
Last edited by a moderator:
FFP said:
If their A1c is 13, they shouldn't have elective surgery, period. It's recipe for complications/malpractice, except it's not the manager's/employer's, so they don't care. Neither does the surgeon (who's probably dumb/greedy enough if he didn't pick up the problem when first seeing the patient). They want the case done, with the patient sent home postop ("it's just a simple surgery", "just give him some insulin" etc.). That's the coming future.

There are more and more situations like this, where the only decent solution should be to postpone the case for 2-3 months (and optimize the patient), and where the anesthesiologist is bullied instead. It's usually because the group is afraid to lose the contract to an AMC, or exactly because it's an AMC.
Click to expand...


which is why you need to be involved in the preop workup of the patient.
 
Mman said:
which is why you need to be involved in the preop workup of the patient.
Click to expand...
I would never-ever (evah!) do anything like that. I only work in the OR. 🙂

Seriously, these are places where the preop "workup" is a phone call by a nurse, unless the surgeon flags the patient. You are missing the big picture: it's not the employees who are not involved, it's the corporate employers/managers. And there is nothing one can do, except finding a less ****ty job in the area; good luck with that.
 
Last edited by a moderator:
FFP said:
I would never-ever (evah!) do anything like that. I only work in the OR. 🙂

Seriously, these are places where the preop "workup" is a phone call by a nurse, unless the surgeon flags the patient. You are missing the big picture: it's not the employees who are not involved, it's the corporate employers/managers. And there is nothing one can do, except finding a less ****ty job in the area; good luck with that.
Click to expand...



if you aren't part of the solution, you are part of the problem. Maybe not you personally, but your department or group is. We have some facilities where the preop workup is as you describe, but we have helped developed protocols for when that nurse should flag the chart for review by the anesthesiologist long before surgery including rescheduling timing of procedure or location as needed.
 
pgg said:
Departments and groups can do that. Partners can agree to present a unified front, and not swoop in to bravely do cases another partner judged unsafe.

Hourly employees of AMCs ... ? I wonder.
Click to expand...
You guessed right, my friend (minus the hourly). Big corporations not only can budget millions for malpractice lawsuits (based on past experience), but can also make more money than that budget from cutting the respective corners. Hence the incentive for the latter. And because of the corners AMCs cut to keep hospitals happy, the private groups in those areas begin to do the same thing, to remain competitive. It's a vicious cycle, where those who stand to lose the most are the people whose names are on the charts.

Also, when in a bad market, one can choose between cutting corners (by going against the textbook and the boss) and becoming unemployed.

@Mman, you're preaching to the choir. In my view, the future role of anesthesiologists will be strongly related to facilitating the surgeons' job everywhere, pre-, intra- and postop, much more than today. The surgeons will deal only with the surgical issues, which is less than 50% of what they do nowadays. It's not something I like, but it's one of the reasons I did CCM. The present problem is that neither surgeons nor AMCs are being paid for optimizing patients for anesthesia, hence neither of them care; as long as the surgery is not postponed (which they insist upon), it's not their careers and not their malpractice history.
 
Last edited by a moderator:
You must log in or register to reply here.

Similar threads

W
Case discussion: why acidosis?
Replies
46
Views
3K
narcotics999
N
Reveler
Preop lines
2
Replies
60
Views
5K
nimbus
nimbus
M
Case logs
Replies
7
Views
3K
Ashers
Ashers
V
CRNA introduced herself as “anesthesiologist” before case
Replies
23
Views
4K
coffeebythelake
coffeebythelake
S
Interesting case
2 3
Replies
114
Views
6K
woopedazz
woopedazz
Top