gtb

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Practicing in Colorado, and it's no longer hypothetical. I cancelled an elective L3/4 laminectomy case on an otherwise healthy man who smoked a joint to relax on the way to the hospital. Eyes were bloodshot, and he reeked of pot. I'd do the same thing if he had a shot of Jack Daniels as a wake up relaxant. Curious how other physicians will handle this.
Thanks in advance,
GTB
 

ruralsurg4now

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Didn't Colorado legalize marijuana? So according to the good people of Colorado, he was just taking his medicine, as prescribed by a doctor. Just let the operation continue and whatever happens happens. :banana:

And before anyone claims I'm being cavalier with someone's life, no, I'm just being consistent with the laws of Colorado. (If I'm wrong about the laws of Colorado, then I withdraw my post.)
 

jeffblue

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Im surprised you did not get push back from the Operator.
I would not have cancelled this case.
 

ruralsurg4now

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Im surprised you did not get push back from the Operator.
I would not have cancelled this case.
Why? If someone showed up for an operation drunk or high on some other substance, I'd cancel the case as the surgeon. People seem to have this weirdly f**ked up attitude that being high on marijuana doesn't count as being high.
 

countingdays

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Practicing in Colorado, and it's no longer hypothetical. I cancelled an elective L3/4 laminectomy case on an otherwise healthy man who smoked a joint to relax on the way to the hospital. Eyes were bloodshot, and he reeked of pot. I'd do the same thing if he had a shot of Jack Daniels as a wake up relaxant. Curious how other physicians will handle this.
Thanks in advance,
GTB
Cancel. Unable to obtain consent.
 

norwood

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Cancel. Unable to obtain consent.
That's the big deal. If I had anesthesia consent beforehand (happens, under certain circumstances), I'd discuss it with the surgeon and likely proceed. But if not...
 

Mman

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I'd also cancel the case, mostly because I can't legally consent somebody under the influence. They wouldn't really be at any higher risk of postop complications, but cancel nonetheless. It's elective, come back another day when not high.
 

chmd

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You cancel a case if a chronic alcoholic had 2 ounces of liquor 6 hours prior to surgery? Don't think I would.
 

ruralsurg4now

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You cancel a case if a chronic alcoholic had 2 ounces of liquor 6 hours prior to surgery? Don't think I would.
a) Yes, I would. I don't do elective cases on people who are drunk/stoned.
b) That's not actually equivalent, since your example is someone who wouldn't even appear drunk, whereas this patient was visibly stoned.
c) If some guy can't abstain from alcohol for one day before a surgery, they're going to give you post-op problems regardless. Same with other drugs, including marijuana.
d) I'm always happy to refer these patients to other surgeons if they feel differently. Note that I haven't actually ever met anyone who needed an operation and was stoned or drunk, so this is all theoretical, but I'm quite confident in how I would handle the situation.
 

pgg

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I care about meth and cocaine and ability to consent, and not much else. I can't imagine canceling a case because someone smoked a joint or had a drink outside the 2-hour clear liquid NPO window.
 
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jeffblue

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If the patient was clearly incoherent and talking jibberish, sure, you can make a case for cancelling the case. However, if he is totally appropriate but admitted to smoking a joint earlier, What's the big deal? What are you trying to prove by cancelling the case?
 

IlDestriero

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Why? If someone showed up for an operation drunk or high on some other substance, I'd cancel the case as the surgeon. People seem to have this weirdly f**ked up attitude that being high on marijuana doesn't count as being high.
I would cancel as well. If you're clearly under the influence of alcohol or drugs or admit to recent use you cannot consent to the anesthetic. Or the surgery for that matter, but that is usually done in advance of the DOS. No consent no procedure.
 

pgg

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I would cancel as well. If you're clearly under the influence of alcohol or drugs or admit to recent use you cannot consent to the anesthetic. Or the surgery for that matter, but that is usually done in advance of the DOS. No consent no procedure.
OK, obviously someone who is clearly intoxicated isn't consentable for an elective case.

But your bar is "admit to recent use"? How recent? You'd really prefer that the raging alcoholic quit the day before surgery so the DTs are nicely timed for POD 1? You really think that someone who smoked pot 2 hours ago is less consentable than the appy who got 1 mg of Dilaudid in the ER?
 

ruralsurg4now

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If the patient was clearly incoherent and talking jibberish, sure, you can make a case for cancelling the case. However, if he is totally appropriate but admitted to smoking a joint earlier, What's the big deal? What are you trying to prove by cancelling the case?
I'm trying to prove nothing. In my judgement as a physician there's no reason to be operating electively on someone who is drunk or stoned. If you feel that has no impact on outcomes, then in the future never ask anyone about their drug or alcohol use in their social history and I'll buy it. Since I'm the surgeon, the fact that I don't operate on that guy means he gets no operation, regardless of what anyone else says. It's not that complicated.
 

pgg

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I'm trying to prove nothing. In my judgement as a physician there's no reason to be operating electively on someone who is drunk or stoned. If you feel that has no impact on outcomes, then in the future never ask anyone about their drug or alcohol use in their social history and I'll buy it.
There's a difference, that seems to be getting lost in this thread, perhaps deliberately so, between "drunk or stoned" and "had a drink or smoked a joint recently" ...

Maybe you don't get out much, but the average person who's recently consumed an alcoholic beverage or smoked a bowl is neither drunk nor stoned.

Since I'm the surgeon, the fact that I don't operate on that guy means he gets no operation, regardless of what anyone else says. It's not that complicated.
;) Aye aye, cap'n.
 

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Cancel. Unable to obtain consent.
100% concur. Even if consented before, what if the patient says after the surgery that he had changed his mind about it, and he does not remember how he got there?
 

ruralsurg4now

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;) Aye aye, cap'n.
It has nothing to do with me being the captain. If an anesthesiologist doesn't want to proceed with a case, then I can't do anything about it because I can't operate without anesthesia. If I don't want to proceed with a case, then the anesthesiologist can't do anything about it. That's just the facts. If the anesthesiologist wants to slip the guy another surgeon's card, that's their business. Of course, if I find out about it, then it becomes my business, but that's then between me and the anesthesiologist.
 

Sonny Crocket

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What do you gain by doing this case?

Cancel, cancel, cancel!!
 

IlDestriero

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There's a difference, that seems to be getting lost in this thread, perhaps deliberately so, between "drunk or stoned" and "had a drink or smoked a joint recently" ...

Maybe you don't get out much, but the average person who's recently consumed an alcoholic beverage or smoked a bowl is neither drunk nor stoned.
.
By recently I mean recent enough to be under the influence of alcohol or drugs at the time of my interview and consent. Like smoked a bowl in the parking lot, not got stoned last night. Or unable to stay awake during a conversation because they took a "couple" of extra oxy, etc. I've seen that one in a parent pre op. Of all the things we cancel for, I don't see the surgeon giving much push back if we say we are cancelling or delaying an case for failure to get consent because they're under the influence in the holding area.
 

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It appears to me that this is more about doctors acting as God representatives and less as physicians.
We know that many of our patients come to the OR already loaded with opiates either because they are "chronic pain patients" or because they were given opiates on the floor or in the ER.
No one would cancel a case because of "legitimate" opiate consumption, but some of us apparently have some moral or religious motives to punish patients who are sinners in their view.
If you feel that your job is to preserve morality then medicine is not the right profession for you, how about clergy???
 

Mman

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It appears to me that this is more about doctors acting as God representatives and less as physicians.
We know that many of our patients come to the OR already loaded with opiates either because they are "chronic pain patients" or because they were given opiates on the floor or in the ER.
No one would cancel a case because of "legitimate" opiate consumption, but some of us apparently have some moral or religious motives to punish patients who are sinners in their view.
If you feel that your job is to preserve morality then medicine is not the right profession for you, how about clergy???
Opiates don't alter your ability to consent to surgery. Taking a percocet or methadone or vidodin, or whatever chronically used pain med they have is perfectly acceptable. In fact, we encourage them to take their morning dose with a sip of water before coming to the hospital. And in preop holding if a patient is in pain, it's perfectly acceptable to give them a dose of fentanyl or hydromorphone prior to their consents being completed. But I can't give them midazolam before their consents are finished.

There is a big difference between a patient taking an opiate for chronic pain and a patient being high or drunk on arrival to the hospital. Separation of church and state. This isn't a playing God issue, it's a legally unable to consent issue.
 

ruralsurg4now

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It appears to me that this is more about doctors acting as God representatives and less as physicians.
We know that many of our patients come to the OR already loaded with opiates either because they are "chronic pain patients" or because they were given opiates on the floor or in the ER.
No one would cancel a case because of "legitimate" opiate consumption, but some of us apparently have some moral or religious motives to punish patients who are sinners in their view.
If you feel that your job is to preserve morality then medicine is not the right profession for you, how about clergy???
Sorry, I'm not as enlightened as you. I'll make sure you get all of my drug-using patients so that you can treat them in a non-judgemental fashion.
 

countingdays

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It appears to me that this is more about doctors acting as God representatives and less as physicians.
We know that many of our patients come to the OR already loaded with opiates either because they are "chronic pain patients" or because they were given opiates on the floor or in the ER.
No one would cancel a case because of "legitimate" opiate consumption, but some of us apparently have some moral or religious motives to punish patients who are sinners in their view.
If you feel that your job is to preserve morality then medicine is not the right profession for you, how about clergy???
You are mistaken. I couldn't care less if someone smokes.
I just don't intend to be the test case regarding whether a consent is valid under the influence of thc or not.
 

nap$ter

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Practicing in Colorado, and it's no longer hypothetical. I cancelled an elective L3/4 laminectomy case on an otherwise healthy man who smoked a joint to relax on the way to the hospital. Eyes were bloodshot, and he reeked of pot. I'd do the same thing if he had a shot of Jack Daniels as a wake up relaxant. Curious how other physicians will handle this.
Thanks in advance,
GTB
J Am Coll Dent. 2010 Winter;77(1):21-34.
The dental patient who is "high:" ethical and scientific recommendations for the standard of care.
Peltier B, Giusti L, Hoover T, Fountain J, Persinger J, Sutter S.
Source
University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, USA. [email protected]

Abstract
Patients sometimes appear for dental appointments after consuming alcohol or marijuana. There is presently no consensus standard of care in this area, and dentists vary in their responses to such patients. This paper includes interviews with practitioners and a review of the relevant biochemical and physiological science. The ethics of various ways to handle this challenging situation are examined, and evidence-based recommendations for dental practice are offered. While there is reason for caution, the authors conclude that a blanket "do not treat" policy is unwarranted. Informedconsent and transportation safety issues pose significant moral challenges when a dental patient is "high."

i would have done the case.
 
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pmichaelmd

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Frequently come across this issue as well. I will postpone until medically appropriate any patient positive for meth, cocaine, or who presents as having altered mental status from the use of illicit substances. I also disqualify those with altered vital signs as a result (tachycardia, HTN). Why take the risk if the case is elective? Of course, the consent issue exists as noted above.
 

ruralsurg4now

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While there is reason for caution, the authors conclude that a blanket "do not treat" policy is unwarranted.
Why is there reason for caution? That implies that there is elevated risk. If there's elevated risk that is preventable, then it is reasonable to postpone the case. That's not debatable.
 

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It appears to me that this is more about doctors acting as God representatives and less as physicians.
We know that many of our patients come to the OR already loaded with opiates either because they are "chronic pain patients" or because they were given opiates on the floor or in the ER.
No one would cancel a case because of "legitimate" opiate consumption, but some of us apparently have some moral or religious motives to punish patients who are sinners in their view.
If you feel that your job is to preserve morality then medicine is not the right profession for you, how about clergy???
Got nothing to do w/God or morality and everything to do with lawyers. Is it any different really then opioids? probably not from a medical sense but if that pt is taking opioids prescribed by a doc (PCP, pain doc, ER doc) whatever, then the pt is optimized aka as good as he's gonna be. If he shows up stoned, and he does not live in a state where weed is a prescribed substance then he is by definition not optimized and should be canceled for an elective surgery. Sure if he's coming in for an appy, I'll do the case and document as such but an elective hernia repair? Peace out b/c if something happens, the first thing the lawyers are gonna say is "How could you get consent if you knew he was stoned?". The defense of "well it's really the same as opioids" ain't gonna hold water and you will lose the lawsuit before it even starts. Might even end up w/an A&B.

As others have said, the best way to proceed with the case is not to ask the question. Once the question has been asked and answered then you must use that information in your judgement.
 

ruralsurg4now

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As others have said, the best way to proceed with the case is not to ask the question. Once the question has been asked and answered then you must use that information in your judgement.
Just to clarify, if that refers to my post, I never said not to ask the question. I just said that if you personally don't take being stoned into consideration, then don't ever ask anyone about their drug habits because it becomes irrelevant. I personally would always ask the question AND take it into consideration.
 

narcusprince

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I would do the case. First is their any evidence based study that shows Marijuana use can impair memory like benzodizapenes and alcohol? I have done some research in Cannibus in undergrad and had not seen a paper regarding memory loss or lose of inhibition to the extent of alcohol or benzos. What if the patient took her AM xanax and PO dilaudid DOS can they still consent to the procedure? Do the case.
 

Gasworks

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If the pt admitted to being high on cocaine or amphetamines I would cancel since both can cause dysrythmias and BP problems. I would cancel a drunk pt as they are clearly not NPO if you can smell wild the wild turkey coming off their breath. Consent issues aside, MJ and narcs have never led to a cancellation in the places I practice. One of the asc's I cover has a pain doc who brings in patients who are so full of narcs they can't see straight and if you're real lucky he'll find someone who ran out of meds 3 days ago and is high on smack waiting for his mandatory fake injection so he can get his pills refilled. Another fun thing is a pt in acute withdrawl, just like in the previous scenario but not resourceful enough to find anything on the street. We had one patient who was living in an abandoned car in front of his mothers house. The asc's car service had specific instructions to not ring the bell just knock on the car window to wake the guy. This guy probably hadn't bathed in week and had fingernails an inch long but got his fakedural and his roxicets all the same. I complained about this once and was never sent back to that center. Not bitter or anything, just sayin..
 

ruralsurg4now

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One of the asc's I cover has a pain doc who brings in patients who are so full of narcs they can't see straight and if you're real lucky he'll find someone who ran out of meds 3 days ago and is high on smack waiting for his mandatory fake injection so he can get his pills refilled.
Yeah, but that's his patient population. It's not mine and neither do I just make an injection into the guy. Honestly, I don't give two s**ts what a pain doctor does, since most of what they do enables continued use of narcotics.
 

Planktonmd

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I love it when people who have no idea what they are talking about decide to be experts :)
I can't believe that someone just said that opiates don't affect the ability to consent!!!
Or another said that chronic opiate use does not alter your judgement...
Very scary ...
 

Mman

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I love it when people who have no idea what they are talking about decide to be experts :)
I can't believe that someone just said that opiates don't affect the ability to consent!!!
Or another said that chronic opiate use does not alter your judgement...
Very scary ...
Where I practice it is both hospital policy and upheld as the law. Maybe you have different courts and different laws where you live.

Do you honestly think a dose of percocet changes the ability to get consent from somebody? Really? That fascinates me.
 

ruralsurg4now

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1. Wait for patient to sober up.
I have better things to do with my time than wait for someone to sober up. They can sober up on their time and return on the reschedule.
 

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Cannot tell you the number of times people mention that they took an extra Valium in the morning preop and are feeling very relaxed.

Since your state has declared Mary Jane legal, it is just like taking an opiate or hypnotic that their body is used to metabolizing.

I vote for doing the case.
 

ruralsurg4now

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Now if the patient was a white supremacist prostitute who smokes marijuana that would be a big problem :)
How hot is she, hypothetically?
 

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But the real question should be what is the appropriate concealed carry weapon if your patient population includes white supremacist prostitutes getting pain injections while stoned? (sorry, we haven't had a gun post in a while. Wasn't feeling quite like the SDN we all know and love.)
 

sevoflurane

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I don't see the big deal here if certain set of criteria are met. I agree with Jay K. That sounds very reasonable and my approach as well.

Patient coming down with a PCA from the floor? I see it all the time. It deserves special attention, but I won't cancel that case either unless the guy is obviously narc'ed up.

Cocaine, amphetamines or alcohol is a little different.
 

sevoflurane

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To my knowledge, cannabis does not have ill affects when combined with GA. I can't say the same for alcohol, amphetamines or cocaine. You can make an argument for narcotics and a full stomach depending on the situation.
 

pgg

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(sorry, we haven't had a gun post in a while. Wasn't feeling quite like the SDN we all know and love.)
Yeah, we are overdue. Guess I better go start one.
 

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I love it when people who have no idea what they are talking about decide to be experts :)
I can't believe that someone just said that opiates don't affect the ability to consent!!!
Or another said that chronic opiate use does not alter your judgement...
Very scary ...
Well does this pt have private ins?

Kidding aside I agree w plank have we lost our abilities to be doctors? We know when someone is alert and able to consent and we know when someone is not. Baring amphetamine and coke, the patient is alert can process the info and can make informed decisions on health care they can consent if not cancel. Yes there may be a letter of the law argument that may be considered but how many times do we do surgery under non ideal situations? RuralSurg would cancel every case that isn't ideal? What about a URI are you going to wait 6 weeks for there risk of post op complications go to zero? There are numerous other examples we can get into but if you waited for your "ideal" you would be broke and ors would be empty. Be a real doctor and not a nurse that uses algorithms to make their decisions.
 

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DUDES. If you proceed and something bad happens, how will you defend yourself in court? Why take a risk on your career for an ELECTIVE case?
 

ruralsurg4now

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RuralSurg would cancel every case that isn't ideal? What about a URI are you going to wait 6 weeks for there risk of post op complications go to zero?
Yeah, I would cancel every elective case that isn't ideal in which you could rectify the issue. What's your point? You mean that if some guy came in with a URI you'd just proceed on an elective case? That's pretty interesting because I'm not sure I've run into someone who would do that in real life yet, either from surgery or from anesthesia. You know why? Not because the person will die of a URI. It's because if anything goes wrong, then someone is going to wonder why you had to rush into an elective case. What happened? Had bills to pay that week or something?
 

pgg

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You mean that if some guy came in with a URI you'd just proceed on an elective case?
Sure. I don't know what kind of anesthesia group you're accustomed to, canceling (adults) over some sniffles. Of course it depends on what procedure is scheduled, but a URI is not a reason to cancel everything, full stop. In the peds world there's a little more gray, but given how often kids get URIs, if you insist on a 6 week sniffle-free window for that 3-year-old, you might be putting off his surgery until he's six.


At my .mil job, everyone is pretty healthy and well optimized, and it's rare for anything else to walk in.

Where I moonlight though (and I would sure fit the ruralanes4now label there) you better believe that if we canceled every patient who blows his nose in preop, or every dehydrated old geezer with a creatinine of 1.4, or every permanent-address-challenged charity case who carries a scent of Wild Turkey, we'd go home early every day. We're not cowboys but we do the cases.