Question - cancel elective case on stoned patient?

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Sonny Crocket said:
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?
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I don't think this is a very sound argument. Bad things happen on elective cases sometimes no matter what.
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ruralsurg4now said:
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?
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Depends on how bad the URI is. Plenty of people have some variation of some crud or another this time of year and I don't ever cancel them (excluding peds).
 
Arch Guillotti said:
I don't think this is a very sound argument. Bad things happen on elective cases sometimes no matter what.
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This is true but if this particular pt has a complication you will have a hard time defending yourself in court. Like smallz was saying, he is not optimized.
 
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pgg said:
Sure. I don't know what kind of anesthesia group you're accustomed to, canceling (adults) over some sniffles.
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I generally don't ask them what prompted them to make their decision, since, as I've said before, I try to work with Anesthesia and not against them. So if I'm in holding and some anesthesiologist comes up to me and says "hey, your next guy has an URI, I'm thinking about cancelling them," I just say "sure." I'm just out and my case load isn't that large, so it's not a big deal to me -- I'm not trying to cram some guy into a schedule that's packed for six months. Additionally, one thing you guys as anesthesiologists aren't taking into account is that, from a surgery standpoint, if you implant something (e.g., mesh) in a patient who can be argued has an "active infection" and it becomes infected, then it's hard to justify why you went ahead. The reality is they probably had nothing to do with each other, but reality has nothing to do with criticism either from other surgeons or from lawyers. (You may or may not know this, but surgeons enjoy lecturing people about how they'd do things perfectly in retrospect. It's not worth that hassle to me.)

Regardless, it's odd how this discussion went from "a guy who is obviously and visibly stoned" to "a guy who has the sniffles." Even if you'd do the latter, that wouldn't mean that you'd do the former. If someone wants to do the former case, that's fine with me, too. Honestly, I don't really care who does any case -- to me, it's tiresome how people try to get involved in other peoples' cases and I always give people the benefit of the doubt even when their cases turn into disasters. (By the way, it's fascinating to me how people I give the benefit of the doubt to in real life have had no problem turning around and criticizing one of my cases, but oh, well.) Physicians have enough to deal with without some douchebag physician playing backseat driver. However, my personal feeling is that if someone is high, then they're going to present me with problems post-op, such as withdrawal. Is that the end of the world? No. Is it avoidable? Yes. So I choose to avoid the avoidable. Does that make me "weak"? I actually don't care if it does, lol. I'm just some guy at a rural hospital, not some high-powered academic institution, and I'm just trying to get people the surgeries they need and then hopefully bail out of this place as soon as possible. I'd like to think I do the right thing for the community, however.
 
ruralsurg4now said:
I generally don't ask them what prompted them to make their decision, since, as I've said before, I try to work with Anesthesia and not against them. So if I'm in holding and some anesthesiologist comes up to me and says "hey, your next guy has an URI, I'm thinking about cancelling them," I just say "sure."
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Your response is totally reasonable. Nothing good comes from trying to talk a patient or another doctor into doing something.

If one of my anesthesiologist colleagues saw a patient who smoked a joint an hour prior to surgery and said "I ain't doing that case" I would not argue or criticize or volunteer to do the case for him. I think there's room for varying opinions on this and I wouldn't undermine or publicly contradict my colleague on a soft call. Likewise, if the surgeon saw that he'd smoked that joint and wanted to cancel, I wouldn't argue with him. I'd just say sure. :)

But otherwise, I'd just do the case, provided the patient wasn't visibly altered to the point that I had consent worries. Yes, that's a judgment call.


ruralsurg4now said:
Additionally, one thing you guys as anesthesiologists aren't taking into account is that, from a surgery standpoint, if you implant something (e.g., mesh) in a patient who can be argued has an "active infection" and it becomes infected, then it's hard to justify why you went ahead.
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There's a world of difference between some viral sniffles and a layer of cellulitis at the intended incision site ...

If you canceled a hernia mesh because the patient had a URI, for fear of implant infection, I'd just say sure, but I'd think you were nuts.


ruralsurg4now said:
Regardless, it's odd how this discussion went from "a guy who is obviously and visibly stoned" to "a guy who has the sniffles."
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Internet discussions tend to ramble and stray a bit. :)
 
pgg said:
If you canceled a hernia mesh because the patient had a URI, for fear of implant infection, I'd just say sure, but I'd think you were nuts.
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I don't know that there's any literature on it, but I know that it's done. How commonly, I don't know. It's fairly well-established that a UTI (I tried to bold the "T") is a contraindication for mesh, however.
 
Do as a barista and point to the sign "No drinks for overtly intoxicated people".

The judge cant go agaisnt you for you not acknowledging sub clinical intoxication, unless there are some new guidelines about doing drugs tests on every pre-op.
 
pgg said:
Not a lot of viral UTIs, I would guess.
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Sure, but neither is there bacteremia in many of them. :)

By the way, this is where an academic guy would start telling you about the activation of the immune system with low-grade inflammatory mediators in a URI.
 
Agree with the parallel to patients who are taking legitimately prescribed CNS-acting drugs.
Patient takes their xanax and dilaudid before coming in for surgery, and is awake appropriate and cognizant? (Like most of them are?) Consent 'em.
Patient takes more than their usual xanax and dilaudid and is loopy, disoriented, sedated, or inappropriate? Wait it out or cancel.
Same idea for MJ.
 
I don't cancel many cases. The most recent one was someone who was transferred from another hospital with a diagnosis of acute coronary syndrome for that admission. There was also a broken humerus (2 weeks old) and the surgeon wanted to fix it a few hours after arrival at our hospital. We did it a few days later after the cardiologist had tested and found that there were no new areas of infarction.

While that was clinically an easy one to delay because of the explicit ACC/AHA guidelines, as a new guy it is hard to say no to the established surgeon who wanted to do it.

I also canceled an ORIF on a broken radius on someone who tested positive for cocaine and admitted to using it a few hours previously. The ortho residents were pretty perturbed. Sure, it has a half life of 30-90 minutes, but waiting until morning wasn't going to hurt anyone.

There is a fracture, I must fix it.
 
Arch Guillotti said:
I don't think this is a very sound argument. Bad things happen on elective cases sometimes no matter what.
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Bad things can happen during any case but that's not the point. Here we have a scenario where some dude used an illicit drug prior to a surgery and is visibly showing signs of intoxication for a purely elective case. I'd have to have a damn good reason to want to proceed with the case b/c if anything goes wrong, you can't defend it from medicolegal standpoint. When you have a 3 y/o w/some sniffles you can make the argument that this pt is as optimized as they can reasonably be expected to be b/c they might get recurrent URIs all winter. Some dude shows up after popping a doctor prescribed xanax and some MS Contin for his pain, again totally different scenerio b/c these are physician prescribed medications and that pt is optimized so assuming he's not visibly stoned we go ahead. Dude smokes a doobie and shows up visibly stoned w/an appy? Sure go ahead, risk of delaying is way worse than proceeding. But a dude who shows up to surgery visibly stoned for an elective surgery shows poor judgement and it's ridiculously easy to optimize this pt by letting him sleep it off. There's just no way I'm putting my license and $$ on the line for some dude who can't lay off the weed for 1 day b/c you know that if any little thing goes wrong the first thing he's gonna say is "I didn't know what I was signing, I was stoned." and then it's not gonna matter whether the weed really affected his care or not b/c informed consent was never obtained and you've gotta start writing the check. Such is the medicolegal situation that we practice in.
 
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Planktonmd said:
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 ...
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Does pain affect your ability to consent? What about withholding pain medicine until someone signs a form? Is that coercive?
 
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ssmallz said:
Bad things can happen during any case but that's not the point. Here we have a scenario where some dude used an illicit drug prior to a surgery and is visibly showing signs of intoxication for a purely elective case. I'd have to have a damn good reason to want to proceed with the case b/c if anything goes wrong, you can't defend it from medicolegal standpoint. When you have a 3 y/o w/some sniffles you can make the argument that this pt is as optimized as they can reasonably be expected to be b/c they might get recurrent URIs all winter. Some dude shows up after popping a doctor prescribed xanax and some MS Contin for his pain, again totally different scenerio b/c these are physician prescribed medications and that pt is optimized so assuming he's not visibly stoned we go ahead. Dude smokes a doobie and shows up visibly stoned w/an appy? Sure go ahead, risk of delaying is way worse than proceeding. But a dude who shows up to surgery visibly stoned for an elective surgery shows poor judgement and it's ridiculously easy to optimize this pt by letting him sleep it off. There's just no way I'm putting my license and $$ on the line for some dude who can't lay off the weed for 1 day b/c you know that if any little thing goes wrong the first thing he's gonna say is "I didn't know what I was signing, I was stoned." and then it's not gonna matter whether the weed really affected his care or not b/c informed consent was never obtained and you've gotta start writing the check. Such is the medicolegal situation that we practice in.
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If a patient takes a "physician prescribed" sedative or opiate before the consent is signed and something goes wrong during the surgery, I can assure you that the lawyer is going to say that the consent was invalid.
There is no difference between a "physician prescribed" drug and "illicit" drug when it comes to consent.
 
If you can demonstrate that the patient has the capacity to make the decision, demonstrating understanding of the risks, benefits, alternatives (including not performing the anesthetic/operation), of their problem, does that change your answer?
 
bigeyedfish said:
Does pain affect your ability to consent? What about withholding pain medicine until someone signs a form? Is that coercive?
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Who cares? And before someone starts writing out a lengthy paragraph about how "we all need to care because blah blah blah," my response is still "who cares?" You're right, I guess you could get sued for withholding pain meds prior to signing consent. And you could get sued by the exact same person for giving pain meds prior to signing consent. So who cares? All you introduced was the well-known concept that lawyers suck. That, plus for some reason everyone is trying to be clever and trying to come up with some ingenious scenario where it's OK for a patient to be stoned. Here's a hint for everyone: there is none. It's an elective case. By definition, you don't have to do it and therefore there's no "good reason" for the patient to be stoned. It actually doesn't even matter if the patient is a chronic narcotic user and you go "oh, so you'd never do the case then?" Uh ...let's check the definition of "elective" again. Yeah, it looks like you actually don't ever need to do it, if you don't want to. Therefore, what's the point of trying to demand justification from anyone for not doing the case that you don't need to do. Literally if I said "I think I'll postpone it because it's a Wednesday" would be acceptable. The patient may not like that, in which case they just need to go to someone who doesn't mind operating on Wednesdays.
 
Planktonmd said:
If a patient takes a "physician prescribed" sedative or opiate before the consent is signed and something goes wrong during the surgery, I can assure you that the lawyer is going to say that the consent was invalid.
There is no difference between a "physician prescribed" drug and "illicit" drug when it comes to consent.
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What state are you in? I'd bet money there is legal precedent in your state that the consent is valid and while a lawyer could say anything they want, they really wouldn't say that because they'd have no legal basis to do so.
 
Planktonmd said:
If a patient takes a "physician prescribed" sedative or opiate before the consent is signed and something goes wrong during the surgery, I can assure you that the lawyer is going to say that the consent was invalid.
There is no difference between a "physician prescribed" drug and "illicit" drug when it comes to consent.
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It comes down to what a "reasonable" person would do in that scenario. Is it really reasonable to proceed with a pt who took her morning Xanax prior to the surgery b/c that's what she takes everyday for anxiety? Yes. Is it reasonable to proceed b/c a dude smoked a joint prior to surgery? No. Sure there's some grey area with all this consent but I draw the line at illicit drugs and I'd feel much better about my chances if the lawyers are arguing about a Norco or Xanax prescribed by my pts PCP than a joint. Is it arbitrary and non medically based? Probably, but that's just how I feel comfortable practicing. Like ruralsurg said, you can justify it to yourself anyway you want but this is still an elective case so there's no need to bend the rules to proceed.
 
Sonny Crocket said:
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?
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There are few reasons to cancel cases... We take risks EVERY DAY, man up know when to cancel! New onset arrhythmia, recent nstemi, uncomp chf, pt refusal, pna, those are reasons... Sniffles and a bit of etoh just means you are either salary or in academics
 
I would've done the case without hesitation.
Weed has an undeserved political and social stigma in this country.
A patient smoking a bowl on the way to the hospital is much less harmful than the 3 Percocets and a 10mg Valium many spine surgery patients take upon awakening on the morning of their surgery before arrival at the hospital.
We as clinicians (appropriately) advocate continuation of meds in chronic pain patients having surgery... fentanyl patches, oral opioids and benzodiazepines....
BUT HOLY S H IT we gotta cancel since
THE DUDE SMOKED A BOWL!!!!


Think about that for a minute.
 
ruralsurg4now said:
Who cares? And before someone starts writing out a lengthy paragraph about how "we all need to care because blah blah blah," my response is still "who cares?" You're right, I guess you could get sued for withholding pain meds prior to signing consent. And you could get sued by the exact same person for giving pain meds prior to signing consent. So who cares? All you introduced was the well-known concept that lawyers suck. That, plus for some reason everyone is trying to be clever and trying to come up with some ingenious scenario where it's OK for a patient to be stoned. Here's a hint for everyone: there is none. It's an elective case. By definition, you don't have to do it and therefore there's no "good reason" for the patient to be stoned. It actually doesn't even matter if the patient is a chronic narcotic user and you go "oh, so you'd never do the case then?" Uh ...let's check the definition of "elective" again. Yeah, it looks like you actually don't ever need to do it, if you don't want to. Therefore, what's the point of trying to demand justification from anyone for not doing the case that you don't need to do. Literally if I said "I think I'll postpone it because it's a Wednesday" would be acceptable. The patient may not like that, in which case they just need to go to someone who doesn't mind operating on Wednesdays.
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You picked up on my point. Who cares?

I would have done the case because I wouldn't have asked the guy if he smoked weed on the way to the hospital. 1. I don't care 2. I'd rather not know 3. If he's got high medication requirements ill find out anyway 4. Most people will lie about drug use.
 
bigeyedfish said:
You picked up on my point. Who cares?
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But you missed my point, which is that your question is what we shouldn't care about. In other words, nobody cares that you're trying to make a clever "ha ha, I win either way, so you have to treat stoned patients" because it's demonstrably false. Nobody in history has ever been sued for postponing an elective case on a stoner, so your hypothetical question is merely an exercise in mental masturbation.
 
I'm not sure I've ever come across a surgeon who was so... indifferent to whether or not a case got done (and I work in a VA). It's refreshing, actually, although I'm surprised you're not feeling financial pressures to be more aggressive.
 
ruralsurg4now said:
But you missed my point, which is that your question is what we shouldn't care about. In other words, nobody cares that you're trying to make a clever "ha ha, I win either way, so you have to treat stoned patients" because it's demonstrably false. Nobody in history has ever been sued for postponing an elective case on a stoner, so your hypothetical question is merely an exercise in mental masturbation.
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Dude,
RELAX, BRAH!!!!!!
Looks like you could use a bowl yourself!
Lol
 
If that
cchoukal said:
I'm not sure I've ever come across a surgeon who was so... indifferent to whether or not a case got done (and I work in a VA). It's refreshing, actually, although I'm surprised you're not feeling financial pressures to be more aggressive.
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How am I being indifferent? You mean, since I didn't operate on someone who was stoned, I'm doing something wrong? OK. That's pretty hilarious.
 
By the way, kudos on the attempted reverse psychology with the implication that I'm lazier than a VA physician, although you'll need to work harder at it, since you follow it up by saying that it's "refreshing."

I'm not saying your kids could see through that, but, well, I bet they don't really fall for it, do they?
 
Spine surgery is a large part of my practice.
50% of those patients are stoned on opioids and benzos.
You wanna make a statement by canceling a case over a little weed?
More power to you, brah.
I'm wheeling the stoner back to the operating room to do what's
RIGHT.
 
Cool story, brah, but we already established that we're not talking about people who are on chronic, prescribed narcotics. Also, you're dealing with people who are getting surgery for their pain, which is markedly different than getting surgery for unrelated issues while stoned. But you do WHAT'S RIGHT. I'm impressed, OK, brah?
 
Sure Brah!!!
Btw if you really are a surgeon (I have my doubts) what would you do if you practiced in Colorado where weed is
Legal
and a dude comes in stoned for surgery?
 
I wouldn't care because it has nothing to do with the legal status of marijuana, brah. By the way, the 1980s called and were wondering when you'd get back home.
 
jetproppilot said:
Sure Brah!!!
Btw if you really are a surgeon (I have my doubts) what would you do if you practiced in Colorado where weed is
Legal
and a dude comes in stoned for surgery?
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The legality has nothing to do with it. If a patient comes in from any substance, legal or not, and they're not consentable, they're not getting elective surgery that day. I see absolutely no benefit whatsoever to moving forward, other than to prove to yourself and your surgeon that you can. There's no good, and enough potential bad, that can come from playing it so loose.
 
Why is he not consentable? If the patient demonstrates capacity to make the decision, how is it any different than any other substance like opiates or benzos, as discussed above. I can drink two fingers of bourbon or a beer and still be able to understand R/B/A and decide whether or not proceeding with an operation is in my best interest. If this patient can do the same, why cancel the case?
 
Physio Doc 2 Be said:
Where does it show that his judgment is impaired because of the marijuana? Again, I ask the question: if the patient demonstrates adequate capacity, why cancel the case?
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Except he's stoned, so he doesn't. This is about as non-sensical as if someone came in drunk and you said "he's consentable because I have no problem with alcohol consumption, it's legal in this state, and also this is no different from chronic narcotic use!! I will begin intubation, you start prepping!!" You pro-marijuana guys are hilarious in your thick-headedness.
 
ruralsurg4now said:
Except he's stoned, so he doesn't. This is about as non-sensical as if someone came in drunk and you said "he's consentable because I have no problem with alcohol consumption, it's legal in this state, and also this is no different from chronic narcotic use!! I will begin intubation, you start prepping!!" You pro-marijuana guys are hilarious in your thick-headedness.
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I don't know that I've stated an opinion on marijuana use one way or another. And other than having blood shot eyes and smelling like weed, we don't seem to have any other known ill-effects of the use. I don't believe OP said he demonstrated any other effects of the drug. If a patient took a shot on their way to the hospital would you cancel a case? What if they were an alcoholic? And my point is still the same, why would cancel the case if the patient can demonstrate to you they understand the risks of the operation, the potential benefits, the alternatives, and they still wish to proceed? There is no guarantee you are going to get them back to the hospital without them lighting up again? If they have documentable capacity, why cancel a case?

Southpaw said:
If he's stoned, or drunk, or high, or whatever, I don't believe the patient has capacity.
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My gut tells me the same thing, but since this is the big make-believe land of the internet, why not play along? I'm just playing the devil's advocate here, anyway. The patient tells you they know what could happen on the table, they believe the benefits to be greater than the risks that they've shown you they understand and they wish to proceed. Because they've smoked a joint, taken a shot, or downed their PRN alprazolam, do you cancel the case?
 
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By the way, I assume that in Colorado surgeons can use marijuana before operating and they don't test for marijuana on employment exams. I mean, it's legal and it's a medicine and we apparently can't tell if someone is impaired and, in fact, if we think they are impaired it's probably just our hatred for marijuana and desire to keep people away from their medicine. So I presume with all that, that I can use marijuana before I operate on your mom. You intubate, I'll start prepping!
 
Oh, also she can't tell that I'm high because I presume your mom has even less clinical judgement than a panel of physicians, none of whom can tell if a patient is high. So she'd have no reason to ask if I had just taken a few drags on the ol' ganja. Let me know when you're ready for me to proceed with incision.
 
I can see you don't have anything valuable to add, so you can start this dribble. No one here argued that a physician should provide care while smoking weed, having a drink, or doin' a bump before the big gallbladder. The standard of behavior for a physician is different, but you can keep on trying to change the subject if you like. And the OP didn't mention anything but conjunctival injection, the smell of weed, and the patient's admission of marijuana use, leading me to believe that (s)he picked it up during the SH in pre-op. Not that the patient was wandering the halls looking for Funyuns, laughing at the floating guy on the couch, or laughing at stupid stuff with the rest of his pals in a circle.
 
Why shouldn't a physician provide care while smoking weed? They're not impaired, as you say, and did someone pass a law that physicians don't have chronic pain conditions, such as back pain? And isn't marijuana legal in Colorado? And isn't there no reason to assume that they're high? It's hilarious because all I had to do was mention that I was on weed while I was operating on your mom and suddenly you grasp that weed is a drug!
 
yo momma so fat u gotta be stoned to operate on that!
 
ruralsurg4now said:
Why shouldn't a physician provide care while smoking weed? They're not impaired, as you say, and did someone pass a law that physicians don't have chronic pain conditions, such as back pain? And isn't marijuana legal in Colorado? And isn't there no reason to assume that they're high? It's hilarious because all I had to do was mention that I was on weed while I was operating on your mom and suddenly you grasp that weed is a drug!
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You are attempting, poorly, to put words into my mouth. I clearly stated that the standard for physician behavior is different than our patients, and it is expected that physicians don't use these drugs while providing care. Whether that's right or wrong (turning my thoughts to those physicians with chronic pain issues), isn't something I can answer with a simple black and white/yes and no. Does it matter if someone has used 5/325 of hydrocodone/acetaminophen q8 or q12 to keep some chronic pain issue at bay for the last 5 or 6 years? I don't know. But that isn't what this is about. This discussion is about canceling a case when a patient smoked some weed on the ride over because he was nervous. You still can't provide a sound reason why you should cancel a case for a patient that demonstrates adequate capacity for making the decision to have an operation. Or why that is different if the patient took a shot on the drive over, or used their Xanax for the same reason. Provide a reason, and I'll concede. But otherwise, I think you are grand-standing with no viable answer.
 
Physio Doc 2 Be said:
I clearly stated that the standard for physician behavior is different than our patients
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And I clearly stated that your statement was entirely arbitrary. In other words, all you did was say "it's different for doctors because ...uh, because I said so!"
 
ruralsurg4now said:
And I clearly stated that your statement was entirely arbitrary. In other words, all you did was say "it's different for doctors because ...uh, because I said so!"
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No, it is different for physician's because your colleagues say so, and by extension I would guess most state licensing boards. And you continue to dance around the subject at hand.
 
Physio Doc 2 Be said:
No, it is different for physician's because your colleagues say so, and by extension I would guess most state licensing boards. And you continue to dance around the subject at hand.
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Actually, you're wrong because if marijuana use isn't illegal then it won't show up for licensing boards.
 
ruralsurg4now said:
By the way, kudos on the attempted reverse psychology with the implication that I'm lazier than a VA physician, although you'll need to work harder at it, since you follow it up by saying that it's "refreshing."

I'm not saying your kids could see through that, but, well, I bet they don't really fall for it, do they?
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Actually, I was being sincere and I sort of agree with you about not doing the case. It's just unusual, as some of the other posters have implied, to encounter a surgeon who's not more aggressive about pushing the safety envelope to do more cases.
 
Physio Doc 2 Be said:
I dunno. Booze isn't illegal, but its use during times of patient care would be an issue for a state medical board methinks.
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That's a pretty irrelevant statement, since no medical board will ask you if you had a drink during work, if you didn't come in falling down drunk. As you say, you could easily throw down a beer and nobody would be the wiser. So, yeah, you could drink on the job, too.
 
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