Question - cancel elective case on stoned patient?

[ruralsurg4now]

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.

I'm aware that there are some surgeons who are single-minded in their determination to operate on anyone regardless of their condition, but I'm quite sure the majority of them aren't like that.

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[sleepallday]

I'm aware that there are some surgeons who are single-minded in their determination to operate on anyone regardless of their condition, but I'm quite sure the majority of them aren't like that.

I'm willing to bet that I've worked with more surgeons than you have and my experience has been that most are willing to push forward with cases that probably should not be done. They usually all eventually agree to postpone/cancel, but do so very reluctantly. And to be clear, I do not look for reasons to cancel. I practice in a group model where I also lose out by not doing the case.

 

[ruralsurg4now]

I'm willing to bet that I've worked with more surgeons than you have and my experience has been that most are willing to push forward with cases that probably should not be done.

I guess all surgeons suck and have poor judgement then, was that your point?

 

[pgg]

I guess all surgeons suck and have poor judgement then, was that your point?

Now you're just looking for something to be disagreeable about.

His point is that there is a near-universal bias amongst surgeons that a patient who shows up for surgery should get cut unless there is a COMPELLING reason to cancel. That is absolutely inarguably true.


IMO most drug users who recently partook but are not intoxicated (ie, are consentable) should go to the OR on time. I include alcohol drinkers, cigarette smokers, and rx-drug takers in that list. I will cancel a meth or cocaine user if their tox screen is positive, whatever they say about recent use. I don't care about marijuana or opiates.

If a patient is drunk or completely baked out of his gourd, the issue is consent - not the physiologic effects of the drugs. Meth and cocaine have lingering physiologic effects which is why most of us treat them much more conservatively. Marijuana is extremely benign.

You can disagree and of course do whatever you feel is right for your patients, but there's no need to play these passive-aggressive debate games and look for reasons to get offended.

 

[ruralsurg4now]

Now you're just looking for something to be disagreeable about. His point is that there is a near-universal bias amongst surgeons that a patient who shows up for surgery should get cut unless there is a COMPELLING reason to cancel.

No, that's not actually at all what he said. Here's EXACTLY what he said:

I'm willing to bet that I've worked with more surgeons than you have and my experience has been that most are willing to push forward with cases that probably should not be done.

That means that even in the face of a COMPELLING reason to cancel, he claims that surgeons refuse to cancel, at least without him arguing them down reluctantly, because their judgement is so poor and they're basically idiots. That's inarguable that this is what he is saying.

 

[sleepallday]

I guess all surgeons suck and have poor judgement then, was that your point?

Haha, no, not my point. Well sort of. Most of the surgeons I work with are very good at what they do. Which is operating. They, however, are not very good at determining if patients are fit for surgery. And I don't entirely blame them for this because this doesn't seem to be within the scope of their training (you could correct me if I'm wrong). For example, my last case for today was a drainage of an abscess on a 87 year old male. I get a call from the nurse taking care of him on the floor that the patient went just went into new onset atrial fibrillation with RVR and they have been unable to control the rate with amiodarone. I tell the surgeon that we'll have to postpone the case until the heart rate is controlled. The surgeon after hearing all of this actually still wanted to proceed. Only after I basically say not a chance, does he reluctantly agree. Now mind you, I consider this surgeon to be extremely level headed and definitely not one of those cut at all costs type.

 

[ruralsurg4now]

Haha, no, not my point. Well sort of. Most of the surgeons I work with are very good at what they do. Which is operating. They, however, are not very good at determining if patients are fit for surgery. And I don't entirely blame them for this because this doesn't seem to be within the scope of their training (you could correct me if I'm wrong). For example, my last case for today was a drainage of an abscess on a 87 year old male. I get a call from the nurse taking care of him on the floor that the patient went just went into new onset atrial fibrillation with RVR and they have been unable to control the rate with amiodarone. I tell the surgeon that we'll have to postpone the case until the heart rate is controlled. The surgeon after hearing all of this actually still wanted to proceed. Only after I basically say not a chance, does he reluctantly agree. Now mind you, I consider this surgeon to be extremely level headed and definitely not one of those cut at all costs type.

No, determining which patients are fit for surgery is one of the cornerstones of surgery. Basically, if you can't tell who to operate or not operate on, it doesn't matter how good you are technically, you still suck as a surgeon. I tell patients all the time that I'm not operating on them because all I'd do is kill them on the table. The operation would be perfect (well, not really, because I'm not Mr. Awesome after only a year), but you'd be dead, so the only person who will care is the Medical Examiner. If your surgeons can't tell who they shouldn't be operating on, then they suck. Now, if this guy was septic and deteriorating due to an abscess, then that may actually be causing his new-onset a-fib. In which case, although you are completely justified to be concerned about it, I might still decide that it's important to proceed. Alternatively, if you just mean it's a superficial abscess, then the guy just plain sucks because I'd just put in some local and tell the guy it's going to hurt because the local will have poor effect in an acidic environment, but it's only going to hurt for a minute. I do that all the time and no patient has ever complained.

My point is that I'm not one of these people who are like "rah rah, everyone in my specialty is brilliant and perfect." I've run into surgeons with poor clinical judgement and we had them in my training program. I've seen people I'd never let operate on anyone, if it were up to me. So if you want to say that some surgeons are *****s, that's absolutely true. When you say that most of them have no idea who they should be operating on, then I just write you off as an imbecile, no offense. I'm quite sure that most surgeons are good and we're not just butchering people and thank God the anesthesiologist is saving them from our stupidity.

 

[e30ftw]

That means that even in the face of a COMPELLING reason to cancel, he claims that surgeons refuse to cancel, at least without him arguing them down reluctantly, because their judgement is so poor and they're basically idiots. That's inarguable that this is what he is saying.

dicto simpliciter.

that is not at all what he said, that is merely how you, in the context of your life experience, interpreted the text.

 

[ruralsurg4now]

dicto simpliciter.

that is not at all what he said, that is merely how you, in the context of your life experience, interpreted the text.

Sorry, but it is what he said. And he even elaborated on it later. It's very clear what he wrote.

 

[Planktonmd]

Most surgeons I have worked with would cut anyone who makes it to the OR with a pulse as long as some internist had "cleared them" for surgery.
I once had an orthopedic surgeon who continued to operate even after we told him that the patient is officially dead!

 

[ruralsurg4now]

Most surgeons I have worked with would cut anyone who makes it to the OR with a pulse as long as some internist had "cleared them" for surgery.
I once had an orthopedic surgeon who continued to operate even after we told him that the patient is officially dead!

Yeah, but that's ortho.

By the way, one thing that you guys should realize is that, just as it would be wrong for me to just characterize anesthesia as "I see you guys walk in, push a few syringes of stuff into the patient, and that's the totality of thought you put into your day," what you often think you know about surgery is grossly off.

 

[Southpaw]

Yeah, but that's ortho.

By the way, one thing that you guys should realize is that, just as it would be wrong for me to just characterize anesthesia as "I see you guys walk in, push a few syringes of stuff into the patient, and that's the totality of thought you put into your day," what you often think you know about surgery is grossly off.

On the whole, especially in private practice, general surgeons are much more in tune as to whether a patient is 'ready' for an operation relative to the surgical subspecialists. Ortho seems to be the worst. I'm not trying to dog them at all, and in many ways I can't blame them since they basically do no non-ortho rotations in residency and they shift in-hospital management of their patients to the medicine people as much as possible.

 

[ruralsurg4now]

On the whole, especially in private practice, general surgeons are much more in tune as to whether a patient is 'ready' for an operation relative to the surgical subspecialists. Ortho seems to be the worst. I'm not trying to dog them at all, and in many ways I can't blame them since they basically do no non-ortho rotations in residency and they shift in-hospital management of their patients to the medicine people as much as possible.

The subspecialists are generally not great at identifying or caring about patient conditions, mostly because they don't ever take care of them. Ortho is famous for not having any concern for anything except "the bone" and they embrace that. Urology is terrible at it, too, if I dare say so myself, since often a lot of what they do, at least in the community, is not very involved. I don't think either ever really has any patients on their primary service, including in community settings. That's not to say that General Surgery is so hot at medical care, either, although it's much more of a spectrum. I've known general surgeons who are the stereotypical "I don't care about medical problems, that's what we have Internists for" (and, honestly, it sort of is), but I've also known surgeons who are very competent at medical care, including all aspects of critical care management. It really is up to the individual surgeon, since the reality is that nobody is consulting us for medical management. That being said, most surgeons can identify when a patient should not undergo an operation, at the minimum. If your surgeons can't, then I'd say that your surgeons suck.

Additionally, my point about Anesthesiologists not knowing the nuances of Surgery is similar. I don't expect you guys to know some of the things we consider when we take people to surgery. That would be silly. But it's equally silly for Anesthesiologists to think that they DO know those things and act like surgeons are just these lunkheads who drag dead corpses into ORs and are like "when can we start?" There have been times when I could tell an Anesthesiologist was questioning my judgement about doing a case and I'd just explain the entire situation to them and they'd be like "oh, OK, now I got you, we'll go right away." Trust me, sometimes you guys don't know what's going on completely after just quickly skimming through a thick chart the night before, either.

 

[ruralsurg4now]

By the way, I have to renew my BLS/ACLS next week and it's sort of pathetic how much I forgot about reading EKGs. Nor do I really care about reading them, to be honest. Like, if some poor schlep is depending on me to differentiate between types of heart block, he's dead already. It'll be pretty funny if I can't pass this thing.

 

[Planktonmd]

But it's equally silly for Anesthesiologists to think that they DO know those things and act like surgeons are just these lunkheads who drag dead corpses into ORs and are like "when can we start?"

I have to say that over the years I have seen way more surgeons who believe that they know everything about anesthesiology than anesthesiologists who think they know everything about surgery.
And that attitude of "dragging dead corpses and when can we start" is way more common than you think or you want to think.
You have been in the real world for one year as you said and that explains your idealistic view of what surgeons do... in a few years you will join the crowd and start dragging corpses to the OR.
But don't worry... there always will be an anesthesiologist making sure you don't kill too many people

 

[ruralsurg4now]

I have to say that over the years I have seen way more surgeons who believe that they know everything about anesthesiology than anesthesiologists who think they know everything about surgery.
And that attitude of "dragging dead corpses and when can we start" is way more common than you think or you want to think.
You have been in the real world for one year as you said and that explains your idealistic view of what surgeons do... in a few years you will join the crowd and start dragging corpses to the OR.
But don't worry... there always will be an anesthesiologist making sure you don't kill too many people

Lol, OK, dude. You keep thinking that stuff while you do your crossword puzzles in the corner, OK?

 

[Planktonmd]

I can keep you out of trouble even while sitting in the corner doing the crosswords, talking on the phone, and watching the stock market... you have to admit that this is amazing!

 

[ruralsurg4now]

I can keep you out of trouble even while sitting in the corner doing the crosswords, talking on the phone, and watching the stock market... you have to admit that this is amazing!

Yeah, it's not hard to keep me out of trouble that I'm not in. You sure are skilled! What's 24 Across?

 

[cchoukal]

Not to take sides, but we often post various scenarios that include, among other aspects, some surgeon who wants to operate on someone we think unfit. And when a surgeon shows up on the board with what seems like a more thoughtful and considerate approach, we dog him about it (after exercising our skepticism). I would have thought many of us would rather work with someone like ruralsurg4now and, would encourage his/her POV.

 

[IlDestriero]

But don't worry... there always will be an anesthesiologist making sure you don't kill too many people

Not at his shop. He's got CRNAs. Maybe that's why he's developed some pre procedure optimization skills.

 

[IlDestriero]

What's 24 Across?

Bloviate.

 

[Planktonmd]

Not to take sides, but we often post various scenarios that include, among other aspects, some surgeon who wants to operate on someone we think unfit. And when a surgeon shows up on the board with what seems like a more thoughtful and considerate approach, we dog him about it (after exercising our skepticism). I would have thought many of us would rather work with someone like ruralsurg4now and, would encourage his/her POV.

He is green and that's why he is "thoughtful and considerate"!

 

[pgg]

By the way, I have to renew my BLS/ACLS next week and it's sort of pathetic how much I forgot about reading EKGs. Nor do I really care about reading them, to be honest. Like, if some poor schlep is depending on me to differentiate between types of heart block, he's dead already. It'll be pretty funny if I can't pass this thing.

No worries, ACLS has been ... simplified. You don't have to be able to tell the difference between type 1 & 2 second degree blocks any more. The bradycardia algorithm now boils down to, if it's slow, try atropine, and if that doesn't work try pacing, or maybe an epi infusion. The old algorithm said to skip the atropine for high grade blocks because it's useless, but apparently they decided it took the average person less time to try atropine and see it fail than figure out what the actual rhythm is and go for pacing right away.