SCS cancelled: again

[Blockit]

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And as far as the pulmonary hypertension goes, echocardiography in January showed PA systolic pressures of 75 with moderate to severe TR, confirmed with a subsequent right heart catheterization.

 

[dabears505]

Sometimes you do things to be nice to the patient, but if a bad outcome happens they sue you. Don't be so sure this 80 year Olds family does not have a lot to gain by suing you for a bad outcome. Just look at the amount of people on here who gave a dissenting opinion to your judegement. Do you think the malpractice lawyers could not find a bunch of legal experts who would say you made a bad decision doing this case at a surgery center?

Always protect yourself and your family before trying to help a patient.

 

[dannyboy1]

Sometimes you do things to be nice to the patient, but if a bad outcome happens they sue you. Don't be so sure this 80 year Olds family does not have a lot to gain by suing you for a bad outcome. Just look at the amount of people on here who gave a dissenting opinion to your judegement. Do you think the defense could not find a bunch of legal experts who would say you made a bad decision doing this case at a surgery center?

Always protect yourself and your family before trying to help a patient.

This was a surgicenter attached to the hospital. As OP has stated this is not an elective case. The patient “needs” dialysis, hence the need for access. Proceed with high risk documented. If you haven’t done hundreds of cases just like this, you haven’t done enough cases…..

 

[Twiggidy]

I knew this would be a controversial thing to post, but I thought it was useful in light of the original case situation that started this thread.
The point of the posting was merely to show many of you how things are in other places.
In this particular situation, a block “could” have been an option, especially for someone like myself with significant regional experience. This was an AV graft with incisions in the antecubital fossa as well as up in the armpit with a tunneling between, so ideally I would’ve performed a pecs2 coupled with an axillary block. However, when you go to lie this patient anywhere near flat, she begins coughing almost incessantly. She literally no longer has any ciliary cell function and no muscular strength or elasticity in her lungs to be able to move air. So all of her phlegm just sits there.
In addition, this is a surgery center where we only do “certain blocks“. Part of long-standing traditions on the part of the medical Director of the surgery center. Any suggestion of doing anything different than what happens there every single day is immediately met with anger, fear, and questions of safety. Let’s forget about the fact that the bigger question of safety is doing general anesthesia on this person in the freaking first place.

This ASC is not truly freestanding, it is on the physical campus of one of our main hospitals. However, the distance between the ICU in the hospital and this ASC OR is at least half a mile of halls.

The accusation made by some of you that my doing this case was reckless is not really fair. I am extraordinarily concerned about NOT being reckless. I did residencies in medicine and anesthesia. I am very familiar with the physiology of chronic pulmonary hypertension. And I work in a private practice, where if one gets a reputation as a “canceler”, one gets talked about when one is not around.

I would have been entirely within my right to cancel this patient. Other members of my group likely would have canceled this case without a doubt.
However, what happens then? She has to come back at another time to have the procedure done again. And she likely won’t be any more improved. You can argue that she needs to be done in the hospital, with an arterial line. However, I will argue back that she is receiving three times a week hemodialysis that removes her blood from her body at flows of 300 to 400 mL per minute. They don’t use an arterial line there. She sometimes falls asleep during dialysis, I’m sure. And I’m sure that when she falls asleep she becomes more hypercapnic and that potentially worsens her pulmonary hypertension.

In the end, I decided that in my hands at that time with that patient in that clinical condition I felt that it was significantly possible that I could achieve the desired goal. And on top of that, if you dose her gently and incrementally without burning bridges I could always stop if she became unstable. Of course if she suffered immediate cardiac arrest after induction with 50 mg of propofol, there will always be someone who will come afterwards and say “you never should’ve done this“. But quite frankly the bigger concern is that this person would be offered chronic hemodialysis in the first place. I’m not in control of that, and that ship has already sailed. If you have a detailed discussion with the patient and their family members and explain how significant the risks are and they elect to proceed and you document this, where is the problem?

What happened with the case was that after the LMA went in and as she breathed spontaneously she continued to cough even with ETsevo 2.5%. It took quite a while for her to settle into a breathing rhythm, but for chrissake she goes to sleep every night without end tidal monitoring and seems to wake up the next day. So she just chugged along throughout the case, her blood pressure remained stable, And at the end when I removed the LMA there was a hock of phlegm in that LMA so large that it took up nearly the entire lumen. And I removed it for her. It was like giving a patient with alveolar proteinosis a pulmonary lavage. 😁
When I went to see her 45 minutes later in recovery, she was sitting upright sucking on a lollipop with her nasal cannula oxygen going. I told her that I was happy that she did so well, and she responded “didn’t I tell you I would?“ 🤷🏻‍♂️

Very reasonable approach. I won't get into the politics involved because we all know politics are present everyone but from an anesthetic standpoint I can't really argue with anything done and I likely would've done the same

 

[coffeebythelake]

So it seems like a case where the surgeon opted for a technique that would preclude a surgical block from being the primary anesthetic. Is there some patient anatomic reason why it can't be done like every other dialysis fistula block sedation case? Maybe what the patient truly needs is a better surgeon.. one that is willing to make a compromise.

 

[Twiggidy]

So it seems like a case where the surgeon opted for a technique that would preclude a surgical block from being the primary anesthetic. Is there some patient anatomic reason why it can't be done like every other dialysis fistula block sedation case? Maybe what the patient truly needs is a better surgeon.. one that is willing to make a compromise.

given the surgeon decided on av graft and not a fistula leads me to believe the vasculature in the patient wasn't great to do a fistula in the wrist or arm distal to the AC/axilla, but i'm just making assumptions

 

[GassYous]

I knew this would be a controversial thing to post, but I thought it was useful in light of the original case situation that started this thread.
The point of the posting was merely to show many of you how things are in other places.
In this particular situation, a block “could” have been an option, especially for someone like myself with significant regional experience. This was an AV graft with incisions in the antecubital fossa as well as up in the armpit with a tunneling between, so ideally I would’ve performed a pecs2 coupled with an axillary block. However, when you go to lie this patient anywhere near flat, she begins coughing almost incessantly. She literally no longer has any ciliary cell function and no muscular strength or elasticity in her lungs to be able to move air. So all of her phlegm just sits there.
In addition, this is a surgery center where we only do “certain blocks“. Part of long-standing traditions on the part of the medical Director of the surgery center. Any suggestion of doing anything different than what happens there every single day is immediately met with anger, fear, and questions of safety. Let’s forget about the fact that the bigger question of safety is doing general anesthesia on this person in the freaking first place.

This ASC is not truly freestanding, it is on the physical campus of one of our main hospitals. However, the distance between the ICU in the hospital and this ASC OR is at least half a mile of halls.

The accusation made by some of you that my doing this case was reckless is not really fair. I am extraordinarily concerned about NOT being reckless. I did residencies in medicine and anesthesia. I am very familiar with the physiology of chronic pulmonary hypertension. And I work in a private practice, where if one gets a reputation as a “canceler”, one gets talked about when one is not around.

I would have been entirely within my right to cancel this patient. Other members of my group likely would have canceled this case without a doubt.
However, what happens then? She has to come back at another time to have the procedure done again. And she likely won’t be any more improved. You can argue that she needs to be done in the hospital, with an arterial line. However, I will argue back that she is receiving three times a week hemodialysis that removes her blood from her body at flows of 300 to 400 mL per minute. They don’t use an arterial line there. She sometimes falls asleep during dialysis, I’m sure. And I’m sure that when she falls asleep she becomes more hypercapnic and that potentially worsens her pulmonary hypertension.

In the end, I decided that in my hands at that time with that patient in that clinical condition I felt that it was significantly possible that I could achieve the desired goal. And on top of that, if you dose her gently and incrementally without burning bridges I could always stop if she became unstable. Of course if she suffered immediate cardiac arrest after induction with 50 mg of propofol, there will always be someone who will come afterwards and say “you never should’ve done this“. But quite frankly the bigger concern is that this person would be offered chronic hemodialysis in the first place. I’m not in control of that, and that ship has already sailed. If you have a detailed discussion with the patient and their family members and explain how significant the risks are and they elect to proceed and you document this, where is the problem?

What happened with the case was that after the LMA went in and as she breathed spontaneously she continued to cough even with ETsevo 2.5%. It took quite a while for her to settle into a breathing rhythm, but for chrissake she goes to sleep every night without end tidal monitoring and seems to wake up the next day. So she just chugged along throughout the case, her blood pressure remained stable, And at the end when I removed the LMA there was a hock of phlegm in that LMA so large that it took up nearly the entire lumen. And I removed it for her. It was like giving a patient with alveolar proteinosis a pulmonary lavage. 😁
When I went to see her 45 minutes later in recovery, she was sitting upright sucking on a lollipop with her nasal cannula oxygen going. I told her that I was happy that she did so well, and she responded “didn’t I tell you I would?“ 🤷🏻‍♂️

I would cancel. There's no way I would do this at a surgicenter and none of my surgeons would bring a patient like this to one.

When she's at the main hospital I would do an interscalene + pecs2 and sit her up a little. No sedation.

If I thought she really couldn't handle laying there then I would tube instead of lma so I can control the co2.

 

[Blockit]

Sometimes you do things to be nice to the patient, but if a bad outcome happens they sue you. Don't be so sure this 80 year Olds family does not have a lot to gain by suing you for a bad outcome. Just look at the amount of people on here who gave a dissenting opinion to your judegement. Do you think the defense could not find a bunch of legal experts who would say you made a bad decision doing this case at a surgery center?

Always protect yourself and your family before trying to help a patient.

I totally see your point and I totally agree. I am under no illusions; there will always be dinguses willing to line up to testify against you if someone pays them to do so.

 

[Blockit]

I would cancel. There's no way I would do this at a surgicenter and none of my surgeons would bring a patient like this to one.

When she's at the main hospital I would do an interscalene + pecs2 and sit her up a little. No sedation.

If I thought she really couldn't handle laying there then I would tube instead of lma so I can control the co2.

Why would you do a block (interscalene) that has such a high risk of hemi phrenic nerve paralysis even when you do low/ultra low volume in such a pulmonary cripple?

 

[ProwlerturnGas]

Infraclavicular with local supplement

 

[deleted643396]

I knew this would be a controversial thing to post, but I thought it was useful in light of the original case situation that started this thread.
The point of the posting was merely to show many of you how things are in other places.
In this particular situation, a block “could” have been an option, especially for someone like myself with significant regional experience. This was an AV graft with incisions in the antecubital fossa as well as up in the armpit with a tunneling between, so ideally I would’ve performed a pecs2 coupled with an axillary block. However, when you go to lie this patient anywhere near flat, she begins coughing almost incessantly. She literally no longer has any ciliary cell function and no muscular strength or elasticity in her lungs to be able to move air. So all of her phlegm just sits there.
In addition, this is a surgery center where we only do “certain blocks“. Part of long-standing traditions on the part of the medical Director of the surgery center. Any suggestion of doing anything different than what happens there every single day is immediately met with anger, fear, and questions of safety. Let’s forget about the fact that the bigger question of safety is doing general anesthesia on this person in the freaking first place.

This ASC is not truly freestanding, it is on the physical campus of one of our main hospitals. However, the distance between the ICU in the hospital and this ASC OR is at least half a mile of halls.

The accusation made by some of you that my doing this case was reckless is not really fair. I am extraordinarily concerned about NOT being reckless. I did residencies in medicine and anesthesia. I am very familiar with the physiology of chronic pulmonary hypertension. And I work in a private practice, where if one gets a reputation as a “canceler”, one gets talked about when one is not around.

I would have been entirely within my right to cancel this patient. Other members of my group likely would have canceled this case without a doubt.
However, what happens then? She has to come back at another time to have the procedure done again. And she likely won’t be any more improved. You can argue that she needs to be done in the hospital, with an arterial line. However, I will argue back that she is receiving three times a week hemodialysis that removes her blood from her body at flows of 300 to 400 mL per minute. They don’t use an arterial line there. She sometimes falls asleep during dialysis, I’m sure. And I’m sure that when she falls asleep she becomes more hypercapnic and that potentially worsens her pulmonary hypertension.

In the end, I decided that in my hands at that time with that patient in that clinical condition I felt that it was significantly possible that I could achieve the desired goal. And on top of that, if you dose her gently and incrementally without burning bridges I could always stop if she became unstable. Of course if she suffered immediate cardiac arrest after induction with 50 mg of propofol, there will always be someone who will come afterwards and say “you never should’ve done this“. But quite frankly the bigger concern is that this person would be offered chronic hemodialysis in the first place. I’m not in control of that, and that ship has already sailed. If you have a detailed discussion with the patient and their family members and explain how significant the risks are and they elect to proceed and you document this, where is the problem?

What happened with the case was that after the LMA went in and as she breathed spontaneously she continued to cough even with ETsevo 2.5%. It took quite a while for her to settle into a breathing rhythm, but for chrissake she goes to sleep every night without end tidal monitoring and seems to wake up the next day. So she just chugged along throughout the case, her blood pressure remained stable, And at the end when I removed the LMA there was a hock of phlegm in that LMA so large that it took up nearly the entire lumen. And I removed it for her. It was like giving a patient with alveolar proteinosis a pulmonary lavage. 😁
When I went to see her 45 minutes later in recovery, she was sitting upright sucking on a lollipop with her nasal cannula oxygen going. I told her that I was happy that she did so well, and she responded “didn’t I tell you I would?“ 🤷🏻‍♂️

For some reason your case bothers me less than doing a spinal cord stimulator in someone with poorly explained worsening dyspnea on exertion. Your patient is sick, but at baseline and not getting better. There is good reason for doing the case sooner rather than later. This is a situation where you explain the risks to all involved and proceed with a reasonable plan, which I think you did.

 

[deleted87051]

What was the procedure?

That being said, unless I saw something else on physical exam or in the clinical history after talking to the patient I wouldn’t have any problem doing this case either. Depending on what it is.

Yesterday I was presented with yet another ASA4 at the surgery center at 5pm for AV fistula creation. Home oxygen, 2 L, 80 years old, 80 pounds, coughing constantly due to end-stage lung disease. Documented severe pulmonary hypertension. Nurses wanted me to cancel. Surgeon really wanted do the case. Each has their own individual motivations.
I looked at the patient thoroughly, listen to her lungs, and there’s virtually no airflow in her lungs due to a loss of strength and tissue. However, I didn’t feel that canceling her yesterday would result in any significant improvement of her in the long run. She would be wheeled back into the surgery center at some later date looking just as crappy. The bigger issue is that she’s being put on dialysis at all, but God forbid I raise that sort of objection.
Patient did fine after receiving general anesthesia. It was a bit rocky tho.

We do cases like this every day…..in the hospital. Why surgicenter? As others have stated, none of our surgeons would think to book a patient like this (esrd on dialysis+pulm htn) at our surgicenter. If they tried, they wouldn’t be allowed.

 

[ucladoc2b]

This was a surgicenter attached to the hospital. As OP has stated this is not an elective case. The patient “needs” dialysis, hence the need for access. Proceed with high risk documented. If you haven’t done hundreds of cases just like this, you haven’t done enough cases…..

Well, I disagree with the “not elective” as there is more than one way to get HD. AVFs typically take a while to mature.

The case was done at an attached surgery center, so they wouldn’t have had to call 911 to transport the pt to the ED. They have an ICU there. It’s closer to an outpatient surgery case done in a hospital. Not as bad as it was made out to be.

 

[vector2]

A permcath placement or two would last as long as this lady's total life expectancy. Absurd they'd put her through an access surgery

 

[Blockit]

A permcath placement or two would last as long as this lady's total life expectancy. Absurd they'd put her through an access surgery

Probably right. But again, in my group in particular we are an independent physician only practice, and while no one *advocates* doing anything unsafe, we ARE encouraged to not cancel for frivolous reasons. This certainly would not have been a frivolous cancellation, but I always cringe a bit for our specialty when I read about someone canceling for excessively “soft” reasons.
And absolutely no one cares about my opinion on the ethics of initiating HD in a patient like this.

 

[Arch Guillotti]

And as far as the pulmonary hypertension goes, echocardiography in January showed PA systolic pressures of 75 with moderate to severe TR, confirmed with a subsequent right heart catheterization.

Seems kind of garden variety.

 

[vector2]

Probably right. But again, in my group in particular we are an independent physician only practice, and while no one *advocates* doing anything unsafe, we ARE encouraged to not cancel for frivolous reasons. This certainly would not have been a frivolous cancellation, but I always cringe a bit for our specialty when I read about someone canceling for excessively “soft” reasons.
And absolutely no one cares about my opinion on the ethics of initiating HD in a patient like this.

Ultimately I agree that the decision as to whether this lady needs surgical access doesn't fall in our lane, so that's not the main reason I object to this case. I object because her clinical presentation is about as far as one could get from a so-called "soft" reason to cancel.

And if I could go one step further and be perfectly frank, my opinion is that your case is not one of those situations where say a cat can get skinned multiple ways or where one can quibble about different institutional or geographic preferences. It is just straight up reckless to do that case with GA on that lady with that history and that current clinical condition at any ASC (hospital attached or otherwise). Even the best the devil's advocates here will offer is maybe block plus generous local.

Furthermore, it sets a bad precedent for you and your partners that any dumbfk surgeon or administrator can book literally anything they want, unsafe or not, and you'll do it. Because really, if you're not gonna cancel her then that means your threshold is essentially near-cardiac arrest or bust.

 

[DrOwnage]

I love doing what I do. But I can honestly say that being the bearer of cancellation has to be the worst part about our job. There is a stigma that comes with it whether you like it or not; especially in private practice. I did a fistula/aneurysm resection with graft placement 2 days ago. This lady had been oozing from a recent dialysis cath placement days prior. Her hgb was 7.4 two days prior to the procedure and she hadn’t had a CBC drawn since. I put in preop labs the night before the case. Came back at 5.8. Had to delay the case and do it later in the day because she needed 2 units. When I walked in that morning one of the nurses said “who ordered the hemoglobin” like it was some kind of annoyance. Since when did thinking about what’s best for our patient, whether it be cancelling or delaying, become such an inconvenience. It’s not even financial, it’s like a $&@? culture we’ve allowed to take hold.

 

[deleted1147063]

I love doing what I do. But I can honestly say that being the bearer of cancellation has to be the worst part about our job. There is a stigma that comes with it whether you like it or not; especially in private practice. I did a fistula/aneurysm resection with graft placement 2 days ago. This lady had been oozing from a recent dialysis cath placement days prior. Her hgb was 7.4 two days prior to the procedure and she hadn’t had a CBC drawn since. I put in preop labs the night before the case. Came back at 5.8. Had to delay the case and do it later in the day because she needed 2 units. When I walked in that morning one of the nurses said “who ordered the hemoglobin” like it was some kind of annoyance. Since when did thinking about what’s best for our patient, whether it be cancelling or delaying, become such an inconvenience. It’s not even financial, it’s like a $&@? culture we’ve allowed to take hold.

This is because we allow them to treat us like we were some hypnagogic monkeys, and not consulting physicians.

You want respect? Great. Dress like a doctor. Wear a white coat outside of the OR. Don't push stretchers, carts etc. even when you work solo. Don't accept to be publicly addressed in any other way than Doctor. Demand to be treated like a doctor, and report those who misbehave. Generally, don't do anything a surgeon wouldn't do, regardless how much money they pay you.

Oh, wait, most American anesthesiologists would need a proper spine implant for these.

 

[dabears505]

Oh, wait, most American anesthesiologists would need a proper spine implant for these.

I went in for one, and of course the lazy anesthesiologist cancelled my case.

 

[deleted641888]

This is because we allow them to treat us like we were some hypnagogic monkeys, and not consulting physicians.

You want respect? Great. Dress like a doctor. Wear a white coat outside of the OR. Don't push stretchers, carts etc. even when you work solo. Don't accept to be publicly addressed in any other way than Doctor. Demand to be treated like a doctor, and report those who misbehave. Generally, don't do anything a surgeon wouldn't do, regardless how much money they pay you.

Oh, wait, most American anesthesiologists would need a proper spine implant for these.

Agree with the first part. Disagree with how we go about getting that respect.

Anyone wearing a white coat around the hospital as an anesthesiologist around here would get laughed out of the building (except for during interdepartmental meetings, presentations, etc.). Don't push stretchers? What? I push my own stretchers if it means getting out of the room faster. I've seen surgeons do this too (get the patient stretcher from outside, help move the patient, prep the patient, position the patient, etc.) if it means faster time in and out of the OR. I respect them 100% more than surgeons who just sit on the computer complaining about how long the turnovers are when they don't do anything to help speed things along. Most of the OR staff and CRNAs address me by "doctor," but the few who don't, know who I am and respect me as a physician, not because I demand to be addressed as "doctor" or refuse to push stretchers but because of the exact opposite.

To get respect in the hospital, it does take good leadership to set a high standard. We have that here. It doesn't take ridiculously outdated, somewhat patriarchal shows of "being a doctor" to get there.

 

[deleted1147063]

Agree with the first part. Disagree with how we go about getting that respect.

Anyone wearing a white coat around the hospital as an anesthesiologist around here would get laughed out of the building (except for during interdepartmental meetings, presentations, etc.). Don't push stretchers? What? I push my own stretchers if it means getting out of the room faster. I've seen surgeons do this too (get the patient stretcher from outside, help move the patient, prep the patient, position the patient, etc.) if it means faster time in and out of the OR. I respect them 100% more than surgeons who just sit on the computer complaining about how long the turnovers are when they don't do anything to help speed things along. Most of the OR staff and CRNAs address me by "doctor," but the few who don't, know who I am and respect me as a physician, not because I demand to be addressed as "doctor" or refuse to push stretchers but because of the exact opposite.

To get respect in the hospital, it does take good leadership to set a high standard. We have that here. It doesn't take ridiculously outdated, somewhat patriarchal shows of "being a doctor" to get there.

You think it's patriarchal? You're wrong. It's basic psychology.

Why do you think generals don't eat with the troops, don't shower with the troops, don't sleep with the troops? And that's just one of tons of examples. Does your hospital CEO or any major bean counter walk around in scrubs or answer their own office phone? Or do they have an assistant? And an office? Etc.

One can be friendly and professional without being servile and/or egalitarian. But if one wants to be treated like a physician, one should look the part and behave like one. If one looks and behave like a nurse or a tech, one will be treated like one, not like the person where the buck stops (legally). Do you see the average surgeon kiss as much ass as the average anesthesiologist?

Keep begging for that respect, and being surprised that physicians are becoming "providers", and anesthesiologists are treated like techs. That's what happens to nice suckers. That's also proven by a lot of studies: nice people finish last.

So, yeah, every time I hear a doctor whine about not getting respect, I ask: And what have you done to change that? Usually I get some BS about being nice and avoiding conflict. And when it obviously doesn't work, they keep making the same mistakes and never standing up for themselves.

There is a reason the best strategy in game theory is repayment in kind, also known as tit for tat.

And obviously I don't refuse to push stretchers etc. But I do encourage my department to stop doing that. To stop bending over backwards for everybody when the other side is not bending for us.

There is a reason we call the president of the United States Mr. President. It's respect for the office, not the person. Why is it OK to not be respected for being a doctor, when the buck stops with you, legally? When they all run to you when the **** hits the fan?

And please don't confuse lack of visible disrespect with respect. If they respected you, they would offer to push that stretcher for you etc.

 

[secretasianman]

You guys are off. Physicians in general no longer get respect, not just anesthesiologists. The recently developing sentiment by nurses is they do all the work anyways and are equivalent or better.

 

[deleted1147063]

You guys are off. Physicians in general no longer get respect, not just anesthesiologists. The recently developing sentiment by nurses is they do all the work anyways and are equivalent or better.

Agree, but we have a particular talent to eat **** and say Thank You, as a specialty.

There is a reason many of us who can work outside of the OR prefer it.

 

[Agast]

Meh. Definitely should have been done as local/sedation. That being said there is virtually no lawsuit risk for this 80 year old sick as $hit ESRD patient. Typically families are somewhat relieved when things go all the way south😉. Even if they did pursue litigation I Doubt there would be too many attorneys willing to take the case because it’s unlikely to pay out significant $$ if at all.

You have not met her daughter, she lives in California and is finishing RN school…

 

[Twiggidy]

Agree with the first part. Disagree with how we go about getting that respect.

Anyone wearing a white coat around the hospital as an anesthesiologist around here would get laughed out of the building (except for during interdepartmental meetings, presentations, etc.). Don't push stretchers? What? I push my own stretchers if it means getting out of the room faster. I've seen surgeons do this too (get the patient stretcher from outside, help move the patient, prep the patient, position the patient, etc.) if it means faster time in and out of the OR. I respect them 100% more than surgeons who just sit on the computer complaining about how long the turnovers are when they don't do anything to help speed things along. Most of the OR staff and CRNAs address me by "doctor," but the few who don't, know who I am and respect me as a physician, not because I demand to be addressed as "doctor" or refuse to push stretchers but because of the exact opposite.

To get respect in the hospital, it does take good leadership to set a high standard. We have that here. It doesn't take ridiculously outdated, somewhat patriarchal shows of "being a doctor" to get there.

Agree. There are nurses, NPs, respiratory techs, etc who wear white coats in the hospital. In some odd way I do feel like people approach anesthesiologists as the most “down to Earth” doctors which can be a blessing and curse. This is where I can agree with FFP because there are time where you have to remind people “we are doctors” and sometimes it’s shown to them when we’re the only ones in the room who knows what they’re doing.

 

[pastafan]

Getting back to original post. There is no such thing as "medical clearance". The physician consulted is being asked to answer one question, is the patient's medical status optimized and to provide a medical history for the anesthesiologist to evaluate.

Instead of a physician you got a midlevel to label patient low risk. They should have ordered PFT's with and without bronchodilators and evaluated the DOE, if they were normal with cardiac workup, to determine if the patient was optimized.

With this information the anesthesiologists would have data and not just a gut feeling resulting in the case being cancelled last minute.

 

[Maz777]

Anesthesia cancelling case.
Reported pneumonia a month ago. H/o asthma.
Off Abx x10 days.
Normal CBC
Normal CXR.
Pre-op eval 2 days before surgery and patient says SOB when waking to car. No sx in office, normal pulse ox on RA.
Cancelled by anesthesia as not at baseline.
Fax today from PCP saying low risk.

Your take?

None of us really care about the PCP's risk stratification. They have never taken care of a perioperative patient before. Can just shred that fax.

Pretty easy cancel if scheduled at an ASC (and even at a hospital). Significant pulmonary infection < 6 weeks ago. Pulmonary symptoms don't appear to be at baseline. Case is the definition of elective. Pain physicians aren't the money makers that make the ORs tick, so it's a pretty easy cancel even in PP.

Do you expect us to print out an RCT for you of this specific patient population with a PNA 4 weeks ago after finishing a course of antibiotics and not at baseline DOE? If so, good luck.

 

[Ronin786]

You think it's patriarchal? You're wrong. It's basic psychology.

Why do you think generals don't eat with the troops, don't shower with the troops, don't sleep with the troops? And that's just one of tons of examples. Does your hospital CEO or any major bean counter walk around in scrubs or answer their own office phone? Or do they have an assistant? And an office? Etc.

One can be friendly and professional without being servile and/or egalitarian. But if one wants to be treated like a physician, one should look the part and behave like one. If one looks and behave like a nurse or a tech, one will be treated like one, not like the person where the buck stops (legally). Do you see the average surgeon kiss as much ass as the average anesthesiologist?

Keep begging for that respect, and being surprised that physicians are becoming "providers", and anesthesiologists are treated like techs. That's what happens to nice suckers. That's also proven by a lot of studies: nice people finish last.

So, yeah, every time I hear a doctor whine about not getting respect, I ask: And what have you done to change that? Usually I get some BS about being nice and avoiding conflict. And when it obviously doesn't work, they keep making the same mistakes and never standing up for themselves.

There is a reason the best strategy in game theory is repayment in kind, also known as tit for tat.

And obviously I don't refuse to push stretchers etc. But I do encourage my department to stop doing that. To stop bending over backwards for everybody when the other side is not bending for us.

There is a reason we call the president of the United States Mr. President. It's respect for the office, not the person. Why is it OK to not be respected for being a doctor, when the buck stops with you, legally? When they all run to you when the **** hits the fan?

And please don't confuse lack of visible disrespect with respect. If they respected you, they would offer to push that stretcher for you etc.

When you look at strong anesthesia departments countrywide (purely from an academics standpoint) you realize a culture of respect from everybody (nurses, patients and surgeons).

Too many groups have let their ORs jump to cater to whatever whim their surgeons have. I find it funny when you have academic centers with anesthesiologists that won't lift a finger to argue with their surgeons. They're not going to go take their cases elsewhere. And if you have a supportive department you should feel supported to do what you think is best.

 

[Silo004]

I would cancel. There's no way I would do this at a surgicenter and none of my surgeons would bring a patient like this to one.

When she's at the main hospital I would do an interscalene + pecs2 and sit her up a little. No sedation.

If I thought she really couldn't handle laying there then I would tube instead of lma so I can control the co2.

Interscalene takes out her diaphragm. How does she do on one lung for 12-18 hrs with baseline RVSP in 70s.

 

[lobelsteve]

None of us really care about the PCP's risk stratification. They have never taken care of a perioperative patient before. Can just shred that fax.

Pretty easy cancel if scheduled at an ASC (and even at a hospital). Significant pulmonary infection < 6 weeks ago. Pulmonary symptoms don't appear to be at baseline. Case is the definition of elective. Pain physicians aren't the money makers that make the ORs tick, so it's a pretty easy cancel even in PP.

Do you expect us to print out an RCT for you of this specific patient population with a PNA 4 weeks ago after finishing a course of antibiotics and not at baseline DOE? If so, good luck.

Normal CXR and you say significant pulmonary infection less than 6 weeks ago. ABC. Abrogate, berate, conflate. When the NP for anesthesia says no and no doc looks at the patient and the history she gets is wrong, not possible, and nonsense- there is a reason a lot of anesthesia docs get treated badly. Not doing their job.

 

[deleted1147063]

Normal CXR and you say significant pulmonary infection less than 6 weeks ago. ABC. Abrogate, berate, conflate. When the NP for anesthesia says no and no doc looks at the patient and the history she gets is wrong, not possible, and nonsense- there is a reason a lot of anesthesia docs get treated badly. Not doing their job.

The resolution phase of a recent pneumonia can be completely invisible on a CXR.

As sensitivity and specificity for many lung diseases (or fluid status) go, CXR is a joke.

And you should know that your patient had a recent pneumonia and should not have elective procedures. That's like perioperative medicine 101. Stop blaming others. Why was this patient even seen by the anesthesia NP? Who was the one who did not get the proper history in the first place?

 

[lobelsteve]

The resolution phase of a recent pneumonia can be completely invisible on a CXR.

As sensitivity and specificity for many lung diseases (or fluid status) go, CXR is a joke.

And you should know that your patient had a recent pneumonia and should not have elective procedures. That's like perioperative medicine 101. Stop blaming others. Why was this patient even seen by the anesthesia NP?

Patterns of Resolution of Chest Radiograph Abnormalities in Adults Hospitalized with Severe Community-Acquired Pneumonia​

Anke H. W. Bruns, Jan Jelrik Oosterheert, Mathias Prokop, Jan-Willem J. Lammers, Eelko Hak, Andy I. M. Hoepelman
Clinical Infectious Diseases, Volume 45, Issue 8, 15 October 2007, Pages 983–991, Patterns of Resolution of Chest Radiograph Abnormalities in Adults Hospitalized with Severe Community-Acquired Pneumonia
Published:

15 October 2007

Abstract​

Background. Timing of follow-up chest radiographs for patients with severe community-acquired pneumonia (CAP) is difficult, because little is known about the time to resolution of chest radiograph abnormalities and its correlation with clinical findings. To provide recommendations for short-term, in-hospital chest radiograph follow-up, we studied the rate of resolution of chest radiograph abnormalities in relation to clinical cure, evaluated predictors for delayed resolution, and determined the influence of deterioration of radiographic findings during follow-up on prognosis.
Methods. A total of 288 patients who were hospitalized because of severe CAP were followed up for 28 days in a prospective multicenter study. Clinical data and scores for clinical improvement at day 7 and clinical cure at day 28 were obtained. Chest radiographs were obtained at hospital admission and at days 7 and 28. Resolution and deterioration of chest radiograph findings were determined.
Results. At day 7, 57 (25%) of the patients had resolution of chest radiograph abnormalities, whereas 127 (56%) had clinical improvement (mean difference, 31%; 95% confidence interval, 25%–37%). At day 28, 103 (53%) of the patients had resolution of chest radiograph abnormalities, and 152 (78%) had clinical cure (mean difference, 25%; 95% confidence interval, 19%–31%). Delayed resolution of radiograph abnormalities was independently associated with multilobar disease (odds ratio, 2.87; P ⩽ .01); dullness to percussion at physical examination (odds ratio, 6.94; P ⩽ .01); high C-reactive protein level, defined as >200 mg/L (odds ratio, 4.24; P ⩽ .001); and high respiratory rate at admission, defined as >25 breaths/min (odds ratio, 2.42; P ⩽ .03). There were no significant differences in outcome at day 28 between patients with and patients without deterioration of chest radiograph findings during the follow-up period (P > .09).
Conclusions. Routine short-term follow-up chest radiographs (obtained <28 days after hospital admission) of hospitalized patients with severe CAP seem to provide no additional clinical value.




And my patient did not have PNA, the Dx came from PCP who gave an Rx for ABX presumptive in an asthmatic. The Anesthesia NP saw patient day before surgery. I am the implanting physician.

 

[vector2]

Normal CXR and you say significant pulmonary infection less than 6 weeks ago. ABC. Abrogate, berate, conflate. When the NP for anesthesia says no and no doc looks at the patient and the history she gets is wrong, not possible, and nonsense- there is a reason a lot of anesthesia docs get treated badly. Not doing their job.

I know you're really far removed from any clinical medicine that doesn't involve a barely efficacious needle-based procedure, but please realize that someone going from essentially normal to short of breath just walking to their car is a serious finding which needs explanation, especially if the presumptive dx of PNA seems unlikely.

 

[chessknt]

Patterns of Resolution of Chest Radiograph Abnormalities in Adults Hospitalized with Severe Community-Acquired Pneumonia​

Anke H. W. Bruns, Jan Jelrik Oosterheert, Mathias Prokop, Jan-Willem J. Lammers, Eelko Hak, Andy I. M. Hoepelman
Clinical Infectious Diseases, Volume 45, Issue 8, 15 October 2007, Pages 983–991, Patterns of Resolution of Chest Radiograph Abnormalities in Adults Hospitalized with Severe Community-Acquired Pneumonia
Published:

15 October 2007

Abstract​

Background. Timing of follow-up chest radiographs for patients with severe community-acquired pneumonia (CAP) is difficult, because little is known about the time to resolution of chest radiograph abnormalities and its correlation with clinical findings. To provide recommendations for short-term, in-hospital chest radiograph follow-up, we studied the rate of resolution of chest radiograph abnormalities in relation to clinical cure, evaluated predictors for delayed resolution, and determined the influence of deterioration of radiographic findings during follow-up on prognosis.
Methods. A total of 288 patients who were hospitalized because of severe CAP were followed up for 28 days in a prospective multicenter study. Clinical data and scores for clinical improvement at day 7 and clinical cure at day 28 were obtained. Chest radiographs were obtained at hospital admission and at days 7 and 28. Resolution and deterioration of chest radiograph findings were determined.
Results. At day 7, 57 (25%) of the patients had resolution of chest radiograph abnormalities, whereas 127 (56%) had clinical improvement (mean difference, 31%; 95% confidence interval, 25%–37%). At day 28, 103 (53%) of the patients had resolution of chest radiograph abnormalities, and 152 (78%) had clinical cure (mean difference, 25%; 95% confidence interval, 19%–31%). Delayed resolution of radiograph abnormalities was independently associated with multilobar disease (odds ratio, 2.87; P ⩽ .01); dullness to percussion at physical examination (odds ratio, 6.94; P ⩽ .01); high C-reactive protein level, defined as >200 mg/L (odds ratio, 4.24; P ⩽ .001); and high respiratory rate at admission, defined as >25 breaths/min (odds ratio, 2.42; P ⩽ .03). There were no significant differences in outcome at day 28 between patients with and patients without deterioration of chest radiograph findings during the follow-up period (P > .09).
Conclusions. Routine short-term follow-up chest radiographs (obtained <28 days after hospital admission) of hospitalized patients with severe CAP seem to provide no additional clinical value.




And my patient did not have PNA, the Dx came from PCP who gave an Rx for ABX presumptive in an asthmatic. The Anesthesia NP saw patient day before surgery. I am the implanting physician.

Disappearing from a chest x ray doesn't mean ****. Do they have pfts to prove their DLCO is normal and there is no restriction? What if they're having asthma issues related to the infection and need steroids? An out of breath asthmatic has to have pfts for any kind of informed optimization period. If their fev is half of their usual value that is a big high risk problem that needs to get fixed first over a period of a few weeks. If fev1 is normal but DLCO has dropped maybe they had a huge PE and that is the problem.

Asking a clinical question about lung disease using a cxr is like me taking a lumbar spine x-ray and saying their spine is fine because it is normal. Ct chest is standard of care for almost all forms of pulmonary disease where there is any concern for parenchymal pathology.

 

[deleted87051]

As anesthesiologists, we rely on pulmonary reserve to keep our patients out of trouble and minimize the risk of a perioperative event. We’ve all had our butts handed to us on a plate enough times to make an impression. If the patient has more dyspnea on exertion than normal, they do not have their usual pulmonary reserve, and will likely desaturate faster if there are any airway or ventilation issues. They are not optimized for a completely elective procedure. If they were getting a pacemaker for heart block or a defibrillator for recurrent VT, it would be a different story.


Our ortho joint, ortho spine, bariatric, cardiothoracic surgeons wouldn’t even send a patient like this to our pre-eval unit. They’d tell the patient they need to wait until they are feeling better. If our joint guys see an ingrown hair anywhere near their incision site on the morning of surgery, they cancel. Same with the spine guys when they see a pimple on the back. I feel like there is more to this story. If the patient is not optimized, why the urgency? No single case is worth an unnecessary complication. There is an endless stream of cases coming down the pike.

If you find more than 1 or 2 of your cases are being postponed by anesthesia every year, you should look at your own preop evaluation process. There’s no anesthesia conspiracy to delay cases. Most of us lose money when we postpone a case.

 

[deleted643396]

Patterns of Resolution of Chest Radiograph Abnormalities in Adults Hospitalized with Severe Community-Acquired Pneumonia​

Anke H. W. Bruns, Jan Jelrik Oosterheert, Mathias Prokop, Jan-Willem J. Lammers, Eelko Hak, Andy I. M. Hoepelman
Clinical Infectious Diseases, Volume 45, Issue 8, 15 October 2007, Pages 983–991, Patterns of Resolution of Chest Radiograph Abnormalities in Adults Hospitalized with Severe Community-Acquired Pneumonia
Published:

15 October 2007

Abstract​

Background. Timing of follow-up chest radiographs for patients with severe community-acquired pneumonia (CAP) is difficult, because little is known about the time to resolution of chest radiograph abnormalities and its correlation with clinical findings. To provide recommendations for short-term, in-hospital chest radiograph follow-up, we studied the rate of resolution of chest radiograph abnormalities in relation to clinical cure, evaluated predictors for delayed resolution, and determined the influence of deterioration of radiographic findings during follow-up on prognosis.
Methods. A total of 288 patients who were hospitalized because of severe CAP were followed up for 28 days in a prospective multicenter study. Clinical data and scores for clinical improvement at day 7 and clinical cure at day 28 were obtained. Chest radiographs were obtained at hospital admission and at days 7 and 28. Resolution and deterioration of chest radiograph findings were determined.
Results. At day 7, 57 (25%) of the patients had resolution of chest radiograph abnormalities, whereas 127 (56%) had clinical improvement (mean difference, 31%; 95% confidence interval, 25%–37%). At day 28, 103 (53%) of the patients had resolution of chest radiograph abnormalities, and 152 (78%) had clinical cure (mean difference, 25%; 95% confidence interval, 19%–31%). Delayed resolution of radiograph abnormalities was independently associated with multilobar disease (odds ratio, 2.87; P ⩽ .01); dullness to percussion at physical examination (odds ratio, 6.94; P ⩽ .01); high C-reactive protein level, defined as >200 mg/L (odds ratio, 4.24; P ⩽ .001); and high respiratory rate at admission, defined as >25 breaths/min (odds ratio, 2.42; P ⩽ .03). There were no significant differences in outcome at day 28 between patients with and patients without deterioration of chest radiograph findings during the follow-up period (P > .09).
Conclusions. Routine short-term follow-up chest radiographs (obtained <28 days after hospital admission) of hospitalized patients with severe CAP seem to provide no additional clinical value.




And my patient did not have PNA, the Dx came from PCP who gave an Rx for ABX presumptive in an asthmatic. The Anesthesia NP saw patient day before surgery. I am the implanting physician.

Why are you focused on pneumonia and CXR if you don’t think that is the cause of your patient’s dyspnea? Why are you asking your anesthesiologist to present evidence about timing of elective procedures after pneumonia when you are suspicious that the patient never had pneumonia in the first place?

Day of surgery cancellations are frustrating, I get it. However, they happen and they often happen for good reason. This is a patient with worsening dyspnea on exertion that was likely misdiagnosed as community acquired pneumonia presenting for elective procedure. Good on the anesthesiologist for the due diligence to catch this and put a halt to it. This patient needs a good internist and not an anesthesia pre-op NP or some primary care doc who’s first reaction is to prescribe a z-pak for everything.

 

[pgg]

Normal CXR

It's been pointed out a number of times in this thread (going back to post #26) that a normal CXR isn't the "all is well" data point you seem to think it is. I don't know why you're still fixated on telling us the CXR was normal.

This person can't walk on level ground without dyspnea.

If you're skeptical of the pneumonia story, you should be MORE curious, not less.

 

[AKMD_1984]

The OP is acting like a spinal cord stimulator is some life saving therapy. Why not wait when the patient is back to baseline and/or optimized?
It’s an elective interventional pain procedure with marginal long term benefit. Patient would probably be fine without it also. Have seen plenty of SCS explanted, or displaced leads or just non-efficacious.
I really question the need to push for this at this time.

 

[deleted87051]

It's been pointed out a number of times in this thread (going back to post #26) that a normal CXR isn't the "all is well" data point you seem to think it is. I don't know why you're still fixated on telling us the CXR was normal.

This person can't walk on level ground without dyspnea.

If you're skeptical of the pneumonia story, you should be MORE curious, not less.

Said patient reported SOB above baseline when walking to car. Patient clarified in my office that is what brought him to PCP the month prior. But with neg CXR for PNA, unsure if he had anything going on.

+1.

Could have a lot going on besides pneumonia ….severe AS, mitral stenosis , CAD, decompensating CHF, poorly controlled asthma, CTEPH, etc, etc. Unexplained, new-onset dyspnea on exertion needs to be investigated prior to elective surgery. Especially since it was was bad enough for him to seek medical attention.

 

[DrMDAware]

I am pain trained….seems like a fair amount of hate on pain.

No need to fire any shots.

 

[secretasianman]

What’s driving this push? Let’s not kid ourselves, this is 100% financially driven, and not because of what’s the best interest for this patient. All you have to do to find out is ask OP how many of these cases he does at the hospital instead of his ASC.

The OP is acting like a spinal cord stimulator is some life saving therapy. Why not wait when the patient is back to baseline and/or optimized?
It’s an elective interventional pain procedure with marginal long term benefit. Patient would probably be fine without it also. Have seen plenty of SCS explanted, or displaced leads or just non-efficacious.
I really question the need to push for this at this time.

 

[D P356]

I am pain trained….seems like a fair amount of hate on pain.

No need to fire any shots.

No intentional hate on pain. The OP had a previous case get cancelled due to hyperkalema (>5.5) and wrote that he would try to get that anesthesiologist fired if they did that again.

He doesn’t understand risk vs benefit of an anesthetic with different co-morbidities. There’s nothing wrong with that as that’s not his job. He is not anesthesia trained. If he has the best interest of the patient as the top priority, there’s not much else that could be asked for.

OP: the next time the anesthesia team cancels the anesthetic to your case, will you sedate the patient yourself? They didn’t cancel the case, just the anesthetic.

 

[lobelsteve]

What’s driving this push? Let’s not kid ourselves, this is 100% financially driven, and not because of what’s the best interest for this patient. All you have to do to find out is ask OP how many of these cases he does at the hospital instead of his ASC.

I work for a hospital. Hospital owns the ASC and main OR. Do all cases for last 2 years in main OR. Anesthesia is now owned by hospital. They have their own pain services separate from my practice. I am on salary with a cap.
1. Patient never had documented pneumonia.
2. Episode of SOB was 4 weeks before seeing me as consult for implant.
3. No labs/imaging showed acute medical condition.
4. At time of consult patient had no signs/sx of any acute illness.
5. Scheduled surgery was 2 weeks after consult.

 

[pgg]

I am pain trained….seems like a fair amount of hate on pain.

No need to fire any shots.

They're the same shots we fire at orthopedics when they go into there-is-a-fracture-I-need-to-fix-it mode, where asystole is merely a condition that may reduce blood loss. OP seems to view anesthesiologists as ancillary servants comparable to hospital food service personnel, or possibly lab techs, where he orders something and it gets done.

Honestly, in these two threads he's taken ortho's game to a new level.

 

[lobelsteve]

No intentional hate on pain. The OP had a previous case get cancelled due to hyperkalema (>5.5) and wrote that he would try to get that anesthesiologist fired if they did that again.

He doesn’t understand risk vs benefit of an anesthetic with different co-morbidities. There’s nothing wrong with that as that’s not his job. He is not anesthesia trained. If he has the best interest of the patient as the top priority, there’s not much else that could be asked for.

OP: the next time the anesthesia team cancels the anesthetic to your case, will you sedate the patient yourself? They didn’t cancel the case, just the anesthetic.

If case posted for OR and MAC/general requested, policy does not allow me to go local only. I do one implant per year with local only. Takes the right patient and 30cc lido, 20cc bupi. Or there abouts.

 

[pgg]

I work for a hospital. Hospital owns the ASC and main OR. Do all cases for last 2 years in main OR. Anesthesia is now owned by hospital. They have their own pain services separate from my practice. I am on salary with a cap.
1. Patient never had documented pneumonia.
2. Episode of SOB was 4 weeks before seeing me as consult for implant.
3. No labs/imaging showed acute medical condition.
4. At time of consult patient had no signs/sx of any acute illness.
5. Scheduled surgery was 2 weeks after consult.

That's all very reasonable.

What's unreasonable is your pushback for the day-of-surgery delay, when the patient showed up with obvious, concerning signs/sx of illness.

 

[lobelsteve]

They're the same shots we fire at orthopedics when they go into there-is-a-fracture-I-need-to-fix-it mode, where asystole is merely a condition that may reduce blood loss. OP seems to view anesthesiologists as ancillary servants comparable to hospital food service personnel, or possibly lab techs, where he orders something and it gets done.

Honestly, in these two threads he's taken ortho's game to a new level.

The surgery I perform is a procedure. The risk from anesthesia and not from the procedure. Either SCS, gasserian RF, or kypho. All other procedures are done in office fluoroscopy suite. Risk from surgery is violating the cord/IT space. Creating a pocket and threading epidural leads is not a colon resection or THA.

 

[lobelsteve]

That's all very reasonable.

What's unreasonable is your pushback for the day-of-surgery delay, when the patient showed up with obvious, concerning signs/sx of illness.

He had no sx from day I saw him to day of anticipated surgery. NP for anesthesia misquoted/misinterpreted his 1 episode of SOB of walking to car as that day and not 6 weeks prior.

 

[D P356]

If case posted for OR and MAC/general requested, policy does not allow me to go local only. I do one implant per year with local only. Takes the right patient and 30cc lido, 20cc bupi. Or there abouts.

Perhaps you should book them all as local. Then you won’t have to deal with anesthesia canceling anything.

As you have to book as a mac/general, you know you want nothing to do with sedating the patient and defer to the anesthesiologist.

Don’t get your feelings hurt when they make a call based upon perioperative clinical knowledge or experience that you don’t have. You already deferred to them with how you booked the case. Every anesthetic has risks.


Or again, book them all as local only.