when do you check the E?

[anbuitachi]

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ASA scores. the E. when do you mark them?
Just for life/limb cases? urgent add ons? only if surgeon/procedurelist documents emergency?

examples are like, femur fracture add ons, TEE post stroke patients, lap chole, lap appy add ons, etc.

 

[vector2]

ASA scores. the E. when do you mark them?
Just for life/limb cases? urgent add ons? only if surgeon/procedurelist documents emergency?

examples are like, femur fracture add ons, TEE post stroke patients, lap chole, lap appy add ons, etc.

I mark it for pretty much every case that is designated and booked as urgent or emergent by the surgeon or proceduralist.

 

[Onefellswoop87]

If it can’t wait til the next business day (and thus “scheduled”), it gets an E.

 

[pgg]

Any case that doesn't get booked through the normal channels, into normal block time, with a normal lead time, isn't routine and therefore gets an E from me. So basically everything added on same-day, or at night, or on a weekend.

 

[deleted87051]

And anything that involves pus…butt pus, foot pus, neck pus, arm pus.

 

[UscGhost]

Does insurance even pay for it anymore?

 

[pocafx]

So the daily add on cystos get an E?

 

[Mofeen]

Does it still pay more? If not, who cares? I do it for the ex lap/CS/appy/crani/etc that must go over the next few hours based on clinical picture, not because of surgeon stomping their feet. That said, either way, my management of the patient doesnt change. Do what you do y'all.

 

[coffeebythelake]

Anything outside of normal hours, or that violates npo guidelines.

 

[Hoya11]

Anything outside of normal hours, or that violates npo guidelines.

Right. Any time the patient is clearly not optimized but I need to proceed anyways.

An add on cysto for a stone or fracture orif in an npo patient not an emergency imo

 

[coffeebythelake]

An add on cysto for a stone or fracture orif in an npo patient not an emergency imo

Eh. If the surgeon wants to do it at 10 pm with the on-call team I would argue it should be considered E. They are using limited nursing and anesthesia staffing resources meant for an emergency.

 

[dchz]

I check when it's emergent.

 

[zizzer]

If there is a threat to life or body part if it's not done in an urgent fashion

 

[coffeebythelake]

If there is a threat to life or body part if it's not done in an urgent fashion

Well yes that is the definition of an emergent or urgent surgery. But how about the surgeon who decides they want to do that uncomplicated, nonperforated lap appy at 10 pm because the patient came to the ER at 7 pm with RLQ pain..

 

[jwk]

Every labor epidural is an E.

 

[anbuitachi]

Every labor epidural is an E.

really?

 

[zizzer]

Well yes that is the definition of an emergent or urgent surgery. But how about the surgeon who decides they want to do that uncomplicated, nonperforated lap appy at 10 pm because the patient came to the ER at 7 pm with RLQ pain..

If I'm not going to give pushback then I'll put an E there to reflect the surgeon's reasoning that there's urgent threat to life or body part.

 

[pgg]

Every labor epidural is an E.

No

 

[Gator7]

Every labor epidural is an E.

I have seen people do this. What is the thought process?

 

[sevoflurane]

Not a single labor epidural is an emergency.
Ever.

As for add-ons after hours. Most are E’s but a big chunk of them are not and are a mere convenience for a surgeon and/or patient. I don’t put E’s on those because they are not emergent in any way.

Non-strangulated hernia that is reducible and painless that has been sitting in the ED for 8 hours due to NPO status? Yeah… that’s not an E in my book.

 

[Arch Guillotti]

Every labor epidural is an E.

5E

 

[coffeebythelake]

I think we all agree there are surgeons that want to do cases in the middle of the night not because they are truly emergent or urgent, but because they are on call and around. Aka for surgeon convenience. My role as the on-call anesthesiologist isn't to do whatever cases the surgeon wants whenever he wants. It is to be available in case of emergencies. If they are going to wake me up to do a case at 10 pm or 2 am in the morning it better be something important, not because the ORs are free. I push back on cases that don't appear to be urgent or emergent. I've taught my residents to do the same. But other anesthesiologists just accept whatever cases that are booked.

What has happened over time with weak leadership and cohesion among anesthesiologists is that petulant surgeons have reframed the role of the emergency call team to be essentially an extension of the day team OR.

 

[coffeebythelake]

5E

Fortunately not ASA6

 

[coffeebythelake]

As for add-ons after hours. Most are E’s but a big chunk of them are not and are a mere convenience for a surgeon and/or patient. I don’t put E’s on those because they are not emergent in any way.

Non-strangulated hernia that is reducible and painless that has been sitting in the ED for 8 hours due to NPO status? Yeah… that’s not an E in my book.

Then why are u doing them in the middle of the night? You spoil your surgeons... and they dont even realize or appreciate it. I would punt to day team.

 

[deleted1130227]

Every labor epidural is an E.

Only to the Mom.

 

[sevoflurane]

Then why are u doing them in the middle of the night? You spoil your surgeons... and they dont even realize or appreciate it. I would punt to day team.

I would and have laughed off 2 am hernia case. 5pm? Not so nuch. Patient is ready, surgeon is ready, I am ready and we have staff. When you are a regional center your add-ons can be 20+ in a day. No need to punt if you can do it at a reasonable time.

 

[sevoflurane]

We follow a matrix schedule and if there is an opening to get a case done it’s better for everyone.

Nothing worse than seeing 8 OR staff getting paid to sit around when you can bang out cases and clear the board for the next day. When I run the schedule that doesn’t happen often. All decks on board until we start coming down on rooms.

 

[sevoflurane]

Community center? that’s a different story.

 

[coffeebythelake]

I would and have laughed off 2 am hernia case. 5pm? Not so nuch. Patient is ready, surgeon is ready, I am ready and we have staff. When you are a regional center your add-ons can be 20+ in a day. No need to punt if you can do it at a reasonable time.

Fair enough 👌

I do think we are imagining different staffing situations.

 

[Arch Guillotti]

We follow a matrix schedule and if there is an opening to get a case done it’s better for everyone.

Nothing worse than seeing 8 OR staff getting paid to sit around when you can bang out cases and clear the board for the next day. When I run the schedule that doesn’t happen often. All decks on board until we start coming down on rooms.

You manage the OR staff?

 

[deleted87051]

Does insurance even pay for it anymore?

I think some do and some don’t. Our group gives us 2units for it.

 

[jwk]

Any case that doesn't get booked through the normal channels, into normal block time, with a normal lead time, isn't routine and therefore gets an E from me. So basically everything added on same-day, or at night, or on a weekend.

Anything outside of normal hours, or that violates npo guidelines.

So wouldn't a labor epidural fit your definitions?

They're unscheduled - typically not NPO - are all potential C-sections - and can happen any time 24/7/365.

 

[sevoflurane]

You manage the OR staff?

OR manager checks in w/ 1st call for every case after 5pm. We open rooms as necessary if we have the staff.

 

[Onefellswoop87]

So wouldn't a labor epidural fit your definitions?

They're unscheduled - typically not NPO - are all potential C-sections - and can happen any time 24/7/365.

Except no pain therapy is an emergency. A spinal or even a dosed up epidural for a c-section can absolutely be an E but an epidural for the purpose of analgesia during labor is not (which is what you originally asked).

The E is related to not only patient presentation (unscheduled, maybe not NPO) but also the procedure and the associated anesthetic.

But I’m presume you know all of that and are trying to trap the above posters with a “gotcha” moment from their short one or two sentence reply.

 

[vector2]

I think we all agree there are surgeons that want to do cases in the middle of the night not because they are truly emergent or urgent, but because they are on call and around. Aka for surgeon convenience. My role as the on-call anesthesiologist isn't to do whatever cases the surgeon wants whenever he wants. It is to be available in case of emergencies. If they are going to wake me up to do a case at 10 pm or 2 am in the morning it better be something important, not because the ORs are free. I push back on cases that don't appear to be urgent or emergent. I've taught my residents to do the same. But other anesthesiologists just accept whatever cases that are booked.

What has happened over time with weak leadership and cohesion among anesthesiologists is that petulant surgeons have reframed the role of the emergency call team to be essentially an extension of the day team OR.

There's a higher-level question in here which really comes down to what the institutional policy is. The call anesthesiologist shouldn't be the one who has to arbitrarily decide what's urgent/emergent, what goes, what doesn't, and when.

Our institution has designated from the top down the max number of rooms we can run by 3pm, by 7pm, and overnight. So if I'm on overnight I know that I could potentially be running 1 elective room plus 1-2 trauma/ bonafide emergency rooms if something comes up. Plus we have a list from each surgery subspecialty listing what cases actually count as their urgent and emergent cases. And if there are many elective cases on the board with surgeons who want to operate in that elective room overnight, the trauma surgeon on-call triages the order or asks the individual surgeons to decide amongst themselves if there's a big disagreement. In our system, there's no ambiguity.

 

[Onefellswoop87]

There's a higher-level question in here which really comes down to what the institutional policy is. The call anesthesiologist shouldn't be the one who has to arbitrarily decide what's urgent/emergent, what goes, what doesn't, and when.

Our institution has designated from the top down the max number of rooms we can run by 3pm, by 7pm, and overnight. So if I'm on overnight I know that I could potentially be running 1 elective room plus 1-2 trauma/ bonafide emergency rooms if something comes up. Plus we have a list from each surgery subspecialty listing what cases actually count as their urgent and emergent cases. And if there are many elective cases on the board with surgeons who want to operate in that elective room overnight, the trauma surgeon on-call triages the order or asks the individual surgeons to decide amongst themselves if there's a big disagreement. In our system, there's no ambiguity.

That sounds refreshingly logical

 

[Ashers]

Only to the Mom.

And often the nurses. The patients NEEDS an epidural RIGHT NOW!!!

I'm so glad I quit doing OB. That one move improved my quality of life exponentially.

And I put E if the surgeon calls it an emergency -- non-NPO and they want to do the case right then, usually ortho, and most typically if it's an truly urgent/emergent case.

 

[anbuitachi]

Except no pain therapy is an emergency. A spinal or even a dosed up epidural for a c-section can absolutely be an E but an epidural for the purpose of analgesia during labor is not (which is what you originally asked).

The E is related to not only patient presentation (unscheduled, maybe not NPO) but also the procedure and the associated anesthetic.

But I’m presume you know all of that and are trying to trap the above posters with a “gotcha” moment from their short one or two sentence reply.

a lot of what i give is for pain in the OR. why not have a BKA without anesthesia? bc patient cant tolerate teh pain...

 

[anbuitachi]

There's a higher-level question in here which really comes down to what the institutional policy is. The call anesthesiologist shouldn't be the one who has to arbitrarily decide what's urgent/emergent, what goes, what doesn't, and when.

Our institution has designated from the top down the max number of rooms we can run by 3pm, by 7pm, and overnight. So if I'm on overnight I know that I could potentially be running 1 elective room plus 1-2 trauma/ bonafide emergency rooms if something comes up. Plus we have a list from each surgery subspecialty listing what cases actually count as their urgent and emergent cases. And if there are many elective cases on the board with surgeons who want to operate in that elective room overnight, the trauma surgeon on-call triages the order or asks the individual surgeons to decide amongst themselves if there's a big disagreement. In our system, there's no ambiguity.

but who decides what goes on the list. do the surgeons from that department determine whats emergent. if that is the case they can try to put as much as possible on the list bc it gives them flexibility.

 

[vector2]

but who decides what goes on the list. do the surgeons from that department determine whats emergent. if that is the case they can try to put as much as possible on the list bc it gives them flexibility.

The departments submit a list (signed off by their respective chairs) and the periop directors (anesthesia, trauma surgery, OR nursing leadership) look over it and approve it. They'd get laughed out of the room if they tried to put lipoma removal and cataract on the list right next to incarcerated hernia and open globe, etc

Obviously in the heat of the moment if some surgeon comes up to the desk and says this BS case is an emergency, we'd do it if we had availability. But the shtstorm that would follow would be so bad that no one has pulled that nonsense.

 

[Arch Guillotti]

The departments submit a list (signed off by their respective chairs) and the periop directors (anesthesia, trauma surgery, OR nursing leadership) look over it and approve it. They'd get laughed out of the room if they tried to put lipoma removal and cataract on the list right next to incarcerated hernia and open globe, etc

Obviously in the heat of the moment if some surgeon comes up to the desk and says this BS case is an emergency, we'd do it if we had availability. But the shtstorm that would follow would be so bad that no one has pulled that nonsense.

This is fine except that there are plenty of cases that don’t neatly fit in the boxes.

 

[vector2]

This is fine except that there are plenty of cases that don’t neatly fit in the boxes.

I think most institutions can pretty easily delineate the vast, vast majority of their urgent/emergent cases if they put any effort into it. And again, at my hospital we run 1 elective OR overnight anyway so anyone with an edge case (like an appy that could probably wait til morning) can go regardless.

 

[Arch Guillotti]

I think most institutions can pretty easily delineate the vast, vast majority of their urgent/emergent cases if they put any effort into it. And again, at my hospital we run 1 elective OR overnight anyway so anyone with an edge case (like an appy that could probably wait til morning) can go regardless.

Institutions may say that they delineate but the reality is that the surgeons do.

 

[vector2]

Institutions may say that they delineate but the reality is that the surgeons do.

Well yeah, if your institution has no guardrails or guidelines and the surgeons can literally book whatever they want whenever they want... then obviously they're gonna take advantage of that.

I remember having to start 5 level thoracic fusions in pts without neuro deficits at 7pm cause "they could get a blood clot at some point from lying in bed." We don't do that sht anymore.

 

[Maz777]

I find doing elective cases in the night soul-crushing. There are very few non-trauma cases that are truly emergent. Appy, ureteral stent, etc. can all wait until the next day without any change in patient morbidity or mortality. One has to convince me that a case is life/limb/brain cell threatening if they want me to come in (then I will appropriately mark it as an E). I would never take a job that expects their anesthesiologists to do elective cases in the middle of the night. Life's too short for that nonsense.

 

[Arch Guillotti]

I find doing elective cases in the night soul-crushing. There are very few non-trauma cases that are truly emergent. Appy, ureteral stent, etc. can all wait until the next day without any change in patient morbidity or mortality. One has to convince me that a case is life/limb/brain cell threatening if they want me to come in (then I will appropriately mark it as an E). I would never take a job that expects their anesthesiologists to do elective cases in the middle of the night. Life's too short for that nonsense.

They can do them the next day except that they may not be available because of something else and/or it would disrupt the surgery schedule. If they wait 24 hours any of those cases can certainly get worse.

 

[coffeebythelake]

They can do them the next day except that they may not be available because of something else and/or it would disrupt the surgery schedule. If they wait 24 hours any of those cases can certainly get worse.

Isn't there solid evidence that uncomplicated appendicitis can be treated with IV antibiotics without worsening patient outcomes? It could easily push til morning or beyond. I don't consider them emergencies.

 

[coffeebythelake]

I find doing elective cases in the night soul-crushing. There are very few non-trauma cases that are truly emergent. Appy, ureteral stent, etc. can all wait until the next day without any change in patient morbidity or mortality. One has to convince me that a case is life/limb/brain cell threatening if they want me to come in (then I will appropriately mark it as an E). I would never take a job that expects their anesthesiologists to do elective cases in the middle of the night. Life's too short for that nonsense.

There should be a "surgeon b.s. modifier" where it deducts from the surgeons pay and add to yours for a case like that.

 

[Maz777]

They can do them the next day except that they may not be available because of something else and/or it would disrupt the surgery schedule. If they wait 24 hours any of those cases can certainly get worse.

It's been pretty well established that perioperative morbidity and mortality increases by doing cases in the middle of the night. As a surgeon, it's impossible to be meticulous and at the top of one's game at 2am. Patients deserve surgeons (and anesthesiologists) that can function at the best of their ability. If you needed a lap chole for acute cholecysitis, would you want to sit around all day until your surgeon and OR are finally ready/available at 2am? Eff no. Why don't you just bag my CBD and sign me up for a biliary drain and hepaticojejunostomy in a week or two?

There's a reluctance to pass off the case to the next on-call general surgeon, urologist, etc. Having surgeons in clinic all day and yet being on call for urgent consults and surgeries is a recipe for poor patient care. There should always be an add-on room to get these non-emergent cases done during daylight hours. Most places can appropriately fill a room or two like this with proper planning if they wanted to. Glad I don't work at a place that can't figure this out.

The corollary is an anesthesiologist staffing a room solo at one hospital while simultaneously taking call another hospital. An urgent case gets booked and the anesthesiologist said they aren't available to do the case until midnight once they finish up the day's cases at the first hospital. Would that ever happen? Would be heresy.

 

[Maz777]

Isn't there solid evidence that uncomplicated appendicitis can be treated with IV antibiotics without worsening patient outcomes? It could easily push til morning or beyond. I don't consider them emergencies.

Correct. The CODA studies in 2020-2021 were published in NEJM and JAMA. Surgeons are slow to change their practice from residency. Appendicitis is never a surgical emergency and can be treated with antibiotics with similar short-term and long-term outcomes.