Who Does the Pre-ops?

[Strength&Speed]

So do you guys do an Anes Pre-Op in addition to a Surgical pre-op for all elective cases? I know occasionally medicine will do a pre-op but thats typically just to clear for medical issues and I wouldn't think would affect either an Anes or Surgical pre-op. Just curious.

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[ecCA1]

A pre-op written by a psychiatrist or FP is enough for me as long as they include the phrase "Clear for surgery."

 

[Planktonmd]

So do you guys do an Anes Pre-Op in addition to a Surgical pre-op for all elective cases? I know occasionally medicine will do a pre-op but thats typically just to clear for medical issues and I wouldn't think would affect either an Anes or Surgical pre-op. Just curious.

I am not sure I understand your question:
Are you asking if we interview the patient, take a history and do a physical exam?
If that is your question then the answer is obviously yes.

 

[Strength&Speed]

I am not sure I understand your question:
Are you asking if we interview the patient, take a history and do a physical exam?
If that is your question then the answer is obviously yes.

well, at the last institution i was at, i didn't see any anes. pre-op notes in the computer, so I wasn't sure how they were doing it.

i assume eeCA-1 was joking...

 

[jetproppilot]

So do you guys do an Anes Pre-Op in addition to a Surgical pre-op for all elective cases? I know occasionally medicine will do a pre-op but thats typically just to clear for medical issues and I wouldn't think would affect either an Anes or Surgical pre-op. Just curious.

Someone from the anesthesia department sees all patients prior to surgery.

 

[fakin' the funk]

well, at the last institution i was at, i didn't see any anes. pre-op notes in the computer, so I wasn't sure how they were doing it.

It's fair to assume that they're on paper then...

The pre-op assessment either happens in a pre-operative anesthesia evaluation clinic, or in the pre-op holding area, depending on local practice.

 

[Strength&Speed]

It's fair to assume that they're on paper then...

The pre-op assessment either happens in a pre-operative anesthesia evaluation clinic, or in the pre-op holding area, depending on local practice.

thanks, that answered it for me. if anyone is still around...what sort of documentation do you need after the case...or do you just sign the flowsheet with all the notes you made during the case. just trying to get an idea of your paperwork.

 

[Bertelman]

thanks, that answered it for me. if anyone is still around...what sort of documentation do you need after the case...or do you just sign the flowsheet with all the notes you made during the case. just trying to get an idea of your paperwork.

PACU orders

 

[drccw]

I love med consults...
they say things like:
avoid hypotension, hypoxia, and acidosis...

thanks for the tip... or my favorite is when they say things like
bla blah blah blah... consider regional anesthesia... like you know anything about regional anesthesia.... not appropriate for a lumbar lami...

 

[Strength&Speed]

I love med consults...
they say things like:
avoid hypotension, hypoxia, and acidosis...

thanks for the tip... or my favorite is when they say things like
bla blah blah blah... consider regional anesthesia... like you know anything about regional anesthesia.... not appropriate for a lumbar lami...

i know, they are basically worthless. what the hell are they going to say that matters? uhh...no he doesn't have glaring ischemia. that's about it.
its a waste of everyone's time. but good legally, apparently.

 

[SleepIsGood]

Someone from the anesthesia department sees all patients prior to surgery.

Yes, but what is the point of it?

All of the residents at my institution, we all go see pre ops. Yes, this way our patients probably benefit from knowing us ahead of time and being less nervous the next day.

9/10 if there's glaring ischemic s/s the medicine personell have already done the appropriate test whether it be echo, stress, etc.

Nothing I've done the day before in terms of doing a preop the day before has ever made me do something glaring different the next day. For example, if the pt has a bad airway, I always have the proper equipment in the room even if I had only seen that patient in the prep and hold area just a few minutes before.

At times I feel like it's more to just make sure that the pre op is done before hand and so we dont waste time preoping right before the case.

I almost get the feeling that fentanyl, midaz, propo with lido, and roc is safe for anyone as long as you titrate everything vigilantly. Please note I'm not saying that anesthesia is easy or that you should just induce anyone. I'm just saying the most important thing is to have an ANESTHESIOLOGIST who is properly trained view the data and make decisions based on what he thinks will benefit the patient.

Maybe my program is different because it's not a university program and here we're trained to constantly be efficient and do safely what's apparently done in PP. Let's be honest, in academia you can cancel cases left and right, in PP apparently that's not so kosher.

 

[Trisomy13]

...medicine personell have already done the appropriate test whether it be echo, stress, etc.

this part made me . i especially like the ortho patients who get a medicine consult for clearance and they write the Goldman cardiac risk index. i guess that's the reality of a university setting with interns caring for pts.

we see our own pre-ops, and our call team sees the in-house pre-ops destined to be in CRNA rooms. occasionally we catch a missing EKG, crazy labs, etc, or an ASA IV scheduled (incorrectly) to be on the ambulatory OR floor.

it's not the most enriching experience, but it doesn't take forever either...

 

[Strength&Speed]

i hate pre-ops....that was part of my problem. they seem so senseless. they deserve about 10 minutes of your time and no more.

 

[SleepIsGood]

this part made me . i especially like the ortho patients who get a medicine consult for clearance and they write the Goldman cardiac risk index. i guess that's the reality of a university setting with interns caring for pts.

we see our own pre-ops, and our call team sees the in-house pre-ops destined to be in CRNA rooms. occasionally we catch a missing EKG, crazy labs, etc, or an ASA IV scheduled (incorrectly) to be on the ambulatory OR floor.

it's not the most enriching experience, but it doesn't take forever either...

I hear you loud and clear.

HOwever, stuff like EKGs...atleast where I'm at, we can call a tech and he will be there in 5min to get one. Again, I know that if it's all about turn over and you arent relieved by an attending to do the preop/start the IV in the prep and hold are until after your case, then there could be a drag.

 

[jetproppilot]

Yes, but what is the point of it?

Your point is a good one.

Believe it or not, Sleep, every once in a while someone is scheduled for surgery that just aint ready.

I'm not talking about all the soft-call-cancellations you see in academia.

I'm talking about patients in the hospital scheduled for a (semi) elective case that any anesthesiologist who walks into the patient's room and looks at the patient...emerges with question marks in their head.

In my previous gold-mine gig I went to pre-op a AAA scheduled for the next day (I've posted this specific incident before).

An "elective" AAA, mind you, meaning waiting a week or a day probably wouldnt matter.

As soon as I saw this dude I knew the patient would fair better if we waited 'til he was optimized.

60s dude, with a AAA, but also had COPD with an acute exacerbation...he was tachypneic, talking in short sentences....

BINGO.

I didnt haffta listen to his lungs, even though I did.

I didnt haffta see PFTs, ABG.

My mom couldda walked into his room and concluded that he needed treatment.

And yet he was still scheduled for tomorrow. This doesnt happen often, but it does happen...especially from our somewhat clinically-challenged orthopedist colleagues.

And yet he was on the schedule for tomorrow.

So what happens if we don't see this dude the nite before?

We look dumb. And the OR schedule is detrimentally altered.

This doesnt happen often, but it happens enough that if we didnt see (at least) the in-house patients beforehand, there'd be some cancellations in the morning that would've been known about the day before.

Seeing in house pre-ops the day before is as much a political effort as it is a clinical effort. And having a great relationship with our surgeon colleagues is paramount for exclusive-contract renewal.

If I didnt see this guy beforehand, he wouldda showed up in holding in the morning. And the case wouldda been cancelled. And the surgeon wouldda been thinking...why didnt this get resolved yesterday? And the OR would be altered with a big space in it where a case couldve been.

I hate seeing preops.

And yeah, mosta the time we could see the in-house patients in the morning.

But every once in a while you run across an obvious cancellation.

That makes the surgeon appreciate you. That makes the OR run better the next day.

So I'll help see the in-house pre-ops.

Keeping surgeons happy and keeping the OR flowing like Masta-P-on-da-mike is as important to you as keeping the patients safe.

And you can accomplish a small part of that by seeing the in-house pre-ops.

 

[Strength&Speed]

Great, thanks Jet. So what is the surgeons role in this whole deal? When do they do their surgical pre-ops? So what your saying is that for elective cases, the surgeon may not have seen the patient for a month or better, and kind of shows up on your doorstep the day before?

 

[jetproppilot]

Great, thanks Jet. So what is the surgeons role in this whole deal? When do they do their surgical pre-ops? So what your saying is that for elective cases, the surgeon may not have seen the patient for a month or better, and kind of shows up on your doorstep the day before?

You may see the patient before the surgeon.

Medicine Dude orders/performs a study (cardiac cath, CT, whatever) which reveals sinister pathology (AAA, fx'ed hip, whatever).

Consults surgeon dude.

Surgeon calls the OR, schedules case. Plans on seeing the patient at some point during the pre-operative day.

If you get to the patient before the surgeon, it may be kinda awkward if they don't need to be cancelled. This is not an uncommon occurance and sometimes you delay the pre-op if you deem with your eyes that they aint gonna be cancelled.

But heres where you can score some politically beneficial points if you come across something awry in your screening.....

You pre-op the patient, something obvious sticks out, you call the surgeon, the patient is safer, the surgeon is happy, you just saved an OR debacle the next morning.....

well worth your ten minutes.

Then theres our orthopedic colleagues.

Mosta their in-house patients that they schedule for surgery are well up in age with broken hips.

And....uhhhhhhh..... hey....I love my ortho dude colleagues....but they ain't so versed in how pre-operative morbidities affect surgical outcome...

"Chris? HEY! Hows it goin? Its Bill. Yeah, that 89 year old you've got on the schedule for tomorrows havin' a problem with a CHF exacerbation right now....I just saw her and she seemed a little short of breath....she's got bilateral rales, external jugulars sticking out, hell, she had to take a breath halfway through a sentence....I think we should wait a day or two on her hip, dude.....she needs some tuning.....I know she needs this fixed but I'm fearless and pre-operative pulmonary edema scares the s hit outta me..."

(true conversation, almost word for word)