Your partner delays a case for...

[urge]

---

Members do not see this ad.

Let's say you work in a group and everybody has gone home but the on call person. An inhouse lap cholecystectomy case gets posted for 7:30am the next day and the on call attendings pre ops it. Pt has some moderate ill defined cardiac disease(angina, poor ef, moderate AS, moderate MR- whatever you want) and refers he has a cardiologist which has done a whole gamut of tests. Your cautious partner talks to the surgeon and both agree to delay the case until these tests can be faxed from the cardiologist's office, 1 or 2 hours...

You arrive the next day. The attending who saw the pt is home post call. You get assigned to that room by the anesthesiologist in charge and get explained what the plan is. "A'right" you say. You talk to the patient and he looks "iffy". Your OR has been on hold until the much awaited fax with the tests arrives at 10am. There isn't any tests. Never have been done. Just an ekg.

Surgeon wants to operate. The anesthesiologist in charge is coercing you to get the case done.

What now? You have been waiting for Godot. Do you go go ahead and tell the pt, the family, and the surgeon you never really needed the tests, you wanted to delay his operation just to get warm fuzzy feelings from looking at them?

Do you insist these tests be done now since your partner put you on the spot?

Should the decision to wait to look at test ever been made?

What if he gets an MI, or worse kicks the bucket? What's your defense for proceeding if something bad happens?

I had something like this happen to me.

 

[pgg]

Let's say you work in a group and everybody has gone home but the on call person. An inhouse lap cholecystectomy case gets posted for 7:30am the next day and the on call attendings pre ops it. Pt has some moderate ill defined cardiac disease(angina, poor ef, moderate AS, moderate MR- whatever you want) and refers he has a cardiologist which has done a whole gamut of tests. Your cautious partner talks to the surgeon and both agree to delay the case until these tests can be faxed from the cardiologist's office, 1 or 2 hours...

You arrive the next day. The attending who saw the pt is home post call. You get assigned to that room by the anesthesiologist in charge and get explained what the plan is. "A'right" you say. You talk to the patient and he looks "iffy". Your OR has been on hold until the much awaited fax with the tests arrives at 10am. There ain't any tests. Never have been done. Just an ekg.

Surgeon wants to operate. The anesthesiologist in charge is coercing you to get the case done.

What now? You have been waiting for Godot. Do you go go ahead and tell the pt, the family, and the surgeon you never really needed the tests, you wanted to delay his operation just to get warm fuzzy feelings from looking at them?

Do you insist these tests be done now since your partner put you on the spot?

Should the decision to wait to look at test ever been made?

What if he gets an MI, or worse kicks the bucket? What's your defense for proceeding if something bad happens?

I had something like this happen to me.

Cardiologist doesn't clear the patient, we do.

I'd assess the patient, with the aid of the AHA/ACC guidelines, and determine if I feel the patient needs those tests. If so, I wait.

If not, I do the case. As for what I tell others:

• The surgeons all know some anesthesiologists are more conservative than others. I wouldn't throw my colleague under the bus and say 'that knucklehead ordered unnecessary tests' but would rather tactfully phrase it as 'per the AHA/ACC guidelines, an echo/cath/stress test isn't required and I feel comfortable doing the case without that information' ... the surgeons aren't *****s, they know the score, they don't care about the reasons, all they want is to do the case with some reassurance that their anesthesiologist isn't cowboying ahead.
  
• I'd tell the patient/family that if the tests had already been done, it would have been worth the time to look at the results, but given the EKG and other records, we don't strictly need an echo or stress test to proceed safely. It's usually possible to be reassuring and tactful when I change the plan originally presented by the preop'ing anesthesiologist.

 

[Sergio99]

Hello,

Start practicing, "Yes, Your Honor, I did know that the patient was not ready for surgery and proceeded anyway," "Yes, Your Honor, I did know the patient could die, but was in a hurry to get the case done and acted negligently," and similar statements to answer the judge's questions.

Getting serious, it all depends on your own medical evaluation of the patient. The previous anesthesiologist may have said a, b or c, and the cardiologist may have said x, y or z, but the final decision to proceed or not is yours. Have clear parameters and guidelines to follow. Don't let fuzzy feelings lead you astray.

Does the patient have a clear indication for further studies? Does the patient have a cardiac history that needs to be investigated further and needs more studies? If yes, no matter what your colleague thought yesterday, you insist that yes, he needs more studies and he is not ready for surgery, therefore you cancel the case. If on the other hand, you decide that there is not enough cardiac history to justify more studies, you say, "the patient is OK, he doesn't need any more studies and proceed."

Now, if the ECG shows any signs of coronary disease or the cardiologist wrote some sort of ambiguous note, or the patient cannot walk or climb stairs without getting dyspneic or having angina, you send him to the cardiologist and ask him to fix it or do something about it.

If you do the case and the patient has an MI or dies, neither your senior partner nor the surgeon will defend you before the family, the judge, the hospital administration or anybody else that comes up against you. They are all going to split and leave you to face the music on your own.

Take a look at the latest AHA guidelines and stick to them. Nobody can argue with you if you have clear, objective, guidelines based on scientific data. On the other hand, if you don't stick to those guidelines and something goes wrong, you don't have a leg to stand on.

Greetings

P. S.: I just noticed Pgg's post. He makes some very good points. I agree with him totally.

Sergio99

 

[deleted126335]

Cardiologist doesn't clear the patient, we do.

I'd assess the patient, with the aid of the AHA/ACC guidelines, and determine if I feel the patient needs those tests. If so, I wait.

If not, I do the case. As for what I tell others:

• The surgeons all know some anesthesiologists are more conservative than others. I wouldn't throw my colleague under the bus and say 'that knucklehead ordered unnecessary tests' but would rather tactfully phrase it as 'per the AHA/ACC guidelines, an echo/cath/stress test isn't required and I feel comfortable doing the case without that information' ... the surgeons aren't *****s, they know the score, they don't care about the reasons, all they want is to do the case with some reassurance that their anesthesiologist isn't cowboying ahead.
  
  [*]I'd tell the patient/family that if the tests had already been done, it would have been worth the time to look at the results, but given the EKG and other records, we don't strictly need an echo or stress test to proceed safely. It's usually possible to be reassuring and tactful when I change the plan originally presented by the preop'ing anesthesiologist.

👍Nailed it.

 

[IlDestriero]

Regardless of what the guidelines say is required, if the case is non emergent and test results are available, you should endeavor to obtain the results before proceeding. They could change the plan. If there are no results, or they are not available, the guidelines are there to try to keep you out of trouble. Following them to the letter should aid in your defense of a bad outcome. Don't forget to document your thoughts in a couple of lines in the chart. If he told you he could walk up 2 flights of stairs, it may be worth documenting. After the MI and lawsuit, he may "recall" telling you about his chest pain at rest.

 

[urge]

Who in here thinks they have time optimize a pt with acute cholecystitits?

Will you delay for 4 weeks, 6 weeks...?

 

[gaspasser2004]

1. Is this operation emergent?
No, this operation is not a true emergency. It is not stated what the exact indication is for lap chole, but I think its safe to assume that while the patient doesn't need to go to the OR STAT, he also shouldn't be discharged before getting his operation.

2. Is the patient optimized?
The patient's history will tell you whether or not he is optimized. Can walk up 2-3 flights of stairs? Optimized. History of angina after walking four blocks without any recent changes? Optimized. History of new onset chest pain at rest? Definitely not optimized. The new guidelines support revascularization when the patient would need it independent of having an operation. Otherwise, the patients do fine with beta blockers and medical management.

Would I do this case? If the history told me the patient was optimized, I would. If the history told me the patient had CHF or acute coronary syndrome, then the benefits of optimization would outweigh the benefits of getting his lap chole right away.

 

[Arch Guillotti]

I am not sure if there is literature to back it up, but I have spoken to surgeons about these exact sort of scenarios and more than one has indicated that they feel the patients do better overall when you just go ahead and get the gallbag out.

 

[Noyac]

Personally, I would probably go with what my partner arranged whether I agreed or not in this case. It's not going to hurt the pt to wait in this case.

If I didn't agree with the partners decision I wouldn't show outsiders (the surgeon) that there is inconsistency in the group. I would back my partner in public and talk with him/her in private.

 

[Noyac]

I am not sure if there is literature to back it up, but I have spoken to surgeons about these exact sort of scenarios and more than one has indicated that they feel the patients do better overall when you just go ahead and get the gallbag out.

Of course they do, they're surgeons not doctors.😉

Like one of the very good surgeons I at my hospital said to me today, "I'm just a technician. Others tell me when to operate and when not to."

 

[2win]

Personally, I would probably go with what my partner arranged whether I agreed or not in this case. It's not going to hurt the pt to wait in this case.

If I didn't agree with the partners decision I wouldn't show outsiders (the surgeon) that there is inconsistency in the group. I would back my partner in public and talk with him/her in private.

👍👍👍

 

[Licoricestick]

Of course they do, they're surgeons not doctors.😉

Like one of the very good surgeons I at my hospital said to me today, "I'm just a technician. Others tell me when to operate and when not to."

Love it!

Agree with PGGs comment about chasing results. If there are questions and there might be test results - it's hard to justify not waiting a couple of hours for them. If they're in the secondary storage facility and it's going to take 3 days - then they're probably old enough not to be worth it and I'd go with clinical assessment + guidelines.

 

[Jay K]

Couldn't have said it better than pgg. AHA/ACC guidelines are available. His advice for waiting vs proceeding is also spot on.

As an aside, ever heard of a patient who was scheduled for "something else," but found to require emergent angioplasty/stent or CABG and then staying on the table for their "emergent" chole (or other) immediately afterwards?

 

[urge]

A'right. I think everybody has had time to chime in.

Here is what I did. I refused to do the case unless such "tests" showed up. If my competent esteemed colleague felt so strongly that we needed to delay the case before proceeding I did not want to create division within our group. I'm usually a gork (God only really knows) and will do anyone based on history. But, in this case my partner already made that decision for me. Think about it. Case goes perfect and you get a couple hundred bucks if you are lucky. Case goes to **** and you get a multimillion dollar lawsuit. It doesn't take a rocket scientist to do the math there.

The anesthesiologist in charge felt I was full of **** and did the case himself. It went to ****. Yep, he is still dealing with that one. Good luck to him.

Learning point: Don't f with urge.

 

[IlDestriero]

A'right. I think everybody has had time to chime in.

Here is what I did. I refused to do the case unless such "tests" showed up. If my competent esteemed colleague felt so strongly that we needed to delay the case before proceeding I did not want to create division within our group. I'm usually a gork (God only really knows) and will do anyone based on history. But, in this case my partner already made that decision for me. Think about it. Case goes perfect and you get a couple hundred bucks if you are lucky. Case goes to **** and you get a multimillion dollar lawsuit. It doesn't take a rocket scientist to do the math there.

The anesthesiologist in charge felt I was full of **** and did the case himself. It went to ****. Yep, he is still dealing with that one. Good luck to him.

Learning point: Don't f with urge.

Good on ya' mate! Too bad the jackhole is your partner.

 

[Jay K]

Case goes perfect and you get a couple hundred bucks if you are lucky. Case goes to **** and you get a multimillion dollar lawsuit. It doesn't take a rocket scientist to do the math there.

The anesthesiologist in charge felt I was full of **** and did the case himself. It went to ****. Yep, he is still dealing with that one. Good luck to him.

Looks like your partner from the night before saved you from a bad case (since you said yourself you probably would have done it had the preop recom's not already been in). Glad it wasn't your ass. 👍

 

[dhb]

You talk to the patient and he looks "iffy".

When i first read the post this stood out as the most important part. As the great Jet said trust that little voice inside your head.

 

[Jay K]

When i first read the post this stood out as the most important part. As the great Jet said trust that little voice inside your head.

.

 

[dhb]

As opposed to the little voice in your pants.... Confucius say...

In the hospital setting I was refering

 

[Voodoo]

Urge, that's what I would have done. It sucks that your group tolerates a partner doing a case that another one refused. We have a unwritten rule about such behavior. I'm not entirely sure I would be happy with a partner trumping me like that regardless of outcome. It encourages doc shopping by surgeons. Not that they would do that.

 

[Camel]

Well, the situation changed (as pgg pointed out) from the night before in that there were no tests actually done. In other words, the fact that he said he had some tests done really does not matter anymore. We approach this patient as he stands that AM. Would you delay the case in that scenario? The attending from the night before had a different scenario, no?

 

[Voodoo]

As posted above, it depends completely upon the preop eval - I get really hesitant to drop anyone's SVR with a "history of mod-severe aortic stenosis." I understand that according to many surgeons getting the gallbladder out is anecdotally the greatest thing since sliced bread, but pumping the patient's chest and frantically searching for pressors and volume lines upon induction is anecdotally bad for patient outcomes according to me.

Maybe dhb would do this under spinal?

 

[IlDestriero]

Maybe dhb would do this under spinal?

After giving him breakfast!

 

[dhb]

Exactly a throracic spinal look it up maybe you'll learn something.

 

[InductionAgent]

Exactly a throracic spinal look it up maybe you'll learn something.

Note the boldface at the end, smartass.

British Journal of Anaesthesia, doi:10.1093/bja/aem058

Background: Laparoscopic surgery is normally performed under general anaesthesia, but regional techniques have been found beneficial, usually in the management of patients with major medical problems. Encouraged by such experience, we performed a feasibility study of segmental spinal anaesthesia in healthy patients.

Methods: Twenty ASA I or II patients undergoing elective laparoscopic cholecystectomy received a segmental (T10 injection) spinal anaesthetic using 1 ml of bupivacaine 5 mg ml–1 mixed with 0.5 ml of sufentanil 5 µg ml–1. Other drugs were only given (systemically) to manage patient anxiety, pain, nausea, hypotension, or pruritus during or after surgery. The patients were reviewed 3 days postoperatively by telephone.

Results: The spinal anaesthetic was performed easily in all patients, although one complained of paraesthesiae which responded to slight needle withdrawal. The block was effective for surgery in all 20 patients, six experiencing some discomfort which was readily treated with small doses of fentanyl, but none requiring conversion to general anaesthesia. Two patients required midazolam for anxiety and two ephedrine for hypotension. Recovery was uneventful and without sequelae, only three patients (all for surgical reasons) not being discharged home on the day of operation.

Conclusions: This preliminary study has shown that segmental spinal anaesthesia can be used successfully and effectively for laparoscopic surgery in healthy patients. However, the use of an anaesthetic technique involving needle insertion into the vertebral canal above the level of termination of the spinal cord requires great caution and should be restricted in application until much larger numbers of patients have been studied.

 

[pgg]

Exactly a throracic spinal look it up maybe you'll learn something.

Did you mean thoracic epidural or are you really talking about thoracic level intrathecal injection?

A thoracic epidural for an open gall bladder (putting aside the NPO issues) isn't impossible or totally freakishly outlandish, but it's obviously very unusual. A thoracic spinal adds another layer of weirdness and there ain't nobody who's going to stand in your corner if it goes bad ... even if the complication isn't your fault.

I guess I don't understand why anybody would ever, ever do this.

 

[IlDestriero]

Exactly a throracic spinal look it up maybe you'll learn something.

Yeah, something I would never do under any circumstances. Even with fluoro guidance. Good luck with that one.
They used to do cervical spinals in the Vietnam era for upper extremity surgery. I'm not planning to bring that one back either.
Your cavalier attitude will not serve you well if you plan to come and practice in the USA.

 

[dhb]

Well the study I remember in Anesthesiology showed by MRI (maybe it was CT) that at the thoracic level you had more space between the dura and the spinal cord than in other segments.

 

[Noyac]

DHB, I haven't read all the posts here but have you done a Thoracic Spinal personally?

 

[dhb]

No but I think it 's safe if you use a pencil point needle and a careful approach.

 

[Voodoo]

Holy crap - I was just ribbing you dhb about the spinal. I thought you were totally kidding about the thoracic spinal. And worse yet, I thought people giving credence to your claim were either screwing around or didn't realize you were kidding. I had no idea you were serious.

In fact, after reading your post again, I am relatively certain you ARE kidding. But if you're not - how about lower than L2 where there is NO spinal cord as opposed to more distance between the dura and the cord?

Also if you're serious and you're ever looking for a job, please don't look at my group.

And if you're kidding around, the joke's on me. I suck.

 

[Arch Guillotti]

No but I think it 's safe if you use a pencil point needle and a careful approach.

I think this is nuts.

 

[Noyac]

I think this is nuts.

I agree. I don't see any good reason to do this what so ever.


BUT, are we sure that this is unsafe in skilled hands? Seriously, has any good study been done that shows any data? When I place a spinal I know almost exactly when I am going to engage the dura. I can feel every little fiber. I get a pop and I stop. I know that I am probably only half way in (if I inject I will possibly give some of my dose outside the dura) I now need to advance ever so slightly to make sure I give the full dose intrathecally. So that brings me to, can it be done?

And on that note, I will probably never attempt this.

 

[sevoflurane]

My N=0. But... sure it can. Just as a CABG can be done under a thoracic epidural as a sole anesthetic. I've seen a number of thoracic wet taps and therefore, the space is there. I have no idea about dosages ie: for an elbow fx vs. a thoracotomy.

 

[sevoflurane]

Not that I would ever do it, but if I were to do a thoracic spinal in a parallel universe... I would have glyco on board in case I piss off T1-T4. Pent, sux, tube handy in case eyes go backwards.
If I was to do one in this parallel universe, I would do a thoracic intrathecal catheter and dose things up to a particular effect to buy me a safety margin.

Just pontificating here. 🙄

 

[dhb]

Well I was half joking I've never done one and probably never will but I know it can be done safely. I've tried to find the study I was refering to to no avail. I've also seen thoracic wet taps with no complication.

 

[IlDestriero]

Not that I would ever do it, but if I were to do a thoracic spinal in a parallel universe... I would have glyco on board in case I piss off T1-T4. Pent, sux, tube handy in case eyes go backwards.
If I was to do one in this parallel universe, I would do a thoracic intrathecal catheter and dose things up to a particular effect to buy me a safety margin.

Just pontificating here. 🙄

I would think that the catheter would be more dangerous than helpful. It better be really soft, with a closed tip. If you're not careful, you'll end up with a nice cord biopsy.

 

[sevoflurane]

I would think that the catheter would be more dangerous than helpful. It better be really soft, with a closed tip. If you're not careful, you'll end up with a nice cord biopsy.

I don't use stiff catheters any more. You can thread those catheters into anything: ligament, fat, cord, etc. Misplacement is more frequent IMO. Springwound catheters on the other hand, will not usually advance if you are not in the right space therefore reducing your false positive placements. Additionally, they are so soft I don't see them ever biopsing the spinal cord. Just not rigid enough.

 

[Voodoo]

I was recently informed that our hospital is experiencing a backorder of the arrow spring-loaded catheter kits. You guys experiencing this??

I trained with the stiff catheters and my practice only uses the springs. At first I was not happy because they were much harder to thread. Then I thought about it and realized that in residency I was probably threading those stiff catheters subcu, into ligaments, and probably even a few into the vertebral bodies In general, I've found with the springs, they only go epidural, intravenous, or subarachnoid 😱 otherwise they don't thread.

1 out of 3 ain't bad 😎 yeah

 

[pgg]

In general, I've found with the springs, they only go epidural, intravenous, or subarachnoid 😱 otherwise they don't thread.

1 out of 3 ain't bad 😎 yeah

Maybe it's just a lucky coincidence but I haven't had an intravascular catheter since we switched to the soft Arrow catheters a year into my residency. I recall a few of my attendings commenting that the intravascular % plummeted after the switch.

 

[Jay K]

.

 

[Noyac]

And the crazy thing is, I can't convince hardly anybody in my group that the flexible catheters are better. As a majority they hate them - the needle's too big, too blunt, the catheter too floppy. I'm unfortunately in the minority - it's hard to effect changes sometimes when habits are ingrained. So, the stockpile is dwindling... I should just hoard.

Let me reiterate - I LOVE the flexible catheters and I especially LOVE a plastic LOR syringe. Glass is wack.

I'm in the complete opposite camp from you here. I prefer the glass syringe, stiffer catheter, smaller needle.

 

[Noyac]

Back to the case, Urge what happened to your partner? Anyone give him a good ripping? Did he learn his lesson?