Garbage clearances

[TheLoneWolf]

In the last month, I have run across a few clearances that are downright ridiculous but I get significant pushback from nursing staff and a few surgeons regarding my concerns. All they seem to hear is "there is a clearance in the chart, let's proceed". This has lead to dicey situations with a few malignant surgeons.

A few that come to mind

90ish year old man for a total shoulder replacement at an ASC. Positive stress test for ischemia. Family doc cleared for surgery noting that that he had a several positive stress tests for years. Patient never saw a cardiologist per the EMR and his family. Strangely enough, his daughter kept insisting we proceed. Luckily old timer orthopod listened to reason.

A 350ish pound patient OSA non-compliant presented for a knee replacement at the ASC. Constantly short of breath. I pulled up a cath report from a year ago and he has a 100% occlusion of the RCA and is right heart dominant circulation. Literally so short of breath he couldn't even walk out of the facility. I recommended he go to the ED but they didn't feel it necessary. Cleared by a primary care NP who makes no mention of the cath report. Normal ekg and cxr.

Patient who had a large nstemi 4 days ago with trops in the morning of procedure in the 300s. Ongoing shortness of breath. TTE shows mitral stenosis. Had a dark bowel movement when he presented to the hospital and none since. Hb stable since admission. They keep insisting on double scopes for a stable patient and got a cardiology np to say no contraindications to the procedure. I speak to the patient and he wasn't aware that he had an MI or has MS.

All on the above i put my foot down and said a hard no.


How do I tactfully deal with the malignant surgeons who readily threaten to go to the hospital CEO if I express my concerns, especially as the admins see any clearance wording as valid no matter how incorrect it is.

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[FatKid]

“I agree Dr. XXXXX that the patient is cleared for Surgery; however, the patient is not cleared for Anesthesia.”

 

[DirtDocMD]

At one time, we had to raise heck because the cardiologists were trying to use their nurse pracs to “clear” patients for surgery, as well as some of the primary care docs.

We told them and admin that we weren’t accepting clearances from anyone that didn’t have MD or DO after their name. If THEY felt confident enough in their nurse pracs “clearance”, then they would have to make that clear by reviewing and co-signing it.

As mentioned above, surgeons can complain “They’re cleared for surgery!”, all they want. Doesn’t mean they’re cleared for MY anesthetic…

 

[circleK]

I have had a few ridiculous cardiac clearances in which I’ve contacted the cardiologist and made them explain their reasoning for the “low CV risk” or why they didn’t feel the need to wait for the results of the echo they ordered. When they have to state it out loud they tend to change their tune.

 

[Dr. Rude]

Those are all pretty harsh. I might relent on #3 if I spoke with the cardiologist and the stated that they were considering anticoagulation but were hesitant because of the dark stool. I would document that in my peop note.

 

[aneftp]

EF matters the most. Most of my cards friends base cardiac risk factors on heart function.

Severe AS 0.7cm 90 year old with low ef 20% is a lot more dangerous than one with normal ef.

 

[TheLoneWolf]

I had noted that systems and cultures rarely change. If you won't do it, they will likely find someone who os ok with doing any case anytime without opening their mouth

 

[ucladoc2b]

It’s always fun when they try to sneak in.

Like a patient at the ASC with multiple recently replaced valves and CABG (but “she has cardiac clearance”).

Severe AS for lumbar fusion (I actually called the cardiologist who then demurred and agreed with cancelling the case).

Sub 20% EF for a TKA.

One of my partners is married to an academic cardiologist. He sends some of clearances to her for a second opinion/laugh/fellow teachable moments.

The key to overcoming garbage clearances and malignant surgeons is having a cohesive anesthesia group. They can’t shop around that way.

 

[Urzuz]

but I get significant pushback from nursing staff

I just wanted to address this part of your post. Who gives a **** what the nursing staff thinks. It’s a discussion between you and the surgeon. I’m not sure why you even are talking to them about your concerns with proceeding with / cancelling a case.

 

[thinkorswim]

EF matters the most. Most of my cards friends base cardiac risk factors on heart function.

Severe AS 0.7cm 90 year old with low ef 20% is a lot more dangerous than one with normal ef.

It’s lazy and downright dangerous to just look at the EF on an echo report and think everything will be fine.

 

[abolt18]

I have had a few ridiculous cardiac clearances in which I’ve contacted the cardiologist and made them explain their reasoning for the “low CV risk” or why they didn’t feel the need to wait for the results of the echo they ordered. When they have to state it out loud they tend to change their tune.

Last year I cancelled a lumpectomy because patient reported relatively new-onset CP and dyspnea on exertion. Said she had just seen a cardiologist last week and he ordered an echo and a stress test and she's scheduled to have them done in 2 weeks. Called the cardiologist and we had this same talk about her risks and why those studies aren't happening sooner. He moved them up and they were negative and she got her lumpectomy the next week. But he had tried to say over the phone "not it's no big deal, she can have her surgery today."

 

[TxGasserMD]

Has anyone used the readily available risk calculators to document relative risk (pulmonary, cardiac)innthe chart? Sometimes I will use them and show directly to surgeon that even with a so called “clearance” nothing is 100% safe/risk-free. So far the calculated number has a postive influence on some of the surgeons who may give me pushback.

 

[TheLoneWolf]

I just wanted to address this part of your post. Who gives a **** what the nursing staff thinks. It’s a discussion between you and the surgeon. I’m not sure why you even are talking to them about your concerns with proceeding with / cancelling a case.

I should clarify the charge nurse on a given unit ie GI

 

[TheLoneWolf]

It’s always fun when they try to sneak in.

Like a patient at the ASC with multiple recently replaced valves and CABG (but “she has cardiac clearance”).

Severe AS for lumbar fusion (I actually called the cardiologist who then demurred and agreed with cancelling the case).

Sub 20% EF for a TKA.

One of my partners is married to an academic cardiologist. He sends some of clearances to her for a second opinion/laugh/fellow teachable moments.

The key to overcoming garbage clearances and malignant surgeons is having a cohesive anesthesia group. They can’t shop around that way.

Yeah our group let's them shop around and we have both conservative people and some who will literally do anything.

 

[aneftp]

It’s lazy and downright dangerous to just look at the EF on an echo report and think everything will be fine.

No. What I’m saying is a normal ef with severe as is a completely different picture than a low Ef with severe as.

Be a doctor. Use ur judgment. Examine ur own patient. We all know clearances mean very little in high risk patients. If it’s a cancer patient. Would u delay it? As long as patient and family aware of risks.

 

[GassYous]

Yeah our group let's them shop around and we have both conservative people and some who will literally do anything.

I am pretty open to things but if my partner said they won't do it then my answer is always the same

 

[Anesthesia_Guy]

How do I tactfully deal with the malignant surgeons who readily threaten to go to the hospital CEO if I express my concerns, especially as the admins see any clearance wording as valid no matter how incorrect it is.

Offer to walk them to the CEO's office personally.

 

[dabears505]

Some of these don't make sense. Like after the cath they must have done something on that second guy? Why would they just let that go? Did you not have all the records? Also I mean I get canceling 3, but if he's having gi bleeding, he might need a scope before he becomes an unstable patient.

 

[TheLoneWolf]

Some of these don't make sense. Like after the cath they must have done something on that second guy? Why would they just let that go? Did you not have all the records? Also I mean I get canceling 3, but if he's having gi bleeding, he might need a scope before he becomes an unstable patient.

Second dude got his cath and it said maximize medical therapy, plan for cardiac followup. He says he was never send to cards outpatient and I can't find records to show he was or wasn't referred. Honestly, my concern is will I do this elective case or not; I am not interested in hunting down and second guessing ehat the patient tells me or what his PCP or NP is thinking or doing in the grand scheme.

For the third case, <4 days from a large NSTEMI, actively symptomatic and resting dyspnea, stable hemoglobin, and no symptoms; I would not do the case. If his hb was dropping or he continued having bloody stools since admit it may change my mind. This was just the GI guys trying to get their rvus as far as I was concerned.

 

[Angus Avagadro]

Had a nice lady for pelvic reconstruction after an MVA. She was pretty healthy except for the fact that she had a closed head inury along with the pelvic fractures and kept falling asleep during my consultation for surgery. I aske for a neurosurg consult and got the " Cleared for surgery. Avoid hypotension and hypoxemia" Spoke with ortho and confirmed this was essentially an elective case as far as they were concerned. Now I'm annoyed and called the fellow who did the neurosurg consult and explained that those recommendations were problematic as I was planning on a hypotensive, hypoxemic anesthetic. Now what am I going to do??? After about a long 5 sec pause where I could almost hear him M F-ing me under his breath, I explained that in his consult I wanted to know what the nature of the injury was, it's natural history, and if it was stable. F/U Ct revealed a subdural, so we deferred and fixed the pelvis later. She did fine.

 

[Angus Avagadro]

It’s always fun when they try to sneak in.

Like a patient at the ASC with multiple recently replaced valves and CABG (but “she has cardiac clearance”).

Severe AS for lumbar fusion (I actually called the cardiologist who then demurred and agreed with cancelling the case).

Sub 20% EF for a TKA.

One of my partners is married to an academic cardiologist. He sends some of clearances to her for a second opinion/laugh/fellow teachable moments.

The key to overcoming garbage clearances and malignant surgeons is having a cohesive anesthesia group. They can’t shop around that way.

Had one of these tight aortic valves for TKR and the cardiologist said "Cleared for Spinal" on the chart. When the patient got to the OR, I had the Pre Op nurse page the cardiologist and tell him the patient was here and we were waiting for him to come do the spinal. Having made my point, we did GA.

 

[aneftp]

Last year I cancelled a lumpectomy because patient reported relatively new-onset CP and dyspnea on exertion. Said she had just seen a cardiologist last week and he ordered an echo and a stress test and she's scheduled to have them done in 2 weeks. Called the cardiologist and we had this same talk about her risks and why those studies aren't happening sooner. He moved them up and they were negative and she got her lumpectomy the next week. But he had tried to say over the phone "not it's no big deal, she can have her surgery today."

That’s different. You talked to the patient. If she said no chest pain and no dyspnea. You would proceed

Like I said. Be the doctor. You make the final decision. If symptoms are alarming like chest pain. You will make the correct the decision. That’s why I say “eyeball test”.

 

[PpfSuxTube]

EF matters the most. Most of my cards friends base cardiac risk factors on heart function.

Severe AS 0.7cm 90 year old with low ef 20% is a lot more dangerous than one with normal ef.

Ejection fraction matters very little. Ef in nearly dead ppl can be near 100%. Or in a poor trained sonographer the number can be so far off. What if the lvedd is 7 or 8cm?

Tte matters very little in general. There are studies that show worse outcomes for patients who have preop tte. Various postulated reasons include practioners inability to read and interpret them and act on the results.

 

[aneftp]

Ejection fraction matters very little. Ef in nearly dead ppl can be near 100%. Or in a poor trained sonographer the number can be so far off. What if the lvedd is 7 or 8cm?

Tte matters very little in general. There are studies that show worse outcomes for patients who have preop tte. Various postulated reasons include practioners inability to read and interpret them and act on the results.

Again. Stop examining purely the numbers. Be the doctor. Examine the patient. Ask the patient questions.

As long as their tolerance is good. Proceed. Document it.

Cardiology risks are either less than 1% of death or severe morbidly or more than 1% risk. That’s it.

 

[jwk]

We get cardiac or pulmonary (or whatever) consultations, which hopefully contain actual useful information, some risk stratification and or statements along the lines of "pt is optimized" or "pt is as good as they're going to get". Unfortunately we get some of those from NPs/PAs but we have no problem going straight to their boss. None of those people get to clear anyone for surgery. That's the job for the physician anesthesiologist who actually evaluates the patient pre-operatively.

 

[kb1900]

hate this *** so much. we have a lot to complain about in our field but for me this is numbers one two and three.


I have a symptomatic AS valve area .2 just got out of the ICU yesterday for his exacerbation but “medically cleared for GA for all procedures, will pursue TAVR workup outpatient following any inpatient procedures”. I have the pleasure of doing his hip with a surgeon who’s average EBL for a routine hip is 2L unless my attending puts their foot down (they wont).


the other day in EP I got so annoyed with the cards fellow I held up my prop stick and told them to push it and see what happens without an a-line to this guy with torrential TR, PAsys of 90 coming to the lab from CCU on epi and milrinone and a completely subq aline.


I hate these cardiologists and their NPs more than the surgeons. The surgeons are too clueless to know any better. Cardiologists on the other hand surely know what an acute drop in preload will do to a ****ty right heart.


I’m supposedly at a top cardiology program in the country

 

[kb1900]

Again. Stop examining purely the numbers. Be the doctor. Examine the patient. Ask the patient questions.

As long as their tolerance is good. Proceed. Document it.

Cardiology risks are either less than 1% of death or severe morbidly or more than 1% risk. That’s it.

Can you explain what you mean in the last sentence? RCRI class IV is 15% risk of death, arrest or MI if I recall correctly.

Where are you getting these numbers from

 

[abolt18]

There are studies that show worse outcomes for patients who have preop tte.

Maybe the TTE actually HARMS the patient? Stop all TTEs! The horror!

Or maybe the outcomes are worse because people get echos on sicker patients, who will naturally have worse outcomes....

 

[aneftp]

Can you explain what you mean in the last sentence? RCRI class IV is 15% risk of death, arrest or MI if I recall correctly.

Where are you getting these numbers from

F the rcri. Risk factor is less than 1% or greater than 1%. That’s all.

Keep it simple stupid. Pardon my language.

 

[PpfSuxTube]

Again. Stop examining purely the numbers.

EF matters the most.

You have 100% percent contradicted yourself there horse.

Maybe you should settle down there and read your own posts

 

[coffeebythelake]

F the rcri. Risk factor is less than 1% or greater than 1%. That’s all.

Keep it simple stupid. Pardon my language.

There is a huge risk/benefit difference of doing a surgery when you tell a patient they have a 1.5% chance of serious morbidity/mortality vs a 15% chance. Both "greater than 1%". So yes it matters. It might be "simple" for you because it involves a lot less thinking and risk stratifying.

 

[aneftp]

You have 100% percent contradicted yourself there horse.

Maybe you should settle down there and read your own posts

I said normal ef. I didn’t state what the range of normal ef. Just stated normal ef.

The only percentage I stated was low ef 20%. Which is clearly a low ef. But I stated normal ef. So didn’t contradict myself.

 

[Anesthesia_Guy]

Had one of these tight aortic valves for TKR and the cardiologist said "Cleared for Spinal" on the chart. When the patient got to the OR, I had the Pre Op nurse page the cardiologist and tell him the patient was here and we were waiting for him to come do the spinal. Having made my point, we did GA.

I'll take "Things That Never Happened" for $300, Alex.

 

[PpfSuxTube]

Question

Why do people think tte done by a tech and signed by the same cards guy that wrote that 'garbage clearance' is of such high utility?

Who do you all think is taking these shots and signing these tte's?

I can assure you a cardiologist does not touch the probe or even see the patients in the majority of these ttes.

 

[coffeebythelake]

Question

Why do people think tte done by a tech and signed by the same cards guy that wrote that 'garbage clearance' is of such high utility?

Who do you all think is taking these shots and signing these tte's?

I can assure you a cardiologist does not touch the probe or even see the patients in the majority of these ttes.

Question. Have you looked through the TTE imaging yourself? Why do you think the people doing them are incompetent and miss the critical views?

 

[DrOwnage]

Question

Why do people think tte done by a tech and signed by the same cards guy that wrote that 'garbage clearance' is of such high utility?

Who do you all think is taking these shots and signing these tte's?

I can assure you a cardiologist does not touch the probe or even see the patients in the majority of these ttes.

I’m just curious. What do you see utility in? If not a TTE… what preoperative testing do you look at to form an educated opinion about your patient? Even when I see a clean TTE it gives me reassurance.

 

[nimbus]

I can assure you a cardiologist does not touch the probe or even see the patients in the majority of these ttes.

It’s true that the cardiologists never touch the probe. That’s because the echo techs who do nothing but echos all day every day are better at getting the views than the vast majority of cardiologists or anesthesiologists. Visit your hospital echo lab and see for yourself. For them, watching a doctor try to do an exam is like us watching an MS3 try to intubate.

 

[Radetzky]

To be fair what are you going to do about the occluded RCA. By definition if he is alive he’s got collateral flow. You’d be hard pressed to find someone whose going to try try bore open a CTO preoperatively.

In general we chase coronary workups too much. Revascularising stable disease doesn’t prevent perioperative cardiac events. Preop TTE on the other hand is worth it’s weight in gold imo

 

[Beeftenderloin]

Question

Why do people think tte done by a tech and signed by the same cards guy that wrote that 'garbage clearance' is of such high utility?

Who do you all think is taking these shots and signing these tte's?

I can assure you a cardiologist does not touch the probe or even see the patients in the majority of these ttes.

I just look at the TTE myself if I’m worried about the patient or I’m questioning the report in any way. If I request a TTE on an inpatient prior to surgery I often don’t even wait for the cardiologist read before proceeding/canceling if I’ve reviewed the images personally. We also have a very high quality phased array probe in our department. If I’m not needing a full exam and just have a specific clinical question in mind, I’ll do a quick bedside TTE myself. Though I recognize this is not feasible for a lot of the folks who aren’t echo trained, a lot of us are, and should be comfortable doing this.

 

[PpfSuxTube]

Question. Have you looked through the TTE imaging yourself? Why do you think the people doing them are incompetent and miss the critical views?

Yes I have. I am a cardiac anesthesiologist.

Im not saying they're incompetent, I just find it ironic that ppl here are complaining about garbage clearances but worship tte signed off by the exact same guy.

Ive seen lvef stated in low normal range but with akinesis of entire walls on cath. Weekly occurrence.

Ventriculogram discordant with tte by as much as 25% every other day.

These are all just tests. They all have built in possible error. They are once snapshot in time.

 

[aneftp]

Exercise capacity matters most eyeball test more than any test. The best example is pistol pete elite basketball player. He died suddenly in his 40s playing pickup basketball. But he lived with his condition throughout his nba career. No symptoms.

Eyeball test guys. Document it. Exercise tolerance.

 

[Angus Avagadro]

I'll take "Things That Never Happened" for $300, Alex.

Hope you didn't bet it all!

 

[dabears505]

A normal resting TEE or TTE is useful, but honestly more than half of the hearts we do have normal echos.

 

[pgg]

I'll take "Things That Never Happened" for $300, Alex.

If it did happen, it was unprofessional and shouldn't have happened. I can't imagine ever playing games like that to shame or embarrass another physician in front of other staff.

 

[Anesthesia_Guy]

Hope you didn't bet it all!

Not a "Daily Double" but had it been I would have doubled my dinero.

 

[DesiredMemberName?]

Exercise capacity matters most eyeball test more than any test. The best example is pistol pete elite basketball player. He died suddenly in his 40s playing pickup basketball. But he lived with his condition throughout his nba career. No symptoms.

Eyeball test guys. Document it. Exercise tolerance.

I agree exercise capacity is one of the most important things to assess, but doesn’t this anecdote demonstrate the opposite of your point?

He probably eyeballed ok if he was out playing basketball. On the other hand, a cath or even an echo may have identified hidden abnormalities.

 

[The Duck Knows]

Recently got pushback for a femur fx because cardiology “cleared” a pt with known history of CAD, CHF, and moderate AS. Note said low to moderate risk.

The kicker was than nothing had resulted. TTE was ordered but hadn’t been done. Didn’t even have basic labs back. There was literally nothing in the chart other than EM, ortho, and cardiology notes. Seemed pretty obvious that they just threw a generic note in and planned to add end it after the echo was done.

 

[Urzuz]

Question

Why do people think tte done by a tech and signed by the same cards guy that wrote that 'garbage clearance' is of such high utility?

Who do you all think is taking these shots and signing these tte's?

I can assure you a cardiologist does not touch the probe or even see the patients in the majority of these ttes.

Yes I have. I am a cardiac anesthesiologist.

Im not saying they're incompetent, I just find it ironic that ppl here are complaining about garbage clearances but worship tte signed off by the exact same guy.

Ive seen lvef stated in low normal range but with akinesis of entire walls on cath. Weekly occurrence.

Ventriculogram discordant with tte by as much as 25% every other day.

These are all just tests. They all have built in possible error. They are once snapshot in time.

I think everyone knows and agrees that they are just tests, snapshots in time, etc…but a TTE/TEE read is a lot more objective than a vague, nebulous “clearance” from someone that doesn’t fully understand what anesthesia / surgery does to a patient’s physiology.

They are experts on the heart. Though anything is possible, presumably they wouldn’t miss complete akinesis of a wall of the heart in their echo read. Presumably their EF calculation is also somewhat correct.

Synthesizing that objective data with how the patient’s physiology will tolerate anesthesia/surgery is where they fall short. You wrote “Why do people think tte done by a tech and signed by the same cards guy that wrote that 'garbage clearance' is of such high utility?” No one is accusing them of being bad people or bad physicians. It’s just that their training doesn’t involve anesthesia physiology — and nor should it! They have enough stuff to learn as is.

Ultimately cardiology clearances shouldn’t be taken as gospel. In the vast majority of cases, if a cardiologist says that the patient needs more work up before proceeding with x y z surgery, I’ll almost certainly agree with them and postpone the case. If they say the patient is cleared for surgery, I will perform my own independent assessment with the objective data I have and ultimately determine if the patient is actually safe to undergo anesthesia.

 

[ucladoc2b]

Honestly, we need to abandon the term cardiology clearance. It’s misleading to patients (and some clueless surgeons). Maybe we should start calling it cardiac advisory or something like that.

 

[kidthor]

Honestly, we need to abandon the term cardiology clearance. It’s misleading to patients (and some clueless surgeons). Maybe we should start calling it cardiac advisory or something like that.

Ironically when you actually want their input for something acute they write stuff like "it's just demand ischemia" or "there's no need to trend troponins" or "they should get a stress test after surgery" and such.