Garbage clearances

[VA Hopeful Dr]

I'm always surprised when I see a PCP write a decent pre-op risk assessment/stratification note. Most of what I get are rcri number and then something saying low risk ok to proceed.

If it helps, apparently CMS is going to start focusing on this sort of thing much more in the near future. My system is already working on a protocol-drive approach that addresses basically everything that we can think of to improve operative outcomes, short and long term.

Things like fall-risk, adequate post-op home care, pre-op nutrition status, smoking cessation, education, and so on in addition to the current CV risk assessment/optimization.

The thinking is it we standardize it then everyone should be brought up to a minimum thoroughness for pre-op care.

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[TheLoneWolf]

Another one

75ish ESRD, 350 lb, BMI>50, OSA cpap non-compliant, IDDM, AFib, CAD with MI just a little over 6 months ago, mets<4, 4+ pitting tense and weeping lower extremity edema. Gfr<10, cr>8. Implantable loop as worsening AFib and going in and out of mobitz type 2. Nephro notes asking for cardiac input on pacemaker placement from a few months ago . Presented for outpatient lower extremity angiography and stent placements.

Family med NP signs off saying cleared for surgery with risk of 0.4%. Not cosigned by any physician.

RCRI risk is>11%. Tell the surgeon my concerns and that patient isn't optimized. They say "not a problem, just do it as a mac"."I explained to them the risk of MACE , and they respond "yeah I have no idea what that means. I never heard of it before". Guy hasn't seen cardio in months which seemed odd to me. I tell them of the tense lower extremity edema and they, with a straight face, tell me "that is just cosmetic, do his lungs sound clear?" Cant really tell on all levels with such a habitus. I tell the vascular surgeon I would like some cardiac input on this guy before proceeding and they had an excellent comeback " Hey everybody, this guy doesn't want to do his job" in preop hold in front of a bunch of nursing staff and patients.

I told em if they want my participation then I get a say and that they can happily do the case with conscious sedation or local only if they want to disregard my concerns. They turn it on me with "hey we are a team and we can't do anything without you doing your part". When I ask them to consult cardio in house, they just cancel saying anesthesia doesn't want to do the case.

Vascular is fairly malignant at my shop. Partners tell me that patients will show up having somehow failed to obtain medical clearance or have some boilerplate NP low risk no workup note held a higher standard over that of a consultant. Vascular surgeons shout them down and pushes for them to proceed. If someone stands firm, older partners usually shop it around.

I wish we had a policy of a physician only cardiac clearance for higher risk patients. No mid-level boilerplate clearances. Real risk stratification and discussions on optimization.

I mean, how did we get to such a culture?

 

[kidthor]

Another one

75ish ESRD, 350 lb, BMI>50, OSA cpap non-compliant, IDDM, AFib, CAD with MI just a little over 6 months ago, mets<4, 4+ pitting tense and weeping lower extremity edema. Gfr<10, cr>8. Implantable loop as worsening AFib and going in and out of mobitz type 2. Nephro notes asking for cardiac input on pacemaker placement from a few months ago . Presented for outpatient lower extremity angiography and stent placements.

Family med NP signs off saying cleared for surgery with risk of 0.4%. Not cosigned by any physician.

RCRI risk is>11%. Tell the surgeon my concerns and that patient isn't optimized. They say "not a problem, just do it as a mac"."I explained to them the risk of MACE , and they respond "yeah I have no idea what that means. I never heard of it before". Guy hasn't seen cardio in months which seemed odd to me. I tell them of the tense lower extremity edema and they, with a straight face, tell me "that is just cosmetic, do his lungs sound clear?" Cant really tell on all levels with such a habitus. I tell the vascular surgeon I would like some cardiac input on this guy before proceeding and they had an excellent comeback " Hey everybody, this guy doesn't want to do his job" in preop hold in front of a bunch of nursing staff and patients.

I told em if they want my participation then I get a say and that they can happily do the case with conscious sedation or local only if they want to disregard my concerns. They turn it on me with "hey we are a team and we can't do anything without you doing your part". When I ask them to consult cardio in house, they just cancel saying anesthesia doesn't want to do the case.

Vascular is fairly malignant at my shop. Partners tell me that patients will show up having somehow failed to obtain medical clearance or have some boilerplate NP low risk no workup note held a higher standard over that of a consultant. Vascular surgeons shout them down and pushes for them to proceed. If someone stands firm, older partners usually shop it around.

I wish we had a policy of a physician only cardiac clearance for higher risk patients. No mid-level boilerplate clearances. Real risk stratification and discussions on optimization.

I mean, how did we get to such a culture?

Dude. That sounds terrible.

I've definitely been at similar places but that sort of poor behavior isn't universal. Sucks that your partners will shop that stuff around - which is a big part of the problem.

 

[kb1900]

Another one

75ish ESRD, 350 lb, BMI>50, OSA cpap non-compliant, IDDM, AFib, CAD with MI just a little over 6 months ago, mets<4, 4+ pitting tense and weeping lower extremity edema. Gfr<10, cr>8. Implantable loop as worsening AFib and going in and out of mobitz type 2. Nephro notes asking for cardiac input on pacemaker placement from a few months ago . Presented for outpatient lower extremity angiography and stent placements.

Family med NP signs off saying cleared for surgery with risk of 0.4%. Not cosigned by any physician.

RCRI risk is>11%. Tell the surgeon my concerns and that patient isn't optimized. They say "not a problem, just do it as a mac"."I explained to them the risk of MACE , and they respond "yeah I have no idea what that means. I never heard of it before". Guy hasn't seen cardio in months which seemed odd to me. I tell them of the tense lower extremity edema and they, with a straight face, tell me "that is just cosmetic, do his lungs sound clear?" Cant really tell on all levels with such a habitus. I tell the vascular surgeon I would like some cardiac input on this guy before proceeding and they had an excellent comeback " Hey everybody, this guy doesn't want to do his job" in preop hold in front of a bunch of nursing staff and patients.

I told em if they want my participation then I get a say and that they can happily do the case with conscious sedation or local only if they want to disregard my concerns. They turn it on me with "hey we are a team and we can't do anything without you doing your part". When I ask them to consult cardio in house, they just cancel saying anesthesia doesn't want to do the case.

Vascular is fairly malignant at my shop. Partners tell me that patients will show up having somehow failed to obtain medical clearance or have some boilerplate NP low risk no workup note held a higher standard over that of a consultant. Vascular surgeons shout them down and pushes for them to proceed. If someone stands firm, older partners usually shop it around.

I wish we had a policy of a physician only cardiac clearance for higher risk patients. No mid-level boilerplate clearances. Real risk stratification and discussions on optimization.

I mean, how did we get to such a culture?

“Patient has a very high risk of decompensating perioperatively including MACE. Discussed with surgical team including recommendation for further cardiology input. Discussed with patient as well. Engaged in shared decision making with final decision X”

At the end of the day this patient has multiple reasons for an actual cardiology evaluation by an actual doctor including a high grade heart block. The patient also deserves to know their likelihood of a MACE. We still proceed with these cases here at ivory craphole but only if everyone is absolutely on the same page most importantly the patient.


If cases get shopped around that is a problem on our end and our duty to fix culturally. The best solution sounds like having one of these boomers take all the liability and work exclusively with these surgeons and liability they’re seemingly happy to deal with.


Frankly if they (surgeon) can’t communicate like reasonable people just document, tell patient and move on. At least that’s the direction I’m going personally. I’m still a resident and a few times I’ve verbally swung back in preop when delaying cases. Couple months ago, pt was afib RVR to 120 for elective procedure. Never worked up, new sob x3 days. Easy delay. Orthopod says something similar along the lines of “you can’t fix that? seriously anesthesia”. Forget what I said but I more or less subtly called the attending surgeon an idiot in front of the patient and nurses in response and immediately regretted it. Nothing came of it and seemed like the surgeon now suddenly respects me (talk about a complex huh). Anyway I still wish I could roll that back and feel bad about it because of how unprofessional it was. I (we) are better than that.


I think at the end of the day these specifically socioemotionally challenged surgeons want a definitive answer of 1) case can go yes/no 2) if no, what is next steps 3) how to avoid this in the future. They simply do not have the knowledge or capacity to appreciate anything beyond a simple 1-2 sentence discussion of 1-3. They stopped being medical doctors a long time ago and having conversations regarding cardiac risks is like talking to the same cardiology NP that wrote the stupid “clearance”.

 

[coffeebythelake]

Another one

75ish ESRD, 350 lb, BMI>50, OSA cpap non-compliant, IDDM, AFib, CAD with MI just a little over 6 months ago, mets<4, 4+ pitting tense and weeping lower extremity edema. Gfr<10, cr>8. Implantable loop as worsening AFib and going in and out of mobitz type 2. Nephro notes asking for cardiac input on pacemaker placement from a few months ago . Presented for outpatient lower extremity angiography and stent placements.

Family med NP signs off saying cleared for surgery with risk of 0.4%. Not cosigned by any physician.

RCRI risk is>11%. Tell the surgeon my concerns and that patient isn't optimized. They say "not a problem, just do it as a mac"."I explained to them the risk of MACE , and they respond "yeah I have no idea what that means. I never heard of it before". Guy hasn't seen cardio in months which seemed odd to me. I tell them of the tense lower extremity edema and they, with a straight face, tell me "that is just cosmetic, do his lungs sound clear?" Cant really tell on all levels with such a habitus. I tell the vascular surgeon I would like some cardiac input on this guy before proceeding and they had an excellent comeback " Hey everybody, this guy doesn't want to do his job" in preop hold in front of a bunch of nursing staff and patients.

I told em if they want my participation then I get a say and that they can happily do the case with conscious sedation or local only if they want to disregard my concerns. They turn it on me with "hey we are a team and we can't do anything without you doing your part". When I ask them to consult cardio in house, they just cancel saying anesthesia doesn't want to do the case.

Vascular is fairly malignant at my shop. Partners tell me that patients will show up having somehow failed to obtain medical clearance or have some boilerplate NP low risk no workup note held a higher standard over that of a consultant. Vascular surgeons shout them down and pushes for them to proceed. If someone stands firm, older partners usually shop it around.

I wish we had a policy of a physician only cardiac clearance for higher risk patients. No mid-level boilerplate clearances. Real risk stratification and discussions on optimization.

the vascular surgeon sound like the slimiest douchebag mechanic out there. the 4 years of medical school was wasted on that clown because he clearly didn't learn anything. he might as well have been in the same online school as that NP.

that worthless NP btw should get a tongue lashing.

the "partners" at your shop are weak, disposable grade tools and should do those damn cases themselves.

 

[abolt18]

Another one

75ish ESRD, 350 lb, BMI>50, OSA cpap non-compliant, IDDM, AFib, CAD with MI just a little over 6 months ago, mets8. Implantable loop as worsening AFib and going in and out of mobitz type 2. Nephro notes asking for cardiac input on pacemaker placement from a few months ago . Presented for outpatient lower extremity angiography and stent placements.

Family med NP signs off saying cleared for surgery with risk of 0.4%. Not cosigned by any physician.

RCRI risk is>11%. Tell the surgeon my concerns and that patient isn't optimized. They say "not a problem, just do it as a mac"."I explained to them the risk of MACE , and they respond "yeah I have no idea what that means. I never heard of it before". Guy hasn't seen cardio in months which seemed odd to me. I tell them of the tense lower extremity edema and they, with a straight face, tell me "that is just cosmetic, do his lungs sound clear?" Cant really tell on all levels with such a habitus. I tell the vascular surgeon I would like some cardiac input on this guy before proceeding and they had an excellent comeback " Hey everybody, this guy doesn't want to do his job" in preop hold in front of a bunch of nursing staff and patients.

I told em if they want my participation then I get a say and that they can happily do the case with conscious sedation or local only if they want to disregard my concerns. They turn it on me with "hey we are a team and we can't do anything without you doing your part". When I ask them to consult cardio in house, they just cancel saying anesthesia doesn't want to do the case.

Vascular is fairly malignant at my shop. Partners tell me that patients will show up having somehow failed to obtain medical clearance or have some boilerplate NP low risk no workup note held a higher standard over that of a consultant. Vascular surgeons shout them down and pushes for them to proceed. If someone stands firm, older partners usually shop it around.

I wish we had a policy of a physician only cardiac clearance for higher risk patients. No mid-level boilerplate clearances. Real risk stratification and discussions on optimization.

I mean, how did we get to such a culture?

That is some major bull crap. Completely unacceptable.

 

[medicine2wallstreet]

Another one

75ish ESRD, 350 lb, BMI>50, OSA cpap non-compliant, IDDM, AFib, CAD with MI just a little over 6 months ago, mets<4, 4+ pitting tense and weeping lower extremity edema. Gfr<10, cr>8. Implantable loop as worsening AFib and going in and out of mobitz type 2. Nephro notes asking for cardiac input on pacemaker placement from a few months ago . Presented for outpatient lower extremity angiography and stent placements.

Family med NP signs off saying cleared for surgery with risk of 0.4%. Not cosigned by any physician.

RCRI risk is>11%. Tell the surgeon my concerns and that patient isn't optimized. They say "not a problem, just do it as a mac"."I explained to them the risk of MACE , and they respond "yeah I have no idea what that means. I never heard of it before". Guy hasn't seen cardio in months which seemed odd to me. I tell them of the tense lower extremity edema and they, with a straight face, tell me "that is just cosmetic, do his lungs sound clear?" Cant really tell on all levels with such a habitus. I tell the vascular surgeon I would like some cardiac input on this guy before proceeding and they had an excellent comeback " Hey everybody, this guy doesn't want to do his job" in preop hold in front of a bunch of nursing staff and patients.

I told em if they want my participation then I get a say and that they can happily do the case with conscious sedation or local only if they want to disregard my concerns. They turn it on me with "hey we are a team and we can't do anything without you doing your part". When I ask them to consult cardio in house, they just cancel saying anesthesia doesn't want to do the case.

Vascular is fairly malignant at my shop. Partners tell me that patients will show up having somehow failed to obtain medical clearance or have some boilerplate NP low risk no workup note held a higher standard over that of a consultant. Vascular surgeons shout them down and pushes for them to proceed. If someone stands firm, older partners usually shop it around.

I wish we had a policy of a physician only cardiac clearance for higher risk patients. No mid-level boilerplate clearances. Real risk stratification and discussions on optimization.

I mean, how did we get to such a culture?

I mean that guy is probably always going to look terrible. It's an angio and stent placement lower extremity right? It's not like this is hernia or boob surgery that's completely elective. I'm not saying your opinion is a bad one but I'd probably do that case if the guy can lie flat and doesn't require oxygen on the day of surgery. Precedex only MAC. Assuming cards intervened on the guy and the anti-platelet therapy situation is okay.

If you delay this patient too much he could get a dead leg and then really show up in extremis from limb ischemia and inflammatory mediators.

 

[kb1900]

I mean that guy is probably always going to look terrible. It's an angio and stent placement lower extremity right? It's not like this is hernia or boob surgery that's completely elective. I'm not saying your opinion is a bad one but I'd probably do that case if the guy can lie flat and doesn't require oxygen on the day of surgery. Precedex only MAC. Assuming cards intervened on the guy and the anti-platelet therapy situation is okay.

If you delay this patient too much he could get a dead leg and then really show up in extremis from limb ischemia and inflammatory mediators.

Agree w what you said except re proceeding except for the fact that this guy has a ILR for his heart block. I push for surgeons like this to document the urgency of the procedure and existence of elevated cardiac risk being discussed with the patient. What are you going to do if this guy goes into unstable type 2 block under mac or decompensates.



In my experience surgeons as crappy as this socially are just as bad surgically both skill wise and decision making wise They won’t use local. Will often bleed. will stent for a necrotic toe and bring the patient back in 5 weeks for the TMA and fem pop bypass and then 5 weeks after for the BKA. No optimization in between interventions. ve$ted interest in the person never actually optimizing their cardiac comorbidities.

 

[coffeebythelake]

I mean that guy is probably always going to look terrible. It's an angio and stent placement lower extremity right? It's not like this is hernia or boob surgery that's completely elective. I'm not saying your opinion is a bad one but I'd probably do that case if the guy can lie flat and doesn't require oxygen on the day of surgery. Precedex only MAC. Assuming cards intervened on the guy and the anti-platelet therapy situation is okay.

If you delay this patient too much he could get a dead leg and then really show up in extremis from limb ischemia and inflammatory mediators.

This isn't exactly the same level as cataract surgery
and next thing you know the surgeon decides the patient needs a bypass and proceeds to do it because the "patient is already in the room"
And the patient had plenty of time to see that worthless NP when some medical optimization should have been taking place. Or at least reach out to relevant care teams to "get their blessing", if this patient didn't see his cardiologist recently.

Anyways, these examples here highlight a need for adequate review of cases well before the day-of-surgery to ensure optimization and avoid cancellations. This person should be an anesthesiologist, or someone actually trained in the nuances of preop assessment. Clearly there are other clinicians out there who think they know how to preop patients and don't.

 

[medicine2wallstreet]

Mobitz type 2 is definitely fighting words I agree and case cancellable. However the loop recorder means that he's seen EP at some point and they weren't worried enough about the mobitz 2 thing to implant a pacemaker. There's no way EP let him out of their sight without a pacemaker if he truly has mobitz type 2. He's already had an MI and they likely intervened, so he shouldn't have revascularization as an optimization. If his lytes look okay and so does physical exam id probably do the case and put pads on if necessary to pace him. But I don't have the full cardiology timeline. Just guessing. Again I'm not firm on this just playing the other side of the coin.

 

[kb1900]

Mobitz type 2 is definitely fighting words I agree and case cancellable. However the loop recorder means that he's seen EP at some point and they weren't worried enough about the mobitz 2 thing to implant a pacemaker. He's already had an MI and they likely intervened, so he shouldn't have revascularization as an optimization. If his lytes look okay and so does physical exam id probably do the case and put pads on if necessary to pace him. But I don't have the full cardiology timeline. Just guessing.

That’s definitely a bigassumption IMO. EP may want to place a dual chamber pacer once ILR is reviewed. We don’t know. Maybe they didn’t show up to their EP appointment.

What would be nice would be for in house EP/cards to come and comment on timeline/planning which it sounds like OP suggested.

We have people coming in as effectively outpatients in CHB, admitted to some medicine NP service then straight to EP lab next day snuck into the outpatient schedule, stay a night or two then discharged. Medicine is wild

 

[Angus Avagadro]

It's not the job of the anesthesiologist to identify the medical issues and pronounce them stable or there is nothing more to optimize. We had an Anesthesiologist the night before review charts for all of the cases in the morning. This blocked many of these poorly worked up cases before they got to pre op holding areas.If the patient's medical issues are not optimized and the case is non emergent, then optimize them. Why accept any additional risk if you dont need to? Declare it an emergency, cold leg, then let's go. If another associate wants to step in and not optimize the patient, then they can have at it. Just because a patient survives suboptimal care,(.surgery and/or anesthetic), that means everyone merely got away with something, and didn't necessarily do the right thing for the patient. I prefer to try to do the right thing for the patient and not just hope to get away with something.

 

[TheLoneWolf]

That’s definitely a bigassumption IMO. EP may want to place a dual chamber pacer once ILR is reviewed. We don’t know. Maybe they didn’t show up to their EP appointment.

What would be nice would be for in house EP/cards to come and comment on timeline/planning which it sounds like OP suggested.

We have people coming in as effectively outpatients in CHB, admitted to some medicine NP service then straight to EP lab next day snuck into the outpatient schedule, stay a night or two then discharged. Medicine is wild

No in house EP lab, no capability to implant pacemaker at this hospital. So only option is transcutaneous pacing. With a 350 lb patient, who knows how well that would go.

 

[woopedazz]

Today I had ortho request orthogeries clear a patient for a knee revision after the ortho intern heard a ESM. Orthogeries wrote a 3 page note about delirium risk, vitamin d and incontinence. Two sentences about cardiac:

"HS: dnm"
"TTE sighted, LVEF 79%, excellent function!"

... Turns out their loud ESM was HOCM. It was even documented in the TTE summary. The physician literally just copied the abnormal EF, misinterpreted it, ignored the rest, and failed to transcribe anything of note.

Then ortho wave an incontinence clearance Infront of our faces.

 

[Beeftenderloin]

Today I had ortho request orthogeries clear a patient for a knee revision after the ortho intern heard a ESM. Orthogeries wrote a 3 page note about delirium risk, vitamin d and incontinence. Two sentences about cardiac:

"HS: dnm"
"TTE sighted, LVEF 79%, excellent function!"

... Turns out their loud ESM was HOCM. It was even documented in the TTE summary. The physician literally just copied the abnormal EF, misinterpreted it, ignored the rest, and failed to transcribe anything of note.

Then ortho wave an incontinence clearance Infront of our faces.

Lol, and this note was supposedly penned by someone who is sub-specialty trained specifically for the care and optimization of old people with fractures? Brilliant.

 

[pgg]

Today I had ortho request orthogeries clear a patient for a knee revision after the ortho intern heard a ESM. Orthogeries wrote a 3 page note about delirium risk, vitamin d and incontinence. Two sentences about cardiac:

"HS: dnm"
"TTE sighted, LVEF 79%, excellent function!"

... Turns out their loud ESM was HOCM. It was even documented in the TTE summary. The physician literally just copied the abnormal EF, misinterpreted it, ignored the rest, and failed to transcribe anything of note.

Then ortho wave an incontinence clearance Infront of our faces.

The most remarkable thing here is that an ortho intern listened to a heart. Guess his program hasn't beaten that out of him yet.

 

[Dr. Rude]

The most remarkable thing here is that an ortho intern listened to a heart. Guess his program hasn't beaten that out of him yet.

Needed to make sure that Cardiac function was sufficient to pump Ancef to Bone.

 

[Gasmd98]

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.

Let me answer your last question. You can’t.

 

[coffeebythelake]

Let me answer your last question. You can’t.

Look for new job, hopefully before the surgeon captain sinks the ship with everyone on it.

 

[Gasmd98]

“Patient has a very high risk of decompensating perioperatively including MACE. Discussed with surgical team including recommendation for further cardiology input. Discussed with patient as well. Engaged in shared decision making with final decision X”

At the end of the day this patient has multiple reasons for an actual cardiology evaluation by an actual doctor including a high grade heart block. The patient also deserves to know their likelihood of a MACE. We still proceed with these cases here at ivory craphole but only if everyone is absolutely on the same page most importantly the patient.


If cases get shopped around that is a problem on our end and our duty to fix culturally. The best solution sounds like having one of these boomers take all the liability and work exclusively with these surgeons and liability they’re seemingly happy to deal with.


Frankly if they (surgeon) can’t communicate like reasonable people just document, tell patient and move on. At least that’s the direction I’m going personally. I’m still a resident and a few times I’ve verbally swung back in preop when delaying cases. Couple months ago, pt was afib RVR to 120 for elective procedure. Never worked up, new sob x3 days. Easy delay. Orthopod says something similar along the lines of “you can’t fix that? seriously anesthesia”. Forget what I said but I more or less subtly called the attending surgeon an idiot in front of the patient and nurses in response and immediately regretted it. Nothing came of it and seemed like the surgeon now suddenly respects me (talk about a complex huh). Anyway I still wish I could roll that back and feel bad about it because of how unprofessional it was. I (we) are better than that.


I think at the end of the day these specifically socioemotionally challenged surgeons want a definitive answer of 1) case can go yes/no 2) if no, what is next steps 3) how to avoid this in the future. They simply do not have the knowledge or capacity to appreciate anything beyond a simple 1-2 sentence discussion of 1-3. They stopped being medical doctors a long time ago and having conversations regarding cardiac risks is like talking to the same cardiology NP that wrote the stupid “clearance”.

A couple things. OP only said that some partners were willing to do these cases. Made no mention of age of said partners so cut the “boomer” nonsense. Secondly, it is one of your attending‘s jobs to deal with sticky situations with surgeons, especially attending surgeons. That is why we get the big bucks. Lastly, from what you write you seem to have a chip on your shoulder regarding surgeons. You don’t want to be the anesthesiologist that every surgeon hates.

 

[coffeebythelake]

Lastly, from what you write you seem to have a chip on your shoulder regarding surgeons. You don’t want to be the anesthesiologist that every surgeon hates.

His exasperation was well justified if that was how the surgeon was acting. You don't think so?

 

[kb1900]

A couple things. OP only said that some partners were willing to do these cases. Made no mention of age of said partners so cut the “boomer” nonsense. Secondly, it is one of your attending‘s jobs to deal with sticky situations with surgeons, especially attending surgeons. That is why we get the big bucks. Lastly, from what you write you seem to have a chip on your shoulder regarding surgeons. You don’t want to be the anesthesiologist that every surgeon hates.

Fair enough that was agesit of me and showed my bias. Thanks for pointing that out to me.

His exasperation was well justified if that was how the surgeon was acting. You don't think so?

This entire thread is about malignant surgeons. There is no chip on my shoulder. These moments are ultimately extremely rare where I work so the extrapolation is pretty far fetched about becoming hated. reading into what I said too much. I get along with pretty much everyone at work and have an excellent relationship with the surgical departments but I do not go out of my way to please people who are disrespectful from the get go. Civility is rule number 1. I never say anything negative about anyone at work. Online on a private forum on the other hand? It’s cathartic as heck to do so.


If they (malignant minority of surgeons) do not want to or are incapable of discussing preop cardiac concerns with their anesthesiologist and become immature when doing so, that’s that. They fall into the category of what I said and I keep it very short and sweet with them to maintain communication as that immediately becomes my primary concern. At least that is my goal - I’m in training after all so all points are still taken. I’m all ears to how others handle such situations graciously.


Finally the point about our anesthesia attendings is a culture for our own program. our ORs are run by the department of anesthesia primarily. We are expected to communicate with surgery attendings as needed. An “easy” cancel is something that falls on the residents as part of training. Towards the end of residency we also manage the board, triage add ons and emergent cases and communicate with surgical services directly. We quite literally sit at the control desk as surgeons come up to us with their concerns. Most times that includes communicating with surgery attendings who have no residents.

 

[PainDrain]

The most remarkable thing here is that an ortho intern listened to a heart. Guess his program hasn't beaten that out of him yet.

Well the ortho intern originally placed the stethoscope on the knee but the nurse corrected him.

 

[TheLoneWolf]

Well the ortho intern originally placed the stethoscope on the knee but the nurse corrected him.

You haven't seen docs use the stethoscope as the poor man's reflex hammer on the wards? I have.

 

[VA Hopeful Dr]

You haven't seen docs use the stethoscope as the poor man's reflex hammer on the wards in clinic 10 minutes ago? I have.

FTFY

 

[medicine2wallstreet]

This thread generally seems like a way to put down surgeons. No reason to be antagonistic to the docs that bring the patients in. Obviously can't allow unsafe things to go on, but old buddy's advice earlier is important....you can't be the anesthesiologist that every surgeon hates. We're a service specialty.

 

[Beeftenderloin]

Was taking care of a pulmonary cripple this morning. FEV1/FVC and DLCO both in low 40s, home O2 use. I had the pleasure of reading their pulmonologist’s clearance note after following this thread for the last couple weeks, it was really nice.

They went down the list, addressed each contributing disease process, what meds they’re on, what’s meds they should be on but can’t be with reasons why, perceived level of control of disease, stated that patient is high risk for post-operative pulm complication (with specific complications listed), then put the chef’s kiss on it with “patient’s respiratory status is at baseline and given the nature of ::reason for surgery:: benefits appear to outweigh the risks”.

And the best part: the word clearance, or any derivation thereof, was nowhere to be found.

 

[IMGASMD]

Was taking care of a pulmonary cripple this morning. FEV1/FVC and DLCO both in low 40s, home O2 use. I had the pleasure of reading their pulmonologist’s clearance note after following this thread for the last couple weeks, it was really nice.

They went down the list, addressed each contributing disease process, what meds they’re on, what’s meds they should be on but can’t be with reasons why, perceived level of control of disease, stated that patient is high risk for post-operative pulm complication (with specific complications listed), then put the chef’s kiss on it with “patient’s respiratory status is at baseline and given the nature of ::reason for surgery:: benefits appear to outweigh the risks”.

And the best part: the word clearance, or any derivation thereof, was nowhere to be found.

So you actually found a real medical doctor for once?

 

[coffeebythelake]

A rarity for sure.

 

[Dr. Rude]

I tell every PCP/Internist/Specialist that I only want two questions answered.

1. How bad are they?
2. Is there anything we should do preoperatively to answer question 1 or make them better?

That's it. If you do that you will make most anesthesiologists grateful.

 

[coffeebythelake]

I tell every PCP/Internist/Specialist that I only want two questions answered.

1. How bad are they?
2. Is there anything we should do preoperatively to answer question 1 or make them better?

That's it. If you do that you will make most anesthesiologists grateful.

patient needs echo and consideration for CRT-D but they should be OK to get their purely elective surgery before all of this.. 💩🤡

 

[Dr. Rude]

patient needs echo and consideration for CRT-D but they should be OK to get their purely elective surgery before all of this.. 💩🤡

note the word "preoperatively" in my post.

 

[vector2]

note the word "preoperatively" in my post.

Yeah I think he knows you wrote that. His point, I believe, is that consultants are so loath to modify or disrupt scheduled surgeries that many times the tests or interventions they'd absolutely get done in a relatively expeditiously manner (because, after all, the pt is sick) somehow magically become ok to do after the surgery.

 

[Beeftenderloin]

So you actually found a real medical doctor for once?

Yea. It was weird.

 

[vector2]

Yea. It was weird.

I once saw a critical care note from a pulm crit guy about a pt with bad pHTN who needed an endo, and the note pretty perfectly described the risks of sedation or GA for pHTN/RVF + outlined generally accurate hemodynamic and ventilation principles for those pts undergoing anesthesia, and then he summed it up with a citation from JCVA.

Never seen anything like it before or since.

 

[DocVapor]

My wife's grandfather (85 yr+) has recently been passing out. Turns out the Holter monitor says his heart is having what sounds to me like some impressive sinus pauses (Trying to get info out of my wife's family is like trying to decipher the Zodiac letters). The rural Cardiologist that he sees told him that he needs a pacemaker but that it was ok to go ahead and get his yearly esophageal dilatation despite him not having any swallowing issues yet.

I try to stay out of my in-law's healthcare but I put a screeching halt to that idea. He got his pacemaker on Monday and feels like a new man of course.

 

[nimbus]

I once saw a critical care note from a pulm crit guy about a pt with bad pHTN who needed an endo, and the note pretty perfectly described the risks of sedation or GA for pHTN/RVF + outlined generally accurate hemodynamic and ventilation principles for those pts undergoing anesthesia, and then he summed it up with a citation from JCVA.

Never seen anything like it before or since.

Great recent review and guidelines in Circulation.

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000001136

 

[cchoukal]

Was taking care of a pulmonary cripple this morning. FEV1/FVC and DLCO both in low 40s, home O2 use. I had the pleasure of reading their pulmonologist’s clearance note after following this thread for the last couple weeks, it was really nice.

They went down the list, addressed each contributing disease process, what meds they’re on, what’s meds they should be on but can’t be with reasons why, perceived level of control of disease, stated that patient is high risk for post-operative pulm complication (with specific complications listed), then put the chef’s kiss on it with “patient’s respiratory status is at baseline and given the nature of ::reason for surgery:: benefits appear to outweigh the risks”.

And the best part: the word clearance, or any derivation thereof, was nowhere to be found.

You should call them and tell them how much you appreciate it. I imagine for a lot of consultants, This appreciation is lost in obscurity.

 

[Full Metal IC]

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.

I get the concept of this thread but for what it's worth from a cardiology perspective these aren't so bad.

Sounds like the 90 year old has stable CAD managed medically for many years. Nothing else to do there. Revascularization does nothing to reduce his periop risk outside of the possibility of left main disease, and we can usually gauge the risk of this from the stress test itself and history. I'm with the family doc here - do the shoulder so gramps can live his life.

350 pound patient isn't short of breath at rest because of a CTO, which is what you described. He's probably short of breath because he is fat. And regardless revascularizing his CTO does nothing to reduce his peri-operative risk. So unless the dyspnea is completely new and acute there's nothing to do here from a cardiology perspective either. Primary care NP probably didn't think about any of this, so I get where you are coming from.

Third one is a little more complicated, the patient should at least be evaluated by the cardiologist supervising the NP. Unfortunately supervision of midlevels is often suboptimal, and I share your frustration in this regard. But in reality unless it was a massive MI or severe MS, conscious sedation for endoscopy isn't the craziest thing in the world. In fact the evaluation for severe MS often involves doing a TEE...with conscious sedation.

 

[TheLoneWolf]

I get the concept of this thread but for what it's worth from a cardiology perspective these aren't so bad.

Sounds like the 90 year old has stable CAD managed medically for many years. Nothing else to do there. Revascularization does nothing to reduce his periop risk outside of the possibility of left main disease, and we can usually gauge the risk of this from the stress test itself and history. I'm with the family doc here - do the shoulder so gramps can live his life.

350 pound patient isn't short of breath at rest because of a CTO, which is what you described. He's probably short of breath because he is fat. And regardless revascularizing his CTO does nothing to reduce his peri-operative risk. So unless the dyspnea is completely new and acute there's nothing to do here from a cardiology perspective either. Primary care NP probably didn't think about any of this, so I get where you are coming from.

Third one is a little more complicated, the patient should at least be evaluated by the cardiologist supervising the NP. Unfortunately supervision of midlevels is often suboptimal, and I share your frustration in this regard. But in reality unless it was a massive MI or severe MS, conscious sedation for endoscopy isn't the craziest thing in the world. In fact the evaluation for severe MS often involves doing a TEE...with conscious sedation.

Appreciate the input and disagree with the conclusions.


Family doc doesn't get to make a call on what he believes is no big deal. Failed stress test at the very least needs eyes by a cardiologist. If dude codes or strokes out intraop or postop, the first question in everyone's mind will be glaringly why this fella wasn't evaluated by a cardiologist for his positive stress test. Open and shut medicolegal case. I am unaware of any board certified anesthesiologist who performs electives cases at an ASC with a recent failed stress test and never seen a cardiologist.

2nd dude...are you telling me that all fatties at 350ish pounds have both dyspnea and diaphoresis just because of excess weight? The guy was so out of breath that all I did was tell the ortho to have 1 look at him and he canceled right away. Guy was so short of breath, he couldn't walk from his bed to the hallway. Nurses had to wheelchair him to his car while I'm telling him this level of dyspnea, tachypnea, and diaphoresis is not a normal baseline and that he needs a cardiologist visit or get to an ED.

Third guy, I'm not arguing against what you recommend as "conscious sedation". Our GIs can provide conscious sedation without our involvement or presence. They want heavy propofol slab of meat immobility level anesthesia. I let them know that if it's so necessary to perform the procedure that day, document it as emergent to life/limb if we delay the case and I will get involved. They refused to call it that so clearly can wait.

There are both subtleties and hard stops in anesthesia. Those were hard stops.

 

[Full Metal IC]

Appreciate the input and disagree with the conclusions.


Family doc doesn't get to make a call on what he believes is no big deal. Failed stress test at the very least needs eyes by a cardiologist. If dude codes or strokes out intraop or postop, the first question in everyone's mind will be glaringly why this fella wasn't evaluated by a cardiologist for his positive stress test. Open and shut medicolegal case. I am unaware of any board certified anesthesiologist who performs electives cases at an ASC with a recent failed stress test and never seen a cardiologist.

2nd dude...are you telling me that all fatties at 350ish pounds have both dyspnea and diaphoresis just because of excess weight? The guy was so out of breath that all I did was tell the ortho to have 1 look at him and he canceled right away. Guy was so short of breath, he couldn't walk from his bed to the hallway. Nurses had to wheelchair him to his car while I'm telling him this level of dyspnea, tachypnea, and diaphoresis is not a normal baseline and that he needs a cardiologist visit or get to an ED.

Third guy, I'm not arguing against what you recommend as "conscious sedation". Our GIs can provide conscious sedation without our involvement or presence. They want heavy propofol slab of meat immobility level anesthesia. I let them know that if it's so necessary to perform the procedure that day, document it as emergent to life/limb if we delay the case and I will get involved. They refused to call it that so clearly can wait.

There are both subtleties and hard stops in anesthesia. Those were hard stops.

Ok. I mean, you obviously know the patients better than I do. But there are thoughtful family docs out there that are capable of interpreting stress test results and appropriately risk stratifying. Your decision is mostly based on covering your ass (and I fully support covering one's ass), but it's not a garbage clearance by the family doc.

 

[TheLoneWolf]

Ok. I mean, you obviously know the patients better than I do. But there are thoughtful family docs out there that are capable of interpreting stress test results and appropriately risk stratifying. Your decision is mostly based on covering your ass (and I fully support covering one's ass), but it's not a garbage clearance by the family doc.

No

Your assertion is simplistic at best and dishonest at worst. You imply we are just trying to cover our behinds and shield ourselves from medicolegal issues.

ACC/AHA guidelines
Mets<4 -> stress test (failed) -> have him see a cardiologist regarding medical optimization or resvascularization.

Didn't see that part in the algorithm for "proceed if the family doc says the positive stress test is no big deal"

BTW I know and am close friends with several family docs. Making that call is simply out of their scope of care.

You can probably read an abdominal MRI, but unless it's signed off by a radiologist, your opinion on the matter means less than the pixels on the screen. Both in a medicalegal and ontological sense.

 

[Full Metal IC]

No

Your assertion is simplistic at best and dishonest at worst. You imply we are just trying to cover our behinds and shield ourselves from medicolegal issues.

ACC/AHA guidelines
Mets<4 -> stress test (failed) -> have him see a cardiologist regarding medical optimization or resvascularization.

Didn't see that part in the algorithm for "proceed if the family doc says the positive stress test is no big deal"

BTW I know and am close friends with several family docs. Making that call is simply out of their scope of care.

You can probably read an abdominal MRI, but unless it's signed off by a radiologist, your opinion on the matter means less than the pixels on the screen. Both in a medicalegal and ontological sense.

"If dude codes or strokes out intraop or postop, the first question in everyone's mind will be glaringly why this fella wasn't evaluated by a cardiologist for his positive stress test. Open and shut medicolegal case."

I'll just let that statement speak for itself. Nothing wrong with CYA. But to deny it's role in this is disingenuous.

The guidelines don't say anything about a "failed" stress test requiring a cardiologist referral. Patients don't "pass" or "fail" stress tests. They're not taking the SATs. It's called risk stratification for a reason. PCPs don't read the stress test itself, but experienced ones know how to interpret the results reported by the reading physician, like any imaging study or test in general medicine. In fact most reports come with a risk category for the study itself. A 90 year old asymptomatic patient with a low risk positive stress test (especially one that has been so for years), for instance, does not need to see a cardiologist before a low risk surgery. A PCP is within their scope to institute medical therapy and make this call. Most won't because they have to cover their own asses as well, but it is often the right thing for the patient, as the referral to cardiology will not change management.

 

[anaesthetic]

Third one is a little more complicated, the patient should at least be evaluated by the cardiologist supervising the NP. Unfortunately supervision of midlevels is often suboptimal, and I share your frustration in this regard. But in reality unless it was a massive MI or severe MS, conscious sedation for endoscopy isn't the craziest thing in the world. In fact the evaluation for severe MS often involves doing a TEE...with conscious sedation.

Speaking of reality, most patients do not get conscious sedation for endoscopy or TEE, especially if we are involved. They get at best deep sedation but more likely general anesthesia without a protected airway.

It’s always funny to me when the interventional cardiology folks want to do TAVRs under “MAC” but don’t want the patient to move at all at any point throughout the procedure as they shove massive sheaths in both groins after giving 2 ccs of local, and then they all clap and pat themselves on the back at how smoothly that MAC TAVR went as the patient is completely unresponsive with an oral airway in place.

It’s never just “conscious sedation.”

 

[TheLoneWolf]

"If dude codes or strokes out intraop or postop, the first question in everyone's mind will be glaringly why this fella wasn't evaluated by a cardiologist for his positive stress test. Open and shut medicolegal case."

I'll just let that statement speak for itself. Nothing wrong with CYA. But to deny it's role in this is disingenuous.

The guidelines don't say anything about a "failed" stress test requiring a cardiologist referral. Patients don't "pass" or "fail" stress tests. They're not taking the SATs. It's called risk stratification for a reason. PCPs don't read the stress test itself, but experienced ones know how to interpret the results reported by the reading physician, like any imaging study or test in general medicine. In fact most reports come with a risk category for the study itself. A 90 year old asymptomatic patient with a low risk positive stress test (especially one that has been so for years), for instance, does not need to see a cardiologist before a low risk surgery. A PCP is within their scope to institute medical therapy and make this call. Most won't because they have to cover their own asses as well, but it is often the right thing for the patient, as the referral to cardiology will not change management.

Really? Are we now playing petty sematic word games? Fine.

Exact guidelines wording is if stress testing is "abnormal" (vs what I called a failed stress test). Same thing ontologically. Again, disingenuous.

Stress test conclusion, as I recall was in all caps. Did not have a risk stratification.

You keep saying it's the right thing to do for the patient, I don't think you know what that means. The right thing might be to let a 90 year old with chronic shoulder issues see a cardiologist who can give his expert input per the above guidelines. We can then go with what they recommend. If they say low risk, do an appropriate risk stratification, and recommend to proceed then so be it.

Letting this dude have a medical catastrophe in a ASC setting because you willfully avoid evaluating the potential risks is hubris. Don't create a false sense of urgency for a shoulder replacement.


Please don't call a total shoulder replacement at an ASC in a 90 year old with <4 mets and a positive stress test low risk. It's liable to have others laugh hilariously at your conclusions.

Thanks for playing (not really)

 

[Full Metal IC]

Speaking of reality, most patients do not get conscious sedation for endoscopy or TEE, especially if we are involved. They get at best deep sedation but more likely general anesthesia without a protected airway.

It’s always funny to me when the interventional cardiology folks want to do TAVRs under “MAC” but don’t want the patient to move at all at any point throughout the procedure as they shove massive sheaths in both groins after giving 2 ccs of local, and then they all clap and pat themselves on the back at how smoothly that MAC TAVR went as the patient is completely unresponsive with an oral airway in place.

It’s never just “conscious sedation.”

TAVR and TEEs are quite different procedures. In many institutions the vast majority of TEEs are done without an anesthesiologist. TAVR is moving that way too. The point is people don't immediately die when they get sedation just because they have heart disease (even stenotic valvular disease), so having a cardiology NP say there's nothing else to do before proceeding with an endoscopy isn't so egregious that it warrants a post like this.

 

[Full Metal IC]

Really? Are we now playing petty sematic word games? Fine.

Exact guidelines wording is if stress testing is "abnormal" (vs what I called a failed stress test). Same thing ontologically. Again, disingenuous.

Stress test conclusion, as I recall was in all caps. Did not have a risk stratification.

You keep saying it's the right thing to do for the patient, I don't think you know what that means. The right thing might be to let a 90 year old with chronic shoulder issues see a cardiologist who can give his expert input per the above guidelines. We can then go with what they recommend. If they say low risk, do an appropriate risk stratification, and recommend to proceed then so be it.

Letting this dude have a medical catastrophe in a ASC setting because you willfully avoid evaluating the potential risks is hubris. Don't create a false sense of urgency for a shoulder replacement.


Please don't call a total shoulder replacement at an ASC in a 90 year old with <4 mets and a positive stress test low risk. It's liable to have others laugh hilariously at your conclusions.

Thanks for playing (not really)

It isn't semantics, it reflects a fundamentally poor understanding of how pre-operative testing and the downstream management works.

Seems like you are going to die on this hill. I'm not saying it is wrong to send this particular patient to a cardiologist, just that the management is not as inappropriate as you think it is. Everything you have stated about this case suggests that the 90 year old does not need more work-up before his surgery, and PCPs are qualified to make this call and know when sending the patient to us will change nothing.

Not once did I say that this particular patient was low risk for complications. He's 90. He could be an active marine with 2 hearts, I'm still calling him high risk. But at the end of the day it doesn't matter. Whether I say low risk, intermediate risk, high risk ultimately changes nothing for the patient when it comes to stable CAD outside of very rare scenarios. There are many primary care physicians who know this and manage patients accordingly. Every cardiologist does primary care clinic in residency, and even at that stage we do these pre-op evals without sending everyone to cardiology even if *gasp* they got a D on their stress test.

At the end of the day for every 1 so-called "garbage clearance" you complain about there are 50 garbage pre-op referrals that accomplish absolutely nothing for the patient and bloat our clinics to no end. These referrals are not about the patient, they are about about YOU and how comfortable YOU feel about doing the case and what the world and jury will think if there is a complication. Which is what 90% of "clearances" are about and the crux of this issue. The surgical team wants a cardiologist's blessing and name in the chart.

 

[Radetzky]

TAVR and TEEs are quite different procedures. In many institutions the vast majority of TEEs are done without an anesthesiologist. TAVR is moving that way too. The point is people don't immediately die when they get sedation just because they have heart disease (even stenotic valvular disease), so having a cardiology NP say there's nothing else to do before proceeding with an endoscopy isn't so egregious that it warrants a post like this.

This comment just highlights our frustration with people’s lack of understanding of, yet no shortage of confidence in, anesthetic management considerations.

Just because you use your 50 fentanyl and 2 of versed on stable valvular patients and it works most of the time does not mean there is all there is to it. If Gastro was able to do it with just light sedation LoneWolf would never have been involved. The spectrum of sedation is quite a lot vaster, the impact of acute on chronic pathology more important than you appreciate, and the acuity of the procedure important when the pathology being treated and the pathology affecting anesthesia are different (as opposed to TAVI)

Your opinion on safe sedation means as little to us as my opinion on which stent to use just because I access alot of femoral arteries would mean to you. Especially as we all have experience with being called to the lab to bail out some frothing disaster on the table who was given versed until he “stopped moving”

 

[anbuitachi]

It isn't semantics, it reflects a fundamentally poor understanding of how pre-operative testing and the downstream management works.

Seems like you are going to die on this hill. I'm not saying it is wrong to send this particular patient to a cardiologist, just that the management is not as inappropriate as you think it is. Everything you have stated about this case suggests that the 90 year old does not need more work-up before his surgery, and PCPs are qualified to make this call and know when sending the patient to us will change nothing.

Not once did I say that this particular patient was low risk for complications. He's 90. He could be an active marine with 2 hearts, I'm still calling him high risk. But at the end of the day it doesn't matter. Whether I say low risk, intermediate risk, high risk ultimately changes nothing for the patient when it comes to stable CAD outside of very rare scenarios. There are many primary care physicians who know this and manage patients accordingly. Every cardiologist does primary care clinic in residency, and even at that stage we do these pre-op evals without sending everyone to cardiology even if *gasp* they got a D on their stress test.

At the end of the day for every 1 so-called "garbage clearance" you complain about there are 50 garbage pre-op referrals that accomplish absolutely nothing for the patient and bloat our clinics to no end. These referrals are not about the patient, they are about about YOU and how comfortable YOU feel about doing the case and what the world and jury will think if there is a complication. Which is what 90% of "clearances" are about and the crux of this issue. The surgical team wants a cardiologist's blessing and name in the chart.

one of the problems is assuming the family doc knows what he/she is doing. most of us do not make that assumption. also related to why guidelines are created, to try to standardize care in a somewhat evidence based way (yes there may be outliers). most of us will choose to follow the guideline, instead of assuming the family doc knows what he/she is doing, etc and chose to not send to a cardiologist, despite guideline saying so.

also like it or not, medicolegal is a part of our healthcare culture. im sure many family docs know how to intubate, and may be good at it. but if they are in a hospital with anesthesiologist on staff and they failed intubation and never called the anesthesiologist, no one will say hey this fam doc knew what to do, there was no need.

in above case, everything will be fine without cardiologist laying eyes on the patient, if everything goes fine. however if it DOESNT go fine for whatever the reason, then everyone will be saying this patient shouldve gone to a cardiologist.

 

[Full Metal IC]

one of the problems is assuming the family doc knows what he/she is doing. most of us do not make that assumption. also related to why guidelines are created, to try to standardize care in a somewhat evidence based way (yes there may be outliers). most of us will choose to follow the guideline, instead of assuming the family doc knows what he/she is doing, etc and chose to not send to a cardiologist, despite guideline saying so.

also like it or not, medicolegal is a part of our healthcare culture. im sure many family docs know how to intubate, and may be good at it. but if they are in a hospital with anesthesiologist on staff and they failed intubation and never called the anesthesiologist, no one will say hey this fam doc knew what to do, there was no need.

in above case, everything will be fine without cardiologist laying eyes on the patient, if everything goes fine. however if it DOESNT go fine for whatever the reason, then everyone will be saying this patient shouldve gone to a cardiologist.

Not once in the ACC/AHA guidelines do they specify who needs to be sent to a cardiologist preoperatively. Your reply illustrates exactly what I am talking about with regards to the role of CYA.

Like I said earlier I have nothing against CYA at all. It is part of practicing medicine in the US and we all do it. But to not acknowledge the dominant role it plays in this space is just ridiculous. In the case we were discussing, my point was that the family doc probably managed the patient appropriately from a medical standpoint. So LoneWolf is essentially getting mad at the family doc for not sending the patient to cardiology to cover HIS OWN ass.