Preoperative Schpeal

[DrOwnage]

Hey guys,

As a CA-1 I find myself still trying to figure out a good way of talking to patients in the pre-op area; mostly telling them about general anesthesia and the risks involved.. Sometimes its hard to come across in a coherent way that's not rushed during the morning dash. Does anyone have a good way of consenting/informing patients that covers all the bases? Thank you.

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[Dejavu]

Not to be a grammar nazi, but I believe the word is "spiel", from the German, but I could be wrong.

Anyway, just try and talk to your patients like you would to your mother, if she had any questions about her upcoming surgery. That way, you will come off kind of " folksy ". Patients love that. It makes them feel that you are a real human being, not some robot. The trouble with anesthesia, as a profession, is that we only have ten minutes to establish rapport, not several office visits. Try to connect on a human level.

Tell them what is going to happen to them in the OR, because fear of the unknown is a serious factor. Plus it lets them know you have done this before.

I once talked to a guy from the ASA Closed Claims Project, and he said that we should tell patients about things that happen more frequently than 1/10,000, and the really big things. That would be things like sore throats, tooth damage, breathing issues immediately postop, blood transfusion permission, etc. The really big things include nerve damage, death, coma, and such like. Lawyers tell me that you need to tell patients " things that are material to their decision making process. " I have been scolded by colleagues for the death discussion, but I figure death and coma, while very rare, is a pretty big thing, and material to them making a decision. Believe me, after 42 years of anesthesia, you will rarely be telling them something that they haven't already thought of. But, given some colleagues' feelings about this, I would feel out your covering staff's thoughts about the death discussion before doing it.

Believe me, it is on every surgical consent form I have ever seen, but a surgical consent isn't as good as your getting consent. You never know what surgeons say, while they are busy blaming anesthesia for everything.

You can minimize it by saying how rare it is and how our 1/250,00 number that a lot of people bandy about isn't really a solid number, but you will have gotten the words out. I tell every patient I meet about death and coma. I tell parents about it for sure, because they really are worried about it.

I say, "A lot of people come in for surgery and worry about things like death, coma, and not waking up. They shouldn't, but they do." Then I tell them how rare that sort of thing is.

I suspect that people might weigh in on this. I've seen it be a touchy topic, and I fully realize I am in the minority on this one.

I don't want plaintiff's attorney to say " Doctor, tell the jury why you didn't warn of the possibility of death or coma, because your patient's wife, my client, testified that her husband never would have had his knee replaced if he knew he could die." I don't want to be answering that question.

Also, you will need an answer to " What if I don't wake up? " and " What if I don't go to sleep, or if I wake up during surgery. I've seen on 60 Minutes that that happens." Because people are worried and will ask about these two things.

Anyway, if you get nothing else out of my post, remember to talk to your patient like you would to your mother or aunt. You will come off as folksy and comforting. I cannot tell you how many times patients have told me, " I like how comfortable I feel with you."

And that is the best you can hope to accomplish with your preop spiel.

 

[Crabbygas]

I work in a busy private practice and I can tell you that there is no way I would have time to go over all the stuff people recommend talking about. So I try to stick to the high probability things. I always mention nausea. I work at high altitude so going home on O2 is not uncommon. I mention that if I think it's likely. Thats about it unless the patient has some particular issue. If there is something the patient is concerned about we talk. I am going to disagree with what many others do and say that I never bring up death or serious injury from anesthesia. On the contrary if the patients ask I will indeed guarantee that they will not die. Why? In fifteen years Ive only had it happen twice and both times they were almost dead already (in those cases I told the family it was not only possible but likely to not end well). The patients like the confidence and really lets face it if a healthy outpatient comes out dead it's not going to make one tiny bit of difference what was discussed in preop. This holds double if the patient expresses that concern as we head to the room and there is nobody else with us. As I pointed out to a nurse one time I can't lose that bet as there will be nobody but me left to testify to what was said if things go bad.

 

[Robotic Wis-Hipple]

In addition to the commons, like PONV, sore throat, and possible oral/dental injury I always mention the possibilities of continued postoperative mechanical ventilation requirement and extra IVs with medicine infusions and the requisite machines if it's a big case or I think it's even remotely possible. I then expand on that and tell the pt and their family that if that's the case it doesn't necessarily mean that anything went wrong, poorly, or that anything unexpected happened. Pt's and their families literally think we put them to sleep and when surgery is done they'll be in the PACU looking just like they do now in preop. I think it helps to provide information to set the expectation while also comforting them that it doesn't mean anything bad occurred. But if you act like it's as simple as taking a nap then they see their family member with a tube in or an infusion pump with lots of green flashing lights they get worried because it wasn't something they saw as a possibility.

I also think ION is something to mention in prone cases, as we all know Surgery isn't telling them that and if a pt goes for back surgery and wakes up blind, i imagine that's going to be quite a shock.

 

[periopdoc]

Understand that 99% of the time, by the time I see the patient, I already know everything I need to to go straight to the OR. My spiel is modified from this for the few situations where I don't have good info before I meet the patient.

Hi, I'm Dr POD from anesthesia, I'll be helping with your surgery today. What are we doing for you? Right or left side? Good. That's what the consent and schedule say.

I see you have had some surgeries before. Any problems with anesthesia that you are aware of? Anyone in your family have weird reactions to anesthesia? I see you are allergic to PCN, what kind of reaction?

Ever have a heart attack or stroke? Any problems with the lungs, liver, or kidneys?

Anesthesia for this will be pretty straight forward, a little medicine in your IV, then you will drift off to sleep. Once you are asleep, I will slip a breathing tube into your mouth. You might have a light cough or a scratchy throat afterward. There is a slight risk of damaging a tooth when we put that in.

I'll be there the whole time with the goal of keeping you safe, minimizing pain and nausea, and keep you from remembering what we did to you.

Risks of anesthesia include a chance allergic reaction, and a chance of something coming out of your stomach, getting into your lungs and giving you pneumonia. The chance of something serious happening like heart attack, stroke, seizure, coma, and death is about the same as if you were shoveling snow. So, it's a it higher than sitting on the couch reading a book, but it's a lot safer than driving to the hospital. So, you've already been through the risky part of your day. Any questions?

I say exactly this for every single anesthetic, to the point that the preop nurses know it word for word. If I ever have to defend myself, there won't be any question of what I told the patient.

If there are specific issues, like rotten teeth, I'll expand a bit on the additional risk. The whole spiel takes about 5 minutes or less if nothing surprising pops up.

 

[periopdoc]

For children, I tell the parents that it's about as risky as running around on the playground.

 

[MirrorTodd]

Do any of you ever tell them how you will mitigate those risks? something like: "There is the risk of having some post operative nausea and vomiting, we minimize that by using certain medications during the course of you operation." Alternatively, what do you say to someone who asks "How do you prevent any damage to my teeth?" I've found myself saying that we go slow and are extra careful while intubating. But that doesn't really seem satisfactory to me.

 

[anbuitachi]

They probably wont remember all of it. I've had plenty of patients ask me if i'll be doing the surgery, AFTER i explained to them im the aneshtesiologist, and what will happen in the OR before you sleep, tube going in etc, risks/side effects/benefits etc. A lot of them are kind of nervous and dont pay attention well esp if you talk fast. Some are just not educated enough to understand. You got to dumb it down, and just say, you go sleep, surgery, you wake up.

And i find it hard for patients sometimes to understand sedation. When you use the word sedation, the patient thinks they are going to sleep. So i always tell them you will be awake for the procedure.

And I agree with above posters, its like pregnant patients getting epidurals. They all think they'll get paralyzed. I just tell them the chances of that happening is lower than you getting shot and dying on your way here to the hospital

 

[imfrankie]

Hey guys,

As a CA-1 I find myself still trying to figure out a good way of talking to patients in the pre-op area; mostly telling them about general anesthesia and the risks involved.. Sometimes its hard to come across in a coherent way that's not rushed during the morning dash. Does anyone have a good way of consenting/informing patients that covers all the bases? Thank you.

I personally do not go into a frightening discussion of risks 15 minutes before a patient is heading into the operating room. And I believe analogously, while waiting to board, I've never heard a pilot or airline representative announce that our plane could go down in a ball of flames. People have different opinions on this--my personal approach is do the very best job I can to keep my patients safe, comfortable and anxiety-free, to speak to them so they know I care deeply about them, and to let the attorneys fight over the malpractice insurance money if ever it comes to that.

 

[Urzuz]

In an average patient, after a brief H&P, I basically tell them that they we will head back to the OR, I'll place them on monitors, then give them medicine to drift off to sleep. After they're asleep I will place a breathing tube that I will take out as they're waking up. They may have a sore throat, they may have nausea.

I will then add in anything that may be particularly pertinent to the patient (50 pack-year smoker gets told of the risks to their lungs, patient with history of MI gets told that I will be paying extra special attention to their heart, etc)

The most important thing you can do in residency is develop a good spidey sense. What I mean by that is you have to be able to develop a keen sense for when you need to pump the breaks from your normal "spiel" and investigate things a little further. For 95% of patients you should be able to complete an H&P and consent in less than five minutes. But, it is those oddball patients where something just seems a little "off" where you need to take time to thoroughly evaluate the patient and make sure there isn't some ticking timebomb that is waiting to explode in the perioperative period (the woman on birth control who has a swollen lower extremity, the patient who was in the ED a couple days back with unexplained chest pain, etc). I personally feel like this sense is best developed by doing a lot of cases, hearing of others' misadventures during M&Ms, talking with colleagues in the lounge, reading SDN, and unfortunately, experiencing your own complications and asking yourself why they happened and what you could have done to prevent them. That would be my best advice to you.

Also, one last thing: I always try to sit down when talking to patients. I really don't like looming over patients while talking to them. I feel like it helps me connect with them.

 

[anbuitachi]

I personally do not go into a frightening discussion of risks 15 minutes before a patient is heading into the operating room. And I believe analogously, while waiting to board, I've never heard a pilot or airline representative announce that our plane could go down in a ball of flames. People have different opinions on this--my personal approach is do the very best job I can to keep my patients safe, comfortable and anxiety-free, to speak to them so they know I care deeply about them, and to let the attorneys fight over the malpractice insurance money if ever it comes to that.

I think the difference is everyone knows the plane can explode. But most people do not understand anesthesia. While explaining to them may not prevent lawsuits, it may decrease lawsuits if we told the patient about it. I hear people suing for feeling some pain during a C section under spinal. I can totally imagine a patient suing for being awake in a sedation case if we didn't explain to them what its not general anesthesia means. Most people think anesthesia just mean you sleep

 

[periopdoc]

Do any of you ever tell them how you will mitigate those risks?

Not unless they specifically ask, or there is other evidence that they may have a specific concern (history of PONV, for example).

If they do ask, I am always careful to couch my response in terms of how we will reduce the risk, and always include the statement that we can't eliminate the risk completely. If they have dental concerns, I explain that I will start with a plastic bladed instrument, but my primary concern is to ensure they keep breathing, so I reserve the right to change the plan midstream to one that is better for getting the breathing tube in, though may not be as safe for the dentition.

 

[Snoozemd77]

I discuss about NPO/nausea vomitting &aspiration,pneumonia,dental injury ,anaphylaxis,cardiac complications and awareness in general and specific LAST and nerve injury for blocks.Rarely have to bring up death for ASA 1-3 patients

 

[sigrhoillusion]

Well to be fair... airlines do have their safety speech on every flight and go through how to use the seatbelt, O2 mask, life jacket, water landing, floatation devices etc. So it's not true that they don't go over the risks.

When it comes to anesthesia I try to keep it short and simple.

For routine cases:
Introduce myself.
Confirm patient and surgery/site.
When was the last time you ate?
Anesthesia before? Any issues?
Allergies?
Currently having CP/SOB? Different from usual? Activity status if applicable...
(Usually don't ask about medical history unless it's unclear)
(Usually don't ask about meds, since the nurses ask and document and the patients never seem to know anyways...)

Go back to the room, put on monitors (O2, HR, BP), give you some o2 to breath and then you'll go off to sleep.
Once asleep secure your airway(if GA). May wake up with sore throat, but otherwise out on wake up. Low risk of damage.
Give you medicine for nausea, which is biggest risk. Also pain medicine so you wake up comfy.
Someone will be in room montioring whole time. Don't expect serious complications, but that's why we're here to keep you safe. Have all emergency stuff available but don't expect to use it.
Afterwards take you to PACU. will continue to monitor and make sure recovering appropriately. Continue to give prn pain/nausea meds.

Here's anesthesia consent form. Goes over everything. Do you have any questions? (Then answer anything)

Obviously I adjust to specific populations. Hx of PONV. Peds. High risk. Difficult airways. But the above takes under 5 minutes.

I personally do not go into a frightening discussion of risks 15 minutes before a patient is heading into the operating room. And I believe analogously, while waiting to board, I've never heard a pilot or airline representative announce that our plane could go down in a ball of flames. People have different opinions on this--my personal approach is do the very best job I can to keep my patients safe, comfortable and anxiety-free, to speak to them so they know I care deeply about them, and to let the attorneys fight over the malpractice insurance money if ever it comes to that.