Wednesday, November 4, 2009

Outrageous surgeon's requests

As an anesthesiologist, I try to make sure everything in the OR runs as smoothly as possible. To do that, it helps not to step on anybody's toes and try to get along with everybody as much as possible. But sometimes a surgeon will make a request that can be simply outrageous, even downright dangerous to the patient.

There was this one surgery center I used to work at that performed a lot of arthroscopies. A surgeon who worked there, and may have been a partial owner, was known to be a real tyrant. He went through dozens of anesthesiologists who all eventually refused to work with him. His main request, or more accurately demand, was that during his arthroscopies, the patient's systolic blood pressure be less than 100, in the 80's if possible. It didn't matter that the patients he brought had all sorts of morbidities: morbid obesity, hypertension, diabetes, coronary artery disease. The preop workup was usually minimal, practically nonexistent. He would have his patients up in the sitting position for the shoulder arthroscopies, constantly looking over the drapes to check the blood pressure. If the BP went over 100, like 101 or 102, you got a good yelling. It got to the point where right before the BP cuff inflated, I would give a small dose of nitroglycerin to make sure the BP appeared low. Cerebral perfusion pressure be damned. After a few months of this, I left that surgery center and got my self esteem and sanity back.

At another site that I used to work in, they did a lot of pain procedures such as epidurals, facet joint injections, etc. The way to make money in a pain center is to drive through huge volumes of patients. The pain doc, really an overpaid egotistical anesthesiologist, didn't want his patients to feel any pain upon injection and didn't want to wait for a routine anesthetic to kick in. So he demanded all his patients receive Versed 10 mg and Fentanyl 100 mcg IV boluses right before he injected. Of course that cocktail put the patient's out like a light switch. Since pain procedures usually take about ten minutes to perform, the patient was usually still sound asleep when he was finished. Now you can't clutter up a small recovery room at a pain center with a bunch of sleeping patients. So the routine there was to give a bolus of Flumazenil and Narcan when the procedure was completed. That usually woke up the patient right away though many still felt groggy. They were discharged pretty quick, before the reversal agents wore off and the patients fell asleep again. It's surprising not more people had complications from this.

There are so many other difficult surgeons I could write about. These are the reasons why I don't understand the desire of many anesthesiologists to work in surgery centers. They are usually owned by the surgeons and your bread and butter really depends on satisfying their every whim, no matter that fulfilling their requests would probably get your anesthesia board certificate revoked. I don't work in these places anymore but it's scary to think that many are still out there.

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