Monday, July 26, 2010

Patients That Make Me Go Hmmm

To paraphrase a famous movie quote, "Preop is like a box of chocolates.  You never know what you're going to get." While I try to read the histories of my patients on the next day's operating schedule the night before, sometimes that is not possible, especially the outpatient or add on cases.  Frequently the outpatients don't have their histories dictated in the hospital computer system but instead are brought in by the surgeons from their private office files. Or the surgeon's history only discusses the surgical symptoms, not the other 20 positive review of system pathologies I'm more interested in. Thus it can be dismaying when confronted with an "interesting" patient ten minutes before the case is supposed to start.

For instance, we receive many patients for outpatient EGD's.  On the schedule it just says "EGD" and I'm thinking, "Great a quick 5-10 minute procedure"  But then I see the patient in preop holding.  She is 450 pounds and stands 5' 2".  She is here for an EGD as part of her preop evaluation for her gastric bypass surgery in the future.  "Hmmm," I ponder. "Should I intubate her for a five minute procedure like the textbooks and the ABA would advocate or risk apnea and aspiration by giving a MAC anesthetic?" Weighty question indeed.

Then there are the patients who are allergic to literally everything.  Their list of allergies runs two pages in single space type.  You know it gets ridiculous when they list Benadryl, atropine, epinephrine, all tapes, and half of California's agricultural industries as allergies.  One patient said she was allergic to morphine, fentanyl, dilaudid, and demerol, practically my entire arsenal of post operative analgesics.  "Hmmm," I'm contemplating. "This is going to be fun when she gets to recovery after her surgery. I hope there is some analgesic property in the L.A. smog we're breathing today."

Then there are the patients who are exactly the opposite.  They are taking every narcotic known to man for chronic pain.  Frequently these are the patients scheduled for major back surgery. The spine surgeon has assured them that their back pain will disappear after he does his miracle work.  I'm standing there looking at the patient who is already in tears because she missed her pain medications 30 minutes ago and I think, "Hmm.  She is on Dilaudid 24 mg every 4 hours and has fentanyl patches covering half her body.  This before a single millimeter of skin has been cut. I better punt this to one of our Pain guys. This is why they get paid the big bucks."

Variety may be the spice of life, but in anesthesia all I want is a simple, predictable, stodgy Hershey's chocolate bar.

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