Monday, May 9, 2011

The Negotiation

At the end of every surgical case, the anesthesiologist holds a negotiation with the surgeon on one of the most tedious aspects of surgery, determining the estimated blood loss (EBL). It certainly is important to estimate how much blood was lost during the case. This helps determine if the patient received an adequate amount of fluid replacement, the need for any blood transfusions, the cause of any acid base disturbances, any potential for kidney injury, etc.. As you can see, getting the proper EBL is essential for a successful operation.

But arguing with the surgeon over the EBL gets really tiresome. Some surgeons feel their manhood is at stake when it comes to how much blood they lost during the case. As the anesthesiologist, I am there watching the entire operation and have a pretty fair assessment of the amount of bleeding going on. But some surgeons always think they know better based on how much blood they see welling up from the patient's wounds. Believe me, they always underestimate how much bleeding has occurred.

In cases with significant hemorrhaging, they always ask how much is the EBL by looking at the suction cannister. If I say 500 cc, then they counter, "Well, there is some irrigation fluid mixed in there." I'm pretty sure I took that into account as the suction fluid looks like thinned Koolaid, not whole blood. I point out to them the huge stacks of dark red lap sponges hanging in the back of the room that the nurses count to make sure none are left inside the patient. That usually gets their attention.

What's worse are the surgeons who quibble over the tiniest amount of bleeding. In cases with minimal blood loss like an inguinal hernia repair or laparoscopic appendectomy, the back and forth can border on the ridiculous. If I say there was a 10 cc blood loss for the case the surgeon will counter that he thinks there was only 3 cc blood loss. Some surgeons will actually state that there was zero cc blood loss even though there are obviously some splotches of red on the surgical sponges. Logically our computerized electronic medical record will not allow an input of zero cc blood loss for any case where skin is cut. With surgeons like that I just sigh and accept whatever EBL the surgeon desires. I am not going to waste my time arguing over a difference of 7 cc EBL out of a total blood volume of five liters. If that's how they maintain their virility by low balling the EBL, let them. Who am I to emasculate a surgeon by saying the patient bled out an excess 7 cc of blood?

This is literally a game that all anesthesiologists have to learn to play. It starts from the very first day in the operating room during residency and it never ends. We want to be accurate about the true blood loss for all the reasons I described earlier yet appease the surgeon so that we can both feel good about ourselves. Perhaps some day we can have truly bloodless surgery like in Star Trek. Somehow I think even in the 24th century a surgeon will still argue with an anesthesiologist about something.

1 comment:

  1. Great article! I found it helpful and explaining to the following case: Anesthesia Report shows EBL 1400 ml; Operative Report shows EBL appr. 600 ml.
    Wow, what a difference!
    What is actual BL by your opinion?