Monday, July 28, 2014

Hell Hath No Fury Like A Cardiologist Scorned

"Anesthesia REFUSED to do (procedure)!! Refused to do it if we were in room with crash cart!!!!"

This was the note left in the patient's chart by the cardiologist the day after I canceled an elective procedure on an unstable patient. During the preop discussion with the surgeon and the cardiologist, I explained my reasons for why the patient was unfit for an elective surgery. The cardiologist's solution was that he would stay in the room during the procedure to monitor the patient and resuscitate him if he experiences sudden death. When pigs fly, I thought. Such arrogance. As if this cardiologist had ever responded to a Code Blue anywhere in the hospital in the past twenty years.

Though surgeons and other doctors may think otherwise, anesthesiologists give very serious thought before cancelling any case. It is a heavy burden that we alone have to make and it is usually not a very popular decision. The surgeon is raring to go, having scheduled this case weeks ahead of time. If he's not operating, he's not making a dime. The operating room usually has already opened the case cart and thus is ready to bill the insurance company for the equipment. The patient and his family have taken time off from work to prepare for the operation. So stopping an operation carries a lot of consequences for everybody involved, including the anesthesiologist. Cancel too many cases and you become an obstructionist. Have too many postop anesthesia complications because of poor preop assessment and you are labeled a cowboy, or worse, reckless. No, it's a very fine line we walk on every patient we meet.

The number one, and really only, reason anesthesiologists cancel cases is because of patient safety. This is absolutely the main purpose of our preop exam. Is the patient well enough to survive an operation? If for any reason we have our doubts, the prudent anesthesiologist will discuss his concerns with the patient and surgeon and explain why the operation should be postponed until the patient has had a more complete work up or optimization. Usually the patient will be sympathetic because it is his life on the table we're discussing. The prudent surgeon also listens to her anesthesiologist since our only goal is to provide the patient with a safe operation. Only the imperious ones fight us to continue the case. When they become nasty and belligerent, it makes it that much easier for us to cancel the case.

Can't the surgeon just ask for another anesthesiologist? Of course she can. And that is certainly her right to ask for a second opinion. The surgeon might happen upon an anesthesiologist who doesn't mind taking on a little more risk than me. Some anesthesiologists tolerate more risks than others, just like some surgeons will perform the most perilous operations on the least favorable candidates, cases that no other surgeon is willing to touch. But we are dealing with a human life here. If the patient and his surgeon are willing to take a chance on his life by finding an anesthesiologist who might give an anesthetic to an unstable patient, then that is the team's mutual decision. Hopefully the logic laid out in my note will be so overwhelming that no other anesthesiologist will dispute it. But if the anesthesiologist disagrees with my clinical judgement and proceeds, well that is his medical license and patient's life that is on the line, not mine.

So to the cardiologist who deemed me an obstructionist in writing on a medicolegal document, you can just shove it up your histrionic behind. I can sleep knowing I helped a patient that day from winding up in intensive care postop with multiple lines and tubes coming out of every body orifice, if he was lucky to survive the operation. Though he didn't get the procedure he was supposed to that day, my act of compassion by stopping the surgery will significantly increase his odds of survival the next time he comes down to the operating room.

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