Tuesday, January 20, 2015

My Easiest Cancellation Ever

Every anesthesiologist has been through this. A surgeon books a case for a procedure and we go evaluate the patient. We examine her and think, "Hmm, this patient probably shouldn't go to the OR. She needs more workup to evaluate and resolve some important issues." We then gird ourselves for the inevitable argument with the surgeon for why the case needs to be postponed. Inevitably we win the argument but they still fight anyway. Or they decide to find another anesthesiologist with looser standards for administering anesthesia.

However that was not the case the other day. The surgeon scheduled a case later in the afternoon. I dutifully went to the ICU, where the patient was located, to preop her. Most anesthesiologists have had the "Holy shit! They want to operate on this patient?" moment. And this was one of them. I could only shake my head at the audacity of the surgeon to even book this case. Did he even examine her?

A quick perusal of the labs revealed the patient had a hemoglobin of 2.9. Platelets were 6K. Not 600,000, or even 60,000. SIX THOUSAND. The patient was highly coagulopathic with an INR of greater than 4. How will the surgeon possibly stop any surgical bleed during the case? And worst of all, on her blood gas her pH was 6.9. And the patient is on dialysis. WTF?!

I called up the surgeon and calmly relayed my concerns. The surgeon replied that the ICU team was giving the patient more blood, though I didn't see any hanging at the moment. Well, they didn't want to give the blood too quickly because of the renal failure. Uh huh. Then I asked, if the patient is on dialysis, why is she so acidotic? Why hasn't the dialysis machine corrected the pH? Well, the patient is on a very expensive experimental drug that costs $20,000 per dose. The team didn't want to dialyze out the drug. Haha. That excuse was too funny to hold back my snort. So the primary team didn't want to waste $20,000 on a patient even though a pH of 6.9 is not compatible with life? This is so not happening. Case cancelled.

P.S. Subsequently the team tanked up the patient with blood to a more sane hemoglobin of 7. They also started a bicarb drip to bring the pH up to 7.3. They found an anethesiologist to do the case the next day after all these corrections were made. The patient then expired less than 24 hours after that. Don't we just love American medicine?


  1. So? What was the case? If it were organ harvest, you shouldn't have been so fussy.
    My curiosity is overwhelming... what could the surgeon have possibly wanted to do?

    1. It was a simple EGD that the primary team insisted they needed. He eventually got the procedure done but as you can see it did not alter the course of his illness.

    2. Thanks. You should have told them that the current trend is not to require (or pay for) anesthesia for simple GI cases.