Medical specialties, especially within the medical community, are known to be identified as comedic stereotypes of themselves.
In addition to (or in conjunction with) being viewed as lazy, anesthesiologists are often stereotyped as being obstructionists to the operating room. A spot-on joke generated during the “first” COVID-19 surge in March of 2020 was in reference to Jerome Adams: “First Anesthesiologist Surgeon General, recommends canceling all elective cases.”
For better or worse, the bottom line is that anesthesiologists are often viewed as the gatekeepers to the operating room.
So what are the reasons an anesthesiologist might cancel a case?
- abnormal, and unexplained laboratory values
- abnormal, and unexplained EKG findings
- inadequate preoperative studies deemed necessary: Echocardiogram, stress test, etc.
- poor blood pressure control
- poor glycemic control (diabetes)
- NPO violations
- unknown COVID status (this was not even a thing two years ago, but here we are)
But here’s the thing:
I don’t cancel cases.
Or at least, it’s very rare that I do.
I’m this way for a few reasons:
1. Comfort with complexity and acuity. For me personally, the most challenging cases are the ones I came to enjoy most. So much so, I chose to pursue a fellowship in cardiac anesthesia, to refine and hone that passion.
As such, the patients that I take care of on a regular basis are next level sick. These patients regularly have multiple organ systems that are failing and need machines to do the work of their heart, lungs, kidneys, and more. Furthermore, a huge number of these indicated surgeries are emergent. There is no canceling. You go to the OR and do everything you can.
Fortunately, the majority of surgical patients are nowhere near as complicated. So it is rare, if ever, that there is a patient that I feel I am inadequately prepared or knowledgeable to take care of. (Caveat: Adult patient. Sick kids scare me.)
2. Recognition of chronic conditions as chronic. What is the systolic blood pressure? What is the heart rate? What is the hemoglobin? What is blood glucose?
These are obviously all important things to know, but these abnormalities often reflect chronic medical conditions. Hypertension is a chronic condition. Diabetes is a chronic condition. Anemia may indeed be a chronic condition. Many of these chronic conditions are poorly suited to fixing in the immediate perioperative setting. Just because I lower the patient’s blood pressure today, it likely has little value in regard to how long-standing hypertension will affect that patient overtime. In fact, trying to treat it too aggressively, too quickly, could be harmful to the patient.
So if it’s a condition that I believe needs to be treated over time, I’m likely to proceed in the absence of immediate danger to the patient.
3. The ability to rapidly correct physiologic abnormalities. The flip-side of the previous point, and somewhat related to my first point, is that if there is a physiologic abnormality that needs to be corrected, I can likely do so faster than anywhere else in the health care system.
That’s one of the most unique and one of my favorite aspects of anesthesia. I’m kind of a one-stop shop. It’s a cornerstone and catchphrase of anesthesiology: “Simultaneously diagnose and treat.”
So if I notice an abnormal lab value, and if I think it’s a minor aberration that does not pose an immediate danger to the patient, but I think it requires correction, I’ll just fix it.
4. A minimalist approach to preoperative testing. A major problem with health care in the United States is doing too much. When you go looking for things, you find things that might not matter in the clinical context of the patient. I don’t mean to be as cavalier as to say “ignorance is bliss,” but it’s kind of true in some ways. And the ASA practice advisory recommends avoiding “routine” testing.
Suffice it to say, I don’t need a stress test for a young woman who normally runs 10 miles a day, but needs surgery because she fell and broke her ankle. I don’t need a chest X-ray. I don’t need an EKG. I don’t even need labs in the absence of other medical problems.
So I try to be very deliberate in the studies I ask for.
5. Respect for my surgical colleagues. One of the other unique aspects of anesthesiology is that I have two “customers:” The patient and the surgeon (yes, always in that order).
Still, it behooves me to facilitate the surgeon’s cases. Medicine is best delivered as a team, and I want to create strong teams. Plus, the surgeon is providing important care to the patient as well. I view it as my job to complement the delivery of that care.
6. Respect for my patients. Surgery is a big deal. It doesn’t matter if it’s a broken finger or a heart transplant. It can inconvenience friends and family, requires time off work, and potentially incurs a loss of wages. And who knows how to quantify the emotional and mental stress scheduling and then rescheduling a procedure can cause.
So to cancel my patient’s case is a major deal to them. Especially because, depending on the reason, it may result in a significant delay to their care. What if the surgeon doesn’t have any availability for 6 weeks? What if the patient can’t get off work for another six weeks? If I cancel for poor blood pressure management, how many weeks will it take their primary care doctor to get it under control? It’s something I really care about and do not take lightly.
So unless there is a compelling reason that I think I cannot get my patient through surgery safely, or that I think the risk of their medical condition outweighs the benefit of the surgery, we’re going to proceed.
So understand, for we humble anesthesiologists, our favorite surgery is not a cancelectomy. Our favorite surgery is one that you sail through safely.
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