Clinical Case for Discussion: You have just graduated from your anesthesia training program. The night before your first day in community practice, your operating room surgery list reads:
7:30 a.m. = 68-year-old male for a thyroidectomy, 11 a.m. = 42-year-old male for laparoscopic cholecystectomy, and 1 p.m. = 56-year-old female for a vaginal hysterectomy. There is no Preoperative Anesthesia Clinic in your new practice.
Who, if anyone, has done the preoperative evaluations? How can anesthesiologists and surgeons function without a preoperative clinic and its employees to evaluate patients prior to surgery?
Discussion: In the academic teaching setting, the Preoperative Anesthesia Clinic is useful. University surgical patients are complex, not all residents in anesthesia and surgery are experienced in preoperative evaluation, and many patients do not have an internist or a primary care provider.
In most community practice models, a Preoperative Anesthesia Clinic is impractical. As community anesthesiologists in private practice, we distribute guidelines to surgeon’s offices regarding the indications for preoperative lab tests, consultations, and medication management. Surgeons or their nurse practitioners do the preoperative evaluations for healthy patients, and surgeons refer more complex patients to internists preoperatively as indicated. When the surgeon wants an anesthesia consult (or else risk a cancellation on the day of surgery), he or she will call the attending anesthesiologist who is responsible for preoperative phone consultations. The surgeon or the surgeon’s nurse practitioner will present the case, and the anesthesiologist will advise whether further diagnostic tests or medicine consultations are necessary prior to scheduling the surgery.
The night before the surgery, each attending anesthesiologist in our practice usually telephones their patients. The anesthesiologist asks medical history questions that are pertinent, and answers the patient’s questions. Patients are advised as to eating and drinking restrictions before surgery, and whether the patient should take or hold any usual oral medications in the day prior to surgery.
On the day of surgery, pertinent labs, ECG’s and consults are on the chart. Any omissions can be supplemented, e.g. bedside ECG or fingerstick blood glucose.
This method works in community private practice of anesthesia, because all the involved M.D.’s are fully trained and they have incentive to complete the surgical cases, not to cancel them. Key advantages of this method are (1) Patients like it. Patients like talking to their attending anesthesiologist the night before, instead of waiting at an anesthesia clinic to be evaluated by a third party. (2 ) There is no expense to rent clinic space and pay clinic employees. (3) Community private practice anesthesiologists do not want to staff a clinic, where there is no financial incentive to be there. (4) For pediatric surgery, parents prefer to talk to the attending surgeon the night before surgery from the comfort of their own home, rather than bringing their child to the hospital twice. (5) This system works. In our practice, each anesthesiologist averages 5 -6 cancellations on the day of surgery, out of 600 cases per year. Example cancellations may occur for patients who have fever the day of surgery, chest symptoms the day of surgery, or elevated blood pressure the day of surgery. Very few patients are cancelled because of incomplete laboratory workup, as current anesthesia standards show that many preoperative lab tests are either not indicated or do not change the management of the anesthetic. American Society of Anesthesiologists (ASA) Practice Advisory for Preanesthesia Evaluation ( http://www.asahq.org/For-Members/Practice-Management/Practice-Parameters.aspx)
Instead of staffing a Preoperative Anesthesia Clinic, your preoperative homework is three telephone calls the night before surgery. Because it is your first day at a new practice, you choose to telephone a senior member of your anesthesia group the night before surgery as well, so he or she can give you advice on what to expect from each surgeon the next day. Time = 25 minutes. Cost = 0.
An occasional patient may need to be evaluated prior to the day of surgery. The American Society of Anesthesiologists (ASA) Practice Advisory for Preanesthesia Evaluation ( http://www.asahq.org/For-Members/Practice-Management/Practice-Parameters.aspx) addresses the issue of the timing of preanesthesia evaluation. For cases of high surgical invasiveness, 59% of ASA members recommended that the preoperative anesthesia history and physical take place prior to the day of surgery.
For patients with a high severity of disease, 89% of ASA members recommended that that the preoperative anesthesia history and physical take place prior to the day of surgery.
In these instances, arrangements can be made for a member of the anesthesia group to meet and evaluate the patient prior to the day of surgery.
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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: