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Ride ‘Em Cowboy

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Hopeful, yet cautious, I walk into the preop holding area to see my next patient.  The night prior, I spoke with her on the phone.  She told me that in the past, she suffered a severe, disfiguring burn to her face and neck.  The resulting scars have put her into the category that will cause any anesthesiologist’s blood pressure to skyrocket – a “difficult airway.”

Hands down, the single most important job of an anesthesia doctor is airway management.  For general anesthesia, that means getting a breathing tube into the trachea so that a patient can be hooked up to the ventilator and oxygenated.  Our worst nightmare is the inability to secure an airway.  Such a situation can rapidly deteriorate, necessitating an emergent tracheostomy.  As precious minutes slip away, a patient’s oxygen levels can rapidly plummet, leading to brain injury, heart attack, or even death.  When a patient tells me that they have been difficult to intubate in the past, I listen.

My patient smiles as I walk in, but it’s almost imperceptible.  The bands of restrictive scar tissue on her face and neck are so severe that she can barely open her mouth and is unable to extend her neck.  From my perspective, these observations are the beginnings of a nightmare.  I sit down and go over her medical history.  She is in her mid-fifties, has hypertension, high cholesterol, obstructive sleep apnea, and obesity.  When I question her about her medications, I discover that she is taking an amphetamine for weight loss.  Amphetamine use can alter a patient’s response to anesthesia and result in wild swings in blood pressure.  Under ideal conditions, patients taking these drugs should be off of them for 10-14 days prior to surgery.  Combined with her list of medical issues, these are less than ideal circumstances for an elective procedure.

This case and so many others like it are the bane of my existence.  Many of my colleagues, I like to call them the cowboys, wouldn’t bat an eye at the situation.  The surgical procedure itself is minor and should take less than half an hour.  Their philosophy would be “get her in, get her done, and get her out.”  These are the people to which I am compared to on a daily basis.  Surgeons love the cowboys.  The hospitals love the cowboys.  Nurses fear the cowboys, but keep their thoughts to themselves.  Completed cases equal revenue.  Cancelled cases cost everyone involved.

The fact is, over my medical career, I’ve learned something from the cowboys.  Most of the time, you can get away with a lot, and everything still turns out okay.  It never ceases to amaze me, when I read another doc’s note or hear about their practice habits from others, just how many things you can screw up and still have the patient come out fine.  But just like everything else in life, luck only carries one so far.  Eventually, their cavalier approach will catch up with them . . . and their patient.

There are too many red flags telling me not to do the case.  I decide to get an EKG on the patient.  She assures me she just had one done within the past week, and it was fine.  I stick to my guns and order one anyway.  It comes back with evidence of abnormalities.  Calmly, I explain to her that the riskiest part of her surgery is not the procedure itself, but the anesthesia, specifically the securement of her airway.  If I run into problems, especially with all of her medical problems, we could quickly get into trouble, even a life-threatening situation.  I recommend that she obtain a thorough cardiac evaluation before we proceed.

In response to my stance, the patient, who was pleasant only minutes prior, crosses her arms across her chest and scowls.  Her face turns a deep shade of red.  If she were a cartoon character, there would undoubtedly be steam shooting out of her ears and nostrils.

In a tone filled with daggers, she asks, “Can’t I just sign a waiver and proceed?”

I’m not sure what expression swept across my face, but I know what was going through my head.  Something along the lines of, “Are you friggin’ kidding me?  A waiver?  I’m sure when you stroke out because I can’t secure your airway, the lawyer who jumps all over your case will use that ‘waiver’ to wipe their backside.”

Inwardly, I’m shocked.  Outwardly, I calmly explain that there is no such thing as a waiver.  Not only is her safety on the line, but so is my medical license.  I’m not willing to risk either.  She decides to push it further and demands another anesthesiologist.  I just told her she could die.  I spent several minutes patiently explaining why.  My reasons are sound and completely justified.  And she wants to trade up?

I cancelled her case, and somehow managed to remain pleasant toward her the entire time.  When I walked out of the room, it was evident that the patient detests me.  But, in the end, at least she’s alive.  It’s possible that I saved her life by refusing to risk it.  I’m not a cowboy, never have been, never will be, and  I’m okay with that.



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