Surgeons v. Anesthesiologists: Why the Tensions?

I often get frustrated when patients attribute to their surgeons more concern for their overall medical well-being and perioperative safety than I have observed. Don't misunderstand - I think surgeons do care about their patients, but I also think they can be fairly goal-oriented and single-minded about operating, sometimes when an operation should be delayed in favor of managing pressing medical issues.

To be fair, I have worked with many wonderful surgeons, especially at St. Boonie's, who deeply care about their patients and open-mindedly listen to anesthesiologists if the latter bring up safety concerns that mean possible cancellation of scheduled operations. Frustrating for all, and potentially costly, but ultimately the right course of action for the patients in question. (That's not to say that some anesthesiologists don't go overboard with the gate-keeping and perhaps apply their standards too conservatively; I've seen that too.)

I've also had surgeons physically help me every step of the way when I've encountered difficult airways, with the helpful, team-spirited attitude, "If we haven't got the airway, we haven't got anything." The chief of surgery at St. Boonie's is like that; Caroline Walsh is like that; one of the young surgeons at New Hospital has been like that. One of the neurosurgeons at New even advocated for my monitoring needs during assisted ventilation of a patient in the recovery room, which I thought exceptionally in-tune and helpful of him.

On the whole, though, what I typically see is a lot of exasperation from surgeons whenever a medical condition precludes speedy progress to the O.R. - perhaps because in many hospital systems, these conditions can easily remain undiscovered or unevaluated until right before the scheduled procedure. I always wonder: didn't they look through the chart themselves and see that the lab value was egregiously abnormal, or examine the patient and hear the lung crackles practically from across the room? Surely they, too, did a history and physical, as we're all expected to do?

The usual pattern I see is this:

-An anesthesiologist reviews a patient's history/chart, does a physical exam, and spots a concern - unevaluated cardiac disease, new heart rhythm problem, wheezing on auscultation of the lungs, a potassium value that is acutely too high or too low, or some such potential danger.

-No one else in charge of the patient's care seems to have noticed the problem, thought it significant as a safety risk for anesthesia and/or surgery, or done anything about it prior to surgery.

-The anesthesiologist delays surgery until the patient's condition is "optimized" or the problem corrected (unless the surgical procedure is an emergency).

-The surgeon gets mad, because he or she wants to help the patient by getting the main job done - the tumor excised, the lung biopsy sent to pathology, the hernia repaired.

If it were up to some surgeons, I suspect they'd go ahead and operate on a patient with a potassium of 2.8 or a loud murmur that could be undiagnosed aortic stenosis. The patients would be none the wiser. Most patients don't realize that if they didn't have an anesthesiologist watching their back, they'd be brought into the O.R. by their surgeons despite some increased risk that could be detected and reduced by a preop evaluation specifically geared toward assessment of anesthetic and surgical risk. (Not that ALL risky conditions are easily detected or successfully addressed; but the anesthesiologists at least try very hard not to miss them.)

The GOOD surgeons understand that the practice of surgery is still the practice of medicine, and that patients need to be seen as more than specimens to be sliced and diced. The GOOD surgeons engage in teamwork with the anesthesiologists and don’t resent it when we bring up concerns they may or may not have considered. The GOOD surgeons don't act on exasperation at the prospect of a civilized discussion regarding the safety of a given procedure for a particular patient, will listen to a competent anesthesia consultant when concern is warranted, and won't personally resent the ensuing delay, postponement, cancellation, or what-have-you.

A good surgeon will also respect an anesthestist’s or anesthesiologist’s instructions inside the O.R. when safety is at issue. Rarely have I seen this to be a problem. Usually when I ask the surgeon to stop operating for a minute, for example because I want to assess a patient’s EKG without them tugging on organs or causing interference with EKG wires, the surgeon will graciously stop. The command is not personal; the patient’s safety is at issue; and no surgeon wants a patient coding on the table.

But I did encounter one surgeon whose behavior I consider among the most appalling I’ve seen. I'll call her Dr. Myrtha Banshee.

I was working with a pleasant and competent nurse anesthetist the day Dr. Banshee's patient, a school-age child named Elly, came to New Hospital for surgery. I spoke to Elly and her family prior to surgery and gave them my usual pediatric anesthesia spiel. Dr. Banshee arrived, already irritable (which, according to the nursing staff, was fairly typical). Elly was living with and being raised by relatives but asked to see her mother before we went to the O.R. Her mother was invited in to give her a kiss. Because of this brief delay, we arrived in the O.R. four minutes past the scheduled surgery time - not bad, reallly, considering the way most hospital schedules go.

Dr. Banshee was displeased. She was in a hurry because her secretary had scheduled her office hours half an hour after the scheduled time for this procedure. This surprised me; the procedure usually took about an hour if you factored in the anesthetic and wake-up time.

Dr. Banshee had asked the nurse anesthetist if the patient could remain on the transport stretcher for the surgical procedure and he had initially said yes. I said I wanted Elly on the proper O.R. table, and we moved her off the stretcher onto it. Banshee asked loudly, "Why is the patient on the O.R. table instead of the stretcher?"

"Dr. T. just asked me to move her," replied the nurse anesthetist.

"Why?" she asked, turning to me, her resentment emanating from her like black smoke billowing from a smoldering fire.

"Because," I answered, as matter-of-factly but emphatically as I could, "if this kid CODES and DIES, I don't want to be performing CPR on a stretcher."

That silenced her for a second, but then she muttered, "Everyone ELSE is willing to do it on the stretcher."

"Well, good for them," I said. "For me it's easier to provide a safe anesthetic on the O.R. table." She couldn't argue with that, but according to the nurse anesthetist she had some choice words for me after I left the room and spent the rest of the case irate and complaining.

Before leaving the room I helped the nurse anesthetist with the induction of the anesthetic. We had agreed that I would place the I.V. once he had given the child enough anesthetic gas to get him to a deep state of unconsciousness.

Kids take several minutes to get anesthetized enough to be ready for the application of painful stimulus. For surgeons the wait can be frustrating, I'm sure. But touch a kid the wrong way before she's ready, and a dreaded pediatric anesthesia complication can occur: laryngospasm. A spasm of the vocal cords that closes off the airway, making mask ventilation difficult if not impossible. Kid's oxygen saturation goes down precipitously; kid turns blue; lack of oxygen causes the heart rate to fall; you've got a code on your hands...unless you can break the laryngospasm and intubate the kid in time. No one wants laryngospasm.

Myrtha Banshee was already infuriated by our "delay" getting into the O.R. "That mother doesn't even have custody," she hissed. "She had no right to be allowed to talk to the patient right before surgery." I thought this a heartless attitude; I was surprised to learn later that Dr. Banshee is a mother herself. But on top of this so-called delay, she had to wait for the patient to "go under." That proved too much for her patience. The nurse anesthetist warned her, "She's still a little light," but she paid no attention and inserted an instrument into one of the child's orifices. The child flinched, of course - even with the mind unaware, the body reacts if a certain level of anesthesia hasn't been reached. I got an I.V. in quickly and administered medication to deepen the anesthetic. The nurse anesthetist intubated the child without incident, and the surgery proceeded.

I left the room feeling angry and having lost every shred of respect for that surgeon.

About half an hour later I went back to the room to check on things, and the nurse anesthetist whispered in my ear, "She punctured an artery. We've lost about a hundred cc's." And this was the case she wanted to do on the transport stretcher?! Myrtha Banshee got control of the bleeder and finished the surgery, complaining the entire time about the scheduling and the way the O.R. was being run.

That night, the call person had to bring this kid back to the O.R. to manage a known and not-uncommon complication of the original surgery. I couldn't help feeling resentful all over again when I heard about it.

I can deal with most surgeons, even the crabby ones. I see them as members of the same team who ultimately want what I want: a patient well-cared for. This surgeon never wanted the same thing and was never on the same team. When surgeons or other anesthesiologists experience trouble or a complication, my usual reaction is sympathy, and it certainly doesn't make me think less of them; this surgeon, however, inspires nothing but incredulity at behaviors and attitudes I simply cannot respect.

I hope I don't have to work with that kind of surgeon too often.