Jacobi Ambulatory Care Service Medical Consultation An Overview

Jacobi Ambulatory Care Service Medical Consultation: An Overview Lori A. Lemberg, MD Fall 2012

Yes, this is Medical Consult, How can I help you? Jacobi Ambulatory Care Service

Learning Objectives • • • Function of the Medical Consultant Goldman’s “Ten Commandments” Surgical Considerations Anesthesia Considerations Appropriate History and Evaluation of Patient ACC-AHA Guidelines Jacobi Ambulatory Care Service

Jacobi Ambulatory Care Service Function of the Medical Consultant to offer an opinion on diagnosis or management

Goldman’s Ten Commandments for Effective Consultation 1. Determine the Question 2. Establish Urgency 3. Look for Yourself 4. Be as Brief as Appropriate 5. Be Specific Jacobi Ambulatory Care Service 6. Provide Contingency Plans 7. Honor Thy Turf 8. Teach …With Tact 9. Talk is Cheap…and Effective 10. Follow Up Goldman et al, Arch Int Med 1983; 143: 1753

1. Determine the Question Ask the requesting service to be as specific as possible Clarify verbally if the question(s) are unclear Jacobi Ambulatory Care Service

Jacobi Ambulatory Care Service 2. Establish Urgency • Emergency, Urgent, Elective • See the patient within 24 hours 3. Look for Yourself • Review pertinent history and physical exam • Make an independent judgment

4. Be as Brief as Appropriate • Do not recopy the history and physical • Highlight important points 5. Be Specific • The more detailed the suggestions the better • Spell out dosing, timing of meds • Less is more Jacobi Ambulatory Care Service

6. Provide Contingency Plans • Anticipate problems 7. Honor Thy Turf • Do not step on other’s toes • Remember your position as consultant Jacobi Ambulatory Care Service

8. Teach with Tact • Encourage collegial relations 9. Talk is Cheap and Effective • Talk with the primary physician or service about your findings and recommendations • Discuss disagreements • Bring the attendings to the table if necessary Jacobi Ambulatory Care Service

10. Follow-Up • • Jacobi Interval as appropriate to the case Improves compliance with recommendations Tell services you are signing off Provide specific outpatient follow-up plan Ambulatory Care Service

Factors Improving Compliance with Recommendations • • • Jacobi Consult within 24 hours More than two follow-up notes Verbal contact with referring MD Limited number of recommendations (<5) Recommendations related to “central reason” of consult Ambulatory Care Service Kammerer, Gross, Medical Consultation

Factors Improving Compliance with Recommendations • • • Definitiveness of recommendation “Crucial” recommendation Details spelled out Medication/treatment vs. diagnostic Severely ill patient Jacobi Ambulatory Care Service

Jacobi Ambulatory Care Service Pre Operative Consultation

Pre Operative Consultation Why? • Elucidate patient’s risks and benefits of surgery • Improve risk by optimizing medical condition • Anticipate perioperative and postoperative complications Jacobi Ambulatory Care Service

Risk of Surgery INHERENT RISKS OF PROCEDURE High: Emergency procedures, Major Vascular, Craniotomy Medium: Orthopedic, Prostate, Abdominal, Thoracic Low: Breast, Plastic Very Low: Cataract, Dental, Endoscopic Jacobi Ambulatory Care Service

Jacobi Ambulatory Care Service Surgeon Specific Risk Hospital Specific Risk

Anesthesia GENERAL • depresses cardiac function • airway control, but reduced lung volumes SPINAL or EPIDURAL • vasodilates • avoid with aortic stenosis No difference in CV events! Jacobi Ambulatory Care Service

When do things go wrong? • Mortality Related to Surgery 10 -15% during induction 30 -40% during surgery 45 -60% post-operative • Peak for Myocardial Infarction Day 0, 1, 2 days postoperatively Jacobi Ambulatory Care Service

Jacobi Ambulatory Care Service Induction Catecholamine surge Blood pressure lability

Post Operative State • • Metabolic demands Pain Fluid Shifts Catecholamine surges CHF, Coronary ischemia Atelectasis, VQ mismatch, Pneumonia DVT Immobilization Jacobi Ambulatory Care Service

Jacobi Ambulatory Care Service If the inherent risk of surgery is low, can I make an impact?

Medical Considerations for Surgery • Cardiovascular: CAD, CHF, HTN, Arrhythmias, Valvular heart disease • Hematologic: Bleeding, DVT risk • Pulmonary: COPD, Asthma, Smoking • Renal: Renal insufficiency • Endocrine: Diabetes, Thyroid, Adrenal Jacobi Ambulatory Care Service

Medical Considerations for Surgery • • • Hepatic: Cirrhosis, Hepatitis Habits: Alcohol, Drugs Medications Endocarditis prophylaxis Pregnancy Geriatric patients Jacobi Ambulatory Care Service

History Include: • • Previous surgery or complications Bleeding Functional capacity / Exercise tolerance Medications Allergies Substance Use Family History (bleeding, malignant hyperthermia) Jacobi Ambulatory Care Service

Exam • Vitals • General Exam • Mental Status Jacobi Ambulatory Care Service

Laboratories Controversial, Low predictive value CBC Anemia? Baseline? Chemistries K+? BUN/Cr? PT, PTT, Bleeding Time not predictive EKG for higher risk or older patients? CXR doubtful Jacobi Ambulatory Care Service

Jacobi Ambulatory Care Service Cardiovascular Risk Assessment

Higher Risk Features Goldman et al • Age > 70 • MI < 6 months • S 3 or JVD • Important valvular AS • Rhythm other than sinus • > 5 PVCs per minute 5 pts 10 pts 11 pts 3 pts 5 pts Jacobi Ambulatory Care Service NEJM 1977; 297: 845

Goldman continued • Poor general medical status 3 pts • Intraperitoneal, 3 pts intrathoracic or aortic surgery • Emergency surgery 4 pts Total 53 pts Medium High Risk Jacobi Ambulatory Care Service 13 -25 pts >25 pts 12% complications 56% complications

Lee et al Risk Factors in Multivariate Analysis of 4315 Patients • • • Jacobi High Risk Surgery Ischemic Heart Disease Congestive Heart Failure History of TIA or Stroke Insulin Therapy for Diabetes Pre Op Creatinine > 2. 0 Ambulatory Care Service Circulation 1999: 100: 1043

Lee et al Jacobi Ambulatory Care Service Circulation 1999: 100: 1043

Table 1. Applying classification of recommendations and level of evidence. Jacobi Ambulatory Care Service

American College of Cardiology American Heart Association Revised 2002/2007 Guidelines MAJOR CLINICAL PREDICTORS • Unstable angina, Recent MI • Decompensated CHF • Significant Arrhythmias (high grade AV block, symptomatic ventricular arrhythmias, SVT uncontrolled • Severe valvular disease Jacobi Ambulatory Care Service

ACC-AHA 2002/2007 Guidelines INTERMEDIATE CLINICAL PREDICTORS • • Jacobi Mild angina Past history of CHF Prior MI Diabetes Ambulatory Care Service

ACC-AHA 2002/2007 Guidelines MINOR CLINICAL PREDICTORS • • • Jacobi Age ECG (LVH, LBBB, ST-T changes) Low functional capacity (< 4 mets) Rhythm other than sinus Uncontrolled hypertension Past history of stroke Ambulatory Care Service