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

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

4. 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

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

6. Jacobi Ambulatory Care Service 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 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

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

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

9. Jacobi Ambulatory Care Service 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

10. 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

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

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

13. Jacobi Ambulatory Care Service Factors Improving Compliance with Recommendations 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 Kammerer, Gross, Medical Consultation

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

15. Jacobi Ambulatory Care Service Pre Operative Consultation

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

17. 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

18. Jacobi Ambulatory Care Service Surgeon Specific Risk Hospital Specific Risk

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

20. 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

21. Jacobi Ambulatory Care Service Induction Catecholamine surge Blood pressure lability

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

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

24. Jacobi Ambulatory Care Service 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

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

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

27. Jacobi Ambulatory Care Service Exam Vitals General Exam Mental Status

28. 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

29. Jacobi Ambulatory Care Service Cardiovascular Risk Assessment

30. Jacobi Ambulatory Care Service Higher Risk Features Goldman et al Age > 705 pts MI < 6 months10 pts S3 or JVD11 pts Important valvular AS3 pts Rhythm other than sinus5 pts > 5 PVCs per minute5 pts NEJM 1977; 297:845

31. Jacobi Ambulatory Care Service Goldman continued Poor general medical status3 pts Intraperitoneal, 3 pts intrathoracic or aortic surgery Emergency surgery4 pts Total 53 pts Medium 13-25 pts 12% complications High Risk >25 pts56% complications

32. Jacobi Ambulatory Care Service Lee et al Risk Factors in Multivariate Analysis of 4315 Patients High Risk Surgery Ischemic Heart Disease Congestive Heart Failure History of TIA or Stroke Insulin Therapy for Diabetes Pre Op Creatinine > 2.0 Circulation 1999:100: 1043

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

34. Jacobi Ambulatory Care Service Table 1. Applying classification of recommendations and level of evidence. Fleisher L A et al. Circulation 2007;116:e418-e500 Copyright © American Heart Association

35. 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

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

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