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Medical Management ofthe Surgical PatientA Textbook of Perioperative MedicineFifth Edition

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Cambridge University Press978-1-107-00916-5 - Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine: Fifth EditionEditor-in-Chief Michael F. Lubin Associate Editors Thomas F. Dodson and Neil H. WinawerFrontmatterMore information

http://www.cambridge.org/9781107009165

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Medical Management ofthe Surgical PatientA Textbook of Perioperative MedicineFifth Edition

Editor-in-Chief

Michael F. Lubin MDProfessor of Medicine, Emory University School of Medicine, Atlanta, GA, USA

Associate Editors

Thomas F. Dodson MDProfessor of Surgery and Chief, Division of Vascular and Endovascular Surgery,Emory University School of Medicine, Atlanta, GA, USA

Neil H. Winawer MDAssociate Professor of Medicine, Emory University School of Medicine, Atlanta, GA, USA andDirector of the Hospital Medicine Service at Grady Memorial Hospital, Atlanta, GA, USA






University Printing House, Cambridge CB2 8BS, United Kingdom

Published in the United States of America by Cambridge UniversityPress, New York

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It furthers the University’s mission by disseminating knowledge in thepursuit of education, learning and research at the highest internationallevels of excellence.

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© Cambridge University Press 2013

This publication is in copyright. Subject to statutory exceptionand to the provisions of relevant collective licensing agreements,no reproduction of any part may take place without the writtenpermission of Cambridge University Press.

First published 2013

Printed in Great Britain By TJ International Ltd. Padstow Cornwall

A catalogue record for this publication is available from the British Library

Library of Congress Cataloguing in Publication dataMedical management of the surgical patient : a textbook of perioperativemedicine / [edited by] Michael F. Lubin, Thomas F. Dodson,Neil H. Winawer. – 5th ed.

p. ; cm.Includes bibliographical references.ISBN 978-1-107-00916-5 (Hardback)I. Lubin, Michael F., 1947– II. Dodson, Thomas. III. Winawer,Neil H.[DNLM: 1. Perioperative Care. 2. Intraoperative Complications–prevention & control. 3. Postoperative Complications–prevention &control. 4. Risk Assessment. WO 178]617.901–dc23 2012016725

ISBN 978-1-107-00916-5 Hardback

Cambridge University Press has no responsibility for the persistence oraccuracy of URLs for external or third-party internet websites referred toin this publication, and does not guarantee that any content on suchwebsites is, or will remain, accurate or appropriate.

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Every effort has been made in preparing this book to provide accurateand up-to-date information which is in accord with accepted standardsand practice at the time of publication. Although case histories aredrawn from actual cases, every effort has been made to disguise theidentities of the individuals involved. Nevertheless, the authors, editorsand publishers can make no warranties that the information containedherein is totally free from error, not least because clinical standards areconstantly changing through research and regulation. The authors,editors and publishers therefore disclaim all liability for direct orconsequential damages resulting from the use of material containedin this book. Readers are strongly advised to pay careful attention toinformation provided by the manufacturer of any drugs or equipmentthat they plan to use.






Michael F. Lubin MD

I would like to dedicate this book toJ. Willis Hurst – my teacherH. Kenneth Walker – my mentor and co-editorRobert Smith – my colleague and co-editor

Their contributions to this book are unseen but were critical to itssuccessful completion

Thomas F. Dodson MD

I would like to dedicate this book to my wife, Jan, and my children,Thomas, Michael, and Amy. Their patience has been remarkable and theirlove and support have been graciously given.

Neil H. Winawer MD

I would like to dedicate this book to my wife Tamara, and my sonMatthew for bearing with me during completion of this project andalways. You are my everything.






Contents

List of contributors xiiPreface Michael F. Lubin xixIntroduction xx

Part 1: Perioperative Care of the SurgicalPatient

Section 1: General1 Anesthesia management of the surgical patient 3

L. Reuven Pasternak

2 Specialized nutrition support in the surgical patient 13Vivian M. Zhao and Thomas R. Ziegler

3 Preoperative testing 26Eva Rimler and Danielle Jones

4 Medication safety for surgical patients 32Nathan Spell

5 Informed consent and decision-making capacity 39J. Richard Pittman and Jason Lesandrini

6 Ethical considerations in the surgical patient 46Carl C. Hug, Jr. and Kathleen Kinlaw

7 Perioperative pain management 61Anne Marie McKenzie-Brown

8 The medical consult 70Michael F. Lubin

Section 2: Cardiology9 Cardiovascular disease: general overview 75

Arrhythmias and conduction abnormalities 92Valvular heart disease 103Niels Engberding and Howard Weitz

10 Postoperative chest pain and shortness of breath 113Taki Galanis and Geno J. Merli

Section 3: Hypertension11 Preoperative and postoperative hypertension 119

Craig R. Keenan

Section 4: Pulmonary12 Perioperative pulmonary risk evaluation and

management for non-cardiothoracic surgery 133Alvaro Velasquez, Michelle V. Conde, and ValerieA. Lawrence

13 Perioperativemanagement of the asthma patient 147Annette Esper

14 Acute lung injury and the acute respiratory distresssyndrome 154Raja-Elie E. Abdulnour and Bruce D. Levy

15 Postoperative pulmonary complications 172Carter G. Co, David A. Quintero, and Eric G. Honig

Section 5: Gastroenterology16 Peptic ulcer disease 191

Frederick Gandolfo and Michael A. Poles

17 Liver disease 196Kristina Chacko and Michael A. Poles

18 Inflammatory bowel disease 203Lorenzo Rossaro and Sooraj Tejaswi

19 Postoperative gastrointestinal complications 208Andrew Boxer and Michael A. Poles

Section 6: Hematology20 Disorders of red cells 215

James R. Eckman

21 Perioperative management of hemostasis 223Mrinal Dutia, Eve Rodler, and Ted Wun

22 Prophylaxis for deep venous thrombosis andpulmonary embolism in surgery 234Taki Galanis and Geno J. Merli

23 Blood transfusion: preoperative considerations andcomplications 252Julie Katz Karp, Christopher D. Hillyer, and Beth H. Shaz

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Section 7: Infectious Disease24 Preventive antibiotics in surgery 265

Stuart H. Cohen and Jennifer Brown

25 HIV infection 282Jeffrey L. Lennox

26 Fever and infection in the postoperativesetting 292James P. Steinberg and Shanta M. Zimmer

Section 8: Renal Disease27 Surgery in the patient with renal

disease 299Andrew I. Chin, Jane Y. Yeun, and Burl R. Don

28 Postoperative electrolyte disorders 331Steven M. Gorbatkin

Section 9: Endocrinology29 Diabetes mellitus 343

Pamela T. Prescott

30 Disorders of the thyroid 350Pamela T. Prescott

31 Disorders of the adrenal cortex 358Pamela T. Prescott

32 Disorders of calcium metabolism 366Pamela T. Prescott

33 Pheochromocytoma 373Pamela T. Prescott

Section 10: Rheumatology34 Rheumatologic disorders 377

C. Ronald MacKenzie

Section 11: Neurology35 Cerebrovascular disease 387

Kumiko Owada, Duncan Borland, andMichael Frankel

36 Management of the surgical patient withdementia 396Monica W. Parker, James J. Lah, and Allan I. Levey

37 Neuromuscular disorders 404Jaffar Khan and Lilith Judd

38 Perioperative management of patients withParkinson’s disease 411Christine D. Esper and Jorge L. Juncos

39 Delirium in the surgical patient 419Neil H. Winawer

Section 12: Surgery in the Elderly40 Surgery in the elderly 425

Yelena Melyakova and Michael F. Lubin

Section 13: Obesity41 Perioperative medical management of

obese patients 441Madhuri Rao and John G. Kral

Section 14: Transplantation42 Transplantation medicine 451

Sudha Tata, Remzi Bag, Ram Subramanian, KathleenNilles, and Stephen Pastan

Section 15: Psychiatric Disorders43 Psychological and emotional reactions to illness

and surgery 465Nisha N. Shah and Charles L. Raison

44 Depression and the surgical patient 468Nisha N. Shah and Charles L. Raison

45 Substance abuse 481Ted Parran, Jr.

Section 16: Peripartum Patients46 Care of the peripartum patient 491

Stacy Higgins

Part 2: Surgical Procedures and theirComplications

Section 17: General Surgery47 Tracheostomy 501

Jyotirmay Sharma and David V. Feliciano

48 Thyroidectomy 504Jyotirmay Sharma and David V. Feliciano

Contents

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49 Parathyroidectomy 507Jyotirmay Sharma

50 Lumpectomy and mastectomy 510Jahnavi K. Srinivasan

51 Gastric procedures (including laparoscopicantireflux, gastric bypass, and gastricbanding) 513Jahnavi K. Srinivasan and DavidV. Feliciano

52 Small bowel resection 518Jahnavi K. Srinivasan and David V. Feliciano

53 Appendectomy 520Jahnavi K. Srinivasan and David V. Feliciano

54 Colon resection 522Jahnavi K. Srinivasan and David V. Feliciano

55 Abdominoperineal resection/coloanal or ileoanalanastomoses 525Jahnavi K. Srinivasan and David V. Feliciano

56 Anal operations 528Jahnavi K. Srinivasan

57 Cholecystectomy 531Edward Lin and David V. Feliciano

58 Common bile duct exploration 533Edward Lin and David V. Feliciano

59 Major hepatic resection 535Edward Lin and David V. Feliciano

60 Splenectomy 537John F. Sweeney and David V. Feliciano

61 Pancreatoduodenal resection 540Edward Lin and David V. Feliciano

62 Adrenal surgery 542Jyotirmay Sharma and David V. Feliciano

63 Lysis of adhesions 544Kevin W. McConnell

64 Ventral hernia repair 546S. Scott Davis, Jr. and David V. Feliciano

65 Inguinal hernia repair 549Rebecca L. Coefield and David V. Feliciano

66 Laparotomy in patients with humanimmunodeficiency virus infection 551Jahnavi K. Srinivasan

67 Abdominal trauma 553Jahnavi K. Srinivasan and David V. Feliciano

Section 18: Cardiothoracic Surgery68 Coronary artery bypass procedures 557

W. Brent Keeling and Vinod H. Thourani

69 Cardiac rhythm management 565Omar M. Lattouf

70 Aortic valve surgery 569Bryon J. Boulton and William A. Cooper

71 Mitral valve surgery 574Bryon J. Boulton and William A. Cooper

72 Ventricular assist devices and cardiactransplantation 578Duc Q. Nguyen and J. David Vega

73 Thoracic aortic disease 582Bradley G. Leshnower and Edward P. Chen

74 Pulmonary lobectomy 585Adil Sadiq and Felix G. Fernandez

75 Pneumonectomy 588Adil Sadiq and Felix G. Fernandez

76 Lung transplantation 591Radu F. Neamu, David C. Neujahr, andSeth D. Force

77 Hiatal hernia repair 594Kamal A. Mansour

78 Esophagomyotomy 596Kumari N. Adams and Allan Pickens

79 Esophagogastrectomy 599Harrell Lightfoot and Allan Pickens

80 Colon interposition for esophageal bypass 602Kamal A. Mansour

Section 19: Vascular Surgery81 Carotid endarterectomy 605

Jayer Chung and Thomas F. Dodson

82 Abdominal aortic aneurysm repair: open 608Naren Gupta

83 Abdominal aortic aneurysm repair:endovascular 611Naren Gupta

84 Aortobifemoral bypass grafting 615James G. Reeves and Ravi K. Veeraswamy

85 Treatment of femoropopliteal disease 618Luke P. Brewster and Matthew A. Corriere

Contents

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86 Lower extremity embolectomy 621Paul J. Riesenman and Thomas F. Dodson

87 Treatment of chronic mesenteric ischemia 624Luke P. Brewster and Karthikeshwar Kasirajan

88 Inferior vena cava filters 627Jayer Chung and Thomas F. Dodson

89 Portal shunting procedures 629Paul J. Riesenman and Atef A. Salam

Section 20: Plastic and ReconstructiveSurgery

90 Breast reconstruction after mastectomy 633Wright A. Jones and Grant W. Carlson

91 Facial rejuvenation 636Kimberly A. Singh and John H. Culbertson

92 Liposuction 639Benjamin L. Moosavi and Albert Losken

93 Facial fractures 641J. Nicolas Mclean and John H. Culbertson

94 Flap coverage for pressure ulcers 644Neil D. Saunders and Mark D. Walsh

95 Muscle flap coverage of sternal woundinfections 647Garrett Harper and Albert Losken

96 Skin grafting for burns 649Walter Ingram

Section 21: Gynecologic Surgery97 Abdominal hysterectomy 651

Cyril O. Spann and Erica C. Dun

98 Vaginal hysterectomy 654S. Robert Kovac and Gina M. Northington

99 Uterine curettage 657Erica C. Dun and Carla P. Roberts

100 Radical hysterectomy 659Leda Gattoc and Sharmila Makhija

101 Vulvectomy 662Ira R. Horowitz and Erica C. Dun

Section 22: Neurologic Surgery102 Craniotomy for brain tumor 665

Kenneth L. Hill, Jr. and Jeffrey J. Olson

103 Intracranial aneurysm surgery 670Mark J. Dannenbaum, Sung Bae Lee, C. Michael Cawley,and Daniel L. Barrow

104 Evacuation of subdural hematomas 675Eric Anthony Sribnick and Sanjay Singh Dhall

105 Stereotactic procedures 679Osama N. Kashlan, David V. LaBorde, andRobert E. Gross

106 Transsphenoidal surgery 683Vladimir Dadashev and Nelson Oyesiku

107 Treatment of the herniated disc 686Gerald E. Rodts, Jr., Maxwell Boakye, and RegisW. Haid, Jr.

Section 23: Ophthalmic Surgery108 General considerations in ophthalmic surgery 693

John F. Payne, G. Baker Hubbard, and TimothyW. Olsen

109 Cataract surgery 696Rupa Shah, Joung Y. Kim, and Timothy W. Olsen

110 Corneal transplantation 698Yuri McKee, Rupa Shah, Joung Y. Kim, and TimothyW. Olsen

111 Vitreoretinal surgery 700Hassan T. Rahman, G. Baker Hubbard, and TimothyW. Olsen

112 Glaucoma surgery 702Bonnie B. Germain, Anastasios P. Costarides, andTimothy W. Olsen

113 Refractive surgery 704Rupa Shah, Yuri McKee, J. Bradley Randleman, andTimothy W. Olsen

114 Strabismus surgery 706Natario L. Couser, Amy K. Hutchinson, and TimothyW. Olsen

115 Enucleation, evisceration, and exenteration 708Jill R. Wells, G. Baker Hubbard, and TimothyW. Olsen

Section 24: Orthopedic Surgery116 Arthroscopic knee surgery 711

Michael S. Sridhar and John W. Xerogeanes

117 Total knee replacement 715Greg Erens and Thomas Bradbury

Contents

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118 Total hip replacement 718Thomas Bradbury and James Roberson

119 Fractures of the femoral shaft 721William M. Reisman

120 Hip fractures 724Thomas J. Moore and Michael B. Gottschalk

121 Lumbar spine surgery 727Dheera Ananthakrishnan and John G. Heller

122 Surgery for adult spinal deformity (scoliosis orkyphosis) 732John M. Rhee and William C. Horton

123 Cervical spine surgery 736Samuel M. Davis, Gerald E. Rodts, Jr., and JohnG. Heller

124 Surgery of the foot and ankle 740Sameh A. Labib and John Louis-Ugbo

125 Lower extremity amputations 743James C. Black, Shervin V. Oskouei, Alonzo T. Sexton,and Lamar L. Fleming

126 Surgical procedures for rheumatoid arthritis 746Michael S. Sridhar and Gary R. McGillivary

Section 25: Otolaryngologic Surgery127 Otologic surgery 751

Adrienne M. Laury and Douglas E. Mattox

128 Tympanotomy tubes 754N. Wendell Todd and Katherine L. Hayes

129 Tonsillectomy and adenoidectomy 758H. Michael Baddour, Jr. and Melissa M. Statham

130 Surgery for obstructive sleep apnea 761Eric E. Berg and John M. DelGaudio

131 Endoscopic sinus surgery: indications, prognosis,and surgical complications 764Adrienne M. Laury, Sarah K. Wise, and GiriVenkatraman

132 Aesthetic facial plastic surgery 767Seth A. Yellin and H. Michael Baddour, Jr.

133 Surgical treatment of head and neck cancer 770William J. Grist

134 Reconstruction after cancer ablation 773Candice C. Colby and J. Trad Wadsworth

135 Surgical management of thyroid malignancies 777Amy Y. Chen

136 Anterior cranial base surgery 780Charles E. Moore

137 Acute airway emergencies 782Francis X. Creighton and Michael M. Johns

Section 26: Urologic Surgery138 Management of upper urinary tract calculi 787

John G. Pattaras

139 Transurethral resection of the prostate 790Muta M. Issa and Adam B. Shrewsberry

140 Radical prostatectomy 794John J. De Caro and Kenneth Ogan

141 Nephrectomy 797John G. Pattaras

142 Cystectomy and urinary diversion 801Peter T. Nieh

143 Female stress urinary incontinence surgery 806Niall T. M. Galloway

144 Vasectomy 809Jordan Angell and John G. Pattaras

145 Inflatable penile prosthesis 811S. Mohammad A. Jafri and Chad M. W. Ritenour

Index 813

Contents

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Contributors

Raja-Elie E. AbdulnourPulmonary and Critical Care Medicine, Department ofInternal Medicine, Brigham and Women’s Hospital andHarvard Medical School, Harvard Institutes of Medicine,Boston, MA, USA

Kumari N. AdamsEmory University School of Medicine, Atlanta, GA, USA

Dheera AnanthakrishnanEmory University School of Medicine, Atlanta, GA, USA

Jordan AngellEmory University School of Medicine, Atlanta, GA, USA

H. Michael Baddour, Jr.Emory University School of Medicine, Department ofOtolaryngology Head and Neck Surgery, Atlanta, GA, USA

Remzi BagEmory University School of Medicine, Atlanta, GA, USA

Daniel L. BarrowEmory University School of Medicine, Atlanta, GA, USA

Eric E. BergEmory University School of Medicine, Department ofOtolaryngology Head and Neck Surgery, Atlanta, GA, USA

James C. BlackEmory University School of Medicine, Atlanta, GA, USA

Maxwell BoakyeStanford University School of Medicine, CA, USA

Duncan BorlandVancouver, WA, Canada

Bryon J. BoultonEmory University School of Medicine, Atlanta, GA, USA

Andrew BoxerManhattan Veteran’s Hospital and Division ofGastroenterology, New York University School of Medicine,New York, NY, USA

Thomas BradburyEmory University School of Medicine, Atlanta, GA, USA

Luke P. BrewsterEmory University School of Medicine, Atlanta,GA, USA

Jennifer BrownDivision of Infectious Diseases, UC Davis Medical Center,Sacramento, CA, USA

Grant W. CarlsonEmory University School of Medicine, Atlanta, GA, USA

C. Michael CawleyEmory University School of Medicine, Atlanta,GA, USA

Kristina ChackoManhattan Veteran’s Hospital and Division ofGastroenterology, New York University School of Medicine,New York, NY, USA

Amy Y. ChenProfessor, Department of Otolaryngology Head and NeckSurgery, Emory University School of Medicine, Atlanta,GA, USA

Edward P. ChenEmory University School of Medicine, Atlanta, GA, USA

Andrew I. ChinUniversity of California Davis, Sacramento, CA andDepartment of Veterans Affairs Northern California HealthCare System, Mather, CA, USA

Jayer ChungDivision of Vascular Surgery, University of TexasSouthwestern, Dallas, TX, USA

Carter G. CoDivision of Pulmonary, Critical Care, Allergy, and SleepMedicine, Department of Medicine, Emory University Schoolof Medicine, Atlanta, GA, USA

xii






Rebecca L. CoefieldEmory University School of Medicine, Atlanta, GA, USA

Stuart H. CohenDivision of Infectious Diseases, UC Davis Medical Center,Sacramento, CA, USA

Candice C. ColbyEmory University School of Medicine, Atlanta, GA, USA

Michelle V. CondeUniversity of Texas Health Science Center at San Antonio;San Antonio, TX, USA

William A. CooperEmory University School of Medicine, Atlanta, GA, USA

Matthew A. CorriereEmory University School of Medicine, Atlanta, GA, USA

Anastasios P. CostaridesEmory University School of Medicine, Atlanta, GA, USA

Natario L. CouserEmory University School of Medicine, Atlanta, GA, USA

Francis X. CreightonEmory University School of Medicine, Atlanta, GA, USA

John H. CulbertsonEmory University School of Medicine, Atlanta, GA, USA

Vladimir DadashevEmory University School of Medicine, Atlanta, GA, USA

Mark J. DannenbaumEmory University School of Medicine, Atlanta, GA, USA

S. Scott Davis, Jr.Emory University School of Medicine, Atlanta, GA, USA

Samuel M. DavisEmory University School of Medicine, Atlanta, GA, USA

John J. De CaroEmory University School of Medicine, Atlanta, GA, USA

John M. DelGaudioEmory University School of Medicine, Department ofOtolaryngology Head and Neck Surgery, Atlanta, GA, USA

Sanjay Singh DhallEmory University School of Medicine, Atlanta, GA, USA

Thomas F. DodsonEmory University School of Medicine, Atlanta, GA, USA

Burl R. DonUniversity of California Davis, Sacramento, CA, USA

Erica C. DunEmory University School of Medicine, Atlanta,GA, USA

Mrinal DutiaDivision of Hematology Oncology, UC Davis School ofMedicine, Sacramento, CA, USA

James R. EckmanEmory University School of Medicine, Atlanta,GA, USA

Niels EngberdingEmory University, Grady Memorial Hospital, Atlanta, GA,USA

Greg ErensEmory University School of Medicine, Atlanta, GA, USA

Annette EsperDivision of Pulmonary, Allergy and Critical Care, EmoryUniversity, Atlanta, GA, USA

Christine Doss EsperEmory University School of Medicine, Atlanta, GA, USA

David V. FelicianoEmory University School of Medicine, Atlanta, GA, USA

Felix G. FernandezEmory University School of Medicine, Atlanta, GA, USA

Lamar L. FlemingEmory University School of Medicine, Atlanta, GA, USA

Seth D. ForceEmory University School of Medicine, Atlanta, GA, USA

Michael FrankelEmory University School of Medicine, Atlanta,GA, USA

Taki GalanisJefferson Vascular Center, Jefferson Medical College, ThomasJefferson University Hospitals, Philadelphia, PA, USA

Niall T. M. GallowayEmory University School of Medicine, Atlanta, GA, USA

Frederick GandolfoManhattan Veteran’s Hospital and Division ofGastroenterology, New York University School of Medicine,New York, NY, USA

Leda GattocEmory University School of Medicine, Atlanta, GA, USA

Bonnie B. GermainEmory University School of Medicine, Atlanta, GA, USA

List of contributors

xiii






Steven M. GorbatkinRenal Section, Atlanta Veterans Affairs Medical Center andEmory University School of Medicine, Atlanta, GA, USA

Michael B. GottschalkEmory University School of Medicine, Atlanta, GA, USA

William J. GristEmory University School of Medicine, Atlanta, GA, USA

Robert E. GrossEmory University School of Medicine, Atlanta,GA, USA

Naren GuptaVA Boston Health System and Brigham and Women’sHospital, Harvard Medical School, Boston, MA, USA

Regis W. Haid, Jr.Atlanta Brain and Spine, Inc., Atlanta, GA, USA

Garrett HarperEmory Division of Plastic and Reconstructive Surgery, EmoryUniversity School of Medicine, Atlanta, GA, USA

Katherine L. HayesEmory University School of Medicine, Atlanta, GA, USA

John G. HellerEmory University School of Medicine, Atlanta,GA, USA

Stacy HigginsEmory University School of Medicine, Atlanta, GA, USA

Kenneth L. Hill, Jr.Emory University School of Medicine, Atlanta, GA, USA

Christopher D. HillyerNew York Blood Center, New York, NY, USA

Eric G. HonigDivision of Pulmonary, Critical Care, Allergy, and SleepMedicine, Department of Medicine, Emory University Schoolof Medicine, Atlanta, GA, USA

Ira R. HorowitzEmory University School of Medicine, Atlanta, GA, USA

William C. HortonEmory University School of Medicine, Atlanta, GA, USA

G. Baker HubbardDivision of Vitreoretinal Surgery and Disease, Department ofOphthalmology, Emory University, Atlanta, GA, USA

Carl C. Hug, Jr.Emeritus, Emory University School of Medicine; EmoryUniversity Hospital, Emory University, Atlanta, GA, USA

Amy K. HutchinsonEmory University School of Medicine, Atlanta, GA, USA

Walter IngramEmory University School of Medicine, Atlanta, GA, USA

Muta M. IssaEmory University School of Medicine and Atlanta VA MedicalCenter, Atlanta, GA, USA

S. Mohammad A. JafriEmory University School of Medicine, Atlanta, GA, USA

Michael M. JohnsEmory University School of Medicine, Atlanta, GA, USA

Danielle JonesEmory University School of Medicine, Atlanta, GA, USA

Wright A. JonesEmory University School of Medicine, Atlanta, GA, USA

Lilith JuddEmory University School of Medicine, GA, USA

Jorge L. JuncosEmory University School of Medicine, Atlanta, GA, USA

Julie Katz KarpMethodist Hospital, Philadelphia, PA, USA

Osama N. KashlanEmory University School of Medicine, Atlanta, GA, USA

Karthikeshwar KasirajanEmory University School of Medicine, Atlanta, GA, USA

W. Brent KeelingDivision of Cardiothoracic Surgery, Emory University Schoolof Medicine, Atlanta, GA, USA

Craig R. KeenanDepartment of Medicine, UC Davis School of Medicine,Sacramento, CA, USA

Jaffar KhanEmory University School of Medicine, Lawrenceville, GA,USA

Joung Y. KimDivision of Cornea and External Disease, Emory UniversitySchool of Medicine, Atlanta, GA, USA

Kathleen KinlawCenter for Ethics, Program Director, Health, Science andEthics, Emory University, Atlanta, GA, USA

S. Robert KovacEmory University School of Medicine, Atlanta, GA, USA


xiv






John G. KralDepartment of Surgery, SUNY Downstate Medical Center,Brooklyn, New York, NY, USA

Sameh A. LabibEmory University School of Medicine, Atlanta, GA, USA

David V. LaBordeEmory University School of Medicine, Atlanta, GA, USA

James J. LahEmory University School of Medicine, Atlanta, GA, USA

Omar M. LattoufEmory University School of Medicine, Atlanta, GA, USA

Adrienne M. LauryEmory University School of Medicine, Atlanta, GA, USA

Valerie A. LawrenceUniversity of Texas Health Science Center at San Antonio;San Antonio, TX, USA

Sung Bae LeeEmory University School of Medicine, Atlanta, GA, USA

Jeffrey L. LennoxEmory University School of Medicine, Atlanta, GA, USA

Jason LesandriniGrady Memorial Hospital, Atlanta, GA, USA

Bradley G. LeshnowerEmory University School of Medicine, Atlanta,GA, USA

Allan I. LeveyEmory University School of Medicine, Atlanta, GA, USA

Bruce D. LevyPulmonary and Critical Care Medicine, Department ofInternal Medicine, Brigham and Women’s Hospital andHarvard Medical School, Harvard Institutes of Medicine,Boston, MA, USA

Harrell LightfootEmory University School of Medicine, Atlanta, GA, USA

Edward LinEmory University School of Medicine, Atlanta, GA, USA

Albert LoskenEmory University School of Medicine, Atlanta, GA, USA

John Louis-UgboEmory University School of Medicine, Atlanta, GA, USA

Michael F. LubinEmory University School of Medicine, Atlanta, GA, USA

C. Ronald MacKenzieHospital for Special Surgery, New York Weill Cornell Center,New York, NY, USA

Sharmila MakhijaUniversity of Louisville School of Medicine, Louisville,KY, USA

Kamal A. MansourEmory University School of Medicine, Atlanta, GA, USA

Douglas E. MattoxEmory University School of Medicine, Atlanta, GA, USA

Kevin W. McConnellEmory University School of Medicine, Atlanta, GA, USA

Gary R. McGillivaryEmory University, Department of Orthopedic Surgery,Atlanta, GA, USA

Yuri McKeeDivision of Cornea and External Disease, Emory UniversitySchool of Medicine, Atlanta, GA, USA

Anne Marie McKenzie-BrownEmory University School of Medicine, Atlanta, GA, USA

J. Nicolas McleanEmory University School of Medicine, Division of Plastic andReconstructive Surgery, Atlanta, GA, USA

Yelena MelyakovaEmory University School of Medicine, Atlanta, GA, USA

Geno J. MerliJefferson Vascular Center and Jefferson Medical College,Thomas Jefferson University Hospitals, Philadelphia,PA, USA

Charles E. MooreDepartment of Otolaryngology Head and Neck Surgery,Emory University School of Medicine, Atlanta, GA, USA

Thomas J. MooreEmory University School of Medicine, Atlanta, GA, USA

Benjamin L. MoosaviEmory University School of Medicine, Atlanta, GA, USA

Radu F. NeamuPulmonary and Critical Care Medicine, Emory UniversitySchool of Medicine, Atlanta, GA, USA

David C. NeujahrEmory University School of Medicine, Atlanta, GA, USA

Duc Q. NguyenEmory University School of Medicine, Atlanta, GA, USA


xv






Peter T. NiehEmory University School of Medicine, Atlanta, GA, USA

Kathleen NillesFeinberg School of Medicine, Northwestern University,Chicago, IL, USA

Gina M. NorthingtonEmory University School of Medicine, Atlanta, GA, USA

Kenneth OganEmory University School of Medicine, Atlanta, GA, USA

Timothy W. OlsenDivision of Vitreoretinal Surgery and Disease, Department ofOphthalmology, Emory University, Atlanta, GA, USA

Jeffrey J. OlsonEmory University School of Medicine, Atlanta, GA, USA

Shervin V. OskoueiEmory University School of Medicine, Atlanta, GA, USA

Kumiko OwadaEmory University School of Medicine, Atlanta, GA, USA

Nelson OyesikuEmory University School of Medicine, Atlanta, GA, USA

Monica W. ParkerEmory University School of Medicine, Atlanta, GA, USA

Ted Parran, Jr.CWRU School of Medicine, Cleveland, OH, USA

Stephen PastanEmory University School of Medicine, Atlanta, GA, USA

L. Reuven PasternakHealth Systems of Stony Brook University Hospital, StormBrook, NY, USA

John G. PattarasEmory University School of Medicine, Atlanta, GA, USA

John F. PayneDivision of Vitreoretinal Surgery and Disease, Department ofOphthalmology, Emory University, Atlanta, GA, USA

Allan PickensEmory University School of Medicine, Atlanta, GA, USA

J. Richard PittmanEmory University School of Medicine, Atlanta, GA, USA

Michael A. PolesManhattan Veteran’s Hospital and Division ofGastroenterology, New York University School of Medicine,New York, NY, USA

Pamela T. PrescottUniversity of California at Davis, Division of Endocrinology,Sacramento, CA, USA

David A. QuinteroDivision of Pulmonary, Critical Care, Allergy, and SleepMedicine, Department of Medicine, Emory University Schoolof Medicine, Atlanta, GA, USA

Hassan T. RahmanDivision of Vitreoretinal Surgery and Disease, Department ofOphthalmology, Emory University, Atlanta, GA, USA

Charles L. RaisonDepartment of Psychiatry and Behavioral Sciences, EmoryUniversity School of Medicine, Atlanta, GA, USA

J. Bradley RandlemanEmory University School of Medicine, Atlanta, GA, USA

Madhuri RaoDepartment of Surgery, SUNY Downstate Medical Center,Brooklyn, New York, NY, USA

James G. ReevesEmory University School of Medicine, Atlanta, GA, USA

William M. ReismanAssistant Professor of Orthopedic Trauma, Emory UniversitySchool of Medicine, Atlanta, GA, USA

John M. RheeEmory University School of Medicine, Atlanta, GA, USA

Paul J. RiesenmanEmory University School of Medicine, Atlanta, GA, USA

Eva RimlerEmory University School of Medicine, Atlanta, GA, USA

Chad M. W. RitenourEmory University School of Medicine, Atlanta, GA, USA

James RobersonEmory University School of Medicine, Atlanta, GA, USA

Carla P. RobertsEmory University School of Medicine, Atlanta, GA, USA

Eve RodlerDivision of Oncology, University of Washington School ofMedicine, Seattle, WA, USA

Gerald E. Rodts, Jr.Emory University School of Medicine, Atlanta,GA, USA

Lorenzo RossaroUniversity of California Davis, Sacramento, CA, USA


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Adil SadiqEmory University School of Medicine, Atlanta, GA, USA

Atef A. SalamEmory University School of Medicine, Atlanta, GA, USA

Neil D. SaundersEmory University School of Medicine, Atlanta, GA, USA

Alonzo T. SextonEmory University School of Medicine, Atlanta, GA, USA

Nisha N. ShahDepartment of Psychiatry and Behavioral Sciences, EmoryUniversity School of Medicine, Atlanta, GA, USA

Rupa ShahDepartment of Ophthalmology, Case Western ReserveUniversity, Cleveland, OH, USA

Jyotirmay SharmaEmory University School of Medicine, Atlanta, GA, USA

Beth H. ShazChief Medical Officer, New York Blood Center, New York,NY, USA

Adam B. ShrewsberryResident in Urology, Emory University School of Medicine,Atlanta, GA, USA

Kimberly A. SinghEmory University School of Medicine, Atlanta, GA, USA

Cyril O. SpannEmory University School of Medicine, Atlanta, GA, USA

Nathan SpellEmory University School of Medicine, Atlanta, GA, USA

Eric Anthony SribnickEmory University School of Medicine, Atlanta, GA, USA

Michael S. SridharEmory University, Department of Orthopedic Surgery,Division of Sports Medicine, Atlanta, GA, USA

Jahnavi K. SrinivasanEmory University School of Medicine, Atlanta, GA, USA

Melissa M. StathamEmory University School of Medicine, Department ofOtolaryngology Head and Neck Surgery, Atlanta, GA, USA

James P. SteinbergEmory University School of Medicine, Atlanta, GA, USA

Ram SubramanianEmory University School of Medicine, Atlanta, GA, USA

John F. SweeneyEmory University School of Medicine, Atlanta,GA, USA

Sudha TataEmory University School of Medicine, Atlanta,GA, USA

Sooraj TejaswiUniversity of California Davis, Sacramento,CA, USA

Vinod H. ThouraniDivision of Cardiothoracic Surgery, Emory University Schoolof Medicine, Atlanta, GA, USA

N. Wendell ToddEmory University School of Medicine, Atlanta, GA, USA

Ravi K. VeeraswamyEmory University School of Medicine, Atlanta, GA, USA

J. David VegaEmory University School of Medicine, Atlanta, GA, USA

Alvaro VelasquezEmory University School of Medicine, Atlanta, GA, USA

Giri VenkatramanDartmouth Hitchcock Medical Center, Lebanon, NH, USA

J. Trad WadsworthEmory University School of Medicine, Atlanta, GA, USA

Mark D. WalshEmory University School of Medicine, Atlanta, GA, USA

Howard WeitzThomas Jefferson University Hospital, Philadelphia, PA, USA

Jill R. WellsDivision of Ocular Oncology, Department of Ophthalmology,Emory University, Atlanta, GA, USA

Neil H. WinawerEmory University School of Medicine, Atlanta,GA, USA

Sarah K. WiseEmory University School of Medicine, Atlanta, GA, USA

Ted WunDivision of Hematology Oncology, UC Davis School ofMedicine and UC Davis Clinical and Translational SciencesCenter, Sacramento, CA, USA

John W. XerogeanesEmory University, Department of Orthopedic Surgery,Division of Sports Medicine, Atlanta, GA, USA


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Seth A. YellinClinical Assistant Professor, Emory University School ofMedicine, Atlanta, GA, USA

Jane Y. YeunUniversity of California Davis, Sacramento, CA andDepartment of Veterans Affairs Northern California HealthCare System, Mather, CA, USA

Vivian M. ZhaoDepartment of Pharmaceutical Services, Emory UniversityHospital, Atlanta, GA, USA

Thomas R. ZieglerNutrition and Metabolic Support Service, Departmentof Medicine, Division of Endocrinology, Metabolismand Lipids, Emory University School of Medicine,Atlanta, GA, USA

Shanta M. ZimmerUniversity of Pittsburgh School of Medicine, Pittsburgh,PA, USA


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Preface

In 1977, Dr. Kenneth Walker called his young colleague,Dr. Michael Lubin, to tell him that there was going to be anew consultation service and he was going to be the firstattending. Dr. Lubin replied, “A consult service? That’s great!I don’t know anything about that stuff.” Dr. Walker said,“Don’t worry,” and hung up the phone.

And now, 35 years later, I and my co-editors are publishingthe fifth edition of our textbook on perioperative consultation!The core of knowledge in perioperative care has changedimmensely; in 1977 there was no information until Dr. LeeGoldman’s seminal paper in the New England Journal of Medi-cine [1]. Since then, there has been an explosion of new infor-mation. Many medical people have built their academic careersin this area.

In some specialties, like cardiology, there has been a hugeamount of exploration and progress, albeit along with somebacktracking. In the previous edition, the latest advance wasperioperative beta blockade; today, there is less enthusiasm forthis intervention. While in the early days of cardiac evaluation,there was great emphasis placed on invasive testing and inter-ventions, for many surgery patients there has been little benefitfound in an aggressive approach to perioperative revascular-ization. The perioperative management of diabetes has alsobeen the focus of much investigation. Indeed, progress is beingmade in a multitude of fields.

On the other hand, there are areas where there have beenfewer advances. I would be very pleased to find better ways todetermine which patients with pulmonary and renal diseaseare at higher risk for complications and death from surgicalintervention.

This fifth edition will update the reader on the latestadvances in perioperative care and surgical techniques. Wehave again gathered together the best people we can find toeducate us in the best ways to handle the evaluation and care ofpatients who may need surgical intervention.

There have been some editorial changes as well. Dr. RobertSmith has retired; Dr. Thomas Dodson, our institution’s Asso-ciate Chairman of the Department of Surgery and the Chief ofthe Division of Vascular Surgery, has taken up Dr. Smith’s job

of handling the surgical part of our book. Dr. Neil H. Winawer,selected as one of the 10 best academic hospitalists by theAmerican College of Physicians, and editor-in-chief of JournalWatch Hospital Medicine, has come on board to help me withthe medical sections.

As in previous editions, we have added new chapters to fillin perceived gaps. There are new chapters on consultation,transplantation medicine, and pain management. There is anew chapter on asthma management (how could we havemissed that for four editions?). New surgical chapters includethoracic aortic disease, lung transplantation, esophagomyot-omy, cervical spine surgery, reconstruction after cancer abla-tion, thyroid malignancies, vasectomy, and inflatable penileprosthesis.

We are firm in our belief that this book is an importantpart of the medical literature. Our target audience is allphysicians who contribute to the care of patients in theperioperative period: anesthesiologists, surgeons, internists,and family physicians. The physician assistants and nursepractitioners who assist in patient care will find informationthat is valuable to them as well. We have again tried to makeMedical Management of the Surgical Patient a usable andwell-documented reference book. While there are excellenthandbooks that address “only the facts,” we feel very stronglythat there should to be a single-volume source for the back-ground information to support the recommendations we haveput forward.

Most of all, we hope that all of our patients receive bettermedical care because of the efforts of our authors.

We are indebted to Cambridge University Press for pub-lishing this fifth edition. Their editorial assistance and patienceare deeply appreciated.

Michael F. Lubin, MD

Reference1 Goldman L, Caldera DL, Nussbaum SR et al.Multifactorial index

of cardiac risk in noncardiac surgical procedures. N Engl J Med1977: 297: 845–50.

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Introduction

The interchange between physicians discussing a patient’scase has been mentioned in written history since ancientGreece. From the time of Hippocrates, physicians have beenencouraged to seek consultation on difficult cases when theywere in doubt. They were urged not to be jealous of oneanother but to realize their own limitations and to use theknowledge of their colleagues to help. “Nor, among phys-icians, do those who treat by diet envy those who employsurgery, but they even call each other into consultation andcommend one another.” It is clear, however, that there weredisagreements in those days: “Physicians who meet in con-sultation must never quarrel or jeer at one another.” Therewere also “wretched quarrelsome consultations at the bedsideof the patient, with no consultant agreeing with another,fearing he might acknowledge a superior.”

Over the next 25 centuries, consultation has had its ups anddowns. Much of what was written had to do with the etiquetteand ethics of the interaction. In medieval Europe, littlechanged from ancient times. Physicians were encouraged toask colleagues for help if needed and to refrain from criticizingeach other in front of non-physicians.

In the fourteenth century, patients were warned againstconsulting large numbers of doctors because there would be“endless disagreements and different suggestions” and “thepatients [would] suffer from lack of care.” The doctor couldcall in another physician for consultations, but the treatmentshould be administered by the one knowing the most about thecase. Physicians, curiously enough, were warned about con-sulting with other physicians. “It is better if he have goodexcuses that he may refuse their demands. He may feign aninjury, or illness, or some other likely excuse. But if he acceptstheir demands let him make a covenant for his work and makeit beforehand . . . . Clearly advise the other leech that he willgive no definite answer in any case until he has seen thesickness and the symptoms of the patient.” At least the last issound advice.

The seventeenth and eighteenth centuries brought out thebest and the worst in physicians. In Italy, Julius Caesar Clau-dinius wrote, “There is no part of a Physician’s Office moreillustrious than Consultation, because by it alone unlearnedphysicians are known from the Learned . . . . And there is

nothing that brings greater advantage to the Sick.” Contrastthis with the following: “On December 28, 1750, Drs. JohnWilliams and Parker Bennett, of Jamaica, having becomeinvolved in a wrangle about their respective views on biliousfever, came to blows, and, the next day, proceeded to a desper-ate hand-to-hand combat with swords and pistols, whichended fatally for both. It is said that Johann Peter Frank wasso disgusted with the behavior of doctors in consultation thathe advised the calling in of the police on all such occasions.”Again, in contrast to the brutish behavior in the British colony,John Gregory wrote that “consultation, when required, is to beconducted in a gentlemanly manner. The chief concern is to bethe relief of the patient’s suffering and not personal advance-ment. That is, the duty to one’s patients takes precedence overpersonal and professional differences.”

During the eighteenth century, there had been (and wouldcontinue to be) a great deal of competition between practition-ers. At the turn of the nineteenth century, there was muchactivity in writing about the ethics of medicine, most of whichwas aimed at avoiding the harmful effect of this competition.Two men in particular bear mention – Johann Stieglitz andThomas Percival.

In 1798, Stieglitz addressed the problem of the profession’sinternal difficulties and the distrust they engendered in thepublic. Many practitioners were afraid to admit their need forhelp and thus avoided consultation with more knowledgeablephysicians. He encouraged consultation for the good of thepatient while exhorting the consultants to treat the consultingphysicians as colleagues and with respect that would onlyimprove the public’s view of the profession.

In 1803, Percival publishedMedical Ethics, a few years afterhe had been requested to write on the subject by his fellowphysicians. Much of the book was devoted to the etiquette ofprofessional interaction, and consultation was addressed inmuch the same manner as in centuries past: consultationshould be obtained to help the patient; no jealousy, competi-tion, or patient stealing should be tolerated; conflict in front ofpatients was to be avoided at all costs. It is a tribute to therelative timelessness of Percival’s work that much of it wasused almost verbatim in the AMA Codes of Ethics in 1847,1911, and 1912.

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In the late 1800s, another problem surfaced in England. Agreat gap had appeared between the eminent consultants andgeneral practitioners. Although the former, because of super-ior knowledge and prestige, were able to command high feesfrom wealthy clients, they apparently continued to see lesswell-to-do patients for the same fees that were being chargedby the general practitioners. This attracted business to theconsultants but left the ordinary physicians with much lesswork and poor incomes. The result, as could have been antici-pated, was ill feeling between the groups. The conflict was ofsuch consequence that the British Medical Journal in 1872 wasmoved to comment entirely against the “great consultants,”who they believed should charge higher fees. This woulddecrease the burden of the overworked consultants and dis-tribute the workload and the income in a more reasonablemanner.

There was great fear among the general practitioners ofsending their patients to consultants, because often thesepatients remained in the care of the more prestigious menwhose care was considered better and whose fees were identi-cal. Thus, the patients had no incentive to return to theirpractitioners. Therefore, in 1886, the Association of GeneralPractitioners was established to try to regulate the relationsbetween these opponents.

In the USA, meanwhile, another problem was developing.In the mid-1800s, many states repealed their laws regulatingmedicine, resulting in a large influx of quacks and cults.Because of this, a code of ethics restricting competition amongdoctors was adopted by the medical profession. This codecondemned practitioners who did not have orthodox training,who claimed secret medications, and, importantly for consult-ants, who offered special abilities. (They may have actually hadspecial abilities.) Although the code did much to discourageunqualified practitioners, as medical practice moved into thetwentieth century, it allowed ill feeling to exist between generalpractitioners and a growing group of medical “specialists.”

A number of other negative results surfaced. Because thecode forbade consultations with unlicensed physicians, if apatient insisted on a consultation with an outsider, the legit-imate physician was forced to withdraw from the case, leavingthe patient in the hands of these unqualified people. The rulesalso provided an opportunity for exclusion of even qualifiedphysicians, and in the late 1800s, women, blacks, and thosewho were trying to specialize were at times subjected to theseconsultation bans.

In the twentieth century, laws have again been passedreducing the numbers of unqualified practitioners. The Inter-national Code of Ethics encourages consultation in difficultcases. The attainment of equal status by osteopathic physiciansis an interesting sidelight to these ancient struggles to protectpatients and the profession.

Today, the problem is entirely different. In previous cen-turies, consultation was requested from a physician who,although similarly trained, was thought to be more knowledge-able overall. Even 60 years ago, in “uncomplicated” cases,

consultation was generally considered unnecessary. The doctorwho took care of the patient was the doctor who did thesurgery, attended to preoperative and postoperative care, andcontinued to do the “primary care” long after.

For the past few decades, however, as medical knowledgehas mushroomed and physicians have specialized and subspe-cialized, these tasks have been divided and subdivided. Thisdivision of labor has helped the great advances in medicine inthe USA, but it also has created some special problems.

The proliferation in consultative medicine has allowedpatients to have a large number of experts taking care of eachseparate part of an illness. The internist asks the cardiologist toconsult on myocardial infarctions; the cardiologist asks theendocrinologist to consult on patients with diabetes; the sur-geon asks the internist for help on patients with hypertensionand congestive failure. Although this accumulation of expertiseis impressive and would seem to lead to the best care possible,it can, and not infrequently does, lead to conflicting orders,incompatible medications, and conflicts between consultingphysicians. Unfortunately, these conflicts are at times per-ceived by the patients and can cause unnecessary insecurity,fear, and anger.

These kinds of problems are common in the perisurgicalpatient who has complicating medical problems before surgeryor who develops complications afterward. The surgeon fre-quently needs to have medical support to help with the compli-cated problems of preoperative and postoperative care.Unfortunately, the internist’s knowledge of the surgical pro-cedures, the recovery course, and complications is oftenscanty. This sets up a situation in which each physician hasknowledge that the other needs to take optimal care of thepatient.

The advantages of the primary care physician, althoughthey should be obvious, have been lost in the tangle of sub-specialization. This physician can be either the internist or thesurgeon. The important concept is that the responsibility forthe integration of therapies falls to that one physician becausehe or she is most familiar with all aspects of the patient’s case.All other physicians must function as advisors (consultants) tothe primary care provider.

The consultant’s role can be a difficult one. It is imperativethat the primary physician be aware of, and approve of, alltherapy, and therefore feel free to accept and reject the adviceof the consultant. Rejection is, thankfully, an unusual occur-rence. Under ideal circumstances, it is best for the consultantto discuss all recommendations with the primary physicianbefore they are written in the chart. In this way, informationcan be exchanged, theories can be discussed, and a mutuallysatisfactory plan of treatment can be formulated. This avoidsthe confusion, anger, and mistakes that can occur when theconsultant must institute therapy without discussion; thisshould be done only in an emergency situation, when delaywould cause harm to the patient.

Another area of potential difficulty for the consultant is indiscussing plans and diagnoses with patients who are

Introduction

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exquisitely sensitive to any discrepancy, real or perceived,between physicians. This can cause misunderstanding andanxiety for the patient, and can require an immense amountof explanation by the primary physician to reestablish thepatient’s trust, to help him or her understand what ishappening, and to allay his or her fears.

In general, it is best for the consultant to communicatetreatment plans through the primary physician. When asked,the consultant can give the patient the broad outline of possi-bilities to be presented to the primary physician. The consult-ant should always make it clear that the final decision aboutwhat is to be done will be made by the primary physician andthe patient.

There seem to be five basic principles behind optimalpatient care. The first is the one-patient/one-doctor principleof primary care, or the “final common pathway” to integratetherapies as discussed above. Second, the primary doctor andconsultant should trust each other. There needs to be a feelingbetween them that each one is able to provide somethingimportant to the patient’s care. Third, communication is indis-pensable. If the physicians take the time to talk to one another,confusion, irritation, anger, and mistakes can be avoided. Thefourth principle is really a corollary of the third, and that iscooperation. It is the natural extension of communication:

if two physicians can talk to each other and each one truststhe other’s judgment and knowledge, they will be able tocooperate, even in areas of disagreement, in taking the bestcare of the patient.

The final principle that ties the others together is etiquette.As in all human interactions, the way people deal with eachother may be as important as the content of the interaction. Abrilliant consultation, handled in a brusque and rude mannermay be no more useful than no consultation at all. Contro-versial or optimal therapies begun before consultation withthe primary physician will make further interaction difficult.Finally, and worst of all, improper therapy instituted errone-ously or because of inadequate information not only willharm the physicians’ relationship but may harm the patientas well.

The art of consultation is one that involves many aspects ofinteraction. The primary physician and the patient must feelthat the consultant is concerned not only with the hard scien-tific facts of the patient’s care from the specialist’s viewpointbut with optimal overall management. The request for consult-ation is not a carte blanche for management; it is a request foradvice in treating some part of the patient’s illness. Thus, theconsultant should feel like an invited guest in someone’s house,not the master of ceremonies.

Introduction

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