Now or Never: Developing Professional Judgment

You have started a new job as an anesthesiologist in private practice. Your first case on your first day seems a simple one. The patient is a 27-yr-old male (weight 90 kg and height 5′8″) scheduled for elective arthroscopy of shoulder, knee, and ankle, all on the left side. He is an unmarried construc- tion worker accompanied by his father. He is a motorbike fanatic and has fallen off his bike in the past. He claims he is perfectly healthy except that in the last 6 mo he has developed a hoarseness of his voice. He tells you that it has not gotten worse. His father nods in agreement. He went to an ear, nose, and throat (ENT) surgeon 3 mo ago, who told him that he has vocal cord polyps. The ENT surgeon indicated that there was no problem. However, you do not agree and you speak to the orthopedic surgeon to relay your concern. You suggest that a new ENT consult be obtained and that his operation be canceled today. The surgeon informs you that it is “now or never” for this surgery, as the patient’s insurance expires tomorrow. You consider regional blocks, but the patient refuses them and states he wants to be asleep. He would rather leave without the surgery than having it done under regional blocks. If you decided to go ahead with a general anesthetic, how would you do it for this patient, remembering that he has to be on right-side down for the shoulder surgery?