Bleeding is part of a surgeon's world. We fear it and do whatever we can to avoid it. As a shoulder arthroscopist, even the slightest amount of oozing can make a routine case turn into Nightmare on Elm Street. Who's to blame for bleeding problems in the OR? Patients, anesthesiologists and surgeons can all contribute.

• Patient-related. Despite our strongest admonitions, patients still either forget to stop their aspirin/Plavix before surgery, or they simply reason, "What harm can one itty-bitty pill do?"

Well, 1 low-dose aspirin can transform a routine shoulder scope into a bloodbath. These oozers can be recognized by the diffuse punctate bleeding that peppers the surgical field. Despite the use of epinephrine in the irrigation bags, oozers morph the shoulder joint into the red tide. The only recourse for the surgeon is to increase the pump pressure to 1,000 atmospheres and work quickly.

Besides the aspirin/Plavix duo, another less celebrated bleeding inducer is fish oil. I had a patient who took so much fish oil with mercury that he could take his own temperature! In their quest to lower cholesterol, many well-meaning patients consume omega 3's without realizing their blood will become more slippery than a freshly mopped OR floor.

Add vitamin E, turmeric and garlic to the blood-thinning all-star list. Even ginger contains appreciable levels of salicylates! So much for adding spice to one's life. Excessive alcohol consumption can deplete vitamin K levels and may work better than warfarin in causing bleeding. Be wary of the patient who casually drinks, but has a dog named Coors.

• Anesthesia-linked. Hypotensive anesthesia is absolutely critical to attaining hemostasis in surgery. But "hypotensive" means different things to different people. Surgeons like systolic pressure less than 100 mm/Hg in a healthy adult. Many anesthesiologists like higher pressures to ensure cerebral perfusion. But does the 16-year-old pitcher really need a systolic of 130 to ensure cerebral blood flow? I perform my shoulder scopes in the lateral position and, unless the patient has a carotid lumen the size of dental floss, blood flow to the cranium should not be an issue. Toradol is a great analgesic agent, but has the blood-thinning capability of a heparin drip. I really don't appreciate well-meaning anesthetists sneaking a little Toradol in before the case is completed. This simple maneuver increases my gastric secretions and puts my epigastrium at risk for a bleed.
• Surgeon-induced. Yes, surgical factors do affect bleeding events. Great surgeons handle tissues with gentleness and kindness. If the surgeon is grabbing instruments with a death grip, has all the gentleness of Conan the Barbarian and inserts an arthroscope into a joint while uttering touch?©, type and cross the patient. If the surgeon refuses to use thermal ablation devices for fear of incurring extra costs, a crimson hue is sure to follow. If the surgeon has an invincible case of testa dura (hard head) and refuses to admit that there is a bleeding problem, make sure that O negative is nearby.

Then there's lack of speed. If a surgeon spends 15 minutes simply getting into the shoulder joint, get reddy. If the surgeon is not quite familiar with anatomy, regularly visits well-vascularized areas and simply was unaware of a known venous plexus, call the Red Cross!

The swift and efficient win the day and negotiate even the most Plavix-laden shoulder. Thank God, all bleeding (usually) stops. I just wish it would never start.