EP lab

[TheLoneWolf]

Busy hospital with multiple EP labs. Sick patients...obviously. Two main patient types cause some concern. Morbidly obese 300+ pounders with big beards and known difficult airways. The others are young drug abusers with EFs of 5-10%. In both populations, keeping them immobile and spontaneously ventilating for 4+ hours is difficult.

EP Docs insist on "mac" for pretty much everything outside of Afib ablations, mitraclips, and watchman procedures. Slow proceduralists so we can be in the case for 4+ hours where they need a motionless field.

Becomes a little more difficult to do in the 300+ pound crowd. Covered briefly for someone who started a case on a 460 pounder for an ablation under mac. Unpleasant, clearly obstructing with intermittent etCo2. So these cases are essentially face mask generals on trainwreck patients.

Any discussion with the EP guys regarding this issue results in complaints to admin for "slowing down their turnover time" and "not being a team player " from the multiple parties involved. The clever(er) ones say that any volatile anesthetic will result in a stabilizing of the arrythmia they are attempting to ablate. All of them refuse to entertain intubated TIVAs citing turnover time. Most but not all refuse any arterial line access, again citing turnover time. They pull ACTs off of their lines.

Partners refuse to work with them. EPs refuse to work with CRNAs. So it's juniors and locums who are stuck with them. Admin keeps reminding us we are contractually obligated to cover their rooms.

Wondering how to deal with such adversarial and frankly unsafe practices.

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[CD125]

No advice here but your hospital sounds very toxic and so does your group if you guys are dumping these on juniors.

 

[coffeebythelake]

Busy hospital with multiple EP labs. Sick patients...obviously. Two main patient types cause some concern. Morbidly obese 300+ pounders with big beards and known difficult airways. The others are young drug abusers with EFs of 5-10%. In both populations, keeping them immobile and spontaneously ventilating for 4+ hours is difficult.

EP Docs insist on "mac" for pretty much everything outside of Afib ablations, mitraclips, and watchman procedures. Slow proceduralists so we can be in the case for 4+ hours where they need a motionless field.

Becomes a little more difficult to do in the 300+ pound crowd. Covered briefly for someone who started a case on a 460 pounder for an ablation under mac. Unpleasant, clearly obstructing with intermittent etCo2. So these cases are essentially face mask generals on trainwreck patients.

Any discussion with the EP guys regarding this issue results in complaints to admin for "slowing down their turnover time" and "not being a team player " from the multiple parties involved. The clever(er) ones say that any volatile anesthetic will result in a stabilizing of the arrythmia they are attempting to ablate. All of them refuse to entertain intubated TIVAs citing turnover time. Most but not all refuse any arterial line access, again citing turnover time. They pull ACTs off of their lines.

Partners refuse to work with them. EPs refuse to work with CRNAs. So it's juniors and locums who are stuck with them. Admin keeps reminding us we are contractually obligated to cover their rooms.

Wondering how to deal with such adversarial and frankly unsafe practices.

These EP folks seem toxic and asking for bad outcomes. I would tube and tiva them and put in an art line. Otherwise refuse or walk. The partners can handle it then. They are playing with your medical license.

 

[abolt18]

Busy hospital with multiple EP labs. Sick patients...obviously. Two main patient types cause some concern. Morbidly obese 300+ pounders with big beards and known difficult airways. The others are young drug abusers with EFs of 5-10%. In both populations, keeping them immobile and spontaneously ventilating for 4+ hours is difficult.

EP Docs insist on "mac" for pretty much everything outside of Afib ablations, mitraclips, and watchman procedures. Slow proceduralists so we can be in the case for 4+ hours where they need a motionless field.

Becomes a little more difficult to do in the 300+ pound crowd. Covered briefly for someone who started a case on a 460 pounder for an ablation under mac. Unpleasant, clearly obstructing with intermittent etCo2. So these cases are essentially face mask generals on trainwreck patients.

Any discussion with the EP guys regarding this issue results in complaints to admin for "slowing down their turnover time" and "not being a team player " from the multiple parties involved. The clever(er) ones say that any volatile anesthetic will result in a stabilizing of the arrythmia they are attempting to ablate. All of them refuse to entertain intubated TIVAs citing turnover time. Most but not all refuse any arterial line access, again citing turnover time. They pull ACTs off of their lines.

Partners refuse to work with them. EPs refuse to work with CRNAs. So it's juniors and locums who are stuck with them. Admin keeps reminding us we are contractually obligated to cover their rooms.

Wondering how to deal with such adversarial and frankly unsafe practices.

Honestly, I'd proceed with my anesthetic the way I feel is safest, making slight accommodations (like TIVA). When the proceduralist complains, I will then inform them that I won't dictate how they do their job, and they will not dictate how I do mine. I am always willing to listen to requests, but ultimately I will determine on my own what is best for my patient. Use the words "patient safety" a bunch. Then you beat them to admin, complaining that they are trying to endanger your patients and not being team players.

I will never do a 3-4hr MAC case. Ever.

I just don't understand why they even get to "entertain" anything. The decision is 100% yours. The liability is 100% yours.

 

[coffeebythelake]

I mean you already pointed out the biggest source of inefficiency in EP lab: Slow proceduralists. You doing GA and an art line isn't going to add much time compared to the hours they waste.

So do what you think is the best and safest for your patient. If EP doesn't want to invite you back, that's even better.

 

[abolt18]

I mean you already pointed out the biggest source of inefficiency in EP lab: Slow proceduralists. You doing GA and an art line isn't going to add much time compared to the hours they waste.

So do what you think is the best and safest for your patient. If EP doesn't want to invite you back, that's even better.

Seriously, if they're doing 20 cases a day, I can understand complaints about inefficiency.

 

[amyl]

I will hear a proceduralists argument for what they want but I decide ultimately what’s best for the patient. In the end the question is anesthesia yes or no? My name on the chart means I diagnose the patient and prescribe the anesthetic plan.
Don’t like it? Work with the crna and you, the ep dr, can prescribe the anesthetic plan.
Belittle them and say what is so pressing that you have to do that trumps patient safety?

That said have you tried using cpaps? I wouldn’t do so for 4 hours but we get through lots of bariatric egd/colons with slow ass fellows and teaching attendings with cpap on and adjusted prior to induction

 

[kidthor]

Sounds like you have a weak or absent leadership problem. As others noted you ultimately decide what’s best and safest for the patient. I played that game before where I bent a bit because the proceduralist wanted something stupid. But now I just won’t do it. Especially with that nurse getting criminally prosecuted at Vanderbilt (for what was largely a systems problem) and then with lots of subpar staff treatment during COVID, I realized that opening patients up to danger is just never the right thing and I won’t do it. If leadership or the hospital doesn’t want to support you then just get out.

At least now we have locums as a backup plan. If something is unsafe, you just absolutely have no reason to do it. You offer the safe options and if the proceduralist or hospital doesn’t want it then at least you were doing the right thing.

 

[Urzuz]

Sounds like you have a weak or absent leadership problem. As others noted you ultimately decide what’s best and safest for the patient. I played that game before where I bent a bit because the proceduralist wanted something stupid. But now I just won’t do it. Especially with that nurse getting criminally prosecuted at Vanderbilt (for what was largely a systems problem) and then with lots of subpar staff treatment during COVID, I realized that opening patients up to danger is just never the right thing and I won’t do it. If leadership or the hospital doesn’t want to support you then just get out.

At least now we have locums as a backup plan. If something is unsafe, you just absolutely have no reason to do it. You offer the safe options and if the proceduralist or hospital doesn’t want it then at least you were doing the right thing.

Not to completely derail this conversation, but do you really think it was largely a systems problem? I can understand the systemic issues contributing to the error, but I think it’s a little generous to blame it largely on the systemic issues where she individually screwed up a number of steps along the way. Granted I didn’t pour over every last detail of the case, but from what I remember, I came away from reading about the case thinking she bears a large degree of responsibility.

 

[kidthor]

Not to completely derail this conversation, but do you really think it was largely a systems problem? I can understand the systemic issues contributing to the error, but I think it’s a little generous to blame it largely on the systemic issues where she individually screwed up a number of steps along the way. Granted I didn’t pour over every last detail of the case, but from what I remember, I came away from reading about the case thinking she bears a large degree of responsibility.

There was definitely significant human error. But there were tons of systems problems that interestingly didn’t get addressed until CMS investigated them. Having been a case reviewer I’ve seen many errors that are equally bad with a human+systems combination that ended badly.

OP is pointing out a systems issue with EP demanding an unsafe practice plus a human component of throwing the cases downstream for new people or locums to be put in an unsafe position. Once a patient is harmed then everyone points at the anesthesiologist as responsible and ignores all the rest. Then you have a case very similar to the Vanderbilt nurse….

 

[sevo00]

not fun cases. agree with others that if EP does not like your plan then they are more than welcome to proceed without you.

That being said, what I have had success with is a cocktail of propofol and ketamine.I give versed and glyco at beginning of case and put on a non-rebreather. Then take a 100ml bottle of propofol and mix in 200mg of ketamine. I then run that as an infusion at 100mcg/kg/min based on lean body mass. Make sure not based on total body mass. I have done that in the past with good success. They remain breathing spontaneously and remain relatively motionless.

 

[nimbus]

not fun cases. agree with others that if EP does not like your plan then they are more than welcome to proceed without you.

That being said, what I have had success with is a cocktail of propofol and ketamine.I give versed and glyco at beginning of case and put on a non-rebreather. Then take a 100ml bottle of propofol and mix in 200mg of ketamine. I then run that as an infusion at 100mcg/kg/min based on lean body mass. Make sure not based on total body mass. I have done that in the past with good success. They remain breathing spontaneously and remain relatively motionless.

This works even better when you paralyze and tube them.

 

[nimbus]

Lol they care about turnover time between their 4 hr cases. Don’t they have rounds or clinic?

 

[sevo00]

This works even better when you paralyze and tube them.

don't disagree with you. its essentially general without airway control at this point. JUst saying what I have done in the past. People are welcome to try it or dismiss it

 

[Status Sciaticus]

Busy hospital with multiple EP labs. Sick patients...obviously. Two main patient types cause some concern. Morbidly obese 300+ pounders with big beards and known difficult airways. The others are young drug abusers with EFs of 5-10%. In both populations, keeping them immobile and spontaneously ventilating for 4+ hours is difficult.

EP Docs insist on "mac" for pretty much everything outside of Afib ablations, mitraclips, and watchman procedures. Slow proceduralists so we can be in the case for 4+ hours where they need a motionless field.

Becomes a little more difficult to do in the 300+ pound crowd. Covered briefly for someone who started a case on a 460 pounder for an ablation under mac. Unpleasant, clearly obstructing with intermittent etCo2. So these cases are essentially face mask generals on trainwreck patients.

Any discussion with the EP guys regarding this issue results in complaints to admin for "slowing down their turnover time" and "not being a team player " from the multiple parties involved. The clever(er) ones say that any volatile anesthetic will result in a stabilizing of the arrythmia they are attempting to ablate. All of them refuse to entertain intubated TIVAs citing turnover time. Most but not all refuse any arterial line access, again citing turnover time. They pull ACTs off of their lines.

Partners refuse to work with them. EPs refuse to work with CRNAs. So it's juniors and locums who are stuck with them. Admin keeps reminding us we are contractually obligated to cover their rooms.

Wondering how to deal with such adversarial and frankly unsafe practices.

Youre the anesthesiologist and no one is going to help you when things go south. Do what is best for the patient and does not directly impede the procedure that requires the anesthetic.

I have patients like this, and every single time, I tube them. If they want MAC, I do TIVA. Its just a heavy MAC, right? I dont want to reach under the drapes and put myself under the fluoro when a morbidly obese patient is obstructing. Your safety is also important.

Sounds like you have a weak or absent leadership problem. As others noted you ultimately decide what’s best and safest for the patient. I played that game before where I bent a bit because the proceduralist wanted something stupid. But now I just won’t do it. Especially with that nurse getting criminally prosecuted at Vanderbilt (for what was largely a systems problem) and then with lots of subpar staff treatment during COVID, I realized that opening patients up to danger is just never the right thing and I won’t do it. If leadership or the hospital doesn’t want to support you then just get out.

At least now we have locums as a backup plan. If something is unsafe, you just absolutely have no reason to do it. You offer the safe options and if the proceduralist or hospital doesn’t want it then at least you were doing the right thing.

Not to completely derail this conversation, but do you really think it was largely a systems problem? I can understand the systemic issues contributing to the error, but I think it’s a little generous to blame it largely on the systemic issues where she individually screwed up a number of steps along the way. Granted I didn’t pour over every last detail of the case, but from what I remember, I came away from reading about the case thinking she bears a large degree of responsibility.

Just to derail the thread a little, this wasn't largely a systems issue but a nursing/human error. The nurse decided to bypass the vecuronium label when she entered the medication, disregarded the paralytic agent sign on the cap, disregarded the paralytic agent sign around the bottle, and then again disregarded or ignored the paralytic agent sign on the metal guard that holds the rubber stopper in place.

It would be like me using an ultrasound to find the RIJ, then ignoring it and cannulating the RIC instead, then ignoring pulsatile blood flow through my needle , and dilating the RIC with a cordis, then leaving the stopcock open and the line unclamped.... that nurse bears like 90% of the responsibility.

 

[Arch Guillotti]

Partners refuse to work with them.

The place is horrible if you aren't afforded the same courtesy.

 

[kidthor]

This works even better when you paralyze and tube them.

I hope you mean paralyzing and tubing the EPs - which may be the best route here.

 

[dannyboy1]

Typically a trap inexperienced anesthesiologists fall into. Trying to please everybody. In this job market tell him politely to fu(k himself.

 

[Status Sciaticus]

I hope you mean paralyzing and tubing the EPs - which may be the best route here.

but please, no volatile since it will stabilize the arrhythmia.

 

[Arch Guillotti]

Who employs you and the cardiologists?

 

[pgg]

I feel your pain.

EP is one of the most frustrating services we cover. They can't start on time. They can't turnover efficiently. They throw in 30-40 minute lunch breaks in the middle of the day. They overbook their cases. They frequently book a couple of cases and then stealthily add on other scheduled elective outpatients. A couple times per week their cases spill over past 6 or 7 PM. Their scheduling people strategically book sick patients the sedation nurses aren't comfortable with for late in the day to enhance their 4 PM sob story about needing anesthesia. They seem to suffer from some kind of post-concussive syndrome that means they're perpetually surprised by the appearance of inpatient pacemaker implantations every afternoon.

We'd all like to tell them to **** off and/or get their **** together BUT everyone is acutely aware that procedures in EP make the hospital a lot of money, and the hospital pays our group a stipend, so we're in this uncomfortable balancing act of covering what the hospital wants us to cover and not letting these clowns get away with starting elective ablations at 5 PM every day. Just some days.

But. We do the anesthetic we feel is best - within the context of providing good conditions for their procedures. E.g. they want to do phrenic pacing sometimes, so no paralysis. Or sometimes TIVAs for the ones they think volatile will obscure the dysrhythmia ... no pushback. A couple times they told me they don't need a-lines, but I tell them I need the a-line and they don't argue.


So if you took one of these patients into the EP room, induced them, intubated them, started a propofol TIVA, and then put in an arterial line ... what would happen? They would whine piteously to admin? Is there an actual consequence to that?

Can you not just tell admin, Hey, the first time there's a sentinel event in the EP lab because we're being strongarmed into unsafe anesthesia practices, any efficiency gains you think you're getting will be erased? Maybe get a little aggressive with the next EP-admin-anesthesia meeting and invite risk management to come. Of course, that would require your own dept leadership to be willing to stand up ... which it sounds like you don't have.

 

[Arch Guillotti]

So if you took one of these patients into the EP room, induced them, intubated them, started a propofol TIVA, and then put in an arterial line ... what would happen? They would whine piteously to admin? Is there an actual consequence to that?

Exactly. Let them go and whine!

 

[Gasworks]

Our EP/cath/IR do their own Mac always.. 1-2 of versed and 12.5-50mcg fentanyl is about what they give on average. If they call us in pt is getting a tube. Half-ass anesthesia makes you an easy target when things go wrong. If the job sucks then find a new one.

 

[coffeebythelake]

Our EP/cath/IR do their own Mac always.. 1-2 of versed and 12.5-50mcg fentanyl is about what they give on average. If they call us in pt is getting a tube. Half-ass anesthesia makes you an easy target when things go wrong. If the job sucks then find a new one.

Exactly. No sense trying to "get away with something" by doing a subpar anwathestic

 

[Bertelman]

We'd all like to tell them to **** off and/or get their **** together BUT everyone is acutely aware that procedures in EP make the hospital a lot of money, and the hospital pays our group a stipend, so we're in this uncomfortable balancing act of covering what the hospital wants us to cover and not letting these clowns get away with starting elective ablations at 5 PM every day. Just some days.

This entire post quite literally described the first several years of my EP experience. Endless head-banging in an administrator's office about late cases, chicanery with posting, etc. First, I made them start the day with their PVIs. Then I told them all non-anesthesia cases get booked at the end of the day, not in the middle.

Round and round, until we lost basically 70% of our EP staff because they were tired of staying until 7 pm 3 nights a week. Combine that with a new hospital administration that understands you must balance efficiency with productivity. Entirely different world now. I could count on one finger the number of times we have been in a lab past 6 pm in the last month. And we run 3 rooms a day. Hired enough staff to allow swaps for lunch. No lab shuts down for lunch. One tech drops the patient off in recovery while another one grabs the next patient.

I wish I could say anesthesiologists made it happen. We didn't. I've been singing the same tune for 5+ years. It won't happen until the Cardiology Director wants it to happen. And they are just following what the C-suite says. But honestly, if you can get a little traction, nearly everyone will be happier. Except maybe the EP docs. Those guys are like money trees.

 

[DrOwnage]

We used to do 8 watchmen placements in a day in EP lab at my old gig. A line and GETA for everyone of them. The proceduralist started complaining about the a lines, but we just made a point that everyone in the group was going to stand up and defend it. If you're going transeptal, we're putting in an a line. Not to mention the patient would sit there for 15-20 minutes ready sometimes and he would be doing a consult and walk in like its perfectly normal. Oh yeah and then there's always an add on pacemaker after 5 when the patient's been sitting with complete heart block for the entire day.

 

[Bertelman]

I would love to get to 8 in a day. We’ve got a couple EP docs that could do it, but our infrastructure isn’t ready. Pre-op and PACU invariably slow us down.

I stop putting in A-lines for Watchman after the first couple months. The A-line is an early indicator for an effusion. Say this is a Bi-V. A-line pressure goes down, you call for a stat echo. But this is a Watchman, I’ve already got the TEE. I figure I’ve already got the tool that’s going to give the diagnosis.

 

[abolt18]

At my training hospital, we weren't even involved in watchman's anymore. Cardiologist-directed nursing sedation. They were slick at it, as I watched a few while I hung out with the cardiologist doing the TEE.

 

[jwk]

not fun cases. agree with others that if EP does not like your plan then they are more than welcome to proceed without you.

That being said, what I have had success with is a cocktail of propofol and ketamine.I give versed and glyco at beginning of case and put on a non-rebreather. Then take a 100ml bottle of propofol and mix in 200mg of ketamine. I then run that as an infusion at 100mcg/kg/min based on lean body mass. Make sure not based on total body mass. I have done that in the past with good success. They remain breathing spontaneously and remain relatively motionless.

That's a general anesthetic.

 

[jwk]

Our EP/cath/IR do their own Mac always.. 1-2 of versed and 12.5-50mcg fentanyl is about what they give on average. If they call us in pt is getting a tube. Half-ass anesthesia makes you an easy target when things go wrong. If the job sucks then find a new one.

Just semantics, but we're the only ones that do MAC. If they do it, it's sedation.

I agree with just about everyone - we don't tell you how to do your ablation, you don't tell us how to do our anesthetic. End of story.

 

[Simba1711]

That's a general anesthetic.

I agree. 99 percent of the time surgeon or doctor requests mac it’s room air general. They don’t want an ett or Lma because it looks slick on their part but they don’t want any movement

 

[LaryngoSpazz]

Obviously the OP’s department needs stronger leadership to push back on these practices. Rather than putting juniors and locums in the cath lab, the higher ups with more political power should do these cases and push back until they establish a safe system that can work for everyone.

Having said that, not all cath lab cases need an ETT and an a-line. If the OP is forced to go down the path of no alines and no ETT than consider the non-invasive clearsight monitor for continuous BP and consider high flow NC for those patients who are larger with OSA and obstruct easily.

 

[patriot6]

crazy the things that go on. i've had all sorts of weird requests through my short three years out in practice. we just started doing TCARs at my institution, and one of our cardiologists requests lma / tiva to facilitate quicker turnover? sorry bro, you don't get to select the airway device in your morbidly obese, active gerd patient. i've learned from many here, and many of my partners, that you can be polite and firm at the same time. no one gets to choose my anesthetic, but i (mostly) will entertain proceduralists' thoughts from time to time.

 

[pgg]

I'm not sure why anyone, least of all readers of this forum, think an ETT or a-line have any impact whatsoever on case or turnover times.

The a-line can get done while they're doing prep.

Induction and intubation doesn't take appreciably longer than putting on supplemental oxygen and getting the patient comfortable. There's plenty of time when they're putting dressings on and/or holding groin pressure to emerge and extubate. (I was repeatedly assured in the des thread that everyone who doesn't suck can wake up any patient on a dime.)

So why is anyone giving a moment of credible listening to any cardiologist who's arguing that these things hurt efficiency?

 

[Bertelman]

I'm not sure why anyone, least of all readers of this forum, think an ETT or a-line have any impact whatsoever on case or turnover times.

The a-line can get done while they're doing prep.

Induction and intubation doesn't take appreciably longer than putting on supplemental oxygen and getting the patient comfortable. There's plenty of time when they're putting dressings on and/or holding groin pressure to emerge and extubate. (I was repeatedly assured in the des thread that everyone who doesn't suck can wake up any patient on a dime.)

So why is anyone giving a moment of credible listening to any cardiologist who's arguing that these things hurt efficiency?

Counter arguments:

An A-line is not a delay in my hands, or the rest of the cardiac anesthesia team. General anesthesiologists? Locums? SRNAs? Please. The EP doc will be calling me, then offering to just put one in the groin.

MAC vs GETA, our MACs go back to the Cath/EP per/post area on the same floor. Once they drop off, they walk two rooms over and pickup the next one.
Generals have to hop in an elevator, head up to PACU for recovery. Then give signout. Then close a chart, turn in narcs upstairs. Easily adds 10-15 min to our turnovers. Our EP lab is far enough away from the other anesthetizing locations that it takes some minutes for the doc to show up for induction. MACs? not necessary.

Obviously we can do some stuff on our end to improve those times, but we really don't do enough PVIs for it to matter. Besides, the staff don't like calling the EP docs until the patient is prepped and draped. At which point they will amble down to cut skin 15 min later. So I'm not really compelled to light any fires on my end, either.

 

[Coffee PRN]

Counter arguments:

An A-line is not a delay in my hands, or the rest of the cardiac anesthesia team. General anesthesiologists? Locums? SRNAs? Please. The EP doc will be calling me, then offering to just put one in the groin.

MAC vs GETA, our MACs go back to the Cath/EP per/post area on the same floor. Once they drop off, they walk two rooms over and pickup the next one.
Generals have to hop in an elevator, head up to PACU for recovery. Then give signout. Then close a chart, turn in narcs upstairs. Easily adds 10-15 min to our turnovers. Our EP lab is far enough away from the other anesthetizing locations that it takes some minutes for the doc to show up for induction. MACs? not necessary.

Obviously we can do some stuff on our end to improve those times, but we really don't do enough PVIs for it to matter. Besides, the staff don't like calling the EP docs until the patient is prepped and draped. At which point they will amble down to cut skin 15 min later. So I'm not really compelled to light any fires on my end, either.

That's a bit of a rediculous statement. I'm a generalist doing locums and my A-lines take less than a minute for the cannulation. Always ultrasound, almost always one attempt. I don't know anyone who struggles with A-lines besides maybe dinosaurs who can't use ultrasound.

 

[Iso4ane]

So if you took one of these patients into the EP room, induced them, intubated them, started a propofol TIVA, and then put in an arterial line ... what would happen? They would whine piteously to admin? Is there an actual consequence to that?

You as a provider may be kicked out and banned from providing anesthesia in the EP Lab…oh noes the horror 😱.

 

[DocMcCoy]

That's a general anesthetic.

It’s an everything but the tube general anesthetic. The absolute worst kind of general

 

[Bertelman]

That's a bit of a rediculous statement. I'm a generalist doing locums and my A-lines take less than a minute for the cannulation. Always ultrasound, almost always one attempt. I don't know anyone who struggles with A-lines besides maybe dinosaurs who can't use ultrasound.

Then please come and work with us. I’m not categorizing all locums. Or all generalists. Just the ones at our facility. “I don’t do that block” “I’d rather not do Neuro” “Wow that vascular patient was sick”

I’ve had surgeons find me in the hall because they are waiting 10+minutes for an A-line. Our full-time staff are tired of being the sounding board for complaints, so we have a very narrow window for appropriate locums assignments.

 

[kidthor]

Then please come and work with us. I’m not categorizing all locums. Or all generalists. Just the ones at our facility. “I don’t do that block” “I’d rather not do Neuro” “Wow that vascular patient was sick”

I’ve had surgeons find me in the hall because they are waiting 10+minutes for an A-line. Our full-time staff are tired of being the sounding board for complaints, so we have a very narrow window for appropriate locums assignments.

Why do you need locums at your shop? I assume it’s because there’s an anesthesiologist shortage (at least where you are)? The surgeon and admins should be thanking the locums doc for helping keep the ORs running than whining like an unaware entitled douche when patient care isn’t maximally convenient for them.

 

[dumbmedstudent]

Then please come and work with us. I’m not categorizing all locums. Or all generalists. Just the ones at our facility. “I don’t do that block” “I’d rather not do Neuro” “Wow that vascular patient was sick”

I’ve had surgeons find me in the hall because they are waiting 10+minutes for an A-line. Our full-time staff are tired of being the sounding board for complaints, so we have a very narrow window for appropriate locums assignments.

Oh wow, surgeon having to wait 10 minutes. How awful

 

[pgg]

Counter arguments:

An A-line is not a delay in my hands, or the rest of the cardiac anesthesia team. General anesthesiologists? Locums? SRNAs? Please. The EP doc will be calling me, then offering to just put one in the groin.

MAC vs GETA, our MACs go back to the Cath/EP per/post area on the same floor. Once they drop off, they walk two rooms over and pickup the next one.
Generals have to hop in an elevator, head up to PACU for recovery. Then give signout. Then close a chart, turn in narcs upstairs. Easily adds 10-15 min to our turnovers. Our EP lab is far enough away from the other anesthetizing locations that it takes some minutes for the doc to show up for induction. MACs? not necessary.

Obviously we can do some stuff on our end to improve those times, but we really don't do enough PVIs for it to matter. Besides, the staff don't like calling the EP docs until the patient is prepped and draped. At which point they will amble down to cut skin 15 min later. So I'm not really compelled to light any fires on my end, either.

Sorta fair points, though I don't think the great majority of generalists are that slow. We don't have trainees. Our CRNAs don't do alines. We don't have physician locums (and never will unless the hospital offers to pay for them). Our EP docs have zero legs to stand on when griping about anesthesia efficiency.

Our cath lab holding area started recovering our general anesthetics a few months ago - though that was mainly to offload work from the PACU. Our PACU is very close to EP so that trip was never an issue.

I would further argue that even a light MAC with a direct-to-phase-II transport by a cath lab RN doesn't save any time, because the rate limiting step in case turnover is their room cleaning and setup for the next case.


But anyway this is all red herring discussion. Because regardless of hospital geography or SRNA/locums handicap, it's us, not them, who have the honor and privilege of choosing what safe anesthetic is most appropriate to provide satisfactory conditions for them. And they can **** right off if they want to get bossy about that.

Besides, the staff don't like calling the EP docs until the patient is prepped and draped.

That's a good thing counterpoint to any EP demand that we alter our practice for "efficiency" reasons.

Something to bring up at a surgeon-prompted meeting with admin. If they're not careful admin may turn their beady soulless doll eyes upon the surgeon and mandate that all surgeons must be physically present at induction of anesthesia.

The last Navy hospital I served at instituted a pre-anesthesia timeout that mandated presence of the surgeon before induction of anesthesia. This was mostly a good idea fairy thinking it would improve safety somehow but an unsaid real factor in that was eliminating the where-the-hell-is-the-surgeon delays as patients lay prepped and draped under anesthesia.

Our full-time staff are tired of being the sounding board for complaints, so we have a very narrow window for appropriate locums assignments.

I think that's the strategy everywhere. Somehow there's this idea that being a locums sucks sometimes because you get dumped into the worst rooms with the worst surgeons. But the truth is that most places using locums docs just wants the day to go smoothly, so they get put in straightforward B&B cases as much as possible.

 

[Bertelman]

Our Cath Lab director has been working on developing their own PACU, but the process is slow. I can’t wait for that.

 

[jwk]

Counter arguments:

The EP doc will be calling me, then offering to just put one in the groin.

All the more reason for us not to mess with them. They have a giant arterial catheter sitting in the femoral that can be utilized as an a-line.

 

[Robotic Wis-Hipple]

Speed or “efficiency” is not a medical indication. If they want a “mac”, no tube, no a-line, etc….. do it yourselves. You consult me, I’m here to help but don’t think you dictate my care. You’re not boarded in my field.

 

[pgg]

All the more reason for us not to mess with them. They have a giant arterial catheter sitting in the femoral that can be utilized as an a-line.

Well

From painful experience I've learned that piggybacking on their femoral arterial line is great until the SHTF and you actually need it. Then they're constantly frantically doing stuff with it and manipulating it and flushing it and closing stopcocks and it's worthless as a monitor for me.

I just put my own in.

 

[DrOwnage]

Well

From painful experience I've learned that piggybacking on their femoral arterial line is great until the SHTF and you actually need it. Then they're constantly frantically doing stuff with it and manipulating it and flushing it and closing stopcocks and it's worthless as a monitor for me.

I just put my own in.

That’s why they call is “slaving” off their line. Agreed. They’re always sticking **** into it making the waveform disappear almost entirely and it’s always at the worst times.

 

[Maz777]

This works even better when you paralyze and tube them.

No no no. That would be considered a safe and controlled general anesthetic. Heaven forbid...