MD to CRNA knowledge gap

[Noyac]

My typical dose is 12-13 as well, I was merely stating for a extremely short statute I'd drop the dose to 10.5. My typical dose is 11.25 to 12 with 10 mcg of fentanyl

Well then, that's not a decreased dose by most standards.

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[Noyac]

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I'm gonna disagree with @Noyac on the fen causing itching. Itching is almost all duramorph induced. Pt's never complain about itching until we are rolling to PACU which fits with the IT duramorph dynamics. I also routinely put 20mcg fent in my ortho joint spinals, and never once has one of those patients ever told me they've itched (we don't do duramorph for joints here).
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It has been my experience that when doing joints under spinal with sedation some pts become fidgety. Many people increase the sedation to keep them from moving. But if you cut it back they become more coherent and all they really want to do is scratch their nose because the fentanyl is making it itch. This occurs at around 30 min into the cases. The duramorph itching doesn't usually occur until around an hour or more. It is anecdotal, I agree.
With all of this being said, I still use fentanyl in my spinal when the case calls for it.

 

[deleted547339]

You're discussing the difference between MD and CRNA, and instead this turns into a fight amongst yourselves on an entirely unrelated topic.

Good job, guys.

 

[MoMoGesiologist]

Man C sections at our place take like 2-3 hours.... a 20min Csx sounds crazy

 

[nimbus]

You're discussing the difference between MD and CRNA, and instead this turns into a fight amongst yourselves on an entirely unrelated topic.

Good job, guys.

Freeform! We don't rhyme around here. It's more like an online dinner party.

 

[JPSmyth]

I started this thread but the discussion shifted to an area that is way over my head lol

 

[Mman]

Man C sections at our place take like 2-3 hours.... a 20min Csx sounds crazy

WTF? 2-3 hours? Dude even the slow academic let the intern close skin c-sections shouldn't take more than about 75-90 minutes at most for a primary. Maybe 2 hours for the 3rd repeat on an obese patient.

I've never seen a 3 hour c-section. I've seen 500 lb patients have a c-section in less than 2 hours.

 

[IlDestriero]

Man C sections at our place take like 2-3 hours.... a 20min Csx sounds crazy

What is your technique for a 2-3 hour c/s? Epidural?


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Il Destriero

 

[deleted162650]

What is your technique for a 2-3 hour c/s?

17g Tuohy straight to my eye.

 

[drmwvr]

17g Tuohy straight to my eye.

Why? I'd just fish around the bottom drawer for a bottle of forane and drink it.

 

[Noyac]

17g Tuohy straight to my eye.

Dude, you crack me up.

 

[IlDestriero]

Their argument is that we are overtrained for the job. They want to see anesthesia as the practice of nursing. The PAs and NPs often think the same way, that they have more than enough training to be independent General practice/derm/whatever "providers" and know enough to recognize things outside the norm that need specialty consults or passing off to a non supervising physician in the practice. It's a dirty and dangerous slippery slope that you hope your family members don't find themselves on.


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Il Destriero

 

[Mman]

Their argument is that we are overtrained for the job. They want to see anesthesia as the practice of nursing.

It's the old you don't know what you don't know thinking. They push the propofol, put the tube in, turn the gas up and down and give some neo periodically and the patients wake up at the end. Good enough for them. The problem is the unrecognized trouble they can get in to that can lead to bad outcomes including death. That's where the medical training and 4 years of residency come in handy.

 

[dhb]

I found a nice picture of the knowledge gap:

 

[imfrankie]

It's the old you don't know what you don't know thinking. They push the propofol, put the tube in, turn the gas up and down and give some neo periodically and the patients wake up at the end. Good enough for them. The problem is the unrecognized trouble they can get in to that can lead to bad outcomes including death. That's where the medical training and 4 years of residency come in handy.

I used to work with CRNAs, many of whom were quite capable and personable in general. Many many times I solved the routine procedural problem they could not--both urgently and electively. I was fine with that for those CRNAs who had a memory of our differential skill later in the day and beyond. I am still befuddled at how a number of them would act with no apparent recall of these episodes, however. As I write this now, I speculate the reason some could easily dismiss and forget these "saves" is that they themselves were never ever forced to have the real fear that a genuine save engenders--the fear that comes with knowing you alone will either solve this problem or not, and that the buck stops here with you. It is this fear that really sears the memory--something that cannot be gotten from calling on another to fix the problem. I must admit that I still resent those who could never offer a much-deserved, "sweet fix man, thank you." Yes, I have issues.

 

[deleted171991]

I used to work with CRNAs, many of whom were quite capable and personable in general. Many many times I solved the routine procedural problem they could not--both urgently and electively. I was fine with that for those CRNAs who had a memory of our differential skill later in the day and beyond. I am still befuddled at how a number of them would act with no apparent recall of these episodes, however. As I write this now, I speculate the reason some could easily dismiss and forget these "saves" is that they themselves were never ever forced to have the real fear that a genuine save engenders--the fear that comes with knowing you alone will either solve this problem or not, and that the buck stops here with you. It is this fear that really sears the memory--something that cannot be gotten from calling on another to fix the problem. I must admit that I still resent those who could never offer a much-deserved, "sweet fix man, thank you." Yes, I have issues.

I love this post. This used to piss the heck out of me. They would almost kill a patient or we would have a smaller near miss, and they would act as if nothing had happened (while I would still be clearing adrenaline). Because literally, in those chicken brains, nothing special had happened.

They don't own the patients, they don't really fear for them; if anything happens, the consequences to them are minimal, compared to the physician. They just shrug their shoulders and don't learn absolutely anything from their mistakes: otherwise, I can't explain why they do risky things even after decades of experience. They only get upset if you make them look bad because, hey, they are professionals.

Still nicking those lips after 20 years? Still desatting to 60% during induction because of insufficient preoygenation, with the mask just sitting on the patient's face? Still pushing the lidocaine one minute before the propofol and causing pain on propofol injection every, single, time? Still masking at 30 breaths per minute? Still not knowing that a long neck will probably require a Mac 4? Still doing RSI with rocuronium, when we don't have suggamadex? Still being too lazy to scissor properly and lean on the teeth instead? Still scratching the front teeth when removing the blade after intubation? Still not having backup airway stuff at arm's length? Still not knowing how to induce difficult airways while maintaining spontaneous ventilation (e.g. with ketamine), and inducing apnea with propofol instead, while praying that "everything will be fine", in a place with limited airway tools? Still not being able to recognize silent upper airway obstruction from OSA? Still not putting obese patients in sniffing position, with the tragus at the level of the sternum? Still having just one stick of propofol drawn up for them? Still not realizing that an LMA is a much better ventilation strategy than desatting while four-hand ventilating with the circulator? Still extubating in stage II, because bucking "doesn't look good"? Still not being able to follow the "drapes down, patient waking up, tube out" rule, and taking extra 10 minutes to wake up the patient after a two hour-case? Still treating laryngospasm with CPAP, even in morbidly obese patients, because succinylcholine is the devil's medicine? Still being too cheap to buy a $40 portable pulseox for patient transport? Still having long PACU recovery times, because of bad planning, all the unneeded meds or elephant doses? Still not knowing how to use nitrous for the entire case? Still running desflurane at 2L/min? Still running patients at 1.4 MAC, instead of thinking what's missing from the imbalanced anesthesia? Still not giving proper doses of anesthetics to the elderly? Still sedating the heck out of patients for a neuraxial block? Still using just one recipe/"protocol" per type of case, instead of personalizing it to each patient? Et cetera, et cetera, et cetera. No problem, i.e. not their problem.

 

[IlDestriero]

Well, I can only speak for our place, but if a CRNA is almost killing patients, they won't get renewed.


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Il Destriero

 

[deleted171991]

Well, I can only speak for our place, but if a CRNA is almost killing patients, they won't get renewed.


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Il Destriero

If you catch them in the act. That's why an EMR is so important.

And btw, "they won't get renewed"? I am sure that makes them soooo scared.

 

[IlDestriero]

The old non EMR Navy hospital had a lot of "creative charting".
Sad, but true. If you're going to ignore significant tachycardia, hypotension, hypertension, whatever, at least own it.


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Il Destriero

 

[pgg]

I must admit that I still resent those who could never offer a much-deserved, "sweet fix man, thank you."

They may not have even been aware that you fixed or avoided a problem, or recognized the importance of what was happening.

The old non EMR Navy hospital had a lot of "creative charting".
Sad, but true. If you're going to ignore significant tachycardia, hypotension, hypertension, whatever, at least own it.

I've seen this everywhere that had paper charts.

Train track vitals charted when the monitor looked like the Himalayas. Extubation and PACU turnover charted before incision was made.

Wish I could say it was only CRNAs doing it.

Obligatory GomerBlog:

http://gomerblog.com/2013/10/vital-signs-electronic-records/amp/