Pushing meds for induction

[vector2]

It's painful to admit that this field sometimes attracts some of the worst personalities in medicine. It doesn't matter how many superstar, knowledgeable anesthesiologists a CRNA meets. All it takes is for one, lazy, do-nothing anesthesiologist to completely hand over the reins to them and/or demonstrate their gross incompetence, and the CRNA will be convinced that they might as well be in the driver's seat.

Not to mention, how many hundreds of thousands (millions?) of dollars does ASA take from AMCs who regularly condone CRNAs going to sleep by themselves if the doc is tied up in another room?

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[fakin' the funk]

I'm in a practice that is mixed MD/CRNA and we docs are essentially 1:3 when not in a room solo. My sense is that our CRNAs are quite good overall, and there is a high level of mutual respect and professionalism, generally.

Typical for our CRNAs to do standard inductions solo. More complicated airways, or cases requiring case-start help like lines/access then we are present. Certainly any sort of active condition like a cardiac comorbidity, anticipated difficult intubation, full stomach, sepsis, hemorrhage etc, we are present throughout induction and other key times until the case is tucked-in.

I spend most of my time not in direct line-of-sight supervision preparing same-day and next days' and next week's patients in a medical consultation fashion, giving a break to the CRNAs or MDs I'm backing up, doing work that advances our specialty (QI, committee meetings), and occasionally even drinking a cup of coffee.

 

[nimbus]

I spend most of my time not in direct line-of-sight supervision preparing same-day and next days' and next week's patients in a medical consultation fashion, giving a break to the CRNAs or MDs I'm backing up, doing work that advances our specialty (QI, committee meetings), and occasionally even drinking a cup of coffee.

What does that mean? Are you screening charts, calling upcoming patients, surgeons offices and consultants? Can’t you get the hospital to hire a nurse to screen patients and work up the ones that fall out? We don’t have anybody dedicated to that role and have a very low reschedule rate. Our surgeons know what we need and get it. Occasionally they get stuff they think we need but actually don’t.

 

[IMGASMD]

What does that mean? Are you screening charts, calling upcoming patients, surgeons offices and consultants? Can’t you get the hospital to hire a nurse to screen patients and work up the ones that fall out? We don’t have anybody dedicated to that role and have a very low reschedule rate. Our surgeons know what we need and get it. Occasionally they get stuff they think we need but actually don’t.

Someone with an axe to grind can claim that while you’re doing those tasks, giving breaks, you’re no longer immediate available. Especially you’re the only physician out…..

 

[coffeebythelake]

With 4 730 cases it is basically impossible to start all of them on time and the schedule should be adjusted. I work in a busy group and might have for example 730, 730, 740 start (not ideal but happens). Most of my cases don't need an extra IV or a-line and get the blocks done in pre-op. Usually things time out fine with one of the 730 getting in early and patient is only waiting in the room for max a couple minutes. If longer then try and get a colleague to help start it. Very rarely there is a 5-10 minute delay but whatever not the end of the world. Anesthesiologist participates in induction no exceptions.

Agreed --- Not really a problem. Even when we do 1:4 first starts which is uncommon, there js usually a combination or GA and MAC cases. And even if there were 3 first start GAs I could usually find another attending to start an uncomplicated case for me, or God forbid tell the room to hold 15 minutes. When your surgeons take 6 hours to do a lap chole that extra 15 minutes isn't going to be the reason why the room runs late. Prioritizing the uncomplicated cases first gets things moving, and we do the complicated intubation multiple IV art line cases after

With our model of medical direction, I would never let the crna induce and intubate by themselves. That's basically fraud.

 

[2Fast2Des]

I take the drugs, end of story. I reach for the syringes the first thing I do when I walk into the room to not give an aggressive CRNA an opportunity, they are not allowed to induce alone regardless. Although the locums nurses boast about how docs don't show up and let them do their own thing at their other gigs...

I was doing a TAP block on a patient in PACU who I did the case with a CRNA, and as I was preparing everything the CRNA starts putting sterile gloves on, in some assumption that he would be doing the block... Because in his other job they do TAP blocks because the docs don't want to be bothered to do them. Yup great gig, him thinking I would prep the block and he walks in and pops it in, LOL! In my place only docs do blocks, so he had no chance no matter how much he would have wanted to

How many of you guys are present for extubation? Our CRNAs routinely emerge and extubate without telling us, unless we specifically tell them to notify us, and even then they'll do it for that one time, and have to keep reminding...

 

[pgg]

How many of you guys are present for extubation? Our CRNAs routinely emerge and extubate without telling us, unless we specifically tell them to notify us, and even then they'll do it for that one time, and have to keep reminding...

There's a required attestation to "present at emergence" but it's arguable that "emergence" is still in process 20 minutes after extubation as the patient is waking in PACU. And indeed this is sometimes when I click that click in the EMR, if the case finishes and I'm busy elsewhere.

I always make it clear that I always want to be called for extubation. And they do. Rarely, I'll tell them to hold up the wakeup and wait for me but usually not. They're good about calling a few minutes in advance so I can almost always be there before the patient is ready to wake up.

No one goes to sleep without me in the room. Sometimes they wait a few minutes. It's never a problem.

 

[GassYous]

I take the drugs, end of story. I reach for the syringes the first thing I do when I walk into the room to not give an aggressive CRNA an opportunity, they are not allowed to induce alone regardless. Although the locums nurses boast about how docs don't show up and let them do their own thing at their other gigs...

I was doing a TAP block on a patient in PACU who I did the case with a CRNA, and as I was preparing everything the CRNA starts putting sterile gloves on, in some assumption that he would be doing the block... Because in his other job they do TAP blocks because the docs don't want to be bothered to do them. Yup great gig, him thinking I would prep the block and he walks in and pops it in, LOL! In my place only docs do blocks, so he had no chance no matter how much he would have wanted to

How many of you guys are present for extubation? Our CRNAs routinely emerge and extubate without telling us, unless we specifically tell them to notify us, and even then they'll do it for that one time, and have to keep reminding...

Damn lol now they want you to prep for their procedures? What is this looney backwards world?

 

[IMGASMD]

Damn lol now they want you to prep for their procedures? What is this looney backwards world?

Any resistance will earn GassYous a title of “not a team player….”

 

[GassYous]

Any resistance will earn GassYous a title of “not a team player….”

I did just do a module about allowing crnas to do whatever they want

 

[IMGASMD]

I did just do a module about allowing crnas to do whatever they want

Did you also complete the one that I did titled “just sign here, or you won’t get paid”….?
🥸

 

[fakin' the funk]

What does that mean? Are you screening charts, calling upcoming patients, surgeons offices and consultants? Can’t you get the hospital to hire a nurse to screen patients and work up the ones that fall out? We don’t have anybody dedicated to that role and have a very low reschedule rate. Our surgeons know what we need and get it. Occasionally they get stuff they think we need but actually don’t.

Looking at usually 20-30 charts per week, most of which are ASA2-4 cancer and spine and Ortho/Ortho trauma cases.

Calling upcoming patients, coordinating with surgeons and hospitalists and medical consultants for same-day to weeks-ahead cases.

Evaluating same-day, next-day upcoming inpatients on the wards.

We have a robust preoperative medical screening and evaluation system and it does a good job of dealing with hold/continue medications and screening for recent illnesses / dynamic conditions, but it's not anesthesia-run.

 

[dabears505]

Busy private practice with fast, good, impatient surgeons. Routinely have 4 730 cases. Would not last if routinely delayed case start with patient in room for 15 minutes. The crnas are not amateurs. I am within 1 minute walk if something starts to happen. They push drugs, they intubate.

 

[ToKingdomCome]

Busy private practice with fast, good, impatient surgeons. Routinely have 4 730 cases. Would not last if routinely delayed case start with patient in room for 15 minutes. The crnas are not amateurs. I am within 1 minute walk if something starts to happen. They push drugs, they intubate.

You are within a 1 minute walk but will they tell you if something happens? I doubt it

 

[pgg]

Brief side message for residents who will graduate soon and go looking for a job:

Not all ACT practices are created equal. Pick a job where you can be meaningfully involved in critical portions of the case. If the job requires you to skip being present for the sake of production pressure, or saving a surgeon 5 minutes, keep looking.

 

[rick roller pump]

Agree with pgg. Also as a new grad you do not want to be delegating all your procedures or you will lose skills fast. At my job anesthesiologists do all spinals/epidurals, nerve blocks, and CVCs. However like most places the default is for the CRNAs to do the airways and after a few months I realized I was getting rusty with airways. Now I make it a point to intubate a couple times a week just to keep up skills. Remember that the second an overconfident CRNA can't intubate, they will point the finger at you.

 

[crash2500]

Busy private practice with fast, good, impatient surgeons. Routinely have 4 730 cases. Would not last if routinely delayed case start with patient in room for 15 minutes. The crnas are not amateurs. I am within 1 minute walk if something starts to happen. They push drugs, they intubate.

So are you billing medical direction or supervision?