attending surgeon, resident anesthesiologist

[Vaporized]

I have been reading this forum for AWHILE, including a lot of the old posts. Time for me to try.

Dealing with a known JERK vascular surgeon, first question he asks everyone is: WHAT YEAR ARE YOU?

I'm a pgy3/ca2 SIR. Gives me a stare down for a hot minute and proceeds to drape for his fem-distal bypass. My attending and other residents have said this dood thinks the purple syringe kills his patients/grafts, avoid at all costs. OK - I know this won't hurt much, attending agrees that we don't have to keep him super deep.

After all - just sewing on a vessel, not drilling into the femur.

Pt is 58yo vasculopath with h/o multiple revascularizations on both legs. No KNOWN cardiac history takes an ASA, plavix (PVD stents) and ACEI/diuretic combo. Hasn't taken the ASA or plavix but was kind enough to swallow a few of the anti_HTN meds this AM. thanks playa. Did I mention he looked 80yo, had a mountain man beard and when we were prepping found some cigs he stowed away in his sock. I'm not even at the VA

After induction, needs a few squirts of neo, no big deal. Open up some fluids, knife and bovie show help bring up my MAP. We are in the 80's, I am happy.

Of course, skin is open vessels exposed, now time for sewing and harvesting, not much pain here. I have the patient on 1% sevo and 50% N2O (and given how much the guy drinks probably requires on the higher side of MAC.) MAPs are in mid 70s now, requiring dinks of neo here and there. 3L NS on board, decide to go with 500mL albumin. Running him a little light because I want to keep MAP as high as possible.

Well of course dood is doing fine when the surgeon grabs the bovie to add exposure and pt gets tachycardic, I notice a little oropharyngeal movement as well. Normally I grab some of the white stuff, get them apneic, add some opioid and deepen gas, but this guy had pressures that were low-ish. I give 50mcg fentanyl and 10mg roc. Surgeon sees on his monitor tachycardia and asks me what is going on.

"Pt was a little light and with the stimulation I needed to given some fentanyl and roc." **** HIT THE FAN FOR 5 minutes. Surgeon went off on how his patients should not receive paralysis, what if they REMEMBER the surgery. This is why he only works with UPPERCLASSMAN. Not to toot my horn but I would consider myself a good resident for my level (>90ile on AKT/ITE, CA1 outstanding resident award - again this means NOTHING, not bragging - but just so you guys know I am not just sitting back drinking beers and coasting through this - I am trying to become a rokkstar gas man).

WHAT WOULD/SHOULD I DO HERE?

What I did - "I am sorry, patient has not been receiving much stimulation, so to keep pressures where we all would like he was a little light." I took a few minutes of him giving me the verbal punishment while being polite and nodding. What I WANTED to do was explain to him that the patient was well above the threshold for MAC awareness and how movement to surgical stimulus is not the same as being awake; that his Rx this am, combined with poor nutrition/hydration made his pressures necessitate less gas; and to boot the two things you want (DEEP gas/NO pressor - all during minimal surgical stimulation) are mutually exclusive. Can we get a little Vaso on board?

My attending came in about 10 minutes later - VAPOR - how is the case going. At this point I explained the whole situation at decent decibels…. light gas, pressures, increase in stim, adding some roc, surgeon worried about awareness. He looked at gas/situation and said dood is not at risk of awareness, I would have done the SAME THING.

So, LONG story short… Is this the best way to handle the surgeon in these situations ( I assume TEACHING them about stuff they know NOTHING about is out of the question ) and any comments on how to manage the gas part are welcomed, too.

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[BuzzPhreed]

WHAT WOULD/SHOULD I DO HERE?

When he's finished his tirade don't respond. If he continues to berate you say, "Oh... where you talking to me?"

After the additional tirade, you say, "I'm sorry, I didn't catch all of that. Can you say it again?"

You're not the one who's going to look stupid in that situation. Trust me. Aside from that, you can have your attending have a man-to-man talk to him in the locker room. If it happens again offer to file a complaint. No one needs to tolerate that ****. Not even a resident.

 

[deleted171991]

NEVER be disrespectful or sarcastic with a surgical attending. For his purposes, you are at the level of a nurse or less. For everybody else's purposes, including your PD, you are a resident while the surgeon is an attending (as in s/he is an officer, you are a grunt). If you have a problem, call in your attending, let him/her fix the situation; actually, you should always offer this option while talking to an unhappy surgeon.

Trust me, if the surgeon is really unhappy, s/he might make a much bigger fuss once the surgery is over, and that won't be with your attending, but with higher-ups in the anesthesia department. Better reach a peaceful compromise before s/he leaves the room. This is a surgeon's world, especially since Obamacare.

Even as an attending, I try to watch my (body) language, although I can't abstain from the occasional sarcasm (see my signature). If you keep being professional and respectful (not submissive, just 100% respectful), you won't be the one looking like a dick when all it's said and done.

 

[deleted9493]

Yeah, this is an attending battle. All the right explanations in the world won't change the mind of an irritable surgeon who believes that they are right. Listen to the diatribe and let your reply be "let me get my attending". Call your attending and audibly (so that the surgeon can hear it) describe the situation. Doing so, the surgeon will tacitly know that though you are a CA-2, you know that you are taking excellent care of the patient. By the time your attending arrives, the surgeon will have had a chance to cool and will in all likelihood be nonchalant about the matter.

 

[BuzzPhreed]

Yeah, you guys are right. It isn't worth it as a resident to get into a pissing match with a surgeon. I read this on this forum sometime back as a way to respond and I thought it was brilliant. But, you'll just piss the guy off more and he has a lot more power to make your life miserable than you do his.

I haven't met a surgeon yet who doesn't think he can give anesthesia better than the anesthesiologist. Just comes with the territory. They don't know what they don't know. It'll be over soon enough and you'll be in private practice. You'll still have to deal with this kind of crap occasionally, but it gets far less frequent.

 

[WholeLottaGame7]

I haven't met a surgeon yet who doesn't think he can give anesthesia better than the anesthesiologist. Just comes with the territory. They don't know what they don't know.

This, x100. To surgeons, anesthesia is this black magic that they don't fully understand. And like all primitive peoples, their reaction to something they don't understand is to lash out out of fear and anger.

Giving them more information is only going to confuse/anger them more, so I started to get more and more vague. With rare exceptions, they only need to know that you're fixing whatever the problem is, not details about how you're doing it. They don't need to know that you're giving fent and roc to treat the tachycardia/moving, only that you're doing it. (If you're having to treat hypotension and tachycardia because they're bleeding out, that's a different story. Learning when and how to communicate is important).

If you're really having problems, just lay it on the line. "Look, you can have the patient not paralyzed and use pressors, or we can paralyze him and not have to use pressors, your choice."

 

[pgg]

Your attending should be fighting this fight. Doesn't work so well if they're not in the room, or if they're doormats.

But nothing good ever comes of an anesthesia resident tangling with an attending surgeon in the heat of the moment. Doesn't matter if you're right and they're wrong, or even if they're flagrantly abusive. The best response is to be unflappable and calm. You can't fix their personality disorder, you can't reason with them, you can't educate them. You aren't the problem here.

In general, in moments like these, be vague when you tell surgeons what you're doing. Details beget confusion or questions or demands.

 

[Vaporized]

A lot of GOOD advice here.

I know the drill, I am the private, he is the decorated general. THANK YOU SIR, CAN I HAVE ANOTHER?!

I like the idea about not giving specifics. In retrospect I should have just said, "He was a little light, which I am correcting now." It lets him know something happened and is being addressed. That never occurred to me!

In general I find our attendings stand up for us, but with the supervisory model they just aren't around at the times these specific issues come up. I don't know if this is better in places that are MD run anesthesia because you can have a frank discussion with the surgeon about needs/expectations. I assume CRNAs run into the same issues that residents do, mainly that the surgeon is boss.

I think pgg hit it on the head, PERSONALITY DISORDER. Dood just wanted to have an issue. This is what I have heard about him. The next case we had together went smooth a BUTTA… right CEA
Deep/Superifical cervical plexus block
precedex drip
coupla squirts of orange and blue

Pt looks all zonked out, surgeon demands patient wiggle his toes, looks over at me. Tap patient on the shoulder MR.SMITH everything is going great, can you move your toes for me. Scrub nurse looks up and says, guy is doing dolphin feet like its going out of style. After unclamp run some cardene just to keep the general quiet. By the time drapes come down pressures is 120/80. Turn off cardene take him to recovery - three hours later off to the floor because his pressure is solid at baseline.

See I don't hold GRUDGES. Every case I do, I make patient care my TOP PRIORITY. It is actually something I think of everyday when I go to work, something I learned here (wish I was active back in the day here):

CHOOSE TO MAKE A DIFFERENCE

To me that means: be prepared about your patient, be prepared about the procedures, know the anesthesia, and do everything you can to get the patient through with the best outcome. There is no EGO, there is no PROVING to anyone. Just get the patient the best outcome possible, go home and sit on the porch with the wife and dog eating burgers.

 

[seinfeld]

I honestly believe that if you are in a hostile working environment you should report it to your states medical board, Here in NYS OPMC is mandated to investigate any complaint especially ones that could result in patient harm or work place violence. Remember a hostile work environment can lead to patient harm. If your attending doesn't support you , talk with your program director and then you Dept Chair. Request to never work with him unless its an emergency.

Now having said that, you are a resident. Despite how good you may be, the surgeon doesn't know you, has seen many good anesthetics ruined by residents being residents, hence the uptight nature and the black & white statements. I am sure he doesnt like the pressers as he has had residents keep a patient dry and deep with anesthesia and then he has tiny little arteries to sew to and distal ones that have no signal. Also i am sure he had a case of awareness and to this day he gets crap from the patient about it. In PP this stuff doesn't fly because for one we all know each other. We call BS, BS when we see it. Surgeons who complain and are nasty to work with will either get the anesthesiologist who doesn't take crap from anyone or they will get the CRNA who is the slowest most methodical of all.

There is a surgeon where I work who can be on occasion a hot head. Overall a reasonable guy but he has his moments. One day he was going off about one of my CRNAs and I got in a very heated argument which ended when i reminded him how i saved 2 of his patients lives after he screwed up.

 

[BobBarker]

Don't say he is a little light. Just say he needed some more fentanyl.

 

[deleted171991]

I had a similar surgeon during residency. Luckily, he was an ICU attending and, while rotating there, I answered correctly some of his favorite questions (the kind that got answered once every 10 years, to quote him). After I finished that month of ICU and went back to the OR, he became one of the most respectful surgeons I have worked with. I actually used to look forward to working with him, because the communication was excellent, based on mutual respect. But you had to win that respect, before he treated you as an equal!

I have had many similar experiences since. Surgeon grumpy at first, friendlier after I got the patient out of ****, or fixed one of his pet peeves. I cannot emphasize enough how important communication is, especially for the patient's safety and outcome. Never burn your bridges, regardless of the surgeon's behavior. Be firm, if needed, but professional. Patient first!

Whatever the surgeons think, we are the captains of the anesthesia ship. We cannot lose our temper, our clear thinking. We must look like leaders, like the smartest people in the room. We should never sink to a surgeon's level.

 

[pgg]

I had a similar surgeon during residency. Luckily, he was an ICU attending and, while rotating there, I answered correctly some of his favorite questions (the kind that got answered once every 10 years, to quote him). After I finished that month of ICU and went back to the OR, he became one of the most respectful surgeons I have worked with. I actually used to look forward to working with him, because the communication was excellent, based on mutual respect. But you had to win that respect, before he treated you as an equal!

Things are always easier if you're a rock star and can impress people with your knowledge or skill. But I'm not so sure "be brilliant" is really useful advice - especially when the point of residency is to acquire that knowledge and skill. Residents shouldn't have to be brilliant to avoid abuse.

Moreover I think this sets too lofty a goal ... no resident should ever expect to be treated as an "equal" by any attending of any specialty.

I have had many similar experiences since. Surgeon grumpy at first, friendlier after I got the patient out of ****, or fixed one of his pet peeves. I cannot emphasize enough how important communication is, especially for the patient's safety and outcome. Never burn your bridges, regardless of the surgeon's behavior. Be firm, if needed, but professional. Patient first!

Whatever the surgeons think, we are the captains of the anesthesia ship. We cannot lose our temper, our clear thinking. We must look like leaders, like the smartest people in the room. We should never sink to a surgeon's level.

+1

In and out of medicine, life always works out better when you take the high road. But in the OR especially, we can't ever be the ones to lose cool.

 

[deleted171991]

Moreover I think this sets too lofty a goal ... no resident should ever expect to be treated as an "equal" by any attending of any specialty.

I agree. To be accurate, he didn't treat me as an equal either, but definitely trusted my judgment and never made fun of me again (like he used to before).

P.S. I am not "brilliant" (far from it); I was just more knowledgeable than the average (and got lucky).

 

[Pooh & Annie]

I personally wouldn't say what specific meds I'm giving unless he needs to know. You don't know much about his craft and he doesn't know much about yours. You're going to be an expert, and presumably your attending already is. Do the right thing and stick with the plan you and your attending came up with. But if you did agree not to use paralytic because this guy has strong feelings about it, and he's obviously horribly unreasonable, get your attending in before doing something you said you wouldn't.
This guy hasn't been trained in the use of hypnotic agents and paralytic pharmacology. You don't have the time to teach a surgeon the specifics of why you do what you do during a surgery, and they really don't want to know.

During the timeout I would've said that I would avoid paralytics as requested, but that in times of hemodynamic instability the patient might move. If the patient moves and the guy complains, call your attending.

 

[k12balla]

People fear what they don't understand. We all know most surgeons have God complexes and want to be in control of every aspect of the procedure, including at times, attempting to dictate our anesthetic care. As someone said earlier, be as vague as possible when handling inquiries as to your management. Being too technical can come off as condescending, and make them insecure, thus compensate with a tirade of how things should be done. You can read all the books you want, but anesthesia is an art. You're there to provide a smooth experience for everyone involved. If bp or hr goes up, or sats go down, you troubleshoot then fix the problem. If the surgeon asks you what's going on, you reassure him that everything is under control, so he can focus on the surgery and you can focus on your management of the patient. Just my two cents, but that's how I approach things and I rarely have issues, even with the more notorious surgeons because I have conveyed to them through action and not dictation my competency.

 

[Ignatius J]

A few things from me. Please take it or leave it.

1.) Learn to deal with these types of personalities. They're everywhere. Remarkably, of all the hospitals I have been to, the patients, nurses surgeons, and medications are always the same.
2.) Learn what to tell and what not to tell. I would have just said "patient is a little light but I'm taking him deeper". I lie my butt off to surgeons. Attending on the way for time out? Of course. Is patient relaxed? Yep. Patient is not relaxed, correct? Of course. Did you give X drug for dogma that I believe in? It was in half an hour ago, sir.

 

[Spinach Dip]

When he's finished his tirade don't respond. If he continues to berate you say, "Oh... where you talking to me?"

After the additional tirade, you say, "I'm sorry, I didn't catch all of that. Can you say it again?"

THAT IS THE BEST PIECE OF ADVICE EVER!!



(if you want to not finish your residency)

 

[Ronin2258]

I was quite fortunate. There is only one cantankerous surgeon that I had to work with my residence. He was a general surgeon, reasonably good, but demanded paralytics be turned on and off like a light switch. He demanded we go from zero twitches too ready to extubate in 2 to 3 minutes. This surgeon got p***y when he didn't have his "favorite room" and his favorite nurses.

One day in my CA-2 year (I wasn't there at the time; secondhand hearing but verifiable,) something didn't go his way, and he threw a tizzy. Such a tizzy he threw one of the plastic laparoscopic trocars against the wall shattering it into a large number of very small pieces. He is also had just finished the primary incision before that. So between the fragments going everywhere in the room and the infection risk from his little temper tantrum he bought himself 30 days of suspended hospital privileges. I suspect the rest of the surgical group was looking for a reason for this SOB to retire. He did so about four months later.

I wish I could have gone to the "wheels up" party for that one.

For the most part, I was rather congenial to my attending surgeons. I would, like attendings would, discuss plans, options, and the like with them. Aside from one cardiac surgeon who ran hot or cold depending on his mood, most were rather good to work with.

One senior vascular surgeon would go through the effort to find me (and whoever was working with him,) in the room as I as setting up for the day with all the data and pre-op evals for his patients for the day. Those are the types I like working with, and humped the pack a little harder to get going. I earned the privilege of first name basis with several mid- to senior level surgeons (as a resident, I consider that an earned thing.) Quite a few surgeons relayed they liked working with me to my attending of record.

A couple of fellows/residents that graduated from the program were employed by the local hospitals I would rotate with. Those were some fun times, especially in my last year. One general surgeon was still trying to get me back on the south side of the drapes. She even was handing ME stuff when I was starting an arterial line on one of her Whipple patients. The other, a vascular surgeon and his fellow (also from the program,) and I would go on like we were at a party, with the elder vascular surgeon (different from the one in the above paragraph,) getting caught up in the fun. However, we all knew that if we were in deep kimchee, we were back to total business. The junior attending and the fellow made the last case of my residency that much more fun.

Perhaps it's just me being a bit of a people person, perhaps it's my past life, perhaps it's the fact I was the oldest person in the class. Either that, or I was so damned old that any underhanded insult or wisecrack they would throw at me would roll off me like water off a duck's back.