Standing your ground

[Random Anesthesiologist]

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[Planktonmd]

So the problem was that she woke up combative... how did keeping her on the OR table improve that situation?

 

[Random Anesthesiologist]

So the problem was that she woke up combative... how did keeping her on the OR table improve that situation?

The logistics of this room I was in makes airway access on a hospital bed less than ideal. I was worried about her yanking her tube out, laryngospasm, bronchospasm, aspiration, etc and not being in an optimal position to ventilate or reintubate. And considering this was an overnight case with nothing following, how would moving her over improve the situation, except for an old battle axe feeling triumphant at the potential risk to the patient (IMO).

 

[gasdoc1]

I was on call overnight and had an "emergent" flank abscess I&D

Pt had gerd, asthma, 1ppd smoker, meth user, crack user (both 2d ago), daily marijuana user, obstructive sleep apnea, and she ate McDonald's, Cheetos and peanut m&ms while in the ED.

We delayed the case 8h, did RSI, easy intubation, quick case, no problem.

Waking her up, had gastric contents with suction. I also had a feeling she was going to be combative and worried about her getting access to her tube (big strong girl). Old nurse wanted to move her over to the bed before extubation, but I said no. I wanted to keep her on the table. Old nurse threw a hissy fit. I pretty much outlined all the badness involved with her, my anesthesia concerns, and that I was keeping her on the table until extubated. Bitching and moaning for the next 10 minutes ensued. She woke up wild, almost pulled the tube, detached her iv tubing, smacked a med student, and got some propofol to calm her down.

There's more, but I'm post call and too tired. My questions are, was I right to stand my ground, when is it appropriate to stand my ground, and how do it do it in the most pc way.

My attending sort of had my back... She just said "I defer to Dr. Resident." Gee, thanks.

When it comes to intubating and extubating, you do what makes you feel comfortable and safe. You are in charge. Anyone else can suck it.

 

[jwk]

When it comes to intubating and extubating, you do what makes you feel comfortable and safe. You are in charge. Anyone else can suck it.

Absolutely this ^^^^^^^

No explanation to the nurse is necessary. End of story. So glad your attending is so "supportive".

 

[Arch Guillotti]

Yeah I don't think you have to give her an explanation at all.

 

[pgg]

Write up the nurse for unprofessional behavior. Seriously. It's the only way they learn.

 

[okayplayer]

Write up the nurse for unprofessional behavior. Seriously. It's the only way they learn.

I wouldn't. You are a resident. Put your head down, don't make waves. Get through that sh&t and move on with your life in a few years (or however long).

 

[cincincyreds]

Don't write her up. You have no right and she has all the rights and if she wants to act like an out of control monster and destroy your career she can.

If you want to do anything, just buy that fat pig a big bag of candy or cookies or a cake. It's amazing how much nicer these fat slobs gets when you inject them with sugar for their diabetes.

 

[pgg]

I wouldn't. You are a resident. Put your head down, don't make waves. Get through that sh&t and move on with your life in a few years (or however long).

Yeah, fair enough. You're absolutely right.

OP's attending should've recalibrated the nurse, informally right there, and if that failed, formally through whatever "professional citizenship" system they have. Here it falls under a generic "patient safety report" ...

 

[k12balla]

But I thought nurses put patient safety first and foremost? ...its almost always right to stand your ground in these situations. You deal with the fallout later. And if a crisis is averted, nobody notices, but at least you can sleep well at night knowing you took a little more time, but did the most optimal thing for your pt.

 

[Pooh & Annie]

That nurse clearly was throwing a fit because you crossed her, not because of the patient staying on the bed. If it's as you said, she has some psych pathology. It's nice that you tried to explain but you can't reason with nuts.

 

[partydoc]

Fellow ca1. I would have stood my ground as well. You do what makes you comfortable, and as said above, anyone else can suck it.

 

[BuzzPhreed]

This is all you should have said, calmly and matter of factly: "We're staying on the OR table until she's awake and extubated."

When she starts to throw a hissy fit about moving over to the bed, "We're staying on the OR table until she's awake and extubated."

When she starts to complain or argue with you, "We're staying on the OR table until she's awake and extubated."

When she continues to argue with you, you look at her firmly and say, "We're staying on the OR table until she's awake and extubated."

End of story. No other explanations necessary. If she's too stupid to later realize you were correct, especially after she wakes up combative, then that's her problem not yours. Some nurses won't consider an alternative to what they've already thought and simply need to have the plan of action stated over and over again. It's the only thing that makes them shut up. Trying to convince them of your plan or argue with them only empowers them to think you actually care about or are considering an alternate plan.

 

[caligas]

If it is your style, as it is mine, being a little self depricating can be effective: "my o.c.d is a little high today, I think ill keep her on the table until extubation"

the fat blowhard nurse will get her sense of superity and all the sane people in the room will get the message that you are being safe.

 

[sleepallday]

Usually I agree that its best not to make waves as a resident. But this nurse was completely in the wrong and has no right ordering you what to do. Plus if she was causing a scene leading up to and during emergence, this is akin to her bitching to the surgery resident while he is operating (which she would likely never do). She definitely needs to be reported ideally through and attending or else by you directly. I'm not sure how an OR nurse can "destroy your career" as others have said above.

BTW your attending should have handled it much better.

 

[Guillemot]

Your attending was there. You could have just let him make the call.

 

[BuzzPhreed]

If it is your style, as it is mine, being a little self depricating can be effective: "my o.c.d is a little high today, I think ill keep her on the table until extubation"

the fat blowhard nurse will get her sense of superity and all the sane people in the room will get the message that you are being safe.

This is precisely what is wrong with medicine these days. And an invitation for people to walk all over you in the future.

I don't want to create an environment where I've endorsed someone questioning a life and death decision of mine in a crisis. If people think I'm a little bit of an a**hole sometimes, so be it. I don't care. I don't go home with or live with those people.

Polite. Firm. No explanations. This is the way we're going to do it. The buck stops with me. In court the plaintiff and the judge aren't going to care if you were self-deprecating. Until the blame is shared equally, I'm in charge.

 

[caligas]

This is precisely what is wrong with medicine these days. And an invitation for people to walk all over you in the future.

I don't want to create an environment where I've endorsed someone questioning a life and death decision of mine in a crisis. If people think I'm a little bit of an a**hole sometimes, so be it. I don't care. I don't go home with or live with those people.

Polite. Firm. No explanations. This is the way we're going to do it. The buck stops with me. In court the plaintiff and the judge aren't going to care if you were self-deprecating. Until the blame is shared equally, I'm in charge.

I understand that sentiment from a more assertive personality, but for me it has worked quite well, leading to functional relationships with these bitchy nurses, rather than them walking all over me.

 

[BuzzPhreed]

I understand that sentiment from a more assertive personality, but for me it has worked quite well, leading to functional relationships with these bitchy nurses, rather than them walking all over me.

Let see how well that works when you are truly in a crisis. I want people who respond to, not question, what I'm doing. I've seen colleagues who are too nice to subordinates. Ironically and almost counter-intuitively, that's not really what they want from you. They are not your friends. If they tend not to respect you or your judgment, whether you think they do or not, they will not get your back if you ever find yourself in an... ahem... "adversarial" situation. Believe me. I've seen it firsthand.

First and foremost is competence. Second, and almost important, is respect. Even if you leave the perception of the first, it doesn't mean much without the second. If you have neither, then you can be the nicest person on the planet and no one will really take you seriously, refer patients to you, request you, trust in you a crisis, etc.

 

[Pooh & Annie]

I don't think there's anything wrong with being self-deprecating. The people who I know that are firm with everything get the reputation of being easily stressed, and they aren't taken very seriously. When the nurses know you don't sweat the small stuff, they'll trust you when you stress that something really is a big deal.

 

[Megalomis]

If you want to do anything, just buy that fat pig a big bag of candy or cookies or a cake. It's amazing how much nicer these fat slobs gets when you inject them with sugar for their diabetes.

Lol lol. It's posts like these that make SDN well worth my time.

 

[BuzzPhreed]

I don't think there's anything wrong with being self-deprecating. The people who I know that are firm with everything get the reputation of being easily stressed, and they aren't taken very seriously. When the nurses know you don't sweat the small stuff, they'll trust you when you stress that something really is a big deal.

self-dep·re·cat·ing
adjective
modest about or critical of oneself, especially humorously so.

im·per·turb·a·ble
ˌimpərˈtərbəb(ə)l/
adjective
unable to be upset or excited; calm.

Don't confuse these two. They are very different concepts.

 

[Random Anesthesiologist]

Your attending was there. You could have just let him make the call.

She did. She said "whatever dr. Resident wants". She's new, very soft spoken. Had she been some of my other attendings, there might not have even been an issue.

I tried to be polite but held firm. The point I started getting annoyed was after the harrumphing started, and I felt I had to reiterate my reasons so the rest of the room could get a very clear picture why. I was cordial and lightly joking after, but I've already been burned by nursing insisting on doing things their way.

I'm definitely not interested in making lasting waves - no write ups. But I feel that I shouldn't compromise my pts safety for an extra 30 seconds.

 

[Random Anesthesiologist]

Also, thanks for the responses. I have dealt with nurses in my former career, but the OR nurse is a special breed I haven't quite understood yet.

 

[BuzzPhreed]

Nurses tend to operate on observation and experience. The "this is the way I've always done it" or "this is the way 'so-and-so' does it, and I trust him/her" with little extra thought as to the reason behind why it's being done that way. It's experiential.

The irony, Random Resident, is that this nurse probably learned something from you that day. She'll probably be loathe to admit it. But I doubt she'll question you like that again in a similar situation. So in the end, you probably "won" (if that even matters... which it shouldn't... just do what's right and damn the naysayers).

 

[imfrankie]

Union nurse versus anesthesia attending: "Dr. So-and-so created a 'hostile work environment'. "

 

[caligas]

Let see how well that works when you are truly in a crisis. I want people who respond to, not question, what I'm doing. I've seen colleagues who are too nice to subordinates. Ironically and almost counter-intuitively, that's not really what they want from you. They are not your friends. If they tend not to respect you or your judgment, whether you think they do or not, they will not get your back if you ever find yourself in an... ahem... "adversarial" situation. Believe me. I've seen it firsthand.

First and foremost is competence. Second, and almost important, is respect. Even if you leave the perception of the first, it doesn't mean much without the second. If you have neither, then you can be the nicest person on the planet and no one will really take you seriously, refer patients to you, request you, trust in you a crisis, etc.

The original situation was not a crisis. An insubordinate nurse in a crisis would produce a different response from me. Patrick Swayze in Roadhouse said it best "Be nice, until its time to not be nice"

 

[BuzzPhreed]

Union nurse versus anesthesia attending: "Dr. So-and-so created a 'hostile work environment'. "

That's why you never lose your cool, never swear, never put your hands on anyone, and always have witnesses.

Filing a false report is considered workplace intimidation and a form of "lateral violence" in most human resources departments. And it is often grounds for counseling and, if repeated, termination.

 

[Ignatius J]

Yeah I don't think you have to give her an explanation at all.

Agreed. No need to get mad or flustered. What you says goes. I have had belligerent and defiant nurses but never had one disobey a clinical decision/order.

 

[bostonblaz]

1) you are always right when it comes to the putting to sleep and waking up of a patient. If you feel something has to be a certain way then that is the way it should be. Matter of fact if someone or something isn't right keep the patient asleep or don't put them to sleep until it is the way you like. I am probably the least conservative anesthesiologist out there and I still feel this way

2) the best way to avoid situations like this is to make the "others" involved in the patient care what you are thinking during the case. In this case you could have walked around to the nurse and just casually told her your concerns and how you wanted to end the case. They eat that up and you will turn out to be that "great" resident that all of the hens will be clucking about. Keep doing number 2 for the extent of your career and you will be loved and respected and the "others" will be looking out for you and helping you out for the next 30 plus years. It was always worked for me. Blaz

 

[deleted59964]

... I also had a feeling she was going to be combative and worried about her getting access to her tube (big strong girl).... I wanted to keep her on the table. ... She woke up wild, almost pulled the tube, detached her iv tubing, smacked a med student, and got some propofol to calm her down.

I absolutely agree with you standing your ground.
I'm not sure about your plan though..

I prefer to keep these sort of patients asleep till they are on their bed, positioned optimally in the bed for reintubation (which is generally also a good position for extubation), I ensure I have (re)induction drugs and equipment ready, and a bite block in place, then I wake them ... if she manages to pull her own tube - that's fine by me - she doesn't need it anymore.

Worst case scenario for me would be agitated obese patient with difficult airway, at risk for failed extubation, gets combative, pulls out IV and falls off operating table - e then gets more hypoxic requiring reintubation on the floor and a crane to get them in bed ... at least in bed they're less likely to fall ... presuming your bed allows proper positioning.

 

[Pooh & Annie]

I spend a great deal of time at work, and fortunately I really enjoy it. Not because I get respect, or because I'm "treated like a doctor". I like almost everyone I work with and they're my friends. With a few exceptions everyone does their jobs well. I rarely need to be "firm" with anyone because I can't remember the last time people didn't do what I asked. They now usually do it BEFORE I ask. I also do what others ask, because most of them are reasonable and I'm not a prima Donna (this is one of the worst possible profession for prima donnas).

Without a doubt, other folks work in different environments, and may or may not enjoy their jobs in the same way I do. Just do what you want and learn from your mistakes. Hopefully you'll be happy.

The only real advice I've got I guess is don't go "looking" for respect as an anesthesiologist. If you show that you're self-sufficient and competent, most folks will be HAPPY to lend a hand and do as you ask, and I'm sure you'll be "respected." And if you're really the cream of the crop, you won't give a **** whether anyone does or not.

 

[fakin' the funk]

I also had a feeling she was going to be combative and worried about her getting access to her tube (big strong girl). ...She woke up wild, almost pulled the tube, detached her iv tubing, smacked a med student, and got some propofol to calm her down.

You had these concerns and did nothing to prevent them? Like...
pre-emergence versed
pre-emergence precedex (0.5mcg/kg)
pre-emergence haldol
pre-emergence droperidol (good luck)
pre-emergence benadryl
deep extubation (not my first choice in this case)

 

[Random Anesthesiologist]

I absolutely agree with you standing your ground.
I'm not sure about your plan though..

I prefer to keep these sort of patients asleep till they are on their bed, positioned optimally in the bed for reintubation (which is generally also a good position for extubation), I ensure I have (re)induction drugs and equipment ready, and a bite block in place, then I wake them ... if she manages to pull her own tube - that's fine by me - she doesn't need it anymore.

Worst case scenario for me would be agitated obese patient with difficult airway, at risk for failed extubation, gets combative, pulls out IV and falls off operating table - e then gets more hypoxic requiring reintubation on the floor and a crane to get them in bed ... at least in bed they're less likely to fall ... presuming your bed allows proper positioning.

Thanks. This is the other side of the coin. I have some attendings who 100% keep them on the table for extubation, and others who rarely do. I feel pretty flexible most times, and generally don't mind keeping the peace. I just had a bad feeling about moving her. I should add that by the time we got her flat on her back from left lateral, she was already starting to buck. She was also surrounded by people and with safety strap on and less likely to fall. In retrospect, I could have moved her if we flipped her more quickly. I usually cut the gas off when they start packing wounds, and she breathed the gas off pretty quick, and by the time they put abd pads on, she was breathing nicely and starting to stir. I just felt more comfortable after that leaving her on the table. It didn't take long to pull the tube, but seems like an eternity when there's tension in the room.

I'm sure with more experience, I won't be as conservative. But we literally only lost 30 secs by not moving over initially.

 

[Random Anesthesiologist]

You had these concerns and did nothing to prevent them? Like...
pre-emergence versed
pre-emergence precedex (0.5mcg/kg)
pre-emergence haldol
pre-emergence droperidol (good luck)
pre-emergence benadryl
deep extubation (not my first choice in this case)

I discussed versed with attending, shot down. No Precedex, haldol, droperidol immediately available. I didn't think about Benadryl. I could have called central pharm, but would be extubated by the time drugs arrived (no droperidol in the hospital)

Deep wasn't really an option.

 

[Random Anesthesiologist]

I spend a great deal of time at work, and fortunately I really enjoy it. Not because I get respect, or because I'm "treated like a doctor". I like almost everyone I work with and they're my friends. With a few exceptions everyone does their jobs well. I rarely need to be "firm" with anyone because I can't remember the last time people didn't so what I asked. They now usually do them BEFORE I even ask. I also do what others ask, because most of them are reasonable and I'm not a prima Donna (this is one of the worst possible profession for prima donnas).

Without a doubt, other folks work in different environments, and may or may not enjoy their jobs in the same way I do. Just do what you want and learn from your mistakes. Hopefully you'll be happy.

The only real advice I've got I guess is don't go "looking" for respect as an anesthesiologist. If you show that you're self-sufficient and competent, most folks will be HAPPY to lend a hand and do as you ask, and I'm sure you'll be "respected." And if you're really the cream of the crop, you won't give a **** whether anyone does or not.

Thanks. I don't want to be confrontational but at the same time I want nurses to stop asking me things like "can you hold this pts arm while I prep" at the same time I'm trying to treat hypotension, start an iv, etc.

For the most part, it's been a positive experience. The negative ones sure stick with you though.

 

[jwk]

I prefer to keep these sort of patients asleep till they are on their bed, positioned optimally in the bed for reintubation (which is generally also a good position for extubation), I ensure I have (re)induction drugs and equipment ready, and a bite block in place, then I wake them ... if she manages to pull her own tube - that's fine by me - she doesn't need it anymore.

Worst case scenario for me would be agitated obese patient with difficult airway, at risk for failed extubation, gets combative, pulls out IV and falls off operating table - e then gets more hypoxic requiring reintubation on the floor and a crane to get them in bed ... at least in bed they're less likely to fall ... presuming your bed allows proper positioning.

Do you put all your patients to sleep on the bed and intubate them before you move them to the OR table? Why, or why not? And I'm not talking about the fracture patient that will hurt if you move them.

If I'm absolutely sure of my airway, I have no problem moving a patient to the bed and extubating them there. If I have the least little doubt, they're staying directly in front of me until they're awake, extubated, and I'm positive they're ready to go. A patient's airway is rarely, if ever, easier to manage on a bed that's further away from your anesthesia machine and presumably all your airway equipment and suction. I take care of the patient, then deal with turnover time - and I wake mine up faster than most in my department.

 

[BuzzPhreed]

Thanks. I don't want to be confrontational but at the same time I want nurses to stop asking me things like "can you hold this pts arm while I prep" at the same time I'm trying to treat hypotension, start an iv, etc.

For the most part, it's been a positive experience. The negative ones sure stick with you though.

WHAT!??!???!!

Dude/Dudette: You seriously need to put a stop to that shit!

 

[Random Anesthesiologist]

WHAT!??!???!!

Dude/Dudette: You seriously need to put a stop to that shit!

I've politely asked them to have the surgery resident help. But still get requests like this. Of course after my attending has left the room!

I appreciate all the feedback. I've had my post call day to chill, it's all good now. Just makes me realize more and more how diplomatic we as a profession have to be.

 

[BuzzPhreed]

I've politely asked them to have the surgery resident help. But still get requests like this. Of course after my attending has left the room!

I appreciate all the feedback. I've had my post call day to chill, it's all good now. Just makes me realize more and more how diplomatic we as a profession have to be.

Wrong. Your answer when they ask "can you hold this patient's arm while I prep?" should be simply be this: "No."

No further explanation needed. You don't need to suggest an alternate course. You don't need to come up with any other solution for them.

If you act like a doormat don't be surprised when people walk all over you.

 

[Triple AAA]

One thing I've learned through a residency that felt like an eternity, is that a significant disadvantage of being in anesthesia is that we often do not get the respect we deserve. Expect plenty of skirmishes with OR staff, surgeons, surgery residents, nurses, ICU staff, CRNAs, your own attendings, etc. The key is to pick your battles. Do not turn every situation into a pissing contest. Learn to give in to certain situations where the outcome won't matter either way, but do stand your ground when there is a legitimate patient safety concern and you are the only person qualified to make that decision.

With that said, the above situation was one in which it was absolutely correct to stand your ground. Kudos to you.

 

[pjl]

Random Resident, are you a girl? I only question because in residency I had a number of my female classmates who had a much harder time with similar issues than the guys. I dont know how to advise you to change the situation, but it seems those around you see you as an equal, not a superior. This also may be due to your training status, but needs to stop. Some of this may occur over time as you become seen as a more experienced provider, but some of it will need to be addressed from your actions.
Throughout your career you will have a tough line to walk, you spend a ton of time at work, and there are a lot of really nice people there, presumably. You want to be friendly towards them, and enjoy your day and time you spend there, but you also need to have their respect for your authority when called for. Everyone has a different method of doing this, and I think that all of us can learn from other methods.
1. Treat them as professionals, do not talk down to them. They also worked "hard" to get where they are (or so they think). Keep joking around professional.
2. Check your body language, there are a number of great books on this topic, read about it, and practice various techniques. You would be surprised what moving a hand to a different location can do to how you are treated.
3. Practice different ways of speaking, primarily slightly increasing your volume and making little tone changes when you want to be seen as "in command." Residency is where you have the option to try all this stuff out with minimal long term consequences, especially since you probably change specialty monthly and see new people.
4. Always stand up for the needs of the patient, even if inconvenient. People respect integrity and good outcomes. If they dont, at least you cant be punished when you make good decisions and have a good rationale for them.
5. When a nurse asks you to hold an arm, while you are busy, politely refuse. "I'm sorry, I am busy managing this patients anesthetic right now" That said, I will hold an arm if they are clearly struggling and I am not busy (assuming it is a nurse I like).
6. Show them you appreciate them. Often a thank you for your help goes a long way to "overworked" nurses. Once you are an attending, randomly buying everyone working on the weekend a meal to thank them for their help does wonders for morale, and costs like 50-100 bucks. Also tax deductible .

I think a lot of us dont realize why we are respected and I attribute a lot of it to a subconscious grasp of body language and voice control that others dont have naturally. Of course you need to be good at your job to back it up. You will have to find your balance, and if you notice a bit too much familiarity or a lack of respect creeping in, alter your behavior slightly.

As for the old hag, some nurses are like that, you are unlikely to change it. Dont waste your time on her, do the right thing in your mind, and use these times to remind yourself how happy you are that your life has more important things in it than mistreating residents.

 

[Noyac]

This crap doesn't occur with any frequency outside of residence, at least in my experience. Let it go. Do your time and try to get out unscathed. if you are worth your salt , they will leave you alone soon enough. If they don't, so what.

 

[deleted171991]

You had these concerns and did nothing to prevent them? Like...
pre-emergence versed
pre-emergence precedex (0.5mcg/kg)
pre-emergence haldol
pre-emergence droperidol (good luck)
pre-emergence benadryl
deep extubation (not my first choice in this case)

Versed? Benadryl? Antipsychotics? Seriously?

My advice would have been a touch of propofol or fentanyl pre-emergence, with prompt extubation when the patient is almost awake, with a nasal airway placed strategically pre-emergence, possibly restraining the patient until fully awake.

 

[Ignatius J]

I discussed versed with attending, shot down. No Precedex, haldol, droperidol immediately available. I didn't think about Benadryl. I could have called central pharm, but would be extubated by the time drugs arrived (no droperidol in the hospital)

Deep wasn't really an option.

Everyone has their preferences, but I agree with your attending. Anesthesia is an art, and just making the patient sleep for another hour in PACU so you don't have to learn to deal with more efficient methods of emergence delirium is silly. That "precedex" wake-up is expensive and there are a lot cheaper and more efficient ways to go about it. Absolutely an academic thing too. A lot of places I go to don't even have Precedex.

 

[IlDestriero]

Union nurse versus anesthesia attending: "Dr. So-and-so created a 'hostile work environment'. "

That's why you just say this is what we will do. And that's it. And that's what you do. They don't need to know why you do what you do.
They can micromanage their nursing duties, and take 10 minutes for a hand off with the preop nurse on the healthy patient while they try to figure when the pt got their ED abx from hand written chicken scratch notes, even though they can actually look it up in 30 seconds in the computer.
The "anesthesia stuff" is what you manage. They may make suggestions, but that's all they are.

 

[IlDestriero]

You had these concerns and did nothing to prevent them? Like...
pre-emergence versed
pre-emergence precedex (0.5mcg/kg)
pre-emergence haldol
pre-emergence droperidol (good luck)
pre-emergence benadryl
deep extubation (not my first choice in this case)

Good.stuff here, and maybe some extra opiate and/or propofol. Man I miss drop.

 

[IlDestriero]

I discussed versed with attending, shot down. No Precedex, haldol, droperidol immediately available. I didn't think about Benadryl. I could have called central pharm, but would be extubated by the time drugs arrived (no droperidol in the hospital)

Deep wasn't really an option.

Extubation planning starts before induction.

 

[deleted59964]

Do you put all your patients to sleep on the bed and intubate them before you move them to the OR table? Why, or why not? And I'm not talking about the fracture patient that will hurt if you move them.

If I'm absolutely sure of my airway, I have no problem moving a patient to the bed and extubating them there. If I have the least little doubt, they're staying directly in front of me until they're awake, extubated, and I'm positive they're ready to go. A patient's airway is rarely, if ever, easier to manage on a bed that's further away from your anesthesia machine and presumably all your airway equipment and suction. I take care of the patient, then deal with turnover time - and I wake mine up faster than most in my department.

I intubate on the table usually - because that's where the operation happens. On induction most patients are cooperative and I don't worry about them getting agitated and throwing themselves off a narrow operating table. If I needed to induce an emergent, hypoxic, and or combative patient ... damn straight - I'm inducing and intubating on the bed, and then I'll transfer to the table.

Whether a patient is a predicted difficult airway or not does not factor into my decision of whether to intubate or extubate on the bed or table ... because either way I optimise the patient position and my environment prior to taking the critical step.

If the bed is further from your anaesthetic machine -- move the bed or the machine so that they are optimally positioned. If the table is in the way once you transfer, have it moved out of the way.
Once on the bed, position the patient to your satisfaction ... THEN wake them up.

If your talking about a difficult extubation ... turn over time is not important.