Supervising junior/semi-experienced residents

[woopedazz]

I'm struggling when supervising junior-ish residents in elective lists.

The ones who have just enough experience to come up with plans and run the case by themselves... But not enough experience that their plans are always good or safe.

I want to give them the opportunity to fail/learn by doing... But I don't want anyone to die or the theatre staff to be put out by ridiculously slow wakeups leading to cancellations, etc.

It's leading to me micromanaging when I feel uncomfortable, which doesn't do them any good. Any tips on how to get more comfortable in these lists?

edited for brevity

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[JiPo]

If their plan is not safe, why do you let them proceed with it? When my residents present unsafe plan, i have a discussion and explain why it is unsafe, and guide them to think of a more safe plan on their own by the end of the discussion, and that is the final anesthetic plan for the patient.

 

[MirrorTodd]

Think about it in the mindset of teaching. You aren't micromanaging, you are offering teaching points. Show them how to wake a pt up faster, explain why their plan is unsafe. If you are dealing with residents who are truly doing unsafe things, then you might need to have a talk with the program director about said resident/s. Personally, I have found that residents are far more capable than we give them credit for. It's possible I've just been lucky that I haven't met any stubborn ones who think they know it all already. Do you have any examples of these unsafe plans? I'm kinda curious.

 

[DocVapor]

I would start by asking why/where they came up with the idea. Maybe they've done it that way several times before with a different attending who has a different level of risk aversion. Then you can teach them why you personally don't want to do it that way. Use phrases like "much of anesthesia is an art" or "in my personal experience" so that way it doesn't come off as you calling the other attending an idiot.

 

[The Duck Knows]

I would start by asking why/where they came up with the idea. Maybe they've done it that way several times before with a different attending who has a different level of risk aversion. Then you can teach them why you personally don't want to do it that way. Use phrases like "much of anesthesia is an art" or "in my personal experience" so that way it doesn't come off as you calling the other attending an idiot.

As a fairly new grad I would agree with this. Especially on some cases or techniques that you don’t get as many reps at. I was fortunate not to have a million different attendings and was able to figure out which staff were risk averse and which ones practice on the borderline (or beyond it). It can be frustrating when one attending rips you to shreds for doing what one of their colleagues do.

I think the pre op case discussion should pattern oral boards (although not as intense and not over the course of 30 min). CA 2 and 3 it’s fun to have an attending ask for a plan then ask follow-up questions to allow you to defend it. Sometimes you realize your plan has some flaws. Sometimes you feel justified in your plan. Sometimes the exact scenario you’re attending warned you about happens and you eat crow. But you’re always thinking and learning with this method

 

[deleted875186]

I too am curious what is being suggested that is unsafe? Put a tube in, give some vasopressors with induction if needed, honestly most other things seem to be just personal preference.

 

[nimbus]

I too am curious what is being suggested that is unsafe? Put a tube in, give some vasopressors with induction if needed, honestly most other things seem to be just personal preference.

Maybe giving NMB before proving mask ventilation is possible

 

[coffeebythelake]

Maybe giving NMB before proving mask ventilation is possible

How many people do this? I don't

 

[Arch Guillotti]

How many people do this? I don't

Always.

 

[nimbus]

How many people do this? I don't

That’s what some of our attendings taught during residency. Other attendings would say the next step if you have trouble ventilating is to paralyze so might as well paralyze up front. Most, but not all, people I work with nowadays paralyze up front and that is what I do as well. I do rapid sequence with no mask ventilation at all for 99% of my inductions.

 

[anaesthetic]

That’s what some of our attendings taught during residency. Other attendings would say the next step if you have trouble ventilating is to paralyze so might as well paralyze up front. Most, but not all, people I work with nowadays paralyze up front and that is what I do as well. I do rapid sequence with no mask ventilation at all for 99% of my inductions.

Sugammadex makes ventilating before paralyzing completely obsolete anyway, IMO.

 

[LaryngoSpazz]

That’s what some of our attendings taught during residency. Other attendings would say the next step if you have trouble ventilating is to paralyze so might as well paralyze up front. Most, but not all, people I work with nowadays paralyze up front and that is what I do as well. I do rapid sequence with no mask ventilation at all for 99% of my inductions.

Agree. What do you really gain by trying to mask before paralyzing? If it turns out to be difficult to impossible you’ve just wasted a bunch of apnea time so now you’ve really gotta be quick.

 

[Anestheezee]

PP here...

Preoxygenate, fill up 1x20 cc syringe = 10 cc prop, 5 cc roc, 5 cc lido 2%, push, intubate (no stylet of course) and use that syringe to fill the pilot balloon. Give your dec / zofran / toradol then check out your narcotic for the case. Use it / waste it, extubate deep using the syringe to deflate the pilot balloon.

Maybe I shouldn't teach in academics later!!!

 

[anaesthetic]

PP here...

Preoxygenate, fill up 1x20 cc syringe = 10 cc prop, 5 cc roc, 5 cc lido 2%, push, intubate (no stylet of course) and use that syringe to fill the pilot balloon. Give your dec / zofran / toradol then check out your narcotic for the case. Use it / waste it, extubate deep using the syringe to deflate the pilot balloon.

Maybe I shouldn't teach in academics later!!!

I’ll be honest. My idea of preoxygenating is putting the mask halfway on the face immediately prior to pushing induction meds and masking/tubing the patient. I can’t remember the last significant desaturation episode where I thought, “Maybe I should have preoxygenated better.”

I remember some attendings invariably waiting for the EtO2 to be 0.8 prior to pushing meds, even if it meant five minutes of preoxygenating on an ASA1 lap chole. What a joke.

 

[T-burglar]

Pre-oxygenation a few breaths then push a syringe with induction agent , roc, dexamethasone, and a little opioid mixed together.

 

[Gasmd98]

PP here...

Preoxygenate, fill up 1x20 cc syringe = 10 cc prop, 5 cc roc, 5 cc lido 2%, push, intubate (no stylet of course) and use that syringe to fill the pilot balloon. Give your dec / zofran / toradol then check out your narcotic for the case. Use it / waste it, extubate deep using the syringe to deflate the pilot balloon.

Maybe I shouldn't teach in academics later!!!

This is a joke, right?

 

[Ronin786]

I’ll be honest. My idea of preoxygenating is putting the mask halfway on the face immediately prior to pushing induction meds and masking/tubing the patient. I can’t remember the last significant desaturation episode where I thought, “Maybe I should have preoxygenated better.”

I remember some attendings invariably waiting for the EtO2 to be 0.8 prior to pushing meds, even if it meant five minutes of preoxygenating on an ASA1 lap chole. What a joke.

I don't do the wait till .8 EtO2 thing, but intubate an obese patient straight off RA and they'll drop like a rock. If anybody's airway looks even remotely challenging, I respect pre-oxygenation.

We all like to be cavalier on SDN, but pre-oxygenation is useless until you need it. It really isn't that hard to let somebody breathe a mask for a minute while you're putting stickers and waiting for the cuff to cycle. It's not like the surgeons are cutting without draping to save time in PP.

 

[patriot6]

inducing a patient as a senior resident, i asked my attending if he'd like me to ventilate before paralytic. he responded, "you gave way too much propofol for that to matter." his comment has stuck with me. i push NMB; it makes everything better. and in a pinch, there's sugammadex.

 

[secretasianman]

This is a joke, right?

I’m usually pretty flexible with anesthetic plans, but admixing 10cc ppf and 5cc roc elicits a negative emotional response from me..

 

[UscGhost]

PP here...

Preoxygenate, fill up 1x20 cc syringe = 10 cc prop, 5 cc roc, 5 cc lido 2%, push, intubate (no stylet of course) and use that syringe to fill the pilot balloon. Give your dec / zofran / toradol then check out your narcotic for the case. Use it / waste it, extubate deep using the syringe to deflate the pilot balloon.

Maybe I shouldn't teach in academics later!!!

Hmm.

Only 100mg of propofol? Seems to be a pretty light dose unless the patient is frail or you use a lot of fentanyl and versed?

I would assume the Roc would increase the burning sensation significantly, but I have never tried mixing it in the prop.

I usually do a 30ml syringe with 20ml propofol, 1cc dex, 5 cc lido, add zofran if it's a quick case.

Roc separately to follow.

 

[MirrorTodd]

Hmm.

Only 100mg of propofol? Seems to be a pretty light dose unless the patient is frail or you use a lot of fentanyl and versed?

I would assume the Roc would increase the burning sensation significantly, but I have never tried mixing it in the prop.

I usually do a 30ml syringe with 20ml propofol, 1cc dex, 5 cc lido, add zofran if it's a quick case.

Roc separately to follow.

dexamethasone or dexmedetomidine?

 

[UscGhost]

dexamethasone or dexmedetomidine?

Dexamethasone. 10mg preferred if available

 

[UscGhost]

I don't do the wait till .8 EtO2 thing, but intubating an obese patient straight off RA and they'll drop like a rock. If anybody's airway looks even remotely challenging, I respect pre-oxygenation.

We all like to be cavalier on SDN, but pre-oxygenation is useless until you need it. It really isn't that hard to let somebody breathe a mask for a minute while you're putting stickers and waiting for the cuff to cycle. It's not like the surgeon's are cutting without draping to save time in PP.

I agree. Preoxygenation is like a seat belt..you don't need it until you do.

That being said, I always cringe a bit when I see some partners strap a mask on an awake patient to preoxygenate them. I just put the mask on comfortably and tell the patient to give me 5 big deep breaths. Gets them sufficiently preoxygenated and gives them something to focus on while I push meds.

 

[BLADEMDA]

Here are my 2 cents:

Residents are there to learn your plan and your technique during CA-1 and CA-2 years. They learn by example from multiple attendings. They can make a plan but until CA-3 year or late CA-2 year they should scrap their plan for yours. This way by the time CA-3 year rolls around that resident has been spoon fed 12-18 attendings way of doing things. After residency , they can choose 1 or 2 techniques or make their own.

When I was a resident decades ago I failed to see the wisdom in this approach. Many decades later I realize just how much it benefited me.

 

[ProwlerturnGas]

I haven’t masked an adult after induction since residency. I’ve been out 15 years. Prop/sux/tube straight away

 

[kidthor]

That being said, I always cringe a bit when I see some partners strap a mask on an awake patient to preoxygenate them.

Same here - I hate that mask strap thing, it weirds me out.

 

[nimbus]

Same here - I hate that mask strap thing, it weirds me out.

I like it when surgeon asks for MAC but really wants GA.

 

[turnupthegas]

Ketamine TIVA. Sux drip. AFOI.

 

[deleted875186]

Here are my 2 cents:

Residents are there to learn your plan and your technique during CA-1 and CA-2 years. They learn by example from multiple attendings. They can make a plan but until CA-3 year or late CA-2 year they should scrap their plan for yours. This way by the time CA-3 year rolls around that resident has been spoon fed 12-18 attendings way of doing things. After residency , they can choose 1 or 2 techniques or make their own.

When I was a resident decades ago I failed to see the wisdom in this approach. Many decades later I realize just how much it benefited me.

I would agree. Most things in anesthesia probably aren’t outright “unsafe”, but significant variation in personnel preference. I now practice somewhat differently than most of my attendings did in training.

 

[deleted875186]

I preoxygenate everyone, doesn’t take much effort, put the mask on as soon as on the table, get BP going, hook up other monitors, pre induction timeout takes another minute, minimum of 3-4 mins breathing oxygen, preoxygenated.

 

[Arch Guillotti]

I haven’t masked an adult after induction since residency. I’ve been out 15 years. Prop/sux/tube straight away

I don't get posts like this. You have never had a pt. with a contraindication to sux that needs intubating and doesn't require high dose roc?

 

[JOHNBROCHILL]

I haven’t masked an adult after induction since residency. I’ve been out 15 years. Prop/sux/tube straight away

I would be pretty bothered as a patient if I developed painful sux myalgias after outpatient surgery and knew it was because the anesthesiologist did not want to wait one minute for rocuronium to work.

 

[Arch Guillotti]

I would be pretty bothered as a patient if I developed painful sux myalgias after outpatient surgery and knew it was because the anesthesiologist did not want to wait one minute for rocuronium to work.

Ask pgg about this.

 

[secretasianman]

Same here - I hate that mask strap thing, it weirds me out.

I cringe when I see it. The crnas seem to be taught to induce with it on.

 

[Greenbayslacker]

1x20 cc syringe = 10 cc prop, 5 cc roc, 5 cc lido 2%, push

This sounds like some CRNA ****

 

[deleted875186]

I cringe when I see it. The crnas seem to be taught to induce with it on.

I use the straps occasionally, typically if I don’t have someone to hold the mask. I think it looks worse than it feels, I attach just two straps fairly loosely, patients don’t seem to mind much.

 

[ProwlerturnGas]

I would be pretty bothered as a patient if I developed painful sux myalgias after outpatient surgery and knew it was because the anesthesiologist did not want to wait one minute for rocuronium to work.

You know how many times I have heard complaints about succinylcholine myalgia? Zero. None. Patients that I’ve taken care of multiple times. I’ve even had it used on me. Let me say this, sux is not an evil drug.

 

[kidthor]

You know how many times I have heard complaints about succinylcholine myalgia? Zero. None. Patients that I’ve taken care of multiple times. I’ve even had it used on me. Let me say this, sux is not an evil drug.

I’ve had several complain about it…

 

[deleted875186]

You know how many times I have heard complaints about succinylcholine myalgia? Zero. None. Patients that I’ve taken care of multiple times. I’ve even had it used on me. Let me say this, sux is not an evil drug.

I view sux the same as spinal headaches. You could use a cutting needle for spinals in every knee or hip replacement in elderly patients, and it’s still pretty rare to get a headache. Myalgias from sux is a known side effect, saying you’ve never seen it means your not following the patients or you don’t use it that often.

 

[ProwlerturnGas]

I know sux isn’t politically correct right now. I accept that. I have done many more blood patches than I have heard of myalgias

 

[deleted875186]

I know sux isn’t politically correct right now. I accept that. I have done many more blood patches than I have heard of myalgias

Perhaps because there is nothing to fix sux myalgias other than time. Also the myalgias resolve much quicker than a PDPH does. Also spinal headaches are more debilitating. Plus we tell people there is a risk of headache with spinal block or LP ….

 

[ProwlerturnGas]

Ok…

 

[deleted875186]

Also, I don’t even know if sux myalgias is widely known in other fields of medicine. If a patient shows up to an ED with these symptoms would it be diagnosed?

 

[ProwlerturnGas]

I practiced a long time without sugammadex. I now practice in hospitals that I have to justify it’s use and it’s not even in my cart. I’m not going to give an intubating dose of Roc for a short case for the small chance that I am preventing myalgia. And to carry your PDPH headache further, since spinals carry that risk, why not do epidurals instead to much lessen that risk?

 

[deleted875186]

I practiced a long time without sugammadex. I now practice in hospitals that I have to justify it’s use and it’s not even in my cart. I’m not going to give an intubating dose of Roc for a short case for the small chance that I am preventing myalgia. And to carry your PDPH headache further, since spinals carry that risk, why not do epidurals instead to much lessen that risk?

Touché …. Can argue that accidental dural puncture can happen and same risk of getting PDPH overall.

I personally use sux not infrequently. I agree it’s somehow deemed a terrible drug for no reason. But I still personally would want a dose of roc and suggamadex as a patient over sux.

 

[ProwlerturnGas]

And I find that acceptable. If you were my patient, and you asked me to not use sux, I would honor that.
I think profound debilitating myalgia from sux maybe should be listed as an allergy??
I personally think in the 20 some odd years in practice, I would have heard complaints or developed a reputation, surgeons saying something to me, or something from my routine use of sux. I just haven’t??? Does it occur, undoubtedly

 

[nimbus]

Touché …. Can argue that accidental dural puncture can happen and same risk of getting PDPH overall.

I personally use sux not infrequently. I agree it’s somehow deemed a terrible drug for no reason. But I still personally would want a dose of roc and suggamadex as a patient over sux.

For me the only indication for sux nowadays is to prevent NPPE from laryngospasm.

 

[deleted875186]

For me the only indication for sux nowadays is to prevent NPPE from laryngospasm.

I disagree. In an RSI I much prefer sux. High dose roc still takes more time to work.

 

[nimbus]

I disagree. In an RSI I much prefer sux. High dose roc still takes more time to work.

Just mix the roc with the induction drug. I give it together, wait a few breaths until the patient becomes apneic and intubate. It has literally never failed me. I haven’t used sux for an RSI in at least 10 yrs.

 

[BLADEMDA]

I have my way of doing things as do so many others. That's why residents benefit from seeing all sorts of ways to skin the proverbial cat. Sux? Mask with strap? Test ventilate before Rocuronium? I think these all benefit Residents in one way or the other even if that resident never adopts that technique post residency.