What lies ahead after residency?

[Noyac]

Buzz's thread got me to thinking.

One of the most difficult adjustments new grads have to deal with when going into PP is the fact that there are times, sometimes many, when you are all alone. Not in the sense that nobody is there to watch what's going on but more in the sense that there isn't another anesthesia person around. This usually occurs at night and on weekends. Most groups will tell you to call someone for backup if you have concerns but as in Buzz's latest thread, you don't always know when trouble is brewing. If you call people in unnecessarily too many times then people don't want to be on call with you. If you don't then you find yourself in trouble. Sure, there is ER and ICU docs around most times but don't kid yourself, the trouble we can get into is frequently over their heads. Respiratory will just standard watch. Surgeons are going to be your friends here since some of them can at least help with an airway if that's the issue. Sometimes it isn't an airway issue and they are less useful. Cardiology isn't present. You get the point.

When interviewing for jobs you need to get a feel for how often this occurs and how easy it may or may not be to get backup. The larger the group the easier it is and vice versa. In today's practice and with the current mental mindset of graduating residents, people cherish their time off and don't want to be "on the hook" for stuff. Therefore, they are gone when their work is done and they don't plan to come back unless called., which may take some persuasion. Coming from academic centers like residencies, you don't get a feel for this very much. You may not have any idea how daunting this can be.

The only way to deal with this is experience and good training (or going somewhere that always has backup present). The more you practice in this field the better you will be at foreseeing these potential disasters. Maybe some will share some of their experiences in this arena. But to me, this may be one of the most difficult adjustments required of a new grad and it may take some time to concur.

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[2ndyear]

Good post. I've been out almost 6 years now in private practice with no backup and have adjusted, but those first few calls (months?) as a new attending are scary no matter how strong your training was. You're just not used to being 'it' and having absolutely nobody around to help and it can be a lonely place when things don't go as planned. I think a large part is what you said, learning to foresee the potential disasters and having a real viable back up plan in your head for what lies ahead.

There's also a lot of people in the hospital who can help you, even if other docs are scarce. Learning how to direct others can be a valuable skill, no reason to spend 15 minutes during a hemorrhage calling for blood, checking blood, and setting up the rapid transfuser. An extra RN or two can go a long way in decreasing workload allowing you to place lines, focus on the patient, etc.

 

[BuzzPhreed]

Excellent post Noyac. And a lot to consider.

As I said in the other thread it can definitely be very lonely in the OR in the middle of the night especially if you have a complete disaster. In my current gig we do have a back-up from home and I can also call a tech in (they get call pay either way so they don't really mind and will come in quickly). This is important if you get a regular trainwreck in the OR and you need to put lines in or an epidural or whatnot. Sometimes just even having a second set of hands to fetch stuff helps.

At the gig I just left the CRNAs were always on call along with the docs. So in essence you always had two sets of hands. We could run up to three rooms on the weekends including OB coverage. So less of a chance for disaster because even if you got into something deep you could call a CRNA in and there was automatically a second person who knew (most of the time) what to do. Most of them were really good. Some would just get in the way in a situation like that.

I was put in a couple of situations on call where I had to tube ICU patients though. In one case the guy had a supraglottic mass post-XRT and no neck. He was sitting at the edge of the bed and his sat was 87% on an NRB when I walked in the room. I looked at the ICU nurse and said "you realize that there is a serious potential for me to kill this patient right now." She said back to me "that might be a good thing." No joke. Not the kind of support I was looking for. Long story short, I rammed a 6.0 in with the Glidescope and I didn't end-up saying "yes your honor, no your honor" after that one. But there are moments when you do feel incredibly alone and it could go either way. In those instances I just document the best I can and always trying to plan an escape route in the figurative sense.

 

[Noyac]

I was put in a couple of situations on call where I had to tube ICU patients though. In one case the guy had a supraglottic mass post-XRT and no neck. He was sitting at the edge of the bed and his sat was 87% on an NRB when I walked in the room. I looked at the ICU nurse and said "you realize that there is a serious potential for me to kill this patient right now." She said back to me "that might be a good thing." No joke. Not the kind of support I was looking for. Long story short, I rammed a 6.0 in with the Glidescope


That is the exact type of case that failed precedex sedation for me. But that's another story.

It is much different in the PP world than the academic world.

 

[Mman]

To me the out of OR airways are by far the most stressful situation I can get into simply because it's possible that I get called in late in the game and after things have been done to the patient I wouldn't have recommended. I mean walking into an ICU with a morbidly obese patient with a sat in the 70s being bagged with a bunch of blood coming out their mouth from all the laryngoscopy attempts prior to calling me is a sinking feeling. Then again I leave a very detailed note at what condition the patient was in when I arrived.

Most things in the OR are less stressful because if it's an emergent airway issue the ENT or trauma surgeon are probably the one operating on the patient and they can be at the ready for a trach. If it's a massive trauma resuscitation, they are going to die anyway and if we get lucky and keep them alive then hooray and if not we tried so I don't lose any sleep.

 

[VolatileNavyDoc]

Had a call late at night to the ICU. Sats 90% on BiPap. Down to 80% quickly on FM. 5'2", 270 lbs, cushingoid fascies due to the steroids for her lupus. I asked the MICU attending (who was standing with one hand on the door avoiding eye contact) if there was a cric kit just in case. Blank stare... A little propofol and glidescope did the trick. Lucky.

 

[Mman]

Had a call late at night to the ICU. Sats 90% on BiPap. Down to 80% quickly on FM. 5'2", 270 lbs, cushingoid fascies due to the steroids for her lupus. I asked the MICU attending (who was standing with one hand on the door avoiding eye contact) if there was a cric kit just in case. Blank stare... A little propofol and glidescope did the trick. Lucky.

I find that often times the people primarily caring for a patient can be obivious to the impending doom from an airway disaster. They think if it's hard for them just call anesthesia and it'll be fine. Sure, it often will be, but I think they lack an appreciation for how dangerous it actually is and when the patient is dead 15 minutes later reality comes crashing down.

 

[seinfeld]

you will learn more in the first 6 months as an attending than you did your CA-3 year. OUr residency programs and administrators/politicians are mostly to blame for not allowing a resident to spread their wings when they have a true back up.

Be confident not cocky, know when to enlist people around you, and LISTEN to people around you. If everyone else including the nurse and the janitor are questioning your decision, make a phone call to a senior partner.

One thing many new attending in a new place can do to help be accepted is to proactively explain, in short order, what your thinking and why it is your making the decision you are. There are local standards that when deviated from cause people to question how good of a doctor you are. For me the best example is the use of albumin. Our PACU/ ICU loves to you 5% albumin for any sort of hypotension. As an ICU doc i have fairly well defined criteria for its use. When i started explaining to people that the SAFE trial showed that in sepsis the bag for the buck was not 3:1 (crystalloid to colloid) but more 1.4 :1 and the cost was significantly different the pacu nurse had a better idea as to why i wasn't using it. I should note that when i make these reasons known its not in the arrogant know it all doctor tone but in the "ah shucks" i wish it mattered but it doesn't tone.

 

[BuzzPhreed]

One thing many new attending in a new place can do to help be accepted is to proactively explain, in short order, what your thinking and why it is your making the decision you are. There are local standards that when deviated from cause people to question how good of a doctor you are.

You are partly right here. Most people don't want an explanation though. They just want you to do what's expected. If you question the status quo - however politely you do it - be prepared to have the whispers behind your back start.

My advice? If you want to survive mostly keep your mouth shut and do it their way for six months especially if a change doesn't really matter or doesn't have an immediate clear safety/efficacy impact. If you start rocking the boat from day one that's all people will notice. What you want them to notice is that you're friendly, you show up when the call you, and that you've got good "get their ass out of hot water" skills.

Leaving everything else for another time. Preferably after you've established yourself and are trusted. No amount of explanation is going to convince anyone early on, especially the ancillary staff, who mostly go on "gut" feeling anyway.

 

[BLADEMDA]

I was put in a couple of situations on call where I had to tube ICU patients though. In one case the guy had a supraglottic mass post-XRT and no neck. He was sitting at the edge of the bed and his sat was 87% on an NRB when I walked in the room. I looked at the ICU nurse and said "you realize that there is a serious potential for me to kill this patient right now." She said back to me "that might be a good thing." No joke. Not the kind of support I was looking for. Long story short, I rammed a 6.0 in with the Glidescope


That is the exact type of case that failed precedex sedation for me. But that's another story.

It is much different in the PP world than the academic world.

I've had a few of those in my career. My plan is a trip to the OR for intubation and General surgery or ENT standby in the room with trash set up. I've had to trach 2 patients urgently in such a setup and those patients would have died without the backup plan in the OR.

 

[BLADEMDA]

you will learn more in the first 6 months as an attending than you did your CA-3 year. OUr residency programs and administrators/politicians are mostly to blame for not allowing a resident to spread their wings when they have a true back up.

Be confident not cocky, know when to enlist people around you, and LISTEN to people around you. If everyone else including the nurse and the janitor are questioning your decision, make a phone call to a senior partner.

One thing many new attending in a new place can do to help be accepted is to proactively explain, in short order, what your thinking and why it is your making the decision you are. There are local standards that when deviated from cause people to question how good of a doctor you are. For me the best example is the use of albumin. Our PACU/ ICU loves to you 5% albumin for any sort of hypotension. As an ICU doc i have fairly well defined criteria for its use. When i started explaining to people that the SAFE trial showed that in sepsis the bag for the buck was not 3:1 (crystalloid to colloid) but more 1.4 :1 and the cost was significantly different the pacu nurse had a better idea as to why i wasn't using it. I should note that when i make these reasons known its not in the arrogant know it all doctor tone but in the "ah shucks" i wish it mattered but it doesn't tone.

http://www.nejm.org/doi/full/10.1056/NEJMoa1305727

Clinical Takeaway: This trial further confirms albumin’s role should be limited in management of shock states. Albumin’s properties as an oncotic “volume expander” are exaggerated, with only about a 1:1.4 efficacy ratio over crystalloid. The lack of benefit in the SAFE study and the severe sepsis arm of the current trial, along with aCochrane analysis suggesting harm, argue for restraint in using this expensive resource. However, albumin advocates will find confirmation of their practices in the hemodynamic benefits seen here, and especially the increased survival among the sickest patients with septic shock. Answering the question of albumin’s proper role in sepsis treatment more clearly will take another randomized trial, preferably one that is properly blinded. This one in Brazil looks interesting, although it won’t be definitive.

 

[chmd]

I've had a few of those in my career. My plan is a trip to the OR for intubation and General surgery or ENT standby in the room with trash set up. I've had to trach 2 patients urgently in such a setup and those patients would have died without the backup plan in the OR.

Doing it in the OR is great, but I don't understand why it wouldn't be an awake fiberoptic with excellent topicalization. That's always my go to if thing look dicey and it works like a charm.

 

[Arch Guillotti]

I've had a few of those in my career. My plan is a trip to the OR for intubation and General surgery or ENT standby in the room with trash set up. I've had to trach 2 patients urgently in such a setup and those patients would have died without the backup plan in the OR.

Did you put them to sleep or did they decompensate?

 

[napman]

http://www.nejm.org/doi/full/10.1056/NEJMoa1305727

Clinical Takeaway: This trial further confirms albumin’s role should be limited in management of shock states. Albumin’s properties as an oncotic “volume expander” are exaggerated, with only about a 1:1.4 efficacy ratio over crystalloid. The lack of benefit in the SAFE study and the severe sepsis arm of the current trial, along with aCochrane analysis suggesting harm, argue for restraint in using this expensive resource. However, albumin advocates will find confirmation of their practices in the hemodynamic benefits seen here, and especially the increased survival among the sickest patients with septic shock. Answering the question of albumin’s proper role in sepsis treatment more clearly will take another randomized trial, preferably one that is properly blinded. This one in Brazil looks interesting, although it won’t be definitive.

 

[napman]

sorry forgot to attach the link

Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial

http://www.ncbi.nlm.nih.gov/pubmed/24108515