After hours non-urgent cases

[DrOwnage]

Was hoping to get some input on peoples’ institutional or group policies regarding after hours cases that are not urgent. What specific criteria can be globally used so individuals are not picked out or pressured on a case by case basis.

We have a generally good understanding of when to call it quits when a surgeon puts on a long lineup of cases. However there’s a couple of repeat offenders who are “on call” but have clinic/outpatient surgery the whole day and tack everything on after 7pm. Talking about temporal artery biopsies, skin grafts in 3-4 week old wounds, jaw hardware removal, stuff like that.

This is a level 4 trauma community hospital with all at home call. Looking for peoples experiences with this.

What’s the best way about this, besides obviously having everyone from anesthesia on the same page?

---

Members don't see this ad.

 

[MirrorTodd]

For the most part at the level 2 center I work at, this is dictated by the nursing availability moreso than the anesthesia side. The hospital itself will only allow a certain number of rooms past 3, then down to 1 room past 5pm. The surgeons seem to understand that unless they want to up all night every night, they can't just throw on cases willy-nilly. Understand it's probably different for a level 4 center.

 

[GassYous]

Add it on for the next day

 

[DrOwnage]

Add it on for the next day

We do have a dedicated add on room for general stuff everyday. However a lot of these surgeons either already have a case lineup the next day or clinic and they would rather knock them out.

 

[IlDestriero]

For the most part at the level 2 center I work at, this is dictated by the nursing availability moreso than the anesthesia side. The hospital itself will only allow a certain number of rooms past 3, then down to 1 room past 5pm. The surgeons seem to understand that unless they want to up all night every night, they can't just throw on cases willy-nilly. Understand it's probably different for a level 4 center.

Pretty much the same at my L1 trauma children’s hospital. We need to be able to provide emergent care for real emergencies so we don’t add on non urgent stuff. We have 2 add on rooms every day and any early rooms also get the stuff off the list. I think we had a new record last week. 31 add on cases one day. 😳

 

[Gasworks]

Realistically speaking as long as the hospital is willing to book and staff all this after hours crap you’re stuck doing it. We have had some success getting additional stipend for excessive amount of after hours work and in turn the hospital tried to curb this behavior to keep costs down.

The best place to start is to review your staffing agreement with the hospital. Our generic agreement is X number of rooms 7-3, down to 1-2 rooms 3-5 and emergencies only after 5pm. You still have the usual offenders with their “septic” gallbladders and kidney stones at 7pm but this goes a long way in curbing some of this behavior.

 

[Dr. Rude]

Realistically speaking as long as the hospital is willing to book and staff all this after hours crap you’re stuck doing it. We have had some success getting additional stipend for excessive amount of after hours work and in turn the hospital tried to curb this behavior to keep costs down.

The best place to start is to review your staffing agreement with the hospital. Our generic agreement is X number of rooms 7-3, down to 1-2 rooms 3-5 and emergencies only after 5pm. You still have the usual offenders with their “septic” gallbladders and kidney stones at 7pm but this goes a long way in curbing some of this behavior.

This has been a perpetual source of friction in our department forever. When they employed us, it mostly became their headache as they also employ the CRNAs. It followed the predictable pattern....Work people past their shifts without choice...People complain...Complaints ignored...Best people leave....Work the remainder harder....More leave....Hire high priced locums....The finance people have a stroke....Have an epiphany...Raise salaries and improve staffing levels and have clear guidelines so you can recruit.

 

[private practice warrior]

Every OR has those surgeons that want to work late. They only get reigned in at a hospital administration level or surgical committee level that define how late elective cases can be scheduled. You will need to have cogent arguments to support why these cases being done late are detrimental to either the anesthesia group or appropriate functioning of the OR, or both. Are these cases impairing your ability to do more urgent and emergent cases, is the group working beyond their contracted times and rooms with these cases, etc. We have added monetary hourly costs to our new contract if extra rooms are run past contracted hours. This has resulted in far better scheduling and extra elective cases are not added anymore so that the rooms end on time to the extent that is possible.

 

[ProPropofol]

Don't have any advice but it's a huge problem where I'm at. There are no set criteria about how many rooms we are to run at certain times so often it leads to cases that were elective and on the board for weeks prior starting at 7PM or later (yes, patient fasts all day). I think establishing clear times on when rooms are to come down is a good goal as mentioned above. Our solution has been to work everyone to death then hire people without US board certifications from other countries and to tell the new hires they need to earn their keep by staying to finish the cases to help the more senior academic people get home to their families. We have attendings asking residents how to study for Step 1/take driver license exams and nurses from other countries who are fascinated by mundane things they haven't seen before. Perhaps, you could look into trying this?

Often times, the call team is stuck doing these non-urgent elective cases instead of being available for emergencies so when an emergency happens, we scramble to pull people out of rooms and figure out how to do the case.

"Mr. Jones, wake up!"
"I think he moved"
*Pops in oral airway and a make a cruel Mapleson F circuit taped to the patient's face*
"Off to PACU so I can do this crani!"

It's a serious problem that I don't think we are well equipped to combat as a specialty in general. The hospital sees us as an paid expense that produces no money for the hospital in and of itself so they can bill for more lucrative things (things that collect facility fees); the admins will never side with the anesthesiologists to move cases around to more reasonable times as this would risk making a surgeon unhappy and lose that revenue stream.

 

[DirtDocMD]

This can be an issue, anywhere, and hospitals aren’t going to care unless you MAKE them care. They care either because, 1) it costs them lots of money, or 2) it creates high turnover in their staff.

You didn’t mention if you were part of an AMC, in a private group, or employed. If you’re in an AMC or employed, an en masse uprising is about all that will stop it. If a private group, you need hard and fast terms in the contract about how many rooms will run at what times, and if that’s not enough, you create some REALLY high penalties ($500/hour plus), for working odd hours.

Many of these surgeons simply don’t care. THEY don’t care if you or the staff is happy. THEY don’t pay overtime. THEY don’t have to replace staff that actually wants to see their families. They will do everything they can to get THEIR office staff home by 3-5 pm, or to not overwork the staff at THEIR surgery center, but they don’t mind abusing the staff at the hospital til all hours of the night.

Sometimes, it requires putting the hospital in a position where they are cutting a $5-$10k check, EVERY WEEK, to see that maybe there are better ways to handle these cases.

And sometimes, unfortunately, the onus is simply on you, to look out for your own well-being, and go where you are treated better. That’s not always an option, but it’s certainly easier to move an anesthesia practice/take a job down the street, than it is some other specialties.

Wish I had better advice, and hope you find a way, but sometimes, like a bad marriage, all the talk/counseling/change is not going to help, if the other party isn’t willing to give. That’s when you cut your losses, and find another place/person that isn’t so comfortable making you miserable.

 

[DesiredMemberName?]

Don't have any advice but it's a huge problem where I'm at. There are no set criteria about how many rooms we are to run at certain times so often it leads to cases that were elective and on the board for weeks prior starting at 7PM or later (yes, patient fasts all day). I think establishing clear times on when rooms are to come down is a good goal as mentioned above. Our solution has been to work everyone to death then hire people without US board certifications from other countries and to tell the new hires they need to earn their keep by staying to finish the cases to help the more senior academic people get home to their families. We have attendings asking residents how to study for Step 1/take driver license exams and nurses from other countries who are fascinated by mundane things they haven't seen before. Perhaps, you could look into trying this?

Often times, the call team is stuck doing these non-urgent elective cases instead of being available for emergencies so when an emergency happens, we scramble to pull people out of rooms and figure out how to do the case.

"Mr. Jones, wake up!"
"I think he moved"
*Pops in oral airway and a make a cruel Mapleson F circuit taped to the patient's face*
"Off to PACU so I can do this crani!"

It's a serious problem that I don't think we are well equipped to combat as a specialty in general. The hospital sees us as an paid expense that produces no money for the hospital in and of itself so they can bill for more lucrative things (things that collect facility fees); the admins will never side with the anesthesiologists to move cases around to more reasonable times as this would risk making a surgeon unhappy and lose that revenue stream.

So… when you scramble to pull people out of rooms and put your patients (and your license) at risk by doing shady ****, you are enabling the current system.

Hospital administration preys upon nurses and doctors who are willing cut corners to make things work. If something goes wrong because you were rushing through your after-hours non-elective case in order to minimize the delay starting the actual emergency that comes in, they will 100% not have your back.

What you should do when this happens is say, “I’m sorry Dr. Neurosurgeon, we can’t start your true emergency crani because the emergency call team is busy doing Dr. GenSurg’s elective lap chole.” Let the neurosurgeon then complain to hospital admin. They will, and it will have more impact than you ever could.

 

[Beeftenderloin]

So… when you scramble to pull people out of rooms and put your patients (and your license) at risk by doing shady ****, you are enabling the current system.

Hospital administration preys upon nurses and doctors who are willing cut corners to make things work. If something goes wrong because you were rushing through your after-hours non-elective case in order to minimize the delay starting the actual emergency that comes in, they will 100% not have your back.

What you should do when this happens is say, “I’m sorry Dr. Neurosurgeon, we can’t start your true emergency crani because the emergency call team is busy doing Dr. GenSurg’s elective lap chole.” Let the neurosurgeon then complain to hospital admin. They will, and it will have more impact than you ever could.

Many of my surgeon’s would seriously prefer to protect their ability to do elective cases at odd hours even if it means their occasional true emergency on call has to wait an extra 30-60 mins. This happens not infrequently at my shop. The put up the littlest of fuss, sigh then go get a coffee.

The only thing that truly moves the needle is if the patient that needs emergency surgery is a VIP/VIPs family. That’s how policy’s change. See Libby Zion. I imagine most lay people would be shocked to find out there isn’t a team of people available to handle true emergencies at a moments notice at nearly every hospital.

 

[DesiredMemberName?]

Many of my surgeon’s would seriously prefer to protect their ability to do elective cases at odd hours even if it means their occasional true emergency on call has to wait an extra 30-60 mins. This happens not infrequently at my shop. The put up the littlest of fuss, sigh then go get a coffee.

The only thing that truly moves the needle is if the patient that needs emergency surgery is a VIP/VIPs family. That’s how policy’s change. See Libby Zion. I imagine most lay people would be shocked to find out there isn’t a team of people available to handle true emergencies at a moments notice at nearly every hospital.

That’s all the more reason not to endanger yourself and your patients to expedite their “emergency” case.

 

[anbuitachi]

its complete BS over here, no real policy, surgeon does whatever they want practically. we are a level 1 trauma center, + other emergencies. we frequently have surgeons book cases until 10pm.. anesthesiologists complain but we dont have the backing from our department. Other day i was on call, scheduled cases went until midnight. Our call team only has 1 anesthesiology overnight trauma team, so clearly it doesnt make sense, and nurses only have 2 teams overnight (one reserved for true emergencies and traumas), so as you can imagine if scheduled case go til midnight, all our other cases get delayed, and follow thru teh rest of the night such as appendectomy, ortho fractures, etc. usually what happens here is from 8-10, scheduled cases start winding down. Then from ~10pm to 7am, we do appys/fractures all night long, one at a time.

 

[Drwine]

My answer was to retire from full time practice and only work per diem. My motto now is "Call me anything but late for dinner." It is out of hand in our hospital system. One site director does his best to reign it in and look out for colleagues while the other one gives the surgeons carte blanche.

 

[ProPropofol]

So… when you scramble to pull people out of rooms and put your patients (and your license) at risk by doing shady ****, you are enabling the current system.

Hospital administration preys upon nurses and doctors who are willing cut corners to make things work. If something goes wrong because you were rushing through your after-hours non-elective case in order to minimize the delay starting the actual emergency that comes in, they will 100% not have your back.

What you should do when this happens is say, “I’m sorry Dr. Neurosurgeon, we can’t start your true emergency crani because the emergency call team is busy doing Dr. GenSurg’s elective lap chole.” Let the neurosurgeon then complain to hospital admin. They will, and it will have more impact than you ever could.

100% agree that we are enabling the current system and the admin definitely doesn't have our back. Fighting the system only results in backlash and discipline on the anesthesia side. The department is completely spineless which is quite infuriating. We are willing to take any and all blame. Seems like @anbuitachi knows what I'm talking about, a department that tolerates this kind of behavior is a sinking ship and should either be abandoned or seriously overhauled with tenacious fervor.

There is a reason I won't be renewing my contract!

 

[Greenbayslacker]

Hire high priced locums....The finance people have a stroke....

Hire locums... they give patients strokes. There is a clear quality difference between locums and the permanent docs at our place.

 

[aneftp]

The paid hourly schedule for anesthesia docs works and crna after hours.

Incentivize it to either make the amc pay more or the amc back charges the hospital more (which is what some amc do).

Do any case they want after hours. Just gonna to cost everyone more. Money talks. It amazing how much less people complain when they are compensated fairly.

Now what is agreeable term to pay a CRNA or doc to work extra as w2. That’s debatable. Some hospitals try to pay docs $200/hr w2 extra (their full time staff). Some pay $250. Some pay $300. Some up to to $325 now. W2 I’m talking about. The locums docs make even more working over their 40/50 hour contracted week.

 

[dannyboy1]

Hourly rate and shift work. Hourly rate and shift work. It’s really the only way do do anesthesia. Add on list a mile long? Not my problem, my shift is up when it is up. If I CHOOSE to stay late the OT rate kicks in.

 

[anbuitachi]

I just went on call, and there are 4 appendectomies waiting for team to do. Each one takes from bringing patient, consenting, to going to pacu, clean up, about 2 hours. So thats my next 8 hours of call with a 1 CA1, unless a trauma hits.

I looked up all four appys. All had CT confirmed appendecitis between the times of 7AM to 3PM. All 4 are booked at category 1 emergencies (technically defined as need to go within 1 hour). THe first one is starting now at 10PM. Due to 2 reasons, one is because surgeons here do their scheduled cases and leave, so they are left for on call attending (unless a true emergency, and they know appy is not, despite them being booked as one), and the other one is bc scheduled cases ran until 8 pm today (actually pretty early day) and nurses go to 1 case at a time after 6PM. So now these cases will go overnight, with our bare bone team in a level 1 trauma hospital, because surgeons like it that way and no admin in other department have courage to fight them, and also because they have support of hospital system because they are doing more cases and generating revenue overnight.

when traumas do hit, surgeon can just leave the appy and attend to trauma. or have their resident finish it up, while the surgery attending and other residents go to trauma. so they dont really care

 

[nimbus]

We have no problem getting trauma, neurosurgery and ortho trauma coverage. Ortho trauma gets block time during the day because they routinely fill their block times and it is their full-time job. It’s baked into the system.

Our hospital struggles to get plastics and OMFS to cover ER and trauma patients. They routinely schedule cases starting at 5pm because hospital call coverage is their side gig. Their days are filled with elective cosmetic cases and dental implants. It’s hard to pull them away from a $30-50k day in their office to do a $200 case at the hospital. Most of the plastics and OMFS in our city won’t take any hospital call. So when the plastics guy is willing to come in at 5pm to do facial fractures and decubitus ulcers, he’s really just there as a service to the community. I was on call last night. I did 2 facial fractures and a decubitus ulcer from 5-9:30pm, relieved our 2nd call guy doing an A-V fistula at 9:45(new, young slow vascular surgeon), neuro IR thrombectomy from 11-12, and an appy from 12-1. Slept from 1-7. It was an average night. 8 solid hours of work, decent amount of collections/units, decent stipend, decent nights sleep, and pre and postcall days off.

No residents or CRNAs so 2nd call went home just before 10pm, 3rd call went home about 8:30.

During Covid, our hospital had staff shortages and could only run 2-3 rooms after 5. That meant call people had to work late into the night because the cases got stacked. Now the hospital has lots of staff so we routinely run 6-7 rooms until 7pm. Not so great if you are #4-7 on the call list but it means the cases get knocked out and call people get home or get to sleep earlier. It’s been a trade off.

 

[nimbus]

I just went on call, and there are 4 appendectomies waiting for team to do. Each one takes from bringing patient, consenting, to going to pacu, clean up, about 2 hours. So thats my next 8 hours of call with a 1 CA1, unless a trauma hits.

I looked up all four appys. All had CT confirmed appendecitis between the times of 7AM to 3PM. All 4 are booked at category 1 emergencies (technically defined as need to go within 1 hour). THe first one is starting now at 10PM. Due to 2 reasons, one is because surgeons here do their scheduled cases and leave, so they are left for on call attending (unless a true emergency, and they know appy is not, despite them being booked as one), and the other one is bc scheduled cases ran until 8 pm today (actually pretty early day) and nurses go to 1 case at a time after 6PM. So now these cases will go overnight, with our bare bone team in a level 1 trauma hospital, because surgeons like it that way and no admin in other department have courage to fight them, and also because they have support of hospital system because they are doing more cases and generating revenue overnight.

when traumas do hit, surgeon can just leave the appy and attend to trauma. or have their resident finish it up, while the surgery attending and other residents go to trauma. so they dont really care

Our trauma surgeons take 24hrs in house, then the next 24hrs as back up call from home. Often the backup person coming off their in-house shift will do the chole or the appy. They consider 6 of these 48hr cycles per month to be full-time. They compress their workdays so they can have many days completely off. A couple of them have a vascular practice on the side.

 

[epidural man]

Was hoping to get some input on peoples’ institutional or group policies regarding after hours cases that are not urgent. What specific criteria can be globally used so individuals are not picked out or pressured on a case by case basis.

We have a generally good understanding of when to call it quits when a surgeon puts on a long lineup of cases. However there’s a couple of repeat offenders who are “on call” but have clinic/outpatient surgery the whole day and tack everything on after 7pm. Talking about temporal artery biopsies, skin grafts in 3-4 week old wounds, jaw hardware removal, stuff like that.

This is a level 4 trauma community hospital with all at home call. Looking for peoples experiences with this.

What’s the best way about this, besides obviously having everyone from anesthesia on the same page?

If you really want to change it, keep meticulous data for a while.

 

[Gasmd98]

Some of this nonsense goes with the territory. Surgeons carry a gene for this condition and some carry two copies. You have a fighting chance if the hospital administration and OR nursing are on board. It is hard to escape this “feature” of anesthesia. I sucked it up for as long as it took to save enough money that I was able to give up call and late duty.

 

[Simba1711]

its complete BS over here, no real policy, surgeon does whatever they want practically. we are a level 1 trauma center, + other emergencies. we frequently have surgeons book cases until 10pm.. anesthesiologists complain but we dont have the backing from our department. Other day i was on call, scheduled cases went until midnight. Our call team only has 1 anesthesiology overnight trauma team, so clearly it doesnt make sense, and nurses only have 2 teams overnight (one reserved for true emergencies and traumas), so as you can imagine if scheduled case go til midnight, all our other cases get delayed, and follow thru teh rest of the night such as appendectomy, ortho fractures, etc. usually what happens here is from 8-10, scheduled cases start winding down. Then from ~10pm to 7am, we do appys/fractures all night long, one at a time.

Why do you stay at your job ? My old job was terrible with surgeons doing non elective cases after hours so I left. We are looking for people if you want to switch jobs for a place in nyc. We have one call every 3 weeks and I did one case past 11pm in the past year. No trauma and No ob so our calls are not busy. Our compensation is very good.

 

[kidthor]

So… when you scramble to pull people out of rooms and put your patients (and your license) at risk by doing shady ****, you are enabling the current system.

Hospital administration preys upon nurses and doctors who are willing cut corners to make things work. If something goes wrong because you were rushing through your after-hours non-elective case in order to minimize the delay starting the actual emergency that comes in, they will 100% not have your back.

What you should do when this happens is say, “I’m sorry Dr. Neurosurgeon, we can’t start your true emergency crani because the emergency call team is busy doing Dr. GenSurg’s elective lap chole.” Let the neurosurgeon then complain to hospital admin. They will, and it will have more impact than you ever could.

This x 100000.

The other day I noticed a bunch of staff rushing around because a surgeon was berating them on turnover/startup time - and this is in an already low staff - shortage environment. The staff is unfortunately perpetuating bad surgeon behavior by accepting it and being subordinate to it. They can just refuse to be harassed, especially in this environment.

Like DMN said, the hospital admins/surgeons prey on people who accept bad behavior.

 

[ucladoc2b]

Our trauma surgeons take 24hrs in house, then the next 24hrs as back up call from home. Often the backup person coming off their in-house shift will do the chole or the appy. They consider 6 of these 48hr cycles per month to be full-time. They compress their workdays so they can have many days completely off. A couple of them have a vascular practice on the side.

We always have two in house. And one who camps out.

The most limiting factor to prevent doing non-urgent cases at ungodly hours is if the surgeon isn’t in house. Case acuity is correlated with having to drive themselves in the hospital.

 

[Maz777]

Overnight (after 7pm) should be reserved for emergent, life-threatening cases. Doing semi-elective, non-urgent surgeries in the middle of the night only increases patient morbidity and mortality (which includes lap appies, ureteral stents, any non-open/non-compartment syndrome Ortho case, etc.). This is a product of spineless departmental leadership, which is unfortunately very common these days. Life is too short to be up all night doing these non-urgent garbage cases. I stopped taking call 5 years into my career, and it is glorious.

 

[kidthor]

I stopped taking call 5 years into my career, and it is glorious.

How’d you maneuver into a no call role?

 

[pgg]

If you really want to change it, keep meticulous data for a while.

Unfortunately, data can't effect change if the people with power are happy with how things are.

Administrators don't have many reasons to care how long or late profitable lines run. I get it ... no margin no mission. Some of our more abusively unprofessional lines (lookin' at you GI) happen to be among our more profitable too. So even we are dis-incentivized to complain.

 

[Gas you down]

We have the surgeons call one another if they have to bump a case. Really cuts down on bs.
But yeah some of this is a career long lasting irritation. You have to fight it some, especially the egregious stuff. but having a lot of work to do is a good problem to have.

 

[anbuitachi]

Why do you stay at your job ? My old job was terrible with surgeons doing non elective cases after hours so I left. We are looking for people if you want to switch jobs for a place in nyc. We have one call every 3 weeks and I did one case past 11pm in the past year. No trauma and No ob so our calls are not busy. Our compensation is very good.

literally thought about that question today. another disaster call. with a patient death

but it seems like the most common answer i get from myself/colleagues is the day to day is not bad for nyc job. do 2-3 cases a day and go home, surgeons are not fast so thats enough to last til 4-5pm. but call is brutal. (also partially bc surgeons are slow)

 

[anbuitachi]

This x 100000.

The other day I noticed a bunch of staff rushing around because a surgeon was berating them on turnover/startup time - and this is in an already low staff - shortage environment. The staff is unfortunately perpetuating bad surgeon behavior by accepting it and being subordinate to it. They can just refuse to be harassed, especially in this environment.

Like DMN said, the hospital admins/surgeons prey on people who accept bad behavior.

we have a ob attending with crna on labor delivery, so the expectation is they start the case while backup is called in. which is still annoying because labor delivery can be pretty busy at night

 

[anbuitachi]

Overnight (after 7pm) should be reserved for emergent, life-threatening cases. Doing semi-elective, non-urgent surgeries in the middle of the night only increases patient morbidity and mortality (which includes lap appies, ureteral stents, any non-open/non-compartment syndrome Ortho case, etc.). This is a product of spineless departmental leadership, which is unfortunately very common these days. Life is too short to be up all night doing these non-urgent garbage cases. I stopped taking call 5 years into my career, and it is glorious.

are there data to support this.
i was even gonna look into level 1 trauma status requirements etc. but i cant find much of anything to back me up other than common sense

 

[anbuitachi]

last time we spoke to our chair about how we should not be doing appys at night as if they are emergencies, the response given to us was so you expect to do nothing and just wait for traumas all night? we cant do that.

i thought institutions get a stipend from state [new york?] for being level 1 trauma hospital?

 

[Sriddymopboi]

last time we spoke to our chair about how we should not be doing appys at night as if they are emergencies, the response given to us was so you expect to do nothing and just wait for traumas all night? we cant do that.

i thought institutions get a stipend from state [new york?] for being level 1 trauma hospital?

In a way isn’t this kind of true though? How do you argue against this?

 

[GassYous]

The more bs cases you do at night, the more displeased staff get and the more staff leave. This is true for us and for the OR staff.

 

[Ronin786]

In a way isn’t this kind of true though? How do you argue against this?

You don't accept the premise that all you're doing is jerking off all night. You explain that there's more than enough actual emergency stuff to go around after hours that these BS cases are hindering the ability to provide patient care in a timely manner when a trauma does roll in. Also that ******* chair should know that after hours aren't intended for non-emergent cases but sounds like he's being jerked off all night by the department of surgery.

Also we have a policy that emergent cases bump surgeons in your own department along with limits on the number of rooms that can be running at one time. So when spine wants to book an "emergent" washout, they have to go tell their partner that he can't start his 3 level fusion and/or has to bump it till the next morning.

 

[aneftp]

Some of this nonsense goes with the territory. Surgeons carry a gene for this condition and some carry two copies. You have a fighting chance if the hospital administration and OR nursing are on board. It is hard to escape this “feature” of anesthesia. I sucked it up for as long as it took to save enough money that I was able to give up call and late duty.

It’s not the surgeon se. They get tired also. It’s the multi surgeons with different practices. You have 3-4 different practices each with 2-5 different surgeons

No skin off one surgeon back to roll in and do some cases cause they are there to work.

Anesthesia level 1 used to be q14-21 in house call many years ago. That’s doable long term.

Once you start getting q6-8 days overnight especially 24 hours (which isn’t done as often but still happens on weekends). It can be tiring.

So it’s the frequency of calls in addition to the pace of calls.

I’ve done (3) 24 hour calls this month on weekend for extra cash. Plus a couple of. Daytime weekend days. Luckily i’m just daytime the weekdays done by 12-3pm. Or else I don’t think I can handle it myself. The 24 hour calls are pretty brutal on weekend. We are officially level 2 but it functions closer to level one on weekend with trauma and transfers from other hospitals since other surround community hospitals like to dump claiming no surgeon call coverage.

 

[anbuitachi]

the only surgeons in house overnight are gen surg, since its a trauma hospital, and obgyn since we have busy labor delivery. all other surgeons are home call. so the general surgeons do their lap appys all night, and gyn also do ectopics frequently, which im fine with.

the appys are claimed to be emergencys by surgeons when they feel like it. but during the day when we tell them to bump their own service to do the appys they say no. because their culture is it is left to overnight attending. sometimes if we have a real trauma or real emergency, and appys are not done overnight, they are often bumped to the following NIGHT, not day because theres no space in schedule, and none of their own surgeons want to bump their scheduled cases to do them.

 

[anbuitachi]

In a way isn’t this kind of true though? How do you argue against this?

well you arent sitting around doing nothing. do you tell police officers to start picking up trash because its a peaceful day and nothing is happening? probably not. do you tell firefighters to grow some trees if there are no fires on that day?

we all got a job, theres 1 team overnight, should you be doing non emergencys and taking up the team or should you wait for emergency? emergencys are emergencys for a reason, they are not scheduled, so you are supposed to wait for them to come. otherwise, remove the level 1 trauma status if they dont want to do that. our 1 team (of 1 attending + 1 resident, often ca1) also covers stroke, floor/icu intubations, PACU) so its not like we are just napping when we arent doing appys.

 

[Maz777]

are there data to support this.
i was even gonna look into level 1 trauma status requirements etc. but i cant find much of anything to back me up other than common sense

There are many retrospective studies on this issue. It's a well-documented phenomenon that makes sense. There is no way a surgeon, anesthesiologist, and nursing can maintain meticulousness, attention to detail, and efficiency in the middle of the night. It's not humanly possible. It's not ethical or feasible to do a multicenter, prospective, randomized study on this issue, so we will never truly know. The only "prospective" studies are in cardiac patients, and they are poorly done.

Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data - PubMed

When considering a nonemergent procedure, surgeons must bear in mind that cases that start after routine "business" hours within the VA System may face an elevated risk of complications that warrants further evaluation.

pubmed.ncbi.nlm.nih.gov

Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study - PubMed

Surgical start times are associated with risk-adjusted patient outcomes. In terms of facility operations management and resource allocation, consideration should be given to the capacity to accommodate cases with differences in risk during different time periods.

pubmed.ncbi.nlm.nih.gov

I absolutely abhor meta-analyses, but this BJA one links to the 40+ studies on the matter: Association between night/after-hours surgery and mortality: a systematic review and meta-analysis - PubMed

 

[Maz777]

How’d you maneuver into a no call role?

Academia in which they sucker the new hires into taking most of the call and is overall very non-democratic.

 

[kidthor]

Academia in which they sucker the new hires into taking most of the call and is overall very non-democratic.

As in you’re in academia and non-call taking?

 

[DocVapor]

The horrible 48 hour weekend call I just completed made me think about this thread. Multiple soft-call "emergencies," drug addicts that had whatever infection that left AMA earlier in the week now back because it's worse, guy just standing on the corner minding his own business then some guy ran up and stabbed him, Lap Choles that ended up needing an ERCP when an ERCP first would have actually fixed the issue instead, blah blah blah.

This morning I'm thinking about all those drug addicted alcoholics that just do whatever the hell they want whenever they want and end up forcing the real schmucks like me to pick them up off the floor at 3 am weekend nights. Maybe they aren't the dumb ones in the room.

 

[Maz777]

As in you’re in academia and non-call taking?

Correct. It seems difficult to be non-call in PP in my area unless you take a surgicenter job (and take a significant pay cut to do so).

 

[kidthor]

Correct. It seems difficult to be non-call in PP in my area unless you take a surgicenter job (and take a significant pay cut to do so).

It’s difficult in most academic places I’ve seen too.

To that end - nicely done!

 

[kidthor]

The horrible 48 hour weekend call I just completed made me think about this thread. Multiple soft-call "emergencies," drug addicts that had whatever infection that left AMA earlier in the week now back because it's worse, guy just standing on the corner minding his own business then some guy ran up and stabbed him, Lap Choles that ended up needing an ERCP when an ERCP first would have actually fixed the issue instead, blah blah blah.

This morning I'm thinking about all those drug addicted alcoholics that just do whatever the hell they want whenever they want and end up forcing the real schmucks like me to pick them up off the floor at 3 am weekend nights. Maybe they aren't the dumb ones in the room.

Yeah that all sounds like a horrific waste of time. It reminds of where I did residency…

I’d imagine that’s a soul sucking weekend.

 

[Drwine]

It’s difficult in most academic places I’ve seen too.

To that end - nicely done!

Given the current shortage of anesthesiologists, there is more bargaining power to have a non call taking position. I see it taking a few years for the shortage to ease.

 

[Dr. Rude]

Given the current shortage of anesthesiologists, there is more bargaining power to have a non call taking position. I see it taking a few years for the shortage to ease.

Some practices don’t like to change their culture.