Anesthesiologists are killing themselves....

[Hamhock]

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I've had it. I give up.

Today's case:

44M PMHx mild HTN on a touch of HCTZ with femur fracture s/p admittedly significant bike accident (vs. car) but without any other significant injuries and excessive trauma work-up (near pan-man CT; no CT Chest but normal AP CXR).

Ortho will actually take the case with little resistance and plans for OR in mid-morning. CRNA comes down (quickly! - yes) for some "pre-op" nonsense and states there must be a medicine consult to "clear" the patient for surgery (acutally, cardiology or IM may have been requested - I don't remember).

No discussion with anesthesiology or resident (I'm told they don't do overnight pre-ops for non-emergent cases).

At my hospital, there is no such thing as a medicine consult in the ED. I (EM attending) finally stop laughing, consider arguing for a MEDICAL evaluation (ie anesthesiologist/doctor), and then realize the path of least resistance is best...I just talk the ortho resident into taking the admission (actually, I just admit the patient to ortho, as we have admitting rights to any service).

Then I sit back and reconsider:

WTF?

Why I am even listening to a nurse when I wouldn't listen to an intern without attending or senior supervision?

Please, for the love of god and the love of medicine (not nursing) - and I hope - the love of anesthesiology, why are nurses making independent MEDICAL evaluations?

Why is this tolerated?

1. Why is it OK for a nurse to make a MEDICAL evaluation without supervision (very different than OR anesthesia, I would argue; indeed, the benefit of medical school in pre-op eval is the key)?

2. How come anesthesiology puts up with the idea of medicine consults for "pre-op clearance"? Are you kidding me? As an educated potential patient, I could care less what some PGY2 IM resident has to say about my care in the OR? Why does anesthesiologists care?

In the constant CRNA vs. anesthesiology battle, this is the one area that I would argue nurses have NO INPUT. This is one more area where anesthesiologist should demand (unless lazy) complete control.

Yes, I am EM-trained and know little about anesthesiology. So, please educate me. Why are nurses allowed to do pre-ops? Shouldn't at least anesthesiologists be supervising?

Granted, I work in a hospital where anesthesiology is not a strong department, but come on! There is a residency and we send some crazy unstable cases from the ED to the OR. I am tired of seeing nurses come to the ED. I am tired as a PHYSICIAN, I am tired as an ED doc, and I am tired as a doc who actually respects ANESTHESIOLOGISTS and has a peripheral interest in anesthesiology (hence me constant reading and occassional posting on this forum).

This has to stop.

HH

Post-script: I DO NOT want to start a CRNA vs. MD war here. Consequently, I would prefer to hear from attendings and residents about this. Please, if you are a CRNA or "health student" or nurse, hold your comments for another thread; especially if the comments detail a CRNAs experience in evaluating the complete patient or describe a CRNAs evaluation of the complete patient based on ICU experience as an RN.

 

[bullard]

Your anesthesia department sucks.

Good anesthesiologists (and good internists) know there is no such thing as a "pre-op clearance." The phrase implies that the internist can look into their crystal ball and see that the patient cannot/won't have complications of their chronic medical problems.

Some surgeons like to get these things because they don't want to do a real H and P and because they think it will result in a lower rate of cancellation on day of surgery. This backfires when they get one from a busy cardiologist who writes "Cleared for surgery" on a prescription pad for his patient with CAD, DM, TIAs, going for endovascular AAA repair with no information in the chart, instead of telling us his patient is on all the right meds, has an EF of whatever, stents from three years ago, etc.

I'm surprised you're telling us about this afterwards instead of insisting on speaking to an attending.

Your point about nursing ruining medicine, especially in the field of anesthesia, stands, but dude,

Your anesthesia department SUCKS.

 

[bullard]

P.S. Even the laziest attendings at my residency program did their own preop evaluation, regardless if they were doing the case with a CRNA. You are right, that is a medical evaluation, not a nursing evaluation. See my notes above about your anesthesia department.

 

[Planktonmd]

Let me be the devil's advocate here:
CRNA's are nurse practitioners and currently nurse practitioners are involved in many aspects of patient care, including requesting consults and communicating with physicians.
The OP is apparently an ER attending and he should be aware of what nurse practitioners do and their expanding role in the current medical environment including Emergency medicine.
When a CRNA says that a medical consult is needed for an orthopedic patient this might simply mean that there is a hospital/ ortho department policy that all ortho patients should be seen by medicine before surgery, which is a very common arrangement and it's probably not the CRNA's Independent decision.

 

[sevoflurane]

"Consult/Medical Clearance" is a waste of time, energy and money for this o/w healthy patient. It is a burden on the entire health care system.

I see Planks devils advocate point of view.... yet still feel the same. If a nurse has taken this on herself, I would hang her out to dry.

Based on the details presented, this guy needs his femur fixed. He doesn't need a consult. Doing so devalues our role in the hospital and delays the unavoidable.

My 2cents.

 

[sevoflurane]

To go along with Plank's devils advocate...

I wasn't there and can only tell so much from an internet forum. But maybe the nurse saw something that worried her. If so, then this should have been related back to an anesthesiologist so he could determine the need of a consult.

CT would have been nice to eval other injuries in the setting of a distracting one. But again, I wasn't there and maybe it was pretty straight forward.

 

[jwk]

To the OP

Plank's post is spot-on. Every patient requires an anesthesia evaluation preoperatively. In a non-academic setting, it's rare that we actually get to see our patients the day before surgery, but if we can, that's great. It helps avoid surprises the day of surgery.

In this exact same situation in our department, we would have sent one of our nurse practitioners (not CRNA or AA, they're in the OR) to see the patient. They are free to order any additional labwork or an EKG if not already done and they think it's indicated or according to our protocols. However, when they're done seeing the patient, they come back to our department and discuss their evaluation with the anesthesiologist. IF a medical or cardiology consult is needed (it most certainly would not be on this case) then the anesthesiologist would be the one to make that decision, not the NP.

On the day of surgery, EVERY patient we do will be seen by an anesthesiologist preoperatively. If they've been seen by the NP, fine, then much of the paperwork is already done. If the anesthesiologist is busy, then it's perfectly acceptable for one of the CRNA's or AA's to go ahead and evaluate the patient, but again, EVERY patient will be seen by an anesthesiologist prior to surgery.

Our ER docs are very thorough and do a full dictated H&P on any patient admistted to the hospital. The ortho (or other) attending physician may not see the patient till the next morning, but they of course will be responsible for making sure that patient is ready for surgery. We do not require consults as a matter of routine, but we do expect patients to be worked up appropriately prior to surgery. So - if your fractured femur patient for some reason didn't have a CBC and BMET done on admission, we'll probably order them and delay surgery briefly to see the lab work just so there are no surprises. Some probably wouldn't worry about it, but since it's not an emergency, we've got the time to be a tad more thorough.

My practice is a high volume anesthesia care team (ACT) practice, with an anesthesiologist involved in and directing the care of each and every patient that we do. Using non-physician providers as part of that team is perfectly reasonable and is the norm in most hospitals and practices around the country. In smaller hospitals, it will not be unusual that there are CRNA-only practices, so like it or not, you would have to deal with the CRNA directly, and they would be deciding what goes and what doesn't.

 

[sevoflurane]

To the OP

Plank's post is spot-on. Every patient requires an anesthesia evaluation preoperatively. In a non-academic setting, it's rare that we actually get to see our patients the day before surgery, but if we can, that's great. It helps avoid surprises the day of surgery.

In this exact same situation in our department, we would have sent one of our nurse practitioners (not CRNA or AA, they're in the OR) to see the patient. They are free to order any additional labwork or an EKG if not already done and they think it's indicated or according to our protocols. However, when they're done seeing the patient, they come back to our department and discuss their evaluation with the anesthesiologist. IF a medical or cardiology consult is needed (it most certainly would not be on this case) then the anesthesiologist would be the one to make that decision, not the NP.

On the day of surgery, EVERY patient we do will be seen by an anesthesiologist preoperatively. If they've been seen by the NP, fine, then much of the paperwork is already done. If the anesthesiologist is busy, then it's perfectly acceptable for one of the CRNA's or AA's to go ahead and evaluate the patient, but again, EVERY patient will be seen by an anesthesiologist prior to surgery.

Our ER docs are very thorough and do a full dictated H&P on any patient admistted to the hospital. The ortho (or other) attending physician may not see the patient till the next morning, but they of course will be responsible for making sure that patient is ready for surgery. We do not require consults as a matter of routine, but we do expect patients to be worked up appropriately prior to surgery. So - if your fractured femur patient for some reason didn't have a CBC and BMET done on admission, we'll probably order them and delay surgery briefly to see the lab work just so there are no surprises. Some probably wouldn't worry about it, but since it's not an emergency, we've got the time to be a tad more thorough.

My practice is a high volume anesthesia care team (ACT) practice, with an anesthesiologist involved in and directing the care of each and every patient that we do. Using non-physician providers as part of that team is perfectly reasonable and is the norm in most hospitals and practices around the country. In smaller hospitals, it will not be unusual that there are CRNA-only practices, so like it or not, you would have to deal with the CRNA directly, and they would be deciding what goes and what doesn't.

Well put JWK. As usual, great post. 👍

And your last sentence is very true.

 

[Idiopathic]

Dear sir

Sorry this happened to you. Let me know when you want me to detail all the ridiculous interactions I have had with EM physicians.

Yours

 

[wine thief]

I find it ironic that an ER doc is calling out another physician as lazy. But we’ll get to that. First, what were the nurse’s concerns? Did you ask her? Second, “Mind if I discuss this patient with your attending?” would have solved your problem, no? Nobody said you aren’t allowed to have physician to physician communication. It just involves a few more minutes of your time, which apparently you weren’t willing to provide. Dispo to ortho, move the meat!

For my prelim surgery internship if we weren’t at the Mothership, we covered small community hospitals where the intern was the most senior surgical person in house at night. I received MANY BS consults from PAs and NPs. Common ones included “G tube fell out.” OK, put it back in the gaping hole from whence it came and get a tube study. “I’m not comfortable doing that.” OK, maybe your attending can help you. “I don’t have one in fast track.” Also included were butt abscesses, simple lac closures, etc. I WASN’T given a chance to speak to a physician. Why is it ok for nurses in the ER to make medical evaluations and call me? The attendings weren’t much better. They called us for chest tubes (my 1st chest tube was on solo call, don’t worry, I googled it first), central lines, “laying on of hands” for belly pain with normal studies/labs before they discharged them home “just wanted to get you on board!” or even better, the laying on of hands before any labs or imaging was back. So give me a break. If you want to speak to an anesthesiologist next time, pick up the phone.

ps- Did it occur to you that the anesthesiologist can't personally come to the ER because he's supervising multiple cases in the OR?

pps- 👍 jwk

 

[chocomorsel]

I find it ironic that an ER doc is calling out another physician as lazy. But we’ll get to that. First, what were the nurse’s concerns? Did you ask her? Second, “Mind if I discuss this patient with your attending?” would have solved your problem, no? Nobody said you aren’t allowed to have physician to physician communication. It just involves a few more minutes of your time, which apparently you weren’t willing to provide. Dispo to ortho, move the meat!

For my prelim surgery internship if we weren’t at the Mothership, we covered small community hospitals where the intern was the most senior surgical person in house at night. I received MANY BS consults from PAs and NPs. Common ones included “G tube fell out.” OK, put it back in the gaping hole from whence it came and get a tube study. “I’m not comfortable doing that.” OK, maybe your attending can help you. “I don’t have one in fast track.” Also included were butt abscesses, simple lac closures, etc. I WASN’T given a chance to speak to a physician. Why is it ok for nurses in the ER to make medical evaluations and call me? The attendings weren’t much better. They called us for chest tubes (my 1st chest tube was on solo call, don’t worry, I googled it first), central lines, “laying on of hands” for belly pain with normal studies/labs before they discharged them home “just wanted to get you on board!” or even better, the laying on of hands before any labs or imaging was back. So give me a break. If you want to speak to an anesthesiologist next time, pick up the phone.

ps- Did it occur to you that the anesthesiologist can't personally come to the ER because he's supervising multiple cases in the OR?

pps- 👍 jwk

Damn, you laid it out. Agreed, but really, he/she didn't call anyone lazy.

 

[pgg]

Ideally, when preop duties are delegated to midlevels, there's some supervision. An opportunity to put the brakes on unnecessary consults, labs, whatever. That is unfortunately not the reality in much of the USA.


jwk's setup is about the best we can hope for, going forward. There are days when I'd kill to be in a good, tight, well run ACT practice like that. (There are other days when I'm just glad I've got no awareness of and nothing to do with what some bottom-decile strip-mall-CRNA-mill trained prodigy is independently doing down the hall ...)


As I've mentioned here before, I work in two types of hospital

Military, with independent CRNAs
Civilian, with independent-ish CRNAs (rural opt-out state)

Both places, they do preops on their own. Sometimes they consult an anesthesiologist, sometimes not. 99% of the CRNA preop problems arise from them being excessively conservative. Which beats the alternative, I guess, but it leads to a lot of unnecessary consults and delayed cases. At the military hospital in particular, there is a extremely heavy CRNA bias toward referring non-ASA 1/2 cases out - this can be especially frustrating when they gripe at me for NOT referring every non-endoscopy patient over 50 to another hospital. But that's fodder for another thread.

It is not optimal, but it's not a problem confined to anesthesia. It's what surgeons and the public have chosen to accept as they chase "good enough" care and the illusion of lower costs from midlevels.


Me, I do a few things

• I don't delegate anything if I'm able to do it myself, including preops and postops.
  
• I don't let CRNAs start my cases while I take a break. I find I'm just never ever 100% happy with the way they decided to do things, and I'm picky. I get this gnawing in the pit of my stomach when I walk in and the patient's got an 8.0 ETT (taped wrong of course), a hard OP airway as a bite block, sticky 3" tape on the eyeballs, no cushy jelly pillow, sevo+nitrous flowing at 4 lpm, a temp of 95.5 deg, etc. It also makes us look interchangeable.
  
• I very, very rarely accept relief from anyone at the end of the day. If at all possible, I finish my own cases even if it means staying late. Again, this shows that I'm not interchangeable with anyone who walks through the door with a silly scrub hat on.
  
• I donate to ASAPAC, every month, by recurring cc transaction. I don't even notice the charges any more.

These are the things that can change the opinions of surgeons and the public.


Oh and 👍 wine thief 🙂

 

[wine thief]

Damn, you laid it out. Agreed, but really, he/she didn't call anyone lazy.

Actually he did. Too lazy to quote it but it's in the post.

Dear sir

Sorry this happened to you. Let me know when you want me to detail all the ridiculous interactions I have had with EM physicians.

Yours

Yes please. It's highly entertaining, and always variations on a theme. No matter what area of the country, what type of hospital, etc.

 

[jwk]

... and I'm picky. I get this gnawing in the pit of my stomach when I walk in and the patient's got an 8.0 ETT (taped wrong of course)...

You must be taping it like me then. 😉

 

[RussianJoo]

You must be taping it like me then. 😉

sorry to be off topic a bit but, i have to say. I constantly got scrutinized as a medical student when i taped ET tubes, and the attending would always re-do them. As a CA-1 I think I still tape my tubes the same way, but no one re-taped them and i rarely get a comment that i didn't tape it securely enough.

 

[jwk]

sorry to be off topic a bit but, i have to say. I constantly got scrutinized as a medical student when i taped ET tubes, and the attending would always re-do them. As a CA-1 I think I still tape my tubes the same way, but no one re-taped them and i rarely get a comment that i didn't tape it securely enough.

Each and every one of the clinical instructors I had during school told me "I know you've seen other ways of doing this, but MY way is THE best way". And they were dead serious. The best way to tape a tube is the one where the tube doesn't come out.

 

[pgg]

sorry to be off topic a bit but, i have to say. I constantly got scrutinized as a medical student when i taped ET tubes, and the attending would always re-do them. As a CA-1 I think I still tape my tubes the same way, but no one re-taped them and i rarely get a comment that i didn't tape it securely enough.

I had an attending who would come in, grab the ETT in his fist, and lift. If the patient's head didn't come up with the tube, it was a piss-poor tape job. Fortunately none of my patients were ever extubated by him ...

Looking back, it's just amazing the **** a couple of those guys did and got away with. Somebody did that to me today, I'd empty the succ syringe into his quadricep and call security.

/ derail

 

[theejay]

Ideally, when preop duties are delegated to midlevels, there's some supervision. An opportunity to put the brakes on unnecessary consults, labs, whatever. That is unfortunately not the reality in much of the USA.


jwk's setup is about the best we can hope for, going forward. There are days when I'd kill to be in a good, tight, well run ACT practice like that. (There are other days when I'm just glad I've got no awareness of and nothing to do with what some bottom-decile strip-mall-CRNA-mill trained prodigy is independently doing down the hall ...)


As I've mentioned here before, I work in two types of hospital

Military, with independent CRNAs
Civilian, with independent-ish CRNAs (rural opt-out state)

Both places, they do preops on their own. Sometimes they consult an anesthesiologist, sometimes not. 99% of the CRNA preop problems arise from them being excessively conservative. Which beats the alternative, I guess, but it leads to a lot of unnecessary consults and delayed cases. At the military hospital in particular, there is a extremely heavy CRNA bias toward referring non-ASA 1/2 cases out - this can be especially frustrating when they gripe at me for NOT referring every non-endoscopy patient over 50 to another hospital. But that's fodder for another thread.

It is not optimal, but it's not a problem confined to anesthesia. It's what surgeons and the public have chosen to accept as they chase "good enough" care and the illusion of lower costs from midlevels.


Me, I do a few things

• I don't delegate anything if I'm able to do it myself, including preops and postops.
  
• I don't let CRNAs start my cases while I take a break. I find I'm just never ever 100% happy with the way they decided to do things, and I'm picky. I get this gnawing in the pit of my stomach when I walk in and the patient's got an 8.0 ETT (taped wrong of course), a hard OP airway as a bite block, sticky 3" tape on the eyeballs, no cushy jelly pillow, sevo+nitrous flowing at 4 lpm, a temp of 95.5 deg, etc. It also makes us look interchangeable.
  
• I very, very rarely accept relief from anyone at the end of the day. If at all possible, I finish my own cases even if it means staying late. Again, this shows that I'm not interchangeable with anyone who walks through the door with a silly scrub hat on.
  
• I donate to ASAPAC, every month, by recurring cc transaction. I don't even notice the charges any more.

These are the things that can change the opinions of surgeons and the public.


Oh and 👍 wine thief 🙂

i cant believe you opt to work at a place where you are not supervising CRNAs. No wonder you feel interchangeable.. If you dont want to feel interchangeable you cant be doing the same job as them. simple as that

 

[Coastie]

Nurses are never allowed to do preops for my cases.

In the rare case a CRNA presents a preop, I simply re-do it.

Thanks for your support, and I'm sorry your hospital anesth dept sucks!

I've had it. I give up.

Today's case:

44M PMHx mild HTN on a touch of HCTZ with femur fracture s/p admittedly significant bike accident (vs. car) but without any other significant injuries and excessive trauma work-up (near pan-man CT; no CT Chest but normal AP CXR).

Ortho will actually take the case with little resistance and plans for OR in mid-morning. CRNA comes down (quickly! - yes) for some "pre-op" nonsense and states there must be a medicine consult to "clear" the patient for surgery (acutally, cardiology or IM may have been requested - I don't remember).

No discussion with anesthesiology or resident (I'm told they don't do overnight pre-ops for non-emergent cases).

At my hospital, there is no such thing as a medicine consult in the ED. I (EM attending) finally stop laughing, consider arguing for a MEDICAL evaluation (ie anesthesiologist/doctor), and then realize the path of least resistance is best...I just talk the ortho resident into taking the admission (actually, I just admit the patient to ortho, as we have admitting rights to any service).

Then I sit back and reconsider:

WTF?

Why I am even listening to a nurse when I wouldn't listen to an intern without attending or senior supervision?

Please, for the love of god and the love of medicine (not nursing) - and I hope - the love of anesthesiology, why are nurses making independent MEDICAL evaluations?

Why is this tolerated?

1. Why is it OK for a nurse to make a MEDICAL evaluation without supervision (very different than OR anesthesia, I would argue; indeed, the benefit of medical school in pre-op eval is the key)?

2. How come anesthesiology puts up with the idea of medicine consults for "pre-op clearance"? Are you kidding me? As an educated potential patient, I could care less what some PGY2 IM resident has to say about my care in the OR? Why does anesthesiologists care?

In the constant CRNA vs. anesthesiology battle, this is the one area that I would argue nurses have NO INPUT. This is one more area where anesthesiologist should demand (unless lazy) complete control.

Yes, I am EM-trained and know little about anesthesiology. So, please educate me. Why are nurses allowed to do pre-ops? Shouldn't at least anesthesiologists be supervising?

Granted, I work in a hospital where anesthesiology is not a strong department, but come on! There is a residency and we send some crazy unstable cases from the ED to the OR. I am tired of seeing nurses come to the ED. I am tired as a PHYSICIAN, I am tired as an ED doc, and I am tired as a doc who actually respects ANESTHESIOLOGISTS and has a peripheral interest in anesthesiology (hence me constant reading and occassional posting on this forum).

This has to stop.

HH

Post-script: I DO NOT want to start a CRNA vs. MD war here. Consequently, I would prefer to hear from attendings and residents about this. Please, if you are a CRNA or "health student" or nurse, hold your comments for another thread; especially if the comments detail a CRNAs experience in evaluating the complete patient or describe a CRNAs evaluation of the complete patient based on ICU experience as an RN.

 

[pgg]

i cant believe you opt to work at a place where you are not supervising CRNAs. No wonder you feel interchangeable.. If you dont want to feel interchangeable you cant be doing the same job as them. simple as that

I had a few potential replies to this in mind, but I'll just leave it at this: if I opted to not work at these places, I'd be cooling my heels in prison, not working at all, because I'd be s/p General Court Martial for desertion.

 

[24858]

I had a few potential replies to this in mind, but I'll just leave it at this: if I opted to not work at these places, I'd be cooling my heels in prison, not working at all, because I'd be s/p General Court Martial for desertion.

I like to do my cases, just because we do cases doesnt mean we dont bring more to the table. Odd comment.

 

[Monty Python]

Each and every one of the clinical instructors I had during school told me "I know you've seen other ways of doing this, but MY way is THE best way". And they were dead serious. The best way to tape a tube is the one where the tube doesn't come out.

Sorry for the momentary highjack here ... I just love it when my, ahem, properly-taped ETT which worked perfectly during the 12-plus hour prone case is immediately untaped by the respiratory tech when I deliver the pt to the ICU. Then they re-tape it THEIR way, and put that torture clamp thingy on it as well.

 

[MRW]

Somebody did that to me today, I'd empty the succ syringe into his quadricep and call security.

 

[periopdoc]

Please, for the love of god and the love of medicine (not nursing) - and I hope - the love of anesthesiology, why are nurses making independent MEDICAL evaluations?

Why is this tolerated?

Personally, I am a lot less concerned with a CRNA filling out a preop screening form according to a protocol that I have set up than I am with admitting a sick patient overnight to the PA/ NP running the cards/ ortho/ CT Surg/ whatever service as happens in so many institutions.

The anesthesiologist doing the case is, at the very least, going to review the CRNA's preop prior to induction. Worst case there is an unnecessary test or consult. Perhaps something gets missed and the case is delayed. Either way a supervisory evaluation is done before any real harm can be done to the patient. This is how our preop clinic is run. RN screening by protocols that we set up and physician consult for patients who are appropriate.

With the PA/NP run service, a lot of harm can come to the patient before sometime the next day when the attending physician is made aware that the patient has been admitted.



- pod

 

[periopdoc]

I like to do my cases, just because we do cases doesnt mean we dont bring more to the table. Odd comment.

I am guessing you missed the point that he is military thus must do what his orders tell him to do or face court martial. He has been ordered to work in this setting so his choice is obey, or go to prison and not work.

- pod

 

[theejay]

I am guessing you missed the point that he is military thus must do what his orders tell him to do or face court martial. He has been ordered to work in this setting so his choice is obey, or go to prison and not work.

- pod

and if his orders told him to change bedpans, change urinals, and give the patient a sponge bath. He would have to do it right? and he would not feel interchangeable with with a nurse or nursing assistant? of course he would becuase he would be doing a nursing assistant job. He would bring a lot of education to said tasks though.

 

[pgg]

and if his orders told him to change bedpans, change urinals, and give the patient a sponge bath. He would have to do it right?

I might take my chances with the court martial in that case.

🙄

On the civilian side, there are no all-physician or ACT model practices within at least a 2 hour drive of where I am (AFAIK). If I didn't moonlight at all, how does one less anesthesiologist working in the area help patients, surgeons, or anyone's efforts to resist further midlevel encroachment? It wouldn't - so I work there. I do my cases, they do theirs.


This thread was about CRNAs doing preops without supervision. The reality is that this is not uncommon. It does sometimes create problems.

 

[24858]

I am guessing you missed the point that he is military thus must do what his orders tell him to do or face court martial. He has been ordered to work in this setting so his choice is obey, or go to prison and not work.

- pod

I didn't miss any point I was trying to quote theejay and pgg but just pgg got quoted. So my point was directed at theejay.

 

[BLADEMDA]

I had an attending who would come in, grab the ETT in his fist, and lift. If the patient's head didn't come up with the tube, it was a piss-poor tape job. Fortunately none of my patients were ever extubated by him ...

Looking back, it's just amazing the **** a couple of those guys did and got away with. Somebody did that to me today, I'd empty the succ syringe into his quadricep and call security.

/ derail

Funny. But that attending showed you,in his one way, the proper manner to Secure an ETT for a prone or ENT type case. Kudos to him even though he is a bit crazy. I bet I would like him.