CRNA concerns

[deleted979844]

I’m just an intern... in medicine no less. I don’t claim to be a master of the airway. I’ve done some 50 intubations in my short time.

But I’ve recently had some experience watching a particular CRNA intubate and I’ve had some concern that she may not exactly know what’s she’s doing. Both times I’ve seen her she has attempted 4 and then 5 times before successfully getting the airway. I always thought the recommended limit was 3? We have an Intensivist on-call that she could’ve called. One time the anesthesiologist actually told her to hand over the blade and she barked at him. And even just watching her maneuver the Mac and hyperangulated VL, I don’t think she knows what she’s doing. I’m just assuming the anesthesiologists that work over her would’ve noticed if that was true so maybe I just caught her a few bad days? Not really sure if I should just move about my day but I would really appreciate any input on the matter. Thank you in advance!

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[GassYous]

Barked at him? lmao

 

[deleted979844]

Barked at him? lmao

A loud sound was briefly emitted. I wasn’t sure what else to describe it as lol.

 

[sevo00]

Best course of action would prob be to communicate this to your chief of medicine service and he can talk to the anesthesiology chief

 

[chessknt]

I’m just an intern... in medicine no less. I don’t claim to be a master of the airway. I’ve done some 50 intubations in my short time.

But I’ve recently had some experience watching a particular CRNA intubate and I’ve had some concern that she may not exactly know what’s she’s doing. Both times I’ve seen her she has attempted 4 and then 5 times before successfully getting the airway. I always thought the recommended limit was 3? We have an Intensivist on-call that she could’ve called. One time the anesthesiologist actually told her to hand over the blade and she barked at him. And even just watching her maneuver the Mac and hyperangulated VL, I don’t think she knows what she’s doing. I’m just assuming the anesthesiologists that work over her would’ve noticed if that was true so maybe I just caught her a few bad days? Not really sure if I should just move about my day but I would really appreciate any input on the matter. Thank you in advance!

I recommend you keep your head down and don't get involved. Not your monkey/circus and you don't understand the political climate if you were to start reporting people for incompetence etc. I agree if there is a problem someone supervising the crna should have noticed and acted. Your role as an intern is not to kill patients and collect information, not raise systemic concerns.

 

[Peterluger]

Next time she bark, ask animal control to come take care of wild dog loose in hospital

 

[deleted979844]

I recommend you keep your head down and don't get involved. Not your monkey/circus and you don't understand the political climate if you were to start reporting people for incompetence etc. I agree if there is a problem someone supervising the crna should have noticed and acted. Your role as an intern is not to kill patients and collect information, not raise systemic concerns.

I’m honestly kind of relieved to hear this. This definitely sounds like the most reasonable thing to do. I appreciate the advice.

 

[dabears505]

I'll take things that didn't happen for 500 Alex.

 

[DrOwnage]

Although I agree this story is probably embelished, you'd be surprised at some stuff that goes unnoticed. One of my colleagues who was team captain and a CA-3 at the time saw a CA-2 do a two-handed DL because they "couldn't see anything" with a one-handed DL.

Edit: I feel stupid even typing one handed-DL

 

[dabears505]

The two handed DL is an interesting technique, but how do you get the tube in? Maybe bite the tube?

 

[GassYous]

The two handed DL is an interesting technique, but how do you get the tube in? Maybe bite the tube?

You hold the tube between your 4th and 5th fingers and use the thumb to push it in.

 

[Arch Guillotti]

Best course of action would prob be to communicate this to your chief of medicine service and he can talk to the anesthesiology chief

No. Keep moving.

 

[TwistedTea]

Barked at him? lmao

The mental picture this provides tho

 

[deleted162650]

Although I agree this story is probably embelished, you'd be surprised at some stuff that goes unnoticed. One of my colleagues who was team captain and a CA-3 at the time saw a CA-2 do a two-handed DL because they "couldn't see anything" with a one-handed DL.

Edit: I feel stupid even typing one handed-DL

Hey, I got a view though didn’t I!

 

[narcusprince]

Not your fight. Keep your head down. Thats why their is supervision.

 

[chocomorsel]

Although I agree this story is probably embelished, you'd be surprised at some stuff that goes unnoticed. One of my colleagues who was team captain and a CA-3 at the time saw a CA-2 do a two-handed DL because they "couldn't see anything" with a one-handed DL.

Edit: I feel stupid even typing one handed-DL

I have been around. I don't believe one second that the above story is embellished. I have seen some stuff in some of these crazy practices. Bad attitudes from nurses and docs who just try to survive because they have no backbone, don't really care and/or probably no admin support.

 

[secretasianman]

The field of anesthesia has a high variance between each practice for the type of shiz that is allowed to happen. I imagine this is is the case in other fields as well.

more impressive is you managed to get 50 intubation a as an fp intern!

 

[deleted875186]

There is 110% a big political history behind this, even if the story is embellished by the OP.

never get involved in any of this as a resident, even if you were about to graduate, don’t burn any bridges.

 

[anbuitachi]

what's wrong with 2 handed DL??? there are a lot of ppl with arm issues.

 

[sevoflurane]

The field of anesthesia has a high variance between each practice for the type of shiz that is allowed to happen. I imagine this is is the case in other fields as well.

more impressive is you managed to get 50 intubation a as an fp intern!

truth

 

[sevoflurane]

I’m just an intern... in medicine no less. I don’t claim to be a master of the airway. I’ve done some 50 intubations in my short time.

But I’ve recently had some experience watching a particular CRNA intubate and I’ve had some concern that she may not exactly know what’s she’s doing. Both times I’ve seen her she has attempted 4 and then 5 times before successfully getting the airway. I always thought the recommended limit was 3? We have an Intensivist on-call that she could’ve called. One time the anesthesiologist actually told her to hand over the blade and she barked at him. And even just watching her maneuver the Mac and hyperangulated VL, I don’t think she knows what she’s doing. I’m just assuming the anesthesiologists that work over her would’ve noticed if that was true so maybe I just caught her a few bad days? Not really sure if I should just move about my day but I would really appreciate any input on the matter. Thank you in advance!

Bro... you are not “proficient” ‘till you hit about 250 ish solo intubations. Just saying dude.

 

[sevoflurane]

You may have seen a crna mill crna.. i’ll give you that. 100%

 

[sevoflurane]

You may have seen a crna mill crna.. i’ll give you that. 100%

I’ve seen fresh icu docs with 50 numbers... it is reminiscent to your crna intubation.

 

[repititionition]

You hold the tube between your 4th and 5th fingers and use the thumb to push it in.

amateur. the pro gets view with two hands in a position like he-man holding up the power sword, clenches the styletted tube between their teeth, drives it between the cords, then gently repositions their mouth to extract the stylette with their teeth. You then spit the stylette out, preferably into someone's waiting hand (this establishes dominance), and only release the two-handed position after declaring the cormack-lehane view that was obtained. If it's a grade two view you have to specify A or B.

I don't know if this is how it's done everywhere but this is standard of care where I train.

 

[vector2]

amateur. the pro gets view with two hands in a position like he-man holding up the power sword, clenches the styletted tube between their teeth, drives it between the cords, then gently repositions their mouth to extract the stylette with their teeth. You then spit the stylette out, preferably into someone's waiting hand (this establishes dominance), and only release the two-handed position after declaring the cormack-lehane view that was obtained. If it's a grade two view you have to specify A or B.

I don't know if this is how it's done everywhere but this is standard of care where I train.

So you're saying hold the laryngoscope like a shake weight

 

[jw3600]

Bro... you are not “proficient” ‘till you hit about 250 ish solo intubations. Just saying dude.

That’s a little extreme. Plenty of docs are very good at airways after 80-100.

 

[GassYous]

That’s a little extreme. Plenty of docs are very good at airways after 80-100.

I was good since day 1

 

[deleted162650]

That’s a little extreme. Plenty of docs are very good at airways after 80-100.

 

[nimbus]

That’s a little extreme. Plenty of docs are very good at airways after 80-100.

Define “very good”. That’s 2 months into CA-1 year. I sucked at that point and so did everybody else.

 

[nimbus]

amateur. the pro gets view with two hands in a position like he-man holding up the power sword, clenches the styletted tube between their teeth, drives it between the cords, then gently repositions their mouth to extract the stylette with their teeth. You then spit the stylette out, preferably into someone's waiting hand (this establishes dominance), and only release the two-handed position after declaring the cormack-lehane view that was obtained. If it's a grade two view you have to specify A or B.

I don't know if this is how it's done everywhere but this is standard of care where I train.

In full PAPR no less.

 

[sevoflurane]

That’s a little extreme. Plenty of docs are very good at airways after 80-100.

lol

 

[sevoflurane]

That’s a little extreme. Plenty of docs are very good at airways after 80-100.

We are a pretty rough crowd here sometimes. I appreciate what you are trying to do and you are probably right with your crna assesment. You are coming into a forum where we know how many reps it takes to become profficient. It is no mystery to us especially those of us that teach AW management to med students, residents, AAs and are quarterbacks for ICU docs. We know what it takes. You are still a baby below 100 tubes- especially for truly difficult AW’s.

 

[deleted162650]

Around 100 is where you can start to say that a patient is a difficult DL because they are actually a difficult DL and not they are a difficult DL because you suck.

 

[mdawarre]

what's wrong with 2 handed DL??? there are a lot of ppl with arm issues.

I also think it's valid for a few reasons- sometimes patients aren't positioned optimally (fat and should have had a ramp but it's a floor tube), some women anesthesiologists are petite, you can sometimes 2 arm it and then lock the left arm in place to intubate, sometimes you realize that you're not going to be able to brute force the view on DL and need a glide, etc. i know everyone on here besides me is 6'4" and jacked. i'm speaking for the rest of us plebes 😘

 

[D P356]

Your role as an intern is not to kill patients and collect information, not raise systemic concerns.

Agree.
Also, discharge summaries, yeah.

and 2am cross cover diet orders, because you just happened to be carrying the pager and the other team’s pt diet order expired.
Ahhh, intern year.

 

[Iso4ane]

Agree.
Also, discharge summaries, yeah.

and 2am cross cover diet orders, because you just happened to be carrying the pager and the other team’s pt diet order expired.
Ahhh, intern year.

Don’t forget the 4am calls regarding Tylenol orders for fevers, when the patient is normothermic.

 

[chocomorsel]

I also think it's valid for a few reasons- sometimes patients aren't positioned optimally (fat and should have had a ramp but it's a floor tube), some women anesthesiologists are petite, you can sometimes 2 arm it and then lock the left arm in place to intubate, sometimes you realize that you're not going to be able to brute force the view on DL and need a glide, etc. i know everyone on here besides me is 6'4" and jacked. i'm speaking for the rest of us plebes 😘

As a petite woman, I can honestly say I have never tried a two handed view. It’s all about angling up the HOB or getting the Glidescope or asking for help.
Is this two handed DL really a thing? For real?

 

[deleted697127]

I’m just an intern... in medicine no less. I don’t claim to be a master of the airway. I’ve done some 50 intubations in my short time.

But I’ve recently had some experience watching a particular CRNA intubate and I’ve had some concern that she may not exactly know what’s she’s doing. Both times I’ve seen her she has attempted 4 and then 5 times before successfully getting the airway. I always thought the recommended limit was 3? We have an Intensivist on-call that she could’ve called. One time the anesthesiologist actually told her to hand over the blade and she barked at him. And even just watching her maneuver the Mac and hyperangulated VL, I don’t think she knows what she’s doing. I’m just assuming the anesthesiologists that work over her would’ve noticed if that was true so maybe I just caught her a few bad days? Not really sure if I should just move about my day but I would really appreciate any input on the matter. Thank you in advance!

Please comment on what you’ve seen observing medicine residents place central lines. I always remind the ortho docs i work with to be ready for a surgical airway if i don’t get it on the first three attempts.


This reminds me of reading stories about 3rd year med students from Stanford wanting to go into consulting to change medicine before actually having any experience.

"I was supposed to be focused on the patient's vital signs and presenting a summary, but I was consumed with thoughts about how to improve the process of rounds,"

Siren Song Of Tech Lures New Doctors Away From Medicine

Medical school graduates around San Francisco Bay are far less likely to pursue medical residencies than those in other parts of the country. Instead, many are heading to health technology ventures.

www.npr.org

 

[abolt18]

Don’t forget the 4am calls regarding Tylenol orders for fevers, when the patient is normothermic.

My worst ever was a midnight call to "update you on ____ patient's vitals."

Those vitals were ALL totally normal. And they had been all day. And there was no reason to be concerned that they'd be changing.

 

[GassYous]

My worst ever was a midnight call to "update you on ____ patient's vitals."

Those vitals were ALL totally normal. And they had been all day. And there was no reason to be concerned that they'd be changing.

ahaha
I will always remember a 3 am phone call because the nurse noticed that one of her patient's heart rate was 120. He's been pounding around at 120 all day and probably had been for months. He was admitted solely for tachycardia. It had been a busy night full of small fires and scutwork and I had just fallen asleep after the 2 am mad rush of phone calls for mildly abnormal vital signs. The nurse was telling me about how she just noticed the patient's heart rate (shift started at 7 pm) and wanted to see if I wanted to do anything about it. Patient is snoring away. Christ.

 

[sevo00]

My worst call was at 3am the nurse was asking for a social work consult. AT 3AM

 

[Iso4ane]

My worst call was at 3am the nurse was asking for a social work consult. AT 3AM

Did you order it STAT?

 

[nimbus]

Did you order it STAT?

Add a stat sponge bath while you’re at it.

 

[Airway]

My worst ever was a midnight call to "update you on ____ patient's vitals."

Those vitals were ALL totally normal. And they had been all day. And there was no reason to be concerned that they'd be changing.

A va nurse called me as an intern to program a PCA pump (at midnight I'm sure). The only button I knew on the pump was the silence.

 

[DocVapor]

A va nurse called me as an intern to program a PCA pump (at midnight I'm sure). The only button I knew on the pump was the silence.

I got called at 3 am to asses the beeping epidural pump and worsening pain. I checked my notes and wasn't aware of any epidural in that patient. I get there and the dude is chilling in the chair doing a crossword. His pain was fine. Also, he had no epidural, the beeping thing was an IV pump with an empty bag of saline.

 

[GassYous]

On the topic of intern year bull****, I remember I got a signout about a patient at 9 pm who they couldn't get a good blood pressure on. Their signout to me was to get a manual cuff and check it again. I figured they had a ****ty day already but I was like wtf?? My phone was already blowing up with floor nonsense and I had to do nighttime icu rounds. Got a call from the floor about that patient right after signout and then immediately heard an overhead rapid response for that room. Ran over and the patient is basically pericode.

IV doesn't work, can't get a pressure, patient breathing all funny and looks like ****. That patient ended up in the unit and died soon after. That team had the gall to report me to leadership for my supposedly poor nighttime management of their patients (that senior was the only mother****er that asked me to wait for him to come in so I can sign out to him as well not just his intern). I am so much happier now.

 

[nimbus]

On the topic of intern year bull****, I remember I got a signout about a patient at 9 pm who they couldn't get a good blood pressure on. Their signout to me was to get a manual cuff and check it again. I figured they had a ****ty day already but I was like wtf?? My phone was already blowing up with floor nonsense and I had to do nighttime icu rounds. Got a call from the floor about that patient right after signout and then immediately heard an overhead rapid response for that room. Ran over and the patient is basically pericode.

IV doesn't work, can't get a pressure, patient breathing all funny and looks like ****. That patient ended up in the unit and died soon after. That team had the gall to report me to leadership for my supposedly poor nighttime management of their patients (that senior was the only mother****er that asked me to wait for him to come in so I can sign out to him as well not just his intern). I am so much happier now.

Always a bad sign. You should have refused the signout until they could get a blood pressure.

 

[chocomorsel]

On the topic of intern year bull****, I remember I got a signout about a patient at 9 pm who they couldn't get a good blood pressure on. Their signout to me was to get a manual cuff and check it again. I figured they had a ****ty day already but I was like wtf?? My phone was already blowing up with floor nonsense and I had to do nighttime icu rounds. Got a call from the floor about that patient right after signout and then immediately heard an overhead rapid response for that room. Ran over and the patient is basically pericode.

IV doesn't work, can't get a pressure, patient breathing all funny and looks like ****. That patient ended up in the unit and died soon after. That team had the gall to report me to leadership for my supposedly poor nighttime management of their patients (that senior was the only mother****er that asked me to wait for him to come in so I can sign out to him as well not just his intern). I am so much happier now.

That happened to me just last month. Literally. Morning sign out not from an intern but from an attending and an NP. I immediately went over and the patient looked like death warmed over. He also died a few hours later on four pressors and BP in the 60s.

 

[jw3600]

We are a pretty rough crowd here sometimes. I appreciate what you are trying to do and you are probably right with your crna assesment. You are coming into a forum where we know how many reps it takes to become profficient. It is no mystery to us especially those of us that teach AW management to med students, residents, AAs and are quarterbacks for ICU docs. We know what it takes. You are still a baby below 100 tubes- especially for truly difficult AW’s.

I am probably a little over 100, finishing EM residency. I see your point. I guess I was just trying compare it to other activities we do. Take someone who skis. It takes a while to log 100 full runs down the mountain (real west coast skiing, not Vermont). By the time you get to ~80 or so it's not unreasonable that you are finessing single blacks. I would say that is very good. Not the expert that is a seasoned attending anesthesiologist (or double/triple black/heliskiing rider). But it seems that many of you think the number is higher than I would have thought and I don't really have a leg to stand on.

Around 100 is where you can start to say that a patient is a difficult DL because they are actually a difficult DL and not they are a difficult DL because you suck.

Hahah.

 

[vector2]

I am probably a little over 100, finishing EM residency. I see your point. I guess I was just trying compare it to other activities we do. Take someone who skis. It takes a while to log 100 full runs down the mountain (real west coast skiing, not Vermont). By the time you get to ~80 or so it's not unreasonable that you are finessing single blacks. I would say that is very good. Not the expert that is a seasoned attending anesthesiologist (or double/triple black/heliskiing rider). But it seems that many of you think the number is higher than I would have thought and I don't really have a leg to stand on.

Hahah.

Every EM program and resident is different, but based on my experience at a Level I TC where the ED intubates, if the attending anesthesiologists are triple black then the majority of senior, graduating EM residents are high green circles/low blue squares. They use VL almost exclusively and can get the tube in in most straightforward airways, but if anything deviates from plan A then the whole thing goes to sht. I don't blame them though, because the variation in their supervising staff's airway skills is enormous.