CRNA intubations supervised in private practice

[Hamhock]

The following is NOT for anesthesiologists working in "academics" or with trainees.

Rather, I am interested in "private practice" models with CRNAs.

(please don't turn this into a CRNA vs. MD thread)

I have been in a couple of ORs with MDs supervising a few rooms of CRNAs (no trainees, medical or nursing). The anesthesiologist is present for every induction and subsequent intubation.

Most often, I have seen the anesthesiologist push the induction and NMB meds and supervise the CRNA place the tube (I have also seen this same "set-up" with RSI in the ICU). A few times the CRNA has struggled with the intubation. After some discussion, the anesthesiologist takes over with either DL or an alternative technique.

Why not just have the anesthesiologist manage the airway from the start? (the CRNA can have everything set up for before and after induction, as they already do)

(again, this is in "private practice" without trainees)

HH

---

Members don't see this ad.

 

[Coastie]

Clearly would be best for the patient.

Isn't the rule to have the best laryngoscopist do the airway?

I guess in some unfortunate cases, that isn't the anesthesiologist.

The following is NOT for anesthesiologists working in "academics" or with trainees.

Rather, I am interested in "private practice" models with CRNAs.

(please don't turn this into a CRNA vs. MD thread)

I have been in a couple of ORs with MDs supervising a few rooms of CRNAs (no trainees, medical or nursing). The anesthesiologist is present for every induction and subsequent intubation.

Most often, I have seen the anesthesiologist push the induction and NMB meds and supervise the CRNA place the tube (I have also seen this same "set-up" with RSI in the ICU). A few times the CRNA has struggled with the intubation. After some discussion, the anesthesiologist takes over with either DL or an alternative technique.

Why not just have the anesthesiologist manage the airway from the start? (the CRNA can have everything set up for before and after induction, as they already do)

(again, this is in "private practice" without trainees)

HH

 

[Dejavu]

That would be one sure way to lose every decent CRNA that practice has, because any CRNA who could walk, would. You would be left with a staff you can be sure is so bad that they cannot go anywhere else.

 

[seinfeld]

I did not go to medical school to learn how to intubate. I am present at induction to make decisions, and provide advanced skills, when things do not go the way they were anticipated.

I agree with Dejavu, if you insist on doing all your own things then you will be guaranted to end up all alone on every case😉

 

[imfrankie]

I am often dismayed how a surgical physician assistant and a CRNA will carry themselves so differently

 

[BLADEMDA]

That would be one sure way to lose every decent CRNA that practice has, because any CRNA who could walk, would. You would be left with a staff you can be sure is so bad that they cannot go anywhere else.

Absolutely Correct.

 

[jwk]

Clearly would be best for the patient.

Isn't the rule to have the best laryngoscopist do the airway?

I guess in some unfortunate cases, that isn't the anesthesiologist.

And clearly you've never been in private practice. Kudos to Seinfeld, Blade, and DejaVu.

Because of the way most ACT practices function, I would wager that most anesthetists perform far more intubations in their careers than most anesthesiologists, especially in an ACT practice. I know more tricks than most simply because I've been doing it forever, and on the uncommon instances I don't get a tube on the first try, my backup plan is already in play before the doc can suggest one. I probably get bailed out once or twice a year on an airway, which balances out with the once or twice a year I bail out one of our anesthesiologists. No brag, just fact. We all bring a variety of skillsets and experience to the table, and we all have our strengths and weaknesses.

Simply because I came along at a time when PA caths were common for all sorts of procedures, I've probably done more Swans than many of our newer docs will ever do or even see in our non-cardiac practice. By the same token, they've done exponentially more epidurals than I have. I still struggle with US anatomy because I was never exposed to it prior to about three years ago, but I can fly through 20 GI cases in an 6 hours that would drive my docs crazy trying to keep up with the logistics of 1 minute turnovers.

If you're in an ACT practice, make use of the skills of everyone in your department. An efficient practice demands it.

 

[Hamhock]

And clearly you've never been in private practice. Kudos to Seinfeld, Blade, and DejaVu.

Because of the way most ACT practices function, I would wager that most anesthetists perform far more intubations in their careers than most anesthesiologists, especially in an ACT practice. I know more tricks than most simply because I've been doing it forever, and on the uncommon instances I don't get a tube on the first try, my backup plan is already in play before the doc can suggest one. I probably get bailed out once or twice a year on an airway, which balances out with the once or twice a year I bail out one of our anesthesiologists. No brag, just fact. We all bring a variety of skillsets and experience to the table, and we all have our strengths and weaknesses.

Simply because I came along at a time when PA caths were common for all sorts of procedures, I've probably done more Swans than many of our newer docs will ever do or even see in our non-cardiac practice. By the same token, they've done exponentially more epidurals than I have. I still struggle with US anatomy because I was never exposed to it prior to about three years ago, but I can fly through 20 GI cases in an 6 hours that would drive my docs crazy trying to keep up with the logistics of 1 minute turnovers.

If you're in an ACT practice, make use of the skills of everyone in your department. An efficient practice demands it.

I completely hear you, jwk...in the sense that you have been practicing for many, many years in a system that has CRNAs intubating nearly all cases (yes, I am inferring/assuming).

However, most CRNAs are not like you...many are less than 5 years out of school.

All: doesn't it make sense to have the CRNAs set everything up but for anesthesiologists to be managing the airway...yes, CRNAs will loose their skills over time and new CRNAs will never gain superior skills -- but isn't that the whole point of the ACT model?

HH

 

[EdPierce]

well they are going to be the ones actually in the room with the patient, dont you think it would be a good idea for them to know how to intubate/place an lma? thats just basic anesthesia...

also to the crna who "bails out" his anesthesiologist on difficult airways... how does that even happen.. after a failed DL by an attending, they ask you to try? find that bard to believe

 

[jwk]

All: doesn't it make sense to have the CRNAs set everything up but for anesthesiologists to be managing the airway...yes, CRNAs will loose their skills over time and new CRNAs will never gain superior skills -- but isn't that the whole point of the ACT model?

HH

I'm an AA, but the sentiment is the same.

Where on earth did you get the idea that this is "the whole point" of how an ACT practice is supposed to work? I understand the politics far better than most, but this is an absurd way to make a political statement.

The idea of an ACT practice is to better utilize everyone's knowledge, skills, and abilities to enhance patient care, hopefully in an efficient and economically viable manner. The docs I work with are not what the CRNAs would have you believe is the stereotypical anesthesiologist who supervise from the lounge while drinking coffee and checking their portfolios. While I'm doing cases, they're seeing the next patient, placing an epidural or a block, and covering 2-3 other rooms. If you've never seen an efficient high volume ACT practice in action, you're welcome to come visit sometime and see how it can be done.

 

[jwk]

also to the crna who "bails out" his anesthesiologist on difficult airways... how does that even happen.. after a failed DL by an attending, they ask you to try? find that bard to believe

It happens because, at least in my practice, we have mutual respect for each other's experience and because we all realize we're there for the patient's benefit.

 

[urge]

also to the crna who "bails out" his anesthesiologist on difficult airways... how does that even happen.. after a failed DL by an attending, they ask you to try? find that bard to believe

Same way nurses sometimes bail you out of IV's.

Sometimes all you need is another set of hands.

 

[Mman]

I have no desire to intubate every patient I'm taking care of. And it wouldn't be any better for the patient if I did all the intubations. When I'm supervising an intubation, the things I most care about are not cutting lips, not chipping teeth, etc. As in the things patients care about. If the CRNA is struggling, I'm good at bailing people out.

It's like preop IVs. I don't start every patient's IV. The preop nurse does. If she can't get it, then I get called to come do it. But it isn't going to improve anything for the patient if I start every IV from the beginning.


Besides, as the posters above mentioned all the good CRNAs would simply leave and you'd be left with crap.

 

[bullard]

I definitely see where the ACT attendings are coming from. I do my own cases but I know that politics/economics may put an end to that at some point in the future. So I'd like to get a better understanding of how you manage your CRNAs who are managing the airway. If the airway is easy, of course have the CRNA intubate while you are getting an art line or managing hemodynamics or whatever.

But what would you guys do in the following 2 examples?

Example 1: 65 yo M with DMII, COPD, PVD with a known 4.5 cm AAA, going for CABG x3. MP III, mouth opening is somewhat limited, neck extension is somewhat limited. But you think you can mask-ventilate him.

Do you take the first look or do you let the CRNA go at it?

Example 2: 40 yo M, type I diabetic, morbidly obese with BMI 48, beard, not much of a neck, but MP I, good mouth opening, going for shoulder scope in lateral position. You have a good interscalene block in place. For sake of argument you're planning to intubate, not LMA. CRNA says "looks like a chip shot." You say, "yeah, but he's gonna desat FAST."

Let the CRNA intubate or do you get the first shot?

 

[MRW]

I definitely see where the ACT attendings are coming from. I do my own cases but I know that politics/economics may put an end to that at some point in the future. So I'd like to get a better understanding of how you manage your CRNAs who are managing the airway. If the airway is easy, of course have the CRNA intubate while you are getting an art line or managing hemodynamics or whatever.

But what would you guys do in the following 2 examples?

Example 1: 65 yo M with DMII, COPD, PVD with a known 4.5 cm AAA, going for CABG x3. MP III, mouth opening is somewhat limited, neck extension is somewhat limited. But you think you can mask-ventilate him.

Do you take the first look or do you let the CRNA go at it?

Example 2: 40 yo M, type I diabetic, morbidly obese with BMI 48, beard, not much of a neck, but MP I, good mouth opening, going for shoulder scope in lateral position. You have a good interscalene block in place. For sake of argument you're planning to intubate, not LMA. CRNA says "looks like a chip shot." You say, "yeah, but he's gonna desat FAST."

Let the CRNA intubate or do you get the first shot?

I was involved in a similar case recently. I did the intubation with the glidescope with the attending next to me.

 

[IlDestriero]

well they are going to be the ones actually in the room with the patient, dont you think it would be a good idea for them to know how to intubate/place an lma? thats just basic anesthesia...

also to the crna who "bails out" his anesthesiologist on difficult airways... how does that even happen.. after a failed DL by an attending, they ask you to try? find that bard to believe

The guy intubating 5 patients a day for 20-30 years has skills, and experience and knowledge. Ignore that and you're making a big mistake. Would I let some fellow or junior nurse anesthetist try if I was struggling? No, of course not.

I definitely see where the ACT attendings are coming from. I do my own cases but I know that politics/economics may put an end to that at some point in the future. So I'd like to get a better understanding of how you manage your CRNAs who are managing the airway. If the airway is easy, of course have the CRNA intubate while you are getting an art line or managing hemodynamics or whatever.

But what would you guys do in the following 2 examples?

Example 1: 65 yo M with DMII, COPD, PVD with a known 4.5 cm AAA, going for CABG x3. MP III, mouth opening is somewhat limited, neck extension is somewhat limited. But you think you can mask-ventilate him.

Do you take the first look or do you let the CRNA go at it?

Example 2: 40 yo M, type I diabetic, morbidly obese with BMI 48, beard, not much of a neck, but MP I, good mouth opening, going for shoulder scope in lateral position. You have a good interscalene block in place. For sake of argument you're planning to intubate, not LMA. CRNA says "looks like a chip shot." You say, "yeah, but he's gonna desat FAST."

Let the CRNA intubate or do you get the first shot?

They would get both. If you are really worried about the airway, you should probably think about a glidescope, fiber, etc.

 

[Mman]

I definitely see where the ACT attendings are coming from. I do my own cases but I know that politics/economics may put an end to that at some point in the future. So I'd like to get a better understanding of how you manage your CRNAs who are managing the airway. If the airway is easy, of course have the CRNA intubate while you are getting an art line or managing hemodynamics or whatever.

But what would you guys do in the following 2 examples?

Example 1: 65 yo M with DMII, COPD, PVD with a known 4.5 cm AAA, going for CABG x3. MP III, mouth opening is somewhat limited, neck extension is somewhat limited. But you think you can mask-ventilate him.

Do you take the first look or do you let the CRNA go at it?

Example 2: 40 yo M, type I diabetic, morbidly obese with BMI 48, beard, not much of a neck, but MP I, good mouth opening, going for shoulder scope in lateral position. You have a good interscalene block in place. For sake of argument you're planning to intubate, not LMA. CRNA says "looks like a chip shot." You say, "yeah, but he's gonna desat FAST."

Let the CRNA intubate or do you get the first shot?

I do whatever I think is best for the patient. And a lot of it depends on the CRNA (or AA) I'm working with. I give a lot less leeway to the new grad. If I want to do the intubation, I'm going to do it. That could be for reasons of potential difficulty or $20K worth of dental work that if I'm going to get sued for it might as well be me damaging it.

In >99% of situations, I let the CRNA go first. The point at which I elbow them out of the way depends on the CRNA and the patient. When it comes to something like an awake FOI, I'm doing it every time.

 

[baller71457]

It happens because, at least in my practice, we have mutual respect for each other's experience and because we all realize we're there for the patient's benefit.

Bravo! Pride and title goes out the window in the best interest of the pt. I remember being new at a hospital and asking the scrub tech that had been there forever a question about the epidural equipment because it was different than what I trained with. I had 2 options, ask someone else who "wasn't an expert" or do a GA on a 22 y/o non emergent section. Easy call

 

[pgg]

Bravo! Pride and title goes out the window in the best interest of the pt. I remember being new at a hospital and asking the scrub tech that had been there forever a question about the epidural equipment because it was different than what I trained with. I had 2 options, ask someone else who "wasn't an expert" or do a GA on a 22 y/o non emergent section. Easy call

I am a little confused.

Are you a medical student? That's what your status line indicates. If so, where was your attending and how was the regional/GA decision in your hands? If you're not a student, how on earth does unfamiliarity with an epidural tray lead a resident or attending to consider GA for a routine section? I've never met a tray or pump I couldn't figure out after a few minutes of looking at it.

I don't believe I've ever met a scrub tech that would know the first thing about an epidural tray. Except maybe, "they keep them over there" ...


I'm not too proud to ask an experienced nurse for help with something, especially monkey skills.

 

[IlDestriero]

I am a little confused.

Are you a medical student? That's what your status line indicates. If so, where was your attending and how was the regional/GA decision in your hands? If you're not a student, how on earth does unfamiliarity with an epidural tray lead a resident or attending to consider GA for a routine section? I've never met a tray or pump I couldn't figure out after a few minutes of looking at it.

I don't believe I've ever met a scrub tech that would know the first thing about an epidural tray. Except maybe, "they keep them over there" ...


I'm not too proud to ask an experienced nurse for help with something, especially monkey skills.

I was wondering the same thing...

 

[baller71457]

I am a little confused.

Are you a medical student? That's what your status line indicates. If so, where was your attending and how was the regional/GA decision in your hands? If you're not a student, how on earth does unfamiliarity with an epidural tray lead a resident or attending to consider GA for a routine section? I've never met a tray or pump I couldn't figure out after a few minutes of looking at it.

I don't believe I've ever met a scrub tech that would know the first thing about an epidural tray. Except maybe, "they keep them over there" ...


I'm not too proud to ask an experienced nurse for help with something, especially monkey skills.

I've posted several times before that my choice of title here was spawned by a post by jet indicating how disrespectful we can be of others when we feel they're "beneath" us. If I remember correctly an attending was going off on a "measly student" because of the title differences AND the thread wasn't even a clinical related one. Then I saw a piece on CNN about this world famous musician playing music at an airport. Pretty much everybody bypassed said musician because they assumed he was a nobody. With that said, my interest in this forum has less to do with beating my chest and bragging about my accomplishments to a group of people I don't know or will ever meet. It's more of me wanting to be a sponge and soak up as much info as I can, so in a sense yes I am and will always be a "student".

In regards to the c section incident. Like I said it wasn't an emergent section, but the OB was calling it an urgent one. Patient already had epidural in place, they roll into the room and as I disconnect the pump and get ready to start bolusing the catheter the entire mechanism fell apart. In retrospect it was an easy fix, but after I fumbled with it a few times I asked the L&D nurse, her response "you're asking me?!?......I dunno, you should ask Jim, I bet he knows".

 

[countingdays]

well they are going to be the ones actually in the room with the patient, dont you think it would be a good idea for them to know how to intubate/place an lma? thats just basic anesthesia...

also to the crna who "bails out" his anesthesiologist on difficult airways... how does that even happen.. after a failed DL by an attending, they ask you to try? find that bard to believe

I also don't see how a crna bailing out an anesthesiologist on an airway happens. A crna would never intubate after my failed DL because if I'm doing the airway, I've already taken over from the crna. There's no way we're going back to having the crna taking a look. If they didn't get it and I'm not getting it, we are going c-mac or lma, not repeating failed attempts at DL.

 

[deepseadiver]

I also don't see how a crna bailing out an anesthesiologist on an airway happens. A crna would never intubate after my failed DL because if I'm doing the airway, I've already taken over from the crna. There's no way we're going back to having the crna taking a look. If they didn't get it and I'm not getting it, we are going c-mac or lma, not repeating failed attempts at DL.

Please recognize the skills of those you work with. I have no problem admitting that the CRNAs where I work have way more intubations these days than I do. I have also had a CRNA intubate a patient that I was struggling to intubate. Do you really think that makes me less of an anesthesiologist?

Do you seriously think any CRNA will work with you if you "attempt" to take away their skills? That has to be the most ridiculous idea I have heard in a long time! Respect the skill set that others bring to the table!!

 

[BLADEMDA]

This is the fundamental problem with the ACT model. The newly minted Anesthesiologist needs a few years (3-5) to perfect his/her skills. I was fortunate that for my first 10 years I did 30-40% of my own cases and personally performed the vast majority of Regional blocks/lines.

If a new graduate comes out of Residency and hardly ever intubates or does a procedure that MDs skill set won't exactly be JPP "superstar" level.

I guess these days you have your FOB, Glidescopes, U/S machines so who needs to be slick any longer?🙄

 

[cincincyreds]

I don't have crans at my place, but I do get a resident every once in a while. I prefer to minimize intubation attempts so if the residents so if they can't get it, I put an lma in and then glidescope.

 

[Benicetoall]

At my place MDA's and CRNA's do there own cases. I was in preop and a circulater
walks up to me and whispers DR. So-and-so needs your help. I ran to his OR. He
got caught with a difficult intubation. The MDA had tried everything. Including
glidescope and FOB. The CRNA's job at this place, is to help mask when called in.
As i was holding the mask and jaw. Without disturbing his current attempts, I had
this OR's circulater set up the Fastrac. The only thing he didn't try. He saw it was
ready. It worked. This was the second scariest intubation i had, only because we
exhaused the ASA difficult algorithm and the only thing left was cancel the case
and "wake up patient".

 

[countingdays]

This is the fundamental problem with the ACT model. The newly minted Anesthesiologist needs a few years (3-5) to perfect his/her skills. I was fortunate that for my first 10 years I did 30-40% of my own cases and personally performed the vast majority of Regional blocks/lines.

If a new graduate comes out of Residency and hardly ever intubates or does a procedure that MDs skill set won't exactly be JPP "superstar" level.

I guess these days you have your FOB, Glidescopes, U/S machines so who needs to be slick any longer?🙄

I probably do 50% of my own cases and 100% of lines and blocks. ~2% of airways if I'm with a crna, because they almost always get it just fine.

My point was that crnas take the first look, so there's no reason for them to take over an airway from you. The failed intubabtion sequence is
crna -> MD -> LMA/C-mac,
not crna -> MD -> crna again /> LMA/C-mac.
It's not meant as a slight to anyone's skills, just a result of who looks first and who looks second.

 

[deleted126335]

There is a mixture of clinical care opinions and unspoken anesthesiologist/crna politics influencing speech in this thread. There are also two probable CRNA trolls on this thread. Or one troll with two ID's

Bottom line:
There are often multiple reasonable options on how to conduct one's day to day practice.
There are often multiple reasonable options within the bounds of professional discretion when faced with managing a difficult airway or any other technical procedure or decision. Turf and place to maintain in the jungle sometimes influence the choice of reasonable options. The coming glut of CRNAs is likely to affect these internal algorithms.

 

[seinfeld]

Some in this thread are arguing a point of view which is not logically sustainable. If the most experienced attending always did the intubation then residents would never intubate, medical residents would never do an H&P, OB residents would never do a delivery, and surgical residents would never touch anything other than a retractor.

I believe that this creep of less independence during residency has promoted the fact the Blade talks about when stating it takes 2-3 years to solidify your skills.

I remember doing my CA-3 pediatric rotation, a 20+ year experienced CRNA in pediatrics anesthesia was having issues with me intubating one of those micronathic syndrome patients. My attending defended me and allowed me to intubate. What was best for the neonate? Obviously it would be to have the CRNA intubate or the attending but the worst time for me to have to my first of these would be when i was all alone, in the middle of the night.

Intubating is a monkey skill, decision making is what makes us physicians. If you feel it will be a difficult intubation decided what tools you want available, decide whether to do it awake or asleep, decide what drugs you want to use on induction.