Do ur attendings come for epidurals?

[drofgas]

Hello everyone, just out of let's say statistical curiosity, if I may say so, I would like to ask the residents here in the forum if at your places the attendings come for your epidurals in your CA1 year let's say, CA2(probably not?!...). Thx. Have a good night and/or a good call everyone!
Thx.
A.

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[SleepIsGood]

Hello everyone, just out of let's say statistical curiosity, if I may say so, I would like to ask the residents here in the forum if at your places the attendings come for your epidurals in your CA1 year let's say, CA2(probably not?!...). Thx. Have a good night and/or a good call everyone!
Thx.
A.

As a CA1 --> yes.

As a CA2-3--> usually no.

 

[countingdays]

As a CA1 --> yes.

As a CA2-3--> usually no.

CA1-3 --> yes (unfortunately)

 

[Leverage]

depends on what time the epidural is being placed... middle of the night...not so much

 

[bigeyedfish]

As a CA1 --> yes.

As a CA2-3--> usually no.

Same here. They stopped coming after I could get it in before they got there.

 

[rsgillmd]

I was doing epidurals by myself in October of my CA-1 year. It could have been September of my CA-1 year but I went on vacation for 2 weeks to India. I think this time frame (September/October CA-1) was similar for the rest of my class also.

I remember because as a CA-1 I had been taught to call the attending or senior resident before doing an epidural. We split the night amongst the two OB residents. When I was working (1st half) I called my attending to say I have to do an epidural in Room X. His response to was, "So? Go ahead and do it. Why are you calling me?" And with those words my strings were cut.

Obviously they came if they were needed. My hospital (Maimonides) also does a lot of OB, so that may have something to do with it. Even up til CA-3 my attendings were in the room when I did an epidural in the main OR, but that's a different situation because they would have to be there for the time out.

As an attending supervising CRNAs and SRNAs I try to be there out of principle if I know an epidural is being done, but I don't ask them to get me unless it is for a C/S. The CRNAs supervise the SRNAs directly. While the CRNAs have their own quirks, they are all excellent from a technical skill standpoint.

 

[Dejavu]

Here we have a policy that an attending will be present for any block done by a resident or fellow. May be legalese, may be billing oriented (don't want to bill for supervision if it didn't happen), I don't know.

I believe most of us obey the policy.

Just because we are present doesn't mean the resident isn't allowed independence of thought and action or allowed to struggle. Although I will say some of my colleagues are "needle grabbers" more than others.

I don't know if the policy is a good idea or not, but it is what it is.

 

[geauxg8rs]

My lazy -SS attendings would never come unless it was a spinal for c/s. The labor epidurals never. Would page in the am to have them sign the forms. (of course they were still cranky at 7 am and would whine about having to "go upstairs" to sign them).
As a CA3 we were the "team leader" and would help out with epidurals when ob was busy, help out with ICU resident with lines, be there for codes and traumas and help the juniors with cases throughout the night. They called it "junior attending." There was nothing "junior" about it.
My fav was when I was up on OB helping do some epidurals for the ob resident and the ob team comes flyin around the corner with fetal distress for emergent c/s. we get to the room and of course I tell the circ nurse to page my attending. We slapped on some 02 and intubate away, hook up some monitors and baby is out. Attending shows up as they are closing and asks if everything is okay. You wanna say "just covering your -SS once again.

 

[Masseter Spasm]

As an attending, I try to be present for epidurals as much as possible. (I am not, however, a "micromanager.") Part of the reason is billing-related. I think that medicaid and some other types of insurance reimburse even worse than their normally meager rates for epidurals that are not placed under "direct" supervision. Because I practice in an academic institution with high risk OB, this population can be a substantial proportion of our population. Has anyone else been told this?

 

[aredoubleyou]

For medicare reimbursement, I believe, the supervising physician must be present for key elements of the procedure to bill for the procedure. To bill for a procendure that you did not witness, in technical terms, is medicare fraud. You can get fined, disciplined, retroactively un-reimbursed, etc from cms. they can do what ever they want. The decision to supervise a ca-3 at midnight is primarily one of cya, more so than being needed.

I think some private insurances have the same rules (that prolly arent policed like medicare), so one applies this to all patients and all procedures, again for CYA reasons.

 

[proman]

Hopefully not too many Medicare patients need labor epidurals.

 

[rsgillmd]

Hopefully not too many Medicare patients need labor epidurals.

Funny! Good catch Proman.

On a related note we get alot of patients on TennCare (TN's version of Medicaid). Even at Maimonides (Boropark Brooklyn) many of the grand multips were on Medicaid. Sucks from a reimbursement standpoint.

Is it just my experience or is it like this at other places also in terms of large number of laboring women being on Medicaid?

 

[Jeff05]

the question is: what if there is a complication during epidural placement? your name is on the chart and the patient/husband WILL know that you weren't there for the procedure.

are we legally required to SEE that patient/be present during procedure?

 

[Pilot Doc]

are we legally required to SEE that patient/be present during procedure?

No, the attending has no legal requirement to be present. Residents are licensed physicians and an anesthesiology (or psych) resident can legally place an epidural solo.

Billing is entirely different. Attendings who routinely bill medicaid for epidurals they don't supervise are committing fraud. All the bad things mentioned above are possible; so is going to jail. It's also a setup for a qui tam lawsuit.

 

[sevoflurane]

During residency... one of my attendings would let me fly starting Ca-2.
I'd do all the epidurals and c/s at night. He would get out of bed around 6:45am., head up to OB half asleep and sign the OB charts before going home. Some attendings would give us less freedom, some were needle grabers (usually the less confidant ones). Either way, I think it's a good idea to let you fly early as you will feel more at ease as you enter PP.

 

[usnavdoc]

As an attending supervising CRNAs and SRNAs I try to be there out of principle if I know an epidural is being done, but I don't ask them to get me unless it is for a C/S. The CRNAs supervise the SRNAs directly. While the CRNAs have their own quirks, they are all excellent from a technical skill standpoint.

lol Maybe thats true in the pocket of the universe you live in, but dont extrapolate that to other places.

 

[Consigliere]

Yeah, where I work, we don't even put in labor epidurals. It's a small hospital and it isn't worth the time or money to come in and place labor epidurals. The CRNAs, who are all hospital employees, are in house 24/7 and take care of it. We are always available, if need be, but we need to come in MAYBE once a year to put in labor epidurals. Sweeeet set-up.

 

[aredoubleyou]

Hopefully not too many Medicare patients need labor epidurals.

We'll see how good the in vitro thing gets 🙂

But the point is, insurance companies generally follow all the silly BS that Medicare come up with. So whats true for medicare can often be assumed to be true for other carriers, if you dont want to go through the hassle of looking it up on a case by case basis

 

[rsgillmd]

lol Maybe thats true in the pocket of the universe you live in, but dont extrapolate that to other places.

Wasn't trying to extrapolate. Sorry if it came across that way.

If I had my choice I would rather work with residents. However, I also believe in giving credit where it is due. These guys here do a very good job when it comes to doing tough IVs, epidurals. I've rarely bailed them out.

 

[TIVA]

Wasn't trying to extrapolate. Sorry if it came across that way.

If I had my choice I would rather work with residents. However, I also believe in giving credit where it is due. These guys here do a very good job when it comes to doing tough IVs, epidurals. I've rarely bailed them out.

At my institution, which is relatively prestigious (usually ranks 1 or 2 or 3 in NIH funding for anesthesia research), the anesthesia attendings who undergo surgery usually ask for CRNA's. I don't think it's meant to be a diss to the residents, but if I was having surgery, I'm pretty sure I would prefer the person who had been doing this 10 years vs. the CA-3 or CA-4 (fellow).

 

[ProRealDoc]

At my institution, which is relatively prestigious (usually ranks 1 or 2 or 3 in NIH funding for anesthesia research), the anesthesia attendings who undergo surgery usually ask for CRNA's. I don't think it's meant to be a diss to the residents, but if I was having surgery, I'm pretty sure I would prefer the person who had been doing this 10 years vs. the CA-3 or CA-4 (fellow).

What does that say about you as a teacher if you can't even trust your senior residents (that you trained) to deliver an excellent anesthetic by the time they are CA-3s/fellows?

 

[sevoflurane]

what if... say you had a choice btw/ a CRNA that has been doing it for 10 years and a PP anesthesiologist that has been out of residency for 1 year....??

I have met some really good CRNA's Excellent ones actually. However, I have also met plenty of not so good ones (that have been out for 15+ years).

The first time I had to supervise (as a resident) an epidural placement by a CRNA who had been out for a while, I tried being a team player. She was clearly clueless about the finer aspects of placing an epidural...and a bit aggressive/dangerous. I am not a needle grabber... but this particular one thought she did not need any helpful advice... until she wet tapped our patient.

I know... they are not all made the same.

When it comes to who will deliver my anesthetic... well, it will be done by someone who is experienced and is not overconfident with their skills. Most of the time this = MD.

 

[veetz]

What does that say about you as a teacher if you can't even trust your senior residents (that you trained) to deliver an excellent anesthetic by the time they are CA-3s/fellows?

👍

 

[IMED4Life]

Based on CMS interpretation of epidurals, I guess supervision isn't needed at all?!?!

 

[Arch Guillotti]

I find the length of time in practice to be irrelevant to the skill of the nurse provider. I have worked with nurses who have been CRNA's nearly as long as I have been alive and they still can't intubate WORTH A CRAP! I have seen other ones grossly underestimate surgical bleeding despite obvious clues and those that would not know ischemia if it were staring them in the face.

On the other hand, I have worked with some new grads who seem pretty competent, vigilant and always let me know if there is a problem or they are concerned about something.

At my institution, which is relatively prestigious (usually ranks 1 or 2 or 3 in NIH funding for anesthesia research), the anesthesia attendings who undergo surgery usually ask for CRNA's. I don't think it's meant to be a diss to the residents, but if I was having surgery, I'm pretty sure I would prefer the person who had been doing this 10 years vs. the CA-3 or CA-4 (fellow).

 

[rsgillmd]

To each their own. The reasons I would prefer to work with residents are multifactorial, and include but are not limited to:

1) Residents tend to have greater critical thinking skills than CRNAs
2) Residents are easier to relate to b/c of similar background/training
3) Residents tend to be more likely to listen and discuss differences of opinion/different anesthetic options
4) Residents are less likely to have a clock-punch mentality
5) Residents tend to care about doing post-op checks

I was told when my hospital had a residency program the CRNAs generally did not want to help the residents in OB. If and when we get the program back, I'll be more than willing to stay up at night to help a resident during his/her rotation.

I realize there are multiple examples of MDs as well as CRNAs providing excellent as well as poor levels of care. But that's just life. There will always be outliers. Those outliers do not affect my opinion.

Having said that: If I were to require a complex surgical procedure, or if I were to develop multi-system disease and need a procedure, I would request a physician to be my provider.

Barring the above situations, I would not want to place anyone under undue pressure by making special requests.

As far as this new CMS rule, it just convinces me even more to support ASA-PAC. I'm glad the ASA had the guts to say they disagree with the CMS statement that an epidural is not anesthesia. If we lie back and do nothing, Blade's Doomsday scenario will definitely come to pass. Teamwork is important, and CRNAs have a role, but you can't let them take over either.