Fighting over procedures

[sevoflurane]

So here is what happened. 59 y/o CAD, HTN, CABG x 4 found at home with AMS eating his own decrement. Vitals 235/140, pulse 90, sats 96%. Gets a CT in the ED and shows Left sided ICB extending to ventricles. Patient still moaning and presumably protecting airway. He gets to the micu and I do his exam, start writing his note. Ed resident at my same level comes in after I initially work him up with a-line and central line kit and says "I'm getting access on this patient". I know some fights are better walked away form, but it was 4:00 am and I'd done quite a bit of work on this guy. I say "No Way Jose". After 5 min. of going back and forth he accepts to "let me put in central access". As I'm pushing the introducer this guy goes bradycardic (30's-40's) and begins to have irregular breathing... Likely Cushings triad. Eyes fixed or minimally reactive... then he starts gaging... left lateral decub as I tie in his line... pukes X3 and aspirates x3. Stat call anesthesia. As I finish my job, I asses his airway, look at his K+, Mallampati II-III, bring up the head of the bead to 35 degrees, get suction, mac 3 and 4 and suction at bedside. Give report to my anesthesia upper level and ask for the intubation. He says great! Meanwhile ED resident moves to the head of the bed and as we approach he asks for the intubation. ED dude bags and preoxygenates. Etomidate and Sux gets pushed and CA-3 tells me to grab the Mac and to prepare for intubation. Ed resident curses and has hissy fit over the scenerio makes me feel uncomfortable. Ends up being a grade III view, but I still am able to pass the tube, +co2, bilat. breath, equal chest rise and good condensation. As mannitol is being pushed I head down to CT to re-evaluate brain parenchyma with hypertonic saline in hand just in case.

This ED resident has tried to push his way into every procedure possible since I arrived to the MICU even on patients that he has not worked on. I'm not a confrontational kind of dude, but c'mmon. Makes the whole atmosphere non-team like and more of a cock fight for procedures. I can't freak'n stand this type of bullsh*t. Any other people feel this way? I've worked with others that readily give up procedures just to be cool... every tiime that happens everybody gets a piece of the pie and everybody is happy. Just venting over what could have been a long but cool call night....

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[sevoflurane]

By the way... Due to my experience, I now see the benefit of the MAC 4.

 

[MacGyver]

I want to expand this out to a larger discussion.

Dealing with random pricks who want to do all the procedures is one thing. If its just one guy who likes to play cowboy then I dont think thats a very big deal.

Poor training programs with poor clinical volume that force residents to fight it out for procedures is something else.

But the WORST case scenario is these places where the clinical volume is low and not only do you have residents competing over procedures, you have to compete against MIDLEVELS for procedures.

The people who run training programs have gotten sloppy and complacent. They try to train hundreds of people on small patient loads, because this gives them extra money from the federal government to run their department.

Something needs to be done about this. Medicare funding for residencies should be tied specifically to patient volume, so that greedy program directors cant just expand way beyond their capacity so they can get an extra 100k per resident from Medicare. Small community hospitals have NO BUSINESS having residents on service who are sitting around getting no training in procedures because the patient volume is small.

Furthermore, procedures should be given out in priority order as follows:

attending --> chief resident --> junior residents --> 4th year med students
--> 3rd year med students --> MIDLEVELS


You guys laugh, but I know programs that are so piss poorly operated that midlevels get the vast majority of exposure to procedures while the residents are forced to do menial labor. Residents, not midlevels should have first access to procedures.

 

[sevoflurane]

I want to expand this out to a larger discussion.

Dealing with random pricks who want to do all the procedures is one thing. If its just one guy who likes to play cowboy then I dont think thats a very big deal.

Poor training programs with poor clinical volume that force residents to fight it out for procedures is something else.

But the WORST case scenario is these places where the clinical volume is low and not only do you have residents competing over procedures, you have to compete against MIDLEVELS for procedures.

The people who run training programs have gotten sloppy and complacent. They try to train hundreds of people on small patient loads, because this gives them extra money from the federal government to run their department.

Something needs to be done about this. Medicare funding for residencies should be tied specifically to patient volume, so that greedy program directors cant just expand way beyond their capacity so they can get an extra 100k per resident from Medicare. Small community hospitals have NO BUSINESS having residents on service who are sitting around getting no training in procedures because the patient volume is small.

Furthermore, procedures should be given out in priority order as follows:

attending --> chief resident --> junior residents --> 4th year med students
--> 3rd year med students --> MIDLEVELS


You guys laugh, but I know programs that are so piss poorly operated that midlevels get the vast majority of exposure to procedures while the residents are forced to do menial labor. Residents, not midlevels should have first access to procedures.

Midlevels should not be doing porcedures at a teaching hospital if a resident lacks or needs experience on that given procedure. I'd be pissed off if I heard that a midlevel provider was doing porcedures on patients i rounded on that same morning.

 

[VolatileAgent]

well, i have to say that macgyver is partially right about the midlevels. and, believe it or not, sevoflurane, this also happens at the program you are transferring into. we are working hard on addressing this within a particular department - and with one particular midlevel. 'nuff said on that for a moment...

as far as competing with other residents from other specialties, i have to say that my experience, this occurs occasionally. but, i'm often more than happy to give up an "easy" airway to someone from another department simply because i get ample experience on a daily basis doing this. in fact, i like to stand by and help teach. we actually have ED residents rotate through our department as well, and their purpose is to get experience managing airways in a controlled environment. in the spirit of collegiality, i'm happy to oblige with the straightforward intubation-type scenarios. now, taking a fiberoptic away from me... ain't gonna happen. and, our department supports this 110%. however, the scenario you describe, sevo, is clearly an example of someone weaseling in. you should have said, "next time when you do all the scutwork, you'll get the procedure. that's the way it works, pal. so, back off now."

but, back to midlevels a minute. again, i think that the best thing you can do if you see this happening within your department or the service you are working on is to mention it to your PD. if you have their support (and you should), this can and should get addressed at the departmental level. we have had a problem with a few specific midlevels in our program on certain specialties - NOT the CRNAs (which are awesome at our institution) - who tend to waltz in late and expect to get all the glory of doing procedures, etc. i think they simply need to be reminded that we are not there to support them, and that in fact it is the other way around. the problem is that this often happens when you are doing an off-service month. there is a natural territorialism that occurs among a particular midlevel. they occassionally feel that they have ownership of that service and that you are just a visitor there to do their scutwork. often this can be traced back to poor leadership above you. again, simply speaking up (and, unfortunately, occassionally confrontation) resolves the problem.

so, in other words, don't bitch or complain about the system that employs too many residents and too many midlevels. go to your higher-ups within your department and identify specific deficiencies in your training - and use those words - with specific examples including names of people, dates, and what the procedure was, etc.

it is imperative that you get these experiences as a resident. if you don't, your career will suffer, and definitely not that midlevel's who's robbing you of your privilege to have first dibs.

 

[sevoflurane]

as far as competing with other residents from other specialties, i have to say that my experience, this occurs occasionally. but, i'm often more than happy to give up an "easy" airway to someone from another department simply because i get ample experience on a daily basis doing this. in fact, i like to stand by and help teach. we actually have ED residents rotate through our department as well, and their purpose is to get experience managing airways in a controlled environment. in the spirit of collegiality, i'm happy to oblige with the straightforward intubation-type scenarios. now, taking a fiberoptic away from me... ain't gonna happen. and, our department supports this 110%. however, the scenario you describe, sevo, is clearly an example of someone weaseling in. you should have said, "next time when you do all the scutwork, you'll get the procedure. that's the way it works, pal. so, back off now."

I hear you on this one. When my experience is equal or below that of another resident who is not anesthesia and at my same level, who decides to waltz in on the patient I have been working up for x amount of time... I tend to have a problem ... especially if I have the opportunity to manage an emergent and possible "difficult" airway I can learn from. If I had more experience and felt that I could intubate person X from twenty feet away I would totally let those who would benefit from the experience attempt to manage the airway. I know my limitations and I know I'm not that type of resident at this time. If I have an opportunity to perfect my airway skills and I've put the time into knowing the patients history, exam, airway, etc... and have upper level anesthesia residents to back me up, I tend to feel that emergent opportunities are those where I can learn skills that may one day influence my decision making and help me fully understand the difficult airway algorithm. These are opportunities I don't readily give up.. so BACK OFF NOW is something I'll have to get used to. I hate confrontation

 

[sevoflurane]

well, i have to say that macgyver is partially right about the midlevels. and, believe it or not, sevoflurane, this also happens at the program you are transferring into. we are working hard on addressing this within a particular department - and with one particular midlevel. 'nuff said on that for a moment...

Yeah... I heard about that. Dr. K is apparently all over it... and correct me if I'm wrong, but it's only during one outside rotation? Right?

 

[sevoflurane]

I'm a chill dude I guess I'll learn to metamorphosize

 

[Gimlet]

I'm a chill dude I guess I'll learn to metamorphosize

It's probably good that you're a chill dude, though. When you flick that switch and get SERIOUS about doing the procedure you earned, the other guy will know that you really mean business.

 

[InductionAgent]

I can relate. I was doing my Medicine Wards last month (I'm an intern) and had yet to get a good paracentesis, and the resident offers the belly tap on one of my patients to the 3rd-year med student! So I had to play the prick in pointing out that I needed the experience.

I was slightly annoyed as a medical student when I hardly got the chance to do procedures since the interns were ahead of me, but I told myself it would be all right as long as I got to do them as intern.

Now I'm in the MICU and the other intern has sidled in (with the resident's blessing) and done procedures on my patients when I'm post-call. It's being done in the guise of being a big help so that I can concentrate on getting my scutwork done and go home. Yeah, thanks a lot. I sure as hell wouldn't bitch about (or report) exceeding my duty hours if I can actually learn something useful. In the meantime, I've learned from experience to play it cool and attempt to make as few enemies as possible while rotating through other Departments. I'll be glad when I'm done rotating on this stupid Medicine service.

InductionAgent
PG-1, Anesthesia

 

[Carm]

I'll be glad when I'm done rotating on this stupid Medicine service.

InductionAgent
PG-1, Anesthesia

I've said this myself about 1,000 times this year. Saying it right now at 1 AM at the VA admitting general medicine patients on my MICU month during night call. What a kick in the teeth.

 

[bigeyedfish]

I can relate. I was doing my Medicine Wards last month (I'm an intern) and had yet to get a good paracentesis, and the resident offers the belly tap on one of my patients to the 3rd-year med student! So I had to play the prick in pointing out that I needed the experience.

Nothing wrong with that. I don't think that's being a prick at all. Interns should get procedures before MS3's.

I had to bite my tongue earlier this year in the MICU where, as an MS4, I was literally bumped out of the way so the NP student could do a central line on a patient I worked up. I was pissed, but kept my mouth shut because I didn't want to be a dick. Plus it was done with the blessing of the attending and the fellow, with the advice that, "You'll get plenty of chances to do this in residency, she won't." Now what is she doing as a NP? Charge nurse in the ED. How many lines will she ever put in?

 

[sevoflurane]

...I had to bite my tongue earlier this year in the MICU where, as an MS4, I was literally bumped out of the way so the NP student could do a central line on a patient I worked up.

That sounds painful. Hopefully you've dropped some lines since then.

 

[VolatileAgent]

Yeah... I heard about that. Dr. K is apparently all over it... and correct me if I'm wrong, but it's only during one outside rotation? Right?

yes, it is being addressed. but, it may still be up to you still to say, "no" if that person thinks you aren't in the loop and will back down if bullied. but, just know you have back-up from above you if this same person in question tries to start a sh*tstorm over it. that's one of the many things that makes our program so great. if you aren't being a complete tool about an issue and also provided that you have made the appropriate people aware that there is an issue in advance - and you do your confrontation the appropriate way - you will always be backed-up. conversely, if you always act like a doormat, you'll get walked on. part of learning to be an effective anesthesiologist - and doctor/leader, for that matter - is knowing when to tell people they can't do certain things to you (or the patient) despite their best efforts to exercise their own agenda.