caligas

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This week I saw each of the following by crnas that I supervise during true, full stomach RSIs:

- aggressive mask ventilation
-propofol 2 cc at a time, checking eyelash reflex after each dose
-my favorite: taping the eyes shut mid-rsi

I educated as best I could.
 

urge

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This week I saw each of the following by crnas that I supervise during true, full stomach RSIs:

- aggressive mask ventilation
-propofol 2 cc at a time, checking eyelash reflex after each dose
-my favorite: taping the eyes shut mid-rsi

I educated as best I could.
Sounds like you were a bystander letting them do whatever.
 

IlDestriero

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I push the drugs myself and dictate the flow. RSIs are my way or the highway.
Styletted tube, etc.
No discussions or weirdo plans for emergencies. You just do what works.
 
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caligas

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Youre right. Bad habit of giving to much leeway when its time to take control. Its why I dont like to supervise, mostly do my own cases. Something to work on.
 

FFP

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Don't feel bad. IlDestriero is Peds, which matters a lot. Even stupid administrators know that they cannot afford a bad Peds outcome.

It's much tougher to stand up to the CRNA wolf pack in a place where the administration is on their side, even when they do illegal things (as in not following physician instructions). One cannot fight such a system.
 
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This week I saw each of the following by crnas that I supervise during true, full stomach RSIs:

- aggressive mask ventilation
-propofol 2 cc at a time, checking eyelash reflex after each dose
-my favorite: taping the eyes shut mid-rsi

I educated as best I could.
whats wrong with that one? seems like the best option out of all three
 

rsgillmd

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When I was a resident I relieved a CRNA who was supposed to go home. MAC/sedation + local by surgeon case for a breast biopsy finishing up. As I settle in and assess the situation I saw he had taped the eyes shut on an awake patient. When I untaped her eyes, the nervous patient said, "Thank God. I can see again!" So remember, eyes taped mid-RSI is better than eyes taped awake.
 

soorg

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Happens to me too. My version, for a healthy, nl BMI adult:

Pre-O2, midaz, fent, 10 mg roc, 100 mg propofol, 100 mg sux, 20 mg more of propofol, mask vent for 5 sec, eyes taped, intubation.

I don't understand the thought process (if there is one) at all.
 

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When I was a resident I relieved a CRNA who was supposed to go home. MAC/sedation + local by surgeon case for a breast biopsy finishing up. As I settle in and assess the situation I saw he had taped the eyes shut on an awake patient. When I untaped her eyes, the nervous patient said, "Thank God. I can see again!" So remember, eyes taped mid-RSI is better than eyes taped awake.
What in the actual F#ck....
 

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My personal bar for WTF was set during residency by someone who moved the ECG leads to make the ST segment depression go away, and my WTF meter hasn't gone further right since then.
 

pgg

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Yeah, but did it work?
The patient lived so it could've been therapeutic, but I may have leaked some troponin when I saw it.
 

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My personal bar for WTF was set during residency by someone who moved the ECG leads to make the ST segment depression go away, and my WTF meter hasn't gone further right since then.
What a brilliant idea. Thanks for the tip. Will definitely try it next time. The troponin was a great move too.
 

chocomorsel

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What about in a peds case
1. Taking the already styleted ETT apart from the stylet
2. Having all and EMERGENCY drugs locked up in pyxis
3. Refusing to give fentanyl till return on spontaneous ventilation when the HR is in the 140's on a 7 year old during intubation. "I want them to breathe before I give fentanyl"
4. 200mg induction dose on a 92 y/o patient. Wasn't there for this one, just happened to be giving lunch. Pressure in the toilet.
5. When I first started got thrown into a case by my partners, that I didn't preop didn't know much about. Walked in right before induction and as I am reading the preop the CRNA pushes a bunch of propofol on a guy who should have received etomidate. B/P drops into the 60's and 50's. Patient goes into a tachyarrythmia that initially looked like Vtach. I cancel the case after giving him pressors/fluids. He goes, "I don't understand why he went into a an arrrythmia" Really? Really? My partners kinda screwed me on that one though.

I ****in hate supervising. Wish I could do my own cases. I am gonna start being the biatch attending. Tired of the stupidity and looking for trouble where there is none.
 
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IlDestriero

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What about in a peds case
1. Taking the already styleted ETT apart from the stylet
2. Having all and EMERGENCY drugs locked up in pyxis
3. Refusing to give fentanyl till return on spontaneous ventilation when the HR is in the 140's on a 7 year old during intubation. "I want them to breathe before I give fentanyl"
4. 200mg induction dose on a 92 y/o patient. Wasn't there for this one, just happened to be giving lunch. Pressure in the toilet.
5. When I first started got thrown into a case by my partners, that I didn't preop didn't know much about. Walked in right before induction and as I am reading the preop the CRNA pushes a bunch of propofol on a guy who should have received etomidate. B/P drops into the 60's and 50's. Patient goes into a tachyarrythmia that initially looked like Vtach. I cancel the case after giving him pressors/fluids. He goes, "I don't understand why he went into a an arrrythmia" Really? Really? My partners kinda screwed me on that one though.

I ****in hate supervising. Wish I could do my own cases. I am gonna start being the biatch attending. Tired of the stupidity and looking for trouble where there is none.
I've never worked at s place where the crna pushed induction drugs. They have the airway, I've got the drugs and can watch what's going on while they ventilate, intubate, tape, etc. Same with residents.
 

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I've never worked at s place where the crna pushed induction drugs. They have the airway, I've got the drugs and can watch what's going on while they ventilate, intubate, tape, etc. Same with residents.
Consider yourself lucky. I have been a part of all the idiocy mentioned in this thread more than once.
 

IlDestriero

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So what are you doing if not pushing drugs and managing the induction? Seriously.
It's your patient. I don't view any patient as their patient. My name, my malpractice, my reputation, my patient.
That's what you pay me for.
 

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It's hard when u come in to place where the culture is for the CRNA'S get to do everything. The only thing they don't do is epidurals PNBs and CVCs. Heck we don't even do CVCs the surgeons do. Soo bored. Looking for a new gig.
 

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I see a lot of not STEPPING UP TO THE MIC WITH THE MICATAN in this thread. Disappointing.
 

chocomorsel

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I see lot of not STEPPING UP TO THE MIC WITH THE MICATAN in this thread. Disappointing.
Easier said than done. You are the new guy, and you insist on pushing all the drugs, doing the spinals where the CRNA's have been given a lot of independence prior to your arrival. You are gonna be the dingus. I know, who cares, but your old partners who let them do all that **** before will, your work environment will be strained, and it's just not worth it. That's why I am outta here soon. Now I know what to look for next time.
 

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Easier said than done. You are the new guy, and you insist on pushing all the drugs, doing the spinals where the CRNA's have been given a lot of independence prior to your arrival. You are gonna be the dingus. I know, who cares, but your old partners who let them do all that **** before will, your work environment will be strained, and it's just not worth it. That's why I am outta here soon. Now I know what to look for next time.
It can be very hard to come into a new practice and deal with this sort of stuff. Not always readily apparent when yo are interviewing either.
 

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Soo so nice. Would love to have this. Screw it, going back for an ICU fellowship. Can't take this **** anymore.
Why? so you can tell even less educated nurses to do things that they still may or may not do? I still have NP/PA to deal with, RT, RNs, dieticians, and consultants who may not do what I consulted them to do. Dealing with other professionals and their shortcoming is part of being a doctor. Learning how to manage people without becoming an a hole is a skill that we don't get taught well enough in training.
 

Arch Guillotti

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Why? so you can tell even less educated nurses to do things that they still may or may not do? I still have NP/PA to deal with, RT, RNs, dieticians, and consultants who may not do what I consulted them to do. Dealing with other professionals and their shortcoming is part of being a doctor. Learning how to manage people without becoming an a hole is a skill that we don't get taught well enough in training.
Noctors run wild in the ICU I deal with unfortunately.
 

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Noctors run wild in the ICU I deal with unfortunately.
I've never worked in an ICU that doesn't have a heavy noctor presence, particularly the PICU at our joint. Sebelius and the current administration have made it quite clear that this is the future of medicine.
 

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hi,..i want to ask...regarding about the small dose that the CRNA gave for RSI...i never gave 2 cc prop, but in case of emergency ..i did often use 5 cc prop for the start and then titrate...because i am quiet afraid about its hypotension effect. what do you think? i can achieved quiet good result with it, i believe i learned it somewhere in the Benumof 's or other airway textbook ( i forgot which one)...
 

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Sucks to be you guys. All-MD is so, so nice.
See, to me all MD is a total waste of my brain power. I do 4x as many CVPs, 4x as many a lines, 4x as many blocks, 4x as much neuraxial, and I don't have to sit there and tweak the gas up or down a click for 4 hours during a boring case.

different strokes
 
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chmd

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All of these occurred for the same drunk, stable trauma patient

1. Staff paged when pt was in room rather than when nurse went to get pt in ED
2. Zonked on midaz and fent when staff got to room - arousable to yelling/a good shake
3. Preoxygenated with whatever slow and shallow effort this sedated pt still had with pop-off valve totally closed
4. Suction off and not within arms length (pt being induced on transport bed, painful to move?)
5. Pulse ox not on properly, ie not reading
6. Unstyleted ETT

I'd love to be a fly on the wall at a CRNA training hospital for a few days to observe how snras are trained. Any resident with this compilation of errors would have had her ass handed to her by attending/senior residents.
 

chocomorsel

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Why? so you can tell even less educated nurses to do things that they still may or may not do? I still have NP/PA to deal with, RT, RNs, dieticians, and consultants who may not do what I consulted them to do. Dealing with other professionals and their shortcoming is part of being a doctor. Learning how to manage people without becoming an a hole is a skill that we don't get taught well enough in training.
Well, because I have always loved the unit. That's the truth. However, right now, I need to accumulate a little bit of wealth and pay some loans down. I had a fellowship lined up last year, but due to not getting a license in a timely manner got dropped. My poor planning. Now bored at my current gig, but looking for something more challenging. Then maybe ICU down the line.
 

chocomorsel

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See, to me all MD is a total waste of my brain power. I do 4x as many CVPs, 4x as many a lines, 4x as many blocks, 4x as much neuraxial, and I don't have to sit there and tweak the gas up or down a click for 4 hours during a boring case.

different strokes
That's not brain power. That's technical skill. As much as I like doing procedures but with the right training, anyone can do that.
To me, brain power is when you are sitting with the sick ass **** ICU ASA4/5 or trauma ASA4/5 or ruptured AAA ASA5 who's trying to die on you and after you've induced, tubed(without killing them), placed lines, you are still trying to keep them alive, by titrating pressors, giving fluids, blood, following labs closely, running thru differentials of what could be going on in your head and treating accordingly, communicating effectively w surgeon, possibly coding a patient and gettting them thru safely instead of worrying about somebody else screwing it up, that to me is using brain power.
Just my opinion.
The things I see frequently, from midlevels done just from rote memorization, and repetition without much thought process just plain scare me.
 

Mman

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That's not brain power. That's technical skill. As much as I like doing procedures but with the right training, anyone can do that.
To me, brain power is when you are sitting with the sick ass **** ICU ASA4/5 or trauma ASA4/5 or ruptured AAA ASA5 who's trying to die on you and after you've induced, tubed(without killing them), placed lines, you are still trying to keep them alive, by titrating pressors, giving fluids, blood, following labs closely, running thru differentials of what could be going on in your head and treating accordingly, communicating effectively w surgeon, possibly coding a patient and gettting them thru safely instead of worrying about somebody else screwing it up, that to me is using brain power.
Just my opinion.
The things I see frequently, from midlevels done just from rote memorization, and repetition without much thought process just plain scare me.
Taking care of 1 patient at a time is not using your abilities to their fullest extent. It's like being in an ICU. I can multi task and think about more than 1 patient at once. I can take care of the sick ass ASA 5 patient and still have a few other rooms with it at the same time. So I can do more technical procedures and come up with differentials and make diagnoses and communicate with surgeons far more often.

To me sitting on the stool for 1 case at a time is slow and easy. Even an ruptured AAA or ruptured aneurysm is not that complicated if it's the only patient I've got.

I also don't spend my day "worrying about somebody else screwing it up", I make sure I am clear on my plan for a patient and I work with people that know what I want to be called for if the plan isn't working well. I'm also the all seeing eye as I can pull up multiple anesthetics at the same time and browse through their vitals and vent settings and such from any computer terminal.
 

saratoga733

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See, to me all MD is a total waste of my brain power. I do 4x as many CVPs, 4x as many a lines, 4x as many blocks, 4x as much neuraxial, and I don't have to sit there and tweak the gas up or down a click for 4 hours during a boring case.

different strokes
look can a surgeon supervise a couple of appys or knee scopes... sure they can. to their credit they have not been foolish enough to go down that road. there are no jobs out that offers total intellectual stimulation EVERYDAY-- esp once you've been doing it a while. besides, what u're mentioning are monkey skills. to me this has more to do with taking pride in personal patient care and less about maximizing income. do you want your internist to titrate your BP med or his assistant nurse? and yes, i'd take less money if it means we hire more MDs instead of nurses. btw, i realize crnas are a necessary reality for many ORs out there but supervising 4 rooms is not ideal IMHO
 

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Taking care of 1 patient at a time is not using your abilities to their fullest extent. It's like being in an ICU. I can multi task and think about more than 1 patient at once. I can take care of the sick ass ASA 5 patient and still have a few other rooms with it at the same time. So I can do more technical procedures and come up with differentials and make diagnoses and communicate with surgeons far more often.

To me sitting on the stool for 1 case at a time is slow and easy. Even an ruptured AAA or ruptured aneurysm is not that complicated if it's the only patient I've got.

I also don't spend my day "worrying about somebody else screwing it up", I make sure I am clear on my plan for a patient and I work with people that know what I want to be called for if the plan isn't working well. I'm also the all seeing eye as I can pull up multiple anesthetics at the same time and browse through their vitals and vent settings and such from any computer terminal.

It appears your idea of monitoring multiple rooms is evolving quite rapidly. Go to the link below, scroll down to the videos section and click on Medical Innovation # 5-Perioperative Decision support system.
http://my.clevelandclinic.org/anesthesiology/default.aspx

This system capitalizes on the "hub-and-spoke" model that had been a topic of conversation at some point in the past. Can you put an ICU nurse in the OR instead of an expensive CRNA and monitor the cases from a distance? Will we need stool sitters in the future? Who knows?!
 

Mman

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look can a surgeon supervise a couple of appys or knee scopes... sure they can. to their credit they have not been foolish enough to go down that road. there are no jobs out that offers total intellectual stimulation EVERYDAY-- esp once you've been doing it a while. besides, what u're mentioning are monkey skills. to me this has more to do with taking pride in personal patient care and less about maximizing income. do you want your internist to titrate your BP med or his assistant nurse? and yes, i'd take less money if it means we hire more MDs instead of nurses. btw, i realize crnas are a necessary reality for many ORs out there but supervising 4 rooms is not ideal IMHO
What does a surgeon supervising a knee scope have to do with anything? They are being paid for both their knowledge of who needs the surgery as well as their own technical ability to do it. We aren't paid for our ability to turn the dial on the vaporizer. If you don't think you can supervise more than 1 room, how do you describe the care an ICU physician provides to more than 1 patient at a time?

Do I want my internist or assistant nurse titrating my BP med? Huh? You imply that a CRNA being supervised is doing whatever they want to and not following the orders I give them.

odd
 

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I won't dispute the fact that sitting on the stool isn't using your brainpower to its utmost extent. I agree that it isn't.

That isn't the point of this thread though. This thread is about silly stuff that you deal with when supervising. I don't want to have to deal with that noise. I'm happy giving up a few procedures and thought processes per day, if in so doing I avoid the headaches, stress, drama, and sheer nonsense that comes with trusting other people to do a job right that I'm extremely particular about.

At the end of the day, it's more satisfying to me to take care of one sick as sheeeit patient at a time, and knowing it's done right.

But different strokes.
 
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saratoga733

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"... I can take care of the sick ass ASA 5 patient and still have a few other rooms with it at the same time. So I can do more technical procedures and come up with differentials and make diagnoses and communicate with surgeons far more often.

...Even an ruptured AAA or ruptured aneurysm is not that complicated if it's the only patient I've got."

the mortality of a ruptured AAA that makes it to the hospital is as high as 60-90%. for most human anesthesiologists it takes their A game, a rock star surgeon, and lady luck on their side to bring the pt off the OR table alive... nevermind hospital discharge. to suggest you can 'supervise a few other rooms at the same time' is incredibly cavalier. i do hope anyone i care about don't end up in your neck of the woods.
 

saratoga733

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What does a surgeon supervising a knee scope have to do with anything? They are being paid for both their knowledge of who needs the surgery as well as their own technical ability to do it. We aren't paid for our ability to turn the dial on the vaporizer. If you don't think you can supervise more than 1 room, how do you describe the care an ICU physician provides to more than 1 patient at a time?

Do I want my internist or assistant nurse titrating my BP med? Huh? You imply that a CRNA being supervised is doing whatever they want to and not following the orders I give them.

odd
some of us choose not to supervise... not because we can't. economics aside, i think most would agree it's superior patient care. we are paid for our knowledge to determine who can safely have surgery and our technical ability to do it-- and yes, turning the dial is a small part of that.

if you are saying no crna ever gives a medication without a specific order by you personally then more power to you. the reality however is plenty of meds are given without the specific orders of their 'supervising' docs intraop. how can you blame them? they are actually there with the patient, probably know the patient's history better than you do, and actually know what the surgeon is doing at that moment...
 

pgg

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That's not brain power. That's technical skill.
I disagree. The thinking part of anesthesia is in evaluating patients, making a plan, and executing the critical portions of the case. Just counting the number of patient encounters, there's a lot more opportunity and need for that in a ACT practice than solo anesthesiologist.

I've done all my own cases since finishing residency, except for very brief periods of supervision / medical direction at a locums gig. On one hand I think I've benefited tremendously from being alone, and from sitting through long cases. Some of my sphincter clenching-est moments have come in the middle of routine cases, and there's value to honing that vigilance and paying attention to what the surgeon's doing ... not just thinking that takeoff and landing are the only times things can go wrong. I had a great attending during residency who very strongly opined that every new anesthesiologist should spend the first couple years out of residency doing nothing but own cases, in the OR for long hours.

But on the other hand I think I've maybe missed out on some learning and management skill development by spending so little time floating between rooms and being involved in 3-4x as many cases.

Mostly though I'm glad it's just me responsible for my patients. (Well, and the surgeon, and PACU nurse, and surgery PA, and floor nurse, and scrub tech ... ninjas and assassins are everywhere.)
 

chocomorsel

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I disagree. The thinking part of anesthesia is in evaluating patients, making a plan, and executing the critical portions of the case. Just counting the number of patient encounters, there's a lot more opportunity and need for that in a ACT practice than solo anesthesiologist.

I've done all my own cases since finishing residency, except for very brief periods of supervision / medical direction at a locums gig. On one hand I think I've benefited tremendously from being alone, and from sitting through long cases. Some of my sphincter clenching-est moments have come in the middle of routine cases, and there's value to honing that vigilance and paying attention to what the surgeon's doing ... not just thinking that takeoff and landing are the only times things can go wrong. I had a great attending during residency who very strongly opined that every new anesthesiologist should spend the first couple years out of residency doing nothing but own cases, in the OR for long hours.

But on the other hand I think I've maybe missed out on some learning and management skill development by spending so little time floating between rooms and being involved in 3-4x as many cases.

Mostly though I'm glad it's just me responsible for my patients. (Well, and the surgeon, and PACU nurse, and surgery PA, and floor nurse, and scrub tech ... ninjas and assassins are everywhere.)
Haha!!! I love that last line.
Anyway, in the process of trying to move back home now and find a new gig. I know what I don't want which is supervising. Really would love to do my own cases. Should I join a group with some limited supervision then I want it to be one where they haven't been let loose and free doing their own thing for so long that my presence doesn't mean ****. I want to be able to to actually medically direct not just sign the charts here, which is kind of the culture where I supervise.
 

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It sounds like a lot of you guys aren't really supervising. Yeah, The care team model is a headache for me sometimes too, but some of the crnas are really pretty good and on board with the team concept. The ones that aren't you just really have to watch and let them know (sometimes subtly sometimes not) who is in charge. I push the drugs, I do all the lines, blocks, etc. CRNA gets one shot at airway and then it is my turn. I make the plan, although I am definitely open for discussion on most things that don't really matter that much (which gas, nmb, etc) - Don't be a micromanager when it's not important. Some of the same ones that act like big shots will be the first ones to need you to bail them out when they get into trouble, and handling these situations shows why physician supervision is absolutely necessary. I do miss doing my own cases sometimes, but with >40 anesthetizing locations how am I gonna find enough docs for that? And then I have to sit on the stool during the boring parts of the case like was already discussed - which is absolutely a waste of my time.
 

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And then I have to sit on the stool during the boring parts of the case like was already discussed - which is absolutely a waste of my time.
It is a waste of your time only if you're your own boss, or close to it. Otherwise, if you are an employee, working with undereducated militant hospital CRNA's can end up being a waste of your... license.
 
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seinfeld

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Well, because I have always loved the unit. That's the truth. However, right now, I need to accumulate a little bit of wealth and pay some loans down. I had a fellowship lined up last year, but due to not getting a license in a timely manner got dropped. My poor planning. Now bored at my current gig, but looking for something more challenging. Then maybe ICU down the line.
I am a practicing ICU doc. My point remains that no matter what branch of medicine you choose you still have to learn how to steer people when you're the captain.
 

RT2MD

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10+ Year Member
Apr 2, 2007
746
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The Great White North
Status
Resident [Any Field]
So... along the lines of these discussions, how important would you all rate experience supervising midlevels and/or jr residents in residency? Specifically I'm wondering who all thinks that senior "supervising" electives during residency is a good idea?