Arch Guillotti
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here's the latest garbage i'm dealing with
Started by VolatileAgent
I agree with your sentiment vis a vis professionalism/handoff culture and how that reflects on the specialty, and I think especially in the case of sicker patients or bigger cases it absolutely is worse for that patient's safety as the number of handoffs increase. However, in the case of hourly or salaried "shift workers" like in EM, CCM, and increasingly in non-private practice anesthesia, the financial incentives unfortunately have to align with patient care goals if you want people staying past their typical designated shifts or hours/week.
I'm working nightfloat and when I came on I relieved my colleague (who worked a busy 12h today) who was medically directing an experienced CRNA in the one case that's going- a healthy 30yo getting his arm fixed. Maybe there's an argument to be made about the professionalism/handoff culture, but there's plenty of situations where it would beggar belief to claim that the handoff was unsafe.
🤔
Do you get paid extra for this?
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deleted87051
Yes. 100% production based compensation so we get paid like we do for any case. Once the case is launched, it is basically an hourly rate which does not vary depending on the time of day.
Our departmental policy is that call people offer relief to noncall people. Most people accept relief. A few of us rarely or never accept relief.
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Money talks. Most people will stay to finish the case especially if it’s started already if it involves extra money. It also depends on the time of day in production base. If its 530pm in LA traffic like my brother group which is blended, you might as wait 2 hours and finish an easy case and leave at 7-730pm and make extra instead of sitting in traffic trying to take the 405 south
If you are salary. It makes zero sense to stay longer than you have to. Obviously if it’s unstable patient. U never hand off salary or production base.
You must have not worked with asshats. There are people who will get the base units, then leave right after 15min mark. So they get the base+1, and let someone else finish…. [emoji869]
Absolutely. There is NO LOYALTY. Loyalty doesn’t pay bills.
When the hospital force our hand even with a “good” contract to employ you or invite an AMC to come in, milk it and get the best contract that you can and protect your own interest.
Same here (mostly) - I really don’t like to hand off a case because I believe I have a duty to that person, especially if it’s a challenging or complicated case. That said, I don’t know if I’d stick it out 5-6 hours over unless it was a truly exceptional case. We do not get paid extra after our shift unless it was “necessary for patient care”.
I’ve also had coworkers hand off stuff like unstable liver resections with something like “oh yeah it’s a guy getting a liver resection and they have lines, it’s fine” then run out the door about 20 min before the patient near arrests from massive blood loss.
Good for you @nimbus! You are always awesome. Way better than me.
Six hours is excessive. Anything less than 45 minutes I am ok with. 20 minutes is ridiculous to hand off IMO.
You need to jump in the locums bandwagon
If it’s 20mins left, has it really even started?
Let me know where it is. I may have the license and ask for 500/hr. Lol
If you do 60hours a week, you are generating at least 1500 units per month if not more. I used to work solo in a community hospital, 4 gastric bypass done by 2 pm.
Lol you must not remember academics well. Did a 4 hour one the other day
Yikes... I'm all for that in theory, except there is no reward for good work anymore. I'm going to go home and spend time with my family, if relief is in sight and patient is stable. Nothing to be gained by staying late and "looking good" or "irreplaceable." Guess what, we're all replaceable, cats outta the bag. Doesn't matter what the surgeon thinks, that's why we picked this field - to do what we enjoy, and also have a life. And the OR nurses, come on, you think they're going to stick around if it's unstable case? LoL
Maybe he gets paid to stay?
We do that at my gig. Not on call and working past 3pm? 275/hr.
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deleted87051
Oh man, SDN needs a remindme function. I got about 2.5 years left in the Army and am still interested in your group.
Pretty sure we are not unique in that regard. My previous group had a similar “after hours” pay structure.
It’s a good way to get all the cases covered after 3pm.
In employment models it’s essential, the hospital needs some ‘skin in the game’ if they want to schedule IR/GI/broken bones all night. In academics it’s common too but they’ll just take what they expect you to make in overtime out of your base pay so you still hit the mediocre MGMA median or whatever they’re targeting.
I can confirm Indiana, pay is also better than that.
Name and shame when its all over with. We all need to know to make them work HARD to find anyone to do cases....
Same here. Its very unprofessional and irritating.
This is what I thought he was doing or they were making him do; working more and not getting paid for it.
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deleted87051
No lunch breaks where I work. What’s wrong with scarfing down lunch during turnover? Or skip breakfast and lunch and do intermittent fasting. 😉
I agree with you but it’s the culture where I work and it is prevalent in residency programs too
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deleted1130227
If you don't get a meal break, you are less likely to need a bathroom break.
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deleted87051
I appreciate your sentiment and see that you do care about your patients. I am also in a 100% production based practice. So when I refuse relief, I am basically taking money away from the call person since they are there to work and relieve people. By staying later, I selfishly will line my pockets while taking money off my partners plate who is coming to do a night shift. Professionalism is also owed to our colleagues in the practice.
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deleted87051
Nobody seems to mind. Usually there is plenty of other work for them to do. I don’t tell my patients, “I’ll take care of you until 5pm when the night guy comes on duty and I’m outta here. He is awesome and will take great care of you.”
Even though it is our policy that call people offer relief to noncall people, we also have a policy that we have the option to finish any case that we start for any reason, including personal preference. If everybody finished the cases that they start, it would all come out in the wash. Some people don’t mind staying late to finish their cases, other people prefer to go home asap. Everybody has a choice.
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deleted87051
That is true. However, 60hrs/week is a lot of work. It would be 7a-7pm 5 days/week. I don’t know many people who work that much or even have the opportunity to work that much.
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deleted641888
Handover of Anesthesiology Care and 1-Year Mortality Among Adults Undergoing Cardiac Surgery
Safety of Complete Anesthesia Handovers in the Cardiac Surgical Patient
Some food for thought. In our practice, we don’t often hand over cardiac cases unless it’s a normal EF CABG, and even that’s rare for any one of us to do unless we have more pressing matters outside of the hospital. IMO, it’s not completely unreasonable to finish cases, even if the perception is that you want more money for yourself. Personally, I don’t enjoy using central lines I didn’t place, drips I didn’t hang, vasoactive drugs I didn’t draw up, lines I didn’t personally connect, rooms I didn’t set up, etc., but that’s probably the type A in me.
I always offer to finish my case if I do somehow get relief. If it’s been a tough anesthetic or complex case, I always finish them no matter what. It’s the culture of our practice, and it’s not a bad thing, IMO.
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deleted641888
We’ve been working that much (or more) for the better part of a year now due to acute/chronic understaffing. The money is good, but it’s been exhausting. I know of a few other practices around the same region that are in the same boat but obviously not all practices have the same production pressure as we do.
Thats a fair point as well. Here, we cant refuse relief unless the case is < 30 min from being completed.
@anaesthetic, I've seen those studies and definitely can see it's validity in cardiac patients or those with severe co-morbid conditions, however, I am skeptical about its generalization to other patients such as laparoscopic procedures, robots, lumps and bumps, etc..
Obviously there are cases that should be handed off rarely (like cardiac) and it’s nice to have camels for partners that don’t need relief.
Having said that I think this discussion is overemphasizing the drawbacks to handoffs and underestimating the benefits.
You can learn a lot about your colleagues by giving them breaks or taking over cases. You provide a fresh perspective on a patient’s anesthetic. You can learn different techniques or ways of doing things. You become more flexible with doing things different ways as sometimes it’s easier to continue with someone else’s plan rather than change to your normal way of doing things. You can have more predictability in your schedule.
Having said that I think this discussion is overemphasizing the drawbacks to handoffs and underestimating the benefits.
You can learn a lot about your colleagues by giving them breaks or taking over cases. You provide a fresh perspective on a patient’s anesthetic. You can learn different techniques or ways of doing things. You become more flexible with doing things different ways as sometimes it’s easier to continue with someone else’s plan rather than change to your normal way of doing things. You can have more predictability in your schedule.
Yeah an ASA 1 or 2 whatever easy case isn't going to be affected by handoff unless it's like multiple handoffs
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deleted87051
Just look at the massive lawsuits posted in the press and on this board. Most are disastrous outcomes after “minor” procedures. Especially if it is a medical direction or supervision practice, I don’t know how often you get an adequate handoff that describes the course of the case, how the patient is behaving in the operating room, if the surgeon is having problems, etc etc.
At my place, you are a salaried employed physician and if you are staying to finish a case for 5-6 hours, now two people are being paid hourly rates to be there (you plus the one who has to be the in house person for coverage). It would double the cost to the hospital for the coverage for that period. The costs are increasingly scrutinized so unnecessary double coverage would be frowned upon. If it is half an hour or even an hour to stabilize things or finish something up, that is different. That practice would likely be shut down pretty quick at my place.
I understand the commitment and applaud it, but there is also secondary gain monetarily that could be driving it. We have had a CRNA paid by the hour that would be dismissed to home only to find them still in the hospital a few hours later giving a break to a colleague at a time when we had plenty of help. First, that is a red flag for diversion, but this guy was simply padding his hours (all paid at overtime rates) and making a ton of unwarranted extra money by claiming he was needed for hours longer than he really was.
We get what we incentivize. If there was no extra money to be had for the commitment, I suspect that level of commitment would go away fairly quickly.
I understand the commitment and applaud it, but there is also secondary gain monetarily that could be driving it. We have had a CRNA paid by the hour that would be dismissed to home only to find them still in the hospital a few hours later giving a break to a colleague at a time when we had plenty of help. First, that is a red flag for diversion, but this guy was simply padding his hours (all paid at overtime rates) and making a ton of unwarranted extra money by claiming he was needed for hours longer than he really was.
We get what we incentivize. If there was no extra money to be had for the commitment, I suspect that level of commitment would go away fairly quickly.
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deleted87051
That’s why it’s important to have incentives that align with good patient care.
If I’ve been up all night and I’m in the midst of a case that has hours to go at 7am, I will hand off the case. In that situation, I feel the benefit of having a fresh anesthesiologist is worth the disruption in continuity. If the case has an hour or less remaining, I will finish it.
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I view handoffs the same as substitutions in basketball. If it's a 20 point lead with a few minutes to go, jordan doesn't need to be in there and can sub out. If it's a playoff game with a tie game, yea he's gonna finish the game. If it's a healthy lap chole, there's zero shame in subbing out.
So basically you’re saying I’m Michael Jordan? I’m in agreement. Thx.
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deleted875186
Don’t hand off an unstable patient. Otherwise, anesthesia is a lot of sitting around, I see no issue handing off in the middle of a case. Just need to sign out important pieces of information.
Hate to see his kidney function test!
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deleted1130227
Foley underneath the scrubs.
You must be in the most efficient OR of all time.
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Or
Take the plunger out of a 60mL syringe. Plug the luer-lock end of the syringe into working suction tubing.
Don’t occlude the suction else negative pressure edema will occur.
I dunno. Some people like to live dangerously.
Is this from experience? Has anyone actually ever relieved themselves in the OR?
I know of no one with this experience. Purely hypothetical.
I've peed once, into the plastic saline bottles that we use for emptying the patient's Foley.
12 hour case, middle of the night. I wear large legged scrubs for a reason.
12 hour case, middle of the night. I wear large legged scrubs for a reason.
