How do you handle this situation...

[oudoc08]

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So let me clarify. I'm starting my anesthesia residency next year and I'm curious about how to handle the following situation.

An attending surgeon or surgery resident pops their head over the drape and disrespectfully barks at you to not do something that you know is clinically indicated.

In the actual case involving one of the residents at my program, it involved infusing an initial 500cc of Hespan in a trauma patient, and was instigated from across the blue by "Don't put that in MY patient!", in a tone reminescent of chastising the dog for planting a load on the carpet.

So what to do? It's said that the reason anesthesiologists get walked on is because they let themselves get walked on. True?

So what should the response be? Does it matter if it's a surgery resident, attending surgeon, etc?

I don't like to work in the "you stay on your own side of the drape" environment, and am more than willing to listen to reasoned opinion, but in the case of utter disrespect, I'm not sure what the appropriate response is, especially if the treatment is obviously indicated.

That'd be like the anesthesiologist leaning over the drape, pointing "DON'T LIGATE THAT VESSEL!"

Does "I'll consider your opinion.", followed by an appropriate treatment, rank high on one's list? (It's on mine).

I typically don't put up with alot of crap, I was a paramedic prior to this, and I don't have a lot of problem speaking up and leading a team, but in those situations, I was in charge, and didn't typically butt heads with anybody. Here, I'd rather know how to appropriately handle such a situation prior from those who've been there.

Thanks

 

[militarymd]

Do what Paul Barash did one time to a CT fellow.

Turn off the anesthesia machine....including the monitors.

And as you walk out of the OR, say, "if you think you can do it better, then do it yourself."

 

[DrDre']

If I couldnt do this myself, I would pay big money to see this.


I know PP is all about the three AAAs (availability...) but I think that anesthesia has brought this lack of respect on themselves over the decades, by always bowing down.

Do what Paul Barash did one time to a CT fellow.

Turn off the anesthesia machine....including the monitors.

And as you walk out of the OR, say, "if you think you can do it better, then do it yourself."

 

[urgewrx]

I know PP is all about the three AAAs (availability...)

I have no idea of whatever it is you are trying to say.

 

[urgewrx]

oudoc08,

Anesthesiologists get walked on because surgeons are the ones who bring money to the or. If you piss him/her off he'll complain and your destiny will depend on how much money he brings to the hospital. Best thing you can do is be top notch and sociable. Make them respect you because you are really good. In that situation I would have said "OK, If you don't like it I'll stop it now. And, I can hear you pretty well without yelling". Once you get to know what their likes and dislikes are, they'll be happy you are around.

Or, if you have a lot of power in your hospital you can have a "yell off" in the or without any problems.
​

 

[me454555]

I'd go with your response and say something along the lines of I'll take it into consideratoin. Ultimately it's your liscence and your a$$ on the line so I'm doing whats right for the patient every time.

 

[Planktonmd]

Do what Paul Barash did one time to a CT fellow.

Turn off the anesthesia machine....including the monitors.

And as you walk out of the OR, say, "if you think you can do it better, then do it yourself."

If you do that even as a joke, most likely you will get written up and lose your license for patient abandonment.

 

[militarymd]

If you do that even as a joke, most likely you will get written up and lose your license for patient abandonment.

Not if you're Paul Barash.

 

[VentdependenT]

If the surgeon says that you can always ask why? If the patient is coagulopathic then o.k., fine, thats reasonable. Hang something else till your FFP n' cryo get there.

If thats not the case then;

You can respond that one can dump about 1.5 Liters or 20 cc/kg (whatever is the smaller number) of the garbage Q 24 hours in somebody before the surgeon can blame his lack of control of bleeding on the hespan.

Or you can say fine. Get a cell saver in here so I don't have to give my 6th bag of normal saline while I wait for the tech to find me albumin.

I don't know the details of the case but generally giving Hespan is not a big friggen deal, or any deal for that matter.

 

[urgewrx]

You can respond that one can dump about 1.5 Liters or 20 cc/kg (whatever is the smaller number) of the garbage Q 24 hours in somebody before the surgeon can blame his lack of control of bleeding on the hespan.

My experience with hespan is: if you give a liter of hespan, you'll be transfusing blood.

Several papers in the lit show the same thing. Even the package insert says if you give 1.5 L you'll probably end up transfusing blood.

I don't use hespan anymore.

 

[CremeSickle]

Well


While I dont let anyone talk down to me, its very important to remember that patients dont come to the hospital for anesthesia, they come for surgery. It would take nothing for a surgeon to have you fired. Sounds bad, but thats just how it is. Surgeon = more money for the hospital than us.

 

[oudoc08]

I'm not knowledgable enough to debate the particular merits of Hespan, but I'm mainly talking about how to handle the rude power trip, regardless of the situation.

(i.e. - how to keep from getting railroaded).

Also the points about the surgeon bringing in the dollars, etc., I understand that concept in a private or for profit hospital, but this is a public teaching hospital in the context of a residency program, so I don't see how that applies.

We have attendings and residents at our program that nobody talks like that to. I guess it's all about being professional and letting it be known that you won't put up with that, and that they can take it somewhere else.

On an aside, there's an anesthesia resident in our program that started CA-1. Apparently when he first started this year, one of 1st year surgery residents popped off some smart-ass comment behind his back to one of the other surgery guys. The comical thing is this particular CA-1 resident had previously completed a general surgery residency prior to switching to anesthesia (and I believe is boarded in GS). The guy looked like a total tool when he was thus informed.😀

 

[johankriek]

So let me clarify. I'm starting my anesthesia residency next year and I'm curious about how to handle the following situation.

An attending surgeon or surgery resident pops their head over the drape and disrespectfully barks at you to not do something that you know is clinically indicated.

In the actual case involving one of the residents at my program, it involved infusing an initial 500cc of Hespan in a trauma patient, and was instigated from across the blue by "Don't put that in MY patient!", in a tone reminescent of chastising the dog for planting a load on the carpet.

So what to do? It's said that the reason anesthesiologists get walked on is because they let themselves get walked on. True?

So what should the response be? Does it matter if it's a surgery resident, attending surgeon, etc?

I don't like to work in the "you stay on your own side of the drape" environment, and am more than willing to listen to reasoned opinion, but in the case of utter disrespect, I'm not sure what the appropriate response is, especially if the treatment is obviously indicated.

That'd be like the anesthesiologist leaning over the drape, pointing "DON'T LIGATE THAT VESSEL!"

Does "I'll consider your opinion.", followed by an appropriate treatment, rank high on one's list? (It's on mine).

I typically don't put up with alot of crap, I was a paramedic prior to this, and I don't have a lot of problem speaking up and leading a team, but in those situations, I was in charge, and didn't typically butt heads with anybody. Here, I'd rather know how to appropriately handle such a situation prior from those who've been there.

Thanks

the question is how would you handle the above>...


I would say you worry about the operation I will worry about the resuscitation... when i want your advice I will ask for it. I am not your bitch.

Sometimes you have to talk to the surgeons like you are on the street... seriously.. usually in academic centers.. Most private practice surgeons are OK. tolerable. some are even very likeable.. but in academic centers.. I cant remember liking any of them they were all a******
since being in private practice i can count on one hand the surgeons that i truly truly despise..

 

[Noyac]

the question is how would you handle the above>...


I would say you worry about the operation I will worry about the resuscitation... when i want your advice I will ask for it. I am not your bitch.

Sometimes you have to talk to the surgeons like you are on the street... seriously.. usually in academic centers.. Most private practice surgeons are OK. tolerable. some are even very likeable.. but in academic centers.. I cant remember liking any of them they were all a******
since being in private practice i can count on one hand the surgeons that i truly truly despise..

Yeah, good luck in the future.😱

Honestly, the only way that I know to handle this situation is to be as knowledgeable as possible. Well at least more knowledgeable than the surgeon. You argue the points and keep it on a clinical basis. If the surgeon can't argue on this level, one of two things will happen. He will give in to your superior knowledge and never question you again or he will resort to lesser means. If the latter happens then just say that you are willing to discuss the pros and cons of hespan but if he wants to take it to another level he will have to wait till after the case and in the company of the administrators ( or attendings if your a resident).

 

[VolatileAgent]

So what to do?

if you're a resident, call your attending. don't get into a pissing match with the surgeons when you're a resident. you could also simply ask, "what is your concern?"

and, as uregewx states, hespan is not without its issues. although the lower weight (pentastarch) formulation appears to be less problematic. albumin is a perfectly suitable, if not more expensive, alternative (although there is currently a nationwide shortage on the 5% concentration).

 

[jetproppilot]

So let me clarify. I'm starting my anesthesia residency next year and I'm curious about how to handle the following situation.

An attending surgeon or surgery resident pops their head over the drape and disrespectfully barks at you to not do something that you know is clinically indicated.

In the actual case involving one of the residents at my program, it involved infusing an initial 500cc of Hespan in a trauma patient, and was instigated from across the blue by "Don't put that in MY patient!", in a tone reminescent of chastising the dog for planting a load on the carpet.

So what to do? It's said that the reason anesthesiologists get walked on is because they let themselves get walked on. True?

So what should the response be? Does it matter if it's a surgery resident, attending surgeon, etc?

I don't like to work in the "you stay on your own side of the drape" environment, and am more than willing to listen to reasoned opinion, but in the case of utter disrespect, I'm not sure what the appropriate response is, especially if the treatment is obviously indicated.

That'd be like the anesthesiologist leaning over the drape, pointing "DON'T LIGATE THAT VESSEL!"

Does "I'll consider your opinion.", followed by an appropriate treatment, rank high on one's list? (It's on mine).

I typically don't put up with alot of crap, I was a paramedic prior to this, and I don't have a lot of problem speaking up and leading a team, but in those situations, I was in charge, and didn't typically butt heads with anybody. Here, I'd rather know how to appropriately handle such a situation prior from those who've been there.

Thanks

Some of this bulls hit, my friend, is part of working in an academic setting.

As a resident, you will work with surgical attendings.

Some of them think they are Jesus Christ.

Problem is they dont act like Jesus Christ (and, uhhh, they don't operate like Jesus Christ...thats why most of them are in academics.......because they're...well, I'll leave it at that.....yes, there are occasional DEFT academic surgeons....but thats it....occasional........). They act like little children, and frequently bark orders at people.

Not too much you can do about that as a resident.

So I suggest that next year when you're a CA-1 and a Jesus Christ-impersonating-academic-general-surgeon barks sh it to you, overlook it.

And comfort yourself by thinking of the fact that in your first year outta residency you'll be making more Benjamins than him.

Gotta surgery resident barking at you?

Completely different ballgame now, Slim.

Had a heart surgery fellow bark some s hit at me when I was a resident.

Dude ended up moving to where I did after we both finished...he even lived with me 'til his house was done....

Posted about it about a year ago.

Maybe somebody can find that post and post a link.......

But back to the incident....

In short, I don't think during-the-surgery is the time to address the surgery resident, but MAKE SURE you talk to him afterwards.

Heres a pretty-close-to-word-by-word-synopsis of my residency run-in with the cocky CT-fellow, after the case was done, now we're both in the ICU, patient tucked in and doing fine:

Bill: "Dude, can I talk to you a minute?"

T Mack: "Sure."

Bill: (calmly, mind you, even though I weighed a near-contest-ready-225 lbs at the time and could bench press a small freight train, and I'm speaking to a skinny, withered, pale, bone-rack CT fellow):

"Dude, I don't know who the F UCK you think you are. You're a fellow. I'm a resident. That s hit you pulled a few hours ago was TOTAL bu ll s hit."

T Mack: "Yeah, you're right. Sorry, man."

Pretty verbatum exchange, even though that was circa 1995.

No more problems from T Mack during our training at Tulane, after our little conversation.

And remember, we eventually became friends.

Sometimes ya gotta step up to the mike with Micatin.

 

[jetproppilot]

Does it matter if it's a surgery resident, attending surgeon, etc?

In the academic setting,

Yes.

Please see my above post.

 

[cfdavid]

Yeah, good luck in the future.😱

Honestly, the only way that I know to handle this situation is to be as knowledgeable as possible. Well at least more knowledgeable than the surgeon. You argue the points and keep it on a clinical basis. If the surgeon can't argue on this level, one of two things will happen. He will give in to your superior knowledge and never question you again or he will resort to lesser means. If the latter happens then just say that you are willing to discuss the pros and cons of hespan but if he wants to take it to another level he will have to wait till after the case and in the company of the administrators ( or attendings if your a resident).

Great response. FYI, this input is very benefitial to us neophytes. Thanks to all you attendings for the input. This is truly a unique, and special (o.k. cheese factor limit reached...) forum. Keep it up guys/gals.

 

[cfdavid]

Some of this bulls hit, my friend, is part of working in an academic setting.

As a resident, you will work with surgical attendings.

Some of them think they are Jesus Christ.

Problem is they dont act like Jesus Christ (and, uhhh, they don't operate like Jesus Christ...thats why most of them are in academics.......because they suck......yes, there are occasional DEFT academic surgeons....but thats it....occasional.....most of them suck....). They act like little children, and frequently bark orders at people.

Not too much you can do about that as a resident.

So I suggest that next year when you're a CA-1 and a Jesus Christ-impersonating-academic-general-surgeon barks sh it to you, overlook it.

And comfort yourself by thinking of the fact that in your first year outta residency you'll be making more Benjamins than him.

Gotta surgery resident barking at you?

Completely different ballgame now, Slim.

Had a heart surgery fellow bark some s hit at me when I was a resident.

Dude ended up moving to where I did after we both finished...he even lived with me 'til his house was done....

Posted about it about a year ago.

Maybe somebody can find that post and post a link.......

But back to the incident....

In short, I don't think during-the-surgery is the time to address the surgery resident, but MAKE SURE you talk to him afterwards.

Heres a pretty-close-to-word-by-word-synopsis of my residency run-in with the cocky CT-fellow, after the case was done, now we're both in the ICU, patient tucked in and doing fine:

Bill: "Dude, can I talk to you a minute?"

T Mack: "Sure."

Bill: (calmly, mind you, even though I weighed a near-contest-ready-225 lbs at the time and could bench press a small freight train, and I'm speaking to a skinny, withered, pale, bone-rack CT fellow):

"Dude, I don't know who the F UCK you think you are. You're a fellow. I'm a resident. That s hit you pulled a few hours ago was TOTAL bu ll s hit."

T Mack: "Yeah, you're right. Sorry, man."

Pretty verbatum exchange, even though that was circa 1995.

No more problems from T Mack during our training at Tulane, after our little conversation.

And remember, we eventually became friends.

Sometimes ya gotta step up to the mike with Micatin.

Amen. I stated that this would be an appropriate respones (given the dynamics of the situation) but was slammed on this very forum by an attending (whom I respect nonetheless). Sometimes you need to alpha-male em.... Oh well.

 

[swpm]

I typically don't put up with alot of crap, I was a paramedic prior to this, and I don't have a lot of problem speaking up

I will humbly submit that your lack of intimidation will be perceived as arrogance, and will therefore buy you more abuse or (worse) a reputation you don't want. You're not the only non-traditional path taker who has endured far more intimidating or dangerous situations than some howling bitch with a bovie ... and it is hard to back down when you're right and he's wrong.

Choose your battles wisely. If an attending surgeon starts riding you, page your own attending - don't allow yourself to be baited into an argument. You won't win, and the moral comfort of standing up to the jerk will wear thin by the time you're sitting before your program director explaining yourself.

 

[Tenesma]

1) Knowledge is power - the more you know, the more you read, the more up to date you are on everything (anesthesia, critical care, etc...) the easier it will be for you to feel confident, stand your ground and make the surgeon/resident on the other side feel like an idiot for even opening up their mouth....

2) over time - as you demonstrate your prowess, the surgeons/residents will come to respect you and your opinion. I remember doing a late-night case with a PG-4 surg resident when i was a CA-3 (we had been in many, many trauma cases together since we both started at MGH), and his PGY-2 junior (rotating from OMFS of all things) decided to give me crap. Before I could even lay the smack down on junior, the surg senior says to him: "shut the f-up - that guy knows what he is doing"...

3) if you are in a situation where your knowledge is truly limited, I would plainly admit it and ask them to teach me... for example "You know I have just started recently using hespan for these types of cases, and have liked the outcomes - what is it about hespan that you don't like?" maybe you will learn something that will make you smarter.... if he can't give you an educated answer, then tell him that you don't make anesthesia decisions based on personal preferences of surgeons. And that your personal preference is for undyed 4.0 monocryl for the skin, but that doesn't mean that he has to agree either...

4) best way to even avoid your scenario? just become friendly with all the surgical residents. Don't start the case (unless it is a crazy trauma) without making sure you know everybody's name in the room. Every morning I used to have the circulating RN write the names of everybody in the OR on the white-board on the wall... It helped me a lot because in big hospitals you never know the scrubs name, the circ rn's name, etc... It is hard for somebody to be a dikk-head when they know your name. I would introduce myself to the surgeons and nurses even when they didn't have the courtesy to introduce themselves to me.... You don't know how much nicer it is to hear your first name as in "John, do you mind not using Hespan in my patient" versus "Anesthesia, don't give hespan to my patient"

5) answer of last resort: "Why don't you just discuss that with my attending? and then ignore them"... of course this only works when your attending isn't a whimp.... i used to have an attending that would just give the surgeons and surgical residents all hell in defending me even when i screwed up... I loved that guy...

6) crazy-dude response: take some white tape and cover up the word hespan on the bag and write with a marker "Normal Saline" and then look over the screen and tell them the problem has been fixed.... that ranks up there with putting a big piece of white paper over the monitor that says "BP 100/60 HR 60 SAT=100%" and then telling the surgeon that everything has been fixed.

 

[Voodoo]

... are not a good idea for a trainee, especially at the beginning of your residency. You DO NOT want to be labeled "that guy" by your program. "That guy" is the one who takes all the holiday calls and gets screwed repeatedly.

To the OP -- while I liked Tenesma's suggestions in the previous post, read VolatileAgent's post about 5 or 6 back. It is more succinct, and is the absolutely right answer when you are starting out. Once you have some experience under your belt (i.e. mid-way through your CA-2 year) it is very appropriate to question the surgeon politely. Towards the end of your training, feel free to get the white tape and Sharpie out, just understand that you will be burning some bridges, and it depends on what you want (e.g. if you're staying on staff, no white tape and sharpie - if it's your last month of training and you have a job elsewhere and the surgeon is that rude, throw a brick at them across the drapes for all I care).

My $0.02

 

[epidural man]

1) Knowledge is power - the more you know, the more you read, the more up to date you are on everything (anesthesia, critical care, etc...) the easier it will be for you to feel confident, stand your ground and make the surgeon/resident on the other side feel like an idiot for even opening up their mouth....

2) over time - as you demonstrate your prowess, the surgeons/residents will come to respect you and your opinion. I remember doing a late-night case with a PG-4 surg resident when i was a CA-3 (we had been in many, many trauma cases together since we both started at MGH), and his PGY-2 junior (rotating from OMFS of all things) decided to give me crap. Before I could even lay the smack down on junior, the surg senior says to him: "shut the f-up - that guy knows what he is doing"...

So True.......

I was doing a case and the CT surgeon was demanding that I start this drip, etc, and then my attending walked in who was very respected and well liked, and the surgeon immediatly started back pedling, being very nice and explaining his reasons for what he wanted me to do and asking my attending if it was appropriate. It was a teaching moment for me. Being brilliant and authoritative, but diplomatic and genuinely caring about all the people in the room really is what seems to get you clout.

I was also in Saint Louis U hospital where the anesthesiologist and the plastic surgeon were yelling over the pt at the top of their lungs about the anesthetic choice (and the pt was fully aware and awake since she had a block.) I think the comments about university setting vs private are very valid. I have been in many private hospitals and surgeons seem much more respectful to their anesthesiologist collegues.


Parenthetically, if you want to know more about hextend and hespan, like why they cause more bleeding, etc - you should read this wonderful review article. It will serve you well for an anesthesia residency.

Kozek-Langenecker, Sibylle A. M.D. * Effects of Hydroxyethyl Starch Solutions on Hemostasis. Anesthesiology. 103(3):654-660, September 2005.