Managing CRNA's

[MommyMD]

I started my 1st job as an attending this month. It is a MD/CRNA group. After working on my own for the past couple weeks, now I have SRNA or CRNA in my room 1/2 the time. Any advice as a new attending who never had to oversee a nurse before?
Its hard to figure out who has which skill set, etc (and many have been working there for years)

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[aneftp]

Believe it or not. But Crnas and MDs do get along (unlike what many here write about). And unlike what u see on other nurse anesthesia message boards.

Ur job as MD in many private practice environment is to facilitate cases and get cases moving quickly. Ask Crnas what they want especially since they don't know you and you don't know them. Ask them for their thoughts on cases. Believe it. They like input. Even experienced ones. I get along great with Crnas I work with. Even retired "military Crnas".

When I cover rooms I always am managing cases unless it quick Mac. If its a long case, pop your head in to check in.

The reason MDs get bad rap is there are some really lazy ones (not many). But they are out there. They just tell Crna to go ahead start case and they aren't in room. They aren't involved. Crnas see this. OR staff see this.

If you read the requirements for medical direction. Being in room for inductions and other important aspects of the case. Many MDs fail to meet these requirement.

Be proactive with Crnas. Unless u are super busy. If they are inducing. I am starting 2nd IV or doing A-line at same time.

Depending on how busy you get. Crnas appreciate getting out of the room even for 5-10 minutes just to take a break in the afternoon. They know if you are busy and can't get them out. But they know if you aren't busy also.

Bottom line. Most MDs do get along with Crnas.

There will be ones who absolutely hate Crnas. But most of us work well with them.

 

[seinfeld]

I remember my first 6 months of supervising. Not only are you nervous about whether you are making the right decisions but you're also worrying about the CRNAs making the right decision.

I am always upfront and emotionally honest with the CRNAs. When I work with a CRNA for the first time I always set some specific expectations.

Ask your colleagues what to watch for with each CRNA, its like asking what your attending in residency like and don't like except now you're asking what do they do right and wrong.

1. I always must know when you are inducing, I will want you to wait in 99% of the time for me but there will be times when I am stuck in another room and I don't foresee any issues that I will be OK with you starting, but I must know that you are starting.

2 It is my job to tell you of my specific concerns for the case and beyond those I only expect you to keep me updated with acute or unexpected changes in the patient.

for instance for a lap chole, I go and see patient, ASA 1, nl airway , when see the CRNA I'll say "nothing special". When i show up to induce, someone pushes drugs, ETT in BP good after induction i leave. For a CRNA I have not worked with I will circle back after lights are out to see what thats person OCD is like, did they place hair hugger, OGT, did they give decadron to a diabetic etc. I do stop and sign the charts every hour, most CRNA now remind me when they haven't seen me, I usually look quick at the vitals, ask the CRNA if they need anything, poke my head over the drapes, if its appropriate talk with surgeon about his/her progress and any issues they foresee or have had, go talk with the circulator if they have had any issues (circulators will tell you if the surgeon is not happy with the anesthetic) and then I leave.

In this scenario what i mean by being emotionally honest with the CRNA is stat things like "Please do not give narcotics for HTN, i would prefer you to use more gas, titrate in some 5-10 of labetatol, but pressure of 140 i am fine with, the reason i don't want too much fentanyl is that these patients don't need it for post op pain and when they are delayed to wake up i get crap from the surgeons and the PACU, please don't not put me in that position"

At the end of the day I have found it to work best to be open to suggestion when it doesn't matter but be firm when it does matter. Like a marriage choose your battles, ask them for how they want to do the case and if it sounds safe and reasonable say "OK". All of my colleagues who micromanage an otherwise safe anesthetic plans tend to have more problems with CRNAs and the more problems they have the more they micromanage, vicious circle. My take is that when an attending micromanages too much of a case the CRNA will tend to either not want to inform you of stuff as it will only lead to more crap from you or they will do what you tell them regardless of whether it is appropriate at the time or not.

 

[deleted126335]

Depends on the local relationships.

You are being evaluated. You can count on the CRNAs reporting their impressions of you to the other anesthesiologists. How much the docs care is another story. You can also count on the surgeons giving their impressions of you to the other anesthesiologists.

I cannot overstate how much the relationship between anesthesiologists and CRNAs can vary in an ACT type practice. If the CRNAs are employed by the docs, it is a much easier relationship to manage. If you are all hospital employees, that is far less desirable.

Everyone has to find and maintain a place in the jungle. You are a new creature in that jungle. You will have to feel things out. This is one more transition from senior to freshman. See JET's posts for new attendings.

 

[MommyMD]

Thanks for the good advice!

 

[urge]

Ask your colleagues what to watch for with each CRNA, its like asking what your attending in residency like and don't like except now you're asking what do they do right and wrong.

At the end of the day I have found it to work best to be open to suggestion when it doesn't matter but be firm when it does matter. Like a marriage choose your battles, ask them for how they want to do the case and if it sounds safe and reasonable say "OK". All of my colleagues who micromanage an otherwise safe anesthetic plans tend to have more problems with CRNAs and the more problems they have the more they micromanage, vicious circle. My take is that when an attending micromanages too much of a case the CRNA will tend to either not want to inform you of stuff as it will only lead to more crap from you or they will do what you tell them regardless of whether it is appropriate at the time or not.

This.

Treat them with respect. If you see something you don't like tell them but not in a demeaning way. A CRNA you get along with is extremely valuable.

 

[Consigliere]

Previously the CRNAs were hospital employees. We hired them and now they are our employees and I can't tell you how much better things are.

 

[Dejavu]

As an ex-CRNA and now an attending, I cannot tell you how impressed I am with the advice so far tendered here.

I thought it would be a flame war.

Do respect them. They are like any group. There is a Bell Curve of "goodness" among them, just like MDs.

If it doesn't make a difference to you or the pt's condition, let them do the case their way. There are 300 ways to do anesthesia, and the discharge from hospital rates and times don't differ that much between the various ways.

Also, a heads up about the plan for the next case lets them set up for it while the current case is going on, and that helps everybody's turnover time.

Probably a lot more if I had time right now, so PM me if you want to discuss anything in particular.

 

[BLADEMDA]

I always treat them with respect or apologize on the rare occasion I'm having a rough day.
Still, there are some "dangerous" ones who don't inform you that they are treating HTN with massive doses of Narcotics or giving 2 bags of Hextend to an ICU patient with kidney disease. The list goes on and on.

Overall, most days go fine but I continually need to explain my rationale for doing things to CRNAs on a daily basis. I always back up my arguments with decades of experience and published literature. I rarely argue over who pushes the Propofol but how much they push is another story.

There is a line between micromanaging and supervising with the intent to improve patient care. I try to walk that line as much as possible. Of course, being technically more proficient than a CRNA always makes you look good in front of the staff and surgeons provided you don't make the CRNA look bad in the process. Be patient and allow the CRNA to try as long as it doesn't interfere with patient safety.

Finally, if you are going to criticize a CRNA For a particular thing do it in private and explain your reason in a professional manner.

 

[gasattack3]

A bit off topic but as a CA3 resident at a large institution with a small program, I've worked with a lot of different attendings.

One thing which has been a universally shared pain in both resident's and CRNA's a.sses is that of the "spaz" attending. Granted I never disparage or talk behind my attending's back to CRNA's. NEVER. But, over the past couple years it's obvious that we, in fact, share favorites and dislike working with (being supervised by) often the same people.

I've even witnessed the impact of the "spaz" attending on the ENTIRE OR. Not just the surgeons, but literally everyone. We only have a few, but they amp up the entire room when they act like spazzes.

Such attendings never read the "being cool and calm in the face of impending doom" mantra. I can't emphasize this enough. If YOU think you may be doing this inadvertently, then please reflect on this as it will help you for sure. (I say this because I'm 99.9999% certain that the spazzes don't know/think they are spazzes)

I can say that as a CA3 I've LEARNED from the good and the bad. I've LEARNED and made myself act and talk calmly (you can move fast, and hustle without causing an utter commotion and freaking everybody out) during situations of high intensity.

It's true that surgeons themselves are often the precipitators of spazziness, and it does "trickle down", but remaining calm is critical guys. Even if you need to calmly tell the surgeon you are "working on it".

That being said, MOST of our attendings are excellent at this and thus I've had great mentors from which to learn. They are WAY more effective anesthesiologists all else being equal and considered. It's soooo important.

 

[Arch Guillotti]

Good advice above.

Let them do what they normally do. Sometimes these things will be unbelievably stupid almost beyond belief, but the vast majority of the time it won't make a difference in terms of patient care and safety.

Don't let them talk you into something you know is wrong. Explain your rationale if needed but do what you know is right.

Try not to micromanage. Treat them with respect and kill them with kindness. Some will still be a pain in the ass despite your best efforts but that comes with the territory.

 

[BobBarker]

A bit off topic but as a CA3 resident at a large institution with a small program, I've worked with a lot of different attendings.

One thing which has been a universally shared pain in both resident's and CRNA's a.sses is that of the "spaz" attending. Granted I never disparage or talk behind my attending's back to CRNA's. NEVER. But, over the past couple years it's obvious that we, in fact, share favorites and dislike working with (being supervised by) often the same people.

I've even witnessed the impact of the "spaz" attending on the ENTIRE OR. Not just the surgeons, but literally everyone. We only have a few, but they amp up the entire room when they act like spazzes.

Such attendings never read the "being cool and calm in the face of impending doom" mantra. I can't emphasize this enough. If YOU think you may be doing this inadvertently, then please reflect on this as it will help you for sure. (I say this because I'm 99.9999% certain that the spazzes don't know/think they are spazzes)

I can say that as a CA3 I've LEARNED from the good and the bad. I've LEARNED and made myself act and talk calmly (you can move fast, and hustle without causing an utter commotion and freaking everybody out) during situations of high intensity.

It's true that surgeons themselves are often the precipitators of spazziness, and it does "trickle down", but remaining calm is critical guys. Even if you need to calmly tell the surgeon you are "working on it".

That being said, MOST of our attendings are excellent at this and thus I've had great mentors from which to learn. They are WAY more effective anesthesiologists all else being equal and considered. It's soooo important.

Always be "beta blocked".

 

[gasattack3]

Always be "beta blocked".

Pretty much.