New CV Surgeon wants his own strike team

[dabears505]

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To be honest, cardiac cases are some of the best cases for supervision. Long periods of downtime like vein/artery harvest, bypass. I think supervision at induction, lines, going on and coming off pump is a good model.

 

[sevoflurane]

I’ll never supervise induction, line placement, blocks or tee. Period.

The above nurse induces by herself “sometimes”? WTF?

Just think of MS/AR + ef 20%.

Ya... No- NEVER.

 

[sevoflurane]

Anesthesiologists at that practice are THE problem for the profession.

 

[sevoflurane]

The only crna supervision I have done was during residency. I occasionally let an AA student in my room but they aren’t placing lines, blocks, etc.

 

[YCAGA]

I know this thread got necro-bumped and is already becoming a CRNA vs anesthesiologist train wreck…but, I am curious about the concepts at play here.

Hospitals that do peds hearts are shut down if they don’t have enough volume so all of the staff involved gets experience and stays fresh. How is this any different from what the CT surgeon in this post is trying to do? He doesn’t seem to be trying to be a jerk for the fun of it…there is a method to the madness.

I don’t know if there is as much research on more volume = better outcomes in adult hearts as there is for peds hearts, but I have to imagine it’s a similar story. From what CT surgeons have told me, peds CT surgery is another level of complexity compared to “normal” CT surgery, but adult CT surgery is still one of the most delicate and complicated fields in medicine.

Also he isn’t asking for 1 MD to cover all of his cases. Why not have the same 3-4 MD’s do it and kick the CRNA’s out? Seems like that wouldn’t be a giant hassle to schedule. Do 3-4 cardiac trained partners all need to take vacation in the same week? Doesn’t make sense.

I’m just a dumb med student but I’m not the only one in this thread that is confused that 250 cardiac cases per year is covered by EIGHT physicians and an even bigger gaggle of “cardiac” CRNA’s.

Someone also mentioned a great point. Isn’t a surgeon asking specifically for highly trained anesthesiologists exactly what physicians in anesthesia should want?! What better job security is there than working with a surgeon that wants to work with a well trained and qualified team in order to absolutely maximize the chance for good outcomes. Sounds like the kind of guy that would fight for anesthesiologists to staff his rooms over CRNA’s in the name of patient saftey. Or if you are more cynical, in the name of keeping good outcome rates high…because hospitals are tracked on that and it matters for everyone involved, anesthesiologists included.

Also, please tell me there is no such thing as a “cardiac” CRNA when it comes to salary and the hiring process. What would that even mean???

 

[chocomorsel]

Anesthesiologists at that practice are THE problem for the profession.

Exactly. So why are people attacking the nurses?

 

[chocomorsel]

I know this thread got necro-bumped and is already becoming a CRNA vs anesthesiologist train wreck…but, I am curious about the concepts at play here.

Hospitals that do peds hearts are shut down if they don’t have enough volume so all of the staff involved gets experience and stays fresh. How is this any different from what the CT surgeon in this post is trying to do? He doesn’t seem to be trying to be a jerk for the fun of it…there is a method to the madness.

I don’t know if there is as much research on more volume = better outcomes in adult hearts as there is for peds hearts, but I have to imagine it’s a similar story. From what CT surgeons have told me, peds CT surgery is another level of complexity compared to “normal” CT surgery, but adult CT surgery is still one of the most delicate and complicated fields in medicine.

Also he isn’t asking for 1 MD to cover all of his cases. Why not have the same 3-4 MD’s do it and kick the CRNA’s out? Seems like that wouldn’t be a giant hassle to schedule. Do 3-4 cardiac trained partners all need to take vacation in the same week? Doesn’t make sense.

I’m just a dumb med student but I’m not the only one in this thread that is confused that 250 cardiac cases per year is covered by EIGHT physicians and an even bigger gaggle of “cardiac” CRNA’s.

Someone also mentioned a great point. Isn’t a surgeon asking specifically for highly trained anesthesiologists exactly what physicians in anesthesia should want?! What better job security is there than working with a surgeon that wants to work with a well trained and qualified team in order to absolutely maximize the chance for good outcomes. Sounds like the kind of guy that would fight for anesthesiologists to staff his rooms over CRNA’s in the name of patient saftey. Or if you are more cynical, in the name of keeping good outcome rates high…because hospitals are tracked on that and it matters for everyone involved, anesthesiologists included.

Also, please tell me there is no such thing as a “cardiac” CRNA when it comes to salary and the hiring process. What would that even mean???

There are absolutely “cardiac CRNAs” out there. As noted above by the CRNA. Welcome to medicine, there are sellout docs in every profession who will sing praises about midlevels and some say they would rather work with them than other docs. It’s everywhere in this country.

 

[sevoflurane]

Exactly. So why are people attacking the nurses?

Isn’t an anesthesiologist supposed to be there for induction? Not to mention a cardiac induction. Cardiac patients code during induction- it happens. Both nurse and anesthesiologist are to blame if they deviate from this.... unless it isn’t supervision. If it’s not supervision, then that is just not something I EVER want to be part of.

 

[sevoflurane]

*medical direction

 

[chocomorsel]

Isn’t an anesthesiologist supposed to be there for induction? Not to mention a cardiac induction. Cardiac patients code during induction- it happens. Both nurse and anesthesiologist are to blame if they deviate from this.... unless it isn’t supervision. If it’s not supervision, then that is just not something I EVER want to be part of.

The nurse said he or she called the attending before induction. And sometimes they come, and sometimes they don’t it looks like. It looks like the nurses have an OK to continue if they don’t come because they are “busy.”

 

[sevoflurane]

They are inducing cardiac patients which code peri-induction. They SHOULD NOT be inducing solo- period. Don’t know how else to explain that.

 

[chocomorsel]

They are inducing cardiac patients which code peri-induction. They SHOULD NOT be inducing solo- period. Don’t know how else to explain that.

Again, the people in the wrong here are the group docs that are letting them do it. Come on, you gonna blame the nurses if they are allowed? Of course they are gonna take it and rub w it and brag to their friends about it. The people in charge are allowing the BS to happen. They are to blame.

 

[sevoflurane]

Again, the people in the wrong here are the group docs that are letting them do it. Come on, you gonna blame the nurses if they are allowed? Of course they are gonna take it and rub w it and brag to their friends about it. The people in charge are allowing the BS to happen. They are to blame.

BOTH to blame. It’s also fraud. If it’s medical direction they are NOT allowed. And yeah I have big issues with a nurse inducing a cardiac patient solo- because they code with critical cardiac pathology- seen it a million times.
Sorry that model is not for me.

 

[sevoflurane]

I have heard horror stories in this exact setup and guess what... when the anesthesia emr is evaluated, the anesthesiologist was called late and enters the room during compressions.
Not for me- or my family. Seconds DO matter.

 

[chocomorsel]

BOTH to blame. It’s also fraud. If it’s medical direction they are NOT allowed. And yeah I have big issues with a nurse inducing a cardiac patient solo- because they code with critical cardiac pathology- seen it a million times.
Sorry that model is not for me.

Not disputing w you that it’s a crap model and has fraud all up in it and not good for patients. Just saying that this happens in certain places where the partners are completely OK with it and ALLOW it. So they are ULTIMATELY the creator of the problem.

Ask yourself, who’s responsible when **** goes south? The CRNA the docs are letting run a mock?

 

[sevoflurane]

Both are to blame.

 

[chocomorsel]

I have heard horror stories in this exact setup and guess what... when the anesthesia emr is evaluated, the anesthesiologist was called late and enters the room during compressions.
Not for me- or my family. Seconds DO matter.

If they aren’t calling the docs till after induction, then yeah that is a problem. That doesn’t seem to be what is happening with @CRNAinPA practice though.

 

[sevoflurane]

But mainly the anesthesiologist.

 

[chocomorsel]

Both are to blame.

Let’s agree to disagree. They are doing what they are allowed. They are allowed to start a case without a doc if the doc doesn’t show up when called.
Let’s agree to disagree.
As everyone knows on here, I, like you prefer to do my own cases and these are the practices I look for.

 

[sevoflurane]

But mainly the anesthesiologist.

or Admin

 

[sevoflurane]

Let’s agree to disagree. They are doing what they are allowed. They are allowed to start a case without a doc if the doc doesn’t show up when called.
Let’s agree to disagree.
As everyone knows on here, I, like you prefer to do my own cases and these are the practices I look for.

I get it, but if the anesthesiologist is not there during induction and something happens they will BOTH be liable for any sentinel events. The CRNA should know that is not what medical direction means, so they are equally culpable.

Ugh.. agree in that this is not in my universe and am very happy for that aspect of my practice.

 

[chocomorsel]

I get it, but if the anesthesiologist is not there during induction and something happens they will BOTH be liable for any sentinel events. The CRNA should know that is not what medical direction means, so they are equally culpable.

Ugh.. agree in that this is not in my universe and am very happy for that aspect of my practice.

Don't you think that it would be quite easy for the CRNA to pass the buck? Simply state in the chart that "MD called before induction, did not show, induction proceeded." And then proceed to state that this was simply an allowed part of the practice. I am sure it wouldn't be hard to figure out after interviewing a few people and our trusty surgeon friends. I am speculating anyway.
All this to say that anesthesiologists are the ones who most often create these CRNA problems that we all complain about. As much as we know that many of these nurses ultimately want to replace us, are taking our titles, we shouldn't be so damned lax.
I worked in a rogue CRNA practice a couple of years ago off and on for about 9 months after fellowship. I found something better and never looked back. Every time my recruiter asks me to help them, I send him expletives. He ought to know by now.

 

[abolt18]

A reasonable approach would be to establish the requirement that the crna WAIT until the anesthesiologist is available, no matter what.

Either cases are going to get delayed and surgeons will be unhappy which will lead to changes, or crnas who don't wait get removed from the cardiac team or fired. Boom, you've fixed that problem.

But this sounds like a place that doesn't want to fix that problem.

 

[vector2]

Either cases are going to get delayed and surgeons will be unhappy which will lead to changes,

Yes. The change will be that the CRNA goes back to inducing without the physician in the room. That's what the clipboard warriors and surgeons demand.


These kind of 3 or 4:1 supervisory practices where one or two of the rooms are CT cases and the other two rooms are also moderate or high acuity are a cancer upon our specialty. Are we really so greedy that we can't just accept the units from one pump case plus an eyeball room?

 

[dabears505]

Some is not greed, it's lack of staff.

 

[deleted162650]

Some is not greed, it's lack of staff.

Running lean (too lean) = greed.

 

[chocomorsel]

Some is not greed, it's lack of staff.

Ehh. Possibly, but often it’s because people don’t want to split the pie even more than it already is. People on this board say that they run lean for that reason.

 

[Southpaw]

Running lean (too lean) = greed.

1) the anesthesiologist should be infinitely more involved in the cardiac cases that are being discussed here.

2) no group is happy to have people sitting around earning nothing.

 

[vector2]

Ehh. Possibly, but often it’s because people don’t want to split the pie even more than it already is. People on this board say that they run lean for that reason.

What's worse is that in my neck of the woods, the health system based groups or AMCs force docs to do 3 or 4:1 including when one of those rooms is a pump case, and then pocket the additional collections since it's a salaried job.

The only thing worse than that model is having to do that model without getting paid for the additional work and risk.

 

[sethco]

These are the kinds of practices that I would gladly be a Medicare whistleblower if they are claiming that they are there for induction when they are not. Otherwise, I find it mind boggling if they are QZ for a Cardiac case (doing all the lines, induction, TEE Insertion, etc). Very dangerous practice indeed