On-call staffing with residents/CRNAs

Discussion in 'Anesthesiology' started by ketadex, Dec 3, 2018.

  1. ketadex

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    I'm curious to see how other programs handle the distribution of cases between residents and CRNAs while on call. Our program has experienced some friction over this issue recently and we are in the process of formalizing a policy about this.

    We have a 24-hour call, where residents are scheduled in normal cases as usual from 6AM-5PM and then emergent/add-on cases from 5PM-6AM. We have a large pool of CRNAs at this program who provide morning breaks, lunch breaks, and relieve residents in the afternoon for lectures. We have CRNAs that come in for a 7PM-6AM overnight shift.

    While on call, the CA3 supervises 3-4 rooms of CRNAs and junior residents, and is in charge of distributing cases.

    Typically the CA3 has protected the CA2s from being stuck in non-educational cases when there are CRNAs available to do them (such as butt puss, lap choleys, etc). The unsaid rule has been that CA2s are woken up to do only Peds/Traumas/Cranis. (The CA1s are treated like a CRNA and do whatever comes up).

    However the CRNAs are arguing to the leadership that this isn't fair, and that the CA2 should be in the rotation with the CRNAs to do whatever cases are scheduled. Due to increasing surgical volumes, every night there is a list of add-on cases (mostly non emergent) that go all night until 6AM running 2-3 rooms.

    At your programs, are CA2s stuck doing BS cases on call or are they protected for more educational cases?
     
  2. jameskimp

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    If they want to be treated equally like residents, let them get paid like residents and see how they like it. In my program, they don’t preop the night before and they are shift work and get relieved on time.

    Residency is for learning and skut should be minimized whenever possible.
     
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  3. DirtDocMD

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    We had that crap when I was in training. As residents, there all day long, then some CRNA’s would show up for their 7-7 SHIFT (NOT call) do ONE gallbladder, then think they were supposed to sleep the rest of the night while the residents picked up subsequent cases (NOT educational, merely garden variety appys/gb’s/ankles). Complete BS.

    Don’t mind being in rotation with someone who has been there all day and is doing night CALL, but not someone who just showed up for a SHIFT....

    The better attendings protected us from that. A couple, who wanted to be liked by the CRNA’s, were not so resident friendly.
     
  4. Psai

    Psai Snitches get zero vicryl
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    If they want things to be "fair" and to be treated like residents they are more than welcome to go to medical school and residency. If they don't like being paid to work then they don't need to work. Theyre not being paid to sit around while ca2s do dumb cases.

    I don't get why this is even an issue. These people get paid a ridiculous amount and they always want more. Now they want to do difficult airways, blocks, lines. No need to bend over and give it to them, they pump out more and more providers every year. Just fire them and get new ones.

    I went into anesthesiology to do procedures and take care of patients, not to stand around watching some nurse do everything while I take the blame.
     
  5. NICMAN

    NICMAN ASA member, MD PhD
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    At my program every year we had that one resident that thought he shouldn’t have to do a single elective B&B case after 3PM because CRNAs were there. It is ok to negotiate (as a supervising CA-3) with CRNSs to take the CA-2 out of the rotation once Or twice to reserve them for traumas, etc but if you have sat in a call room from 3PM to 2AM then you are fair game to do an elective case. Suck it up and realize that you have it better than most programs who don’t even have CRNAs at night (because they would cost a program upwards of $6 million dollars to employ on Call which is the going rate for a CRNA stipend at a level 1 trauma center whereas resident Call labor is essentially free). Also it is really annoying as a CA-3 who is up most of that 24 hours to hear CA-2s complain when they have to get up at 3 AM after getting a solid 6 - 7 hours rest. Suck it up, be a team player, and know that when you are hiring CRNAs in private practice or academics that you need to be a good employer who can negotiate with some sense of fairness or else the good CRNAs will head to the cushy ASC jobs and leave you to relieve CRNAs (or pay 1.5x salary directly out of your pocket).
     
  6. Southpaw

    Southpaw ASA Member
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    Sounds like you’re awful pampered if you ask me. You want to decide when and what cases you do simply bc a CRNA is there with you? You learn by being in the OR. Period. Do the work. I had no CRNAs overnight in my program. Residents did all night and weekend cases. Didn’t matter if it was butt puss or a liver transplant. Do the work. No complaining.
     
  7. POW16

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    CA-2s similarly only did more educational cases when on call but this didnt typically start until 9-11 PM when we were down to the call team. CRNAs worked late but not overnight.
     
  8. dhb

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    Your problem is doing but cases and lap choles all night.
     
  9. vector2

    vector2 ASA Member
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    Either tell the CA2s to suck it up or change the dept policy so the CA2 call is of the sub specialty variety. There is honestly no such thing as a case being "too easy" for a CA2 imo. If you deem the case to be below them, then use that case an an opportunity to stretch their independence- I.e. Stand in the room and make them induce and intubate using their least comfortable blade, make them responsible for safe pt positioning, tell them to figure out how to do the anesthetic using substitutes for our most common drugs, make them do a deep extubation on a fat person and see how well they manage the airway and assist ventilation, run through a ministem of what they'd do if this lap chole pt went into unstable SVT or suddenly desatted etc etc.
     
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  10. jthedestroyr

    jthedestroyr ASA Member
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    Sounds like my program. We would kill to have any crna that's just a late or weekend coverage.
     
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  11. anbuitachi

    anbuitachi ASA Member
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    Yea try intubating everyone with a Miller 00.

    But anyway, it sounds like CRNAs are treated like CA1 and Ca2 are treated like seniors. It also sounds like your hospital is very busy overnight thus the crna coverage. At my institution there is no written rule but usually CA1 does easy cases and CA2 does ''senior level cases'. The Ca1s rotate with the CA1s.

    It sounds 100% fair what you are saying in my opinion. CRNA should be in rotation with CA1s and CA2s should be allowed to rest until they are needed. For those who say residents should do as many cases as possible, i call that BS. I bet no one here wants to stay til 8pm everynight and relieve CRNAs . Rest is important too. Those CRNAs are getting paid ridiculous money to work with minimal liability, and they work 40 hours a week. Now they want to slack on their shift while only working 40 hrs a week? GTFO.

    If the institution does side with the CRNA and forces the CA2s to be in rotation with CRNAs, you should reveal the program so applicants know which program this is.
     
    #11 anbuitachi, Dec 4, 2018
    Last edited: Dec 4, 2018
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  12. IDGARA

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    Overnight CRNAs?! Never had those in training. Residents did all cases after 11pm.

    I agree with people above: if nurses are being paid to work an overnight shift, make them work. They're not residents and shouldn't be treated as equals.
    As far as residents learning from doing BnB cases in the middle of the night: f-that noise. If I've been awake since 6am, my brain isn't functioning in any useful way during a heathly lap appy at 3am.
     
  13. T-burglar

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    Lol at my program there were 3 residents overnight for everything including livers and trauma. Your situation sounds like utopia
     
  14. narcusprince

    narcusprince Rough Rider
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    Man up..... So what if you get called to do a case at night. The educational value is doing a case when your dog tired. Finding what you minimally need to get xyz rolling. As an attending their are times you have to work without sleep. I don’t ever want to be compared to a crna. If you get called to do a case zu ze case!
     
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  15. Man o War

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    Yeah I agree with this.
    I get it though, CRNA entitlement mentality is out of control. This is hugely dependent on the program/hospital. I’ve never worked anywhere where they had any say in anything, so I haven’t experienced the other side. They’ve basically been told if you don’t like it you can leave. The reality is there are plenty of CRNA grads and lots more in the pipeline, and also AAs depending on your state.
    This isn’t the 90s anymore where they can make ridiculous demands and actually be taken seriously.
    They will still complain though. A lot. That doesn’t change ever.
     
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  16. anbuitachi

    anbuitachi ASA Member
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    Yea so you can age faster ? my opinion is SLEEP when you can. there is a fresh CRNA who probably slept enough during the day, who is there during the shift. i hope we all know how important sleep and sleep cycle is to our physical/mental health. while it can't always be achieved in our profession, i would reach for it as much as possible, even as a resident. As a CA3 supervising, or even the residency program, they should 100% be protecting the residents.

    We dont have overnight CRNAs, we have CRNA until 8 or 10pm I believe, and i can tell you that unless there is NOTHING going on, they WILL be in a case. The resident call team could all be out eating dinner or sitting there, but the CRNAs will be in the case until their out time, because that is their job. There is no rotation. They have defined hours and get paid well to do it. I have NEVER heard of any resident or attending, tell a resident to relieve the CRNA early from a lap chole for more educational experience. that is just BS.

    Those of you saying they have it good because call team is large, or they have CRNAs.. it all depends on the number of cases they have at night and how busy they are. Also by having a large resident call team, that means each resident has to take more overnight call!
     
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  17. Man o War

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    On another note....if this is a big issue for many in your department, I would strongly suggest hiring AAs if it’s possible in your state. Best thing my old group ever did. The CRNAs chilled out almost immediately when they realized we could and would replace them. We ended up with half our mid level work force being AAs- they complained far less, worked much harder, and had better attitudes as a whole. I’d go as far to say they were our preferred choice when we had to hire a mid level.
     
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  18. anbuitachi

    anbuitachi ASA Member
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    Are they paid less? or the same as CRNA?
     
  19. Man o War

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    They were paid the same. There was just so much less drama.
     
  20. DM27

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    First of all I love the name Ketadex. I rarely hear anyone else use that term. I did a residency where we did ALL cases overnight whether they were overtly education or not. Ultimately if you are creative you can make any case educational. I felt the experience of being hands on all the time to be extremely useful. A lot of these "non-educational cases" will make up >75% of the cases you do in an average day, so it is useful to have a facility doing them before you supervise them. I often find myself troubleshooting or advising people for simple cases I am supervising, and had I not done these cases so many times myself, I am not sure I would be able to provide as clear guidance.
     
  21. GravelRider

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    It sounds like you may be overstaffed at night? How many rooms can you run? In my experience, CRNAs like to get paid for doing nothing. Threaten to take the (easier) overnight shift away from them completely and see if the CRNAs still complain. My guess is the residents are still pretty busy at night even with the occasional lighter call while sleeping through the 20yr old appy.
     
  22. Mman

    Mman Senior Member
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    when I was a resident we had a junior resident and a CRNA overnight doing most of the work. They alternated cases with senior resident supervising both (with attending obviously). If something truly fun or interesting came up the resident did it. Everything else just alternated.
     
  23. Southpaw

    Southpaw ASA Member
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    Protecting the resident? Protecting them from what? You learn by doing so you have to do. Just because you, as a resident, can’t find value by doing simple cases doesn’t mean it’s not there. There’s is definitely a problem in this medical field related to work ethic, changing out residents/attendings/CRNAs 4 times in a case, breaks all morning and afternoon, constantly trying to absolve ourselves of responsibility when something bad happens. A setup of picking and choosing cases and dumping on the CRNA certainly doesn’t help in my opinion.

    Do the work. No complaining. If you don’t want to work at night, go home. Don’t waste hours ‘on call’ if you’re unwilling to work. I guarantee you the same residents whining about butt puss at night would complain if a CRNA did a complex case while the CA2 SLEPT. You can’t have it both ways. You’re there to work and learn, so do it.

    And you’re earning an average American salary. Not enough for you? Great - head down, keep quiet, do the work, and you’ll be an attending soon enough.
     
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  24. San Marzano

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    I remember being on call at night in residency and thinking I hated doing these crap cases at all hours. I wish I could go back to my young resident self and tell him to sit down shut up and do work. Residency lasts a few years then it’s over...it’s really not that bad.
     
  25. narcusprince

    narcusprince Rough Rider
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    You cannot outcomplain crnas but you darn sure can outwork them. I took it as a badge of honor when my attending called me in the middle of the night. Answer the call, and show them your better!
     
  26. Man o War

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    Yes, THIS.
     
  27. anbuitachi

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    Protect them from what? Protect them from Crnas. The OP mentioned that the CRNAS are having issues with their current system. They are the ones complaining. The attending overnight should be the one making the shots. If the attending doesn't care then the CA3 has that power. Clearly the nurses are trying to take that away. I also see zero problems with ca3s giving ca2 bigger cases and I don't see any problems with CA3 reserving seniors for those cases. The education value of doing these non emergency cases overnight is that you probably shouldn't be doing them in the first place. Your brain does not work or learn as well after 20 hrs of straight working whether you think you are the greatest anesthesiologist on Earth or not.

    I think OP isn't sayings residents are complaining about doing cases. But they clearly have a system in place that's working for them but now crnas are complaining cause they want to work even less than 40 hrs a week and still get paid the same. It's fine to be prideful of what you do but I think it's important to protect yourself from these complaints or before you know it the CRNA will be the one calling the shots at night and telling where the residents should go
     
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  28. btbam

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    Exactly. My surgery resident wife laughs when she reads these threads. Their mentality is just so, so different.
     
  29. DM27

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    The generic warning I would give is the second you consider yourself "too good" to do a certain job or say it's "too easy" you are leaving an opening for someone less qualified to be able to justify their ability to do that job. You are better off instead making everything seem crucial and important enough to require your attention unless you want to repeat the mistakes of some of our predecessors.
     
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  30. Mr.S

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    I honestly dont care what level resident you are, every case is challenging in its own way. You have to challenge yourself to make it challenging. So I kinda stopped reading you made the narrative that CA2s are stuck doing BS cases. There are no BS cases. Especially at night. They all have full stomachs, theyre all infected and bleeding and rupturing etc etc.

    Some of the most challenging cases are the easiest during the day

    Do whatever case comes up.....

    I am not necessarily siding with the CRNAs.. but too often I see residents miss out on great cases because they are trying to cherry pick the ones that will be challenging and many times they guess wrong.
     
    #30 Mr.S, Dec 4, 2018
    Last edited: Dec 4, 2018
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  31. Shimmy8

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    This is an administrative issue.

    If your leadership wants to have CRNAs overnight, then you need to have a defined plan. A senior resident shouldn’t be in the position to have to choose, because I know who I would have picked for this job.

    Maybe the CA2 carries the pain pager or airway pagers instead? This was a bit of an issue for my program because we needed more overnight staffing than residents could provide, but we made sure there were clear rules.
     
  32. anbuitachi

    anbuitachi ASA Member
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    Why does she have time to read these threads? :)
     
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  33. 2Fast2Des

    2Fast2Des to become No One, one must be PP slick
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    Everyone is a snowflake these days, it's just the culture unfortunately, talk big game about how great they are but don't want to put in the face time. I felt I was well regarded by attendings because I would volunteer to do cases, stay late, generally not run away from responsibility. I tried to mentor this to the juniors, some are great, some don't want to hear it. Can't hate on CRNAs if you don't want to show your skills..
     
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  34. Southpaw

    Southpaw ASA Member
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    She logged in during morning, lunch, or afternoon tea time. Or maybe late at night when she was waiting for a real SPECIAL surgery patient to be admitted/require surgery.
     
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  35. narcusprince

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    These youngesters carrying a lot of miller 0’s in their pants these days. In my day I dont recall a call where I was not up all night. And every call you got better. I second the viewpoint that their are bs cases every case every patient is unique.
     
  36. Mman

    Mman Senior Member
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    we found the middle of the night boring cases were the ones we could actually experiment on. Maybe practice your fiberoptic skills, ketamine induction, do some transthoracic echo under the drapes during the case, etc.
     
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  37. 2Fast2Des

    2Fast2Des to become No One, one must be PP slick
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    We were frowned upon to try anything "different", told that it's not time to experiment, just to get cases done..
     
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  38. anbuitachi

    anbuitachi ASA Member
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    Yea the attending usually isnt super thrilled about trying different things after working for 20 hrs straight

    But anyway, all this talk about how there should be no complaints and residents should do every case possible b/c every case is a learning experience reminds me of the work hour discussion that often involves surgery residents. Old attendings would call current residents soft for not working 130 hours a week, and believe there should be no hour restrictions b/c it makes them better surgeons. I recently just had a large case in the middle of the night, and the surgery attending kept yelling at his fellow for being slow when he asked him to do something and in my head i thought to myself, i'm not surprised his reaction speed is slow.. he's been operating for 20 hours already before this case, while the attending just came from home.
     
    #38 anbuitachi, Dec 4, 2018
    Last edited: Dec 4, 2018
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  39. nolagas

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    I hope you are reading these threads to her as she does surgery, eats, or sleeps. Anything else is for the weak.

    I think on their deathbeds all surgeons say, “My only regret... is that... I didn’t do more surgery, eeeegggghhh...”
     
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  40. btbam

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    Fairly accurate.
     
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  41. Mman

    Mman Senior Member
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    when the hell else do you get to experiment with stuff? Normal scheduled cases have far more time and turnover pressure than random BS in the middle of the night. If they can let the intern suture the wound at 3 in the morning...
     
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  42. dhb

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    So why with their supertraining do they take so GD long to do a BS case?
     
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  43. dhb

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    Careful not to sit on your Miller 4 there ;)
     
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  44. Psai

    Psai Snitches get zero vicryl
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    Yeah well maybe if your wife didn't take 6 hours to do that asa1 lap chole then we could both get a good night's sleep.
     
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  45. anbuitachi

    anbuitachi ASA Member
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    a lot of academic places are not that fast. at least at my program there's often time to do stuff, like if you want to try out a new block or a run a new anesthetic. in the middle of the night the attending does not want to be there for extra things to supervise
     
  46. chocomorsel

    chocomorsel Senior Member
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    Same here. I do remember calling a CA1 to come relieve me from a long as hell ENT flap case. You know the ones that take 24hours +. I was a senior and she was the junior and was pissed at me that I would dare call her to relieve me after she'd been sleeping all night till about 1am and I had been trying hard to stay awake in that boring case. Low and behold, I got a bad evaluation from her husband, one of the attendings. I hated that place.
     
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  47. anbuitachi

    anbuitachi ASA Member
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    That is messed up
     
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  48. ketadex

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    Thanks everyone for your input. Its clear that I should have provided more context.

    On a given night, there are usually at least 1-2 'big cases' (traumas, septic ICU patients, kids, etc), so it's not like the CA2s are sleeping the entire time. It's more like they're getting a 2-3 hour break between cases.

    The question boils down to: should they be put in a PEG tube at 3 AM after doing a trauma because it's 'their turn' again? Often times two other cases will have started and finished before a long case is finished, so after finishing a big one, you're up again. This is what the CRNAs are pushing for.

    Another issue with this is that these big cases have sometimes been assigned to CRNAs because the CA2 is stuck in said PEG tube when the trauma rolls in (and the CRNAs/SRNAs want to do these big cases as well).
     
    #48 ketadex, Dec 5, 2018
    Last edited: Dec 5, 2018
  49. Robotic Wis-Hipple

    Robotic Wis-Hipple ASA Member
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    While I agree with the sentiment of do the case and that there is education/experience in doing “simple” cases middle of the night I don’t think this is the issue here.

    The CRNAs are shift workers. These night shift ones are likely getting a shift differential. They would like nothing more than to get the senior residents in the “rotation”. This serves a few purposes, it leads to crnas getting more break/lounge time which they want (all while making 2.5x what the residents are), and, most importantly and dangerously, if they win this they will quickly learn they can keep pushing and getting equivalency within this program. If residents are seen as just another “provider” in the rotation it sends the message to these crnas that they’re equal. It’s a slippery slope, and one I think that crna group is testing. Give in, and there’s a lot more coming. Trust me.
     
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  50. vector2

    vector2 ASA Member
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    You should've mentioned this scenario in the OP. If the resident has just finished a massive, tiring case while two other small cases have been going then they should get a pass to recuperate. If they're in some small case when a trauma rolls in, the CRNA should 100% of the time be relieving them so they can set up for the big case.
     

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