Peds case

[Lonestar]

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11 yo healthy ASA 1 child undergoing ORIF of Left radius. Child is afraid of needles and does not want an IV. NPO > 12 hrs. How would you proceed with this case?

Would an inhalation induction be below the standard of care?

 

[ProRealDoc]

11 yo healthy ASA 1 child undergoing ORIF of Left radius. Child is afraid of needles and does not want an IV. NPO > 12 hrs. How would you proceed with this case?

Would an inhalation induction be below the standard of care?

inhalational induction with sevo/N2O, touch of glyco, get breating spontaneously and proceed with IV.

 

[aredoubleyou]

inhalation induction, iv, lma. No reason to torture the kid.

 

[Lonestar]

unfortunately, a militant CRNA thought it would be prudent to let me know that this was below the standard of care. She did it in the docs lounge in front of me with 2 other CRNAs lounging around.

Case went smoothly as expected.

 

[zippy2u]

Holy shiit, if ya allot more than 3 brain cells for this case you'd be pushin' it. This is "bread and butter" to the infinite power! Inhalational induction, IV and call it a day. Regards, ----Zip

 

[Lonestar]

I Have a question for Jet/mil/Noyac or the other private practice dudes out there? How would you go about handling this issue since it has happened more than once?

BTW, i work well with everyone else out there. I haven't said a thing to this CRNA, but i am afraid that if i don't this will continue.

 

[core0]

I Have a question for Jet/mil/Noyac or the other private practice dudes out there? How would you go about handling this issue since it has happened more than once?

BTW, i work well with everyone else out there. I haven't said a thing to this CRNA, but i am afraid that if i don't this will continue.

 

[OB1🤙]

What I think you really mean to say is:

 

[core0]

What I think you really mean to say is:

Yours appears to be fighting back

 

[doctor712]

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that couldn't be bas rutten, on the bottom, could it? nobody does that to the Bas...!

 

[DrRobert]

At our Children's hospital we do inhalation inductions on ALL kids less than 12 years old unless they have an IV that was placed in the ER, floor, etc. or if there is an indication for RSI.

 

[core0]

^
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that couldn't be bas rutten, on the bottom, could it? nobody does that to the Bas...!

Its Brock Lesnar on top. I'm pretty sure its Randy Couture on the bottom (UFC91)

 

[huktonfonix]

unfortunately, a militant CRNA thought it would be prudent to let me know that this was below the standard of care. She did it in the docs lounge in front of me with 2 other CRNAs lounging around.

Case went smoothly as expected.

i believe that CRNAs have a place in our health care model, but if she pulled that **** she had better be willing to back it up. REALLY, what is standard of care? Whos defining it. Whats the literature. Is there a difference in outcome....Uhuhuhuh....whats that? No answer.....then shut up and think before you call me out. If you do, you'd better come with something stronger than that.

 

[zippy2u]

From my vantage point, this is a rare example of flirtation. If she's a hottie, work the whole Mars/Venus angle. Flowers, dinner date, choice of disinhibiting concoction and a strong, slow, methodical tongue will getcha where you need to be... Regards, ----Zippy

 

[ProRealDoc]

I Have a question for Jet/mil/Noyac or the other private practice dudes out there? How would you go about handling this issue since it has happened more than once?

BTW, i work well with everyone else out there. I haven't said a thing to this CRNA, but i am afraid that if i don't this will continue.

Would you please refer this CRNA to our forum to deal with them appropriately? That's our specialty.

Also, if you are in private practice do you have hiring/firing power with this individual? If so, make sure they get reprimanded. You got to put a stop to these actions before they tell you how to do your job.

 

[Consigliere]

unfortunately, a militant CRNA thought it would be prudent to let me know that this was below the standard of care. She did it in the docs lounge in front of me with 2 other CRNAs lounging around.

Case went smoothly as expected.

Dude,

Grow a set and let this b itch have it! Don't allow someone with half the training as you to punk you out in front of her "colleagues". I would never, ever allow this to occur where I practice. She disrespected you by blabbing her nonsense in front of others, so next time it happens, tear her a new one.

 

[Noyac]

I Have a question for Jet/mil/Noyac or the other private practice dudes out there? How would you go about handling this issue since it has happened more than once?

BTW, i work well with everyone else out there. I haven't said a thing to this CRNA, but i am afraid that if i don't this will continue.

If this nurse is a problem then you need to go about changing her. There are a few ways that I can think of and while all of those ideas put forth here (UFC style) are immediately gratifying the one with the most punch is the one that deals with her job security. If you have the power in the group to influence whether or not she remains at the job then great. But you need to but very diplomatic about your mission (to get rid of the virus). You need to put things in writing with names (witnesses), dates, times, and explain her lack of clinical understanding. Submit these records to those with authority. Once they have this in writing they must act. The paper trail is your friend. And it is your support or defense if she plans action later.

The problem occurs if your partners are not interested, then you are going to have to make a better case of it. If you have any control of her cases then you know how to get under her skin so that she is aware. Limit her good cases. Supervise her with an iron fist, no freedom. YOu are smarter and better trained than her, show her. Question everything she does and pounce when she is wrong.

Or you could just let it go.🙁

But the paper trail works wonders, trust me. I just used it this past few months. This OB nurse had a bad attitude especially towards my partners and I which was affecting pt care. I submitted a formal complaint to the nurse supervisor and the Chief of Staff. I was professional and at the same time I outlined the nurse supervisors responsibility in the matter. I was informed this week that the nurse was given 2 options, resign or be fired. She resigned. The other nurses are extremely helpful right now.

 

[G0S2]

Could you also use some oral midazolam before the inhalation induction?

 

[coprolalia]

I gotta agree with Noyac here.

You don't owe the courtesy of direct response to this individual. What you should do is send an email to their supervisor.

In that email you should use words like "inappropriately discussing specific patient-related information in a public area" and "disturbing and worrisome display of lack of compassionate patient care" and "demonstration of inability to grasp variability of practice and, within that, what still constitutes appropriate standard of care"... etc... etc.

Don't get into a tete-a-tete with this individual. You don't owe them that. Create the paper trail.

Also, for what it's worth, I've mask induced a 30-year-old before when both me and my attending couldn't get an IV started for what was a relatively minor lower extremity case. Is this something I'd normally do? No. But, it was either sit there another 20 minutes stabbing the guy's arms, or get the case underway.

For the record, he did fine. It was actually really cool. Pretty much single breath induction. And, once those veins popped out under the GA, he was an easy stick.

Adaptability and a full understanding of the risk/benefit ratio is what separates you from "just another technician."

-copro

 

[urge]

unfortunately, a militant CRNA thought it would be prudent to let me know that this was below the standard of care. She did it in the docs lounge in front of me with 2 other CRNAs lounging around.

Case went smoothly as expected.

Are you a pp attending?

Did she do the case with you?



I agree with Noy. Start a paper trail. Talk to her boss and your partners about her inadequacy.

I would have said on the spot that you are sure what you are doing is standard and that if she is afraid of children this job might not be the best for her.

 

[Planktonmd]

A CRNA who criticizes your care publically should be dealt with promptly so it does not become a habit.
I would ask her to show me a study that says that the standard of care is to avoid mask induction in all 11 Y/O kids.
Then I will explain to her that the "standard of care" is a legal not medical term and that since this is a hospital not a lawyer's office we prefer to use medical terms.
Then I would tell her that as long as I am signing the chart I define what the "standard of care" is, and if she doesn't agree that would be too bad.

 

[aphistis]

Agree with Noyac.

 

[Foghorn Leghorn]

[youtube]http://www.youtube.com/watch?v=Rvwh9_HsUmU[/youtube]

 

[drmwvr]

At our Children's hospital we do inhalation inductions on ALL kids less than 12 years old unless they have an IV that was placed in the ER, floor, etc. or if there is an indication for RSI.

My concern with inhal. induction on the older child is their size. An 11 or 12 year old boy can be quite large in relation to me (I'm not a big fellow). If he becomes excited on the table, I'm concerned about mishap. If we were to give oral midaz (and wait the appropriate time interval) and start the iv with n20/o2 in the or, we'd be better able to control him.

 

[Noyac]

My concern with inhal. induction on the older child is their size. An 11 or 12 year old boy can be quite large in relation to me (I'm not a big fellow). If he becomes excited on the table, I'm concerned about mishap. If we were to give oral midaz (and wait the appropriate time interval) and start the iv with n20/o2 in the or, we'd be better able to control him.

Are you serious?

How small are you?

New "standard of care", if the pt is larger than the anesthesiologist then inhalation induction is contraindicated.

 

[drmwvr]

Are you serious?

How small are you?

New "standard of care", if the pt is larger than the anesthesiologist then inhalation induction is contraindicated.

My 11 year old comes up to my eyebrows and will no doubt outweigh me by the time he's 13 unless I start drinking a lot of beer now. And that's not a "new" standard of care. I've been using it for 15 years

 

[Noyac]

My 11 year old comes up to my eyebrows and will no doubt outweigh me by the time he's 13 unless I start drinking a lot of beer now. And that's not a "new" standard of care. I've been using it for 15 years

I'm happy to help you with that BEER issue.👍

 

[Monty Python]

unfortunately, a militant CRNA thought it would be prudent to let me know that this was below the standard of care. She did it in the docs lounge in front of me with 2 other CRNAs lounging around.

Case went smoothly as expected.

Tell that jerk militant CRNA several things, if you please:

1. there's no reason to be discourteous to anyone at anytime. Professionals should be able to disagree without being disagreeable.

2. that militant CRNA is being publicly called-out by another CRNA (me). Please have her show you written "standard of care."

3. I did a case earlier this week on-call with similar details, except my patient was eight. Patient was very hospital-wise and I didn't want to torture her. PO versed, sevo induction, IV, LMA, yada yada.

4. That CRNA needs a talking-to by the chief CRNA or the department chairperson on various aspects of professionalism.

 

[Monty Python]

From my vantage point, this is a rare example of flirtation. If she's a hottie, work the whole Mars/Venus angle. Flowers, dinner date, choice of disinhibiting concoction and a strong, slow, methodical tongue will getcha where you need to be... Regards, ----Zippy

As usual, the unique and spot-on Zippy analysis and plan of action. 👍

 

[DET0897]

I have an attending who does inhalation induction on anybody and everybody, regardless of age/size. His standard of care is to not open the drug box.

On the otherhand, I tend to get the kids with so many previous surgeries that they hate the mask, and beg for a preop IV

 

[Monty Python]

I have an attending who does inhalation induction on anybody and everybody, regardless of age/size. His standard of care is to not open the drug box.

On the otherhand, I tend to get the kids with so many previous surgeries that they hate the mask, and beg for a preop IV

Do you have the luxury of time to allow EMLA cream to work? If so, great. I wish our place did.

 

[DET0897]

Do you have the luxury of time to allow EMLA cream to work? If so, great. I wish our place did.

Never used it

 

[Lonestar]

Trinity,

I agree with you. Some people regardless of their title have a hard time working with other people. This particular CRNA seems to think that I provide substandard care and continues to disrespect me in front of the other hospital staff.

The only reason why I brought this up is because I don't see her attitude changing. Just this past weekend, I did a case involving a 54 yo white male for I&D of abdominal abscess. pt had a h/o of IDDM and most recent Blood glucose was 300 (1 hr ago) after receiving some regular insulin in the ER. Surgeon tells me it will take 5-10 min for the procedure and that the abscess was pretty wide and deep. My decision was to do GETA and check the blood glucose in the PACU. She walks in to the holding area, looks at the chart and i tell her the h/o about diabetes and that we will check the sugar in the pacu. Her exact words were in front of the pt "wow, we don't do cowboy medicine here" without realizing that the procedure was short. She says that she will check the glucose in the room. Then she goes on to tell me that she doesnot feel that this case would be done under local and sedation and that the local anesthetic would not work under acidotic tissue (all this time she hasn't even given me the chance to tell her that I plan to do General Anesthesia).

Well, the case ends and I am in the room the entire time and she tell me "you did a good job." Atleast she thinks she is doing me a favor by teaching me something. BTW, we checked the glucose in the pacu and it was 288.

Oh and to answer Zippy she is not hot. Just old and crusty.

 

[huktonfonix]

Trinity,

I agree with you. Some people regardless of their title have a hard time working with other people. This particular CRNA seems to think that I provide substandard care and continues to disrespect me in front of the other hospital staff.

The only reason why I brought this up is because I don't see her attitude changing. Just this past weekend, I did a case involving a 54 yo white male for I&D of abdominal abscess. pt had a h/o of IDDM and most recent Blood glucose was 300 (1 hr ago) after receiving some regular insulin in the ER. Surgeon tells me it will take 5-10 min for the procedure and that the abscess was pretty wide and deep. My decision was to do GETA and check the blood glucose in the PACU. She walks in to the holding area, looks at the chart and i tell her the h/o about diabetes and that we will check the sugar in the pacu. Her exact words were in front of the pt "wow, we don't do cowboy medicine here" without realizing that the procedure was short. She says that she will check the glucose in the room. Then she goes on to tell me that she doesnot feel that this case would be done under local and sedation and that the local anesthetic would not work under acidotic tissue (all this time she hasn't even given me the chance to tell her that I plan to do General Anesthesia).

Well, the case ends and I am in the room the entire time and she tell me "you did a good job." Atleast she thinks she is doing me a favor by teaching me something. BTW, we checked the glucose in the pacu and it was 288.

Oh and to answer Zippy she is not hot. Just old and crusty.

Should have asked her, "really, thats interesting. Why won't the local work with acidotic tissue?" If she knows the answer, more power to her, but she probably just memorized something she was told once. If not teach her something, and shut her up.

 

[Fastrach]

Wow... all i can say is, wow... if I was one of the partners of your group and was making the schedule, this gal would get the MAC eyeball room every day from that day forward, and consider herself lucky to not be fired on the spot... inexcusable arrogance.

 

[ProRealDoc]

Trinity,

I agree with you. Some people regardless of their title have a hard time working with other people. This particular CRNA seems to think that I provide substandard care and continues to disrespect me in front of the other hospital staff.

The only reason why I brought this up is because I don't see her attitude changing. Just this past weekend, I did a case involving a 54 yo white male for I&D of abdominal abscess. pt had a h/o of IDDM and most recent Blood glucose was 300 (1 hr ago) after receiving some regular insulin in the ER. Surgeon tells me it will take 5-10 min for the procedure and that the abscess was pretty wide and deep. My decision was to do GETA and check the blood glucose in the PACU. She walks in to the holding area, looks at the chart and i tell her the h/o about diabetes and that we will check the sugar in the pacu. Her exact words were in front of the pt "wow, we don't do cowboy medicine here" without realizing that the procedure was short. She says that she will check the glucose in the room. Then she goes on to tell me that she doesnot feel that this case would be done under local and sedation and that the local anesthetic would not work under acidotic tissue (all this time she hasn't even given me the chance to tell her that I plan to do General Anesthesia).

Well, the case ends and I am in the room the entire time and she tell me "you did a good job." Atleast she thinks she is doing me a favor by teaching me something. BTW, we checked the glucose in the pacu and it was 288.

Oh and to answer Zippy she is not hot. Just old and crusty.

hmm. hmm. hmm and to think I have this to look forward to. I cannot wait!!! ,

 

[Planktonmd]

Wow... all i can say is, wow... if I was one of the partners of your group and was making the schedule, this gal would get the MAC eyeball room every day from that day forward, and consider herself lucky to not be fired on the spot... inexcusable arrogance.

What makes you think that giving her the "MAC eyeball" room everyday would be perceived as a punishment?? 😉

 

[rsgillmd]

Do you have the luxury of time to allow EMLA cream to work? If so, great. I wish our place did.

Maybe it was just my n=3, but in my limited experience EMLA actually seemed to cause vasoconstriction of the blood vessels. I swear they looked smaller than before I applied the EMLA cream.

 

[jetproppilot]

Tell that jerk militant CRNA several things, if you please:

1. there's no reason to be discourteous to anyone at anytime. Professionals should be able to disagree without being disagreeable.

2. that militant CRNA is being publicly called-out by another CRNA (me). Please have her show you written "standard of care."

3. I did a case earlier this week on-call with similar details, except my patient was eight. Patient was very hospital-wise and I didn't want to torture her. PO versed, sevo induction, IV, LMA, yada yada.

4. That CRNA needs a talking-to by the chief CRNA or the department chairperson on various aspects of professionalism.

Nicely said, Sir.👍

Agree with Trin. And Noy.

Ya gotta address it.

How you address it is up to you.

 

[maceo]

If this nurse is a problem then you need to go about changing her. There are a few ways that I can think of and while all of those ideas put forth here (UFC style) are immediately gratifying the one with the most punch is the one that deals with her job security. If you have the power in the group to influence whether or not she remains at the job then great. But you need to but very diplomatic about your mission (to get rid of the virus). You need to put things in writing with names (witnesses), dates, times, and explain her lack of clinical understanding. Submit these records to those with authority. Once they have this in writing they must act. The paper trail is your friend. And it is your support or defense if she plans action later.

The problem occurs if your partners are not interested, then you are going to have to make a better case of it. If you have any control of her cases then you know how to get under her skin so that she is aware. Limit her good cases. Supervise her with an iron fist, no freedom. YOu are smarter and better trained than her, show her. Question everything she does and pounce when she is wrong.

Or you could just let it go.🙁

But the paper trail works wonders, trust me. I just used it this past few months. This OB nurse had a bad attitude especially towards my partners and I which was affecting pt care. I submitted a formal complaint to the nurse supervisor and the Chief of Staff. I was professional and at the same time I outlined the nurse supervisors responsibility in the matter. I was informed this week that the nurse was given 2 options, resign or be fired. She resigned. The other nurses are extremely helpful right now.

it is not standard of care. Just because one does things others dont doesnt make it a standard of care issue.. this bitch crna has no idea what she is talking about

i agree with noyacfor the first and only time in my life. Write a letter to the medical staff office and the vp of nursing delineating the unprofessional behavior(which is what it was in my opinion) and the insubordination. She should be reprimanded in writing. Moreover, DONT WORK WITH THIS BITCH ANYMORE. PEriod. or at least limit your time working with her.

I was at a hospital once where one of the other anesthesiologist came to the room to talk to me and said someting derogatory towards another anesthesiologist on staff. something along the lines of.. he is lazy or something like that. Nothing too too bad. the surgeon overheard and reported this guy to the medical staff affairs. This guy got a professional misconduct ding on his record. So its a big big deal this issue and I woulld report it.

 

[zippy2u]

Well, it looks like we got ourselves a lil' noobie problem out in PP land. When the herd goes left, we'll take a right. OK, a crusty old female CRNA... Let's put a beat down on this paper trail thing. Remember when you were a kid there was always another kid who was a tattle-tail. How about the kid who ratted ya out when ya stole some cigarettes at the 7-11. Maybe a supposed friend who "outed" you concerning your sexual persuasion when you weren't ready. That cousin who narked on ya to your parents for experimenting with some herb. These people didn't die, in adulthood they morphed into the "whiners and complainers", the nosy neighbor that peeks over fences and past window blinds, the "do-righters", the "finger-pointers" and last but not least, the PAPER-TRAILERS. As kids ya didn't care to be around them and as adults the same applies. Resist the temptation to become a paper-trailer. The health field paper trail is a one-way street. Anyone can fill out the mindless forms and the "beaners" will submit it to your file without your side of the story. It's not democratic, it goes against everything you learned from the time you were a child--"there's at least two sides to a story..." The paper trail should be reserved for people that come at ya with a weapon like a syringe full of pavulon, a knife, a gun or deliverance of a haymaker sucker punch. The enduring qualities of a decent anesthesiologist consist of the triad--- compassion, patience and most important, tolerance. So invite her out to dinner and give her a gift. Befriend her. Really listen to her and care. Discuss what is important in her life and remember the details.. Treat her like your Mom. Smoke her with kindness. Walk into her room and chit chat with her. Remember her birthday and other important dates in her life. It may take weeks or months for her to see the light and this is where patience comes in. Let us know how it goes, Diplomat. Regards, -----Zippy

 

[Jeff05]

i mask induced a mentally ******ed HIV+ 35 year old without an IV. no one would come next to him with a ketamine dart...
security called. 4 dudes hold him down. gas on.