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Procedural Boundaries?

0kazak1

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Soon to be attending, will be working at an academic center, and already seen a lot of other people place lines in (with questionable skills), when is it right to speak up and offer guidance? I'm not talking about just anesthesia residents.
 

dchz

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If your goal is to take care of the pt, speak up whenever.

If your goal is to be tactful and have everyone like you, just pretend like you're an anesthesia tech. :)

I personally don't say anything unless they are about to get it in the artery.
 

abolt18

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I think it's definitely worth speaking up if there is concern for the safety of the patient or the success of the line placement. But criticising just because it's not how YOU do it doesn't usually go well and closes people off to learning your way.

But if you approach things with "hey, I realize you already know how to do this, but I'd like to teach you the way I like to do it. That way you learn a new technique and I am satisfied with the line being placed in a way I'm comfortable with."

We have 1 attending out of 50 something that I -- and many others -- have seriously hated working with. This individual came straight out of residency at another institution. He/she is very smart, but would incessantly criticise and demean residents for doing things in any way different from "the right way." Things have gotten a LOT better after 2 years and it's easy to have a good day in the OR and soak up the knowledge they have to share, but it was rough getting to this point.

Point is, you can teach and correct and even critique (and you should, ESPECIALLY when it comes to patient safety) but you don't have to be a douche canoe to do it.
Soon to be attending, will be working at an academic center, and already seen a lot of other people place lines in (with questionable skills), when is it right to speak up and offer guidance? I'm not talking about just anesthesia residents.
 
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ambiturner

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As long as you don’t embarrass the trainee/CRNA I think any guidance is fine. If you want to talk privately after the event you can be critical, but people hate being humiliated in front of nurses and surgeons and this will be reflected in any evaluations they give you.

In my practice it’s rare to see something truly unsafe during line placement, but it’s common to see slowness that threatens the flow of the OR. In this case you often will have to help. Remember that, as an attending, you are building long term relationships with the attending surgeons and OR staff. Just like you get irritated at the surgeon that lets the new resident close for 90 minutes, so too will they get irritated if you let your resident try an a-line for 45 minutes. Step in when you need to so that when you encounter a truly difficult procedure, no one will question that you need some extra time.

Also recognize how useless most commentary is during ultrasound guided procedures - trying to explain to a new trainee how to follow a needle tip without them having seen it before is I think the most difficult procedure to teach, other than how to feel different tissues during an epidural. Sometimes I’ll ask them to watch some videos the day before if I think this will be an issue.
 
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deleted171991

Also, do remember: cushy criticism is worthless. In one ear and out the other, in most cases.

If you want to teach for life, you have to create psychological discomfort, make them sweat, or you'll have to keep repeating stuff like a broken record (and hope that, by the time they graduate, they will remember). A good sports coach is never one's buddy; why should one's attending be?

I have not learned sh!t from most of my "nice" attendings. Shame on them, as far as I am concerned.
 
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abolt18

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Also,when they get in the artery, don't advance the wire for them unless they want you to!

Twice I have been burned this year by an attending getting overzealous and as soon as I got crimson gold in what had been a difficult art line, they say "now hold still" and proceed to grab the wire on the arrow and advance it forcefully (against resistance) before I was ready for them. Seriously idiotic.
As long as you don’t embarrass the trainee/CRNA I think any guidance is fine. If you want to talk privately after the event you can be critical, but people hate being humiliated in front of nurses and surgeons and this will be reflected in any evaluations they give you.

In my practice it’s rare to see something truly unsafe during line placement, but it’s common to see slowness that threatens the flow of the OR. In this case you often will have to help. Remember that, as an attending, you are building long term relationships with the attending surgeons and OR staff. Just like you get irritated at the surgeon that lets the new resident close for 90 minutes, so too will they get irritated if you let your resident try an a-line for 45 minutes. Step in when you need to so that when you encounter a truly difficult procedure, no one will question that you need some extra time.

Also recognize how useless most commentary is during ultrasound guided procedures - trying to explain to a new trainee how to follow a needle tip without them having seen it before is I think the most difficult procedure to teach, other than how to feel different tissues during an epidural. Sometimes I’ll ask them to watch some videos the day before if I think this will be an issue.
 

abolt18

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It's certainly a balance. Harsh criticism for no real good reason other than personal preference will go in one ear and out the other. At the same time, when patient safety is the issue, the criticism has to be stern enough that the recipient pays heed and doesn't blow it off.
Also, do remember: cushy criticism is worthless. In one ear and out the other, in most cases.

If you want to teach for life, you have to create psychological discomfort, make them sweat, or you'll have to keep repeating stuff like a broken record (and hope that, by the time they graduate, they will remember). A good sports coach is never one's buddy; why should one's attending be?

I have not learned sh!t from most of my "nice" attendings. Shame on them, as far as I am concerned.
 
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Hoya11

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Soon to be attending, will be working at an academic center, and already seen a lot of other people place lines in (with questionable skills), when is it right to speak up and offer guidance? I'm not talking about just anesthesia residents.

A great piece of advice that was given to me about starting a new job:

For the first 6 months you keep your mouth shut and your eyes open..
 
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jwk

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If your goal is to take care of the pt, speak up whenever.

If your goal is to be tactful and have everyone like you, just pretend like you're an anesthesia tech. :)

I personally don't say anything unless they are about to get it in the artery.
Uh, I'm not sure, but I think the bubble in the introducer sideport tubing is pulsating... ;)
 
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Airway

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It is really hard to make a good balance between resident autonomy, patient safety, and best practice education for residents. What I would suggest is that when things are high stakes (for instance - a recent learning for me: liver transplant, 30k platelets, obese and thick neck) you make the resident do exactly what you want...and then you can't be annoyed when things don't go exactly as you want.
 
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vector2

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Uh, I'm not sure, but I think the bubble in the introducer sideport tubing is pulsating... ;)

"chillax bro if the line is in the ascending aorta the meds are making it to the whole body anyway " *secures line with paper tape, no suture no teg, walks back to callroom*
 
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Angus Avagadro

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As an attending, you must be able to undo anything the res/fellow does. Otherwise, you probably shouldn't be supervising house staff. If I see something dangerous, I'll say "Please dont do that." Then I take over. If asked for a reason, I'll say say "it's dangerous, we'll talk about it later". I'm not one for public humiliation, (although that was the basis for my education in the East), but have little reservation in providing it if the resident isnt satisfied with my suggestion. There's diplomacy, then there Gunboat diplomacy.
 

Ronin1

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Soon to be attending, will be working at an academic center, and already seen a lot of other people place lines in (with questionable skills), when is it right to speak up and offer guidance? I'm not talking about just anesthesia residents.
If you are soon to be an attending that means you are most likely a resident or a fellow. Certainly correct/coach/take over for residents under your supervision otherwise back off. The way you learned to do things may not be the way others learned or do the same procedures. If asked give assistance otherwise chill
 

Ronin786

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From the school of Bill Belichik:

"“Everybody knows who Bill Belichick is, right?” Saban asked the room, rhetorically. “I worked four years for the guy and the guy is great, organized, but I will tell you one thing he does: He defines what everybody in the organization is supposed to"

Your resident should know what your expectations of them are ahead of time, rather than after they've punctured the artery. My usual spiel is as follows:

"I know you've probably done plenty of these, but if you talk me through what you're doing it'll make both of our lives easier and give you more latitude. I want you to visualize the tip of the needle at all times. We're going to verify venous access by x, y and z. Studies have shown that after three individual attempts the rate of complications increase. If we get to that point I'm going to have to take over."

We are terrible at communicating and defining expectations in medicine, but you can change that one person at a time.
 
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