Pushing meds for induction

[Steege305]

I was just perusing Gaswork to look at the CRNA jobs in my area and there was header for the percent that Anesthesiologists push induction meds vs. CRNAs. Is this a thing?

I’m not gonna lie, I don’t let the CRNAs I work with push induction meds all the time. I pick my spots, but if they’re sick then I want to be in control. I’ve been burned before, and I have kids to feed.

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[Arch Guillotti]

Pick your spots.

 

[Dr. Rude]

I was just perusing Gaswork to look at the CRNA jobs in my area and there was header for the percent that Anesthesiologists push induction meds vs. CRNAs. Is this a thing?

I’m not gonna lie, I don’t let the CRNAs I work with push induction meds all the time. I pick my spots, but if they’re sick then I want to be in control. I’ve been burned before, and I have kids to feed.

It's a Turf thing. Says something about the culture of the department.

 

[MirrorTodd]

I can't think of a single good reason for why one WOULDN'T want someone else there. lol

 

[anbuitachi]

I was just perusing Gaswork to look at the CRNA jobs in my area and there was header for the percent that Anesthesiologists push induction meds vs. CRNAs. Is this a thing?

I’m not gonna lie, I don’t let the CRNAs I work with push induction meds all the time. I pick my spots, but if they’re sick then I want to be in control. I’ve been burned before, and I have kids to feed.

dont really understand what you are asking. is what a thing? crnas pushing meds?

i let crna push med if its healthy. or i tell them how much to push. if patient is sick i absolutely push myself.

ive been slightly burnt before because i worked w veteran crna, excellent in many areas, then once i pushed drugs and i realized i guess he can be excellent in the stuff he usually does but he doesnt usually push meds. and imo he pushed too much propofol than needed for induction. patient was okay. but a 60 year old 50 kg man doesnt need 200 of propofol for intubation.

vast vast majority of time >95% of time im pushing

at the same time, we had anesthesiologist recently push 3.5mg/kg of propofol for induction (in addition to other meds like fent) for intubation for a 75 year old patient.
patient almost coded on induction. anesthesiologist cancelled the case due to cardiac instability and wanted cardiology consult. patient ended up getting an echo, which was normal, and proceeded with case next time. next anesthesiologist didnt give 3.5mg/kg of propofol and all went fine

 

[vector2]

Sick pt or other special concern I'm definitely pushing the meds.

Newer CRNA who has barely internalized the sequence of steps required to induce, intubate, and start the case, I'm likely pushing there too.

Healthy or healthy'ish patient for relatively uncomplicated case with a CRNA I know, I don't care.

 

[IMGASMD]

Depends on the crna. Depends on the culture. Depends when they’re trained.

 

[coffeebythelake]

I was just perusing Gaswork to look at the CRNA jobs in my area and there was header for the percent that Anesthesiologists push induction meds vs. CRNAs. Is this a thing?

I’m not gonna lie, I don’t let the CRNAs I work with push induction meds all the time. I pick my spots, but if they’re sick then I want to be in control. I’ve been burned before, and I have kids to feed.

Is this a medical direction vs medical supervision thing? We do direction. I can count with one hand how many times I've let a cRNa induce over my years as an attending. And I would never let a cRNa induce a sick patient by themselves.

 

[TxGasserMD]

I generally always push meds on RSI, hearts and Peds. And any other patients deemed “unstable”.

 

[Dr. Rude]

I can't think of a single good reason for why one WOULDN'T want someone else there. lol

I can.
From some CRNAs’ perspective: They like the feeling of autonomy and independence of inducing alone while having a doc close by as the fire department and liability sponge. Also some like projecting an image of not needing an anesthesiologist.

 

[IMGASMD]

I can.
From some CRNAs’ perspective: They like the feeling of autonomy and independence of inducing alone while having a doc close by as the fire department and liability sponge. Also some like projecting an image of not needing an anesthesiologist.

There are some attendings who will tell crnas to “go ahead….”

I’ve had crnas who doesn’t
even call for inductions. I was PO, but they aren’t our employees, no one to complain to.

I’ve also had crnas shoo me out of the room right after induction. I make it a habit to wait until the baby is out before I leave for sections. Apparently that’s not what some of colleagues do. So I get eye rolls too.

Right now I am at an institution historically train a lot of their crnas. (They’re definitely the largest crna producers in the state.) Also let them do “fellowships”…. Thankfully, I usually am in my own rooms, unless on call….

 

[anaesthetic]

I’ve done both direction and supervision at different hospitals/practices. Luckily, I’ve not had many bad interactions with CRNAs.

Every one of them has handed me the syringes when it’s a critically ill patient. I think it comes down to mutual trust and respect, and at the end of the day, they want the responsibility and liability to be on me (and so do I).

It also helps that they know I won’t push 200 mg of prop on a 81-year-old patient with low flow, low gradient severe AS and EF 20-25% like some of our non-cardiac colleagues would. You can guess how that went.

 

[MirrorTodd]

I can.
From some CRNAs’ perspective: They like the feeling of autonomy and independence of inducing alone while having a doc close by as the fire department and liability sponge. Also some like projecting an image of not needing an anesthesiologist.

Those aren't good reasons though. That's just people that need to work on their ego's.

 

[rick roller pump]

If the CRNA is pushing the drugs, are you guys doing the airway then? Sometimes I let the CRNA push the drugs but then I do the airway.

 

[ToKingdomCome]

If the CRNA is pushing the drugs, are you guys doing the airway then? Sometimes I let the CRNA push the drugs but then I do the airway.

I do this sometimes

 

[Arch Guillotti]

If the CRNA is pushing the drugs, are you guys doing the airway then? Sometimes I let the CRNA push the drugs but then I do the airway.

sometimes

 

[Teillard]

If a new doc decides to do this, I also hand him (almost always a 'him') the laryngoscope (if he doesn't ask for the VL) along with the induction meds and go take a break. But not before reminding him I've done 10,000 inductions/intubations before he had his cherry popped....

 

[vector2]

If a new doc decides to do this, I also hand him (almost always a 'him') the laryngoscope (if he doesn't ask for the VL) along with the induction meds and go take a break. But not before reminding him I've done 10,000 inductions/intubations before he had his cherry popped....

Imo this makes you look more like an insecure tool than a billy badass

 

[drmwvr]

Imo this makes you look more like an insecure tool than a billy badass

Well I guess you'd just intubate the patient and wait for me to come back...

 

[vector2]

Well I guess you'd just intubate the patient and wait for me to come back...

I'd tell him to stop and get back to the head of the bed. I got other rooms to attend to, not to mention the hospital pays for a break CRNA. If he wants to escalate it from there ("it" being the fact that he's not willing to do his job) then we can go down that road *shrug*

 

[woopedazz]

I give every drug as a slow infusion via a 100ml bag. Just like MIMS tells me. Pushing is for cowboys.

 

[GonnaBeADoc2222]

I'd tell him to stop and get back to the head of the bed. I got other rooms to attend to, not to mention the hospital pays for a break CRNA. If he wants to escalate it from there ("it" being the fact that he's not willing to do his job) then we can go down that road *shrug*

Man I dunno how you guys deal w these CRNA tools

 

[Dr. Rude]

Man I dunno how you guys deal w these CRNA tools

One or more of the following strategies seems to cover it.

1. Eat ****.
2. Mentally disengage so you don’t care.
3. Have a strong department of docs so this type of CRNA has to bite their tongue or leave.

 

[vector2]

One or more of the following strategies seems to cover it.

1. Eat ****.
2. Mentally disengage so you don’t care.
3. Have a strong department of docs so this type of CRNA has to bite their tongue or leave.

And I would bet the vast majority of supervisory practices are 1 or 2.

Just think of all the too-lean AMC depts, or academic depts with feckless chairmen where if the docs complain about not meeting strict medical direction or complain about CRNAs idiotically peacocking wrt who pushes drugs / does procedures, the docs are immediately gaslit into believing they're the problem and they're not being "team players" etc, etc

 

[pgg]

If a new doc decides to do this, I also hand him (almost always a 'him') the laryngoscope (if he doesn't ask for the VL) along with the induction meds and go take a break. But not before reminding him I've done 10,000 inductions/intubations before he had his cherry popped....

We have essentially no tolerance or patience for this on the forum. Begone.

 

[rick roller pump]

Unfortunate to see the culture in different parts of the country. I'm new in my career but have worked at a few different hospitals in two states and never had issues noted above. Most CRNAs are actually pretty easy to work with. Never had them tell me not to do something, and if they acted like the guy above we would not tolerate it.

 

[zizzer]

Unfortunate to see the culture in different parts of the country. I'm new in my career but have worked at a few different hospitals in two states and never had issues noted above. Most CRNAs are actually pretty easy to work with. Never had them tell me not to do something, and if they acted like the guy above we would not tolerate it.

The first CRNA I worked with at my first job out of residency had an attitude not far off from this. Fortunately, she was a very part-time employee who I never saw again and none of the others acted like anything even close to that and we have great working relationships and are friends outside of work.

 

[Hoya11]

If a new doc decides to do this, I also hand him (almost always a 'him') the laryngoscope (if he doesn't ask for the VL) along with the induction meds and go take a break. But not before reminding him I've done 10,000 inductions/intubations before he had his cherry popped....

That sounds like a good deal to me!

I don’t need anyone in the room during induction . I’m not sure why we even have CRNAs there for induction? I’ll call you when it’s all set and time to chart and I need to move onto my next room .. that would indeed be a great system

I think we just let them do airway so they feel somewhat important and keep showing up to write down the vitals when we are gone

 

[Ronin786]

Honest question, if you're not pushing meds and the CRNA is putting the tube in and sitting in the room, what are you guys doing?

Not that pushing drugs is some huge task, but even just the symbolism of it matters. I've been in practices where CRNAs throw a fit if they don't get to push drugs (thankfully no longer) and I always take it as another sign of them thinking they don't need us.

 

[D P356]

I don’t work with CRNAs presently. Most were pleasant and did a fine job when we communicated effectively.

A snarky comment as above wouldn’t be met with animosity by me,

More so

“why are you choosing to be here?”
I’d probably go a step further and bring some job postings back to them where they can work independently. If you’re choosing to be in a position that is subordinate to someone that could be your child’s age and that is bothersome, make a move.

No personal disrespect from me. I’d treat people fairly and communicate my expectations as well as the fact that we’d both chosen to be in a team model .

If the department leadership is spineless, that’s another issue.

 

[Arch Guillotti]

If a new doc decides to do this, I also hand him (almost always a 'him') the laryngoscope (if he doesn't ask for the VL) along with the induction meds and go take a break. But not before reminding him I've done 10,000 inductions/intubations before he had his cherry popped....

Keep the crap out of here.

 

[coffeebythelake]

That's just people that need to work on their ego's.

Yep

If a new doc decides to do this, I also hand him (almost always a 'him') the laryngoscope (if he doesn't ask for the VL) along with the induction meds and go take a break. But not before reminding him I've done 10,000 inductions/intubations before he had his cherry popped....

We got a keyboard warrior there. What u are claiming doesn't happen in real life because it would represent a serious level of immaturity and unprofessionalism. Some would even say patient abandonment. But good for you pretending that you can get away doing this without being disciplined or fired from your job. A real AANA hero.

 

[Endee]

I think the anesthesiologist should always push meds. In a perfect world that would happen. It's often not a perfect world. But there's a lot of things people can do or think about that would put the patient in a safer place. Can a colleague be called, like the board runner, to induce the patient, if you're tied up in another room?

I think another critical question is--will this nurse anesthetist call you if something goes south, or not? Lots of inductions go bad unexpectedly for one reason or another. Lots of nurses are known to not call for help. Don't let those people induce without you.

 

[IMGASMD]

Yep



We got a keyboard warrior there. What u are claiming doesn't happen in real life because it would represent a serious level of immaturity and unprofessionalism. Some would even say patient abandonment. But good for you pretending that you can get away doing this without being disciplined or fired from your job. A real AANA hero.

Hahahha. He doesn’t care about patient abandonments, because his attending is ultimately responsible. He’s only a nurse at that point…..
simple logic.

 

[IMGASMD]

I think the anesthesiologist should always push meds. In a perfect world that would happen. It's often not a perfect world. But there's a lot of things people can do or think about that would put the patient in a safer place. Can a colleague be called, like the board runner, to induce the patient, if you're tied up in another room?

I think another critical question is--will this nurse anesthetist call you if something goes south, or not? Lots of inductions go bad unexpectedly for one reason or another. Lots of nurses are known to not call for help. Don't let those people induce without you.

I think we had this discussion or similar discussion at some point.
For those 1:4 practices with 4 730 starts what do you do?!
I think someone mentioned to stagger them…. But what if one runs into complication, what do you do with the other three?
People always say they will just delay the other ones. I live in a more realistic world…. That’s why I always want to do my own cases, and not live based on the whims of my nurses.

 

[nimbus]

I think we had this discussion or similar discussion at some point.
For those 1:4 practices with 4 730 starts what do you do?!
I think someone mentioned to stagger them…. But what if one runs into complication, what do you do with the other three?
People always say they will just delay the other ones. I live in a more realistic world…. That’s why I always want to do my own cases, and not live based on the whims of my nurses.

Complications?? In what world?

 

[IMGASMD]

Complications?? In what world?

Not in my practice.

I never have a spinal that took more than 2 tries. All my IV placed in pre-op work 100% of the time, they are all 18G too. Only once in blue moon, when pre-op nurses are PO’ed at me, I get a 20G. Oh, and obviously, my CRNAs place all their tubes on the 1st try. Never have I encountered any CRNAs fighting me when I suggest just use a glide or McGrath to simplify my life. I can’t even understand why any induction would take more than 3 minutes, tops.

 

[Dr. Anonymouss]

If a new doc decides to do this, I also hand him (almost always a 'him') the laryngoscope (if he doesn't ask for the VL) along with the induction meds and go take a break. But not before reminding him I've done 10,000 inductions/intubations before he had his cherry popped....

Someone sounds bitter they didn't go to medical school...

 

[Dr. Rude]

I think we had this discussion or similar discussion at some point.
For those 1:4 practices with 4 730 starts what do you do?!
I think someone mentioned to stagger them…. But what if one runs into complication, what do you do with the other three?
People always say they will just delay the other ones. I live in a more realistic world…. That’s why I always want to do my own cases, and not live based on the whims of my nurses.

A little bit of staggering. A little bit of surgeons being late or not getting their paper work done. Everyone hustling, The post first call guy stays over to start the first wave, judicious room assignments, e.g. Guy with big case with lines gets a MAC first start in another room. Somebody else who's available starts a room, a little bit of delaying a case or two, etc. etc., It works out.

 

[rick roller pump]

With 4 730 cases it is basically impossible to start all of them on time and the schedule should be adjusted. I work in a busy group and might have for example 730, 730, 740 start (not ideal but happens). Most of my cases don't need an extra IV or a-line and get the blocks done in pre-op. Usually things time out fine with one of the 730 getting in early and patient is only waiting in the room for max a couple minutes. If longer then try and get a colleague to help start it. Very rarely there is a 5-10 minute delay but whatever not the end of the world. Anesthesiologist participates in induction no exceptions.

 

[GonnaBeADoc2222]

Stalking this thread over from EM world.

What's the general practice w CRNAs and intubation / induction? If I were an anesthesiologist I would tube everyone and let the CRNA (nurse) do what they do best - sit and chart. Do they throw tantrums if you do this?

In my world, all sorts of people come out of the woodwork wanting to intubate: Paramedic students, CRNAs, ED midlevels. I tell them all no way, and either myself or (more often) the ED resident intubates.

I appreciate you guys; you've helped me out of a couple sticky situations.

 

[rick roller pump]

Stalking this thread over from EM world.

What's the general practice w CRNAs and intubation / induction? If I were an anesthesiologist I would tube everyone and let the CRNA (nurse) do what they do best - sit and chart. Do they throw tantrums if you do this?

In my world, all sorts of people come out of the woodwork wanting to intubate: Paramedic students, CRNAs, ED midlevels. I tell them all no way, and either myself or (more often) the ED resident intubates.

I appreciate you guys; you've helped me out of a couple sticky situations.

The culture is to basically throw them a bone and let them do the airway. To be fair, they are setting up the room, getting the patient, charting, sitting the case, etc. This is much different than some random student showing up and expecting to do the airway. There needs to be some balance though. I will still do airways just to keep skills up and never had a CRNA have a problem with this.

 

[vector2]

Stalking this thread over from EM world.

What's the general practice w CRNAs and intubation / induction? If I were an anesthesiologist I would tube everyone and let the CRNA (nurse) do what they do best - sit and chart. Do they throw tantrums if you do this?

In my world, all sorts of people come out of the woodwork wanting to intubate: Paramedic students, CRNAs, ED midlevels. I tell them all no way, and either myself or (more often) the ED resident intubates.

I appreciate you guys; you've helped me out of a couple sticky situations.

The standard expectation in supervisory practices is that the CRNA (or resident) takes the first crack at intubation unless there is some special clinical concern which dictates that they shouldn't.

 

[anbuitachi]

Stalking this thread over from EM world.

What's the general practice w CRNAs and intubation / induction? If I were an anesthesiologist I would tube everyone and let the CRNA (nurse) do what they do best - sit and chart. Do they throw tantrums if you do this?

In my world, all sorts of people come out of the woodwork wanting to intubate: Paramedic students, CRNAs, ED midlevels. I tell them all no way, and either myself or (more often) the ED resident intubates.

I appreciate you guys; you've helped me out of a couple sticky situations.

Here, students/residents from everywhere rotate on anesthesia for intubation experience. this includes EM, IM, residents. Pulm crit fellows. med students, SRNA. cant turn everyone away since thats a major part of their rotation. at least for CRNAs, theyve had plenty of intubation experience in their training where ever that was so most feel comfortable with them intubating. way less stressful than ED/IM residents/med students intubating first time and are freaking out

 

[ToKingdomCome]

How do we feel about CRNAs inducing and doing GETA themselves on ASA 1 if you’re tied up doing other stuff

 

[nimbus]

According to one of our charge nurses who also works at Kaiser, some of the doctors there will say to the CRNA in preop, “Are we good here?” and then go back to bed. According to him, some of the doctors never step foot into the OR during the case. Maybe they don’t need to follow TEFRA at Kaiser.

 

[Lecithin5]

According to one of our charge nurses who also works at Kaiser, some of the doctors there will say to the CRNA in preop, “Are we good here?” and then go back to bed. According to him, some of the doctors never step foot into the OR during the case. Maybe they don’t need to follow TEFRA at Kaiser.

And we wonder why crnas behave the way they do

 

[rick roller pump]

How do we feel about CRNAs inducing and doing GETA themselves on ASA 1 if you’re tied up doing other stuff

Slippery slope. Soon enough they will want to induce by themself for every case.

 

[coffeebythelake]

How do we feel about CRNAs inducing and doing GETA themselves on ASA 1 if you’re tied up doing other stuff

If I'm not supervising them and i'm not signing the chart, they can do whatever they want.

 

[gunnershow]

It's painful to admit that this field sometimes attracts some of the worst personalities in medicine. It doesn't matter how many superstar, knowledgeable anesthesiologists a CRNA meets. All it takes is for one, lazy, do-nothing anesthesiologist to completely hand over the reins to them and/or demonstrate their gross incompetence, and the CRNA will be convinced that they might as well be in the driver's seat.