Question About an OR Incident

[madiso30]

So I'm a medical student. Anesthesia is high on my specialty list but I'm only an M1 so I am keeping an open mind. I just want to grasp the culture in the OR a little better with regards to an incident I witnessed.

As a premed, I worked under a vascular surgeon who let me come shadow him during a AAA. This guy had every comorbidity you could imagine (or I guess not be surprised at because he had a AAA). He had HTN, Emphysema, T2DM, etc.

It's worth saying I only saw the anesthesiologist at the beginning of the case. So at some point in the case, his vitals started dropping. The surgeon told the CRNA to fix something and she began doing her thing. Vitals began to get worse and he told her to call for assistance. I assumed he meant the anesthesiologist. About 2 minutes later another CRNA comes in and begins helping behind the curtains. Vitals still aren't improving. Eventually the surgeon begins yelling at them to get a physician not a nurse into the OR. The doc shows up a minute later, asks some questions, and then fixes the issue in a minute. Unfortunately the patient died later that night.

So my questions are this:

1. Is it normal for the nurses to ask for help from other nurses first before getting the doc?
2. Is it normal for a doc to not be present for this long during, what appeared to be, a seriously sick Pt's surgery?
3. Just in general, did this case sound normal? Or was this as odd as it appear to be?

Sorry if this isnt appropriate for this forum and I'm not trying to cause drama. I know the CRNA issue can be a hot topic. I'm just genuinely trying to learn more about the culture in the OR. Thanks.

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[dchz]

So my questions are this:

1. Is it normal for the nurses to ask for help from other nurses first before getting the doc?
2. Is it normal for a doc to not be present for this long during, what appeared to be, a seriously sick Pt's surgery?
3. Just in general, did this case sound normal? Or was this as odd as it appear to be?

Sorry if this isnt appropriate for this forum and I'm not trying to cause drama. I know the CRNA issue can be a hot topic. I'm just genuinely trying to learn more about the culture in the OR. Thanks.

Culture of the OR depends on the institution. There are no standard "norms". In regards to your questions:

1. Yes
2. Yes
3. Yes

4. Would this be the way it is if profits and scarcity wasn't an issue? Answer: No.

 

[psychbender]

Yes, it's a little weird.

At any practice where I've been, if the CRNA was having issues and called for help, they would call the doc assigned that case, not another nurse.

If a doc was called with issues, they would go themselves, or send a colleague (physician) if they were tied up, not another nurse.

As for is it normal for the doctor to be in the room 1:1 during "sick a case," not always. What you perceive as "really sick" may not actually be all that acutely bad. As a med student, you lack some of that perspective. A long list of comorbidities may seem scary, but most of our run of the mill pts have HTN, CAD, DM, PVD, HFpEF, etc. When medically directing cases, I and most of my partners will generally stop by each room about once every 30-60 minutes, depending on case and acuity, and are available throughout should issues arise between those visits. Also, in my group, we rarely medically direct cases like this (these are nearly always physician-only), but if we are, we go down to 2:1, or ensure that the other rooms are really low acuity and/or long and boring (maybe a healthy pt undergoing robotic hernia repair with a slow surgeon and a healthy spinal fusion pt in another room).

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[2010houston]

You accurately assessed that this was NOT being handled well, but as others have pointed out, it is not necessarily totally outside the norm.

 

[chocomorsel]

^^Unfortunately true.
Rogue CRNAs who don’t want to be supervised, but yet for some reason work in an ACT model, run abound.

 

[T-burglar]

Lmao @ nurses doing a sick open AAA

 

[jw3600]

Like any of these supervising docs would let a nurse do their AAA when they’re 60. El o effing el.

 

[madiso30]

You accurately assessed that this was NOT being handled well, but as others have pointed out, it is not necessarily totally outside the norm.

It was kind of an odd sight to see. My boss was extremely well respected and normally very calm. In fact he was calm for 10.5 of the 11 hours of the surgery. It was the only tiem I saw a surgeon freak out at someone and I was surprised it was him out of all the surgeons I got to know. Dissapointing to see him pushed to that point.

 

[madiso30]

Culture of the OR depends on the institution. There are no standard "norms". In regards to your questions:

1. Yes
2. Yes
3. Yes

4. Would this be the way it is if profits and scarcity wasn't an issue? Answer: No.

Does this sort of obvious over-confidence and ignorance begin to drain on you? Or do you just get used to it? Because I left the hospital that day feeling like crap and a bit disheartened about Anesthesia.

 

[caligas]

I had a scary moment in Interventional Radiology once and said, among others things, “call for anesthesia help!”

an anesthesia TECH showed up 5 minutes later, (after the issue was resolved).

the lesson: Be Specific in what or WHO you want

 

[deleted697535]

I'm trying to figure out what 'it' was that was fixed in a minute that could have contributed to this patients demise.

I can't easily think of anything.

Was this an evar? Ruptured aaa? Elective? Was there a clamp on or recently unclamping? Level of clamp? GA? Epidural?

There are so many details missing for us to actually comment.

It doesn't sound like massive bleeding. And even if it was that's ultimately a surgical issue, we just keep up most of the time.

Hypovolemia? Also unlikely to cause death in a day.

Periop MI cva or pe? Again not really our fault.

Reperfusion injury from unclamping. Possibly the most likely.

Can you give us more details?

 

[MoMoGesiologist]

Does this sort of obvious over-confidence and ignorance begin to drain on you? Or do you just get used to it? Because I left the hospital that day feeling like crap and a bit disheartened about Anesthesia.

You are welcome to become a vascular surgeon...

 

[narcotics999]

11 hours of AAA? That's why the pt died.

What kind of thing was it that freaked the surgeon, took an anesthesiologist only 1 minute to fix but 2 CRNA had no idea of ?

 

[deleted697535]

11 hours of AAA? That's why the pt died.

Omg I just saw that now.
Yep. 100% a surgical problem.
Your boss can't operate, sorry.


Most of these take 3 hours, some 1 hour. 11 hours!?! Wtf. Even if it needed 11 hours or time, it should have been divided. This is crazy.

 

[Doughy315]

“Remember every second we are there we just can’t figure out the problem” - AANA

 

[deleted875186]

I'm trying to figure out what 'it' was that was fixed in a minute that could have contributed to this patients demise.

I can't easily think of anything.

Was this an evar? Ruptured aaa? Elective? Was there a clamp on or recently unclamping? Level of clamp? GA? Epidural?

There are so many details missing for us to actually comment.

It doesn't sound like massive bleeding. And even if it was that's ultimately a surgical issue, we just keep up most of the time.

Hypovolemia? Also unlikely to cause death in a day.

Periop MI cva or pe? Again not really our fault.

Reperfusion injury from unclamping. Possibly the most likely.

Can you give us more details?

I’m also trying to figure out what could have been fixed

Perhaps they were in the chest and a DLT was used, bronchial cuff herniated or something?

Hypovolemia? Hypocalcemia? Maybe just a dampening or non functioning arterial line?

 

[madiso30]

I'm trying to figure out what 'it' was that was fixed in a minute that could have contributed to this patients demise.

I can't easily think of anything.

Was this an evar? Ruptured aaa? Elective? Was there a clamp on or recently unclamping? Level of clamp? GA? Epidural?

There are so many details missing for us to actually comment.

It doesn't sound like massive bleeding. And even if it was that's ultimately a surgical issue, we just keep up most of the time.

Hypovolemia? Also unlikely to cause death in a day.

Periop MI cva or pe? Again not really our fault.

Reperfusion injury from unclamping. Possibly the most likely.

Can you give us more details?

So I wish I could answer all of this but I just am not experienced/educated enough yet to. I will answer what I can though. My memory isn't perfect, as this was a year ago.

I recall the patient was hypotensive at the time the surgeon said to get help. I can't remember whether or not it was at this time, but the renal arteries were clamped for just under 30 minutes which seemed like an insane amount of time. AAA was not ruptured but was huge. Would that count as elective? Pt had an epidural before the surgery or at least it appeared to me that he did. Doubtful of an MI or anything like that.

Sorry for not providing this in the beginning.

 

[madiso30]

11 hours of AAA? That's why the pt died.

What kind of thing was it that freaked the surgeon, took an anesthesiologist only 1 minute to fix but 2 CRNA had no idea of ?

Totally beats me. I just remember that whatever was the problem, it seemed to end as soon as the physician showed up. Could've been that the CRNAs were on there way to fixing the issue already. I gave some more details in another post if that helps.

 

[madiso30]

Omg I just saw that now.
Yep. 100% a surgical problem.
Your boss can't operate, sorry.


Most of these take 3 hours, some 1 hour. 11 hours!?! Wtf. Even if it needed 11 hours or time, it should have been divided. This is crazy.

I didn't know this. I will say that later on in the surgery, the patient needed a femoral bypass. Is that a normal complication for a AAA?

I am sorry if this is all confusing. I am trying to use what little knowledge I have to try to explain this so I can learn from it.

 

[deleted697535]

I didn't know this. I will say that later on in the surgery, the patient needed a femoral bypass. Is that a normal complication for a AAA?

I am sorry if this is all confusing. I am trying to use what little knowledge I have to try to explain this so I can learn from it.

I wouldn't say 'normal' but it does occur. It really should have been part of the plan preop based on the ct.

'Huge' is important obviously but morphology is more important and level even more so. This was a AAA that required 30 mins of supra renal cross clamp.

That's important also but the most important predictor of mortality here is rupture or no. This was unruptured(as he had an epidural) so mortality for this should be <2% for a vascular centre.

A vascular surgeon must do enough of these each year to keep his skills up and mortality down

It sounds to me like your boss doesn't do enough and shouldn't be doing these cases without some retraining

 

[MoMoGesiologist]

Also, why are you upset about this case? The anesthesiologist came in and fixed the problem quickly it sounds like. The surgeon recognized he needed a doctor at the head of the bed. What is there to feel crap about? CRNAs help each other, MDAs help each other, and gasp! We help each other!

 

[nimbus]

I wouldn't say 'normal' but it does occur. It really should have been part of the plan preop based on the ct.

'Huge' is important obviously but morphology is more important and level even more so. This was a AAA that required 30 mins of supra renal cross clamp.

That's important also but the most important predictor of mortality here is rupture or no. This was unruptured(as he had an epidural) so mortality for this should be <2% for a vascular centre.

A vascular surgeon must do enough of these each year to keep his skills up and mortality down

It sounds to me like your boss doesn't do enough and shouldn't be doing these cases without some retraining

Open AAAs are becoming a rare beast these days. Getting adequate numbers is becoming a challenge.

 

[madiso30]

Also, why are you upset about this case? The anesthesiologist came in and fixed the problem quickly it sounds like. The surgeon recognized he needed a doctor at the head of the bed. What is there to feel crap about? CRNAs help each other, MDAs help each other, and gasp! We help each other!

I wouldn't say I was upset. Just uneasy at the decision made by the CRNA to get another CRNA instead of the physician. It just felt off to me. I'm just trying to learn. And I think my uneasiness was also from inexperience and lack of understanding.

Probably a bit dramatic saying I felt like crap.

 

[MoMoGesiologist]

I wouldn't say I was upset. Just uneasy at the decision made by the CRNA to get another CRNA instead of the physician. It just felt off to me. I'm just trying to learn. And I think my uneasiness was also from inexperience and lack of understanding.

Probably a bit dramatic saying I felt like crap.

You said in a prior post you left feeling like crap and disheartened about anesthesia. Why? A nurse asked a fellow nurse for help. Why does that bother you? Is it you felt a physician should be involved?

Sometimes I have technical issues where a monitor isn’t working or I can’t find some equipment so I’ll ask a nurse or tech for help. Sometimes patient is dying and I need any hand available. I’m not sure what was going on with your patient, but hopefully the person at the head of the bed was wise enough to know who to ask for help. If not, it’s not really a reflection on this field but rather the individual. If you like anesthesia, go into it, be the best, then ppl will call you first for help when the kaka hits the fan.

 

[vector2]

I wouldn't say I was upset. Just uneasy at the decision made by the CRNA to get another CRNA instead of the physician. It just felt off to me. I'm just trying to learn. And I think my uneasiness was also from inexperience and lack of understanding.

Probably a bit dramatic saying I felt like crap.

It should make you uneasy that you witnessed something like that. That anesthesia practice (or at least that particular anesthesiologist) sounds terrible. Most CRNAs, even the so called "cardiovascular" CRNAs are simply not equipped to deal with complex aortic surgery, or for that matter any vascular surgery where things are not going according to plan A.

If I'm supervising a CRNA in an open AAA, even an experienced one, I'm in the room a lot, and if I'm not in the room I'm probably following along in the office on my EMR. These cases can quickly go south without frequent monitoring and titration of fluids, blood products, vasopressors, and adjustments to acid/base status. What's worse, CRNAs don't have a good grasp of the surgical procedure and they usually feel uncomfortable directing the surgeon to do what needs to be done (after all, they're nurses talking to a physician). After a prolonged X-clamp, especially a high clamp, the pt is susceptible to unclamping shock. I have no problem telling the surgeon that he has to reclamp if the pt is not responding to conventional therapy. The CRNA otoh is likely to keep doing dumb sht like pushing more and more vasopressin and bicarb even though nothing is happening.

If you are considering anesthesia and think you may end up in a geographic area where supervision predominates, you need to understand that there are practices where CRNAs are on a tight leash (particularly ones where the CRNAs are employed the MDs), and there are ones where the CRNAs are the inmates running the asylum. If I wasn't geographically limited, I would leave to a MD-only practice in a heartbeat.

 

[madiso30]

You said in a prior post you left feeling like crap and disheartened about anesthesia. Why? A nurse asked a fellow nurse for help. Why does that bother you? Is it you felt a physician should be involved?

Sometimes I have technical issues where a monitor isn’t working or I can’t find some equipment so I’ll ask a nurse or tech for help. Sometimes patient is dying and I need any hand available. I’m not sure what was going on with your patient, but hopefully the person at the head of the bed was wise enough to know who to ask for help. If not, it’s not really a reflection on this field but rather the individual. If you like anesthesia, go into it, be the best, then ppl will call you first for help when the kaka hits the fan.

I think I felt the way I felt just because of how things were handled. It was disheartening to see, what seemed like, the nurse going over a doctors head. I'm not sure if that's the right phrasing but does that make sense?

 

[deleted697535]

He had an epidural. It was an 11 hour case. There was a suprarenal clamp. It was open

 

[madiso30]

I don’t think OP has any knowledge to fully understand what happened. We are just grasping at straws to guess what could have been the case

Absolutely. I was more curious about the nurses actions. Between me being an M1 and this occurring a year and a half ago, theres no way I can relay enough info.

 

[okayplayer]

Lawyer posing as MS1?

 

[madiso30]

Lawyer posing as MS1?

Anatomy is making me wish this were true.

 

[anbuitachi]

too many variables. totally possible the CRNA asked for help. and the closest person was another CRNA, which is totally appropriate. but otherwise, should definitely call the attending and not another nurse not involved in the case.

we dont know the problem so we cant say much about it. could be as simple as patient is hypertensive on the arterial line... anesthesiologist walks in and notices transducer on teh floor. or it could be something much more complicated. too little info to tell

 

[dabears505]

You guys go to the or as an M1?

 

[deleted697535]

There are so many missed elements to this we can't comment. But as for a vascular surgeon 'telling' me to fix something. That's not a thing. Cardiac is the only surgeon that maybe knows more about what anesthetic he needs than I do. And that's probably just their massive overconfidenc. Some will say block or no block, bed up etc but that's about it.

Do surgeons often in your country try to tell you to fix things based on knowledge of a minimum data set maybe even a 1 off value with no understanding of what other drugs or pathology could be going on?

That must be wild

 

[chocomorsel]

There are so many missed elements to this we can't comment. But as for a vascular surgeon 'telling' me to fix something. That's not a thing. Cardiac is the only surgeon that maybe knows more about what anesthetic he needs than I do. And that's probably just their massive overconfidenc. Some will say block or no block, bed up etc but that's about it.

Do surgeons often in your country try to tell you to fix things based on knowledge of a minimum data set maybe even a 1 off value with no understanding of what other drugs or pathology could be going on?

That must be wild

Well, I think as the surgeon, if they look up and see that BP is in the toilet they can and should ask you what’s going on if you seem clueless and aren’t fixing it.
I mean, what’s the problem with that?

It’s their patient first and you are assisting them. I don’t see anything wrong with that. Clearly the surgeon saw a clueless nurse who wasn’t communicating with he or she about the BP and asked questions.

It’s a AAA and of course if it’s ruptured they are gonna have crappy pressures. But you gotta communicate that sh.. and attempt to fix it on your end if you can.

 

[deleted697535]

Well, I think as the surgeon, if they look up and see that BP is in the toilet they can and should ask you what’s going on if you seem clueless and aren’t fixing it.
I mean, what’s the problem with that?

It’s their patient first and you are assisting them. I don’t see anything wrong with that. Clearly the surgeon saw a clueless nurse who wasn’t communicating with he or she about the BP and asked questions.

It’s a AAA and of course if it’s ruptured they are gonna have crappy pressures. But you gotta communicate that sh.. and attempt to fix it on your end if you can.

This was a non ruptured AAA.

If an anesthesiologist doesn't forsee 99. 9% of issues before they appear on a monitor that a surgeon can lift his head from the field for long enough to notice then really that anesthesiologist is useless. That includes massive hemorrhage that we often alert them to.

I've never been in a massive hemorrhage and not known it, very often if not always before the surgeon who in fairness has tunnel vision at that point.

Honestly in 8 years in 2 continents I've never had a non cardiac surgeon 'tell me' to fix something that I've not known about for a long time. So this sounds very unusual to me and I want to find out why this happened? Is it surgical culture to think they can give orders to or indeed a better anesthetic themselves? Why?

 

[chocomorsel]

This was a non ruptured AAA.

If an anesthesiologist doesn't forsee 99. 9% of issues before they appear on a monitor that a surgeon can lift his head from the field for long enough to notice then really that anesthesiologist is useless. That includes massive hemorrhage that we often alert them to.

I've never been in a massive hemorrhage and not known it, very often if not always before the surgeon who in fairness has tunnel vision at that point.

Honestly in 8 years in 2 continents I've never had a non cardiac surgeon 'tell me' to fix something that I've not known about for a long time. So this sounds very unusual to me and I want to find out why this happened? Is it surgical culture to think they can give orders to or indeed a better anesthetic themselves? Why?

How about it sounds like the surgeon was dealing with a CRNA who sounds useless. And doesn’t communicate.

And yes, in this country some surgeons like to bark orders from the other side of the drape. Typically Heart surgeons, but it depends on the local culture and relationships with the anesthesiologists.
Noticed a lot of spineless attending a when I was a resident.

 

[HalO'Thane]

Unless the anesthesiologist was dealing with a coding patient in another room I don’t think there should ever be a situation where the CRNA calls in another CRNA before calling in the attending.

This to me means either the CRNA thinks that they can handle the situation better than a physician and has some sort of agenda, the anesthesiologist works in a flawed practice where they cannot always be readily available for critical events, or the CRNA doesn't have faith in that particular anesthesiologist.

None of those scenarios are any good.