Resident-Attending Question

[RxBoy]

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At your teaching institution, are attendings directly supervising all resident procedures? Even for seniors?

Examples:
Labor epidurals
Post op pain epidurals
Arterial lines
Central lines
Regional blocks
Swans

What about extubations?

 

[pgg]

At your teaching institution, are attendings directly supervising all resident procedures? Even for seniors?

Examples:
Labor epidurals
Post op pain epidurals
Arterial lines
Central lines
Regional blocks
Swans

What about extubations?

Policy at my program was an attending in the room for ALL inductions and extubations, even up to the last day of residency. I thought it was ridiculous. I expect to be back there as an attending in a couple years, and I haven't yet decided how vigorously I'm going to object or ignore that rule.

They usually weren't in the room for labor epidurals after the first few weeks of CA1 L&D time. We had 1:1 attending:resident staffing in the OR so they were usually around for epidurals placed for intra or post op use.

100% supervision for blocks. They were around for most central lines and PA catheters placed in the OR, if only because those naturally followed induction and they were already there. Outside the OR they weren't always present for lines.

 

[WholeLottaGame7]

At your teaching institution, are attendings directly supervising all resident procedures? Even for seniors?

Examples:
Labor epidurals - No
Post op pain epidurals - Yes
Arterial lines - No
Central lines - Yes
Regional blocks - Yes
Swans - I presume so

What about extubations? - No

See above

 

[UTKB]

They are required to be present, for billing purposes. Even with CRNAs. If CMS finds out that they are documenting their presence but actually aren't there, the institution can be charged with fraud. However, they will stand outside the door or sit in a chair in the corner or something.

 

[BobBarker]

Labor Epidurals - Yes, 95% of the time
Art lines - Yes, if as we are starting a case, no otherwise
Central lines - Yes, if in the OR. Did 100 as an intern with no supervision, not supervised in the ICU
Blocks/Pain Epidural - Yes
Swan - I think maybe 1 a year gets placed in our ORs

 

[Gimlet]

Labor epidurals +/-, dependent on staff. Our "OB anesthesiologists" almost all come no matter what. "Non-OB staff that cover on nights/weekends generally let us go solo after a month or two of OB, always willing to come in and help for tough ones though.
Post op pain epidurals - 100% if thoracic
Arterial lines - only because they happen to be in the OR for induction
Central lines - 99%
Regional blocks - 100%
Swans - 100%

What about extubations? I stopped calling staff for extubation early in my CA-2 year. Never heard any negative feedback about it until just recently when a new faculty mentioned he'd like me to call for extubation on his cases. 😳

 

[bigdan]

Of course things vary with specific attendings, but in general, as a CA3:

Labor epidurals - no
Post op pain epidurals - these are VERY rare at my place. VERY. Like 5 thoracic epidurals in all of residency rare. All of those were supervised.
Arterial lines - no
Central lines - in general, yes (90% of the time)
Regional blocks - in general, yes (>90%)
Swans - in general, yes (>90%)
extubations - depends (maybe 50% of the time)

 

[BLADEMDA]

Of course things vary with specific attendings, but in general, as a CA3:

Labor epidurals - no
Post op pain epidurals - these are VERY rare at my place. VERY. Like 5 thoracic epidurals in all of residency rare. All of those were supervised.
Arterial lines - no
Central lines - in general, yes (90% of the time)
Regional blocks - in general, yes (>90%)
Swans - in general, yes (>90%)
extubations - depends (maybe 50% of the time)

Is that because at Pitt they prefer Paravertebral catheters like me?😀

 

[Mman]

They are required to be present, for billing purposes. Even with CRNAs. If CMS finds out that they are documenting their presence but actually aren't there, the institution can be charged with fraud. However, they will stand outside the door or sit in a chair in the corner or something.

No, the requirement is to be immediately available. It's a little nebulous. It doesn't say "must be standing in the room at the exact moment of extubation".

 

[Idiopathic]

What about extubations? I stopped calling staff for extubation early in my CA-2 year. Never heard any negative feedback about it until just recently when a new faculty mentioned he'd like me to call for extubation on his cases. 😳

you still need to call, even if you are doing it as you are pulling the tube, send that text page.

 

[bigdan]

Is that because at Pitt they prefer Paravertebral catheters like me?😀

Yessir

 

[michigangirl]

Agree with idiopathic. I didn't always understand why some attendings got annoyed when residents didn't call about extubation. I get it now, as an attending. I need to know its actually going on. If I can (i.e. not inducing elsewhere) I will always show up in the room and be very hands off based on the trainees experience. Maybe this is cause I deal with twitty, laryngospastic little boogers that I insist on a page. But if I don't know extubation is happening, then I won't know to look for the patient in the pacu, or that you're running into trouble and haven't asked for help yet.

As a resident, as others have stated, after the first few weeks on OB noone showed up for epidural placements. always someone present for blocks, PA caths, usually for central lines.

 

[psychbender]

At your teaching institution, are attendings directly supervising all resident procedures? Even for seniors?

Examples:
Labor epidurals
Post op pain epidurals
Arterial lines
Central lines
Regional blocks
Swans

What about extubations?

Labor epidurals: After the resident has done 'enough,' then no
Post-op epidurals: Very rare, yes -ish
Arterial lines: No
Central lines: only those in the OR
Regional blocks: yes
Swans: yes
Extubations: as a CA1, most of CA2 year, yes; CA3, not so much anymore

Post-op blocks of any sort are fairly rare at my institution. We are generally aggressive about putting them in before if we feel they are indicated. However, the few times that it has come up, the attending has been involved in the decision to place the block, and depending on the type, may be present, or just outside of the room. For an injured soldier that accidentally pulled out his epidural on the ward, I'd likely be re-placing the CLE, while my attending is talking to the family or otherwise available for backup in our block area or PACU. For a rescue nerve block on a gentleman who refused the block preop, the attending will be there supervising, as usual.

Regarding extubations, the first time that I extubated a patient on my own, was the first day of CA2 year (middle of the night broken penis case, refused spinal). For most of that year, though, the attendings were present. For CA3 year thusfar, I'd say an attending was physically in the room for maybe 30-50% of my extubations. Half of those were them walking into the room as the tube came out. In a sufficiently matured resident, I believe that such independance is necessary, as we are going to be staff in a matter of months, and will need to be able to carry out these tasks without someone standing over our shoulders going "Wait for it. Wait for it. NOW!" Some staff are less comfortable with granting this level of autonomy to residents, and you just have to remember that you are operating under their license, and should respect their wishes.

 

[RussianJoo]

Wow I guess I have a lot more autonomy at my program or my attendings don't care as much, or they trust me more. Since I haven't observed too many other residents cases this is strictly what I've experienced in my program.

Labor Epidurals: No after the first 3-5 epidurals. Then they say just have the nurse page me if you have a problem.

Post op Pain epidurals: No from attendings, but senior residents were present for the first
3 or so then No. Unless thoracic then either an attending or CA-3 there.

A-lines: No

Central lines: Yes either attending or CA-3. (mostly attending)

Regional Blocks: Yes either attending or CA-3. (mostly attending)

Swans: Yes (attending)

Extubations: No after the first month of CA-1, even during the first month of CA-1 most of the time the attending would send a senior resident (CA-2 or CA-3) to help.
Even extubating laryngospastic kids I was told I didn't have to call the attendings after they saw me do one extubation.

As a general rule it's pretty hard to get an attending to help you if it's something routine at my program. I've had multiple attendings tell me that the surgery wasn't invasive enough to warrant an epidural or a regional block if they were too lazy or weren't comfortable enough doing that procedure.

I kind of wish I had more supervision at first, but now, if an attending sticks around for a second after the tube is in I feel like they don't trust me or something is wrong.

 

[ssmallz]

For Seniors

Labor epidurals - No
Post op pain epidurals - Yes
Arterial lines - No
Central lines - Yes
Regional blocks - Yes
Swans - Yes

What about extubations? No

 

[UTKB]

No, the requirement is to be immediately available. It's a little nebulous. It doesn't say "must be standing in the room at the exact moment of extubation".

You're right, it doesn't say that exactly. I should have been clearer. On our records there is a box for "I was present" and a box for "I was immediately available." If one checks the former even if they weren't there, that is fraud and that's not debatable. You can probably get away with it though, for now. Trust me, CMS is all up my county hospital's ***** right now. There is also such things as recovery audit contractors, who I affectionately call "bounty hunters," who will investigate an institution for fraud on behalf of CMS, and they get a percentage of collections. So they want to find instances of fraud. Gotta be mindful when charting.

That being said, my program is probably the same as most other programs. Attendings let us extubate alone (except for a couple of attendings), but they do expect us to text page them so they at least know it's happening. Sometimes they'll pop in the room and ask if you're ok, other times they meet you in PACU, other times they don't show up at all.

For lines: in the ICU, no supervision for CA-2/CA-3 but they want us to call and ask permission prior to placing central lines. They're present for lines in the OR since they're there for induction. Except cardiac, we can start on the preinduction art line before they arrive. Inductions/intubations: We can proceed with induction after paging the attending, by the time they arrive is usually when you start masking anyway. All of this is, of course, assuming the patient isn't unstable or may have a difficult airway.

Labor epidurals: depends on the attending and the resident. One of our regular OB attendings wants to be involved in every aspect, she hovers while you're putting the epidural in, it's annoying. Others want me to call during the day but don't call at night unless there's a problem. C-sections: always present for the block then they leave if it's routine. They stay for complicated sections.

 

[gasattack3]

As a CA2, i always call them to notify them (usually just after pushing reversal) and let them know where we're at. 90% of the time they come and if not, they always ask "you o.k. with it?" etc.

 

[RxBoy]

As I suspected, it seems to be institution specific. I was curious about the rules myself seeing as a CA3 I operate almost autonomously aside from induction.

As a newly minted CA1, we were supervised heavily. Majority of our non core faculty attendings are actually poor at procedures especially at U/S. We generally never work with non core faulty (except random calls). They work primary with CRNAs. THey let us do all the blocks/lines for their CRNA cases. Truthfully they wouldn't be able to bail me out on ultrasound guided block because they themselves don't know how to do it. They would probably send another attending.

Our program has a "procedure" month for seniors and we basically do procedures all month and act as an attending for resident rooms. A majority of the time I am assisting other juniors and we work autonomously with very little attending presence (except induction).

Only during my peds rotations did attendings insist they be present for extubations. Otherwise there was always a free senior who help with the flow of cases. Attendings do randomly pop in and are always present for extubation of difficult airways.

Labor epidurals, our rule was 2 pokes and then page an attending.

Any given day during a senior month, I would do 5-10 procedures completely unsupervised by attendings except swan placement. They were "around".

Our program director recently came down hard on our faculty for resident automony. Now they are present for everything. I have to admit, it is very annoying. Not sure how long it will last. My guess in 1 month we'll be back to where we were. I was just curious how it was at other institutions.

 

[Gern Blansten]

I think autonomy is an important aspect of training and should be given to upper level residents in straightforward situations. If autonomy is given after a month of CA-1, it is a detriment to your training in my opinion.

 

[michigangirl]

Extubations: No after the first month of CA-1, even during the first month of CA-1 most of the time the attending would send a senior resident (CA-2 or CA-3) to help.
Even extubating laryngospastic kids I was told I didn't have to call the attendings after they saw me do one extubation.

As a general rule it's pretty hard to get an attending to help you if it's something routine at my program. I've had multiple attendings tell me that the surgery wasn't invasive enough to warrant an epidural or a regional block if they were too lazy or weren't comfortable enough doing that procedure.

I kind of wish I had more supervision at first, but now, if an attending sticks around for a second after the tube is in I feel like they don't trust me or something is wrong.

Agree with GB-- all this autonomy in the first month to first year of residency just seems like pure laziness on the attendings' parts. Do they at least come in and try to teach you something during a quiet part of the case? In what way do they serve as teaching attendings?

 

[WholeLottaGame7]

Extubations: No after the first month of CA-1, even during the first month of CA-1 most of the time the attending would send a senior resident (CA-2 or CA-3) to help.
Even extubating laryngospastic kids I was told I didn't have to call the attendings after they saw me do one extubation.

Really, no attendings for extubations for kids? Are we talking adolescent/teens or are we talking infant/toddlers? That seems crazy.

 

[RussianJoo]

Agree with GB-- all this autonomy in the first month to first year of residency just seems like pure laziness on the attendings' parts. Do they at least come in and try to teach you something during a quiet part of the case? In what way do they serve as teaching attendings?

I didn't say it was a good thing and was very pissed and disappointed at the program during my CA-1 year because of that. Most of the attendings are super lazy, to the point where they didn't want to let me place pre-op blocks or epidurals and would say something like "oh that's not a very painful surgery you don't need that", just so they wouldn't have to do extra work, unless the surgeon specifically asked for it, and most surgeons didn't really care if the pt got a block or an epidural, because the residents would have to deal with pages after the case was over. That's the thing there was very little if any intra-op teaching, unfortunately I can honestly say that I learned almost everything from either text books, journals, or senior residents. Also the few attendings that were known to teach, would see that I didn't struggle with procedures and would ask me a question or two and after I get them correct would also leave me alone in the room. A few attendings would even go as far as saying this is your senior resident for the day, call him if you have any problems.

I can only think of maybe 4 attendings that actually taught, and even then it would be one teaching point for the whole day.

So yes these "teaching" attendings did everything but teach, but they did collect the extra paycheck for being "teaching" attendings. Now that I am a senior resident, this fact doesn't bother me as much because I am used to learning on my own. My attendings see me as a reliable hard working resident who has a good skill set and thus feel comfortable letting me do whatever I want even when they themselves don't know how to do something and wouldn't be able to help me out.

I've learned to not rock the boat, to graduate and get the hell out. Hopefully I match at top program for fellowship where they'll be a lot more teaching. It's sad but I am just happy I was given the opportunity to be an anesthesiologist, something that I've dreamed about since high school.

 

[RussianJoo]

Really, no attendings for extubations for kids? Are we talking adolescent/teens or are we talking infant/toddlers? That seems crazy.

adolescents/teens, the attendings would say are just like adults and were there for the ~10min it takes to induce, start an IV, and intubate and I never hear from them again.

Infants/toddlers: they would stick around for an additional 5min to make sure the kid is stable before leaving.

After a month at the peds rotation, I did my first solo intubation, my attending brought the pt to the room with me, I induced the kid, started the IV, he quickly pushed the drugs I had drawn up and said "ok I have a really sick kid next door go ahead and secure the airway and hook up all the monitors I'll be back." As he was walking out I asked him if he wanted me to intubate or place an LMA, it was a short ortho case, he said do whatever you want as the door was closing behind him. I looked at the circulating nurse and asked her if he was for real, she said I guess so. So I tubed the kid on my own and we got started with the case. That attending didn't come back to the room until after I extubated the kid and was just holding the mask over his face to make sure he wasn't laryngospasiming before moving him to the stretcher and heading to pacu, that was on a 5 year old boy.

At this hospital the attendings just more or less watch us intubate and provide some criciod pressure if we ask for it, they don't hand us the tube or anything, unlike during our adult rotations where the attendings insist on holding on to the tube and handing it to us as soon as we ask for it, so it will be something I'll need to get used to once I go back to the adult world.


When I just started the rotation (that first week or so) I would work with a new attending almost everyday and would ask them how they wanted me to extubate, deep vs awake, they all started out by saying call me for extubation, and after 2 or so cases they would say ok I see you know what you're doing and when I asked them what they wanted me to do, they would just say do whatever you want/feel comfortable doing. We do about 6 to 8 cases a day on average. 12 to 14 if we're in the ENT, urology, or endoscopy rooms, 99% of the time I'll tube the kid.

I've had a few times where I had to call for an attending stat to the room because I couldn't break the laryngospasm, or the kid would also bronchospasm at the same time. Twice the OR nurses would freak out and call the attending even though I would say there's no need, and by the time the attending would show up I would break the laryngospasm and the kids saturation would be 100%. Once when an attending was called to them room because of a laryngospasm he didn't even take over, because I was doing everything he would have done and he just stood there next to me. Yes there were some very scary times where my hands were shacking for a few hours after the case, but I learned from those experiences and it definitely made me a much better clinician.

Our PACU nurses are amazing and if I have a very busy room and I don't want to delay it too much, I would just get the kid breathing and take him/her tubed to the PACU with blow by oxygen.

All I have to say is that I can't wait to get to the adults side of things again where a laryngospasm doesn't happen so frequently. I think I started to lose some hair because of the stress sometimes.