RNs intubating

[Fluffy Pomeranian]

Overheard a nurse at the hospital talking about how she wishes the nurses were allowed to intubate patients at our hospital because they were allowed to at the hospital she previously worked at. I was just wondering if this is the norm at hospitals you guys have worked at because I was under the impression that this wasn't within an RN's scope of practice.

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[sinombre]

Hey, nurses are doctors too.

 

[tdram]

Hey, nurses are doctors too.

Yeah, I mean, they get great patient satisfaction scores. Isn't that the only thing that matters?

 

[Mad Jack]

There's plenty of hospitals around here where RNs, RTs, PAs, and NPs intubate. If a paramedic can do it, there is no reason a nurse can't. Usually you find non-physicians intubating in settings where resources are more limited, such as rural hospitals, understaffed VAs, flight ambulance services, etc.

 

[Fluffy Pomeranian]

There's plenty of hospitals around here where RNs, RTs, PAs, and NPs intubate. If a paramedic can do it, there is no reason a nurse can't. Usually you find non-physicians intubating in settings where resources are more limited, such as rural hospitals, understaffed VAs, flight ambulance services, etc.

Yeah but the paramedic is the first responder to the scene of an emergency, so it's necessary for them to know how to do it. There are plenty of people in the hospital who can intubate, so why add more?

 

[DermViser]

Overheard a nurse at the hospital talking about how she wishes the nurses were allowed to intubate patients at our hospital because they were allowed to at the hospital she previously worked at. I was just wondering if this is the norm at hospitals you guys have worked at because I was under the impression that this wasn't within an RN's scope of practice.

Sure why not? As long as they get the malpractice and can't pawn off their f'ups on physicians.

 

[Mad Jack]

Yeah but the paramedic is the first responder to the scene of an emergency, so it's necessary for them to know how to do it. There are plenty of people in the hospital who can intubate, so why add more?

Because in a lot of hospitals, there aren't "plenty" of people who can intubate. In some rural or low resource hospitals, there might be no physician capable of intubating available during the night, so they train alternative providers to do so. In other places, it's just been delegated away from anesthesia to other providers so that they can focus on the OR. Hell, even in my nice academic hospital, the only physicians that intubated were anesthesia and the ED physicians. I wouldn't be surprised if, in the future, anesthesia delegates the duty off to CRNAs, RTs, or midlevels simply because the hospital has gotten so large that they can lose literally hours of OR time a day just intubating.

 

[PL198]

Everyone always wants to expand and do more and more and more. Well a physician really can't do that obviously as they are the top of the ladder. It's just hilarious how they want to do more and more, yet not have the responsibility of making sure it goes well. They want to intubate, but the moment they f*ck it up, you know you'd hear, " well resident X I saw you walking by going to another room, you should have made sure I didn't mess it up."

 

[Mad Jack]

Everyone always wants to expand and do more and more and more. Well a physician really can't do that obviously as they are the top of the ladder. It's just hilarious how they want to do more and more, yet not have the responsibility of making sure it goes well. They want to intubate, but the moment they f*ck it up, you know you'd hear, " well resident X I saw you walking by going to another room, you should have made sure I didn't mess it up."

Usually a physician wouldn't take the fall in this sort of scenario, the hospital would. In my years of practice, I've seen quite a few things get ****ed up over the years, and never once did it turn into a "this is the doctor's fault" scenario. Maybe I'm fortunate enough to have worked with a very skilled and professional group of people, but I generally feel that the constant "everyone's throwing everyone else under the bus" mantra around here is very overblown. Hell, I've made a number of mistakes over the years, and after each one I blamed no one but myself.

It's the malpractice attorneys that will go after the biggest fish they can find though. If you've got an intubating nurse with no physician present that is operating on protocol, that'll generally fall on the hospital or the medical director that approved the protocol. The nurse doesn't have enough money to make it worth their while, generally.

 

[Kahreek]

Usually a physician wouldn't take the fall in this sort of scenario, the hospital would. In my years of practice, I've seen quite a few things get ****ed up over the years, and never once did it turn into a "this is the doctor's fault" scenario. Maybe I'm fortunate enough to have worked with a very skilled and professional group of people, but I generally feel that the constant "everyone's throwing everyone else under the bus" mantra around here is very overblown. Hell, I've made a number of mistakes over the years, and after each one I blamed no one but myself.

It's the malpractice attorneys that will go after the biggest fish they can find though. If you've got an intubating nurse with no physician present that is operating on protocol, that'll generally fall on the hospital or the medical director that approved the protocol. The nurse doesn't have enough money to make it worth their while, generally.

that is the case in immediate consequences. Malpractice by nurses done perniciously can fall on physicians lap.

 

[Mad Jack]

that is the case in immediate consequences. Malpractice by nurses done perniciously can fall on physicians lap.

It can. But to say whether or not it would be the case in the issue of a non-physician performing intubation depends on the individual circumstances, which are far too difficult to speculate on without an actual case and institutional policy pertaining to that case sitting in front of us. I just tire of people playing the "what if" card about this sort of BS. Plenty of hospitals allow non-physicians to intubate and have done so for longer than I've been alive. That would not be the case if the liability were as extreme as people on SDN always seem to imply.

 

[tdram]

It can. But to say whether or not it would be the case in the issue of a non-physician performing intubation depends on the individual circumstances, which are far too difficult to speculate on without an actual case and institutional policy pertaining to that case sitting in front of us. I just tire of people playing the "what if" card about this sort of BS. Plenty of hospitals allow non-physicians to intubate and have done so for longer than I've been alive. That would not be the case if the liability were as extreme as people on SDN always seem to imply.

Let's get a list together of the hospitals that allow this. I definitely don't want to go to those hospitals!

Boycott any hospital that gives non-physicians too much scope!

 

[Mad Jack]

Let's get a list together of the hospitals that allow this. I definitely don't want to go to those hospitals!

Boycott any hospital that gives non-physicians too much scope!

Well, where to start... How about Mass General, where PAs and NPs can intubate in the ICUs and nonphysician providers can intubate on their transport teams? That's a good one to start with, I suppose. And how about you boycott basically every air ambulance service ever, where some of the best trained nonphysicians around will be intubating some of the most ill or injured people out there in the back of a freakin' helicopter no less. Or the great number of VAs that let RTs, RNs, and midlevels intubate? Or how about Yale, where Neonatal NPs can intubate newborns, which can be some of the most difficult intubations you can imagine? Or Columbia University Medical Center, where midlevels also intubate? Surely, you know better than they, oh wise medical student.

 

[tdram]

Well, where to start... How about Mass General, where PAs and NPs can intubate in the ICUs and nonphysician providers can intubate on their transport teams? That's a good one to start with, I suppose. And how about you boycott basically every air ambulance service ever, where some of the best trained nonphysicians around will be intubating some of the most ill or injured people out there in the back of a freakin' helicopter no less. Or the great number of VAs that let RTs, RNs, and midlevels intubate? Or how about Yale, where Neonatal NPs can intubate newborns, which can be some of the most difficult intubations you can imagine? Or Columbia University Medical Center, where midlevels also intubate? Surely, you know better than they, oh wise medical student.

I like how every day someone adds one more thing that mid-levels can handle "just as well as doctors". At some point we should just close all medical schools, because what's the point of having doctors if midlevels can do all of the same stuff, just as well (if not better!) and cheaper?? Makes no sense to me. Everyone should just go to nursing or PA school, because it's all the same isn't it? You're all getting ripped off.

And of course, just because a hospital is an ivy league, they must know how to do everything right.

 

[Mad Jack]

I like how every day someone adds one more thing that mid-levels can handle "just as well as doctors". At some point we should just close all medical schools, because what's the point of having doctors if midlevels can do all of the same stuff, and cheaper?? Makes no sense to me. Everyone should just go to nursing or PA school, because it's all the same isn't it? And then we have people arguing that x number of years of residency "isn't enough". **smh**

Intubations have been performed by nonphysician providers for a long, long time- damn near as long as they've been around. It's not like it's this magical new thing that's just coming off the pipe or something. That's why your complaining is coming off as ridiculous. If it were always a physician skill, that would be one thing. But it's kind of like arguing only physicians should provide anesthesia- sure, there are certain cases that physicians are the only ones capable of handling, but nurses were administering anesthesia decades before physicians created the profession of anesthesiology, so you can't just say that a previously acceptable practice is suddenly unacceptable unless you have damn good data to back it up.

 

[tdram]

Intubations have been performed by nonphysician providers for a long, long time- damn near as long as they've been around. It's not like it's this magical new thing that's just coming off the pipe or something. That's why your complaining is coming off as ridiculous. If it were always a physician skill, that would be one thing. But it's kind of like arguing only physicians should provide anesthesia- sure, there are certain cases that physicians are the only ones capable of handling, but nurses were administering anesthesia decades before physicians created the profession of anesthesiology, so you can't just say that a previously acceptable practice is suddenly unacceptable unless you have damn good data to back it up.

Then why don't we abolish anesthesiology? If a nurse can do it with a fraction of the training why are we letting these poor anethesiologists waste their time and money?

I'm going to stop here because I don't know more on the subject, but if what you're saying is true, then a lot of physicians are getting horribly cheated by the system. They should be going to nursing school instead. Let's have an anesthesiologist explain.

 

[CherryRedDracul]

Then why don't we abolish anesthesiology? If a nurse can do it with a fraction of the training why are we letting these poor anethesiologists waste their time and money?

I'm going to stop here because I don't know more on the subject, but if what you're saying is true, then a lot of physicians are getting horribly cheated by the system. They should be going to nursing school instead. Let's have an anesthesiologist explain.

Surely there must be an anesthesiologist browsing this site on his/her tablet right now.

 

[Mad Jack]

Then why don't we abolish anesthesiology? If a nurse can do it with a fraction of the training why are we letting these poor anethesiologists waste their time and money?

I'm going to stop here because I don't know more on the subject, but if what you're saying is true, then a lot of physicians are getting horribly cheated by the system. Let's have an anesthesiologist explain.

Because more complex cases require an anesthesiologist, and CRNAs need to have an anesthesiologist available during routine cases in case things go south and they end up in over their head. A few states have decided that independent CRNA practice is a great idea though, so supervision has gone out the window and no one knows if it's ever coming back or how many people will die because of it. That's a whole mess that you could read about all day, I don't even want to try to sum it up here.

There's a reason anesthesiology is getting less and less competitive each year- CRNAs have flooded the market and AMCs have stripped away the independence of anesthesiologists. In the future, they're just going to be one more warm body to fill a schedule unless they push hard to differentiate themselves in the perioperative arena.

 

[Mad Jack]

You could just browse the Anesthesia forum and find literally tens of thousands of posts on this topic rather than asking them to rehash something they've gone over time and time again.

 

[calvnandhobbs68]

Intubations are a technical skill...just like most other procedures. If you've learned how to intubate and done it enough times under supervision, there's really no reason you need to be a physician to intubate someone. Having RNs capable of intubating while a physician is on the way over to handle a critical situation can be essential in many smaller hospitals with limited physician supervision. If you all are so morally against it, go work out in the boonies where we don't have any doctors.

 

[DermViser]

Then why don't we abolish anesthesiology? If a nurse can do it with a fraction of the training why are we letting these poor anethesiologists waste their time and money?

I'm going to stop here because I don't know more on the subject, but if what you're saying is true, then a lot of physicians are getting horribly cheated by the system. They should be going to nursing school instead. Let's have an anesthesiologist explain.

Isn't that what CRNAs are trying to accomplish?

 

[DermViser]

Intubations are a technical skill...just like most other procedures. If you've learned how to intubate and done it enough times under supervision, there's really no reason you need to be a physician to intubate someone. Having RNs capable of intubating while a physician is on the way over to handle a critical situation can be essential in many smaller hospitals with limited physician supervision. If you all are so morally against it, go work out in the boonies where we don't have any doctors.

Wow.

 

[tdram]

Wow.

I love how many doctors / med students defend non-physician providers. I wonder how many non-physician providers defend doctors? Haven't met a single one yet. If you have, I'd love to hear about it.

 

[tdram]

Intubations are a technical skill...just like most other procedures. If you've learned how to intubate and done it enough times under supervision, there's really no reason you need to be a physician to intubate someone. Having RNs capable of intubating while a physician is on the way over to handle a critical situation can be essential in many smaller hospitals with limited physician supervision. If you all are so morally against it, go work out in the boonies where we don't have any doctors.

Knowing how to intubate and when to intubate are two totally different things. I have heard many stories of paramedics overzealously intubating when it wasn't neccessary (from other paramedics).

 

[Mad Jack]

Knowing how to intubate and when to intubate are two totally different things. I have heard many stories of paramedics overzealously intubating when it wasn't neccessary (from other paramedics).

Physicians make the decision to intubate in most hospital situations. Deciding to have something done and doing it are two entirely different things. Sometimes there are protocols in place for certain emergency situations, but generally the physician is making the call via phone if it's a boonies hospital, or directly if it's a regular hospital.

I really don't think you understand the realities of health care practice and time management. Let's look at a small hospital that has one physician working the ICU per shift with no resident support and two midlevel assistants that work opposite shifts to one another- one works with the physician during the day, the other covers at night. This setup is utilized at a one of the community hospitals I trained at. Now, a physician is on call during the night but not physically present in the unit the vast majority of the time after 7 pm. This hospital has no anesthesia staff at night, no surgical staff at night, and two nocturnists that keep things running smoothly for the entire facility, one in med, one in surg, with a few midlevels helping out. The ED is staffed mostly by midlevels, with one physician present to make sure everything runs smoothly. Place is well over a hundred beds and most of the time you've got all of three physicians in the building at night that aren't in the ER. So you've got 3 physicians in the whole facility, and you want to drag one of them off to intubate? Truthfully, they have more important things to do, like manage the little emergencies that manage to pop up during the night, keep people stable, etc. The whole night for them is putting out fires left and right most nights, it sucks.

What they decided to do was create a team with an RT, RN, and PA/NP to do night intubations. Intubation is a skill, and the more you do it, the more proficient you get at it. One RT that has done every intubation on nights for every shift he's worked over the last ten years is better than a doctor that does a quarter of the intubations on a given shift for the last ten years, basically. Physician makes the call, midlevel oversees the procedure, RN pushes the drugs, RT places the tube. Since the night shift is really small, you've got a consistent team that's doing basically every single procedure. It works well for the hospital- a whole lot better than dragging off your only surg physician to do an intubation while 8 patients need their attention.

 

[Mad Jack]

I love how many doctors / med students defend non-physician providers. I wonder how many non-physician providers defend doctors? Haven't met a single one yet. If you have, I'd love to hear about it.

How many non-physician providers do you know personally? How many have you worked closely with? You make a great deal of presumptions without backing them with any real experience.

 

[alpinism]

I wouldn't worry too much about this. In a hospital setting having a RN intubate is very very rare. Even at rural hospitals there are usually experienced Anes, IM, and FM docs around nearly 24/7. Experienced RTs can intubate as well.

CCRNs have been intubating for many years in the back of helicopters and ambulances.

 

[calvnandhobbs68]

Wow.

What I'm gathering from your response is that you'd rather have someone die than get intubated by a non-physician. Because that's pretty much what we're describing in some of these situations. How self-important can you get?

Don't worry though the most emergent thing you have to deal with is deciding whether to cut that mole off today or next clinic visit.

 

[tdram]

What I'm gathering from your response is that you'd rather have someone die than get intubated by a non-physician. Because that's pretty much what we're describing in some of these situations. How self-important can you get?

Don't worry though the most emergent thing you have to deal with is deciding whether to cut that mole off today or next clinic visit.

Pointless argument. Would you rather let someone die or let a gas station attendant intubate? If there's no physician around, sure. If there is, then I'd sure as hell only want the physician to do it.

 

[tdram]

How many non-physician providers do you know personally? How many have you worked closely with? You make a great deal of presumptions without backing them with any real experience.

I have actually worked with quite a few because my institution has tons of non-physician providers and we are a state that allows NPs to practice indepedently, and I have even had a preceptor who was an NP. Also, I was previously a paramedic and know quite a few paramedics, many of whom have gone onto become various types of non-physician providers.

 

[tdram]

Physicians make the decision to intubate in most hospital situations. Deciding to have something done and doing it are two entirely different things. Sometimes there are protocols in place for certain emergency situations, but generally the physician is making the call via phone if it's a boonies hospital, or directly if it's a regular hospital.

I really don't think you understand the realities of health care practice and time management. Let's look at a small hospital that has one physician working the ICU per shift with no resident support and two midlevel assistants that work opposite shifts to one another- one works with the physician during the day, the other covers at night. This setup is utilized at a one of the community hospitals I trained at. Now, a physician is on call during the night but not physically present in the unit the vast majority of the time after 7 pm. This hospital has no anesthesia staff at night, no surgical staff at night, and two nocturnists that keep things running smoothly for the entire facility, one in med, one in surg, with a few midlevels helping out. The ED is staffed mostly by midlevels, with one physician present to make sure everything runs smoothly. Place is well over a hundred beds and most of the time you've got all of three physicians in the building at night that aren't in the ER. So you've got 3 physicians in the whole facility, and you want to drag one of them off to intubate? Truthfully, they have more important things to do, like manage the little emergencies that manage to pop up during the night, keep people stable, etc. The whole night for them is putting out fires left and right most nights, it sucks.

What they decided to do was create a team with an RT, RN, and PA/NP to do night intubations. Intubation is a skill, and the more you do it, the more proficient you get at it. One RT that has done every intubation on nights for every shift he's worked over the last ten years is better than a doctor that does a quarter of the intubations on a given shift for the last ten years, basically. Physician makes the call, midlevel oversees the procedure, RN pushes the drugs, RT places the tube. Since the night shift is really small, you've got a consistent team that's doing basically every single procedure. It works well for the hospital- a whole lot better than dragging off your only surg physician to do an intubation while 8 patients need their attention.

The reality is that we have an artificial cap on physicians. The solution to a lack of physicians is more physicians, not loading up with less qualified people. Add more residency spots. Make agreements with other countries to facilitate IMG licenses transferring over. Plenty of IMGs would be happy to work in the boonies getting paid 10x what they do in their home countries. Figure out why medical school costs so much when PA school and NP school cost just a fraction and we're not doing something radically different than they are.

Physicians want to keep making big money so they don't want to make it easier for more to come in and compete. That's really the problem here. Unfortunately you can only play that game for so long before others find a way around it.

 

[Mad Jack]

The reality is that we have an artificial cap on physicians. The solution to a lack of physicians is more physicians, not loading up with less qualified people. Add more residency spots. Make agreements with other countries to facilitate IMG licenses transferring over. Figure out why medical school costs so much when PA school and NP school cost just a fraction and we're not doing something radically different than they are.

Physicians want to keep making big money so they don't want to make it easier for more to come in and compete. That's really the problem here.

I've said as much in the other thread. But the simple fact is, hospitals have to work with what they've got for now, and that isn't physicians a lot of the time. Until congress or the AMA do something really innovative, they have to stretch their resources as best they can. For now, that means that physicians are often either not the most feasible or not the best choice to intubate in many environments.

 

[link2swim06]

The question isn't can they intubate.

To intubate by themselves they need to be able to:
-prescribe meds (for the induction itself)
-do a surgical airway (when they cannot intubate or ventilate)
-do it often enough to keep the skill up

You have to ask yourself if you would be comfortable with a new RN doing a cric on you because they couldn't intubate/ventilate you?

 

[tdram]

I've said as much in the other thread. But the simple fact is, hospitals have to work with what they've got for now, and that isn't physicians a lot of the time. Until congress or the AMA do something really innovative, they have to stretch their resources as best they can. For now, that means that physicians are often either not the most feasible or not the best choice to intubate in many environments.

That's fair. I think that all of this is going to create a good market for customers who do not want to have midlevels involved in their care and have plenty of money to spend. Like an MD only, cash only hospital for the rich.

 

[Mad Jack]

That's fair. I think that all of this is going to create a good market for customers who do not want to have midlevels involved in their care and have plenty of money to spend. Like an MD only, cash only hospital for the rich.

Unfortunately Obama banned new physician-owned hospitals, so even if such a place exists in the future, it will be a self-serving AHA conglomerate that milks physicians for every dollar it can.

 

[tdram]

Unfortunately Obama banned new physician-owned hospitals, so even if such a place exists in the future, it will be a self-serving AHA conglomerate that milks physicians for every dollar it can.

Oh geez... Maybe we'll have to go the medical tourism route. Set it up in Mexico or something, and we can fly people out for all their procedures.

 

[Mad Jack]

Oh geez... Maybe we'll have to go the medical tourism route. Set it up in Mexico or something, and we can fly people out for all their procedures.

I'm not going to lie, I'm a businessman at heart and was looking into the feasibility of doing something like this in the Caribbean. There's a similar venture being set up on an island already, but it is taking international physicians. I'd want to do an all U.S. staffed venture. Impossibly crazy, I know. But I cam dream...

I actually have an even crazier plan involving the mainland, but I'm not stating that one publicly lest someone steal my idea.

 

[tdram]

I'm not going to lie, I'm a businessman at heart and was looking into the feasibility of doing something like this in the Caribbean. There's a similar venture being set up on an island already, but it is taking international physicians. I'd want to do an all U.S. staffed venture. Impossibly crazy, I know. But I cam dream...

I actually have an even crazier plan involving the mainland, but I'm not stating that one publicly lest someone steal my idea.

I have a friend who is also working on this, maybe I should hook you guys up. He's an MBA though, not a doc. It's not crazy at all. It's gonna eventually be more common than you think.

 

[Mad Jack]

I have a friend who is also working on this, maybe I should hook you guys up. He's an MBA though, not a doc.

I'm not going public with my bigger idea until I'm board certified and have some pull. As a medical student, I don't have the time to devote to wrangling venture capital and writing business plans. Needless to say, I'm pretty sure it's reasonably original and would be a win for everyone involved.

 

[tdram]

I'm not going public with my bigger idea until I'm board certified and have some pull. As a medical student, I don't have the time to devote to wrangling venture capital and writing business plans. Needless to say, I'm pretty sure it's reasonably original and would be a win for everyone involved.

Good move, I tried to do that stuff and it was a bad idea during med school... though I really love it. I'm also a businessman at heart.

 

[Microshaft]

Pointless argument. Would you rather let someone die or let a gas station attendant intubate? If there's no physician around, sure. If there is, then I'd sure as hell only want the physician to do it.

as a gas station attendant and part time RN, i am extremely offended by this post.

 

[Fluffy Pomeranian]

To clarify, I wasn't saying that I am against all non-physicians intubating patients. I'm aware that PAs, NPs, and RTs can intubate. I was asking specifically about RNs because I feel giving another large group of people the responsibility of intubating just means there will be more people in the hospital who need to maintain competency by doing enough intubations each month, which means less practice and thus less competency for everyone all around, no?

It does make sense to have a designated group of nurses trained to intubate in rural/under-staffed hospitals. I wasn't really thinking about those types of places when I posted this. But in a larger hospital or teaching hospital I think it makes more sense to have the nurse continue to ventilate and maintain the airway in other ways until someone else can get there to place the tube.

 

[Spinach Dip]

FWIW, I could intubate somebody if the need arose. It's only hard if you have some weird neck anatomy or limited range of motion. (I've had some practice on animals.)



That DOES NOT mean I feel entitled to do so, nor would I insist upon the RIGHT to do so if I was employed in a hospital.

 

[tdram]

as a gas station attendant and part time RN, i am extremely offended by this post.

i don't think you're serious, but if you are - unless the standard gas station attendant training includes intubation, i don't see any reason for offense. feel free to substitute any non-medical job title in there instead- lawyer, banker, construction worker, baker, truck driver, whatever you want.

 

[DocVapor]

i don't think you're serious, but if you are - unless the standard gas station attendant training includes intubation, i don't see any reason for offense. feel free to substitute any non-medical job title in there instead- lawyer, banker, construction worker, baker, truck driver, whatever you want.

If you look at it a certain way, when you pump gas, you are technically intubating your cars fuel system.

 

[tdram]

If you look at it a certain way, when you pump gas, you are technically intubating your cars fuel system.

Hahaha, I suppose that's true!

Personally, I prefer pumping the gas myself. I have experience from having to let someone else pump gas- it definitely takes longer because you have to wait for the guy to finish other cars before pumping yours, and then often the guy has a bad attitude as if you're bothering him by giving him business. Another reason not to live in Oregon in addition to the fact that they seem to hate physicians over there!

 

[Psai]

We need to clearly delineate what's appropriate for each field. It's ridiculous for different people to be fighting over procedures and scope of practice.

 

[tdram]

We need to clearly delineate what's appropriate for each field. It's ridiculous for different people to be fighting over procedures and scope of practice.

Or just let everyone do everything and let things naturally sort themselves out.

 

[KnuxNole]

I don't see what the problem is with a PA or NP intubating people...

 

[Psai]

I don't see what the problem is with a PA or NP intubating people...

Because if something goes wrong, who is going to be responsible for cleaning up the mess and taking responsibility?