Scope Creep

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GassYous

GassYous

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I had a patient from an outside hospital the other day who had their arterial line and central line placed by an RN. What next, the janitor intubating in preop?
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picc team RN
patient was in the icu
I couldn't believe my eyes
I mean yea nps are basically rns that wrote a few essays about their feelings but come on

There was a patient I heard about in residency where the icu np dilated the carotid and patient stroked out.
 
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Hmm. Give the mods your ASA ID so you can visit the private forum, but I have a feeling you won’t be able to do that....
 
GassYous said:
Think it's absurd. An a line takes what, two minutes? Their job is to facilitate yours, not to do it for you.
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How about when you get the call in the middle of the day to the ICU while supervising four rooms. Or at 2 am for the ICU? :hurting:
 
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dr doze said:
How about when you get the call in the middle of the day to the ICU while supervising four rooms. Or at 2 am for the ICU? :hurting:
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You have a anesthesia tech 24/7 that would do a-line for you?

I’ve worked with anestheia tech and “anesthesia tech”. Even the best ones are not “medically” trained. How’s this different than let that CEO to open up the chest?
 
IMGASMD said:
You have a anesthesia tech 24/7 that would do a-line for you?

I’ve worked with anestheia tech and “anesthesia tech”. Even the best ones are not “medically” trained. How’s this different than let that CEO to open up the chest?
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Nope. I was referring to having RTs or PICC nurses putting in lines in ICU patients.
 
SaltyDog said:
WTF are the intensivists doing??
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We have “eICU” here at night, which is an abomination, and this is in a Level 1 Trauma Center. Worse, it was one of the first initial sites in the country apparently to adopt it so there’s a lot of fanfare around it. It’s so strange, you’ll just hear a “this patient needs airway assistance” from the speakers in the ceiling like the voice of God or something. All of this of course happened prior to my arrival.

For a while we were the “lines and airway” team for the ICUs after hours. A few years ago we extricated ourselves from lines (thank the anesthesia gods) and just have airways now. We are actively trying to get EM to take over that (they have residents, including those on ICU service at night, and we don’t).
 
dr doze said:
Nope. I was referring to having RTs or PICC nurses putting in lines in ICU patients.
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My bad.

I’ve always been taught, you can do the procedures when you understand and can deal with the complications. Our RT can barely bag the patient properly, I certainly wouldn’t trust them to do anything else if they cannot properly do what they’re trained to do.

We have a few RT who want to maintain their “skills” who would try to intubate during airway emergency or code blue. GTFOH. Not the time to refresh your skills.
 
AdmiralChz said:
We have “eICU” here at night, which is an abomination, and this is in a Level 1 Trauma Center. Worse, it was one of the first initial sites in the country apparently to adopt it so there’s a lot of fanfare around it. It’s so strange, you’ll just hear a “this patient needs airway assistance” from the speakers in the ceiling like the voice of God or something. All of this of course happened prior to my arrival.

For a while we were the “lines and airway” team for the ICUs after hours. A few years ago we extricated ourselves from lines (thank the anesthesia gods) and just have airways now. We are actively trying to get EM to take over that (they have residents, including those on ICU service at night, and we don’t).
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As a L1TC do you have an in house trauma/cc surgeon? Surgery upper levels? Who covers the SICU overnight?
 
zizzer said:
What do you guys think about anesthesia techs doing arterial lines?
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15+ years ago at the hospital where I practice, there was an anesthesia tech who was very good at alines and he would do them all the time for an anesthesiologist who was terrible at them (crani would be done before Aline went in if the tech wasn’t around.) He’d also help out 2 others when they had problems which was often.
 
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AdmiralChz said:
We have “eICU” here at night, which is an abomination, and this is in a Level 1 Trauma Center. Worse, it was one of the first initial sites in the country apparently to adopt it so there’s a lot of fanfare around it. It’s so strange, you’ll just hear a “this patient needs airway assistance” from the speakers in the ceiling like the voice of God or something. All of this of course happened prior to my arrival.

For a while we were the “lines and airway” team for the ICUs after hours. A few years ago we extricated ourselves from lines (thank the anesthesia gods) and just have airways now. We are actively trying to get EM to take over that (they have residents, including those on ICU service at night, and we don’t).
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That is just insane. It is crazy the length the administrators will go to to save a few bucks. How can you have an icu without intensivist coverage? Lines and airways don't pay enough for me to sleep in the hospital to do them for someone else.
 
vector2 said:
As a L1TC do you have an in house trauma/cc surgeon? Surgery upper levels? Who covers the SICU overnight?
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Yeah, we have in house Trauma but they aren’t running to the MICU, neuro or cardiac ICUs for airways or lines. They basically just cover the trauma/SICU (pretty questionably at that).
 
GassYous said:
picc team RN
patient was in the icu
I couldn't believe my eyes
I mean yea nps are basically rns that wrote a few essays about their feelings but come on

There was a patient I heard about in residency where the icu np dilated the carotid and patient stroked out.
Click to expand...
PICC team filled w RNs are in lots of places.

As an ICU doc, I am thankful for them. Unless you want to come and help me put in my lines during my crazy busy day. Doing procedures in the ICU when you have a crazy census is a time suck. It’s not as easy as the OR because the anesthesia techs in the OR are more efficient and know how to help. It hurts my back, gotta find help to assist in positioning patient, ICU RNs are not the best helpers and they have another sick patient, wires are in the way, and the rooms are small, and it just sometimes blows honestly. No need to make my already twelve or thirteen hour day longer.

And you all already know how I feel about CRNAs. They are really helpful on a busy day.
 
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SaltyDog said:
WTF are the intensivists doing??
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Carrying an often large census of often very complex/severely ill patients and there is not enough time in the world to do all those procedures. Especially in these days of Covid. Communicating w families, nurses, other consultants, reviewing studies. And let’s not forget the time sucking notes as well.
Yeah, there are some lazy intensivists out there, just like lazy Anesthesiologists.

But the rest of us that are not, appreciate the help.
 
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chocomorsel said:
PICC team filled w RNs are in lots of places.

As an ICU doc, I am thankful for them. Unless you want to come and help me put in my lines during my crazy busy day. Doing procedures in the ICU when you have a crazy census is a time suck. It’s not as easy as the OR because the anesthesia techs in the OR are more efficient and know how to help. It hurts my back, gotta find help to assist in positioning patient, ICU RNs are not the best helpers and they have another sick patient, wires are in the way, and the rooms are small, and it just sometimes blows honestly. No need to make my already twelve or thirteen hour day longer.

And you all already know how I feel about CRNAs. They are really helpful on a busy day.
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A lot of this comes down to economic forces. (Choco and the senior members, I am sure you all know this).

I remember when the attendings would go out to the floor and do their own picc with a busted ultrasound. Because they could bill for it. Then there’s a picc team who would go and do it, because the hospital can bill. Why all this? Because IR didn’t think it was worth their time to do it under fluor.... but when does it stop? We have IR PAs doing biopsy under “supervision...”. They are really not doctors, I cannot have any sort of discussion about the patient, condition or just general physiology.

Be as it may, I think we started the discussion with a CVL, 7 Fr placed by a picc line nurse? No thank you..... you’re telling me, these people who cannot even take their own consent (at least in my state), will stick a f-ing long straw in my neck, that can be reach closer to my heart to give me medicine? Thanks but no thanks.
 
IMGASMD said:
A lot of this comes down to economic forces. (Choco and the senior members, I am sure you all know this).

I remember when the attendings would go out to the floor and do their own picc with a busted ultrasound. Because they could bill for it. Then there’s a picc team who would go and do it, because the hospital can bill. Why all this? Because IR didn’t think it was worth their time to do it under fluor.... but when does it stop? We have IR PAs doing biopsy under “supervision...”. They are really not doctors, I cannot have any sort of discussion about the patient, condition or just general physiology.

Be as it may, I think we started the discussion with a CVL, 7 Fr placed by a picc line nurse? No thank you..... you’re telling me, these people who cannot even take their own consent (at least in my state), will stick a f-ing long straw in my neck, that can be reach closer to my heart to give me medicine? Thanks but no thanks.
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I try to do my own procedures when I can. When I am over with very sick patients that required a lot more of my brain and other kinda time, I get the necessary help.
It’s great. Because ICUs sometimes get train wrecks who other services have neglected or quite simply messed the hell up and now you gotta figure out how to fix them.
 
My hospital decided a few years ago that they wanted to have the PICC RN’s learn to place IJ cvl’s and tapped the intensivists to train them. That lasted about 6 weeks and they had to bag it because of all the complications. Part of the problem was that most of the patients that couldn’t get a PICC and needed an IJ had esrd and a lot of them were difficult lines due to their prior vascular access procedures.
 
FFP said:
Still... nurses should insert multi-lumen PICCs/midlines, not IJs.

We are letting hospitals get away with overworking intensivists by shifting our duties to less-qualified people. Not cool. What's the solution? The solution is to stop working in places like this. They can go full midlevel as far as I am concerned; I won't be part of crappy care.

One of the reasons I am very apprehensive to switch to 100% critical care is that I can't control the work volume. Intensivists should spend most of their time thinking about their patients and rounding on them (many times a day), and not writing notes and doing procedures. It's ridiculous that we do the former in the OR, on much healthier patients, but it's not a priority for the sickest patients in the hospital.
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This was the case at my shop. I was furious. Trust me eventually theyll place an IJ too. The solution is to just do them yourself. Or get a doc on the PICC team. seriously they some creep in the room once the order is placed with some zonked out patient and place a line.
 
bigtuna said:
My hospital decided a few years ago that they wanted to have the PICC RN’s learn to place IJ cvl’s and tapped the intensivists to train them. That lasted about 6 weeks and they had to bag it because of all the complications. Part of the problem was that most of the patients that couldn’t get a PICC and needed an IJ had esrd and a lot of them were difficult lines due to their prior vascular access procedures.
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My question is what prompted the change and who does them now?
 
This sounds crazy. What next? RT going to start intubating? OB RNs place epidurals? And what constitutes a central line? Will they place double MAC lumens? trialysis catheters? PA catheters? . Allowing techs and RNs to start doing medical procedures and being happy about it is what is making them think they are now fully capable of autonomy in medicine.
 
codeb1ue said:
This sounds crazy. What next? RT going to start intubating? OB RNs place epidurals? And what constitutes a central line? Will they place double MAC lumens? trialysis catheters? PA catheters? . Allowing techs and RNs to start doing medical procedures and being happy about it is what is making them think they are now fully capable of autonomy in medicine.
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Start? RT’s were intubating patients and inserting alines back in the 1990’s
 
We should not let midlevels place alines or central lines or epidurals or do other anesthesiology procedures. Its akin to CT surgeons not letting the PA place annular stitches or suturing in a valve or doing a LIMA to LAD. How can PAs harvest vein and conduit but not do a LIMA takedown? Basically surgeons have drawn a line in the sand. We need to draw a hard line in the sand what constitutes a good anesthesiologist and in my book its speed and efficiency at procedures in addition to critical thinking under pressure. You can't be an armchair anesthesiologist. You become replaceable and exactly why we got ourselves in this mess in the first place. I cannot for the life of me figure out why we keep carving out niches and then giving them away to midlevels. Regional, Blocks, pain, TEE, ECMO, ICU, ultrasound.

When will we learn? Your skills and knowledge is your livelihood. Do it well and don't give it away.
 
dabears505 said:
Man I would love if the ob rns started to do epidural. Life would go so much better.
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Really? What are you going to bill for then when you are covering OB? Just C-sections? Is there no desire to "protect your turf"? There is another thread just below this one about happily giving up regional blocks to orthopods. At this rate if we forego all the procedural aspect of our field, what do you think will happen to our overall reimbursement and pay over time? Not to mention the likelihood of increased complications we will see in our patients (e.g. epidural hematoma, LAST, etc.)
 
Everyone keeps talking about anesthesia techs doing procedures- what kind of techs do you all have?! Ours, while very helpful, often have no more than a high school diploma and are currently in college. They are there to help transport, retrieve/set up equipment for us, turn over rooms, etc. They can barely pull out the ETT stylet when asked, let alone place lines
 
Whatever happened to the whole “you can teach a monkey how to do a procedure, it is knowing the indication for the procedure that differentiates us?”
Is that no longer a thing?
I would love it if there were other attendings to do this for us instead. Somehow though it is not.
The downfall of medicine in this country started more than 30 years ago. We have plenty NPs/CRNAs/PAs running around acting like doctors, trying to talk like doctors and patients haven’t a clue nor do they seem to care.
That ship has sailed. It’s not a program I would ever push for but once it’s in place there is no undoing it. So I am gonna go with it. Or call the OR for help if I am drowning in procedures and need help. I am sure the anesthesiologists would love to help a colleague out.
 
chocomorsel said:
Whatever happened to the whole “you can teach a monkey how to do a procedure, it is knowing the indication for the procedure that differentiates us?”
Is that no longer a thing?
I would love it if there were other attendings to do this for us instead. Somehow though it is not.
The downfall of medicine in this country started more than 30 years ago. We have plenty NPs/CRNAs/PAs running around acting like doctors, trying to talk like doctors and patients haven’t a clue nor do they seem to care.
That ship has sailed. It’s not a program I would ever push for but once it’s in place there is no undoing it. So I am gonna go with it. Or call the OR for help if I am drowning in procedures and need help. I am sure the anesthesiologists would love to help a colleague out.
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We don’t get paid for thinking about it. We get paid for doing it. And even now the thought process is literally just: what does the algorithm say?
 
Arch Guillotti said:
My question is what prompted the change and who does them now?
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I think the PICC Rn's got the idea from a conference they were at. We're back to the intensivists doing them in the unit and anesthesia will do CVL's on the rare floor patient that needs one.
 
RadsWFA1900 said:
We don’t get paid for thinking about it. We get paid for doing it. And even now the thought process is literally just: what does the algorithm say?
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So then it's all about the money.
Well in that case, DUH choco.
For some reason I thought it was about preventing harm to patients.
When I am back at work next week I am going to ask how this whole thing came about at this specific facility though, who trained them and who is their attending physician.
 
chocomorsel said:
So then it's all about the money.
Well in that case, DUH choco.
For some reason I thought it was about preventing harm to patients.
When I am back at work next week I am going to ask how this whole thing came about at this specific facility though, who trained them and who is their attending physician.
Click to expand...

Where have you been choco? This is 21st century medicine.
 
RadsWFA1900 said:
Where have you been choco? This is 21st century medicine.
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I just really hate all the BS about patient safety, when it's really about money.

Maybe because I am a traveler I don't care about the billing of it. But knowing me, if I am drowning at work and need the help, damn the money. I would rather get some decent sleep after a 12-13 hour day than worry about making even more money and being exhausted, grumpy and not thinking clearly.

If you are in the OR and this is a non issue for you, why worry about it? Just don't let it happen to you if you feel so strongly about it. And of course, be willing to help out your intensivist colleagues if they call you for assistance because they are swamped. It may be hard to tell who's lazy and can't do a line to save their life versus who's swamped but suspect their story behind asking you for help and talking to the nurses can clue you in. If you aren't swamped and busy next time. Otherwise, I will call the PICC/CVL team.
 
chocomorsel said:
I just really hate all the BS about patient safety, when it's really about money.

Maybe because I am a traveler I don't care about the billing of it. But knowing me, if I am drowning at work and need the help, damn the money. I would rather get some decent sleep after a 12-13 hour day than worry about making even more money and being exhausted, grumpy and not thinking clearly.

If you are in the OR and this is a non issue for you, why worry about it? Just don't let it happen to you if you feel so strongly about it. And of course, be willing to help out your intensivist colleagues if they call you for assistance because they are swamped. It may be hard to tell who's lazy and can't do a line to save their life versus who's swamped but suspect their story behind asking you for help and talking to the nurses can clue you in. If you aren't swamped and busy next time. Otherwise, I will call the PICC/CVL team.
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What I am going to say is for units that are not being overwhelmed with Covid.

You can't blame anesthesiologists for not helping out in the unit, when the pay for a line is peanuts. It's just not worth it. Also, many have the experience of having worked with lazy intensivists who run pressors over a short 20G peripheral catheter, while being treated like intubation- and line-monkeys. I still remember discussions with stupid/arrogant attendings over intubating patients that definitely did not need to be intubated.

As far as I am concerned, RNs could do all the lines, except they are not safe to do them. It's painful even to watch a PICC line placement. Those people are generally slow and not bright. Good luck to them when placing an awake IJ CVL, especially if they get into trouble.

I didn't get into critical care for the procedures. I did it for the knowledge and thought process, to become a better doctor and really save lives. In non-Covid times, I try not to work in ICUs where I have to run around like an idiot, covering 15-20 patients (even with midlevels/residents) and writing notes on them. That's not critical care for me; that's slaughterhouse (aka recipe) medicine. It may be the "American way" of practicing critical care; I couldn't give a fart. When the hospital is that greedy, I don't fault anyone else who is.

That being said, I will always do the right thing for a patient in an emergency, regardless of the stupidity of his attending physician or hospital.
 
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FFP said:
What I am going to say is for units that are not being overwhelmed with Covid.

You can't blame anesthesiologists for not helping out in the unit, when the pay for a line is peanuts. It's just not worth it. Also, many have the experience of having worked with lazy intensivists who run pressors over a short 20G peripheral catheter, while being treated like intubation- and line-monkeys. I still remember discussions with stupid/arrogant attendings over intubating patients that definitely did not need to be intubated.

As far as I am concerned, RNs could do all the lines, except they are not safe to do them. It's painful even to watch a PICC line placement. Those people are generally slow and not bright. Good luck to them when placing an awake IJ CVL, especially if they get into trouble.

I didn't get into critical care for the procedures. I did it for the knowledge and thought process, to become a better doctor and really save lives. In non-Covid times, I try not to work in ICUs where I have to run around like an idiot, covering 15-20 patients (even with midlevels/residents) and writing notes on them. That's not critical care for me; that's slaughterhouse (aka recipe) medicine. It may be the "American way" of practicing critical care; I couldn't give a fart. When the hospital is that greedy, I don't fault anyone else who is.

That being said, I will always do the right thing for a patient in an emergency, regardless of the stupidity of his attending physician or hospital.
Click to expand...

You hit in on the head with this 15, 20, sometimes 25 pt census nonsense. With censuses that big there isn’t time to properly do critical care medicine on each patient let alone critical care procedures, while still ensuring the best care for everyone. Give me an 8-10 pt census and competent nurses and everyone could be getting the best A/P and all their procedures done personally by me every day and twice on Sundays.
 
bigtuna said:
I think the PICC Rn's got the idea from a conference they were at. We're back to the intensivists doing them in the unit and anesthesia will do CVL's on the rare floor patient that needs one.
Click to expand...
Interesting that they would cede their turf so readily. Going to do central lines in the ICU is a huge pain but no way I would ever cede to anyone but a physician. No way either I would do a CVL on a floor patient. U/S guided IV or PICC by radiology.
 
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