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duplicate post
Stressful situations as a CA-1
- Thread starter BostonBrunette
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You're facing the normal pressures of the first month of residency. The important thing is to remain focused and not to be afraid of asking the attending for tips, help, etc. when necessary.
Documentation of unused medications for myself means, documenting unused hypnotics or narcotics. I could give a rat's ass if some pencil pusher is wondering what happened to the remaining 60 mg of Sux that I didn't use.
Keep track of your narcs and hypnotics but if you are having trouble with that or the case is long and involved, document that you gave everything and just waste any remaining med you have left (literally shoot it out of the syringe, do not just put a container or vial into the sharps basket: people have actually gone into those things to retrieve vials of fentanyl or morphine that appear to have fluid in it). Now don't do this if you used only 1 mg out of 10 mg of morphine, or 25 mcg out of 250 mcg of fentanyl, etc. If however, you have only 10 mcg of fentanyl or one mg of morphine left, chart it, shoot it into the sharps container, and save everyone the headache of extra signatures and paperwork. In residency, this will vary with attending so you will have to develop a feel for who will allow what. Varying institutions now include ephedrine on the controlled substances list so that may also be another source of paperwork.
Create a system for your charting that you can repeat over and over again from case to case.
Example: For the narrative I follow a pretty standard format I used in residency. With tweaking for prone cases, cranis, hearts, etc.
0645-0651: 18 ga PIV placed. Pt preTx. (BP 122/56, O2 97%RA, PR 88)
0715: To OR 32. PreOx X > 5 min. Mon on VSS.
RSI, eyes taped. DLX1 with Miller 3. Grade 1 view
LTA X 1. 7.5 ETT (down arrow drawn here)
Atraumatic. 4 cc's to cuff. =BBS (+), EtCO2 (+)
Secured @ 22 cm.
0723: L 20 ga radial A line placed with sterile prep and drape
BPPP (Bilateral pressure points padded).
OGT/NGT/ET (Esophageal thermometer) placed.
Bair hugger on.
0728: Ready for prep.
0740: Case start
0750: Begin controlled hypotension. MAP at >=65 at all times
0847: Case end
VSS. TO4 4/4 no fade, (+) 5 sec sustained tetany
(+) Sp. vent. Extubated with purposeful movement.
To PACU w/ O2 FM.
Document your times correctly on your billing sheet. This is one of the biggest problems that causes lost revenue to academic programs. If you have discontinuous time (Placed an IV 30 minutes before you rolled back to the OR), note that time on both your record and billing sheet and document a set of vital signs for that time period (sat, bp, PR are enough). You don't have to put it on the anesthesia record grid, you can just document it on the narrative as I did above. That five to 8 minutes of time adds up over the length of your residency and private practice career to hundreds of thousands of dollars of lost billing.
When you chart your vital signs, be reasonable. I had attendings who insisted that you chart every mean pressure, peak inspiratory pressure, etc. The reality is that you are wasting a lot of time looking at those numbers and recording them when you should be paying attention to the patient and what the surgeons (i.e. rookie, novice early in the year) are doing. I don't record a mean, simply because if they need it later, then they can calculate it with a calculator later. If the peak pressures are staying within a nominal range, then just record your best estimate. I hated seeing young residents scrolling back through the OR vital sign records as the surgeon was putting a trocar through the IVC or aorta, etc.
If you know what cases you are going to be doing the next day and can take blank OR records home with you, pre-write some of the work before the case so that pressure is alleviated somewhat and you have a written record of what you plan to do the next day. Just leave the times blank. Again, some attendings will be OK with it, some will not. Don't waste the records you get on the day of the surgery, keep them for the next day and put stickers in the appropriate places to reflect the correct patient.
One pet peeve I have: The SHARP'S container is for SHARPS. Disconnect the needles from your syringes and put the needles into the sharps container and put everything else into the trash. We don't put coca cola bottles into sharps containers, so why do we put empty bottles of succinylcholine, propofol, etc. into the sharps container. Do your part to prevent filling our landfills with underfilled sharps containers.
If a vial accidentally breaks before you can draw it up, you should have a nurse or your attending immediately witness it, request more narcotic, and record the waste on your narrative and narc sheet (0746: 2 cc vial of fentanyl wasted after vial fell to floor. Witnessed by ___ ).
When you are on break, ideally, the person giving you a break should record any narc usage. If you suspect that the person may have a "habit", draw up a little blood into your narc syringe to give it a beautiful pink-red tint. That will highly discourage anyone from "losing" narcs on break. Also keep track of and anonymously report anyone you suspect of having a "problem."
Unhelpful techs are the norm for academic centers. You can try to force them to do what is necessary, but the majority of these people have been there since the Pleistocene Era and will be highly resistant to change. I encountered this at Parkland but used it as an opportunity to learn every detail of the setup and preparation. It has served me well in private practice, where I have been able to trouble shoot problems that leave my techs scratching their heads. I can also start all of my hearts in 20 minutes or less with all of the line placements, TEE, etc., without a tech, 15 minutes or less with a GOOD tech, so it makes me a more desired candidate for the surgeons and increases my value to the group.
You are still early in training. Develop your routines as you see others use theirs and adopt what you think would fit into your routine. Everyone at your stage, will tell you that their way is the best way and the safest way. You will need to stay open to all suggestions and methods and formulate the one that will work best for your patient and yourself.
Everything will start to slow down for you after a couple of months. You can make it easier on yourself by being there a little earlier at this point in your residency experience. As you develop your routine, little things like knowing exactly how many 20 cc, 10 cc, and 5 cc syringes you will want to open for each case type and each attending will become second hand to you.
Keep little notes on the preferences of each attending. Which one likes sux, which ones refuse sux no matter what, which like morphine and fentanyl, which like sufentanil only, two IV's only, etc. This type of knowledge will make your life a lot easier during the rest of the residency. Leave out overly personal judgements, but know who is temperamental, who is going to leave you out to dry no matter what happens, etc. Those people are easily pacified/mollified by the resident who is knowledgeable, confident (not arrogant), and flexible with different styles/techniques. Ask good questions, not incessant questions on things that you already know or ask to try to look good. Attendings will pick up on that. Ask questions on things that truly concern or confuse you. If someone is unwilling to spend time teaching you, at least you know that up front and don't have to waste time later trying to dig out pearls of wisdom.
Above all else, no matter how tired you are, you MUST read at least one hour a day, preferably two. That is the minimum amount of time you need to spend to both maintain and enlarge your knowledge base. This is residency, and this is the only time you can practice medicine under someone else's license. Use the opportunity to explore all techniques and avenues and it will make you a dynamic and desirable candidate after residency.
Don't hesitate to ask questions here. We've all been through or are going through the training period. Good to share your misery and your triumphs.
Documentation of unused medications for myself means, documenting unused hypnotics or narcotics. I could give a rat's ass if some pencil pusher is wondering what happened to the remaining 60 mg of Sux that I didn't use.
Keep track of your narcs and hypnotics but if you are having trouble with that or the case is long and involved, document that you gave everything and just waste any remaining med you have left (literally shoot it out of the syringe, do not just put a container or vial into the sharps basket: people have actually gone into those things to retrieve vials of fentanyl or morphine that appear to have fluid in it). Now don't do this if you used only 1 mg out of 10 mg of morphine, or 25 mcg out of 250 mcg of fentanyl, etc. If however, you have only 10 mcg of fentanyl or one mg of morphine left, chart it, shoot it into the sharps container, and save everyone the headache of extra signatures and paperwork. In residency, this will vary with attending so you will have to develop a feel for who will allow what. Varying institutions now include ephedrine on the controlled substances list so that may also be another source of paperwork.
Create a system for your charting that you can repeat over and over again from case to case.
Example: For the narrative I follow a pretty standard format I used in residency. With tweaking for prone cases, cranis, hearts, etc.
0645-0651: 18 ga PIV placed. Pt preTx. (BP 122/56, O2 97%RA, PR 88)
0715: To OR 32. PreOx X > 5 min. Mon on VSS.
RSI, eyes taped. DLX1 with Miller 3. Grade 1 view
LTA X 1. 7.5 ETT (down arrow drawn here)
Atraumatic. 4 cc's to cuff. =BBS (+), EtCO2 (+)
Secured @ 22 cm.
0723: L 20 ga radial A line placed with sterile prep and drape
BPPP (Bilateral pressure points padded).
OGT/NGT/ET (Esophageal thermometer) placed.
Bair hugger on.
0728: Ready for prep.
0740: Case start
0750: Begin controlled hypotension. MAP at >=65 at all times
0847: Case end
VSS. TO4 4/4 no fade, (+) 5 sec sustained tetany
(+) Sp. vent. Extubated with purposeful movement.
To PACU w/ O2 FM.
Document your times correctly on your billing sheet. This is one of the biggest problems that causes lost revenue to academic programs. If you have discontinuous time (Placed an IV 30 minutes before you rolled back to the OR), note that time on both your record and billing sheet and document a set of vital signs for that time period (sat, bp, PR are enough). You don't have to put it on the anesthesia record grid, you can just document it on the narrative as I did above. That five to 8 minutes of time adds up over the length of your residency and private practice career to hundreds of thousands of dollars of lost billing.
When you chart your vital signs, be reasonable. I had attendings who insisted that you chart every mean pressure, peak inspiratory pressure, etc. The reality is that you are wasting a lot of time looking at those numbers and recording them when you should be paying attention to the patient and what the surgeons (i.e. rookie, novice early in the year) are doing. I don't record a mean, simply because if they need it later, then they can calculate it with a calculator later. If the peak pressures are staying within a nominal range, then just record your best estimate. I hated seeing young residents scrolling back through the OR vital sign records as the surgeon was putting a trocar through the IVC or aorta, etc.
If you know what cases you are going to be doing the next day and can take blank OR records home with you, pre-write some of the work before the case so that pressure is alleviated somewhat and you have a written record of what you plan to do the next day. Just leave the times blank. Again, some attendings will be OK with it, some will not. Don't waste the records you get on the day of the surgery, keep them for the next day and put stickers in the appropriate places to reflect the correct patient.
One pet peeve I have: The SHARP'S container is for SHARPS. Disconnect the needles from your syringes and put the needles into the sharps container and put everything else into the trash. We don't put coca cola bottles into sharps containers, so why do we put empty bottles of succinylcholine, propofol, etc. into the sharps container. Do your part to prevent filling our landfills with underfilled sharps containers.
If a vial accidentally breaks before you can draw it up, you should have a nurse or your attending immediately witness it, request more narcotic, and record the waste on your narrative and narc sheet (0746: 2 cc vial of fentanyl wasted after vial fell to floor. Witnessed by ___ ).
When you are on break, ideally, the person giving you a break should record any narc usage. If you suspect that the person may have a "habit", draw up a little blood into your narc syringe to give it a beautiful pink-red tint. That will highly discourage anyone from "losing" narcs on break. Also keep track of and anonymously report anyone you suspect of having a "problem."
Unhelpful techs are the norm for academic centers. You can try to force them to do what is necessary, but the majority of these people have been there since the Pleistocene Era and will be highly resistant to change. I encountered this at Parkland but used it as an opportunity to learn every detail of the setup and preparation. It has served me well in private practice, where I have been able to trouble shoot problems that leave my techs scratching their heads. I can also start all of my hearts in 20 minutes or less with all of the line placements, TEE, etc., without a tech, 15 minutes or less with a GOOD tech, so it makes me a more desired candidate for the surgeons and increases my value to the group.
You are still early in training. Develop your routines as you see others use theirs and adopt what you think would fit into your routine. Everyone at your stage, will tell you that their way is the best way and the safest way. You will need to stay open to all suggestions and methods and formulate the one that will work best for your patient and yourself.
Everything will start to slow down for you after a couple of months. You can make it easier on yourself by being there a little earlier at this point in your residency experience. As you develop your routine, little things like knowing exactly how many 20 cc, 10 cc, and 5 cc syringes you will want to open for each case type and each attending will become second hand to you.
Keep little notes on the preferences of each attending. Which one likes sux, which ones refuse sux no matter what, which like morphine and fentanyl, which like sufentanil only, two IV's only, etc. This type of knowledge will make your life a lot easier during the rest of the residency. Leave out overly personal judgements, but know who is temperamental, who is going to leave you out to dry no matter what happens, etc. Those people are easily pacified/mollified by the resident who is knowledgeable, confident (not arrogant), and flexible with different styles/techniques. Ask good questions, not incessant questions on things that you already know or ask to try to look good. Attendings will pick up on that. Ask questions on things that truly concern or confuse you. If someone is unwilling to spend time teaching you, at least you know that up front and don't have to waste time later trying to dig out pearls of wisdom.
Above all else, no matter how tired you are, you MUST read at least one hour a day, preferably two. That is the minimum amount of time you need to spend to both maintain and enlarge your knowledge base. This is residency, and this is the only time you can practice medicine under someone else's license. Use the opportunity to explore all techniques and avenues and it will make you a dynamic and desirable candidate after residency.
Don't hesitate to ask questions here. We've all been through or are going through the training period. Good to share your misery and your triumphs.
