Surgeons you hate

[SilverStreak]

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Let me start by saying that there are the surgeons I love, they take excellent care of their patients, they are always courteous, friendly, cut up with everyone, and have a great reputation all around. And then, there are the ones, you know the ones, they get pissy over no big deal, quick to yell at whoever is in close proximity for something that was their fault, don't want to be bothered for pretty much anything minor or major with a patient. This is the distinction I make in the ICU, I can only imagine if you're in a case that goes bad what hell the bad surgeon could unleash, I've heard enough bits and pieces to make me cringe. As anesthesia, do you just shrug it off and let it go? This is the only drawback for doing anesthesia for me is dealing with some of these surgeons on a daily basis that are so difficult to work with.

 

[The_Sensei]

Let me start by saying that there are the surgeons I love, they take excellent care of their patients, they are always courteous, friendly, cut up with everyone, and have a great reputation all around. And then, there are the ones, you know the ones, they get pissy over no big deal, quick to yell at whoever is in close proximity for something that was their fault, don't want to be bothered for pretty much anything minor or major with a patient. This is the distinction I make in the ICU, I can only imagine if you're in a case that goes bad what hell the bad surgeon could unleash, I've heard enough bits and pieces to make me cringe. As anesthesia, do you just shrug it off and let it go? This is the only drawback for doing anesthesia for me is dealing with some of these surgeons on a daily basis that are so difficult to work with.

If you let them get to you, then you are empowering them. I NEVER empower anyone. At the end of the day, I go home to my nice wife/house/kids and nothing that went on in the hospital matters. Just take a global view on things and all will be well.

 

[rn29306]

While not empowering anyone, there is this one surgeon who can get to just about anyone. I'm all up for pointers on this one. He really got me going my first year, but now it is more amusing than anything.

His overall kicker is that, as a GYN, his patient's abdomens are not relaxed enough, especially when he is doing something in the retroperitoneal area. The only people to catch hell worse than anesthesia are the residents assisting him. Eventually the residents themselves start saying the patient is "tight" just to alleviate some of the pressure from themselves. We will have no twitches whatsofreakingever and he goes into a tirade about how they are "tight". Check patient's TOF on left eye. Nothing. Check TOF on right eye. Nada. Check a wrist just for the hell of it. Same. This is done after checking the battery on my forearm at about 7 on the 0-10 scale on TOF.
One person actually did keep giving Norcuron everytime he said the patient was "tight" and I'll bet you don't have to think too long and hard about who spend the night on the ventilator for no reason........And he hung her out to dry as expected. Not in her defense in any way, only an idiot would give over 20 mg of norcuron as she did..

What really gets under his skin is to say something along the lines of "my patient has no twitches" (implying that there is no way in hell I'm giving any more norcuron). Boy does he hit the roof and goes on and on about how "I don't give a GD about your twitches....blah blah f'ing blah..

My last run-in with him was immediately after intubation. We induced with fentanyl, lidocaine, propofol, vecuronium (10mg mind you). Smooth induction. Forane on. He jacks the legs up in stirrups, starts doing an EUA of the vaginal area and the patient takes a nice, slow, oozing poop all over his sterile gown. Ladies and gentlemen, my personal pinnacle of anestheisa has been reached because I have been waiting for this for a LONG time. He is infuriated and looks at me and blames me for her being "tight". I mean, come on dude, 10 mg of norcuron on a ASA II patient without any enzyme-induction disease process. I must not have a poker face on the upper part of my face because I am grinning like a fool under the mask. I think he sees this and he gets absolutely pissed. He asks me if I am impressed by what just happened. I play Tar Baby on this one and keep my mouth shut, mostly to keep from laughing. He just stares at me, then asks the question again. I tell him that the manner in which the poop continues to come out is suggestive of a completely flaccid (man do I hate that word) abdomen and incomplete bowel evacuation on her part. I point at her abdomen and note the lack of muscle contraction anywhere as she continues to passively poop all over him. I turn up the tidal volume just to help squeeze any additional excrement out onto him. He blasts out of the room and goes to scrub again. High fives from the staff.

Sorry for the long post, but my point is that while you would expect a surgeon to at least make an intellectual rant, sometimes they are just looking for someone to pass the buck onto. For whatever reason, they are pissed and so it goes, as usual, to anesthesia. His arguements have no scientific or logical reasoning. He throws the basis of nerve monitoring with TOF out the window and blames inadequate bowel prep evacuation on us also.

He would survive about 5 minutes in PP, only in academia can neanderthals such as this hide.

 

[SilverStreak]

While not empowering anyone, there is this one surgeon who can get to just about anyone. I'm all up for pointers on this one. He really got me going my first year, but now it is more amusing than anything.

His overall kicker is that, as a GYN, his patient's abdomens are not relaxed enough, especially when he is doing something in the retroperitoneal area. The only people to catch hell worse than anesthesia are the residents assisting him. Eventually the residents themselves start saying the patient is "tight" just to alleviate some of the pressure from themselves. We will have no twitches whatsofreakingever and he goes into a tirade about how they are "tight". Check patient's TOF on left eye. Nothing. Check TOF on right eye. Nada. Check a wrist just for the hell of it. Same. This is done after checking the battery on my forearm at about 7 on the 0-10 scale on TOF.
One person actually did keep giving Norcuron everytime he said the patient was "tight" and I'll bet you don't have to think too long and hard about who spend the night on the ventilator for no reason........And he hung her out to dry as expected. Not in her defense in any way, only an idiot would give over 20 mg of norcuron as she did..

What really gets under his skin is to say something along the lines of "my patient has no twitches" (implying that there is no way in hell I'm giving any more norcuron). Boy does he hit the roof and goes on and on about how "I don't give a GD about your twitches....blah blah f'ing blah..

My last run-in with him was immediately after intubation. We induced with fentanyl, lidocaine, propofol, vecuronium (10mg mind you). Smooth induction. Forane on. He jacks the legs up in stirrups, starts doing an EUA of the vaginal area and the patient takes a nice, slow, oozing poop all over his sterile gown. Ladies and gentlemen, the my personal pinnacle of anestheisa has been reached because I have been waiting for this for a LONG time. He is infuriated and looks at me and blames me for her being "tight". I must not have a poker face on the upper part of my face because I am grinning like a fool under the mask. I think he sees this and he gets absolutely pissed. I tell him that the manner in which the poop continues to come out is suggestive of a completely flaccid (man do I hate that word) abdomen and incomplete bowel evacuation on her part. I point at her abdomen and note the lack of muscle contraction anywhere as she continues to passively poop all over him. I turn up the tidal volume just to help squeeze any additional excrement out onto him.

Sorry for the long post, but my point is that while you would expect a surgeon to at least make an intellectual rant, sometimes they are just looking for someone to pass the buck onto. For whatever reason, they are pissed and so it goes, as usual, to anesthesia. His arguements have no scientific or logical reasoning. He throws the basis of nerve monitoring with TOF out the window and blames inadequate bowel prep evacuation on us also.

He would survive about 5 minutes in PP, only in academia can neanderthals such as this hide.

Well if I ever think I have it bad in the ICU, at least your story will give me a good laugh. Something to look forward to when I start anesthesia school.

My kicker was on behalf of another nurse. We have one of the most arrogant cardiac surgeons ever born. We called a code on a patient, she suddenly went asystole, am labs fine, no bradying down or hypoxia or any warning signs, she's SR 70's one minute, my friend is next door, and her alarm starts screaming, the patients eyes rolled back, she's out...we hook her up by her epicardial leads to a temporary pacer, getting inconsistent capture, adjusting pacer to full power, got the crash cart at the bedside, the whole works. She calls to let him know, and his response is that she should be giving report to the oncoming nurse, not him at 6 am. Hello? We called a code on her, she's still not looking good and he's fussing about getting a call so early. Then he proceeds to tell her "well, I thought you might be like another nurse who used to do stuff just to get to call me" Yep, that's right doc, I have nothing better to do at shift change than come up with a way to get your patients heart to peter out so I can call and see how you're doing this morning. I was so pissed, so we're talking about it as he comes in, and he heard me say to her "next time he starts, just tell him to write you an order on all his patients do not call me from 7p to 7a and he won't hear from you". Of course, by this time he sees her and realizes what a complete jerk he's been, but he plays it off like he didn't know how bad off she was. My friend had called him the morning before also on something he thought was no big deal, so he figured this day was a repeat of the same thing. This is the same surgeon that got wrote up in the OR for splashing some of the OR staff with blood on purpose and laughed about it.

 

[Leukocyte]

I turn up the tidal volume just to help squeeze any additional excrement out onto him.

Next time you are in the OR with him get a medical student to come in with you. While you are teaching the medical student say with a load voice, "when I work with REAL surgeons, you know General surgeons, Orthopods, ENTs, Urologists, Plastics, Neurosurgeons, and Ophthalmologists, I do it this way....."

Seriously though, he is taking advantage of you because you are a resident. An attending Anesthesiologist would say to him, "watch it dude, DO NOT tell me what to do. You do your job, and I will do mine."

 

[augmel]

I turn up the tidal volume just to help squeeze any additional excrement out onto him.

Holy smokes that is brilliant. Pure inspiration at just the right time. I salute you.

 

[rn29306]

Next time you are in the OR with him get a medical student to come in with you. While you are teaching the medical student say with a load voice, "when I work with REAL surgeons, you know General surgeons, Orthopods, ENTs, Urologists, Plastics, Neurosurgeons, and Ophthalmologists, I do it this way....."

Seriously though, he is taking advantage of you because you are a resident. An attending Anesthesiologist would say to him, "watch it dude, DO NOT tell me what to do. You do your job, and I will do mine."

Sorry man, but I'm just a lowly SRNA. Not a resident.

If you anesthesiologist residents think you get crap, senior CRNA students get absolutely drilled when we are alone in the room by surgeons when our MD leaves, for no damn reason. Funny how all the anal reaming takes place just after my anesthesiologist is out of the room. The MD would tell him, certainly, calling him by his first name of course, to go to hell. It def keeps you on your toes.

My MO is to have a reason for everything I do, don't cry wolf ever, and concentrate on staying ahead of the continual one-upmanship that always is occurring in the OR, be it the surgeon, anesthesiologist, or OR nurse. That and the yo-momma routine. Do things for a patient that you would want someone to do for yo-momma if that was her on the table.

Speaking of that, who rides you residents the worst during a case when your attending is out of the room? I have found that jealousy rears its ugly head in academia and most times it is the OR nurse or scrub tech that rides senior SRNAs when we are soloing a room. The gloves come off for more than one uncalled for smart azz remark. How about you guys? PP is wonderful. Sometimes academia simply sucks because of the attiutdes.

 

[Laryngospasm]

I know what you guys are talking about, as you get further along in your training, you tolerate less, and are some what more resistant to this rediculousness. I reccomend that you develop a plan for these situations and implement it without bias. I am in my last year of residency, and the rules are that as a resident it is bad news, and even as staff unless done diplomatically, to tell a surgeon to go f himself. The sensei has a good approach, which is not to let them get to you. We have this one dumbarss pediatric surgeon who is always asking for more relaxant, for ONE HOUR CASES WITH FAST TURNOVER!!!, such as an inguinal hernia repair. These are usually thin little kids with tight abdomens, and what he really wants is for us to make the abdominal musculature dissapear. I allways say " the patient is very relaxed, but I can have my staff come in and see if we can give more NDMB. Usually he shuts up for a minute, then starts back saying "you guys just dont understand how important relaxation is". Really? At this point I just Say to the OR nurse "would you please call Dr. X in here for me?" Usually, the patient starts to get more relaxed at this point, amazingly. The other alternative is to say well let me give some more, at which point you act like you are giving something, or if you cant lie give some miniscule dose. Its often psychological with some of these guys, kinda like tourrettes, and crap just spontaneously comes outta their mouth periodically. Then there are some that just like to harass people. Having a plan will keep you from getting into trouble. Good luck, and remember that work is just that.

 

[Gator05]

Sometimes good people have bad days, and you get asked about tight bellies.

I've tried pre-empting the surgeons. Just keep asking them if the abd is loose enough. If/when the answer is no, you can elect to push (very) dilute solutions of vec (heck, you could even use mivacron), and ask again 2 minutes later. Eventually they move on or acquiese.

If not, well, some things just can't be handled at a resident:surgical attending interface.

 

[CambieMD]

Sometimes good people have bad days, and you get asked about tight bellies.

I've tried pre-empting the surgeons. Just keep asking them if the abd is loose enough. If/when the answer is no, you can elect to push (very) dilute solutions of vec (heck, you could even use mivacron), and ask again 2 minutes later. Eventually they move on or acquiese.

If not, well, some things just can't be handled at a resident:surgical attending interface.

I have been burned by a surgeon constanly complaining about a tight abdomen and asking for more relaxation. I have started to ask ,"is that better?" after I give a low dose of relaxer or turn up the gas. Also you can let them now that you recently gave relaxer. This beats the pt having no twitches at the end of the surgery.

Cambie

 

[Carm]

It's called the old syringe shuffle. Fumble around at the head of the bed and surprisingly the patient 'is better' in the eyes of the surgeon.

 

[jwk]

It's called the old syringe shuffle. Fumble around at the head of the bed and surprisingly the patient 'is better' in the eyes of the surgeon.

That often works wonders.

My favorites are the ones who want more relaxation when the patient has a spinal or epidural. Duh. And of course then there's the OB docs who can't get an 8# baby out of a C/S incision about the size of a paper clip and think it's our fault.

Remember - anesthesia makes surgery possible, not easy.

 

[Misterioso]

You know how it goes...
You play 2nd fiddle to the surgeons.
It's always been like that and always will be.
You knew this before signing on for anesthesia.
No need to be playa' hattin' now

 

[cloud9]

You know how it goes...
You play 2nd fiddle to the surgeons.
It's always been like that and always will be.
You knew this before signing on for anesthesia.
No need to be playa' hattin' now

Still listenin' to and lovin' that "paper plate cold diarrhea" is ya?

 

[Tenesma]

Please see my previous posts about surgeon interactions... The primary reason there are misgivings across the ether screen revolves around no emotional attachment. When there is a dialogue between anesthesiologist and surgeon outside of the OR and friendships and collegiality develops, then these situations never occur.

As far as GYN - very few of those guys are actually trained surgeons (the older guys might have done a gen. surg residency). Think about it during 4 years of OB/GYN ONLY 11 months are spent in the OR operating (i don't consider a c-section operating FYI)...

When a surgeon complains about tightness and you are confident the diaphragm is paralyzed then tell them that it is a matter of optimizing the field of view by lengthening the incision, as the tightness isn't going to get better w/ more drugs. So my reply is: "I can see that you are struggling w/ your operative field - increasing the incision may be helpful cause more drugs aren't going to do it". If they insist on more drugs then I just inform them that the patient will take an extra hour to wake up, and if they are okay w/ that and it doesn't appear to harm the patient then I comply (because honestly some good surgeons can actually feel tightening before you can even notice).... and remember TOF of the eye is useless, and TOF of the wrist is a POOR indicator of diaphragmatic relaxation...

I don't like to fumble and make believe i am giving something just to appease the surgeon - my role isn't that of an appeaser, but rather of a consultant in anesthesia.

There was a surgeon at the MGH (dave berger) who operates faster than any surgeon I have ever worked with (i routinely ran succinylcholine drips for his hepatectomies cause they took 45 mintues!!!) - and he could tell the difference between succinylcholine, non-depolarizers and propofol boluses... it freaked me out - but i loved being in the room w/ him (we would do 9-10 cases from 7:30 to 5pm)

 

[rn29306]

There was a surgeon at the MGH (dave berger) who operates faster than any surgeon I have ever worked with (i routinely ran succinylcholine drips for his hepatectomies cause they took 45 mintues!!!) - and he could tell the difference between succinylcholine, non-depolarizers and propofol boluses... it freaked me out - but i loved being in the room w/ him (we would do 9-10 cases from 7:30 to 5pm)

A 45 minute hepatectomy....Good lord. 😱

9-10 cases / day. Not a bad collection of units huh?

 

[lvspro]

Still listenin' to and lovin' that "paper plate cold diarrhea" is ya?

He's coming back for seconds. Apparently one mouthful of $hit wasn't enough.

 

[Gator05]

".... and remember TOF of the eye is useless, and TOF of the wrist is a POOR indicator of diaphragmatic relaxation..."

Poor indicator of diaphragmatic relaxation, AND the diaphragm is one of the first muscles to come back from relaxation. TOF of the wrist is a great indicator for readiness to reverse since it comes back late. Does anyone know what the most sensitive indicator of relaxation is?

By the by, used the peroneal nerve for twitch stimulation the other day (you use what you can reach somedays!), and was pretty impressed. Didn't know how the sensitivities compared. Does anyone have a table or chart comparingspecific muscle group sensitivities to relaxant?