Volatile - you wanted proof.

[Mike MacKinnon]

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Buddy

In regards to that other thread where you called me the problem. This isnt my first rodeo, just a different sret of clowns. Ive been doing this since you were watching hair grow on your "dinky".

I KNOW the rules and I have always followed them. I was right, you are wrong.

Here is the proof about the increased ,mortality rates.

New Hospital Residents and Increased Mortality
New Hospital Residents and Increased Mortality

"The average, major teaching hospital experiences an increase in risk-adjusted mortality of roughly 4 percent in the July-August period."

Nearly all managers must deal with the consequences of employee turnover within their organizations. Turnover appears in multiple forms. Many firms face a continuous stream of individual turnover in which employees leave and are replaced by new workers at various points throughout the year. In such settings, there is no one particular time during the year when managers are required to train and orient a large portion of their workforces.

In contrast, other firms bring on new employees in large numbers at discrete points in the year. For example, law and consulting firms tend to start most of their new employees in late summer or early fall. These new employees must all be trained and integrated into the firm at one time. In the law and consulting examples, the potential negative effects of the large inflow of new workers may be buffered by the fact that firms do not face the simultaneous exit of large portions of their experienced workers. Rather, departures occur in a roughly continuous manner throughout the year.

In Cohort Turnover and Productivity: The July Phenomenon in Teaching Hospitals (NBER Working Paper No. 11182), authors Robert Huckman and Jason Barro investigate a third form of turnover, the extreme, though not uncommon, scenario that they term cohort turnover. This type of turnover involves the simultaneous exit of a large number of experienced employees and a similarly sized entry of new workers. Cohort turnover raises concerns about adverse effects on productivity attributable to factors such as operational disruption or the loss of the tacit knowledge held by departing workers.

The authors consider cohort turnover among house staffs (that is, residents and fellows) in teaching hospitals. This turnover leads to a significant lack of continuity and a discrete reduction in the average experience of the labor force at teaching hospitals every summer. In addition, this changeover may disrupt established teams of doctors and other caregivers within hospitals. Either of these effects may have potentially troubling consequences for the two determinants of hospital productivity -- resource utilization and clinical quality. This "July phenomenon" is often mentioned in the lore of medical professionals.

Using data on all patient admissions from a large, multi-state sample of American hospitals over a five-year period, the authors find that both minor and major teaching hospitals experience a significant increase in resource utilization -- measured by average length of stay (LOS) -- immediately following the July turnover, and that the effect appears to last for several months. They also find that teaching hospitals with medium teaching intensity experience a significant increase in patient mortality over the same period. The confluence of increased resource utilization and increased mortality (in other words, decreased quality) during the July-August period implies that this cohort turnover reduces medical productivity.

Nevertheless, those hospitals with the highest teaching intensities (the greatest reliance on residents for the provision of care) seem to avoid the disruption of the July phenomenon with respect to average mortality rates. The authors' preliminary evidence suggests that higher supervision levels play a role in mitigating the impact of the July turnover in major teaching facilities.

The magnitude of the estimated effects is substantial and appears to last for roughly six months. The average LOS for the average, major teaching hospital increases by roughly 2 percent following the July turnover and remains between 1 percent and 2 percent higher throughout the final six months of the calendar year. Similarly, the average, major teaching hospital experiences an increase in risk-adjusted mortality of roughly 4 percent in the July-August period. This effect also remains at levels between 2 percent and 4 percent for the last six months of the calendar year. For the average major teaching hospital, this translates into between 7.8 and 13.8 "accelerated" deaths (that is, deaths that occur earlier than they would have in the absence of the July turnover) per year. Based on a total of roughly 200 major teaching hospitals in the United States, the July phenomenon is thus associated with roughly 1,500 to 2,750 accelerated deaths per year in the United States. The authors do not estimate the social cost of this increase in mortality.

Beyond their findings with respect to the July phenomenon, the authors offer empirical support for the contention that cohort turnover has negative implications for productivity on average, although these effects do not increase linearly with the intensity of turnover. Their initial evidence suggests that supervision can mitigate this negative effect. Even if firms are not able to reduce their levels of turnover, they may be able to manage its effects

-- Les Picker

Cite this page as: "New Hospital Residents and Increased Mortality." NBER Website. Wednesday, August 30, 2006. <http://www.nber.org/digest/sep05/w11182.html>.

 

[VolatileAgent]

i can't believe i'm even going to respond to this... but, here goes...

1) first off, don't try to play the "older, more experienced" card. i'd be willing to bet big money that i am, as well as many of my fellow colleagues, older than you and was knocking the bottom out of it before your testicles dropped. nonetheless, your ad hominem is noted despite the fact that it is still completely irrelevant to the issue at hand.

2) you amply illustrate by referencing this economic "working paper" as some sort of "evidence" that you have no grasp of what constitutes a rigorous, peer-reviewed scientific publication.

3) okay. anyway. so, let's take this non-peer reviewed, non-scientific "working paper" and try to look at it objectively. first, there are no direct causal links and no attempt to make any, just author speculation. there is no attempt to offer other possible explanations (i.e., increased traumas in the summer months, certain illnesses/infections that may influence outcome, lower summer census artificially inflating numbers, etc.). they just "attribute" what they speculate (understand the importance of that concept) to be the result of "lack of continuity" and a "discrete reduction in the average experience of the labor force" that may be at play. and, where is their control (ie, a private hospital) data? in fact, they don't even tell us from where or how they got their "data" that they are presenting here. who independently (another important concept) reviewed it? there are additionally no references available on PubMed to this article. there is no other forum where this information exists or has been commented on... except maybe here. why haven't they put this data and methodology up for public scrutiny and discussion? this seems pretty important and disconcerting, if actually correct. you see, the reality itself is that this "working paper" admits it's only looking at certain variables (eg, increased length of stay) and attempting to assign causation. any direct conclusions are only inference, which don't mean anything in the grand scheme of things.

4) additionally, let's say for arguments sake that we actually believe and take at face value the facts of this "working paper". if so, you can equally conclude that nurses aren't doing such a good job, are they? after all, you'd think that they'd be able to mitigate this phenomenon with their ability to choose which orders they should carry out, as you suggested. after all, you are the gate-keepers, right? no order can get carried out without you there to "save us from having to testify in front of the MAN", right? so, how can it be that this happens each and every year (at least since they've been doing this "research"), and then after six months goes away if the nursing staff is assumed to be the only consistent variable. sounds like you're actually not doing a very good job at policing the new residents, as you suggest is your responsibility. you can't have it both ways, pal.

5) BUT, the single biggest flaw in their conclusions (which, to me, demonstrates that they do not fully understand what they are commenting on) is that they don't account or make a comment on the monthly turnover of residents as they rotate onto new services. this equally affects continuity of care and requires staff and patients to adjust to new faces, new teams, and new working styles. so, any "cohort effect" should only really exist if there is no senior or attending oversight, which doesn't actually happen (and you know that too, mike). furthermore, there would be not a six-month cycle, but a month-to-month cycle, which their data (they would admit) doesn't show. additionally, all the residents don't leave every year, just new ones come on board, and they are heavily supervised during the entire year, not just the first few months (at least at my institution, and others i've trained at).

so, dude, if you honestly - HONESTLY - believe this proves anything - this singular, non-crossreferenced, non-peer-reviewed "working paper" produced by some economist ivory-tower think tank on which there exists no other discussion to be found anywhere on the internet - you are, quite simply, completely misinformed.

you want to keep dragging this debate on, so be it. i'm still waiting for you to prove something... what that is, i'm not quite sure. but, i'm pretty sure you don't know what it is either.

 

[Pilot Doc]

Authors Claridge JA. Schulman AM. Sawyer RG. Ghezel-Ayagh A. Young JS.

Title The "July phenomenon" and the care of the severely injured patient: fact or fiction?.

Surgery. 130(2):346-53, 2001 Aug.

Abstract BACKGROUND: The "July phenomenon," a common belief in medical academia, refers to purported errors, inefficiency, and negative outcomes during the summertime transition of the house staff. We hypothesized that care in a trauma service is consistent throughout the year and that the July phenomenon therefore is a myth. METHODS: The records of adults admitted to a trauma service between July 1994 and September 1999 were evaluated. The care of and outcomes for patients admitted in July and August were compared with those of patients admitted in April and May. RESULTS: Nine hundred seventeen patients were evaluated over 5 years. Patients were well matched by the Injury Severity Score, the Glasgow Coma Score, by mechanism, and by survival probability. Patients admitted in the spring were significantly older, by a mean of 5.1 years. Length of stay and intensive care unit stay were similar. Emergency department times were similar, as were resuscitation times, infection rates, and hospital costs. The mortality of patients was similar between the 2 times. CONCLUSIONS: There was no evidence of an increase in negative outcomes early in the academic year compared with the end of the academic year. We believe that a systematic approach to the diagnosis, resuscitation, and treatment of trauma prevented a July phenomenon.

 

[BIS]

Have seen if first hand recently more than I would like to admit it. Its not only new residents but new SRNA's, pharmacists in training, RN students ect.

ICU interns straight out of med school managing a sick as all hell pt without a clue puimping him so full of fluids, not starting pressors early enough. Going to the ICU and picking up a pt to bring to the OR that should have been optimized by now but is still getting ****ty care all the way around. Hey we are all learning but believe me this does exist.

 

[VolatileAgent]

'nuff said...

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1494902

 

[Noyac]

If everyone can keep it clean here, this thread will continue. As soon as it deteriorates, I close it. 🙂

 

[The_Sensei]

...
so, dude, if you honestly - HONESTLY - believe this proves anything - this singular, non-crossreferenced, non-peer-reviewed "working paper" produced by some economist ivory-tower think tank on which there exists no other discussion to be found anywhere on the internet - you are, quite simply, completely misinformed.

you want to keep dragging this debate on, so be it. i'm still waiting for you to prove something... what that is, i'm not quite sure. but, i'm pretty sure you don't know what it is either.

My God I can't believe it but I've got a new hero!!😍 Brilliant dissection, my man!

 

[Mike MacKinnon]

Wow

Since i have been published i think i know how to research and publish. I couldnt be bothered, initially, to look up the mortality rate changes since it makes sense. Brand new people, doing things they are brand new at, WILL make more mistakes. Seems like common sense, but then, you appear not to believe it.

As for experience, you know nothign about me. Sufficed to say im not new at this.

* Rosenthal GE,
* Harper DL,
* Quinn LM,
* Cooper GS.

Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH 44106-4961, USA. [email protected]

CONTEXT: Major teaching hospitals are perceived as being more expensive than other hospitals and, thus, unattractive to managed care. However, little empirical data exist about their relative quality and efficiency. The current study compared severity-adjusted mortality and length of stay (LOS) in teaching and nonteaching hospitals. DESIGN: Retrospective cohort study. SETTING: Thirty hospitals in northeast Ohio. PATIENTS: A total of 89851 consecutive eligible patients discharged in 1991 through 1993 with myocardial infarction, congestive heart failure, obstructive airway disease, gastrointestinal hemorrhage, pneumonia, or stroke. MAIN OUTCOME MEASURES: In-hospital mortality and LOS of patients in major teaching (n=5), minor teaching (n=6), and nonteaching (n=19) hospitals were adjusted for admission severity of illness using multivariable models based on demographic and clinical data abstracted from patients' medical records. RESULTS: The adjusted odds of death was 19% lower (95% confidence interval [CI], 2%-34%; P=.03) for patients in major teaching hospitals compared with non-teaching hospitals but was similar (95% CI, 7% lower to 28% higher; P=.28) for patients in minor teaching hospitals. The findings were generally consistent in analyses stratified according to diagnosis, age, race, predicted risk of death, and other covariates. In addition, risk-adjusted LOS was 9% lower (95% CI, 8%-10%; P<.001) among patients in major teaching hospitals relative to nonteaching hospitals but was similar (95% CI, 2% lower to 11% higher; P=.17) in minor teaching hospitals. Major teaching hospitals also cared for higher proportions of nonwhite and poorly insured patients. CONCLUSIONS: Risk-adjusted mortality and LOS were lower for patients in major teaching hospitals than for patients in minor teaching and nonteaching hospitals. If generalizable to other regions, the results provide evidence that hospital performance, as assessed by 2 commonly used indicators, may be higher in major teaching hospitals. These findings are noteworthy at a time when the viability of many major teaching hospitals is threatened by powerful health care market forces and by potential changes in federal financing of graduate medical education.


* Khuri SF,
* Najjar SF,
* Daley J,
* Krasnicka B,
* Hossain M,
* Henderson WG,
* Aust JB,
* Bass B,
* Bishop MJ,
* Demakis J,
* DePalma R,
* Fabri PJ,
* Fink A,
* Gibbs J,
* Grover F,
* Hammermeister K,
* McDonald G,
* Neumayer L,
* Roswell RH,
* Spencer J,
* Turnage RH;
* VA National Surgical Quality Improvement Program.

VA Boston Healthcare System, West Roxbury, Massachusetts 02132, USA. [email protected]

OBJECTIVE: To determine whether the investment in postgraduate education and training places patients at risk for worse outcomes and higher costs than if medical and surgical care was delivered in nonteaching settings. SUMMARY BACKGROUND DATA: The Veterans Health Administration (VA) plays a major role in the training of medical students, residents, and fellows. METHODS: The database of the VA National Surgical Quality Improvement Program was analyzed for all major noncardiac operations performed during fiscal years 1997, 1998, and 1999. Teaching status of a hospital was determined on the basis of a background and structure questionnaire that was independently verified by a research fellow. Stepwise logistic regression was used to construct separate models predictive of 30-day mortality and morbidity for each of seven surgical specialties and eight operations. Based on these models, a severity index for each patient was calculated. Hierarchical logistic regression models were then created to examine the relationship between teaching versus nonteaching hospitals and 30-day postoperative mortality and morbidity, after adjusting for patient severity. RESULTS: Teaching hospitals performed 81% of the total surgical workload and 90% of the major surgery workload. In most specialties in teaching hospitals, the residents were the primary surgeons in more than 90% of the operations. Compared with nonteaching hospitals, the patient populations in teaching hospitals had a higher prevalence of risk factors, underwent more complex operations, and had longer operation times. Risk-adjusted mortality rates were not different between the teaching and nonteaching hospitals in the specialties and operations studied. The unadjusted complication rate was higher in teaching hospitals in six of seven specialties and four of eight operations. Risk adjustment did not eliminate completely these differences, probably reflecting the relatively poor predictive validity of some of the risk adjustment models for morbidity. Length of stay after major operations was not consistently different between teaching and nonteaching hospitals. CONCLUSION: Compared with nonteaching hospitals, teaching hospitals in the VA perform the majority of complex and high-risk major procedures, with comparable risk-adjusted 30-day mortality rates. Risk-adjusted 30-day morbidity rates in teaching hospitals are higher in some specialties and operations than in nonteaching hospitals. Although this may reflect the weak predictive validity of some of the risk adjustment models for morbidity, it may also represent suboptimal processes and structures of care that are unique to teaching hospitals. Despite good quality of care in teaching hospitals, as evidenced by the 30-day mortality data, efforts should be made to examine further the structures and processes of surgical care prevailing in these hospitals.

* Cram P,
* Hillis SL,
* Barnett M,
* Rosenthal GE.

Division of General Internal Medicine, Department of Internal Medicine, University of Iowa College of Medicine, Iowa City 52242, USA. [email protected]

PURPOSE: The effect of reduced hospital staffing during weekends on in-hospital mortality is not known. We compared mortality rates between patients admitted on weekends and weekdays and whether weekend-weekday variation in rates differed between patients admitted to teaching and nonteaching hospitals in California. METHODS: The sample comprised patients admitted to hospitals from the emergency department with any of 50 common diagnoses (N = 641,860). Mortality between patients admitted on weekends and those admitted on weekdays (the "weekend effect") was compared. The magnitude of the weekend effect was also compared among patients admitted to major teaching, minor teaching, and nonteaching hospitals. RESULTS: The adjusted odds of death for patients admitted on weekends when compared with weekdays was 1.03 (95% confidence interval [CI]: 1.01 to 1.06; P = 0.0050). Three diagnoses (cancer of the ovary/uterus, duodenal ulcer, and cardiovascular symptoms) were associated with a statistically significant weekend effect. None of the 50 diagnoses demonstrated a statistically significant reduction in mortality for weekend admissions as compared with weekday admissions. Mortality was similar among patients admitted to major (odds ratio [OR] = 1.06; 95% CI: 0.94 to 1.19) and minor (OR = 1.03; 95% CI: 0.97 to 1.09) teaching hospitals, compared with nonteaching hospitals. However, the weekend effect was larger in major teaching hospitals compared with nonteaching hospitals (OR =1.13 vs. 1.03, P = 0.03) and minor teaching hospitals (OR = 1.05, P = 0.11). CONCLUSION: Patients admitted to hospitals on weekends experienced slightly higher risk-adjusted mortality than did patients admitted on weekdays. While overall mortality was similar for patients admitted to all hospital categories, the weekend effect was larger in major teaching hospitals and is cause for concern.

* Bell CM,
* Redelmeier DA.

Department of Medicine, University of Toronto, Sunnybrook and Women's College Health Sciences Centre, ON, Canada.

BACKGROUND: The level of staffing in hospitals is often lower on weekends than on weekdays, despite a presumably consistent day-to-day burden of disease. It is uncertain whether in-hospital mortality rates among patients with serious conditions differ according to whether they are admitted on a weekend or on a weekday. METHODS: We analyzed all acute care admissions from emergency departments in Ontario, Canada, between 1988 and 1997 (a total of 3,789,917 admissions). We compared in-hospital mortality among patients admitted on a weekend with that among patients admitted on a weekday for three prespecified diseases: ruptured abdominal aortic aneurysm (5454 admissions), acute epiglottitis (1139), and pulmonary embolism (11,686) and for three control diseases: myocardial infarction (160,220), intracerebral hemorrhage (10,987), and acute hip fracture (59,670), as well as for the 100 conditions that were the most common causes of death (accounting for 1,820,885 admissions). RESULTS: Weekend admissions were associated with significantly higher in-hospital mortality rates than were weekday admissions among patients with ruptured abdominal aortic aneurysms (42 percent vs. 36 percent, P<0.001), acute epiglottitis (1.7 percent vs. 0.3 percent, P=0.04), and pulmonary embolism (13 percent vs. 11 percent, P=0.009). The differences in mortality persisted for all three diagnoses after adjustment for age, sex, and coexisting disorders. There were no significant differences in mortality between weekday and weekend admissions for the three control diagnoses. Weekend admissions were also associated with significantly higher mortality rates for 23 of the 100 leading causes of death and were not associated with significantly lower mortality rates for any of these conditions. CONCLUSIONS: Patients with some serious medical conditions are more likely to die in the hospital if they are admitted on a weekend than if they are admitted on a weekday.

* Ensminger SA,
* Morales IJ,
* Peters SG,
* Keegan MT,
* Finkielman JD,
* Lymp JF,
* Afessa B.

Division of Pulmonary and Critical Care Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA. [email protected]

STUDY OBJECTIVES: Previous studies have suggested that patients are more likely to die in the hospital if they are admitted on a weekend than on a weekday. This study was conducted to determine whether weekend admission to the ICU increases the risk of dying in the hospital. DESIGN: Retrospective cohort study. SETTING: ICU of a single tertiary care medical center. PATIENTS: A total of 29,084 patients admitted to medical, surgical, and multispecialty ICUs from October 1994 through September 2002. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The weekend ICU admissions comprised 27.9% of all ICU admissions (8,108 ICU admissions). The overall hospital mortality rate was 8.2% (2,385 deaths). Weekend ICU admission was associated with a higher unadjusted hospital mortality rate than that for weekday ICU admission (11.3% vs 7.0%, respectively; odds ratio [OR], 1.70; 95% confidence interval [CI], 1.55 to 1.85). In multivariable analyses controlling for the factors associated with mortality such as APACHE (acute physiology and chronic health evaluation) III predicted mortality rate, ICU admission source, and intensity of treatment, no statistically significant difference in hospital mortality was found between weekend and weekday admissions in the overall study population (OR, 1.06; 95% CI, 0.95 to 1.17). For weekend ICU admissions, the observed hospital mortality rates of the medical, multispecialty, and surgical ICUs were 15.2%, 17.2%, and 6.4%, respectively, and for weekday ICU admissions the rates were 16.3%, 10.1%, and 3.5%, respectively. Subgroup analyses showed that weekend ICU admission was associated with higher adjusted hospital mortality rates than was weekday ICU admission in the surgical ICU (OR, 1.23; 95% CI, 1.03 to 1.48), but not in the medical or multispecialty ICUs. CONCLUSIONS: The overall adjusted hospital mortality rate of patients admitted to the ICU on a weekend was not higher than that of patients admitted on a weekday. However, weekend ICU admission to the surgical ICU was associated with an increased hospital mortality rate.

 

[VolatileAgent]

Wow

Since i have been published i think i know how to research and publish. I couldnt be bothered, initially, to look up the mortality rate changes since it makes sense. Brand new people, doing things they are brand new at, WILL make more mistakes. Seems like common sense, but then, you appear not to believe it.

As for experience, you know nothign about me. Sufficed to say im not new at this.

mike,

you make statements and assertions, and then you post a hodge-podge of information that is either irrelevant or has little to do with the discussion at hand. you are continuously moving the target, as evidenced by a string of studies you just list apparently as some "evidence" to support your claims, which has nothing to do with your original premise: that nurses have a "legal obligation to refuse any order they are not comfortable performing" (your exact words) and that this somehow protects the patient. i called hogwash on that, and yet you still wanted to argue this point by starting a new thread posting data and studies that either are irrelevant or have nothing to do with your original, arrogant assertion!

i'm already getting tired of playing this game with you, mike. but, just to humor you (and everyone else reading this) i'm going to - again - shred your lame attempt at counterargument and reiterate why you need to stick to doing your job and perform within the legal boundaries of your licensure, i.e. not continue to delude yourself that you are actually doing patient management or practicing medicine.

1) first study you quote: conclusion is that risk-adjusted mortality and length of stay is lower at major teaching institutions. wait a minute! did you actually read this? you are proving my point! having residents, apparently, involved in care is a good thing and outcomes are better. so, which is it, mike?

2) second study you quote: teaching hospitals in the VA system? come on, mike! this is often an elderly, very sick, and/or polysubstance abuse-type population that does not often have access or insurance to afford to be treated elsewhere. attending physicians at these hospitals are government employees who get a paycheck whether they work 30 hours a week or 80. you can't possibly be trying to use THIS study to add to your argument. again, did you actually read this abstract? teaching hospitals, even in the VA system, will always take the more difficult cases. in fact, within the VA system certain hospitals will not even offer services. they send all of their patients to main centers that perform only those specialty operations, and often they are on the sickest patients. did you even know that, mike? i doubt it. i doubt you even read this abstract. or, if you did, you didn't understand it because, again, it basically argues that the care is just as good at teaching VA facilities and mortality outcomes are the same as at others (which is amazing, when you think about it, based on what i just told you about the bigger, tougher cases that get turfed to the VA teaching centers, a fact i happen to know firsthand and which this abstract also clearly reiterates.)

3) third study you quote: wait a minute, mike. now you want to bring in the "weekend effect". what does this have to do with anything? are different residents working on the weekends? perhaps it's different nurses or different food staff or different housekeeping? no. the study itself says there is no statisitically significant change in mortality between type of hospital, be it teaching or private. that's what we were talking about, right mike? nurses saving the residents' rear-ends? otherwise, what was the point of posting this study. everyone knows that attendings take home call on the weekends. are you suggesting that we need to mandate having attending-level care in the cath lab 24/7/365? is that a good use of limited resources? and, this happens equally at all hospitals, private and teaching, so you can't blame this one on the stupid residents, mike. i guess you can only blame the nurses watching the patient for not calling the doctor soon enough.

4&5) fourth/fifth studies you quote: ditto my comments for #3. you are trying to change the argument and move the target, mike. i'm not going to keep playing this game with you.

stick to your job, do it to the best of your ability, check your ego once in a while, and remember the patient is paramount in all this, mike. next time you get a little high and mighty, come back and read this thread.

 

[dhb]

Sufficed to say im not new at this.

Maybe not but you did prove Volatile's point with the first study 😱 and the last three were irrelevant (at best)...😕
You've got to admit defeat on this one...😎

 

[The_Sensei]

Damn, Volatile......you just keep destroying that chump! I didn't think it was possible, but I respect you even more!! 👍

 

[Gern Blansten]

Well-done Volatile. I just feel bad for you that you had to waste your time explaining all of this to him.

 

[Mman]

within the VA system certain hospitals will not even offer services. they send all of their patients to main centers that perform only those specialty operations, and often they are on the sickest patients

Tell me about it. I spent last month taking care of vets from a roughly 600 mile radius for cardiac and thoracic surgery because we were the only VA in the region that offered major cardiothoracic surgery. I'm glad to be back in my good old University hospital driving down the mortality rate in August 😉

 

[Lizard1]

Geez - I'll admit I had some respect for McKinnon prior to this thread but now he showed us his stubborness and "holier than thou" attitude so.....

i'm all for the team concept but this guy has made me realize that you can't have rational conversations with irrational people.........i'll just respond to MDs now so all you para's talk yourselves silly 🙂

 

[seattledoc]

MacKinnon keeps posting...

and Volatile Agent keeps spanking him!

it's like he can't stop himself, just pretend you've lost interest

 

[VolatileAgent]

i really don't want to continue this discussion as well. it's not entirely fair to continue to have a battle of wits with someone who's unarmed. but, i didn't start this thread either.

still, i hope i've made my point clear. and, i'm sure mike is a fine, caring, and extremely competent nurse who does a great job in the hospital. he just needs to remember that he's a nurse, not a doctor.

i'm also sure that it feels good to come onto a doctor's forum and talk tough and work out some of the frustrations of having to carry out the occassionally seemingly stupid "orders" from some young whipper-snapper who's still wet behind the ears. but that's the way the system works. there is a chain of command and, quite frankly, doctors - even interns - just simply don't answer to nurses (even though some of the more "seasoned" nurses mistakenly operate under the opposite impression).

i know mike knows all of this. and, as much as he may want to believe otherwise or argue against it now not to lose face, i also am fairly confident that he's well aware that it's just not his or any other nurse's right or "legal obligation" to refuse orders they are "uncomfortable" with. they don't have some supervening prerogative to pick and choose, and - forget their jobs - nurses have lost their licenses when they repeatedly engage in such behavior.

so, let's put aside all the rhetoric, remember these things, and just be grateful that we all work as a team more often than not.

 

[Lee]

Initially closed as courtesy to OP. Reopened based on request of forum members who posted in this thread.

Just a reminder, please be courteous when engaging in heated professional discussion.

 

[BIS]

Still pretty pathetic here. Some things never change.

 

[sevoflurane]

ha.. 😀 😀

 

[TheSandMan]

yikes, talk about a beat down!😱

 

[ecCA1]

The value of this lies in the demonstration of a nurse's disobedience in the face of overwhelming evidence that their position is faulty. We all see it at work, but now it's been committed to print, where it might live in infamy for quite a long time.

Too bad there are interns who will be falling for Mike's argument left and right, to the patients' disadvantage.

 

[GasEmDee]

That was a fun read =)

Nice analysis, Volatile.

 

[VolatileAgent]

first, i'd like to say "thank you" to noyac for helping re-open this thread. i'm not going to call any administrator who closed it a coward, because they probably did not have all the facts at the time when it was closed. however, whomever requested that it be closed in the first place... you want to have a discussion, then let's have a discussion. if you're going to make statements, some of them potentially inflammatory, then don't be surprised at what it is said in response. remember, this is a doctor's forum.

but, the real irony in all of this is that, in no small way, the fact that this thread was closed at all completely underscores exactly what we've been discussing here! think about it. a poster (who's a nurse) asked a separate moderator (probably a resident) to close a thread. and, that moderator who wasn't involved in the situation just simply swooped in and fulfilled the request without really looking into it or making him/herself aware of the background and what was really going on.

i ask you physicians: how many times as a resident have you simply put in what appeared to be a reasonable order when called by a nurse without finding out all the facts and exactly why that order was needed? you just simply did it. isn't this exactly what just happened here? and, didn't it have the potential to blow up in your face when you think about it?

EVERYONE READING - ESPECIALLY THE MOD WHO CLOSED THIS THREAD INITIALLY, THERE IS A LESSON TO BE LEARNED RIGHT HERE, RIGHT NOW. REMEMBER THIS.

The value of this lies in the demonstration of a nurse's disobedience in the face of overwhelming evidence that their position is faulty. We all see it at work, but now it's been committed to print, where it might live in infamy for quite a long time.

Too bad there are interns who will be falling for Mike's argument left and right, to the patients' disadvantage.

well, actually, we need to be careful here. playing devil's advocate, mike actually does have a minor point. and, there are regulations in some states that do actually say such things. these regulations, although not always ideally written, are intended to protect the patient, and there's nothing wrong with that. the intent and spirit of such "nursing practice guidelines" is to reduce medical errors - and that's a good thing. nurses can be and have been held liable in court if they knowingly administer a wrong or dangerous medication to a patient under the guise of "just following doctor's orders."

here's an example:

- nurse is taking care of patient A and B.
- doctor C tells nurse he will prescribe antibiotic for patient A.
- doctor C writes order for antibiotic in patient B's chart.
- patient B is afebrile and also happens to have an allergy to antibiotic prescribed.

it is clearly the nurses duty to double-check this and not administer the drug to patient B. in this case, it may save a life. but, it is also his/her duty to notify doctor C (or whomever is ultimately responsible for the care of the patient), though, before canceling or modifying or changing or ignoring that order, because the nurse can't and shouldn't automatically assume - which is equally dangerous - that doctor C made an error. iow, there may be a reason doctor C prescribed that antibiotic for patient B that the nurse doesn't know or understand. (it's always good practice to explain what may appear to be whacky orders to the nurse when you write them and clearly document your reasons in the chart.)

back to the discussion at hand... where mike goes terribly awry is his seemingly blanket interpretation and application of such practice guidelines - that they have the "obligation" to "refuse" any order they are "not comfortable" with, and that he leaves the impression that it ends there. lately nurses have been fed this crap by their supervisors and instructors and nursing boards, and it's simply hogwash. such a mindset implies that they can question medical decisions no matter what. interpreted and implied in such a manner, this becomes the de facto practice of medicine. for instance, since the inception of such regulations and standards, nurses have used this sentiment to do things such as refuse to administer the "morning after pill" when it has been legally prescribed.

in the extreme, where such misplaced and misapplied sentiments concerning these regs are the most dangerous (and where i've personally had an issue) is during codes. in two separate instances, i'd asked nurses to push certain drugs and i was questioned inappropriately. each time, this clearly could've resulted in patient demise. you just don't have time to explain your decisions during a code, and both times i had to draw the drug up and administer it myself. both times i got "sassed" by the nurses as i was carrying out my own orders. both were perfectly appropriate, standard, and approved methods of correct medication admininstration in the (obviously) correct patient. both times the nurses were actually not acting in the patient's best interest in refusing to do what was ordered - and remember i was right there. and, they simply refused because they were not fimiliar with the drug/technique of administration. this was a "nurse training/education" and not an "order error" issue, and it was completely unacceptable to question me given the circumstances.

that's enough to chew on for now. this is a complex issue. i'm sure jet didn't intend to cause such a storm when he originally posted this issue, but it is important that everyone is clear on what we're suppose to do. we need to ultimately act as a team and care for the patient to the best of our abilities and training remembering to check our egos and not assume - whether nurse or resident or attending - that we always "know better" or have the best information. that is what's most important.

 

[phillyfornia]

wow. that was brutal but well deserved. good job volatile

 

[person2006]

Hey. New intern here who has yet to hurt anyone and who is well supervised by my upperlevels when needed.
It's funny to me what orders the nurses 'just can't follow'. My order that they have repeatedly ignored is to d/c the Foley. I read somewhere that the two simplest things you can do to decrease hospital stay is to give dvt prophylaxis and to d/c Foleys asap. Seems like my nurses were more interested in avoiding occasional messes for them to clean up than in patient well being.
I would be happy to have them point out any actual mistakes though. That hasn't happened yet, but I'm glad to have a back-up if/when I do make an inappropriate order. I have had several misguided recommendations from them already in addition to some reasonable advice.

 

[Noyac]

First of all, the person that closed the thread is not a resident or a moderator. He is a wise administrator. I say wise b/c he is level headed and has been here longer than ayone. This forum exists b/c of him and anyone that comes hear to learn, comment, critisize, or waste time should be thanking him. I also say wise b/c unlike some mods, him is able/willing to recant his previous decisions when enough evidence is put forth. He did not have to return this thread to the forum but decided that a nurse requesting one thing on a doctors forum meant less than the doctors that were requesting the opposite. He chose in your favor, so be greatful.


Secondly, Volatile you made a few good points. And hopefully young physicians will learn something that I had to figure out on my own. And that is that nurses think less and less of you as a physician and they are encouraged more and more by their peers to stand up against the physicians (regardless of the patients needs). Their knowledge is limited, mostly b/c they don't read true medical journals and they learn on the job. They believe what they "FEEL" to be right. The younger they are, the more difficult they are and the more nieve they are. Now with that being said, a good nurse can save your ass as well. Don't think for one second any differently.

While I'm on my soap box. To me, this is a forum about anesthesia. It is geared towards doctors. It is also public. That means anyone can come here and talk anesthesia, doctors, nurses, AA's, students, anyone. We can use this forum in a constructive way (education) or we can encite rivalries and discoarse. It is up to us.

 

[militarymd]

Hey. New intern here who has yet to hurt anyone and who is well supervised by my upperlevels when needed.
It's funny to me what orders the nurses 'just can't follow'. My order that they have repeatedly ignored is to d/c the Foley. I read somewhere that the two simplest things you can do to decrease hospital stay is to give dvt prophylaxis and to d/c Foleys asap. Seems like my nurses were more interested in avoiding occasional messes for them to clean up than in patient well being.
I would be happy to have them point out any actual mistakes though. That hasn't happened yet, but I'm glad to have a back-up if/when I do make an inappropriate order. I have had several misguided recommendations from them already in addition to some reasonable advice.

You know...if you really wanted that Foley d/c'ed....there is nothing wrong with you doing it yourself.....just like a-lines, central lines, pulmonary artery cathethers....

 

[VolatileAgent]

You know...if you really wanted that Foley d/c'ed....there is nothing wrong with you doing it yourself.....just like a-lines, central lines, pulmonary artery cathethers....

agreed. but, if you are my intern/med student just come ask me - not the nurse - how to do it. 😉

 

[person2006]

You know...if you really wanted that Foley d/c'ed....there is nothing wrong with you doing it yourself.....just like a-lines, central lines, pulmonary artery cathethers....

That's true but beside the point really. I actually volunteered to just do it myself and was told just to write the order again, but anyway, that has nothing to do with the order being ignored both times.

 

[militarymd]

That's true but beside the point really. I actually volunteered to just do it myself and was told just to write the order again, but anyway, that has nothing to do with the order being ignored both times.

I wonder why your orders get ignored? Are everyone else's orders ignored too? ....or just yours?

 

[SleepIsGood]

You know...if you really wanted that Foley d/c'ed....there is nothing wrong with you doing it yourself.....just like a-lines, central lines, pulmonary artery cathethers....

To reply to this.

Mil, I know at the hospital that I work, Nurses can only do this. Additionally, docs are not allowed to change vent settings (only resp therapists..unless you're an attending.). Furthermore, we are not supposed change the rate of how the IVF are ran at. It's red tape once again. Sure it's just a matter of taking something out or pressing a button, but the nurse has to do this...atleast at the hospitals I've rotated at.

 

[militarymd]

To reply to this.

Mil, I know at the hospital that I work, Nurses can only do this. Additionally, docs are not allowed to change vent settings (only resp therapists..unless you're an attending.). Furthermore, we are not supposed change the rate of how the IVF are ran at. It's red tape once again. Sure it's just a matter of taking something out or pressing a button, but the nurse has to do this...atleast at the hospitals I've rotated at.

Your hospital does not allow you to do procedures?😱

 

[TheSandMan]

To reply to this.

Mil, I know at the hospital that I work, Nurses can only do this. Additionally, docs are not allowed to change vent settings (only resp therapists..unless you're an attending.). Furthermore, we are not supposed change the rate of how the IVF are ran at. It's red tape once again. Sure it's just a matter of taking something out or pressing a button, but the nurse has to do this...atleast at the hospitals I've rotated at.

On top of this, even if there are no set policies, alot of nurses really get pissed off when you do those kind of things unless they know and are friends with you, in which case it doesnt matter (its kind of like a teratorial thing). as a an attending you will never realize it, but as an intern you definitely don't want to be on their sh$t list 😱 After all the talk you hear from attendings about how intern year would always hold a special place in our hearts, can't believe how much i dont miss it 😉

 

[SleepIsGood]

Your hospital does not allow you to do procedures?😱

?

No, they dont allow you to go up to the vent machine and change the tidal volume to 500,etc. Also they dont allow you to d/c foleys and change IVF fluids from say 90 to 100cc. YOu have to put in an order for the nurse to do this.

I dont really think these are considered 'procedures'. Most consider it to be minimal scut work. Sort of like how we do not have to roll patients down to the CT scan. But I think the real reason they have this in place is so that the nurses can sign off to each other and wont oversee the fact that the IVF was turned from 90 to 100cc/hr. Sure, in a hypothetic world, they should be monitoring this every hour and should know what goes on with a patient.

But as someone stated. If you are 'cool' with the nurse/RT, you can make these changes and it's no big deal. It's definitely a teratorial thing. As an attending you can do whatever you wish, but this is what residents have to go through. Welcome to Medicine in the year 2006.

 

[VolatileAgent]

did anyone else notice that mike mackinon's name doesn't come up by his posts anymore? also, he's no longer listed as an active member on this forum.

in addition to asking for this thread to be withdrawn, he must have also asked for his account to be closed.

😱 👍

 

[VolatileAgent]

But as someone stated. If you are 'cool' with the nurse/RT, you can make these changes and it's no big deal. It's definitely a teratorial thing. As an attending you can do whatever you wish, but this is what residents have to go through. Welcome to Medicine in the year 2006.

this is a big (and, imho growing) problem. it is a "you have to prove yourself to me" mentality that, gradually over the years, paraprof's have been empowered to hold over residents. i know because i've been in healthcare for a long time, more recently as a physician, and i've seen the change firsthand. as i said before, physicians don't ultimately answer to nurses/techs. but, this sentiment has been creeping into our training lately. why exactly, i don't know.

now, this may be done under the guise of "patient protection", but more often than not i've seen it done solely as bullying. i could tell numerous stories here about that. fact is, you are being tested as a resident on a daily basis. people are observing you. they are talking about you behind your back. they are making a determination whether or not you "know your ****" or are a "dumb***" (exactly how you're described... i've heard it).

i would just say this: remember you are the doctor. you don't need to fear any repercussions from being questioned a medical decision from a nurse (unless that nurse is the wife of your attending, which could be the case). you have to develop a thick skin. you have to have that professional, carefree attitude where you demonstrate that really don't care what they think about you when you order something. you have to be above their pettiness. ultimately, you have more training. you should have a better understanding on what's going on an physiologic level (you'd better!). but, whenever in doubt, call your senior or your attending.

this is part of the lesson of learning medicine at the GME level. you have to learn how to effectively deal with people to get the job done. and, unfortunately, paraprof's are getting more and more power to interefere with your decisions. many times, i agree with noyac that this does save your butt. other times, it is done solely as a power trip.

 

[militarymd]

this is a big (and, imho growing) problem. it is a "you have to prove yourself to me" mentality that, gradually over the years, paraprof's have been empowered to hold over residents. i know because i've been in healthcare for a long time, more recently as a physician, and i've seen the change firsthand. as i said before, physicians don't ultimately answer to nurses/techs. but, this sentiment has been creeping into our training lately. why exactly, i don't know.

now, this may be done under the guise of "patient protection", but more often than not i've seen it done solely as bullying. i could tell numerous stories here about that. fact is, you are being tested as a resident on a daily basis. people are observing you. they are talking about you behind your back. they are making a determination whether or not you "know your ****" or are a "dumb***" (exactly how you're described... i've heard it).

i would just say this: remember you are the doctor. you don't need to fear any repercussions from being questioned a medical decision from a nurse (unless that nurse is the wife of your attending, which could be the case). you have to develop a thick skin. you have to have that professional, carefree attitude where you demonstrate that really don't care what they think about you when you order something. you have to be above their pettiness. ultimately, you have more training. you should have a better understanding on what's going on an physiologic level (you'd better!). but, whenever in doubt, call your senior or your attending.

this is part of the lesson of learning medicine at the GME level. you have to learn how to effectively deal with people to get the job done. and, unfortunately, paraprof's are getting more and more power to interefere with your decisions. many times, i agree with noyac that this does save your butt. other times, it is done solely as a power trip.

I do know why. Over time, there is a push for "systems" to protect patients against errors....a la FAA style......Proponents like Gaba from Stanford has made a career out of talking about "systems" which protect patients.

Part of the mantra is this .....NO ONE is at fault....Don't BLAME ANYONE individual.....Look at the SYSTEM, don't look at the INDIVIDUAL.

In an era of Gaba's crap, this is what happens.....empowerment of EVERYONE ELSE....and un-empowerment of the physician.

Where do I stand? I think Gaba is full of ****....I think there is always SOMEONE at fault when something goes wrong.

However, learning how to work with nurses, no matter what their attitude/experience/motivation is, is YOUR responsiblity....because guess what....there will ALWAYS be people around who will question your decision.

I think we need to lynch Gaba.

 

[BIS]

?

No, they dont allow you to go up to the vent machine and change the tidal volume to 500,etc. Also they dont allow you to d/c foleys and change IVF fluids from say 90 to 100cc. YOu have to put in an order for the nurse to do this.

I dont really think these are considered 'procedures'. Most consider it to be minimal scut work. Sort of like how we do not have to roll patients down to the CT scan. But I think the real reason they have this in place is so that the nurses can sign off to each other and wont oversee the fact that the IVF was turned from 90 to 100cc/hr. Sure, in a hypothetic world, they should be monitoring this every hour and should know what goes on with a patient.

But as someone stated. If you are 'cool' with the nurse/RT, you can make these changes and it's no big deal. It's definitely a teratorial thing. As an attending you can do whatever you wish, but this is what residents have to go through. Welcome to Medicine in the year 2006.

Are you talking about not being able to change vent settings and fluid rates in the OR or ICU/Floor. If you are talking about the OR than that is crazy. If in the ICU than thats another thing. The problem is that in the ICU residents and interns walk up to the bedside without their attending or fellow/senior resident and try to make changes. Many times they will just maybe look at the blood gas walk up to the vent and dial in some new settings them walk away. The the RN or RT doesnt see them do it then they dont know changes were even made until they come back in the room and maybe catch the changes quickly or maybe not. They either a sentinel event occurs b/c the incorrect call was made or the attending later rounds and sees changes that have been made without an order while and the resident that made the changes has left the hospital. The RN/RT then catch heat for for changing things without an order and practicing beyond their scope. To prevent this many units have gone to order for changes policy. Even if the attending himself walks up and dials in vent settings he or one of his residents must write the order so we are all clear who is making these decisions.

I have heard the old saying things are why they are for a reason here many times. Its all about the pt as well as professional liablilty. As a RN I am not gonna take the heat for allowing an intern to make a decision that I am questioning. As a SRNA if i relieve a resident and am questioning a drug that was given or any other thing that I have not done than I am for sure covering my Assssesss and going to call my attending to discuss what was done.

 

[TheSandMan]

I do know why. Over time, there is a push for "systems" to protect patients against errors....a la FAA style......Proponents like Gaba from Stanford has made a career out of talking about "systems" which protect patients.

Part of the mantra is this .....NO ONE is at fault....Don't BLAME ANYONE individual.....Look at the SYSTEM, don't look at the INDIVIDUAL.

In an era of Gaba's crap, this is what happens.....empowerment of EVERYONE ELSE....and un-empowerment of the physician.

Where do I stand? I think Gaba is full of ****....I think there is always SOMEONE at fault when something goes wrong.

However, learning how to work with nurses, no matter what their attitude/experience/motivation is, is YOUR responsiblity....because guess what....there will ALWAYS be people around who will question your decision.

I think we need to lynch Gaba.

one of the funniest posts i've seen in a while, no offense intended to mil, just funny how he said it

 

[VolatileAgent]

Part of the mantra is this .....NO ONE is at fault....Don't BLAME ANYONE individual.....Look at the SYSTEM, don't look at the INDIVIDUAL.

perhaps this is the problem in a nutshell. and, the push for "responsibility diffusion" will continue - everyone will share the blame so no one will have to.

but, unfortunately, juries don't see it this way. until nurses carry the same legal liability as physicians and are equal parties when something goes wrong, they shouldn't carry the same level of veto power in the hospital.

gaba may be part of the academic impetus to move towards this "shared responsibility" nonsense, but it's (still) not the reality of what happens daily in the medmal tort system.

 

[Beck928]

As an intern, I thought that it was just that I was new, or the fact that I'm female that nurses tried to bully me (especially during codes). I have had several encounters during codes where I asked for something and got lip.

For example, if you can believe this, RT's are allowed to intubate at a community hospital where we rotate (not that I have anything against them, I just think that if a physician is available first, they should be the ones to do it). They are pretty much self-sufficient without residents because most patients are managed by private attendings. But they only give Versed before intubation, and the other night I arrived at a pre-code where they were about to intubate without true sedative/paralytics. I should have just pushed the RT outta the way, but in any event I stated that we needed Etomidate and Sux because this patient is awake and breathing on her own. Everyone got all pissed off, and said that a "doctor" needed to give these meds. Mind you, I'm with another intern and our 3rd year resident (and this is Medicine since I'm prelim). I had to get assertive at this point because I'm being ignored. Finally, they gave the meds, and successfully intubated.

Then, again the other night, pre-code situation, where RT tried to intubate and tubed the goose, so I get called by my team to come tube. The RT was like "her cords are really tight" and I'm thinking, gee, I wonder why that is, maybe because she isn't paralyzed! So, I'm bagging and we check the most recent ABG showing that K is 5.5. So I request Roc to paralyze, and get all kinds of hassle. They only have sux and Pancuronium (I have never personally seen it used) but I had to stand my ground and insist that someone gets it from Pharmacy, because Pancuronium takes a long a** time to work.

I'm glad to see that it's not just me that gets hassled in an emergency situation...lucky that I'm loud and can be fairly obnoxious if provoked!

 

[Tenesma]

beck...

hate to say this out loud - "wait till you're an anesthesia resident for a year or two then re-read your above post - then you will smile and laugh at yourself"

out of all the floor intubations i have EVER done i have NEVER used a paralytic... there is just no indication for it... i always intubated everybody awake and breathing - cause trust me, if you have difficulty intubating you still have a breathing patient...

 

[militarymd]

As an intern,..............that I'm loud and can be fairly obnoxious if provoked!

As an intern, the above is NOT a highly regarded quality....and Tenesma beat me to it.

 

[The_Sensei]

beck...

hate to say this out loud - "wait till your an anesthesia resident for a year or two then re-read your above post - then you will smile and laugh at yourself"

out of all the flood intubations i have EVER done i have NEVER used a paralytic... there is just no indication for it... i always intubated everybody awake and breathing - cause trust me, if you have difficulty intubating you still have a breathing patient...

I wholeheartedly disagree and I have been in private practice for 3 years. Obviously if you anticipate a difficult airway, put in the tube awake. That being said, the VAST majority of patients can at least get some Versed and Etomidate.

 

[militarymd]

I wholeheartedly disagree and I have been in private practice for 3 years. Obviously if you anticipate a difficult airway, put in the tube awake. That being said, the VAST majority of patients can at least get some Versed and Etomidate.

You do know that etomidate is associated with increased mortality in the severely ill/injured patient right?

I would give whatever you're going to give for sedation while intubated anyways......ativan/versed/morphine/fentanyl....and then just muscle it in....

9 years practice in or and icu.

 

[TheSandMan]

beck...

hate to say this out loud - "wait till your an anesthesia resident for a year or two then re-read your above post - then you will smile and laugh at yourself"

out of all the flood intubations i have EVER done i have NEVER used a paralytic... there is just no indication for it... i always intubated everybody awake and breathing - cause trust me, if you have difficulty intubating you still have a breathing patient...

Question for you guys. I was at a code recently where pt was given etomidate and for the life of me i could not open her mouth- luckily attending was present and she was a fairly easy bag, so we gave succ, which she responded well to. How often does this hapen and are there any ways around it without paralytics

 

[The_Sensei]

You do know that etomidate is associated with increased mortality in the severely ill/injured patient right?

I do....but c'mon.....let's be realistic here. If you're intubating a critically ill patient, how good do they end up doing? Really.

 

[militarymd]

I do....but c'mon.....let's be realistic here. If you're intubating a critically ill patient, how good do they end up doing? Really.

All comers, death in the ICU range from as low as 10% to as high as 70%......so a lot of people will survive, and it is our job to help as many of them to survive as possible....

ie...number needed to treat to prevent a death.....

ie....after 100 patient encounters with you....you want more of them to eventually go home...than your competition.

 

[jetproppilot]

So I request Roc to paralyze, and get all kinds of hassle.

Pretty bold.

I've been in private practice ten years....and yeah, I occasionally give an intermediate-neuromuscular blocker for an out-of-the-OR intubation....but not very often. I certainly wouldnt order this as an intern.

I'd venture to say that until you know in your heart you can intubate a fire-ant, I wouldnt give any paralysis.

Once prowess is reached, though, I humbly disagree with most posting here.

If acceptable, 40 mg sux is the way to go. Gives you a (brief) window of optimal intubating conditions. But again, the prerequisite is that you can intubate a fire-ant.

 

[Tenesma]

sensei --- you didn't read my post ... i said i never used a paralytic...

sedatives are appropriate of course in the right circumstances as are beta-blockers etc depending on the pt's underlying disease...

by the way i don't care how many years of private practice you have...