When to call the Attending... for residents or CRNAs.

[Soparklion]

I'm trying to find a guideline for when a hands-on provider should call the attending anesthesiologist. Does anyone have something that they can share with me?

Acute Blood Loss
Surgeon Concern for coagulopathy - Coag/TEG Studies sent
Hemodynamic instability requiring an increase in vasopressor requirement: Initiating an infusion, adding a second pressor
Hemodynamic instability requiring ACLS drug intervention: bradycardia requiring atropine, glycopyrrolate, or epinephrine
Increasing Peak Airway Pressures
Increasing Oxygen Requirements

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[San Marzano]

Definitely if you are having a bathroom emergency and need to relieve yourself ASAP.

 

[narcusprince]

Attending specific confirm with your morning plan of the day. You will learn tendancies.

 

[pgg]

Before you're in over your head. When you're still in the "prevention of badness" phase as opposed to the "treatment of badness" phase.

Key to the above is honest self awareness and knowledge of where you are on the Dunning-Kruger continuum. Yes, that's an internally inconsistent sentence.

 

[kidthor]

I agree with the others - call before things get bad and when things are bad be sure you're calling not texting.

As an attending you'll have to call others for help too at times. Hopefully also before things get bad...

 

[Psai]

When I think "wtf is going on I should call my attending"

 

[deleted162650]

Don’t ever call - it’s a sign of weakness.

 

[T-burglar]

When you ****ed up and are in over your head

 

[2Fast2Des]

For residents: When the surgeon doesn't care for your opinion and wants the attending, who then confirms what you said in the first place.

For CRNAs: *attending who?* never, do whatever you want until patient is circling the drain and need a fall person to rescue them

 

[Soparklion]

Before you're in over your head. When you're still in the "prevention of badness" phase as opposed to the "treatment of badness" phase.

Key to the above is honest self awareness and knowledge of where you are on the Dunning-Kruger continuum. Yes, that's an internally inconsistent sentence.

Yes, I'm trying to define those instances of escalating care wherein the attending should be called....

 

[deleted59964]

when you think "hmmm maybe I should call the boss"

 

[deleted162650]

When you hear:

Beep, beep, beep, boop, boop, boop, bump, bump, bump, bomp, bomp, bomp. . . bomp . . . . . bomp. . . . . . . . . . . . bomp . . . . . . . . . . . . . . . . . . .

 

[ambiturner]

If you're a resident, simply think:

If it was my name on the chart and I was supervising (and someday it will be), is this something I would like to have heard about ahead of time?

 

[DeadSpace]

I would have called my attending once I started the second pressor and noticed things didn't immediately improve. A couple of interventions and things are still declining I know it's time to get a second set of hands involved. I haven't had a patient completely crash on me before but I did jump in and help in a case where the patient had a pericardial effusion and sudden arrest. He had one 20G IV. It took 3 anesthesiologists and 2 CRNAs to get him back while the surgeon did a sternotomy.

I just remember thinking, please God, don't let me be egotistical and not call for backup until it's too late.

 

[anbuitachi]

I'm trying to find a guideline for when a hands-on provider should call the attending anesthesiologist. Does anyone have something that they can share with me?

Acute Blood Loss
Surgeon Concern for coagulopathy - Coag/TEG Studies sent
Hemodynamic instability requiring an increase in vasopressor requirement: Initiating an infusion, adding a second pressor
Hemodynamic instability requiring ACLS drug intervention: bradycardia requiring atropine, glycopyrrolate, or epinephrine
Increasing Peak Airway Pressures
Increasing Oxygen Requirements

It depends on what level of training you are in. If you are a CA1, who just started being left alone, you should not hesitate to call attending with questions or concerns. For any resident, senior or not, always page/call attending when there is arrest/impending arrest. I would say use common sense, cause it's their license. For example, I think most senior residents can handle anaphylaxis for the most part, but I would still definitely page my attending to let them know. If you were the attending, I bet you'd want to know if your patient had anaphylaxis when it happened, not at the end of the case. And i always page my attending for intubations, including if the tube falls out in the middle of the case, cause technically they are supposed to be there for all induction/intubations. I also page them for emergence/extubation, but often times I just pull the tube. The page is more of a heads up. Obviously lots of variations depending on attending.

From that list, I would not page/call my attending for increasing peak airway pressures or increasing O2 requirements, unless it's substantial. I'd troubleshoot it myself. For acute blood loss, it depends on how much blood loss. Acute 100ml is very different from acute 5L blood loss. With coagulopathy/acute blood loss, i usually shoot them a text or page indicating i'm planning on transfusing. Mostly because each attending got their own quirks, and transfusing is not super common. I've had attendings who wanted transfusion up to crit of 30 in some cases, and attendings who didn't want a transfusion even at crit of 20 cause patient was stable on no pressors. Hemodynamic instability I'd usually treat and troubleshoot myself unless it's due to major issue (perforated heart, aortic dissection, nicked major blood vessel, MI, etc)

I've also had attendings who wanted to be present for flips (for spines)

 

[deleted697535]

I'd say first 6 months call them for everything. Especially ob anything. Even more so if there's an lma.

With an ET you're generally safer and can figure things out for a second.

Around 12 to 18 months you can figure stuff out. But there are a few times you just have to have to call.
Giving more than 2 units of prbc. Tubing a section from inadequate spinal. Cardio version.

Prior to giving a lot of beta blockers, I'd call too.

I wouldn't call about glyco or atropine if you can id the cause. If it's a vasovagal fine or oculocardiac etc. But if it's part of they're about to code then call asap

 

[Lecithin5]

Broadly speaking, residents have a better sense of when to call than crnas. The ego thing often gets in the way of a nurse calling for help. The irony is that a resident (ie physician) usually has better judgement, and if I had to choose between a crna or a resident updating me or calling for help, it would be a crna. Too bad it often doesn’t work that way.

 

[DeadSpace]

Broadly speaking, residents have a better sense of when to call than crnas. The ego thing often gets in the way of a nurse calling for help. The irony is that a resident (ie physician) usually has better judgement, and if I had to choose between a crna or a resident updating me or calling for help, it would be a crna. Too bad it often doesn’t work that way.

The problem with CRNAs is they are controlled and licensed by their board of nursing. If we controlled their training programs and practice we could enforce a more AA type practice and behavior. As it is now they are militant and if you push them or do what they think is micromanagement they could leave the practice and potentially open up their own anesthesia practice competing with yours. I've seen a few CRNAs leave the ACT model and go work in CRNA only practices. While these practices don't threaten the big academic settings it does edge out the smaller practices that could be MD ran. For now, it looks like we have to humor them and allow them to behave how they want.

As for us residents, we can't leave and go practice on our own yet. We can be smacked down pretty hard if we step out of line and don't call for help. I will follow whatever the attendings want as long as I'm not board certified and practicing on my own yet.

 

[Mehd School]

Deadspace I pray that, no matter what, during my anesthesia training I don't learn to fear CRNAs the way that you do.

"if you push them or do what they think is micromanagement they could leave the practice and potentially open up their own anesthesia practice competing with yours. I've seen a few CRNAs leave the ACT model and go work in CRNA only practices."

I mean good grief.

 

[nimbus]

When CPR is not working....

 

[Planktonmd]

I'm trying to find a guideline for when a hands-on provider should call the attending anesthesiologist. Does anyone have something that they can share with me?

Acute Blood Loss
Surgeon Concern for coagulopathy - Coag/TEG Studies sent
Hemodynamic instability requiring an increase in vasopressor requirement: Initiating an infusion, adding a second pressor
Hemodynamic instability requiring ACLS drug intervention: bradycardia requiring atropine, glycopyrrolate, or epinephrine
Increasing Peak Airway Pressures
Increasing Oxygen Requirements

All of the above.

 

[DeadSpace]

Deadspace I pray that, no matter what, during my anesthesia training I don't learn to fear CRNAs the way that you do.

"if you push them or do what they think is micromanagement they could leave the practice and potentially open up their own anesthesia practice competing with yours. I've seen a few CRNAs leave the ACT model and go work in CRNA only practices."

I mean good grief.

It's not fear. I just acknowledge the reality that we're currently in. I think the shape of the anesthesia field is where it's at because previous anesthesiologists let their ego convince them that CRNAs are nurses that are no threat to us. I won't let ego be my downfall nor will I put my head in the sand convinced I can say and do whatever I want and there will be no repercussions.

 

[deleted162650]

It's not fear. I just acknowledge the reality that we're currently in. I think the shape of the anesthesia field is where it's at because previous anesthesiologists let their ego convince them that CRNAs are nurses that are no threat to us. I won't let ego be my downfall nor will I put my head in the sand convinced I can say and do whatever I want and there will be no repercussions.

Wrong. The field is where it is for one reason, and one reason alone:

 

[Noyac]

You people all have it so damn easy. You get to sit around all day while others do your work for you. Something like a pimp. Then you get to come in and save the day from time to time and look like a rockstar.
While people like me have to sit in the freezing OR day in and day out listening to the beep beep. Never seeming to be stressed out or rushed. Chatting with the nursing staff. Picking on the surgeons. Blah blah blah.


Oh, wait. I think I have it all backwards. Never mind.

 

[jwk]

The problem with CRNAs is they are controlled and licensed by their board of nursing. If we controlled their training programs and practice we could enforce a more AA type practice and behavior. As it is now they are militant and if you push them or do what they think is micromanagement they could leave the practice and potentially open up their own anesthesia practice competing with yours. I've seen a few CRNAs leave the ACT model and go work in CRNA only practices. While these practices don't threaten the big academic settings it does edge out the smaller practices that could be MD ran. For now, it looks like we have to humor them and allow them to behave how they want.

As for us residents, we can't leave and go practice on our own yet. We can be smacked down pretty hard if we step out of line and don't call for help. I will follow whatever the attendings want as long as I'm not board certified and practicing on my own yet.

Depends on who the employer is. Hospital vs academia vs group, etc. Our CRNAs and AAs are private practice group employees. They follow our policies, procedures, and hospital and group-defined scope of practice - period. They learn during the interview process way before they are hired that this is a by-the-book ACT practice. We ask specifically if they're fine with working in that type of environment. Any waffling and they'll most likely not even receive an offer. Set the expectations up front and enforce them from Day One.

 

[Mman]

you call for help when things aren't going according to plan. BP requiring on going interventions to keep in target range, blood loss exceeding what was expected, oxygenation/ventilation not going as well as previously, etc. Basically if the anesthetic doesn't look like it's on cruise control give them a page to let them know what's going on.

 

[Planktonmd]

You people all have it so damn easy. You get to sit around all day while others do your work for you. Something like a pimp. Then you get to come in and save the day from time to time and look like a rockstar.
While people like me have to sit in the freezing OR day in and day out listening to the beep beep. Never seeming to be stressed out or rushed. Chatting with the nursing staff. Picking on the surgeons. Blah blah blah.


Oh, wait. I think I have it all backwards. Never mind.

Yes you do! And I think most anesthesiologists envy you, and you know it

 

[Noyac]

Yes you do! And I think most anesthesiologists envy you, and you know it

Yes I know it and I’m trying to keep this thing going as long as possible.