Who does pre-ops for your midlevels?

[chocomorsel]

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Was wondering about the rest of you guys. At my hospital, we do the preops for all the midlevels if they are inpatient. Is this common practice. Why the hell can't they do their own pre-ops? (Apparently it's in their contracts thaty they don't have to do inpatient pre-ops). They are the ones who will be doing the cases after all, not us. But I remember interviewing at another school where this was also happening. Any thoughts?

 

[militarymd]

Was wondering about the rest of you guys. At my hospital, we do the preops for all the midlevels if they are inpatient. Is this common practice. Why the hell can't they do their own pre-ops? (Apparently it's in their contracts thaty they don't have to do inpatient pre-ops). They are the ones who will be doing the cases after all, not us. But I remember interviewing at another school where this was also happening. Any thoughts?

I don't know...this is the one thing that I think physicians should always do if possible.

Why would you not want to do a preoperative "MEDICAL ASSESSMENT" of a patient getting ready to go to the OR....even if it may be a very limited assessment.....for non-physician providers when you are given the opportunity?

I suppose the current generation thinks it's more important to sit on a stool, chart vital signs, monitor urine output, and read the newspaper? Rather than seeing patients for medical assessments?

Oh well...

 

[EternalMD]

So the mid-levels want to be treated like physicians and yet not do all the things that come with it. Oh well, i guess its better to be sold out by the older generation instead.

 

[pgg]

At my hospital, we do the preops for all the midlevels if they are inpatient.

I admit it sucked as a resident to see CRNAs and attendings on their way to the parking lot as I was on my way upstairs to see their patients for the next day. But this was just reason #32 why residency is painful. The patients and consulting surgeon still deserved a consult written by a physician.

 

[Leverage]

I don't know...this is the one thing that I think physicians should always do if possible.

Why would you not want to do a preoperative "MEDICAL ASSESSMENT" of a patient getting ready to go to the OR....even if it may be a very limited assessment.....for non-physician providers when you are given the opportunity?

I suppose the current generation thinks it's more important to sit on a stool, chart vital signs, monitor urine output, and read the newspaper? Rather than seeing patients for medical assessments?

Oh well...

Because I put in twice as many hours as a CRNA and 95% of the time this is simply paper work.

If we are talking about a pt with significant co-morbids or illness then yes, I ll more than gladly make a medical assessment and take it as a learning oppertunity.

In my short stent as a resident I have learned a few things. One, CRNAs want to work a little as possible. Two, they have been and will likely be at your training institution longer than you. Three, so when it comes to makeing people happy you as a resident are last on the list. This means you get to preop the 5th abd washout for the pt in bed 5 of the SICU.

 

[militarymd]

Because I put in twice as many hours as a CRNA and 95% of the time this is simply paper work.

If we are talking about a pt with significant co-morbids or illness then yes, I ll more than gladly make a medical assessment and take it as a learning oppertunity.

In my short stent as a resident I have learned a few things. One, CRNAs want to work a little as possible. Two, they have been and will likely be at your training institution longer than you. Three, so when it comes to makeing people happy you as a resident are last on the list. This means you get to preop the 5th abd washout for the pt in bed 5 of the SICU.

and you think these patients don't need a "medical assessment" before heading to the OR for another intermediate risk procedure?

You think just because it's scheduled....you can just plug and play?

You think just because they are in the unit that metabolic derangement's don't occur or develop that may require some tweaking before heading to the OR again:
- hyper/hypo volemia that's needs intervention
- electrolyte disburbances
- worsening renal function
- development or worsening of sepsis/sirs with worsening coag profiles

ahhh hell....I guess you guys think that "medical assessment" of patients is unncessary....they've had this done 5 times already....must be the same again....so simple even a caveman can do it?


Just because MOST of the time it doesn't matter, doesn't mean that you shouldn't do a THOROUGH AND complete job.

Think about the above statement......and how it applies to how crna's and md's interact.....MOST of the time crna's DO NOT NEED md's...and yet WE are saying we should be involved.

fu ck it.....I guess you guys know it all already.....and I guess I don't care what you think....


just make sure to give some money to the ASA PAC....if you can at least do that....then I guess I can tolerate your rant.

 

[Coastie]

I'm glad you're back.

Residents, do your own damn medical assessments. No CRNAs preop my patients, and if a NP/CRNA does, I re-do it.

and you think these patients don't need a "medical assessment" before heading to the OR for another intermediate risk procedure?

You think just because it's scheduled....you can just plug and play?

You think just because they are in the unit that metabolic derangement's don't occur or develop that may require some tweaking before heading to the OR again:
- hyper/hypo volemia that's needs intervention
- electrolyte disburbances
- worsening renal function
- development or worsening of sepsis/sirs with worsening coag profiles

ahhh hell....I guess you guys think that "medical assessment" of patients is unncessary....they've had this done 5 times already....must be the same again....so simple even a caveman can do it?


Just because MOST of the time it doesn't matter, doesn't mean that you shouldn't do a THOROUGH AND complete job.

Think about the above statement......and how it applies to how crna's and md's interact.....MOST of the time crna's DO NOT NEED md's...and yet WE are saying we should be involved.

fu ck it.....I guess you guys know it all already.....and I guess I don't care what you think....


just make sure to give some money to the ASA PAC....if you can at least do that....then I guess I can tolerate your rant.

 

[Masseter Spasm]

As an academic attending, I make sure I review the medical record (at a minimum) for all patients scheduled for surgery the next day. If it is a complex inpatient, I make sure I do a pre-op visit. I do this whether I am supervising residents or CRNA's. I do not like last minute surprises, and occasionally catch something important that a resident or CRNA did not identify. I appreciate it when someone else preops a patient, but do not rely on others to perform what is ultimately my responsibility.

For example, a "healthy" child scheduled for tonsillectomy turns out to have known vWD when I review our EMR. I was able to locate office note from pre-operative visit to hematologist and locate recommendations.

 

[Consigliere]

My partner and I are in private practice at a small community hospital. EVERY outpatient comes through our pre-op clinic and is seen by a physician. EVERY inpatient add-on scheduled for the next day is seen by one of us. It's the LEAST we can do, and when the pt. gets a bill, they remember who it's coming from.

 

[fastosprintini]

well , i do think that every patient has to be seen by a physician even if it increases the workload . the reasons are 1. professional pride , e.g. we are running the show and devise a plan for this patient 2. crna work ups are more often than not poor as there is no liability involved 3 . i always make sure that the patient understands that he will be in the room with a nurseanesthetist who is being supervised by a physician , just to set the expectations...
just sayin..
fasto

 

[jwk]

All of our patients are seen by an anesthesiologist before surgery. Those of you in medically directed ACT practice should already know about TEFRA, and the seven requirements related to your PERSONAL participation in a case.

#1 is the pre-op evaluation, and #2 is prescribing the plan of care.

Many of our patients are also seen by our nurse practitioners, who work in our pre-op clinic, and also do chart reviews for the next-days patients as well as see add-on inpatient cases. AA's and CRNA's will on occasion write up the pre-op anesthesia evaluation (not unusual on the weekends or with add-on cases - we're usually in the OR otherwise). Regardless, an anesthesiologist personally evaluates and examines EVERY patient that we do, without exception.

Isn't the idea supposed to be that an anesthesiologist is involved with the care of EVERY patient? Isn't that the goal? C'mon guys.

 

[militarymd]

I'm glad you're back.

Residents, do your own damn medical assessments. No CRNAs preop my patients, and if a NP/CRNA does, I re-do it.

thx.

and

Hallelujah ..... for once more people agree with me than NOT..

 

[panetrain]

At my training program the residents did all the pre-ops and post-ops. The anesthesia nurses refused to do their own in-house pre-ops and post-ops. Super scary stance to take for a care provider who thinks they are equivalent to a physician.👎thumbdown👎thumbdown

 

[mille125]

thx.

and

Hallelujah ..... for once more people agree with me than NOT..

I agree with everything that you have said. Do your own preops and stop belly aching

 

[DrRobert]

I agree with everyone that we should be doing our own preops. But I think the original poster is referring to residents doing preops for CRNA cases that have no resident involvement whatsoever. So you are basically doing preops on patients that you will never see in the OR. I think this is a legitimate gripe to a certain extent.

 

[Coastie]

Attendings should preop CRNA only cases.

I agree with everyone that we should be doing our own preops. But I think the original poster is referring to residents doing preops for CRNA cases that have no resident involvement whatsoever. So you are basically doing preops on patients that you will never see in the OR. I think this is a legitimate gripe to a certain extent.

 

[Southpaw]

Attendings should preop CRNA only cases.

...That'd never ever happen at my institution. CRNAs preop their own cases during the week, and residents do it for them on the weekend. Yes the residents gripe about it. And yes, residents at other programs I interviewed at griped about it when I asked what they didn't like about their program.

Mil's right on the money about this issue.

 

[Dryacku]

This is the exact problem of our speciality, we are lazy. Honestly it does not matter who does the preop but it is the "Doctors" responsiblity to make sure they do a complete eval themselves and "speak" to the patient.

I have worked with too many attendings who just come in push the drugs and bounce. Never speak to the patient. Happens over and over again.

I ask each and everyone of you, to speak to your patients before the case. Make it clear that you are the doctor running or supervising the case. If your colleague fails to do that, then make it a point that he/she does.

Awarness to the general public is key and they must understand our role in their care.

Just the other day I was doing a preop for a patient who has had multiple previous surgeries done. I explained to her I was the resident anesthesiologist responsible for her care and I even introduced myself as a doctor. At the end of our interview she asked me why I just didnt go to med school???

I explained to her I did and what our role in the case is. She was enlighted by our conversation.

I know that they are nurses out there that think they can take our job, but in reality that will never happen to a complete extent. Just ask any patient one simple question who would you rather have taking care of your anesthesia and pain relief a doctor or nurse, I am pretty sure most people will chose doctor.

 

[Leverage]

Ok, I was probably unclear and each training program varies.

I preop every patient I deliver anesthesia to, every time, plain and simple. I also make my best effort to not just data collect but document what I feel good assessment and plan. This provides me with a great learning opportunity, gets me ready for the case, lets me know what I need to read about the evening prior, and I can have thoughtful discussion with attending on how my A/P may need some adjustments, and I have no problems with it. In fact I enjoy that process. I am very early in my training and appreciate good learning opportunities.

What I am talking about is all the other pre-ops I do on patients that I will not be a part anesthesia team. There are way more CRNAs at my program than residents and we do all their pre-ops. Ultimately an attending MD will make a “medical assessment” on every single case done, but they need the preop form completed to do so. Filling out the form with pmh, meds, allergies, labs, diagnostics, ect… is something a midlevel can do. Then I have no idea how the case went, what the attending ultimately decided on for a medical assessment, if my plan was altered or what. This is extremely low yield in terms of learning anything.

Make no mistake ,I do think every patient needs an MD assessment and this happens by an attending MD where I am at.

 

[flashgordon]

This is the exact problem of our speciality, we are lazy. Honestly it does not matter who does the preop but it is the "Doctors" responsiblity to make sure they do a complete eval themselves and "speak" to the patient.

I have worked with too many attendings who just come in push the drugs and bounce. Never speak to the patient. Happens over and over again.

I ask each and everyone of you, to speak to your patients before the case. Make it clear that you are the doctor running or supervising the case. If your colleague fails to do that, then make it a point that he/she does.

Awarness to the general public is key and they must understand our role in their care.

Just the other day I was doing a preop for a patient who has had multiple previous surgeries done. I explained to her I was the resident anesthesiologist responsible for her care and I even introduced myself as a doctor. At the end of our interview she asked me why I just didnt go to med school???

I explained to her I did and what our role in the case is. She was enlighted by our conversation.

I know that they are nurses out there that think they can take our job, but in reality that will never happen to a complete extent. Just ask any patient one simple question who would you rather have taking care of your anesthesia and pain relief a doctor or nurse, I am pretty sure most people will chose doctor.

Most?? How 'bout anyone with 1/2 a brain cell. I bet even the most militant nurse would choose a doctor to take care of their sick child or parent when the time came. Of course they would never admit that.

 

[Narcotized]

Attendings should preop CRNA only cases.

Definitely the Joke of the Day!!
The chance of that happening where I trained was zilch, zippo, zero, nada, nunca, not a chance in hell.

 

[Narcotized]

What I am talking about is all the other pre-ops I do on patients that I will not be a part anesthesia team. There are way more CRNAs at my program than residents and we do all their pre-ops.

That was the same dynamic of my small program. Maybe we trained together? I had a research month and an elective month cancelled to bring me back to the big house for the sole purpose of having residents do all of the preops while attendings and crnas ideally did zero.

Agree with you; much of it was low yield.

 

[mille125]

Ok, I was probably unclear and each training program varies.

I preop every patient I deliver anesthesia to, every time, plain and simple. I also make my best effort to not just data collect but document what I feel good assessment and plan. This provides me with a great learning opportunity, gets me ready for the case, lets me know what I need to read about the evening prior, and I can have thoughtful discussion with attending on how my A/P may need some adjustments, and I have no problems with it. In fact I enjoy that process. I am very early in my training and appreciate good learning opportunities.

What I am talking about is all the other pre-ops I do on patients that I will not be a part anesthesia team. There are way more CRNAs at my program than residents and we do all their pre-ops. Ultimately an attending MD will make a “medical assessment” on every single case done, but they need the preop form completed to do so. Filling out the form with pmh, meds, allergies, labs, diagnostics, ect… is something a midlevel can do. Then I have no idea how the case went, what the attending ultimately decided on for a medical assessment, if my plan was altered or what. This is extremely low yield in terms of learning anything.

Make no mistake ,I do think every patient needs an MD assessment and this happens by an attending MD where I am at.

sounds like you guys need a preop screening clinic...bring it up to your PM.... makes a great rotation as well...

 

[chocomorsel]

I'm glad you're back.

Residents, do your own damn medical assessments. No CRNAs preop my patients, and if a NP/CRNA does, I re-do it.

Please re-read my post. I asked who does the pre-ops for the midlevels. Not the other way around. Do you think if we have to do their pre-ops they are going to lend a helping hand and do ours. Please. We do our own, and theirs to clarify as you certainly did not understand that.

And to mil, the midlevels have an attending who can and should review the preops once they are done, just like they do with us residents. So again, why can't they do their own? And by the way, I'm just a CA1 and there are a lot of things that I don't know that many seasoned midlevels have run across and can probably handle pre-emptilvely better than me at this level of my training. Either way, whatever I miss, and whatever the CRNA misses should be caught and intervened on by the attending physician.

 

[chocomorsel]

sounds like you guys need a preop screening clinic...bring it up to your PM.... makes a great rotation as well...

We have one of those, but only for the outpatients. But for the inpatients, the residents have to see them and preop them for the midlevels. Sometimes I wonder whether or not they even review their pre-op before they leave for the next day and discuss any questions/plan of action with the attendings. I will ask some of them today.

 

[militarymd]

Please re-read my post. I asked who does the pre-ops for the midlevels. Not the other way around. Do you think if we have to do their pre-ops they are going to lend a helping hand and do ours. Please. We do our own, and theirs to clarify as you certainly did not understand that.

And to mil, the midlevels have an attending who can and should review the preops once they are done, just like they do with us residents. So again, why can't they do their own? And by the way, I'm just a CA1 and there are a lot of things that I don't know that many seasoned midlevels have run across and can probably handle pre-emptilvely better than me at this level of my training. Either way, whatever I miss, and whatever the CRNA misses should be caught and intervened on by the attending physician.

They can....but why can't you, DOCTOR in training?

I hate it when I hear "why can't so and so do it?"....I have NEVER said..."why can't someone else do it?"

Just like the ASAPAC....why can't my partner donate? They can do it....It's not my job....

IT'S THE ATTITUDE.

JUST DO IT....

 

[hoyden]

I agree with everyone that we should be doing our own preops. But I think the original poster is referring to residents doing preops for CRNA cases that have no resident involvement whatsoever. So you are basically doing preops on patients that you will never see in the OR. I think this is a legitimate gripe to a certain extent.

It is more or less universal in residency. If the resident, who runs the board for the day is vigilant enough - those are done way before the night starts. And the million add-ons throughout the night are the most painful ones.
But it's residency - it sucks altogether.

 

[Intrathecal]

Well that goes with the territory of being a CA-1, essentially the lowest on the totem pole in the anesthesia department. You are asked to do all the scut and often expected to do so without complaining and say "sir may I have another?!" with a smile.

Yes it is BS to have to preop for them. No there's no educational value in it. What's even more BS is being asked to post-op a patient with an anesthetic complication and explain to the patient what happened when you had nothing to do with the case. I was asked to do this as a resident on the consult service: the SRNA did an intubation and caused significant trauma to the airway with laceration of the uvula and tonsillar pillar. I was asked to see the patient, write a note in the chart, consult ENT, essentially apologize for the f*up, while the anesthesia providers who actually DID the case did not so much as to stop by to see the patient. Did I complain, hell yeah. Did anyone listen, no, cuz I was the consult resident and this was the expectation.

I did learn something from that though, it's to always see the patient myself and not be lazy like the others when a complication occurs. (also to not let SRNA's intubate my patients).

One approach to make it more beneficial to you as a CA-1 is to actively talk to the people who are going to be taking care of the patient. Call them up and tell them about their patient, what the concerns may be, what YOUR plan for anesthetic care is, and pretend you are the attending for the case. Ask whether they want additional labs/studies and for their reasoning. People will appreciate your effort, and you look good at the same time and might learn something.

 

[militarymd]

Yes it is BS to have to preop for them. No there's no educational value in it.

Sort of like memorizing the embden meyerhof pathway when you were a MS1..what's the point? right....we should just get rid of all the non-essentials and get good at doing the anesthetic.....forget all that other bs

What's even more BS is being asked to post-op a patient with an anesthetic complication and explain to the patient what happened when you had nothing to do with the case. I was asked to do this as a resident on the consult service: the SRNA did an intubation and caused significant trauma to the airway with laceration of the uvula and tonsillar pillar. I was asked to see the patient, write a note in the chart, consult ENT, essentially apologize for the f*up, while the anesthesia providers who actually DID the case did not so much as to stop by to see the patient.

Oh wait.....so I guess you expect to non-physician to go ahead and do the medical evaluation for the complication?

I guess they should do that then....no need for a doctor at all...right? is that what you are saying?

Have the non-physician contact the OTHER medical service for the consult?

Or is this just another one of those wasting time kind of thing?

Can't have it both ways.....

 

[mille125]

Sort of like memorizing the embden meyerhof pathway when you were a MS1..what's the point? right....we should just get rid of all the non-essentials and get good at doing the anesthetic.....forget all that other bs




Oh wait.....so I guess you expect to non-physician to go ahead and do the medical evaluation for the complication?

I guess they should do that then....no need for a doctor at all...right? is that what you are saying?

Have the non-physician contact the OTHER medical service for the consult?

Or is this just another one of those wasting time kind of thing?

Can't have it both ways.....

What should happen is that the attending from the case should come by.........

 

[mille125]

Sort of like memorizing the embden meyerhof pathway when you were a MS1..what's the point? right....we should just get rid of all the non-essentials and get good at doing the anesthetic.....forget all that other bs




Oh wait.....so I guess you expect to non-physician to go ahead and do the medical evaluation for the complication?

I guess they should do that then....no need for a doctor at all...right? is that what you are saying?

Have the non-physician contact the OTHER medical service for the consult?

Or is this just another one of those wasting time kind of thing?

Can't have it both ways.....

not a good comparision........

 

[militarymd]

What should happen is that the attending from the case should come by.........

that's how it works for me....but it has been in my experience during training that NO attending goes by until a resident has gone by.

 

[militarymd]

not a good comparision........

why not?

I would submit that any PREOP, no matter how routine is worthwhile because it is something that we all do for the rest of our careers.....residency is about repetition of certain tasks until it is MORE than second nature...while being able to pick out the red herrings and zebras.

 

[Intrathecal]

Sort of like memorizing the embden meyerhof pathway when you were a MS1..what's the point? right....we should just get rid of all the non-essentials and get good at doing the anesthetic.....forget all that other bs




Oh wait.....so I guess you expect to non-physician to go ahead and do the medical evaluation for the complication?

I guess they should do that then....no need for a doctor at all...right? is that what you are saying?

Have the non-physician contact the OTHER medical service for the consult?

Or is this just another one of those wasting time kind of thing?

Can't have it both ways.....

Nope, that was not my point. I think the attending for the case should have been more involved. Also I think the student at the very least owes the patient an apology or should have the decency to face the patient and explain what happened.

I'm definitely not saying that they (SRNA, CRNA) should be consulting other medical services, but that should have been done by the anesthesia attending of record.

The point is that as a resident, you are often asked to do others dirty work and its expected of you, so I wouldn't feel too bad about having to do a few preops here and there. Just think about all the poor surgical residents. THey do all the H&P's, consents, orders, for patients who they likely will never operate on. Plus they get shat on much worse by their attendings, upper levels etc.

 

[DannyOcean11]

I don't know...this is the one thing that I think physicians should always do if possible.

Why would you not want to do a preoperative "MEDICAL ASSESSMENT" of a patient getting ready to go to the OR....even if it may be a very limited assessment.....for non-physician providers when you are given the opportunity?

I suppose the current generation thinks it's more important to sit on a stool, chart vital signs, monitor urine output, and read the newspaper? Rather than seeing patients for medical assessments?

Oh well...

Hey MilMD, you know, there exists a term that fits you perfectly.

"Bitch". But not in the female dog sense, nor in the over-complaining caustic personality sense either. I'm talking about the definition that would apply in a prison setting to the smaller cell-mate.

Someone should check your crotch to make sure your testicles have dropped.

 

[militarymd]

Hey MilMD, you know, there exists a term that fits you perfectly.

"Bitch". But not in the female dog sense, nor in the over-complaining caustic personality sense either. I'm talking about the definition that would apply in a prison setting to the smaller cell-mate.

Someone should check your crotch to make sure your testicles have dropped.

Hey D.O.

I'm sorry you feel that way....perhaps I left off the list, some of YOUR personal favorite activities:

- moving the or bed up and down?
- or even better...maybe you're a homo (seeing how you're thinking about what they do in prisons) and you really like to grab that pager from the surgeon's waist when it goes off in the OR and he's all scrubbed in.

- or if I left anything else off that list....please let us know.

I'll go do the preop.

xmil M.D.

 

[Consigliere]

Hey D.O.

I'm sorry you feel that way....perhaps I left off the list, some of YOUR personal favorite activities:

- moving the or bed up and down?
- or even better...maybe you're a homo (seeing how you're thinking about what they do in prisons) and you really like to grab that pager from the surgeon's waist when it goes off in the OR and he's all scrubbed in.

- or if I left anything else off that list....please let us know.

I'll go do the preop.

xmil M.D.

You forgot:

- emptying the piss bottle
- putting on the Bair Hugger blanket
- changing the CD/iPod when it finishes

 

[tucker27705]

When I was a resident, the CRNAs were collectively responsible for doing their inhouse pre and post ops. Residents did their own pre and post ops, except Friday's cases which the oncall residents did all the post ops on Sat and Sunday. Residents came in to do their own inhouse preops for Monday.
In PP we have some nurses on salary from the hospital who work in our preop screening unit. They see pts scheduled to come in, and go to the floor to see the inhouse pts. They follow strict guidelines for ordering additional tests depending on the pts condition and the scheduled procedure. A physician who is supervising that day is always available to answer any Q's they might have regarding appropriate application of the guidelines, or whether an exception may be made (e.g., an ecg was done 91 days ago in a . . . . do we have to do one today in accordance with our guidelines? NO.) Then on the day of surg the MD looks at the pre-op, reviews it with the pt, and 98/100 will proceed with the case. AICD/PM are a frequent problem no matter how many times we go over them. We are formulating new guidelines w/r/t them now to clarify matters.
It works very well for us.
We have, on occasion, asked the midlevels, predominantly AAs here, to do preops. Frankly, they suck at it. They copy down the info, but have no idea what to do with it. The CRNAs at my academic institution where I did residency, were, by contrast, very good at pre-ops. I think because they did them all the time and were expected to be good at it.

My current place of practice is a 450 bed hospital with 20 ORs. All specialties except transplant.