Who is in charge when there are CRNA and a resident in a room?

[IkeBoy18]

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I was on a case, emergent bowel perforation, extremely hypotensive pt, getting setup in the OR. CA1 and CA2 are in the room, CRNA is helping. CRNA decides she wants to show CA1 a "quick and easy way" to do a art line, it wasnt so quick and easy. The CA2 wanted to get a pressure on the patient, couldnt use the right arm, forgot the reason why, the left arm had the BP cuff on it, which is also the arm the CRNA and CA1 are working on. Pt diaphoretic and the CA2 was practically begging the CRNA to hold for a second to get a pressure, but she kept insisting just give us a second. CA2 clearly annoyed and agitated but just kept pleading. CRNA eventually gets the line after a 7 min wait for a pressure-line was a no go anyway.

The question I have, in this situation, you have a CA2 and a CRNA with 10 yrs experience, is the CA2 helpless?

 

[deleted126335]

I was on a case, emergent bowel perforation, extremely hypotensive pt, getting setup in the OR. CA1 and CA2 are in the room, CRNA is helping. CRNA decides she wants to show CA1 a "quick and easy way" to do a art line, it wasnt so quick and easy. The CA2 wanted to get a pressure on the patient, couldnt use the right arm, forgot the reason why, the left arm had the BP cuff on it, which is also the arm the CRNA and CA1 are working on. Pt diaphoretic and the CA2 was practically begging the CRNA to hold for a second to get a pressure, but she kept insisting just give us a second. CA2 clearly annoyed and agitated but just kept pleading. CRNA eventually gets the line after a 7 min wait for a pressure-line was a no go anyway.

The question I have, in this situation, you have a CA2 and a CRNA with 10 yrs experience, is the CA2 helpless?

Depends on the perception of the resident and CRNA who the attending will side with.

Clinical assesment in the absence of BP reading... Feel for the pulse on the right arm. If ****ty or not palpable you have more evidence to do what you think is right. Also look at amplitude of plethysmograph on pulse ox and ETCO2 wave morphology.

 

[urge]

I was on a case, emergent bowel perforation, extremely hypotensive pt, getting setup in the OR. CA1 and CA2 are in the room, CRNA is helping. CRNA decides she wants to show CA1 a "quick and easy way" to do a art line, it wasnt so quick and easy. The CA2 wanted to get a pressure on the patient, couldnt use the right arm, forgot the reason why, the left arm had the BP cuff on it, which is also the arm the CRNA and CA1 are working on. Pt diaphoretic and the CA2 was practically begging the CRNA to hold for a second to get a pressure, but she kept insisting just give us a second. CA2 clearly annoyed and agitated but just kept pleading. CRNA eventually gets the line after a 7 min wait for a pressure-line was a no go anyway.

The question I have, in this situation, you have a CA2 and a CRNA with 10 yrs experience, is the CA2 helpless?

Don't know. They should have placed the cuff on a leg and there would not have been an issue.

 

[sleepallday]

Where was the attending?

 

[IkeBoy18]

Im not sure why the leg wasnt used either, I was just an bystander. The attending was finishing up a case, was on his way over, arrived for induction but wasnt there for the first 15 min of prep.

 

[IlDestriero]

Call for ultrasound.
Get non invasive pressure while they're getting it.
Use ultrasound to place line.
Line is in before the 3 min auto cycle on the BP cuff.

Alines can be a pain in the septic, trauma, etc. Don't f around. Get the US and put it in.

The answer to the question is the attending physician of record is in charge.
Where were they while your patient was circling the drain?

If you need a BP, you announce "you need to stop now so I can get another BP now. This is your last attempt.". And let them flail one more time blindly before you cycle the cuff. You don't need an aline to assess and treat hypotension, but you need to know what the pressure is to determine the proper course of action. Palpation can help but a non invasive number is better. We use legs for BPs all the time when you need the arms for surgery, lines, etc.
Use the US on your next few alines. You'll never go back, especially in this type of patient.

I'm not sure how things go where you are, but our CRNAs almost never place more than an IV, and they don't place many of them either. The CA2 probably should have done it himself. Maybe your CRNAs get big cases and place lines. If so, that's a shame.

 

[TrustMe]

CA-2 should have been in charge. But more importantly, attending should have been around. As an attending now that supervised residents, CRNA's, CRNA students I treat each fairly different. I let residents do everything first (in these kinds of cases they get one or two shots and then I start on the other arm). Students, I usually let try the a-line while I'm putting in another IV. If they don't have it in by the time I'm done with the IV, then I start on the other arm and see who finishes first. CRNA's are variable. The ones that are good and respectful and easy to work with I usually give a choice (a-line or IV). The one that are not those things I usually start on the a-line while they're masking after vec is in and then whoever gets done first gets to put in IV. I never let CRNA's or students do central lines.

Attending should have come in and said, "Dr. CA-2, would you please put the a-line in." Given them one or two shots, and then stepped in (especially since there was only one arm to work with).

 

[Mac or Miller]

The answer to this question is dependent on the institution. The short answer is that the attending who has independent practice privileges at the hospital is in charge, so he or she is accepting the patient safety liability for this encounter regardless of who is "in charge" in the room.

I will say that if you are in a community program or at a site in which residents are not given much respect, if there is a safety issue that goes to risk management in which the circulating RN's notes are reviewed, it can be seen from admin to go either way.

 

[jwk]

Call for ultrasound.
Get non invasive pressure while they're getting it.
Use ultrasound to place line.
Line is in before the 3 min auto cycle on the BP cuff.

Alines can be a pain in the septic, trauma, etc. Don't f around. Get the US and put it in.

The answer to the question is the attending physician of record is in charge.
Where were they while your patient was circling the drain?

If you need a BP, you announce "you need to stop now so I can get another BP now. This is your last attempt.". And let them flail one more time blindly before you cycle the cuff. You don't need an aline to assess and treat hypotension, but you need to know what the pressure is to determine the proper course of action. Palpation can help but a non invasive number is better. We use legs for BPs all the time when you need the arms for surgery, lines, etc.
Use the US on your next few alines. You'll never go back, especially in this type of patient.

I'm not sure how things go where you are, but our CRNAs almost never place more than an IV, and they don't place many of them either. The CA2 probably should have done it himself. Maybe your CRNAs get big cases and place lines. If so, that's a shame.

Best answer ^^^

Our anesthetists start A-lines all the time, but none of us is too proud to let someone else try especially if we're clearly having difficulty. The docs get some that I don't, I get some that they don't. We just want to get the job done.

 

[Idiopathic]

cycle the cuff, for crying out loud, get a pressure - this isnt an issue of skill or training or who owns the room or proper art line insertion technique. you can even do this case without arterial access.

 

[Mman]

I was on a case, emergent bowel perforation, extremely hypotensive pt, getting setup in the OR. CA1 and CA2 are in the room, CRNA is helping. CRNA decides she wants to show CA1 a "quick and easy way" to do a art line, it wasnt so quick and easy. The CA2 wanted to get a pressure on the patient, couldnt use the right arm, forgot the reason why, the left arm had the BP cuff on it, which is also the arm the CRNA and CA1 are working on. Pt diaphoretic and the CA2 was practically begging the CRNA to hold for a second to get a pressure, but she kept insisting just give us a second. CA2 clearly annoyed and agitated but just kept pleading. CRNA eventually gets the line after a 7 min wait for a pressure-line was a no go anyway.

The question I have, in this situation, you have a CA2 and a CRNA with 10 yrs experience, is the CA2 helpless?

Who is in charge? The attending. It's up to them to delegate the chain of command beneath them if they aren't there.

 

[Wiscoblue]

I would stop screwing around with trying to get a blood pressure reading. Place a large IV or a neck line. Slam a liter of crystalloid via level 1. Then the pulse should be palpable and easier to get an Aline. Also the patient won't die when you induce.

 

[RxBoy]

Clinical assesment in the absence of BP reading... Feel for the pulse on the right arm. If ****ty or not palpable you have more evidence to do what you think is right. Also look at amplitude of plethysmograph on pulse ox and ETCO2 wave morphology.

👍👍👍 First thing I was thinking. If they have a strong carotid pulse, think of other ways of obtaining BP. Leg if possible, even if it means getting under the drapes. If you have a faint pulse, you are losing time waiting for a BP to cycle as your pt dies.

As for who is in charge?

We had some serious militant CRNAs where I trained... very territorial as well. But what it always came down to was who is doing the case... CRNA? CRNA is next in charge. Resident? Resident is next in charge. Only exception was the chief resident, they always had free reign. Of course attending trumps all once present.

 

[somedumbDO]

Best answer ^^^

Our anesthetists start A-lines all the time, but none of us is too proud to let someone else try especially if we're clearly having difficulty. The docs get some that I don't, I get some that they don't. We just want to get the job done.

U must be in academics...

 

[Southpaw]

I believe jwk is in a very busy, well respected private practice group.

 

[jwk]

U must be in academics...

Why?

I believe jwk is in a very busy, well respected private practice group.

Correct - thank you. 🙂

 

[musli]

Yow. What a lousy situation. As several posters have said, the attending is in charge. Ideally s/he would have been there. If not, s/he should have clarified the situation in advance.

In non-emergency situations I keep residents and CRNA's separate for just this reason. The chain of command is otherwise completely ambiguous: The resident is a doctor and the CRNA is not... but the CRNA is fully trained and may have considerable experience, while the resident is a trainee. No good answer.

In an emergency or unstable situation, additional people from both categories will help and are nearly always cooperative and professional. But in a situation like that, I will almost always be in the room as well. It is difficult for me to imagine a case where the situation was so acute that I needed both a CRNA and a resident, yet stable enough that I would leave the room for long periods.

Okay, okay, if you set me up with two simultaneous emergencies... and no other faculty around... I suppose you could paint me into a corner. In that case, I would say that in my absence the case is controlled by whoever else--CRNA or resident--is the person who will actually sign the anesthesia record.

 

[G-Man82]

Where I am right now, the first call resident is in charge after hours and on nights/weekends/holiday, second only to the Attending on call. As the first call, I'm not technically sitting in the room; like the attending, I'm overseeing junior Residents and CRNAs in up to 2 rooms. If a patient is sick, then what I think we should do trumps the juniors and CRNAs. I'll usually be the one to get the Attending involved, too if things start going south. It's a pretty nice system to get us used to being in a supervisory role. Not only am I overseeing the 2 rooms, but I'm also taking consults from other services, being first responder to airways if the CA-2 and/or CRNA are in rooms, and managing PACU. During the regular day it's a little different - I'm the schedule runners helper. But all in all, I like it. It clearly designates who's in charge.