working with CRNAS

[jon stewart]

for those seasoned attendings out there, how do you approach CRNAS who dont listen to you during critical moments like intubations, for example you tell them to come and ventilate the patient for a bit because because the patient is desaturating ...but they dont want to listen and to try and get their view, they say im so close i can get it but are only cranking the laryngoscope harder to no avail.......


this is just one of many examples

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[Anestheezee]

It helps to use the phrase "I'm concerned about..." then finish it with something different than "...you..." or "...your..." as those will immediately put the person on the defensive.

Instead of: "I'm concerned you are going to hurt the patient with the way you are doing it."

You might try: "I'm concerned about the patient's safety if we don't agree on a plan together."

If anything, lead with "I'm concerned about the patient's safety" because it directly uses the language that RNs use every day.

Along those same lines, you can structure your concerns using the SBAR format in your head, while simultaneously steering clear of any blaming and accusatory language.

 

[teacher2md]

Elevate the incident to the attention of your department chair.

If your department doesn’t act (in whichever way is appropriate given the individual involved, the context, etc), then find a new group.

 

[zizzer]

As for your specific example, I'd likely wait two-three more seconds to see if they're as close as they think, then more adamantly say, "Ok, we need to ventilate now." If they're still not listening to repeated directions like this you've got a problem. I could imagine the example you gave being not a big deal but also a very significant issue depending on the specifics.

Also, agree with use of the word concern above in relation to safety. Works well if you ever disagree with surgeons and need to defend your plan too.

 

[vector2]

for those seasoned attendings out there, how do you approach CRNAS who dont listen to you during critical moments like intubations, for example you tell them to come and ventilate the patient for a bit because because the patient is desaturating ...but they dont want to listen and to try and get their view, they say im so close i can get it but are only cranking the laryngoscope harder to no avail.......


this is just one of many examples

It's gonna go something like this for me:

1. A gentle, quiet "Let's come out and ventilate"

2. A quiet but firmer "Pt is desatting, let's come out and ventilate"

3. A louder "Sat is 82, Come out so we can mask the patient"

4. Very loud "Nurse call the board runner to come to the room. CRNA move away from the patient now so I can take over"


I don't think I've ever gone past 3.

 

[pgg]

If they're militant CRNAs who hate being directed, and the local culture has tolerated blatant insubordination to the point that they won't follow direct instructions in the heat of the moment, then the problem probably isn't fixable. You need to quit and find a better job. That place is broken. Life's too short to put up with toxic groups. Leave.


If this is an aberration, not usual behavior, explain at the earliest private opportunity that it's important that when you make a decision and communicate that decision during a time-critical event, that they need to follow instructions right away. Emphasize that it's always OK for them to speak up if they think a mistake is being made or if there's an imminent safety issue, but in all other circumstances they need to follow your lead. Discussion OK later.

I wish I could say I do this all the time, and do it well. Call it an aspirational goal. Just a couple weeks ago after a CRNA did something contrary to what I directed (through carelessness - not willful insubordination) I was alarmed and more than a bit upset about it. I corrected her on the spot and explained how dangerous what she did was in front of the surgeon and scrub. This was dumb ... the issue was already resolved and behind us in the case, and correcting her in that moment was the wrong thing to do. It also gave the surgeon and scrub reason to doubt the quality of care we were giving. I should've done it in a private debrief afterwards. I have undermined my future ability to work with that CRNA a little, and it'll take effort to fix that mistake.


To get back to your original question about a CRNA who wouldn't yield a procedure to you as it was going poorly, it's better to avoid that entirely. You can largely do so by being direct and unambiguous in those situations. Use words/phrases like "stop" and "give that to me" if you need to interrupt them and take over. If they hesitate, be direct in word and tone ... "no stop give that to me" is better than "let me take a look". You're not asking.

In order to do this without being resented, you need to have previously established a reputation for being reasonable, competent, and collegial. You do this by

• Genuinely respecting them as advanced practice nurses. Even quiet disrespect or contempt is always perceived. And if you can't respect them for what they know and can do, then you shouldn't be working in an ACT model.
• Not micromanaging them over stuff that doesn't matter. Most stuff doesn't matter.
• Not being a dick. Be friendly. It's not hard. Say thank you and mean it.
• Be competent. If you take over a procedure, you can't flub around with it. If you make a plan, it can't be ridiculous. It helps if you do some solo work and they know you do some solo work. I'm convinced that many CRNAs in 1:4 practices really think that their supervising anesthesiologist just sits around most of the time. They do all the grunt work and probably wonder if their supervisor actually could do what they do. Sadly we know there actually are some of us who are so ACT-institutionalized that they can't run a case by themselves any more. Don't be that anesthesiologist.

It helps to use the phrase "I'm concerned about..." then finish it with something different than "...you..." or "...your..." as those will immediately put the person on the defensive.

Instead of: "I'm concerned you are going to hurt the patient with the way you are doing it."

You might try: "I'm concerned about the patient's safety if we don't agree on a plan together."

If anything, lead with "I'm concerned about the patient's safety" because it directly uses the language that RNs use every day.

Along those same lines, you can structure your concerns using the SBAR format in your head, while simultaneously steering clear of any blaming and accusatory language.

This generally works in the plan-making stage when there's time to discuss but overall I think your "good" example is still too wishy-washy.

I think this is not great:

You might try: "I'm concerned about the patient's safety if we don't agree on a plan together."

CRNAs aren't dumb. They're clinicians who spend 100% of their time in direct patient care, and they largely despise administrators and admin-speak as much as we do. Like us, they know that consultant lingo buzzwords, the sharing of feelings, and safe-space empowerment is all complete bull****, one step removed from passing the talking stick around the hippie drum circle to express points of personal privilege. That example is too general and vague to be useful anyway.

Better:

"This patient has coronary disease and awful hypertension so we should keep his MAPs above 75 at all times. We'll hit start on a phenylephrine infusion as soon as we push the propofol."

It's specific. It sets a benchmark for what you consider acceptable vitals and it tells the CRNA exactly how to do it. It explains why. It's not demeaning. The CRNA will happily go along with it. The patient will get better care. Your pulse will stay in the 50s all day because you won't have to sign a chart where such a patient had a blood pressure of 74/36 for the 20 minutes between induction and incision.

 

[jon stewart]

If they're militant CRNAs who hate being directed, and the local culture has tolerated blatant insubordination to the point that they won't follow direct instructions in the heat of the moment, then the problem probably isn't fixable. You need to quit and find a better job. That place is broken. Life's too short to put up with toxic groups. Leave.


If this is an aberration, not usual behavior, explain at the earliest private opportunity that it's important that when you make a decision and communicate that decision during a time-critical event, that they need to follow instructions right away. Emphasize that it's always OK for them to speak up if they think a mistake is being made or if there's an imminent safety issue, but in all other circumstances they need to follow your lead. Discussion OK later.

I wish I could say I do this all the time, and do it well. Call it an aspirational goal. Just a couple weeks ago after a CRNA did something contrary to what I directed (through carelessness - not willful insubordination) I was alarmed and more than a bit upset about it. I corrected her on the spot and explained how dangerous what she did was in front of the surgeon and scrub. This was dumb ... the issue was already resolved and behind us in the case, and correcting her in that moment was the wrong thing to do. It also gave the surgeon and scrub reason to doubt the quality of care we were giving. I should've done it in a private debrief afterwards. I have undermined my future ability to work with that CRNA a little, and it'll take effort to fix that mistake.


To get back to your original question about a CRNA who wouldn't yield a procedure to you as it was going poorly, it's better to avoid that entirely. You can largely do so by being direct and unambiguous in those situations. Use words/phrases like "stop" and "give that to me" if you need to interrupt them and take over. If they hesitate, be direct in word and tone ... "no stop give that to me" is better than "let me take a look". You're not asking.

In order to do this without being resented, you need to have previously established a reputation for being reasonable, competent, and collegial. You do this by

• Genuinely respecting them as advanced practice nurses. Even quiet disrespect or contempt is always perceived. And if you can't respect them for what they know and can do, then you shouldn't be working in an ACT model.
• Not micromanaging them over stuff that doesn't matter. Most stuff doesn't matter.
• Not being a dick. Be friendly. It's not hard. Say thank you and mean it.
• Be competent. If you take over a procedure, you can't flub around with it. If you make a plan, it can't be ridiculous. It helps if you do some solo work and they know you do some solo work. I'm convinced that many CRNAs in 1:4 practices really think that their supervising anesthesiologist just sits around most of the time. They do all the grunt work and probably wonder if their supervisor actually could do what they do. Sadly we know there actually are some of us who are so ACT-institutionalized that they can't run a case by themselves any more. Don't be that anesthesiologist.

This generally works in the plan-making stage when there's time to discuss but overall I think your "good" example is still too wishy-washy.

I think this is not great:



CRNAs aren't dumb. They're clinicians who spend 100% of their time in direct patient care, and they largely despise administrators and admin-speak as much as we do. Like us, they know that consultant lingo buzzwords, the sharing of feelings, and safe-space empowerment is all complete bull****, one step removed from passing the talking stick around the hippie drum circle to express points of personal privilege. That example is too general and vague to be useful anyway.

Better:

"This patient has coronary disease and awful hypertension so we should keep his MAPs above 75 at all times. We'll hit start on a phenylephrine infusion as soon as we push the propofol."

It's specific. It sets a benchmark for what you consider acceptable vitals and it tells the CRNA exactly how to do it. It explains why. It's not demeaning. The CRNA will happily go along with it. The patient will get better care. Your pulse will stay in the 50s all day because you won't have to sign a chart where such a patient had a blood pressure of 74/36 for the 20 minutes between induction and incision.

thanks everyone

 

[jon stewart]

In another case I induced a patient and the crna ventilated the patient appropriately, then right as about they are about to intubate another crna comes in with a student crna...student Crna just takes over the intubation without asking me if it's ok if they give it a try, What the heck

The crna they came in with just stood in the corner

I don't know anything about this student crna I had no idea if they even know anything about this patient, I don't know how many intubations they have even done ...

I need to speak up but I don't want to come off as mean or something, BUT at the end of the day it's my name on the record

 

[pocafx]

I would absolutely stop that student. Letting people walk in tube and leave is not okay. Seen plenty of attendings stop that.

 

[abolt18]

Also would stop it. Had med students roll in as we are inducing, hoping to intubate. I ask them what they know about the patient, did they introduce themselves to the patient in pre-op, and IF I like those answers I'll ask how many intubations they've attempted & performed. If I'm not happy with the first 2 answers I'll tell them that can watch this airway and if they want to perform an intubation they'll have to come prepared with knowledge (history and airway assessment) and a plan, and they need to have introduced themselves to the patient.

 

[GassYous]

Also would stop it. Had med students roll in as we are inducing, hoping to intubate. I ask them what they know about the patient, did they introduce themselves to the patient in pre-op, and IF I like those answers I'll ask how many intubations they've attempted & performed. If I'm not happy with the first 2 answers I'll tell them that can watch this airway and if they want to perform an intubation they'll have to come prepared with knowledge (history and airway assessment) and a plan, and they need to have introduced themselves to the patient.

As a med student I didn't know that these were the expectations. Nobody was taking me around being like hey hang out with this attendings for the day and they will probably expect this this and this. Just tell them what you want them to know and let them tube the patient Jesus Christ

 

[Southpaw]

In another case I induced a patient and the crna ventilated the patient appropriately, then right as about they are about to intubate another crna comes in with a student crna...student Crna just takes over the intubation without asking me if it's ok if they give it a try, What the heck

The crna they came in with just stood in the corner

I don't know anything about this student crna I had no idea if they even know anything about this patient, I don't know how many intubations they have even done ...

I need to speak up but I don't want to come off as mean or something, BUT at the end of the day it's my name on the record

I would not allow this. Unfortunately a lot of our practice and day to day depends on culture. You may want to ask around with other attendings to get the vibe. And you may be totally disappointed in the answers you get!

However what you describe is disrespectful to everyone, especially the patient. Your name is in the chart. If a crna brings in a SRNA you need to meet the SRNA to get a feel for their experience, and importantly the SRNA needs to meet the patient. What you describe is not okay and I don’t care that it happens all the time.

 

[MirrorTodd]

I would not allow this. Unfortunately a lot of our practice and day to day depends on culture. You may want to ask around with other attendings to get the vibe. And you may be totally disappointed in the answers you get!

However what you describe is disrespectful to everyone, especially the patient. Your name is in the chart. If a crna brings in a SRNA you need to meet the SRNA to get a feel for their experience, and importantly the SRNA needs to meet the patient. What you describe is not okay and I don’t care that it happens all the time.

In addition to this @jon stewart that may be medical malpractice. Depending on your consent process, the patient may not have consented to have students participate in their care and the consent may say something to that effect on it. Odd's are that it is in the consent but I would double check to be sure.

 

[Anestheezee]

As a med student I didn't know that these were the expectations. Nobody was taking me around being like hey hang out with this attendings for the day and they will probably expect this this and this. Just tell them what you want them to know and let them tube the patient Jesus Christ

It's not an "all you can eat" buffet, it's anesthesia. Just like you get your hands slapped if you touch the wrong thing in surgery, we have expectations as well in anesthesia. Humility and a sense of respect and it will get you further than entitlement. It is beyond easy to spot the ladder as an attending, and it doesn't help med students get ahead.

 

[jon stewart]

Thank you everyone for the replies. I have a lot to learn from seasoned attendings on how to approach these issues

 

[kidthor]

It's not an "all you can eat" buffet, it's anesthesia. Just like you get your hands slapped if you touch the wrong thing in surgery, we have expectations as well in anesthesia. Humility and a sense of respect and it will get you further than entitlement. It is beyond easy to spot the ladder as an attending, and it doesn't help med students get ahead.

Just showing up to intubate is the functional equivalent of just showing up to put the chest tube in in the ED then walking away, or just popping in for a sec to do the sternotomy "because I need the numbers". The latter two are clearly absurd. But for some reason some of us made to believe we should let randoms intubate our patients.

When this has happened in my OR I kick them out ASAP.

 

[jwk]

Just showing up to intubate is the functional equivalent of just showing up to put the chest tube in in the ED then walking away, or just popping in for a sec to do the sternotomy "because I need the numbers". The latter two are clearly absurd. But for some reason some of us made to believe we should let randoms intubate our patients.

When this has happened in my OR I kick them out ASAP.

We had a med student for a few weeks in our private practice for an "anesthesia rotation". He would just go room to room - an intubation here, an a-line there, run to OB for an epidural, come back for a central line. Never once did he sit and actually see or do a case from start to finish, so he never ever actually did an anesthetic. It was irritating as hell. Saw him later when he finished an anesthesia residency. His personality hadn't changed.

 

[abolt18]

As a med student I didn't know that these were the expectations. Nobody was taking me around being like hey hang out with this attendings for the day and they will probably expect this this and this. Just tell them what you want them to know and let them tube the patient Jesus Christ

I did tell them what I wanted them to know. They missed one airway due to their lack of preparation and they do better going forward with plenty of learning opportunities. The expectations have been set. I do the same thing with off-service residents coming to just learn airways. I think there's a minimum amount of professionalism that should be expected.

 

[Onefellswoop87]

Just showing up to intubate is the functional equivalent of just showing up to put the chest tube in in the ED then walking away, or just popping in for a sec to do the sternotomy "because I need the numbers". The latter two are clearly absurd. But for some reason some of us made to believe we should let randoms intubate our patients.

When this has happened in my OR I kick them out ASAP.

Had a similar experience when I was a CA3, and an emergency pgy2 came through. He just wanted intubations because it was all about the numbers. I knew he didn’t care about gas anesthetics or the maintenance but tried to talk with him about hemodynamics, RSI meds/techniques and other airway devices, such as supraglottic airway. He wanted none of it, and it was incredibly frustrating.

 

[neutro]

In another case I induced a patient and the crna ventilated the patient appropriately, then right as about they are about to intubate another crna comes in with a student crna...student Crna just takes over the intubation without asking me if it's ok if they give it a try, What the heck

The crna they came in with just stood in the corner

I don't know anything about this student crna I had no idea if they even know anything about this patient, I don't know how many intubations they have even done ...

I need to speak up but I don't want to come off as mean or something, BUT at the end of the day it's my name on the record

Sounds like a Northstar practice with an SRNA training site...

 

[pgg]

As a med student I didn't know that these were the expectations. Nobody was taking me around being like hey hang out with this attendings for the day and they will probably expect this this and this. Just tell them what you want them to know and let them tube the patient Jesus Christ

I'd kick the SRNA out because an anesthesia trainee should know better than to pull some kind of drive-by tube jockey stunt.

If a med student or ER resident rolls through though, it's a learning opportunity to help them understand that there's a set of airway management skills to practice and learn beyond intubating. Mask ventilation is a more important skill and most show up oblivious to that. If you throw them out they don't benefit.

 

[Blockit]

Thank you everyone for the replies. I have a lot to learn from seasoned attendings on how to approach these issues

Maybe so, but the most important aspect of this has already been alluded to by someone else in the thread. You must have a good understanding for what the culture of your particular shop is. If this type of stuff is allowed to happen all the time by the other senior attendings, the best thing to do is leave. Trying to make it different because your name is on the chart will just make you a target, both of the CRNAs, as well as some of your other lackadaisical partners.

 

[nimbus]

I'd kick the SRNA out because an anesthesia trainee should know better than to pull some kind of drive-by tube jockey stunt.

If a med student or ER resident rolls through though, it's a learning opportunity to help them understand that there's a set of airway management skills to practice and learn beyond intubating. Mask ventilation is a more important skill and most show up oblivious to that. If you throw them out they don't benefit.

In residency some of our attendings made us mask entire cysto lineups. No LMAs or ETTs allowed. It’s a good exercise for med students and EM residents too.

 

[Urzuz]

In another case I induced a patient and the crna ventilated the patient appropriately, then right as about they are about to intubate another crna comes in with a student crna...student Crna just takes over the intubation without asking me if it's ok if they give it a try, What the heck

The crna they came in with just stood in the corner

I don't know anything about this student crna I had no idea if they even know anything about this patient, I don't know how many intubations they have even done ...

I need to speak up but I don't want to come off as mean or something, BUT at the end of the day it's my name on the record

You’re at a place that trains cRNas AND they are indoctrinating them to bypass the MD or view then as superfluous? 🤮

Awful. No idea how you guys put up with **** like this.

 

[jwk]

In residency some of our attendings made us mask entire cysto lineups. No LMAs or ETTs allowed. It’s a good exercise for med students and EM residents too.

Best way to learn mask technique. My first 12 years of practice were ETT or mask. That's all we had. LMAs weren't invented yet. We did lots of long mask cases in training because it was "character building". I learned quickly in private practice that the first indication for intubation was convenience for the anesthetist/anesthesiologist.

 

[Anesthesia_Guy]

Elevate the incident to the attention of your department chair.

If your department doesn’t act (in whichever way is appropriate given the individual involved, the context, etc), then find a new group.

Department chair?!? Hahahahaha! They are invertebrates.

 

[teacher2md]

Department chair?!? Hahahahaha! They are invertebrates.

Then leave…?

 

[Anesthesia_Guy]

I need to speak up but I don't want to come off as mean or something, BUT at the end of the day it's my name on the record

Yes it is so grow a pair.

 

[Anesthesia_Guy]

Then leave…?

I was never in that sort of practice environment. My personal opinion is that those who can't cut it in private practice hide in the ivy towers of academia. I have always, and will always, do what I was trained to do - provide quality anesthesia. My residency had 0.0 hours on learning how to supervise anesthesia nurses. I really don't see how people do it, and feel genuinely sorry for them. Hanging your balls in your locker every morning and then tip toeing around all day so as not to bruise the precious, fragile egos of CRNAs sounds like hell to me.

 

[jwk]

I was never in that sort of practice environment. My personal opinion is that those who can't cut it in private practice hide in the ivy towers of academia. I have always, and will always, do what I was trained to do - provide quality anesthesia. My residency had 0.0 hours on learning how to supervise anesthesia nurses. I really don't see how people do it, and feel genuinely sorry for them. Hanging your balls in your locker every morning and then tip toeing around all day so as not to bruise the precious, fragile egos of CRNAs sounds like hell to me.

Gotta remember it's all very practice specific. I'm in a very large practice (that went from private, to AMC, then hospital). Ever since the group's inception, it has never been anything other than "the doc is in charge". Period. That tone was set long ago. Anything less IMHO means someone has wimped out along the way, whether recently or decades ago. My group is very collegial and all of us get along just fine. We are not "collaborative". Never have been, never will be. Any disagreements on patient care are discussed in a professional manner - but in the end, the doc always has the final say. I've been doing this more than 40 years so have tons more experience and time in the OR than any of our docs. They're still the boss. I never understand why people with less education think they should have the final say.

 

[Anesthesia_Guy]

Gotta remember it's all very practice specific. I'm in a very large practice (that went from private, to AMC, then hospital). Ever since the group's inception, it has never been anything other than "the doc is in charge". Period. That tone was set long ago. Anything less IMHO means someone has wimped out along the way, whether recently or decades ago. My group is very collegial and all of us get along just fine. We are not "collaborative". Never have been, never will be. Any disagreements on patient care are discussed in a professional manner - but in the end, the doc always has the final say. I've been doing this more than 40 years so have tons more experience and time in the OR than any of our docs. They're still the boss. I never understand why people with less education think they should have the final say.

I understand that it is practice specific. I'm sure you realize that the utopia you describe is extremely, extremely rare.

 

[jsep1995]

for those seasoned attendings out there, how do you approach CRNAS who dont listen to you during critical moments like intubations, for example you tell them to come and ventilate the patient for a bit because because the patient is desaturating ...but they dont want to listen and to try and get their view, they say im so close i can get it but are only cranking the laryngoscope harder to no avail.......


this is just one of many examples

In another case I induced a patient and the crna ventilated the patient appropriately, then right as about they are about to intubate another crna comes in with a student crna...student Crna just takes over the intubation without asking me if it's ok if they give it a try, What the heck

The crna they came in with just stood in the corner

I don't know anything about this student crna I had no idea if they even know anything about this patient, I don't know how many intubations they have even done ...

I need to speak up but I don't want to come off as mean or something, BUT at the end of the day it's my name on the record

Good evening, I am a senior SRNA and anytime I arrive at a new site I introduce myself to the MD anesthesiologists. If I am asking to do something with the MD or I walk in to do something and the MD is in the room, I always ask if they are okay with me performing whatever task or procedure I may be intending to perform. That is a component of showing respect and professionalism. I am never going to ask to do something if I am not fully prepared to explain the procedure, the mechanisms of action, the risks, contraindications, the complications, and the diagnostic & corrective actions for various complications. Nor am I comfortable doing anything on a patient if I know nothing about the patient. That is just my philosophy as a student and person. Anytime I want to do a procedure, the CRNAs in my area require that you ask the MD yourself to be sure that it is okay and further that is an expectation by the administrators of my program, as they were/are all colleagues of the MDs in my area. As an SRNA, it is 100% appropriate and you’re right as the MD to say or ask whatever you would like to ensure that you are comfortable allowing someone to attempt something. I also think it is appropriate to say, I will intubate this one but we can talk after and see about you possibly doing the next one with me. Last, If you tell me you don‘t feel comfortable with allowing you to do this, then a rationale would be appropriate (after the case or procedure is completed). I say this because it allows me to understand what I need to study more of or be aware of as a student and future practicing provider.

 

[vector2]

Good evening, I am a senior SRNA and anytime I arrive at a new site I introduce myself to the MD anesthesiologists. If I am asking to do something with the MD or I walk in to do something and the MD is in the room, I always ask if they are okay with me performing whatever task or procedure I may be intending to perform. That is a component of showing respect and professionalism. I am never going to ask to do something if I am not fully prepared to explain the procedure, the mechanisms of action, the risks, contraindications, the complications, and the diagnostic & corrective actions for various complications. Nor am I comfortable doing anything on a patient if I know nothing about the patient. That is just my philosophy as a student and person. Anytime I want to do a procedure, the CRNAs in my area require that you ask the MD yourself to be sure that it is okay and further that is an expectation by the administrators of my program, as they were/are all colleagues of the MDs in my area. As an SRNA, it is 100% appropriate and you’re right as the MD to say or ask whatever you would like to ensure that you are comfortable allowing someone to attempt something. I also think it is appropriate to say, I will intubate this one but we can talk after and see about you possibly doing the next one with me. Last, If you tell me you don‘t feel comfortable with allowing you to do this, then a rationale would be appropriate (after the case or procedure is completed). I say this because it allows me to understand what I need to study more of or be aware of as a student and future practicing provider.

Other than the fact I don’t think I’ve ever met an SRNA who’s been “fully prepared to explain the procedure, the mechanisms of action, the risks, contraindications, the complications, and the diagnostic & corrective actions for various complications,” one of my main rationales for teaching you guys as little as possible is the following:

 

[coffeebythelake]

Other than the fact I don’t think I’ve ever met an SRNA who’s been “fully prepared to explain the procedure, the mechanisms of action, the risks, contraindications, the complications, and the diagnostic & corrective actions for various complications,” one of my main rationales for teaching you guys as little as possible is the following:

View attachment 364628

Despite numerous studies showing significantly worse patient outcomes with CRNA-only care.
Despite their long-debunked misinformation campaign about CRNA care being cheaper to patients.
Despite claiming to be better than anesthesiologists while at the same time also misrepresenting themselves as anesthesiologists.
Only the AANA can be arrogant enough to spin less education, less experience, less backup support, and less safe patient care as the "right thing for patients".
They aren't deluded. But they sure hope their patients are to believe this nonsense.

 

[coffeebythelake]

for those seasoned attendings out there, how do you approach CRNAS who dont listen to you during critical moments like intubations, for example you tell them to come and ventilate the patient for a bit because because the patient is desaturating ...but they dont want to listen and to try and get their view, they say im so close i can get it but are only cranking the laryngoscope harder to no avail.......


this is just one of many examples

So your approach will vary depending on your relationship with the particular CRNA (or AA, or resident) you work with. Some are reasonable and more open. Others get defensive. It also depends on how urgent the situation is.

My responsibility is to get the patient through the procedure safely. I recognize that there are many ways to "skin a cat" so I don't dictate care unless there is something specific that I think will negatively affect patient care.

And even then I often phrase what I want like this: "because of XYZ should we do ABC?". For more urgent situations I am more direct: "let's try this" or "let's do this... (to improve patient saturations), (to give us time to reassess the patient's situation), (etc)". For truly critical situations I tell them I intend to take over. And I take over. I have no ego when it comes down to patient safety. This should NOT be about YOU vs. the CRNA

You describe an urgent-emergent procedural scenario. Patient desaturation during intubation. What sometimes happens is the operator gets tunnel vision doing a challenging task and their only goal becomes to accomplish that task (intubation). They don't hear the sats. They don't recognize how much time they've spent struggling. They forget about the big picture. In your particular case I would do this:

1. When they are struggling to get a view but before the patient starts to desaturate, I would suggest alternate intubation tools.
"It seems like the intubation isn't so straightforward (factual statement). Do you want to switch to a different blade? Should we get a glidescope? Do you want a bougie? (offer possible solutions)"

2. When the patient begins to rapidly desaturate (recognizing there is typically a 7-second delay in the pulse ox averaging of saturations)
"The patient is desaturating hard (factual statement). Let's come out and mask this patient up and we'll try again (directed solution)"

3. When the patient is truly decompensating. This should not happen if you've done 1. and 2.
"Sats are [...]. The patient is not doing well. I'm taking over."

 

[coffeebythelake]

I would absolutely stop that student. Letting people walk in tube and leave is not okay. Seen plenty of attendings stop that.

Agree 100%. This also applies to RT students, medical students, ER residents, pulm/ccm fellows as well. If they haven't seen the patient in preop holding, and they didn't introduce themselves to me beforehand they aren't doing the procedure.

 

[jon stewart]

So your approach will vary depending on your relationship with the particular CRNA (or AA, or resident) you work with. Some are reasonable and more open. Others get defensive. It also depends on how urgent the situation is.

My responsibility is to get the patient through the procedure safely. I recognize that there are many ways to "skin a cat" so I don't dictate care unless there is something specific that I think will negatively affect patient care.

And even then I often phrase what I want like this: "because of XYZ should we do ABC?". For more urgent situations I am more direct: "let's try this" or "let's do this... (to improve patient saturations), (to give us time to reassess the patient's situation), (etc)". For truly critical situations I tell them I intend to take over. And I take over. I have no ego when it comes down to patient safety. This should NOT be about YOU vs. the CRNA

You describe an urgent-emergent procedural scenario. Patient desaturation during intubation. What sometimes happens is the operator gets tunnel vision doing a challenging task and their only goal becomes to accomplish that task (intubation). They don't hear the sats. They don't recognize how much time they've spent struggling. They forget about the big picture. In your particular case I would do this:

1. When they are struggling to get a view but before the patient starts to desaturate, I would suggest alternate intubation tools.
"It seems like the intubation isn't so straightforward (factual statement). Do you want to switch to a different blade? Should we get a glidescope? Do you want a bougie? (offer possible solutions)"

2. When the patient begins to rapidly desaturate (recognizing there is typically a 7-second delay in the pulse ox averaging of saturations)
"The patient is desaturating hard (factual statement). Let's come out and mask this patient up and we'll try again (directed solution)"

3. When the patient is truly decompensating. This should not happen if you've done 1. and 2.
"Sats are [...]. The patient is not doing well. I'm taking over."

I said out loud multiple times what's the sats were and how many attempts had been made...and that we can always try again no need to rush (could see them vigoursly cranking the larynsgysope )

But they said I can get a view (and they did soon after they said that) but it could have gone the other way

 

[jon stewart]

whats going on with the ican act ?

 

[Maz777]

So your approach will vary depending on your relationship with the particular CRNA (or AA, or resident) you work with. Some are reasonable and more open. Others get defensive. It also depends on how urgent the situation is.

My responsibility is to get the patient through the procedure safely. I recognize that there are many ways to "skin a cat" so I don't dictate care unless there is something specific that I think will negatively affect patient care.

And even then I often phrase what I want like this: "because of XYZ should we do ABC?". For more urgent situations I am more direct: "let's try this" or "let's do this... (to improve patient saturations), (to give us time to reassess the patient's situation), (etc)". For truly critical situations I tell them I intend to take over. And I take over. I have no ego when it comes down to patient safety. This should NOT be about YOU vs. the CRNA

You describe an urgent-emergent procedural scenario. Patient desaturation during intubation. What sometimes happens is the operator gets tunnel vision doing a challenging task and their only goal becomes to accomplish that task (intubation). They don't hear the sats. They don't recognize how much time they've spent struggling. They forget about the big picture. In your particular case I would do this:

1. When they are struggling to get a view but before the patient starts to desaturate, I would suggest alternate intubation tools.
"It seems like the intubation isn't so straightforward (factual statement). Do you want to switch to a different blade? Should we get a glidescope? Do you want a bougie? (offer possible solutions)"

2. When the patient begins to rapidly desaturate (recognizing there is typically a 7-second delay in the pulse ox averaging of saturations)
"The patient is desaturating hard (factual statement). Let's come out and mask this patient up and we'll try again (directed solution)"

3. When the patient is truly decompensating. This should not happen if you've done 1. and 2.
"Sats are [...]. The patient is not doing well. I'm taking over."

If they can't get the airway on the 1st attempt, it's my turn. I don't care if that hurts their feelings. I don't want them jacking up the airway and hindering further attempts. If they can't see the cords or display any lack of confidence in being about to pass the tube, I just say, "I am going to take a look." Never had an issue with that. Don't ask. Just do. They had their shot.

 

[jsep1995]

Other than the fact I don’t think I’ve ever met an SRNA who’s been “fully prepared to explain the procedure, the mechanisms of action, the risks, contraindications, the complications, and the diagnostic & corrective actions for various complications,” one of my main rationales for teaching you guys as little as possible is the following:

View attachment 364628

That is entirely your right to teach whatever you would like to whomever you would like to teach it to. Have a great day

 

[coffeebythelake]

I said out loud multiple times what's the sats were and how many attempts had been made...and that we can always try again no need to rush (could see them vigoursly cranking the larynsgysope )

But they said I can get a view (and they did soon after they said that) but it could have gone the other way

Perhaps they should be reminded what kills the patient is hypoxemia not the absence of an endotracheal tube. I would still do what i discussed earlier. And i would be more likely to pull the trigger and take over sooner next time. Sorry you had such a difficult person to work with.

 

[jon stewart]

Perhaps they should be reminded what kills the patient is hypoxemia not the absence of an endotracheal tube. I would still do what i discussed earlier. And i would be more likely to pull the trigger and take over sooner next time. Sorry you had such a difficult person to work with.

I'm going to be more assertive for sure

 

[kidthor]

Why are you guys waking on eggshells with your midlevels? Just take over if they aren’t doing what you want. Not saying we should be rude about it - rather, it just a matter of fact thing.

Do the cardiac surgeons coddle their PAs when they do stupid stuff? No, nor do they even attempt to do stupid stuff really - they know their place in the system.

 

[IMGASMD]

That is entirely your right to teach whatever you would like to whomever you would like to teach it to. Have a great day

That is entirely your right to teach whatever you would like to whomever you would like to teach it to. Have a great day

“Northwestern State University of Louisiana- Doctor of Nursing Practice in Nurse Anesthesia”

Not gonna lie, this rubs me the wrong way.
I, maybe odd, doesn’t exactly like to tell people my profession. Not because I am not proud of what I do, it’s because I know the expectations and responsibilities that come with my title. You sir, did you get your doctorate yet, while being a SRNA?

You will not win anything here, in an anesthesiologists’ dominated board. Nor will us, convince you of anything. Some of us tolerate to work with crnas out of necessity, financial, oftentimes both. If I can make same amount of money with or without crnas….. I know what I’d pick.

Have a super-dee-duper day!

 

[Fpg1245]

So your approach will vary depending on your relationship with the particular CRNA (or AA, or resident) you work with. Some are reasonable and more open. Others get defensive. It also depends on how urgent the situation is.

My responsibility is to get the patient through the procedure safely. I recognize that there are many ways to "skin a cat" so I don't dictate care unless there is something specific that I think will negatively affect patient care.

And even then I often phrase what I want like this: "because of XYZ should we do ABC?". For more urgent situations I am more direct: "let's try this" or "let's do this... (to improve patient saturations), (to give us time to reassess the patient's situation), (etc)". For truly critical situations I tell them I intend to take over. And I take over. I have no ego when it comes down to patient safety. This should NOT be about YOU vs. the CRNA

You describe an urgent-emergent procedural scenario. Patient desaturation during intubation. What sometimes happens is the operator gets tunnel vision doing a challenging task and their only goal becomes to accomplish that task (intubation). They don't hear the sats. They don't recognize how much time they've spent struggling. They forget about the big picture. In your particular case I would do this:

1. When they are struggling to get a view but before the patient starts to desaturate, I would suggest alternate intubation tools.
"It seems like the intubation isn't so straightforward (factual statement). Do you want to switch to a different blade? Should we get a glidescope? Do you want a bougie? (offer possible solutions)"

2. When the patient begins to rapidly desaturate (recognizing there is typically a 7-second delay in the pulse ox averaging of saturations)
"The patient is desaturating hard (factual statement). Let's come out and mask this patient up and we'll try again (directed solution)"

3. When the patient is truly decompensating. This should not happen if you've done 1. and 2.
"Sats are [...]. The patient is not doing well. I'm taking over."

At that point you might as well sit the case yourself. Just imagine what can happen as soon as you leave the room.

I cant imagine having to play this game every day of my life with the CRNAs.

 

[coffeebythelake]

At that point you might as well sit the case yourself. Just imagine what can happen as soon as you leave the room.

I cant imagine having to play this game every day of my life with the CRNAs.

My post isn't just about CRNAs. It is about working with others. As many of us are faculty at academic hospitals that includes anesthesiology residents as well.

I dont disagree with your statement. It is often much easier just to do everything myself

 

[epidural man]

for those seasoned attendings out there, how do you approach CRNAS who dont listen to you during critical moments like intubations, for example you tell them to come and ventilate the patient for a bit because because the patient is desaturating ...but they dont want to listen and to try and get their view, they say im so close i can get it but are only cranking the laryngoscope harder to no avail.......


this is just one of many examples

You can't really do anything.

The CRNA is an educated and trained adult who has ZERO obligation to listen to you - AND they know you are 100% responsible for their actions, so why would they do what you ask or say? (Most will I suppose because they are human beings with feelings and understanding of how a community should work - but they certainly don't have to or maybe they don't care about the community.)

This scenario is about the worst scenario one could even imagine to subject an anesthesiologist (or human being) to.

Why we let it happen is beyond ridiculous.

 

[jon stewart]

Also, there is a push by crnas at institutions to have their students be called residents.

The student crnas wear badges that say "resident"

 

[Anesthesia_Guy]

Also, there is a push by crnas at institutions to have their students be called residents.

The student crnas wear badges that say "resident"

Misappropriation of title.

 

[coffeebythelake]

Also, there is a push by crnas at institutions to have their students be called residents.

The student crnas wear badges that say "resident"

Hospital admin want this. It placades the nurses and tricks patients into thinking they are being taken care of by someone with more training than reality.

The misappropriation of physician titles is a long time coming. We have staff nurses refer to themselves as attending nurses. RT trainees call themselves RT residents. Nursing certificates are called fellowships.