Left alone in OR

athomas91 · Dec 15, 2004

i have been at two different clinical sites...

at one the MD is always present for induction and a CRNA has to be present for emergence when the student is running the room

at the other... the CRNA/SRNA do induction and emergence alone unless there is an issue that belies the need for add'l help...

on the "being alone" issue... we start that after our first year... and sometimes a little earlier if our clinical staff is ok with that... there is always someone there to help - yet it is like getting your wings a little at a time, which has to be better than trial by fire. From what I have seen and heard from my clinical coordinator - they have a pretty good idea of who will be fine and who needs another person in the room.

TennRN2004 · Dec 16, 2004

Even at hospitals where the MD's PARTICIPATE in the induction and emergence, most of them don't actually DO IT. Do your CRNA's literally stand off to the side while the MD intubates and extubates?

The case I remember the MDA actually did the induction/emergence, pushing meds. The CRNA already had the pt intubated when MDA came in. Usually, the CRNAs extubate in PACU if pt stable. I guess it just seems to me CRNAs are trained to be independent, but don't get to practice at a full scope, at least where I work. I know this is a long, ongoing issue....but seriously, if CRNAs are able to do things like put lines in, check preop for anesthesia, why do the MDAs do it? I'm wondering now that we have SRNAs at my hospital for the first time how things will change.

CougRN · Dec 16, 2004

The case I remember the MDA actually did the induction/emergence, pushing meds. The CRNA already had the pt intubated when MDA came in. Usually, the CRNAs extubate in PACU if pt stable. I guess it just seems to me CRNAs are trained to be independent, but don't get to practice at a full scope, at least where I work. I know this is a long, ongoing issue....but seriously, if CRNAs are able to do things like put lines in, check preop for anesthesia, why do the MDAs do it? I'm wondering now that we have SRNAs at my hospital for the first time how things will change.

Extubate in the PACU? That's kind of unusual. Patients should be awake coming into PACU unless they are to remain on a vent or the anesthesia provider is lazy and doesn't want to wait for the pt to wake up, at least where i used to work.

If the patient is already intubated then what where they pushing for induction? And if they were already intubated what kind of emergence was happening there? I'm not sure this makes sense to me.

TennRN2004 · Dec 16, 2004

Extubate in the PACU? That's kind of unusual. Patients should be awake coming into PACU unless they are to remain on a vent or the anesthesia provider is lazy and doesn't want to wait for the pt to wake up, at least where i used to work.
If the patient is already intubated then what where they pushing for induction? And if they were already intubated what kind of emergence was happening there? I'm not sure this makes sense to me.

Okay, first realize I have some ignorance (obviously lots of it- not in CRNA school yet), and what I'm recalling happened a year ago from a BSN student's perspective. I got there AFTER the pt was intubated, the CRNA had given I think versed for intubation, the OR staff was getting last minute stuff set up while the surgeon was scrubbing in. MDA and surgeon come in about the same time. So, this is where I recall MDA pushing meds, not sure what or how much- can't remember. I just know CRNA said MDA usually does induction for the open hearts. I assumed MDA pushing was the induction, maybe I'm wrong because CRNA might have already had given pt anesthetics before I got there too, but I don't remember it that way. Again, I was just questioning if other hospitals require/have MDA do induction because I've heard our hospital does it this way when I thought CRNAs could be independent to do induction- I realize this is a state/hospital regulation about need for MDA, just wondering what other places were doing.

About extubating in PACU, we have had problems with this lately.I work in the MICU and we get some surgeries as well. I know it sounds crazy, but we've had several pts lately who went to PACU on vent to wake up/stabilize a little more, and were extubated "too early"- ABGs sucked (as in pH 7.2 somthing and CO2 in the 70's) and pt ended up reintubated and back on vent for at least overnight. I got a pt this happened to and the PACU RN tells me in report the MDA went ahead and pulled the tube anyway and said pt "will be all right" and left. They don't plan on these pts staying on vent I know for a fact because my pt was supposed to go to floor until she ended up reintubated and on vent. This also happened at shift change 1830-1900 timeframe, so not sure but some of us have the idea that anesthesia is just not wanting to wait around to wake pt up but go home for the day...anyway my pt ended up being reintubated by RT in PACU. If it's anticipated pt will remain on vent then the pt is brought to us in MICU and we do recovery. I want to continue working where I'm at hopefully even after CRNA school, that's why I'm questioning how the anesthesia side happens. From what I've seen lately though I've been thinking I may not want to work there.

TennRN2004 · Dec 16, 2004

Extubate in the PACU? That's kind of unusual. Patients should be awake coming into PACU unless they are to remain on a vent or the anesthesia provider is lazy and doesn't want to wait for the pt to wake up, at least where i used to work.
If the patient is already intubated then what where they pushing for induction? And if they were already intubated what kind of emergence was happening there? I'm not sure this makes sense to me.

Okay, first realize I have some ignorance (obviously lots of it- not in CRNA school yet), and what I'm recalling happened a year ago from a BSN student's perspective. I got there AFTER the pt was intubated, the CRNA had given I think versed for intubation, the OR staff was getting last minute stuff set up while the surgeon was scrubbing in. MDA and surgeon come in about the same time. So, this is where I recall MDA pushing meds, not sure what or how much- can't remember. I just know CRNA said MDA usually does induction for the open hearts. I assumed MDA pushing was the induction, maybe I'm wrong because CRNA might have already had given pt anesthetics before I got there too, but I don't remember it that way. Again, I was just questioning if other hospitals require/have MDA do induction because I've heard our hospital does it this way when I thought CRNAs could be independent to do induction- I realize this is a state/hospital regulation about need for MDA, just wondering what other places were doing.

About extubating in PACU, we have had problems with this lately.I work in the MICU and we get some surgeries as well. I know it sounds crazy, but we've had several pts lately who went to PACU on vent to wake up/stabilize a little more, and were extubated "too early"- ABGs sucked (as in pH 7.2 somthing and CO2 in the 70's) and pt ended up reintubated and back on vent for at least overnight. I got a pt this happened to and the PACU RN tells me in report the MDA went ahead and pulled the tube anyway and said pt "will be all right" and left. They don't plan on these pts staying on vent I know for a fact because my pt was supposed to go to floor until she ended up reintubated and on vent. This also happened at shift change 1830-1900 timeframe, so not sure but some of us have the idea that anesthesia is just not wanting to wait around to wake pt up but go home for the day...anyway my pt ended up being reintubated by RT in PACU. If it's anticipated pt will remain on vent then the pt is brought to us in MICU and we do recovery. I want to continue working where I'm at hopefully even after CRNA school, that's why I'm questioning how the anesthesia side happens. From what I've seen lately though I've been thinking I may not want to work there.

loisane · Dec 17, 2004

I got there AFTER the pt was intubated, the CRNA had given I think versed for intubation........... I assumed MDA pushing was the induction.....

Induction refers to putting the patient asleep, and intubating (if that intubation is part of the plan). So if the tube was in, you missed induction (unless the patient came to the OR already intubated, which doesn't sound like the case in this instance). But induction isn't the only time drugs are given.

I realize this is a state/hospital regulation about need for MDA, just wondering what other places were doing.

The primary driving force behind requirind an 'ologist presence for induction is BILLING. Not one of the 50 states requires that an 'ologist supervise a CRNA. Some hospitals do have such a policy. The rationale for the existence of such policies depends on who you talk to. I have my opinions, others have theirs.

About extubating in PACU, we have had problems with this lately.

Patients coming to the PACU still intubated happens occasionally, even with the best and most well intentioned anesthesia provider. It isn't always the best use of resources to keep a patient in the OR if they are having a prolonged emergence. In my experience, PACU is well qualified to take care of these patients, and evaluate the next appropriate step-extubate and to floor, or leave the tube and to ICU. This allows anesthesia to proceed with the next case, and not hold up the OR schedule.

Now if your having a pattern of this, well there may indeed be something else going on. Just wanted to present another possible explanation to those who have never seen this practice.

loisane crna

loisane · Dec 17, 2004

I got there AFTER the pt was intubated, the CRNA had given I think versed for intubation........... I assumed MDA pushing was the induction.....

Induction refers to putting the patient asleep, and intubating (if that intubation is part of the plan). So if the tube was in, you missed induction (unless the patient came to the OR already intubated, which doesn't sound like the case in this instance). But induction isn't the only time drugs are given.

I realize this is a state/hospital regulation about need for MDA, just wondering what other places were doing.

The primary driving force behind requirind an 'ologist presence for induction is BILLING. Not one of the 50 states requires that an 'ologist supervise a CRNA. Some hospitals do have such a policy. The rationale for the existence of such policies depends on who you talk to. I have my opinions, others have theirs.

About extubating in PACU, we have had problems with this lately.

Patients coming to the PACU still intubated happens occasionally, even with the best and most well intentioned anesthesia provider. It isn't always the best use of resources to keep a patient in the OR if they are having a prolonged emergence. In my experience, PACU is well qualified to take care of these patients, and evaluate the next appropriate step-extubate and to floor, or leave the tube and to ICU. This allows anesthesia to proceed with the next case, and not hold up the OR schedule.

Now if your having a pattern of this, well there may indeed be something else going on. Just wanted to present another possible explanation to those who have never seen this practice.

loisane crna

Pete495 · Dec 17, 2004

I can relate to your experiences in getting patients from PACU. I've had to give narcan to patients once they've arrived, and I've also had to re-intubate patients too sleepy to breathe. But I have also been in a situation where I 've had to re-intubate because I extubated too early (he was a crazy man who had a lot of morphine, but nothing else, and I didn't have a choice because doc wouldn't give me any other meds to sedate). Nevertheless, I took that one on the chin when he went to sleep after extubation. I still stand by my decision however because I felt I had no choice but to take a chance, cuz the damn dr. wouldn't hear what I was saying when I told her I had 4-5 people holding the guy down (boy that kills me). In any case, I'm not saying the providers are goofing. I think patient's react individually. That's what makes anesthesia so exciting.

In bigger hospitals I couldn't see this being as much as a problem, because they typically have the anes. staff on full time. In smaller hospitals, maybe. You must consider also whether one would rather have had the patient be more awake during said procedure or surgery just so one could extubate immediately as the case was ending. I think not, and not every patient reacts the same to meds even if they are sufficiently and properly dosed as was the case with my crazy man. In any case, it might not be the anes. provider, but the patient who finds the drugs he's been given catch up with him.

I'm just sharing my experiences. I'll let the pros handle the rest.

Pete495 · Dec 17, 2004

I can relate to your experiences in getting patients from PACU. I've had to give narcan to patients once they've arrived, and I've also had to re-intubate patients too sleepy to breathe. But I have also been in a situation where I 've had to re-intubate because I extubated too early (he was a crazy man who had a lot of morphine, but nothing else, and I didn't have a choice because doc wouldn't give me any other meds to sedate). Nevertheless, I took that one on the chin when he went to sleep after extubation. I still stand by my decision however because I felt I had no choice but to take a chance, cuz the damn dr. wouldn't hear what I was saying when I told her I had 4-5 people holding the guy down (boy that kills me). In any case, I'm not saying the providers are goofing. I think patient's react individually. That's what makes anesthesia so exciting.

In bigger hospitals I couldn't see this being as much as a problem, because they typically have the anes. staff on full time. In smaller hospitals, maybe. You must consider also whether one would rather have had the patient be more awake during said procedure or surgery just so one could extubate immediately as the case was ending. I think not, and not every patient reacts the same to meds even if they are sufficiently and properly dosed as was the case with my crazy man. In any case, it might not be the anes. provider, but the patient who finds the drugs he's been given catch up with him.

I'm just sharing my experiences. I'll let the pros handle the rest.