Negative Parts of the Job

bubba · Jun 1, 2002

I don't think there are any negative aspects except as you mentioned, on call and long hours.

kmchugh · Jun 1, 2002

Down sides. Hmmmm

I love what I am doing, but no matter what else is said, hours, hours, hours. Of course, due to some vacations, I've been first call for the last two weekends in a row. That translates as follows. In the 19 days since the 13th May, I have worked for at least part of 18 of those days. I have worked the last 12 days without a day off. I'm off this weekend, and am first call again next weekend. That means this week, I'll be first call Mon, Wed, Fri, Sat and Sun. The week after I'll be first call Tue and Thurs. I am so tired, with no real relief in sight for at least two more weeks. Still, I do love what I do.

Otherwise, the biggest downside is the occasional run in with a physician, and those aren't too bad, really. I did a carotid this week, and set it up to do it with a remifentanil gtt. I like remi, I think it greatly reduces the swings in BP when doing a carotid under a general anesthetic. The physician came in for induction, and I told him "this is how I'm doing it, so this is how I'm doing induction." He basically said "I'm supervising, so leave the remi out, do it this way." Too tired to argue (and the patient was still awake), so, we did it his way. Spent the whole case chasing blood pressure as it varied from 90 systolic (VERY bad for someone with stenosed carotid arteries) to 210 systolic.

Don't get the wrong idea, though. Part of that was my fault. I knew who was supervising, and I should have given him more notice than telling him at induction what I was planning to do. I'll probably have a talk with him this week (at a professional level, which is how he will respond) about doing my cases my way, unless he knows something I don't. I'm always willing to listen to new ideas or advice from experience.

This was NOT really a big deal, and I don't want to make it sound like one. I get along very well with this physician. He has over 30 years experience, and is a great teacher. I'm rambling.

Kevin McHugh

meandragonbrett · Jun 1, 2002

Kevin,

You should come down here to memphis. The largest group in the city his hiring. M-F 7-3, only 40 hrs a week, no call, no weekends, no holidays, malpractice is paid, 5 weeks vacation and 15 sick leave. They are also offereing nice salaries right now too~ I couldn' believe it when I heard the 7-3 M-F only!

Brett

lgcv · Jun 1, 2002

Brett,

Do CRNA's provide anesthesia for all types of surgeries, or are there limitations? I guess no call makes me think they are only doing the B&B cases while physicians are doing the major cases. Do you have any knowledge as to these issues? Thanks

nrw350 · Jun 1, 2002

Hey kevin, I would like some clarification again lol. Its on this paragraph I have put my questions in brackets after that which I am curious about:

"I did a carotid this week, and set it up to do it with a remifentanil gtt. I like remi, I think it greatly reduces the swings in BP when doing a carotid under a general anesthetic [what is a carotid, and what about it causes a person's bp to "swing"]. The physician came in for induction, and I told him "this is how I'm doing it, so this is how I'm doing induction." He basically said "I'm supervising, so leave the remi out, do it this way."[what does the "remi" do to prevent the bp from "swinging"] Too tired to argue (and the patient was still awake), so, we did it his way. Spent the whole case chasing blood pressure as it varied from 90 systolic (VERY bad for someone with stenosed carotid arteries) to 210 systolic. "[again about the carotid thingy, why is it bad?"

Thanks for the help. I know I am posting all the time with questions, and I really appreciate everyone's responses. You folks are the people who give medicine a great name.

Thanks.

Nick

meandragonbrett · Jun 1, 2002

Lgcv,

No, the CRNAs do the complex cases too, not just B&B, there are two anesthesia groups that service the hospital system. one does the 7-3 M-F then the other takes the nights, call, weekends and holidays. In fact, yesterday I was in surgery w\a CRNA again and we did a CABG, then they had some brain procedure scheduled for the room and some other complex cases. Of course they do the B&B as well. This group is doing VERY well and keeps growing. If you have anymore questions let me know.

Brett

meandragonbrett · Jun 1, 2002

Another plus w\the group is there is a physican there if the CRNA needs him\her, but they are not there standing over you the entire case either.

alansmith52 · Jun 3, 2002

I am no CRNA but I'll bet those pressure problems are in part due to the messing around near the crotid bodies. plus you gotta keep the pressure up in these people inorder to keep the graft open.

matt

kmchugh · Jun 3, 2002

Most carotid endartarectomy patients have PVD, and are hypertensives. Their bodies have become used to higher mean arterial pressures, so low blood pressures can be catastrophic. Its a perfusion issue. Even though the carotid we are working on is obviously stenosed, we are still occluding that artery, which is a major supplier of blood to the brain. Therefore, pressure must be maintained at a higher level to ensure the brain is adequately perfused. It is not uncommon to see a patient with preop systolic pressures of 170 or greater. We put all these patients on a neosynepherine gtt to maintain pressures close to preop levels. This is less of a problem when the surgeon places a shunt in the artery being worked on. As you might imagine, there are a number of factors in surgery that contribute to blood pressure variation. Anesthetic agents are all vasodilators. The neo gtt is a vasoconstrictor. Both of these are under my control. But one of the most powerful mediators of cardiovascular status is the sympathetic nervous system. It will respond to painful stimuli with increased blood pressure, and to less painful points of the surgery with lower blood pressure. Hence, the swings in blood pressure that are often seen in most surgery. Hypertensives react with wider swings. As well as being a narcotic, remi helps by essentially "damping" the SNS effect, leaving me in nearly complete control of the BP through the adjustment of volitile agent and neosynepherine gtt. The only smoother way I know of to do a carotid is with a regional block, and do the surgery on an awake patient. Unfortunately, many surgeons don't like this approach, as the patient has a tendency to move occasionally.

This is a short explanation, but covers most of the bases for using a remi gtt in carotid surgery.

Kevin McHughy

jfpruitt · Jun 3, 2002

I'm no CRNA, but would standing on your feet for long hours in an operating room be hard?

meandragonbrett · Jun 3, 2002

yes it would be, but most CRNAs that i've seen do get chances to sit down every once and awhile at the head of the table during the procedure. Correct me if i'm wrong. It's not imperative that you stand is it?

brett