You and the Anesthesiologist disagree on pt care. Now what?

allnurses Guide · Sep 13, 2012

I am currently in school for nurse anesthesia. I have been several different places with clinicals and have certainly experienced a lot of variation in "this is the right way to do it." Something I was curious about is how should you handle things when there is a discrepancy between what you (the CRNA) and the anesthesiologist believe is the right way to do something. Especially when it is something you feel is poor practice or patient care. Do you do whatever it is because he/she is the attending and signs as the supervising attending to the case? Do you step back with risk of ruffling feathers and say if that is what you think should be done, then you do it, because it is you that is also signing the chart? Or do you put your foot down and say it really needs to be done this way? If anyone has any experiences and examples, I would really love to hear them. Thanks!

The CRNA and the anesthesiologist are both licensed professionals, if you both cannot come to an agreement on what is safe for the patient then you should not proceed with the case. It is your license on the line. Most of the time it is more about comfort levels and one provider being used to doing something one way (usually the way they did it where they were trained) vs another way.

Guest343211 · Sep 14, 2012

I am currently in school for nurse anesthesia. I have been several different places with clinicals and have certainly experienced a lot of variation in "this is the right way to do it." Something I was curious about is how should you handle things when there is a discrepancy between what you (the CRNA) and the anesthesiologist believe is the right way to do something. Especially when it is something you feel is poor practice or patient care. Do you do whatever it is because he/she is the attending and signs as the supervising attending to the case? Do you step back with risk of ruffling feathers and say if that is what you think should be done, then you do it, because it is you that is also signing the chart? Or do you put your foot down and say it really needs to be done this way? If anyone has any experiences and examples, I would really love to hear them. Thanks!

Well, there really isn't another information given. I know you have to be discreet, but it's a hard to make a judgment based on, well, no information.

Where's the standard of practice and the P&P on whatever it is? What does it say? Do you have supported literature that says otherwise? Will it be considered/adopted by the deparment? You are considered a student, so that definitely puts you at a major disadvantage.

Either way, you have to be careful in how you approach the situation. If it is something grossly unsafe, well, then you have to put your foot down. Go on the side of safety. I have had similar disagreements with people in ICUs, even with some ologists backing me up. Some people make an issue out of things, and some people just consider it a learning experience and move on.

Follow the standard of practice, P&Ps, and that which is the safest thing to do. If safety will be sacrificed, you have to back up away from it, and then document why.

There are usually systems and channels for dealing with these kinds of things--but politics IS ALWAYS a factor--so just be careful. Is the issue definitely worth fighting over now? I mean will the patient absolutely be compromised? How big of a deal is the thing really?

Only you can answer this. Our information is just too limited. Darn, what is it the ologist wants you to do?

norlns24 · Sep 15, 2012

I believe if you deem a situation to be serious/ potentially life-threatening, you need to strongly advocate your position. This is the exact phrase used in Crew Resource Management lingo. "I am advocating my position." CRM also champions using the "CUS" words (phrases), such as "I am concerned, I am uncomfortable, and this is a safety issue " to try to get one's point across to others. A basic motto of CRM is: "It's not who's right, it's what's right."

CRM was originally developed many years ago after a plane went down in Oregon when it ran out of fuel. The plane had been circling due to bad weather, and the First Officer kept quiet about how dire the situation was beyond periodicially reporting the fuel levels to the Captain when prompted, as was customary, because at that time, one did not question the Captain's authority. He failed to advocate his position that they were about to completely run out of fuel and crash, something he could clearly see was the case. In the aviation culture at that time, you simply did not question the Captain's authority.

Listening to the black box recording after this totally preventable crash, investigators and the airline involved realized something needed to be amended about commercial aviation's top-down command structure to avoid a repeat of this tragedy. Other industries have since adopted CRM training including, including some areas of the health care industry. This makes sense since the medical profession has its own command structure not unlike aviation.

If one sees that a patient is in a (potentially) unsafe situation or position, and one believes the proper course of action is not being taken to right this dangerous course, one definitely needs to advocate one's position. What exactly constitutes a potential "nose dive" in one particular area of medicine or another, however, is obviously not necessarily always black-and-white. What I might see as the wrong course with potentially serious consequences, someone else might not. CRM is no way intended to be an exact science, but rather, it is a way to address situations with potentially negative, serious outcomes in a professional manner.