Is there such a thing as too much experience?

[TranMan]

Can too much experience make us less effective in the OR? I have met a few Anesthesia Personal that refuse to do certain cases b/c of the risks involve citing that in their vast experience, they'd been burn before by similar situations.

Just this last week a locums CRNA refuse to do 2 cases citing differing reasons which I thought were rediculous.

1st case was a Posterior Vitrectomy b/c the patients Blood sugar was 312 preooperatively. I asked him why he wouldn't just give the patient some Regular insulin and recheck the sugar later if he was really worried about it. His response was that it wasn't his patient and that he had been burned before doing this. I told him that this surgeon usually just wants anesthesia to be available in the room and he usually doesn't want any sedation to be given. He usually just does a retrobulbar block on all his patients without sedation. All his patients usually tolerate this without any complaint. I also said that this patient probably has a high blood sugar all the time anyway. The CRNA didn't really care to discuss it much and was open to switching cases with me if I wanted to do it. So I quickly obliged, ordered some insulin for the patient, sat through the case, and recheck the patients bld sugar in the PACU. Patient did fine.

2nd case, was a hip pinning in an elderly patient who was confused and pulled out her IV. Since she has poor IV access, she was sent down to radiology to get a PICC line. Now I'm not a fan of picc lines but will use them if I have too. Well my CRNA coworker refused to do the case b/c he stated that it is a contra-indication to push meds through a Picc line. ????? Frankly, I've never heard such a thing. So if you don't want to use a PICC line, why not just put in a central line. He didn't have a response for this. Well, I know that you can't infuse large volumes through a picc line quickly and maybe he was concerned about having to give a lot of fluids or blood later, but is that any reason to refuse to do a case. BTW she wasn't a really sick patient either, just elderly. So I sent this CRNA home and I did the case under a SAB. She required a little neosynephrine throughout the case but did fine without complication. I suppose she could've had pressure problems not responsive to meds. In which case I would've had to place a central line to give fluids and/or blood. I wasn't too worried about it since I felt confident I could do this with not too much difficulty in a pinch.

I guess what it comes down to is that we all have to decide how much risk is too much. And this will vary from practioner to practioner base on our personal experiences. I didn't mind that he didn't feel comfortable doing the cases, but to state those reasons to me followed by the fact that he'd been doing anesthesia for 20 years seemed a little "weak". So can too much experience or shall I say too many bad experiences prevent us from getting work done in the OR?

Just as an example of a case that I would cancel is....
Last week, I evaluated an elderly lady scheduled for a BKA (below knee amputation) who had "a cardiac event" that require resusitation at the nursing home 6 days prior. She was brought to the ER and it was documentated that she was in a wide complex ventricular tachycardia that switched to Afib with a HR of 200. Troponins were all negative and 12 lead didn't reveal an infarction. Needless to say, that was 6 days ago. She hasn't had any other issues in the last 6 days and hadn't been seen by cardiology yet. She had a few necrotic toes and this surgeon wanted to do an BKA. Her case got delayed and it was now 8pm. I told the surgeon that she should be seen by cardiology 1st since this wasn't an Emergent case and if she coded on the table, we wouldn't have enough help around. She agreed and I was glad. I felt that the patient probably would've done fine, but if she didn't it wouldn't be defensible.

What do you all think?

[RN29306]

Hey Tran. Nice post.

First off, man I've never seen a retro done without significant sedation and I'd really like to see how pts handle it without it. I completely believe you, but this is something I would have to see to believe. Most people get a 80-150 shot of propofol and while they still squirm and move around, that's just how its done here. Maybe its just an institution specific thing.

As far as the PICC thing, there is a chance of shearing the catheter if you were to hook it to a rapid infuser and go balls-out with the max pressure, but hopefully no one would do this. I know the same goes for unit pts having CT studies done with rapid injection of IV contrast. While a valid concern about fluids under pressure, I do not think it really applies in this situation. If he was that concerned about a hip pinning surgery, then put a line in beforehand. I think he lacked confidence in his central line abilities, handling pressure under fire, and it showed in this case.

Your a man that makes things happen and that experience is invaluable in a group. GO TRAN!

[beechnut]

Hi Guys,

I have seen a few retrobulbars done without sedation. The surgeon blocked the facial nerve first then went in with the retrobulbar. I would still prefer to be asleep if you ask me!!!, but, it worked.

Back to the original question. Experience IS one of the things that I have relied on as a CRNA for many years. But, as profesionals we still need to be able to communicate to others our reasons for our decisions and courses of actions. You are absolutely correct when you said his excuse for not doing the case due to "experience" was weak. An experienced CRNA could come up with a much more creative excuse for not doing the case! :)!

Cheers!

[yoga]

Tran,
This is an excellent question. Given the fact that I probably have the most experience of anyone who frequently posts on this board, I would like to offer some thoughts.

Lots of experience generally gives one a degree of confidence in anesthesia, provided one was a good practitioner from the beginning. Be careful when someone says they have 25 years experience--is it 25 years or 1 year 25 times? Unfortunately, I know a lot of colleagues with experience who are not up to date with medications, techniques or pathophysiology.

However, with respect to experience, I have become a very intuitive anesthetist through the years and make a lot of judgments based on that intuition. Of course those instincts are based upon being able to read a situation, knowing my own or others (surgeon, nurses, facility) limitations and applying scientific and clinical standards to the situation.

Regarding the situations you posted, I think the CRNAs were lazy or felt inadequate. I would have been comfortable with both of those cases. A high blood sugar is certainly something to be treated, but a vitrectomy can be surgery that may keep the patient from going blind. I have done many of them with retro/peribulbar blocks and work on the blood sugar while the surgery is going on. Now, I don't have that much experience with PICC lines, but wonder if a peripheral line would have been attainable after vasodilation from general anesthesia.

While I love this profession, I am very much a realist. I know many CRNAs who are lazy, would do almost anything to get out of a case, or who want to just do certain ones. In private practice, canceling cases is something I rarely do, and if I do, it is for a very good reason. I canceled a young lady who wanted breast implants before Christmas because she came in with laryngitis and was diagnosed with strep throat. Also, in private practice, when you cancel cases, you have two problems, no income from that case, and if you cancel too many without good reasons, you also may lose that contract.

Now, don't make me feel too old to do anesthesia.

Jan

[betterlatethanever]

P.S-

As a student starting in Jan I thank u guys for these forums. It helps me learn a great deal about the rofession and trials I will face..Enjoy your holidays!
Chris

[TranMan]

Nice response all. Mike I agree with you and it may very well be the case with this inidividual. More experience is never a bad thing, but like Yoga said, is it quality experience? Having years of experience doing simple cases in healthy patients does not compare to less years with sick patients in different situations. I'm also glad that I've been able to work at 4 different hospitals in the last 4 yrs. I always appreciate working with different anesthesia ppl, surgeons, and staff b/c I truely believe you can learn something from everyone. Sometimes it is learning how not to do something.

Just to clarify, this was the same CRNA that didn't want to do both cases in 1 day and the case were one after the other. Between the 2 cases, he came to my room and told me he had to go home. It was around 5p and we normally go down to 2 rooms anyway. I said, well don't you have another case? He said he wasn't sure if they were going down to 2 rooms but he was tired and needed to leave. I said "Okay, have a nice weekend". He never told the charge RN, and she came in my room later and told me that she had to call him back. He was mad, but they were running a 3rd room and needed aneshesia. He came back but refused to do the case.

I like what yoga said about experience garnering one with intuition on how to deal with different clinical situations. And I agree that each situation is complex and has many variables that can sway us to proceed or cancel. I don't fault him for not wanting to do the cases. It wasn't right for him for one reason or another. I respect that. What I didn't like was that he hid behind his years of experience and made it sound like I would make the same decision if I had more experience. I don't think I would have done things different even with more experience. I don't believe I was taking on an inordinate amount of risk by proceeding.

Drew, at 1st I too was uncomfortable about watching a RB block done without sedation. As a matter of fact, I would give the patient 1mg of versed without the surgeons awareness anyway, but he started the block before the versed could take full effect. He talks to the patient and tells them that there be a little sting and a little presure and it will get better. He uses a very small needle and injects very slowly. Does it very smooth and I was very impress. After seeing several of these, I've changed my mind and don't think sedation is absolutely neccessary, IF the person doing the block can do a good block.
Also reminds of a time that I tried to talk a patient into getting sedation for a toe block. She was adamant about not getting any sedation. I hesitantly said "okay". Guess what? she did just find. Then I heard about ppl who didn't get any local to have wisdom teeth pulled. Didn't think it was possible, but it is. Amazing what you feel or don't feel by using your mind to distract yourself. Mind over matter I guess.
I try to be flexible and have an open mind to new experiences. I am experienced enough to know that I don't know everything, but actually have MUCH to learn. It just amazes me that I see ppl everyday who refuse to learn anything outside their limited views. I have worked with many "experienced ppl" that are very closed minded.
Not always a bad thing, b/c we develop our own patterns of practice based on our experiences (good and bad). It's just as we all get older, some of use become so inflexible that we actually stop learning and growing. This is a shame and I hope I can avoid this to some extent as I gain more experience.
Here's another example. I worked with a very experience and good CRNA who resisted using a lower CNC - higher volume Ropivicaine mixture for L&D epidurals. When asked why she was so resistant, she said a CRNA friend of hers who is very good at OB doesn't like it. She, herself did not have experience with the mixture, but trusted her friend enough to know it wasn't right for her.
I thought "you got to be kidding me". How about trying it and developing your own opinions. Now this is a friend of mine and I have learned A LOT from her, but I also remember some of the silly things I hear ppl say.
Anyways, got to go for now. Be interested in hearing more on the topic.

[MmacFN]

Hey Tran

Interesting discussion.

I think that it isnt "too much" experience that is the issue, but lack of initive in keeping up with standards and research. I see this all the time in various professions.

For example:

The was a large study done on physicians about 7 years ago which proved that 90% of physicians working outside academic environments stop learning 3 years post residency. Essentially, they get out of the academic envirnoment after residency then slowly lose the academic accumen they learned in residency and school. So 10 years post residency many are practicing the same medicine they learned 7 years previous. Medicine is a moving target, what was right then (or questionable) isnt what is now.

I would suggest this is a stat which crosses all medical professions. Sayings like "because we have always done it that way" comes to mind. I think this traveler you have is probably a victim of that same condition.

[jwk]

Jan - always remember, we're not getting older, we're getting better!!

To me, the examples that Tran provided are more like a "cookbook" approach to anesthesia, involving little if any independent thought. BS >300? Cancel. PICC line? Cancel if you don't have something else. It's not a matter of too much experience by any stretch of the imagination.

The point about intuition is right on - after a while, you do tend to get a feel for things in all sorts of situations. You can glance at someone and without even examining their airway, you know they'll be a difficult intubation. You can have cardiology clearance and just know you'll still have problems. Everything looks fine and you just have this sinking feeling that something is about to hit the fan.

For the eye case - we would do that case without reservation. Although increasingly tighter BS control seems to be coming all the time, a MAC case for a potentially sight-saving procedure far outweighs the risks of an elevated BS.

PICC's - so what? We use them all the time. They're there for two reasons - the patient either has lousy veins, need prolonged access, or both. Do I want them for a trauma case? Nope. But for a routine case, they're fine.

[deepz]

....... as we all get older, some of use become so inflexible that we actually stop learning and growing. .....


All too common a problem with our brethren and sistren out in the one-holer facilities of America. When you must pay for your own time off, CME may be neglected. One old guy I knew would say, with a straight face, "I don't think I'll try that technic (or drug, or approach -- whatever new thing) until I've had more experience with it."

No, not Yogi Berra.

!

[MmacFN]

Yup.

Another word for it is Lazy