r/anesthesiology

What stops a surgeon to declare every case as emergent? If they want to do a case and the patient ate but surgeon wants to do cases so he can go home what stops then from calling it emergent?

Just to clarify not that i cannot say no to a surgeon but I always wonder is there any repercussions if the surgeon declared the case is emergent but the case is not actually emergent. Like the administration will talk to the surgeon about it because of the resources use, reimbursement issues etc...

I'm sorry, another "should I do fellowship" post, truly looking for honest advice. I am very grateful to anyone who reads and offers their opinion.

I am a CA-2 at a large academic program. We have all ACGME accredited fellowships and some non-ACGME fellowships in-house. I have scored very well on exams, published/presented research, and am overall a good fellowship candidate. Generally interested in academics post-residency, PP not out of the picture though.

Since starting residency, I have wanted to do fellowship. I have been driven by the desire to be an expert in a field and to feel solidified in my career with the mid-level explosion. Currently, I am very stuck. I generally could see myself enjoying parts of every ACGME fellowship, as well as being content without fellowship. I do feel scared for the future of being a generalist, I understand this is highly debated, but I don't want to be stuck in 15 years feeling like I need to find a fellowship when programs are more competitive than ever, and then having to take a step back for a whole year.

One big important part to this all is my desire to return to my hometown. Since leaving for med school 6+ years ago, I have been on a journey of trying to return home and haven't been able to. Currently, only peds and pain fellowships are offered by programs in my hometown. Even one more year of not being able to go home doesn't sit the best with me.

Going to list my feelings on each ACGME fellowship below.

Critical Care: Initially my goal/main interest coming into residency. I love being able to expand my horizon past anesthesia. I feel competent and confident from the skills I obtain while working in the ICU. I just feel like the pay differential upon getting out of fellowship will undoubtedly push me towards working anesthesia after graduation, and I may just end up losing my skills and not practicing CC after all. Only interested in CC if I can pursue split practice between OR and ICU. No fellowship option in my hometown.

Cardiac: I really like cardiac cases. By far the most engaged I have ever been in the OR. I love the active participation in the case with the surgery team. What I don't like are the very early mornings and the supreme effort that every case demands. I'm a bit concerned that the stress/effort will feel burdensome when the pay differential is small. I also like time flexibility. I like to be able to take 2-3 weeks off at a time. I feel like the reduced cardiac pool will squander this chance. Also no fellowship in my hometown.

Peds: I enjoyed peds cases a lot, but I didn't love the tiny babies. I felt almost useless, as my interventions were unlikely to change the tides significantly. Most neonate cases I was just praying nothing went wrong lol. I'm not the best with kids but I didn't feel like it made much of a difference during my peds months. To me, without a pay differential, it doesn't seem like a worthwhile endeavor.

Pain: Pharm is my favorite part of medicine, so I could see myself enjoying pain, especially with new medications and uses of old medications. The procedures are pretty cool overall. I didn't like my clinic time much as a resident, but it's also because it was filled with lots of downtime and I didn't have much decision-making power. Because of my time as a resident, I never really considered pain much. I'm sure as an attending, it would be much different. I like the aspect of leaving the OR for a bit. I would probably still want to do per diem anesthesia, but from what I understand, you generally need to dedicate yourself to pain practice coming out of fellowship in order to make this work.

Feel free to call me out where I'm wrong and provide any opinions or advice. Thank you so much for taking the time to read this.

Patient: “I’ll take the one covered by insurance.”

Anesthesiologist: “Alright. Rock-a-bye baby, on the treetop…”

Practicing for 30 years done, thousands upon thousands of G.I. cases. Today I saw something for the first time. 49 year-old man physically active echo normal except for moderate AI. CBC and BMP as well as thyroid this year normal. Works a technical job without difficulty no psychiatric history no psychiatric meds whatsoever. No alcohol abuse or drug abuse. No migraines. Coming in for screening colonoscopy. wife tells me that 10 years prior after an appendectomy he had a prolonged period, which she was very fuzzy about but it was certainly long enough for her to be disturbed by it, of complete retrograde global amnesia where he didn’t know who she was where he was and was completely disoriented. She was very unclear as to how long it took for this to resolve, but it did resolve spontaneously. Today was his first anesthetic since then. he received 220 mg of propofol and 50 mg of lidocaine and for about 40 minutes after the colonoscopy he was completely awake but completely unaware of who he was where he was who his wife was what he was doing there. It was if he had advanced dementia. No motor deficits no focal deficits.. I reassured the wife and left them in the cubicle and he slowly came out of it and after an hour, he was back to baseline. I’ve never seen anybody recover from propofol like that before and it is especially interesting because it happened 10 years before just the same way. I would’ve liked to have known how long it took to recover from a true general aesthetic. I didn’t know what to tell the family, but I will call them tomorrow and see how he is doing. Has anybody ever seen this before? Any thoughts?

CA1 still on struggle bus with intubation. First I could not find the epiglottis when I did DL. That issue has been corrected with advancing the blade slowly. Now I have problems where I saw the epiglottis, I thought I am in the vallecula space but I can't make the epiglottis open or pop up for me to see the vocal cord. I tried to advance more, it still did not work. I tried to lift, I absolutely could not lift. What do you think I did wrong here?

Also any tip for the LMA, especially the igel. My LMA always stucks somehow.

What makes you gag?

Can anyone help to shed light on the current landscape of the generalist jobs in the Seattle area and Seattle metro?

I don’t see very many jobs on gasworks and the groups I’ve spoken seem to be offering 500-550k w2 for a full time call taking position.

I saw Kaiser Seattle was offering: 488-574k for their full time positions but also had full time locums gigs for 450k? This seems low for the area given how pricey the area is. I am assuming with the 488-574k range, a 1.0 call taking FTE will be started at 488k.

Are there any good groups hiring that anyone knows about?

Cheers

Hello fellow members of the gas board. Was hoping to get some tips regarding pain management in Gynae patients.

For context, I am a UK anaesthetist and work in a mid sized teaching hospital. This is my 5th year in Anaesthetics. As a centre, we have a notable/well renowned gynae service and it turns out I actually like providing an anaesthetic for this service. I like the variety of anaesthetic techniques and the discussions with patients. My colleagues generally do not like this service so I now get a lot of these lists.

One aspect that I'm finding difficult is judging pain requirements post operatively for these patients. I've had patients turn up for very routine / minimally invasive procedures who are in rip roaring pain afterwards that sometimes even require them to stay overnight. Nearly always, it is an intense cramping pain in the mid-lower abdomen.

My regular practice is roughly 0.1mg/kg of morphine as well as fentanyl on induction. I always give paracetamol (acetaminophen) and diclofenac. If I have time and the blood pressure allows I will also give magnesium. If the patient is very anxious I'll give a smidge if midazolam (Versed) if I don't think the procedure is going to be that painful or clonidone if it is. I do TIVA if it is a medium / long case.

Does anyone have any good tips or advice for this patient population? I have spoken to a few of my colleagues who seem to just say that not much can be done and it just happens with gynae patient's sometimes. In which case, what sort of discussion do you have with these patients post-operatively?

Thanks in advance and sorry for the essay!

Wanted to revisit this since a lot of the older threads are a few years old (but super helpful). Also interested in seeing if any programs that previously had a bad reputation have improved. TIA!

Hello all. I am a M4 working on my residency application — just wanted to know if anyone initially chose anesthesia for “lifestyle” versus passion. I am not the most passionate about heart/lung physiology, but really not super passionate about any specific physiology in general lol. My electives that I have rotated on include mostly supervising CRNAs, preops, and light PACU work. Some intubations and IV starts, but nothing super thrilling. I can also appreciate and understand the other side of the coin where work is extremely stressful (patient coding, hemodynamically unstable during a case), as I have seen these cases on electives. I do enjoy running cases on different units, fixing hemodynamics, and pharmacology. I do not mind the idea of taking call either. Was just curious if anyone decided on anesthesia or were influenced “lifestyle” (good compensation, shift work, no notes like IM/patients coming in with 20 problems for 1 visit in FM, PTO, etc), and whether or not you’re happy with your choice. All the physicians I have asked in person are all happy with their career, so I am curious if anyone has or has had similar sentiments as me. Input from any current residents or attendings would be great. Just looking for honest advice and career outlook. Possibly looking into pediatric fellowship after residency — on a peds anesthesia rotation now and am liking it! TIA!

CA3 here,

I’m about 150 epidurals in and I always struggle with those difficult patients who are screaming at every little part of the procedure. I do my best to numb up the skin and a little bit on either side of the ligament but they still complain and start arching their back on me. Of course this makes placement even worse and then it becomes a truly terrible experience for everyone. Even when I feel like I’m midline and in ligament they are screaming.

Any tips for these patients?

I’m finishing my pain fellowship this month and the job I was considering most will not work due to a change in my family. I have two good pain prospects but since they’re both starting interviews now, if I get one of these job I presume the earliest I would get an offer/review contract/sign wouldn’t be before the end of September. With credentialing that means I wouldn’t start until October or November I’m guessing.

I’m planning to get cobra to cover insurance in the interim to continue my fellowship coverage. But does it also make sense to do some anesthesia locums work until I start so I have some income? I won’t have other benefits but assuming it is just a month or two is it realistic to find locums for such a short period of time? Anything else I should be considering?

Do you get platelets before every spinal, even for an outpatient knee surgery?

And are people giving an OB dose of hyperbaric bupi for their knees or something else?

I was under the impression that most people are doing adductor canal blocks and a purely local anesthetic spinal, no opioid

A job that pays 20% more and I can nearly pay off all my student loans, but is academic and amount of vacation sucks. Also not near family. Would be a 1 year deal for us.

OR

PP in a great area near family but the pay is lower with more frequent call. No post call day off.

Where can I learn more on what is the max safe dose to avoid LAST when two separate local anesthetics are used.

Example, 20ml of 0.5% ropivacaine used for an interscalene block in preop. Followed by the surgeon doing their own 2 hours later but uses 20ml of 0.5% bupivacaine.

Its easy to see the safe dose of a single agent but I'm not sure about when more than one agent is involved with a X amount of time inbetween.

Any help in being pointed in the right direction would be appreciated.

Does anyone have any ideas or protocols for reducing loss of equipment in the ORs?

Background: Medium sized academic center with Attendings, CRNAs, SRNAs, Residents, Locums attendings and CRNAS. We have been dealing with attrition of our handheld Video Laryngoscopes.

What do you do at your institution?

What are things that have worked?

Things we have considered: Tracking like narcotics in our omnicells, assigning 1 per provider and having to buy another if you lose it.

Edit: We think our initial loss was likely due to improper training/handling - likely lost a fair amount to remote locations/trash.

However since then we have had steady continued loss - and potentially an uptick right before resident graduation.