Locums Again

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Noyac

Noyac

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More problems with locums. Now the surgeons are saying they don't want to work with locums any longer. Many of you think I am picking on the locums physicians and that I have some sort of prejudice towards them. Fair enough! But it's not just me. And it's not unfounded. Just last week we had 2 unexpected ICU admissions, both locums anesthesiologists. Our surgeons are revolting. And we are very selective of the locums that we use. They all have good educations, work experience is heavy and diverse, and references are without a blemish.

Once again I highly discourage locums work for new grads except for only the right situation.
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Noyac said:
More problems with locums. Now the surgeons are saying they don't want to work with locums any longer. Many of you think I am picking on the locums physicians and that I have some sort of prejudice towards them. Fair enough! But it's not just me. And it's not unfounded. Just last week we had 2 unexpected ICU admissions, both locums anesthesiologists. Our surgeons are revolting. And we are very selective of the locums that we use. They all have good educations, work experience is heavy and diverse, and references are without a blemish.

Once again I highly discourage locums work for new grads except for only the right situation.
Click to expand...


What's the degree of acuity in your patient population? What were the causes for the ICU admissions and were they directly linked to periop complications?
 
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Noyac said:
Not any more than any other place. Can locums not take care of sicker pts?
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If these were not acutely ill/trauma patients or patients with life threatening issues then maybe your locums are deficient. Knowing the context of the events would help in that regard.
 
Noyac said:
Not any more than any other place. Can locums not take care of sicker pts?
Click to expand...

I've got limited experience with locums docs, but haven't been impressed much so far. I think part of it is a "use it or lose it" kind of thing. I worked with a doc last summer that had done absolutely nothing but supervise anesthetists in a GI center for three years straight out of residency - then she decided she was bored (wow, what a surprise) and her first locums assignment was a Level 1 trauma center / teaching hospital with loads of sick patients. She was more than a tad overwhelmed and didn't last a month.
 
jwk said:
I've got limited experience with locums docs, but haven't been impressed much so far. I think part of it is a "use it or lose it" kind of thing. I worked with a doc last summer that had done absolutely nothing but supervise anesthetists in a GI center for three years straight out of residency - then she decided she was bored (wow, what a surprise) and her first locums assignment was a Level 1 trauma center / teaching hospital with loads of sick patients. She was more than a tad overwhelmed and didn't last a month.
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That's an absolute No No. We won't even consider someone that supervises. They must be doing their own cases.
 
Noyac said:
More problems with locums. Now the surgeons are saying they don't want to work with locums any longer. Many of you think I am picking on the locums physicians and that I have some sort of prejudice towards them. Fair enough! But it's not just me. And it's not unfounded. Just last week we had 2 unexpected ICU admissions, both locums anesthesiologists. Our surgeons are revolting. And we are very selective of the locums that we use. They all have good educations, work experience is heavy and diverse, and references are without a blemish.

Once again I highly discourage locums work for new grads except for only the right situation.
Click to expand...


this again ... YAWN. you brought this thread up already months ago. We get it. DONT DO LOCUMS. you hate locums, new grads shouldnt do locums. all locums are evil. OK. we get it. You stated your opinion. and thats all it is, your opinion. Now can we close this thread. If your place was soooo great. you wouldnt need locums.
 
Noyac,

I have heard it rumored that it's a regular occurrence that the locums dude/dudette gets all of the crappiest cases with the hardest-to-work-with surgeons. Couple that with the fact that they are an "unknown entity" trying to, in a rapid timeframe, adjust to a specific culture within a hospital that may have a prejudice against them and trying to figure out how to navigate a group of people used to having their cases done a certain way. It's a difficult situation for even the best of locums practitioners to be in.

So, in short, your story doesn't really suprise me. And, I'm not specifically or necessarily defending or castigating the actions of anyone.

-copro
 
We don't give the crappiest cases to the locums b/c we have learned that it does not help the situation. We try to give them the straight forward cases, one of the 2 cases last week was a routine Lap Chole and the other was a small bowel obstruction. Not difficult cases.

Maceo, while expected nothing different from you I will still address your response. The reason I bring this up again is b/c the stakes have changed. Now our surgeons are saying they won't work with locums. And it's not a question of whether my gig is "soooo great" or not. If you have been paying attention you will remember that I am a hospital employee. We don't control the number of anesthesiologist the hospital chooses to employ. We just do the cases and if they choose to run lean and fill in the gaps with locums then that is their choice, not mine. So do you care to tell us why locums can't do bread and butter cases? Or do you prefer to just pick fights? I won't argue with you on this thread unless you want to discus the issue.
 
Noy whats your take on military guys who work locums to keep their skills up? Any prejudice against working with those guys? Is their a market for guys to work 1-2 weekends a month?
 
Noyac said:
We don't give the crappiest cases to the locums b/c we have learned that it does not help the situation. We try to give them the straight forward cases, one of the 2 cases last week was a routine Lap Chole and the other was a small bowel obstruction. Not difficult cases.

Maceo, while expected nothing different from you I will still address your response. The reason I bring this up again is b/c the stakes have changed. Now our surgeons are saying they won't work with locums. And it's not a question of whether my gig is "soooo great" or not. If you have been paying attention you will remember that I am a hospital employee. We don't control the number of anesthesiologist the hospital chooses to employ. We just do the cases and if they choose to run lean and fill in the gaps with locums then that is their choice, not mine. So do you care to tell us why locums can't do bread and butter cases? Or do you prefer to just pick fights? I won't argue with you on this thread unless you want to discus the issue.
Click to expand...

Well, this is a serious issue if the actions of an anesthesiologist directly led to an ICU admission in a patient undergoing a routine laparoscopic cholecystectomy. However, an SBO may or may not necessarily be a "routine" or "healthy" case, at least I don't think of them as such ("full stomach", usually altered metabolic status, dehydrated, etc.), and may as a course of their illness end up in the SICU, depending on findings intra-op and/or extent of their surgery.

Care to elaborate on the specifics of each of these cases? Was the lap chole SICU admission due directly to the actions of the locums, and how so if so? What was the pre-op status of the SBO? Was it emergent? Was it someone in-house who'd already been resuscitated? Co-morbidities? Adequate pre-op work-up?

Please help us learn from these people's mistakes. Thanks in advance.

-copro
 
Noyac said:
We don't give the crappiest cases to the locums b/c we have learned that it does not help the situation. We try to give them the straight forward cases, one of the 2 cases last week was a routine Lap Chole and the other was a small bowel obstruction. Not difficult cases.

Maceo, while expected nothing different from you I will still address your response. The reason I bring this up again is b/c the stakes have changed. Now our surgeons are saying they won't work with locums. And it's not a question of whether my gig is "soooo great" or not. If you have been paying attention you will remember that I am a hospital employee. We don't control the number of anesthesiologist the hospital chooses to employ. We just do the cases and if they choose to run lean and fill in the gaps with locums then that is their choice, not mine. So do you care to tell us why locums can't do bread and butter cases? Or do you prefer to just pick fights? I won't argue with you on this thread unless you want to discus the issue.
Click to expand...

I like the truth. I hate bias. Thats why it is very difficult for me to watch primetime cable news.

I need to know why those patients went to the ICU? Difficult intubation unable to extubate. pulm edema from fluid overload? they were very sick to begin with? whats the deal? IS it a personality issue? ask them directly. WHy dont you want to work with LOCUM A? or LOCUM B? Surgeons are a picky group you know that. They may feel slighted because none of you permanent big dogs want to work with them? do they feel the locums is actively killing their patients. If its a personality issue tell them they get the locums or they get nobody and there is nothing you can do about it. Sounds like they are primadonas.

copro said it right. It is not so much the skill of a locum, it is adjusting to the environment in a quick fashion. Anesthesia becomes easy as pie once you know all the variables. Once you know surgeon a takes 27.5 mins to do his lap chole and then he goes down to the cafeteria to get a BJ from the lunchlady for exactly 17 mins every monday then comes back up sees the patient first then scratches his nuts before he goes to the room. once you got it down like that anesthesia is EASY. or at least easier.
 
Noy,

If you did locum yourself, would you be automatically bad?
 
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narcusprince said:
Noy whats your take on military guys who work locums to keep their skills up? Any prejudice against working with those guys? Is their a market for guys to work 1-2 weekends a month?
Click to expand...

I don't have any problems with people doing locums per se. I am talking about doing it solely. Not to mention right out of residency. Granted, this is an internet forum. You don't know me and I don't know you. So take what I say with a grain of salt. People can pick fights with me on this and that is fine. I'm just giving my impression. If you don't like it, ignore it or give me hell. It's your life.

Military or otherwise, walking into a strange environment and expecting to perform as those that routinely work there is difficult. Everything is less familiar to you including surgeons, staff, instruments/supplies, administration, consultants, and on and on. You may be a solid provider but you are at a disadvantage. If it is a place with many locums then you will likely shine but if its just you and the regulars you will struggle at times.

So if you want to make some extra cash and "keep the skills up" then go for it but realize that the game has changed.

Contrary to some beliefs here, I am not trying to say that I am better than anyone that does locums, except for you Maceo :)laugh: thats a joke). I'm just trying to give one practices perspective on the locums pool.
 
maceo said:
I need to know why those patients went to the ICU? Difficult intubation unable to extubate. pulm edema from fluid overload? they were very sick to begin with? whats the deal? IS it a personality issue? ask them directly. WHy dont you want to work with LOCUM A? or LOCUM B? Surgeons are a picky group you know that. They may feel slighted because none of you permanent big dogs want to work with them? do they feel the locums is actively killing their patients. If its a personality issue tell them they get the locums or they get nobody and there is nothing you can do about it. Sounds like they are primadonas.
Click to expand...

Yes the surgeons are primadonnas. Are you saying that the ones you work with are not?

Yes, we have made it clear that certain cases and certain surgeons get locums for different reasons. They do feel slighted at times. To the point that whenever they get a locums they think they are getting the shaft. But in all honesty, the locums guy has to go somewhere, right? We give the locums the easiest cases we have (ie: lap chole).

I won't go into details of the cases but lets say your pt took a long time to recover from zemuron after an ERCP and you reintubated him in the pacu then sent hi to the ICU. Now you get to do his lap chole the next day, would you be careful with the zemuron this time? This isn't that difficult.
 
urge said:
Noy,

If you did locum yourself, would you be automatically bad?
Click to expand...

It depends. Am I working with a bunch of regulars? Then yes, I am at a disadvantage.

If its a bunch of locums I'm compared to then who knows.
 
Noyac said:
I won't go into details of the cases but lets say your pt took a long time to recover from zemuron after an ERCP and you reintubated him in the pacu then sent hi to the ICU. Now you get to do his lap chole the next day, would you be careful with the zemuron this time? This isn't that difficult.
Click to expand...

Your guy did an ERCP with GA? Is that routine at your hospital?
I was always able to do those under (very big) MAC, with GA only for one patient who was sick as ****.
 
So how do you guys plan to handle the situation? Is the hospital giving up on locums? Are you going to hire more permanent people?
 
powermd said:
Your guy did an ERCP with GA? Is that routine at your hospital?
I was always able to do those under (very big) MAC, with GA only for one patient who was sick as ****.
Click to expand...

Depends on the pt, provider, GI guy, etc. Some do MAC some do GA.
 
Noyac said:
Yes the surgeons are primadonnas. Are you saying that the ones you work with are not?

Yes, we have made it clear that certain cases and certain surgeons get locums for different reasons. They do feel slighted at times. To the point that whenever they get a locums they think they are getting the shaft. But in all honesty, the locums guy has to go somewhere, right? We give the locums the easiest cases we have (ie: lap chole).

I won't go into details of the cases but lets say your pt took a long time to recover from zemuron after an ERCP and you reintubated him in the pacu then sent hi to the ICU. Now you get to do his lap chole the next day, would you be careful with the zemuron this time? This isn't that difficult.
Click to expand...

Yes. I would be more careful with the zemuron. Am I hired??;)
 
powermd said:
Your guy did an ERCP with GA? Is that routine at your hospital?
I was always able to do those under (very big) MAC, with GA only for one patient who was sick as ****.
Click to expand...

We do almost all our ERCP's under geta. I don't really know why, just is the usual routine.
 
What part of the country are you in and what are the terms of your group, Noyac? I am currently in search of a new home, since my wife hates our current location :laugh:
 
Noyac said:
I won't go into details of the cases but lets say your pt took a long time to recover from zemuron after an ERCP and you reintubated him in the pacu then sent hi to the ICU. Now you get to do his lap chole the next day, would you be careful with the zemuron this time? This isn't that difficult.
Click to expand...

Without knowing the details it is hard to judge what happened but it isn't exactly rocket science in dosing the roc for an ercp. Screwing that up is pretty weak.
 
Arch Guillotti said:
Without knowing the details it is hard to judge what happened but it isn't exactly rocket science in dosing the roc for an ercp. Screwing that up is pretty weak.
Click to expand...

Did he use the roc for RSI due to a succ contraindication? Dosing roc at the 1.2mg/kg for that = a prolonged paralysis.
 
Surgeons don't want locums. Sounds like the anesthesiologists would prefer not to have locums. Sounds like the hospital needs to bite the bullet and keep the surgeons happy. Hiring someone can't be more expensive than a locums.
 
I agree! And I plan on doing locums right out of residency for 1-2 weekends/month during my pain fellowship for financial and clinical reasons. Not everyone just graduates and goes right into anesthesia. Some of us want additional training, which takes us outside the OR or at least to the other side of the drape for a year. Locums allows up to maintain our skills during this period. Noyac, is my reasoning flawed????? It's not a perfect system, everyone's circumstances are different. I would personally work with a known surgeon rather than a Locums surgeon as well (which I do often), but unlike the surgeons at your institution I deal with it rather than piss in my pull-ups.


maceo said:
this again ... YAWN. you brought this thread up already months ago. We get it. DONT DO LOCUMS. you hate locums, new grads shouldnt do locums. all locums are evil. OK. we get it. You stated your opinion. and thats all it is, your opinion. Now can we close this thread. If your place was soooo great. you wouldnt need locums.
Click to expand...
 
Last edited:
panetrain said:
I agree! And I plan on doing locums right out of residency for 1-2 weekends/month during my pain fellowship for financial and clinical reasons. Not everyone just graduates and goes right into anesthesia. Some of us want additional training, which takes us outside the OR or at least to the other side of the drape for a year. Locums allows up to maintain our skills during this period. Noyac, is my reasoning flawed????? It's not a perfect system, everyone's circumstances are different. I would personally work with a known surgeon rather than a Locums surgeon as well (which I do often), but unlike the surgeons at your institution I deal with it rather than piss in my pull-ups.
Click to expand...

GO back and read the last line of my first post in this thread.:slap:
 
So I guess you wanted me to interpret "only the right situation" to mean during pain fellowship? I love it when attendings expect us to read their minds.:D I don't bother anymore, their minds aren't worth reading.:thumbdown:


Noyac said:
More problems with locums. Now the surgeons are saying they don't want to work with locums any longer. Many of you think I am picking on the locums physicians and that I have some sort of prejudice towards them. Fair enough! But it's not just me. And it's not unfounded. Just last week we had 2 unexpected ICU admissions, both locums anesthesiologists. Our surgeons are revolting. And we are very selective of the locums that we use. They all have good educations, work experience is heavy and diverse, and references are without a blemish.

Once again I highly discourage locums work for new grads except for only the right situation.
Click to expand...
 
So I guess you wanted me to interpret "only the right situation" to mean during pain fellowship? I love it when attendings expect us to read their minds.:D I don't bother anymore, their minds aren't worth reading.:thumbdown: :diebanana:


Noyac said:
More problems with locums. Now the surgeons are saying they don't want to work with locums any longer. Many of you think I am picking on the locums physicians and that I have some sort of prejudice towards them. Fair enough! But it's not just me. And it's not unfounded. Just last week we had 2 unexpected ICU admissions, both locums anesthesiologists. Our surgeons are revolting. And we are very selective of the locums that we use. They all have good educations, work experience is heavy and diverse, and references are without a blemish.

Once again I highly discourage locums work for new grads except for only the right situation.
Click to expand...
 
panetrain said:
So I guess you wanted me to interpret "only the right situation" to mean during pain fellowship? I love it when attendings expect us to read their minds.:D I don't bother anymore, their minds aren't worth reading.:thumbdown: :diebanana:
Click to expand...

What more do you want me to say? If the situation is right "for you" then do it. You are an adult, act like one and make up your own mind.

Why are you so sensitive about this?

I have only said that the locums pool seems to be pretty poor, in so many words. I didn't mention anyone here b/c I don't know any of you, as far as you know. I'm sure that all of you are studs and studettes. So why some much insecurity?

And I don't expect you to read my mind but I do expect you to understand what I am saying out loud. Why don't you ask your mommy if she can help you out here?
 
Noyac said:
What more do you want me to say? If the situation is right "for you" then do it. You are an adult, act like one and make up your own mind.

Why are you so sensitive about this?

I have only said that the locums pool seems to be pretty poor, in so many words. I didn't mention anyone here b/c I don't know any of you, as far as you know. I'm sure that all of you are studs and studettes. So why some much insecurity?

And I don't expect you to read my mind but I do expect you to understand what I am saying out loud. Why don't you ask your mommy if she can help you out here?
Click to expand...

What if we know who you are? ;)

-copro
 
SexPanther said:
Did he use the roc for RSI due to a succ contraindication? Dosing roc at the 1.2mg/kg for that = a prolonged paralysis.
Click to expand...


I missed the part about an RSI being necessary. Even if it was the scenario shouldn't have happened. if an RSI is absolutely necessary and sux is contraindicated the use the hidose roc and then just wait it out w/propofol gtt afterwards if necessary before reversing and extubating. If the RSI is a soft call do a "modified" RSI and use a lower dose of roc
 
I like alfenta + induction agent in this situation when sux is contraindicated and roc will last too long. May be a sqosh of ephedrine to chase it PRN. Works great.



Arch Guillotti said:
I missed the part about an RSI being necessary. Even if it was the scenario shouldn't have happened. if an RSI is absolutely necessary and sux is contraindicated the use the hidose roc and then just wait it out w/propofol gtt afterwards if necessary before reversing and extubating. If the RSI is a soft call do a "modified" RSI and use a lower dose of roc
Click to expand...
 
Locums would suggest I make more than 50K a year!

Is it inappropriate to elucidate more why roc was used? In RESIDENCY, we have all burned ourselves with RSI dose Roc or panc, but we should know better after the first time...

Noyac said:
Your obviously not a locums.
Click to expand...
 
DrDre' said:
Locums would suggest I make more than 50K a year!

Is it inappropriate to elucidate more why roc was used? In RESIDENCY, we have all burned ourselves with RSI dose Roc or panc, but we should know better after the first time...
Click to expand...

RSI dose panc:hungover: :prof: :slap:

I routinely give roc for ERCP but it is usually low dose, sometimes they don't even lose all their twitches.
 
Sorry, I am a slow typist so I try to economize. I meant rsi dose roc or normal dose panc, as examples of agents that can last a long time.

Arch Guillotti said:
RSI dose panc:hungover: :prof: :slap:

I routinely give roc for ERCP but it is usually low dose, sometimes they don't even lose all their twitches.
Click to expand...
 
So lets say you gave a pt roc for an ercp and that pt took forever to recover. So long that you reintubated and sent the pt to the ICU. Now the next day, you are assigned to the same pt for a Lap Chole. Are you going to give ROC? How much?

This locums gave the same f*cking drug, extubated a weak pt again, reintubated in pacu, and sent the pt back to the ICU. Really!:eek:
 
Noyac said:
So lets say you gave a pt roc for an ercp and that pt took forever to recover. So long that you reintubated and sent the pt to the ICU. Now the next day, you are assigned to the same pt for a Lap Chole. Are you going to give ROC? How much?

This locums gave the same f*cking drug, extubated a weak pt again, reintubated in pacu, and sent the pt back to the ICU. Really!:eek:
Click to expand...

Wowzers.

Also, I look forward to the days where the time it takes to do a lap chole contraindicates the use of roc on induction.
 
Hawaiian Bruin said:
Wowzers.

Also, I look forward to the days where the time it takes to do a lap chole contraindicates the use of roc on induction.
Click to expand...

Yeah, now you see what we are dealing with.

ANd if you do locums, this is what you may be lumped into. It's your choice. I'm sure you are better than this panechoochoo but it is reality and unless you arrange the locums gig yourself and personally know the folks you are helping out, you may find locums to be a rude awakening.

But something tells me you are the "exception".:laugh: (I'm not talking about you HB).
 
Noyac said:
So lets say you gave a pt roc for an ercp and that pt took forever to recover. So long that you reintubated and sent the pt to the ICU. Now the next day, you are assigned to the same pt for a Lap Chole. Are you going to give ROC? How much?

This locums gave the same f*cking drug, extubated a weak pt again, reintubated in pacu, and sent the pt back to the ICU. Really!:eek:
Click to expand...


First, who sends a pt to the ICU because of prolonged neuromuscular blockade?

Second, is the locums familiar with twitch monitors?
 
Noyac said:
Answer to first, Locums

Answer to second, well it appears not.
Click to expand...

Who accepted the patient in ICU? What's the policy at your hospital for post op ventilator in PACU? I mean the reason for ICU admission was respiratory support for 1h? And another bill for the ICU physician for admission and another one maybe for discharge. And again - one of the problems is not rocuronim used for induction - it is the failure to proper asses before extubation. And of course the failure to learn from previous mistake. The locums that I've met were good phsycians facing an unknown variable - the surgeon.
 
Noyac said:
This locums gave the same f*cking drug, extubated a weak pt again, reintubated in pacu, and sent the pt back to the ICU. Really!:eek:
Click to expand...

The mind, it boggles.


Hawaiian Bruin said:
Also, I look forward to the days where the time it takes to do a lap chole contraindicates the use of roc on induction.
Click to expand...

Ain't that the truth ...

30 minute skin closure on a c-section at 4 AM this morning ... almost an hour total post-delivery. (Followed by the nurse taking 15 more to "get ready" to move the patient to the gurney ... guess an hour wasn't enough to chart and surf the Entertainment Weekly web site.)

This anti-efficiency vortex is sucking the life out of me.
 
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