Ask an Attending Anesthesiologist Anything!

[Matthew9Thirtyfive]

---

Members don't see this ad.

The Army uses an adapted ACT model. The CRNAs are trained to work very independently since they may deploy to areas without anesthesiologist support. So the way that plays out stateside is that I would manage multiple ORs with CRNAs in each. For ASA 3 and 4 patients, I steered the ship -- I had to sign the charts and I was directly involved in the patients' care. On ASA 1 and 2 patients, however, the CRNAs were allowed to function much more independently -- I didn't sign charts, and they determined their own anesthetic plan with me functioning more as a consultant. The caveat to that is that I was empowered to relieve a CRNA from duty if I felt his/her anesthetic plan was unsafe.

That sounds awesome. Thanks! I'll have to look into how the Navy does things.

 

[95ragtop]

What is your opinion on using ketamine for conscious sedation of battlefield casualties?

What is your go to drug of choice for controlling pain in severe burns?

 

[Microbug]

The Army uses an adapted ACT model. The CRNAs are trained to work very independently since they may deploy to areas without anesthesiologist support. So the way that plays out stateside is that I would manage multiple ORs with CRNAs in each. For ASA 3 and 4 patients, I steered the ship -- I had to sign the charts and I was directly involved in the patients' care. On ASA 1 and 2 patients, however, the CRNAs were allowed to function much more independently -- I didn't sign charts, and they determined their own anesthetic plan with me functioning more as a consultant. The caveat to that is that I was empowered to relieve a CRNA from duty if I felt his/her anesthetic plan was unsafe.


I honestly don't know a whole lot of MD/PhD anesthesiologists, but my department skews toward the clinical side of things. I know that some institutions' anesthesiology departments maintain divisions for both basic science and clinical research, and I imagine those are very MD/PhD-friendly.


I've had numerous exciting and/or interesting cases, though the majority of my cases are very routine. (Also, interventions most people consider "heroic" actually become very routine after you've done them enough.) I blog some of my noteworthy cases here: Gas Words.

1. That's an interesting way to put it, I don't think I've ever heard it expressed quite like that. I did plan to become a surgeon, but halfway through my MS3 year an anesthesiology resident convinced me to do an elective rotation and see if it was something I liked. I found that it was very much to my liking for several reasons, including that I love acute care; I like the interplay of physiology, pharmacology, and procedures; I enjoy spending my days in the OR; I get to provide care for all sorts of patients and procedures; and my lifestyle is much better than that of most of my surgical colleagues.
2. Pros: pretty much the things I've listed. I love what I do and I get paid very well to do it. I don't have to round and I rarely do clinic (really just the preanesthesia clinic, which I enjoy as long as it's not every day). I handle diverse cases in diverse settings, which helps keep things fresh for me. Cons: The OR is full of big egos that can be...challenging. Many patients don't know the difference between anesthesiologists and CRNAs.
3. This is an exciting field that involves much more than simply rendering patients unconscious and playing sudoku. We work hard and are trained to be the calmest people in the room when emergencies arise. The field is growing and changing, but the sky is not falling.

Do you see a scenario where a 80/20 (research/clinical) time split can work?

Also: Huge fan of your posts, sense of humor and travel stories.

 

[HomeSkool]

What is your opinion on using ketamine for conscious sedation of battlefield casualties?

In appropriate patients, it's a great thing.

What is your go to drug of choice for controlling pain in severe burns?

Buttloads of opioids and some ketamine.

Do you see a scenario where a 80/20 (research/clinical) time split can work?

Absolutely. You just have to find the right department and negotiate that as part of your employment.

Also: Huge fan of your posts, sense of humor and travel stories.

Thanks!

I mean I do get my information from reliable sources. I have a friend who is currently a PGY4 in anesthesiology and he said ever since the CRNA takeover has started attendings have been requiring to work more and more hours for the same pay... 15-20 years ago they used to make 350-400k working 40 hours a week. Now he says, they have to work 60 hours a week for the same pay. When accounting for inflation (2% per year), this is almost a 33% pay-cut. Objectively, that does seem like a pretty sweet gig. But, what is the guarantee that this pay-cut won't go even further. And your point about hospitals hiring more residents for cheap further proves my point that hospitals care 0% about patient safety, only to the point that it screws their reimbursements over/when a law-suit occurs. If there has been a 33% pay cut in a decade and a half, what is going to happen when the ratio of CRNA to attending is 6 or 8:1?

A CA-3 with no experience as an attending is hardly a reliable source, and I'm unsure why you'd take one resident's word on this matter over that of two attendings. (Actually, I do know why: it's called "confirmation bias.") Still, you're entitled to your own opinions, ill-informed though they may be. But I do ask that you stop trying to derail my AMA thread with your "the sky is falling" routine. If that's really what you want to talk about, go to the Anesthesiology forum and start your own thread there.

 

[Matthew9Thirtyfive]

Well, I would argue that a huge chunk of US and foreign medical students are thinking along the same lines of me maybe because they have heard of the same things... and the minor increase in residency spots is not explanation for how much of a joke it is to get into anesthesia now. A chunk of people applying to competitive specialties nowadays BACKUP with anesthesia because if you can't match into the specialty of your choice, at least you have a shot of matching/scrambling into a brand name anesthesia program. BTW someone from my school who didnt match ENT, scrambled into an IVY league anesthesia program. Some of my friends applying to it applied just because you have a decent chance of matching into a major city, even when being wayyyy below average. One of my friends applied to anesthesia knowing it is going to tank, but will try to land a pain fellowship, which has all the $$$$.

We get it. Anesthesiology suxorz. Now can we get back to the ama, or do I need to tell some more bad jokes?

 

[DubbiDoctor]

Well, I would argue that a huge chunk of US and foreign medical students are thinking along the same lines of me maybe because they have heard of the same things... and the minor increase in residency spots is not explanation for how much of a joke it is to get into anesthesia now. A chunk of people applying to competitive specialties nowadays BACKUP with anesthesia because if you can't match into the specialty of your choice, at least you have a shot of matching/scrambling into a brand name anesthesia program. BTW someone from my school who didnt match ENT, scrambled into an IVY league anesthesia program. Some of my friends applying to it applied just because you have a decent chance of matching into a major city, even when being wayyyy below average. One of my friends applied to anesthesia knowing it is going to tank, but will try to land a pain fellowship, which has all the $$$$.

I actually used to be very pessimistic about anesthesia, but this thread has helped change my mind. Hospitals will always want a board certified anesthesiologist for when SHTF. And fellowship opportunities exist that allow anesthesiologists to differentiate themselves, obtaining specialized education that CRNAs cannot even pretend to have. It's simply inefficient to train midlevels to the degree that physicians are trained. The purpose of midlevels is to relieve the shortage to access to healthcare by allocating less acute needs to midlevel practitioners who receive less training, as not all healthcare services require a MD/DO with many years of residency/fellowship training. Unless you think that all anesthesia cases are so simple that midlevels can handle them, you should recognize that there will always be a need for physician experts in anesthesia. Of course CRNAs will continue to lobby for independent practice - but not out of concern for patients but for the chance to make more money. For every midlevel posting an article demanding autonomy (VA denial of full practice authority for nurse anesthetists coming home to roost | TheHill), a board certified physician should pen an article in the same publication demonstrating how that would endanger patients.

All specialties will have to deal with midlevel encroachment to a greater or lesser degree. Midlevels are very common in the ED, but are they trained to handle the most acute emergencies? Absolutely not. They are there to handle more minor problems, freeing the board certified ED physicians to handle complex cases and save lives. It simply would not be efficient to train and hire enough physicians to address all ED presentations. But that doesn't mean that ED doctors will be replaced. I have no doubt that midlevels will increasingly demand autonomy in the ED. Should then ED doctors acquiesce and flee the field, despairing that they will be replaced? No, they should fight back. You may work with friendly, competent midlevels, but you must understand that their professional interests run counter to yours.

While there may be a mismatch in supply and demand - perhaps we are pumping out too many anesthesiologists, when the market demands a fewer number of physician experts in anesthesia - there will always be a demand for anesthesiologists. @HomeSkool Going off what I wrote, do you believe that an increasing number of anesthesiologists will obtain fellowship training to position themselves in the market as experts offering specialized care that CNRAs cannot provide? What fellowships are the most useful? Which are the least?

 

[HomeSkool]

Well, I would argue that a huge chunk of US and foreign medical students are thinking along the same lines of me maybe because they have heard of the same things... and the minor increase in residency spots is not explanation for how much of a joke it is to get into anesthesia now. A chunk of people applying to competitive specialties nowadays BACKUP with anesthesia because if you can't match into the specialty of your choice, at least you have a shot of matching/scrambling into a brand name anesthesia program. BTW someone from my school who didnt match ENT, scrambled into an IVY league anesthesia program. Some of my friends applying to it applied just because you have a decent chance of matching into a major city, even when being wayyyy below average. One of my friends applied to anesthesia knowing it is going to tank, but will try to land a pain fellowship, which has all the $$$$.

You seem very invested in defecating all over a field about which it's clear you have zero actual knowledge or perspective. (But hooray for your anecdotes! If you save them up in a jar, someday they might be worth something!) My only guess as to why you persist in this behavior despite me very politely asking you to stop is that you're trying to compensate for your own insecurities by lording over others.

By the way, if your friend is convinced anesthesiology is a dying field, then he's an absolute fool to go into it. Anesthesiology is not the only way into a chronic pain fellowship.

Look, I understand you're a troll; I've seen your type before. You like to look down your nose at those you deem "inferior" (golly, you're going to be a joy to work with in the OR!). I'm going to respond the way one should respond to trolls like you:

1. Report you to the mods
2. Engage the "Ignore" function

And to everyone else who comes upon this thread,
:troll:

I actually used to be very pessimistic about anesthesia, but this thread has helped change my mind. Hospitals will always want a board certified anesthesiologist for when SHTF. And fellowship opportunities exist that allow anesthesiologists to differentiate themselves, obtaining specialized education that CRNAs cannot even pretend to have. It's simply inefficient to train midlevels to the degree that physicians are trained. The purpose of midlevels is to relieve the shortage to access to healthcare by allocating less acute needs to midlevel practitioners who receive less training, as not all healthcare services require a MD/DO with many years of residency/fellowship training. Unless you think that all anesthesia cases are so simple that midlevels can handle them, you should recognize that there will always be a need for physician experts in anesthesia. Of course CRNAs will continue to lobby for independent practice - but not out of concern for patients but for the chance to make more money. For every midlevel posting an article demanding autonomy (VA denial of full practice authority for nurse anesthetists coming home to roost | TheHill), a board certified physician should pen an article in the same publication demonstrating how that would endanger patients.

All specialties will have to deal with midlevel encroachment to a greater or lesser degree. Midlevels are very common in the ED, but are they trained to handle the most acute emergencies? Absolutely not. They are there to handle more minor problems, freeing the board certified ED physicians to handle complex cases and save lives. It simply would not be efficient to train and hire enough physicians to address all ED presentations. But that doesn't mean that ED doctors will be replaced. I have no doubt that midlevels will increasingly demand autonomy in the ED. Should then ED doctors acquiesce and flee the field, despairing that they will be replaced? No, they should fight back. You may work with friendly, competent midlevels, but you must understand that their professional interests run counter to yours.

While there may be a mismatch in supply and demand - perhaps we are pumping out too many anesthesiologists, when the market requires a fewer number of physician experts in anesthesia - there will always be a demand for anesthesiologists.

Couldn't have said it better myself!

@HomeSkool Going off what I wrote, do you believe that an increasing number of anesthesiologists will obtain fellowship training to position themselves in the market as experts offering specialized care that CNRAs cannot provide? What fellowships are the most useful? Which are the least?

I think many are doing fellowships for that reason, though I'm not sure whether the proportion of fellowship-trained anesthesiologists is increasing. Some of the subspecialties are pushing for (and achieving) board-certified status, which is appropriate and desirable. The fellowships that provide the most separation from the general body of anesthesiologists are, IMO, chronic pain, critical care, cardiothoracic anesthesia, and pediatric anesthesia.

 

[FlavivirusProtease]

You have more composure than I could possibly ask for for not flaming that troll @HomeSkool.

 

[DubbiDoctor]

:troll:
I think many are doing fellowships for that reason, though I'm not sure whether the proportion of fellowship-trained anesthesiologists is increasing. Some of the subspecialties are pushing for (and achieving) board-certified status, which is appropriate and desirable. The fellowships that provide the most separation from the general body of anesthesiologists are, IMO, chronic pain, critical care, cardiothoracic anesthesia, and pediatric anesthesia.

Critical care is a field that deeply interests me, but I'm confused about the different pathways toward board certification. As I understand it, you can either go IM then Pulm/CC, anesthesia then CC or EM then CC. Do all three pathways provide you with the same job i.e. as an intensivist? Or are these separate jobs? That is, is an anesthesiologist trained in CC an intensivist or an anesthesiologist who can work in the ICU?

 

[DBC03]

Honestly, I don't have a top five list. I'm much more likely to put on an album and play it through, then switch to another one. Top five albums:

1. AFI - Crash Love
2. Green Day - American Idiot
3. Pearl Jam - Ten
4. U2 - Achtung Baby
5. Weezer - The Blue album

As you can probably tell, I'm a child of the grunge/alternative revolution. 🙂

Oh my gosh, I just realized I’m probably the same generation as you.

That said, I have a few questions:

- why do I (or others)get nauseated and puke for an entire day after receiving light sedation (think wisdom tooth removal or colonoscopy) and What should I say to the anesthesiologists/CRNAs in charge when I’m going under that will lead them to believe me?

Is it possible to be in a surgical field and get along with the anesthesiologist?







Sent from my iPhone using SDN mobile

 

[TypeADissection]

Big ups to @HomeSkool and other anesthesiology colleagues. We can't do our job without them, or I guess we could, but that'd just be barbaric. They're great assets to have for your trauma patients in shock, patients with ruptured/dissected aortas, and overall critical care skills with multiple comorbid conditions. Do choose anesthesia if you like applied physiology, procedures, and a healthy amount of self-esteem and confidence. This really isn't a question. Just more of plug for how great anesthesia is and that more students should investigate it during their clinical years. Cheers.

 

[Lucca]

Keep this thread on topic please. Disciplinary action has been taken but I don’t want to close this thread.

 

[getdown]

Critical care is a field that deeply interests me, but I'm confused about the different pathways toward board certification. As I understand it, you can either go IM then Pulm/CC, anesthesia then CC or EM then CC. Do all three pathways provide you with the same job i.e. as an intensivist? Or are these separate jobs? That is, is an anesthesiologist trained in CC an intensivist or an anesthesiologist who can work in the ICU?

Traditionally, critical care used to be a field run by anesthesiologists but was given up due to lack of reimbursement. Unfortunately, reimbursements are up now but Anesthesiologists have competition in that with IM/pulm trained, ED trained and even surgery trained MDs. Once you're critical care certified you are qualified to staff the ICUs. This usually depends and varies from hospital to hospital who was there first. IM/pulm and ED trained guys tend to staff the MICU and Anesthesia and surgery trained guys tend to staff the SICU but technically they can cross cover. Although if you think about it a surgeon probably won't be as comfortable staffing MICU pts that have nothing to do with surgical complications. The other caveat is that your background will make you more or less comfortable with certain aspects of managing ICU patients. Someone from an Anesthesia background probably will be more adapt managing vented patients vs someone from IM/pulm managing MICU pts and the bevy of weird diseases that come through there vs someone from surgery being comfortable managing surgical complications of SICU pts.

The only other difference is that the weeks you're not covering the ICU you can potentially work in your other field. So most ICUs are setup that you're on for a week at a time and then switch with another attending. This is done to prevent burnout since the ICU can be a pretty stressful place. During your off weeks you do other stuff. In my VA, it's staffed by Anesthesia so when not in the ICU they staff the ORs. Where I trained, the ICU was staffed by trauma surgeons and on their off days they operate just like any other surgeon. They will also operate on the trauma admits while on ICU duty and then take care of them in the SICU. A lot of times groups and hospitals prefer these fellowship trained docs because they can fill multiple roles.

 

[Matthew9Thirtyfive]

Is it possible to be in a surgical field and get along with the anesthesiologist?

My n is only about 20 or so, but most of the surgeons I worked with got along with the anesthesiologists. Sure, they’d get upset when their cases got cancelled, but for the most part, everyone respected each other. There are dinguses in both fields, but if you’re not a douche bag, you’ll get along fine (and you’ll get better patient care, as the rest of the staff will actually be happy to help you).

 

[ekmf27050]

It was almost certainly unconscious movement. Remember, our bodies feel pain and discomfort even when we're asleep. That's why we shift our position while we sleep so we don't wake up with DVTs or neuropathies. It's why my wife can elbow me in the ribs and I'll roll over without waking up.

@getdown's answer can be distilled down to the four goals of anesthesia:

1. Hypnosis (i.e., unconsciousness)
2. Analgesia
3. Amnesia
4. Akinesis

The degree to which we satisfy each of those depends on the patient, procedure, and surgeon. For example, if I have a sick old man with a broken hip, I may do a spinal block that will render him insensate and motionless from the waist down, but I might then give him minimal or no sedation during the case if I felt his comorbid diseases made such medications excessively risky. In a healthier patient, I'd probably induce general anesthesia (hypnosis and amnesia), provide pain relief with opioids and some other medications (analgesia), and provide muscle relaxation with both inhalational anesthetic and IV neuromuscular blocker (akinesis). So the choice of anesthetic varies from patient to patient. But back to your comment about movement: I try to teach my residents that surgeons asking for "paralysis" often just need akinesis (i.e., they don't need the patient's muscles to be paralyzed, they just need the patient to not move), and I try to teach my surgeons that...
View attachment 230699


It depends entirely on what you find boring. Rounding? Super boring for me. Clinic every single day? Good heavens, just kill me now. Providing perioperative care for a person who's effectively enduring a controlled assault? Now we're talking! 😀

The science reassured me 50%, but the Star Trek meme brought me the rest of the way

 

[HomeSkool]

Critical care is a field that deeply interests me, but I'm confused about the different pathways toward board certification. As I understand it, you can either go IM then Pulm/CC, anesthesia then CC or EM then CC. Do all three pathways provide you with the same job i.e. as an intensivist? Or are these separate jobs? That is, is an anesthesiologist trained in CC an intensivist or an anesthesiologist who can work in the ICU?

As a corollary to @getdown's great answer, several subspecialties have multiple access routes. Right off the top of my head, I can tell you that anesthesiology, PM&R, and diagnostic radiology all allow you to do a chronic pain fellowship. I'm pretty sure sleep medicine has multiple feeder specialties, too, and there are probably others.

- why do I (or others)get nauseated and puke for an entire day after receiving light sedation (think wisdom tooth removal or colonoscopy) and What should I say to the anesthesiologists/CRNAs in charge when I’m going under that will lead them to believe me?

Great question, and one that's near and dear to me both professionally and personally (I learned as a patient that morphine makes me violently ill). In the interest of not derailing this thread, I'll send you a PM with more information. But for the benefit of all who read this, it's helpful when patients tell us a.) that they've had postoperative nausea/vomiting (PONV) in the past, b.) what they've received for it in the past, and c. ) whether any particular antiemetic regimen happened to work better for them.

Also, here's a public service announcement for all SDNers: "regimen" and "regiment" are two very different things.

Is it possible to be in a surgical field and get along with the anesthesiologist?

Sure, I get along very well with the large majority of my surgical colleagues (shout-out to @TypeADissection: thank you for the very kind and complimentary post!). The ones who don't get along well with me and my friends were generally guilty of one or more of the following behaviors:

• Questioning our management decisions and trying to direct the anesthetic care. I don't mind them asking my reasoning on a decision, but I do mind them scoffing and acting like my management decisions and concerns are silly and unreasonable. I don't sit there telling them they're putting their incision in the wrong place or using the wrong suture, do I? (Hint: I don't.)
• Bitching about being five minutes late into the room because we took the time to instruct our residents while doing blocks. If they can let their intern and med student take an hour to close a three-inch incision, I can claim a couple minutes for my trainee's education.
• Attempting to get a second OR when we're short on resources by posting an "emergency" case two minutes after we induce anesthesia on their elective case. They knew they had that consult, so that kind of behavior gets the add-on delayed (if it's not a real emergency) or the surgeon written up (if it is a real emergency).
• Fighting and whining if we express concerns and need to cancel a case. I didn't go to work today hoping to cancel cases; if I have concerns or ask questions, it's because I want to provide safe, responsible care for the patient.
• Acting like an an entitled prima donna or general arsehole.

So basically, do unto others and all that. We like it when surgeons act like we're all professionals working on the same team, not adversaries with competing interests.

And to my anesthesiologist colleagues: we need to be less passive-aggressive. Don't hate the messenger.

But like I said, I get along very well with virtually all of my surgical colleagues. We laugh, joke around, communicate well, and collaborate to deliver the best possible care to the patient. I really couldn't ask for a more outstanding group of people with whom to share my workdays.

Keep this thread on topic please. Disciplinary action has been taken but I don’t want to close this thread.

Thank you!

 

[paper_cut]

.

 

[ekmf27050]

Follow-up questions:
1) Have patients ever told you the location of buried treasure while going under/emerging?
...
2) But seriously, do people actually disclose weird stuff while on the periphery of anesthesia, or is it just normal-ish conversation that they don't remember later?
3) Regarding akinesis vs. paralysis-- in general, which types of surgeries necessitate which option? Do more ortho-type surgeries require paralysis vs. chest/abdominal surgeries, or vice versa? Does it depend more on the patient comorbidities than the type of surgery? Is there a recovery advantage to only medicating for akinesis instead of paralysis? (sorry for the question block, but that's really interesting to me 🙂 )

 

[Terry Toma]

I don't have any specific questions at the moment, but I just wanted to thank you for doing this (and getdown for offering additional thoughts). Anesthesiology wasn't on my radar when I decided to apply to med school, but my interest in the field has grown as I've learned more about it. Your posts on this thread and others have given me a better picture of what an anesthesiologist does.

IM is my very tentative plan as I start med school, but I'll definitely give some serious consideration to anesthesiology as well (especially if I find myself hating rounds).

 

[impendingdoom]

Hopefully this isnt too off topic.

Is there a physiological reason why anesthesia (or pain meds in general) make me panic - or for pain meds give me anxiety - or am I just a wimp lol. Is it related at all to what DBC03 asked about anesthesia causing nausea and vomiting?

 

[RTC19]

Thank you so much for making this thread, @HomeSkool! 🙂 🙂

Can you tell me about peds anesthesiology?

How's the job market if one is tied to a particular area due to family commitments?

Is it primarily under 5's or do people tend to get a nice spread from preemies-18?

Are there community peds gas jobs or is it like some other peds specialties that tie people to academics?

Also, how difficult was it for you to get a job as a general anesthesiologist? I may or may not snoop on the Gas forum on occasion and I got the impression that it was often easier to find a job with a fellowship as opposed to without.

 

[1203xx]

What is your salary and how much do you work per day/week/month?

 

[mestielest]

Hi! Thanks for the interesting thread.

I want to ask about a situation that I see often in my country (Turkey). Anytime we (attendings from surgical branches) consult a preoperative patient to the anesthesiologists in our hospital, they are trying to find some pretext to turn the case down. They are also refusing to carry out some respectively special procedures i.e. caudal block for children or epidural anesthesia for C/S. Therefore we often lead our patients to external hospitals because of these problems.

I'm working in a state health-care, training and research hospital (tertiary center); if it holds importance.

I wonder if the same things happen in the US as frequent as here?

 

[IlDestriero]

Do you see a scenario where a 80/20 (research/clinical) time split can work?

That would be consistent with a tenure track research job in academia. They’re actually not all that common in anesthesia where you need a lot of boots on the ground in 30 ORs, and offsites, and out of OR stuff, and ASCs.
But it can be done. If that’s what you want consider a PhD or research years to prepare you for getting your own grants, etc.
50/50 is much easier to do. But you won’t have the research time to be a tenure track anymore.


--
Il Destriero

 

[IlDestriero]

Hi! Thanks for the interesting thread.

I want to ask about a situation that I see often in my country (Turkey). Anytime we (attendings from surgical branches) consult a preoperative patient to the anesthesiologists in our hospital, they are trying to find some pretext to turn the case down. They are also refusing to carry out some respectively special procedures i.e. caudal block for children or epidural anesthesia for C/S. Therefore we often lead our patients to external hospitals because of these problems.

I'm working in a state health-care, training and research hospital (tertiary center); if it holds importance.

I wonder if the same things happen in the US as frequent as here?

That’s all routine stuff here in the US. Everyone can do a caudal, epidural, routine nerve blocks/catheter, etc.
I wouldn’t say we look for reasons to not do cases, as they need to get done eventually, but we look to see if they’re optimized and if additional stuff should be done before the elective or semi elective cases (labs, imaging, consults, echo, etc.)
I’ve been at several major academic centers. We’re the end of the line for lots of the strange cases, not the place where we say no and punt them to another hospital. The other hospitals say no and punt them here.


--
Il Destriero

 

[HomeSkool]

Homeskool, can you shed any light on the prospects of an anesthesiologist being involved in EMS. I know EM docs generally serve as medical directors for EMS services, but is there any sort of overlap or opportunity for anesthesia to be involved too? Seems to me with the anesthesia skill set and knowledge of critical care medicine an anesthesiologist could be a useful part of an EMS agency.

There's absolutely an opportunity to be involved! Anesthesiologists are similar to EM physicians in many respects: we're acute care physicians used to handling trauma, resuscitating unstable patients, managing airways, and adjusting management plans on the fly as situations unfold. I'm aware of at least one paper discussing the role of anesthesiologists in pre-hospital care (Role of Anesthesia Team in Prehospital Care: The Hidden Treasure in Critical Settings), and anesthesiologists often work with surgeons and other professionals to teach BLS, ACLS, and the ACS's Advanced Trauma Life Support course. Depending on how trauma centers manage their staffing, anesthesiologists may be involved as soon as a patient hits the door or may defer to our EM colleagues until the decision is made to proceed to the OR.

Follow-up questions:
1) Have patients ever told you the location of buried treasure while going under/emerging?
...
2) But seriously, do people actually disclose weird stuff while on the periphery of anesthesia, or is it just normal-ish conversation that they don't remember later?
3) Regarding akinesis vs. paralysis-- in general, which types of surgeries necessitate which option? Do more ortho-type surgeries require paralysis vs. chest/abdominal surgeries, or vice versa? Does it depend more on the patient comorbidities than the type of surgery? Is there a recovery advantage to only medicating for akinesis instead of paralysis? (sorry for the question block, but that's really interesting to me 🙂 )

1. I've heard all sorts of weird stuff. Probably the most memorable was when a minimum-security inmate emerging from anesthesia loudly announced to the entire OR that the corrections officer accompanying him (who was present in the room) was "hung like a donkey." I don't even wanna know how that thought found its way into his head, but the joke's on you because now it's in your head, too.
2. Mostly, it's normal conversation that they may or may not remember clearly afterward, kinda like when someone's talking to you as you fall asleep and later you're like, "Wait, did I say something about my corrections officer being hung like a donkey or did I dream that?"
3. Questions like that are part of the reason anesthesiologists spend several years in residency (the other reason is so we can learn how to cancel cases and time our breaks to bust our surgeons as efficiently as possible). Some cases require paralysis because even small movements could be catastrophic, such as when IR is coiling an intracranial aneurysm. Other times, it's because a patient's anatomy necessitates it to facilitate surgery, such as to relax a patient's abdominal wall musculature to facilitate surgical exposure during an intraabdominal case. Other times, muscle relaxation is counterproductive. If surgeons want to monitor motor evoked potentials during a spine case, for example, paralytics shouldn't be given. Paralytics aren't benign, either, and most of them need to be reversed with other medications. But if I keep going down this road, we're gonna derail, so I'll finish with one word of advice to all the female SDNers: if you have surgery, ask your anesthesiologist if they plan to give you sugammadex (a paralytic reversal drug that hit the US market pretty recently) (it's pronounced "soo-gamma-dex"). Sugammadex is a great drug, but it effs up your birth control for about a week.

Is there a physiological reason why anesthesia (or pain meds in general) make me panic - or for pain meds give me anxiety - or am I just a wimp lol. Is it related at all to what DBC03 asked about anesthesia causing nausea and vomiting?

We're all wired differently and there's no single "right" way to respond. You know how some people are happy when they're drunk, others are sad, some are mean, etc.? Alcohol affects the GABA receptor complex in your brain, and some anesthetic medications also affect that receptor complex. So just like people respond all sorts of ways to alcohol, they also react different ways to anesthetics.

Thank you so much for making this thread, @HomeSkool! 🙂 🙂

Can you tell me about peds anesthesiology?

How's the job market if one is tied to a particular area due to family commitments?

Is it primarily under 5's or do people tend to get a nice spread from preemies-18?

Are there community peds gas jobs or is it like some other peds specialties that tie people to academics?

Also, how difficult was it for you to get a job as a general anesthesiologist? I may or may not snoop on the Gas forum on occasion and I got the impression that it was often easier to find a job with a fellowship as opposed to without.

I'm going to have to do a little research on the peds stuff since it's not stuff I've ever really looked at before.

It was quite easy for me to get my job, which I think is a combination of good timing, excellent networking, and personal awesomeness (just sayin'). I applied to my current medical center at a time when they'd been very short-handed and were just beginning the hiring process. Several of my colleagues and I have strong mutual ties to certain hospitals and training programs, which bolstered my credibility, and I came with a letter of recommendation from an internationally renowned anesthesiologist with a huge amount of name recognition in the right circles. And I won't lie: I interview damn well (and I clean up pretty good, too!). The timeline for me was: send CV to department secretary on Friday, get e-mail Monday morning inviting me to come out and interview, interview two weeks later, receive job offer next day. It was a great offer, my wife and I prayed and felt really good about it, and it's basically been a dream job for me. I couldn't be happier! 😀

 

[Matthew9Thirtyfive]

There's absolutely an opportunity to be involved! Anesthesiologists are similar to EM physicians in many respects: we're acute care physicians used to handling trauma, resuscitating unstable patients, managing airways, and adjusting management plans on the fly as situations unfold. I'm aware of at least one paper discussing the role of anesthesiologists in pre-hospital care (Role of Anesthesia Team in Prehospital Care: The Hidden Treasure in Critical Settings), and anesthesiologists often work with surgeons and other professionals to teach BLS, ACLS, and the ACS's Advanced Trauma Life Support course. Depending on how trauma centers manage their staffing, anesthesiologists may be involved as soon as a patient hits the door or may defer to our EM colleagues until the decision is made to proceed to the OR.

1. I've heard all sorts of weird stuff. Probably the most memorable was when a minimum-security inmate emerging from anesthesia loudly announced to the entire OR that the corrections officer accompanying him (who was present in the room) was "hung like a donkey." I don't even wanna know how that thought found its way into his head, but the joke's on you because now it's in your head.
2. Mostly, it's normal conversation that they may or may not remember clearly afterward, kinda like when someone's talking to you as you fall asleep and later you're like, "Wait, did I say something about my corrections officer being hung like a donkey or did I dream that?"
3. Questions like that are part of the reason anesthesiologists spend several years in residency (the other reason is so we can learn how to cancel cases and time our breaks to bust our surgeons as efficiently as possible). Some cases require paralysis because even small movements could be catastrophic, such as when IR is coiling an intracranial aneurysm. Other times, it's because a patient's anatomy necessitates it to facilitate surgery, such as to relax a patient's abdominal wall musculature to facilitate surgical exposure during an intraabdominal case. Other times, muscle relaxation is counterproductive. If surgeons want to monitor motor evoked potentials during a spine case, for example, paralytics shouldn't be given. Paralytics aren't benign, either, and most of them need to be reversed with other medications. But if I keep going down this road, we're gonna derail, so I'll finish with one word of advice to all the female SDNers: if you have surgery, ask your anesthesiologist if they plan to give you sugammadex (a paralytic reversal drug that hit the US market pretty recently) (it's pronounced "soo-gamma-dex"). Sugammadex is a great drug, but it effs up your birth control for about a week.

We're all wired differently and there's no single "right" way to respond. You know how some people are happy when they're drunk, others are sad, some are mean, etc.? Alcohol affects the GABA receptor complex in your brain, and some anesthetic medications also affect that receptor complex. So just like people respond all sorts of ways to alcohol, they also react different ways to anesthetics.


I'm going to have to do a little research on the peds stuff since it's not stuff I've ever really looked at before.

It was quite easy for me to get my job, which I think is a combination of good timing, excellent networking, and personal awesomeness (just sayin'). I applied to my current medical center at a time when they'd been very short-handed and were just beginning the hiring process. Several of my colleagues and I have strong mutual ties to certain hospitals and training programs, which bolstered my credibility, and I came with a letter of recommendation from an internationally renowned anesthesiologist with a huge amount of name recognition in the right circles. And I won't lie: I interview damn well (and I clean up pretty good, too!). The timeline for me was: send CV to department secretary on Friday, get e-mail Monday morning inviting me to come out and interview, interview two weeks later, receive job offer next day. It was a great offer, my wife and I prayed and felt really good about it, and it's basically been a dream job for me. I couldn't be happier! 😀

This is such an awesome thread. Did you have any crazy airways while on deployment in the Army (if you deployed)? I’ve seen some case reports of guys with extreme trauma to the face and anterior neck. How do you manage the airway in a guy whose mandible has been split in two and torn to shreds?

 

[DrRiker]

Absolutely. You just have to find the right department and negotiate that as part of your employment.

Regarding one's ability to negotiate a preferable balance between research and clinical duties, how much does the reputation of one's residency matter? Would a top-10 anesthesia residency be necessary to negotiate an 80/20 research/clinical split, or vice versa? Would you speculate these conclusions remain true for other specialties?

 

[IlDestriero]

I’ve seen some case reports of guys with extreme trauma to the face and anterior neck. How do you manage the airway in a guy whose mandible has been split in two and torn to shreds?

Surgical cricothyrotomy.
They make a kit with some moderately complicated instructions, but all you actually need is a blade, your pinkey and a tube.
I did a few in my Navy days to GSW to the face.
I don’t think I’d do it in my peds practice unless the kid was pretty big and we were way way down the rabbit hole with no ENT to be found.


--
Il Destriero

 

[Matthew9Thirtyfive]

Surgical cricothyrotomy.
They make a kit with some moderately complicated instructions, but all you actually need is a blade, your pinkey and a tube.
I did a few in my Navy days to GSW to the face.
I don’t think I’d do it in my peds practice unless the kid was pretty big and we were way way down the rabbit hole with no ENT to be found.


--
Il Destriero

Yeah, I guess my question was more would you do that as an anesthesiologist on deployment, or would you defer to the surgeon? Obviously he’s getting criched. But you answered that I guess when you said you did a few. Thanks!

 

[HomeSkool]

This is such an awesome thread. Did you have any crazy airways while on deployment in the Army (if you deployed)? I’ve seen some case reports of guys with extreme trauma to the face and anterior neck. How do you manage the airway in a guy whose mandible has been split in two and torn to shreds?

I've had some crazy airways, but not as crazy as I've seen in some PowerPoint presentations. Several months ago, I had a dude who'd been shot in the face and was bleeding into his oropharynx. I topicalized his airway and did an awake fiberoptic intubation in order to secure his airway while he could still protect it, then induced general anesthesia. At my institution, awake fiberoptic intubations aren't all that uncommon.

I've seen deployment slides with airways are just bloody messes. In those cases, you put the tube where the bubbles are. (Or cut the neck, as @IlDestriero mentioned.)

Regarding one's ability to negotiate a preferable balance between research and clinical duties, how much does the reputation of one's residency matter? Would a top-10 anesthesia residency be necessary to negotiate an 80/20 research/clinical split, or vice versa? Would you speculate these conclusions remain true for other specialties?

Nearly all anesthesiology residency programs are tied to major academic medical centers or very large health systems, and the reputation of one's training can help open doors. But people in this field typically don't know or care what programs are ranked; the rankings are really a BS thing Doximity came up with in the last few years, so people don't pay them much mind and think instead about a program's reputation. For example, everyone knows UT Southwestern turns out terrific anesthesiologists. Could I have told you that Doximity has that program ranked at #27? Not until about four seconds ago.

In addition to reputation, the other thing that matters is the networking opportunities your program provides. As I mentioned above, I went to my job interview at my current hospital and found that I shared strong ties to certain training sites with several of the department's faculty, and that connection helped me get my foot in the door here. Many academic centers are heavily inbred, too, with residents frequently graduating and staying on as faculty members.

So the answer to your question, I guess, is that the rankings are BS and nobody cares about them, but reputation is important and networking is HUGE. One of the best ways to get a job on a program's faculty is to do your residency there and be the kind of resident they want to keep after graduation. And one of the best ways to get a research/clinical split is to train at a place that's friendly to that sort of thing and start sowing the seeds during residency. If you do your residency elsewhere, make sure you have the research bona fides to be credible asking for a research-heavy position. But I don't think the program you trained in will impair you as long as it's a reputable place.

 

[Matthew9Thirtyfive]

I’ll stop hogging your time. Thanks for all the great info!

 

[Matthew9Thirtyfive]

Surgical cricothyrotomy.
They make a kit with some moderately complicated instructions, but all you actually need is a blade, your pinkey and a tube.
I did a few in my Navy days to GSW to the face.
I don’t think I’d do it in my peds practice unless the kid was pretty big and we were way way down the rabbit hole with no ENT to be found.


--
Il Destriero

Also, @HomeSkool said the Army uses a modified ACT model. Do you know if the Navy is similar @IlDestriero I had heard CRNAs were essentially independent and used interchangeably with MDs.

 

[Terry Toma]

Also, here's a public service announcement for all SDNers: "regimen" and "regiment" are two very different things.

https://gomerblog.com/2018/03/disas...l-regiment/?utm_source=FB&utm_campaign=DIRECT

 

[HomeSkool]

https://gomerblog.com/2018/03/disas...l-regiment/?utm_source=FB&utm_campaign=DIRECT

 

[DBC03]

I have a few additional questions! When in your undergraduate medical education did you finally settle on anesthesiology?

Did you have research specifically in that field when you matched or did you have other types of research?

For those of us unsure of what field we want to match into, is it possible to start research during medical school that would be beneficial for multiple specialties?

If someone takes a long time to pick out a specialty, do you recommend the possibility of taking a year between 3rd and 4th year for additional research?

What have been some of your most difficult cases? I had the opportunity to spend around 40 hours in the OR - not much - but during a few cases the anesthesiologist told me a lot about the case and the complications. We had one case with an obese woman who had cirrhosis of the liver and hemophilia (might have been temporary or from medication - I don’t remember the details). It was fascinating to talk with the anesthesiologist before the case, watch throughout the case how complicated it was to keep her under and keep her CO2 and O2 levels where they needed to be, and then watch the surgeon try to finish the surgery as quickly as possible while having all sorts of internal bleeding that was difficult to stop. It was followed by a case with someone in almost impossibly good health whose surgery and anesthesia went by the textbook. The differences between the two cases revealed how much more complicated poor health makes surgery and anesthesia.


Sent from my iPad using SDN mobile

 

[HomeSkool]

I have a few additional questions! When in your undergraduate medical education did you finally settle on anesthesiology?

Fixed that for you. 😉 I did my first anesthesiology rotation in April of my MS3 year, and I formalized the decision to go into this field in June.

Did you have research specifically in that field when you matched or did you have other types of research?

I didn't have any research in the field. I did have research in a microbio lab during med school (my school gave us a dedicated block of several months for research) and quite a lot of molecular bio research (including a few papers and posters) from beforehand.

For those of us unsure of what field we want to match into, is it possible to start research during medical school that would be beneficial for multiple specialties?

I'm not really sure if any one type of research would be broadly beneficial. A lot of it depends on whether given fields want specialty-specific research or if they're just happy with research in general, as it shows willingness to participate in scholarly activity. Perhaps @aProgDirector can provide additional insights on this subject.

If someone takes a long time to pick out a specialty, do you recommend the possibility of taking a year between 3rd and 4th year for additional research?

I don't know the extent to which that would be beneficial versus seen as a red flag to PDs. @aProgDirector's insights would be very useful here, too.

What have been some of your most difficult cases?

My most challenging cases are those involving very sick patients with multiple comorbidities needing major surgical procedures. Classic example: 90-year-old patient with a broken hip, severe heart failure (like, EF 15%), anticoagulated, and with severe COPD and chronic renal insufficiency. Most anesthetics are myocardial depressants so general anesthesia can worsen the heart failure, and severe COPD means it's going to be very hard to wean the patient from the ventilator and extubate at the end of surgery. The patient could potentially lose a lot of blood during this procedure, which they'll tolerate very poorly given their pre-existing burden of disease, so we'll probably have to transfuse them, but the combination of heart and renal failure means they won't mobilize excess fluid well and I'll be walking an exceedingly fine line between giving them an appropriate amount of fluid and and flipping them into decompensated heart failure. I'd really love to do a spinal block and avoid general anesthesia, but the patient's anticoagulation makes that contraindicated. And you may think I've given you an impossibly complex nightmare of a patient, but I see that sort of presentation all the time. Those are very challenging cases that I monitor very, very closely.

 

[Matthew9Thirtyfive]

Fixed that for you. 😉 I did my first anesthesiology rotation in April of my MS3 year, and I formalized the decision to go into this field in June.

Not to nitpick, but the AAMC and many med schools refer to medical school as undergraduate medical education and residency as graduate medical education.

 

[IlDestriero]

Not to nitpick, but the AAMC and many med schools refer to medical school as undergraduate medical education and residency as graduate medical education.

That’s must be some kind of new age hippy crap.
I’ve never heard of a US medical school refer to what it’s teaching as undergraduate medical education.


--
Il Destriero

 

[DBC03]

That’s must be some kind of new age hippy crap.
I’ve never heard of a US medical school refer to what it’s teaching as undergraduate medical education.


--
Il Destriero

I *do* agree that the wording is weird. It’s been drilled into my head this year at all of my interviews, hence my use of it. However, it can probably be assumed that I was implying the medical school portion of the medical education, so the term undergraduate was unnecessary. I’ll see if I can find a website with the term for those interested.

EDIT: here are just two schools that use the term now:
Undergraduate Medical Education – University of Virginia School of Medicine
https://medschool.vanderbilt.edu/ume/

Apologies for additional off-topic posts. Back to your regularly scheduled Anesthesiology Questions!!

Sent from my iPad using SDN mobile

 

[Matthew9Thirtyfive]

That’s must be some kind of new age hippy crap.
I’ve never heard of a US medical school refer to what it’s teaching as undergraduate medical education.


--
Il Destriero

Sounds weird to me too, but it is what it is.

https://www.aamc.org/download/472906/data/howmedicaleducationischanging.pdf

Following a highly selective admissions process, medical
education is divided into three phases: medical school
(undergraduate medical education), residency training
(graduate medical education [GME]), and continuous
education and improvement (continuing medical education)

 

[DBC03]

My most challenging cases are those involving very sick patients with multiple comorbidities needing major surgical procedures. Classic example: 90-year-old patient with a broken hip, severe heart failure (like, EF 15%), anticoagulated, and with severe COPD and chronic renal insufficiency. Most anesthetics are myocardial depressants so general anesthesia can worsen the heart failure, and severe COPD means it's going to be very hard to wean the patient from the ventilator and extubate at the end of surgery. The patient could potentially lose a lot of blood during this procedure, which they'll tolerate very poorly given their pre-existing burden of disease, so we'll probably have to transfuse them, but the combination of heart and renal failure means they won't mobilize excess fluid well and I'll be walking an exceedingly fine line between giving them an appropriate amount of fluid and and flipping them into decompensated heart failure. I'd really love to do a spinal block and avoid general anesthesia, but the patient's anticoagulation makes that contraindicated. And you may think I've given you an impossibly complex nightmare of a patient, but I see that sort of presentation all the time. Those are very challenging cases that I monitor very, very closely.

I've heard a few Anesthesiologists jest that you get paid not to put patients to sleep, but to wake them back up. Sounds legit. One significant problem is that sick patients are often the ones that need surgery. And this, as you posted, can lead to significantly more complicated solutions for anesthesia.

Is there a difference in the types of cases - and the numbers of complications - an anesthesiologist would see at, say, a teaching hospital in a major metropolitan location compared to a small hospital in a small town? I know there must be significantly different anesthesia choices between inpatient and outpatient procedures (something I really didn't understand until recently, and I'm learning more about as time goes on), but I am interested to know if your location as an anesthesiologist would have a significant impact on your cases.

Also, we have an anesthesiologist in town who has a reputation for a significant proportion of patients with fairly severe nausea after procedures (it should be noted he has never done my anesthesia). Do you follow the outcomes of your patients after they wake up? Have you ever heard of similar problems with other anesthesiologists who tend to have less than stellar outcomes? Or is this too hard to track as choice of anesthesia is somewhat related to patient physiology, and outcome is not necessarily directly correlated with the anesthesiologist (ie the anesthesiologist's hands are tied and has limited options)?

 

[getdown]

I've heard a few Anesthesiologists jest that you get paid not to put patients to sleep, but to wake them back up. Sounds legit. One significant problem is that sick patients are often the ones that need surgery. And this, as you posted, can lead to significantly more complicated solutions for anesthesia.

Is there a difference in the types of cases - and the numbers of complications - an anesthesiologist would see at, say, a teaching hospital in a major metropolitan location compared to a small hospital in a small town? I know there must be significantly different anesthesia choices between inpatient and outpatient procedures (something I really didn't understand until recently, and I'm learning more about as time goes on), but I am interested to know if your location as an anesthesiologist would have a significant impact on your cases.

Also, we have an anesthesiologist in town who has a reputation for a significant proportion of patients with fairly severe nausea after procedures (it should be noted he has never done my anesthesia). Do you follow the outcomes of your patients after they wake up? Have you ever heard of similar problems with other anesthesiologists who tend to have less than stellar outcomes? Or is this too hard to track as choice of anesthesia is somewhat related to patient physiology, and outcome is not necessarily directly correlated with the anesthesiologist (ie the anesthesiologist's hands are tied and has limited options)?

Where you work will definitely have an impact on the type of cases that you will see and to some extent the complexity as well. Generally speaking, patient's who go to tertiary care centers (i.e teaching hospitals) will be very sick and complicated since the community hospitals will have transferred them there compared to the patient's in either community or outpatient surgery centers. All the weird cases are usually sent to these centers so you definitely get a bunch of those patients with rare pathologies. Also, these big centers tend to be "centers of excellence" where they do a lot of particular type of case like cardiac or transplants. Most community hospitals won't be doing too many transplants of any types. It also makes sense since these community or rural hospitals won't always have certain doctors or the necessary equipment in order to handle a particular type of case. Hence, it's always best to TRAIN in these big centers and then WORK in the community since acquity is less and chances of pts dying and you getting sued is less.

With regards to your second question. Like in any field there will always be those who are competent and those that are not as competent. There are people who I trained with that I would trust with my life and others that I would not trust with a dog's life. Thankfully, the latter is only one or two individuals. Another thing to consider is that a particular Anesthesiologist's choice of technique will gradually trend towards what's worked for them in the past and what they're most comfortable with. Regional anesthesia, for example, has made a huge comeback since the introduction of ultrasound. It's become more accurate and precise. However, those that trained before ultrasound are often more wary at using it as they're just not as comfortable as someone who trained throughout residency using it and may default to general anesthesia.

Ultimately, the choice of technique will depend on surgical necessity first and the patient's comorbidities second. If the surgery definitely needs general anesthesia but the patient's physiology may not be the best for it then you just have to bite the bullet and manage the physiology the best you can (emergency cases) or cancel the case and have their issues optimized.

 

[HomeSkool]

Not to nitpick, but the AAMC and many med schools refer to medical school as undergraduate medical education and residency as graduate medical education.

I *do* agree that the wording is weird. It’s been drilled into my head this year at all of my interviews, hence my use of it. However, it can probably be assumed that I was implying the medical school portion of the medical education, so the term undergraduate was unnecessary. I’ll see if I can find a website with the term for those interested.

EDIT: here are just two schools that use the term now:
Undergraduate Medical Education – University of Virginia School of Medicine
https://medschool.vanderbilt.edu/ume/

Apologies for additional off-topic posts. Back to your regularly scheduled Anesthesiology Questions!!

Sent from my iPad using SDN mobile

Well dang, that's a new one to me. (The "undergraduate medical education" thing, I mean. I've been hearing "GME" for years.) Still, I'm not one to go down without a fight, so I say "You damn kids and your newfangled hippie terms. Get off my lawn!"

Is there a difference in the types of cases - and the numbers of complications - an anesthesiologist would see at, say, a teaching hospital in a major metropolitan location compared to a small hospital in a small town?

As @getdown said, the larger tertiary care centers typically get the sickest patients. In addition, many larger hospitals (including mine) are level 1 trauma centers, which means we take any trauma that comes through the door -- there's nothing we ship elsewhere. I agree that it's best to train in a large tertiary care center so you can get the most extensive training with the sickest patients, but I disagree with my esteemed colleague about it being better to work in the community after training. My ideal job is what I've got right now: I spend most of my time in the big hospital with all the sick people, but I go to our satellite sites occasionally and those serve as a pressure release valve for me. Different strokes for different folks. 🙂

Also, we have an anesthesiologist in town who has a reputation for a significant proportion of patients with fairly severe nausea after procedures (it should be noted he has never done my anesthesia). Do you follow the outcomes of your patients after they wake up? Have you ever heard of similar problems with other anesthesiologists who tend to have less than stellar outcomes? Or is this too hard to track as choice of anesthesia is somewhat related to patient physiology, and outcome is not necessarily directly correlated with the anesthesiologist (ie the anesthesiologist's hands are tied and has limited options)?

I'll defer to getdown's answer and add this: everybody has bad outcomes sometimes, but there are some people around whom bad outcomes tend to cluster. Spend enough time in a department and you'll figure out which of your colleagues are more or less reliable, which ones always show up late, which ones more frequently have bad outcomes, which ones are brilliant clinicians, and which ones are Swiss Army Knives that just seem to be good at any task you throw their way (this is true for all specialties, not just anesthesiology).

 

[getdown]

As @getdown said, the larger tertiary care centers typically get the sickest patients. In addition, many larger hospitals (including mine) are level 1 trauma centers, which means we take any trauma that comes through the door -- there's nothing we ship elsewhere. I agree that it's best to train in a large tertiary care center so you can get the most extensive training with the sickest patients, but I disagree with my esteemed colleague about it being better to work in the community after training. My ideal job is what I've got right now: I spend most of my time in the big hospital with all the sick people, but I go to our satellite sites occasionally and those serve as a pressure release valve for me. Different strokes for different folks. 🙂

Hahah. I totally agree with the bolded. I think one of the benefits or our specialty is that we're able to somewhat tailor our job to our lifestyle. If you like to take care of sick and challenging patients or you like to work with residents you can work in an academic center like @HomeSkool . If you want to make a lot of money, you can potentially do that by joining a private practice OB anesthesia group. If you want to take have a good lifestyle you can just do per diem or you can do locums tenens and just travel the country covering different practices. If you like clinic (and I don't know why anyone would) you can do a pain fellowship and do chronic pain. Or if you like peds or cardiac you can do those fellowships and work in a specialty hospital and just do those cases. This is just to name a few. Personally, I kind of miss doing traumas and the excitement of taking care of those patients as they crash into the OR. But I definitely don't miss doing OB and the 3 AM screaming parturient wanting an epidural.

 

[NotAProgDirector]

If someone takes a long time to pick out a specialty, do you recommend the possibility of taking a year between 3rd and 4th year for additional research?

If students make a late decision to go into a field, a gap year is mainly helpful to get more clinical experience in that field. Research is nice, but usually the goal is to get the letters / experience needed for that field. Occassionally someone who is academically weak for a field will do a year of research to help strengthen their application.

And regarding "undergrad Med Ed"

UME = Medical School
GME = Residency
CME = Med Ed during practice.

 

[HomeSkool]

What does it take to match into a competitive Anesthesiology residency program? Does EC's matter in med school? Or research and step 1 are weighed heavily?

I asked our PD about research and this was his response:

So quality ECs matter, but research isn't mandatory. (Our program is a top-tier one.)

Can you tell me about peds anesthesiology?

How's the job market if one is tied to a particular area due to family commitments?

Is it primarily under 5's or do people tend to get a nice spread from preemies-18?

Are there community peds gas jobs or is it like some other peds specialties that tie people to academics?

I spoke with one of our peds people, and she said the job market is pretty decent, especially since peds is now a board-certified subspecialty and many hospitals require that children two years of age and younger be handled by a fellowship-trained pediatric anesthesiologist. Peds anesthesia jobs come in a few different flavors:

• Faculty at an academic medical center
• Attending at a standalone children's hospital
• Member of a private practice group

So there's some flexibility there. The case mix is very dependent on where you are. If you're a member of a community-based private practice group, you may just be doing a lot of tonsils, ear tubes, and fractures on healthy kids. If you come work in my department, you'll do all that, but you'll also do peds hearts and syndromic kids and all sorts of congenital anomalies.

Please don't hurt me. >.<

1)How must are anesthesiologists paid?

2)what is malpractice? how does it work? who pays for it?

3)how much does the insurance cost per ketamine infusion?

4)How many patients are anesthesiologists allowed to attend to at one time?

5)how common is it to run into legal trouble, and what are the top reasons it happens?

6)what other expenses are associated with being an anesthesiologist?

7)Where might I find an anesthesiologist who is interested in starting a ketamine clinic?

8)what would make you want to work in a ketamine clinic?

9) Is anyone else permitted to administer ketamine? if so, under what conditions?

First, it that profile pic is really you, I recommend changing it to protect your privacy (not because of your post, but because that's the standard for personal and professional protection on SDN).

1. Anesthesiologists typically make between $300K and $400K. There are outliers, though, and I personally know people who are outside that range on either side.
2. Malpractice is defined as negligent or inappropriate care, and malpractice insurance is insurance doctors carry to cover them in the case of a lawsuit. Depending on your practice model, malpractice may be covered by your institution, department, practice group, or yourself.
3. I've never seen malpractice insurance sold on a per-procedure basis; I'm only aware of annual contracts. The price varies by specialty, location, and amount of coverage purchased, among other things.
4. I can cover four procedures simultaneously, though I may decrease that temporarily of I have a case that's particularly challenging.
5. Many malpractice lawsuits initially name anyone who was involved in a patient's care, regardless of whether they were involved in the harmful event. Defendants are dropped from those suits as it becomes clear they were uninvolved. As shown here, the large majority of anesthesiologists will be named in such a lawsuit during their career; just under 10% will be named as the sole defendant in a suit, and only about 2% of these lawsuits end in a verdict for the plaintiff. The most common reason anesthesiologists are sued is "patient suffered an abnormal injury", which could mean anything from dental damage to death.
6. This depends on your practice model. Private practice groups have all the expenses of a medical business. As an academician, those kinds of expenses flow through my department.
7. I haven't the foggiest idea.
8. Me personally? Nothing at all. I was born for OR work.
9. Technically, any physician with an unrestricted medical license has the state's permission, but that doesn't mean their institution will allow it. Institutions will vary greatly on those whom they allow to play with the drug we affectionately know as Special K.

 

[RTC19]

I spoke with one of our peds people, and she said the job market is pretty decent, especially since peds is now a board-certified subspecialty and many hospitals require that children two years of age and younger be handled by a fellowship-trained pediatric anesthesiologist. Peds anesthesia jobs come in a few different flavors:

• Faculty at an academic medical center
• Attending at a standalone children's hospital
• Member of a private practice group

So there's some flexibility there. The case mix is very dependent on where you are. If you're a member of a community-based private practice group, you may just be doing a lot of tonsils, ear tubes, and fractures on healthy kids. If you come work in my department, you'll do all that, but you'll also do peds hearts and syndromic kids and all sorts of congenital anomalies.

Thanks so much! I really appreciate it!

 

[Matthew9Thirtyfive]

lol at your PD using "tho" in a text. That made me laugh for some reason.

 

[RockMcat520]

I asked our PD about research and this was his response:
View attachment 230941
So quality ECs matter, but research isn't mandatory. (Our program is a top-tier one.)


I spoke with one of our peds people, and she said the job market is pretty decent, especially since peds is now a board-certified subspecialty and many hospitals require that children two years of age and younger be handled by a fellowship-trained pediatric anesthesiologist. Peds anesthesia jobs come in a few different flavors:

• Faculty at an academic medical center
• Attending at a standalone children's hospital
• Member of a private practice group

So there's some flexibility there. The case mix is very dependent on where you are. If you're a member of a community-based private practice group, you may just be doing a lot of tonsils, ear tubes, and fractures on healthy kids. If you come work in my department, you'll do all that, but you'll also do peds hearts and syndromic kids and all sorts of congenital anomalies.


View attachment 230943


First, it that profile pic is really you, I recommend changing it to protect your privacy (not because of your post, but because that's the standard for personal and professional protection on SDN).

1. Anesthesiologists typically make between $300K and $400K. There are outliers, though, and I personally know people who are outside that range on either side.
2. Malpractice is defined as negligent or inappropriate care, and malpractice insurance is insurance doctors carry to cover them in the case of a lawsuit. Depending on your practice model, malpractice may be covered by your institution, department, practice group, or yourself.
3. I've never seen malpractice insurance sold on a per-procedure basis; I'm only aware of annual contracts. The price varies by specialty, location, and amount of coverage purchased, among other things.
4. I can cover four procedures simultaneously, though I may decrease that temporarily of I have a case that's particularly challenging.
5. Many malpractice lawsuits initially name anyone who was involved in a patient's care, regardless of whether they were involved in the harmful event. Defendants are dropped from those suits as it becomes clear they were uninvolved. As shown here, the large majority of anesthesiologists will be named in such a lawsuit during their career; just under 10% will be named as the sole defendant in a suit, and only about 2% of these lawsuits end in a verdict for the plaintiff. The most common reason anesthesiologists are sued is "patient suffered an abnormal injury", which could mean anything from dental damage to death.
6. This depends on your practice model. Private practice groups have all the expenses of a medical business. As an academician, those kinds of expenses flow through my department.
7. I haven't the foggiest idea.
8. Me personally? Nothing at all. I was born for OR work.
9. Technically, any physician with an unrestricted medical license has the state's permission, but that doesn't mean their institution will allow it. Institutions will vary greatly on those whom they allow to play with the drug we affectionately know as Special K.

What is considered ECs of significant matter?