Dryacku said:
Do any of you have much experience with cardiac anesthesia? I find it very interesting and much more stimulating then other cases Ive seen so far (besides trauma and transplant)....
Is there a need for cardiac anesthesia? Is pay greater? Is the training more intense or can anybody do it? also are crnas certfied to do these cases?
also is it necessary to do a fellowship?
just some general info would be helpful...
thanks
In the past year in private practice, I have so far done about 110 - 120 hearts, mostly CABG's and AVR's with or without root replacements, with a few Ross procedures, MVR's, TVR's, and open or closed chest MAZE and TMR procedures. In other words, there is plenty out there in private practice.
There is a need in the sense that not many people want to do cardiac anesthesia because pay for it sucks. For a 4-5 hour off pump CABG, you bill 25 base points, plus about 20 points for art line, central lines, and PAC, and TEE (TEE is usually not paid for unless you do a complete exam plus have justification for doing it like preexisting A-fib, aortic aneurysm, etc.). For a 4-5 hour case, you would add another 20 points. So 65 points sounds great. At a medicare rate of 12-15 dollars/point, it adds up to about $800 (after throwing out the TEE, although in Texas you can now get reimbursed about $100 for TEE if your patient has < 30% EF documented in your report). Compare that with 4 hours of ENT or lap chole's or lap bands (roughly $2,000-$3,000 of billing). As Jet stated on another post, you need to find a practice with a low medicare/medicaid/free rate of reimbursement, but especially if you want to do a lot of cardiac and you are getting paid what you bill straight up. A young, privately insured patient turns that 65 point case into a 40-90 dollar/point reimbursement scenario.
Every anesthesiologist gets at least some cardiac training in residency, so you can do it in private practice without a fellowship. However, you better hope that a complication that you never saw in training doesn't all of a sudden rear its ugly head and you better hope your surgeon doesn't ask you to do a TEE exam in that case. That happened to a guy in a facility I don't have priveleges at nor do I want to have priveleges at, but the surgeon ends up calling me asking me to go there to "proctor" the person doing the cardiac anesthesia for the case, because after the patient is in the room for 1.5 hours, the case still had not started and when the patient's pulmonary pressures skyrocketed, the surgeon asked where the TEE was to evaluate whether or not the patient's preop AI or MR had significantly worsened (which it would in this case with the manipulation of the heart for off pump).
Can CRNA's do these cases? Yes with supervision, but not the TEE's which is a critical part of cardiac anesthesia, especially as you see fewer straight forward CABG's coming out of the cath labs and more valve repairs and replacements coming in.
If you plan to do hearts without a fellowship, you had better be sure that you do a ton in residency and get tons of experience with the TEE probe. In residency, I used my rotations at private practice facilities as round the clock cardiac rotations, using TEE in cardiac cases as well as liver transplants. I finished with 186 documented cardiac cases in residency as well as over 240 recorded TEE examinations. If your residency cannot provide you with at least 50-100 cardiac cases, I would advise you to spare yourself the future close calls in the heart room and do the cardiac fellowship, if you are truly interested in doing cardiac at least partly in private practice. The training you would receive would also make you a stronger clinician in general. You have to decide if another year of education is worth the cost of a year of pay ($45-$55K pay as a fellow versus $200-$350K in your first year in private practice). I chose the latter because I made my third year my cardiac fellowship.
