Cardiothoracic Surgery in Military?

[skeyboard]

Current 3rd year undergrad considering mil med. Shadowed a cardiothoracic surgeon recently and fell in love. I realize that many (if not most) medical students change their minds during med school on specialty and that this is a very real possibility for me as well but the experience got me thinking. When I looked for integrated CT residency or CT fellowships through mil GME, I couldn't find anything and I've read on this forum that the mil outsources most of that to civ anyway. Is it even possible to get trained as a CT surgeon today through HPSP (using civilian sponsored/civilian deferred) or no given it's reduced demand by the mil?

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[DrMetal]

Shadowed a cardiothoracic surgeon recently and fell in love.

With who, the surgeon or the specialty? I knew this was one, she was so . . . .[I'll stop there, not appropriate.]

No, we don't do CT Surgery in the military. Also, you have to do a GS residency first, and there's no guarantee (in the mil) that you'll be allowed to go out to do a CT surgery fellowship.

If CT surgery is what you truly desire, stay way from military medicine.

Also, change your handle, not a good idea to use your first/last name, especially if you get involved in mudslinging (a favorite pastime on SDN).

 

[militaryPHYS]

If your goal is to be a high volume cardiothoracic surgeon I would stay civilian.

There is only one MTF that still does cardiac. There are still some thoracic cases being done at the larger MTFs but not many.

Cardiothoracic surgeons still exist but very few. No guarantee you'd get a spot. The ones that are around are all on MOU's with local institutions and have established practices outside of the MTF. But they still get pulled for operational things which takes them away from patient care for who knows how long.

So again, if you want to be a high volume CT surgeon best to stay civilian.

 

[undecided25]

Is the advice roughly similar for general surgery?

Current med student, applying to gen surg residencies this cycle and graduating in '25. Considering FAP, open to Army or Navy.

Dad was Army so grew up mostly around Ft. Campbell and Ft. Bragg, few other places. Was enlisted Navy for ~10 years, got out and went to college now med school. So I have some understanding of how the military broadly works, but milmed I'm sure has a ton of its own nuance and I've read a lot about massive changes to the system over the recent years...

Interested in fellowship eventually, likely trauma but possibly colorectal, thoracic, who knows what else I may find I love during residency.

Hard to get a good idea of what general surgery is currently like or expected to be like in 5-7 years on active duty... thanks for any advice!

 

[Nontrad_FL_LGBT]

General surgery is one of the higher demand specialties for milmed afaik. Should be fine on that end, though the competition could be high since that and Ortho are the main available surgical specialties available. There's like 1 slot for all the services for Neurosurgery for example.

 

[MedicalCorpse]

General surgery is one of the higher demand specialties for milmed afaik. Should be fine on that end, though the competition could be high since that and Ortho are the main available surgical specialties available. There's like 1 slot for all the services for Neurosurgery for example.

There are two words in military health care for patients who need either a neurosurgeon or a cardiothoracic surgeon, depending on the patient's location.

If they are anywhere under combat conditions: Expectant.

If they are in CONUS (Continental United States) other than the above: Referral.

Also, have you considered the future of cardiothoracic surgery?

Applications of Nanotechnology in the Field of Cardiology

Feature | Robotics in Cardiac Intervention: An Update - American College of Cardiology

It's all just glorified roto-rooting of plumbing, with a few valves added in to increase the degree of difficulty.
Cutting open sternums is so 20th century.

Might as well envision your future as a barber-surgeon with a fellowship in bloodletting.

In the near future, you won't need to be a surgeon to fix things like coronary arteries or cardiac valves. You will just need a good robot and a high school student to make sure it stays plugged in. Eventually, the high school student will be replaced by a cheaper trained monkey that has been Uplifted to an intelligence level far greater than our present-day politicians.

"The robot will see you now that your nanobots are prepped."

PS The best part will be that your robo-anesthesia provider will never "cancel" your cases!

 

[militaryPHYS]

There are still multiple neurosurgeons at each of the large Medical Centers. Most also have civilian partnerships set up locally. Not all patients are referred.

The point though, is that the military volume for CT and neuro surgery is relatively low and skill atrophy is felt hardest the further you subspecialize, especially in to a complex coordinated care type of subspecialty. So if you get pulled away your skills will suffer (not unlike other surgical specialties).

If you are gung ho for any specialty and see yourself being very mad if you can’t train in it or have low volume/complexity then best to stay civilian.

For example, one of the main reasons I think I am still happy is that I didn’t care what specialty I ended up in. I started USUHS wanting to be primary care flight surgeon, then shifted to trauma surgery, then to ortho based off of opportunity and what I personally saw myself enjoying and being needed in a MHS setting.

You can’t be mad at a system that doesn’t necessarily value you but you can take advantage of the opportunities that it does give you.

 

[MedicalCorpse]

You can’t be mad at a system that doesn’t necessarily value you but you can take advantage of the opportunities that it does give you.

Oh, I can be mad. Watch me.

The system I knew from 1981-1998 did value me. Then, overnight, they didn't.

Imagine that you are an orthopedic surgeon who wakes up to find out that the U.S. military has decided to replace all physician orthopedists with the PAs and NPs that they have been training for the past several decades, with occasional referrals downtown for the most complicated cases not involving basic arthroscopies, ORIFs, or open shoulder repairs, because DHA (Defense Health Agency) deems non-physician providers "OK enough" to fill that role for active duty troops.

That's exactly what we went through in anesthesiology, as I have documented extensively over the past two decades.

The only training site in the Air Force for anesthesiologists: closed.

Interns interested in anesthesiology: shunted to Flight Surgery, due to a perceived need that never existed.

Staffing slashed across the board by more than 50% in five years. Andrews went from 10-->2.1 functional anesthesiologists from 1999-2001, as I've stated (useless boss was worth 0.1 FTE [Full Time Equivalent], and that's being generous), with the same Ops Tempo (workload) expected by command from the two of us that ten used to provide, including 24/7 coverage of OB.

CRNAs were put in command of anesthesiologists, just as optometrists were put in command of ophthalmologists.

I was given the opportunity to be assigned to Elmendorf, AK, for three years without my three special needs children or my active duty (then) wife as reprisal for my speaking out for medical direction of anesthesia as the Medical Director of Anesthesia.

Just before I left, I was given the opportunity to PCS (move) with my Chinese-American family to Keesler AFB in the heart of the most racist state in the nation to be commanded by a CRNA with date of rank on me just prior to Katrina.

Then, in 2007, a CRNA was made acting Surgeon General of the Army, before another nurse was made actual Surgeon General of the Army in 2011.

You know all this. What you don't yet feel deep down is the nagging sense that penny-pinchers at the Pentagon are just *this close* to replacing all physicians in uniform with cheaper, more pliant, non-Hippocratic Oath-quoting "providers". It may happen next year, or five years from now, but the writing is on the wall.

Any medical student considering a career as a U.S. military physician should keep in mind that "a system that doesn't necessarily value you" is not one you should join for any reason, let alone just for money to pay for med school. You'll thank me for this advice one day.

 

[militaryPHYS]

I would just get out at the next opportunity and not take it so personally. They can change your whole life on a dime. The mid-level changes are occurring everywhere, not just in MilMed.

Now, if there were things changing that weren't just negative for my family but down right dangerous to the family unit or persons within the family I would push back hard. Such an instance happened with us during COVID. It was related to poor local leadership and we resolved it. I don't blame the military for that. We understand there are bad leaders some places and that will happen. We did everything in our power to respectfully push back, work through other avenues within our chain of command and then left that situation. If there wasn't a good resolution there are congressional or IG routes. Thankfully we didn't have to take that route with this leader but some did.

edit: also, reprisal is a big deal. Easy IG submission. You local congressperson also wouldn't stand for that.

 

[Res Rehab]

Just dropping my two cents on that last part.. your congressman and IG will most certainly do nothing about your situation. My case.. from my youtube video..



involved me filing 3 EO complaints over a 3 year period, another one was filed by someone other than me against the same department.
I filed two IG complaints and I wrote Steny Hoyer twice, he is the congressman who sent me to West Point. In the end, he was given evidence showing that there was something wrong, but didn't even realize what he was looking at. He said "if there's still a problem, you should call a lawyer."

Your average lawyer knows better than to bother with lawsuit against the military for destruction of career or lost income.

Sadly, the grievance process is made to create the illusion of justice. So that we don't start thinking that we are living in the Soviet Union or something. It is not meant to actually achieve justice. I remember filing my EO complaint and IG complaints with E7s and E8s and thinking.. "I believe this is a case for a very senior attorney. Why are they having enlisted men handle this?" The cases were eventually investigated by Lieutenant Colonels and Colonels without a medical background or a legal background. The attorneys in the legal department weighed in only at the end, to ensure that their findings did not implicate the command any wrongdoing or negligence.

I appreciate your optimism @militaryPHYS but this system is not built for individual justice, big picture only. Are people getting surgery and not dying for the most part? Good.

 

[pgg]

I'm a cardiac anesthesiologist. Retired from the Navy in 2022. Portsmouth and San Diego closed their CT surgery programs around the end of 2017. Bethesda still has some, but it isn't enough.

They've been sending CT surgeons to work at civilian institutions part time. It isn't enough.

Don't join if you think you'll want to do CT surgery. Most surgical specialties are underemployed. A notable exception being ortho.

 

[militaryPHYS]

Just dropping my two cents on that last part.. your congressman and IG will most certainly do nothing about your situation. My case.. from my youtube video..



involved me filing 3 EO complaints over a 3 year period, another one was filed by someone other than me against the same department.
I filed two IG complaints and I wrote Steny Hoyer twice, he is the congressman who sent me to West Point. In the end, he was given evidence showing that there was something wrong, but didn't even realize what he was looking at. He said "if there's still a problem, you should call a lawyer."

Your average lawyer knows better than to bother with lawsuit against the military for destruction of career or lost income.

Sadly, the grievance process is made to create the illusion of justice. So that we don't start thinking that we are living in the Soviet Union or something. It is not meant to actually achieve justice. I remember filing my EO complaint and IG complaints with E7s and E8s and thinking.. "I believe this is a case for a very senior attorney. Why are they having enlisted men handle this?" The cases were eventually investigated by Lieutenant Colonels and Colonels without a medical background or a legal background. The attorneys in the legal department weighed in only at the end, to ensure that their findings did not implicate the command any wrongdoing or negligence.

I appreciate your optimism @militaryPHYS but this system is not built for individual justice, big picture only. Are people getting surgery and not dying for the most part? Good.

I appreciate the detail of what you ended up having to do to have your voice heard. I think the point is you did it. When you hit a roadblock you didn’t stop.

If you stop and then just complain, the battle is lost.

 

[MedicalCorpse]

I appreciate the detail of what you ended up having to do to have your voice heard. I think the point is you did it. When you hit a roadblock you didn’t stop.

If you stop and then just complain, the battle is lost.

You are right. It is better to just shut up about problems with the system and not make waves.

Because the system spits out those who speak up and/or those who are not chosen ones by:

1) Kicking them out of residency for no good reason
2) Denying residency of choice
3) Career-ending reprimands without any ability to defend oneself
4) Adverse assignments as personal reprisals...unaccompanied if possible
5) Career-ending Unfavorable Information File generation
6) Placing non-physician "providers" in command of doctors
7) Going through the motions of IG inspection without any chance of uncovering the truth
8) Putting surgeons in command of anesthesiologists (fox running chicken house)
9) Passing over for promotion anyone who speaks out (stake that sticks up gets hammered down)
10) Ensuring the dumbest of the dumb are selected for command over smarter people (see my "use fewer sutures" anecdote)

I could go on, but you know this already. However, when you live to fix bones for 1/5th civilian pay, it may
all seem like hog heaven.

I hope it stays that way for you until your retirement. It would be sad if DHA replaced all physicians with PAs and NPs the way anesthesiologists were neutralized in favor of CRNAs, or if they just decided to outsource all care in CONUS the way they outsourced the overseas TRICARE function to the civilian International SOS corporation...but they wouldn't do that, would they?

...because I'm told the problems have been identified.

 

[militaryPHYS]

You are right. It is better to just shut up about problems with the system and not make waves.

Because the system spits out those who speak up and/or those who are not chosen ones by:

1) Kicking them out of residency for no good reason
2) Denying residency of choice
3) Career-ending reprimands without any ability to defend oneself
4) Adverse assignments as personal reprisals...unaccompanied if possible
5) Career-ending Unfavorable Information File generation
6) Placing non-physician "providers" in command of doctors
7) Going through the motions of IG inspection without any chance of uncovering the truth
8) Putting surgeons in command of anesthesiologists (fox running chicken house)
9) Passing over for promotion anyone who speaks out (stake that sticks up gets hammered down)
10) Ensuring the dumbest of the dumb are selected for command over smarter people (see my "use fewer sutures" anecdote)

I could go on, but you know this already. However, when you live to fix bones for 1/5th civilian pay, it may
all seem like hog heaven.

I hope it stays that way for you until your retirement. It would be sad if DHA replaced all physicians with PAs and NPs the way anesthesiologists were neutralized in favor of CRNAs, or if they just decided to outsource all care in CONUS the way they outsourced the overseas TRICARE function to the civilian International SOS corporation...but they wouldn't do that, would they?

...because I'm told the problems have been identified.

Huh? I said the opposite of shutting up. If you hit a roadblock (dead end IG or congressional) keep pushing like resrehab did.

Please don’t blatantly spin things to suit your needs

 

[DrMetal]

8) Putting surgeons in command of anesthesiologists (fox running chicken house)

I agree with this point whole-heartedly! (CRNAs are now in charge of anesthesiologists)

 

[MedicalCorpse]

Huh? I said the opposite of shutting up. If you hit a roadblock (dead end IG or congressional) keep pushing like resrehab did.

Please don’t blatantly spin things to suit your needs

You wrote: "If you stop and then just complain, the battle is lost."

I tried appealing my LORs (for advocating sending a child from Malcolm Grow to Walter Reed persuant to the wishes of the patient's mother, etc.) to the idiot who issued them. Surprisingly, he refused to admit he was an idiot.

I appealed to my specialty Consultant, who was also my immediate boss. She said she was so sorry that she wouldn't put her neck on the line to support me, because it would make waves and might take time away from staying home with her kids instead of working for most of her remaining time before retirement.

I went to the Inspector General on base, who said that their job is not to "inspect" anything, but rather to cover up messy issues in order to protect the powerful people in the system. O-6s and above are powerful. Since I wasn't one, I was out of luck. "Better luck next incarnation" was their attitude.

I didn't bother with appealing to my hospital commander, who was a nurse who spent most of her time traveling around the country as assistant Air Force Surgeon General for Nursing advocating for empowerment and and leadership of her wonderful nurses over the stinking doctors under her.

I certainly didn't bother with Congress after our rights had been grossly trampled by the Patriot Act and the subsequent ignoring of the blatantly illegal wiretapping of millions of Americans, for which no one has gone to jail to this day. We were in a needless war of choice led by a war president in order to get back at the bad dude who had tried to kill his dad. Our military was the best, and anyone who said otherwise was with the terrorists.

After I got out, I did write and pay for a web site with my own money without any paid ads for more than a decade, until personal circumstances intervened. I recently resurrected it. Just like an old starship in a science fiction show, different areas are gradually coming back online.

I stopped (my service in uniform) and complained (online, in person, to the pigeons around my park bench, wherever).

I haven't lost the battle to reverse the destruction of military medicine by doing everything I suggested in 2006.

Sometimes all we have left is complaining. At least it's better than drinking the artificially flavored and colored powdered drink mix and not speaking out.

I fully understand the limitations in free speech that active duty military members face. That's why I had to leave in order speak the truth without being thrown in jail or, worse, sent to Minot.

It just bothers me and others when people repeat the same old canards for decades ("There's a plan in place; it's not so bad; issues have been identified!") without anyone at the top doing actually doing anything to fix the real, systemic problems that endanger the lives of our troops, their dependents, and what few retirees the military can still provide with healthcare now that almost every MTF (military treatment facility) has been "right-sized" to the point of mission failure over the past 30 years.

 

[MedicalCorpse]

I agree with this point whole-heartedly! (CRNAs are now in charge of anesthesiologists)

That was point 6, my friend.

Every time I mention this sad fact to the physicians I have worked with over the 19 years since I left, not one of them believes that the U.S. military would put a CRNA in command of an anesthesiologist, or that any anesthesiologist worth anything would put up with that blasphemous, heretical, and dangerous situation for one second.

I then go on to tell the true story of the optometrists at Travis taking over command from the ophthalmologists. In order to mark their territory as wolves do, the optometrists kicked the physicians out of the nice first floor clinic next to the main entrance (where they had been since the medical center opened) to the other side of the hospital several floors up, so the poor cataract patients with low vision had to make their way hundreds of yards further than they ever had to before the Objective Medical Group (OMG) made all animals equal based on what was on their shoulders rather than what was in their brains.

Nobody believes this either. Now, let's talk about nurse midwives with date of rank on OB/GYNs...

 

[DrMetal]

believes that the U.S. military would put a CRNA in command of an anesthesiologist,

I don't think I need to break this news flash to you . . .but the CRNA model was not invented in the milmed. It was a spawn of the civilian world (milmed certainly followed suit, but it was not the milmed's brainchild).

In fact, you anesthesiologists demonstrated this model---of midlevel provider getting trained by you, then you happily handing them the job, at a fraction of cost to the hospital system---that many other specialties have followed suit!

I consult cardiology . . .I get a NP-run heart failure service. I consult Neurology . . . I get an walking tele-NP. Etc etc.

I don't expect it long now until my job (rounding hospitalist) is also replaced by a iPad-wielding-chatGPT-fueled NP or PA. So be it.

If anything, in the milmed, I've seen a lot of resistance to using so many mid-levels to do MD jobs. (I've seen some resistance, no doubt the resistance is futile).

But again, this is a product of the civilian world.

 

[MedicalCorpse]

I don't think I need to break this news flash to you . . .but the CRNA model was not invented in the milmed. It was a spawn of the civilian world (milmed certainly followed suit, but it was not the milmed's brainchild).

In fact, you anesthesiologists demonstrated this model---of midlevel provider getting trained by you, then you happily handing them the job, at a fraction of cost to the hospital system---that many other specialties have followed suit!

...

But again, this is a product of the civilian world.

I'm talking the destruction of the Anesthesia Care Team model I was taught during my military residency, with an anesthesiologist as unquestioned captain of the ship REGARDLESS of the military rank of the CRNA(s).

This destruction and reversal of decades of medical policy was shoved down the throat of all branches of the military by our first president to have a CRNA mother...Bill Clinton...

The problem was that a long line of surgeons general and other physician leaders lined up to salute "Sir, yes sir!" instead of saying "Sir, no sir!" and resigning their commissions in protest as I did. I've documented here and on my web site my personal interactions with a particular Air Force surgeon general whom I had met during residency and who later visited Travis to tell everyone in the hosptial auditorium about his "vision" to replace RNs with ADNs like his daughter, physicians with PAs and NPs, and anesthesiologists (who are barely physicians in the eyes of general surgeons like himself) with much more pliable, cheaper and cuter CRNAs.

The only answer is for anesthesiologists in both the civilian and military world to stop slitting our own throats (to quote one of my fellow Air Force docs from back in the day) by refusing to teach CRNAs, especially now that they officially style themselves to the public and patients as "Dr X, nurse anesthesiologist".

Sadly, that horse left the barn years ago.

 

[DrMetal]

I'm talking the destruction of the Anesthesia Care Team model I was taught during my military residency, with an anesthesiologist as unquestioned captain of the ship REGARDLESS of the military rank of the CRNA(s).

This destruction and reversal of decades of medical policy was shoved down the throat of all branches of the military by our first president to have a CRNA mother...Bill Clinton...

The problem was that a long line of surgeons general and other physician leaders lined up to salute "Sir, yes sir!" instead of saying "Sir, no sir!" and resigning their commissions in protest as I did. I've documented here and on my web site my personal interactions with a particular Air Force surgeon general whom I had met during residency and who later visited Travis to tell everyone in the hosptial auditorium about his "vision" to replace RNs with ADNs like his daughter, physicians with PAs and NPs, and anesthesiologists (who are barely physicians in the eyes of general surgeons like himself) with much more pliable, cheaper and cuter CRNAs.

The only answer is for anesthesiologists in both the civilian and military world to stop slitting our own throats (to quote one of my fellow Air Force docs from back in the day) by refusing to teach CRNAs, especially now that they officially style themselves to the public and patients as "Dr X, nurse anesthesiologist".

Sadly, that horse left the barn years ago.

Do you still practice (as a civilian anes)?

The civilian world is now fraught with non-MDs telling MDs what to do. In fact, it's the norm. From hosp admin MBAs setting ridiculous metrics that physicians have to abide by, to nurse directors creating automated treatment protocols that result in much un-necessary testing and admissions . . . it's rampant.

 

[MedicalCorpse]

Do you still practice (as a civilian anes)?

The civilian world is now fraught with non-MDs telling MDs what to do. In fact, it's the norm. From hosp admin MBAs setting ridiculous metrics that physicians have to abide by, to nurse directors creating automated treatment protocols that result in much un-necessary testing and admissions . . . it's rampant.

If that happened, I would quit and look for another job.

That's a luxury unavailable to our physicians in uniform.

QEFD.

 

[DrMetal]

If that happened, I would quit and look for another job.

That's a luxury unavailable to our physicians in uniform.

QEFD.

Not that easy to quit your job as a civilian either (not always a good idea).

If you leave milmed because of pay discrepancies (the neurosurgeon making a fraction of what she'd make in the civilian world) or per the hassles of deployments . . .I get that.

If items 1 thru 10 (from your post above) is why you're leaving the milmed, I'd caution that the civilian world bears much of the same, especially now in 2024. It might make more sense to leave medicine altogether.

 

[pgg]

(CRNAs are now in charge of anesthesiologists)

For all of my gripes and dissatisfactions with the structure and organization of military medicine, I will say that in my entire career as a Navy anesthesiologist, I never once had a CRNA tell me how to practice, or tell me I couldn't do something, or that a case would or would not proceed in conflict with my judgment. I have heard stories from other commands; I'm sure it has happened. I'll just say it never happened to me or within my personal range of observation.

There were a couple years at Lemoore when I was an O4 just out of residency that the dept head was an O5 CRNA. It was a small department, me and 3 CRNAs. She handled the administrative work. I was the medical director. It was not a problem. If there are clear lines between the military and medical side of leadership, I don't see a big problem with having nurses or other non-physicians in the chain of command.


As for the "independent" practice of CRNAs in the military, it's not ideal (understatement of the year) but there are some caveats the more aggressively militant CRNAs like to gloss over. At the small commands, it really is a free-for-all of independent, unsupervised, unrestrained practice. However at the larger MTFs where the more complex cases[1] are done, scheduling is run by an anesthesiologist and there is very real triage to the cases they get. For ASA 3+ patients they're required to consult with an anesthesiologist. At least at my MTF, CRNAs asked to do things like thoracic and craniotomies and sick peds cases, and they asked for their SRNAs to get put in those cases, but we always said no. Residents needed those cases more.

The only time I've ever had a SRNA in the room with me when doing a heart was actually when I was moonlighting and the civilian institution had SRNAs.


I'll close with a possibly unpopular opinion, but it's honest. I don't advocate for independent CRNA practice - they should always be medically directed by an anesthesiologist, and never above 1:4 ratios. (Even that is too much if the cases are complex, or the patients are sick, or if the turnover is high.) HOWEVER it is certainly preferable as an anesthesiologist to be completely uninvolved with their cases if they are working independently, than to be "supervising" belligerent or militant or otherwise terrible CRNAs in a badly run ACT setting.


[1] Yes "complex cases" is a relative term. We used to do hearts, big thoracic and vascular cases, awake cranis, wacky peds stuff like craniosynostosis and other lifesaving preemie work.

 

[Trajan]

Cardiothoracic surgery is not going away entirely. However, the number of CT surgeons that will be needed in the next few decades is relatively small. A CT surgeon I know at a well known academic center put it this way: "there will always be a place for someone in this field if you are good enough." Many aspiring CT surgeons do several fellowships ("super-fellowships") these days to have a chance to get to that level. Even then, it's not guaranteed. There is no way that the military would ever support someone doing this, and even if they did, the attending job waiting for you would be at a place that doesn't do enough cases to maintain your skills.

In short, I can't think of a specialty less compatible with military medicine today than CT surgery -- ok, maybe pedi CT surgery, but you get the point.

 

[MedicalCorpse]

[1] Yes "complex cases" is a relative term. We used to do hearts, big thoracic and vascular cases, awake cranis, wacky peds stuff like craniosynostosis and other lifesaving preemie work.

I've hesitated for months to say this, but you really mean: "wacky peds stuff like craniosynostosis that should never be done at a military training facility where the CA-2 anesthesiology resident had never even seen such a case and the pediatric anesthesiologist attending that day was a flaky loon infamous for running out of an OR while another pediatric patient without an IV was having laryngospasm in order to look up the IM dose of succinylcholine in a book while the CA-3 helped the CA-2 to administer the correct dose which any CA-1 should know, because to proceed with a massively risky case under those dangerous conditions could be fatal".

Very sad story.

Relevance to cardiothoracic surgery: the only thing worse than losing skills from not practicing high risk/low volume surgery at military hospitals is that one day per year you get to do your sexy case and the patient dies from the overall incompetence of the entire system (as I have said before).

 

[pgg]

I've hesitated for months to say this, but you really mean: "wacky peds stuff like craniosynostosis that should never be done at a military training facility where the CA-2 anesthesiology resident had never even seen such a case and the pediatric anesthesiologist attending that day was a flaky loon infamous for running out of an OR while another pediatric patient without an IV was having laryngospasm in order to look up the IM dose of succinylcholine in a book while the CA-3 helped the CA-2 to administer the correct dose which any CA-1 should know, because to proceed with a massively risky case under those dangerous conditions could be fatal".

No.

Please don't just make stuff up.

We had peds surgeons and peds anesthesiologists who were up to the task. A busy, well-staffed NICU. And sufficient volume that the ancillary support was there too.

That was 15+ years ago. I don't know if I can draw a line in time when that particular MTF quit doing them. I left that hospital and was stationed elsewhere 2009-2014 and when I came back none of those cases were happening. The people were largely gone. The patients deferred out.

Broadly speaking, I get the impression that the Air Force was 1-2 decades ahead of the Navy and Army in chopping hospital volume down. I know you had a nightmare of a time in the AF and they did you dirty, but the large Navy MTFs still had respectable volume and complexity though most of the '00s.

Very sad story.

Relevance to cardiothoracic surgery: the only thing worse than losing skills from not practicing high risk/low volume surgery at military hospitals is that one day per year you get to do your sexy case and the patient dies from the overall incompetence of the entire system (as I have said before).

When I came back from my cardiac anesthesia fellowship in 2017, the volume between two surgeons was perhaps 2-3 cases per week. For a short while anyway - they had some backlog to get through because the Navy semi-gapped the CT anesthesia billets there for a couple months. (By semi-gapped I mean the ACTA trained attending there at the time hadn't been doing hearts for years and didn't want to). 100-150 cases per year would've been OK for lower risk routine cardiac surgery, but that volume didn't continue. Within a few months, volume dwindled to a case, maybe two per week. That's why they closed the program.

It left me in a bind, and thus began my multi-year ordeal of chasing locums work halfway across the country to scratch together 40-50 hearts per year. For a while I had a sweet local gig - I started moonlighting at a nearby hospital where the administration burned the anesthesia group to the ground and all the cardiac anesthesiologists left. I was the only one who could do their cases, so they scheduled elective hearts on weekends and late afternoons so I could leave the Navy job and go do cases. My CO signed a moonlighting waiver for me, to permit outside work (and cardiac call) within the usually-prohibited 8 hours prior to a Navy shift. Post-pandemic, I was flying to St. Louis every month to get cases. It was a grind.

 

[MedicalCorpse]

No.

Please don't just make stuff up.

Please see my PM.

It was at Wilford Hall, the supposed mecca of Air Force medicine, circa 1992-1993, and it's all true.

 

[pgg]

Please see my PM.

It was at Wilford Hall, the supposed mecca of Air Force medicine, circa 1992-1993, and it's all true.

I'm just going to quote you again:

I've hesitated for months to say this, but you really mean: "wacky peds stuff like craniosynostosis that should never be done at a military training facility where the CA-2 anesthesiology resident had never even seen such a case and the pediatric anesthesiologist attending that day was a flaky loon infamous for running out of an OR while another pediatric patient without an IV was having laryngospasm in order to look up the IM dose of succinylcholine in a book while the CA-3 helped the CA-2 to administer the correct dose which any CA-1 should know, because to proceed with a massively risky case under those dangerous conditions could be fatal".

You were responding to what I wrote with the specific phrase "but you really mean: [your own diatribe of craziness and malpractice]"

I believe you when you say those things happened at your Air Force hospital.

I take exception to your attempt to correct me and tell me what happened at my Navy hospital.

If that's not what you meant, you should write more clearly and communicate better.

 

[MedicalCorpse]

I believe you when you say those things happened at your Air Force hospital.


I take exception to your attempt to correct me and tell me what happened at my Navy hospital.

If that's not what you meant, you should write more clearly and communicate better.

I have no idea what happened in the Navy.

How could I? The USAF never allowed me to get credentialed at NNMC when I was at Andrews for five years. They were so short-staffed after 2001 that they kept us on short leashes.

You were wrong to say I was making things up. Read my PM.

I take exception to your taking exception to me telling the truth about my Air Force experience. At no point did I actually mention the U.S. Navy.

In the future, if you object to the words I write, please ask me for clarification before accusing me of lying.

Thanks in advance.

--R

 

[pgg]

I read your PM.

I'll let you read your own words from your post above one more time -

I've hesitated for months to say this, but you really mean

Perhaps that's just a careless turn of phrase. But if you don't see how that is an attempted "correction" of what I wrote, I don't know what else to tell you.

 

[MedicalCorpse]

I read your PM.

I'll let you read your own words from your post above one more time -



Perhaps that's just a careless turn of phrase. But if you don't see how that is an attempted "correction" of what I wrote, I don't know what else to tell you.

It was never a correction.

I know squat about what your Navy experience was.

Maybe it was a careless turn of phrase. If it offended you, I apologize.

But.

Let's get back to basic logic 101:

Condensed summary of what I wrote: "wacky peds stuff like X...should never be done UNDER CONDITION Y and CONDITION Z".

If neither condition applied to your situation, why did you think I was talking about your experiences and not my own?

You assumed it was all about you.

You should know what happens when you assume.

I hesitated because I knew there was a chance that my residency colleague and/or attending might one day read these words, and be crushed emotionally all over again when remembering the tragedy they contributed to, as I detailed in my PM.

Nobody spoke up to say: "This is not safe. Let's refer this patient to a civilian pediatric specialty hospital."

It was never about you. It was always about them.

However.

I changed my mind because I realized that today, this moment, some surgeon at some degraded MTF with inadequate overall staff training, experience, and/or judgment and poor infrastructure is committing surgery in the first degree that should have been referred downtown to ensure patient safety. Whether due to Dunning-Kruger false assumption of their own godly surgical prowess; complete ignorance of the perioperative (not just intraoperative) anesthetic implications of their surgery; command pressure to do sexy cases to improve the hydraulic status of their supervisors; or a combination of the above, some poor soul is getting operated on in an unsafe milieu just because no one had the courage to say "Sir, no Sir".

Overheard on hole 6 of the Joint Base Andrews golf course: "We did three AAAs last year, and you did none at your hospital, so my parts are bigger than yours. Of course, we have yet to have one survive to discharge, but problems have been identfied. They say they're mainly between my ears, which I don't really understand, but, hey..."

When you're a hammer, the whole world looks like a nail. Sadly, when we are talking high risk/low volume surgery, those just might be coffin nails.

Next time, please PM me (or text me) for clarification before calling me a liar.

Many thanks.

 

[pgg]

I'm not your enemy.

 

[MedicalCorpse]

I'm not your enemy.

Likewise.

I guess the whole Nemo Me Impune Lacessit thing gets overlooked.

Peace, bro.

P.S. If I make stuff up, it's pretty obvious, such as my science fiction short story
published in the June, 2024 issue of Anesthesiology: "So, to Recap"...which is
relevant to this thread (future anesthesiologist walks into the OR to see that he
is assigned to a high risk/no volume anesthetic, and his reaction).

 

[pgg]

Likewise.

I guess the whole Nemo Me Impune Lacessit thing gets overlooked.

Peace, bro.

P.S. If I make stuff up, it's pretty obvious, such as my science fiction short story
published in the June, 2024 issue of Anesthesiology: "So, to Recap"...which is
relevant to this thread (future anesthesiologist walks into the OR to see that he
is assigned to a high risk/no volume anesthetic, and his reaction).

Oh for the love of tacos and hot sauce from Ace Hardware

Settle down. Put up your halberd and raise the portcullis.

I wrote this yesterday:

I believe you when you say those things happened at your Air Force hospital.

Quit demanding an apology. I believe you. I also don't doubt the excruciatingly detailed and horrific story you PM'd me.


Again:

I described the nice case load we used to enjoy at my MTF, in happier days of yore.

A month later you interjected a story of personal trauma and horribleness from your career, quoting my post, in a way that explicitly "corrected" my description of the circumstances at the Navy hospital where I worked. The implication was not vague or open to fuzzy interpretation by any reasonable reader: my assertion that my hospital was an OK place was wrong, and you fixed my assertion with a not-OK scenario.

I called you out on it, and you went off on this tangent of insulted honor and hurt feelings.


I believe all of the stories you've told here over the years, about the malignant and dangerous places you worked in the Air Force. I believe you when you say you stood up for safe anesthesia care at those places, and I believe you when you say you suffered retaliation and other unjustified (even illegal) responses.

I also suspect, based on the absolutely incessant verbal assault you respond to fellow physicians and allies with here, that a big reason you had such interpersonal struggles with peers and leaders on active duty, is because of your inability to communicate clearly and the way you resort to aggression at any perceived slight.

I'm not your enemy.

 

[militaryPHYS]

And why should we feel anger at the world? As if the world would notice

 

[armytrainingsir]

I remember Tripler in the late 80s and early 90s.

A team of cardiologists and CT surgeons would go to Micronesia, near some atoll we bombed for fun in and after WWII and see patients for a week. A few months later Continental Micronesia would drop off 25ish patients and we did 2-3 valves per day three days a week for about a month.

Ah, back in the good ol days.

Those days are never coming back.

 

[militaryPHYS]

I remember Tripler in the late 80s and early 90s.

A team of cardiologists and CT surgeons would go to Micronesia, near some atoll we bombed for fun in and after WWII and see patients for a week. A few months later Continental Micronesia would drop off 25ish patients and we did 2-3 valves per day three days a week for about a month.

Ah, back in the good ol days.

Those days are never coming back.

Those pathways still exist but they aren’t as robust. I utilized them during my recent deployment. Not CT but other sub-specialty access to care for our partner nations.

We discussed how to build the regular use of those pathways back. Will see if we can keep the momentum going. Current Tripler POC’s were open to the idea and excited about the opportunity

 

[pgg]

Those pathways still exist but they aren’t as robust. I utilized them during my recent deployment. Not CT but other sub-specialty access to care for our partner nations.

We discussed how to build the regular use of those pathways back. Will see if we can keep the momentum going. Current Tripler POC’s were open to the idea and excited about the opportunity

That could be a good source of volume.

Better if they bring the patients to us. There are some serious hazards to traveling abroad to do the cases there.

A few years before I left active duty, as part of a pilot project of sorts, I went with a group of other doctors, nurses, and surgical techs to what is technically (I guess) a "developing" country but very urban and modern in many respects. We worked in one of their hospitals for a couple months seeing patients and doing cases. The underlying ideas were to provide aid to one of our allies, promote good will, and get our medical personnel exposure to more cases (particularly trauma).

There were some positives to the experience. The people were wonderful. Medically, it was a disaster. The standard of care was unacceptable. They were good people and did a lot of good given their limits of resources, facility support, and training - but I felt and still feel working in that environment was not useful to the US Navy in terms of developing or maintaining skills. Worse, for some of our junior nurses and techs, doing a few months of work the wrong way probably instilled some bad habits. And then there was the moral hazard - some ethically questionable and flat-out wrong things were going on that we were ultimately party to simply by being present. (Ethically unacceptable by western standards - I am hesitant to flat out condemn another culture for doing things they felt were the best option for their circumstances, even if those acts would get people fired and prosecuted in the USA.)

I had a better experience going to Central America, where surgical patients were brought aboard the Kearsarge for care.

The Tripler program described above in which patients are evaluated and selected by a team visiting the other country, but brought to the USA for treatment, sounds great.