doom and gloom for anesthesiology? Maybe not....

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It will translate into more CRNAs, higher supervision ratios, more work. Same money (or less).

My colleagues were getting in 2007 the same salaries the same employer offers 10+ years later. They worked solo, 8 hours/day, then went home and had a nice afternoon. Today, you work 10 for the same money (minus the 30% inflation!), medically "directing" 3 CRNA rooms, dead tired at the end of the day. That's the anesthesiologist shortage for ya. There is no shortage of anesthesiologists, just a shortage of suckers.

This is the famous fable about boiling the frog. Only the stupid can't see. Every year it's getting worse. Ten years ago I would have not taken the jobs I'm calling "good" today. We are going through the same motions IT and law went through decades ago.
 
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FFP said:
It will translate into more CRNAs, higher supervision ratios, more work. Same money (or less).

My colleagues were getting in 2007 the same salaries the same employer offers 10+ years later. They worked solo, 8 hours/day, then went home and had a nice afternoon. Today, you work 10 for the same money (minus the 30% inflation!), medically "directing" 3 CRNA rooms, dead tired at the end of the day. That's the anesthesiologist shortage for ya. There is no shortage of anesthesiologists, just a shortage of suckers.

This is the famous fable about boiling the frog. Only the stupid can't see. Every year it's getting worse. Ten years ago I would have not taken the jobs I'm calling "good" today. We are going through the same motions IT and law went through decades ago.
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What are you doing that I’m not? When I supervise 3 CRNA’s I’m bored out of my mind. Not dead tired......
 
If you're bored when medically directing, you're not directing you're supervising. Which is exactly my usual point about 1:3 being a joke (i.e. the nurses do whatever the heck they want most of the time).
 
FFP said:
It will translate into more CRNAs, higher supervision ratios, more work. Same money (or less).

My colleagues were getting in 2007 the same salaries the same employer offers 10+ years later. They worked solo, 8 hours/day, then went home and had a nice afternoon. Today, you work 10 for the same money (minus the 30% inflation!), medically "directing" 3 CRNA rooms, dead tired at the end of the day. That's the anesthesiologist shortage for ya. There is no shortage of anesthesiologists, just a shortage of suckers.

This is the famous fable about boiling the frog. Only the stupid can't see. Every year it's getting worse. Ten years ago I would have not taken the jobs I'm calling "good" today. We are going through the same motions IT and law went through decades ago.
Click to expand...

our partner salary increases have outpaced inflation the last 10 years and we pay new hires nearly double
 
dannyboy1 said:
What are you doing that I’m not? When I supervise 3 CRNA’s I’m bored out of my mind. Not dead tired......
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Try doing 15-20 inductions, 15-20 preop visits and exams 15-20 emergences if you get there, make up the plan for 15-20 patients, fix crna screw ups daily after having to have the first attempt now you are behind the 8 ball. In addition to answer calls constantly about this ones bp this ones family this ones temperature, this one not waking up this ones pain orders. d.c orders . This one didnt have a break. This surgeon wants to talk to you,. And that is everything goes smoothly. One of those 20 will be difficult to intubate, difficult iv, difficult emergence, and it goes on and on.. Repeat everyday. Why didnt you do the block on that patient? block doesnt work? labor epidurals, c sections catheters that cant come out, mri is calling.. It is truly endless.......
 
PieOHmy said:
Try doing 15-20 inductions, 15-20 preop visits and exams 15-20 emergences if you get there, make up the plan for 15-20 patients, fix crna screw ups daily after having to have the first attempt now you are behind the 8 ball. In addition to answer calls constantly about this ones bp this ones family this ones temperature, this one not waking up this ones pain orders. d.c orders . This one didnt have a break. This surgeon wants to talk to you,. And that is everything goes smoothly. One of those 20 will be difficult to intubate, difficult iv, difficult emergence, and it goes on and on.. Repeat everyday. Why didnt you do the block on that patient? block doesnt work? labor epidurals, c sections catheters that cant come out, mri is calling.. It is truly endless.......
Click to expand...

Supervising can be boring or busy depending on the day. Making most anesthesia plans takes no time at all. Also, it’s not like CRNA’s are constantly messing up, mostly they’re charting vitals and maybe occasionally giving neo. I don’t know where you work with 15-20 emergencies a day that you cover all of them on top of 3 other rooms, sounds suspicious.

I’m not saying it isn’t busy or stressful to supervise, it can be, but give me a break with all those exaggerations.
 
nolagas said:
Supervising can be boring or busy depending on the day. Making most anesthesia plans takes no time at all. Also, it’s not like CRNA’s are constantly messing up, mostly they’re charting vitals and maybe occasionally giving neo. I don’t know where you work with 15-20 emergencies a day that you cover all of them on top of 3 other rooms, sounds suspicious.

I’m not saying it isn’t busy or stressful to supervise, it can be, but give me a break with all those exaggerations.
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On the worst day, everything that can go wrong does go wrong.

But most of the time things should go as expected.

Unless he's exaggerating, he's either bad at managing or he's in a terrible job in a terrible hospital in a twilight zone episode.
 
nolagas said:
Supervising can be boring or busy depending on the day. Making most anesthesia plans takes no time at all. Also, it’s not like CRNA’s are constantly messing up, mostly they’re charting vitals and maybe occasionally giving neo. I don’t know where you work with 15-20 emergencies a day that you cover all of them on top of 3 other rooms, sounds suspicious.

I’m not saying it isn’t busy or stressful to supervise, it can be, but give me a break with all those exaggerations.
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I didnt say 15-20 emergencies. I said emergenc(es). As in wake ups. Y ou know you have to be there for those right?
 
PieOHmy said:
I didnt say 15-20 emergencies. I said emergenc(es). As in wake ups. Y ou know you have to be there for those right?
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I usually stay out of threads like these because I have no dog in the fight, but since when is emergence from anesthesia an emergency?
 
dr doze said:
Emergence does not equal extubation. It begins from the time the anesthetist begins to lighten up the patient and continues in the PACU.
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What does that mean? Yo ustill have to be there and attest to it.
 
PieOHmy said:
What does that mean? Yo ustill have to be there and attest to it.
Click to expand...

CMS very clearly does not require presence at extubation and is hazy as to what emergence is. So while you have to document your presence during emergence, that does not necessarily mean during extubation.
 
Mman said:
CMS very clearly does not require presence at extubation and is hazy as to what emergence is. So while you have to document your presence during emergence, that does not necessarily mean during extubation.
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Yep. There’s an entire thread about this.

forums.studentdoctor.net

PACU nurse-led extubation.

Hi all. Do PACU nurses extubate patients in your recovery room? Do you proceed with the next case if your previous patient is still intubated in PACU? I mean spontaneously breathing, stable, not on ventilator? thank you.
forums.studentdoctor.net forums.studentdoctor.net
 
Mman said:
CMS very clearly does not require presence at extubation and is hazy as to what emergence is. So while you have to document your presence during emergence, that does not necessarily mean during extubation.
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And theres a difference between checking a box and doing what's right for your patient. One is more likely to give you an easier day than the other.
 
Mman said:
CMS very clearly does not require presence at extubation and is hazy as to what emergence is. So while you have to document your presence during emergence, that does not necessarily mean during extubation.
Click to expand...

Honest question for you since I dont work in an ACT practice:

In addition to the emergence rule, the guidelines also state that you must be present for critical portions of the anesthetic. How is it that you don’t consider extubation one of the critical portions of the anesthetic?
 
SaltyDog said:
Honest question for you since I dont work in an ACT practice:

In addition to the emergence rule, the guidelines also state that you must be present for critical portions of the anesthetic. How is it that you don’t consider extubation one of the critical portions of the anesthetic?
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Of course you're right.

These are the rules, by the way:
www.law.cornell.edu

42 CFR § 415.110 - Conditions for payment: Medically directed anesthesia services.

www.law.cornell.edu www.law.cornell.edu
So one doesn't just have to be present during induction/emergence. One has to "personally participate" in them, and the most demanding aspects of the anesthesia plan. Which means at least participating in both intubation and extubation.

The system has been corrupted. If CMS did their job and fined JUST one group millions for not playing by the TEFRA rules (because most don't, not 100%), the entire ACT house would crumble. The reason they don't do that is because of the hospital corporate lobby who likes it as it is: illegal. In the meanwhile, thousands of law-abiding anesthesiologists are caught between the law and their employer.
 
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I feel like the “system” just sees CRNAs as Andy Dalton. He’s not gonna win you a Super Bowl but he might be win you like 8-10 games and may even get you in the playoffs. Somewhere along the line he will have a 4 INT game but you just have to hope your defense plays well that game.

They’re just good enough. Sure a
few are Nathan Peterman but they’re not Tom Brady.

It’s the first thing I think of when CRNAs are brought up.
 
Twiggidy said:
I feel like the “system” just sees CRNAs as Andy Dalton. He’s not gonna win you a Super Bowl but he might be win you like 8-10 games and may even get you in the playoffs. Somewhere along the line he will have a 4 INT game but you just have to hope your defense plays well that game.

They’re just good enough. Sure a
few are Nathan Peterman but they’re not Tom Brady.

It’s the first thing I think of when CRNAs are brought up.
Click to expand...

So you're saying Gisele is in my league?
 
FFP said:
Of course you're right.

These are the rules, by the way:
www.law.cornell.edu

42 CFR § 415.110 - Conditions for payment: Medically directed anesthesia services.

www.law.cornell.edu www.law.cornell.edu
So one doesn't just have to be present during induction/emergence. One has to "personally participate" in them, and the most demanding aspects of the anesthesia plan. Which means at least participating in both intubation and extubation.

The system has been corrupted. If CMS did their job and fined JUST one group millions for not playing by the TEFRA rules (because most don't, not 100%), the entire ACT house would crumble. The reason they don't do that is because of the hospital corporate lobby who likes it as it is: illegal. In the meanwhile, thousands of law-abiding anesthesiologists are caught between the law and their employer.
Click to expand...


as you point out, CMS specifically dictates that you must participate in induction and emergence. They specifically do not say intubation and extubation. I'm too lazy to create them but I feel some Venn diagrams might be helpful in understanding the legal distinction.

We can argue that it should mean intubation and extubation, but that is not relevant to the way the rule is written or enforced in a legal sense.

(all intubations are part of induction, but not all of induction is intubation....all extubation is part of emergence, but not all emergence is extubation)
 
SaltyDog said:
Honest question for you since I dont work in an ACT practice:

In addition to the emergence rule, the guidelines also state that you must be present for critical portions of the anesthetic. How is it that you don’t consider extubation one of the critical portions of the anesthetic?
Click to expand...

we have a current thread here talking about unsupervised RNs routinely extubating pediatric patients in a PACU so it would be difficult to argue that extubation is always that critical of a portion of the anesthetic
 
Not to mention that a great many patients are extubated every day in ICUs without physician immediate presence.
 
Mman said:
we have a current thread here talking about unsupervised RNs routinely extubating pediatric patients in a PACU so it would be difficult to argue that extubation is always that critical of a portion of the anesthetic
Click to expand...

I think it’s being disingenuous to say that extubation is not a critical portion of the anesthetic.

I also don’t think that unsupervised RN’s extubating in PACU is a great idea. That however, took place after anesthesia end time, so at least they were not committing billing fraud.
 
SaltyDog said:
I think it’s being disingenuous to say that extubation is not a critical portion of the anesthetic.

I also don’t think that unsupervised RN’s extubating in PACU is a great idea. That however, took place after anesthesia end time, so at least they were not committing billing fraud.
Click to expand...

like I said, we can all debate what we think the wording should mean, but from a legal point of view it is fairly clear that they do not mean extubation.
 
SaltyDog said:
I think it’s being disingenuous to say that extubation is not a critical portion of the anesthetic.

I also don’t think that unsupervised RN’s extubating in PACU is a great idea. That however, took place after anesthesia end time, so at least they were not committing billing fraud.
Click to expand...
I hate to use the old pilot cliche but it’s the same as saying “landing isn’t that important.” *Clay Davis voice* Sh******t.
 
Mman said:
as you point out, CMS specifically dictates that you must participate in induction and emergence. They specifically do not say intubation and extubation. I'm too lazy to create them but I feel some Venn diagrams might be helpful in understanding the legal distinction.

We can argue that it should mean intubation and extubation, but that is not relevant to the way the rule is written or enforced in a legal sense.

(all intubations are part of induction, but not all of induction is intubation....all extubation is part of emergence, but not all emergence is extubation)
Click to expand...
certainly we at least agree that extubation is the most demanding part of the emergence?
Why would you not want to be there? If you attest to it and are NOT there.CMS can bankrupt your system if a whistleblower decides to blow the whistle.

So plan to be there for emergence extubation whatever you wanna call it. and dont leave it for the pacu nurses. This field is soooo perverted.
 
PieOHmy said:
certainly we at least agree that extubation is the most demanding part of the emergence? Why would you not want to be there?
Click to expand...

Because it’s boring most of the time and I have better things to do.
 
PieOHmy said:
Try doing 15-20 inductions, 15-20 preop visits and exams 15-20 emergences if you get there, make up the plan for 15-20 patients, fix crna screw ups daily after having to have the first attempt now you are behind the 8 ball. In addition to answer calls constantly about this ones bp this ones family this ones temperature, this one not waking up this ones pain orders. d.c orders . This one didnt have a break. This surgeon wants to talk to you,. And that is everything goes smoothly. One of those 20 will be difficult to intubate, difficult iv, difficult emergence, and it goes on and on.. Repeat everyday. Why didnt you do the block on that patient? block doesnt work? labor epidurals, c sections catheters that cant come out, mri is calling.. It is truly endless.......
Click to expand...

lol what “plan” are you making for a bunch of endoscopies or total joints or gallbladders or whatever?

Otherwise I agree with you 100%, supervising is exhausting - not just the cases you are doing but everything else that you have to deal with.
 
Arch Guillotti said:
lol what “plan” are you making for a bunch of endoscopies or total joints or gallbladders or whatever?

Otherwise I agree with you 100%, supervising is exhausting - not just the cases you are doing but everything else that you have to deal with.
Click to expand...

Im routinely doing 4-6 level fusions on patients with multiple problems, 400 pounders with bad airways, busy oral surgery svc who have frx jaws as their bread/butter they are getting their mouth wired shut.. CRNAs who routinely giving too much opiates.. try doin that 15x per day and letting the crnas dictate your plan..
The endos i do are all bleeders with hemoglobins in the 4-6 range who are still actively bleeding.
this is in addition to the other rooms i do.
 
Extubation is about meeting specific criteria for removing the endotracheal tube. Simple delegated act. Next.
 
PieOHmy said:
certainly we at least agree that extubation is the most demanding part of the emergence?
Why would you not want to be there? If you attest to it and are NOT there.CMS can bankrupt your system if a whistleblower decides to blow the whistle.

So plan to be there for emergence extubation whatever you wanna call it. and dont leave it for the pacu nurses. This field is soooo perverted.
Click to expand...

you are incorrect as to the legal standard for CMS. You are not required to be present for extubation no matter how much you believe it. This isn't a potential whistleblower situation unless CMS changes their rule since you do not have to attest being present for extubation, merely emergence which is a more nebulous concept.

Also IMHO extubation is only as demanding as the intubation was. If a patient was an easy ventilation and easy intubation, their extubation should not be difficult.
 
PieOHmy said:
Im routinely doing 4-6 level fusions on patients with multiple problems, 400 pounders with bad airways, busy oral surgery svc who have frx jaws as their bread/butter they are getting their mouth wired shut.. CRNAs who routinely giving too much opiates.. try doin that 15x per day and letting the crnas dictate your plan..
The endos i do are all bleeders with hemoglobins in the 4-6 range who are still actively bleeding.
this is in addition to the other rooms i do.
Click to expand...

You're describing a typical practice for anesthesiologists.

Now, if you also mentioned that your entire slate of CRNAs looks like they belong in the movie "Idiocracy", I'd start to feel sorry for you.
 
Consigliere said:
Right. You can stick your head in the room, make the sign of the cross or something, and roll. BAM! "Present for emergence." You're welcome.
Click to expand...
08B8EEAE-B558-422A-A0AD-40BF4C34E724.jpeg
 
Comparing nurses extubating in the icu vs immediately after surgery in the or is not a fair comparison. Typically the ICU patient being extubated is following commands and has had a resolution of whatever problem got him intubated. In the or, this is a patient 5 minutes ago was not moving when someone was cutting him. It's much different. Get in the room during extubation. When is it important to be in the room?
 
Large academic institution on the east coast settled with a very large payout for a post op kid who larygospasmed and developed NPPP and anoxic brain injury after a nurse extubated post T&A.
 
sevoflurane said:
Large academic institution on the east coast settled with a very large payout for a post op kid who larygospasmed and developed NPPP and anoxic brain injury after a nurse extubated post T&A.
Click to expand...
So ugh... who’s considered the doctor responsible? The intraop guy who isn’t even there prolly?
 
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