Exit strategy

[pgg]

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Oh, we definitely do things like close military bases. So let me ask you: did our government budget then drop as a result? Nope. Look all over Wikipedia for that and it didn't. In fact, it went up because it goes up every year.

As far as sequestration, it's a decrease in the rate of increase in the budget. It says so on Wikipedia, look it up. And look at how Democrats wailed about that, acting like it was the end of the world. Guess what? We spend the amount we "save" with sequestration in a week or so. And sequestration takes places over a decade. And it only happened after a huge battle.

So as I said, I'll believe it when I see it. So I'll never believe it.

This particular thread derailment was about real estate prices bombing because of military cuts and changes. It has happened in many locales, and it will happen again.

The last decade of wars has created a military industrial complex 'bubble' of sorts. The level of spending can't continue, and it won't. Nobody - NOBODY - disputes that it's unsustainable. Trendy sarcastic cynicism aside, there are cuts underway and there will be more. I can pull up the current 'consumable status of funds' spreadsheet on our command intranet right now and look at the cuts. They're right there. The 'amount authorized' is 20% less than the planned budget.

Your belief or disbelief doesn't influence reality.

 

[ProRealDoc]

I have called around to a few companies that do medical tourism, and all of them told me that they hire their anesthesia on site.
Goes back to revenue generator vs. necessary overhead

I was referring to the idea of owning an ASC in a caribbean or other location in Central or South America, where you and your surgeon buddies team-up to bring cash-paying patients to said ASC, perform the surgery and do the postop follow-up back in the states. You can do it all for a fraction of the cost while providing significant discounts to the patient and making a profit due to the abundance of cheap labor in those countries. Clearly it requires a base and local connections (i.e., a US-based physician with ties to that country that can help you navigate the local system), tour operator to set up airport pick-ups, hotel stays, etc. Practice would be limited to ortho and plastics. Speaking the local language would be a great asset (English or Spanish unless you're thinking of Brazil). Medical licensing laws are pretty laxed depending on the location.

The patient gets an all-American surgical team, a trip to an exotic location with an accompanying family member, postop follow-up back in the states and a much lower surgery bill.

I was in Central America two weeks ago, did 60 ortho cases (TKAs/THAs) in a week with a group of 5 American orthopods as part of a medical mission. The topic of medical tourism came up and this is what we envisioned.

 

[Silent Cool]

 

[repititionition]

I was referring to the idea of owning an ASC in a caribbean or other location in Central or South America, where you and your surgeon buddies team-up to bring cash-paying patients to said ASC, perform the surgery and do the postop follow-up back in the states. You can do it all for a fraction of the cost while providing significant discounts to the patient and making a profit due to the abundance of cheap labor in those countries. Clearly it requires a base and local connections (i.e., a US-based physician with ties to that country that can help you navigate the local system), tour operator to set up airport pick-ups, hotel stays, etc. Practice would be limited to ortho and plastics. Speaking the local language would be a great asset (English or Spanish unless you're thinking of Brazil). Medical licensing laws are pretty laxed depending on the location.

The patient gets an all-American surgical team, a trip to an exotic location with an accompanying family member, postop follow-up back in the states and a much lower surgery bill.

I was in Central America two weeks ago, did 60 ortho cases (TKAs/THAs) in a week with a group of 5 American orthopods as part of a medical mission. The topic of medical tourism came up and this is what we envisioned.

Forgive my ignorance (seriously), but why not simply build an ASC in the United States and serve the same patients locally (eg cash payment, no third party payors involved or accepted)?

The savings can't only be from differential in the physical costs of facility acquisition and maintenance U.S. vs. ex-U.S.?

 

[norwood]

Forgive my ignorance (seriously), but why not simply build an ASC in the United States and serve the same patients locally (eg cash payment, no third party payors involved or accepted)?

The savings can't only be from differential in the physical costs of facility acquisition and maintenance U.S. vs. ex-U.S.?

Level of regulation in the US is simply insane.

A family friend wanted to start a small shop - your typical storefront business - selling clothing. She was told she'd have to get full architectural plans, at a cost of some thousands of dollars, then refurbish this one-room shop to have not only an ADA-compliant bathroom but an ADA-compliant REAR exit (front door was already ADA-compliant). And so on, and so on. She finally gave up.

And that's a clothing shop, not an ASC. One day I was at the ASC and the nurses had to prepare an MSDS on every single substance at the ASC. Not just cleaning agents or other things like that, but every single substance. Yep, even sterile water, replete with instructions on what to do if the stuff were to catch fire - no kidding.

 

[repititionition]

Level of regulation in the US is simply insane.

A family friend wanted to start a small shop - your typical storefront business - selling clothing. She was told she'd have to get full architectural plans, at a cost of some thousands of dollars, then refurbish this one-room shop to have not only an ADA-compliant bathroom but an ADA-compliant REAR exit (front door was already ADA-compliant). And so on, and so on. She finally gave up.

And that's a clothing shop, not an ASC. One day I was at the ASC and the nurses had to prepare an MSDS on every single substance at the ASC. Not just cleaning agents or other things like that, but every single substance. Yep, even sterile water, replete with instructions on what to do if the stuff were to catch fire - no kidding.

I live in the Bay Area, where (spurious) ADA compliance lawsuits are something of a cottage industry, so I get the frustration.

That said, not all ASC's are even licensed (New Jersey, for example, only requires state licenses of facilities with >1 OR, and obviously one can simply opt out of dealing with CMS), so I'm not sure why it would be impossible to run a shop that doesn't deal with the type of nonsense you mentioned above.

Also, without being glib, it took me <5 seconds to find an MSDS for water, so even at charge nurse pay, the costs of that work are low. As someone who comes from the business world, having a nurse do admin and operational compliance work is inefficient, but that's another issue entirely.

I know that someone posted about an (ortho?) ASC in Oklahoma that had a transparent cash-pay "menu", and I've got to think that the numbers of this type of facility will grow. The ACA's unintended consequence of limiting network size is going to mean that more people can't go to their #1 (or 2-5, potentially) choice anyway, so why not get on a plane and have it done in OK?

 

[Impromptu]

Exit Strategy: Become full partner. Cash out when the national groups come with a hostile takeover. Continue working for a while, but with the security of knowing you could quit at any time.

If I had enough saved up and actually grew tired of anesthesiology I would become a teacher. But I would have to get tired of anesthesiology first, and I don't foresee that happening for several decades.

 

[DermViser]

There's only so much one can cut skilled labor income.

Remember you got lots of federal folks with barley bachelors degrees making easy 100k money by age 28-30 years old.

Having lived in DC area half my life (along with friends in all higher income parts of the country (San Fran, New York, LA etc). I know many folks with psych degrees working as contractors making very good money.


It's very hard to imagine anesthesiologist income being lower than 200k and that's a straight 40 hour week job no call.

The market will dictate income.

Right now Sheridan can't find any suckers to worker at Winnie Palmer hospital in orlando for 260-280k. Even with working more hours they cannot find people to work for 350k at Winnie Palmer.

Which is why they are reduced to advertising for CRNAs there: https://rmax.shcr.com/candidate/def...&szOrderID=7527&szCandidateID=0&szSearchWords=

 

[ruralsurg4now]

Which is why they are reduced to advertising for CRNAs there: https://rmax.shcr.com/candidate/def...&szOrderID=7527&szCandidateID=0&szSearchWords=

Yeah, but you guys need to be careful what you wish for. While it may be empowering to see people reduced to advertising for CRNAs, once they hire them you're basically aced out. I interviewed at rural hospitals where no anesthesiologist would go (I guess) and they told me up front "we only have CRNAs here." Now, older surgeons will apparently run for the hills from that, but even in residency programs that are not attached to an Anesthesia residency program, you'll have CRNAs under the supervision of an anesthesiologist. So to me, I didn't really mind it. Point being that at some point someone is going to rightly or wrongly say that they only need CRNAs and then you're not going to be talking about a 200K floor. Your goal is to make sure you can't be replaced, so it doesn't bode well that at least some places are doing that.

 

[countingdays]

Yeah, but you guys need to be careful what you wish for. While it may be empowering to see people reduced to advertising for CRNAs, once they hire them you're basically aced out. I interviewed at rural hospitals where no anesthesiologist would go (I guess) and they told me up front "we only have CRNAs here." Now, older surgeons will apparently run for the hills from that, but even in residency programs that are not attached to an Anesthesia residency program, you'll have CRNAs under the supervision of an anesthesiologist. So to me, I didn't really mind it. Point being that at some point someone is going to rightly or wrongly say that they only need CRNAs and then you're not going to be talking about a 200K floor. Your goal is to make sure you can't be replaced, so it doesn't bode well that at least some places are doing that.

That add isn't for a crna-only model. It's a care team job.

 

[ruralsurg4now]

That add isn't for a crna-only model. It's a care team job.

OK, truthfully I didn't read the ad. I'm just trying to make a generalized point here about when people say someone is "reduced" to hiring CRNAs. The problem is that once they do, unless it's a complete and total disaster, then that becomes acceptable. And that's the start of losing your profession.

 

[Mman]

OK, truthfully I didn't read the ad. I'm just trying to make a generalized point here about when people say someone is "reduced" to hiring CRNAs. The problem is that once they do, unless it's a complete and total disaster, then that becomes acceptable. And that's the start of losing your profession.

Yeah, except when they go with only CRNAs and then it's a disaster and the surgeons beg the hospital to hire the anesthesiologists back. Because I've seen that before....

Surgeons don't like having all the added liability on their shoulders from CRNAs that they can't even really make an accurate judgment on the quality of care they are providing. It's just that some don't realize the time bombs ticking in those rooms for a period of time. Eventually they explode and then they realize what was happening.

 

[ruralsurg4now]

Yeah, except when they go with only CRNAs and then it's a disaster and the surgeons beg the hospital to hire the anesthesiologists back.

Perhaps, but you're still starting a trend. Don't think I'm advocating for any of this, I'm just telling you what I see in my limited travels. I would ignore it at your own professional peril. We have nurses who apparently are trying to do "minor surgeries" in some places and we're not ignoring it, trust me.

 

[Mman]

Perhaps, but you're still starting a trend. Don't think I'm advocating for any of this, I'm just telling you what I see in my limited travels. I would ignore it at your own professional peril. We have nurses who apparently are trying to do "minor surgeries" in some places and we're not ignoring it, trust me.

I'm not starting any trend. I'm just telling you what I've seen in small hospitals that my group has been begged to take over from the previously quasi-independently practicing CRNAs to step up the efficiency and quality of care delivered. The surgeons have thanked us and we have no plans on leaving.

 

[ruralsurg4now]

I'm not starting any trend. I'm just telling you what I've seen in small hospitals that my group has been begged to take over from the previously quasi-independently practicing CRNAs to step up the efficiency and quality of care delivered. The surgeons have thanked us and we have no plans on leaving.

I didn't mean "you" as in "you personally." If you'd prefer, I'll use the passive voice and say "yes, but a trend has been started." Sure, I believe that what you say happened. But ask yourself, what's more prevalent? Small hospitals, particularly in underserved areas, hiring CRNAs when they can't staff with anesthesiologists? Or the reverse, where they used to staff exclusively with CRNAs and now they found some anesthesiologists who are willing to go there? People (perhaps not you, but probably a lot of medical students who only know the academic world of their medical school) think that there's an intensivist at every hospital in America, or a cardiologist, or an anesthesiologist, or a surgeon. At some point, someone's going to say "hey, we can cut costs!" Not tomorrow or next year, but maybe in a decade.

 

[Mman]

I didn't mean "you" as in "you personally." If you'd prefer, I'll use the passive voice and say "yes, but a trend has been started." Sure, I believe that what you say happened. But ask yourself, what's more prevalent? Small hospitals, particularly in underserved areas, hiring CRNAs when they can't staff with anesthesiologists? Or the reverse, where they used to staff exclusively with CRNAs and now they found some anesthesiologists who are willing to go there? People (perhaps not you, but probably a lot of medical students who only know the academic world of their medical school) think that there's an intensivist at every hospital in America, or a cardiologist, or an anesthesiologist, or a surgeon. At some point, someone's going to say "hey, we can cut costs!" Not tomorrow or next year, but maybe in a decade.

But what you don't know is that the reason for those hirings of CRNAs is purely political. There is legislation known as the rural pass through via Medicare that let's small hospitals be guaranteed they can't lose money hiring a nurse (CRNA). So they get reimbursed 100% of their cost of hiring. The same does not apply to their hiring a physician.

So basically the government has decided small hospitals can hire nurses at any salary and get fully paid for it, while if they hired a phyisican for the same salary they can still lose money.

So the "hey we can cut costs" isn't related to spending less money, it's related to bringing in more reimbursement from Medicare to cover it.


Twisted, twisted system.

 

[Mman]

From the ASA....

Although Medicare normally pays for the services of anesthesia providers under the Medicare Part B fee schedule, a statutory exception has existed since the 1980s for reimbursing services of an anesthesiologist assistant (AA) or nurse anesthetist rendered to patients in certain rural hospitals. At present, under regulations issued by the Centers for Medicare and Medicaid Services (CMS), an AA or nurse anesthetist employed by or contracting with a hospital located within a rural area can be reimbursed under Medicare Part A on a reasonable cost "pass through" basis as long as the total number of hours per year does not exceed 2,080 and the surgical volume at the hospital does not exceed 800 cases. Under the CMS regulation, the caseload may be covered by more than one AA or nurse anesthetist as long as the total maximum hours do not exceed 2,080.

When the permissible number of surgical cases was increased from 500 to 800 in 2002, ASA formally commented to CMS that such a caseload was not unusual for many anesthesiologists and urged that the pass-through methodology be applied to anesthesiologists as well as AAs and nurse anesthetists. CMS responded that in view of the fact that the statutory exception (42 USC § 1395ww) covered only nurse anesthetists (and, curiously, anesthesiologist assistants who can work only under the supervision of an anesthesiologist), it did not enjoy the power to extend the exception.

 

[ruralsurg4now]

Hm, I didn't know that. It's interesting, but it still portends a trend for the future.

 

[Mman]

Hm, I didn't know that. It's interesting, but it still portends a trend for the future.

The trend is that CRNAs like to pass themselves off as a cheaper but equally effective replacement for anesthesiologists. 2 problems with the logic:

1) they aren't cheaper to the system especially as they advocate for equal reimbursement
2) they aren't equally effective which is more difficult to prove but I strongly believe that 2 years of post undergrad training cannot replicate 8 years of medical school and residency

The problem is that there are more RNs than MDs and they have acted politically as a fairly effective union and politicians only care about votes.

 

[ruralsurg4now]

2) they aren't equally effective which is more difficult to prove but I strongly believe that 2 years of post undergrad training cannot replicate 8 years of medical school and residency

The problem is that most cases are routine and they're fine with routine cases. I wouldn't want a CRNA with me alone if a patient started crashing, but the truth is that for other patients they're just fine. But you're right about nurses and lobbying and unionizing.

 

[Mman]

The problem is that most cases are routine and they're fine with routine cases. I wouldn't want a CRNA with me alone if a patient started crashing, but the truth is that for other patients they're just fine. But you're right about nurses and lobbying and unionizing.

Anesthesiologists have made routine anesthetics so safe compared to the past thanks to instituting standards like capnography and pulse oximetry that the vast majority of the time everything is fine. It's just that you can't always predict when things will go south. And when stuff hits the fan, the surgeon can't be worrying about trying to tell the CRNA what to do while they also try to do their job.

 

[sevoflurane]

The problem is when a routine case turns into a life threatening emergency. That's when you can tell the difference. Most cases are routine, yes… but where the rubber meets the road is when a routine case goes south fast. That's when our true worth is seen. Let's take one of my cases from last year as an example:

Patient with multiple ex-laps/adhesions and malpositioned colostomy bag (more central than it should have been) is transferred from outside hospital for a "simple" septic lap chole. Verres needle needed to be placed more laterally. Verres needle goes in. What happened next required careful thinking, diagnosing and implementation of a quick plan as minutes meant the difference between life and death.

So, verres needle goes in, loss of etCo2 on ventilator and cardiorespiratory collapse quickly follows. Of course I've read and studied this scenario a million times and actually have seen a very similar presentation during residency (vena cava puncture). No one had noticed the needle went into the liver as it is a blind procedure. Soon after insufflation I looked at my ventilator and hemodynamics, drew on my training and experience and figured out what happened. Dropped a TEE, made the diagnosis, had my staff call my CT surgeon and told him we needed to crash onto bypass NOW. Head down/left lateral, a-line, big cordis and sucked out a bunch of C02. Made it onto bypass in 15 minutes.
Sternotomy, big dilated anoxic heart, opened up the RA and saw massive amount of C02 making it's way out of the heart. Decompressed the rest of the heart. The heart then quickly picked up as did cerebral sats. Separated from bypass and the patient made it to the ICU alive.

That's the **** people don't get. It's also when you can really tell the difference between a nurse anesthetist and a board certified anesthesiologist.

My .02 cents.

Edit: Looks like Mman beat me to the punch as I was typing this.

 

[emergentmd]

ED doc here. I have always been confused as to why an anesthesiology group gets "bought out" and partners given a golden parachute while ED groups gets taken over without any buyouts.

Our Anesthesiology group was just bought out and partners did well. EM groups never get bought out.

To clarify, the gas group and EM group have exclusive contracts with the hospital. I am not sure why an AMC would want to pay the gas group other than for good will. Possibly disrupting the Gas group would cost alot of lost revenue b/c of cancelled surgeries. Disrupting the ED would have very little financial impact on the hospitals.

 

[deleted126335]

ED doc here. I have always been confused as to why an anesthesiology group gets "bought out" and partners given a golden parachute while ED groups gets taken over without any buyouts.

Our Anesthesiology group was just bought out and partners did well. EM groups never get bought out.

To clarify, the gas group and EM group have exclusive contracts with the hospital. I am not sure why an AMC would want to pay the gas group other than for good will. Possibly disrupting the Gas group would cost alot of lost revenue b/c of cancelled surgeries. Disrupting the ED would have very little financial impact on the hospitals.

ORs are the hospital's cash cow. If there is a buyout for the existing group when transitioning to an AMC or an employee model, frequently comes down to the existence and perception of strength of the noncompetes, and the perception of the unity of the anesthesia group on their willingness to fight. It has zero to do with goodwill.

 

[Mman]

ED doc here. I have always been confused as to why an anesthesiology group gets "bought out" and partners given a golden parachute while ED groups gets taken over without any buyouts.

Our Anesthesiology group was just bought out and partners did well. EM groups never get bought out.

To clarify, the gas group and EM group have exclusive contracts with the hospital. I am not sure why an AMC would want to pay the gas group other than for good will. Possibly disrupting the Gas group would cost alot of lost revenue b/c of cancelled surgeries. Disrupting the ED would have very little financial impact on the hospitals.

A buyout only exists to shift future revenue from a group to the partners at once in a lump sum in order to "persuade" them to walk away from their business and work as employees for the AMC. More profitable group equals bigger buyout. Why don't ED groups get "bought out"? I have no idea. I presume it has something to do with profitability and exclusive contracts and other such things. I mean you can't just forcibly take a group over that has an exclusive contract with the hospital just like I can't walk into McDonald's and demand that I'm now the owner and everybody works for me.

 

[Mman]

The problem is when a routine case turns into a life threatening emergency. That's when you can tell the difference. Most cases are routine, yes… but where the rubber meets the road is when a routine case goes south fast. That's when our true worth is seen. Let's take one of my cases from last year as an example:

Patient with multiple ex-laps/adhesions and malpositioned colostomy bag (more central than it should have been) is transferred from outside hospital for a "simple" septic lap chole. Verres needle needed to be placed more laterally. Verres needle goes in. What happened next required careful thinking, diagnosing and implementation of a quick plan as minutes meant the difference between life and death.

So, verres needle goes in, loss of etCo2 on ventilator and cardiorespiratory collapse quickly follows. Of course I've read and studied this scenario a million times and actually have seen a very similar presentation during residency (vena cava puncture). No one had noticed the needle went into the liver as it is a blind procedure. Soon after insufflation I looked at my ventilator and hemodynamics, drew on my training and experience and figured out what happened. Dropped a TEE, made the diagnosis, had my staff call my CT surgeon and told him we needed to crash onto bypass NOW. Head down/left lateral, a-line, big cordis and sucked out a bunch of C02. Made it onto bypass in 15 minutes.
Sternotomy, big dilated anoxic heart, opened up the RA and saw massive amount of C02 making it's way out of the heart. Decompressed the rest of the heart. The heart then quickly picked up as did cerebral sats. Separated from bypass and the patient made it to the ICU alive.

That's the **** people don't get. It's also when you can really tell the difference between a nurse anesthetist and a board certified anesthesiologist.

My .02 cents.

Edit: Looks like Mman beat me to the punch as I was typing this.

You are correct that **** hits the fan quickly and when it does, seconds save lives. The most dangerous thing I interact with on a day to day basis are inexperienced CRNAs that either don't recognize a bad situation or overconfident ones that don't know when they need help. It's my job to keep them safe. I can't even imagine the bad **** that happens with unsupervised CRNAs from the things I've seen walking into rooms.

 

[pgg]

I can't walk into McDonald's and demand that I'm now the owner and everybody works for me.

Sure you can, but you have to climb in through the drive-thru window.

 

[Arch Guillotti]

ED doc here. I have always been confused as to why an anesthesiology group gets "bought out" and partners given a golden parachute while ED groups gets taken over without any buyouts.

Doesn't always happen this way. If your contract is up for review every couple of years I don't think there is anything from keeping an AMC from grabbing the new contract. I know at least one place where this happened. One day you are PP, the next day you are an AMC employee.

 

[lwen5]

The problem is when a routine case turns into a life threatening emergency. That's when you can tell the difference. Most cases are routine, yes… but where the rubber meets the road is when a routine case goes south fast. That's when our true worth is seen. Let's take one of my cases from last year as an example:

Patient with multiple ex-laps/adhesions and malpositioned colostomy bag (more central than it should have been) is transferred from outside hospital for a "simple" septic lap chole. Verres needle needed to be placed more laterally. Verres needle goes in. What happened next required careful thinking, diagnosing and implementation of a quick plan as minutes meant the difference between life and death.

So, verres needle goes in, loss of etCo2 on ventilator and cardiorespiratory collapse quickly follows. Of course I've read and studied this scenario a million times and actually have seen a very similar presentation during residency (vena cava puncture). No one had noticed the needle went into the liver as it is a blind procedure. Soon after insufflation I looked at my ventilator and hemodynamics, drew on my training and experience and figured out what happened. Dropped a TEE, made the diagnosis, had my staff call my CT surgeon and told him we needed to crash onto bypass NOW. Head down/left lateral, a-line, big cordis and sucked out a bunch of C02. Made it onto bypass in 15 minutes.
Sternotomy, big dilated anoxic heart, opened up the RA and saw massive amount of C02 making it's way out of the heart. Decompressed the rest of the heart. The heart then quickly picked up as did cerebral sats. Separated from bypass and the patient made it to the ICU alive.

That's the **** people don't get. It's also when you can really tell the difference between a nurse anesthetist and a board certified anesthesiologist.

My .02 cents.

Edit: Looks like Mman beat me to the punch as I was typing this.

God bless you and all other anesthesiologists. CRNAs, politicians, and the educational lobby are a threat to human life.

 

[deleted126335]

God bless you and all other anesthesiologists. CRNAs, politicians, and the educational lobby are a threat to human life.

You'll forgive us if we take offense that the hardest thing that we have ever done, the work that we have invested, the work that we do every day, and our most expensive investment and valuable asset is being denigrated by people who have worked far less and accomplished far less.

 

[CVRN]

SRNA here. While the management of the case below sounds superb it doesn't take a physician to make this diagnosis. You even mentioned you have studied this case scenario a million times but so have CRNAs and probably AAs I would imagine. You actually had the technology and a CT surgeon immediately available to save the patient which is awesome but this is basic anesthesia knowledge. So when I hear things like "the surgeon doesnt want to have be telling the CRNA what to do when an emergency arises" I just scratch my head a bit. Having rotated through a few solo CRNA rural clinical sites I can tell you that this would never happen. Its the exact same dynamic as is seen at the larger centers. A "supervising" surgeon is not somehow blessed with more anesthesia knowledge because they work with CRNAs.

I dont plan on debating anyone on here as this is a physicians forum and I am happy to lurk and learn. I acknowledge that physician training is "better" on average than CRNA training and personally feel that certain requirements for CRNA training need to be elevated. I believe CRNAs and anesthesiologists abilities as providers are two bell curves which overlap to some degree and I hope that the solo CRNAs are falling onto the far right of the curve the majority of the time but we'll never know. Just throwing that caveat in there to hopefully ward off those who think Im just a militant SRNA trolling. Im really not. But some of the stuff posted about midlevels as if they all just follow a protocol and dont critically think is just ridiculous. Happy holidays everyone

The problem is when a routine case turns into a life threatening emergency. That's when you can tell the difference. Most cases are routine, yes… but where the rubber meets the road is when a routine case goes south fast. That's when our true worth is seen. Let's take one of my cases from last year as an example:

Patient with multiple ex-laps/adhesions and malpositioned colostomy bag (more central than it should have been) is transferred from outside hospital for a "simple" septic lap chole. Verres needle needed to be placed more laterally. Verres needle goes in. What happened next required careful thinking, diagnosing and implementation of a quick plan as minutes meant the difference between life and death.

So, verres needle goes in, loss of etCo2 on ventilator and cardiorespiratory collapse quickly follows. Of course I've read and studied this scenario a million times and actually have seen a very similar presentation during residency (vena cava puncture). No one had noticed the needle went into the liver as it is a blind procedure. Soon after insufflation I looked at my ventilator and hemodynamics, drew on my training and experience and figured out what happened. Dropped a TEE, made the diagnosis, had my staff call my CT surgeon and told him we needed to crash onto bypass NOW. Head down/left lateral, a-line, big cordis and sucked out a bunch of C02. Made it onto bypass in 15 minutes.
Sternotomy, big dilated anoxic heart, opened up the RA and saw massive amount of C02 making it's way out of the heart. Decompressed the rest of the heart. The heart then quickly picked up as did cerebral sats. Separated from bypass and the patient made it to the ICU alive.

That's the **** people don't get. It's also when you can really tell the difference between a nurse anesthetist and a board certified anesthesiologist.

My .02 cents.

Edit: Looks like Mman beat me to the punch as I was typing this.

 

[ProRealDoc]

SRNA here. While the management of the case below sounds superb it doesn't take a physician to make this diagnosis. You even mentioned you have studied this case scenario a million times but so have CRNAs and probably AAs I would imagine. You actually had the technology and a CT surgeon immediately available to save the patient which is awesome but this is basic anesthesia knowledge. So when I hear things like "the surgeon doesnt want to have be telling the CRNA what to do when an emergency arises" I just scratch my head a bit. Having rotated through a few solo CRNA rural clinical sites I can tell you that this would never happen. Its the exact same dynamic as is seen at the larger centers. A "supervising" surgeon is not somehow blessed with more anesthesia knowledge because they work with CRNAs.

I dont plan on debating anyone on here as this is a physicians forum and I am happy to lurk and learn. I acknowledge that physician training is "better" on average than CRNA training and personally feel that certain requirements for CRNA training need to be elevated. I believe CRNAs and anesthesiologists abilities as providers are two bell curves which overlap to some degree and I hope that the solo CRNAs are falling onto the far right of the curve the majority of the time but we'll never know. Just throwing that caveat in there to hopefully ward off those who think Im just a militant SRNA trolling. Im really not. But some of the stuff posted about midlevels as if they all just follow a protocol and dont critically think is just ridiculous. Happy holidays everyone

There is a sea of difference between knowing what to do and being able to actually do it.

Unless you can replicate exactly what Sevo did with the same degree of skill or better, I would just congratulate the man and move on.

Accept there others who will always be much better than you'll ever be. Be glad they exist as they may save your life someday.

 

[Mman]

SRNA here. While the management of the case below sounds superb it doesn't take a physician to make this diagnosis. You even mentioned you have studied this case scenario a million times but so have CRNAs and probably AAs I would imagine. You actually had the technology and a CT surgeon immediately available to save the patient which is awesome but this is basic anesthesia knowledge. So when I hear things like "the surgeon doesnt want to have be telling the CRNA what to do when an emergency arises" I just scratch my head a bit. Having rotated through a few solo CRNA rural clinical sites I can tell you that this would never happen. Its the exact same dynamic as is seen at the larger centers. A "supervising" surgeon is not somehow blessed with more anesthesia knowledge because they work with CRNAs.

I dont plan on debating anyone on here as this is a physicians forum and I am happy to lurk and learn. I acknowledge that physician training is "better" on average than CRNA training and personally feel that certain requirements for CRNA training need to be elevated. I believe CRNAs and anesthesiologists abilities as providers are two bell curves which overlap to some degree and I hope that the solo CRNAs are falling onto the far right of the curve the majority of the time but we'll never know. Just throwing that caveat in there to hopefully ward off those who think Im just a militant SRNA trolling. Im really not. But some of the stuff posted about midlevels as if they all just follow a protocol and dont critically think is just ridiculous. Happy holidays everyone

I could go on and on and on about dumb things I've seen SRNAs do. And my wife is a CRNA so I'm well aware of what she knows and doesn't know. When the stuff hits the fan, you don't want a unsupervised CRNA taking care of you. You just don't. But you don't have the knowledge base to make that connection, so I don't fault you, because you don't know what you don't know.

 

[deleted171991]

Why not fault him/her? That's exactly the problem with CRNAs: most of them don't know how little they know and treat anesthesiologists as their peers (or worse). It's the typical nursing attitude, where they think they know better than many doctors, because they have more "experience". They think that experience can replace knowledge most of the time, that doing maintenance on cars for a long time puts you on equal footing with a mechanic.

 

[sevoflurane]

SRNA here…..but this is basic anesthesia knowledge.

No offense, but your arrogance as a student CRNA underlines my exact point.

Basic knowledge? That's just too funny. Just because I've read up on this scenario a million times, doesn't mean all CRNA's have (MD = USMLE I, II, III, Multiple ITE, ABA certification via written and oral boards + far superior numbers of difficult cases during training) . That is a big leap of faith suggesting basic knowledge for CRNAs.

I forget how many TEE exams you do during your CRNA training. How many open heart cases do CRNA's get during those exhausting 2 years? What's the minimum amount of CVL you need to place in order to graduate? How fast can you get one done when push comes to a shove? Can you comment on that? What can your TEE exam yield in this situation and how can you use it? Are you looking for PFO's? What does it mean when you have a PFO in this situation? What maneuvers are you going to use if you see one? Where are you going to commence bypass? Are you going to move in the CPB machine into the general OR or are you going to move the patient to the CT ORs. Are you prepared to take charge of the ENTIRE room, including the general surgeon… delegating specific jobs to every person involved? Are you going to keep the patient in steep head down, left lateral when the surgeon is getting ready to make incision? What if he says he wants the patient supine? Are you going to object? I can go on and on.

There is NOTHING BASIC ABOUT THIS CASE. Your overconfidence in your response in astonishing.

Overconfidence is a very dangerous situation in the ORs. My hats goes off to Mman and those who supervise.

My patient had a PFO, btw. I know you don't know what you don't know, so I don't blame you.

 

[sevoflurane]

CVRN, I'm sure you'll become a great CRNA, but please understand that there is and always will be a huge difference. Be a team player. That's all we ask.

 

[BLADEMDA]

Minors= CRNA
League= Anesthesiologist

 

[BLADEMDA]

CVRN, I'm sure you'll become a great CRNA, but please understand that there is and always will be a huge difference. Be a team player. That's all we ask.

I hate to say it but the future is arrogant CRNA solo practice with Fireman MD (A) backup. If a patient or two dies as a result of it the Obamacare health system will cover it up. What matters is cost then quality care.

 

[IkeBoy18]

I hate to say it but the future is arrogant CRNA solo practice with Fireman MD (A) backup. If a patient or two dies as a result of it the Obamacare health system will cover it up. What matters is cost then quality care.

what about all of the other things MDs are trained to do ie, critical care/ICU etc, is that not worth something over someone who is chained to the gas cart?

 

[BLADEMDA]

Minors= CRNA
League= Anesthesiologist

As long as there are malpractice lawyers and surgeons who care about quality there will be a need for a Physician Anesthesiologist to supervise those CRNAs who fall outside the overlap of the bell shaped curves.

 

[Mman]

Minors= CRNA
League= Anesthesiologist

Funny that you post that. I was thinking of some baseball analogies along those lines as well. It's like the guy in AA that thinks he's hitting fastballs just fine, so he'll be just like Miguel Cabrera or Mike Trout when he gets up to the big leagues and is facing Clayton Kershaw or Justin Verlander. He thinks it's the same thing, but he has no way of knowing that and no basis for the comparison other than seeing all the minor leaguers he's been around.

 

[GasEmDee]

SRNA here. You actually had the technology and a CT surgeon immediately available to save the patient which is awesome but this is basic anesthesia knowledge.

This is frightening. There is nothing basic about this case, and it is scares me that you can say this as a student. I suspect one day, after you have had some actual experience, and you will look at this statement with some humility and embarrassment.

This comment exemplifies what is scary about newly trained nurses. I have seen a great many similar examples.

When I was a medical student, I knew only the vocabulary of medicine, but I didn't realize that I actually knew nothing practical. The day I finished all my clinical training was the humblest I had ever been about medicine. Knowledge is like a sphere. The larger the sphere, the larger the surface area beyond which is your ignorance. To paraphrase, the more you know, the more you realize what you don't know.

A little knowledge (especially whence coupled with little to no experience) is really dangerous!!

*Shudder*

P.S: Sevo: that was incredibly fine clinical work. Nice job.

 

[JoBreeze]

SRNA here. While the management of the case below sounds superb it doesn't take a physician to make this diagnosis. You even mentioned you have studied this case scenario a million times but so have CRNAs and probably AAs I would imagine. You actually had the technology and a CT surgeon immediately available to save the patient which is awesome but this is basic anesthesia knowledge. So when I hear things like "the surgeon doesnt want to have be telling the CRNA what to do when an emergency arises" I just scratch my head a bit. Having rotated through a few solo CRNA rural clinical sites I can tell you that this would never happen. Its the exact same dynamic as is seen at the larger centers. A "supervising" surgeon is not somehow blessed with more anesthesia knowledge because they work with CRNAs.

I dont plan on debating anyone on here as this is a physicians forum and I am happy to lurk and learn. I acknowledge that physician training is "better" on average than CRNA training and personally feel that certain requirements for CRNA training need to be elevated. I believe CRNAs and anesthesiologists abilities as providers are two bell curves which overlap to some degree and I hope that the solo CRNAs are falling onto the far right of the curve the majority of the time but we'll never know. Just throwing that caveat in there to hopefully ward off those who think Im just a militant SRNA trolling. Im really not. But some of the stuff posted about midlevels as if they all just follow a protocol and dont critically think is just ridiculous. Happy holidays everyone

You. Don't. Know. What. You. Don't. Know.

 

[Spinach Dip]

The greatest threat to discovery is the illusion of knowledge.

 

[GasEmDee]

Why not fault him/her? That's exactly the problem with CRNAs: most of them don't know how little they know and treat anesthesiologists as their peers (or worse). It's the typical nursing attitude, where they think they know better than many doctors, because they have more "experience". They think that experience can replace knowledge most of the time, that doing maintenance on cars for a long time puts you on equal footing with a mechanic.

Yep. My cousin went to a one-year nursing program. In her first few months of work, she was lamenting how she had to "teach" things to residents. After gaining a tad more experience, she would spout off lots of "knowledge", which was actually anecdotal assumption. For example, she knew lithium is a first-line anti-depressant, because she had seen it on the med list of patients who were depressed.

Also had an experienced ED nurse poke his head in the room when i was doing a supraclavicular block. He later asked me how far I had inserted the needle. Later he thanked me, because now he knew how to do a supraclavicular block. Didn't notice the ultrasound, didn't ask anything about surface landmarks or nerve stimulation. I told him that one cannot just shove the needle in some predetermined length, and that I had used a localization technique (ultrasound). He retorted that I was simply worried about legal liability. I replied, "No, I am also worried about nerve damage, intravascular injection, and pneuothorax."

Both knowledge AND experience are necessary.

 

[CVRN]

For the record, I described the management of the case as superb if i recall. I also never said it was a basic case. I said it was basic anesthesia knowledge and I will stand by that. Sudden loss of EtCO2 and cardiopulmonary collapse during insufflation screams of co2 embolism. I think the route to go for you all would be to focus on the TEE side of the management which sevo has done. That's one area where MD's consistently have the upper hand as far as i know. Like ive said i believe requirements should be elevated for certain aspects of clinical crna training. i dont actually know what the minimum TEE experience and knowledge is for an anesthesia resident. I have met recent graduate anesthesiologists who have admitted they have had very little TEE knowledge and have had to learn it post residency but i presume this is the exception.

Sevoflurane, I appreciate the vote of confidence in my future abilities as a CRNA and I plan on working as a team player in an ACT practice. Hopefully i love working there and its the last job ill ever have. However, if there isnt a "team" atmosphere i'll be gone and maybe even "militarized" to pursue independent practice. I acknowledge that there will be crnas who slip through the cracks and really dont belong in advanced practice nursing roles but what of those CRNAs on the far right of the bell curve? This is a rhetorical question obviously but hopefully some of you who supervise or plan on supervising one day can see that micromanaging or belittling CRNAs will only serve to push them away from ACT practices and into more autonomous practices. lets say for arguments sake that increased solo crna practice would result in a small rise in M and M for a tiny fraction of patients. Now consider that this fraction of very sick patients will be even less likely to be cared for in small crna only hospitals. So how many patients are we talking here? is there a study that could be powered enough to show a difference? Now Im just spitballing here so dont take my words out of context im not suggesting a minor increase in M and M is ok. But many of you have already acknowledged that this could easily be covered up by the system and no one will ever know. I would be pessimistic about the future of MD anesthesia too Im not gonna lie. I would be focusing on a more sustainable solution for CRNAs and MDs to coexist thats all im saying. I believe a model where CRNAs and MDs do their own cases independently with MD consultation available as needed is probably in the future.

 

[Mman]

For the record, I described the management of the case as superb if i recall. I also never said it was a basic case. I said it was basic anesthesia knowledge and I will stand by that. Sudden loss of EtCO2 and cardiopulmonary collapse during insufflation screams of co2 embolism. I think the route to go for you all would be to focus on the TEE side of the management which sevo has done. That's one area where MD's consistently have the upper hand as far as i know. Like ive said i believe requirements should be elevated for certain aspects of clinical crna training. i dont actually know what the minimum TEE experience and knowledge is for an anesthesia resident. I have met recent graduate anesthesiologists who have admitted they have had very little TEE knowledge and have had to learn it post residency but i presume this is the exception.

Sevoflurane, I appreciate the vote of confidence in my future abilities as a CRNA and I plan on working as a team player in an ACT practice. Hopefully i love working there and its the last job ill ever have. However, if there isnt a "team" atmosphere i'll be gone and maybe even "militarized" to pursue independent practice. I acknowledge that there will be crnas who slip through the cracks and really dont belong in advanced practice nursing roles but what of those CRNAs on the far right of the bell curve? This is a rhetorical question obviously but hopefully some of you who supervise or plan on supervising one day can see that micromanaging or belittling CRNAs will only serve to push them away from ACT practices and into more autonomous practices. lets say for arguments sake that increased solo crna practice would result in a small rise in M and M for a tiny fraction of patients. Now consider that this fraction of very sick patients will be even less likely to be cared for in small crna only hospitals. So how many patients are we talking here? is there a study that could be powered enough to show a difference? Now Im just spitballing here so dont take my words out of context im not suggesting a minor increase in M and M is ok. But many of you have already acknowledged that this could easily be covered up by the system and no one will ever know. I would be pessimistic about the future of MD anesthesia too Im not gonna lie. I would be focusing on a more sustainable solution for CRNAs and MDs to coexist thats all im saying. I believe a model where CRNAs and MDs do their own cases independently with MD consultation available as needed is probably in the future.

A future where CRNAs do their own thing and ask me to come save them after it's an unrecoverable situation is not in the patient's best interest.

The funniest thing to me about the CRNAs that want independence is wondering when they stopped being a nurse. Nurses are supposed to advocate for the best possible care for their patients. Yet they will fight tooth and nail to try to get 100% independent practice for a new grad CRNA with zero experience. And don't say they won't, because that is what they want. There is no comparison between 2 years of CRNA school and 8 years of med school + residency. I did more cases my first year as a resident than SRNAs do their entire 2 years at many programs and then I had an additional 7 years of training beyond that. Hell, I took care of more ICU patients in 2 months as a resident than those same SRNAs did in 2 years working in the ICU since they only had 1-2 patients at a time and then I had 5 more months of ICU time beyond that. You claim that MDs have the upper hand in TEE? Yes, also in epidurals, spinals, nerve blocks, arterial lines, central lines, PA catheters, and critical thinking skills.

There is an extremely small percentage of CRNAs that would probably be capable of being safe in an independent environment. Unfortunately, that requires all the rest of them to also be independent which means people are going to die and suffer morbidity they didn't need to.



As to the hypothetical being described, I find it amusing that you think the MD would focus on the TEE side of things. I'd focus on everything. I'd have the a-line, central line, and TEE done in about 10-15 minutes total time all while resuscitating the patient (and that's actual time on the clock, not surgeon time, as I've clocked myself doing every possible procedure in every situation so I know how long it takes). The CRNA algorithm for hypotension tends to be fluid followed by phenylephrine followed by ephedrine and that's about where the train of thought ends.

 

[ssmallz]

However, if there isnt a "team" atmosphere i'll be gone and maybe even "militarized" to pursue independent practice.

Your use of quotes in the word team tells me everything I need to know about how you view yourself and the anesthesiologists around you.

I acknowledge that there will be crnas who slip through the cracks and really dont belong in advanced practice nursing roles but what of those CRNAs on the far right of the bell curve?

They should consider going to medical school and become anesthesiologists.

 

[CVRN]

Your use of quotes in the word team tells me everything I need to know about how you view yourself and the anesthesiologists around you.



They should consider going to medical school and become anesthesiologists.

Perhaps I should have been more careful in my posting. I'll avoid posts at 3am in the future. The quotes were supposed to reference the "team" in which the MD micromanages everything and treats the CRNAs like a glorified staff nurse who can intubate and turn dials. I would honestly be happy in an ACT setting if i was treated right.

 

[IlDestriero]

I'd be curious what you consider micromanagement without using ridiculous theoretical examples.
Des vs sevo, tube vs LMA? Or 2.8% sevo at 0.6L fresh flow 45% O2$ and pressure limited vent to 18 with a peep of 4? Or tape the tube this way, place the esoph temp probe to x depth? Etc.
There are some things I care about and some I do not. If you want one thing and I do not, I'll give the courtesy of a reason. You could counter, but if it's something I care about for that situation, it's not a democracy.
Of course you're still a SRNA, so I'm sure you're heavily micromanaged anyway. Hopefully the attendings at least briefly explain their reasoning. That's part of teaching. We infrequently have SRNAs and when we do, you're never alone in a room and you can't come until after you've completed your PEDs rotations elsewhere. That's the price you pay to rotate here. It's really a month long interview for potential hires, training SRNAs is not part of our mission.