It’s not MAC

[MediCane2006]

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Speaking as a surgeon (peds plastics), it is insane to me that your attendings are letting the surgeon dictate your anesthetic plan.

In my practice (and granted, I know my anesthesiologists very very well) I let the anesthesia resident and attending know what my surgical plan is, my (realistic) duration of the case, and what the patient position will be and then I let them do their thing. Once in awhile I will suggest an LMA over ETT, but ultimately it’s their call. And I always let them be the ones to volunteer just masking a patient while I do a quick excision.

My logic is that its your (anesthesiology) case from an anesthesia perspective, and I don’t want to have to worry about two specialty’s worth of issues while I’m operating. I’m a big fan of engaging all the brain power in the room in their respective roles.

 

[IMGASMD]

Speaking as a surgeon (peds plastics), it is insane to me that your attendings are letting the surgeon dictate your anesthetic plan.

In my practice (and granted, I know my anesthesiologists very very well) I let the anesthesia resident and attending know what my surgical plan is, my (realistic) duration of the case, and what the patient position will be and then I let them do their thing. Once in awhile I will suggest an LMA over ETT, but ultimately it’s their call. And I always let them be the ones to volunteer just masking a patient while I do a quick excision.

My logic is that its your (anesthesiology) case from an anesthesia perspective, and I don’t want to have to worry about two specialty’s worth of issues while I’m operating. I’m a big fan of engaging all the brain power in the room in their respective roles.

Are you in a niche sub-speciality or academics? Do you have a team of pediatric trained anesthesiologists that do your cases? You also sound like you can do multiple surgeries and can improvise. (I’d imagine anyone who call themselves plastic surgeon, especially a pediatric plastic surgeon would probably fit all those criteria.)

Some of the community surgeons are one, two or three trick ponies if you deviate from anything they do everyday, they throw a fit or just lost. If it can be done safely, usually I let it go.

 

[MediCane2006]

Are you in a niche sub-speciality or academics? Do you have a team of pediatric trained anesthesiologists that do your cases? You also sound like you can do multiple surgeries and can improvise. (I’d imagine anyone who call themselves plastic surgeon, especially a pediatric plastic surgeon would probably fit all those criteria.)

Some of the community surgeons are one, two or three trick ponies if you deviate from anything they do everyday, they throw a fit or just lost. If it can be done safely, usually I let it go.

I do have the luxury of pediatric anesthesiologists because I work at a dedicated pediatric hospital...that said, I have worked in a low-resource safety net hospital as well and my philosophy was the same. I think there is to some degree a culture issue in surgery that needs to change if we want to maintain anesthesiology as a medical specialty, and that is treating our anesthesiologist colleagues as fellow physicians with equal stake in determining the optimal plan for our patients. It frustrates me when I read these forums and realize that my model is often a minority.

 

[chocomorsel]

Very reputable regional and national institution, big name. Heavily advertises, tv, radio, billboard, sports team sponsor.

Pays well but salaried, calls not too bad, no ED so few emergencies. Nice deal on paper but I have never seen attendings so stressed and insulted on a daily basis by their surgical "peers". When you see the department chair chewed out by a head and neck surgeon over tiny trivial items really puts the big stuff in perspective.

Surgeons interfering with how I perform an anesthetic is ridiculous. Its the same as if I pointed to random items on their standard trays and said they cant use it.

Ahh, sounds like the TMC. Full of egos and dinguses. Good luck. Keep your mouth shut and do what you are told. Certainly try to convince them nicely that you can accomplish the same thing w a secure airway but if they aren’t listening and your attendings are weak, just suck it up and pray.

 

[deleted171991]

I do have the luxury of pediatric anesthesiologists because I work at a dedicated pediatric hospital...that said, I have worked in a low-resource safety net hospital as well and my philosophy was the same. I think there is to some degree a culture issue in surgery that needs to change if we want to maintain anesthesiology as a medical specialty, and that is treating our anesthesiologist colleagues as fellow physicians with equal stake in determining the optimal plan for our patients. It frustrates me when I read these forums and realize that my model is often a minority.

Peds people have a tendency to always put the patient above their egos. I have seen it again and again. Probably because nobody gets into a pediatric specialty unless they really love children. While adult specialists dislike not just each other, but the patients, too. 😉

 

[Robotic Wis-Hipple]

Speaking as a surgeon (peds plastics), it is insane to me that your attendings are letting the surgeon dictate your anesthetic plan.

In my practice (and granted, I know my anesthesiologists very very well) I let the anesthesia resident and attending know what my surgical plan is, my (realistic) duration of the case, and what the patient position will be and then I let them do their thing. Once in awhile I will suggest an LMA over ETT, but ultimately it’s their call. And I always let them be the ones to volunteer just masking a patient while I do a quick excision.

My logic is that its your (anesthesiology) case from an anesthesia perspective, and I don’t want to have to worry about two specialty’s worth of issues while I’m operating. I’m a big fan of engaging all the brain power in the room in their respective roles.

What is this prophylactic discussion of your “realistic duration” of a case you’re talking about? Do you know your conversion factor? Lol.

Your posts may be the most refreshing two posts I’ve read regarding anesthesia in, well, ever.

 

[Big Swinging Doc]

I agree that we should get rid of the term MAC altogether.

I've also heard it called GAWAC (General Anesthesia Without Airway Control). Room Air General is the more common term, of course.

At one place I occasionally cover for they have had trouble getting reimbursed for "MAC" cases in the GI suite, so now the routine is to call every GI "sedation" case a TIVA (Total Intravenous Anesthetic), and to specifically note LOC (Loss of Consciousness) in the note.

At another place GI suite a nurse holding a clipboard tried to tell me that there was NO WAY I had just performed a general anesthetic (loss of consciousness, lack of response to surgical stimulation), because HER PAPERWORK indicated that "the anesthesiologist is only credentialed to perform MACs at this center."

((On a separate note, does anyone want to join with me in noting how crazy it is that a nurse is so accustomed to bossing physicians around that she thinks her clipboard outranks my board certification when it comes to explaining what anesthetic I just performed? It's madness.))

I have long since stopped offering my services for cataracts. Those are, rightly, true MAC cases: sometimes nothing but topical, occasionally a little versed and/or fentanyl; mostly just charting and hand-holding. I will do some vitrectomies with retrobulbar blocks. In that case, I give a (smallish) induction bolus of propofol, rendering the patient unconscious for the application of the RBB, in which case I bill for a TIVA. I don't think I've clicked "MAC" on a billing ticket in over ten years.

 

[MediCane2006]

What is this prophylactic discussion of your “realistic duration” of a case you’re talking about? Do you know your conversion factor? Lol.

Your posts may be the most refreshing two posts I’ve read regarding anesthesia in, well, ever.

Haha I am pretty sure my conversion factor is close to 1 but so does every surgeon so I’m probably flattering myself.

 

[OneTyme]

Deep enough to tolerate an LMA = GA in my book

I dunno man... there’s a person in my program that can place a #4 igel on themselves and then walk around breathing through it.

 

[woopedazz]

I dunno man... there’s a person in my program that can place a #4 igel on themselves and then walk around breathing through it.

He can also suck a golfball through a size 6 ETT.

 

[jwk]

He can also suck a golfball through a size 6 ETT.

That's TMI 😉

 

[deleted162650]

I dunno man... there’s a person in my program that can place a #4 igel on themselves and then walk around breathing through it.

Female? If so, have her PM me.

 

[deleted171991]

Female? If so, have her PM me.

You're only a size 4?