Net Cash flow

[davvid2700]

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Your're absolutlye right about many aspects of our specialty, but you pointed out...we recognize the red flags, etc.

We recognize those flags before surgery, and we treat before surgery, and after surgery. Once your're in the OR.....things that you do are simple.

99% of the OR is charting vital signs, administer fluids, maybe vasoactive drugs......who does that everywhere else in the hospital? Nurses, not physicians.

I'm not in the OR to chart vitals and perform nursing duties. I come into the OR to do the things that you mentioned above. I do that also before the OR, in the PACU, and in the ICU.

I chart vital signs at night because it makes more economic sense for me to do it myself than to pay someone $100 per hour to do it.

Hey you mean everyone who does an anesthesia residency spends three years training to be a nurse? cmon military gimme a break? thats what we do in residency stay in a room all day. Thats what I DO all day right now

 

[bell412]

davvid. Please tell me one MD specialty that dumps pee and turns a bed on command of another MD?

 

[davvid2700]

You are cheapening and undermining your education and the training and education of Anesthesiologists without even knowing it. You are conceding that it doesnt matter what education or training you receive to be an anesthetist. Am i arrogant? not really I am? Am i conceited? not really!. Do i know my worth as an anesthesiologists? you bet your ass I do. DO i know my worth as a physician? you bet your ass i do. DO i know what i bring to the table? you bet your ass I do.

I know military thinks that sitting in a room charting vitals and taking care of the patient intraoperatively is a nurses job. I differ completely. and so do most residencies, since thats what we do for 3 years. at least thats what I did It is this mentality that has given the specialty to the crnas. That and the greed of our predecessors. Thats fine. But in order to save our specialty from literally becoming taken over by the CRNAS, WOuld you do your own cases for the next 10 years? Would you do that if you knew for fact that by doing so you would save the specialty of anesthesia? Or are you just too damn comfortable right now chasing surgeons and chasing or nurses etc.. being or manager. (thats a nurses job)

There are 14 states that opted out of the supervision requirement. As i said before there will probably be more in the future. This is a serious situation that if the ASA leadership does not address will become out of hand in the upcoming years.

 

[davvid2700]

The leadership of the ASA is putting their heads in the sand? You, who trained at a no name program in the NE with a whopping 18 months of experience at one practice, know what's going on with the specialty, and the leaders of the ASA do not?



Why the concern about jobs? and job security? Why are you so insecure about your specialty? Please answer those questions.

Dude,

The ASA leadership work in academic institutions. academic institutions are cesspools of inefficiency They are tenured professors. They have a job "for life" if they want. They dont even have to come in to work. Do you think they give a **** or have any idea about the job market? I am acutely aware of whats going on with the job market!

The jobs that require you to supervise 4 crnas at a time dont pay you more money anyway. They start at about 220.. at a mid size city. Even less at larger ones.

Hey military, do you try to go on the cheap if someone is fixing your brakes in the car? maybe you do? I dont because its pretty important. Why would I try to go on the cheap with someone who is putting me to sleep. WHy would I say hey "janitor" come over here put me to sleep.

 

[militarymd]

Anyways, what's up with the animosity? What's up with the name calling? What's up with the "there is only one way to do things....the Davvid2700 way"?
QUOTE]

What anonymity? what are you talking about? do you want my full name first and last name? what does it matter to the discusiion at hand dude

ANIMOSITY, not anonymity

 

[militarymd]

davvid. Please tell me one MD specialty that dumps pee and turns a bed on command of another MD?

 

[bell412]

Davvid. Do you or do you not dump pee when you are in the OR? If you answer yes then military and jet are right, you are wrong. I know what the answer is and so do you.

 

[militarymd]

You are cheapening and undermining your education and the training and education of Anesthesiologists without even knowing it. .

While you dump pee, raise and lower the table at the surgeon's beckon call, and chart vital signs, I'm seeing patients in the ICU and seeing patients, addressing perioperative medical issues related to anesthesia, and directing nurses......

Who's cheapening their medical training?

And, I'm not "military man".....it is "military MD"....i don't dump pee, or move OR tables.

 

[davvid2700]

davvid. Please tell me one MD specialty that dumps pee and turns a bed on command of another MD?

Anesthesia is a medical specialty that dumps pee and turns the bed. I turn the bed because I dont want the OR nurse turning the bed for me. I dont dump pee; the or nurse does. ANd sometimes I do, so what? are you too damn good to dump pee? its sterile anyway. hopfully.

 

[davvid2700]

Who's cheapening their medical training?

.

You are by saying that the administration wants to minimize costs. Its all about the bottom line.. Ok! if its all about the bottom line, why not hire janitors and train them. would be cheaper.

 

[militarymd]

You are by saying that the administration wants to minimize costs. Its all about the bottom line.. Ok! if its all about the bottom line, why not hire janitors and train them. would be cheaper.

Now that's just being silly. You would have to send the janitor to nursing school first, then a few years experience, then CRNA school.

It wouldn't save any money.

 

[davvid2700]

My point is. why save money? this is not "i wont pay a lot for this muffler". This is someones life. maybe yours, maybe mine, maybe somones loved one. Do you want a crna digging in your neck trying to put a central line in because some bureacrat said they can work indepedently. DUDE I say ******* NO , some of them can do it without incident but that doesnt say everyone of them should be allowed to do it.. You can ******* somebody up good if you screw that procedure up.

 

[davvid2700]

While you dump pee, raise and lower the table at the surgeon's beckon call, and chart vital signs, I'm seeing patients in the ICU and seeing patients, addressing perioperative medical issues related to anesthesia, and directing nurses......


.

Dude,

who is kidding who? while i dump pee you are either on your way to the cafeteria, going to surf the internet or jacking off in the bathroom stall.

so dont lie....

 

[militarymd]

Dude,

who is kidding who? while i dump pee you are either on your way to the cafeteria, going to surf the internet or jacking off in the bathroom stall.

so dont lie....

d2
you know that, by insulting me, you are just supporting everything that I say to all the lurking readers of this forum.
I'm confident with what I believe is a good way to deliver perioperative care.

You insult me, and say that I'm a money grubbing fat lazy MD want to be....while saying that it is a doctor's job to dump pee.

I would submit to you that your posts are hurting you more than helping you.

 

[davvid2700]

d2
You insult me, and say that I'm a money grubbing fat lazy MD want to be.....

No im not saying that. but im saying to sugar coat what you do all day when you are not in the room.. I know what you do.. Im an anesthesiologist too..

 

[CambieMD]

My point is. why save money? this is not "i wont pay a lot for this muffler". This is someones life. maybe yours, maybe mine, maybe somones loved one. Do you want a crna digging in your neck trying to put a central line in because some bureacrat said they can work indepedently. DUDE I say XXXX no , some of them can do it without incident but that doesnt say everyone of them should be allowed to do it.. You can XXXX somebody up good if you screw that procedure up.

You are right, this is not like paying for a muffler. A mechanic can pass all of the cost of installing a muffler onto you. Healthcare providers have to deal wth third party payers. Financial constraints are driving a lot of what happens in medicine today. That is a reality of medicine.

CamieMD

p.s.

y drop the "F" bomb

 

[militarymd]

My point is. why save money? .

I'm not sure where you live or where you think all this money is going to come from to pay for the aging baby-boomers who are going need more and more medical care.

Saving money is the only way for the healthcare system to continue to exist, and it does include mid-level providers, OR efficiency, HMOs, etc.

It is the reality of medicine in the 21st century....ignoring that reality doesn't change the simple facts.

 

[militarymd]

No im not saying that. but im saying to sugar coat what you do all day when you are not in the room.. I know what you do.. Im an anesthesiologist too..

You've said yourself that you don't supervise....so how can you know what we do when we're not in the OR?

So which is it? You've either worked in the team model....or you haven't.

 

[militarymd]

Do you want a crna digging in your neck trying to put a central line in because some bureacrat said they can work indepedently.

I really don't care who is "digging in your neck"....as long as that person is trained. Don't confuse "monkey skills" with making medical decisions.

Monkey skills = line placement, intubation, fluid administration, regional blocks, etc.

Medical decisions = deciding who needs a central line, deciding whether a patient needs to be intubated for impending respiratory failure vs continuing with medical therapy, deciding whether a patient is medically acceptable to go to the OR, etc.

"monkey skills" can be done by the doctor or a nurse....

Medical decisions are made only by physicians.

You seem to confuse "monkey skills" with medical decision making. That is a very common mistake made by junior attendings.

 

[davvid2700]

I'm not sure where you live or where you think all this money is going to come from to pay for the aging baby-boomers who are going need more and more medical care.

Saving money is the only way for the healthcare system to continue to exist, and it does include mid-level providers, OR efficiency, HMOs, etc.

It is the reality of medicine in the 21st century....ignoring that reality doesn't change the simple facts.

"save money" is code for The hospital, the insurance company, the ceo make the money.
I believe there is money..... its just a matter of who gets it.. the provider.. the insurance company.... the hospital or the one who is actually the one delivering the service..

I went into BEST BUY last week.. I wanted the nikon d100. ALmost 800 dollar digital camera. I said to myself, "I dont have the money". Now is that true? No its not true. I do have the money. and I do have the money for THAT digital camera. So I went in "dere" tuesday and bought that camera.. for 800 dollars.

Same thing with medicine.. There is money.. Its just a matter of who gets it and what you negotiate for..

Its just like our country.. We dont have money.. but we are in the middle of a war and spending a **** load of money...

 

[davvid2700]

You've said yourself that you don't supervise....so how can you know what we do when we're not in the OR?

So which is it? You've either worked in the team model....or you haven't.

Simple answer!

I remember when I was supervised for three friggin years. I got all the lines, " I have a meeting to go to". blah blah blah.. Meanwhile they are all in the cofee shop having pastries.. on the internet.. in the cafeteria..
Not thats illegal and wrong.. because i needed my training.. but dont tell me that you are doing all those things that you are doing when in essence you are taking a dump, paying your magazine subscriptions, surfing porn. Hey you may be seeing a patient once in a while Im not denying that but most of the time you are F ing off.

DOnt lie!!

 

[militarymd]

Simple answer!

I remember when I was supervised for three friggin years. I got all the lines, " I have a meeting to go to". blah blah blah.. Meanwhile they are all in the cofee shop having pastries.. on the internet.. in the cafeteria..

Academics is not private practice, but I guess you must have slept at the Holiday Inn Express last night, giving you clairvoyance.....otherwise how could you know it all??

 

[militarymd]

"save money" is code for The hospital, the insurance company, the ceo make the money.
I believe there is money..... its just a matter of who gets it.. the provider.. the insurance company.... the hospital or the one who is actually the one delivering the service..

Guess what? Paying doctors more is not in the future.

 

[davvid2700]

I really don't care who is "digging in your neck"....as long as that person is trained. Don't confuse "monkey skills" with making medical decisions.

.

You seem to confuse "monkey skills" with medical decision making. That is a very common mistake made by junior attendings.

I said digging in "your" neck not "my" neck. I know you dont care who is "digging in my neck" Im here to tell you "Oh yes you do care who is digging in your neck" That is the skill left for a physician. so much so its on my priveieges sheet. ANd no its not a monkey skill. there are landmarks, subtle techniques you have to know, know planes of tissue, know compliabilty of certain vessels etc. Its not a monkey skill..

Next you will tell me operating is a "monkey skill". that you want left to nurse practicioners and the physician assistants.

You are a dangerous man for our profession. Please tell me you are just bringing up these things for the sake of "socratic discourse". please tell me that. Because if not, I totally disagree with you and Now Im going to Have to go to every friggin meeting imaginable to try to undo years of what people like you have done to anesthesiologists like me .

 

[davvid2700]

Now Im going to Have to go to every friggin meeting imaginable to try to undo years of what people like you have done to anesthesiologists like me .

starting with the PGA next month

 

[militarymd]

so much so its on my priveieges sheet.

Guess what? It's on CRNA privilege sheets too. Don't be so full of yourself. As I said, don't confuse monkey skills with being a doctor.

It appears that you have a lot of monkey skills and appear very proud of them.

That is good. It is important to have monkey skills, but that is only half of being a physician.

I will submit to you that many PAs can do every part of the operation....all those folks who get patients onto bypass so that the CT surgeon can come in to do the anastomosis...the difference is all the stuff before the OR and after...clinic , hospital course, followup, etc.

If you think the monkey skills is all there is to being a doctor, then you are a very poor physician.

 

[militarymd]

You are a dangerous man for our profession.

Like I said, I'm just repeating views held by some senior members of the ASA. Are you saying the ASA is dangerous for our profession.....and only guys with 18 months experience who trained at no name NE programs are the future??

 

[bell412]

david,david,david. Doctors do not dump pee, nurses do. Nurses can chart and dump pee better than any doctor any day any time. Look bud nurses are task masters and their f***ing good at it. Military is right doctors make medical decisions for patients. Turning the gas on / off, drawing up syringes, gettin the tools ready for the next case is for task masters. Why the F**ck do you think CRNA's have existed for the last 100 years. The intraop phase is just gonna get easier. Pretty soon every frin OR suite is gonna have a BIS ect, ect. Someday the laryngoscopy machine will throw tubes in everbody. The anesthesiologist will be able to observe 4 rooms on his palm. Its reality.

 

[davvid2700]

.and only guys with 18 months experience who trained at no name NE programs are the future??

Why you wanna dis my experience.. and my program.. sure its no name and no frills but i went there so now it has a name.. I freakin scored pretty high on my board exam. in the 300s plus there was NO QUESTION about my orals.They couldnt trip me up. I knew every single controversial issue in anesthesia cold. Well not all ;most of them cold some not so cold. it got a little hairy with the "preeclamptic, unruptured intracranial aneurysm going for a csection" with a difficult airway. And of course, never forget this one not my case but an actual stem question from last fall. verified by several people

(2 yo 12 kg for tonsils and adenoids pmh: recurrent tonsillitis, and sleep apnea, downs syndrome, corrected av canal, glaucoma and a gastrostomy tube. residual asd and 3 degree heart block for which she is pacemaker dependent. asthma and frequent pneumonias. meds include albuterol and ipratroprium bromide and timoptic eyedrops. The patient is crying inconsolable no iv is in place and the parents would like to be present for induction.

 

[jetproppilot]

Why you wanna dis my experience.. and my program.. sure its no name and no frills but i went there so now it has a name.. I freakin scored pretty high on my board exam. in the 300s plus there was NO QUESTION about my orals.They couldnt trip me up. I knew every single controversial issue in anesthesia cold. Well not all ;most of them cold some not so cold. it got a little hairy with the "preeclamptic, unruptured intracranial aneurysm going for a csection" with a difficult airway. And of course, never forget this one not my case but an actual stem question from last fall. verified by several people

(2 yo 12 kg for tonsils and adenoids pmh: recurrent tonsillitis, and sleep apnea, downs syndrome, corrected av canal, glaucoma and a gastrostomy tube. residual asd and 3 degree heart block for which she is pacemaker dependent. asthma and frequent pneumonias. meds include albuterol and ipratroprium bromide and timoptic eyedrops. The patient is crying inconsolable no iv is in place and the parents would like to be present for induction.

She survived the anesthesia given for the av canal correction, she'll survive this one.

6mg midazolam PO in holding/day surgery. Parents cant come to induction. Once she's somnulent from the midazolam, whisk her back, sevo induction, start the IV after shes asleep, deepen her with the sevo, put the tube in. No need for muscle relaxant. Toradol IV. No opiods.

Cuppla puffs albuterol thru the tube before you pull it at the end.

 

[davvid2700]

She survived the anesthesia given for the av canal correction, she'll survive this one.

6mg midazolam PO in holding/day surgery. Parents cant come to induction. Once she's somnulent from the midazolam, whisk her back, sevo induction, start the IV after shes asleep, deepen her with the sevo, put the tube in. No need for muscle relaxant. Toradol IV. No opiods.

Cuppla puffs albuterol thru the tube before you pull it at the end.

the mother says this is my only child, i wanna be in the room with my baby

WHy wouldnt you oblige her?

 

[jetproppilot]

the mother says this is my only child, i wanna be in the room with my baby

WHy wouldnt you oblige her?

Not really my decision. The hospital doesnt allow people to go back in the OR. Actually I've never worked at a hospital that did.
I know some pedi hospitals allow it. The pedi hospital I did 6 months at as a resident did not.

 

[davvid2700]

Not really my decision. The hospital doesnt allow people to go back in the OR. Actually I've never worked at a hospital that did.
QUOTE]

sorry, that answer wont fly on the boards.. try again jet!!!!! The mother insists on being in the room. WHy would you not oblige her??



Thats like saying on the boards, my hospital doesnt have LMAs so i would not use it to rescue the patient. Hey if the examiners dont want it available they will let you know.

 

[blocks]

It's hard enough dealing with one patient sometimes...if things start going bad, and the mom is in the room, you'll be dealing with 2.

 

[bigdan]

starting with the PGA next month

Hey! I was gonna ask if anyone was going to this.

I'm a lowly medical student, but it'd be great to meet some of the folks on this forum.

dc

 

[davvid2700]

It's hard enough dealing with one patient sometimes...if things start going bad, and the mom is in the room, you'll be dealing with 2.

thats all that has to be said. good,


Jets approach is good.

 

[davvid2700]

Hey! I was gonna ask if anyone was going to this.

I'm a lowly medical student, but it'd be great to meet some of the folks on this forum.

dc

Im only going to one meeting to try to undo some things my predecessors did to ruin the specialty.. Then Im gonna hit up some cardiac lectures, and neuro lectures.

 

[davvid2700]

Hey! I was gonna ask if anyone was going to this.

I'm a lowly medical student, but it'd be great to meet some of the folks on this forum.

dc

the pga is the post graduate assembly of the new york state society of anesthesiologists

 

[kmurp]

One practical problem with 1:3 or 1:4 ratios arises when you have a small hospital with 5-6 operating rooms. If you are 1:3, you only have 2 docs per day in the OR. If you usually have 3 rooms after 3:30 as we do, you must either pay regular OT to the nurses or have 10 hr. shifts- both of these eat into the economic advantage of the CRNAs. The bigger problem is the call frequency, which would be rather high;especially if you need a doc for backup call. In our scenario, that would be every other night with the max of four docs we could afford while maximizing our CRNA ratios.
By the way, our new CEO wants us in house for call now. Does anyone have any experience in negotiating a fee for this? What would be a customary $ number?