Regional Anesthesia in Private Practice?

[Pinky]

I was wonering how much regional blocks are used in private practice? It seems quicker to just place an LMA.

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[UTSouthwestern]

I was wonering how much regional blocks are used in private practice? It seems quicker to just place an LMA.

Although it still depends on where you are at, you will encounter a lot of regional requests especially for orthopedic cases. You may still use an LMA for general anesthesia, but the block will be your primary anesthetic/pain management modality. You can tell your colleague "thanks, I would rather not put in a block" but you will risk having them use another anesthesiologist who is comfortable and fast in putting in blocks.

The combined intra and post op pain control that the blocks provide are an attractive combination to the surgeons and delegating pain control to the anesthesiologist means one less headache for the surgeon.

Get comfortable using the disposable continuous nerve block pumps and of course the continuous catheter techniques. Just another skill set that will set you apart.

 

[jetproppilot]

Regional anesthesia, such as epidurals (thoracic and lumbar), spinals, axillary blocks, interscalene blocks, fem-sciatic blocks, etc are, in my humble opinion, in most cases (not all), far superior to general anesthesia if able to be used alone, or are very useful adjuncts to general anesthesia for the patient AND the anesthesiologist. Several reasons confirm my position.
1)Recent literature has proven that cognitive deficits in the elderly (albeit small deficits, like increased difficulty with crossword puzzle prowess) exists after an operating room experience. It is my humble opinion that the less CNS "stuff" we give an eighty year old, the better off he/she will be after the operation. So give 2-4 mg midazolam IV, put in an epidural making them numb from the belly button down for their total knee, run a little propofol infusion during the case, and PRESTO! Less post-op cognitive deficit, less sundowning incidence, less post operative opiod requirement, quicker ability to endure rehab, faster trac back to mowing the lawn and babysitting the grandchildren.
2) Ever put in a thoracic epidural for a thoracotomy? GEEZ! Drastic difference. Intra-op volatile anesthetic/opiod requirements are LOW, patients wake up comfortable, post-op opiod requirements much lower, less post-op N/V.
3) Interscalene for shoulder surgery? A NO-BRAINER. DO IT. See 2).
4) Femoral-sciatic blocks for ACL repair? SAme as above.
The benefits for the patient are HUGE and obvious. But wait, theres benefits for the anesthesiologist as well. The disadvantage, if you look at it that way, is you have to get to work early because if you have blocks to do on 3 or 4 patients for 0730 cases, it takes a little time. So come to work at 0600, pre-op everybody, go to the holding area, and do all your blocks. Advantages? Our colleague CRNAs can take the epidural total-knee patients to the room at 0710 and the anesthetic is already in place, freeing you up to go put the CABG to sleep, or whatever. That interscalene block you put in for the shoulder, and the fem-sci block you placed for the ACL will provide a smooth intra-op course, and you won't be getting calls from the PACU every 15 minutes for post-op pain/ nausea problems. Needless to say, my partners and I use regional anesthesia whenever we can. Nuff said.

I was wonering how much regional blocks are used in private practice? It seems quicker to just place an LMA.

 

[MAC10]

Regional anesthesia, such as epidurals (thoracic and lumbar), spinals, axillary blocks, interscalene blocks, fem-sciatic blocks, etc are, in my humble opinion, in most cases (not all), far superior to general anesthesia if able to be used alone, or are very useful adjuncts to general anesthesia for the patient AND the anesthesiologist. Several reasons confirm my position.
1)Recent literature has proven that cognitive deficits in the elderly (albeit small deficits, like increased difficulty with crossword puzzle prowess) exists after an operating room experience. It is my humble opinion that the less CNS "stuff" we give an eighty year old, the better off he/she will be after the operation. So give 2-4 mg midazolam IV, put in an epidural making them numb from the belly button down for their total knee, run a little propofol infusion during the case, and PRESTO! Less post-op cognitive deficit, less sundowning incidence, less post operative opiod requirement, quicker ability to endure rehab, faster trac back to mowing the lawn and babysitting the grandchildren.
2) Ever put in a thoracic epidural for a thoracotomy? GEEZ! Drastic difference. Intra-op volatile anesthetic/opiod requirements are LOW, patients wake up comfortable, post-op opiod requirements much lower, less post-op N/V.
3) Interscalene for shoulder surgery? A NO-BRAINER. DO IT. See 2).
4) Femoral-sciatic blocks for ACL repair? SAme as above.
The benefits for the patient are HUGE and obvious. But wait, theres benefits for the anesthesiologist as well. The disadvantage, if you look at it that way, is you have to get to work early because if you have blocks to do on 3 or 4 patients for 0730 cases, it takes a little time. So come to work at 0600, pre-op everybody, go to the holding area, and do all your blocks. Advantages? Our colleague CRNAs can take the epidural total-knee patients to the room at 0710 and the anesthetic is already in place, freeing you up to go put the CABG to sleep, or whatever. That interscalene block you put in for the shoulder, and the fem-sci block you placed for the ACL will provide a smooth intra-op course, and you won't be getting calls from the PACU every 15 minutes for post-op pain/ nausea problems. Needless to say, my partners and I use regional anesthesia whenever we can. Nuff said.

kewl

 

[NYCAnesthesia]

Excellent posts Jetproppilot - thanks for the information and your contribution of knowledge to this forum. Its great having some attendings around!

 

[chillindrdude]

maybe JetProp or someone can chime in about this....even tho regional anesthesia is not an accredited fellowship...would doing one make you more attractive and/or higher pay at a private group?

also, if your anesthesiology residency program has a pretty strong regional rotation, and you decide to do a 6 month "mini-fellowship" during your CA-3 yr, would that be just as desireable to a private group?

thanks

 

[jetproppilot]

maybe JetProp or someone can chime in about this....even tho regional anesthesia is not an accredited fellowship...would doing one make you more attractive and/or higher pay at a private group?

also, if your anesthesiology residency program has a pretty strong regional rotation, and you decide to do a 6 month "mini-fellowship" during your CA-3 yr, would that be just as desireable to a private group?

thanks

Very good question, dude. Private practice is a funny thing- and anesthesia is a funny thing because the longer you are in anesthesia, the more you realize that there is usually not one "right" way to do an anesthetic for an operation. Typically there are many ways to accomplish an anesthetic, different "styles" if you will, all with acceptable outcomes. Because of this, you may interview with a group that does a ton of regional stuff, then travel across town and interview with another group that does very little regional. Its all kinda up to the clinicians that have been at their location before you.
I hate to say this, because I know most of you are still in the stage in your lives where competition is emphasized (i.e. am I in a "big name" program? Am I the best at central lines? etc), but unless you are planning to do research or stay practicing in academia, YOU, and not your skills, and not the name of your residency program, are more important to a group than anything. Most people (of course there are exceptions) coming out of residency are well trained. Of course residencies vary on their strengths and weaknesses, so you may be strong in cardiac anesthesia, for example, but not as strong with regional stuff, or whatever. Noone in private practice expects someone right out of residency to be a star in everything. What is VERY important, and is not emphasized enough in residency, is: what kind of PERSONALITY do you have? Are you generally a nice person? Can you get along with people easily? Are the surgeons, who we are consultants to, going to like you? Or are you going to pick every battle, and have an orthopedic surgeon who brings a million bucks a year into the practice talking to the senior partner about what a jerk you are? Or is that ortho dude gonna tell the senior partner that you're well liked and he/she likes having you in his/her room? Can you handle stress? What happens to you when the CABG patient goes south after induction? Are you Iceman from Topgun, or are you reaching for a paper bag to put over your mouth to stop from hyperventilating?
Yeah, you may not be deft at interscalene blocks (or whatever), and lets say the group you go to work for does them routinely. THATS OK. As long as you are willing to learn, are humble and easy going, and can pick up on stuff taught to you, you're golden. Like I said, anesthesiologists for the most part want someone who is EASY TO GET ALONG WITH, who DOESNT COMPLAIN, and doesnt PISS OFF THEIR CLIENTS (surgeons).
I can teach you how to do an interscalene block/subclavian/femoral block/etc. I cannot teach you how to handle pressure when the chips are down. I cannot teach you an easygoing personality if you have a chip on your shoulder.
I would much rather hire an individual who is going to be a good fit into the group and have to spend some time with them concerning procedures, etc, than hire a jerk who is already good at everything.
The only way to make more money right out of residency concerning regional anesthesia is to do a pain fellowship, and go into pain. And "more money" isnt really accurate, since reembursement is so variable according to where you are located. A buddy of mine from residency is in a group in a small town in the southeast- he made a ton of money last year, probably more than most pain guys. SO, like I said before, things are variable in anesthesia, folks. The way you do cases and the way you get paid totally depends on where you live and what group you are in.
I would add that my humble opinion is not to do a fellowship if you are like 90% of anesthesiologists who want to work in a group, unless you wanna do exclusively hearts, critical care, pain, or kids. Sometimes you'll see a group looking for a fellowship trained cardiac or peds dude/dudette, but mostly not. And doing a fellowship does not mean you will make more money.
SO, in summary, the most important thing when interviewing for a job is to convey to the partners a team player/easy going personality. I can't emphasize that enough.

 

[NupeMD2B]

Thanks Jetproppilot!!! That was one of the most informative, greatest posts I've ever read. You answered most if not all questions I have about an upcoming residency in GAS with the ptoential for a life in regional vs private practice. I hope I have the honor of meeting most of you some day...this is what I envision life as an anesthesiologist as being. Hope to meet you all very soon!

 

[joshmir]

just wanted to thank jetproppilot again

i know it takes time to post, and we REALLY appreciate what you gave us

 

[jetproppilot]

just wanted to thank jetproppilot again

i know it takes time to post, and we REALLY appreciate what you gave us

No problem, folks. Glad to be able to give you useful information about your new profession.

 

[jetproppilot]

I was wonering how much regional blocks are used in private practice? It seems quicker to just place an LMA.

thread revived

 

[Noyac]

Very good question, dude. Private practice is a funny thing- and anesthesia is a funny thing because the longer you are in anesthesia, the more you realize that there is usually not one "right" way to do an anesthetic for an operation. Typically there are many ways to accomplish an anesthetic, different "styles" if you will, all with acceptable outcomes. Because of this, you may interview with a group that does a ton of regional stuff, then travel across town and interview with another group that does very little regional. Its all kinda up to the clinicians that have been at their location before you.
I hate to say this, because I know most of you are still in the stage in your lives where competition is emphasized (i.e. am I in a "big name" program? Am I the best at central lines? etc), but unless you are planning to do research or stay practicing in academia, YOU, and not your skills, and not the name of your residency program, are more important to a group than anything. Most people (of course there are exceptions) coming out of residency are well trained. Of course residencies vary on their strengths and weaknesses, so you may be strong in cardiac anesthesia, for example, but not as strong with regional stuff, or whatever. Noone in private practice expects someone right out of residency to be a star in everything. What is VERY important, and is not emphasized enough in residency, is: what kind of PERSONALITY do you have? Are you generally a nice person? Can you get along with people easily? Are the surgeons, who we are consultants to, going to like you? Or are you going to pick every battle, and have an orthopedic surgeon who brings a million bucks a year into the practice talking to the senior partner about what a jerk you are? Or is that ortho dude gonna tell the senior partner that you're well liked and he/she likes having you in his/her room? Can you handle stress? What happens to you when the CABG patient goes south after induction? Are you Iceman from Topgun, or are you reaching for a paper bag to put over your mouth to stop from hyperventilating?
Yeah, you may not be deft at interscalene blocks (or whatever), and lets say the group you go to work for does them routinely. THATS OK. As long as you are willing to learn, are humble and easy going, and can pick up on stuff taught to you, you're golden. Like I said, anesthesiologists for the most part want someone who is EASY TO GET ALONG WITH, who DOESNT COMPLAIN, and doesnt PISS OFF THEIR CLIENTS (surgeons).
I can teach you how to do an interscalene block/subclavian/femoral block/etc. I cannot teach you how to handle pressure when the chips are down. I cannot teach you an easygoing personality if you have a chip on your shoulder.
I would much rather hire an individual who is going to be a good fit into the group and have to spend some time with them concerning procedures, etc, than hire a jerk who is already good at everything.
The only way to make more money right out of residency concerning regional anesthesia is to do a pain fellowship, and go into pain. And "more money" isnt really accurate, since reembursement is so variable according to where you are located. A buddy of mine from residency is in a group in a small town in the southeast- he made a ton of money last year, probably more than most pain guys. SO, like I said before, things are variable in anesthesia, folks. The way you do cases and the way you get paid totally depends on where you live and what group you are in.
I would add that my humble opinion is not to do a fellowship if you are like 90% of anesthesiologists who want to work in a group, unless you wanna do exclusively hearts, critical care, pain, or kids. Sometimes you'll see a group looking for a fellowship trained cardiac or peds dude/dudette, but mostly not. And doing a fellowship does not mean you will make more money.
SO, in summary, the most important thing when interviewing for a job is to convey to the partners a team player/easy going personality. I can't emphasize that enough.

I feel like I need to say something. But Jet has just said it all, so nevermind.

 

[beezar]

What exactly is the billing for regional techniques? I heard that something like continuous femoral catheters for postop pain control tacks on like 6 units or something to a case. Seems like if you are at a place that does a lot of ortho, it might even make sense to have a dedicated regional guy doing a bunch of blocks per day.

 

[Disse]

Regional anesthesia, such as epidurals (thoracic and lumbar), spinals, axillary blocks, interscalene blocks, fem-sciatic blocks, etc are, in my humble opinion, in most cases (not all), far superior to general anesthesia if able to be used alone, or are very useful adjuncts to general anesthesia for the patient AND the anesthesiologist. Several reasons confirm my position.
1)Recent literature has proven that cognitive deficits in the elderly (albeit small deficits, like increased difficulty with crossword puzzle prowess) exists after an operating room experience. It is my humble opinion that the less CNS "stuff" we give an eighty year old, the better off he/she will be after the operation. So give 2-4 mg midazolam IV, put in an epidural making them numb from the belly button down for their total knee, run a little propofol infusion during the case, and PRESTO! Less post-op cognitive deficit, less sundowning incidence, less post operative opiod requirement, quicker ability to endure rehab, faster trac back to mowing the lawn and babysitting the grandchildren.
2) Ever put in a thoracic epidural for a thoracotomy? GEEZ! Drastic difference. Intra-op volatile anesthetic/opiod requirements are LOW, patients wake up comfortable, post-op opiod requirements much lower, less post-op N/V.
3) Interscalene for shoulder surgery? A NO-BRAINER. DO IT. See 2).
4) Femoral-sciatic blocks for ACL repair? SAme as above.
The benefits for the patient are HUGE and obvious. But wait, theres benefits for the anesthesiologist as well. The disadvantage, if you look at it that way, is you have to get to work early because if you have blocks to do on 3 or 4 patients for 0730 cases, it takes a little time. So come to work at 0600, pre-op everybody, go to the holding area, and do all your blocks. Advantages? Our colleague CRNAs can take the epidural total-knee patients to the room at 0710 and the anesthetic is already in place, freeing you up to go put the CABG to sleep, or whatever. That interscalene block you put in for the shoulder, and the fem-sci block you placed for the ACL will provide a smooth intra-op course, and you won't be getting calls from the PACU every 15 minutes for post-op pain/ nausea problems. Needless to say, my partners and I use regional anesthesia whenever we can. Nuff said.

I know this is a somewhat older thread but this is an important point. Currently (to my knowledge at least) there is little evidence (i.e. literature)supporting the advantage of regional over GA (in general, not for thoracotomies where there is some known benefit). While there is plenty of anecdotal and clinical experience why some may favor one over the other the research (again, to my knowledge.. please someone post something if I'm wrong) simply isn't there. All that being said, I like regional

Now why did I bold the above statement? During a "discussion (i.e. nothing was thrown but it was a bit heated)" between some pro-regional folks and pro-anything folks it was thrown out that perhaps the reason why the literature hasn't supported one technique over the other is that, oftentimes, the regional technique gets snowed so hard during the case that they have essentially had a GA as well. Thus, using cognitive deficits as an example, they may not be spared the possible negatives of having a GA even though they've had a regional technique performed.

I really think the issues of cognitive deficits in the elderly post-anesthesia are going to get more press in the years ahead (especially with all those aging boomers). I also think it will also be shown that what & how much sedation you provide these folks will also be critically important (i.e. it may not be in the patients best interest to make them snooze so much).

Something to think about next time when you're reaching for the propofol syringe because your total knee patient is continuing to talk about their 4th great grand child who is apparently the second coming...

 

[militarymd]

I must humbly disagree with Jet on this one. The literature finds no difference between use of regional technique vs GA in the elderly when looking at POCD as an outcome.

Intuitively, spinals in the old broken hip should decrease POCD, but the data does not bear that out.

As for everything else on what jet said.....

 

[jetproppilot]

I must humbly disagree with Jet on this one. The literature finds no difference between use of regional technique vs GA in the elderly when looking at POCD as an outcome.

Intuitively, spinals in the old broken hip should decrease POCD, but the data does not bear that out.

As for everything else on what jet said.....

Yep,

Mil's absolutely right. No good data supporting my opinion. But I stand by it.

POCD in the elderly is a poorly understood entity...if I'm not mistaken, stratifying the data hasnt even identified the anesthetic as the major contributor...in other words, taking Granny to the OR in itself (independent of other contributing factors) may in itself cause POCD.

But the idea to study something starts with anecdotal observation.

We'll see how it pans out in the next few years.

 

[Noyac]

Yep,

Mil's absolutely right. No good data supporting my opinion. But I stand by it.

POCD in the elderly is a poorly understood entity...if I'm not mistaken, stratifying the data hasnt even identified the anesthetic as the major contributor...in other words, taking Granny to the OR in itself (independent of other contributing factors) may in itself cause POCD.

But the idea to study something starts with anecdotal observation.

We'll see how it pans out in the next few years.

The variable most often quoted as contributing to POCD is environmental changes, ie: hosp rooms, ICU's, visual disturbances, hearing changes. These are things that in and of themslves lead to an unfamiliar environment. Not to mention benzo's, barb's, anti cholinergics, and narcotics (possibly). Oh, and sleep deprivation as we all see in the hospital environment.

 

[militarymd]

The variable most often quoted as contributing to POCD is environmental changes, ie: hosp rooms, ICU's, visual disturbances, hearing changes. These are things that in and of themslves lead to an unfamiliar environment. Not to mention benzo's, barb's, anti cholinergics, and narcotics (possibly). Oh, and sleep deprivation as we all see in the hospital environment.

As I posted in another thread, benzodiazepine levels in the blood are not correlated with risk for POCD.

Hypotension and hypoxia are 2 risk factors. Surgery itself, and not the type of anesthesia is a risk factor.

A lot we don't know right now about POCD.

 

[militarymd]

As I posted in another thread, benzodiazepine levels in the blood are not correlated with risk for POCD.

Hypotension and hypoxia are 2 risk factors. Surgery itself, and not the type of anesthesia is a risk factor.

A lot we don't know right now about POCD.

I meant hypotension, hypoxemia, asa stauts, anesthetic techniques, and post operative analgesia method are all factors that did not affect risk of POCD.

 

[jetproppilot]

I meant hypotension, hypoxemia, asa stauts, anesthetic techniques, and post operative analgesia method are all factors that did not affect risk of POCD.

Man, Mil, with that being said, what was the incidence of cognitive dysfunction in the control group that was at home watching Monday Night Football?

 

[Noyac]

I meant hypotension, hypoxemia, asa stauts, anesthetic techniques, and post operative analgesia method are all factors that did not affect risk of POCD.

You beat me to it by correcting your previous statement. I find it hard to believe that hypotension and hypoxia are not factors but your right they have not been proven to be a correlation to POCD.

 

[militarymd]

Man, Mil, with that being said, what was the incidence of cognitive dysfunction in the control group that was at home watching Monday Night Football?

That rate is directly correlated with the number of empty Bud light cans found on the carpet.

However, this phenomenon is not called POCD, but rather named MNFCD.

 

[jetproppilot]

That rate is directly correlated with the number of empty Bud light cans found on the carpet.

However, this phenomenon is not called POCD, but rather named MNFCD.

HAHAHAHAHHA

Dude, I'm serious, though.

Take 50,000 80 year olds who have surgery..and lets say just for arguments sake that 3% have POCD, but a causative factor cannot be identified. Risk factors, yes; causes, no.

Now compare to 50,000 who havent had surgery..(I know this explanation is way too simplistic for your Jedi-intensivist mind, but hey, I'm closer to Joe Dirt than John Tinker, so hear me out...)...

will the percentage of cognitive dysfunction in the general population approach that of the surgical population?

 

[jetproppilot]

HAHAHAHAHHA

Dude, I'm serious, though.

Take 50,000 80 year olds who have surgery..and lets say just for arguments sake that 3% have POCD, but a causative factor cannot be identified. Risk factors, yes; causes, no.

Now compare to 50,000 who havent had surgery..(I know this explanation is way too simplistic for your Jedi-intensivist mind, but hey, I'm closer to Joe Dirt than John Tinker, so hear me out...)...

will the percentage of cognitive dysfunction in the general population approach that of the surgical population?

HA! DUUUUUUDE!

Yeah, that sounds stupid at first, but think about it...

ARE WE SEARCHING FOR AN EXPLANATION TO SOMETHING THATS GONNA HAPPEN ANYWAY????

Deep. Real deep.

Sometimes I even amaze myself.

 

[Noyac]

HA! DUUUUUUDE!

Yeah, that sounds stupid at first, but think about it...

ARE WE SEARCHING FOR AN EXPLANATION TO SOMETHING THATS GONNA HAPPEN ANYWAY????

Deep. Real deep.

Sometimes I even amaze myself.

Jet, Some studies are quoting a 60% incidence of POCD in pts. >70yrs. I see were you are coming from and I doubt that it even approaches 60% but I think there really is something to this POCD. But you're right that some of these pts would have some cognitive dysfunction whether they had any surgery or not. Lets compare the rate of cog. dysfxn in >70 yr admitted to the hosp for medical issues not requiring surgery and those that did have surgery and see if there is a correlation. Maybe its the hosp. environment as much as it is anything else.

 

[jetproppilot]

Jet, Some studies are quoting a 60% incidence of POCD in pts. >70yrs. I see were you are coming from and I doubt that it even approaches 60% but I think there really is something to this POCD. But you're right that some of these pts would have some cognitive dysfunction whether they had any surgery or not. Lets compare the rate of cog. dysfxn in >70 yr admitted to the hosp for medical issues not requiring surgery and those that did have surgery and see if there is a correlation. Maybe its the hosp. environment as much as it is anything else.

I agree, Noy.

But if Granny's in Kmart a little past closing time, and the lights go out, is she gonna manifest something analagous to POCD?

 

[militarymd]

All very interesting. I wish I knew the answer....and I wish the lawyers and families stop blaming me for their wacked out grandparents.

 

[Noyac]

All very interesting. I wish I knew the answer....and I wish the lawyers and families stop blaming me for their wacked out grandparents.

And surgeons.