Man o War

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That's thoracic. Cardiac will probably be the same. Open vascular the same. And I am sure there are others, although not many I can think about. Although, in many places, all these are done with supervised CRNAs, even in a 3:1 model (one cardiac and two non-cardiac rooms per anesthesiologist).

Most cases are not like that. They are bread and butter, just ripe for takeover (and there are cases where outpatient surgeons/proceduralists hire their own experienced CRNA for anesthesia). They are also the biggest moneymakers: the simple elective (semi)outpatient procedures on ASA 1-3 patients.

I'd rather be "eat what you kill" in an endoscopy suite than in a thoracic or cardiac room. Even just an employee, because it's easier and because, sooner or later, some dumb bean counter will wonder why they are paying me more than a CRNA for a room that brings in less money.

Also, ask yourself: why do they rather pay YOU these rates, instead of hiring a permanent doc for the same money? Maybe because they don't want to pay anybody well enough, long-term, hence the reason for having a staffing problem in the first place. These places will always exist, in every country; there is usually a reason people don't want to work/live there. But I am talking about most jobs (which are where most people are, on the coasts and in metropolitan areas), not these outliers.

To those who disagree with me: let's just look again in a decade. Even the most optimistic of my friends agree that things are worse now than 10 years ago. Usually, when the sky is falling in a profession, people tend to not notice it until it's close, because that's when things speed up. See also my post above, about SLOWness in change. Leaders have been advised to do that at least since Machiavelli.
You keep saying all of this, over and over, yet none of this has happened in places where right now they could fire every anesthesiologist and they have not done so. They could’ve been doing it years ago and didn’t.
How is a CRNA going to be used interchangeably and be put in the call pool when they have done a handful of those cases, and possibly only ever watched them based on what I witnessed?
I brought up my locums offers because again, they could pay a nurse half what they pay me and they choose to keep paying me. And it’s not because they don’t have nurses willing to work there. I’m old enough that I only do locums in desirable areas or close to desirable areas that allow me to enjoy myself while I’m there, and see my kids at college. They pay me because they’re covering vacations/sudden illnesses and surgeries/family leave etc. Mix of PP groups and hospitals doing the paying.
I’ve been hearing the exact same thing for decades, and as a whole we are doing just fine- MGMA still looks great, job offers still look great...I mean, if you insist on living in certain pockets of the country you’re going to take a hit financially but what else is new, this is a different conversation than this supposed CRNA takeover that has been allegedly imminent for decades.
 
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You keep saying all of this, over and over, yet none of this has happened in places where right now they could fire every anesthesiologist and they have not done so. They could’ve been doing it years ago and didn’t.
How is a CRNA going to be used interchangeably and be put in the call pool when they have done a handful of those cases, and possibly only ever watched them based on what I witnessed?
I brought up my locums offers because again, they could pay a nurse half what they pay me and they choose to keep paying me. And it’s not because they don’t have nurses willing to work there. I’m old enough that I only do locums in desirable areas or close to desirable areas that allow me to enjoy myself while I’m there, and see my kids at college. They pay me because they’re covering vacations/sudden illnesses and surgeries/family leave etc. Mix of PP groups and hospitals doing the paying.
I’ve been hearing the exact same thing for decades, and as a whole we are doing just fine- MGMA still looks great, job offers still look great...I mean, if you insist on living in certain pockets of the country you’re going to take a hit financially but what else is new, this is a different conversation than this supposed CRNA takeover that has been allegedly imminent for decades.
I only see practices which go from solo to ACT, or from ACT 2:1 to ACT 3-4:1, and never the other way round. All those changes are jobs lost for anesthesiologists. A lot of jobs. Hence some of us now work for various corporations.

I also see more anesthesiologists being "encouraged" to leave for not getting along with CRNAs than the opposite. When a CRNA gets into trouble, I usually see things being brushed under the carpet, or a slap on the wrist, because administrators know that going to war with one means going to war with all. Let's not mention "hurting their feelings" by actually telling them what to do, when medically directing.

This is all my subjective n=1. In my own geographical area (which is clearly one of the worst markets in the country), things are always getting only worse.

And, seriously, you're going to argue that the market is the same because you're still getting locum offers? How many of us want to work as a locum tenens? Even in the middle of the Covid pandemic, New York hospitals were paying out-of-state locums much more than what they were paying the local temps, because they didn't want the income levels to "stick". Many locum tenens docs also say that it's not worth anymore, because the offers are not worth the sacrifices (in non-Covid times); not everybody has kids in college.
 
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Man o War

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I only see practices which go from solo to ACT, or from ACT 2:1 to ACT 3-4:1, and never the other way round. All those changes are jobs lost for anesthesiologists. A lot of jobs. Hence some of us now work for various corporations.

I also see more anesthesiologists being "encouraged" to leave for not getting along with CRNAs than the opposite. When a CRNA gets into trouble, I usually see things being brushed under the carpet, or a slap on the wrist, because administrators know that going to war with one means going to war with all. Let's not mention "hurting their feelings" by actually telling them what to do, when medically directing.

This is all my subjective n=1. In my own geographical area (which is clearly one of the worst markets in the country), things are always getting only worse.

And, seriously, you're going to argue that the market is the same because you're still getting great locum offers? How many of us want to work as a locum tenens? Even in the middle of the Covid pandemic, New York hospitals were paying out-of-state locums much more than what they were paying the local temps, because they didn't want the income levels to "stick".

No, that’s not what I’m arguing. I’m arguing the market is good because every year I see a fresh class of residents who rotate through our sites and I know every one of their job offers. I see a very big picture.
The locums is being brought up because you seem to think nurses are actively replacing doctors, and if that were the case they wouldn’t be paying me times 2 to sit the stool.
 
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No, that’s not what I’m arguing. I’m arguing the market is good because every year I see a fresh class of residents who rotate through our sites and I know every one of their job offers. I see a very big picture.
The locums is being brought up because you seem to think nurses are actively replacing doctors, and if that were the case they wouldn’t be paying me times 2 to sit the stool.
They would, if it's a doctor you're replacing on that stool. Some practices/surgeons just don't want CRNAs for certain cases (yet). That's why there are solo MD practices even in independent CRNA practice states.

I'm glad that your program/market is so good that your residents still get good offers.

Believe me when I tell you: I have seen exactly one practice go almost solo MD from ACT (and that happened because they couldn't replace the CRNAs who left for various personal, not professional, reasons). It's almost always the other way round, so MD jobs are being lost. And working ACT for basically the same (or less) money as one used to do solo MD for, or covering more rooms, is a pay cut.
 
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Man o War

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They would, if it's a doctor you're replacing on that stool. Some practices/surgeons just don't want CRNAs for certain cases (yet). That's why there are solo MD practices even in independent CRNA practice states.

I'm glad that your program/market is so good that your residents still get good offers.

Believe me when I tell you: I have seen exactly one practice go almost solo MD from ACT (and that happened because they couldn't replace the CRNAs who left for various personal, not professional, reasons). It's almost always the other way round, so MD jobs are being lost. And working ACT for basically the same (or less) money as one used to do solo MD for, or covering more rooms, is a pay cut.
Fair enough. We all have anecdotal evidence on both sides of this coin. But the job market as a whole is what we need to look at, and if you don’t limit yourself to a couple handfuls of super tight markets there are plenty of well paying jobs where you’re not a chart monkey praying a nurse doesn’t kill someone on your watch.
 
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Rocky222Balboa

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Just got this email:

We are very happy to report that Governor Cuomo’s Executive Order 202.58, which was issued late last night, reinstates section 405.13 of the New York State Health Code pertaining to anesthesia services in Article 28 facilities. These regulations require physician supervision of nurse anesthetists either by a physician anesthesiologist or the operative surgeon. New York state hospitals performing surgeries and other procedures will be required to adhere to the anesthesia standards that have been in effect since 1989. This is a very positive step for patient safety in our state.
 
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Southpaw

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Fair enough. We all have anecdotal evidence on both sides of this coin. But the job market as a whole is what we need to look at, and if you don’t limit yourself to a couple handfuls of super tight markets there are plenty of well paying jobs where you’re not a chart monkey praying a nurse doesn’t kill someone on your watch.

I've paid attention to our field since I was a medical student and decided to do anesthesiology. I tend towards cynicism and 'sky is falling' mentality so in a lot of ways anesthesia was never a good match for me. Still, I've enjoyed my career so far.

There have been definite changes to the job market in the last 10-15 years for those looking closely enough. And if you don't think there'll be more negative changes in the next 10-15 years you are simply being illogical. AMCs came, killed a lot of private practices, and have showed their hand as the money-grubbing Wall Street types they are. Still, they're here. They'll pay as little as humanly possible to staff rooms and work you as hard as they can. There are AMC-type setups in other medical fields also. EM, Neonatology, Derm, etc. But to this day, aside from working for a hospital, I don't see this occurring in surgery.

There are fewer private practices. A lot of people think/hope that as AMCs fade then private practices will see a resurgence. It's unlikely because most hospitals can't find a group of anesthesiologists to reliably staff their ORs without issues. Or at best you'll see private practices take contracts and become pseudo-AMCs with a pyramid scheme where a few predatory partners are making a killing off of a lot of worker bee anesthesiologists. This already occurs in parts of the country. That doesn't sound good for the field to me. I'm willing to bet there are people on this board on both sides of that coin.

So hospitals will move to the hospital-employed model. Once that occurs then in my opinion the game is over. You won't go back. That model, for now, appears better than working for an AMC but still, the end goal is the same. Pay as little as you can to get as much work as you can out out of the workers. Unfortunately, hospital employment is occurring across ALL medical fields and in my opinion it's not good for any of us. However it's one thing to work for the hospital and another thing to be beholden to the hospital. Anesthesia both works for and is beholden to the hospital. Surgery may work for the hospital but they are not beholden to them.

ACT. Anesthesiologists have shot themselves in the foot by letting CRNAs do the anesthesia. Contrast us to GI - it's the exact opposite where midlevels see/workup patients and consult with the physician. But the GI physician does the scope. We are the exact opposite. We see/evaluate and then let the midlevel do the anesthesia. In my opinion, it's not working out well for us.

I've seen one previously MD only group go ACT due to cost. I've seen lots of private practices go either hospital employed or AMC. Neither of those things are good for us. But I don't think anyone can reliably claim that things will improve in the next 10-15 years. However, the biggest problem in my opinion is that in most places the CRNAs are the ones doing the actual anesthesia. And in doing so they tend to gain control and power as a group.

The VA is letting CRNAs be independent in a time where there is no shortage of anesthesiologists. The same applies to lots of other states. How many surgical NPs are actually performing surgery?

If I were to advise a medical student today I'd encourage them to either do surgery, or if they can't envision themselves doing surgery, then they should learn business and do an office-based specialty and open their own medical clinic/office. Do not be dependent on the hospital. And do the work yourself. If they want to hire a mid-level, so be it, but the mid-level will work for them and that relationship will be clear. The roles will never be in question or pseudo-reversed.
 
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MoMoGesiologist

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Exactly what I was told by a colleague who failed his oral boards, when I wanted to do gentle LMA for a 90 year-old with EF of 20% and ugly baseline EKG.

Etomidate is another marker of people who don't really know what they are doing, no offense. Same for phenylephrine for everybody (I was asked intraop why I preferred ephedrine first, at a HR of 50 and BP of 60/30). Etc.
You were asked this by a CRNA or MD?
 

Man o War

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Anyway, we had better hope the remote rural hospitals dont go out of business or we are going to get hit with an avalanche of militant formerly Indy CRNAs looking for work who won’t know their head from their arse when they encounter an actual sick patient or big case.
 
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ShockIndex

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Don’t hold your breath. The ASA’s response to the continuous erosion of anesthesiologists’ practice realm is akin to politicians’ responses to gun violence following a mass shooting.

“This is deeply concerning.” “Thoughts and prayers to the (anesthesiologists) who have lost their live(lihood)s.” “Keep sending us checks.”

Funny you should use a gun violence analogy. Do you know the difference between a bullet and a VA nurse? You can fire a bullet. A bullet will draw blood. And, a bullet can only kill one person at a time...

The first thing to remember when dealing with the VA is that their unspoken mission has nothing to do with providing high-quality care to veterans and everything to do with containing their healthcare costs - quality be damned.
 
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DrZzZz

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Excerpt from the canned response to an email I sent one of my senators -

"I support policies that increase access, reduce cost, and provide for greater patient choice. I understand your concerns with respect to patient safety, and I believe that patient safety should always be our top priority when considering policy changes related to the delivery of patient care. At the same time, I do believe that when appropriately deployed, CRNAs operating at the full scope of their licensure can serve as a critical force multiplier, thereby increasing our health systems’ ability to provide timely and quality care to all patients.
...
I believe that taking care of veterans should be among our top priorities"

A lot of contradiction there and sadly, no support for actual quality care for our veterans.
 
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Man o War

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Excerpt from the canned response to an email I sent one of my senators -

"I support policies that increase access, reduce cost, and provide for greater patient choice. I understand your concerns with respect to patient safety, and I believe that patient safety should always be our top priority when considering policy changes related to the delivery of patient care. At the same time, I do believe that when appropriately deployed, CRNAs operating at the full scope of their licensure can serve as a critical force multiplier, thereby increasing our health systems’ ability to provide timely and quality care to all patients.
...
I believe that taking care of veterans should be among our top priorities"

A lot of contradiction there and sadly, no support for actual quality care for our veterans.
Ask him/her what “when appropriately deployed” means. I agree with that, but “when appropriately deployed” to me does not mean unsupervised. I am genuinely curious. Isn’t that the heart of the whole matter? You might also ask if he/she is aware of how expensive CRNAs are for the hours they work and most don’t take call. If they made NP wages I could sort of understand that argument, but they don’t.
 
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Excerpt from the canned response to an email I sent one of my senators -

"I support policies that increase access, reduce cost, and provide for greater patient choice. I understand your concerns with respect to patient safety, and I believe that patient safety should always be our top priority when considering policy changes related to the delivery of patient care. At the same time, I do believe that when appropriately deployed, CRNAs operating at the full scope of their licensure can serve as a critical force multiplier, thereby increasing our health systems’ ability to provide timely and quality care to all patients.
...
I believe that taking care of veterans should be among our top priorities"

A lot of contradiction there and sadly, no support for actual quality care for our veterans.

We need to stop fighting the bull**** supervision argument. It’s very plainly clear where this is all heading. If the ASA said tomorrow we recommend all anesthesiologists do their own cases, CRNAs do theirs and all training of SRNAs by anesthesiologists stop completely, we may finally start a fight worth fighting.

As it stands we release statements and write letters and in the end it all amounts to nothing. The AANA does not want us supervising their SRNAs/CRNAs. Enough SRNAs/CRNAs do not want us supervising them. I personally do not want to supervise them. They go through their training. We go through ours. Let’s stop this bull**** supervision, start doing our own work, and let the dust settle. If they can stand on their own, so be it. They deserve what they get. But I’m confident in my training and my skills. I know the level of care I provide. I know patients benefit from anesthesiologists providing anesthesia.
 
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Man o War

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We need to stop fighting the bull**** supervision argument. It’s very plainly clear where this is all heading. If the ASA said tomorrow we recommend all anesthesiologists do their own cases, CRNAs do theirs and all training of SRNAs by anesthesiologists stop completely, we may finally start a fight worth fighting.

As it stands we release statements and write letters and in the end it all amounts to nothing. The AANA does not want us supervising their SRNAs/CRNAs. Enough SRNAs/CRNAs do not want us supervising them. I personally do not want to supervise them. They go through their training. We go through ours. Let’s stop this bull**** supervision, start doing our own work, and let the dust settle. If they can stand on their own, so be it. They deserve what they get. But I’m confident in my training and my skills. I know the level of care I provide. I know patients benefit from anesthesiologists providing anesthesia.

But patients don’t get a choice when they show up to the hospital emergently ill. I have very little sympathy for people who choose midwives and NPs for their elective care. It terrifies me to think of myself or someone I love showing up for an emergent surgical procedure with nobody there but a nurse. Maybe it’s because I’m well into the second half of my life and I know my surgical needs will increase, but holy [email protected]@t what a terrifying thought. So I continue to fight for that reason.
I agree we need to stop training them. Let them train each other.
 
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zero0

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We need to stop fighting the bull**** supervision argument. It’s very plainly clear where this is all heading. If the ASA said tomorrow we recommend all anesthesiologists do their own cases, CRNAs do theirs and all training of SRNAs by anesthesiologists stop completely, we may finally start a fight worth fighting.

As it stands we release statements and write letters and in the end it all amounts to nothing. The AANA does not want us supervising their SRNAs/CRNAs. Enough SRNAs/CRNAs do not want us supervising them. I personally do not want to supervise them. They go through their training. We go through ours. Let’s stop this bull**** supervision, start doing our own work, and let the dust settle. If they can stand on their own, so be it. They deserve what they get. But I’m confident in my training and my skills. I know the level of care I provide. I know patients benefit from anesthesiologists providing anesthesia.
The ASA would never say that though. They're too wishy-washy to even take an official stance on CRNAs, other than "stop being mean to us."
 
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chocomorsel

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Excerpt from the canned response to an email I sent one of my senators -

"I support policies that increase access, reduce cost, and provide for greater patient choice. I understand your concerns with respect to patient safety, and I believe that patient safety should always be our top priority when considering policy changes related to the delivery of patient care. At the same time, I do believe that when appropriately deployed, CRNAs operating at the full scope of their licensure can serve as a critical force multiplier, thereby increasing our health systems’ ability to provide timely and quality care to all patients.
...
I believe that taking care of veterans should be among our top priorities"

A lot of contradiction there and sadly, no support for actual quality care for our veterans.
Got the same response. I stopped trying to decipher it and figured they support independent NPs and CRNAs.
 
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Southpaw

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But patients don’t get a choice when they show up to the hospital emergently ill. I have very little sympathy for people who choose midwives and NPs for their elective care. It terrifies me to think of myself or someone I love showing up for an emergent surgical procedure with nobody there but a nurse. Maybe it’s because I’m well into the second half of my life and I know my surgical needs will increase, but holy [email protected]@t what a terrifying thought. So I continue to fight for that reason.
I agree we need to stop training them. Let them train each other.

It’s happening whether you want it to or not. I guarantee that many of your patients could meet a CRNA and head to the OR and never once wonder where the anesthesiologist is. It’s been a PR battle for the last 10-15 years and we’ve been getting our ass kicked.

We need to stop carrying the weight of the anesthesia world on our shoulders. There’s only so much we can do. If we pull completely out of this nonsensical political battle and start controlling our own narrative at least it’d be a fight worth fighting.
 
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aneftp

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What exactly is full scope practice? The crnas I talk to say it means those who want to practice solo can practice solo. Those who want to practice with supervision. Can practice with supervision?

That doesn’t seem like full scope to me.
It sounds a lot like cherry picking. They can choose whatever the full scope practice means. Look what the aana said about them going back to do icu nursing during pandemic. The aana letter says if they aren’t comfortable they shouldn’t do it. Wtf?? They can’t claim all this icu nursing experience and than immediately back down saying those who don’t feel comfortable shouldn’t do it. Bunch of hypocrites.

either they are independent or not. None of this getting to choose. And yes that means they can’t cherry pick the easy gyn eyeballs and gi cases.
 
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PainDrain

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I have had two of the more militant crnas I know come up to me recently and literally make the claim that in New York State they were being used as “intensivists” because covid was so bad. I don’t know where they are getting this stuff.
 
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Exactly what I was told by a colleague who failed his oral boards, when I wanted to do gentle LMA for a 90 year-old with EF of 20% and ugly baseline EKG.

Etomidate is another marker of people who don't really know what they are doing, no offense. Same for phenylephrine for everybody (I was asked intraop why I preferred ephedrine first, at a HR of 50 and BP of 60/30). Etc.

Etomidate is a drug of the devil. I see no good reason to use it over the plethora of other medications that could be given for intubation. There are several studies pointing toward increased mortality; although that is debated. Etomidate in my experience produces a jerky myoclonus and takes a few seconds longer to take full effect compared to other meds. And if you are so worried about dropping a septic or crashing patient’s pressure with propofol, here are some novel thoughts, give less propofol, use another drug or give a bolus of pressor preinduction.
 
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aneftp

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Etomidate is a drug of the devil. I see no good reason to use it over the plethora of other medications that could be given for intubation. There are several studies pointing toward increased mortality; although that is debated. Etomidate in my experience produces a jerky myoclonus and takes a few seconds longer to take full effect compared to other meds. And if you are so worried about dropping a septic or crashing patient’s pressure with propofol, here are some novel thoughts, give less propofol, use another drug or give a bolus of pressor preinduction.

The studies on etomidate were flawed. Of course highly death rates but due to sicker patients being use with etomidate. I’ve read the studies.

Looks like you probably finished your training between 2006-2014 judging by your attitudes. Am I correct?

if it’s such a bad drug why don’t they just pull it? Like USA doesn’t use mivacurium any more.

you probably think chloroprep is superior to betadine as well.
 
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PainDrain

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The studies on etomidate were flawed. Of course highly death rates but due to sicker patients being use with etomidate. I’ve read the studies.

Looks like you probably finished your training between 2006-2014 judging by your attitudes. Am I correct?

if it’s such a bad drug why don’t they just pull it? Like USA doesn’t use mivacurium any more.

you probably think chloroprep is superior to betadine as well.
I take the studies with a grain of salt but again if you can’t get a septic patient off to sleep and tube them without using without using etomidate then.....
Also, the adrenal suppression is real and has been validated. Show me that effect from propofol or ketamine.

As for chloroprep it actually has a very high incidence of anaphylaxis and don’t even get me started on fire risk.
 

MoMoGesiologist

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Anyone else tired of hearing how some people are such superior doctors because they dont use etomidate? I don’t care if you induce anesthesia with a wooden mallet, do whatever works for you and gets the job done safely and efficient.
 
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SaltyDog

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I don’t care if you induce anesthesia with a wooden mallet, do whatever works for you and gets the job done safely and efficient.

Tough to do it safely with a wooden mallet. It’s a really fine line you have to walk there.

Definitely a CA-3 skill.
 
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MoMoGesiologist

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Tough to do it safely with a wooden mallet. It’s a really fine line you have to walk there.

Definitely a CA-3 skill.
CA3 year was where I really fine tuned my ability to push the stretcher. By the middle of the year I could push an ICU bed while ambu-ing and bringing the pole with drips on it. It was very impressive and what surgeons would compliment me most on... my transport and turnover... FML
 
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SaltyDog

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CA3 year was where I really fine tuned my ability to push the stretcher. By the middle of the year I could push an ICU bed while ambu-ing and bringing the pole with drips on it. It was very impressive and what surgeons would compliment me most on... my transport and turnover... FML

I still kick myself for not doing that stretcher driving fellowship at Hopkins.
 
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CA3 year was where I really fine tuned my ability to push the stretcher. By the middle of the year I could push an ICU bed while ambu-ing and bringing the pole with drips on it. It was very impressive and what surgeons would compliment me most on... my transport and turnover... FML
Those skills are the first to atrophy when you become an attending.
 
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Feb 12, 2020
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The VA ship may have sailed, but....
In the private world do you guys believe a hospital’s medical executive committee or Board of Trustees consisting exclusively of MD/DO’s instead of DNPs/RNs may provide some protection to this problem? They are the ones that ultimately decide what is allowed to happen in their hospital.

This may be something job applicants need to pay close attention to when interviewing at XYZ hospital going forward.
 

D P356

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Love the Q3 second call too. You are always available to take the blame.

As they are looking for 3, you may be Q2 call or worse until they get that third (or even second) person.
 
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jthedestroyr

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Things I find funny about this post.

1) I met president of premier. He talked about being Physician run only and physician leading team models. Definitly lip service as we read what they allow the CRNA to do.

2) i interviewed for another group, part of the Sentara group but not the group in that post.

They had SRNAs and basically let the SRNA and CRNA run free, but under the anesthesiologist license. Doesn't surprise me as thats part of the Sentara hospital systems MO
 
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BLADEMDA

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Al Head, MD, FASA, Chief Medical Officer
After 20 years of experience as a practicing physician and 11 years serving as an academic department chairman and director of a perioperative service line for a health system, it became clear to Al Head, MD, FASA, that the current healthcare system was not sustainable without significant changes. Reimbursements were declining while quality measures and regulatory services were increasing, and healthcare organizations needed guidance on how best to navigate this paradigm shift. Dr. Head is a former anesthesia residency director and academic chairman at the Medical College of Georgia. He received his medical degree from Emory University, where he was chief resident and completed his fellowship in cardiac anesthesia. He obtained an additional clinical and research thoracic fellowship at the Massachusetts General Hospital (MGH) at Harvard University, and stayed on staff at MGH for nine years.
 
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