What’s the point of doing a pediatric fellowship

[voxveritatisetlucis]

When CRNAs from an online program do pediatric cases of all complexities? I’m on a pediatric surgery rotation and have literally yet to see one MD anesthesiologist

---

Members don't see this ad.

 

[CopaceticOne]

They don’t do “all complexities”. What sort of cases have you seen while on your rotation? What type of hospital are you rotating at? Is it in an opt out state?

 

[voxveritatisetlucis]

They don’t do “all complexities”. What sort of cases have you seen while on your rotation? What type of hospital are you rotating at? Is it in an opt out state?

It’s a level 1 trauma center so a wide variety there has been a CRNA doing every case so far

 

[CopaceticOne]

So they are probably doing Medical Direction.

And it doesn’t mean you’ve seen the complex patient / cases, just because a hospital is level 1 trauma center.

 

[NicholasPavona]

Sounds like a surgery resident, anesthesia hater.

 

[NicholasPavona]

I STRONGLY suspect the OP has no idea what they are talking about.

 

[CopaceticOne]

Sounds like a surgery resident, anesthesia hater.

Nope, post history clearly makes them a med student - LORs and Sub-Is

 

[NicholasPavona]

Nope, post history clearly makes them a med student - LORs and Sub-Is

Makes sense.

 

[voxveritatisetlucis]

This wasn’t meant to be disparaging toward anesthesiologists rather to show the absurd lengths hospitals are willing to go to save money. Sad part is that parents probably aren’t even allowed to choose anesthesiologist and hospital probably charges same price for crna

 

[aneftp]

This wasn’t meant to be disparaging toward anesthesiologists rather to show the absurd lengths hospitals are willing to go to save money

I tell everyone anesthesiologists get paid for the 1-2% complicated cases.

So yes. Go ahead if u have a routine peds case. Have it done with a solo crna

If u have a complicated peds case. Go to that same crna. If they refuse or not comfortable. You are out of luck.

 

[nimbus]

Yeah what’s the point? As @saltydog liked to say, they’re just small adults.

 

[SRYSPAC]

It may be a level 1 trauma center but it's probably not a "real" children's hospital per the American College of Surgeons Verification System.
(http://anesthesiology.pubs.asahq.org/journal.aspx)

"A pediatric anesthesiologist (Level I or Level II) or an anesthesiologist with pediatric expertise (Level III) must administer or directly oversee the administration of general anesthesia to all patients two years or younger who are undergoing a surgical procedure."

The point of doing a pediatric fellowship is to be comfortable taking care of the smallest patients if you enjoy it. Historically it paid less than adult generalists, but that seems to be changing depending on your practice setting.

 

[aneftp]

OP is a med student. There are routine age 2 and up cases and there are complex peds cases.

They have a lot of learn from how surgery and anesthesia works.

Anesthesia is easy till it’s not easy.

 

[pgg]

Yeah what’s the point? As @saltydog liked to say, they’re just small adults.

He had it backwards. Adults are the burnt out empty husks of children.

 

[pgg]

Anesthesia is easy till it’s not easy.

Also, anesthesia's easy till the surgeon makes it hard.

Like when you're doing a perc trach and the surgeon gets the landmarks mixed up and puts the needle through the cricothyroid membrane for some reason and pops the ETT balloon and you abruptly lose the ability to ventilate the patient. That's what I heard, anyway.

 

[kidthor]

It may be a level 1 trauma center but it's probably not a "real" children's hospital per the American College of Surgeons Verification System.
(http://anesthesiology.pubs.asahq.org/journal.aspx)

"A pediatric anesthesiologist (Level I or Level II) or an anesthesiologist with pediatric expertise (Level III) must administer or directly oversee the administration of general anesthesia to all patients two years or younger who are undergoing a surgical procedure."

The point of doing a pediatric fellowship is to be comfortable taking care of the smallest patients if you enjoy it. Historically it paid less than adult generalists, but that seems to be changing depending on your practice setting.

This is likely the case. I've seen some garbage Level 1 trauma centers with essentially independent CRNAs - note these are adult Level 1s, not pediatric. Those hospitals suck and I'd never want care there.

 

[voxveritatisetlucis]

Well I guess it doesn’t just apply to anesthesia. An NP was running a trauma code today and was actually arguing with the physician who was there about certain aspects lmao

What happened to mid levels “filling the primary care gap”

Soon they’ll be doing whipples, what a joke

 

[gunnershow]

Well I guess it doesn’t just apply to anesthesia. An NP was running a trauma code today and was actually arguing with the physician who was there about certain aspects lmao

What happened to mid levels “filling the primary care gap”

One place I locumed at was a Level 1 where RTs did the off-floor airways but I still had to respond to full traumas. I walk into a (stable) penetrating airway trauma with air bubbling through the neck. RT confidently DL's and causes complete airway transection, turning a stable situation into a disaster.

Of course the first thing the ED did when I walked in was write my name down. I left that place after that... I never agreed to lend out my liability to bozos working outside their depth.

 

[Dynamis]

One place I locumed at was a Level 1 where RTs did the off-floor airways but I still had to respond to full traumas. I walk into a (stable) penetrating airway trauma with air bubbling through the neck. RT confidently DL's and causes complete airway transection, turning a stable situation into a disaster.

Of course the first thing the ED did when I walked in was write my name down. I left that place after that... I never agreed to lend out my liability to bozos working outside their depth.

RTs intubating... I think I recall one of the VA hospitals trying to arrange this setup, unfortunately.

Regarding this airway trauma, can I please get a more in-depth explanation? Was the DL technique that bad? (ie. too forceful or deep)

 

[Arch Guillotti]

RTs intubating... I think I recall one of the VA hospitals trying to arrange this setup, unfortunately.

Regarding this airway trauma, can I please get a more in-depth explanation? Was the DL technique that bad? (ie. too forceful or deep)

Every now and then ones gets a good one but they are terrible for the most part.

 

[gunnershow]

RTs intubating... I think I recall one of the VA hospitals trying to arrange this setup, unfortunately.

Regarding this airway trauma, can I please get a more in-depth explanation? Was the DL technique that bad? (ie. too forceful or deep)

A stable penetrating airway injury I would choose to intubate the OR with a surgeon available for rigid bronchoscopy as backup (not always feasible). I'd maintain spontaneous ventilation, so either doing it awake or with inhalational induction. And I'd secure the airway with flexible bronchoscopy so I know the cuff is past the level of injury and so I can advance the ETT over a guide instead of blindly advancing via DL and turning a partial injury into a complete disruption.

 

[sevo00]

Level 1 trauma doesn’t mean it’s all complexities. All that means is they can handle trauams. Have you sat in on peds cardiac cases?

 

[PpfSuxTube]

When CRNAs from an online program do pediatric cases of all complexities? I’m on a pediatric surgery rotation and have literally yet to see one MD anesthesiologist

Anyone can do any case if they got enough insurance

 

[PpfSuxTube]

Or a fall guy

 

[IlDestriero]

A stable penetrating airway injury I would choose to intubate the OR with a surgeon available for rigid bronchoscopy as backup (not always feasible). I'd maintain spontaneous ventilation, so either doing it awake or with inhalational induction. And I'd secure the airway with flexible bronchoscopy so I know the cuff is past the level of injury and so I can advance the ETT over a guide instead of blindly advancing via DL and turning a partial injury into a complete disruption.

Yes! If they have a known tracheal trauma, like an air leak out the neck, I would only use a fiber to intubate, and have. Put the suction on there so if there’s blood in the trachea you can Hoover it up as you go. Downsize the tube by 1/2 and lube it up. I like to use O2 blowing until you get to the glottic opening, but they’d probably F it all up in the ED and you’d get a pneumothorax blowing O2 when you thought they had changed to suction like you asked. Then put the fiber on the carina and gently advance the tube. You can transect the trachea in a trauma, and that would be a very bad day. You still could do it with a fiber as your guide, but then you’d theoretically be able to do some type of emergency jet vent with O2 for a few min and have a target in place when they start the emergent slash trach.

 

[gasmd98]

One place I locumed at was a Level 1 where RTs did the off-floor airways but I still had to respond to full traumas. I walk into a (stable) penetrating airway trauma with air bubbling through the neck. RT confidently DL's and causes complete airway transection, turning a stable situation into a disaster.

Of course the first thing the ED did when I walked in was write my name down. I left that place after that... I never agreed to lend out my liability to bozos working outside their depth.

Many reasons why the $$$ doing locums was never worth it to me. I liked working with competent people I knew and trusted. So many sketchy hospitals out there.

 

[Bryan O’Blivion]

One reason I can see is to avoid OB.

 

[markneil]

One reason I can see is to avoid OB.

Medical students rarely rotate in OB anesthesia during medical school. If they did, who knows how many would avoid the specialty. I would've thought twice or probably avoided it.

 

[gasmd98]

Medical students rarely rotate in OB anesthesia during medical school. If they did, who knows how many would avoid the specialty. I would've thought twice or probably avoided it.

Given the alternatives out there anesthesia is a pretty good deal. Long unpredictable hours but no clinic and no patient portal to deal with. The procedural docs I know get killed with inbox messages from patients. There is only so much screening that an MA or RN can do, especially with an irate patient. Nope, I am good with my choice even with OB call.

 

[nimbus]

Medical students rarely rotate in OB anesthesia during medical school. If they did, who knows how many would avoid the specialty. I would've thought twice or probably avoided it.

I actually followed an anesthesia resident on L&D for 1 day of my 2 week anesthesia elective in medical school. At the time it seemed pretty cool. But I no longer think OB is cool.

 

[dumbmedstudent]

I actually followed an anesthesia resident on L&D for 1 day of my 2 week anesthesia elective in medical school. At the time it seemed pretty cool. But I no longer think OB is cool.

my experience exactly

 

[arsene19]

Have a CRNA do your kids anesthesia. Good luck

 

[voxveritatisetlucis]

Have a CRNA do your kids anesthesia. Good luck

I wouldn’t, but do most patients really have a choice? It’s not like patients get to pick their anesthesiologist

 

[abolt18]

Have a CRNA do your kids anesthesia. Good luck

Have had 2 of my kids cared for by crnas I trust (both of which do a lot of peds, and I have worked as their attending), under the direction of very involved pediatric anesthesiologists I also trust.

crnas by themselves? Never!

 

[arsene19]

Seems like we have answered the question then. At all the areas I’d take anyone I cared about under 8 yo, I’d ask the surgeon for a peds anesthesiologist and get one. Granted I don’t live in the boonies.

If you know, you know

 

[kidthor]

Have had 2 of my kids cared for by crnas I trust (both of which do a lot of peds, and I have worked as their attending), under the direction of very involved pediatric anesthesiologists I also trust.

crnas by themselves? Never!

The CRNAs I've worked with at peds specialty hospitals have almost all been very good. Most peds anesthesia departments are very selective about the CRNAs they hire. Of course they're always, always supervised by a peds anesthesiologist at at 1:2 ratio (1:3 in super rare cases).

Now in mixed adult/peds hosptials with CRNAs who think they can do everything - it can be a scary disaster. Some of the most horrifying peds care I've ever seen is at mixed hospitals. The mix of know-it-all adult CRNA hubris with highly fragile pediatric patients is a recipe for death.

 

[PainInTheAnes]

The CRNAs I've worked with at peds specialty hospitals have almost all been very good. Most peds anesthesia departments are very selective about the CRNAs they hire. Of course they're always, always supervised by a peds anesthesiologist at at 1:2 ratio (1:3 in super rare cases).

Now in mixed adult/peds hosptials with CRNAs who think they can do everything - it can be a scary disaster. Some of the most horrifying peds care I've ever seen is at mixed hospitals. The mix of know-it-all adult CRNA hubris with highly fragile pediatric patients is a recipe for death.

Yup, the crnas at peds hospitals don’t ever mess with attendings either. It’s care team model the way it was intended. If peds crnas step out of line or go against orders they’re definitely disciplined or fired. Those jobs are very desirable for crnas so they want to stay in them