Why do people think CC will save anesthesia?

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ctsicu

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I get irritated by this statement sometimes. How many PP groups have people staffing the icu? I'll tell you-very very few! You are kind of resigned to academics which sucks in many ways as hospital politics etc are rampant. And if we think that we won't have to deal with midlevels, think again. Lots of "critical care" NP who are beyond obnoxious, ESP in CT ICUs. Most hospitals have ICUs staffed with pulmonary guys who are in charge of hiring etc. think they are going to hire an anesthesiologist? Think again.
Maybe I'm just bitter but if someone can tell me otherwise, I would love it.
 
I am IM/CCM and trained in a place where the MICU was all IM or IM/Pulm for CCM. The CTICU was mixed IM and anesthesia. The neuro ICU was almost all anesthesia, but starting to have a neuro/CCM presence. SICU and trauma were all surgeons. The anesthesia CCM trainees did electives in the MICU, and would always say, "wow these patients are SICK."
All this having been said, each discipline (IM/Anes/Surg) brings different training and skills to the table. I would not want to manage a trauma patient alone without a surgeon, or a neuro patient without a neurologist or neurosurgeon. Some anesthesiologists can manage medicine patients without an IM consultant, some might have difficulties.
Where I practice now, we have a semi-closed ICU, with all disciplines, but all of the intensivists are medicine trained.
However, 2 of the anesthesia CCM guys I trained with went to non-academic places and do mixed CCM one week per month.
I would say it exists outside academics, but isn't common.
 
I think I would feel fairly comfortable with most of the MICU but the things I didn't, I wouldn't hesitate to call a medicine colleague. You may not be able to manage a neurosurgical or trauma patient without a surgeon, but I think we can. Obviously they are still involved but I don't think our reliance on them would be as extensive.
The bias medical guys have against anyone else doing CC ticks me off . In the rest of the world CC is done by anesthesia btw.
 
Intensive care is already dominated by internists and pulmonologists, we lost this battle decades ago.
If anyone is planning their future based on the assumption that anesthesiologists are going to somehow take intensive care back then that would be a very delusional prospective.
 
Anesthesia does not need to be saved it is changing and CC is going to be a large part of it in my opinion. Why are you frustrated with your current situation?
 
ctsicu said:
I think I would feel fairly comfortable with most of the MICU but the things I didn't, I wouldn't hesitate to call a medicine colleague. You may not be able to manage a neurosurgical or trauma patient without a surgeon, but I think we can. Obviously they are still involved but I don't think our reliance on them would be as extensive.
The bias medical guys have against anyone else doing CC ticks me off . In the rest of the world CC is done by anesthesia btw.
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Resuscitationists or traumatologists. Bullhonkey you dont need a neurosurgeon or surgeon to comanage NICU or SICU patients. You gonna put that skull drain in, you call final shots on those pts, you gonna do the chest and abdomen washouts at bedside, you manage operative complications without a surgeon, you gonna rush em back to the OR and cut em? F'n bullsheaut dude. We all have a role and there is NO ONE MAN SHOW.

Anyone can hang hypertonic and increase drainage from a ventricle. Uhh put the head up more guys and lower peak pressures on vent and by the way get the F'N surgeon in here.

The US anesthesiology model IS NOT equal to the european model for fuksake! Go to europe, here flip da room, keep pts and surgeons happy, and the flip the room again.
 
chessknt87 said:
I dont understand this line. You have all disciplines, but they are only medicine trained? What?
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Well what he means is all surgical subspecialty icu players get admitted there. ie optho, vascular, gen surg, uro, thoracic, etc. Then the intensivists, which happen to be contracted out to pulm/cc dudes gets consulted. They got the contract. Just like the group ill be joining has a contract for their hospitals MICU and neurosurg icu. =)
 
Look vent-of course the surgeon is still involved but I don't need help with the ICU management. And yes Europe and US model is NOT equivalent but if you do a FELLOWSHIP, then IT IS.
 
Per his sig

__________________
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Luvin Life everyday baby.
 
Venty was a prolific anesthesia poster back in the day.
Glad to see you back here Vent.

I miss the Afro avatar tho.
 
I didn't want to start a thread for this and this seemed the most appropriate place.

Which fellowship would do sick pediatric hearts (congenital anomalies)? Would that fall under the scope of cardiac or peds?
 
I don't think anesthesia needs to be saved in its current form. I think it needs to adapt to the pressures that are in all of healthcare. We are in a vulnerable position being that we don't "own" the patients, we don't bring them into the hospital. I think anesthesia groups need to expand their involvement within their hospitals. With more government over reach and regulations into healthcare, hospitals will close ICUs. The evidence is there and continues to mount. I see more and more jobs posted for employed ICU jobs of any primary specialty. I think PP anesthesia groups would be wise to go to their hospital administrators and say we will take care of closing the ICUs with An/CC, ED/CC, and IM/CC.
 
So I don't see how they can just close ICUs without replacing the services they provide.

Maybe I just need someone to explain the concept of how to close down ICUs because that's not something I'm familiar with. But in my mind if they turf patients to anywhere but home that just means someone else in the hospital has to deal with it. So now you have complex patients spread throughout the respective services (pulm, cardiac, GI) and the resources to manage the patients are not centrally located where the patients are, which just makes things more difficult.
 
TeamZissou said:
So I don't see how they can just close ICUs without replacing the services they provide.

Maybe I just need someone to explain the concept of how to close down ICUs because that's not something I'm familiar with. But in my mind if they turf patients to anywhere but home that just means someone else in the hospital has to deal with it. So now you have complex patients spread throughout the respective services (pulm, cardiac, GI) and the resources to manage the patients are not centrally located where the patients are, which just makes things more difficult.
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I think he was referencing the idea of a "closed" unit, or one where the ICU is the primary team on most patients and the surgeons persist as consultants still involved in the care, but not writing most of the orders. In an "open" unit the ICU team acts as consultants monitoring the standard ICU things (delirium, vent settings, etc) but does not write orders.

I have not looked in to it, but it would make sense that a closed unit has better outcomes. This coupled with he fact that medicare is looking for any possible reason to not reimburse, having a dedicated team streamlining up-to-date care that can reduce readmissions will save hospitals money.
 
Ronin786 said:
I didn't want to start a thread for this and this seemed the most appropriate place.

Which fellowship would do sick pediatric hearts (congenital anomalies)? Would that fall under the scope of cardiac or peds?
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Generally you go peds, then spend extra time in the heart room. Your heart time can be arranged after you have completed the peds fellowship, at the academic center where you will inevitably be working.
 
chessknt87 said:
I think he was referencing the idea of a "closed" unit, or one where the ICU is the primary team on most patients and the surgeons persist as consultants still involved in the care, but not writing most of the orders. In an "open" unit the ICU team acts as consultants monitoring the standard ICU things (delirium, vent settings, etc) but does not write orders.

I have not looked in to it, but it would make sense that a closed unit has better outcomes. This coupled with he fact that medicare is looking for any possible reason to not reimburse, having a dedicated team streamlining up-to-date care that can reduce readmissions will save hospitals money.
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Aye, after taking the time to reread the thread you're explanation would make a hell of a lot more sense, thanks.:uhno:

Closing ICUs and government in the same sentence made me think the sky was falling when it was just a leaf.
 
No it won't. You can always have a job if you are CCM trained no matter what happens to anesthesia. However, too few people are doing CCM fellowship because 1) it goes against why they went into anesthesia first (lifestyle, less paperwork etc) 2) you are not getting paid more.

The only way CC could save anesthesia is to add one mandatory CCM year training into Anesthesia so that every graduating resident is boarding eligible in both CCM and Anesthesia.
 
sevoflurane said:
Venty was a prolific anesthesia poster back in the day.
Glad to see you back here Vent.

I miss the Afro avatar tho.
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Sevo beat me to it. I'll echo what he said above about Venty... including the Prince Avatar! (It was Prince, wasn't it?) :meanie:
 
Venty -

Another vote for Prince. I remember searching for your replies was easy 'cause you could just look for Prince's 'do along side the computer screen. Ahh...the good old days...
 
safe_image.php


- pod
 
Mac4 said:
No it won't. You can always have a job if you are CCM trained no matter what happens to anesthesia. However, too few people are doing CCM fellowship because 1) it goes against why they went into anesthesia first (lifestyle, less paperwork etc) 2) you are not getting paid more.

The only way CC could save anesthesia is to add one mandatory CCM year training into Anesthesia so that every graduating resident is boarding eligible in both CCM and Anesthesia.
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So how many of these CCM jobs are out there, really, if you think that is going to save anesthesiology? In my residency the group employed 40 anesthesiologists. Exactly 3 of them had CCM experience and worked the unit, for a total of like 12 weeks per year. The critical care dept wasn't exactly knocking on our door for staffing. In fact, they didn't need us at all. Even if they did, it would have taken maybe like 4 full time docs to staff it fully.

I'm not seeing how CCM is some incredible safety valve for thousands of displaced anesthesiologists.
 
Bertelman said:
So how many of these CCM jobs are out there, really, if you think that is going to save anesthesiology? In my residency the group employed 40 anesthesiologists. Exactly 3 of them had CCM experience and worked the unit, for a total of like 12 weeks per year. The critical care dept wasn't exactly knocking on our door for staffing. In fact, they didn't need us at all. Even if they did, it would have taken maybe like 4 full time docs to staff it fully.

I'm not seeing how CCM is some incredible safety valve for thousands of displaced anesthesiologists.
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Exactly. Anesthesia critical care staffing exists largely just to meet the RRC requirement for anesthesiology training with CC anesthesiologists. I think we are tolerated there more than needed for staffing or expertise.

For Anesthesia to be saved by CC we would basically have to become an IM subspecialty with an Anesthesia/CC fellowship. Even then, what's the point? IM doesn't care about the future of anesthesiology.
 
Not sure why everyone keeps going back to CC is going to safe anesthesia. Anesthesia does not need to be saved. Anesthesia departments will likely be changing and extension into CC will likely be part of it at some level in my opinion. In regards to community hospitals with pop<100,000 ICU are often run by either having the surgeon or internist admit to the ICU and then maybe consult an intensivist if resources are available. What does it hurt if an anesthesia group who has CC trained anesthesiologists negotiates with a hospital to cover all pts that are admitted to the ICU (closed unit) with or without other intensivist (IM/EM/surgery).
 
The idea is that there a several forces that are eroding our specialty. Namely, CRNA practice right expansions, cost of healthcare, coming changes from Obamacare, accountable care organizations(bundled payments) AND anesthesia management companies. I think in order to preserve anesthesia in a form close to what exists today we need to reject AMCs and adapt to the other forces. Private practice groups could strengthen their contracts and relationships with their hospitals by providing critical care services. And by securing their positions within their hospitals they protect themselves from the threats mentioned above. Extrapolate this to the 1000s of groups across the country and you can see how this could help preserve this field as it is.
 
Seba said:
The idea is that there a several forces that are eroding our specialty. Namely, CRNA practice right expansions, cost of healthcare, coming changes from Obamacare, accountable care organizations(bundled payments) AND anesthesia management companies. I think in order to preserve anesthesia in a form close to what exists today we need to reject AMCs and adapt to the other forces. Private practice groups could strengthen their contracts and relationships with their hospitals by providing critical care services. And by securing their positions within their hospitals they protect themselves from the threats mentioned above. Extrapolate this to the 1000s of groups across the country and you can see how this could help preserve this field as it is.
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The economics don't add up and will add up less in the future with bundled payments.

Anyone do CC in private practice that isn't subsidized by the hospital or your group?
 
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I am about to finish my anesthesiology residency and begin CCM fellowship at a very reputable spot. I realize that most jobs allowing me to do both would be in academics, and the discussion on this board has been informative, but are there private jobs out there? Are any groups contracting with hospitals or surgical centers to provide ICU coverage? What about e-icu? thanks guys:luck:
 
No doubt, the economics are not favorable to provide critical services. The money is in the OR....for now. This is of course conjecture but I think that will change to the point that it will be financially advantageous to have critical care as part of your group. I should also mention that I am starting my CCM fellowship in July so, I am biased. Another smart move is to form an acute pain service. We all know patient satisfaction in the future will account for up to 30% of Medicare/caid reimbursement.
 
I don't think that it will "save anesthesia" but it may be a safe haven or alternative for individual critical care trained docs. How many pulmonologists or noctors can deal with the morbidly obese sleep apneic patient who needs intubation, a-line, central line, dialysis catheter at 2 am in an ICU bed with the least experienced nurses to assist?
 
dr doze said:
I don't think that it will "save anesthesia" but it may be a safe haven or alternative for individual critical care trained docs. How many pulmonologists or noctors can deal with the morbidly obese sleep apneic patient who needs intubation, a-line, central line, dialysis catheter at 2 am in an ICU bed with the least experienced nurses to assist?
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I can. Unfortunately its a common scenerio and any CC trained doc should be able to handle this set of issues. My favorite is when they are also seizing from the toxins built up from their AKI. AKA uremic encephalopathy. I dont remember seeing one of those in the OR.
 
VentdependenT said:
I can. Unfortunately its a common scenerio and any CC trained doc should be able to handle this set of issues. My favorite is when they are also seizing from the toxins built up from their AKI. AKA uremic encephalopathy. I dont remember seeing one of those in the OR.
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Agree with "should be able". How many ICUs, including community hospitals actually can provide this level of service 24/7?
 
Seconded. I also can do all of these and though it is badass to be, I am not full anesthesia + IM trained like venty. Classic case. May of my INTERN year. 280 pound sleep apneic guy suspected ethylene glycol intox. Seized as I was drawing up the succ. Tubed him. Right IJ via US. Right rad a-line via US. About an hour later nephrology concurred with our dz and agreed to dialyse immediately. I Put in a left sublcav for general access and changed out my IJ for a dual lumen marukhar HD cath over a wire. Done.

Keep in mind when you refer to us as pulmonologists (them now, me in the future) it is "pulmonary/critical care"......there is a lot of MICU in those three years, on top of the 8 months during 3 years of residency.

The procedures are cake, it is the medicine that requires the training.

Ps, I am an IM resident at a small 200 bed COMMUNITY hospital, although I am not in the MiCU 24/7 so you win at point 😛
 
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dr doze said:
Agree with "should be able". How many ICUs, including community hospitals actually can provide this level of service 24/7?
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Any one with inhouse ER trained doctor and home call critical care guy. ER to tube while CC dude come in to figure all the crap out. How many community hospitals have 24h in house anesthesia?

There are fat people with AKI's and respiratory failure everywhere dude. That $hit is bread n butter CC. A better example would be " how many trained intensivists at community hospitals would be comfortable taking care of 22y/o drowning victim with refractory Hypoxemia secondary to ARDS and cardiogenic shock." Very few unless its a tertiary care center will all the bells n whistles. Those folks get life flighted out otherwise.

Its ALL about RESOURCES.
 
Bostonredsox said:
Seconded. I also can do all of these and though it is badass to be, I am not full anesthesia + IM trained like venty. Classic case. May of my INTERN year. 280 pound sleep apneic guy suspected ethylene glycol intox. Seized as I was drawing up the succ. Tubed him. Right IJ via US. Right rad a-line via US. About an hour later nephrology concurred with our dz and agreed to dialyse immediately. I Put in a left sublcav for general access and changed out my IJ for a dual lumen marukhar HD cath over a wire. Done.

Keep in mind when you refer to us as pulmonologists (them now, me in the future) it is "pulmonary/critical care"......there is a lot of MICU in those three years, on top of the 8 months during 3 years of residency.

The procedures are cake, it is the medicine that requires the training.

Ps, I am an IM resident at a small 200 bed COMMUNITY hospital, although I am not in the MiCU 24/7 so you win at point 😛
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kick ass case! Howd you guys figure out it was EG? Did his kidneys get fried or did you get that crap outta him before that happened?
 
VentdependenT said:
Any one with inhouse ER trained doctor and home call critical care guy. ER to tube while CC dude come in to figure all the crap out. How many community hospitals have 24h in house anesthesia?

There are fat people with AKI's and respiratory failure everywhere dude. That $hit is bread n butter CC. A better example would be " how many trained intensivists at community hospitals would be comfortable taking care of 22y/o drowning victim with refractory Hypoxemia secondary to ARDS and cardiogenic shock." Very few unless its a tertiary care center will all the bells n whistles. Those folks get life flighted out otherwise.

Its ALL about RESOURCES.
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In my neck of the woods, this service is spotty during the daytime. Very spotty after dark.
 
well then ask if they will hire you as 24h inhouse procedure/airway guy. Lack of procedural knowledge, not medical knowledge is what your getting after I believe. If one trained in CC (any discipline) then procedural acumen will NOT be an issue....i hope.

Having a procedure guy for the hospital so other peeps dont have to come in is fairly common. Its a good suppliment to income BUT does NOT require critical care training.
 
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VentdependenT said:
kick ass case! Howd you guys figure out it was EG? Did his kidneys get fried or did you get that crap outta him before that happened?
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Fried kidneys. .I got sign out from my day senior, I was the night guy, and it just didn't add up. I could tell it wasn't adding up to him too. Reading through the acidosis numbers and the story and such....something not right sounds like a psych case with an ingestion. I finish my evening round, go talk with the wife...hey is they're any chance he could have ingested any chemicals or anything unusual. She says no. About 10 min later nurse brings the wife back to me saying she has a question. "Sorry doctor I have just been thinking about this for a while, does antifreeze count as a toxic chemical.".... Yes it would mam Why do you ask?.....well I found him On the floor of the garage and there was a fluorescent green tinge in the corners of his mouth and an empty container next to him, to tell you the truth I me never thought much of it at the time"...... That will do mam thank you..turn to nurse..get me the oncall nephrologist and call ex to see if we have any fomepizole. Once I actually sat down to go over all his stuff he did have the classic osmolar gap of like 18.

The senior presented it as an M and M. Kind of a famous case amongst our very young IM program, which was in its first year at that time. He dialized daily for almost 2 months. Trached/PEGd, got VAP, long long complicated stay. I saw him in the Ed with his mom, another colossal train wreck who comes in septic routinely from the NH. he's about 130 pounds lighter now.
 
VentdependenT said:
Any one with inhouse ER trained doctor and home call critical care guy. ER to tube while CC dude come in to figure all the crap out. How many community hospitals have 24h in house anesthesia?

There are fat people with AKI's and respiratory failure everywhere dude. That $hit is bread n butter CC. A better example would be " how many trained intensivists at community hospitals would be comfortable taking care of 22y/o drowning victim with refractory Hypoxemia secondary to ARDS and cardiogenic shock." Very few unless its a tertiary care center will all the bells n whistles. Those folks get life flighted out otherwise.

Its ALL about RESOURCES.
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Agreed. I'm tubing the 22 year old, getting him onto low tidal volume ARDSnet, throwing in lines and a swan, starting his dobutamine or milrinone and Levo, and calling my nearest transfer center. That kid needs help my community shop just cannot provide.

And there is a growing number of critical care hospitalists at community shops that might be short of intensivists and thou they are not the same, most will be fine with the aforementioned sleep apneic guy needing HD. ANY attending medicine doc should be able to put in a femoral and tube the guy. The Aline can wait till morning of they can't do it it's not an absolute need though it is ideal to have, and the nephrologist can put in the HD cath themselves, as they are coming in anyway to dialyse the pt. so even if its a community shop that doesn't have the likes of me or vent in house at night, a good hospitalist can still manage most.
 
Bostonredsox said:
Agreed. I'm tubing the 22 year old, getting him onto low tidal volume ARDSnet, throwing in lines and a swan, starting his dobutamine or milrinone and Levo, and calling my nearest transfer center. That kid needs help my community shop just cannot provide.

And there is a growing number of critical care hospitalists at community shops that might be short of intensivists and thou they are not the same, most will be fine with the aforementioned sleep apneic guy needing HD. ANY attending medicine doc should be able to put in a femoral and tube the guy. The Aline can wait till morning of they can't do it it's not an absolute need though it is ideal to have, and the nephrologist can put in the HD cath themselves, as they are coming in anyway to dialyse the pt. so even if its a community shop that doesn't have the likes of me or vent in house at night, a good hospitalist can still manage most.
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Now that is the real world right there brother. Amen.
 
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