Co-fellow fired

[dhcofc]

I think the main idea here is this probably wouldn’t happen at an ACGME fellowship. You’re not being personally attacked. You took a risk by going the non accredited route. Complaining that it isn’t fair just isn’t going to help. Also, you’ll probably never stop hearing that you’re fellowship wasn’t as good as an ACGME fellowship as far as prestige (and your experience supports that). Saying that you’ll finish with more procedures than most fellows is really not very meaningful.

If you stick it out the rest of your career should be a cake walk in comparison.

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[TheLoneWolf]

These non ACGME fellowships seriously need to be shut down. We need to do a better job off limiting who does these procedures. I mean any Tom Dick and Harry off the streets can set up shop and bill for these procedures. It’s insane and sad to say the least. I mean what makes you any better than “Dr.” Nevills

Our Team

Clinic specializing in traditional and alternative pain management techniques. The team of physicians and chiropractors does not only treat the pain but eliminate the cause and provide relief.

www.flinthillspainmanagement.com

You mean NURSE Nevills

 

[TheLoneWolf]

I think there was some older posts about private insurances requiring pain fellowship to tie to the reimbursement. I dont know if that is the case and wheather it has to be acgme. Perhaps some of the more senior posters have more info.

 

[blockstar]

What is the point of doing a non accredited fellowship outside of learning how one guy does things? I could get my fellowship trained friends to teach me procedures and take courses after being board certified.

Do these jobs looking for “fellowship” trained docs include non accredited fellowships?

Im not trying to insult anyone who did non accredited but if youre being mistreated at a non accredited fellowship whats the difference between quitting that and quitting a bad job where youre mistreated?

Quitting residency and an accredited fellowship would take you out of the insurance pool I would think and you have to put up with whatever is dealt your way but it seems to me there would be no difference leaving this job vs leaving any other bad job with nasty leadership.

 

[deleted131481]

Well there is an "expectation" that we are within 30 minutes of the hospitals -again it's rare to be called in (the last fellow that graduated said he got called twice in the entire year and he never had to go in) but if for whatever reason they did call, you couldn't be more than 30 minutes away. Also since I moved from out of state I tend to travel to see family, etc so it would be problematic.

The call doesn't sound so burdensome as you make it seem . Seems like you could work your out of town visits to every other weekend, and even if you had to be called in no one is going to care if it's 45 min or even an hour so you don't need to sit at home all weekend.

Like others have stated they are "on call" 24/7. I can't think of a true pain emergency requiring you to be there in less than 30 min that you at least can't jumpstart the workup on by talking to the ER doc.

 

[BobBarker]

Geez. Look at his old posts. He isn’t a medical student.

 

[Piebaldi]

Geez. Look at his old posts. He isn’t a medical student.

I don't look at people's old posts. That's what his posting says. To suggest that anyone cares or discusses the "prestige" of their fellowship is very med-studenti. Plenty of threads on that. In my recent group we had people who went to Harvard (literally) to people who went to podunk med school, and people who went to really prestigious programs vs very average program. Do we have daily conversations about this? No. Does anyone care about this?No. Except in academia, no one cares - to suggest the above is what your average med student asks - will I make 10 million more per year if I went to Harvard vs. average med school?No.

 

[Piebaldi]

I think there was some older posts about private insurances requiring pain fellowship to tie to the reimbursement. I dont know if that is the case and wheather it has to be acgme. Perhaps some of the more senior posters have more info.

Nope. Know tons of people including current attending, who have non-ACGME accredited fellowships and get paid just fine. Current attending is making a killing in particular - even without fellows.

 

[PMR’s chill]

Yes I understand that, but can't get better without practice.

You shouldn’t be concerned about not doing cervical and thoracic procedures 2 months in. That will hopefully come once you get really good at your lumbar cases. Just pay attention, and keep learning. You can always ask your attending what’s the typical timeline he likes to work on. I’d recommend going to SIS courses to reinforce text book procedure skills.

l

 

[Piebaldi]

You shouldn’t be concerned about not doing cervical and thoracic procedures 2 months in. That will hopefully come once you get really good at your lumbar cases. Just pay attention, and keep learning. You can always ask your attending what’s the typical timeline he likes to work on. I’d recommend going to SIS courses to reinforce text book procedure skills.

l

Right I get that. Again I am not expecting to be an expert from the bat. I have noticed that as I have gotten better, faster I have been allowed to do more - but there is so much to learn sometimes I worry that there wont be enough time to learn everything I want/need to. Thanks.

 

[Ronin1]

you can get paid without a fellowship or even a residency if that is what’s it is all about. However to suggest that there is no difference in doing an accredited fellowship from a non accredited one is simply incorrect.

 

[chudat]

you can get paid without a fellowship or even a residency if that is what’s it is all about. However to suggest that there is no difference in doing an accredited fellowship from a non accredited one is simply incorrect.

I think what the poster is saying is that the differences are negligible. As someone who went to interview at both accredited and nonacredited fellowships, I tend to agree.

 

[blockstar]

you can get paid without a fellowship or even a residency if that is what’s it is all about. However to suggest that there is no difference in doing an accredited fellowship from a non accredited one is simply incorrect.

if this is the case and end goal is private practice then you can probably learn more in a non accredited fellowship from someone who is practicing without an accredited fellowship than a lot of accredited fellowships.
If end goal is academics then accredited would be better
If piebaldis walking on eggshells and not learning than whats the point unless you can get approved by hospitals and get referrals from them only by finishing the non accredited

 

[dhcofc]

Are you really giving "advice" as a med student? No one worth their salt talks about the "prestige" of their anything in real practice - no one cares where people went to med school, residency, or anything. Give me a break. Not to mention, there is plenty of abuse at plenty of residency programs. Are you serious? Please don't give "advice" as a med student.

Sorry, but it does matter where you train.

Rather than attack those on this thread trying to give professional advice, whether you like it or not, it would probably serve some people better to think about what a poster’s point is.

I don’t know you. You don’t know me. I’m a dual boarded anesthesia and pain management physician (who is too busy I guess to update my profile that made you think I was a student).

Good luck. I’m done with these threads.

 

[No Pain All gain]

Patients care where I trained. I hear them talk about it all the time because they are “big name” institutions.

I don’t think the name matters at all, but I hear it at least a few times a week from new patients.

My opinion of your situation is simple - suck it up. Most of us in PP are “on call” 365 days a year. I can only think of one weekend in the past 4 years where this was an inconvenience.

As a fellow, we took 8 weeks a year of call in 2 week blocks. That included ever after hours call from clinic patients, the acute pain service from the hospital, and the chronic pain inpatient service for which we were primary. That was horrendous and really disruptive to my life. In practice it’s never been that way.

Regarding procedural volume, clearly you have to prove to this attending you can do the things he is allowing you to do well and without complication before you move on. Not the way i was trained, but not unreasonable either. This is your opportunity to earn your experience.




Sent from my iPhone using Tapatalk

 

[Orin]

Patients care where I trained. I hear them talk about it all the time because they are “big name” institutions.

They probably know about the basketball or football coaches there more than the pain training, but brand matters for marketing.
Good clinical work and a focus on practice building can overcome that though.

 

[deleted993114]

Are you really giving "advice" as a med student? No one worth their salt talks about the "prestige" of their anything in real practice - no one cares where people went to med school, residency, or anything. Give me a break. Not to mention, there is plenty of abuse at plenty of residency programs. Are you serious? Please don't give "advice" as a med student.

There is some truth to that. I went to some very highly ranked training programs and was surprised that people who went to crap schools and training programs were considered to be on equal footing- but that is life and medicine. Some of the guys who went to marginal programs really devoted themselves to improving and have become outstanding practitioners. The converse is true as well.

I personally think that people learn a lot more after their training than during training, so there is some merit to that contention.

However, you can certainly tell guys who were trained by real surgeons when observing stim implants. Also, good programs provide better didactic information and ways to stay out of trouble.

A non-accredited program is not accredited for a reason. When getting a job, most practices will not give a damn and most patients and referral sources can’t tell a quality practitioner from a poor one.

I am thinking about going back to academics, as I let residents and fellows do everything and never got testy with them. Part of the training is showing guys how to keep a cool head, which is just as important as procedural skills.

 

[Piebaldi]

I think what the poster is saying is that the differences are negligible. As someone who went to interview at both accredited and nonacredited fellowships, I tend to agree.

Yes, precisely that is exactly what I am saying. There are no "mystery" procedures that I won't get to do coming from this vs an accredited program. I will get the whole gamut of procedures. Having rotated at my residency's accredited anesthesia program, I don't think I am missing much.

 

[No Pain All gain]

They probably know about the basketball or football coaches there more than the pain training, but brand matters for marketing.
Good clinical work and a focus on practice building can overcome that though.

Agreed - university reputation has no bearing on clinical training. Just saying that patients do recognize this and mention I frequently. More so at a location I’m at which is more rural than my others.


Sent from my iPhone using Tapatalk

 

[Piebaldi]

if this is the case and end goal is private practice then you can probably learn more in a non accredited fellowship from someone who is practicing without an accredited fellowship than a lot of accredited fellowships.
If end goal is academics then accredited would be better
If piebaldis walking on eggshells and not learning than whats the point unless you can get approved by hospitals and get referrals from them only by finishing the non accredited

My goal is entirely private practice. Academics is not even in consideration. I was also walking on eggshells during my residency. I didn't say I am not learning - I have learned leaps and bounds in these less than 2 months, I complained that at this timeI have not been able to do certain procedures like cervical and thoracic. Per other posters that seems normal. So hopefully they are right. Yes you can get approved by hospitals and get referrals without a problem. That's not the issue.

 

[Orin]

I was also walking on eggshells during my residency.

Maybe consider some self-reflection and work on your own demeanor then? You may come across as lacking confidence or untrustworthy? It may just be both training environments, but a little external coaching or time with a therapist doesn't hurt anything other than your pride and wallet.

https://www.inc.com/maya-hu-chan/got-executive-presence-hint-its-important.html

In private practice, your ability to build faith in your personal brand leads to business, so understand how you project yourself friend and it may make things easier moving forward.

 

[Piebaldi]

Maybe consider some self-reflection and work on your own demeanor then? You may come across as lacking confidence or untrustworthy? It may just be both training environments, but a little external coaching or time with a therapist doesn't hurt anything other than your pride and wallet.

https://www.inc.com/maya-hu-chan/got-executive-presence-hint-its-important.html

In private practice, your ability to build faith in your personal brand leads to business, so understand how you project yourself friend and it may make things easier moving forward.

Being quiet is not a crime you know nor is it pathological in any way. Some people are introverted, others are extroverted. Perhaps I should just not have gone into Medicine. Oh well. Kind of late now.

 

[dhcofc]

Maybe consider some self-reflection and work on your own demeanor then? You may come across as lacking confidence or untrustworthy? It may just be both training environments, but a little external coaching or time with a therapist doesn't hurt anything other than your pride and wallet.

https://www.inc.com/maya-hu-chan/got-executive-presence-hint-its-important.html

Good stuff from Orin’s link...

7. Be positive.
Notice how often you complain or use sarcasm to make a point. Your complaints may be justified, but the act of complaining projects powerlessness. You are essentially saying, "Not only is this situation bad, unfair, or intolerable, but I expect someone else to fix it!" If you are the complainer, you aren't the leader.

 

[Orin]

It's okay to be introverted, but society is generally biased against it. It's not a crime or pathologic at all, but it is something you may need to compensate for in this type of work.

Embracing Introversion in Medicine

My former pediatrician always had the brightest smile. She was an effervescent “people-person.” Between her and episodes of Grey’s Anatomy, I always thought that all physicians were outgoing butterflies flapping back and forth between patients and their vibrant social lives. Physicians are...

in-training.org

Are You an Introvert? It Might Mean You’re a Good Leader

Natural skills such as listening and thoughtfulness can be an advantage when working toward leadership positions.

www.physicianleaders.org

Can physicians be introverts? A introverted physician speaks her mind.

Do you have an introverted physician? Good for you!

www.kevinmd.com

Don't take it as an affront. The social/relational aspect of medicine is challenging and they don't teach you it. It doesn't make you a bad physician or person.

It's just something you need to work on, like cervical ESIs but without anyone keeping you from it other than yourself.

You'll eventually get there procedurally, but if you projecting this as a problem with others or a system, it may limit your enjoyment of your chosen profession.

I will tell you, I prefer working with introverted residents/fellows as they listen better, but at the same time, it's hard to get them to engage and talk out loud in the procedural areas.

 

[Piebaldi]

It's okay to be introverted, but society is generally biased against it. It's not a crime or pathologic at all, but it is something you may need to compensate for in this type of work.

Embracing Introversion in Medicine

My former pediatrician always had the brightest smile. She was an effervescent “people-person.” Between her and episodes of Grey’s Anatomy, I always thought that all physicians were outgoing butterflies flapping back and forth between patients and their vibrant social lives. Physicians are...

in-training.org

Are You an Introvert? It Might Mean You’re a Good Leader

Natural skills such as listening and thoughtfulness can be an advantage when working toward leadership positions.

www.physicianleaders.org

Can physicians be introverts? A introverted physician speaks her mind.

Do you have an introverted physician? Good for you!

www.kevinmd.com

Don't take it as an affront. The social/relational aspect of medicine is challenging and they don't teach you it. It doesn't make you a bad physician or person.

It's just something you need to work on, like cervical ESIs but without anyone keeping you from it other than yourself.

You'll eventually get there procedurally, but if you projecting this as a problem with others or a system, it may limit your enjoyment of your chosen profession.

I will tell you, I prefer working with introverted residents/fellows as they listen better, but at the same time, it's hard to get them to engage and talk out loud in the procedural areas.

I laughed at the "like cervical ESIs" comment, however, while I am overall introverted, I am pleasant, professional, quite funny, and talk with other staff, strike up conversations so in the work place I am perfectly normal and pleasant. I am also a woman in a mostly male field, conservative, etc. And if society has an issue with "introverts" that's society's problem because there is nothing wrong with introversion in general. That in and out of itself is a big part of the problem - suggesting that there is something "wrong" with being introverted. No difference with being brown, or black or yellow or whatever - personality traits are something that one does not choose. It's like me saying I can straighten my hair to reduce the waves but at the end of the day it's still wavy.
I have done perfectly well overall professionally and in life with tons of obstacles of all sorts - and I'm perfectly pleasant and professional and well liked by patients.

 

[jettavr6]

ACGME fellowship 10 years ago -- is it just me, or did we all take call every third or fourth night? Maybe I've forgotten--

 

[neutro]

Sorry, you’re just complaining. I have like zero empathy for your situation.
You are working Clinic hours without any inpatient or REAL call for intrathecal pumps, blood patches in ER, or trouble shooting regional Anesthesia catheters.

Your life isn’t REALLY that bad compared to the average pain fellow out there.
Learn to be efficient in clinic. Speed will help you feel less stressed.

 

[Ducttape]

1. I have to agree on this point with Doctodd.

and I am talking like an codger, but the attitude when I did my initial residency the thought was just that - being on call every other day meant missing half the cases. and if you missed half the cases, you weren't learning.

2. you are 2 months in. all of us still have increased sphincter tone with doing cervicals and we all have done thousands of them. why do you think your attending would be willing to let you go all in over his cervical cases when he still isn't sure you know how to drive a needle?

you'll understand when you have kids - you will not let them drive on the highway until they master the empty parking lot.

3. in terms of quitting, im not sure that would look good to any other fellowship program you might want to join. the other program might look appealing, but if they are so appealing, they would have filled that spot already. the grass is always greener. just think. only 10 months to go, vs. another 12.

4. it also sounds like you have never really been on call before. ive been on call for 9 years and almost 4 months, minus 10 hours - 5 for pain boards, and 5 for oral boards. now Doctodd would say that it has driven me mad, but there is clear evidence that I was so before starting call.

being on call doesn't mean you have to be cooped up at home. explore your new environment. go on Yelp and find great spots to go out for dinner. spend weekend nights watching the entire Seinfeld series. 180 episodes total. start working out with some goal in mind - a triathlon, say. invite your family to visit you in your new city. etc.

listen, I have lived in probably one of the most boring places in the entire continental US, and you cant tell me that there aren't fun things to do to keep you occupied for a year...

5. what clubdeac is saying is that non-accredited fellowships are allowed to do whatever they want, with no real monitoring for compliance, that is meant to protect not only patients but the fellows. in an ACGME accredited fellowship, for example, there is a system and some review board that will hear the fellows complaints and determine proper course of action.

Section IV.C.1:

https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRFellowship2019.pdf

my understanding, from talking to my ACGME residency director friend - it is exceedingly difficult to "fire" someone from an ACGME certified program.

one could also file a complaint directly to the ACGME if one could certify that the firing violated ACGME regulations...

Office of Complaints

www.acgme.org

 

[Baron Samedi]

In the lumbar spine you have more space to work with, (usually) more reliable LOR, and less severe consequences if you screw it up(in fact, you might even get another procedure out of it!).

In the cervical spine you have less space to work with, less reliable or nonexistent LOR, and more potential for harm if you screw it up.

You're 2 months in. You should be focused on basics of fluoroscopy and needle driving techniques and put the ego part of it aside.

 

[lobelsteve]

LOR.

LOL.

 

[Piebaldi]

1. I have to agree on this point with Doctodd.

and I am talking like an codger, but the attitude when I did my initial residency the thought was just that - being on call every other day meant missing half the cases. and if you missed half the cases, you weren't learning.

2. you are 2 months in. all of us still have increased sphincter tone with doing cervicals and we all have done thousands of them. why do you think your attending would be willing to let you go all in over his cervical cases when he still isn't sure you know how to drive a needle?

you'll understand when you have kids - you will not let them drive on the highway until they master the empty parking lot.

3. in terms of quitting, im not sure that would look good to any other fellowship program you might want to join. the other program might look appealing, but if they are so appealing, they would have filled that spot already. the grass is always greener. just think. only 10 months to go, vs. another 12.

4. it also sounds like you have never really been on call before. ive been on call for 9 years and almost 4 months, minus 10 hours - 5 for pain boards, and 5 for oral boards. now Doctodd would say that it has driven me mad, but there is clear evidence that I was so before starting call.

being on call doesn't mean you have to be cooped up at home. explore your new environment. go on Yelp and find great spots to go out for dinner. spend weekend nights watching the entire Seinfeld series. 180 episodes total. start working out with some goal in mind - a triathlon, say. invite your family to visit you in your new city. etc.

listen, I have lived in probably one of the most boring places in the entire continental US, and you cant tell me that there aren't fun things to do to keep you occupied for a year...

5. what clubdeac is saying is that non-accredited fellowships are allowed to do whatever they want, with no real monitoring for compliance, that is meant to protect not only patients but the fellows. in an ACGME accredited fellowship, for example, there is a system and some review board that will hear the fellows complaints and determine proper course of action.

Section IV.C.1:

https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRFellowship2019.pdf

my understanding, from talking to my ACGME residency director friend - it is exceedingly difficult to "fire" someone from an ACGME certified program.

one could also file a complaint directly to the ACGME if one could certify that the firing violated ACGME regulations...

Office of Complaints

www.acgme.org

Again no one is suggesting I'm going to go in and do anything on my own - But if i never even get the chance to do certain things there's no way to get better. Taht's the point. And you are a Pain attending - this is much different. I'm not working in an attending capacity at this time. So of course you are on call all the time for your patients. Different scenario. And yes I am aware that non-accredited fellowships are allowed to do as they wish.

 

[Baron Samedi]

LOR.

LOL.

LOR to contrast flow?

I've been proven wrong many times when I thought I was superficial, injected to contrast to verify, and saw epidural spread.

 

[lobelsteve]

LOR to contrast flow?

I've been proven wrong many times when I thought I was superficial, injected to contrast to verify, and saw epidural spread.

LOR= loss of resistance
LOL= laughing out loud.

LOR is outmoded and not very useful. Dogma and not science.
Don't get me wrong, I use LOR to air for SCS, then go immediately lateral. I'm always surprised as no CSF shoots out.

Using LOR for ESI seems so antiquated in the day and age of CLO.

 

[Ducttape]

Again no one is suggesting I'm going to go in and do anything on my own - But if i never even get the chance to do certain things there's no way to get better. Taht's the point. And you are a Pain attending - this is much different. I'm not working in an attending capacity at this time. So of course you are on call all the time for your patients. Different scenario. And yes I am aware that non-accredited fellowships are allowed to do as they wish.

you are still in the "wax on wax off" phase of training.

im sure when you get proficient at doing lumbar epidurals he will have you start cervical epidurals. at 2 months in, you are probably not yet proficient even at SI injections. we must all learn to walk before we run.

 

[deleted993114]

LOR= loss of resistance
LOL= laughing out loud.

LOR is outmoded and not very useful. Dogma and not science.
Don't get me wrong, I use LOR to air for SCS, then go immediately lateral. I'm always surprised as no CSF shoots out.

Using LOR for ESI seems so antiquated in the day and age of CLO.

What method are you using to identify the epidural space? It seems like LOR, then verifying with contrast in a laterals is extremely fast. I guess one could place an epidural needle simply radiographically, but it would take more time and might be more "messy" with more contrast use. I know a guy who places his stim needles this way- seems like too much work to me.

My rule of thumb with cervicals is that I want to see at least 100 lumbar interlams before I will allow someone to do interlam cervical epidurals. Selective n root blocks, cervical test blocks, and cervical rf can be done on day one, as can stims, cryos, and fascial rf techniques. In all of the latter you have several fluro images for localization that will prevent disaster; for cervical interlam epidurals, you don't have that safety net. I always like to see people new to cervicals get false losses of resistance a few times (and be able to verify incorrect placement) before they can appreciate what a cervical epidurogram looks like.

For the legal work I do, I can say the most common case I am sent is a botched cervical epidural. So the fellow above needs to understand that a cervical epidural, in my opinion, is one of the most dangerous things we do, far more dangerous than what others would consider to be "exotic" procedures.

Pain procedures are always fun until someone loses an eye, and we must be aware of relative risks vs benefits in a given procedure.

 

[lobelsteve]

What method are you using to identify the epidural space? It seems like LOR, then verifying with contrast in a laterals is extremely fast. I guess one could place an epidural needle simply radiographically, but it would take more time and might be more "messy" with more contrast use. I know a guy who places his stim needles this way- seems like too much work to me.

My rule of thumb with cervicals is that I want to see at least 100 lumbar interlams before I will allow someone to do interlam cervical epidurals. Selective n root blocks, cervical test blocks, and cervical rf can be done on day one, as can stims, cryos, and fascial rf techniques. In all of the latter you have several fluro images for localization that will prevent disaster; for cervical interlam epidurals, you don't have that safety net. I always like to see people new to cervicals get false losses of resistance a few times (and be able to verify incorrect placement) before they can appreciate what a cervical epidurogram looks like.

For the legal work I do, I can say the most common case I am sent is a botched cervical epidural. So the fellow above needs to understand that a cervical epidural, in my opinion, is one of the most dangerous things we do, far more dangerous than what others would consider to be "exotic" procedures.

Pain procedures are always fun until someone loses an eye, and we must be aware of relative risks vs benefits in a given procedure.

25G 3.5" quinke. Touch lamina in AP, turn to CLO, advance to 2mm from line. 1 drop of contrast to prove it is not there yet, advance in 1mm increments until across line and shoot in a drop of contrast. Once in the epidural space based on epiduragram, inject NSS+steroid.

 

[SommeRiver]

To the OP...

My fellowship year was very hard. Inpatient call is real call, and you're talking outpt call which is probably very minimal. My inpt call was like being punched in the heart with a steel glove. Very, very busy and I had to drive into the hospital for thoracic catheters and blood patches at 3AM.

The busier you are now the better your life will be as an attending. My first year out was not easy.

Right now you're helping to manage someone else's clinic, and that may not mean a lot to you but whoever owns that clinic is ALLOWING you to potentially give HIS clinic a bad name.

In exchange you write his notes and do the BS he doesn't want to do and over the course of the year you'll do more and more as he begins to trust you.

He isn't being protected by the ivory towers of a large academic institution like an ACGME program.

Fellowship chaos = A chance to screw up.

 

[Piebaldi]

To the OP...

My fellowship year was very hard. Inpatient call is real call, and you're talking outpt call which is probably very minimal. My inpt call was like being punched in the heart with a steel glove. Very, very busy and I had to drive into the hospital for thoracic catheters and blood patches at 3AM.

The busier you are now the better your life will be as an attending. My first year out was not easy.

Right now you're helping to manage someone else's clinic, and that may not mean a lot to you but whoever owns that clinic is ALLOWING you to potentially give HIS clinic a bad name.

In exchange you write his notes and do the BS he doesn't want to do and over the course of the year you'll do more and more as he begins to trust you.

He isn't being protected by the ivory towers of a large academic institution like an ACGME program.

Fellowship chaos = A chance to screw up.

Well I would say this is a balanced, and helpful view into my situation. Thank you for your insight.

 

[lonelobo]

LOR= loss of resistance
LOL= laughing out loud.

LOR is outmoded and not very useful. Dogma and not science.
Don't get me wrong, I use LOR to air for SCS, then go immediately lateral. I'm always surprised as no CSF shoots out.

Using LOR for ESI seems so antiquated in the day and age of CLO.

MY guess is 90% out there use LOR

 

[paindoc007]

MY guess is 90% out there use LOR

That’s conservative. I’d wager 97-99%
It’s an interesting method, I’m not against it. But no means is that standard of care. Never even heard that discussed at sis it other mtgs either.

 

[clubdeac]

Precisely. I went to an excellent residency program. I will be board certified in a few months. I have done a significant and diverse number of procedures throughout residency. I get the same procedures as everyone else in other programs. There is legitimacy - yes obviously as others have pointed out there is less "protection" in terms of something going wrong or work hours. But otherwise not much difference. Even the chair of our PM&R program was practicing pain (he was in his 70's) and never did a fellowship. There is a big big difference between nurses - NPs, CRNAs and physicians doing this. Not sure why the other poster is trying to instigate.

If you're in an ACGME pain fellowship you will be board certified. Only then. Otherwise your board certification is no different than the CRNAs "pain board" certification. We need some standards.... that's the point!

 

[SommeRiver]

25G 3.5" quinke. Touch lamina in AP, turn to CLO, advance to 2mm from line. 1 drop of contrast to prove it is not there yet, advance in 1mm increments until across line and shoot in a drop of contrast. Once in the epidural space based on epiduragram, inject NSS+steroid.

Why do you use loss during SCS? I am probably 50% loss during SCS and the other times if I'm in the ligament and the lead won't advance I retract the lead about 5mm into the needle, advance a mm, try the lead, etc...

You don't ever do that?

 

[Baron Samedi]

Am I crazy for using the actual guidewire that comes in the kit?

 

[No Pain All gain]

Am I crazy for using the actual guidewire that comes in the kit?

Not crazy. Psychopath?
I do LoR like a regular guy. Use CLO for all epidural approaches especially SCS


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[lobelsteve]

LOR seems reliable using a 14g tuohy at L1. I dont trust it otherwise. Literature on it says not to trust it.

 

[No Pain All gain]

I should say I do LOR but also pay close attention to CLO and if it appears I’m potentially violating laminar line I will put a drop of contrast in as Lobel notes.


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[Taus]

Why do you use loss during SCS? I am probably 50% loss during SCS and the other times if I'm in the ligament and the lead won't advance I retract the lead about 5mm into the needle, advance a mm, try the lead, etc...

You don't ever do that?

I do this. Used to use lead blank, but it’s of smaller caliber than lead and sometimes lead won’t go after blank goes. Lor sometimes gives me inability to pass lead without wiggling the needle ventral a little more to get more of the large bevel opening in epi space. Just a bit of leading edge bevel opening past ligament will give lor to air or saline but not necessarily space for lead. Most reliable and fast for me is needle on clo, try to pass real lead. Firm. Retract lead. 1mm needle advance. Repeat til lead smoothly passes.

 

[clubdeac]

Do you guys ever just use the lead for your loss. Get the needle in ligament, take out stylet and press on the lead and needle at the same time until the lead pops through into the epidural space? I do this sometimes when I'm not getting great resistance or mushy resistance on my LOR syringe

 

[SommeRiver]

Do you guys ever just use the lead for your loss. Get the needle in ligament, take out stylet and press on the lead and needle at the same time until the lead pops through into the epidural space? I do this sometimes when I'm not getting great resistance or mushy resistance on my LOR syringe

I have, but my experience is that you can damage the lead doing that if it takes you a few attempts at it. That's why I retract it a few mm back into the needle before I advance.

Someone mentioned the guidewire and I have used it a few times when I'm hitting obstructions in the canal and can't advance but to get through the ligament never have.

 

[chudat]

You guys jacked the thread