How Long?

[thinkorswim]

I'm confused how you interpret what I wrote as this?

I think there is "less on the line" when doing a block for analgesic purposes compared to a surgical block. The latter requires a "perfect block" and that needs more time to do and confirm. This is true regardless of PP or academics.

However PP is more likely to do blocks for analgesic purposes and put the patient under GA after

and you don't need "narcotics and full paralysis" with the GA. that's red herring and you know it.

Well, you said this:

PP don't need it to be perfect so doing it in 5 minutes is fine. the GA is the heavy lifting.

Which implies that there's a lower standard for adequate nerve blocks in private practice, which just isn't true. I'm not arguing that a 45 minute block isn't hyperbole.

So... do you sedate the patients you do your blocks for? Or do you GA them? Is it an analgesic block or a surgical block? That is at the heart of my comments.

A block is a block. Whether it's a surgical or analgesic nerve block would depend on the procedure being performed, but either way the technique itself doesn't change and the time to perform it is the same.

And really how many "surgical" blocks are we really talking about? This only truly applies to a select few upper and lower extremity procedures, and really the only difference is the amount of narcotic used to supplement. I usually just place an LMA and let the patients cruise on around 0.5 MAC of gas, not only for billing, but because frankly it's just easier. Do you really want to deal with an obstructing airway in beach chair position? Or have an awake patient complaining about the tourniquet pressure or their back pain? What patient wants to be fully awake and hear the conversation, terrible music selection, and sounds of the instruments in the OR? Do you really want to spend most of the case babysitting the patient instead of checking your stock portfolio?

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[psychbender]

I would assume that @UscGhost conflated doing a 5-minute SCB as being PP and doing a 45-minute multi-block for AKA or a catheter as being academics.

Perhaps you can elaborate on the benefit to the patient (not to your billing) of doing an analgesic block plus general anesthesia, when just a surgical block would be sufficient? IMO the worst offenders are doing a spinal followed by a general anesthetic. Seems like taking upon extra risk. And the patient is going to get good postop analgesia either way. Actually seems like a pretty inefficient way of doing things with the extra steps but i'm sure it pads the paycheck quite nicely.

I often say that the best sedation involves an LMA. I can give midaz and a prop infusion, then have to get under the drapes periodically jaw thrust or tilt the head to relieve obstruction. Or, I can drop an LMA and run 0.5MAC sevo, and let them sit there with an open airway, and be even more alert in PACU.

It's also not about "padding" the paycheck, it's about knowing how you're paid. Quit it with the snideremarks, insinuating everyone in PP is greedy and incompetent. In the military and in my first job, I was just paid salary. It didn't matter how hard I worked, or what I did for the patient. Now, though, in order to justify the same (lesser, actually, compared to my first job) income, I have to ensure that my billing is appropriate for the work I actually did. If I do extra work (blocks, lines), then I'll absolutely ensure that they're documented and justified in such a way that I will get paid for my work. If not, there is nothing for collections.

I also don't get SAB plus GA. Not only does it not make medical sense, you can't bill for both, either (unless the SAB is purely for duramorph, and you're rounding on then the next day).

 

[Status Sciaticus]

I'm not bitter (okay maybe a little bit) about PP guys, but I want to push back against all the snide comments made by PP about academics. Decision-trees about "efficiency" and "what to be worried about" is largely dependent on the type of surgery and the type of surgeon. Is this a bread-and-butter case? Is this a good surgeon that a single IV will be fine? Or is this a surgeon that often downplay the patient's condition, get themselves into unexpected blood baths that a second IV and an art line will be needed? What else is there to be efficient about? I concede that I am a little more aggressive in my approach compared to some of my academic colleagues. I am pretty quick with my wake ups, usually within 5 minutes of case end even after those 6 hour surgeries. I don't violate NPO guidelines. I don't pull the ETT and wheel the patient to PACU when the patient is unconscious because the PACU nurses will lose their minds. Do you do these things?



Yes, and that's exactly why PP rarely do block + sedation. They do block + GA so even if that block is patchy or didn't set up correctly the case still goes on. There is less pressure to do it right because they aren't relying on the block to do the heavy lifting. When a block "must be perfect" every time, it will take more than 5 minutes to put it in... that's reality.



Perhaps you are talking about solo PP where you "do everything yourself".
I doubt the same can be said of PP where you are supervising 4+ CRNAs from your computer workstation.



I think I'm pretty slick and efficient. I do a lot of solo cases as an attending. I know the in-and-outs of the anesthesia machine and can trouble shoot most problems. When I do my room checks I draw up my drugs and set up my equipment and machine in about 5 minutes (the machine itself takes about 4 minutes to do a boot up and system check). I can intubate, place a couple IVs and an art line in a deathly ill patient in the space of 10 minutes. Add another 10 minutes to place a central line. BUT I disagree that solo approach is the best approach for a truly unstable trauma case where mortality is in the cards. This is a situation that slickness isn't enough. You need extra hands, from techs if not from other anesthesiologists. To watch the monitors. To push levo or bolus fluids when I am in the middle of working on that extra access. I don't have any preconceptions that I myself can and will do everything. I don't have that kind of ego. And face it when a patient is so sick they could die that's when it really matters. Not the "patient broke a bone must fix" kind of trauma. And also face it, the academic anesthesiologists taking "trauma call" aren't usually from the general pool of academics.

I don't disagree.


It makes it easier when everyone is on the same page about management of a patient. And that means some degree of solidarity among the anesthesiologists. You can't have one anesthesiologist refuse to the do the case because the patient needs medical optimization, and then the anesthesiologist next door says "it's fine I'll do it"


I mean the same can be said about academics going into PP.


It would be considered substandard care because that is not how it is taught in the textbooks. But I will digress about the semantics.

Right, this is why when I cancel a case, none of the other anesthesiologists in the group will do it. Thats called being team players and having each others backs. In academia, not so much. If one anesthesiologist doesn't want to do it, plug in another one. We also don't give our surgeons the luxury of requesting specific anesthesiologists. Learn to play nice with the one that's in the room or STFU.

Recent one and a simple one. Anesthesiologist wanted to delay elective case for NPO violation. Upset the surgeon and got chided by the head of the anesthesia group because the "patient is going to be intubated anyway". I don't have to deal with this sort of crap in academics. I do what I feel is in the best interest of my patient without having to simultaneously navigate a minefield of OR politics.

I've never had any pushback like this in academia or private practice. I also document the NPO time. It helps once you make things permanent in the EMR. Surgeon suddenly has the time to wait or can call it an emergency.

Then, can you please elaborate on what constitutes efficient care that is wholly missing in academics? I've described how I practice above.

Sure. The patient comes in with fluids and antibiotics hanging. Nurse puts on the monitors and cycles the blood pressure. I intubate and do my part. Nurses put in second IV and position/pad the patient while I document. Techs turn over the room while I wheel the patient to PACU. Turnovers aren't more than 20-30 minutes long. Surgeons are actually good in PP because you don't have the luxury of being slow or incompetent. My blocks don't take more than a few minutes to place. Certainly not more than 5 minutes. I also add lidocaine in to speed up time. I also do GA since my blocks are for post-op pain control unless there's clear-cut indications to avoid GA. I also do blocks in pre-op after I wheel my prior patient to PACU while the OR is being cleaned. Plenty of time for those blocks to set in.

 

[DesiredMemberName?]

This guy sounds like he learned everything he knows about private practice from the water (koolaid?) cooler in the academic center physician lounge.

We regularly do regional w sedation at the surgery centers. If those blocks fail, it’s a big problem, and you will be uninvited in a hurry. You don’t get to blame it on the resident, either.

We also do liver transplants, heart transplants, LVADs, etc. at our hospital. In fact, I have taken care of several patients the (elite) academic center in town declared too sick for intervention.

The things academic anesthesiologists tell themselves about what goes on in PP never cease to entertain.

 

[anaesthetic]

This guy sounds like he learned everything he knows about private practice from the water (koolaid?) cooler in the academic center physician lounge.

We regularly do regional w sedation at the surgery centers. If those blocks fail, it’s a big problem, and you will be uninvited in a hurry. You don’t get to blame it on the resident, either.

We also do liver transplants, heart transplants, LVADs, etc. at our hospital. In fact, I have taken care of several patients who the (elite) academic center in town declared too sick for intervention.

The things academic anesthesiologists tell themselves about what goes on in PP never cease to entertain.

Our practice is the same. Tertiary, level I trauma center, huge referral base for heart/lungs/livers, LVADs, mechanical circulatory support, solo all cardiac/transplants. We never ship out a case (no peds). Care team for other general cases but often solo them as needed as the CRNA shortage continues. We also do regional for vascular stuff (often without GA unless converting for failed block, which happened twice over the last two years for me).

Most of my partners are pretty slick. I can describe maybe one or two attendings in residency who were “slick,” and they usually came from a busy PP. I think it’s rare for academics to have opportunities to solo cases. Either way, there are some partners who cut corners for the sake of speed, but it’s definitely not the majority. We follow NPO guidelines and do things safely. Surgeons may complain, but we are a united front and are well-respected.

I am very biased because we get feedback from the local cardiac fellows who rotate with us for a month to see what PP cardiac is about. They all tell us the same things: we aren’t unsafe, we are 1000% faster, we know what we’re doing, and we look good doing it. They are our bridge to the academic world, and they always come away with great things to say about our practice and are grateful for a perspective outside of academics. The surgeons are definitely way better in PP, and that makes us look good too.

Obligatory “everyone is a superstar on SDN” warning.

 

[narcusprince]

I will say this. My first job out of the military was surgicenter I made about 400k in one year. I left that ish show and now work for a hospital. I love the hospital but I work like a dog. My compensation for 3months of work so far has been 200K. Again I take extra paid calls and work extra weekends. But im in a ugly phase right now and want to make everything I am worth.

 

[DocMcCoy]

I would assume that @UscGhost conflated doing a 5-minute SCB as being PP and doing a 45-minute multi-block for AKA or a catheter as being academics.

Perhaps you can elaborate on the benefit to the patient (not to your billing) of doing an analgesic block plus general anesthesia, when just a surgical block would be sufficient? IMO the worst offenders are doing a spinal followed by a general anesthetic. Seems like taking upon extra risk. And the patient is going to get good postop analgesia either way. Actually seems like a pretty inefficient way of doing things with the extra steps but i'm sure it pads the paycheck quite nicely.

Meh. Same guys that do a spinal and run a prop drip at 120+ talking sht about guys that just drop in an LMA and run 0.7 MAC sevo. Both are “general anesthesia” LMA way easier for me. Far fewer desats and jaw thrusts. Both groups get zero narcs. Negligible difference in PONV rates if you screen appropriately 🤷‍♂️ don’t see the big deal

 

[coffeebythelake]

I often say that the best sedation involves an LMA. I can give midaz and a prop infusion, then have to get under the drapes periodically jaw thrust or tilt the head to relieve obstruction. Or, I can drop an LMA and run 0.5MAC sevo, and let them sit there with an open airway, and be even more alert in PACU.

It's also not about "padding" the paycheck, it's about knowing how you're paid. Quit it with the snideremarks, insinuating everyone in PP is greedy and incompetent. In the military and in my first job, I was just paid salary. It didn't matter how hard I worked, or what I did for the patient. Now, though, in order to justify the same (lesser, actually, compared to my first job) income, I have to ensure that my billing is appropriate for the work I actually did. If I do extra work (blocks, lines), then I'll absolutely ensure that they're documented and justified in such a way that I will get paid for my work. If not, there is nothing for collections.

I also don't get SAB plus GA. Not only does it not make medical sense, you can't bill for both, either (unless the SAB is purely for duramorph, and you're rounding on then the next day).

Not to sound like a broken record.. but again... what is the patient benefit from doing it this way?

And I'm not saying you don't deserve your PP paycheck. I didn't insinuate it is greedy. *You* did that by taking such offense to my line of questioning.

I am pointing out the distinct differences in the way anesthesia is practiced between academics and private practice, which we *all* agree exists, and this is one of the big glaring instances. In academics we wouldn't do analgesic blocks ("it's for post-op pain control!!") + GA when a surgical block (the same damn needle in the same spot but with 0.5% bupi instead of 0.2% ropi) would provide the same conditions for the surgeon and the same postop analgesia. And in PP you wouldn't do it either (since you are such slick, efficient workers) if it wasn't for the billing aspect of it as you've so explained.

And yes a surgical block does take a little more time. To test it and make sure it works. To let the block set up. The surgery cannot start if a surgical block hasn't set up, or is patchy, or *gasps* fails (and I know this is SDN where every patient has perfect anatomy, blocks work immediately without fail, and nobody ever have bad outcomes but phleeaze). But it is much less of a concern when the patient is getting a general anesthetic on top as I've said once, twice, thrice.

 

[GravelRider]

You read intently but miss the point entirely. Maybe the same with your blocks. I'm done.

I mean you kind of answered your own question about efficiency when you were comparing your super-awesome extra dense 45 minute block and whatever complicated sedation cocktail you use to my 5 minute block and LMA on 1% sevo (I’m a narcotic minimalist, so usually none). Resident teaching aside, if it’s taking you 45 minutes to do a block, you need to practice more. That’s akin to a general surgeon taking 4 hours to do an appy. Is the 1 hour appy somehow not as good as the 4 hour appy?

 

[coffeebythelake]

I mean you kind of answered your own question about efficiency when you were comparing your super-awesome extra dense 45 minute block and whatever complicated sedation cocktail you use to my 5 minute block and LMA on 1% sevo (I’m a narcotic minimalist, so usually none). Resident teaching aside, if it’s taking you 45 minutes to do a block, you need to practice more.

What is up with the 45 minute block? This is something you PP guys keep repeating. I've only said it is ridiculous and nobody takes that amount of time. You are slick but a little too quick to read the details.

That’s akin to a general surgeon taking 4 hours to do an appy. Is the 1 hour appy somehow not as good as the 4 hour appy?

Is it? I don't even know what conclusion you are trying to get to here. It doesn't follow.
On the one hand you argue that slow is bad, and now you are saying it doesn't matter? Or are you trying to take a piss on slower surgeons?

 

[coffeebythelake]

Right, this is why when I cancel a case, none of the other anesthesiologists in the group will do it. Thats called being team players and having each others backs. In academia, not so much. If one anesthesiologist doesn't want to do it, plug in another one. We also don't give our surgeons the luxury of requesting specific anesthesiologists. Learn to play nice with the one that's in the room or STFU.

Where do you come up with this stuff? Do you think we have anesthesiologists sitting around at the surgeon's beck-and-call?

I've never had any pushback like this in academia or private practice. I also document the NPO time. It helps once you make things permanent in the EMR. Surgeon suddenly has the time to wait or can call it an emergency.

When someone is paid by the units they generate there can be a stronger incentive to just push the case along. Maybe it doesn't happen in PP because that does not factor in your decision making.

Sure. The patient comes in with fluids and antibiotics hanging. Nurse puts on the monitors and cycles the blood pressure. I intubate and do my part. Nurses put in second IV and position/pad the patient while I document. Techs turn over the room while I wheel the patient to PACU. Turnovers aren't more than 20-30 minutes long.

What you describe is not what you do as the anesthesiologist and has nothing to do with *your* efficiency. Yes having a well-oiled nursing and ancillary staff is important. Techs to turn over the room. I'm happy you decided to recognize the custodian staff, which is an important part of the team and sometimes the reason why OR cases get delayed.

Surgeons are actually good in PP because you don't have the luxury of being slow or incompetent.

Great, but nothing to do with *your* efficiency. Having a fast, good, predictable surgeon does help with the decision of single IV vs. putting in another bigger IV "just in case" and helps with timing your wake ups.

My blocks don't take more than a few minutes to place. Certainly not more than 5 minutes. I also add lidocaine in to speed up time. I also do GA since my blocks are for post-op pain control unless there's clear-cut indications to avoid GA. I also do blocks in pre-op after I wheel my prior patient to PACU while the OR is being cleaned. Plenty of time for those blocks to set in.

I implore you to re-read the 5-minute vs 45-minute block talk. I didn't start this.

 

[psychbender]

Not to sound like a broken record.. but again... what is the patient benefit from doing it this way?

And I'm not saying you don't deserve your PP paycheck. I didn't insinuate it is greedy. *You* did that by taking such offense to my line of questioning.

I am pointing out the distinct differences in the way anesthesia is practiced between academics and private practice, which we *all* agree exists, and this is one of the big glaring instances. In academics we wouldn't do analgesic blocks + GA when a surgical block (the same damn needle in the same spot but with 0.5% bupi instead of 0.2% ropi) would provide the same conditions for the surgeon and the same postop analgesia. And in PP you wouldn't do it either (since you are such slick, efficient workers) if it wasn't for the billing aspect of it as you've so explained.

And yes a surgical block does take a little more time. To test it and make sure it works. To let the block set up. The surgery cannot start if a surgical block hasn't set up, or is patchy, or *gasps* fails (and I know this is SDN where every patient has perfect anatomy, blocks work immediately without fail, and nobody ever have bad outcomes but phleeaze). But it is much less of a concern when the patient is getting a general anesthetic on top as I've said once, twice, thrice.

I already explained the patient benefit of light GA with an LMA vs deeper sedation with an unsecured airway. My current patient population is not like my active duty population, when given the choice, they always "don't want to remember anything, doc, put me the **** out!" I can oblige them that, and the safest way is with a secured airway and enough gas or propofol to ensure they are unconscious, but rapidly awakening in PACU.

Also, to say that nobody in academics would ever perform an analgesic block plus GA is a lie. Where do you think we all learned the technique? Block plus GA is a very common technique at every academic institution with which I've ever been affiliated, and same with my partners.

 

[GravelRider]

What is up with the 45 minute block? This is something you PP guys keep repeating. I've only said it is ridiculous and nobody takes that amount of time. You are slick but a little too quick to read the details.

I could ask the same question about the assertion that blocks in PP are subpar and patchy. What are you doing differently that makes your blocks better?

Edit: I also have never claimed any sort of superiority of academic vs PP attendings. I’ve had some really terrific, skilled, and efficient attendings in residency and known some fat slugs in PP. The PP vs academic argument is really a false dichotomy. I just took exception to your assertion that somehow all PP anesthesiologists are efficient because they are “cutting corners.”There could not be a more false statement in this whole thread.

 

[coffeebythelake]

I already explained the patient benefit of light GA with an LMA vs deeper sedation with an unsecured airway. My current patient population is not like my active duty population, when given the choice, they always "don't want to remember anything, doc, put me the **** out!" I can oblige them that, and the safest way is with a secured airway and enough gas or propofol to ensure they are unconscious, but rapidly awakening in PACU.

An LMA is a secured airway? And what is running a patient as a "light GA"?
You worry about airway obstruction?

Also, to say that nobody in academics would ever perform an analgesic block plus GA is a lie. Where do you think we all learned the technique? Block plus GA is a very common technique at every academic institution with which I've ever been affiliated, and same with my partners.

I wrote "In academics we wouldn't do analgesic blocks + GA when a surgical block (the same damn needle in the same spot but with 0.5% bupi instead of 0.2% ropi) would provide the same conditions for the surgeon and the same postop analgesia". You see my statement is qualified with certain conditions. We do analgesic AC blocks with our knee replacements, thoracic epidurals for our large abdominal and chest cases, and we do GA because we make no claim that these block would provide full surgical anesthesia coverage. Or would be acceptable for a laparoscopic case. That's the key distinction.

 

[GravelRider]

An LMA is a secured airway? And what is running a patient as a "light GA"?
You worry about airway obstruction?

View attachment 370520


I wrote "In academics we wouldn't do analgesic blocks + GA when a surgical block (the same damn needle in the same spot but with 0.5% bupi instead of 0.2% ropi) would provide the same conditions for the surgeon and the same postop analgesia". You see my statement is qualified with certain conditions. We do analgesic AC blocks with our knee replacements, thoracic epidurals for our large abdominal and chest cases, and we do GA because we make no claim that these block would provide full surgical anesthesia coverage. Or would be acceptable for a laparoscopic case. That's the key distinction.

So you’re the guy that’s teaching them to have 15 drips running and two nasal trumpets with boogers blowing out of them. Please stop doing that and just pop an LMA and crack a whiff of sevo.

 

[coffeebythelake]

I could ask the same question about the assertion that blocks in PP are subpar and patchy. What are you doing differently that makes your blocks better?

Edit: I also have never claimed any sort of superiority of academic vs PP attendings. I’ve had some really terrific, skilled, and efficient attendings in residency and known some fat slugs in PP. The PP vs academic argument is really a false dichotomy. I just took exception to your assertion that somehow all PP anesthesiologists are efficient because they are “cutting corners.”There could not be a more false statement in this whole thread.

Look back in the thread bud (oh so sorry, you are too busy for that and hence never get the whole picture! but you are damn opinionated about whatever limited background you have about the discussion thus far). I didn't start that assertion about cutting corners. Your PP buddies did and seemed damned proud of it. The same about blocks. Started with the claim that PP do in 5 minutes what academics takes 45. And somehow my comment about "not needing a perfect block" in the face of an analgesic block is construed as meaning substandard, fake block, and billing fraud. Patchy and subpar blocks happen... no-one is perfect... not all anatomy is textbook... my technique is no different... the difference is I recognize this possibility and take the time to check to make sure it works and set up appropriately if I depend on it to keep the patient comfortable.

 

[coffeebythelake]

So you’re the guy that’s teaching them to have 15 drips running and two nasal trumpets with boogers blowing out of them. Please stop doing that and just pop an LMA and crack a whiff of sevo.

What are you talking about? About fake blocks and fraudulent billing. Now this? Dude you need to settle down and read instead of putting out ridiculous fiction.

 

[Anesthesia_Guy]

Ahhh FFS would you 2 bitch_es stop the god_damn cat fight?!

 

[coffeebythelake]

Ahhh FFS would you 2 bitch_es stop the god_damn cat fight?!

Veterinary Student
😸😸😸

people come to the anesthesia forums for the entertainment.

 

[DazedWanderer]

Just focus on learning the trade for the sake of your patients. As a new grad you don't have the knowledge, speed or skill to demand the same pay as a 20 year vet. The last few new grads we hired were the perfect combination of lazy, incompetent and entitled. Almost makes you want to burn down the whole thing down rather than hand them the keys.

Anyway, with rising Medicare, the No Surprises Act and astronomical labor costs it's almost better to be employed or do locums now. Perfect timing for me to slow down. Probably will be closing shop sooner than later.

Funny, I know quite a few 30 year vets who feel entitled to sit back and collect fat pay checks who are quite literally unable to perform their own anesthetic because they've been supervising for so long that they have lost all their speed and skill. They also don't keep up to date on their knowledge at all because they are grandfathered in with no need for board recertification. You know exactly the type im talking about. But please, continue to lecture on how the new grads are too slow, inefficient and lack the knowledge or skill to deserve a pay check that simply consists of their own billed units.

 

[dabears505]

45 minutes is much too long to do a block. You need to stop or call one of the pp guys to take over at that point

 

[chessknt]

ITT

 

[coffeebythelake]

45 minutes is much too long to do a block. You need to stop or call one of the pp guys to take over at that point

Actually @GravelRider is credentialed at all the area academic hospitals. When a block takes more than 45 minutes he is paged stat, he rushes out of his OR while shaking his head, drives over to the other hospital, parks in his reserved parking space, pushes the academic anesthesiologist aside while muttering how stupid they are, does the block with ease while blindfolded, walks away with both middle fingers up amidst the cheering and clapping of everyone, drives back to his hospital, and sits back down in his OR chair without anyone noticing.

*fiction

 

[DocMcCoy]

Unpopular opinion but…Part of the problem in PP is sooner or later you are going to have a block fail or become suboptimal at some point during a case and have to pause things to convert. Stopping a case to unscrew up your anesthetic can happen about one time before eyebrows are raised everywhere. Much easier jus to get them deeper when the LMA/tube is already in and the vapor is running. 🤷‍♂️

 

[psychbender]

An LMA is a secured airway? And what is running a patient as a "light GA"?
You worry about airway obstruction?

View attachment 370520


I wrote "In academics we wouldn't do analgesic blocks + GA when a surgical block (the same damn needle in the same spot but with 0.5% bupi instead of 0.2% ropi) would provide the same conditions for the surgeon and the same postop analgesia". You see my statement is qualified with certain conditions. We do analgesic AC blocks with our knee replacements, thoracic epidurals for our large abdominal and chest cases, and we do GA because we make no claim that these block would provide full surgical anesthesia coverage. Or would be acceptable for a laparoscopic case. That's the key distinction.

Yes, an LMA is a secured airway that I don't have to mess with during surgery. The same can't be said about an NPA. You also know exactly what a light GA is, and are just being obtuse. Not every GA is 1MAC gas with paralytic and opioids. Provide enough drug to maintain the definition of GA, in light of the nice block stopping all surgical stimuli.

Regarding analgesic blocks and GA, you are still wrong. Blocks plus GA are done regularly in academics for cases that can be handled by just a surgical block. Are all of your shoulder scopes ISB and sedation only? I had mine with just an ISB, used to couple these with light to moderate sedation in my initial practice, but realized it was easier and safer with my current population to place an ETT. The same goes for distal radial fractures (block plus LMA). What other procedures are you doing just under block and sedation?

 

[Status Sciaticus]

Where do you come up with this stuff? Do you think we have anesthesiologists sitting around at the surgeon's beck-and-call?

Having done a residency in an entirely academic program is where I come up with that stuff. If an anesthesiologist didnt want to do a particular case, they would swap residents and effectively swap out of that room. So if anesthesiologist A didnt want to do a case because of mild hyperkalemia, the floor runner would ask another anesthesiologist who is covering two residents and have Anesthesiologist B now cover the hyperkalemia patient and move Anesthesiologist A to cover one of the residents that Anesthesiologist B was covering.

When someone is paid by the units they generate there can be a stronger incentive to just push the case along. Maybe it doesn't happen in PP because that does not factor in your decision making.

It doesnt factor into my decision making. If I cancel a case and now have time, I can go do epidurals (we have a busy OB service) to generate more units. Or I can give breaks to my colleagues. I know theres lots of breaks and downtime in academia, but most PP get 1-2 15min breaks per day so that extra break does go a long way, especially in MD-only practices. Also many PP pay out a daily rate regardless of how many cases you do, so this deters any "incentive" to do what you are suggesting.

What you describe is not what you do as the anesthesiologist and has nothing to do with *your* efficiency. Yes having a well-oiled nursing and ancillary staff is important. Techs to turn over the room. I'm happy you decided to recognize the custodian staff, which is an important part of the team and sometimes the reason why OR cases get delayed.

So perhaps your problem with a slow academic practice is not the physicians, but the nursing staff and custodian staff who have literally zero incentive to move cases along since they are paid the same regardless of how fast they hustle. Regardless of how efficient you are, it wont matter if the team isnt, and academic settings will never be as efficient as community settings in that regard.

Great, but nothing to do with *your* efficiency. Having a fast, good, predictable surgeon does help with the decision of single IV vs. putting in another bigger IV "just in case" and helps with timing your wake ups.

Again, "your" efficiency is irrelevant. Its the efficiency of the whole team.

I implore you to re-read the 5-minute vs 45-minute block talk. I didn't start this.

Are you doing blocks in the room? If so "your efficiency" can be improved by doing it before-hand. I also dont waste my time with catheters. You can prolong blocks with adjuvants in the single-shots and also reduce any potential risk of infection or malpractice (when the surgeon blames the hardware infection on your catheter).

 

[sevo00]

An LMA is a secured airway? And what is running a patient as a "light GA"?
You worry about airway obstruction?

View attachment 370520


I wrote "In academics we wouldn't do analgesic blocks + GA when a surgical block (the same damn needle in the same spot but with 0.5% bupi instead of 0.2% ropi) would provide the same conditions for the surgeon and the same postop analgesia". You see my statement is qualified with certain conditions. We do analgesic AC blocks with our knee replacements, thoracic epidurals for our large abdominal and chest cases, and we do GA because we make no claim that these block would provide full surgical anesthesia coverage. Or would be acceptable for a laparoscopic case. That's the key distinction.

I’d much rather have a GA with a LMA…than a GA with a NPA

 

[teacher2md]

What are the objective benefits of regional block + native airway TIVA vs. analgesic block + GA?

We often act as though regional is obviously safer/better, but is that really the case?

PONV is about the only disadvantage I can see. I don’t really buy the cardio/pulmonary advantages of deep MAC over GA.

 

[anbuitachi]

As much as people on SDN talk down on academics, we've had a few "solid" PP guys that joined our academic department that are absolutely terrible and led to disastrous patient outcomes.

but were they fast?

 

[GassYous]

What are the objective benefits of regional block + native airway TIVA vs. analgesic block + GA?

We often act as though regional is obviously safer/better, but is that really the case?

PONV is about the only disadvantage I can see. I don’t really buy the cardio/pulmonary advantages of deep MAC over GA.

Do some av fistula cases. Way better with block and sedation than lma. Don't move with stimulation, hemodynamics better, everyone happier

 

[anbuitachi]

the hospitals around me are recruiting less now. i noticed a bunch of posts are no longer available. we are also getting rid of all our locums in couple months as new residents graduate. so i do think this hot market is coming to an end. at least here

 

[Beeftenderloin]

Having done a residency in an entirely academic program is where I come up with that stuff. If an anesthesiologist didnt want to do a particular case, they would swap residents and effectively swap out of that room. So if anesthesiologist A didnt want to do a case because of mild hyperkalemia, the floor runner would ask another anesthesiologist who is covering two residents and have Anesthesiologist B now cover the hyperkalemia patient and move Anesthesiologist A to cover one of the residents that Anesthesiologist B was covering.

If the goal is to rapidly convince the rest of the hospital your dept is full of a bunch of 🤡s who don’t know what they’re doing, I don’t think I could come up with a better way. I absolutely despise this aspect of where I did residency. Chair/board runner club loved throwing colleagues under the bus and talking ****, calling them weak. It didn’t make them look strong (as I imagine they thought it did), it just made the whole department look weak and chased off good docs who didn’t feel supported.

Plus it you aren’t united, surgeons start to think every cancellation is negotiable/provider dependent. This is a bad position to be in as a group.

 

[ambiturner]

the hospitals around me are recruiting less now. i noticed a bunch of posts are no longer available. we are also getting rid of all our locums in couple months as new residents graduate. so i do think this hot market is coming to an end. at least here

I think we’re still a year or two away from stabilizing but I’ve noticed the same. Nursing staffing also seems to be improving but they are now used to bigger incentives for evening and overtime shifts and I don’t see that going away easily.

 

[coffeebythelake]

I’d much rather have a GA with a LMA…than a GA with a NPA

I'm confused by your false dichotomy. I'd much rather have a sick patient under surgical block with less sedation than with a block and GA. The latter appears to be the default choice for many PP.

 

[UscGhost]

What are the objective benefits of regional block + native airway TIVA vs. analgesic block + GA?

We often act as though regional is obviously safer/better, but is that really the case?

PONV is about the only disadvantage I can see. I don’t really buy the cardio/pulmonary advantages of deep MAC over GA.

You have to keep them deeper to tolerate the the LMA.

With tiva, you just need them deep enough to not drive everyone nuts in the OR

 

[coffeebythelake]

If the goal is to rapidly convince the rest of the hospital your dept is full of a bunch of 🤡s who don’t know what they’re doing, I don’t think I could come up with a better way. I absolutely despise this aspect of where I did residency. Chair/board runner club loved throwing colleagues under the bus and talking ****, calling them weak. It didn’t make them look strong (as I imagine they thought it did), it just made the whole department look weak and chased off good docs who didn’t feel supported.

Plus it you aren’t united, surgeons start to think every cancellation is negotiable/provider dependent. This is a bad position to be in as a group.

Seems like a pretty toxic place you did your residency.

 

[Beeftenderloin]

Seems like a pretty toxic place you did your residency.

Yea, it was. “Group unity” wasn’t the only problem though, there were others. Eventually dept chair, PD and ~1/3 of group were forced to resign, or left, contract wasn’t renewed and docs that remained were offered employment.

 

[nimbus]

What are the objective benefits of regional block + native airway TIVA vs. analgesic block + GA?

We often act as though regional is obviously safer/better, but is that really the case?

PONV is about the only disadvantage I can see. I don’t really buy the cardio/pulmonary advantages of deep MAC over GA.

I went from a practice that did block+propofol to block+lma and sevo. First option yields less hypotension and need for pressors.

 

[dizzy21]

but were they fast?

In PP half the time the surgeon is not even in the room during induction and prepping/draping. So 3 minutes to anesthesia ready vs 20mins doesn’t really matter and no one notices nor does anybody give you credit. Sure if you take 1.5 hours people will say something but being a few minutes “slicker” is a silly metric that no one cares about.

I think I can move plenty fast but I can tell you people don’t give a s—t. The surgeons will waltz into the room after 20 minutes of us waiting around with the drapes up. They usually do office work while you’re inducing. All this concern or pride that I see from people that they take 3 vs 10 minutes is silly.

Only reason I can think to move fast is so i can hurry and sit down or if I’m at the surgical center so I can hurry and get out a few minutes earlier…. That plan is usually torpedoed by the surgeon being slow or taking forever to consent his or her patient.

 

[anaesthetic]

In PP half the time the surgeon is not even in the room during induction and prepping/draping. So 3 minutes to anesthesia ready vs 20mins doesn’t really matter and no one notices nor does anybody give you credit. Sure if you take 1.5 hours people will say something but being a few minutes “slicker” is a silly metric that no one cares about.

I think I can move plenty fast but I can tell you people don’t give a s—t. The surgeons will waltz into the room after 20 minutes of us waiting around with the drapes up. They usually do office work while you’re inducing. All this concern or pride that I see from people that they take 3 vs 10 minutes is silly.

Only reason I can think to move fast is so i can hurry and sit down or if I’m at the surgical center so I can hurry and get out a few minutes earlier…. That plan is usually torpedoed by the surgeon being slow or taking forever to consent his or her patient.

Agree with this 100%. Also nurses training nurse “interns” how to place a foley, wiping down the patient, prepping the patient, etc. There’s usually not a whole lot of “hurry it up” even in PP unless the surgeon’s been waiting to get their case started, it’s an emergency, or they have clinic/a flight to catch.

Otherwise, being fast is just to pat yourself on the back as the surgeon strolls in 20 minutes after the drapes have been up and asks, “What took so long?”

 

[thinkorswim]

Agree with this 100%. Also nurses training nurse “interns” how to place a foley, wiping down the patient, prepping the patient, etc. There’s usually not a whole lot of “hurry it up” even in PP unless the surgeon’s been waiting to get their case started, it’s an emergency, or they have clinic/a flight to catch.

Otherwise, being fast is just to pat yourself on the back as the surgeon strolls in 20 minutes after the drapes have been up and asks, “What took so long?”

It’s also great that surgeons think the turnover clock starts as soon as they leave the room. But of course the fault never lies with slow surgical techs that would rather chat than take the drapes down or circulating nurses that absolutely need to finish their charting before bringing in the gurney and moving the patient.

I know we get paid by time, but my patience wears thin as the day gets later.

 

[GravelRider]

Actually @GravelRider is credentialed at all the area academic hospitals. When a block takes more than 45 minutes he is paged stat, he rushes out of his OR while shaking his head, drives over to the other hospital, parks in his reserved parking space, pushes the academic anesthesiologist aside while muttering how stupid they are, does the block with ease while blindfolded, walks away with both middle fingers up amidst the cheering and clapping of everyone, drives back to his hospital, and sits back down in his OR chair without anyone noticing.

*fiction

There is no way that is true. I would never rush. And I would probably stick around to hear your lecture on how these precision directed micro injections of local anesthetic are far superior to the archaic Neanderthal-like blocks done in 3 minutes in the community.

 

[Dr. Rude]

There is no way that is true. I would never rush. And I would probably stick around to hear your lecture on how these precision directed micro injections of local anesthetic are far superior to the archaic Neanderthal-like blocks done in 3 minutes in the community.

True private practice wizards do not even bother with regional anesthesia. Takes too damn long. Every anesthetic is the same. Half of the big syringe. All of the little syringe. In fact, we give the little syringe first so the paralytic gets in sooner so we can shave a few seconds off the case.

 

[anbuitachi]

health services continue to add employees at a high pace. the numbers are way up.

 

[nimbus]

View attachment 370667

health services continue to add employees at a high pace. the numbers are way up.

Jobs! Jobs! Jobs!!

 

[DocMcCoy]

True private practice wizards do not even bother with regional anesthesia. Takes too damn long. Every anesthetic is the same. Half of the big syringe. All of the little syringe. In fact, we give the little syringe first so the paralytic gets in sooner so we can shave a few seconds off the case.

TWO syringes. What is this the JV squad. 😂

 

[Dr. Rude]

TWO syringes. What is this the JV squad. 😂

You are right. In fact I also try to minimize the volume of injectate. I dissolve vecuronium powder in 1 ml of Ketamine 100mg/cc concentration. I induce anesthesia with 1 ml. In the old days I used to use sux powder.

 

[Thepassageofgas]

Literally all the PP groups in my area have upped their partner track pay from 70-80% of partners to 90-100% starting day 1 with 100% equitable distribution of cases, call, and vacation, regardless of experience. This is the market right now. Good luck hiring if you aren’t offering this as a PP group, at least in my neck of the woods. It’s that or pay 1.5-2x for locums.

Hi, where do you live so I can move there pls.

Thanks.

 

[ambiturner]

Hi, where do you live so I can move there pls.

Thanks.

This happened in my area but salaries are bad. 100% of 350k w2 is still 350k w2. But at least it’s not 275 anymore!

 

[GassYous]

This happened in my area but salaries are bad. 100% of 350k w2 is still 350k w2. But at least it’s not 275 anymore!

You can go out and get 5-600 jobs right now. That's the track pay. 350 is unacceptable for a full time anesthesiologist.