Anyone have experience working in Pain in a VA system and wanting to shed some light on the pros/cons?

Also, hoping Academic Pain staff here can add their insight on why they chose that over PP pain.

For context...

Thinking about a Pain Fellowship but trying to envision the sort of job that minimizes some key negatives (constant insurance denials/fighting ins companies, prior auth headaches). My experience shadowing Pain docs as a med student as well were only in the PP world. will do my pain rotation early spring. While I haven't been able to see the practice of Pain in a VA system, I've heard from a few (n=2) Pain/Anesthesia docs who practice in it enjoy being able to adjust their schedule more freely to their preference when it comes to med management/clinic vs procedure volume. They've also mentioned less production pressure compared to the PP world, don't have to deal with insurance denial headaches, and enjoy having the assistance of wider spectrum pain therapies (pain psychology, acupuncturists, etc) in-house for the patients. Basically, having the time to practice full "comprehensive" pain medicine. Obviously the pay will be significantly less than doing PP or even OR anesthesia but the docs I spoke with both seem content. One of them even works part-time pain and fills her other time doing locums at a community hospital doing OR anesthesia just to make up that extra $$$ and keep her anesthesia skills up which sounds like an ideal set-up for me at least early on in career but don't know how feasible it is to find a job like this.

Who all wo

Curious to hear your thoughts, and I’ll try to be as precise as possible: Yesterday, I anesthetized a man in his sixties for a right upper lobectomy (neoplasia). He was in good overall health, slightly hypertensive and diabetic but well-controlled, with a BMI of 22 and a non-smoker.

Basic monitoring setup included an arterial line, a central line (right jugular under ultrasound guidance), and an epidural that seemed functional.

Everything proceeded without issue until the surgeon inspected the sutures using three Valsalva maneuvers under water. The surgeon assured me that everything was fine on his end. I resumed two-lung ventilation. Then, intermittently, I began to experience massive leak alarms on my ventilator, with insufficient flow to generate adequate tidal volumes. I increased the flow, which helped for a while… but the issue kept recurring. I informed the surgeon, who, of course, claimed the problem was with my circuits. In any case, there were no hemodynamic or respiratory destabilizations, so I let it be. The procedure ended with these recurring phenomena but was otherwise unremarkable. The patient was repositioned supine, and the drain was set to suction (-20 cmH2O). The leaks described earlier persisted, but now continuously (target volume 450 mL, exhaled VTe at 160 mL, no PEEP). EtCO2 dropped to around 25 mmHg, while arterial CO2 pressure remained normal at 40–43 mmHg. I’d like to mention that blood gases were excellent: normal pH at 7.4, no lactates, hypoxemia, or other issues. I informed the surgeon again, but he insisted everything was fine surgically and that this wasn’t a surgical issue.

Clinically, I noted faint transmitted breath sounds on the left and asymmetric chest expansion (L > R). I replaced the double-lumen tube with a single-lumen one, reversed neuromuscular blockade, and allowed the patient to transition to spontaneous ventilation. However, it was impossible to achieve any exhaled volume due to the massive leak.

The double-lumen tube showed no signs of blood or trauma suggesting damage during placement. A chest X-ray in the operating room showed no left pneumothorax, good expansion of the right middle and lower lobes, and a mild right apical pneumothorax (dismissed as expected given the procedure). I performed a bronchoscopy, which was unremarkable except for a drop of blood near the staple line of the right upper lobe bronchus—also deemed normal by the surgeon.

I decided to stop the suction on the chest drain, and everything normalized. No tension pneumothorax developed over 20 seconds. But I find this to be strange as well.

Ultimately, I transferred the patient to the ICU, intubated and without a clear explanation.

In my opinion, a parenchymal breach wouldn’t cause leaks of this magnitude. However, a suture breach might… but the Valsalva tests were fine, and I tend to trust the surgeon, who communicates well and stayed by my side.

Additional details that might interest you: Insufflation pressures always remained normal, with no significant changes during single-lung ventilation (VT reduced to 390 mL). Unsurprisingly, pressures were relatively low during two-lung ventilation at the end.

Any immediate ideas about what could have happened? Or similar stories? I love thoracic surgery—the anesthetic aspect is fascinating, and the potential complications are entirely different from those in many other surgeries.

Thanks (and sorry if this was a long read!).

EDIT: thanks for all the quick and interesting answers and returns. Conforts me in what I thought. I'll be even more confident next time. I guess everyday work is to be improved by discussions with fellow anesthesiologists (and surgeons). Have a great weekend all.

Resident here so please take this with a grain of salt. How do experienced providers accurately measure blood loss?

Yes, I can look at the Neptune but they always use irrigation and that throws off the total. I ask the circulators how much irrigation they used and I get conflicting answers. I can ask the cell saver worker but not every case uses cell saver.

I was taught a blood soaked sponge (lap) is roughly 25 mL per sponge give or take but that's also vague and dependent on how saturated the sponge is. If I look at the field or OR floor it's difficult to quantify how much blood is in little pools of blood that form around the field. How am I supposed to accurately quantify that into 150 mL versus 250 ml versus 500 ml of blood loss? Serious question looking for serious answers please.

I need to accurately quantify blood loss so I can determine if I need to give any units back please. Thank you

Recently I attended an ultrasound course for POCUS and peripheral nerve blocks. The course was amazing but I forgot to ask for good textbooks or literature I can use to improve my knowledge. Do you have any suggestions?

Is this really the solution we want?

https://www.huffpost.com/entry/rfk-jr-biden-ozempic_n_67477925e4b04f61b2995549

Hi just wanted to see what other Doctors would do if ASC has no sedative MAC policy for bmi >50 for rfa blocks. I am not a particular fan of singing or hand holding or pep-talks. What drugs would you use, non sedating, ie you would not be held liable if they drive home. Tylenol, toradol, zofran, labetalol? No benadryl, no precedex, no narcotics, no ketamine. Ok thanks everyone I will take voice lessons… Nitrous is an option as it is pretty standard for dentists to let patients drive home after but probably not best idea for someone prone obese and on stomach. ASC asked pain doc to cancel, he refused, and then asked for anesthesiologist to be present in room, I declined as consent was not d/w pt and procedure had started, I just did the walk about, and talked with pt in recovery, he agreed he was overweight and tolerated procedure fine and was more than ok to not pay an anesthesia bill for monitoring only MAC.

Tried suctioning aswell as recruitment manouver without change. VCV works find so I suspect something on the machine side.

Thank you to everyone here for some great advice, I've decided to apply for CT fellowship and had a few questions (not sure where to ask/find these things without asking directly, so please bare with me!).

If anyone has any other advice for the match, I'd really appreciate it!

Biggest question:

- How do I figure out which programs might be malignant/to avoid? Which ones more supervisory/do own cases, call schedules etc? Cut off scores for ITE? Very little information online to answer these questions when I look it up online and so many programs overall!

SF Application questions:

-  In the required documents, you can only upload one document per subject. If I merge my ITE reports together, it won’t upload; similar with USMLE score reports. What do I do? I have a screenshot from my residency portal that shows all my scores (ITE/USMLE in one), do you think programs would mind if I uploaded that? The application also makes you write out your ITE/USMLE scores in another section.

- I find it odd they want us to populate much of our CV. Did people write extensively in the research/activities section, or leave more details for the CV, and keep activities straight to the point?

- For the 3 mini essays, do people just incorporate why cardiac into those 3 given there is no overall PS?

- For presentations, you are allowed to list presentations you didn't present, but you were a coauthor on, correct? That's what it seems like to me looking online, but unsure.

Thank you all in advance!

More specifically, for those of you that trained and then did fellowship about 5-10 years ago

Here’s my question, was the culture of considering fellowship similar to now? Choose if you love it otherwise start earning that attending salary instead of spending another year in training?

I think this answer obviously would change for pain medicine but how did you guys navigate this back then? I know a few pain docs who regret the fellowship because “back then” the field was financially very promising

And follow up question, if that culture was different, any way/shape/form that we can anticipate the culture to change in 5-10 years from now?

So... I'm a consultant in an EU country, I do mostly adult cardiac and vascular but am also experienced in neuro- and other types of general anesthesia. I did some pediatric (unfortunately not cardiac since we don't do pediatric cardiac in our hospital). I'm pretty experienced in upper extremity blocks, cervical blocks (plexus and stellate ganglion), spinal/epidural and trunk blocks (PECS, PIFB, TTPB)…. I also work a lot in the ICU.

I’m looking to relocate to UAE as it seems like a great place to live (family member lives there and is thrilled with quality of life over there).

Has anyone here taken the DHA exam? How difficult is it for an experienced anesthesiologist?

Thanks

I’ve been doing a lot of craniotomies for tumor/aneurysm clipping.

Our surgeons prefer to run MEPs for most cases and the neurophys/anesthesia culture here means we do a full TIVA with remi.

My questions:

How low are you comfortable going on the propofol? If the patient is very suppressed or even isoelectric, will you go below say 150? I’m basically not allowed to go below 150 until vault is closed or swap to volatile + roc after final MEP.

I’m being taught to run the remi at 0.2, then do whatever I want for wake up. Too high? Too low?

I don’t think I’m being trained enough to do an MEP case without remifentanil.

Most of my attendings have worked here for years and don’t really have a broad perspective on how to do these cases without the above recipe.

Would appreciate any and all perspectives.

Original thread https://www.reddit.com/r/anesthesiology/s/TKZhPqzauW

I wanted to first off say thank you for all the thoughts and wisdom. I knew in my gut this wasn’t appropriate for me at a new hospital, let alone the question of if it appropriate for the patient (which it wasn’t).

I went in to work today at peace because I decided I wasn’t going to do the case period, but hoped it wouldn’t come to that needing to be said out loud.

I discussed it with the head anesthesiologist and he understood where I was coming from. Didn’t give me a hard time. One of their cardiac guys did the case and it went without issue. Super nice woman and said “they were out of line putting this in your room”. I did feel sheepish and told her I’m sorry she got roped into it.

Case went on without any further conversation about preop optimization or info. Artline and 2 iv’s. He tolerated everything without needing any pressors or inotropes. Olv without a hitch. Unreal.

Anyway I did what I felt was right, didn’t burn any bridges, and patient is safe. Still wasn’t probably an appropriate case given the risk.

What is your anesthetic choice when doing cranis with no NM. I have seen a combo of gas/remi, gas/fent/opioid. Not usually going full TIVA unless we can get BIS on.

Edit: : New CRNA

Testing out a pinned post for anesthesiologists, soon-to-graduate residents, and fellows to ask questions and share information about regional job markets, experience with locum agencies, and more.

This is not a place to discuss CRNA or AA careers. Please use r/CRNA and r/CAA for that. Comments violating this will be removed.

Please follow rule 6 and explain your background or use user flair in the comments.

If this is helpful/popular we may decide to make this a monthly post similar to the monthly residency thread.

Separate posts along these lines are still welcome unless they are about matching to residency or break other rules in the sidebar. Please feel free to make separate posts asking about the job market or specific groups in X city/region. We welcome all posts from anesthesiologists about the field and want to support career searches. This is just an additional place to ask/contribute/learn.

I’ll start us off in the comments. Suggestions welcome.

• u/ethiobirds

Why is it acceptable that every few months we get a random insult hurled our way? This one really got under my skin for no reason really. I was on call last night (a Sunday) and we were finishing up a case at like 10pm. I was called about an esophageal FB which didn’t involve the current team I was working with. I said something like “oh don’t worry about me I’ll just keep working” and the circulator says “we won’t, nobody ever does”. It was late and I was so taken aback I didn’t have a witty reply. The comment was followed by an awkward silence then things just moved on like nothing happened. The thing is, I usually have some sort of reply back that puts at least a little shame in the person who made the comment. Last night I had nothing and it bugs me out of pride.

We literally keep people alive through procedures that would otherwise kill them and somehow get insulted by people whose job consists of fetching stuff that they are asked to fetch- and they get to wear t shirts that say “I save lives”. Just ranting, I feel a little better now, thanks Reddit

Has anyone done or currently doing this to obtain board certification? Do you know of any institutions that participate in hiring under this program? Specifically under the Clinical Educator Pathway. I'd be interested in connecting with you. Curious to know how the pay compares to a typical full time clinician role at the same hospital.

https://www.theaba.org/training-programs/alternate-entry-pathway/

I'm a recently new critical care fellow having some trouble getting comfortable with DL intubations. My main issue seems to be getting the blade (almost always Mac 4) into the vallecula. Either I'm too deep and on the epiglottis or too shallow and unable to get fully under the tongue. Obviously if I'm using VL this becomes less of an issue since I can easily see where I am and adjust. Any tips would be greatly appreciated.

Out of curiosity, how competitive is it to get an abstract accepted to this conference? It’s my first time applying this year and I know they tell us in December but I’m trying to mentally prepare lol

Context: young healthy adult male with absolute hosepipes for veins.

Neurosurgeon had been nagging me all night for an emergency burr-hole (we’d been swamped with shocked trauma laps, his patient triaged below them).

Arrives with the gelco suspiciously covered in opaque tape. I opened it and found a yellow catheter. YELLOW.

For a patient he claimed was very sick (but wasn’t).

I will never understand neurosurgeons.

75 year old for wedge for possible ca, will need one lung ventilation obviously.

Cardiac hx is s/p TAVR 2020 with restenosis current area of 0.7 with DI 0.3, mean is 30. Mod MR. Severe TR rvsp 90 with septal bowing due to pressure overload. Normal LVEF. She’s not on home o2 or vasodilator therapy. Stents in the past but negative stress test recently.

I’m prn at a facility and don’t know the system or cultures. Would you recommend cardiac anes do this type of case?

Im a general anesthesiologist handful of years out of practice.

Cheers

Iam anaesthetic registrar in Europe , Iam oncall 24 hr

on my shift in maternity hospital since morning I get called for cannula and blood samples from all over the hospital, antenatal, post natal, everywhere .

The usual scenario goes : hi anaesthetic,we have a patient here ,the nurse tried to get bloods and the SHO “senior house officer also tried and couldn’t any bloods ,would you mind to come please ?”

If the patient is in ED ,labour ward or seriously sick lady I would understand , but I feel I have become free cannula service for people who want someone to do their job for them , given the fact that I usually have no support when I try to put the cannula they couldn’t get , and also Iam the only anaesthetic in the hospital My question is ,from your own experience, for cannula and blood samples,when do you say yes and when do you decline

Edit : apologies for all the mistakes ,I wrote the post in such frustration that I missed a lot

At my hospital the OB nurses are not allowed to meddle with the epidurals whatsoever. They can’t even change the rate on the pump with an order.

However, last night at shift change, a nurse discovered that the epidural catheter had disconnected from the alligator clamp. She didn’t know how long it had been disconnected. She asked another nurse for advice, and the two of them wiped the catheter off with an alcohol swab and reconnected it to the pump (which was still running). I was informed a half hour later when I was called for another epidural. I immediately pulled it and replaced it because of the potential for contamination.

The nurses said that’s what they were told to do by other anesthesiologists in my group and doubled down when I asked why I wasn’t informed right away.

What’s your practice with disconnected epidurals? What would you do if a nurse had decided to manage a disconnect this way?

Hey, I saw a recent post about trauma anesthesia which piqued my interest given its niche focus. Anyone have any experience with what shock trauma fellowship in baltimore might be like? I know it's a very unique center and one of the only trauma anesthesia fellowships left with grads who've done well career wise. I know a trauma fellowship in general isn't considered worthwhile, but what about this one at Maryland which has stood the test of time (aka not shut down) thus far? Thanks in advance!

https://www.washingtonpost.com/health/2024/11/21/rfk-physician-payments/

Paywall article.

Excerpt:

By Dan Diamond Updated November 21, 2024 at 6:35 p.m. EST|Published November 21, 2024 at 5:24 p.m. EST

Robert F. Kennedy Jr. and his advisers are considering an overhaul of Medicare’s decades-old payment formula, a bid to shift the health system’s incentives toward primary care and prevention, said four people who spoke on the condition of anonymity to discuss private deliberations. The discussions are in their early stages, the people said, and have involved a plan to review the thousands of billing codes that determine how much physicians get paid for performing procedures and services.

The coding system tends to reward health-care providers for surgeries and other costly procedures. It has been accused of steering physicians to become specialists because they will be paid more, while financial incentives are different in other countries, where more physicians go into primary care — and health outcomes are better. Although policymakers have spent years warning about Medicare’s billing codes and their skewed incentives, the matter has received little national attention given the challenge of explaining the complex issues to the public, the technicalities of billing codes and the financial interests for industry groups accustomed to how payments are set.

“It’s a very low-salience issue,” said Miriam Laugesen, a Columbia University professor who has written a book, “Fixing Medical Prices,” about Medicare’s physician payments. “The prominent stakeholders in this area would probably prefer to keep it that way.”