Tranman

Dang, you've made a liar out of me. Ok, hopefully this is my last post. OK you really have no idea how bad surgeons can be. I know everyone's had their run ins with surgeons on the unit, but it's not the same as working side by side 8-12 hours a day everyday. Having said that, most of all surgeons I have ever worked with are not egostistical maniacs and are very caring and wonderful people. Yes these are all RN issues, but like I said in the above post. CRNA is more different than it is similar to regular RN work (not my words..."Regular RN"). You've made some insightful points here about job dissatisfaction and local CRNA retention. My original post was not targeted at you per se, just a blanketed statement. I found it humorous that the OP ended his message seeking other CRNA's advice and many responses I remembered reading started out with, "Well, I'm not a CRNA, but....". No biggie b/c there have been good advice posted thus far. Mainly everyone saying the same thing, "get a new job!". Also, sorry if I came off as a jerk, not my intention. Anyways, enough advice has been given here. I too would really like any update or clarification from our Unhappy CRNA.

Though they share some commonalities, both professions being nurses per se, they couldn't be more different. Or should I say they are more different than they are alike.

Uhhh...I don't feel threatened at all. why would I feel threatened that you (a non-CRNA) is giving advice to a CRNA? Give all the opinion that makes you happy. I was merely pointing out the fact that the OP was seeking advice from other CRNA's in a CRNA forum. You then retorted with some non-sense about actually understanding all patients. Advice? hmmm, idunno about advice. Maybe opinion is ok, but not advice. Just as I don't give legal advice, because I'm not a lawyer or financial advice because I'm not a CFA. But YOU can do as you please b/c apparently you are not ruled by logic. That was just a joke. I'm just kidding ok. This banter is really silly and not the original intention of this thread, so this is my last response to you. Anyways, the fact that you're here indicates that you may have some interest in becoming a CRNA. I hoped I haven't deterred you in that decision. If you need any advice about CRNA as a career choice, PM me.

I guess not, but it sure does help. You mean if a patient who is addicted to drugs tell you that you don't know what it's like and you've never been an addict that you suddenly can understand where the patient is coming from?

hmmm, just wanted to point out that the original poster asked if there were other CRNA's out there unhappy with their job. Not sure why we have people from every other profession giving this person advice. Not to say that your opinions don't count, but how is a person to advise another when you don't truly understand the nature of his complaints. So things you hate about your job. Surgeons who think they are God. Well, fortunately not all surgeons think this way, you may just work with a high number of them. My advice, get a new job and work with some different surgeons!! Another complaint is that MDA's that are condescending. Hmm, let's see...not all MDA's are like this and you may just be working many who are. Not sure if you knew this, but CRNA's can practice independently without the supervision of MDA's. There are many independent practices out there at smaller community hospitals that don't have the quick turn over times between cases as well. IF you have been stuck in a dead end job for 12 years and have chosen not to move on, then you have no right to complain. That's all...Good luck and don't forget to write when you have found a new job.

Just wanted to post some generalizations here. Well of course we are all here to advocate for the patient. Unfortunately some of us disagree with one another on how to handle situations like this in the OR. UDSCIRN, don't know if you know the politics of the OR or not. Although it shouldn't matter if cases get cancelled or not, and the patients safety should always come 1st, this is not the reality in many ORs. Frankly I'm surprise the Surgeon cancelled. Many times, surgeons will press Anesthesia to do cases despite putting the patient at risk (low platelets, high coags, low hbg, no cardiac clearance in patients who report recent CP, c-spine fx not yet cleared by nuero, etc). It is likely, the Resident's decision to call the attending may have been influenced by what bwt02 told him. He could have simply stated that the patient is having ST changes and despite not having BP problems, the ST changes remain. Or he could have said the same and added, and I strongly reccommend we not proceed with this case. Surgeons (and even more so, residents) know very little or next to nothing about anesthesia and rely heavily on our expertise in these situations. And this is where it gets a little confusing. Where 1 anesthesia provider may encourage the surgeon to cancel a case, another may not. Of course cancelling is always safetest b/c there is no continued risk of agitating a stress heart. I'm not sure what was said in this situation. At my last job, I did not find it neccessary to cancel not 1 case over a year. But a colleague routinely cancel cases. Does that make me a not safe practitioner over my ultra conservative colleague? That's debateable with lots of gray here. Surgeons appreciate us looking out for them, b/c no one wants a bad outcome or to get sued. But cancel too many cases and they get really really upset with anesthesia. BWT02, letting a surgeon know what's happening with the patient is never a wrong move. Stating them in such a way to manipulate a surgeon's decision is wrong. Now I'm sure you didn't do this, but I have witness CRNAs and MDAs do this to delay and cancel cases. so let's look at the case more specifically. Talk to your colleague and remind them that it was the surgeon who cancelled the case not you, and that you merely brought the patients status to the resident's attention. I understand that the patient has not been taking his labetalol and that you wanted to get him normotensive prior to surgery. Not bad judgement, but obviously this (I believe) lead to his drastic BP drop after induction. I am suprise that it wasn't immediately after induction. Sounds like this along with the 10mg of MS and deepening the anesthetic didn't help your situation either. 1st, in over 4 yrs of being a CRNA, I haven't had the pleasure of having ST changes post induction. I have had on occassion seen it intra-op and it was always due to a low BP problem and gone after BP was brought up. I have also never given labetalol preop much less 20mg. 20 mg post op max and that was on very rare occasions. Labetalol, like hydralazine can peak in 15-20 mins and can add to the HPN of induction. This is why I'm surprised that his BP was 130 sys post induction, unless you only gave 100mg of Propofol at induction. Not 2nd guessing you here, but it is possible that his BP was in the 60's which cause the ST changes and only after you saw the ST changes did the BP cuff cycle to reveal his true BP (60's systolic). If this is the case, giving 10mg of MS and deepening the anesthetic is not the right decision b/c it can only worsen the situation. I seriously doubt that the 10mg of MS had anything to do with his HPN though. MS usually takes a good 15min to peak. By deepening the anesthetic, I assume you turned up the gas. Depending on what you use, it takes at least 5 mins before that extra gas can get on board and cause that severe of HPN. It is likely the HPN is due to that labetalol peaking and then aggravated by the extra gas and dehydration. Keep in mind most patients come to the OR dehydrated from not having fluids since the night before. At a systolic of 60 and ST changes, I would have given more than 100ug of Neo followed by lots of fluid if there are no contraindications to the fluid. 200ug of Neosynephrine and depending on the HR, 5mg of ephedrine to follow as well. I know you said that you hung NTG and that it help after 5 min, so I assume that the BP was within normal limits prior to hanging the NTG. NTG is good for VD of coronaries, but if his ST changes was due to low BP (HPN) which I believe it is, then a NTG gtt, depending on the dose, can actually worsen the problem here. If only after bringing up the BP with VPs and fluids and the ST changes do not improve and the patient is also not Tachy, then I would consider low dose NTG. This may be the case, I don't know. So back seat driving and Monday quarterbacking is always easier. acknowledged. What I would have done.... Not given the labetalol preop or at least not 20mg. Setting yourself up for trouble here. a few mg of metoprolol is a better choice. 50ug of Fent and 1-2mg of versed is ok. I agree with JWK, about this patient being an appropriate candidate for surgery and no need for the cardiac clearance. Just curious BWT02, how old is this patient and any Hx of CP, cardiac issues/sx, etc? If he is older (50's +), only 50ug of Fent for induction, since he had 50 already. 150 mg of Prop, no more. Open up the fluids. Don't give him a lot of gas. Usually prep time takes a while and many many dehydrated patients have precipitous drops in BP during this time d/t to lack of stimulation. Give neosynephrine to keep the BP up and you should be able to avoid post induction ST changes. I'm glad the EKG, labs, etc were all negative. Count yourself lucky, get what you can out of it and move on. It's a good learning experience.

I have a hard time believing that call is the demand of the hospital. What does hospital admin know about anesthesia. They usually leave scheduling and call issues up to the department heads. I would look there 1st. Sounds like you're getting worked over.

gosh sounds like a pickle. I'm not at all suprised. This seems to happen all to often. Obviously the lesson is to get everything in writing. When you don't, it gives the other party the excuse to change the agreement. And they keep screwing ya till ya scream. The more you roll over and play along the worse it will seem to get. That is rediculous to have the CRNAs take call when the RRNAs and Anesthesia Residents have taken all the call in the past. It sucks that they changed the agreement, but I was thinking 168 on a W-2 doesn't sound all too bad. Especially if you all are new grads. If you all are really pissed about this, then get together and start meeting. How many are willing and able to walk. Stick to your guns and have a new job lined up before you start threatening to leave/negotiating. If enough of you are willing to leave and cases don't get done, then maybe they'll listen. I doubt it though, since there are so many students around. Only takes a few crnas, and mda's and a bunch of students to run the place, so they may do ok without you guys. Look around, if you find a better job, then move. If you don't than don't complain too much when it gets worse. Sorry about your situation.

I see what's going on here. this is all very funny to me. 1st BeatOU and the other students, I commend you for asking the questions. It makes us practitioners think and learn. So keep it up. So you are on the right track, but if you are still confused, don't worry about it too much. When you are in the OR and facing these situations, what you learn will make more sense and you will have no trouble remembering it. I say this situation is funny, because many of us in the OR do not (as Nitecap stated) follow a cook book of when to give blood, how much, etc. You use many indications (VS, skin color, hgb value, sat value, patients overall health, type & length of case, surgeons hx of bld loss, etc.) including your gut feeling. Just as Nitecap stated, you assess all of these things at once, and then you get resounding audible voice in your head that says "GIVE THE BLOOD or DON"T THE BLOOD yet" Many of us at times also wrestle with the decision of is it appropriate to give blood yet? It's not always clear cut to us either and we are suppose to be the experts. This is funny to me..b/c with all our learning we can go right back to step one, a beginner. The simply answer is when a patient loses blood to the point that his VS are adversely affected AND you can no longer compesate for him by use of IV fluids (crystalloid & colloid) and meds (VPs, catecholamines, etc), you give blood to replace the blood loss and to maintain O2 carrying capacity (keep VSS). No one simply just gives blood b/c of a sat value, or a hgb value, or even a BP, or even if your math calculations says give blood when you've loss 700cc of blood. I mean you can, but it's not the best way to practice anesthesia. Again, asses the whole patient and the whole situation. Anesthesia can be very complicated and simply at the same time. What is very simple to us practioners (like when to give blood) can be very complicated and convuluted to the outsider. Anesthesia is both an art and a science, with lots of grey areas. This is what makes it special and fun. So if this is still confusing, don't sweat it. When you get in the OR, they'll be another 100 different & confusing issues waiting for ya to wrestle with.

Thanks. Again you have to look at all the specifics of any offer. You can post a job offer and everyone here will give you their take on it. I hope I am making myself clear. To avoid being misunderstood, I feel like I have to do more explaining. There are certain things you can successfully negotiate for even as a new grad. For example, the amount of sign on bonus, and moving expenses. I do also advocate always negotiating. You have nothing to lose except offending the other party. You can avoid this by asking tactfully. They can always say no. And of course you never know, they might just say yes. This is NOT at all contradictory to what I said about new grads not having work experience and not negotiating. Look, you can always negotiate and I will always urge you to, but I highly doubt that as a new grad with NO experience you can successfully negotiate your salary up (that much) as some may think. Negotiating your salary as a new grad may in fact cost you the job. They are looking for motivated individuals that want to be team players and want to join their specific group. Groups are NOT looking for financially needy individuals. Also $30 less per hour on a W-2 is close to $100/hr on a 1099. Here's the breakdown (according to me). $30/hr over a yr is ~ to $60K/yr. Benefits usually run about $30K and Vacation at $5K/wk x 6 wks = $30K => $60K. So a job that pays $140 on a W-2 with full benefits (health, dental, malpractice, disability, 401K, etc) and 6 wks of paid vacation is equivalent to $200K on a 1099. The financial difference now depends on availability of OT, time and a half vs hourly wage for those OT hours, sign on bonus, moving expense reimbursement, tax write offs (deductions). This can sway your decision one way or the other.. Other things to definitely consider. The group, how supportive are they of new grads, CRNAs, etc. Why they are needing more CRNA's. Was it b/c the previous CRNA's left b/c of unfair treatment or did he/she retire. Big difference. Call vs no call, OB and Peds experience (reccommended), type of cases, case load, (basically - what type of work experience and knowledge can you gain from working at this institution). Finally, the state/city/town. The area. cost of living, cost of housing. crime rate, weather, fun activities to do during your time off. Let me state this clearly. Many CRNA's that I know who have made the BIG bucks will all tell you that the money IS NOT worth it if you have a crappy practice, live in a crappy place, or are working all the time. You must be happy with the group, the work, your living environment, and have time to enjoy the money, otherwise it is pointless. Money is nice, but is not the answer to everything. Sorry to be so darn long winded, I hope these post are helpful to even a few people out there. Good night...

What do mean by "the expected distortion of the Svo2"? It is either distorted (dropped) or it is not. You don't give blood b/c you are expecting the sat to drop from low hgb. You'll give blood 1st to keep the pt/VS stable. The BP is where you'll see the effects of low hgb 1st, then later you may see a drop in sats (due to low hgb or low o2 carrying capacity: same difference), then even later you'll definitely see a drop in sats. This point is really late in the game to be thinking about transfusing. He is saying that a person with low Hgb doesn't necessarily present with desaturation. This is b/c the person can compensate by increasing HR or CO = Increase tissue perfusion = Sats are maintained. At the point that you see the sats dropping (due to blood loss i.e. low hgb), this is really late in the game and you need to give blood ASAP now. One may say that this is not the point to give blood, but what they mean to say is that you should've been giving blood already to avoid getting to this point. He is also saying you don't give blood for low Hbg but you give blood for loss of o2 carrying capacity 2nd to loss of bld (or low hgb). This is being a bit technical. Technically correct, but loss of o2 carrying capacity is due to loss of hgb. Initially a little loss of Hgb is compensated for by Inc HR/CO. Later, more loss of hgb leads to loss of O2 carrying capacity b/c the tissues extract more O2 than what is delivered ( = lowered sats). So in the spirit of keeping it simple. loss of blood => loss hgb (don't necessary see drop in sats yet). More loss of hgb => loss of O2 carrying capicity => lowered sats. Get it?

Also don't get me wrong. I am NOT saying a 1099 is better than a W-2. 1099 works better for some people. One example is that Single people or couples who are young and don't need comprehensive medical insurance. You can buy your own insurance for much less, insurance that you're not likely going to use anyway. I do agree with everyone in that you have to sit down and consider everything about an offer before signing the dotted line. That is sound advice offered by all. And guys don't neccessarily be swooned by the Anesthesia groups that offer great benefits, malpractice, diability, paid CE time off, etc. Calculated out the total package worth. For example $180 (total package). The anesthesia you provide for these groups is probably worth around $300K in anesthesia billing. Guess who's pocketing the rest. Yeah, you're friends in the anesthesia office drinking coffee while you do cases. These things you'll learn once you're in the business of anesthesia. Good luck all.

what in the world are you talking about? I never changed the terms of the proposal? I said," $98/hr on a 1099 for a GRNA with no call is a Great Postion! Basically $98/hr = $200+/yr." I know this position is for no call. I'm NOT counting call as OT. Many times there is opportunity to work OT above a regular "8" hour shift. Many times, you can pick up an extra shift on a saturday that is considered OT. But these details need to be worked out before signing the contract. My 1st and 2nd job were both on a 1099. My 1st job's base was $176K on a 1099 with light call. With some OT it was above 200K by the end of the year. I didn't take vacation b/c b/t post call days off and early outs, occ 3-4 day weekends, and holidays, I didn't feel the need for vacation. I considered my first job a great one. 2nd job was similar 200K on a 1099 w/ 6wks paid vacation, and no call. I averaged 55hrs a wk and made $250K. That was a great job as well. And you're 2nd argument about $88 vs $98 is insane. How long do you expect to work as a GRNA? 1-2 months while you wait for results of your certification exam. After that, you'll be making $98 for the MAJORITY of the year. And if you didn't pass, I doubt you'd be sticking around? Are you a CRNA? What are the specifics of your experience. Can you offer any better an argument for W-2 over a 1099 other than this drivel. Keep in mind that 200K on a 1099 with NO call is a still a great position for a NEW GRAD. I'm not saying this is the best out there. I'm saying this is a great paying job for a new grad. Someone advised on negotiating? What are you negotiating with? This person is a NEW GRAD! There's probably 3-4 others looking at the same position. You don't have a lick of experience to negotiate with. Sh!t, even at a $150K that's great for a NEW GRAD. I don't know quite honestly where any of you are coming from. When I got out of school 4 yrs ago, I thought $100K was making the big Bucks. Everyone's perspective has changed. I'm all for making more money, but let's not lose sight of reality ok? I bet YOU CAN't find on gaswork a better job right now than this for a new grad. If you do, send me the link and I will send you a $50 gift certificate for a steak dinner on me. I've scoured gaswork for jobs so I know what I'm talking about. And I'm not talking about the jobs that promise $300K for north of mexico either. Many factors to consider when it comes to a good job: The group, the work load, types of cases (OB,PEDS), whether there is an 8hr guarantee, call vs no call, state/town/city you'll be living in, weather, cost of living in that state, etc. Do me a favor. Actually goto gaswork, put in any state and look at the pay offer. The majority is around 110K on a W-2 with benefits and Call. So if all things being equal and there does exist opportunity to make OT here (and I'm not talking about taking call), this is one heck of a job for a new grad. Again, there are tax benefits from a 1099 that can easily put an extra 20K in your pocket over a w-2. :trout: OK sorry, I don't mean to sound like a jerk, but I'm not sure that you truely understand the CRNA market.

Saw on the news tonight, one of the actresses from the tv show "Lost" was busted in LA for DUI. She served 4hrs jailtime out of a possible 2 months. Reasons stated was b/c they need to make room for more serious offenders. Not sure if she got preferential treatment b/c of her hollywood status, but it sure does seem suspicious.

I normally extubate most of my patients deep anyway. I understand your point about popping stitches, but I would be hestitant to extubate deep on a 10 hour case with 600-800cc bld loss neccesitating lots of blood and fluids and having spend any significant time towards the end of the case in T-bird. Meaning if I had significant 3rd spacing and/or any trouble with the intubation. This is a hypothetical situation I'm talking about here. Obviously this is not how your case went and the surgeon only loses 300cc bld loss normally. So in this case, yes deep extubation. You can also do awake extubations without coughing/bucking or minimal coughing/bucking. Lido ETT while deep prior to extubation, and make sure you have enough Narc on board. Also surgeon should have the abdominal binder on before you pull the tube anyway. Remember also that you are dealing with a post Gastric bypass patient. One who has a very small stomach. These patients are at high risk for reflux all the time which is a contraindication to extubating deep. So do I deep extubate pt's with a history of reflux? Selectively yes. Usually if they are also not obese or if I didn't have any trouble with the intubation. If having had your experience with popping abdominal sutures, I understand your hesitation to extubating awake. I too would probably extubate deep despite the risk for reflux. I see the risk for reflux as less likely than the risk for popping sutures, so I agree with you there. Just making sure all areas have been covered first.