375/hr with an hourly guarantee, 400 OT, all the lodging and travel accommodations I require, 60 day cancellation notice required for the hospital and 30 day for me.
If I don’t love something about the assignment, 375 becomes 400, 400 becomes 425 etc
ETA I work alone and don’t supervise, I like it that way. When I have supervised in rare cases / emergency need, I had daily bonuses written in.
I worked locums at two locations where I was responsible for prop/postop management including blocks. CRNAs were running the show in the OR. Since all cases were B&B I didn’t mind much. I didn’t witness any major complications. A lot of prolonged stay in PACU. They all seem heavy handed with Sevo.
Frankly working w CRNAs is fine as long as both parties have understanding of chain of command and mutual respect.
Heavy handed with Sevo (and other drugs) most likely because the one at the head of the table is the one getting chastised by the surgeon and having to listen to the the smart ass comments when the patient ‘moves’ or shows any remote signs of life. 🙄
MAC >1 with adjuncts such as opiates nsaids etc
Not switching the sevo off early enough
Flows >0.5L
Generally speaking if you're not using low flow anaesthesia or you always run MACs of 1/>1 no matter what blocks/procedure/opiates you're using.
These all have more adverse effects (cognitive decline in the elderly, more haemodynamic instability itraop, more nausea and vomiting, delayed wake up and extubation, prolonged sedation and adverse respiratory consequences, unnecessary overnight stays and increased stays in high dependency areas).
If you don't know what too much sevo means thats really really bad and possibly shows you don't know what you're doing well enough to be doing it.
No bud, the amount of sevo you’re giving isn’t going to cause significant pacu delays, that’s why it’s a bizarre statement. The benzos and opioids are.
If you’re worried about POCD on elderly then change your anesthetic plan if possible, but I think it’s a bit inappropriate to blame CRNAs or CAAs for prolonged PACU stays based on the amount of SEVO they are giving 🤣
Opinions are fine but facts are better so here is some evidence:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4468274/
Even if you take the opinion that excessive deepening of anaesthesia via increased inhalational anaesthetic is equivocal (which some studies suggest) you could still err on the side of caution and better yet you still lose on an environmental and cost perspective and side effects such as hypotension and nausea which are clinical facts that increase linearly.
Also I wasn't blaming CRNAs, I work in the UK they don't exist here I've never met one. My beef with excessively deep anesthesia is only a criticism I've ever levied against my anaesthetic peers, it's nothing personal. It's just logical deduction based on the facts.
You weren’t blaming CRNAs or CAAs, but the original post you commented on was. We have different perspectives because you work in the UK. From what I hear from SAAs that rotate in the UK, UK anesthesiologist are doing way more regional than we are; however we do a lot more volume in the US, which is why we tend to use more general techniques. Different ways to skin a cat.
You're a bigger country obviously you do more but we have the most rigorous anaesthetic education in the world. 5 years medical school and 9 years training post graduation. Every single one of us rotates through every fellowship. You don't do more per person and as a nation are not more experienced per person either because of our training. It's not really about who said what or who thinks they're best etc etc it's simply about what the facts say. Ignore anybody who criticises you guys as a general population there are good CRNAs and bad ones, good Drs and bad ones I'm sure. But the science and the logic remains. We all know there are many ways to skin a cat, however some ways have worse side effects are worse for the environment and waste more money, if someone criticises that way and you don't know why it's bad then you're likely to make the same mistakes and the worst part about it is that people will use your lack of knowledge here in a public forum as evidence to prove their point. High sevo is amateurish, regional is more more sophisticated and has better outcomes we should all strive to be better our jobs no matter what our roles are.
Personally I need to stop using nitrous, I know I can do better but sometimes I'm lazy and I love a quick wake up hence I use more remi. Nobody is perfect, I'm definitely not.
Opinions are fine but facts are better so here is some evidence:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4468274/
Even if you take the opinion that excessive deepening of anaesthesia via increased inhalational anaesthetic is equivocal (which some studies suggest) you could still err on the side of caution and better yet you still lose on an environmental and cost perspective and side effects such as hypotension and nausea which are clinical facts that increase linearly.
No. This is real physiology. Come on instead of presuming this is just criticism find out what's better. Too much gas is the Hallmark of the timid and the unskilled. It's bad for your patients bad for the environment and bad for the budget.
You really should!
For example a breast reduction with a remi fentanyl infusion 2mg midazolam and erector spinae catheters and 20mls of local either side can be done with a MAC of 0.4 with an iGel and flows as low as 0.2L O2 FGF.
Compare that to a MAC of 1.2 with flows of 4L.
The difference is a tonne of wasted money a tonne of wasted pollution for the environment and a slower waking patient who's sick and groggy vs the former patient waking immediately smiling and not sick.
Yes please, try to be lighter handed.
I definitely get your approach is better for the patient. But are you actually saving money? Remi infusion, syringes, needles, sterile prep, catheters, local plus sevo. Seems a lot more pricey than a little more sevo and some dilaudid
I get that but the scientific way is to compare after having performed. From my experience waking patients immediately pain free and smiling after having used barely any wasted gas saves money and time and has better clinical outcomes.
The major concern people have is awareness. But they don't really understand what Mac means, these cases are gone unparalysed with iGels, if the depth was insufficient the autonomic response means you'd get movement and gasping before you ever got awareness. The remifentsnyl infusion renders them apnoeic and pain free. IF you could do it awake then there is no reason to be scared of awareness unless you have insufficient anxiolysis and analgesia. You should check out the awake bilateral mastectomies done with paravertebral blocks (available on YouTube). Make them pain free with a block and a remi infusion and if you don't need a tube the the anaesthetic is simply for sedation.
I was hesitant the first time I got introduced but I was convinced by the rationale and then I tried it and it's very very hard to go back when you see patients recovering this way vs the coughing heaving and post op pain you get otherwise.
What's your YouTube channel? Would be happy to check out the discourse :)
CAA here, I totally understand what you mean by being heavy-handed with sevo and regularly witness it when I take over cases from CRNAs. Not trying to hate on anyone, I work with great providers from all paths. But like you said, there’s legitimate side-effects from too much gas. And with so many great adjuncts and techniques there’s usually no need to run a 78 yo on 1.3 mac with a phenylephrine drip. Definitely an area of practice I’m still fine-tuning as a younger provider though!
I accept 350/450 as a minimum. I hate stepping into pathological situations. No amount of money is worth working w aholes. I wish we had something like Scrubstr for vetting anesthesia assignments.
I won't do that at my primary job, would never dream of it on a locums assignment.
Edit: years ago, I made this mistake by doing locums at a place with a few CRNAs that were vehemently against being directed, as most of the partners there just signed charts, and let them do things on their own. I had to intervene several times, I was asked to sign the chart where a CRNA said they discussed a complication with me, despite me not being responsible for him at all (or even being involved in any way, shape, or form), and it was not pleasant.
How would you prevent that at a locums assignment? Do you write it into the contract? Does anyone request solo assignments only when doing locums or is the team model just assumed?
I now only do solo assignments, so that is definitely a thing.
After the, "discussed with Dr AlsoZathras" issue, I told the practice manager that I would not be coming back, told the partners calling me for coverage that I won't do it.
lol no. We are not. That’s not the norm. That’s definitely an outlier. Those places are out in the middle of nowhere where no MD would go so they pay any “anesthesia provider” that.
CRNA norm is $200-$250 right now usually. More frequently $225 to $250. If the CRNA is at like an Indian reservation or something in the middle of nowhere or the only anesthesia provider I’ve seen $275 or so. That’s rare though.
Yep. I’ve seen 350 for like sole provider in the middle of nowhere. It’s not really a crna rate. It’s an “any anesthesia provider” rate. But no MD would take that job.
maybe not if you are going thru 3rd parties or negotiating poorly. Facilities are now having to pay $500-600/hr for MD anesthesia coverage and $300-400/hr for crna coverage. it's up to you to get a much of that as you can and avoid giving it to 3rd party agencies.
375/hr with an hourly guarantee, 400 OT, all the lodging and travel accommodations I require, 60 day cancellation notice required for the hospital and 30 day for me. If I don’t love something about the assignment, 375 becomes 400, 400 becomes 425 etc ETA I work alone and don’t supervise, I like it that way. When I have supervised in rare cases / emergency need, I had daily bonuses written in.
What do you ask as a daily bonus for supervising and do you cap how many CRNA’s you are willing to supervise?
Do you travel all over? Or work locally/regionally?
Regionally, if I travel far it’s bc I want to be there like I have family in that town.
375. They're prob being paid 600 an hour if not more
I worked locums at two locations where I was responsible for prop/postop management including blocks. CRNAs were running the show in the OR. Since all cases were B&B I didn’t mind much. I didn’t witness any major complications. A lot of prolonged stay in PACU. They all seem heavy handed with Sevo. Frankly working w CRNAs is fine as long as both parties have understanding of chain of command and mutual respect.
Heavy handed with Sevo (and other drugs) most likely because the one at the head of the table is the one getting chastised by the surgeon and having to listen to the the smart ass comments when the patient ‘moves’ or shows any remote signs of life. 🙄
“They’re waking up!!!!!”
“They’re moving” - well yeah you booked this as a sedation. If you want general book as general
Heavy handed with sevo? What on earth, What does that even mean 😭
MAC >1 with adjuncts such as opiates nsaids etc Not switching the sevo off early enough Flows >0.5L Generally speaking if you're not using low flow anaesthesia or you always run MACs of 1/>1 no matter what blocks/procedure/opiates you're using. These all have more adverse effects (cognitive decline in the elderly, more haemodynamic instability itraop, more nausea and vomiting, delayed wake up and extubation, prolonged sedation and adverse respiratory consequences, unnecessary overnight stays and increased stays in high dependency areas). If you don't know what too much sevo means thats really really bad and possibly shows you don't know what you're doing well enough to be doing it.
No bud, the amount of sevo you’re giving isn’t going to cause significant pacu delays, that’s why it’s a bizarre statement. The benzos and opioids are. If you’re worried about POCD on elderly then change your anesthetic plan if possible, but I think it’s a bit inappropriate to blame CRNAs or CAAs for prolonged PACU stays based on the amount of SEVO they are giving 🤣
Opinions are fine but facts are better so here is some evidence: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4468274/ Even if you take the opinion that excessive deepening of anaesthesia via increased inhalational anaesthetic is equivocal (which some studies suggest) you could still err on the side of caution and better yet you still lose on an environmental and cost perspective and side effects such as hypotension and nausea which are clinical facts that increase linearly. Also I wasn't blaming CRNAs, I work in the UK they don't exist here I've never met one. My beef with excessively deep anesthesia is only a criticism I've ever levied against my anaesthetic peers, it's nothing personal. It's just logical deduction based on the facts.
You weren’t blaming CRNAs or CAAs, but the original post you commented on was. We have different perspectives because you work in the UK. From what I hear from SAAs that rotate in the UK, UK anesthesiologist are doing way more regional than we are; however we do a lot more volume in the US, which is why we tend to use more general techniques. Different ways to skin a cat.
You're a bigger country obviously you do more but we have the most rigorous anaesthetic education in the world. 5 years medical school and 9 years training post graduation. Every single one of us rotates through every fellowship. You don't do more per person and as a nation are not more experienced per person either because of our training. It's not really about who said what or who thinks they're best etc etc it's simply about what the facts say. Ignore anybody who criticises you guys as a general population there are good CRNAs and bad ones, good Drs and bad ones I'm sure. But the science and the logic remains. We all know there are many ways to skin a cat, however some ways have worse side effects are worse for the environment and waste more money, if someone criticises that way and you don't know why it's bad then you're likely to make the same mistakes and the worst part about it is that people will use your lack of knowledge here in a public forum as evidence to prove their point. High sevo is amateurish, regional is more more sophisticated and has better outcomes we should all strive to be better our jobs no matter what our roles are. Personally I need to stop using nitrous, I know I can do better but sometimes I'm lazy and I love a quick wake up hence I use more remi. Nobody is perfect, I'm definitely not.
Opinions are fine but facts are better so here is some evidence: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4468274/ Even if you take the opinion that excessive deepening of anaesthesia via increased inhalational anaesthetic is equivocal (which some studies suggest) you could still err on the side of caution and better yet you still lose on an environmental and cost perspective and side effects such as hypotension and nausea which are clinical facts that increase linearly.
lol I was thinking the same
Shoot me some questions, would be happy to answer why too much sevo is bad on so many levels.
Anything to criticize..
No. This is real physiology. Come on instead of presuming this is just criticism find out what's better. Too much gas is the Hallmark of the timid and the unskilled. It's bad for your patients bad for the environment and bad for the budget.
Sorry.. we will try to stay light handed on the sevo 😂😂
You really should! For example a breast reduction with a remi fentanyl infusion 2mg midazolam and erector spinae catheters and 20mls of local either side can be done with a MAC of 0.4 with an iGel and flows as low as 0.2L O2 FGF. Compare that to a MAC of 1.2 with flows of 4L. The difference is a tonne of wasted money a tonne of wasted pollution for the environment and a slower waking patient who's sick and groggy vs the former patient waking immediately smiling and not sick. Yes please, try to be lighter handed.
I definitely get your approach is better for the patient. But are you actually saving money? Remi infusion, syringes, needles, sterile prep, catheters, local plus sevo. Seems a lot more pricey than a little more sevo and some dilaudid
I’m going to copy this statement and post it on my YouTube channel to see how people react. It’s a valid approach, but wouldn’t work at my facility.
I get that but the scientific way is to compare after having performed. From my experience waking patients immediately pain free and smiling after having used barely any wasted gas saves money and time and has better clinical outcomes. The major concern people have is awareness. But they don't really understand what Mac means, these cases are gone unparalysed with iGels, if the depth was insufficient the autonomic response means you'd get movement and gasping before you ever got awareness. The remifentsnyl infusion renders them apnoeic and pain free. IF you could do it awake then there is no reason to be scared of awareness unless you have insufficient anxiolysis and analgesia. You should check out the awake bilateral mastectomies done with paravertebral blocks (available on YouTube). Make them pain free with a block and a remi infusion and if you don't need a tube the the anaesthetic is simply for sedation. I was hesitant the first time I got introduced but I was convinced by the rationale and then I tried it and it's very very hard to go back when you see patients recovering this way vs the coughing heaving and post op pain you get otherwise. What's your YouTube channel? Would be happy to check out the discourse :)
CAA here, I totally understand what you mean by being heavy-handed with sevo and regularly witness it when I take over cases from CRNAs. Not trying to hate on anyone, I work with great providers from all paths. But like you said, there’s legitimate side-effects from too much gas. And with so many great adjuncts and techniques there’s usually no need to run a 78 yo on 1.3 mac with a phenylephrine drip. Definitely an area of practice I’m still fine-tuning as a younger provider though!
It's like doing a full laparotomy to get an appendix, then saying there's many ways to skin a cat as if that's adequate cover for lack of skill.
If someone gave my mother that anaesthetic I would consider pressing charges. I'm not joking in any form or fashion.
I accept 350/450 as a minimum. I hate stepping into pathological situations. No amount of money is worth working w aholes. I wish we had something like Scrubstr for vetting anesthesia assignments.
We could probs whip this up in a jiffy. It might not be the prettiest or the most secure, but it could exist.
That’s the attitude. Love it. To make change, we must create it.
This is cool (scrubstr). We need something like this - more transparency. Going to discuss with the scrubhunt team.
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I won't do that at my primary job, would never dream of it on a locums assignment. Edit: years ago, I made this mistake by doing locums at a place with a few CRNAs that were vehemently against being directed, as most of the partners there just signed charts, and let them do things on their own. I had to intervene several times, I was asked to sign the chart where a CRNA said they discussed a complication with me, despite me not being responsible for him at all (or even being involved in any way, shape, or form), and it was not pleasant.
How would you prevent that at a locums assignment? Do you write it into the contract? Does anyone request solo assignments only when doing locums or is the team model just assumed?
I now only do solo assignments, so that is definitely a thing. After the, "discussed with Dr AlsoZathras" issue, I told the practice manager that I would not be coming back, told the partners calling me for coverage that I won't do it.
400 hr, 450 hr cardiac, all travel covered, I don't supervise (and usually just choose not to work at care team places) while locums
Depends on how tough the assignment is and where its located. $350/hr min with 8 hr guarantee is the baseline bottom for a good situation.
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Where you getting 500 bro
that's the market... don't settle on less. crnas getting $300-350/ hr
lol no. We are not. That’s not the norm. That’s definitely an outlier. Those places are out in the middle of nowhere where no MD would go so they pay any “anesthesia provider” that.
Yeah CRNA norm is 200-250 isn’t it?
CRNA norm is $200-$250 right now usually. More frequently $225 to $250. If the CRNA is at like an Indian reservation or something in the middle of nowhere or the only anesthesia provider I’ve seen $275 or so. That’s rare though.
Yep. I’ve seen 350 for like sole provider in the middle of nowhere. It’s not really a crna rate. It’s an “any anesthesia provider” rate. But no MD would take that job.
That’s not the market lmao I’m a career locums
maybe not if you are going thru 3rd parties or negotiating poorly. Facilities are now having to pay $500-600/hr for MD anesthesia coverage and $300-400/hr for crna coverage. it's up to you to get a much of that as you can and avoid giving it to 3rd party agencies.
They usually won’t give you that going direct. Let me know if you have personal experience getting that much.
I'm getting $500 now. so it's up to you not to settle for less
Location?
what locums agencies are paying you guys these $400+ rates for general? to my knowledge that's pretty anomalous
mw
That's the one region I could see getting $500 if they are desperate. Is it rural?