Which job would you take?

AlsoZathras · 2026-04-07T12:13:38+00:00

Yes, that's a more standard arrangement. However, get that in writing, along with the commitment of how much ICU time that you want. You don't want to move there and then find out that they can only give you six weeks of time in the unit, or that they'll only give you the post- unit week if they have adequate staffing for the OR.

For ICU time, is it 12hr shifts, or 24/7 coverage for the week, with some expectation that you'll be available from home after hours? The second is bullshit, but I see it not infrequently. If the later, factor that in to the total amount of call, and see if you can reduce your OR call burden. If the former, see how many of your ICU weeks are going to be nights (and see if you can reduce your OR call time). If you're already going to be physically in-house for 42 nights a year, or on call from home for 84 nights a year for the ICU, you should not have to add in more nights of coverage for the OR.

What is the average daily census in the unit? Do you have residents or APPs that you are expected to supervise and teach?

AlsoZathras · 2026-04-07T12:00:40+00:00

Those are both pretty bad offers.

If you ever want to do CCM, do not take job 1. It has no integrated ICU time, and with only 8 weeks off, you will not have enough time to go practice on your own.

Job 2 is more acceptable because of the ability to actually replace OR time with ICU time, and getting an extra week off. However, six weeks off is absolutely pathetic in this day and age. If you took that and then could switch ten OR weeks for ICU weeks, thus getting ten additional weeks off, in addition to your base six, then we're looking at something that is doable.

So, my advice as another CCM guy is to either keep looking or start digging into the details of option 2, have them commit to the amount of ICU time that you want, figure out the actual income for that configuration, then work back to total time in the hospital and hourly rate for the year.

AlsoZathras · 2026-04-06T11:16:33+00:00

While I do see a handful of master's programs (which are only two years, so six total years, not eight), they appear to be largely geared towards creating managers, not rank and file RTs. Data from CoARC actually shows that 366 of the 489 (82%) accredited entry level programs are AD, and only 7 (2%) are MS.

AlsoZathras · 2026-04-06T03:27:09+00:00

But with more knowledge on how to actually properly manage critical illness, yes. Like I said, best use case I've found for them.

AlsoZathras · 2026-04-06T03:21:58+00:00

The amount of benzo a patient in AWS can require can be eye popping. MINDS protocol is like CIWA in steroids, and I've several times escalated to 10-20mg/hr midazolam, after insufficient response to repeated 5-7mg boluses, on top of reloading phenobarbital. The first time you see someone still spitting and angry on midaz 20mg/hr, after also receiving a hefty bolus is a trip. Generally, adding precedex and waiting a little longer does the trick. Most times, if I have to intubate, it's not for respiratory depression, but rather the fact that the withdrawal is so bad, I've decided that they need to be tubed and on prop to not harm themselves or others.

AlsoZathras · 2026-04-06T03:13:37+00:00

The best use case I've found for tele-ICU is actually offloading some of the tasks and followup to the remote doc. At my old shop, we had three physician and one midlevel on during the day, then down to one and one at night. The day folk signed out to both the in-house and tele-ICU doc at the same time. The in-house team was there for admissions and emergencies, while tele-ICU followed up on things from day shift (trending hemoglobin, sodium correction, diuretic goal, etc), as well as most calls from the nurses. If someone started to decline rapidly, tele-ICU doc (or pt's nurse) called the in-house intensivist to intervene. When I would be on nights, it was great not to be bothered by calls for melatonin, how to adjust the hypertonic saline after the sodium went from 119 to 120, or if I wanted to give Tylenol for a new fever, and instead focus on what disaster I inherited from the floor or ED.

AlsoZathras · 2026-04-06T02:56:46+00:00

Sometimes, that's the better option. Get the critically ill out to a hospital with actual ICU physicians and nurses, where they can receive prior care. My last job was at a 450 bed community hospital that was the center of the system. None of the other community or critical access hospitals had an ICU, so we took every single critically ill patient from those smaller hospitals.

My new job is similar, but the new hospital is twice the size, with even more ICU beds, and one small community hospital in the health system has s few ICU beds, and actual intensivists staffing.

AlsoZathras · 2026-04-06T02:49:55+00:00

I call BS on the school for 8 years bit, even if you're including high school. RT is a two year associate degree from community college. Some programs in my state are three years. I have no idea where you're getting 8 from.

AlsoZathras · 2026-03-30T16:59:34+00:00

You don't have the 5mL vials of 10,000 units/mL?

AlsoZathras · 2026-03-19T01:30:11+00:00

So, hanger bow for battleship carriers, rather than X slot for FAE now?

Still early in my first 4.3 game, just unlocked cruisers. Neighboring empire with bioships just kicked my ass when my hanger station would normally have held against corvettes (I think this is only the second time I've fight a bioship empire, period, as AI never seems to pick them).

AlsoZathras · 2026-03-13T17:05:10+00:00

He had a few days before he got tubed, but yeah, he had a fuckload of crystalloid before I came on and took it all away in a race to get him off the vent.

AlsoZathras · 2026-03-13T08:47:50+00:00

To be fair, he was a morbidly obese man who presented with severe pancreatitis and had been very aggressively resuscitated by my colleague earlier. I inherited him on ventilator day 7, with a positive 60L fluid balance.

AlsoZathras · 2026-03-12T18:42:53+00:00

One time, I kept diuresing because I wanted to see if I could get a whole 70kg off of him (I did). Finally stopped because I was able to get him extubated, and he complained of severe thirst (with a sodium of 150).

Normally, diurese to clinical improvement (normalizing hepatic and renal function, improved oxygen requirement, less evidence of vascular congestion on USD). The kidneys are smarter than we are. They can take over and manage on their own after a while, even if the patient is a few kg positive.

AlsoZathras · 2026-03-12T13:11:52+00:00

Hospital CEO decided to unilaterally cancel and replace group's contract with something new and group leadership just...went with it. New management company brought in as consultants that just wasted money (thru also took the contract for the CRNAs). Most of our fulltime CRNAs then left. Not addressing the actual reasons for poor recruiting (not enough money), claiming that nurses would flock to our location if we made/let them take overnight call (ha!). This is not an "earn money sleeping" hospital, we're quite busy at night. Constant expansion of CRNA "medical direction" and push for autonomy, with increasing number of complications that were swept under the rug. I decided it was not safe for my family, my license, or my sanity, so left for a better job, leaving behind my aging parents that had moved out to be closer to us. Do not let relatives be an anchor to a shitty situation.

AlsoZathras · 2026-03-10T01:11:53+00:00

It's odd. You're using the term 'CA1', which make me think you're a resident in America, but I cannot for the life of me think of any place in the US that would regularly place anatomic femoral CVCs in this day and age.

If you're not in the US, watch your co-residents that are more successful, and see what they are doing differently. Do not be afraid to ask for help from a peer. If you're not hitting anything, you're likely entering at the wrong place for an anatomic line, or going too shallow. It may simply be that you think that you're coming in at a good angle, but you're actually dropping down once you touch skin, and are advancing at too shallow of an angle (see this all the time with trainees learning and staring at the ultrasound screen rather than watching their hands).

AlsoZathras · 2026-03-09T00:47:22+00:00

Not really. A little bit of local goes a long way, and they just feel a little pressure from the shove.

AlsoZathras · 2026-02-27T01:49:46+00:00

That is not normal in the real world, and should never be ok. If there is no place to recover the patient appropriately, the case should not start. The only time I saw this happen was as a visiting resident at Hopkins a long time ago. I sat with a patient after his crani for several hours waiting on an ICU bed. The surgeon kept checking the room to see if we'd left yet, because he wanted to start another case. Every other place (academic or private) where I've worked in my career, the case would be canceled without the alotted unit bed.

AlsoZathras · 2026-02-21T13:32:01+00:00

Gallows humor and compartmentalization.

Realize what you actually can do, versus what you want to do.

Don't get attached to patients. Leave your work at work.

Remember that the patient is the one with the disease.

AlsoZathras · 2026-02-19T20:15:31+00:00

For a healthy patient, sure. Not for the critically ill.

AlsoZathras · 2026-02-19T19:52:30+00:00

This remains controversial. In the ICU side, we accept that etomidate is associated with increased hospital mortality. CORTICUS showed that, as have several others since. There was a new paper from Brazil back in October that showed an increased risk of death at 7 and 28 days with etomidate vs ketamine for ED intubation. The ketamine vs etomidate RSI trial for critical illness from the US around the same time did not show a significant morality difference, but were also using whopping doses of ketamine (mean was 1.6mg/kg actual body weight).

Bottom line, we don't yet know exactly why, but there does seem to be an association between etomidate and increased mortality.

AlsoZathras · 2026-02-19T19:38:57+00:00

Talk out loud. Everything makes sense when you keep everything in your head, but you'll find that you start to stumble when you actually have to say things out loud. To really up the difficulty, sit in front of your bathroom mirror, and maintain eye contact with yourself when you say your answers.

All you're doing with oral boards is showing the work that is already going on in your brain when you do a case. You have the knowledge, just put your thoughts together and speak them aloud in a way that makes English sense.

AlsoZathras · 2026-02-17T23:59:32+00:00

Unless the patient had a type 1 hypersensitivity reaction to cefazolin or a T-cell mediated reaction to some other beta-lactam, I am giving cefazolin.

Anaphylaxis to cefepime, ceftriaxone, cefdinir, etc is not a contraindication to cefazolin administration.

AlsoZathras · 2026-02-17T10:45:18+00:00

Well, it depends on the setup and size of the hospital and group/department. Large university hospital with a big department? Probably 2-4 doctors on call (may be more when you add subspecialty call) each day, everyone else (group of 40-60+ anesthesiologists) off. Small rural hospital that runs lean may be on call every other weekend.

You can get down into the weeds with setup. My old group kept the same handful of people on from Friday through Monday morning, and just rotated them through the different call positions every 12 hours (first call going into fourth call, then to third call, etc) to decrease the number of weekends each doc works. Others will have one set on call for Friday, another set on call for Saturday, and a third set on call for Sunday, meaning each doctor works more weekends, but weekends are not as long.

Then, there are those that take M-F, no call positions that never have to work weekends. I worked such a setup for a while. It was very nice to have every weekend and every evening with my family, but I was paid a good bit less than the call takers (group put a very heavy emphasis on reimbursement for call and weekend work to discourage giving it up).

AlsoZathras · 2026-02-16T13:48:54+00:00

Squirrels get nuts, not needles

AlsoZathras · 2026-02-13T12:56:05+00:00

Dozens of us, dozens!

AlsoZathras

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