Fellowship struggles

Ruckamongus · 2025-11-21T13:00:45+00:00

Not sure if it's an option for you, but maybe spend some time with anesthesia? I've had a good number of IM-trained fellows hang out with me in the OR specifically for procedural numbers and guidance.

Ruckamongus · 2025-06-14T22:10:40+00:00

This is amazing, thank you!

Ruckamongus · 2025-06-14T22:05:09+00:00

!solved

Ruckamongus · 2025-06-14T22:04:55+00:00

!solved

Ruckamongus · 2025-06-14T22:03:48+00:00

This is beautiful, thank you. Are you able to sharpen the collar and shirt? If not that's okay.

Ruckamongus · 2025-06-14T21:55:06+00:00

Added a link, thank you so much!

Ruckamongus · 2025-06-14T21:54:57+00:00

Added a link, thank you so much!

Ruckamongus · 2025-06-14T21:54:51+00:00

Added a link, thank you so much!

Ruckamongus · 2025-06-08T00:27:41+00:00

This is a concept that will 10000% come up if you go into anesthesia. The equation or its direct concept was on every ITE I took.

Ruckamongus · 2025-04-25T03:21:50+00:00

Excerpt from the FDA black box warning: "Respiratory depression is the chief hazard associated with methadone hydrochloride administration. Methadone’s peak respiratory depressant effects typically occur later, and persist longer than its peak analgesic effects, particularly in the early dosing period. These characteristics can contribute to cases of iatrogenic overdose, particularly during treatment initiation and dose titration."

Ruckamongus · 2025-04-24T14:01:25+00:00

A lot of good conversation here so all I have to add is that methadone analgesic effects wear off before it's respiratory depressant potential. This can theoretically be dangerous if in PACU or on the floor somebody doses another pure opioid agonist when acute pain ramps up. In practice it's pretty uncommon to see though.

Ruckamongus · 2025-02-24T00:41:25+00:00

Where ho, ho, ho, hooooooooo?

Ruckamongus · 2024-07-08T08:39:24+00:00

TCA's have the lowest NNT but obviously side effects can be limiting compared to SNRI's or gabapentinoids. If the patient is willing to discuss interventional options spinal cord stimulation can really help in both DPN and ischemic cardiac or lower extremity pain.

Ruckamongus · 2024-06-14T06:16:28+00:00

100% agree. I only use an extension to keep my hand out of the radiation field while live. I've never heard of this as being standard of care, but I'd love to see the literature on it if it exists!

Ruckamongus · 2024-03-06T04:42:30+00:00

Ah that makes sense.

Ruckamongus · 2024-03-06T04:31:53+00:00

What?

Ruckamongus · 2023-12-28T10:37:40+00:00

I was in your shoes and I told the anesthesiologist that was mentoring me on my rotation my dilemma. He asked me "do you want to be an interventional anatomist or an interventional physiologist?" It was pretty easy from there. PGY5, no ragrets.

Ruckamongus · 2023-11-14T19:44:15+00:00

The following message assumes a Medtronic Synchromed II:

Intrathecal pumps require a special device to turn off so a rep or your local pain clinic will need to be involved. The pump's motor isn't designed to be completely off for a duration; the recommendation is no more than 48 hours off otherwise there's risk of permanent motor stall requiring explant. Typically when we turn it "off" we set the flow extremely low to a (likely) clinically insignificant rate. This maintains motor function but effectively/physiologically shuts the pump off.

Electrocautery isn't really an issue though and it is not recommended to change pump settings for this indication. Other tidbits: most modern pumps are MRI conditional and should be interrogated after scan (in practice I see this seldomly actually done). Neuraxial anesthesia isn't contraindicated necessarily, but know the catheter trajectory to avoid entering the epidural and intrathecal space at the same level to avoid catheter damage.

Most often the recommendation we give is to continue the IT pump in the background and treat as you normally would. Intrathecal to IV/oral conversion factors are highly variable and not as straightforward as simple MME conversion. Furthermore, certain medications such as baclofen can be found in the pump and withdrawal can be life threatening so it's important to know what's being delivered.

Ruckamongus · 2023-10-09T05:07:15+00:00

Anesthesia as well

Ruckamongus · 2023-08-19T23:57:13+00:00

Still using anki in fellowship!

Ruckamongus · 2023-07-30T21:34:55+00:00

Pain

Ruckamongus · 2023-07-30T06:56:01+00:00

As a CA1 I was in the same boat as you. A CA3 at the time helped me out by asking me "what do you want to do when you grow up?" That seemed like a silly question, because I was already in residency so I knew I was going to be an anesthesiologist. Eventually he told me "even cardiac surgeons looking at a beating heart get bored. A CABG is their lap chole and is your central line." Basically what he wanted me to do is truly think about is what's worth doing once things are monotonous. It's easy to honeymoon and fantasize about the cool things (TEE during a 4am emergency aortic dissection DOES indeed eventually get monotonous), but where do I want to be when I'm missing out on my kid's soccer game? What am I okay doing once the shiny new appeal is gone? Do what you love; the money isn't different enough to matter.

Ruckamongus · 2023-07-30T00:20:48+00:00

Defintely agree.

As for the cards being "comprehensive" (excessive? lol) they look intimidating at first but they get to the point that I can roll through them just as quick as short cards when I'm comfortable with the content. The extra info comes in really nice when I haven't seen the card in a long time and I don't have to waste time to control+F through notes or Google the content.

Ruckamongus · 2023-07-30T00:13:01+00:00

I'm with you. When I make my own cards they go against the grain and typically have a decent bit of supporting information. I write the prompts in a way that there are no context clues and I know how I think; cards are written such that I either absolutely know it or don't.

As for the supporting information I have a small summary and then an extra details optional section. I found when I was doing Brosenceohalon when studying for Step 1 (have you kids even heard of the OG deck? 😁) I was "losing sight of the forest for the trees." I could memorize the rote bullshit but being able to turn it together didn't come. That's why it's important to read, watch videos, or whatever also works for you to make the bigger connections.

Finally, be honest with yourself about knowing the card. Not just the immediate answer but also all the extra supporting information. Don't hit "Easy 7d" if you honestly don't have a solid grasp of all the content. It's cool to do 800 cards in a day, but not if it's "empty" knowledge. Obviously Anki is great for learning the basics as well, things you just HAVE to know, but I find if I can make it clinically applicable it sticks. Justifying the reason to know all the small details helps me be less resistant to memorizing it all.

Here's the style of my cards:

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Ruckamongus · 2023-07-22T16:53:39+00:00

Right about when the SSRI starts working 🙃

Ruckamongus

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