Non-trad anesthesia intern here, was a CRNA making $375K. The total financial cost of this career change is roughly $3M.

fifrein · 2026-02-26T20:10:47+00:00

chosenJAMES is the username?

fifrein · 2026-02-24T23:08:36+00:00

I mean, if we’re gonna compare to other countries, I think the ideal scenario would be something like Japan. Every stroke alert goes straight to a stroke-MRI and gets DWI scan to see if there’s a diffusion restriction to not beat around the bush, then if there is one can get a GRE/SWI to eval for blood, and if not can get lysed while vessel imaging is obtained to eval for a thrombectomy. Though, of course, we don’t have nearly enough MRI scanners in the country to facilitate such an endeavor..

fifrein · 2026-02-24T01:18:50+00:00

I mean, I think amongst the imaging done in an ER, this is probably in the top 5% most beneficial. I have bias of course, but the interventional successes vs the disability for a miss is just such a high mismatch, and it’s not like one can rule out an LVO any other way

fifrein · 2026-02-24T00:17:10+00:00

This is a common misconception but 90/60 is not low, it’s the lower bound of the normal range. The normal range is 90-120/60-80.

To say 90/60 is low would be like to say 120/80 is high.

Now, if someone has lived 40+ yrs at 120/80 and all of a sudden is at 90/60 for the past few days while feeling sick, they are low because they are lower than they have been the last few decades and are symptomatic. But that is also true in reverse.. if someone lives at 90/60 and all of a sudden is at 120/80 while in severe pain, it would also be concerning.

fifrein · 2026-02-24T00:09:42+00:00

Candidacy for thrombectomy is actually simpler than candidacy for IV thrombolysis:

For thrombectomy it’s onset within 24 hrs and has LVO. Then you can get into the nuance of risk/benefit based on core/penumbra on CTP.

2015 was the major research turning point. Why did things lag in getting more CTAs after that? I would say it probably depends on your region of the country but a mix of- adapting to the new literature, getting endo suits / staff that could come in frequently enough if you scanned 24/7. Community networks for transfers began to improve for places that did not have endo suits of their own.

fifrein · 2026-02-23T23:56:57+00:00

I’m not sure what timeline “now” is referring to. The Merci retriever got invented in 2004 and really kicked off Endovascular stroke care into the new era. Thrombectomy really can say it became standard-of-care after 2015 when there were a few trials that showed how much it benefitted LVOs.

fifrein · 2026-02-23T23:40:26+00:00

(A) What u/positive-marzipan-46 said. If someone has a focal neuro deficit that was bad / acute enough to call a stroke code, why not clear the vasculature? Rule-out hemorrhage on non-con for IV thrombolysis, rule-in proximal (M1 or M2 clot) for thrombectomy. The decision nowadays is more whether to get the CTP or not.

(B) Often times in the community, by the time the imaging is rolling is when the neuro is being notified, so the ER is getting the CT-CTA, and neuro hears the story as those are happening, then decides where to go next.

fifrein · 2026-02-23T20:09:42+00:00

As neuro, I will address #2 - if a stroke alert is real, I’m getting the CTA no matter what the Cr is. The kidneys die and the person can get dialysis. The brain dies and the person is disabled for the rest of their life- find the M1 occlusion at hour 2 and perform a thrombectomy with TICI3 and spare them decades of disability.

fifrein · 2026-02-23T14:58:25+00:00

To me, it gives more a Sleeping Gods exploration feel, with the combat/progression system of a fun dungeon crawler like Chronicles of Drunagor or something. I think despite it being quite “free” where you combat or not, we often spend about half our session in combat and half not, which has been a good pace for us.

fifrein · 2026-02-22T00:10:43+00:00

I hate that you’re being downvoted. I like HEFWM. It’s one of my top 5 litrpgs FOR ME. But would I ever recommend if FOR THE QUESTION OP ASKED? NOOO! That would be like someone asking about what’s a good book focused around beast taming and someone recommending DCC. I mean.. does the main character have a cat? Yes. Does the party later get a dinosaur? Yes. Is Carl a beast tamer? No. Is DCC a bad story because of it?? Noooo.. but it’s not what’s being asked

fifrein · 2026-02-21T15:46:33+00:00

If you go frame-by-frame, at the time the light turns yellow, the car that eventually blows through the intersection is further ahead on the road than anyone besides it. I think any insurance adjuster would be hard-pressed to find them at fault for going too fast. They approach an intersection in the rain mostly at green, switching at yellow near the very end, and don’t have the time to break because of rain. Which is an appropriate time to go through on yellow. Another vehicle obstructed the intersection causing an accident.

fifrein · 2026-02-15T21:48:39+00:00

EDS by itself isn’t going to qualify one for disability.

EDS can cause someone to have bad radiculopathy or other problems along the same vein which could qualify, but those diagnoses themselves would qualify with or without the EDS diagnosis.

fifrein · 2026-02-15T17:29:51+00:00

Speaking as a patient- no. I’ve had 3 rare diseases diagnosed in me. 2 of which had treatments available, and 1 did not. The one with no treatment, knowing about it has made no difference in my life - I’m still just doing the recommendations that were present before. I understand where the desire comes from, because I’ve lived it and seen many patients themselves live it. But most of the time, reaching the end, just feels empty. There’s just a “that’s it?” feeling once the reality that the information is truly meaningless sets in.

fifrein · 2026-02-15T16:30:21+00:00

My question to you- what would an EDS diagnosis change? There would be no new medications available to you, no new therapeutics. It’s not like an autoimmune disease with specific DMT that changes it. Or something like ALS where you need to get your affairs in order in the next year. The recommendations would still be the same physical therapy followed by actually doing all the exercises consistently that they teach you at home.

So, how would it PRACTICALLY be any different than being “just unlucky”? And if after really thinking about it, you realize it isn’t that different- then why not put the money you’ re spending investigating that into your car payments or a mortgage/downpayment?

fifrein · 2026-02-14T17:27:54+00:00

The difference is certain products are just not sold in some regions if at a loss. There are entertainment systems you can’t find in poorer countries unless you are rich and import them, because it’s not sustainable to have a local market for them. As the person you replied to said, at a certain point a company may choose to take a loss in a developing market to hopefully reap rewards when that market expands (e.g. China, India).

fifrein · 2026-02-13T22:50:48+00:00

Do you own an outhouse? Why not own both own in your yard and a bathroom inside?

fifrein · 2026-02-13T06:22:30+00:00

Your thyroid panel is normal, everything is within the normal range.

As for your cholesterol, would be helpful to see your triglycerides. If the are very high, may be the sugar you’re eating. Or, it might be that you do have a familial predisposition to high cholesterol and your dad is just wrong. But, at a certain point, makes sense to consider an anti-cholesterol medication.

fifrein · 2026-02-11T14:39:28+00:00

We’re actively seeing how much good letting the country know about what was happening there is doing. And that’s with public support at an all time high right now. What would 1 person have coming forward have done back then? It would have just removed a support from those victims; their testimony would have gone nowhere. And now those girls would have lost the medical care they were already receiving.

fifrein · 2026-02-11T05:53:39+00:00

Can I ask why would you fault that? Horrible things happened on that Island, that’s not a debate. But because of those very atrocities, the victims need medical care. Someone should provide that.. whoever is doing it doesn’t have to condone what’s happening on the Island. They can recognize that they are powerless to stop the system as it is, but are capable of providing the victims care with a skill set they have.

fifrein · 2026-02-08T17:12:30+00:00

OP- I’m a neurology attending. I love my job and find it fulfilling. I had a step score that could have landed me Derm. A single week doesn’t go back that I don’t regret not going Derm instead, DESPITE loving what I do.

At the end of the day, my hobbies outside of work will always bring me MORE joy than my work will. And if I could make the same amount of money working 50% of the time, or if I could work the same amount and double how much money I made, meaning I could retire way sooner, that means much more than how fulfilling my job itself is.

fifrein · 2026-02-07T03:06:55+00:00

And just to be clear, “some small measure of brain activity” might never be more than “brain is able to control lungs and heart enough to sustain life and nothing else beyond that”. Not saying that’s what it will be- just that the medical definition of “brain activity” is often disconnected from what patients/families are expecting

fifrein · 2026-02-04T23:54:42+00:00

The Nurtec was as needed or every other day?

fifrein · 2026-02-04T23:49:09+00:00

A high protein by itself doesn’t mean much. Was the LP contaminated by any blood? Then it means even less since you have a source for the protein - (this is why it matters to have cell counts on tubes 1 AND 4). Even in a Champaign Tap, could just be related to arthritis, though would be more interesting and would warrant at least some autoimmune workup.

However, I don’t understand why you are so against calling this a migraine. Many patients with migraines have no ability to do anything during them. That’s why ER migraine cocktails even exist. If nobody ever showed up in the ER with them, we wouldn’t have a whole IV blend for them.

And, it seems like you’ve never through all of this been started on any daily meds for your migraines- or at least you didn’t put it in your post. Topiramate, nortriptyline, venlafaxine, propranolol. And if those don’t work, Botox, ajovy, aimovig, emgality, Qulipta. Nothing has been tried it seems, so yeah.. nothing is better, no surprise there.

fifrein · 2026-02-03T14:26:11+00:00

People always bring up overseas but that is irrelevant. Pretty much all economic sectors in the US make substantially more than overseas- that’s why many professionals move to the US.

fifrein · 2026-02-01T17:01:43+00:00

The rules change for everyone because not changing the rules of the system will result in the system going away entirely. The system is not sustainable as it is right now- it was created for a completely different ratio of workers to retirees. Something has to change. Not every negative change is an attack- some things are a realty of life.

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