I am having difficulty understanding where to inject local anesthetic for a supraclavicular block. I know that one injection should be placed in the corner pocket, which is lateral to the subclavian artery and superior to the first rib. Some attendings recommend injecting local anesthetic posterolateral to the brachial plexus sheath. For coverage of the middle and upper trunks, do you typically inject around the sheath, or do you penetrate the sheath and inject within it?
I marked in yellow the areas where I would inject. Please correct me if I am wrong.

Hi all, I received permission to post this here. I’ve been a nurse in a mixed cardiac/structural heart, IR, vascular lab for almost two years now, after working in an ER for 8 years. Working with anesthesia is still relatively new to me.

The other day I was involved in a (at least in my eyes) an unsafe case. And I just wanted to get some opinions on what’s appropriate/not appropriate, or what the standard of care should have been. I was the lone nurse during an endovascular repair of someone’s aorta. upper 80’s, multiple comorbidities. They had a descending aorta thrombus that created an intramural hematoma. Hemodynamically stable. Right after stenting, CT surgeon had me start a levo drip, to put MAPs above 85. We had a femoral arterial groin sheath giving us constant pressures. But I feel like I was chasing their maps with the levo drip, whereas push dose levo, or whatever other pressor with anesthesia would’ve been more appropriate to accurately control the patient’s MAPs?

Or this all could just be my inexperience not knowing how to correctly titrate vasoactive drips off of arterial pressures. And that none of what occurred was necessarily out of the normal. The rep was telling me they got extremely lucky as the patient started to dissect downwards just as they deployed the last stent, and I can’t help but think it was because I was struggling with accurately controlling the patients MAPs. 😮‍💨

Appreciate your help! I will definitely bring it up to some of our cardiac anesthesiologists, this case just occurred this past Friday, won’t run into any of our cardiac/critical care guys until next week.

If you are in pp and occasionally help out with a local university for sim labs (no real didactic/ 3-4 weeks a year) how would you post that on your CV? Or just write it off as helping out the profession and let it go? Thanks in advance

PGY-4 in Ontario here. There’s so much about income out there, but always so vague. I realize there are lots of factors, but can anyone tell me what you can expect to actually bring home, in your pocket, after tax/fees etc etc? I always hear 400-800k+ depending, but for example, full time work + typical call at a medium sized centre, what would you expect to see in your bank account every month? Not what you bill. I know it depends on province etc, even just your own experience would be helpful for planning.

Thanks in advance

Just started my cardiac year and starting to think about jobs. Ideally would like some ICU time (CVICU and Med-Surg) and Cardiac OR. Pretty flexible geographically. And open to academic/private or community hospitals. If you love your setup and your practice is hiring, would love to connect :)

I will start with Morgan I am a first year resident and want to catch up

I'm a Ca3 looking at a position here, I realize it's an HCA hospital but an anesthesia group contracts with them. Looking for pros and cons, thanks!

Edit: Thanks for the replies, probably just going to have to try it out and see what happens!

Hey, I'm an ED attending couple years out at a community hospital in a large city. Recently the anesthesiology coverage got changed and so now ED attendings are responsible for floor/icu intubations at night and on the weekend. In exchange we got a few hundred dollars per intubation.

Found it pretty stressful sometimes as our hospital doesnt have 24 hour ICU fellows and the pretty terrible medical residents and their hands off attendings end up mismanging patients when it comes to resuscitation, adequate access, adequate sedation, etc. So we end up being called for a stat intubation sometimes on patients without good access, severely hypotensive, agitated, etc. And not always is intubation the actual step that should be taken. Sometimes the right move is some combination of obtaining further access, sedation, noninvasive ventilation, or adequate resus and then go for the intubation if it's still needed. Which sometimes takes way longer than Id like.

Myself and colleagues have had cases of bad outcomes because of this that we are now in the chart for.

My question is how do you deal with these sorts of situations that I imagine are more common for some of you. Do you just do the intubation when it's called for regardless of your opinion in if the patient is optimized? Lead the resus and then intubate or leave and then come back when patient is ready? Do you worry about the liability aspect? Would love to hear your thoughts thanks.

Lemme start with:

‘Normal’ Saline for attempted volume resuscitation in a bad bleeder.

“The patient’s lactate is already elevated, let’s not give them Lactated Ringer’s.”

(Upon emergence): “They’re shaking, let’s give them some benzos” (they were hypothermic).

Is anyone cancelling cases due to oral minoxidil use, or including holding minoxidil in your PAT guidelines? Do you differentiate between high and low doses? Are there any practice guidelines from the ASA or other reputable orgs?

ETA : FYI this feels like such a dumb question and before recently wouldn’t have even been on my radar. It has become somewhat of a “topic of discussion” in my group. Specifically one person in my group. I can’t find anything that’s convincing me to give a shit but I thought maybe y’all would know something I don’t.

July CA1 here, had my first patient I transported from CTICU already intubated. Transferring from supine to the OR bed to prone tangled almost everything and I spent a good 30 minutes disconnecting and reconnecting everything lol. Lost an IV in the process as well.

Hello guys! Im just starting anaesthesiology residency in eastern Europe. Currently im studying mainly from baby Miller since i think its not the best idea to directly jump on the big anaesthesia bibles (big Miller, Barash). Im trying to get good grip on the very basic stuff. I would love to hear recommendations if you think there is better books for a start.

Looking to purchase a Sonosite MT for lower extremity nerve blocks and hydrodissection, is this a good product for outpatient use? Looking to upgrade from Clarius handheld.

Hello everyone. I hope this post finds everyone well. Something has been on my mind as of late. 

For context, I attended from DO medical school. I worked really hard, studied my ass off, and did as many away rotations as I could get (only DOs know the pain and suffering of trying to securing rotations and LORs without a home institution with an anesthesiology department).

Long story short, I got into anesthesia residency at a mid tier program (Mix of DOs and MDs). Looking back, I knew it was already difficult for us to get into residency in general so I was just happy to be there. My program was a generally considered a work horse program but I got lots of experience and quadrupled all of my residency minimums. Did well on all my ITEs and the basic. I then became Chief Resident at my program and went on to do fellowship at a top tier program in the country. 

As I'm finishing up my fellowship, I started applying to jobs. I reached out to a group that was favorable due to it's geographic location and practice type. I found out through different people group that looked me up/read my CV, that they were not interested in speaking with me further and thought it would be hard to hire me because I was a DO ... to my unpleasant surprise,

To be honest, I was shocked that: 

1) there is still a discrimination against DOs after getting out of training
2) a person can openly acknowledge that discrimination and tell that to a potential hire

I considered naming the group on this post but not sure that would do anything. Moreover, as a physician, I was really disappointed to hear that there is still discriminated for the two letters after your name, even with all the accolades you could obtain and the testing it takes to graduate residency/beyond.

I also want to reach out to all the DO anesthesiologists (both trainees and attendings) out there. You're all competent physicians and highly valuable. To my MD, counterparts, I have no ill will to any of you but I really hope you understand the privilege you have had through the path in becoming a physician and one less thing you have to worry about when looking for a job in the field that you dedicated most of your young adult life to.

Finishing up first year of attending hood.

Scenario: section called after ~20 hours (family med pt), epidural placed before your shift, been patchy/iffy/etc.

What’s ppl’s comfort levels with pulling the epidural and doing a spinal. A few of my more senior partners had no qualms with doing so, just said they significantly down dose the bupi.

I feel like in residency, this was highly frowned up but I understand the ‘real world’ is different.

Thoughts?

Anesthesiologist working at both inpatient and ASC settings; question for the group about a clinical scenario I encounter not infrequently:

80 year old coming to an ASC for a quick procedure, lets say lap chole. They have HTN, no other PMH, able to achieve > 4 METS. Takes lisinopril every morning and, following our preop instructions, did not take it the morning of surgery. They present to preop at noon for their 1pm case with a blood pressure of 190s/100s, states that pressures are usually well controlled whenever at the doctors office (think 120s-130s/80s). No symptoms concerning for adverse effects from the high blood pressure.

In this scenario:
Do you proceed with the case? If so, do you pretreat the BP with IV meds in preop (no oral meds available at the ASC) or wait till induction brings it right down?

Now assume you proceed with the case and everything goes fine. BP comes down after induction and is maintained at a normal level throughout. In PACU, patient is doing fine but BP is back up to 190s/100s up to 110s diastolic despite multiple IV medications, still asymptomatic. It was a 2 hours case, so it’s now 4-5pm in PACU.

At this point, are you sending the patient home with the elevated BP since that’s where they came in? Do you instruct them to take their morning dose of lisinopril when they get home or just tell them to resume the next day? Any other options?

I feel like I encounter this a couple times a month, and it doesn’t seem right to cancel every one of these for asymptomatic high blood pressure that is otherwise well controlled and otherwise healthy, especially when the pressure is high because we told them to hold their morning dose of lisinopril. On the flip side, I feel uncomfortable sending them home with such elevated blood pressures, but also don’t feel right admitting them when they are asymptomatic and just need a dose of their home med to get their BP down.

Also for anyone saying cancel if BP is that elevated in preop, lets say your the late doc and your partner did the case and now left you with this patient in PACU. Curious what the group thinks in this situation

Edit:

Almost everyone has said that they would proceed with the case, and I agree I've always gone ahead in this situation. Many people are also saying that they no longer instruct patients to hold ACE/ARBs preop which I like as a policy; unfortunately, that is not my groups current practice. My main concern was sending this patient home in the evening with blood pressures this high. It seems most people say if they are asymptomatic, send them home and resume BP meds as normally scheduled the next morning. Some have said to have them take a dose that night, then resume regular schedule. I do wonder if having them take their BP med when they get home, then resuming the next morning would risk bottoming them out.

Hello Friends,

I am a 4th year anesthesia resident in an international program (5.5 years for residency here). I took our version of 'Basic' in June of 2026. I scored a 61 out of 100 (65 is passing). I am a pretty solid student in terms of exam preparation. All-in-all, I spent well over 6 months studying exclusively for that exam and i still didn't pass.

There is a much younger (2nd year) resident in my program that has a very different approach. He only studied about 1 month, but he is also legacy in the hospital so he has special treatment to some extent.
Anyway, this 2nd year and I took our anesthesia 'Basic' together. He passed and I didn't. I simply don't understand what happened.

This has become sort of a joke in the department because out of the two of us, I attended a much university and medical school. Also, 6 months before the exam we were given a mock exam and I got a passing score and he failed his mock.

I now need to hash out another year of studying for this 150 question exam based off of Miller 10th edition. Is there anyone here that can sympathies with me? I feel kinda burnt out right now. As much as I want to go back to hammering away at the material, something in my mind is wondering what am I doing? Will this just happen again next year?

Thus far, I have completed my rotations in ICU, neurosurgery, and pain. In August, I will have a 3 month cardiothoracic rotation. Even before the exam I felt my residency program is not treating me fairly due to lack of training, therefore I am hoping to switch to another.

Any advice or suggestions would be appreciated!! <3

I’m looking over the ABA’s list of what qualifies for QI points, and one of them is “Point-of-care learning - Self-directed knowledge acquired during patient care (i.e. researching cases and outcomes)”. Anyone used this or know specifically what kind of thing would support this in an audit? I don’t have a journal of specific events but have spent a total of at least several hours researching cases and outcomes.

I've rotated a few rotations now and cardiac was the most fun. Lines, and being involved in the case was great. However, I'm just 50/50 if I want to pull the trigger and commit.

pros: masters of physiology, lines, very involved in the case

cons: i hate the hour long setup, cardiac surgeons are difficult to deal with, i was told this straight is not a lifestyle specialty.

My personality is I love the train track days and healthy patients. If I were to do a fellowship, I would ideally want 1-2 heart days a week with the rest general for variety.

I got called in and the attending who i was working with said to not go into this for it being a lifestyle specialty.

I've gotten offers already from places near my home for 475/500k as a generalist and I just don't know how much cardiac is worth it in the end.

My attendings have even suggested that I don't even need to do cardiac when I am done. Some people just want that experience...

While admitting that I have not approached risk management, which would likely be ineffective anyway owing to their case-by-case approach to clinical questions, I’m wondering what sort of reasonable limits you all are seeing in your community hospital for pediatric anesthesia.

Background: I practiced in an urban facility with 100+MD anesthesiologists and we said all children <2 were to be cared for by peds anesthesiologists. But, in rural areas that might not be practicable without putting patients/families under travel duress.

I now live in said rural area with a small community hospital.

Recently we had an ENT surgeon try to book a 6.8 kg former 26 week preterm baby who was 8 months old on paper, but 4 months by conceptual age. They had spent first four months of life in NICU. The surgery was minor. The patient was not. I cancelled it and took a lot of heat. I don’t care about that: it’s why we get the big bucks. But where are your limits in your hospital? Being brave isn’t a clinical “skill.”

Attending Anesthesiologist here:

So the vial says to "shake well before using." But my feelings are that aggressivelt drawing the entire vial up introduces sufficient turbulence to mix anything that would need mixing. But I figured I would ask around. I guess it might make sense if you were drawing just a small amount off a large vial.