Bitterbarn’s Weblog

aka “The Bull” (some content not suitable for children or religous zealots)

10,000 Hits woot woot.

     Not that I check every second. But I happened to notice that yesterday my blog finally hit the 10,000 Hits mark.  What a glorious time in our nations history this is.  Why, I remember it like it was only a year ago that I was writing my first post about having to shop with my wife to pick out a bra.  Since that time the Blog has taken on a life of its own, always “keeping it real”.  Blogs and Blogging in general has gained so much popularity so that everyone whose anyone has a blog.  Even though some of the time I think. “some people”shouldn’t be allowed to voice their opinion publicly.  Most blogs I’ve noticed are of the Christmas card type though which I enjoy checking very often.

    Anyway I was up all night and this blog posting is horrific.  Thanks for your continued interest about what I think and say. I will continue to try and keep it real by bringing in stuff that’s awesome.


    one last Gigantic thanks to the administrators at Texas Tech University; specifically the Anesthesia department.   I thank you for your blinding Ignorance.  The department chair and the school of medicine dean have showed me and 8 of my colleagues a new level of business ineptitude.  For  without your frail inabilities; I and my friends would not be in the situation we are in  now.  The best jobs of our lives. We had no Idea we were providing you with free Anesthesia. 🙂

September 5, 2008 Posted by | Uncategorized | , , , , | 1 Comment

Over Trained and not missing it.

What an eye opener I’ve had. Sometimes, When wondering when my paradigm will shift again; I imagine myself a well frog. I think about the well frogs often . The well frogs reside in the safety of a kingdom that is all theirs. Even while living in the dank and darkest recess, they are king of their Domain; and the asset of safety is the crown jewel.

I recently left my well, and have discovered the ocean. The journey from well to ocean is scary and fraught with peril. There is failure to be had.

OK time for Confucius to take a rest.

Anesthesia these days comes in many flavors. ok three flavors. When you next have an anesthetic it will come in one of the following three forms.

1. and Anesthesiologist; MD trained will preform your anesthetic by himself. He will bill your insurance and you will pay him. He alone will be responsible for your safety throughout the procedure.

2. A Nurse Anesthetist (CRNA); Nurse trained will perform you anesthetic by himself. He will bill your insurance and you will pay him. He alone will be responsible for you safety throughout the procedure.

3. ACT or Anesthesia Care Team; In this instance Both an Anesthesiologist and a Nurse Anesthetist will provide your anesthesia; (theoretically in tandem) This model is touted as the most safe because; as with all things two heads are better than one. Your insurance will be billed about 8% more for this duo but you may decide it worth it.

Millions and millions of dollars are thrown at lobbyist each year to protect both these professional from being “gobbled up” by the other. Almost no other professional “turf battle” consumes more money and time than this one.

My experience;

I am a Nurse Anesthetist and I acknowledge my bias; I was trained in the house of nursing where the patient is the center of the caring model. I only realize now that my training is unique. Though I have my roots in nursing I have spent the last 5 years in a medical anesthesia residency program. When I first came on board they were very short handed for labor so as a nurse anesthetist student I was thrown into a mix of Anesthesiology residents. I did the same cases they did, attended the same conferences they did and when I graduated, I stayed on as faculty in the School of Medicine and continued the identical “clinical training” as my physician counterparts. “Hell”, comes closest to describing my experience/training in these years. As staff we practiced the ACT model. A model in which one Anesthesiologist “presides” over 4 (ideally) nurse anesthetists. It is often stated in our craft that this model is the “MOST SAFE”. We are made to believe that it is not because Anesthesiologists are soooo much smarter than we are but rather because there is always safety in numbers. I wondered if that was some kind of sweet lullubaye sung to our conscious. Anyway, I have moved on now and am now practicing in the model of nurse anesthetist in “solo” practice. Incidentally, this is the most commonly type of model practiced in our country today. 65% of all anesthetics are by nurse anesthetist in solo practice.

In hind site I now believe the Anesthesia Care Team is the least effective, safe and economic way of delivering anesthesia. When an Anesthesiologist and Nurse Anaesthetist work together they each practice in a false sense of security.

Some patients are at higher risk than others for anesthesia as example; the pediatric patient with a cold or fever, patients who recently have had chest pain, certain disease states that put patients at risk for certain types of anesthesia. When these unfavorable conditions present themselves in the ACT ;each of the professionals may have a tendency to lapse into complacency with the ever present sub-conscious plan that if something were to go “wrong” one would simply blame the other for any resemblance of malpractice or negligence. WHEREAS, when a provider is on their own to provide anesthesia. The sense of responsibility and culpability is heightened and the above mentioned cases are treated with a far more conservative approach.

Both types of professionals are very good at their craft, each is capable of performing anesthesia and rescuing patients found in 98% of our hospitals and surgical centers. In my unique training experience I feel like I can certifiably say that there is a component of education missing in the medical model. It is intangibleand unexplainable; the years of nursing in critical care are simply irreplaceable by any amount of time or rotation in an internship. On the other hand an anesthesiologist my argue that my education as far as disease process and physiology is laking compared to his. Their is something to that argument I would concede that when it comes to the kind of fungus you can get from a hot tub, or what kind antibiotic I should prescribe for your chlamydia i am completely at a loss.

IN SHORT my new paradigm is that Anesthesiologist should work alone in their practice and Nurse Anesthetist should work alone in their practices. I have watched the ACT cost tax payers Millions over the last few years and this does not happen otherwise.

6/23/08 disclaimer; if you post a lie or attack what I have stated is my personal paradigm you will be deleted. Otherwise, all are welcome to contribute.

June 23, 2008 Posted by | Uncategorized | | 13 Comments


I wish I new a single surgeon with a tenth the talent these guy’s got.

March 17, 2008 Posted by | Uncategorized | , | 1 Comment

Dude, read my blog… maaannn

well, I am sorry I have been delinquent in my blogging as of late. To be honest I came into a creative slump; and was waiting. Last week, I was reminded of an old corollary of mine.

Its the Dude/man command buffer. This is a great piece of wisdom sure to make all your communications greasy smooth. As human beings we are saddled with the unbearable duty to communicate. Personally I wish we could telecommunicate. It would be man-bliss to just go around not saying anything and yet knowing all things. I am sure that if we could telecommunicate; our wives would still verbalize their needs just for fun:) (is telecommunication the right word?)

Ok back to the Dude/man command buffer. The next time you have to give a command to a co-equal ie your friend, spouse, co-worker or sibling, simply say dude in front of the command and man at the rear. You will find that you can get anyone to do anything if you do this and they will not esteem thee to be their enemy. example:

example A

1) Turn of the lights!!!

2) Dude; Turn of the lights man.

example B

1) stop touching me !!!

2) Dude, Stop touching me man

example C

1) Get out of this bed and go feed you children some breakfast, get them ready and take them to school.

2) Dude,, get out of this bed and go feed you children some breakfast, get them ready and take them to school. man…

example D

1) Don’t smoke in the house

2) dude, don’t smoke in the house man.

Now, the caveat is this. Notice in my qualifying statement I said it had to be a co-equal. The command buffer doesn’t work on kids or those who fancy themselves to be above you (funny thing about that). I tried the command buffer as a matter of shear second nature on a surgeon last week. Which category do you think he falls into. He is also elderly; so maybe I should ask myself next time “can this person check their own email”? that would be a good litmus test to go along with the command buffer. needless to say, the surgeon did not feel buffered at all.

January 23, 2008 Posted by | Uncategorized | , , | 4 Comments