After Death in the GI Suite, Patient's Family Sues CRNA

[TwilightDoc01]

No way.

Plenty of nurses who have nothing to do with the military have this mentality. Many seem to be male and many seem to be recent graduates.

The vast majority of nurses I work with are a pleausre to deal with and we all get along very well.

The "militant" subset is very small however this mentality appears to drive the AANA.

YOu are definitely correct that they are Male.

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[jwk]

The surgeons have other work to do.



Seriously, you'd rather have an IJ placed by a 19-year-old medic with the equivalent of EMT training and ZERO experience with lines? Isn't that taking the CRNA turf war a little bit far?



It's the exception, not the rule, for GMOs to be colocated with surgical teams. Even when they are, hanging out at the FRSS isn't their primary duty. During my 2nd deployment as a GMO, the majority of my time during operations was spent doing echelon 1 duty (frequently watching casualties overfly me straight to the FRSS).



Who said anything about TLCs? Yeah yeah, the 20 cm 18/20 gauge tube you get from a TLC isn't appropriate; a pair of 14s is better for volume. But are you really arguing that big neck lines don't have a place in trauma?




They will never do that. If we didn't train CRNAs, they'd simply accept the consequences of less capable care from CRNAs in combat zones. After all, the Feres doctrine grants absolute immunity should there be an adverse outcome. Whether we teach them or not, there will come a day when they're called upon to put something large in an IJ. Seems like the right thing to do is try to minimize the chances they'll drop a lung or dilate a carotid. If the patient dies the military will chalk it up to a combat death.

Only we will be wondering if a little less political grandstanding could've helped avoid a procedure complication.



No, the argument is substantially different - and that's the point of my posts here.

The argument against teaching CRNAs in the civilian world is equal parts politics/turf and quality of care.

Those economic and political incentives aren't part of the equation in the military. You think some wounded lance corporal who shows up at a FRSS staffed by a CRNA is going to be comforted by the knowledge that military doctors withheld training from that CRNA for turf protection reasons?

The military makes a number of compromises regarding the standard of care available in forward positions. CRNA vs anesthesiologist is only one of them.

If I was a civilian I'd decline to teach CRNAs out of professional self-preservation. In the military I personally won't make that stand.

I'm glad someone on this thread has some common sense and a real-life-experience perspective. Some of you are TOTALLY off the wall with your political grandstanding. Coastie - medics can do central lines but not anesthetists? And seriously, IlDest, you "usually don't let the CRNAs even put in IVs" ? You gotta be friggin kidding me.

A LOT of anesthetists, both CRNAs and AAs, put in central lines and swans, and spinals and epidurals every day, including some that work in practices with some of the ASA officers. In an ACT practice, the anesthesiologist can decide whether or not they think that is appropriate or not. You may think that's fine, you may not. If it's YOUR practice, then by all means you can make that decision. But for many of you who have NO real-world experience, and/or NO taste of life outside of academia, I'm sorry, you just don't know what the hell you're talking about.

Whether in the civilian world or the military, there has never been, nor is there every likely to be a time when every anesthetic will be administered by an anesthesiologist. Even countries that have traditionally been all-MD are looking at or trying varying levels of non-physician anesthesia, including Canada and Great Britain. Too many people, too many procedures requiring anesthesia, and far too few providers in many cases. Simple fact.

 

[Gastrapathy]

Interesting thread with a number of issues. Not going to respond to the typical GI bashing but do want to make a couple of points.

The vast majority of endoscopic procedures do not need an anesthesia provider of any type. The cost is simply untenable. The anesthesiologist bills twice what the gastroenterologist bills for the procedure. Moderate sedation with versed and demerol (gasp) is safe and effective in the correctly selected patients. The transition (particularly in the northeast) away from moderate sedation could mean the end of screening colonoscopy because medicare has said that as soon as >50% of procedures are performed with propofol sedation, they will review reimbursement.

Sedation for patients with significant comorbidities and, particularly, OSA is tricky. Some MDs are definitely better at it than others. We share the same space as the anesthesiologist some of the time. Doctors who don't do a lot of this type of procedure are always uncomfortable and, sometimes, I'd rather work (and it was safer) with a CRNA who does this all day than the MD who has the dreaded "endo day". Making things worse, since anesthesiologists don't generally like doing this, we don't exactly get the cream of the crop.

For someone to die from a screening colonoscopy is an absolute disaster. This is the sort of patient that I talk to about unsedated or minimally sedated colonoscopy. Its done around the world, its safe and it just requires a little more finesse.

 

[pgg]

How many times have you had a CRNA outrank you? Who is in charge then? Its gotta be awkward at times.

There's certainly potential for problems there, and I have heard some horror stories. My personal experience post-residency has been fine. I did my PGY1 year and PGY2-4 years at different hospitals; one had an absolutely poisonous atmosphere surrounding CRNA-MD conflicts, the other was very smooth (though occasionally there was friction).

At present I'm an O4 at a very small Navy hospital - just me and three CRNAs. One of them is an O5 and has actually been the department head since I arrived last July. She just deployed and I took over the DH job. It's a fair amount of administrative work - can't say I really wanted it, but now it's mine. Yay me.

She and I had no problems arising from CRNA vs anesthesiologist, O5 vs O4, or department head vs worker bee issues. She didn't assert her rank and try to tell me how to do my cases. I didn't try to medically direct her or the other CRNAs' cases, though I helped when they asked. There weren't any military-specific duties that got inappropriately shoveled onto me. Basically all four of us would go to work, do our work, and then go home. I genuinely like and respect all three of them as people and anesthetists, and never got the idea that they didn't value my input.

Stay safe.

Thank you. The great irony in this is that the Navy is very unlikely to deploy me while I'm stationed at this hospital, primarily because doing so would deprive the hospital of its only anesthesiologist and leave the CRNAs alone.

Those "military CRNAs" are the ones that usually come out into the civilian world and become the "militant' CRNAs. They then go on to brag that in the military "I put this line in and that line in, we're just as good as anesthesiologists".

Again I don't entirely disagree with you. I know that lots of uppity militant CRNAs point to the military as "proof" that "unrestricted independent practice" exists and is safely functioning. But usually it's clear from their misconceptions, false assumptions, and warped depiction of actual military CRNA practice that they themselves are not former military ... or are deliberately lying.

 

[IlDestriero]

And seriously, IlDest, you "usually don't let the CRNAs even put in IVs" ? You gotta be friggin kidding me.

No joke or exaggeration. I work at a Children's Hospital. When I work with them, they do the mask induction and I do the IV. They rarely do an IV of mine. I always place any Alines, central lines or blocks. I like working with them, but lines and blocks are skills CRNAs don't need. I don't think ANYONE here lets them place any lines or blocks. And yes, we do nearly all the IVs as well. Not because that's a skill that they don't need, but because I can do it faster, with fewer sticks and go home a few minutes earlier. A little irony is that when I work alone, the OR nurses place almost all of my IVs.
The military was a completely different situation. I helped the CRNAs with block skills and practiced difficult airway techniques, etc because it was all about giving the best possible care for the troops. Period. When they deploy they're on their own. Right or wrong, they've got to be able to do the job, and do it well. If they suck, the troops get hurt, or worse. One of the CRNAs asked me if she could do a fiberoptic intubation with me a couple weeks ago. Ahhh, no.

 

[deleted126335]

Interesting thread with a number of issues. Not going to respond to the typical GI bashing but do want to make a couple of points.

The vast majority of endoscopic procedures do not need an anesthesia provider of any type. The cost is simply untenable. The anesthesiologist bills twice what the gastroenterologist bills for the procedure. Moderate sedation with versed and demerol (gasp) is safe and effective in the correctly selected patients. The transition (particularly in the northeast) away from moderate sedation could mean the end of screening colonoscopy because medicare has said that as soon as >50% of procedures are performed with propofol sedation, they will review reimbursement.

Sedation for patients with significant comorbidities and, particularly, OSA is tricky. Some MDs are definitely better at it than others. We share the same space as the anesthesiologist some of the time. Doctors who don't do a lot of this type of procedure are always uncomfortable and, sometimes, I'd rather work (and it was safer) with a CRNA who does this all day than the MD who has the dreaded "endo day". Making things worse, since anesthesiologists don't generally like doing this, we don't exactly get the cream of the crop.

For someone to die from a screening colonoscopy is an absolute disaster. This is the sort of patient that I talk to about unsedated or minimally sedated colonoscopy. Its done around the world, its safe and it just requires a little more finesse.

I had mine with demerol and versed by the GI doc. A little uncomfortable, but not bad.

 

[pd4emergence]

Interesting thread with a number of issues. Not going to respond to the typical GI bashing but do want to make a couple of points.

The vast majority of endoscopic procedures do not need an anesthesia provider of any type. The cost is simply untenable. The anesthesiologist bills twice what the gastroenterologist bills for the procedure. Moderate sedation with versed and demerol (gasp) is safe and effective in the correctly selected patients. The transition (particularly in the northeast) away from moderate sedation could mean the end of screening colonoscopy because medicare has said that as soon as >50% of procedures are performed with propofol sedation, they will review reimbursement.

Sedation for patients with significant comorbidities and, particularly, OSA is tricky. Some MDs are definitely better at it than others. We share the same space as the anesthesiologist some of the time. Doctors who don't do a lot of this type of procedure are always uncomfortable and, sometimes, I'd rather work (and it was safer) with a CRNA who does this all day than the MD who has the dreaded "endo day". Making things worse, since anesthesiologists don't generally like doing this, we don't exactly get the cream of the crop.

For someone to die from a screening colonoscopy is an absolute disaster. This is the sort of patient that I talk to about unsedated or minimally sedated colonoscopy. Its done around the world, its safe and it just requires a little more finesse.

I agree with you that we are not needed for most ASA 1 and 2 cases. But how many times have you called us in for that 22 year old who you have given 10 of versed and 200 of demerol to who now thinks they are at a frat party? I wish I could never do an endo again but I would rather get involved early than have to come in and clean up a mess. Where do you live? (just a rhetorical question) I would like to come live there and do nothing but endos all day long. In my state we make about what you would pay your plumber for a service call for an endoscopy. This is less than half what the GI guys get reimbursed (this is pretty much across the board, all insurance carriers including medicare). I have no problem with the percentages. I have no problem with how much somebody else makes off of a procedure. I am just pointing out that your numbers are probably off. My practice does not make much off of endos, I work in a medical direction practice. By the time we get done paying our CRNA's there is just not that much left over. Maybe it just the state I live in.

 

[jwk]

No joke or exaggeration. I work at a Children's Hospital. When I work with them, they do the mask induction and I do the IV. They rarely do an IV of mine. I always place any Alines, central lines or blocks. I like working with them, but lines and blocks are skills CRNAs don't need. I don't think ANYONE here lets them place any lines or blocks. And yes, we do nearly all the IVs as well. Not because that's a skill that they don't need, but because I can do it faster, with fewer sticks and go home a few minutes earlier. A little irony is that when I work alone, the OR nurses place almost all of my IVs.
The military was a completely different situation. I helped the CRNAs with block skills and practiced difficult airway techniques, etc because it was all about giving the best possible care for the troops. Period. When they deploy they're on their own. Right or wrong, they've got to be able to do the job, and do it well. If they suck, the troops get hurt, or worse. One of the CRNAs asked me if she could do a fiberoptic intubation with me a couple weeks ago. Ahhh, no.

There's a difference between "I don't let them do IV's", and "I usually do the IV's because they're managing the airway".

 

[IlDestriero]

There's a difference between "I don't let them do IV's", and "I usually do the IV's because they're managing the airway".

Really? I don't let them do IVs. The reasons are irrelevant. If the patient needs 2 IVs, I still do both. They can chart. If I'm having trouble with a hotel NICU player, they're welcome to help, while I call another anesthesiologist for assistance and the ultrasound.
Either way, they're not doing my IVs. They can practice that when they moonlight.

 

[SleepIsGood]

Really? I don't let them do IVs. The reasons are irrelevant. If the patient needs 2 IVs, I still do both. They can chart. If I'm having trouble with a hotel NICU player, they're welcome to help, while I call another anesthesiologist for assistance and the ultrasound.
Either way, they're not doing my IVs. They can practice that when they moonlight.

nice....I agree with this. Nice to see someone's keeping the midlevel providers at bay. They really dont need to be 'enlightened' more than how to chart.

 

[Gastrapathy]

I agree with you that we are not needed for most ASA 1 and 2 cases. But how many times have you called us in for that 22 year old who you have given 10 of versed and 200 of demerol to who now thinks they are at a frat party? I wish I could never do an endo again but I would rather get involved early than have to come in and clean up a mess. Where do you live? (just a rhetorical question) I would like to come live there and do nothing but endos all day long. In my state we make about what you would pay your plumber for a service call for an endoscopy. This is less than half what the GI guys get reimbursed (this is pretty much across the board, all insurance carriers including medicare). I have no problem with the percentages. I have no problem with how much somebody else makes off of a procedure. I am just pointing out that your numbers are probably off. My practice does not make much off of endos, I work in a medical direction practice. By the time we get done paying our CRNA's there is just not that much left over. Maybe it just the state I live in.

I don't call anesthesia in during a case unless I'm in trouble and need help (basically a code). If I try to sedate someone and can't get there safely, I just reschedule and let anesthesia preop them, etc. Its really not an appropriate expectation to continue the case at that point.

As for the economics, my numbers may be off and are from fellowship (but they were what both the chief of GI and the anesthesiologist stated). Now I'm in the .mil and find our CRNAs militant, inexperienced and annoying.

 

[jwk]

nice....I agree with this. They really dont need to be 'enlightened' more than how to chart.

Startlingly unrealistic and unreasonable.

 

[SleepIsGood]

Startlingly unrealistic and unreasonable.

Well it looks like ILDestro does it all the time...

It takes cajones to do what he's doing and 'regulate' the midlevels. Obviously since you are a midlevel you would be against this. But the reality is that. I for one would NEVER let a CRNA do a block or put in an invasive monitor period. These are tasks for a physician. Physicians shouldnt be lazy and let others do what they ought to be doing....it's better for the patient.

 

[greatwhite]

no, it does not take "cajones" it takes an unreasonable and irrational attitude, note he has no problem letting RN's place the IV just CRNA's.

This thread has demonstrated the most irrational irresponsible unrealistic attitudes of a few zealots that have absolutely no idea of what happens outside of their own little world, you are truly a disgrace to the medical profession.

 

[pd4emergence]

I don't call anesthesia in during a case unless I'm in trouble and need help (basically a code). If I try to sedate someone and can't get there safely, I just reschedule and let anesthesia preop them, etc. Its really not an appropriate expectation to continue the case at that point.

As for the economics, my numbers may be off and are from fellowship (but they were what both the chief of GI and the anesthesiologist stated). Now I'm in the .mil and find our CRNAs militant, inexperienced and annoying.

I wish our GI guys had your attitude. We would try to tell them that coming in at the middle of the case was not ideal. Their response was to try to have us kicked out of that particular surgery center. So now we do all of them. Business is business. Now they do 5-8 more endos a day and seem reasonably happy for now. Academic folks rarely know or care how much a particular procedure pays. The anesthesiologist might have been telling you that so he would not have to do too many endos.

 

[IlDestriero]

no, it does not take "cajones" it takes an unreasonable and irrational attitude, note he has no problem letting RN's place the IV just CRNA's.

This thread has demonstrated the most irrational irresponsible unrealistic attitudes of a few zealots that have absolutely no idea of what happens outside of their own little world, you are truly a disgrace to the medical profession.

I'm no zealot, and you don't know what you're talking about. You read what you want into what I wrote. When I'm alone, managing the airway, the nurse places the iv (usually). I'd rather have them place the IV than try to manage the airway. Once intubated, I do any remaining lines, if any. When I'm working with a CRNA, I place all the lines. I do it because I can do it faster and better. Missed IVs may be no problem for many patients, but I think than they are a big problem with kids. The other 50+ anesthesiologists I work with all seem to practice the same way. I guess we're all zealots, right? We have a good relationship with our well paid CRNAs. Too bad that they can't see that we're really plotting their doom.
Get off your high horse troll and spare us your hyperbole. I'm also the guy that helped refine block and airway techniques with my military CRNAs and SRNAs. Well, look at that, I guess I'm more of a rebel traitor than a zealot afterall. Did you even read the thread? Guess not.

 

[greatwhite]

let me get this straight, a regular RN can place the IV but not a CRNA, if you taught military CRNA's how block and line up patients you know they can do it safely but in PP you are torqued over an IV.

Yupper makes sense to me.

 

[ProRealDoc]

let me get this straight, a regular RN can place the IV but not a CRNA, if you taught military CRNA's how block and line up patients you know they can do it safely but in PP you are torqued over an IV.

Yupper makes sense to me.

Don't take anything personal. It's just business.

 

[IlDestriero]

Yes, it does make sense. This isn't the military. When I'm providing the anesthetic myself it is usually safer for the OR nurse to place the IV, though I have asked another anesthesiologist to help with known difficult IV patients. When I'm working as a team, I do it myself. I do it because I am free to, and see it as my responsibility and I'm pretty good at it. If the CRNA asked to place the IV, and it looked easy, I would probably let them place the IV (only). They don't ask. I guess we all want to be done quickly and leave early, and maybe we all recognize the senior staff anesthesiologist as the best guy for the job. All those extra minutes add up pretty quickly.
And, BTW, I do get torqued up about missed IVs. If we have to stick the child multiple times, parents WILL notice, and I make a point to apologise when I see them in the PACU. They understand, but I still feel bad.
See if you can twist that into some anti CRNA stance. Faster, safer and fewer attempts.

Out.

 

[GasEmDee]

Yes, it does make sense. This isn't the military. When I'm providing the anesthetic myself it is usually safer for the OR nurse to place the IV, though I have asked another anesthesiologist to help with known difficult IV patients. When I'm working as a team, I do it myself. I do it because I am free to, and see it as my responsibility and I'm pretty good at it. If the CRNA asked to place the IV, and it looked easy, I would probably let them place the IV (only). They don't ask. I guess we all want to be done quickly and leave early, and maybe we all recognize the senior staff anesthesiologist as the best guy for the job. All those extra minutes add up pretty quickly.
And, BTW, I do get torqued up about missed IVs. If we have to stick the child multiple times, parents WILL notice, and I make a point to apologise when I see them in the PACU. They understand, but I still feel bad.
See if you can twist that into some anti CRNA stance. Faster, safer and fewer attempts.

Out.

Makes total sense to me.

 

[Arch Guillotti]

If you feed the troll, burp it afterwards.

 

[Coastie]

jwk,

I don't want CRNAs trained in the military to then come out and destroy our profession. Giving our boys in combat sub-par providers instead of physicians is pathetic, and the gov't should do better. Corpsmen/PAs/surgeons/GMOs should be trained to do it. SRNAs in the military aren't any more or less capable of learning these procedures than the above folks.

They shouldn't be putting in lines in the civi world either. What, that's somehow the practice of nursing? Give me a break.

I think it's fine for AAs, but the attending should be the one who does it if at all possible.

I don't care if ASA officers are selling out their profession by letting others do the procedures in their practices: How do you think we got here in the first place?

I'm glad someone on this thread has some common sense and a real-life-experience perspective. Some of you are TOTALLY off the wall with your political grandstanding. Coastie - medics can do central lines but not anesthetists? And seriously, IlDest, you "usually don't let the CRNAs even put in IVs" ? You gotta be friggin kidding me.

A LOT of anesthetists, both CRNAs and AAs, put in central lines and swans, and spinals and epidurals every day, including some that work in practices with some of the ASA officers. In an ACT practice, the anesthesiologist can decide whether or not they think that is appropriate or not. You may think that's fine, you may not. If it's YOUR practice, then by all means you can make that decision. But for many of you who have NO real-world experience, and/or NO taste of life outside of academia, I'm sorry, you just don't know what the hell you're talking about.

Whether in the civilian world or the military, there has never been, nor is there every likely to be a time when every anesthetic will be administered by an anesthesiologist. Even countries that have traditionally been all-MD are looking at or trying varying levels of non-physician anesthesia, including Canada and Great Britain. Too many people, too many procedures requiring anesthesia, and far too few providers in many cases. Simple fact.

 

[Coastie]

Startlingly unrealistic and unreasonable.

So, what's reasonable jwk? All invasive procedures, ASA 1-6's, some slightly independant practice? I know you're AA, and AA's rock, but is the only line drawn that of supervision?

Dude, it's gotta stop somewhere.

 

[Coastie]

let me get this straight, a regular RN can place the IV but not a CRNA, if you taught military CRNA's how block and line up patients you know they can do it safely but in PP you are torqued over an IV.

Yupper makes sense to me.

Just another murse-anesthesia boy riled up..using the military as an excuse for the dismissal of the medical specialty known as anesthesiology.

Gotta love these guys.

 

[Mman]

http://webapps.aana.com/AccreditedP...vMenu_TSMenuTargetType=5&ucNavMenu_TSMenuID=6

Here is a link to the list of accredited CRNA programs. Through a brief search, I cannot find a single program that is less than 24 months. You'll see that 24-36 months is a more accurate description of the length of CRNA school.

They can post whatever they want, but of the 4 programs I know inside and out, 3 of them do not have accurate listings of program length on that website. For example, one lists "24 months" yet their first day of orientation is the 3rd week of August and their graduation is the 2nd week of May 2 years later. That sounds more like 20-21 months to me. I've also had students tell me they had 2-3 months off at the end of their program because of accumulated time off from earlier.

I mean really? They only work 3-4 days a week in the first place.

 

[jwk]

So, what's reasonable jwk? All invasive procedures, ASA 1-6's, some slightly independant practice? I know you're AA, and AA's rock, but is the only line drawn that of supervision?

Dude, it's gotta stop somewhere.

Didn't really intend on hijacking the thread, but Arch can always split it off if he likes.

AA's are committed to the ACT concept, with the anesthesiologist as head of that team. Probably not much disagreement there, right?

CRNA's, as far as the AANA and many individials are concerned, claim they should be able to do anything and everything in anesthesia. Total disagreement there I'm sure.

The reality is that all AA's work under the ACT mode of practice, and 2/3 of CRNA's do so at some widely varying level. That reality varies widely, based on local and regional differences, size of facility, academia vs private practice, etc.

As I stated before - if you're the boss, you of course get to call the shots. If IlDest doesn't want his CRNA's doing simple IV's on kids, that's his call, although I think that's patently absurd and I would personally never work under that type of control. I mean really - what takes more skill? Intubating a kid or starting an IV?

Whether you like it or not, CRNA's and AA's do SOME of what you would consider invasive procedures every day. I would assume just about all do arterial lines. Many put in central venous lines, including introducers and swans (part of the original AA concept was based on the need for personnel who were familiar and comfortable with invasive monitoring, something that was fairly new 40 years ago), especially those in cardiac and trauma centers. ALL of the AA programs (and I assume most CRNA programs) teach these skills at some level.

Likewise, many CRNA's and AA's perform some regional anesthesia. Spinals and epidurals would likely comprise most of those procedures, although some do other blocks as well. There is wide variation on the teaching of regional anesthesia skills in both CRNA and AA programs - some get a lot of exposure, some get very little.

The other reality is that both CRNA's and AA's administer anesthesia for all surgical specialties and ASA 1-6 patients. Hearts, liver transplants, complex peds, neuro, trauma - all of it done utilizing anesthetists. The difference comes in the level of supervision or medical direction involved. The higher the acuity, the more likely the involvement of an anesthesiologist, whether that means 1:1 the whole time, or present for induction/emergence/at intervals (as TEFRA requirements call for), or some other level of involvement. With AA's, there will always be an anesthesiologist involved with every case that we do. Unfortunately, some ACT practices only function until 7-3 M-F, and the other 128 hours of the week, the anesthesiologists happily let the CRNA's have it all. The CRNA's think that's great - because it's additional fodder for their concept that they CAN do it all, and it's one of the first things they point out when pushing the independent practice concept.

Regardless, the anesthesiologist at the local level should be able to make the decision how best to utilize the personnel he or she has available. My license allows me to "administer anesthesia" under the direction of an anesthesiologist, and perform all types of invasive monitoring. However, my medical staff job description can, and does, limit my scope of practice. At my current practice, I do arterial lines, no central lines, and the only regional I do is a Bier block. At my previous practice, I did tons of central lines including swans (which now seem to be a rarity), and a boatload of spinals (but no epidurals) because of our high caseload of lower extremity vascular procedures.

So - what crosses the line into the practice of medicine? I think clearly chronic pain management does. TEE, although probably performed by some anesthetists who have a basic understanding of the anatomy on the screen, should be in the physician's realm. And management/direction of the anesthesia care team clearly is from an anesthesiologist. The 7 parts of the TEFRA requirements, whether Medicare patients or not, are actually pretty reasonable, because they mandate involvement of an anesthesiologist with every single patient. I'm perfectly fine with that. Many CRNA's are not, but you would be surprised how many ARE, and in fact work under those guidelines every day.

At some point, you have to balance egos and chest-thumping, practicality and economic reality. There will never be enough anesthesiologists to do every anesthetic. But docs at the local level should be able to decide, within reason, how best to use the resources of the people they have to work with. There are a LOT of technical skills, including invasive monitoring, spinals and epidurals, and even kiddie IV's, that don't mandate a physician performing them, but at the same time, there is no substitute for a physician's judgment based on their knowledge and skillset.

 

[Coastie]

Refreshing read after spending day after day with militant crnas and the anesthesiologists who let them thrive.

Didn't really intend on hijacking the thread, but Arch can always split it off if he likes.

AA's are committed to the ACT concept, with the anesthesiologist as head of that team. Probably not much disagreement there, right?

CRNA's, as far as the AANA and many individials are concerned, claim they should be able to do anything and everything in anesthesia. Total disagreement there I'm sure.

The reality is that all AA's work under the ACT mode of practice, and 2/3 of CRNA's do so at some widely varying level. That reality varies widely, based on local and regional differences, size of facility, academia vs private practice, etc.

As I stated before - if you're the boss, you of course get to call the shots. If IlDest doesn't want his CRNA's doing simple IV's on kids, that's his call, although I think that's patently absurd and I would personally never work under that type of control. I mean really - what takes more skill? Intubating a kid or starting an IV?

Whether you like it or not, CRNA's and AA's do SOME of what you would consider invasive procedures every day. I would assume just about all do arterial lines. Many put in central venous lines, including introducers and swans (part of the original AA concept was based on the need for personnel who were familiar and comfortable with invasive monitoring, something that was fairly new 40 years ago), especially those in cardiac and trauma centers. ALL of the AA programs (and I assume most CRNA programs) teach these skills at some level.

Likewise, many CRNA's and AA's perform some regional anesthesia. Spinals and epidurals would likely comprise most of those procedures, although some do other blocks as well. There is wide variation on the teaching of regional anesthesia skills in both CRNA and AA programs - some get a lot of exposure, some get very little.

The other reality is that both CRNA's and AA's administer anesthesia for all surgical specialties and ASA 1-6 patients. Hearts, liver transplants, complex peds, neuro, trauma - all of it done utilizing anesthetists. The difference comes in the level of supervision or medical direction involved. The higher the acuity, the more likely the involvement of an anesthesiologist, whether that means 1:1 the whole time, or present for induction/emergence/at intervals (as TEFRA requirements call for), or some other level of involvement. With AA's, there will always be an anesthesiologist involved with every case that we do. Unfortunately, some ACT practices only function until 7-3 M-F, and the other 128 hours of the week, the anesthesiologists happily let the CRNA's have it all. The CRNA's think that's great - because it's additional fodder for their concept that they CAN do it all, and it's one of the first things they point out when pushing the independent practice concept.

Regardless, the anesthesiologist at the local level should be able to make the decision how best to utilize the personnel he or she has available. My license allows me to "administer anesthesia" under the direction of an anesthesiologist, and perform all types of invasive monitoring. However, my medical staff job description can, and does, limit my scope of practice. At my current practice, I do arterial lines, no central lines, and the only regional I do is a Bier block. At my previous practice, I did tons of central lines including swans (which now seem to be a rarity), and a boatload of spinals (but no epidurals) because of our high caseload of lower extremity vascular procedures.

So - what crosses the line into the practice of medicine? I think clearly chronic pain management does. TEE, although probably performed by some anesthetists who have a basic understanding of the anatomy on the screen, should be in the physician's realm. And management/direction of the anesthesia care team clearly is from an anesthesiologist. The 7 parts of the TEFRA requirements, whether Medicare patients or not, are actually pretty reasonable, because they mandate involvement of an anesthesiologist with every single patient. I'm perfectly fine with that. Many CRNA's are not, but you would be surprised how many ARE, and in fact work under those guidelines every day.

At some point, you have to balance egos and chest-thumping, practicality and economic reality. There will never be enough anesthesiologists to do every anesthetic. But docs at the local level should be able to decide, within reason, how best to use the resources of the people they have to work with. There are a LOT of technical skills, including invasive monitoring, spinals and epidurals, and even kiddie IV's, that don't mandate a physician performing them, but at the same time, there is no substitute for a physician's judgment based on their knowledge and skillset.

 

[IlDestriero]

... and even kiddie IV's

If you're better than I am, you can do them when you work with me.
It's not about control, it's about speed and efficiency (and fewer sticks). The standard practice where I am is that the CRNA manages airway, MD gets lines. The difficult airway may reverse these roles. In the really difficult airway patient (neonatal craniofacial, etc.), a fellow bumps the CRNA. If you don't like it, don't work here.
If you think that's control, you should see the Peds Cardiac ORs. The CRNA's sole job is to chart and hand things to the attendings, really. They're ridiculous. The Fellows don't do a whole lot more.
The AANA may say that XXX Children's Hospital uses CRNAs in most of their cases, even Pedi Hearts! BUT, that's not exactly true.

 

[IlDestriero]

Refreshing read after spending day after day with militant crnas and the anesthesiologists who let them thrive.

What's the deal with CRNAs that are "supervised" from home after hours?
When I was in the military, some of our CRNAs worked at these places on weekends or overnight. This was in CA, pre opt out. Always seemed like fraud to me, and probably against internal hospital policy. They didn't mind, but back at the big house there was someone to help them if needed (MD, resident, etc) there they were really on their own.
I think most CRNAs are perfectly happy in the ACT model. Where I work, 36 hours a week is full time, no call, no weekends. Leaves them plenty of time to pick up a few extra shifts a month in town and get the boat, benz, etc.

 

[fastosprintini]

it really blows my mind what some crna's think of themselves....
i 'm in this business for 19 years and still , when i am called for a stat c section and i stand in the elevator all alone , riding up to l&d , yes , i am scared out of my wits, when i am called to the er at 3 am because the er docs are having problems, again , i am scared , when the ruptured aaa, or the r/o epiglottitis consult arrives i am scared BECAUSE i know what might happen, some fools who are happy to play doctor on my license are not scared because they do not know....
most people in the biz, be it physicians or nurses are scared because they have have been humbled at some point in their anes. carreer and have realized how dangerous these things are , none of those touts crap like "independent" practice...
ok, rant over
fasto

 

[Arch Guillotti]

I don't consider this a rant at all and I agree with you 100%.

it really blows my mind what some crna's think of themselves....
i 'm in this business for 19 years and still , when i am called for a stat c section and i stand in the elevator all alone , riding up to l&d , yes , i am scared out of my wits, when i am called to the er at 3 am because the er docs are having problems, again , i am scared , when the ruptured aaa, or the r/o epiglottitis consult arrives i am scared BECAUSE i know what might happen, some fools who are happy to play doctor on my license are not scared because they do not know....
most people in the biz, be it physicians or nurses are scared because they have have been humbled at some point in their anes. carreer and have realized how dangerous these things are , none of those touts crap like "independent" practice...
ok, rant over
fasto

 

[Arch Guillotti]

What's the deal with CRNAs that are "supervised" from home after hours?
When I was in the military, some of our CRNAs worked at these places on weekends or overnight.

I think it was greedy sell-outs. It may be hard for some to believe but these type of arrangments probably aren't all that uncommon.

Non opt-out state, physician "supervises" from home while CRNA does case in the middle of the night.

 

[pgg]

it really blows my mind what some crna's think of themselves....
i 'm in this business for 19 years and still , when i am called for a stat c section and i stand in the elevator all alone , riding up to l&d , yes , i am scared out of my wits, when i am called to the er at 3 am because the er docs are having problems, again , i am scared , when the ruptured aaa, or the r/o epiglottitis consult arrives i am scared BECAUSE i know what might happen, some fools who are happy to play doctor on my license are not scared because they do not know....
most people in the biz, be it physicians or nurses are scared because they have have been humbled at some point in their anes. carreer and have realized how dangerous these things are , none of those touts crap like "independent" practice...
ok, rant over
fasto

In a way it's reassuring to hear the fear never goes away ...

The at-school-in-underwear nightmares I had as a kid seem to have been replaced with crashing-patient-and-a-locked-anesthesia-cart nightmares.

 

[GasEmDee]

it really blows my mind what some crna's think of themselves....
i 'm in this business for 19 years and still , when i am called for a stat c section and i stand in the elevator all alone , riding up to l&d , yes , i am scared out of my wits, when i am called to the er at 3 am because the er docs are having problems, again , i am scared , when the ruptured aaa, or the r/o epiglottitis consult arrives i am scared BECAUSE i know what might happen, some fools who are happy to play doctor on my license are not scared because they do not know....
most people in the biz, be it physicians or nurses are scared because they have have been humbled at some point in their anes. carreer and have realized how dangerous these things are , none of those touts crap like "independent" practice...
ok, rant over
fasto

Totally agree.

I met this one girl at a party who was a medical assistant that was applying for study to become optometry technician. She claims that the ophthalmologist let her do retrobulbar blocks. I expressed my amazement and discomfort at that idea. I asked her about complications. She blew it off. Her reply, as she flashed a big smile of confidence, was "It's no problem, I'm good."

Either she is lying about her involvement in these, or she has done so few that she has not had a complication, or she has really no understanding at all of the procedures and its risks. It is not about being "good." No matter how good you are, you WILL eventually experience a complication.

The point is, if you have an unsophisticated understanding of something, or if you are completely inexperienced in it, it is totally easy to be overconfident, i.e., you dont know what you dont know.

 

[Jay K]

it really blows my mind what some crna's think of themselves....
i 'm in this business for 19 years and still , when i am called for a stat c section and i stand in the elevator all alone , riding up to l&d , yes , i am scared out of my wits, when i am called to the er at 3 am because the er docs are having problems, again , i am scared , when the ruptured aaa, or the r/o epiglottitis consult arrives i am scared BECAUSE i know what might happen, some fools who are happy to play doctor on my license are not scared because they do not know....
most people in the biz, be it physicians or nurses are scared because they have have been humbled at some point in their anes. carreer and have realized how dangerous these things are , none of those touts crap like "independent" practice...
ok, rant over
fasto

 

[allopurinol]

it really blows my mind what some crna's think of themselves....
i 'm in this business for 19 years and still , when i am called for a stat c section and i stand in the elevator all alone , riding up to l&d , yes , i am scared out of my wits, when i am called to the er at 3 am because the er docs are having problems, again , i am scared , when the ruptured aaa, or the r/o epiglottitis consult arrives i am scared BECAUSE i know what might happen, some fools who are happy to play doctor on my license are not scared because they do not know....
most people in the biz, be it physicians or nurses are scared because they have have been humbled at some point in their anes. carreer and have realized how dangerous these things are , none of those touts crap like "independent" practice...
ok, rant over
fasto

Not to hijack your rant, but I went to the OR for a simple procedure and the anesthesia provider shot me a "who-the-hell-are-you-look." I introduced myself to him and the patient as "Dr. X, the resident physician working with Dr. Y." In turn, the anesthesia provider introduced himself as "Dr. Z." I noticed his badge and it had "John Doe, CRNA." When I shot him a dirty look, he quickly added "nurse anesthetist." The anesthesiologist never appeared.
Okay, I'm sorry that this turned into a hijack. I just needed to vent...

 

[WholeLottaGame7]

Totally agree.

I met this one girl at a party who was a medical assistant that was applying for study to become optometry technician. She claims that the ophthalmologist let her do retrobulbar blocks. I expressed my amazement and discomfort at that idea. I asked her about complications. She blew it off. Her reply, as she flashed a big smile of confidence, was "It's no problem, I'm good."

Either she is lying about her involvement in these, or she has done so few that she has not had a complication, or she has really no understanding at all of the procedures and its risks. It is not about being "good." No matter how good you are, you WILL eventually experience a complication.

The point is, if you have an unsophisticated understanding of something, or if you are completely inexperienced in it, it is totally easy to be overconfident, i.e., you dont know what you dont know.

Haha, I've been told by several surgeons that if you haven't dropped a lung on a subclavian central line, it doesn't mean you're good, it just means you haven't done enough subclavians.

 

[Licoricestick]

In a way it's reassuring to hear the fear never goes away ...

The at-school-in-underwear nightmares I had as a kid seem to have been replaced with crashing-patient-and-a-locked-anesthesia-cart nightmares.

Or the CICV-too-afraid-to-make-the-call-to-cut-the-neck nightmares I started having when I first started working nights (still have them, generally before night shifts - which is when I'm most likely to be working on my own).

I hope i never lose that slight bit of fear about airways, cause no matter how good you are, there is always an airway out there that you can't manage without a scalpel (sometimes even with).

 

[Licoricestick]

If you feed the troll, burp it afterwards.

Don't forget the vomit cloth - don't want that stuff on your clothes!

 

[Surfer]

Haha, I've been told by several surgeons that if you haven't dropped a lung on a subclavian central line, it doesn't mean you're good, it just means you haven't done enough subclavians.

I thought i was the world's best subclavian line guy... then i dropped a lung on a sick patient. surgery put in the chest tube and rode me about it for a week. now i fear complications. if you do enough procedures, you WILL have complications. fear is justified, and healthy.

 

[ksidoc]

Totally agree.

I met this one girl at a party who was a medical assistant that was applying for study to become optometry technician. She claims that the ophthalmologist let her do retrobulbar blocks. I expressed my amazement and discomfort at that idea. I asked her about complications. She blew it off. Her reply, as she flashed a big smile of confidence, was "It's no problem, I'm good."

Either she is lying about her involvement in these, or she has done so few that she has not had a complication, or she has really no understanding at all of the procedures and its risks. It is not about being "good." No matter how good you are, you WILL eventually experience a complication.

The point is, if you have an unsophisticated understanding of something, or if you are completely inexperienced in it, it is totally easy to be overconfident, i.e., you dont know what you dont know.

NO WAY! A retinologist would never allow a tech to perform retrobulbar injections, no matter how well trained. I have watched several retina procedurs and the ophtho allways did his own block. Maybe trying to impress you!

 

[jwk]

NO WAY! A retinologist would never allow a tech to perform retrobulbar injections, no matter how well trained. I have watched several retina procedurs and the ophtho allways did his own block. Maybe trying to impress you!

You must live a sheltered life or haven't seen much of real world private practice - never say never.

We had a retina guy at a previous gig let his self-taught surgical assistants (neither were PA's, RNFA's, or NP's, nor were they CSA's or CST's) start all his cases, including putting in the little drain tubing thingies and isolating the eye muscles. Why the hospital allowed this is beyond me, but this was 20 years ago in the "pre-credentialling" era.

I also know a rogue GYN doc who hired dental hygienists to be his surgical assistants because they were far cheaper than any other option. They were totally clueless, but he was a cheap SOB and didn't care. The OR staff had to teach them what to do.

 

[PharmaTope]

I would not mind being an expert witness for this case. I actually would cherrish that role.

i highly recommend you contact the family and attorney and volunteer to be an additional expert at no cost.

 

[IlDestriero]

i highly recommend you contact the family and attorney and volunteer to be an additional expert at no cost.

Why would anyone work for free? Expert witnesses get paid no matter what, up front. His time and expertise are very valuable. There's time for review, planning, preparation, travel, etc. It's a great gig if you can get it. Unfortunately there's no lack of legitimate work either.

 

[valerod]

What CRNA's reading this thread need to understand is that this is not an issue about "this case is worthless because this could have happened to an anesthesiologist too". This is about when it comes to medicine the physician is the "gold standard". In this case, the anesthesiologist is the gold standard. Anything less than that means you're a "higher risk" from an insurance perspective and hospital privileges point of view. We need more cases like this to drive up the premiums for independent CRNA's and NP's and restrict their hospital privileges. Anybody who has worked in a hospital knows that they are extremely risk adverse and it only takes one bad case to change policies.

Therefore, do not cover up the mistakes of CRNA's. I think physicians too often don't report the mistakes of CRNA's and NP's and instead just quietly fix them. As a resident, I see it all the time. Talk to any physician and they will tell you their horror stories about CRNA's and NP's, especially independent ones. Physicians should not be hiding these stories. Let the public and lawyers know full well what's really happening in healthcare today. That should be our ethical duty to public safety.

Ok, I know anesthesiologists I wouldn't go near. So, don't think that because you have an MD title it makes u invincible.

 

[IlDestriero]

Ok, I know anesthesiologists I wouldn't go near. So, don't think that because you have an MD title it makes u invincible.

Not invincible, just better trained.
BTW, MD is not just a title...

 

[valerod]

Not really.

1) The CRNA obviously had a duty to the patient
2) If anesthesiologist supervising is the standard of care, that has been violated
3) Did lack of #2 cause the damage? Maybe. Depends on expert testimony and details of the case.
4) Death obviously counts as a damage.

IMHO the case easily meets 3 of the 4 criteria and it's not hard to argue the 4th.

1) yes he had a duty
2) "If" does not count since supervision is not always required.
3) No comment
4) Unfortunate

A good provider is always thinking ahead and puts patients safety first in their priorities. The CRNA in fact did not anticipate complications. I'm sure in medical school they miraculously gifted you all with common sense which makes you better practitioners.
You can take this case as a way to talk about CRNA practice. I can also easily find an even worse case where the anesthesiologist was the provider. Again, I'm sure in medical school they miraculously gifted you all with common sense.

 

[valerod]

As a nurse and as a prior patient, I put 100% trust in anesthesia MD's because they do have the educational background and training to make these decisions. I never understood how these PMD's could "clear" a patient like this without any real workup. In some cases, it then leaves you as the "bad guy" when you cancel the case and the patient and surgeon are pissed. This is why we need anesthesiologists making these decisions, or at least mandating CRNA's to discuss the case with an attending before proceeding. I think the problem with some CRNA's, is that the ones that are intimidated by the surgeon/GI, will go ahead and do the case because they don't want to lose out on the paycheck or be fired if they cancel. The inequality in training can make the CRNA feel that the surgeon/GI "knows better" because they are the MD and they are not. When you have MD to MD disagreement, the anesthesia attending in most cases will not be intimidated by the surgeon/GI doc, and will not go ahead with a case against his/her better judgement.

Intimidated by GI? are you kidding? Yeah, the GI doc will intubate the patient if something goes wrong. There is obviously something wrong with your view of CRNA's. If a good CRNA does not think something is feasible they would simply not do it. I would not risk my license for an old GI fart.

 

[valerod]

This is actually one of the huge advantages of the anesthesia care team model. No matter how well trained a CRNA is, they lack the perspective of medical school training. Therefore when these more complicate patients come in, or have problems intraop, they can, with the input of the surgeon/proceduralist better determine a course of action. A less knowledgable, less experienced CRNA is going to have real problems when working independently with an agressive surgeon.

A surgeon is no anesthesia provider, in any case I would rather consult with the anesthesiologist.

 

[IlDestriero]