Consult for IV Start

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ZzzPlz

ZzzPlz

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Post call rant:

its 2:45am. Busy day. Lecture in about three hours. I make it to the call room and can't be 15 minutes after I shut my eyes, pager goes off.

Family Med resident answers and tells me that she wants to consult me for a difficult IV. I ask her about the patient and I can tell she's flipping through a sign off sheet, can't give me a reason why the patient needs an IV right this minute. Guess none of the nurses on that ward knew how to start an IV?

I handled it as politely as possible. Generally don't like to stir the pot if I don't have to.
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Maybe I should have just walked over and done it. Then call the resident q30 minutes the rest of the night to make sure it's running ok
 
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Make a mental note of that moment. If you take a job with an AMC such as Northstar, you will regularly get called in from home as an attending for s&*t like that. Don't like it? AMC's only provide claims-made malpractice insurance so you can always pay your own $15K tail and walk, while leaving behind any retirement that isn't "vested". Welcome to the future.
Oh, and if they deny this when presenting you a job, I've got a bridge I'll sell you too.
 
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ZzzPlz said:
Post call rant:

its 2:45am. Busy day. Lecture in about three hours. I make it to the call room and can't be 15 minutes after I shut my eyes, pager goes off.

Family Med resident answers and tells me that she wants to consult me for a difficult IV. I ask her about the patient and I can tell she's flipping through a sign off sheet, can't give me a reason why the patient needs an IV right this minute. Guess none of the nurses on that ward knew how to start an IV?

I handled it as politely as possible. Generally don't like to stir the pot if I don't have to.
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It's not about you, it's about the patient. Go do it and don't bitch about it. That's what I'd look for in future partners who interview at my group. Just get the job done and don't complain.
 
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We used to have this problem. Successfully negotiated a process. Before we are called, the senior resident and the house nursing supervisor both have to try before anesthesia is consulted. Cut down these calls dramatically.
 
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The best answer, assuming you accept this task, is to require the intern or resident who paged you to gather the supplies and be present while you do it so you can teach. They're not delegating a task that way. At best they learn something, at worst they might think twice before calling again if they have to sit there and watch.

Caveats -

They do need to know WHY the patient needs an IV right away. Scheduled antibiotics are one thing, a non-NPO patient who needs maintenance fluids another.

They need to have made a good faith effort first. None of this "I heard she was a tough stick so I didn't want to torture the patient" ...

They do need to accept that if they are consulting us for IV access, and if we can't get an IV, we will place a line. Don't need a central line? Well, you don't need an IV either. (And our resident will do the procedure, not you.)
 
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we have an IV team that goes for difficult IVs (it's RNs). If that doesn't work the patient probably needs a central line. They are doctors, they can place a central line themselves.
 
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I agree with most of the above with one caveat: sometimes an ultrasound-guided PIV will be the optimal choice for the patient, and nobody else around is capable of doing one. In that scenario, I don't mind being asked, provided the request is done appropriately.

You can get good IVs in brachial or cephalic veins with ultrasound that most people in the hospital simply can't do.
 
Hawaiian Bruin said:
I agree with most of the above with one caveat: sometimes an ultrasound-guided PIV will be the optimal choice for the patient, and nobody else around is capable of doing one. In that scenario, I don't mind being asked, provided the request is done appropriately.

You can get good IVs in brachial or cephalic veins with ultrasound that most people in the hospital simply can't do.
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That may be true. However our IV team is the same ones that place PICC lines with an ultrasound so they are already trained how to do it.

I guess what you can and will do also depends on your situation. Personally I'm in a 1000+ bed hospital. We simply can't be bothered for every time they have a difficult IV 24/7.
 
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We don't get those calls where I am now. :)
When I was a resident, I used to make them bring the patient to the PACU.
If they were in the ICU, I'd go there.
If they did call me now, depending on the circumstances, I'd probably recommend consulting IR for a PICC line.
 
To clarify:

I've done this in the past a lot.

No problem doing iv or other line on a sick patient

No problem doing it on kids/neonates that have been poked a lot

I do have a problem with getting called at 3am to start an IV when it can wait until morning

Regardless of my training status I'm not going to be an IV monkey
 
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okayplayer said:
It's not about you, it's about the patient. Go do it and don't bitch about it. That's what I'd look for in future partners who interview at my group. Just get the job done and don't complain.
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I hope all your future partners don't end up being tools.
 
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okayplayer said:
It's not about you, it's about the patient. Go do it and don't bitch about it. That's what I'd look for in future partners who interview at my group. Just get the job done and don't complain.
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I think you are begging to be abused. once people in PP find out you're that eager, it gets old really fast. because when a doc gets a call in the middle of the night, it's too easy to just say call anesthesia and roll back back over.
and I'm definitely a "just get the job done and don't bitch kind of guy."
 
okayplayer said:
It's not about you, it's about the patient. Go do it and don't bitch about it. That's what I'd look for in future partners who interview at my group. Just get the job done and don't complain.
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Hell no!

I understand that no one wants to work with a lazy partner. Everyone probably has at some point or another and it is a royal pain. I am not an IV service though. I drag myself out of bed plenty of times for other stuff in the middle of the night and doing IV's is not one of them. A CRNA, ED nurse or someone else can go start the IV. If they are not successful I will be glad to put in a central line if the patient really needs it. I don't want floor nurses assuming they can call the anesthesiologist in the middle of the night for an IV. If you take home call, do you think an anesthesiologist who may have to work the next day is going to trudge to the hospital in the middle of the night for an IV?
 
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pgg said:
The best answer, assuming you accept this task, is to require the intern or resident who paged you to gather the supplies and be present while you do it so you can teach. They're not delegating a task that way. At best they learn something, at worst they might think twice before calling again if they have to sit there and watch.

Caveats -

They do need to know WHY the patient needs an IV right away. Scheduled antibiotics are one thing, a non-NPO patient who needs maintenance fluids another.

They need to have made a good faith effort first. None of this "I heard she was a tough stick so I didn't want to torture the patient" ...

They do need to accept that if they are consulting us for IV access, and if we can't get an IV, we will place a line. Don't need a central line? Well, you don't need an IV either. (And our resident will do the procedure, not you.)
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I find that when I ask what happens if we don't get the IV - and they respond "what do you mean" and I say - so if I don't the IV, I am going to place a central line right? - I find that half the IV's go away after they discuss with their staff.

The other day, we got a call from the ICU about an IV stick. That never happens - the ICU folks are GOOD at IVs. I was happy to do that one. Obviously, they needed an IV. Obviously, it was an opportunity to let the best IV stickers know that anesthesia is STILL the shiz no matter what. Also, when I say "I"...i really mean the residents, so I guess I should qualify that. I just stood and watched and made fun and critiziced just like a good attending.
 
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Also, I like the idea of asking them to get all the supplies ready waiting - and I had a buddy that would also add an ICE COLD DIET COKE to that supply list, and most of the time it was there waiting.
 
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Last time I blew off an iv in residency for several hours I ended getting bitched out by my attending who told me to go do it now because they were calling him now. I went to do it and it was an "A" list rock star who was the patient. Imagine my surprise..


You look like.......


Oh.....
 
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There is a CPT code for physician peripheral venous cannulation. It pays like $12 but still. Bill them and it will stop.

Hawaiian Bruin said:
You can get good IVs in brachial or cephalic veins with ultrasound that most people in the hospital simply can't do.
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Just don't pooch those veins. If you're going to that location just take a PICC line kit and the ultrasound and put one in at the bedside and bill them for a PICC line (unless there is some contraindication). That actually pays well. Be sure to tie-up the nurse who called you -- and make sure she wears a cap and mask while in the room with you -- while you're putting the PICC in. Do that every time and enough and the calls will eventually stop.
 
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Get IR and fluoroscopy privileges, place a PICC using ultrasound and fluoro guidance, bill $$$$$.
 
I usually don't want a sluggish PICC line as my only access.

I want a short IV with a reasonable flow rate that will serve me for surgery.
 
I went to the A listers room and looked at him/her and looked at the rock star's daugher looked at the A lister again then looked back at the daugher. The daughter then nods her head. Yes that is (A list rockstar). You are not seeing things.. Then the rockstar says, you are the man who has been keeping me waiting. I said I apologize.

Proceeded to put his iv in first shot. Then I Bsd with him about all the hits and told him/her my favorite hit. His daughter got a big kick out of it :)
 
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criticalelement said:
I went to the A listers room and looked at him/her and looked at the rock star's daugher looked at the A lister again then looked back at the daugher. The daughter then nods her head. Yes that is (A list rockstar). You are not seeing things.. Then the rockstar says, you are the man who has been keeping me waiting. I said I apologize.

Proceeded to put his iv in first shot. Then I Bsd with him about all the hits and told him/her my favorite hit. His daughter got a big kick out of it :)
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I think I know what A-lister it is

image.jpg
 
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Hawaiian Bruin said:
I usually don't want a sluggish PICC line as my only access.

I want a short IV with a reasonable flow rate that will serve me for surgery.
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Aren't we talking about floor patients that have nothing to do with coming to the OR? Obviously you wouldn't place a PICC in preop holding for a patient about to have surgery.
 
I got these consults for IVs and central lines from the medicine service when I was a surgical resident. It was like they didn't want to touch the patient. When I was a junior resident, the intern that consulted me scrubbed with me and learn how to place central lines with me teaching them. That slowed down the central line request real quick.

When I get consulted for peripheral IVs nowadays, it means that they need me and the toys that I use to make things easier for them to start IVs. These include other IV catheter types, vein lights, ultrasound, and other things. I'll still use the toys myself, but it earned some street cred and kudos for saving the services' collective bacon.
 
BuzzPhreed said:
PowerPICCs are not sluggish. That's all we use.

http://www.powerpicc.com/

Or are you saying you always start a PIV if they already have a PICC? Just curious.
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Those flow at best a liter an hour (gravity flow, not power-injection flow). I say that's sluggish.

If there's any possibility of needing quick volume or blood, I'll definitely put in a PIV in a patient that came with any PICC.

My issue with PICCs is that they're central lines. If I'm going to put in a central line, I'll put in a real central line. Part of this is medicolegal- I don't need the CLABSI police watching my every move. But really, I think for most hospital inpatients, even non surgical ones, a PIV is usually better than a PICC. There will be obvious exceptions.
 
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It would be an extreme rarity for us to start an IV anywhere outside the OR environment. Our hospital IV team uses ultrasound as needed for both PIV's and PICC's, so there really is no need for us to be involved. If the IV team can't get it with US, they need central access, and they can call the hospitalist on duty. It's simply not a service that we offer.
 
What kind of hospitals are you working at if I may ask? I find it hard to believe that in a level one facility the nurses could not place a PIV or a PICC if needed. I have never seen anesthesia or even the IM team place a PIV. I guess maybe I am just insulated from this scenario. As a baby RN I was taught how to use US to place difficult IVs. Maybe this just isn't the norm in most places.

If I cannot place an PIV with US in the arms or legs then I will use US and a 2" 18 or 16 gauge to place one in the EJ. With ultrasound, 99.9% of the time you can hit the EJ even if the patient is obese. If on the incredibly slim chance I cannot hit the EJ I will get orders for a PICC line. If they are renal I can place an IJ with an order.

I am sorry that you are bothered with something so tiny. Even I as a the rapid response nurse get tired of being an IV bitch. Just tell them you wont come unless they have tried twice and their charge nurse has tried at least once. Additionally just make them stay in the room with you and learn how to place difficult lines. As a nurse I should support my profession but y'all need to hold them to a higher standard. Nurses on the floor need help but there is not a single reason an ICU nurse should have to call anesthesia to place a PIV.

Maybe this kind of thing happens at smaller hospitals but at my facility, level one regional medical center, nurses are generally capable of getting any type of access they need. Granted I am coming from a hospital where they encourage RNs to be very autonomous. I can place any type of line ranging from artlines, to internal jugular lines. The only type of access I cannot do is subclavian and cordis lines. For god sake this is why y'all refer to us as "just nurses." Sadly, it is nursing fault as a whole for not stressing more clinical knowledge and manual dexterity.
 
RapidResponseNurse said:
I can place any type of line ranging from artlines, to internal jugular lines.
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I have a problem with RNs placing a line in the IJ. That's a much higher risk procedure than a peripheral IV. Higher complication rates. I'm not entirely convinced an RN has the knowledge and training to diagnose and treat complications that would arise from that procedure. I mean are you putting the chest tube in after the tension pneumothorax develops? What's your algorithm for diagnosing if it ends up in the carotid and how are you proceeding from there?

I'm actually amazed a hospital would allow that as their liability would be sky high.
 
Second day in a row we've been asked to start a kids iv in the ed. I feel like that's something an ed should be able to handle.
 
Mman said:
I have a problem with RNs placing a line in the IJ. That's a much higher risk procedure than a peripheral IV. Higher complication rates. I'm not entirely convinced an RN has the knowledge and training to diagnose and treat complications that would arise from that procedure. I mean are you putting the chest tube in after the tension pneumothorax develops? What's your algorithm for diagnosing if it ends up in the carotid and how are you proceeding from there?

I'm actually amazed a hospital would allow that as their liability would be sky high.
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Agreed. A nurse placing any central venous line is just insane. I know of one instance where an APRN placed a central line and caused a major arterial bleed. Patient became hypotensive and rather than do the proper thing she started giving fluid boluses and then blood. Attending was finally called, patient was almost coding at this point, taken to OR for surgical repair and ended up expiring shortly after surgery. Almost 3 hours went by before she realized maybe she hit the artery. You don't know what you don't know.


Same with arterial lines. Say you place it and two hours later the guys hand is blue and cold? It's rare but it happens.
 
so got a call to place a very vital IV in a guy with gastric varices who is ESRD. Bring my ultrasound and see that he is a morbidly obese guy with active LUE AV fistula and 2 old right arm AV fistulas one in the forearm and one in the mid upper arm. I scan up towards the patients armpit and find a nice axillary vein and place my line there. Given that these 2 old fistulas are not being used but still feel a palpable thrill there is there any issue with putting an IV proximal to the AV fistula? I don't see how it would be.
 
GaseousClay said:
so got a call to place a very vital IV in a guy with gastric varices who is ESRD. Bring my ultrasound and see that he is a morbidly obese guy with active LUE AV fistula and 2 old right arm AV fistulas one in the forearm and one in the mid upper arm. I scan up towards the patients armpit and find a nice axillary vein and place my line there. Given that these 2 old fistulas are not being used but still feel a palpable thrill there is there any issue with putting an IV proximal to the AV fistula? I don't see how it would be.
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the issue is that the nurses put a 'do not use' band on that arm and you went ahead and used it! :scared:
 
RapidResponseNurse said:
I I can place any type of line ranging from artlines, to internal jugular lines. The only type of access I cannot do is subclavian and cordis lines.
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If this is true (I sincerely hope it isn't), that is scary.

Watching 4 NPs huddled around the head of a bed sticking an IJ is bad enough, I couldn't imagine being at a place that allowed RNs to do CVLs.
 
Libertas said:
the issue is that the nurses put a 'do not use' band on that arm and you went ahead and used it! :scared:
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That's why he's a physician, so he can overrule the nurses. Especially in that specific situation, I think he did the right thing.

You don't wanna know how many times I ended up using a "restricted" arm for an IV. Many times the restriction is *****ic (sentinel node biopsy in the past).
 
RapidResponseNurse said:
What kind of hospitals are you working at if I may ask? I find it hard to believe that in a level one facility the nurses could not place a PIV or a PICC if needed. I have never seen anesthesia or even the IM team place a PIV. I guess maybe I am just insulated from this scenario. As a baby RN I was taught how to use US to place difficult IVs. Maybe this just isn't the norm in most places.

If I cannot place an PIV with US in the arms or legs then I will use US and a 2" 18 or 16 gauge to place one in the EJ. With ultrasound, 99.9% of the time you can hit the EJ even if the patient is obese. If on the incredibly slim chance I cannot hit the EJ I will get orders for a PICC line. If they are renal I can place an IJ with an order.

I am sorry that you are bothered with something so tiny. Even I as a the rapid response nurse get tired of being an IV bitch. Just tell them you wont come unless they have tried twice and their charge nurse has tried at least once. Additionally just make them stay in the room with you and learn how to place difficult lines. As a nurse I should support my profession but y'all need to hold them to a higher standard. Nurses on the floor need help but there is not a single reason an ICU nurse should have to call anesthesia to place a PIV.

Maybe this kind of thing happens at smaller hospitals but at my facility, level one regional medical center, nurses are generally capable of getting any type of access they need. Granted I am coming from a hospital where they encourage RNs to be very autonomous. I can place any type of line ranging from artlines, to internal jugular lines. The only type of access I cannot do is subclavian and cordis lines. For god sake this is why y'all refer to us as "just nurses." Sadly, it is nursing fault as a whole for not stressing more clinical knowledge and manual dexterity.
Click to expand...

That is freaking scary if you are placing IJ, EJ, and arterial lines. Please let me know which city you work in so I can avoid it. Happening at a level one trauma city? I find that extremely hard to believe. I would be curious how that liability goes when you dilate the carotid, drop a lung or cause 3rd degree heart block. Is the attending billing for you doing the procedure? Sounds fraudulent and unsafe to me.

Red
 
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FFP said:
You don't wanna know how many times I ended up using a "restricted" arm for an IV. Many times the restriction is *****ic (sentinel node biopsy in the past).
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It's usually the patient who is most adamant about not using that arm. And who can blame them? They've been told to never ever use that arm for anything by virtually everyone they've encountered since the surgery. I usually won't invest the time to attempt to re-educate them. No matter what you say, you're the lone person telling them it's OK, and if they get a hangnail on that side it'll be your fault.
 
Usually the restricted limb is the last resort. Also, if I have the operative note from the sentinel node biopsy, I will tell them that there is no risk for lymphedema based on it. Many times, a knowledgeable general surgeon will confirm my opinion. (That's actually how I learned first about it.)

I always involve the patient in this kind of decision. They will prefer it to me going in their foot etc. I will never take chances with a truly restricted limb in a non-emergent setting.

I don't have the resources for the inhalational induction game in adults, just to get an iv. If the patient is adamant, she gets postponed for surgery at the hospital, where they have ultrasound for iv.
 
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So here is the thing, yes there are a lot of complications that can arise from placing invasive lines and I acknowledge that. At my facility all my line placement is ultrasound guided and it is pretty obvious what is an artery and what is a vein. Second, line placement takes good clinical judgement but it is also a technical skill that is developed by repetition. I started doing PICC lines after hundreds of US PIV lines. After successfully placing many PICC lines I was trained on more advanced CVLs. If on the remote chance I cause a pneumo we have the surgery team available to place a chest tube. In the case of dilating the artery, before any attempt at dilation is performed I trace the guide wires location with the ultrasound this allows me to be sure I am in the correct vessel, if there is any question the procedure is stopped and I ask for expert (MD, CRNA, NP, PA) guidance. Regarding 3rd degree heart block, this complication is exceedingly rare and the main case studies I have found have described this occurring mostly in subclavian lines which I am not allowed to do.

I am not trying to turn this into a pissing contest but the example of "4 NPs huddling at the top of the bed" was brought up. While that may have happened, I could mention the multiple times I have seen an intern and a resident try over and over to get IJ access only to cause a pneumo. When they do cause a pneumo they have to call surgery just like I would have to because they cannot place chest tubes without an attending present. At the end of the day which is better, an intern and a resident whos interest in dermatology and hemo/onc, or a nurse who has placed 10xs more invasive lines then both of them combined?

I do not claim to have more medical knowledge than them by any means. The thing you have to see is that I learned US line placement by doing PICCs first. I had to hit a target (basilic/brachial) a fraction the size of the IJ. At the end of the day line placement is first about knowing when to attempt and when not to. Second, knowing the signs of potential complications and when call for help. Third, having the manual dexterity gained by placing lines over and over again.

You would be surprised with our first time success rate. I mean look guys, you all have stated that PHYSICIANS will consult anesthesia for difficult line placement. Do these physicians who cannot place even a PIV have any business placing a central line? Line placement should be based on skill and clinical judgement not a title. I totally agree, 95% of nurses should not be placing central lines only high skilled and highly educated ones should have that privilege.

In the case of artlines.... What if there is vasospasm and circulation is lost? After the provider comes and places a line who monitors for complications? The ICU nurse does not the doctor. Beyond pulling the line what is internal med or the critical care docs going to do about restoring circulation? If that big of a complication arises vascular surgery gets involved.

Oh and last thing to address, How is a nurse placing and EJ scary? An EJ is simply a peripheral line that happens to be located in the neck.
 
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Are CRNAs Licensed Independent Practitioners in terms of Central Line Placement? In my hospital CRNAs are not permitted to place Central Lines without MD supervision. but in other instituttions the CRNA/NP would qualify as a LIP.



The Joint Commission has defined, for the purpose of its standards, a "licensed independent practitioner" as any individual who is permitted by law and who is also permitted by the hospital to provide patient care services without direction or supervision within the scope of his or her license and in accordance with individually granted clinical privileges. Therefore, the identity of licensed independent practitioners within a hospital is a matter decided by state law and the hospital.
 
RapidResponseNurse said:
So here is the thing, yes there are a lot of complications that can arise from placing invasive lines and I acknowledge that. At my facility all my line placement is ultrasound guided and it is pretty obvious what is an artery and what is a vein. Second, line placement takes good clinical judgement but it is also a technical skill that is developed by repetition. I started doing PICC lines after hundreds of US PIV lines. After successfully placing many PICC lines I was trained on more advanced CVLs. If on the remote chance I cause a pneumo we have the surgery team available to place a chest tube. In the case of dilating the artery, before any attempt at dilation is performed I trace the guide wires location with the ultrasound this allows me to be sure I am in the correct vessel, if there is any question the procedure is stopped and I ask for expert (MD, CRNA, NP, PA) guidance. Regarding 3rd degree heart block, this complication is exceedingly rare and the main case studies I have found have described this occurring mostly in subclavian lines which I am not allowed to do.

I am not trying to turn this into a pissing contest but the example of "4 NPs huddling at the top of the bed" was brought up. While that may have happened, I could mention the multiple times I have seen an intern and a resident try over and over to get IJ access only to cause a pneumo. When they do cause a pneumo they have to call surgery just like I would have to because they cannot place chest tubes without an attending present. At the end of the day which is better, an intern and a resident whos interest in dermatology and hemo/onc, or a nurse who has placed 10xs more invasive lines then both of them combined?

I do not claim to have more medical knowledge than them by any means. The thing you have to see is that I learned US line placement by doing PICCs first. I had to hit a target (basilic/brachial) a fraction the size of the IJ. At the end of the day line placement is first about knowing when to attempt and when not to. Second, knowing the signs of potential complications and when call for help. Third, having the manual dexterity gained by placing lines over and over again.

You would be surprised with our first time success rate. I mean look guys, you all have stated that PHYSICIANS will consult anesthesia for difficult line placement. Do these physicians who cannot place even a PIV have any business placing a central line? Line placement should be based on skill and clinical judgement not a title. I totally agree, 95% of nurses should not be placing central lines only high skilled and highly educated ones should have that privilege.

In the case of artlines.... What if there is vasospasm and circulation is lost? After the provider comes and places a line who monitors for complications? The ICU nurse does not the doctor. Beyond pulling the line what is internal med or the critical care docs going to do about restoring circulation? If that big of a complication arises vascular surgery gets involved.

Oh and last thing to address, How is a nurse placing and EJ scary? An EJ is simply a peripheral line that happens to be located in the neck.
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Excellent reply.

This also proves that one can train anybody to do a procedure (no offense, RRN), but complicated medical judgment is something much more difficult to replace. Medical students should expect this to become the norm in the future, supervising and assuming liability for what a bunch of nurses and midlevels are doing. Anything that implies simple procedures is ripe for this, be it regional anesthesia, or healthy outpatient anesthesia (including peds), or simple surgeries, or colonoscopies (or teeth whitening) etc. Unless there is need for frequent physician-level judgment, or there is (high) risk for (severe) complications, no procedure or part of clinical medicine is safe.

When patients will have to choose between having the procedure for $x by an experienced APRN/PA/RN/tech or $4x by a physician, the choice will not be so obvious anymore. And based on the North Carolina Dental Board vs. FTC February 2015 SCOTUS rule, physicians might not be able to restrict all these people from doing these procedures. What is "practice of medicine" today might become "practice of nursing" tomorrow. Until we have a clash among the boards and another SCOTUS case to clear things up. I personally can't understand how independent CRNAs or APRNs are regulated by nursing boards, when what they do is clearly practice of medicine, but it seems not to bother anybody else.

The rumble y'all are hearing are the tanks of market economy running over the classic healthcare model. Think about the future before you commit to a (sub)specialty and become a dinosaur.
 
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FFP said:
Excellent reply.

This also proves that one can train anybody to do a procedure (no offense, RRN), but complicated medical judgment is something much more difficult to replace. Medical students should expect this to become the norm in the future, supervising and assuming liability for what a bunch of nurses and midlevels are doing. Anything that implies simple procedures is ripe for this, be it regional anesthesia, or healthy outpatient anesthesia (including peds), or simple surgeries, or colonoscopies (or teeth whitening) etc. Unless there is need for frequent physician-level judgment, or there is (high) risk for (severe) complications, no procedure or part of clinical medicine is safe.

When patients will have to choose between having the procedure for $x by an experienced APRN/PA/RN/tech or $4x by a physician, the choice will not be so obvious anymore. And based on the North Carolina Dental Board vs. FTC February 2015 SCOTUS rule, physicians might not be able to restrict all these people from doing these procedures. What is "practice of medicine" today might become "practice of nursing" tomorrow. Until we have a clash among the boards and another SCOTUS case to clear things up. I personally can't understand how independent CRNAs or APRNs are regulated by nursing boards, when what they do is clearly practice of medicine, but it seems not to bother anybody else.

The rumble y'all are hearing are the tanks of market economy running over the classic healthcare model. Think about the future before you commit to a (sub)specialty and become a dinosaur.
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I totally agree, you can train just about anyone to do a procedure competently. Again, I totally agree that complicated medical judgement is something that is very hard if not impossible to replace. That is why in my facility I have no problems with going to my Docs and clearing up anything I am uncomfortable with. I love to just sit around on the rare quite night and let them educate me. I love the fact that when I have a patient who is very sick they will ask me, "what would you do if your were placing the orders?" They are not doing it because I know more, FAR FROM! They ask it that way because they want us to be the best we can so that when **** hits the fan they can count on us to make the right decisions to keep their patients alive. Inversely, if I choose the wrong choices hypothetical or in reality they take me to task and make damn sure I know why I made a mistake. I love the fact that I have such awesome resources and I am humbled to be one of the few RNs who is allowed to do the things I do.

It also goes beyond cost, in my MICU we have 45 beds filled with the sickest of the sick with a million comorbitities. We do ECHO, CRRT, Hi-Fi vents, and therapeutic hypothermia routinely. You know have many MDs we have at nights covering 45 super sick patients? TWO - one resident and one intern with fridays being the exception when we have one fellow and one intern. The attending is available but usually at least 30min to an hour out. Not to mention our Docs cover any procedures done in CVICU (30 beds) and respond to any emergencies on the floors ~450 beds.

Believe me, the love the fact that they have a few trained RNs who can hold down the fort when they are super busy. I'll give an example, about a month ago a patient coded in CVICU and the docs responded to intubate, place lines, and lead the code and where tied up for about an hour and a half. Not long after they left one of our patients coded and was managed by my fellow nurses until ROSC was achieved, after which they needed pressors which where initiated by the nurses taking care of the patient. During that time my patient with severe GI bleed secondary varacies began to vomit liters of blood profusely, became tachycardic ~170's and had a MAP in the low 30's. Another RRT nurse and I started him on vasopressin and norepinephrine, activated mass transfusion protocol, started 14 gauge access, and bolused NS until the blood and plasma arrived. Both patients survived and after our docs got back (and about $h!% themselves) they finished medically managing our patients.

Does this happen all the time? Hell no. Does our hospital grant certain nurses such as myself the authority to place emergent orders under standing delegation? Absolutely and it saved these two patients lives. Of course we know nothing in the realm of practicing medicine but we have the clinical judgement, training, and experience to recognize a **** storm and not let everything go to hell because there is no doctor around.

With the way medicine is heading, especially with the expansion of healthcare to millions of people, situations like this will happen more frequently. Ideally we would have more doctors at the units disposal but being a county facility we have to work with what we have. FFP you are correct when you talk about nurse's scope being in the realm of medicine at times. Is it ideal? NO. Could we ever hope to provide the level of care a physician could? NO. Is it necessary at times to save lives? Absolutely.

I see future physicians not only being medical experts and skilled in invasive procedures but also masters of building strong teams who don't just follow orders but have the knowledge to know why they are doing what they do. Lets face it, nursing school is a joke. The best nurses learned their medical knowledge from you guys not our professors in school. Great doctors make great nurses and great nurses have their docs back when everything goes to hell.
 
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