How can surgeons help stop the crna movement?

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europeman

Trauma Surgeon / Intensivist
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Let me be clear. Crna's, just like any clinician, come in several flavors. Where I'm at the CRNAs are amazing. Most is them are vastly more experienced and capable than any anesthesia resident and many junior attendings. But that said, their ability is different, more narrow, and in short their role is additive but not a substitute for my MD anesthesia colleagues. I feel very strongly about this.

I know many surgeons who will not work in a hospital where there are no MD anesthesiologists.

Yet crna's autonomy is slowly creeping in. As much as anesthesia MDs can be against this, I think what may be more helpful is recruit surgeons and approach the surgical community to help your cause.

In that regard, how can I as a surgeon do that?

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Refuse to work with low level providers.
 
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To answer the question in the title of this thread: pancuronium 1 mg/kg IV (the dose is not a mistake :p).
Let me be clear. Crna's, just like any clinician, come in several flavors. Where I'm at the CRNAs are amazing. Most is them are vastly more experienced and capable than any anesthesia resident and many junior attendings. But that said, their ability is different, more narrow, and in short their role is additive but not a substitute for my MD anesthesia colleagues. I feel very strongly about this.

I know many surgeons who will not work in a hospital where there are no MD anesthesiologists.

Yet crna's autonomy is slowly creeping in. As much as anesthesia MDs can be against this, I think what may be more helpful is recruit surgeons and approach the surgical community to help your cause.

In that regard, how can I as a surgeon do that?
First of all, you should refuse doing sick patients (ASA 3 or above) or high-risk surgeries with unsupervised CRNAs, or if the supervision is more than 1:2 for cases that are shorter than 2 hours. You should also promptly report any CRNA that does not take proper care of his/her patient, or any significant anesthetic complication. Hold them to the same standard as you would hold an anesthesiologist, but be more proactive in reporting the problems, because the bean counters are more tolerant when about CRNAs (because they think they cost less).

Don't forget: as long as you have an independent CRNA in the room, if anything happens you are the captain of the ship, because you are the MD (and thus more competent in the eyes of the law). If an anesthesiologist is involved, any anesthesia problem is her problem.
 
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Let me be clear. Crna's, just like any clinician, come in several flavors. Where I'm at the CRNAs are amazing. Most is them are vastly more experienced and capable than any anesthesia resident and many junior attendings. But that said, their ability is different, more narrow, and in short their role is additive but not a substitute for my MD anesthesia colleagues. I feel very strongly about this.
Wait, most of the CRNAs at your institution are better than many junior attendings? Sure, their abilities are "different, more narrow," but at what are they superior to a board certified anesthesiologist?
 
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At saying yes sir no sir to the surgeons, thus inflating their egos.


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Let me be clear. Crna's, just like any clinician...

And let me be clear.... CRNA's are NOT clinicians. They are algorithm-following automatons whose deepest level of thinking is "if 'a' happens, do 'b'."
 
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To the OP:
You stated the solution. Surgeons should refuse to work at centers that don't employ physician anesthesiologists. That's your part and it will be heard loud and clear.

As far as crna's being "vastly more experienced and capable than the junior attendings" I'd say, that is the impression from the outside. But crna's are regimen oriented. If issues arise outside of their scope or experience then they are out of ideas. I will agree that they may be more experienced but that only comes with time which your junior attendings don't have yet. But "capable" I highly doubt. Your junior attendings have far more knowledge and when tested are more than likely more capable than the nurses. Please don't take offense to this, but as a surgeon your anesthesia knowledge is extremely superficial. Much like my surgical knowledge.
 
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Until complications happen or a case gets postponed, I don't think surgeons care who does their anesthesia or whether it's done by a nurse, doctor, or machine.
I think the only way they get involved is on a local level in that "I've worked with Bill for 30 years..." kind of thing.

Maybe I'm just jaded.
 
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I thought you were an "intensivist"?
I'm a trauma surgeon and ICU doc.


To the rest if you who are bashing me. Are you serious? Taking out the trash? The tone if your comments? Explain to me how in any way shape or form that helps the situation? Here I am, a surgeon who is interested in the Anesthesia MD movement of limiting autonomy for CRNAs, precisely for the reasons you have listed (albeit recognizing that doesn't mean that CRNAs are all robot *****s like you keep saying which doesn't change anything.... They aren't physicians and therefore should be supervised).

Anyway, to more clear.... Here is what I'm asking. Do any of you have any knowledge of this issue being addressed formally by any surgeon groups (ie the American college of surgeons who has a strong lobby group in DC) in coordination from your professional societies.

Of course, me as an individual at one hospital being a strong proponent for anesthesiologists is an important aspect of this support. But what about more broadly?

The letter from Shinsheki before left trying to essentially allow complete autonomy in all states for CRNAs if very very scary stuff. I have a strong feeling no surgeons were consulted or a part is the discussions that went into that decision.
 
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At my hospital, the chief of surgery has already made it clear he won't work with a CRNA so as a result they haven't been hired. Management would like nothing more than to hire a bunch of them to work independently. I personally try to educate the others when it comes up that they better study up on anesthesia if they work with independent CRNAs since a lawyer will probably include them if there is any issue. So far it has worked but as soon as we have a bad year I'm sure management will push again.

The OP is correct. Without the buy in from Surgeons and/or management we have an uphill battle (at least where I am).
 
Hey Europeman, don't be discouraged by some of us here. We get trolls from time to time that start out like you did and then turn the conversation into a **** storm. Every single anesthesiologist should be encouraged by your interest in securing anesthesiologist for your OR. Keep the faith. We will prevail, maybe!
 
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To the rest if you who are bashing me. Are you serious? Taking out the trash? The tone if your comments? Explain to me how in any way shape or form that helps the situation?

Please excuse Consigliere. He hates his job and thinks that calling other people names will somehow help.



Do any of you have any knowledge of this issue being addressed formally by any surgeon groups (ie the American college of surgeons who has a strong lobby group in DC) in coordination from your professional societies.

Sounds like a group which the ASA should ally themselves with. Not like that'll happen any time soon though....
 
Please excuse Consigliere. He hates his job and thinks that calling other people names will somehow help.





Sounds like a group which the ASA should ally themselves with. Not like that'll happen any time soon though....


Is there a poor relationship between Asa and acs (American college of surgeons)?
 
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Is there a poor relationship between Asa and acs (American college of surgeons)?
Not sure about that one but definitely a poor relationship between the AMA and every other medical group.
 
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Is there a poor relationship between Asa and acs (American college of surgeons)?

Im not well versed in the politics of individual groups.

What I can attest to is that many of the anesthesiologists I know (friends, mentors...) think the ASA is failing to protect the profession they represent.

:shrug:
 
Where I'm at the CRNAs are amazing. Most is them are vastly more experienced and capable than any anesthesia resident and many junior attendings.
Great backhanded compliment.
 
Let me be clear. Crna's, just like any clinician, come in several flavors. Where I'm at the CRNAs are amazing. Most is them are vastly more experienced and capable than any anesthesia resident and many junior attendings...

By what metric are you making this assessment? How are they "more experienced and capable"? In what regard, specifically?
 
By what metric are you making this assessment? How are they "more experienced and capable"? In what regard, specifically?

Perhaps my backhanded compliment was too liberal . I was nearly trying to establish that there is a role for crna's. My point remains.... Anesthesia and surgery should team up to help prevent total autonomy of crna's
 
I think having the surgeons on board is an excellent idea that for some reason our ASA leaders seem to have completely ignored so far!
Maybe some of the active ASA people here could help us understand why the ASA is not approaching the surgeons and their organizations?
ASA representatives should be speaking at every surgical conference and highlighting why having an anesthesiologist is better for the surgeons and their patients.
 
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Europeman it is disheartening to hear that the anesthesiologist at your institution have not illustrated their value to you in a way for you to understand b/c the CRNAs at your institution clearly have impressed you. I am very curious to what skills these CRNAs bring to the table that the anesthesiologist do not? I am also CC trained and had the experience of rotating through multiple ICUs during my fellowship including units run by trauma surgeons and based on personal discussions and experiences I suspect you do not have a good grasp on our skill set and scope regarding patient care which is not necassarily your fault....anesthesiologist and surgeons need to work together more closely in patinet care and break out of their department silos for this understanding to occur. So I appreciate you coming to this forum to do just that and I hope you do it within your own institution as well.
 
At my institution crna's are supervised by anesthesiologists. Thank god. This is a predominant trauma hospital. So these crna's only do trauma. That's it . All day long . So naturally they have become accustomed to certain things. So when I'm the surgeon with a super sick trauma patient.... Yes I prefer the crna with 10 years experience at this unit over the Pgy-3 rotating resident. Of course. It's all within a context . But of course even that resident has more broad exposure, training, and overall ability than the crna example I'm giving. That doesn't change anything. At my shop to attending anesthesiologist likewise mostly do trauma.... They are awesome. But sometimes (very rare) when a covering attending is on who hasn't done trauma in 5 years..... It's helpful having an experienced crna. That said I'm still not going to count on they crna for a complicated regional block, thoracic epidural , etc. I get that.


This is apples and oranges though. . The whole point of my post was precisely that I strongly feel the value of an MD anesthetist is such that non supervised crna is a bad bad idea. And I think asa should approach my people to help their cause cuz so far whatever asa is doing isn't working
 
At my institution crna's are supervised by anesthesiologists. Thank god. This is a predominant trauma hospital. So these crna's only do trauma. That's it . All day long . So naturally they have become accustomed to certain things. So when I'm the surgeon with a super sick trauma patient.... Yes I prefer the crna with 10 years experience at this unit over the Pgy-3 rotating resident. Of course. It's all within a context . But of course even that resident has more broad exposure, training, and overall ability than the crna example I'm giving. That doesn't change anything. At my shop to attending anesthesiologist likewise mostly do trauma.... They are awesome. But sometimes (very rare) when a covering attending is on who hasn't done trauma in 5 years..... It's helpful having an experienced crna. That said I'm still not going to count on they crna for a complicated regional block, thoracic epidural , etc. I get that.


This is apples and oranges though. . The whole point of my post was precisely that I strongly feel the value of an MD anesthetist is such that non supervised crna is a bad bad idea. And I think asa should approach my people to help their cause cuz so far whatever asa is doing isn't working


This whole post is confusing...you're asking how you can help the cause of the anesthesiologist...then you say on super sick patients you'd prefer a more tenured crna over a newly minted anesthesiologist...?

Of course the experienced crna's have a certain finesse from experience (same as any anesthesia provider who has done the same thing 5 times a day for the past 15 years)...but if the patient's life is literally on the line...or the health history is complex... i go with the anesthesiologist every-time...whether they graduated in the last 6 months or not
 
My favorite type of interaction with some 30+ year CRNA who's taking care of a kid (or anyone else for that matter) and doing something risky and/or stupid and/or outdated:

BP: "Why are you doing that?"
CRNA: "I've been practicing for 30 years and I've always done it this way."
BP: "Then you've been doing it wrong for 30 years."
 
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This is a predominant trauma hospital. So these crna's only do trauma. That's it . All day long .

Huh? What? And they are happy? Pfft. I find this a little hard to believe. Sorry.
 
Huh? What? And they are happy? Pfft. I find this a little hard to believe. Sorry.

Okay I'm lying. U got me ;)

Pm me if interested. I'm at one of , if not the busiest, trauma center in the country.

The MD anesthesiologists likewise only do trauma here. Occasionally, and very occasionally, one of them may cover a case next door at the normal ORs, but by and large we have our own trauma staff. That includes the trauma surgeons, intensivists, nurses, OR tech.... Crap even the ID docs. So the crna's are just part is the trauma party. :)
 
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Oh I don't doubt you. I just doubt that they're happy. Most CRNAs get upset when they are relegated to doing only one thing like endoscopy. Especially when there are other anesthesiologist jobs to do because, you know, there's no difference in what we do. :rolleyes:

I'm at one of , if not the busiest, trauma center in the country.

There's only really three who claim to compete among each other for that distinction. Ryder in Miami, Harborview in Seattle, or Shock Trauma in Baltimore. Am I warm?
 
Oh I don't doubt you. I just doubt that they're happy. Most CRNAs get upset when they are relegated to doing only one thing like endoscopy. Especially when there are other anesthesiologist jobs to do because, you know, there's no difference in what we do. :rolleyes:




There's only really three who claim to compete among each other for that distinction. Ryder in Miami, Harborview in Seattle, or Shock Trauma in Baltimore. Am I warm?



Warm. U r right on. I can't speak for them but they seem happy . Trauma is very diverse. Neuro, Ortho, plastics, thoracic, vascular, and belly. I mean it's pretty diverse.
 
U r right on.

Okay. Then you really want to stop the CRNA movement, quantify your near misses. Get IRB approval for a retrospective case control study where you look at in your trauma/gen surg patients the number of patients that have things like unplanned ICU admissions, post-op shock, post-op pressor requirements, post-op multiorgan failure, ARDS, time to discharge just to name a few. You could have this triggered off of the primary surgical intervention and who was the primary anesthesia provider. The data is already there. You just have to mine it. Forget this 30-day mortality bullsh*t. Look at the softer endpoints. That's where you're going to see the difference. And it's going to take a fairly big dataset. I smell a publication for you.
 
Okay. Then you really want to stop the CRNA movement, quantify your near misses. Get IRB approval for a retrospective case control study where you look at in your trauma/gen surg patients the number of patients that have things like unplanned ICU admissions, post-op shock, post-op pressor requirements, post-op multiorgan failure, ARDS, time to discharge just to name a few. You could have this triggered off of the primary surgical intervention and who was the primary anesthesia provider. The data is already there. You just have to mine it. Forget this 30-day mortality bullsh*t. Look at the softer endpoints. That's where you're going to see the difference. And it's going to take a fairly big dataset. I smell a publication for you.

Assuming there is a difference. What is there isn't?
 
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