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A CRNAs nightmare

Discussion in 'Anesthesiology' started by toughlife, Mar 24, 2007.

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  1. toughlife

    toughlife Resident
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  3. urgewrx

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    They have an AA school and a CRNA school. It is no surprise that they prefer AA's. Being that AA's were pre med students who couldn't get into med school, due to high competition, as opposed to nursing school, where there in no competition at all.
     
  4. W222

    W222 2K Member
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    Can AAs practice solo? Also, I was looking for a list of the 20+ states where CRNAs are allowed to practice solo and couldn't find it. What states allow CRNAs solo practice?
     
  5. VolatileAgent

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    careful... this is a double-edged sword... what's going to happen in 20-30 yrs if there becomes an equal number of aa's and crna's? you guessed it. aa's looking for independent practice rights. you're only kidding yourself if you think otherwise.
     
  6. VolatileAgent

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    no. they are currently directly supervised. and, the anesthesiologist must be present during all critical portions of the case.

    crna's can bill independently in 14 states. they cannot practice independently anywhere (i.e., they must be supervised by a physician, dentist, or podiatrist who have specific anesthesia training).

    before anyone says, "here we go again", do a search. this has been beaten to death. the facts are the facts, and they are correct as i've stated them.
     
  7. EtherMD

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    Yet. Give them ten years and a DNAP.
     
  8. me454555

    me454555 Senior Member
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    Then we'll train AAAs (assistant anesthesiology asistants) to replace the AAs and the cycle will repeat again buying us another 20 years :laugh:
     
  9. Monty Python

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    Just FYI, that link takes you to Case Western University. JWK please correct any inaccuracies, but for decades the country's two AA schools were CW and Emory in Atlanta. So it would make perfect sense to have a large number of AAs on CW's anesthesia department roster.
     
  10. jwk

    jwk CAA, ASA-PAC Contributor
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    MetroHealth is a CWRU-affiliated hospital, but I don't think they're the only one in their system. Case has both an AA program and a CRNA program. I know several of the names on that list - not all of them are Case grads however. One of the AA's listed is also the director of the Case AA program.

    Case and Emory were the only AA schools for about 30 years. South graduated their first class last year, Nova's first class is going strong, and UMKC is working hard to ramp up their program. Several others are in the planning stages but have not announced publicly.

    There are a handful of groups that are MD / AA only. Most groups that have AA's have CRNA's as well - the dominant type of provider fluctuates year to year. My large group of about 70 anesthetists is usually a pretty even split.
     
  11. jwk

    jwk CAA, ASA-PAC Contributor
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    Please don't assume that AA's are med-school rejects. That's insulting to all of us.
     
  12. LostTommyGuns

    LostTommyGuns ASA Member
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    I love how toughlife seems to be able to find even the most obscure attack on CRNAs. :laugh:
     
  13. toughlife

    toughlife Resident
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    I am always ready for the guerrilla-style ambush :D Gotta admit it scared the pants off some unsuspecting NA given the # of times it's been viewed.
     
  14. urgewrx

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    I'm not the one who came up with that to begin with. Read the 30 something year old papper by Gravenstein where he says something like "we have all this kids who cannot get into medschool....which can be trained into an anesthesia physiologist (assistant)"

    www.anesthetis.org under Media Resource Room "Analysis of manpower in anesthesiology"
     
  15. LostTommyGuns

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    Sun Tzu would be so proud :)
     
  16. jwk

    jwk CAA, ASA-PAC Contributor
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    Trust me - I've memorized that paper. It's from Gravenstein, Steinhaus, and Volpitto in 1970. Back then the overall medical school acceptance rate was about 1:10. That was then - this is now. Many of today's applicants are not those that are trying for med school. Some come straight out of college, but many have been in other careers such as respiratory therapy, nursing, or biomedical engineering. Most of today's students have chosen this career instead of med school, not because they didn't get in.
     
  17. Stimulate

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    How are the AAs doing as far as states where they can practice in? Last I heard the AANA-extremists had succeeded in getting them banned in Louisiana and were putting up billboards near military bases trying to scare the soldiers into thinking that they would die during surgery because AA's lacked a year of critical care experience.

    Here is another CRNA nightmare:

    The Louisiana Supreme Court threw the final strike against the CRNAs recent attempt at getting practice rights for chronic pain management. This attempt does accurately reflect disregard for public safety on the part of the Louisiana Board of Nursing and the AANA. As many of you know the B.o.N in LA decided to issue a "ruling" or "opinion" that stated CRNAs are qualified to practice chronic pain management (because pain management counts as administering anesthetics and CRNAs can administer "all anesthetics" according to LA law).

    What they basically did was side-step the legislative process associated with expanding scope of practice (a process put in place to protect patients). Clearly, no individual with regard for patients would extend a CRNA's scope of practice to include interventional pain management without at least going through proper channels.

    These are the under-handed tactics that anesthesiology is up against and yet there are many who sit by in apathy.
     
  18. eutopia CRNA

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    Now why would this pose a nightmare to us? They aren't running us out of the business. There are just so many jobs available and not enough CRNA's that the AA's have found a niche. I think it's great for them. It's no different than PA's and NP's. We all have our place. By the way, try looking at www.gaswork.com sometime. Choose CRNA jobs. After you choose a state scroll through and select a few to view. There will be a list of # docs, # CRNA's, and # AA's employed at the facility. 9 out 10 times there will be a "0" next to AA's. There just aren't many of them yet. There is a desperate need for them though. I find it humerous that you think AA's will work in your favor to destroy all CRNA's. They aren't doing anything other than helping to reaffirm that anesthesia is not a "nursing" role so that insurance companies won't be able to change the reimbursement to such. Good for the AA's!
     
  19. eutopia CRNA

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    Oh ye of little knowledge......Nursing schools are extremely competitive to enter. There are many people who just give up after being turned down over and over. When I went to nursing school back in the 80's the lowest GPA in my accepting class was 3.72. I should know because it was mine! There were 223 applicants to my program and 22 of us were admitted. No competition? Try again! The average GPA today is still around 3.7 or higher. As for CRNA programs, it is HIGHLY competitive to enter. My CRNA program interviewed 300 people and accepted 90 the year I was accepted. So, please, have respect for other professions. Most CRNA's will tell you up front that we know we don't have & will never have the education you do. But please don't belittle us.
     
  20. eutopia CRNA

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    I don't know about other states but we can practice "solo" in Texas. However, a CRNA is never really practicing solo because a physician ALWAYS is available to make final medical decisions (even if it's the surgeon; and yes, they are physicians!).
     
  21. urgewrx

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    My young grasshopper: 3.75, 3.9, or even 4.0 in nursing school is not a great deed. I'm pretty sure the dumbest med student in america will ace nursing school without even opening a book.

    That's what I mean by competition.


    I could provide you with an analogy if it makes it easier for you to understand.

    Olympics vs. Special olympics

    I'm pretty sure the guys in the special olympics work very hard to get there, but there is now way you can compare them to the other guys.
     
  22. eutopia CRNA

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    Oh, I didn't realize you were mentally challenged. Let me start again....just try to read slower ok? You see, my dear delayed one, unless you have walked in the shoes you should not judge. You are very offensive. You belittle nursing and the knowledge we have, and for what? Does it give you an overly inflated sense of self worth? I hope so, because my dear one, you are not getting the message. It is all relative. I doubt seriously that the dumbest med student in America could ace nursing school. That is just a cruel, highly insulting remark. It is not pre-school work, and is very challenging. I know that many of your peers out there understand that nursing school is challenging. We are not ******ed, we are not stupid, as you imply. Many of us can actually count to 20 without taking our shoes off. All I can hope is that you will someday mature and realize that your words are extremely tacky and not called for. Oh, and I might add, my FIRST BS was in biology. I did my RN post-BS. My GPA post biology BS was a 3.6. How ever did I do that?????? Why didn't I go to med school? My live-in boyfriend was an anesthesia resident & talked me out of it. Told me it would be the worst mistake I ever made. He's still practicing, and is one of the docs at the hospital I work at. He's always telling me how smart I was to go RN to CRNA. Hmmmmm........Gee, and I remember staying out almost every night partying during the years I did my BS in Biology (reminder, GPA 3.6). I must be a freakin' genius or something to have scored so high in such a difficult curriculum!
     
  23. Stimulate

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    I agree that typically a pre-medical curriculum in college is much more demanding and rigorous than the typical nursing curriculum.

    That doesn't mean that nurses are not intelligent and hard-working people but you simply can't draw a meaningful comparison the two.
     
  24. poster

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    You are right that there are some smart nurses. I don't think that anyone is arguing that but you need to be realistic. The reason they are competitive is because almost anyone with an algebra class, statistics, and a chemistry can apply and become a nurse. Why I am quite sure you can even become a Registered Nurse by mail or online or something. I believe it is called excelsior or something. You will never become a physician this way nor should you. So you may have attended a good nursing school but not all schools are this way and I would be willing to bet that a few CRNA's went this route. Please quit trying to prove to everyone that you are so wonderful, we really don't care because there are thousands of wonderful, smart nurses that have no intention of trying to become on the same level as a physician. They are very happy doing what they love as a nurse.
     
  25. urgewrx

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    eutopia, why are you trying to cover the sun with one hand? How many people dream of being a nurse? How many people dream of being a physician? Who wants to go to college for 4 years to clean SHT? Why are there so many ads on TV saying "become a nurse at the ghetto community college"? How many ads have you seen "become a physician at the ghetto community college"? Why is there a shortage of nurses, where hospitals have to close entire wings for lack of them? The answer is obvious: nobody wants to be nurse, and most nurses dream of getting out of it. There is no competition in nursing, plain and simple.
     
  26. johankriek

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    this is freakin hysterical... nitecap fighting with himself between the 2 pseudonames he made up.. Furthermore, he is saying he is a girl and he had a live in bf who was an anesthesiology resident. someone go over to the psych forum to come on here to analyze this guy. one pseudoname claims to be a doctor(urgewrx) and the other claims to be a middle aged CRNA who is just as good as a doc(eutopiaCRNA). and they are fghting with each other
     
  27. Gasboy07

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    It's interesting this debate. I can understand why people want to be nurses - there are a lot of very good ones and I really enjoy being around them, at work as well as socially.

    However, I don't get why people would want to do nursing specifically to be a CRNA. You still have to work with guidelines, protocols, and that one doesn't necessarily understand the science behind what you're doing. Personally I'd find that extremely frustrating. I have enough problems trying to understand all the material for the anaesthetic exam (in Oz)... I'm very junior, yet I'm constantly teaching nurses (good ICU and Anaesthetic nurses with decades of experience) stuff.

    The most interesting test is to ask yourself - if you were getting an anaesthetic would you let a CRNA give it, or would you expect (and pay for) a physician to be there giving it 1:1. I want a physician looking after me (but I guess you can say I'm biased - tough!)
     
  28. The_Sensei

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    Big deal 90/300 = 30% acceptance rate

    My medical school class = 4500 applicants/125 accepted = 2.7% acceptance rate

    Not even close......:cool:
     
  29. Conflicted

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    It is silly to drawn a comparison between pre-med and nursing.

    Not knowing what my direction was going to be I did all the pre-meds before i decided to become an RN. I have two words, Organic Chem. I & II. Bar none, the hardest classes i have ever taken in undergrad. No 6 nursing classes (combined) compared.

    However, its also silly to have such hubris as to assume that everyone who isnt a MD/DO wants to be or wanted to be but didnt make it. Thats simply not the case and it is insulting.

    Do i think i have the training of a physician? Of course not. Do i think medical school is as much a right of passage as a mental marathon, absolutely. Its hell. Many of my friends went through it and I watched how horrible it was for them. Physicians have earned the right to be called Doctor through rigorous training.

    However, that does not mean that everything can be done better by a physician or only by a physician. It also doesn't mean that physicians are always the best people for the job or the sole proprietors of knowledge. That is a fallacy.

    My friends who went through med school also said they absolutely used NONE of their pre med classes, little of their med school classes and 100% of their clerkship, internship & residency. Where, and i quote "I actually learned something useful". These are people who have been physicians for now over 10 years.

    Secondly, its a universal truth that "if you dont use it,you lose it". So how helpful is med school training 5 years out of residency when your only doing simple "B&B for Bills" cases? Well, I guess you might ask the surgeon the otherday who asked me "It's the ventricular rhythms that are the bad ones, right?" and no, he wasn't joking.

    Where I believe anesthesiologists have a real edge over CRNAs is in the academic centers where the HIGH acuity, intensive (and sometimes experimental) cases are done. If i was having a serious surgery and was a "high risk pt" I would have no problem being anesthetized by a CRNA but i'd want a supervising anesthesiologist there.

    Here is the kicker. Where ever these cases are being performed, it IS already and ACT practice.
     
  30. toughlife

    toughlife Resident
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    You can try to come in here and sugar-coat the argument with all your nice comments but we all know you and your cronnies are nothing more than cunning nurses.

    I know for a fact you and your comrades despise AAs and always try to block their practice rights. Just look at what happened in North Carolina where your leadership used baseless and dirty tactics to block AAs from obtaining licensure. The same is going on in TX right now.

    So save your smelly BS for another day because I know all CRNAs (ok 99.9999%) of them are backstabbing, cunning and sly.

    You will get ZERO sympathy from me.
     
  31. toughlife

    toughlife Resident
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    Get real, the only thing you need to get accepted to nursing school is a high school diploma or a GED (good enough diploma) and a pen to fill out the application. As far as the GPA goes, that is the GPA you need to have coming from a COMMUNITY COLLEGE. How hard is it to get a 4.0 at a CC where you are competing (as chris rock put it) with the 'community' which includes crackheads, prostitutes, drug dealers, high school drop outs, etc?
     
  32. Gasboy07

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    Conflicted - you miss the point. You never know which patient turns into a high acuity patient which is part of the excitement of anaesthesia. Sure your ASA 1 patient is unlikely to run into trouble, but there's always the one. It's my life and I don't want chances to be taken with it.

    That is precisely what you're doing. Having Anesthesiologists supervising CRNAs is taking chances. He cannot be in two places at once.
     
  33. Conflicted

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    Hi Gas

    Thanks for being civil.

    The thing is what you say has no proof (empirical or otherwise) behind it. If the case was that CRNAs killed more patients that MDAs under any ASA 1-4 it would be well established by now.

    First, lets ignore the research evidence and lets look at it sheerly from an economic perspective. If a CRNA was causing more complications and costing the hospital (or medicare) more money due to negative outcomes (or an MDA grp which employs CRNAs for that matter), this would CERTAINLY be evident by now (100 years since it started). While hospitals want to make money they also like to minimize risk as that costs them money (as it does the government). So why isnt this reflected in hospitals, practices or medicare/medicaid?

    In fact, if you look at the anesthesia claims the #1 reason is lack of ventilation, no excuse for that and anyone can be taught to recognize and do it. Also, while CRNAs are 50% of the USA's anesthesia workforce, they have a disproportionately lower rate of suits than MDAs. Why would that be?

    See, there is much more to the whole thing than "b/c im a doctor im safer". Its just not true and has no quantitative or qualitative power behind the statement. Thats clearly evidenced by the fact that the #1 cause of lawsuit vs anesthesiologist is for hypoxia due to no ventilation which is often directly related to not recognizing that a pt isnt being ventilated. How could this happen is MDAs were so much safer? Really, thats as basic as it gets.

    Your statement should also suggest AAs are not OK since you cannot be in 2 places at ones with them either.
     
  34. Stimulate

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    This statement only reinforces my point that supervision of CRNAs by a non-anesthesiologist (surgeon/podiatrist/dentist) is only a window-dressing to distract the general public, and exists simply to provide a route for the patient to sue a physician instead of the CRNA.

    Also, you state that CRNAs get sued with less frequency yet fail to recognize that in many cases of alleged medical malpractice the CRNA/resident never actually gets named in the lawsuit. Often only the supervising physician or institution itself are named. So data regarding CRNA claims only reflects the cases where the plaintiff attorneys actually name the CRNA personally in the lawsuit. Typically this would only occur if there was a lack of sufficient coverage available on the physician/institution's med mal policy. This represents a HUGE flaw in the statistics you are citing.
     
  35. urgewrx

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    Conflicted, what are your thoughts regarding CRNA's stand that AA's are not safe?
     
  36. me454555

    me454555 Senior Member
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    This statement right here shows your lack of understanding of the medical legal world and/or lack of knowledge of statistics. I suggest you do some more research into WHY cases are brought against attendings rather than residents or CRNAs.
     
  37. Conflicted

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    well

    Thats actually not true at all. The "captain of the ship" doctrine has been invalid for many many years. This has been proven in case law over and over again. If there is an incident in the case the Surgeon or podiatrist or dentist will be sued and so will the CRNA. If it was found to be an anesthesia fault then the CRNA takes the full force of the lawsuit. There is no 'vicarious liability" of surgeons due to supervision.

    The only time this is not true is in the ACT practice where the CRNA and the supervising MDA would be sued as one unit.

    So no, there isnt a huge flaw in the statistics. The CRNA would be named and has been in all instanced where the anesthesia was directly given by a CRNA (in an ACT practice or not).


     
  38. Conflicted

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    I think that currently there is not enough research to prove any real relationship over another. There was a nice study done at CW which would suggest no difference b/t CRNA or AA in M&M.

    A larger study with more providers in more than ONE institution is needed for it to be scientifically palatable.

    Since i have not worked with an AA i really cannot comment on what they are like in practice directly.


     
  39. Conflicted

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    Hi Me

    Well id suggest this is an opinion without evidence. Dont challenge me about how wrong i am when you bring no proof suggesting it. Could you please post the case law which shows CRNAs not to be litigated against when there is supervision and the problem was anesthesia? I can find it for residents, but i can assure you, it dosent exist for CRNAs. Maybe you should do your research.


     
  40. Gasboy07

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    If all you care about it scientific proof and statistics then you shouldn't be doing anaesthesia at all since we don't even know why general anaesthesia occurs. In addition anaesthesia is as much art as science - the very nature of our practice means that proof isn't always available...

    I did not say because I'm a doctor I'm safer - in fact I wouldn't be surprised if the statistics show that physicians have much worse safety records because we take on cases you wouldn't touch with 60 foot pole. ASA 4Es, obstetric disasters - you know where I'm headed. And while you're at it - some references from yourself would be handy since you're accusing us of not providing research.

    The education philosophy of the two groups are different - a physician is called a physician as we are capable of looking after the patient as a whole. We can answer most enquiries from a patient regarding their health and how it interacts with anaesthesia, and refer them to a colleague if necessary. We can also consider all of the patients co-morbidities, and understand how they are likely to impact on the patients pre, intra and post operative course.

    A CRNA is a technician, pressing buttons, chasing numbers and doing procedures according to protocol and guidelines.

    As I keep telling people comment on my good procedural skills - you can train a monkey to do any procedure. However, a superior anesthesiologist uses his superior knowledge to avoid using his superior skills, which is also a significant part of our training.

    And yes, I'm against AAs as well. I'm from Oz and am against anyone other than physicians providing anaesthesia. There are very few other specialties where you become the human life support system for a patient, and yet a technician is allowed to undertake this task. There are multiple reasons why Australia consistently has the best figures for patient safety in anaesthesia and the fact that it is a physician only specialty is one of the many.

    Like I said - if it's my anaesthetic I'll pay for a physician to be the the whole time. I would not let a nurse be my primary anaesthetist. Would you conflicted?
     
  41. Conflicted

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    Hi Gas

    I apologise that i can no longer be involved in the discussion. It has been made clear by the moderators here that there is no interest in any other opinion but that of the other physicians, right or wrong. This IS a physicians forum.

    Anywho, you have been very professional to discuss it with. Appreciated.
     
  42. me454555

    me454555 Senior Member
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    Bringing up simple stats sayin anesthesiologists get sued more than CRNAs b/c that doesn't tell the whole story. In order to compare these 2 groups we must know

    1) What types of cases each group was doing? If anesthesiologists were doing the higher risk cases then it stands to reason they are more likely to get sued

    2) How many cases are each doing? I know your famous stat that "CRNAs deliver 65% of all anesthetics" or whatever the number is. What you fail to mention is what percentage of those cases are supervised by an MD/DO. If anesthesiologists are involved in more cases, it stands to reason they are more likely to get sued by sheer volume alone

    3) Whose responsibility is it? In the end, anytime a nurse is practicing under an MD/DO, it is their responsibility in the end. Lawyers may choose to go after the MD/DO rather than the CRNA for any number of reasons. I'm not trying to say there is a specific law that states CRNAs should not be litagated against just that they are not the primary targets of malpractice lawyers b/c in the end the desicion maker is the Dr, not the nurse. Its his a$$ on the line and when the $hit hits the fan, the buck stop w/him, not his subordinates. Hence the difference in malpractice insurance.

    5) Just plain common sense - No one, including your colleagues will argue that MD/DOs have better and more extensive training than CRNAs. This is a fact that no one argues. It stands to reason that if all other factors are equal, an MD/DO should have as good or better outcomes than a CRNA practicing on their own. Can you provide a reason for why an anesthsiologist would provide worse care than a CRNA? Doubtful

    Are you really so naive or arrogant to state that CRNA care is superior to anesthesiologist care just based on a simple stat?

    Statistics can be twisted and changed to tell any story or support any theory. Sure it sounds professional when people spout them off but in the end it doesn't mean jack unless you know the basis for where they come from and how they were aquired as well as the context that they were taken in.

    Its just very sad that this is what some of my future coworkers are focusing on. Every attack on us is one less reason for us to hire one of you when we're out in practice. Like tauras has pointed out, we need to be working together, not against each other.
     
  43. me454555

    me454555 Senior Member
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    BLTLs are a pretty popular procedure. I'd say a good percentage of the pts's we did C-sections on got them. On top of that, a fair number of pts had them done laproscopically. Not to sound like an a$$ but why go into anesthesia if this is a moral dilemma for you? BLTLs are common enough that it should have crossed your mind before cosidering this as a field.
     
  44. cfdavid

    cfdavid Membership Revoked
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    That's not a fair statement at all, dude.
     
  45. cfdavid

    cfdavid Membership Revoked
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    Ah, yeah, and that was probably an assumption of Gravestein's as well. How does anyone know the motivations of someone pursuing an AA, other than that person himself?

    I'm currently in med school, and was seriously considering applying to Case's AA program OVER med school. So, there goes your arguement, in at least one instance. And from the dudes I met at Case, I'd say most of them would have been very successful med school applicants had they chosen that route. Easy on the assumptions.
     
  46. Stimulate

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    The decision as to who gets named in the lawsuit is up to the plaintiff counsel. They take into account who is ultimately responsible for the damages (the ultimate responsibility is with the physician), what amount of insurance coverage is available (does the anesthesiologist/surgeon/institution policies suffice), and sometimes they evaluate which insurance carriers are involved.

    For example, if the CRNA is not an employee of the anesthesia group (i.e. hospital employee) they will evaluate his/her insurance carrier because that will have an effect on which defense counsel are brought in and sometimes even conflict-of-interest issues arise. The plaintiff firm may have a conflict-of-interest because perhaps they represent the CRNAs carrier in other actions, etc.

    The CRNA has an excellent defense with regards to medical malpractice claims because they can always say that they were working under the supervision of the physician. When it comes to litigation I doubt the CRNA will be pushing the AANA's claim at equivalence to MD. Maybe I am wrong and it would go like this:

    "Yes, Mr. Plaintiff counsel, I demand that I be brought into this lawsuit. Please name me personally in this matter. I am equivalent to the MD/DO supervising me, and therefore I have just as much culpability in this matter. In "x" number of other states I can practice independent of the anesthesiologist and therefore my personal assets should be just as subject to this litigation as the physician's. My organization, the AANA, is fighting a battle to increase CRNA independence and as we win equivalency in practice rights, we desire to be held to the same level of accountability. Therefore I humbly request that I be held legally and financially responsible for my involvement in the care of your client."

    Conficted's statement that the supervising physician (surgeon/dentist/podiatrist) is not legally responsible for the CRNA's actions is also false. The CRNA is working under the physician's license and supervision and that makes the surgeon just as liable as the CRNA for any mishaps. Surgeons have also been successfully sued when an anesthesiologist makes an error (even when the surgeon really had little to do with it). The juries typically attribute them a much smaller percentage of damages than the anesthesiologist but nobody is immune. Who gets sued is up to the plaintiff counsel.

    Personally, if I were a surgeon, I would insist on having an anesthesiologist involved in the care of my patients. Whether it be an ACT model of solo MD/DO practice doesn't matter, but I wouldn't want to be held accountable for the CRNA. I would want to focus on my operation at hand and not have to worry about what the latest guidelines in anesthesia are, is the CRNA following them, and is my knowledge base adequate to a) identify if something unsafe is occuring and b) can I successfully intervene in the case of an emergency. Some surgeons may work in small towns where they cannot successfully recruit an anesthesiologist and CRNA may be their only choice, that would be a different story and that could help in the surgeons defense. He/Her can say that they have tried to recruit an anesthesiologist unsuccessfully, etc.
     
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