A Victory for Anesthesiologists!
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personally i don't consider myself in training to be just an anesthetist, but instead a specialist in peri-operative medicine - i.e. a medical doctor and physician who also happens to give anesthesia as part of his scope of care.
to me that's the difference. crnas are otherwise here to stay and i got no problem with that.
to me that's the difference. crnas are otherwise here to stay and i got no problem with that.
Drew - if you've come to what is primarily an MD board looking to get your ego stroked, you're looking in the wrong spot. Go back to "the other board", where I go when I'm feeling masochistic.anesthesiadrew said:
I know plenty about AA's since I am one. I know plenty about CRNA's since I have worked with them every day for 25 years. You on the other hand know nothing about AA's except what you regurgitate from your professional organizations, so I won't bother getting into that pi**ing contest with you.
JPP, as always, you rock. 😉 You and I both know how the real world works.
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Disclaimer: I recognize that this is and anesthesiologist's forum and that everyone has the right to give their opinion. I'm not going to disrespect anyone. (Disclaimer over).
Most CRNAs, prior to CRNA school, had to have 2 to 4 years of ICU experience in various areas from surgical, medical, trauma, cardiac, and open-heart recovery experience. With this experience, we learn and master the ability to 1) anticipate what could possible happen and 2) If something did happen what to do about it. Good ICU nurses are ability to do both, and only the good ICU make it in CRNA school. If anything, we are trained to follow protocols AND to realize when an adjustment to the protocols need to be done. We carry this mindframe with us into CRNA. I have worked in both teaching hospitals and private hospitals, hospitals overseas in the army and in the U.S. where the last instructions from my MD/DO was " Just keep him/her alive till the morning". I ask that the physicians on this site remember when you were a 3rd/4th year or even an intern and remember you had to rely on an experience RN for info what they thought your patient needed. IF you feel that NEVER happened to you, then that's fine. It has happened to someone that was in your class. So I say this to say that we aren't C3PO protocol droids. Learning the true art of anesthesia and when to think "out of the box" is something most CRNAs should and are able to do because ever since we started in nursing, that is what we do.
Okay, another point. Disclaimer: I personally have no problems with AAs or Anesthesiologists for the simple fact that I'm not worrying about getting a job after I graduate and I can work anywhere and make the best of it.
So I say "coom by ya my Lord, coom by ya!" 😀
Most CRNAs, prior to CRNA school, had to have 2 to 4 years of ICU experience in various areas from surgical, medical, trauma, cardiac, and open-heart recovery experience. With this experience, we learn and master the ability to 1) anticipate what could possible happen and 2) If something did happen what to do about it. Good ICU nurses are ability to do both, and only the good ICU make it in CRNA school. If anything, we are trained to follow protocols AND to realize when an adjustment to the protocols need to be done. We carry this mindframe with us into CRNA. I have worked in both teaching hospitals and private hospitals, hospitals overseas in the army and in the U.S. where the last instructions from my MD/DO was " Just keep him/her alive till the morning". I ask that the physicians on this site remember when you were a 3rd/4th year or even an intern and remember you had to rely on an experience RN for info what they thought your patient needed. IF you feel that NEVER happened to you, then that's fine. It has happened to someone that was in your class. So I say this to say that we aren't C3PO protocol droids. Learning the true art of anesthesia and when to think "out of the box" is something most CRNAs should and are able to do because ever since we started in nursing, that is what we do.
Okay, another point. Disclaimer: I personally have no problems with AAs or Anesthesiologists for the simple fact that I'm not worrying about getting a job after I graduate and I can work anywhere and make the best of it.
So I say "coom by ya my Lord, coom by ya!" 😀
Disclaimer: JPP, I've been watching studentdoctor forums for awhile and you have a very positive and energy and seem really cool.
BUT. MIs, PEs, DKAs, AAAs, Disections, SIADH, and a slew of other disorders are regularly seen by experienced ICU nurses. Why wouldn't we know what to do when a problem occurs? (Especially when we are the first ones calling the resident, or the attending at 3 in the morning when he is at home asleep) 😀 There might consideration as appropriate for a patient on the operating room table but if it is that different from a patient in a ICU bed, it can be learned.
BUT. MIs, PEs, DKAs, AAAs, Disections, SIADH, and a slew of other disorders are regularly seen by experienced ICU nurses. Why wouldn't we know what to do when a problem occurs? (Especially when we are the first ones calling the resident, or the attending at 3 in the morning when he is at home asleep) 😀 There might consideration as appropriate for a patient on the operating room table but if it is that different from a patient in a ICU bed, it can be learned.
jwk said:
Your wrong jwk. I happen to have worked with many AAs as a student and don't have a problem with them.
This guy thinks CRNAs only do ASA I cases and thinks this happens in alot of places. I almost thought you would have something to say about that since CRNAs and AAs are used interchangeably in some areas. Guess I was wrong...
I wanted to see what this dude's opinion of why he prefers AAs over CRNAs. Notice I used the word PERCEIVED control, not actual control. If he thinks CRNAs use cookbook anesthesia, then why the preference for AAs since both are considered midlevels. Have no beef with AAs dude.
jetproppilot said:
These are all good points and I have to ask myself as an aspiring CRNA, if a CRNA's performance is not at the quality level it should be, then why are there CRNAs in the first place? Either you guys are exaggerating their shortcomings or the governing bodies have decided cost effective care is more important than quality care. Does anyone have some statistics showing CRNAs perform less than optimal compared to MDAs?
Thanks
Alpha13 said:
Michael Pine, BC cardiologist has his own opinions about this subject.
Alpha13 said:
there is data out there. there needs to be more. but here's a start.
"Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. These results suggest that surgical outcomes in Medicare patients are associated with anesthesiologist direction, and may provide insight regarding potential approaches for improving surgical outcomes."
http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10861159&query_hl=7
most of the time, thanks to the great equipment we have to work with delivering anesthesia is not a problem. it's when the s*** hits the fan that the differences are apparent, i.e. at the margins.
i fully agree with jpp's sentiment about truly caring and treating patients' medical conditions, both anticipated and unanticipated. i've already worked with crnas too, even ones with 10+ years experience who are great anesthetists. they may know the "what" and "how" as good as any anesthesiologist, but i've yet to be impressed with their understanding of the "why". again, to me that's the difference. this just quite simply comes down to the different level of training, which anesthesiologists clearly get more of.
long story short, there will always be anesthesiologists and crnas/aas. we have to remember to first do what's best for the patient, putting all this political rhetoric aside.
I agree with the last paragraph of this statement, wholeheartedly. But that data from that study is 11-14 years old. We probably need something alittle more current. Most of my experience is from CRNAs in the US ARMY who are trained to be the only provider and to rely on equipment that is not at you average medical center. If CRNAs are trained at hospitals like Toughlife, then they aren't going to have the opportunity to truly learn why with respect to the anesthesia complications. If you train at a Virginia Commonwealth or a RUSH then its a different story.VolatileAgent said:
SigmaSRNA said:
SigmaSRNA,
I dont mean to dis on an RN and you can look back at my posts b/c I have never replied to these pi$$ing contests. The problem with your thinking is that you think just because you worked in the ICU and have seen an MI, DKA, PE, etc being treated you know how to treat it. Then you state you are the first one to call the resident or attending. Just b/c you see something does not mean you know the physiology, pathology, biochemistry, Differential diagnosis it maybe masking, the pharmacology behind the treatment you choose, the side effects/complications that may arise b/c of the treatment, the physiology, biochem, pathology of those complications. Do you see my point.
I am not saying that you can not learn all of this, but there is a reason in this country we have medical school, Boards, and credentialing. It creates a standard and if this is what you want to do in your career (make difficult decisions and be held accountable for them) then go to Medical school.
People on this forum try to use it(the forum) as propaganda that the field of anesthesia sky is falling. They are WRONG. IT will NEVER happen.
The moderator on this site should cut out all the CRNA SRNA AA bull$hit replys and close their accounts. This is a Physician site and not a place for them to air their propaganda.
I can predict there threads for the next ten years. I will put them on a separate thread.
I am out
Thanks for the replies, I found some info after looking up Michael Pine:
http://www.aana.com/press/2003/073003_pine_talk.asp
It goes on to say why Sibler's study (VolatileAgent's link) is flawed.
I agree that knowing more is always better and that MDAs may have a better knowledge of the why, but as far as I can tell this knowledge is not any more beneficial to patient care. You said when problems come up the differences are apparent but I see no evidence to support this statement. Even with their lesser knowledge/experience/education the study showed that CRNAs performed equally to MDAs. So basically they may not know the "why" as well, but the why is irrevelent enough that they can do their jobs equally as well as an MDA. Until I see see meaningful evidence to the contrary I'll have to assume this CRNA bashing is nothing more than conjecture.
http://www.aana.com/press/2003/073003_pine_talk.asp
It goes on to say why Sibler's study (VolatileAgent's link) is flawed.
VolatileAgent said:
I agree that knowing more is always better and that MDAs may have a better knowledge of the why, but as far as I can tell this knowledge is not any more beneficial to patient care. You said when problems come up the differences are apparent but I see no evidence to support this statement. Even with their lesser knowledge/experience/education the study showed that CRNAs performed equally to MDAs. So basically they may not know the "why" as well, but the why is irrevelent enough that they can do their jobs equally as well as an MDA. Until I see see meaningful evidence to the contrary I'll have to assume this CRNA bashing is nothing more than conjecture.
My bad - at least you've worked with some AA's. Most CRNA's haven't and bash them anyway.anesthesiadrew said:
Interestingly, SRNA's are prohibited by their own accreditation organization from working with AA's. AA students have no such prohibition. Don't let the AANA know - they might get mad 😉.
As you and I, and many of the out-of-academia anesthesiologists know, anesthetists (both CRNA's and AA's) do pretty much everything. Variations in practice are dependent more on location and politics than anything, but many of us do hearts, transplants, neuro, peds, etc.
I don't think the preference of some MD's for AA's over CRNA's has much to do with competence or control. I think a lot of it is because AA's, by definition, are always going to be part of the anesthesia care team. You will never find an AA claiming that they don't need an anesthesiologist because we're just as good as they are. We don't carry that illusion that many CRNA's and their state and national organizations do.
I understand what you saying but I think you underestimate the level of knowledge a Good ICU nurse has ( I stress a good one ). Most would know the patho, pharm etc., of the disorders that we see the most of. Now if you are talking about a disorder like Pierre-Robin Syndrome or Kearns-Sayre Syndrome, you definitely would have a point. Anesthesiologists have more training in anesthesia. That's a given. But even amongst anesthesiologists there are different levels of knowledge and training (especially those who do a fellowship in critical care). And technically, a physician doesn't have to be board certified to practice medicine ( correct me if I'm wrong ).apellous said:
Like I said, this is a physician site. I'm new here and I want to be able to learn from both allnurses and studentdoctor. So you will never see me go into the political side of things. I just want to learn. Period. Respect that, and everything is okay
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jwk said:
My whole post was to see the real reason TL wanted to use AAs vs CRNAs and whether it has to do with the ACT design or personal reasons. Oh yeah, I got in trouble by my school when they found out about the whole working with AA deal. Not a good day for me....
SigmaSRNA said:
SRNA, don't make such generalizations. My wife graduated from Nurse Practitioner school 2 years ago. Among the 12 females and 5 males who she became friends with that were going the CRNA route only 3 had ever worked in an ICU. The other 14 weren't even nurses, including my wife (she went the ARNP route). They began the program together in the accelerated BSN route where you get your BSN in 9 months and then do the 24 months at the graduate level. This was at what US News and World report states is a top 10 program. Don't make it sound as if CRNA's have years of experience in critical care much less even nursing. Bye the way, before you say "I said most have 2-4 years experience" 10-20% doesn't equate to "most".
Alpha13 said:
Who said anything about shortcomings? Is it in a CRNAs scope of practice to treat DKA? Who said anything about their care being less optimal?
Look, you know what? I'm really kinda sorry (not TO anyone, just sorry in general) that I even responded to the posts now, because it has degenerated into something that isnt even useful. I just had a hard time reading some of the posts under "A Victory For Anesthesiologists"....any time I see UT responding, I like to read his posts....so I go further down and an SRNA (keep in mind this is a physician oriented website) posts something I found odd coming from someone without alot of experience...who isnt a doctor..since this IS called SDN...which means its doctor oriented...the victory will be shortlived, the victory isnt that bigga deal, etc etc etc. I was like, WTF? I dont spend my time infiltrating CRNA websites with the goal being to post very politically controversial posts.
So then anesthesiadrew comes in, another SRNA, and starts posting how much CRNAs do, how little the anesthesiologists are involved, etc etc.
Once again I was taken back....
I'm not doubting anesthesiadrews stories, nor do they really bother me (we have SRNAs rotate here and I'm very liberal with them if they show prowess and enthusiasm, and I enjoy having them here). What bothered me was "what is the intent of these student nurses' posts?" Heres an SRNA thats gonna come to this forum and post all this stuff that could be interpreted as abrasive? I just found it needlessly abrasive.
BTW, I felt the same way, and posted the same way, to some anti-CRNA med students and residents that used to hang out here a while back.
How can a med student/resident/SRNA have any clue about the "real world" interactions between the 2 professions...actually 3 (sorry jwk), and who are you to pontificate on this subject WHEN YOURE NOT EVEN OUT OF TRAINING YET??? EVER HEARD OF HUMILITY WHEN YOU'RE NEW AT SOMETHING????
We have several CRNA/AA posters here, and they are enjoyed/respected. We have periodic disagreements, but in a cerebrally stimulating way. One can tell their intent is not to post here for militant reasons.
I know I'm rambling, but to summarize, it pissed me off, not WHAT was said but HOW it was said and BY WHOM it was said by.
Why would I go to ultimatecrna.com, browse around until I found a thread kinda like the one in question here, and start posting things that might stir the pot or could be interpreted abrasive? I WOULDNT. Hence my point.
bailey-b said:
Okay. First, last I checked a nurse practitioner is still a nurse. Second, where did you get 10-20% from? ( An actual source please)Third, if you check the AANA website or go to allnurses.com you will see that most schools (stress most like I said in my thread) require 2 -4 years of critical care experience before the first day of class. Some schools let you in with one but the people actually getting in school have more. That's why I say MOST. The school that your wife is at might consider other areas in nursing ( ER, PACU, NICU) as critical care experience.. And if the 14 weren't nurses when they start that accelerated BSN program, then they became nurses afterward. So what is your point? There nurses now right. 1 school doesn't constitute the rest of the more than 90 out there, even if it is a so-called top-ten school. Good Luck to your wife by the way 😀
SigmaSRNA,
Glad to see you are passionate about your views andf not sure where you go to crna school and if you have many oppotunities to actually work with MDA's. I go to a crna school that is within a medical school and subsequent anesthesia residency program. The two branches of the anesthesia dept. work well togehter. If a srna needs some trauma or PEDs cases the residents give them to us, and we do the same if they really want a particular case. There are rules all attending CRNA, SRNA's, MDA's and residents follow. That is what goes on between CRNA and MDA professional organizations is not one bit brought into the clinical environment. The SRNA's are well respected by all, we get pimped way more, we take the same A & P, chem, neuro sciences classes as the med students. We know our s*** though of course we dont know it all. My point is funnel your energy and emotions thru the AANA and state or local associations so you can actually get things done.
Im not saying don't hit back if someone is beating up on you but this continuose argument is just getting old and your most of the time aurguing with residents or med students that have know idea what is even going on in the professional WORLDS of the branches of anesthesia.
Of course the 2 professsions think differently, but there is no proof that patient care is effected in anyway when different providers deliver the care. I have CRNA attendings that deliver way better anesthesia than most MDA's on faculty, there are many MDA 's that deliver anesthesia better than most CRNA's. I see reckless residents just as I see reckless srna's.
Within my CRNA program, though we do not have medical degrees we actually take more anesthesia geared classes than that of the residents. Organic chem, physics, pharm, a ton of simulation labs all with focus on anesthesia.
Just the other day I taught a 1st year resident about local anesthesia free base form membrane permiability and its dissociations between free base and protonate forms effecting permiability and activity. So though they have medical degrees if your program has a strong science base and you get the big picture you will be just as effective in the OR.
Glad to see you are passionate about your views andf not sure where you go to crna school and if you have many oppotunities to actually work with MDA's. I go to a crna school that is within a medical school and subsequent anesthesia residency program. The two branches of the anesthesia dept. work well togehter. If a srna needs some trauma or PEDs cases the residents give them to us, and we do the same if they really want a particular case. There are rules all attending CRNA, SRNA's, MDA's and residents follow. That is what goes on between CRNA and MDA professional organizations is not one bit brought into the clinical environment. The SRNA's are well respected by all, we get pimped way more, we take the same A & P, chem, neuro sciences classes as the med students. We know our s*** though of course we dont know it all. My point is funnel your energy and emotions thru the AANA and state or local associations so you can actually get things done.
Im not saying don't hit back if someone is beating up on you but this continuose argument is just getting old and your most of the time aurguing with residents or med students that have know idea what is even going on in the professional WORLDS of the branches of anesthesia.
Of course the 2 professsions think differently, but there is no proof that patient care is effected in anyway when different providers deliver the care. I have CRNA attendings that deliver way better anesthesia than most MDA's on faculty, there are many MDA 's that deliver anesthesia better than most CRNA's. I see reckless residents just as I see reckless srna's.
Within my CRNA program, though we do not have medical degrees we actually take more anesthesia geared classes than that of the residents. Organic chem, physics, pharm, a ton of simulation labs all with focus on anesthesia.
Just the other day I taught a 1st year resident about local anesthesia free base form membrane permiability and its dissociations between free base and protonate forms effecting permiability and activity. So though they have medical degrees if your program has a strong science base and you get the big picture you will be just as effective in the OR.
I'm sure that the CRNA training is wonderful, and they are probably capable of providing care during anesthesia as well as most anesthesiologists. However, to the flamer SRNAs, I would hesitate before boasting about doing the same job as someone else when you will make less than half the salary and get a quarter of the respect. Any casual observer would wonder what kind of idiot would choose the same kind of career as someone else for so much less benefit. (Of course, among the anesthesia community, everyone knows you're no less important).
Very interesting statement. Actually, in the nursing community we probably are one of the most, if not the most, respected professions (my vote would be for oncology nurses but that's besides the point). The casual observer would need to be educated about the amount of time and school needed for both professions. That difference is the biggest reason I have alot respect for physicians in general and that difference is the reason that any idiot (including myself) would choose CRNA over Med school. Couldn't imagine going to school for 8+ years after undergrad and don't mention a fellowship. Much love 🙂Pooh & Annie said:
Right back at ya 🙂
By the way, 5 seconds of considering earning potential (vs a couple more years of total training), probably would have made the career choice more "imaginable".
By the way, 5 seconds of considering earning potential (vs a couple more years of total training), probably would have made the career choice more "imaginable".
Alpha13 said:
huh? how could it not be? your statement makes no sense.
Alpha13 said:
i quoted a study that showed that when there are complications, having an mda to direct care decreases the likelihood of morbidity and mortality. you then want to compare apples and oranges by presenting a study of bread and butter cases. one can pontificate and opine all one wants on the perceived validity of either study, but the silber study still stands. no one is bashing crnas and there is no conjecture. we are merely pointing to the facts. it doesn't probably normally require an mda hovering over a crna for an asa1 bunionectomy, but if that patient codes...
checking out of this devolving discussion now.
jetproppilot said:
Note my lack of posts.
militarymd said:
already noticed, dude.Noticeably absent. I shouldve been so wise.
I also respect CRNAs and appreciate the skill level of those that I have worked with. I greatly appreciate ICU nurses and the knowledge they have, and share with me as an intern. But at the same time, I as a young physician have taken the road less traveled, and invested a considerable amount of time in the most rigorous depth and breadth of training. My clinical intensive care training is in its early stages, and is being built upon years of basic and advanced science training, as well as critical thinking required to excel in a broad undergraduate curriculum. My training is not better or worse, it is different just as the nature of the job of physician is different than ICU nurse or CRNA.
Part of the difference is about accountability, and a board certified physician is in a position to be ultimately accountable and make critical decisions in acute care, because they have earned their stripes and taken on that added responsibility in their job description.
An experienced legal assistant can function independently in a law office, and responsible for making decisions, be effective, and when the attorneys are stretched for time, work indepently on a case with a client and do an excellent job. I have seen no studies showing that a lawyer is more effective than an experienced legal assistant. Can they then practice law independently without law school or passing the bar exam?
A TA (teacher's assistant) can lesson plan, work with groups of students within the classroom, and in an underserved area, fill many of the functions that a teacher does very effectively. Do we then give them teacher's certification without a bachelor's degree/master's in education/competency testing/teaching internship?
An experienced CT surgery PA can actually do the cutdowns, skillfully assist, and likely be trained to perform the entire CABG procedure as well as a CT fellow can. Shall we go down that road as well?
CRNAs do their job very effectively, can make decisions in the OR, and can run a case as well as anyone the vast majority of the time. They also serve a valuable role in underserved areas. But their skill set is not equivalent to MD anesthesia providers. Just ask Bill Clinton. Certainly most powerful advocate of CRNA/midlevel indepentdent practice rights, his mother was a CRNA. And who was doing the anesthesia during HIS CABG? Was there an unsupervised CRNA in the room for any period of time?
Part of the difference is about accountability, and a board certified physician is in a position to be ultimately accountable and make critical decisions in acute care, because they have earned their stripes and taken on that added responsibility in their job description.
An experienced legal assistant can function independently in a law office, and responsible for making decisions, be effective, and when the attorneys are stretched for time, work indepently on a case with a client and do an excellent job. I have seen no studies showing that a lawyer is more effective than an experienced legal assistant. Can they then practice law independently without law school or passing the bar exam?
A TA (teacher's assistant) can lesson plan, work with groups of students within the classroom, and in an underserved area, fill many of the functions that a teacher does very effectively. Do we then give them teacher's certification without a bachelor's degree/master's in education/competency testing/teaching internship?
An experienced CT surgery PA can actually do the cutdowns, skillfully assist, and likely be trained to perform the entire CABG procedure as well as a CT fellow can. Shall we go down that road as well?
CRNAs do their job very effectively, can make decisions in the OR, and can run a case as well as anyone the vast majority of the time. They also serve a valuable role in underserved areas. But their skill set is not equivalent to MD anesthesia providers. Just ask Bill Clinton. Certainly most powerful advocate of CRNA/midlevel indepentdent practice rights, his mother was a CRNA. And who was doing the anesthesia during HIS CABG? Was there an unsupervised CRNA in the room for any period of time?
Alpha13 said:
WOW, I can't believe I read all this ****!!!!
But I am glad that I stayed out of it. OOPS until now.
Well so long for good. This thread really bites.
But I am glad that I stayed out of it. OOPS until now.
Well so long for good. This thread really bites.
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VolatileAgent said:
Please let me know of the study, name, researcher, location, stats, lets see proof of this study you quote. For every study that shows MDA are safer providers there is a study that claims there is no difference between providers. please let me know of the study though, I have here a book suming up all studies comparing the care and pt outcomes from both fields with stated flaws in each.
If you are going to talk studies and research at least back your claim up man.
Listen I give you props and all for going to med school, know doubt you have an enormous knowledge base. Can you please inform me of the percentages of practicing board certified MDA's. Pretty low from the last numbers I saw. You speak as if every MDA is board certified. you assume all MDA's and CRNA's are of equal skill levels within their professions.
So let me ask you this. Who would you prefer to admin anesthesia if you were in BFE you needed an emergent or you would die CAB.
1- The MDA who has only done bread and butter cases for the past ten years , maybe doing 1 cab a year if that.
2- The CRNA who has been a nurse in a CTRR then worked as a CRNA for 10 years doing hearts and major vascular and neuro cases for a mid sized community hospital.
you can only choose between the 2 and without the CAB your dead you have 3 vessel disease with 99% Left main occlusion and 97% RCA occlusion.
Would you go with your MDA in this case knowing they had far less vascular
over the past years. Who has the greater skill set here for your emergent bypass. Who has more experience here? Just because the MDA is an MD would you put your life in their hands though they lack credible experience in hearts. Both are on call, and you can only choose one here. The other has to run a emergent appy in the other room. Hopefully the MDA would give the case up here realizing their inexperience compared to that of the CRNA that has only done major vascular cases sine graduating 10 yrs ago.
Accountablity you mention. As long as a specific function or action is in a CRNA's scope of practice they are held to the same standards as MDA's. For the most part involving legal issues, MDA's serve as expert witnesses against CRNA's involved in malpractice issues. The standards, Guidelines, position statements of the AANA and ASA are nearly identicle when it involves an action within a CRNA's scope of practice. The ASA and AANA have a few joint position statements as well. If they were any less CRNA's would not exist today. CRNA's are held liable for independent descisions made if they are working in an anesthesia care team unless of course vicarious liability on the MDA's part exists. CRNA's are held every bit accountable as MDA's for their decisions. You act as if just because one works in a supervised care team environment that the CRNA is not accountable and not sued if mistakes or damages occur.
So let me ask you this. Who would you prefer to admin anesthesia if you were in BFE you needed an emergent or you would die CAB.
1- The MDA who has only done bread and butter cases for the past ten years , maybe doing 1 cab a year if that.
2- The CRNA who has been a nurse in a CTRR then worked as a CRNA for 10 years doing hearts and major vascular and neuro cases for a mid sized community hospital.
you can only choose between the 2 and without the CAB your dead you have 3 vessel disease with 99% Left main occlusion and 97% RCA occlusion.
Would you go with your MDA in this case knowing they had far less vascular
over the past years. Who has the greater skill set here for your emergent bypass. Who has more experience here? Just because the MDA is an MD would you put your life in their hands though they lack credible experience in hearts. Both are on call, and you can only choose one here. The other has to run a emergent appy in the other room. Hopefully the MDA would give the case up here realizing their inexperience compared to that of the CRNA that has only done major vascular cases sine graduating 10 yrs ago.
Accountablity you mention. As long as a specific function or action is in a CRNA's scope of practice they are held to the same standards as MDA's. For the most part involving legal issues, MDA's serve as expert witnesses against CRNA's involved in malpractice issues. The standards, Guidelines, position statements of the AANA and ASA are nearly identicle when it involves an action within a CRNA's scope of practice. The ASA and AANA have a few joint position statements as well. If they were any less CRNA's would not exist today. CRNA's are held liable for independent descisions made if they are working in an anesthesia care team unless of course vicarious liability on the MDA's part exists. CRNA's are held every bit accountable as MDA's for their decisions. You act as if just because one works in a supervised care team environment that the CRNA is not accountable and not sued if mistakes or damages occur.
blocks said:
To all the physicians on this board I want to say I'm embarrassed from the posts some SRNA's have made on this thread. Jetproppilot I'm old enough and wise enough to pick out a seasoned individual in any field of medicine. You are truly one of them. These SRNA's truly do not know what they are talking about. Many of you have seen some of my obnoxious posts but its been because pre-meds and residents have been extremely malicious and condescending toward nurses. I was just merely defending my existence.
I've been an RN for 14 years. Six in a SICU and eight as a flight nurse for a busy 911 service. Now I'm in my second year as a SRNA and I will make a fine CRNA someday soon. Anesthesiadrew, sorry bud we are technicians. Not JUST technicians but technicians we are. Do you know why we are technicians? Its because were NOT doctors bud.
If you were doing a case and the patient all of a sudden started having an acute MI would you know exactly what to do? Come on bud you wouldn't have a clue how to manage an acute MI. If a patient started bleeding from every orifice in their body would you know exactly the right thing to stop the process? If your patient had a chunk of meat stuck in their right main stem how would you get it out? What would you do if your ER admission needed their belly ripped open and they subsequently had a lithium OD. The list could go on and on and I know exactly what you would do. Call the Anesthesiologist. I'm not trying to put down what we do. We do an excellent job providing intraoperative anesthesia to all populations ASA I-III but please do not come to a physicians forum and start talking out of your ass. Your making us look bad.
I've been an RN for 14 years. Six in a SICU and eight as a flight nurse for a busy 911 service. Now I'm in my second year as a SRNA and I will make a fine CRNA someday soon. Anesthesiadrew, sorry bud we are technicians. Not JUST technicians but technicians we are. Do you know why we are technicians? Its because were NOT doctors bud.
If you were doing a case and the patient all of a sudden started having an acute MI would you know exactly what to do? Come on bud you wouldn't have a clue how to manage an acute MI. If a patient started bleeding from every orifice in their body would you know exactly the right thing to stop the process? If your patient had a chunk of meat stuck in their right main stem how would you get it out? What would you do if your ER admission needed their belly ripped open and they subsequently had a lithium OD. The list could go on and on and I know exactly what you would do. Call the Anesthesiologist. I'm not trying to put down what we do. We do an excellent job providing intraoperative anesthesia to all populations ASA I-III but please do not come to a physicians forum and start talking out of your ass. Your making us look bad.
I don't know the percentages, but you make it sound like board certified anesthesiologists are a minority of those in practice. I don't believe that for a second. Also - those that are not board certified will find many if not most practices closed to them, unless they are recently out of residency and actively pursuing their board certification.nitecap said:
Your question is pretty lame. It's not an apples to apples comparison, and not a realistic situation anyway.nitecap said:
My practice does zero open hearts, but does 18,000 deliveries a year. The practice across the street from us does tons of heart surgery, but zero OB. All of us, MD's, CRNA's, and AA's, at both of these practices, are extremely competent. But take any one of us that has been in practice at one place or another and switch sides of the street, and we're going to be in an uncomfortable and unfamiliar situation. Not the best scenario for the patient.
In the scenario you propose - if that's the only two choices available at that particular facility, I'd be airlifted to a facility that has their head on right. ANY hospital doing cardiac surgery that does not have an anesthesiologist with cardiac experience available should not be doing cardiac surgery. This is a type of scenario that should never happen. Yeah, yeah, I know - the CRNA has more cardiac experience in this particular case, but tell me how many hospitals are going to have their CRNA's flying solo on emergency hearts with no anesthesiologist around. Very very few.
Actually, you should review some of the ASA's material regarding CRNA's and AA's. They make a clear delineation between the groups as far as what they perceive the scope of practice should be.nitecap said:
MD's, CRNA's and AA's are responsible and accountable for their own actions, as they should be. In an ACT practice, if you have a lawsuit where an anesthetist and anesthesiologist are both involved with the case, both will be named in the lawsuit.
bell412 said:
The voice of reason. I will gladly take the shirt off my back and give it to you anyday. I have a lot of respect for people who recognize boundaries. One of the reasons I type hurtful and annoying comments is because it makes my blood boil to see how disrespectful some here are towards those who have more knowledge and education than them.
That is what I find annoying and downright sickening from many CRNA/SRNAs to the point that I have a hard time respecting them.
jetproppilot said:
JPP's relationship with CRNAs (and other people in general):
1. his anesthesia pre-ops are very easy to read, because they're sometimes done using a sharpie when he forgets his pen 🙂 😀 😛
2. in all seriousness, I will now score JPP on what I consider to be the ultimate test of a person's concern for his/her fellow man, no matter what the initials after their name: how does a person relate to someone else who is in absolutely no position to be of any business-world value to him?: JPP knew each and every orderly, nursing assistant, and housekeeper in the OR suite (13 rooms) by first name and always interacted with them in a courteous, professional, and friendly manner. That speaks volumes.
JWK,
Im sure the ASA does differentiate between different providers. I am saying that the when actions taken by a crna are in that crna's scope of practice ( CRNA can legally say my profession allows me to make these type of decisions) then the standards of care the AANA holds are equal to that of a MDA. Im not saying the standards are exactly the same, I know MDA's have a for the most part a broader scope of practice. Im am just saying that the scopes of practice between the 2 groups are similar if the CRNA is legally able to perform that function. The AANA would not be where it is today if the standards were lower than that of the ASA. Sorry JWK, not really farmiliar (never have read) the actually list of standards, scope of practice, clinical guidelines ect for that of a AA. Im sure your scopes of practice similar to that of a MDA's are similar. You wouldnt be let off the hook for harming a pt from breeching a standard while a MDA that breaches the same standard is held liable. Thats the point I tried to make earlier. The ASA has no say so in the AANA standards, scopes and I quote you "what scopes should be" ect. If that were so rural underserved areas would have no anesthesia what so ever and patients as well as the healthcare system would without a doubt suffer. All do to what the ASA thinks, please they think they should control the entire industry, including more retraints on you guys.
JWK these situations can and do exist. Not all providers work in large groups like yourself. Im talking about being in podunct Texas near the border or in Wyoming or a rural to medium sized area where anesthesia providers and short. It is not a totally unrealistic scenario if thought of in that way. Of course you had to spin it though, instead of just giving a straight answer. Hey not gonna lie, if I needed an emergent CAB, was arresting and about to die, I would much rather a heart expereinced AA than a MDA or CRNA with minimal heart experience and I am an SRNA. At least be man enough to state a non spun answer. No offense meant.
Im sure the ASA does differentiate between different providers. I am saying that the when actions taken by a crna are in that crna's scope of practice ( CRNA can legally say my profession allows me to make these type of decisions) then the standards of care the AANA holds are equal to that of a MDA. Im not saying the standards are exactly the same, I know MDA's have a for the most part a broader scope of practice. Im am just saying that the scopes of practice between the 2 groups are similar if the CRNA is legally able to perform that function. The AANA would not be where it is today if the standards were lower than that of the ASA. Sorry JWK, not really farmiliar (never have read) the actually list of standards, scope of practice, clinical guidelines ect for that of a AA. Im sure your scopes of practice similar to that of a MDA's are similar. You wouldnt be let off the hook for harming a pt from breeching a standard while a MDA that breaches the same standard is held liable. Thats the point I tried to make earlier. The ASA has no say so in the AANA standards, scopes and I quote you "what scopes should be" ect. If that were so rural underserved areas would have no anesthesia what so ever and patients as well as the healthcare system would without a doubt suffer. All do to what the ASA thinks, please they think they should control the entire industry, including more retraints on you guys.
JWK these situations can and do exist. Not all providers work in large groups like yourself. Im talking about being in podunct Texas near the border or in Wyoming or a rural to medium sized area where anesthesia providers and short. It is not a totally unrealistic scenario if thought of in that way. Of course you had to spin it though, instead of just giving a straight answer. Hey not gonna lie, if I needed an emergent CAB, was arresting and about to die, I would much rather a heart expereinced AA than a MDA or CRNA with minimal heart experience and I am an SRNA. At least be man enough to state a non spun answer. No offense meant.
jwk said:
This has gone too far. I realize no one on this board gives two cares about CRNAs and people talk smack all day long about how uneducated CRNAs are and blah, blah, blah...That's cool, everyone has an opinion.
My post was initially at a poster who thinks that CRNAs should only do cases that are easy, that MDs don't want, that residents don't want, or will find no "educational value". My post was supposed to be a simple counterpoint that that is not the truth in many places and that CRNAs provide quality care, esp for ASA I - III cases. Period.
Obviously this came across about 180 deg of what I meant for it to be. I thought readers could follow the dialogue and see that it was aimed at him and not as a blanket statement of how great and mighty CRNAs are. That was never my intention.
For the last MF'ing time:
Did I ever state that I was equal to or better than an MD? No.
Did I ever state that I support working solo? No.
Did I ever state I didn't need MD oversight? Don't think so.
Did I ever state I could take care of all the complex scenarios that people have listed? Nope.
All my comments were from an ATC model. I have not said one derogatory or bad statement about physicians. I said I respected them for their time involvement and I quote - "liked having them around". They actually bail my ass out of situations at times. So for all those making stuff up that I NEVER SAID, .....appreciate the lies.
What is really funny from a situational standpoint is that you actually agree with what I said in those posts and just now.
And since you actually agree with me, does that mean that you also are
I wanted to make one post about how, in most places, CRNAs are utilized effectively for ASA I-III cases and do quite well. Most would agree to that on this board I think. Perhaps my delivery was way off and for that I apologize.
Besides, who in their right mind would pick an online discussion with JPP? Being on the receiving end of that ordeal is not kewl.
My post was initially at a poster who thinks that CRNAs should only do cases that are easy, that MDs don't want, that residents don't want, or will find no "educational value". My post was supposed to be a simple counterpoint that that is not the truth in many places and that CRNAs provide quality care, esp for ASA I - III cases. Period.
Obviously this came across about 180 deg of what I meant for it to be. I thought readers could follow the dialogue and see that it was aimed at him and not as a blanket statement of how great and mighty CRNAs are. That was never my intention.
For the last MF'ing time:
Did I ever state that I was equal to or better than an MD? No.
Did I ever state that I support working solo? No.
Did I ever state I didn't need MD oversight? Don't think so.
Did I ever state I could take care of all the complex scenarios that people have listed? Nope.
All my comments were from an ATC model. I have not said one derogatory or bad statement about physicians. I said I respected them for their time involvement and I quote - "liked having them around". They actually bail my ass out of situations at times. So for all those making stuff up that I NEVER SAID, .....appreciate the lies.
What is really funny from a situational standpoint is that you actually agree with what I said in those posts and just now.
bell412 said:
And since you actually agree with me, does that mean that you also are
or what?bell412 said:
I wanted to make one post about how, in most places, CRNAs are utilized effectively for ASA I-III cases and do quite well. Most would agree to that on this board I think. Perhaps my delivery was way off and for that I apologize.
Besides, who in their right mind would pick an online discussion with JPP? Being on the receiving end of that ordeal is not kewl.
nitecap said:
With all due respect, Nitecap, enough is enough. Noone here is interested in your justifications of CRNA=MD.
I want to come home from work, click on SDN, hear about Military's motorcycle, be stimulated by a case presented by Military/myself/Trinity/JWK/Vent, I want to provide relevant "real world" info to people in training irrelevant of what level anesthesia provider they are,
I wanna hear funny stories, I want to interact with the regulars on this board concerning how everyone would handle a certain case, I want to convey the message that the real world in no way resembles academia and that academia and its practitioners need to be less obstructionalist in their philosophy, I want to read UTs eloquent posts, I want to watch in awe as Military's knowledge of "everything anesthesia" puts an arrogant academic professor to rest, I want to hear from positive/motivated residents/med students/SRNAs/CRNAs/MDs/AAs, I want to read negative/angry/frustrated posts when they are not politically motivated, etc etc etc.
These politically motivated posts are downers, and I'm sorry to say I've responded to some of them. I'll try to practice the "inner peace" and "the force" that Military and UT have most of the time.
So in closing, take your ASA vs AANA/CRNA vs MD crap somewhere else.
jetproppilot said:
As a soon to graduate SRNA, the main reason I frequent this board is to read valuable CLINICAL info which will help further my knowledge base, while gaining other insights into the art of anesthesia. I too wish all the political BS going on here would go bye-bye.
Understood, but sometimes you just have to speak your word. I am not one to start crap, and again am not claiming CRNA's = MDA's. When I see someone blabbing about things especially things geared toward CRNA practice that are false, I just have to set the record straight.
nitecap...
what kind of heart surgeon would do an emergent CABG for a 99% Left Main and a 97% RCA.... now I know you are pulling numbers out of your ass... go to medical school and then do residency, and then you will understand how silly your scenario is... or you could just read the AHA or the STS or the AAC recommendations for indications for CABG (based on literature that shows survivability).... Now if your heart surgeon is crazy enough he can just go ahead and do a RVAD/LVAD combo since the heart is ****ed already
what kind of heart surgeon would do an emergent CABG for a 99% Left Main and a 97% RCA.... now I know you are pulling numbers out of your ass... go to medical school and then do residency, and then you will understand how silly your scenario is... or you could just read the AHA or the STS or the AAC recommendations for indications for CABG (based on literature that shows survivability).... Now if your heart surgeon is crazy enough he can just go ahead and do a RVAD/LVAD combo since the heart is ****ed already
Guess My mind set is geared toward the facility where i train. At the Debakey hrt center they would most definitley cab this guys, more than likely end up with balloon, maybe temp LVAD and if doesnt recover bridge to TP vad. Anyway though scenario may not be ideal I still got no direct answers. Too proud to answer correctly i guess, all spin.
Actually you got your answer here:
Which is followed by this:
And supported by this:
Following all this information from myriad of sources we can conclude the following:
A) If this patient is in podunk, NE (no offense to Nebraska, the state I'm originally from has lots of podunks as well). They are dead for a couple of reasons. Main reason being, there isn't a CT surgeon in podunk and the general surgeon sure as hell isn't going to do a CABG so it doesn't matter who the hell is there to anesthetize the patient anyways.
and
B) If this patient is at the Debakey heart center I highly doubt that the only choices would be:
Unfortunately, I am not in Texas and I haven't been to Texas for many many many years so I'm unclear what the staffing like is at Debakey. I doubt those two choices are what you'll find there though
What this topic has reaffirmed (for me anyway) is that there are arrogant and unrealistic freaks on both sides of this argument who would rather spout nonsense than realize their limitations (this is a very dangerous way to think by the way).
Similarly, I also realize that most of these tail end posts are more to "get the last word."
So, someone (anyone) post your "you anesthesiologists/AAs/CRNAS suck , as an anesthesiologists/AAs/CRNA I'm great, blah blah blah blah" crap and then someone (anyone) close this before it completely taints the view of those who would rather respect each other, recognize and appreciate the values of different experience/training and get along all hunky dory with eachother.
*sigh*
Why did I bother even posting in this?
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my initial point was regarding coronary flow.... if you have both your right coronary and your left coronary taken out by an ACS (unlikely) then your heart would be so hypoxic (as absolutely no coronary collateral flow) that you wouldn't make it to the hospital - and if you did make it then you would be lucky to survive it all the way to the OR.
I have a feeling you meant LAD 99% (instead of left main) w/ RCA 97% that is an operable emergent event as you have collateral flow.... the primary indications for emergent CABG are cardiogenic shock due to AMI, coronary dissection, etc.
Your question is an unfair question because you aren't comparing two comparable situations... Anybody who hasn't done a CABG in a while will be at a disadvantage - and I would much rather have the CRNA who has experience in the cardiac OR who can be told what to do by the cardiac surgeon... What you should be comparing is: would I rather have an MD with 10 years of Cardiac exposure post training or a CRNA w/ 10 years of cardiac exposure post training.... or rather should I have an MD who can make up his own mind or a CRNA who will do whatever the heart surgeon thinks is appropriate...
can we please close this thread... these are the same old boring postings...
I have a feeling you meant LAD 99% (instead of left main) w/ RCA 97% that is an operable emergent event as you have collateral flow.... the primary indications for emergent CABG are cardiogenic shock due to AMI, coronary dissection, etc.
Your question is an unfair question because you aren't comparing two comparable situations... Anybody who hasn't done a CABG in a while will be at a disadvantage - and I would much rather have the CRNA who has experience in the cardiac OR who can be told what to do by the cardiac surgeon... What you should be comparing is: would I rather have an MD with 10 years of Cardiac exposure post training or a CRNA w/ 10 years of cardiac exposure post training.... or rather should I have an MD who can make up his own mind or a CRNA who will do whatever the heart surgeon thinks is appropriate...
can we please close this thread... these are the same old boring postings...
Tenesma said:
So you are claiming that the CT surgeon developes the pt specific anesthetic plan when an MDA is not present to do so. That is so bogus, as well as ridiculous of you to say. Why doesnt the surgeon then just administer and manage the anesthesia, control bypass pump and have no scrub assistant as well. I really doubt that no matter whether you work in BFE or a large metro area that many CT surgeons are making all anesthesia related decisions when MDA's are not present. I have seen surgeons make suggestions intra op to both MDA's and CRNA's. Tenesma from reading many of your post in the past on here and allnurses.com CRNA board you usually sound like a pretty rational guy very knowledgable about clinical practice as well as CRNA/MDA bullcrap. Saying that the CRNA relies on the CT surgeon to make anesthetic decisions is bogus and you know it. A comment that broad I guess incenuates JWK must rely on the surgeon when his MDA isnt present as well.
Moderaters, PLEASE STOP THIS, thank you.
militarymd said:
I agree. 97, now 98, posts later and absolutely nothing has been accomplished. 😡
This has swirled into the CRNA/MDA/FU toilet of no return. Somewhere out in cyberspace some unfortunate computer has to store all of this.
closed by request. chalk up another one to the crna/mda pissing match.
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