Attendings: like/dislike CRNAs?

[ecCA1]

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I'm curious to know what our forum attending staff feels about CRNAs. Anyone care to throw their opinions into the mix, both good and bad?

 

[Conflicted]

this can only lead to negative comments and fighting.

 

[VolatileAgent]

as a "soon-to-be" attending, suffice it to say that crnas are a reality. the "like/dislike" of them is irrelevant. thus, it is pointless to try to boil it down to such an overly simplistic "this or that" sentiment.

what we do need to learn to do is how to work together more effectively politically. crnas are poised to get f***ed - pehaps even harder - just like the rest of us, and they are too busy fighting us instead of joining ranks and figuring out how to better our distinct but similarly aimed professions. this in-fighting plays well into the hands of politicians and policy decision makers in washington.

vote, people. this is the one of the few and limited ways you can start to protect your interests.

 

[chicamedica]

I'm just an intern, but I like CRNAs for the fact that because of their presence I can spend more time learning from complex, thought-provoking cases once i get a handle on simpler cases, and having CRNAs in my program will allow me to do spend some time in the lab.

What bothers me is when some of them start badmouthing anesthesiologists and trying to broaden their scope of practice to beyond what their foundation of knowledge & training in clinical decisionmaking should allow.

I agree, CRNAs and anesthesiologists should work together not against each other. Each brings different skill sets to the table. Both parties should acknowledge this and appreciate each other, and work together for the benefit of the patient.

 

[johankriek]

I'm just an intern, but I like CRNAs for the fact that because of their presence I can spend more time learning from complex, thought-provoking cases once i get a handle on simpler cases, and having CRNAs in my program will allow me to do spend some time in the lab.

What bothers me is when some of them start badmouthing anesthesiologists and trying to broaden their scope of practice to beyond what their foundation of knowledge & training in clinical decisionmaking should allow.

.

you will be surprised how similar all the cases are.. be it a thoracic case or a long vascular case or a mac case on a healthy patient the principles are all the same.. so in your stage please dont start thinking that because its a 25 year old healthy patient.. its not challenging or thought provoking.. all the general principles are the same.. when you are having a dilemma.. go back to the basics to figure out the answer... If you think that you are beyond the healthy patients ..... your training program is remiss in my opinion.. and im not saying that as a slam... Im saying it because i think you should approach every single patient the same.. apply the same exact principles and you will see how similar all the patients are...

2) crnas are just that.. they are not physicians... they have erroneously believed that their education suffices to provide anesthesia services independently....... and the politicians are buying into it.... when it comes down to what we do for a living... the more training the better.... period.. no rhetoric will be able to change that fact..

 

[Conflicted]

2) crnas are just that.. they are not physicians... they have erroneously believed that their education suffices to provide anesthesia services independently....... and the politicians are buying into it.... when it comes down to what we do for a living... the more training the better.... period.. no rhetoric will be able to change that fact..

This is funny

It dosent take "rhetoric" it takes "proof". Its been well established that CRNAs are as safe as anesthesiologists. However, even after all the attempts by the ASA, it cant be proven otherwise.

Where is your evidence that all the extra training is better?

Just so you know:

Rhetoric is the art or technique of persuasion, usually through the use of language.

Which is exactly what you did here, nothing more, nothing less.

 

[ecCA1]

Conflicted,

I asked for attendings' views on CRNAs. Are you an attending?

 

[bullard]

1) Wrong.
2) Is this nitecap yet AGAIN? 🙄

Its been well established that CRNAs are as safe as anesthesiologists. .

 

[Conflicted]

Hey there bullard

No im not an attending anesthesiologist. That dosent make the truth any different tho.

Im not nitecap either, while i have seen his posts in the past, i do not operate that way. Im also not a CRNA. You might say ive seen both working.

Really. Im just asking for evidenced based statements. Is that so wrong? I can provide evidence for mine.

Bullard, you said "wrong". Go ahead and prove that statement for me.

 

[ecCA1]

You're hijacking a thread for attendings to respond regarding CRNAs. You probably shouldn't be posting here, given your defensive tone and all...

 

[Conflicted]

I apologise ecCA

You are being reasonable.

Bullard and johankriek:

Are you attendings?

If you want the truth about the issue i suggest you PM Mil or JPP.

You're hijacking a thread for attendings to respond regarding CRNAs. You probably shouldn't be posting here, given your defensive tone and all...

 

[johankriek]

I apologise ecCA

You are being reasonable.

Bullard and johankriek:

Are you attendings?

If you want the truth about the issue i suggest you PM Mil or JPP.

yes i am a board certified practicing attending anesthesiologist..

there is no proof that driving blindfolded is not safe either...... you dont need proof.... trying to get proof will kill too many people.... on the road

 

[blocks]

There is no proof that physician assistants operating indepently are any less safe than residency-trained, MD surgeons. Shall we allow PA's to practice surgery indepently? How about any pilot with the cajones and a little flight time fly a commercial 747? Hell, why require licensure for anything when you can just do it? That's a great philosophy when people's life are in your hands: less is equal.

 

[pgg]

Its been well established that CRNAs are as safe as anesthesiologists.

Maybe this has something to do with the fact that CRNAs always have an anesthesiologist around to bail them out when things go wrong.

Or maybe there's some connection between good outcomes and CRNAs discussing non-trivial cases with anesthesiologists before beginning them.

Just idly speculating, you know. 🙄

 

[underdog27]

There is no proof that physician assistants operating indepently are any less safe than residency-trained, MD surgeons. Shall we allow PA's to practice surgery indepently? How about any pilot with the cajones and a little flight time fly a commercial 747? Hell, why require licensure for anything when you can just do it? That's a great philosophy when people's life are in your hands: less is equal.

I don't know about the size of JPP's sack, but I think that he could probably do this!!!

 

[The_Sensei]

Where is your evidence that all the extra training is better?

.

When Bill Clinton had his heart surgery, did a CRNA or an anesthesiologist provide the anesthesia? 'Nuff said...

 

[VolatileAgent]

It dosent take "rhetoric" it takes "proof". Its been well established that CRNAs are as safe as anesthesiologists. However, even after all the attempts by the ASA, it cant be proven otherwise.

Outcomes Worse When CRNAs Administer Routine Cardiac Care

San Diego—Hospitals that routinely use anesthesiologists during off-pump coronary artery bypass (OPCAB) graft surgery have better risk-adjusted survival rates for the surgery than hospitals that routinely use certified registered nurse anesthetists (CRNAs), according to preliminary evidence.

“We are not saying that nurse anesthetists aren’t doing careful monitoring, and this was not a double-blind study on the use of CRNAs,” Phillip P. Brown, MD, told Anesthesiology News. “However, we believe the information is thought-provoking for hospitals that are doing off-pump procedures.” Dr. Brown is Medical Director of the Hospital Corporation of America (HCA) Clinical Cardiovascular Management Network in Nashville, Tenn.

Terry Wicks, President of the American Association of Nurse Anesthetists, took issue with the study conclusions, asserting that poor design invalidated the results.

Mr. Wicks said the study had several methodological flaws, and that the database the authors used was not designed or intended to be used to provide the kind of outcome data that were extracted.

“For example, there was no way to determine in any group of patients whether the cases were performed by anesthesiologists or by CRNAs,” said Mr. Wicks, a staff nurse anesthetist at Catawba Valley Medical Center in Hickory, N.C. “Thus it is unjustified to conclude that better outcomes were associated with cases performed by anesthesiologists.”

Mr. Wicks said the authors did not define the term “routinely” when referring to how often a CRNA or anesthesiologist was used for OPCAB surgery. Did the individual participate totally in a particular case, or only part of the time?

“Some hospitals in the study performed as few as 10 cases of OPCAB surgery yearly,” Mr. Wicks told Anesthesiology News. “It is widely accepted in surgical circles that for high-risk procedures in particular, the more cases performed, the more likely a good outcome.”

According to Dr. Brown, substantial debate continues concerning the appropriate role of CRNAs in complex cardiac surgery cases. Little is known about average survival rates in hospitals that routinely use CRNAs for OPCAB surgery versus hospitals that do not.

The study findings were presented by Steven Culler, PhD, an outcomes researcher at the Rollins School of Public Health at Emory University in Atlanta, at the 2006 annual meeting of the Society of Cardiovascular Anesthesiologists.

The primary source for study data was the HCA Heart Services Standards Database, a Web-based survey containing detailed information about structures and processes in place at 158 HCA hospitals. Dr. Culler’s group analyzed 54 of these facilities, at each of which OPCAB surgery had been performed on at least 10 patients during 2004.

Hospitals were divided into those that routinely used CRNAs for OPCAB surgery and those that did not. A risk-adjusted model that controlled for 21 demographic and comorbidity factors in coronary artery bypass graft (CABG) surgery mortality was used to predict the number of expected deaths at each hospital.

The number of risk-adjusted lives saved was calculated for each hospital as the difference between the expected number of deaths and the number of observed deaths.

Of the 54 HCA hospitals, 17 (31%) did not routinely use CRNAs during OPCAB surgery, Dr. Culler said. Hospitals that did not routinely use CRNAs performed significantly more CABG surgeries and had significantly (defined as P<0.05) better average outcomes—i.e., more lives saved and more lives saved per 1,000 patients—than those hospitals routinely using CRNAs. There was no statistically significant difference between the two hospital groups in the proportion of CABG surgeries performed off-pump.

The estimated Pearson correlation coefficient indicated a negative—and significant—relationship between hospitals’ routine use of CRNAs and the risk-adjusted number of lives saved (–0.31; P=0.023) and the risk-adjusted number of lives saved per 1,000 patients (–0.28; P=0.037; Table).

“This study includes data on a large number of hospitals and provides some preliminary evidence that having a process in place where an anesthesiologist is usually doing off-pump surgery is associated with a slightly improved outcome,” Dr. Culler told Anesthesiology News.

He noted that in the two arms of the study average outcomes were reported, and it was not known which cases were performed by anesthesiologists and which were not.

Very little is known about the relative efficacy of MDs compared with CRNAs for cardiac surgery, said Martin J. London, MD, Professor of Clinical Anesthesia at the University of California, San Francisco. The hypothesis is that OPCABs require a higher level of expertise than routine CABG procedures.

“These analyses are important, because both payers and government are obviously very interested in allocation of resources,” he said. “However, a number of complex variables must enter into interpretation of results—including what care is delivered, who delivers it and in what setting.”

Based on a poster presentation and oral review at the 2006 annual meeting of the Society of Cardiovascular Anesthesiologists and interviews with Phillip P. Brown, MD, Steven Culler, PhD, Martin J. London, and Terry Wicks.

http://www.anesthesiologynews.com/index.asp?section_id=1&show=dept&issue_id=181&article_id=5472

 

[militarymd]

It's all good and fine for anesthesiologists to beat their chests and strut ariound like little bantam roosters when studies like this get published in FREE journals....


...the physicians among the anesthesia providers DO realize that outcomes in non-CPB CABG's are 99.999999% determined by the guy holding the knife.

 

[VolatileAgent]

It's all good and fine for anesthesiologists to beat their chests and strut ariound like little bantam roosters when studies like this get published in FREE journals....


...the physicians among the anesthesia providers DO realize that outcomes in non-CPB CABG's are 99.999999% determined by the guy holding the knife.

no doubt. but, this was a variable that showed a difference. proof was asked for. i wasn't the one who started "beating my chest" or calling facts into question by making unsubstantiated statements (if you'll re-read my first post on this thread above).

so, what's your conclusion from this data anyway, mil? crna's need to pick better surgeons to work with? 🙄

Based on a poster presentation and oral review at the 2006 annual meeting of the Society of Cardiovascular Anesthesiologists and interviews....

 

[militarymd]

no doubt. but, this was a variable that showed a difference. proof was asked for. i wasn't the one who started "beating my chest" or calling facts into question by making unsubstantiated statements (if you'll re-read my first post on this thread above).

so, what's your conclusion from this data anyway, mil? crna's need to pick better surgeons to work with? 🙄

The data is flawed....NO conclusions can be drawn from it......different surgeons ...different hospitals....different volumes....

You werent' beating your chest....but....the physicians were the ones who WERE beating their chests....and over flawed data....I just wanted to point that out.....from the point of view of someone who I would dare say has more "training" than anyone else who posts on a regular basis.

 

[VolatileAgent]

The data is flawed....NO conclusions can be drawn from it......different surgeons ...different hospitals....different volumes....

it is data. it shows outcomes. it is there for intepretation. you are right, as was the crna who commented on it, to suggest that it was not the best kind of study (eg., we don't know what cases were balanced against which). but, you tried to impugn it immediately by stating that it was from a "free" journal, therefore could not be trusted. i did not see the original presentation because i did not go to the soca meeting. i imagine that it will be published in the a&a supplement. their methodology may be flawed and no firm conclusions drawn, but the data is what it is.

You werent' beating your chest....but....the physicians were the ones who WERE beating their chests....and over flawed data....I just wanted to point that out.....from the point of view of someone who I would dare say has more "training" than anyone else who posts on a regular basis.

i don't think it's fair to categorize anyone as "beating their chest" over this data. it was a mined database that showed a difference between hospitals that routinely use crnas and those that don't within one of the largest healthcare organizations in this country. now, whether that speaks to the fact that some of these hospitals should not be doing ANY off pump cards cases is a separate and possibly equally compelling debate. but, the point is that they commented on this, and the data shows a difference.

is this association and not causation? perhaps. but, they identified a common variable. and, the most important take home message is that no one knows, from formal evidence-based prospective study, whether it is safe to put a crna in charge of a cardiac case, and this retrospective analysis suggests grossly that it might not be. it is not concluding anything else.

this is a hugely controversial subject, and this provides some data. will this ever be formally and prospectively studied? who knows. but, i liked the analogy above about letting anyone with a pilot's license take a whack at flying a 747. this is tantamount to the current "license" (in a figurative sense) we give to crnas at this point to take primary control in cardiac cases. this study, at the very least, hints at the possibility that this may not be a good idea.

is this proof? depends on how loosely you want to apply the definition. but, it's funny how methodologically similar "outcomes" studies which show there is no difference between anesthesiologist and crna-directed care are heralded by the aana as "proof" that they can do the same exact job as us without our supervision.

i'd also suggest you look at silber's studies if you want more data.

 

[johankriek]

When Bill Clinton had his heart surgery, did a CRNA or an anesthesiologist provide the anesthesia? 'Nuff said...

i will correct you.. there were FIVE (5) anesthesiologists in the room.. NO CRNAs.. with bill clinton.. according to surgeon at the press conference

 

[militarymd]

i will correct you.. there were FIVE (5) anesthesiologists in the room.. NO CRNAs.. with bill clinton.. according to surgeon at the press conference

That's very interesting.

You would think that a VIP like Clinton would rate a well-trained anesthesia provider who could do a simple case on his or her own........rather than boobs that require the assistance for 4 other boobs.

 

[militarymd]

i'd also suggest you look at silber's studies if you want more data.

As I said...no conclusions can be drawn.

 

[blocks]

That's very interesting.

You would think that a VIP like Clinton would rate a well-trained anesthesia provider who could do a simple case on his or her own........rather than boobs that require the assistance for 4 other boobs.

Correction, you would think that the key note speaker at this year's CRNA national conference, whose own mother is a CRNA, would be satisfied with a CRNA performing his anesthesia, all things being equal...or are they...

 

[militarymd]

That's very interesting.

You would think that a VIP like Clinton would rate a well-trained anesthesia provider who could do a simple case on his or her own........rather than boobs that require the assistance for 4 other boobs.

Correction, you would think that the key note speaker at this year's CRNA national conference, whose own mother is a CRNA, would be satisfied with a CRNA performing his anesthesia, all things being equal...or are they...

Which part of my observation are you correcting?

 

[jetproppilot]

I don't know about the size of JPP's sack, but I think that he could probably do this!!!

HAHHAHAHHAHAHAHHA

Have been in a 747 cockpit many times as a pre-teen/teenager, sitting behind my dad.....watching his professionalism....watching him sit back with the big-old-bird level at thirty-some-thousand feet, autopilot on, doing a crossword puzzle during some of the 11-plus hour flight from LAX to London...watching in awe as he greased the landing at London Heathrow....man, he knew how to fly that big sonofabitch!

Ain't no way I could land a 747.

Well, yeah, I could land it. But thered be a broken plane and bodies scattered around.

 

[jetproppilot]

I'm curious to know what our forum attending staff feels about CRNAs. Anyone care to throw their opinions into the mix, both good and bad?

Next question.

 

[VolatileAgent]

Well, yeah, I could land it. But thered be a broken plane and bodies scattered around.

well, i, for one, appreciate the candor of you knowing and, more importantly, admitting your own limitations. that speaks volumes about what-is-undoubtedly your impeccable character.

 

[VolatileAgent]

That's very interesting.

You would think that a VIP like Clinton would rate a well-trained anesthesia provider who could do a simple case on his or her own........rather than boobs that require the assistance for 4 other boobs.

why do you hate your professional colleagues so much? do you genuinely possess such openly loathsome disdain for your profession in the real world, or is this just a caricature of the real person behind the posts portrayed for us all on the sdn forums? i'm sure the attending staff at columbia would be most interested in your comments. perhaps you should email them a link to this post.

 

[militarymd]

That's very interesting.

You would think that a VIP like Clinton would rate a well-trained anesthesia provider who could do a simple case on his or her own........rather than boobs that require the assistance for 4 other boobs.

why do you hate your professional colleagues so much? do you genuinely possess such openly loathsome disdain for your profession in the real world, or is this just a caricature of the real person behind the posts portrayed for us all on the sdn forums?

Does it take 5 anesthesia providers to provide anesthesia for a CABG?

Where I trained and where I've practiced...the answer is no....usually one physician or one CRNA or at the MOST a CRNA and a physician .

For some reason, it took 5 anesthesia providers to take care of one patient undergoing CABG......either they were boobs.....or they were boobs.

 

[johankriek]

Does it take 5 anesthesia providers to provide anesthesia for a CABG?

Where I trained and where I've practiced...the answer is no....usually one physician or one CRNA or at the MOST a CRNA and a physician .

For some reason, it took 5 anesthesia providers to take care of one patient undergoing CABG......either they were boobs.....or they were boobs.

that patient happened to be the former president of the united states you nimrod

 

[Conflicted]

Hmm

First, EcCA1 : Im very sorry and i do apologize. I think the sortof question your asking isnt going to be answered by newbies and residents. You need to talk to experienced attendings for answers.

Volatile, thanks for the post. I actually read both those "studies" neither of which can any conclusions be drawn from but they are all thats out there. Essentially the answer to my questions is "No, there isnt any evidence that Anesthesiologists are safer than CRNAs in any situation".

As to what Bill clinton does, thats not evidence but is rhetoric at its finest.

As for the silly attempts at further rhetoric again, not evidence. The parachute theory dosent apply to evidence. If there was such a difference in saftey it would be obvious (negative outcomes). It isnt, ergo there isnt (following the posted analogy logic).

Mil: thank you for trying to be honest. If there were more anesthesiologists and CRNAs like you, there would be much less BS insulting and politic between the two groups.

 

[militarymd]

that patient happened to be the former president of the united states you nimrod

I know who he is...I assisted with his anesthetic (from outside the OR) for his first surgery in 1997....He had only one anesthesiologist then.......

Like I said....if it took 5....then they were boobs.

 

[dogbone65]

[

QUOTE=The_Sensei;4336956]When Bill Clinton had his heart surgery, did a CRNA or an anesthesiologist provide the anesthesia? 'Nuff said...

[/QUOTE]

hhmmmm....don't know if that's the endorsement of someone I'd want given his previous, er misjudgements.

Relax....that's a clinton joke not an md slam]

 

[Gern Blansten]

I know who he is...I assisted with his anesthetic (from outside the OR) for his first surgery in 1997....He had only one anesthesiologist then.......

I am confused. You assisted with his anesthetic (from outside the OR)? He had only one anesthesiologist then....
Those statements seem to contradict eachother. How do you assist from outside. Were you on some sort of 2 way radio communication telling someone else which dials to turn? How many others would say that they assisted with the anesthetic for that surgery? If we found 3 others that say they assisted, then guess what.... Obviously, it would be pretty cool to say that you helped take care of the former president. Surely even you could admit that since you make the same claim. So I suspect that he had a primary anesthesiologist and a few colleagues who wanted to be a part of the experience by being in the room. I do not believe that this in any way classifies them or you as being boobs by wishing to be a part of the team that cares for such a VIP. I know pretty well that a lot of background checking goes into the facility and staff of the hospital that is going to care for a president. I suspect that the same checks are in place for the ex-presidents. I seriously doubt that such a high ranking official would be allowed to be cared for by boobs as you refer to them.
You seem like a really smart person and you offer so much to this forum, but I wonder why you hate other anesthesiologists so much.

 

[Conflicted]

hi Gern

I dont think Mil hates anyone. I think he judges CRNAs and Anesthesiologists on an individual basis and does not blanket either profession with single bad experience. To me, its the most honest opinion ive ever seen on here.

Many here are a little militant vs CRNAs and many CRNAs are militant vs anesthesiologists. I think each are driven by their association politics to be so. Cant blame them in a way, its all about protecting your piece of the $$ "pie".

Mil hates Boobs, regardless of profession and I think its that simple.

Really, what does he have to gain by defending CRNAs? Absolutely nothing. So what could his motivation possibly be except to impart honest information, as he has always done here? Yet people are bashing him for it, and they say Nurses eat their own.

 

[dogbone65]

I dont think Mil hates anyone. I think he judges CRNAs and Anesthesiologists on an individual basis and does not blanket either profession with single bad experience. To me, its the most honest opinion ive ever seen on here.Many here are a little militant vs CRNAs and many CRNAs are militant vs anesthesiologists. I think each are driven by their association politics to be so. Cant blame them in a way, its all about protecting your piece of the $$ "pie".

Mil hates Boobs, regardless of profession and I think its that simple.

Really, what does he have to gain by defending CRNAs? Absolutely nothing. So what could his motivation possibly be except to impart honest information, as he has always done here? Yet people are bashing him for it, and they say Nurses eat their own.

ding ding ding...we have a winner.....I think you are spot on....just my $0.02

 

[militarymd]

I am confused. You assisted with his anesthetic (from outside the OR)? He had only one anesthesiologist then....
.

I was a resident....the attending made me make up the drugs for Bill....so I assisted from outside the OR.

 

[bigdan]

Mil hates Boobs

So Mil...are you a "butt" guy or a "legs" guy?

dc

 

[Gern Blansten]

I am not bashing anyone. I simply question why he refers to the anesthesiologists as boobs. If he personally knows the people and that is his opinion, then he should say so. If he is unfamiliar with the case or the physicians, I question why he refers to them in such a derogatory way. I don't bash anyone on this forum. I am just curious. I know and have a good relationship with many CRNAs as well and have a great deal of respect for them. Yet I also have respect and admiration for my physician colleagues. I am certainly not trying to stir anything up with Mil, just curious about his dislike for other anesthesiologists that seems to creep into many of the threads here.

 

[Conflicted]

Gern

Your post have always been respectful of everyone.

 

[dogbone65]

I

am certainly not trying to stir anything up with Mil, just curious about his dislike for other anesthesiologists that seems to creep into many of the threads here.

I'm merely speculating, but this seems reasonable...perhaps the word "other" should be replaced with "certain". Perhaps he is like myself in that I know not all anesthesiologists are like certain ones on here with much more ego than intellect; just the same as I know not all crna's are like a previous favorite of this forum named nitecap......ya think?

 

[rn29306]

Nitecap was a first year SRNA that hadn't even set foot in an OR...but came on here and acted like a jackleg to the likes of Jet and the other MDs on here....running 'round acting like a '****......... Set a bad tone for alotta people.

In no way was he an established CRNA.

Just wanted to clarify.

 

[militarymd]

So Mil...are you a "butt" guy or a "legs" guy?

dc

BOTH

 

[BIS]

Did Nitecap effect you guys that much. Come on I have not seen that guy here in sometime. Lets get over him already.

Both professions have practitioners that are weak and some that are strong. In the real world most of the time we work together well.

Volatile the data in this study is hella flawed. I hope you dont base the way you practice anesthesia on similar studies.