CRNA skill level

[IlDestriero]

Disagree here. It is very common in many programs in my State. You have no idea what % of programs tolerate or "turn a blind eye" to this practice and it could be 50% or more of all the programs.

They tolerated it in the .mil when I was there and they needed the #s.

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[Tenerife]

Sure, buddy. COA accredits programs. They are the ones that determine if a program is meeting requirements to graduate students. If you recall, NBCRNA is the entity that determines if the student has appropriately met their case/numbers, in order to sit for boards.

Come on. The AANA, NBCRNA, and COA are in collusion.

Again, please show me, from ANY of those governing bodies, descriptive standards for SRNA clinical experiences.

The COA is failing to address the significant issue of substandard educational programs.

Dumbing down the profession to the least common denominator while aggressively advancing the independent practice mindset is, at best, irresponsible.

 

[deansrv72]

Come on. The AANA, NBCRNA, and COA are in collusion.

Again, please show me, from ANY of those governing bodies, descriptive standards for SRNA clinical experiences.

The COA is failing to address the significant issue of substandard educational programs.

Dumbing down the profession to the least common denominator while aggressively advancing the independent practice mindset is, at best, irresponsible.

I'm not disagreeing with you. I think the COA should totally step up and increase minimum standards. The fact that they're more concerned that programs will be hurt that they would have to close vs increase better providers is quite concerning.

As to showing you the evidence, I suppose I can look for it at another time. But you can't tell me, from your past education/program, that the NBCRNA ever stated that sharing, or even taking part of a case, was equal to (and should be the same as) counting a whole case number.

 

[KETMAG]

It is neither tolerated or accepted. In fact it is cause for suspension of a program and its on page 30

"Counting clinical experiences - Students can only take credit for a case where they personally provide anesthesia for the case. A student may only count a procedure (e.g., central venous catheter placement, regional block, etc.) that he or she actually performs. Students cannot take credit for an anesthetic case if they are not personally involved with the management of the anesthetic, or only observe another anesthesia provider manage a patient’s anesthetic care. Two learners should not be assigned to the same case, except when the case provides learning opportunities for 2 students and 2 anesthesia providers are necessary due to the acuity of the case. The program will need to justify any deviation from this requirement."

What are you? A student?

Please show me the specific language corroborating your assertion that "cases are [only] supposed to be counted if the SRNA does the case from start to finish" in this document:

http://home.coa.us.com/accreditation/Documents/Standards for Accreditation of Nurse Anesthesia Education Programs.pdf

The COA is a multidisciplinary body, separate from the AANA, that evaluates nurse anesthesia programs. The COA also approves new programs. So where do you think the efforts have been focused for the past several years?

Please just stop posting now. You will make us look even worse.

What are you? A student?

Please show me the specific language corroborating your assertion that "cases are [only] supposed to be counted if the SRNA does the case from start to finish" in this document:

http://home.coa.us.com/accreditation/Documents/Standards for Accreditation of Nurse Anesthesia Education Programs.pdf

The COA is a multidisciplinary body, separate from the AANA, that evaluates nurse anesthesia programs. The COA also approves new programs. So where do you think the efforts have been focused for the past several years?

Please just stop posting now. You will make us look even worse.

 

[BLADEMDA]

I'm not disagreeing with you. I think the COA should totally step up and increase minimum standards. The fact that they're more concerned that programs will be hurt that they would have to close vs increase better providers is quite concerning.

As to showing you the evidence, I suppose I can look for it at another time. But you can't tell me, from your past education/program, that the NBCRNA ever stated that sharing, or even taking part of a case, was equal to (and should be the same as) counting a whole case number.

They count them all over the South this way. I know several programs which simply don't have enough cases for the SRNAs so they are forced to double up.
In addition, they do a lot of "observation" only cases which they count as well.

 

[BLADEMDA]

It is neither tolerated or accepted. In fact it is cause for suspension of a program and its on page 30

"Counting clinical experiences - Students can only take credit for a case where they personally provide anesthesia for the case. A student may only count a procedure (e.g., central venous catheter placement, regional block, etc.) that he or she actually performs. Students cannot take credit for an anesthetic case if they are not personally involved with the management of the anesthetic, or only observe another anesthesia provider manage a patient’s anesthetic care. Two learners should not be assigned to the same case, except when the case provides learning opportunities for 2 students and 2 anesthesia providers are necessary due to the acuity of the case. The program will need to justify any deviation from this requirement."

Typical AANA/COA/WHatever B.S and lies. They do it all the time and count the cases. I'm willing to bet the higher ups know this is going on in dozens of programs but choose to look the other way.

 

[Turtlez]

Why is my thread getting hijacked by hostile intruders?

 

[vector2]

CRNA skill level, you ask?

Here's the first couple hours of my recent carotid endarterectomy on a 70-some year old ASA 3 gentleman:

And here's one from the same week on a similar patient performed by a CRNA at my institution:

Has the CRNA performed enough cardiac/vascular cases on sick patients to really understand the concept of a balanced induction? Have they recently presented a keyword on incidence of CEA complications and their management, or understand why a remifentanil infusion provides excellent hemodynamic stability? Do they know (or care) that small boluses of nicardipine will serve them better than absentmindedly flipping the infusion on and off every couple minutes? Do you think even a fraction of them understand the difference between putting in a shunt versus cross-clamping solely with reliance on contralateral ICA/vertebral perfusion?

This is just one of a bazillion examples in anesthesia where a CRNA's training/skill set can't compare with a physician's...

 

[Man o War]

CRNA skill level, you ask?

Here's the first couple hours of my recent carotid endarterectomy on a 70-some year old ASA 3 gentleman:

And here's one from the same week on a similar patient performed by a CRNA at my institution:

Has the CRNA performed enough cardiac/vascular cases on sick patients to really understand the concept of a balanced induction? Have they recently presented a keyword on incidence of CEA complications and their management, or understand why a remifentanil infusion provides excellent hemodynamic stability? Do they know (or care) that small boluses of nicardipine will serve them better than absentmindedly flipping the infusion on and off every couple minutes? Do you think even a fraction of them understand the difference between putting in a shunt versus cross-clamping solely with reliance on contralateral ICA/vertebral perfusion?

This is just one of a bazillion examples in anesthesia where a CRNA's training/skill set can't compare with a physician's...

BAM.

 

[Baller MD]

CRNA skill level, you ask?

Here's the first couple hours of my recent carotid endarterectomy on a 70-some year old ASA 3 gentleman:

And here's one from the same week on a similar patient performed by a CRNA at my institution:

Has the CRNA performed enough cardiac/vascular cases on sick patients to really understand the concept of a balanced induction? Have they recently presented a keyword on incidence of CEA complications and their management, or understand why a remifentanil infusion provides excellent hemodynamic stability? Do they know (or care) that small boluses of nicardipine will serve them better than absentmindedly flipping the infusion on and off every couple minutes? Do you think even a fraction of them understand the difference between putting in a shunt versus cross-clamping solely with reliance on contralateral ICA/vertebral perfusion?

This is just one of a bazillion examples in anesthesia where a CRNA's training/skill set can't compare with a physician's...

Hey buddy, haven't you heard? Nobody gives a **** as long as the patient comes out alive at the end, okay? That's the new standard now. /s

 

[Ezekiel2517]

Damn looks like the crna's systolics were in the 50's for well over 5 min there

 

[NOsaintsfan]

Sure thing, Spinach. Keep eating the dip.

I am in medical school and I actually have come close to many of the requirements. That frightens me. I am in no way ready to be turned loose upon the anesthesia world. Its scary that anyone would think they are ready to be independent after such little experience. I guess ignorance is bliss.

 

[deleted171991]

CRNA skill level, you ask?

Here's the first couple hours of my recent carotid endarterectomy on a 70-some year old ASA 3 gentleman:

And here's one from the same week on a similar patient performed by a CRNA at my institution:

Has the CRNA performed enough cardiac/vascular cases on sick patients to really understand the concept of a balanced induction? Have they recently presented a keyword on incidence of CEA complications and their management, or understand why a remifentanil infusion provides excellent hemodynamic stability? Do they know (or care) that small boluses of nicardipine will serve them better than absentmindedly flipping the infusion on and off every couple minutes? Do you think even a fraction of them understand the difference between putting in a shunt versus cross-clamping solely with reliance on contralateral ICA/vertebral perfusion?

This is just one of a bazillion examples in anesthesia where a CRNA's training/skill set can't compare with a physician's...

I am a known CRNA critic, but no two patients are alike, not even two anesthetics on the same patient. Hence your example doesn't mean anything.

 

[deleted171991]

Hey buddy, haven't you heard? Nobody gives a **** as long as the patient comes out alive at the end, okay? That's the new standard now. /s

Exactly. What matters are the cost and the outcome, not the tram track. This is not new at all.

That's why people who want to be appreciated for their art should go into a different specialty. Nobody really gives a **** (except about the artistic impression for stupid staff and surgeons), as long as the job gets done and the patient does well.

 

[pgg]

I am a known CRNA critic, but no two patients are alike, not even two anesthetics on the same patient. Hence your example doesn't mean anything.

That induction was awful, I don't care who the provider or patient is.

 

[sevoflurane]

That induction was awful, I don't care who the provider or patient is.

Absolutely agree my friend. Do I see all 3 inhaled agents being used on this patient? I see a lot of systolics in the 200 range... fine if it happens a time or two, but pretty soon after induction, you have to have that figured out... Wild swings in blood pressures like what is shown in the EMR above shows me a certain skill set that needs to be further developed.

 

[CriTICAL]

Typical AANA/COA/WHatever B.S and lies. They do it all the time and count the cases. I'm willing to bet the higher ups know this is going on in dozens of programs but choose to look the other way.

I went to a very large program in a very large city and can attest this indeed happens. While doing my peds rotation as a resident, I noticed SRNAs were doubled up in all peds cases at a standalone childrens hospital since there were not enough cases for the ridiculous number of SRNAs that were rotating at the time.

Also on rare occasion that SRNAs found themselves in the cardiac room at the VA, they would always be doubled up. I clearly remember one particular SRNA who was literally DAYS from graduating needing to place a CVC for her #'s and was clear she had never placed a CVC in her life. The average medicine intern on July 1st would have looked like a Pro compared to this graduating SRNA.

My 2cents

 

[vector2]

Exactly. What matters are the cost and the outcome, not the tram track. This is not new at all.

That's why people who want to be appreciated for their art should go into a different specialty. Nobody really gives a **** (except about the artistic impression for stupid staff and surgeons), as long as the job gets done and the patient does well.

Agreed that no two patients are the same, but most vasculopaths on multiple hypertension meds getting a CEA are going to be prone to having wild swings. Although I didn't snapshot the med administration, you can tell from looking at my record that my patient was well on his way to having wild swings to the up- or downside, and these were preemptively intervened upon. This kind of management actually requires paying attention the entire time so you can titrate based on anticipation and not chase your tail once things are out of hand.

I guess it's also true that this kind of attention to detail or caring about the "art" really doesn't matter as long as the patient does fine at the end, but in the last month at my shop we also had a CEA on an asymptomatic retired physician who did crossfit 3x a week whose case went OK and he ended up having a STEMI in the PACU. Long story short he expired a week later in the CICU. Careful intraop management like this doesn't matter until it does.

Do I see all 3 inhaled agents being used on this patient?

The CRNA used sevo and iso during the case. The switch to iso was actually incidental and was based upon the fact that the goddamned bean counters at my institution actually audit records and scold you when the more expensive agent is used for a case longer than 2 hrs without some sort of medical justifications.