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CRNA vs. Anesthesiologist

Discussion in 'Anesthesiology' started by patelakshar, Nov 11, 2002.

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  1. patelakshar

    patelakshar Member
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    Hey...I was reading some newspapers and I came across a story saying that Medicare changed its policy on paying hospitals: Hospitals no longer have to have an Anesthesiologist supervising a CRNA [CRNA can provide Anesthesia without an Anesthesiologist] to be eligible for Medicare payout. Is this going to affect the demand for Anesthesiologist? What do you guys think?


    ~Aki
     
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  3. Castro Viejo

    Castro Viejo Papa Clot Buster
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    Probably not, as I don't believe Medicare reimbursement was the main issue in having CRNAs supervised by Anesthesiologists.

    Most surgeons and most chiefs of staff I've spoken to prefer to have an MD attending Anesthesiologist on a case rather than a CRNA for a variety of reasons, all having to do with complications, emergencies (if any intraoperatively), and I guess "peace of mind" for those involved in care.

    What I've written, however, does not imply that CRNAs are incompetent or cannot handle emergencies if the need arises. There are some facilities where CRNAs do run the show, and run the show well. In New York State, I've heard of no such facility.
     
  4. Doc_Halo

    Doc_Halo Junior Member
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    I agree. The CRNA's I've seen in action are pretty knowledgable, competent, and are every bit as cool as the anesthesiologists they work with.
     
  5. Tenesma

    Tenesma Senior Member
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    yes, medicare no longer requires anesthesiology supervision for CRNAs - and instead their care is "directed" by the physician performing the procedure (which can be anybody from GI, Heme/Onc, to Surgery) - because the law as of now still doesn't allow prescription privileges to CRNAs (for gases, narcotics, etc...)... now that doesn't apply in every state (mainly those states that tend to have a high rural population with low MDA density have chosen to opt-out of MDA supervision)... will this affect jobs? not for the next 10 years or so... down the road? who knows - so far no study has effectively compared outcomes between MDA/CRNA in the basic operative setting, so until they can prove that CRNA can provide the exact same care then MDAs will have find a new niche in anesthesia... there will always be academic jobs, there will always be research job, subspecialty jobs (ie: pedi/cardio-thoracic/ICU/pain/interventional pain)....
     
  6. Su4n2

    Su4n2 Senior Member
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    Tim,
    i am wondering if there are any cRNA's in NYC because my husband is thinking of going into it but has gotten the feeling that there are no jobs for cRNA's in NYC. thanx. susan
     
  7. gasdoc

    gasdoc Member
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    from my understanding as a CA-1, Bush II cancelled Clinton's CRNA independence law in term's of medicare payments. At the same time, a "compromise" was made. That is, Bush left it up to the states (i.e. governors) to decide whether they allow for CRNA independent practice or not. So far, 4 states have opted for that option. The last state was Wisconsin, where Gov. Jesse Ventura's mother, as our immediate past president's mother, is a CRNA.

    Now, the anesthesiologists are not stupid either. Besides the active lobbying that persuaded Bush II to immediately change the law once he went into office, the MDA's have recently created the position of "anesthesiologist's assistant". Essentially, the AA is a PA (i.e. physician assistant) trained in anesthesia for 2 years. The AA position has a provision built into it that makes it illegal for them to seek independence from the anesthesiologist. That is, there has to be always supervision by the MDA of the AA. Now guess what? The CRNAs are up in arms and saying that the AA's are not qualified to practice anesthesia. Guess what? "What comes around goes around." The CRNAs have for years competed w/ the MDAs and said they are just as good as us. Now w/ the AA's around, they are getting a taste of their own medicine. From what I am told via the grapevine, one of the motives for the creation of the AAs is to weaken the CRNA's strong lobbying. Now, insteadof channelling all their energy and money into fighting the anesthesiologists, they have to also fight against AA's encroaching into their territory. Some anesthesiologists feel that this will significantly weaken their fight for more independence.
     
  8. emedpa

    emedpa GlobalDoc
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    FYI-
    AA'S ARE NOT PA'S, THEY HAVE A SEPARATE TRAINING PROGRAM THAT DOES NOT INCLUDE ANYTHING OTHER THAN ANESTHESIA RELATED CARE. SEPARATE BOARDS, APPLICATION PROCESS, ETC.
     
  9. gasdoc

    gasdoc Member
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    perhaps an AA is not a PA, but that's to say that a DO is not an MD. I believe in terms of purpose, the AA works similar to a PA. A PA is under the supervision of say a surgeon or an internist. In terms of training, the PA has something like a premed background (ie. 4 year college degree w/ premed courses) followed by 2 years of schooling in physician assistant. The AA also has 4 years of college, then go on a train especially in anesthesia practice for 2 years, for the sole purpose of working in anesthesia under the supervision of an anesthesiologist. If I am way off on this, let me know. The boards, licensing,etc may be different, but so they are different for a surgeon vs an anesthesiologist vs an internist. AAs and PAs are in the same category, just as surgeons, internists, anesthesiologists, etc are all doctors. ...Gala apples, granny apples, all apples...lol
     
  10. meandragonbrett

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    AA's cannot practice in any state they want to. I believe that only 14 or 15 states allow them. I will not have anesthesia provided by an AA.
     
  11. Tenesma

    Tenesma Senior Member
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    hey meandragonbrett....

    AAs wouldn't be providing your anesthesia - that responsibility falls on the shoulders of the MDA who is supervising the AA... just like if you were to have heart bypass surgery, the person harvesting your saphenous vein and sowing your leg up again wouldn't be a doctor - but instead somebody specifically trained to so under the supervision of the surgeon...
     
  12. womansurg

    womansurg it's a hard life...
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    Gee, do you know any?

    Of the anesthesia personnel whom I know and work with, the two individuals I would choose for myself and for whom I've made personal recommendations to others happen to both be CRNA's.
     
  13. Tenesma

    Tenesma Senior Member
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    just out of curiosity, is the anesthesia dept. weak at your surgical residency for you to recommend CRNA over MD?
     
  14. womansurg

    womansurg it's a hard life...
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    I'm sure that our anesthesiologists would take great exception to the suggestion of this, and would accordingly produce their prestigious degrees and research and accolades to prove otherwise.

    No, our anesthesiologists are not 'weak'. Rather, my point was that the two people whom I have aquired the greatest faith in HAPPEN to be CRNAs - in other words, I choose them not because they are CRNAs or because they are not MDs, but instead without much regard to which of the two they are. This is meant as a testiment to their competence in their role.

    In my experiences, these two people are extremely thorough in their evaluation of the patient, extremely competent in their handling of the airway and the anesthesia, extremely knowledgable and capable, just as are the other anesthesia personnel. The difference for these two people (which I'm sure would hold true were they MDs or RNs) is their exceptional kindess to the patient and families, their congeniality and cooperation with the other members of the medical team - free from actions of arrogance or ego, and their extreme attentiveness to the patient's comfort and emotional state throughout all stages of the procedure.

    They practice noteworthy professional excellence...and they happen to be RNs.
     
  15. OldManDave

    OldManDave Fossil Bouncer Emeritus
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    I have already encountered more than 1 scenario why there is a subtantial difference b/t a CRNA & an anesthesiologist...it is not the technical skills! My brother is an extremely talented musician and not medically-minded in the least. However, I know I could train him to start IVs, IJs and to intubate -- the ability to do those things are not what makes one an anesthesiologist anymore than the ability to hold a knife w/o excessive drooling makes one a surgeon or the ability to perform a rectal exam make one an internist. The difference comes in the education, the ability to intake vast amounts of information, collate & process it and then yield a decision that is, hopefully, proactive and not reactive -- but when the situation madates reaction, to do so in maner which maximizes the potential for the most positive outcome.

    CRNAs are provided with an education that is more procedural and technical in orientation than didactic focused. A similar parallel can be drawn b/t LPN/LVN (lic practical/vocational nurse) and an RN/BSN (reg nurse/BS in nursing) or b/t a CRT (certified respiratory therapist) and a RRT (registered respiratory therapist). In a very diluted explanation, the LVN/LPNs & CRTs are HOW to do things & something of WHEN to do them. However, the RN/BSNs & RRTs are taught WHY you do them and the science behind the rationale -- and are taught how to remain abreast of the information base as it changes. I know this because I went through both a CRT & an RRT program.

    The reason RN/BSNs & RRTs are paid significantly more $$ is not because they are more able to perform the specific tasks attributed to their professional roles. They are paid more for the valuable education, a knowledge base that exceeds procedural competence and ability to apply these extras to a multitude of unique and highly variable clinical situations. LVN/LPNs & CRTs assert their lesser stature as being unfair because they perform the same procedures as the advanced practitioners and they feel that they should be paid the same & have the same priviledges. Does this sound familiar?

    The argument cited by CRNAs: "We do the same procedures as MD/DO anesthesiologists, so we should be paid similarly and be able to do them independently" is essentially the same, except on much larger scale of responsibility.

    For example, this is an actual case I witnessed, a lady with massive comorbities is rushed to the OR for thromboembolism of distal aorta with 100% occlusion of flow distal to the aortic division into the common femorals. She had collapsed early in the day and was suspected to have been in this state for in excess of 8 hours. From the perimeun distal, she was cold, pasty white and with dependent venous accumulation in both legs -- the legs were actually stiff already. Comorbidities: PVD, CAD, DM1, Renal dysfunction and LEF of ~25% & an old CVA.

    She was to undergo an emergent axillo-bifemoral bypass grafting.

    The anesthesiologist started her case. As a proactive measures, low-dose dobutamine and Bicarb were given, in anticipation of the immense lactic acidosis that would occur post revascularization. The Doc knew that with her heart in sad shape, that she would not be able to tolerate or compensate for the sudden, profound acidosis that would result from returning bloodflow to her lower extremity. However, not wanting to stress her with excessive alkalosis, he monitored her A/B status closely...and her UO among a thousand other things.

    Trauma call to the ER! The Doc anesthesiologist was called to an inbound trauma and asked the on-call CRNA to babysit while he assessed the truama patient. The CRNA, seeing the most recent ABG values and a stable HR & adequate BP stopped giving BiCarb and stopped the dobutamine gtt.

    Upon his return, the Doc immediately restarted everything and asked the CRNA why she had stopped it. The CRNA replied, "well her numbers looked good; so did not see any indication for them".

    Granted this is a single & anecdotal incident. However, it served to profoundly underscore the difference in how the CRNA saw things vs the anesthesiologist. The CRNA was reacting to numbers and thinking from a purely reactive & procedural perspective...just as I would have expected a CRT that I was in charge of to have done. But, the physician was not only abreast of what was currently ongoing, he was aggressively trying to anticipate potential negative outcomes, evaluate them in context with the patient's comorbidities and to make proactive decisions in an effort to prevent those negative potentials.

    My 2 cents, for it is worth...
     
  16. womansurg

    womansurg it's a hard life...
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    Well now, it's not necessary to be totally drool FREE...

    Clearly, the greater education and training of the physician brings added benefit to patient management in complex scenarios. I would venture that this is often most evident in cases of complex airway, where margins for error are small and outcome differences profound. It's also probably fair to generalize to some extent, and say that folks who pursue a longer, more difficult level of training are more scholarly, possibly more intelligent, and very likely more committed to ongoing education than their counterparts who took the short path.

    For me, in weighing the merits and drawbacks of various people's performances, I'm led to have faith in the practices of at least these two individuals who arrived at their expertise by this different way. I would defend their professional practices vigorously, and do so in a roundabout way by speaking against blacklisting of people with their training background (as meandragonbrett seemed to do).

    Many factors go into what makes people more effective in their jobs. The 'jumping off point' of your training is one; what you do from that point on is another.
     
  17. Tenesma

    Tenesma Senior Member
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    for womansurg...

    i think i understand your point of view.... you weren't recommending those 2 people because of their degree, but rather for their competence and more importantly their interaction with patients... out of my own experience, i chose a surgeon for a family member not based on his expertise, but instead because i knew he would hold their hand when it was most important... It is funny how the longer i am a physician, the more i realize how patient interaction actually matters more to patients than how great somebody is with a laryngoscope/blade/endoscope, etc...

    kinda weird... huh?
     
  18. womansurg

    womansurg it's a hard life...
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    :::: grinning happily ::::

    I'm glad we connected on that....
     
  19. gasdoc

    gasdoc Member
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    old man dave made a very good analogy w/ the example about the MDA vs. CRNA in terms of the MDA taking a proactive rather a reactive stance to intraoperative problems, etc.

    I was taught by my MDA preceptor the very 1st day or 2 in my CA 1 training, when I was literally held by the hand by the MDA, that "The great anesthesiologists are the ones who never have to solve or react to problems b/c they anticipate them and prevent them from happening in the first place." Also, other MDAs have been telling me that the main difference between MDAs and CRNAs is not so much technical know-how, but our understanding of WHY things happen b/c we understand the physiology and pharmacology behind them.

    In an ideal world for me and for most MDAs, CRNAs and MDAs work together in the "anesthesia team" model.
     
  20. Sandpaper

    Sandpaper Member
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    Every once in a great while one is treated to an insightful and intelligent post in this forum that stirs dormant thoughts in the reader and makes one say hmmmm. The above, regretfully, is not one of them. One wonders what a self-professed surgeon is doing lurking around the anesthesiology forum and then springs the revelation that "anesthesia personnel" to her are all equally competent save for those special nurses who hold patients hands. Not one who is big on fancy-shmancy title, but "personnel"? What strikes as intelligent thoughts soon wither to nothing but ignorant testaments. If hand holding and thoughtful attitudes towards patients are all one needs to become a qualified anesthesia "technician", then by all means, let us anoint the Dai Lama, the Pope, and bring Mother Teresa back from the dead. And putting the science of medicine, specifically anesthesiology, in the hands of "faith" shows total lack of regard for the advancement of the field that has helped your own field advance in scope. I need not remind you that surgeons once were not too far removed from their butcher and barber cousins.

    With the decline in the appeal of surgery and the decrease in the quality of surgical applicants, MDAs will play a doubly important role in protecting patients from knife wielding egolomaniacs with little thought process whirling up top. And if one is to judge the quality of care delivered by the criteria listed in the above post, most surgeons would fail miserably. Loosely used terms like "congeniality", "cooperation with other members of the medical team", "free from actions of arrogance or ego", are laughable when applied to most surgeons. Look into a mirror and tell me what you see. Your obliviousness to the reality of the practice of medicine is astounding and is further magnified when you would choose a person with lesser training than your own colleagues, just because the person holds your hand? Hand holding is not going to decrease the risk of surgery for a ASA IV patient.

    This type of posting further demonstrate the total lack of unity amongst different physician groups, allowing third-party providers and the insurance industry to trample over us. I have nothing against CRNAs and what they do. However, I won't dignify their position by comparing the quality of care patients receive from CRNAs vs. MDAs. Comparing apples and oranges is a waste of time. Convincing fools of their ignorance is also a waste of time, for ignorance is bliss, or is it the propofol dripping in?
     
  21. OldManDave

    OldManDave Fossil Bouncer Emeritus
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    I could not agree more! In fact, I know from personal experience that earning your stripes amongst your fellow healthcare professionals (nurses, resp terrorists & other physicians) is far more about performance, results and earned respect than merely which diploma you possess and where it came from...sorry to all you folks who thrive on the all-too-fatiguing MD v DO debate, in the real professional world, largely, no one gives a rat's ass.

    I have learned a ton from not only CRNAs, but a few anesthesia techs as well. Even more profound, my many years of hands-on clinical medicine (before I was an RRT, I spent 5 years as a cardiac monitor tech runing EKGs and reading cardia telemetry), I know that every single person you encounter, be that patient, peer, allied health professional, patient or family member -- each one of them has something of value to teach you. However, YOU must take responsibility for gleaning that pearl of wisdom from each encounter!
     
  22. NikiVIBES

    NikiVIBES Junior Member

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    Hello, I'm doing a research on the mortality rates and safety issues related to anesthesia delivered by a CRNA and Anesthesiolgist. So far, I've found only one article which states that there is no difference at all. Does anyone know or have any tangible evidence to support this issue? Your opinion is appreciated however, I need proof. Thankyou.
     
  23. jetproppilot

    jetproppilot Turboprop Driver
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    Yeah, OK. Are you really doing research on this subject, or are you a s hit stirring troll?

    I vote the latter.

    Venty, close this thread, please, before I cap him Dre style.
     
  24. AlexCCRN

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    NYS is bumping up CRNA scope to include prescription and billing priviledge with the ARNP designation.
     
  25. nitecap

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    At least we know the forum search engine is back up and running strong again.

    Please quit bumping these ancient assss posts, if your doing research than do it. A public forum isn't the best and most accurate place to get research info. Try more legit sources if you are at all going to do a legit study. Seems like you would know this if you know anything about research or any anesthesia related issues. I call your bluff.
     
  26. AlexCCRN

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  27. nitecap

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  28. rn29306

    rn29306 Drugs are bad, m'kay?
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    You moron. These people don't give two ****s about your rants. You just personally undermined about 4 weeks of a pleasant atmosphere with no CRNA bashing. Congrats tool. If your shortsighted synapses ever think of posting here again, stay off the politics. It makes us all look like you and that ain't kewl.
     
  29. NikiVIBES

    NikiVIBES Junior Member

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    Jet, why are you so mean? seriously, I'm looking for data to support my paper. I'm an undergrad. student and I'm seriously looking into anesthesia as a career. I currently work in the OR as a tech and have seen anesthesia administered by both crna and md. both professionals are quite good at what they do. I really don't see any difference except that the crna's are just more down to earth. which is why i'm wondering whether to go to med school and spend of most of my youth studying or getting a career before age 30. that's all. by the way, I forgive you for you have been stigmatized.
     
  30. NikiVIBES

    NikiVIBES Junior Member

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    i know this isn't the best place to do any research... (so much aggression) but i'm at the end of my wits. since this is a PUBLIC FORUM, i was just wondering if any one is generous enough to help out a fellow student. that's all. :) :)
     
  31. jetproppilot

    jetproppilot Turboprop Driver
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    No worries here.

    Still a pleasant atmosphere.

    The trolls will come and go.
     
  32. ear-ache

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    May I suggest you start with pubmed, OVID, and Cochrane review searchs. ;)
     
  33. bullard

    bullard Senior Member
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    Try the following:

    Abenstein JP, Warner MA. Anesthesia providers, patient outcomes, and costs. Anesthesia and Analgesia. 1996; 82(6):1273-83.

    Silber JH, Kennedy SK, Even-Shoshan O, Chen W, Koziol LF, Showan AM, Longnecker DE. Anesthesiologist direction and patient outcomes. Anesthesiology. 2000;93(1):152-63.

    These folks have probably authored some more recent stuff; I'm too lazy to look.
     
  34. TXANESTHETIST

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    CRNAs are provided with an education that is more procedural and technical in orientation than didactic focused. A similar parallel can be drawn b/t LPN/LVN (lic practical/vocational nurse) and an RN/BSN (reg nurse/BS in nursing) or b/t a CRT (certified respiratory therapist) and a RRT (registered respiratory therapist). In a very diluted explanation, the LVN/LPNs & CRTs are HOW to do things & something of WHEN to do them. However, the RN/BSNs & RRTs are taught WHY you do them and the science behind the rationale -- and are taught how to remain abreast of the information base as it changes. I know this because I went through both a CRT & an RRT program.

    While I do not downplay the education of a physician at all, I think many physicians & residents downplay the education of CRNA's. In that one incident you sited maybe the CRNA wasn't thinking, but you also have to think about the circumstances and the type of report about the patient which may have been given. You all know sometimes what kind of report you give sometimes when you're only going to the bathroom, etc. Sometimes it's not great CRNA's and MDA's alike. Enough on that i think you get my drift.

    About education of CRNA's I don't think enough folks understand that CRNA's go through intense didactic. Unlike AA's education (which I have just gotten a hint of here), we do go through advanced pharmacology classes, pharmacology of anesthetics, pathophysiology, physiology, chemistry, etc. What we do not do is internal medicine residencies, pediatric residencies, etc. In no way am I saying that the education of an MD and CRNA are equal. MD's do it for a lot longer and rack up much more debt, but anyone who graduates a school of nurse anesthesia should definitely know the why and be anticipating problems, etc.

    Personally I am glad that we have both types of providers. I think MD's should be used for their vast knowledge. I think most are willing to share and teach which is good. They still have many more opportunities that CRNA's don't have or it's not as easy to get into. Pain mgmt, ICU anesthesia, etc.

    I have also been doing research about the whole medicare opt out thing trying to get a better understanding of it all. From what i understand CRNA's in the states that do not opt out need a signature from an MD (of any kind, surgeon, MDA) so the facility will be reimbursed for anesthesia related supplies. What this also translates into is that the "supervising" physician if he/she is an anesthesiologist gets a percentage of the billing for the case. That = a whole lot of $$$ lost for the MDA if the CRNA's don't need that "supervision". I would not want CRNA independence if i were an MD either! Think about it, I am sitting in my office (the good MD's actually walk around and see if anyone needs anything) 4 rooms are running at the same time. I am getting a cut of each room. Not a bad deal. Someone please correct me if I am wrong on the whole medicare thing. I have seen a whole lot of "it's for patient safety" stuff and I just don't believe it because at most facilities either the CRNA is doing everything or the doc comes in pushes propofol, watches the CRNA intubate then leaves the room.
     
  35. timtye78

    timtye78 Senior Member
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  36. NikiVIBES

    NikiVIBES Junior Member

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  37. nitecap

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    Try this resource:

    Pine, M, Holt, KD, Lou, YB."Surgical Mortality and Type of Anesthesia Provider." AANA Journal.2003; 71:109-116
     
  38. davvid2700

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    who sponsored the study? and who is the lead author before I read it
     
  39. nitecap

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    Who cares who sponsored it. IF you are really doing research then a contemplation of info and studies is best anyway so you can come to your own conclusions, and so your study isnt totally skewed.
     
  40. bullard

    bullard Senior Member
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    Pine is a cardiologist. I don't find the study particularly convincing, but then I don't find the studies that I posted particularly convincing either. It's not something one can easily design a study for, IMHO.

     
  41. davvid2700

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    If sevo is sponsoring a study.. they are going to make sure that the study show sevo is clearly better than any other inhalational agent.. or if it doesnt show that.. they are going to abort the study.. period.. Sevo is not going to sponsor a study that shows desflurane is better.. so it does matter
     
  42. nitecap

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    Exactly, so please keep that in mind next time a group of MDA's or the ASA do a study on Anesthesia Outcomes. Thanks for making the point as strongly as you did. Lets go ahead and disregard all the other bogus attempts the ASA made by biased and skewed research on provider outcomes. You make this to easy David.
     
  43. davvid2700

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    I say let the AAs practice in all 50 states..
     
  44. ear-ache

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    Perhaps the same could be said for Pine et al. study?

    This study was authored by Michael Pine, M.D., President of Michael Pine and Associates, Inc, a Chicago firm hired by the AANA Foundation for this study.

    Nearly all studies have some form of bias.
     
  45. AlexCCRN

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    disclaimer: if you could read you would see there is no bashing, i was just opining in a cheerful vibe - reflecting aloud about the rich opportunities we enjoy... and then... you... and niteflap...so, my private messages to you both were an impulsive yet sincere cathartic expression of my instant and slightly cathartic response to the steatorrhea that is you.
     
  46. rn29306

    rn29306 Drugs are bad, m'kay?
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    Dude you are full of oral garbage. I'm sure your English teacher loved this pile of s h i t that you so graciously bestow upon both nitecap and I as a PM, but don't send me a message that explicitly states "don't mess with the unknown". Bring it son and go ******* yourself. No one wants to hear CRNA rants on this board. Tried it once, didn't help. Makes you look like the imbecile and a s s that you are.
    We had one of our most brillant MDAs teach our CV class these past few months. He quoted his experience with PA caths in terms of raw numbers. Our whole class added together will not have this number, even if we all practiced until the age of 79.5 years of CRNA practice. Not to say I don't understand PA caths and the numbers they generate, how I might manipulate them coming off pump, CO, and SVR alike with various pharmacologic agents, but we are nowhere near his understanding. We might sit a stool and run cases damn well, but MDAs are physicians. CRNAs are not. Me personally, I like picking up the phone and having an MDA come to see what my problem is. I am regarded as the top 3 in my class clinically and I'm on top of my game in the OR. I run into problems like anyone else. You want to go and do s h i t yourself, then go be it.
    Your post directly undermined all CRNA efforts to get along with people on this board and you can go jack off somewhere else as far as I'm concerned.
    This is my sincere response to you a s s h o l e.

    I'm going to borrow one of the most humorous individual's sig on this board and say:


    Regards - rn29306
     
  47. tkim

    tkim 10 cc's cordrazine
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    everyone take a cold shower. please.
     
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