CRNA wearing white coat administers fatal treatment

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I'm an APRN and the amount of hubris demonstrated by these two CRNAs is terrifying. I had a C5-6 TFESI done yesterday. I've had several of them - by a board certified pain doctor. No way in h*ll am I letting a CRNA do any kind of interventional pain procedure on me. I've also never needed sedation. Yes, it's uncomfortable when he gets right on the nerve. It's over pretty quickly. I've never had an RFA but I've had stellate ganglion blocks, lumbar TFESIs, epidural injections, CT guided piriformis botox injections, pectoralis minor block for nTOS. Always been done by a pain physician, neurosurgeon, or radiologist. The one exception was an experienced PA under a radiology group doing an injection for a CT myelogram. It's actually the smoothest lumbar puncture I've had. Would I let him near a nerve root? No.

I've never been sedated for any such procedure. How do I justify the risk, even if minimal? I don't understand the compulsion to sedate so many patients undergoing pain procedures. These CRNAs doing these "pain" fellowships are taking advantage of patients who don't understand the difference in capabilities between a CRNA and a physician doing these procedures. More important than technical ability is knowing enough to make the correct diagnosis. Pain medicine is complex. Can't learn that in a mini "fellowship." What a joke.

I was highly encouraging to receive IV diazepam as sedation for a liver biopsy. What a joke. It didn't phase me. I was awake the entire time and local was plenty. If I ever have that again, I'll forgot sedation and the NPO requirements.
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Crnas definitely can wear white coats like docs. First year crna makes 300k as w2 (so this is no locums). Probably includes sign on bonus and overtime but it’s not a bad pay for a 31 yo new grad crna. The pay gap between crna and docs is getting smaller and smaller. Remember many of these crnas don’t do nights or have compressed 3 day work schedules as well. Most places give crnas the same vacation time as docs also (8-10 weeks).

 
I think the white coat is irrelevant to the story. Many kinds of clinicians wear white coats. Never seen a one worn in a procedure area. It's gross negligence with or without the coat.
 
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As outdated as it seems to us, white coats send a strong signal to patients. It’s yet another tactic to deliberately mislead patients while maintaining plausible deniability.

It’s even used to fool doctors. At one hospital, the chief CRNA required the others to wear white coats into the doctor’s lounge to reduce the likelihood doctors would raise a stink.
 
A Deep Breath said:
As outdated as it seems to us, white coats send a strong signal to patients. It’s yet another tactic to deliberately mislead patients while maintaining plausible deniability.

It’s even used to fool doctors. At one hospital, the chief CRNA required the others to wear white coats into the doctor’s lounge to reduce the likelihood doctors would raise a stink.
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Lol

That’s precisely what a crna would do.
 
aneftp said:
Crnas definitely can wear white coats like docs. First year crna makes 300k as w2 (so this is no locums). Probably includes sign on bonus and overtime but it’s not a bad pay for a 31 yo new grad crna. The pay gap between crna and docs is getting smaller and smaller. Remember many of these crnas don’t do nights or have compressed 3 day work schedules as well. Most places give crnas the same vacation time as docs also (8-10 weeks).

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Spot on. They then can work more during the week for other facilities and vacation time.
 
EMdoc254 said:
There’s a Reddit forum where people brag about salaries like this?? These people must be so insecure. This is so cringy.
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Yeah it's called gasworks, SDN,or any other recruitment site.
 
aneftp said:
Crnas definitely can wear white coats like docs. First year crna makes 300k as w2 (so this is no locums). Probably includes sign on bonus and overtime but it’s not a bad pay for a 31 yo new grad crna. The pay gap between crna and docs is getting smaller and smaller. Remember many of these crnas don’t do nights or have compressed 3 day work schedules as well. Most places give crnas the same vacation time as docs also (8-10 weeks).

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This is the way. Any dunderheads becoming physicians get what they deserve.
 
addoncase said:
Spot on. They then can work more during the week for other facilities and vacation time.
Click to expand...
How many crnas work 7-3p (5 days week) these days? Especially hospital based crnas. Very few.
Who are full time

How many docs make themselves available who are full time 7 days a week at the beckon of their employers (outside of schedule time off). That answer is 80-90% of docs need to be available to work 7 days a week when schedules are made and they aren’t on vacation.

That’s the huge difference I am seeing in staffing models.
 
psycho-matic said:
I'm an APRN and the amount of hubris demonstrated by these two CRNAs is terrifying. I had a C5-6 TFESI done yesterday. I've had several of them - by a board certified pain doctor. No way in h*ll am I letting a CRNA do any kind of interventional pain procedure on me. I've also never needed sedation. Yes, it's uncomfortable when he gets right on the nerve. It's over pretty quickly. I've never had an RFA but I've had stellate ganglion blocks, lumbar TFESIs, epidural injections, CT guided piriformis botox injections, pectoralis minor block for nTOS. Always been done by a pain physician, neurosurgeon, or radiologist. The one exception was an experienced PA under a radiology group doing an injection for a CT myelogram. It's actually the smoothest lumbar puncture I've had. Would I let him near a nerve root? No.

I've never been sedated for any such procedure. How do I justify the risk, even if minimal? I don't understand the compulsion to sedate so many patients undergoing pain procedures. These CRNAs doing these "pain" fellowships are taking advantage of patients who don't understand the difference in capabilities between a CRNA and a physician doing these procedures. More important than technical ability is knowing enough to make the correct diagnosis. Pain medicine is complex. Can't learn that in a mini "fellowship." What a joke.

I was highly encouraging to receive IV diazepam as sedation for a liver biopsy. What a joke. It didn't phase me. I was awake the entire time and local was plenty. If I ever have that again, I'll forgot sedation and the NPO requirements.
Click to expand...
curious, why would you opt for a cervical TFESI as opposed to a paramedian cervical ESI knowing that cervical TFESIs are not standard and have significant risk?
 
aneftp said:
How many crnas work 7-3p (5 days week) these days? Especially hospital based crnas. Very few.
Who are full time

How many docs make themselves available who are full time 7 days a week at the beckon of their employers (outside of schedule time off). That answer is 80-90% of docs need to be available to work 7 days a week when schedules are made and they aren’t on vacation.

That’s the huge difference I am seeing in staffing models.
Click to expand...
 
AKMD_1984 said:
curious, why would you opt for a cervical TFESI as opposed to a paramedian cervical ESI knowing that cervical TFESIs are not standard and have significant risk?
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I think your comment is bordering on giving medical advice? I am not versed in the various approaches and their risks. The main questions I asked before the first injection were about what they were injecting and making sure it wasn't a particulate solution. I've seen this same doctor for 3 years. The injections work. His did a pain fellowship at Emory and he's head of the the interventional pain department at a well-known academic hospital. I was referred to him by an excellent spine surgeon. I trust that they know what they are doing. I've been putting off surgery. The injections take away pain in both arms and the left leg (suspected funicular pain) for months. I'm actually going back to see the surgeon next week. I'm considering a C5-6 ADR.
 
psycho-matic said:
I think your comment is bordering on giving medical advice? I am not versed in the various approaches and their risks. The main questions I asked before the first injection were about what they were injecting and making sure it wasn't a particulate solution. I've seen this same doctor for 3 years. The injections work. His did a pain fellowship at Emory and he's head of the the interventional pain department at a well-known academic hospital. I was referred to him by an excellent spine surgeon. I trust that they know what they are doing. I've been putting off surgery. The injections take away pain in both arms and the left leg (suspected funicular pain) for months. I'm actually going back to see the surgeon next week. I'm considering a C5-6 ADR.
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Im also fellowship trained in pain mgt and dual boarded and do injections.

Yes we all use non particulate steroids for cervical ESI (inter laminar). It’s safer given vascularity.

I have never done or needed to do a cervical TFESI because risks and benefits do not typically justify that procedure based on evidence. It is not something that’s routinely done - paramedian approach is far safer than a TFESI. That’s why I was asking out of curiosity. I wasn’t offering medical advice by any means.

Cheers.
 
AKMD_1984 said:
Im also fellowship trained in pain mgt and dual boarded and do injections.

Yes we all use non particulate steroids for cervical ESI (inter laminar). It’s safer given vascularity.

I have never done or needed to do a cervical TFESI because risks and benefits do not typically justify that procedure based on evidence. It is not something that’s routinely done - paramedian approach is far safer than a TFESI. That’s why I was asking out of curiosity. I wasn’t offering medical advice by any means.

Cheers.
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Maybe because my injection is at C5-6 and "Cervical interlaminar injections are most often administered at the C6–C7 or C7–T1 interspaces because the dorsal epidural space above this is scant [63, 64•, 65]. Unfortunately, lateral imaging of the lower cervical spine can be obscured by shoulder anatomy, making it difficult to confirm the needle tip position. This has resulted in inadvertent needle advancement and injection into the spinal cord producing a permanent myelopathy [62]. A study of cervical injections for chronic pain in the American Society of Anesthesiologists’ closed-claims database found that direct needle trauma and injection during interlaminar epidural injections was responsible for a greater number of spinal cord injuries than any other mechanism, including incidental arterial injection during transforaminal procedures [17••]. Interestingly, the spinal cord injured patients were fve times more likely to be unresponsive from sedation during the procedure.

Like transforaminals, interlaminar injections also have a vascular mechanism underlying potential catastrophic injuries, however the exact mechanisms differ. Excluding a major vascular malformation, the dorsal epidural space is void of arterial communication to central nervous system tissues, so arterial injection is not a major concern. What is of concern is the creation of a symptomatic hematoma [59•, 60, 61, 66, 67]. Hematomas are more commonly reported in patients receiving continuous instead of single-shot epidural anesthesia [68]. Currently, there are no published estimates of the risk of epidural hematoma from single-shot epidural anesthetics, or in patients receiving epidural corticosteroid injections.

Even with proper technique and optimal needle placement, an epidural hematomas can occur following an interlaminar injection. On the other hand, needle placement in the cervical foramen has not been linked to symptomatic epidural hematoma formation. Certainly foraminal venous bleeding must occur in some transforaminal injections. Possibly, excess blood in the foramen flows preferentially into the extraforaminal tissues instead of building pressure in the spinal epidural space, whereas bleeding in the dorsal epidural space has no such escape. Because of this, some consider transforaminal injections a better option in any patient with increased bleeding risk, although here caution is also warranted."

And

" By targeting the anterior epidural space at a single level, transforaminal injections do provide more localized medication delivery [13, 14], and they are particularly target specific for foraminal and extraforaminal disc herniations."

And

"Debate continues on the ideal cervical epidural injection approach. This dispute arises from issues surrounding effectiveness and safety. The comparative effectiveness of these two approaches has never been determined in a prospective randomized trial, and each technique risks similar minor and serious complications [10, 17••, 18–20, 21•, 22–29]. Despite the absence of evidence for a superior technique, authors have voiced strong opinions on which injection to use in practice. "

link.springer.com

Cervical Foraminal Versus Interlaminar Epidurals: Risks, Benefits, and Alternatives - Current Physical Medicine and Rehabilitation Reports

The goal of cervical epidural corticosteroid injections is to ameliorate pain from cervical radiculopathy. Controversy remains regarding the use and optimal delivery route of epidural medications in the cervical spine. The purpose of this review article is to compare the risks and benefits...
link.springer.com link.springer.com

You clearly have a strong preference for paramedian. As the article says, others have a strong preference for transforaminal. The preference at the place one trains can lead to understandable bias either way. Unless evidence has changed in the last 12 years, you're not necessarily wrong but also not necessarily right.
 
Hi.

Interlaminars are injected at lower cervical levels for safety reasons. Medications spread since the cervical epidural space is quite small.

Even T1-T2 is considered cervical ESI
Most common places to inject is C6-7 and C7-T1.

Not sure what you mean things have changed in the last 12 years?

The only thing that has changed in more use of non particulate steroid and contra lateral oblique technique.

Cervical TFESIs specifically are a high risk procedure - quite different than lumbar TFESIs in contrast…due to significant vascularity and variable course of arteries which are not visible on fluoroscope. If a needle hits the vessel there can be vasospasm and you may not even catch it…
 
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AKMD_1984 said:
In your speech above you failed to list why cervical TFESIs are not performed.

Here’s a primer from perplexity.


Click to expand...
Today I went for a C6 injection on the contralateral side. I asked him about what you said. He said that it is higher risk compared to an interlaminer approach. He said he does a lot of high risk things and it's not something you'd want just anyone doing. He said he injects in the posterior 2/3 to avoid vasculature. He said he can get better coverage from a TFESI and this helps the surgeon due to its selectivity. He said intralaminar is more common for C7-T1. Seems like he knows what he's doing.

I asked him what was the highest risk procedure he does. He said installing cervical SCSs. Like I didn't even know cervical SCSs were a thing.
 
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