CRNA's and Pain procedures, need advice

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SIIMS

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Hello, long time follower, first post, need some advice

I am an acgme pain fellowship trained PM&R doc, recently joined spine group with 4 pain and 3 spine surgeons. We are in a large midwest metropolitan area and all physicians do some outreach within 1 to 1 1/2 hours away one day a week.

I am taking over an outreach site for a physician who is overstretched at a small hospital in a town of about 5,0000 people.

His practice is fairly busy. He informed me that anyone he saw needing a procedure was brought back to the metropolitan office because the hospital administration in this town was using/allowing two CRNA's to do procedures and he obviously wasn't on board with this. The procedures are limited to ILES's and possibly some facets and SI's.

Long story short I had a brief meeting with the hospital CEO and he would like me to start doing procedures in house, they have a small fluoro suite and he would obviously like some business kept in house.

He asked me to give him some reasons why he shouldn't allow the CRNA's to do procedures.

I explained the obvious reasons, i.e., out of their scope of training, handling complications, technical aspects aside more important to know with experience and training who is a candidate for what procedure etc.

So with this in mind he asked me to provide some "specific research or evidence" that CRNA's should not be doing interventional pain procedures.

That is why I am reaching out to you guys, do you have any fire-power for me.

Thanks, sorry for long post

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Ask him who he would prefer to do an interventional pain procedure on him or his momma?
 
File a complaint with the medical board. Pain procedures are the purview of medicine and not nursing. Ask the medical society and asipp for support as amicus briefs to your medical board complaint. The nurses are practicing medicine without a license.
 
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Would he let you start doing lumbar and cervical fusions? Id assume not because that is not in your scope of practice. Same idea.

Finally, I do agree with the previous comments about informing ISIS, ASIPP etc and letting this guy AND his superiors know that he is putting his hospital at significant legal risk for any complications. This is likely the argument that he will respond best to.

Good luck.
 
Thanks for the posts

While it would certainly be entertaining to start a "s%&t storm" with the societies and boards......my job and expectation from my group is to develop this practice site beyond its current state so I don't want to come in all inflammatory and such

I agree that the legal ramification spiel will likely resonate more with him than anything else but I'm surprised the CEO of a hospital hadn't thought that one through yet.


Thanks again
 
Thanks for the posts

While it would certainly be entertaining to start a "s%&t storm" with the societies and boards......my job and expectation from my group is to develop this practice site beyond its current state so I don't want to come in all inflammatory and such

I agree that the legal ramification spiel will likely resonate more with him than anything else but I'm surprised the CEO of a hospital hadn't thought that one through yet.


Thanks again


He's a CEO, not an M.D. right? That's where half the problems start with hospitals......... They just don't get things like that unless you really lay it out for him.

I'd tell him, it's not for you as the pain physician to prove that CRNAs aren't qualified to do procedures, it's on the CEO/CRNAs to provide evidence that they are. Because the first time the CRNAs have a significant complication, (and they will) the plaintiff's lawyers will have the pick of expert board-certified pain doctors to testify on their side and the hospital/CRNA will have nothing to prove or testify for their side.

----The burden of proof is on the CEO and CRNAs, and they got nada.
 
Found a link that somewhat addresses what you are dealing with. This info is straight off a CRNA blog(so I can't speak of complete accuracy here),but the references to legislation in the text give insight as to how CRNAS are working to try and legitimize what they are doing.

I don't see how they are doing procedures without PHYSICIANS medically evaluating to determine a treatment plan first. I would look to see what doctors at this hospital are referring the patients to the CRNAs for injections, and argue that these guys are not pain specialists themselves and should not be deciding what injections may or may not be appropriate for chronic pain patients. When the PCP suspects a patient to have coronary artery disease, you don't see him running off to tell the cardiologist how many stents to put in.


On that same note, what self respecting physician is going to develop a pain treatment plan and then pass the patient off to a CRNA for injections. In my idealistic healthcare views, a primary care physician will evaluate a patient, realize the patient needs SPECIALIZED treatment, and therefore refer the patient to the appropriate specialist. Doctors refering to nurses sends patient care in the opposite direction from my perspective.... but hey what do I know...... apparently my pain fellowship was just to give the CRNAS of the world an extra year on me to get a strong hold on my profession.

http://www.crnabiz.com/site/content/noridian-crna-practice-chronic-pain-management

From: (a Minnesota Hospital Patient Financial Services Manager )
Sent: Thursday, March 24, 2011 11:04 AM

To: Bernice Hecker, Noridian Medical Director
Subject: CRNA Practice and Chronic Pain Management

Dr. Hecker:

We received Noridian’s Carrier Medical Directive regarding “CRNA Practice and Chronic Pain Management” last Friday 3/18. At (a hospital in Minnesota), (Provider number xx.xxx, NPI xxxxxxx) our physicians examine, order diagnostic tests and make the diagnosis that requires interventional injections for pain management. Our CRNAs, as part of the pain management team, perform those injections as per the physician’s orders.

By Minnesota Statute 148.284, the CRNAs are by definition and Certification, Advanced Practice Registered Nurses. They also have in place signed Advanced Practice Registered Nurse Prescriptive Agreements, Minnesota Statute 148.235 Subd. 2a, with physicians who also practice at this hospital. This is all in compliance with the Minnesota Board of Nursing and the Minnesota Board of Medical Practice. Section 140.4.3 from the Medicare Claims Processing Manual - Payment for Medical and Surgical Services Furnished by a CRNA (Rev 1, 10-01-03, B3 – 16003H), states “Payment can be for medical or surgical services furnished by non-medically directed CRNAs if they are allowed to furnish these services under State Law”.

It is our understanding that our current practice is appropriate, but would like you to confirm. Thank you for your time and attention to this matter.

Signed: (Minnesota Hospital Patient Financial Services Manager)






From: Bernice Hecker, Noridian Medical Director
Sent: Thursday, March 24, 2011 9:54 PM
To: (Minnesota hospital Patient Financial Services Manager)
Subject: RE: CRNA Practice and Chronic Pain Management

Absolutely. In Medicare (BBA, 1997), non-physician practitioners (NPPs) may provide the medical services within their state scope of practice and be reimbursed at 85% of the PFS (physician Fee Schedule.) Now, we do expect that any practitioner who performs any procedure on any patient independently assesses the patient and their suitability for the procedure as is consistent with decent patient care and CPT Manual instructions and payment. That is, a referral for a treatment from one MD to another or to a NPP does not necessarily mean that the procedure must be done. The practitioner providing the service must make that determination and is completely liable for the determination.

Excellent question. Thank you.
 
1. Just because CRNAs want to do procedures is not evidence they are qualified.
2. Qualifications come from education, training, and experience. They cannot simply be due to experience. A person that is inferiorly trained in background education is still inferior even if they have done hundreds of procedures. They can do 1000 right but one wrong and both the hospital and the CRNA are screwed.
3. ASA, NASS, ASIPP, ISIS have released position statements that interventional pain is the practice of medicine. It is not the practice of social work, doctorates of psychology, or Nobel laureates in genetics. It is the practice of medicine by those with background training in specific related medical specialties or those with a pain fellowship. It is just as inappropriate for a CRNA, family practitioner, NP, allergist, PA, ENT surgeon, radiology tech, or cardiologist to be practicing interventional pain and for identical reasons: none have any relevant training. CRNA programs offer virtually no training in interventional pain medicine and only a couple of lectures in comprehensive pain medicine. Epidurals for labor have little to do with precision guided pain procedures.
4. There are 9,000 doctors practicing interventional pain medicine with relevant training, background education, and experience ready to serve as expert witnesses for the plaintiff, including me.
 
Ill happily take the stand for the second trial. After they've been made to pay in the civil case, I'll work with the DA's office to get them max jail time. Criminal negligence, assault, and hopefully not manslaughter.
 
I would tell CEO -

1) Legal risk: hospital will be sued as clearly their credentialing committee/privilege determination is in the gray zone
2) I would not do procedures in his hospital as long as he creates an unsafe procedure environment - and point out that your procedures (RFs, Stim trials, etc) are more lucrative anyway than what CRNAs currently doing
3) There is no evidence showing that monkeys can't do cholecystectomies - so it is not up to you to find evidence of CRNA equivalency/safety
 
Thanks everyone, I love this last post!!
 
Thanks everyone, I love this last post!!

I've worked in rural environments with CRNA's for a long time. I've never taken the confrontational approach - while those around me have - and I've done fine. My experience has been that, over time, 99% of patients will gravitate to the person who provides better overall care.

None of the CRNA's that I've worked with have been zealot's & neither am I.
 
I would tell CEO -

1) Legal risk: hospital will be sued as clearly their credentialing committee/privilege determination is in the gray zone
Great advice, this is language a CEO can understand. I would avoid making it personal or coming across as threatened b/c that will undermine the point every CEO will understand: LEGAL RISK to the hospital. If you could find a case where a hospital was sued because it allowed personnel do something they were not formally trained in, that would underscore your point.
 
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So CRNA's are just doing procedures. no evaluation of patients and follow up in office after. Thats insane and they wouldnt know where to start to properly evaluate a pain patient anyway. Love what this country is coming to and quality of healthcare going to garbage by take over of midlevels.
And CEO's of hospital and congress are to blame. Nurses go from taking doctors orders and learning nursign stuff to being able to treat pain paitents with interventional prcedures with no ability to diagnose, evaluate and follow up.
 
I've worked in rural environments with CRNA's for a long time. I've never taken the confrontational approach - while those around me have - and I've done fine. My experience has been that, over time, 99% of patients will gravitate to the person who provides better overall care.

None of the CRNA's that I've worked with have been zealot's & neither am I.

I have too worked in places where CRNA's have done procedures(ie IESI for every diagnosis)
The problem becomes that the pts have had inferior procedure performed by someone with inferior training-which in many if not most cases was not an appropriate procedure and did not work.

Problems:
1. No matter what what you say these pt refuse to have further injections because they didn't work.
2. Last "Dr." did series of three twice a year, why cant you do that doc?
3. CMS sees number of pain procedures go up, so consequently reimbursement goes down.

CRNA's doing pain procedures is just plain bad care and more states should follow the Iowa and Louisiana models to ban them
 
further talking points:

-what happened in Lousiana; you could google for an article, to give him, mention it got reviewed at multiple levels before the decision was made

-insinuate that scope of practice is "evidence of evidence" they should not be praticing

- use the "pulse ox-evidence based medicine" argument in a nice way; ie that there is no evidence that the pulse ox saves lives, but it has contributed to a huge drop in anesthesia malpractice premiums and adverse events

I would review the position statements from ASIPP and ISIS and see if you could derive ammo from them; or just give him a hard copy of them as he has already requested you provide him "evidence"

-point out the study he is envisioning (CRNA vs MD) will never be done, and the reasons why

I know this is hard, but if you gently and diplomatically push you can do the profession a great service;it sounds like the CEO has opened the door for you to do this; every one of these that gets shut down sends a message; I was a locum at a VA where a CRNA was doing all the procedures and after I established myself as the go-to expert I worked to end that; it burned bridges between me and his friends in the anesthesia dept, but I was persistent and diplomatic and it turned out all good
 
I have too worked in places where CRNA's have done procedures(ie IESI for every diagnosis)
The problem becomes that the pts have had inferior procedure performed by someone with inferior training-which in many if not most cases was not an appropriate procedure and did not work.

Problems:
1. No matter what what you say these pt refuse to have further injections because they didn't work.
2. Last "Dr." did series of three twice a year, why cant you do that doc?
3. CMS sees number of pain procedures go up, so consequently reimbursement goes down.

CRNA's doing pain procedures is just plain bad care and more states should follow the Iowa and Louisiana models to ban them

We are using CRNA's as an example of 'bad professional behavior'. But where I've worked they've been pretty cool. When I showed up they realized that there was a different knowledge level and there wasn't any confrontation. There didn't need to be.

Also where I work is a family practice physician who completed his FP residency in 2005. He - rural area- hung a shingle and labeled himself a "pain management physician" without a fellowship or any formal training. He just performs procedures, no narcotics or medicine management. He performs cervical procedures and stim trials.

Since we are painting with broad strokes here; not all CRNA's are bad people, and not all physicians are good people.
 
further talking points:

-what happened in Lousiana; you could google for an article, to give him, mention it got reviewed at multiple levels before the decision was made

-insinuate that scope of practice is "evidence of evidence" they should not be praticing

- use the "pulse ox-evidence based medicine" argument in a nice way; ie that there is no evidence that the pulse ox saves lives, but it has contributed to a huge drop in anesthesia malpractice premiums and adverse events

I would review the position statements from ASIPP and ISIS and see if you could derive ammo from them; or just give him a hard copy of them as he has already requested you provide him "evidence"

-point out the study he is envisioning (CRNA vs MD) will never be done, and the reasons why

I know this is hard, but if you gently and diplomatically push you can do the profession a great service;it sounds like the CEO has opened the door for you to do this; every one of these that gets shut down sends a message; I was a locum at a VA where a CRNA was doing all the procedures and after I established myself as the go-to expert I worked to end that; it burned bridges between me and his friends in the anesthesia dept, but I was persistent and diplomatic and it turned out all good

I'm very happy to hear that the VA gig worked out that way. Out of curiosity, I do know there was a neurologist at that gig as well. Did that MD make accurate diagnosis based on H&P/imaging that lead to accurate order of correct procedure by CRNA? Did said CRNA accurately and safely do the ordered procedure within SOC? Or was it still a ESIx3 for all situation?
 
I also know some CRNAs that are "pretty cool". But any CRNA engaging in interventional pain is an ignorant fool, not knowing what they don't know, are unqualified, potentially dangerous, and don't give a flip about patient safety. Same for family practice without a pain fellowship. They all need to be burned in court.
 
This SIIMS person might be a CRNA himself. not sure about a new member starting to post about an inflammatory issue
 
This SIIMS person might be a CRNA himself. not sure about a new member starting to post about an inflammatory issue

SIIMS is no poser. He is a good friend of mine and a long time follower of the thread, although he did not take the time to register like I did SIX YEARS ago. Hopefully things are gonna work out for him. I agree with others that if we as physicians provide superior care, then patients will gravitate to our services.
 
This SIIMS person might be a CRNA himself. not sure about a new member starting to post about an inflammatory issue


REALLY????

Did you read my post, what kind of loser would spend that much time sparking a flame in a chat room

I really appreciate all the "non paranoid" posters

This matter is being dealt with in a professional and non-threatening matter

Again , I appreciate the responses and advice from the "more seasoned" posters
 
I also know some CRNAs that are "pretty cool". But any CRNA engaging in interventional pain is an ignorant fool, not knowing what they don't know, are unqualified, potentially dangerous, and don't give a flip about patient safety. Same for family practice without a pain fellowship. They all need to be burned in court.


Check this out:
http://www.apmhealth.com/component/sobi2/?sobi2Task=sobi2Details&catid=3&sobi2Id=95

Board Certified in "anesthesiology pain mgt". However not on the ABA's website....
 
It seems he did a fellowship program but isn't board certified by the ABMS subspecialty pain additional credentials.... perhaps he is in the exam process??
 
Yes, but if you're actually in the examination process, as I am, it'll say you're in the examination process (i.e. you've paid the fee to register for the exam). His doesn't even have that. Depends on how long he's been out, but he might not really be able to take the exam yet because he hasn't passed his primary board certification.

I'm from a PM&R background, fellowship trained and boarded, but when you query the ABPM website with my name doesn't come up. I don't trust the ABPM website.
 
Check this out:
http://www.apmhealth.com/component/sobi2/?sobi2Task=sobi2Details&catid=3&sobi2Id=95

Board Certified in "anesthesiology pain mgt". However not on the ABA's website....


This guy was FP before fellowship, I'm not sure who / what website will have his BC (I'm PMR so ABA doesn't have it, you have to check ABPMR). Weird to think of an FP doing IPM. MUCH better than a PA or CRNA though. Anyone (with decent hands) can learn procedures; learning how to eval/exam/read MRIs, who NOT to inject, where NOT to inject, i.e. be a doc is much harder to learn on the fly. Our PAs can follow instructions and do simple pts. I have never seen them surprise me with a diagnostic breakthrough. I have even tried to train them on complex pain pts, no dice.

They want me to teach them U/S guided procedures. Only after you show me you can do a MD/DO level w/u, then... well not even then
 
It seems he did a fellowship program but isn't board certified by the ABMS subspecialty pain additional credentials.... perhaps he is in the exam process??



It says board eligible in family and pain. To be technical this is untrue. He is board eligible in family but is not board eligible in pain even though he did a fellowship. One of the prerequisites of board eligibility in pain is to be certified in your primary specialty. It is semantics I know. But if any of you know him you should tell him because he could get sanctioned by his state for advertising himself this way even though I do not believe that his intention is to deceive.
 
Yes, but if you're actually in the examination process, as I am, it'll say you're in the examination process (i.e. you've paid the fee to register for the exam). His doesn't even have that. Depends on how long he's been out, but he might not really be able to take the exam yet because he hasn't passed his primary board certification.

not board certified. Board ELIGIBLE.
it would appear that he has not passed the primary specialty exam.


Board Eligible in Pain Management - American Board of Anesthesiology
  • Board Eligible in Family Practice - American Board of Family Medicine
another quesiton, would he be board eligible from the ABA?
 
I don't think that he is ABA eligible as I believe that is restricted to anesthesiology, PM&R, neuro, psych, and maybe neurosurgery. There is a pain fellowship associated with a FM residency in Texas and they say that their graduates are board eligible. Even if the fellowship is ACGME I don't think that an FM graduate can take the ABA exam, so may be eligible for the American Board of Pain Medicine exam but not ABA.
 
To the original post, I have seen 2 types of CRNA doing pain. One is a CRNA who was employed by a pain group to function as a needle jockey and then left the group, and the other is a CRNA who is being asked by referring provider's to perform injections but may have no training in pain. Most of this is in relatively rural or at least suburban areas with no other pain provider. For the most part they seem happy to have a pain physician come in and take over and some have asked me to do that. I'm sure that there are CRNAs who are more aggressive and intend to compete with MDs but I haven't seen them.
 
To the original post, I have seen 2 types of CRNA doing pain. One is a CRNA who was employed by a pain group to function as a needle jockey and then left the group, and the other is a CRNA who is being asked by referring provider's to perform injections but may have no training in pain. Most of this is in relatively rural or at least suburban areas with no other pain provider. For the most part they seem happy to have a pain physician come in and take over and some have asked me to do that. I'm sure that there are CRNAs who are more aggressive and intend to compete with MDs but I haven't seen them.

1+. I've only seen the latter, although I am sure the former exists as well.
 
Mike Burdine was the doc that sued the CRNAs in Louisiana. John Wolfe was his attorney. Alton Ashy was the lobbiest who fought back the CRNA sponsored legislation.

Pleaes PM me if you'd like to be put in touch with any of these folks, as they would be most likely to be able to provide the documentation they presented in their particular venues.
 
File a complaint with the medical board. Pain procedures are the purview of medicine and not nursing. Ask the medical society and asipp for support as amicus briefs to your medical board complaint. The nurses are practicing medicine without a license.

In Illinois CRNA's are regulated by the nursing board. Complaining to the medical board will get you nowhere unfortunately.
 
In Illinois CRNA's are regulated by the nursing board. Complaining to the medical board will get you nowhere unfortunately.
CRNAs performing pain procedures are practicing MEDICINE without a license. The Medical Board is the right place to address your concerns.
 
CRNAs performing pain procedures are practicing MEDICINE without a license. The Medical Board is the right place to address your concerns.

I hope it works in his state. Several years ago in Illinois I made a complaint about a group of CRNA's to the medical board. They could not do anything because they were under the control of the nursing board. I believe Lax also made a similar complaint
 
From Wikipedia: I don't see the part where it states the Board of Nursing has decided they can practice Medicine or Law...this has to be stopped...it's like the blind leading the blind over in the nursing world


United States

The scope of practice of registered nurses is the extent to and limits of which an RN may practice. In the United States, these limits are determined by a set of laws known as the Nurse Practice Act of the state or territory in which an RN is licensed. Each state has its own laws, rules, and regulations governing nursing care. Usually the making of such rules and regulations is delegated to a state board of nursing, which performs day-to-day administration of these rules, qualifies candidates for licensure, licenses nurses and nursing assistants, and makes decisions on nursing issues. It should be noted that in some states the terms "nurse" or "nursing" may only be used in conjunction with the practice of a Registered Nurse (RN) or licensed practical or vocational nurse (LPN/LVN).
The scope of practice for a registered nurse is wider than for an LPN/LVN because of the level and content of education as well as what the Nurse Practice Act says about the respective roles of each.
In the hospital setting, registered nurses are often assigned a role in which they delegate tasks to LPNs and unlicensed assistive personnel.
RNs are not limited to employment as bedside nurses. Registered nurses are employed by physicians, attorneys, insurance companies, governmental agencies, community/public health agencies, private industry, school districts, ambulatory surgery centers, among others. Some registered nurses are independent consultants who work for themselves, while others work for large manufacturers or chemical companies. Research Nurses conduct or assist in the conduct of research or evaluation (outcome and process) in many areas such as biology, psychology, human development, and health care systems. The average salary for a staff RN in the United States in 2007 was over $60,000.
 
How is this different from 99% of radiologists doing pain procedures?

This reminds me of a scenario with a radiologist who was reading plain films and trying to drum up business for himself.

A patient was sent for a lumbar spine X-ray, and facet OA was seen (minimal info was mentioned on the requisition). He then indicated that this patient could benefit from medial branch blocks.

Interesting - no history, no physical exam. Just straight to blocks.

This really cuts down on the old timing wasted with a patient, eh?

Unfriggin believable. I guess it was just a coincidence that this particular rad had taken a recent interest in blocks!!
 
Nursing boards want to expand the scope of practice of nursing, so they will laugh at you for complaining about the same to them.

In states where the MDs have a different board than the nurses, the MD board won't usually try to take on the nursing board for what they see to be minor or controversial topics, but would rather spend their time chastising physicians for not being perfect.

It's like the CIA trying to tell the FBI they are not obeying the law.
 
This reminds me of a scenario with a radiologist who was reading plain films and trying to drum up business for himself.

A patient was sent for a lumbar spine X-ray, and facet OA was seen (minimal info was mentioned on the requisition). He then indicated that this patient could benefit from medial branch blocks.

Interesting - no history, no physical exam. Just straight to blocks.

This really cuts down on the old timing wasted with a patient, eh?

Unfriggin believable. I guess it was just a coincidence that this particular rad had taken a recent interest in blocks!!

I just had a radiologist send me the same thing (after a frickin' lumbar xray)! They must have taken the same online course. The statement after the interpretation was kinda like this:

"Xrays confirm this patient has facets joints....I'd be happy to inject something into them under CT guidance and then dump them back on you to address any post-procedural complaints and narcotic requests that may ensue. Have a good day."

The dude wanted to do them under CT guidance! To give him the benefit of the doubt, he must have seen a mass on xray that he felt needed to be irradiated.
 
This reminds me of a scenario with a radiologist who was reading plain films and trying to drum up business for himself.

A patient was sent for a lumbar spine X-ray, and facet OA was seen (minimal info was mentioned on the requisition). He then indicated that this patient could benefit from medial branch blocks.

Interesting - no history, no physical exam. Just straight to blocks.

This really cuts down on the old timing wasted with a patient, eh?

Unfriggin believable. I guess it was just a coincidence that this particular rad had taken a recent interest in blocks!!

Dude they do this routinely here is Washington state!
 
I just had a radiologist send me the same thing (after a frickin' lumbar xray)! They must have taken the same online course. The statement after the interpretation was kinda like this:

"Xrays confirm this patient has facets joints....I'd be happy to inject something into them under CT guidance and then dump them back on you to address any post-procedural complaints and narcotic requests that may ensue. Have a good day."

The dude wanted to do them under CT guidance! To give him the benefit of the doubt, he must have seen a mass on xray that he felt needed to be irradiated.

CT guidance makes for an easier block into joints, pays a lot more, and exposes the patient to a lot more radiation. CT guided blocks require very little physician skill. Once the trajectory is mapped, its easy.
 
From Sermo:


God dammit, this makes me so angry. I'm actually involved in a lawsuit now for wrongful death in a patient who was put under anesthesia without knowledge of the attending anesthesiologist or my attending (when I was a fellow), and decompensated while under the care of the CRNA. Apparently, the LMA wasn't adequately placed and the patient became hypercapnic and their BP lowered. My only involvement in this case was walking in to start the case but being told that the patient was unstable and that we would have to cancel. After offering my help, and offering to get the anesthesiologist (which was refused), I stepped out.
It turns out that the anesthesiologist and CRNA were in a bit of a power struggle at the hospital for a while. The kicker is that the CRNA is now the president of the AANA.
 
if the Board of Nursing states that interventional pain is the practice of nursing - then there is little that the board of medicine can do... it just becomes a major legal cluster-f*k...
 
Whats the thread title? Sounds interesting. Thanks.

From Sermo:


God dammit, this makes me so angry. I'm actually involved in a lawsuit now for wrongful death in a patient who was put under anesthesia without knowledge of the attending anesthesiologist or my attending (when I was a fellow), and decompensated while under the care of the CRNA. Apparently, the LMA wasn't adequately placed and the patient became hypercapnic and their BP lowered. My only involvement in this case was walking in to start the case but being told that the patient was unstable and that we would have to cancel. After offering my help, and offering to get the anesthesiologist (which was refused), I stepped out.
It turns out that the anesthesiologist and CRNA were in a bit of a power struggle at the hospital for a while. The kicker is that the CRNA is now the president of the AANA.
 
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