CRNA's and regional anesthesia

[Planktonmd]

I have no intention to start a fight here but I need to clarify one thing:
Practicing regional anesthesia requires in depth understanding of several things:
1- Anatomy
2- Physiology of the nervous system
3- Pharmacodynamics and pharmacokinetics of local anesthetics and additives.
4- Ability to diagnose and treat immediate and delayed complications.

I have worked with CRNA's every day for many years, and still have to see a CRNA who has these abilities.
This is why regional anesthesia is beyond the capacity of CRNA's.
Unless we are talking about some form of super CRNA I haven't been privileged to meet yet.

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[rmh149]

I have no intention to start a fight here but I need to clarify one thing:
Practicing regional anesthesia requires in depth understanding of several things:
1- Anatomy
2- Physiology of the nervous system
3- Pharmacodynamics and pharmacokinetics of local anesthetics and additives.
4- Ability to diagnose and treat immediate and delayed complications.

I have worked with CRNA's every day for many years, and still have to see a CRNA who has these abilities.
This is why regional anesthesia is beyond the capacity of CRNA's.
Unless we are talking about some form of super CRNA I haven't been privileged to meet yet.

Plankton, I agree with you that in depth understanding of list above is required. I have worked with some older CRNA's that have had no training in regional anesthesia. Obviously they dont practice regional anesthesia. However, I graduated in 2003. I cant imagine how I could place a needle in a body and inject a drug without fully knowing the above list.

Also, CRNA's are the ones who tought me how to perform these difficult procedures. If I didnt answer all of their questions correctly they were not going to let me get within 10 feet of their patient with a needle. I had to have extensive knowledge in anatomy, physiology, pharmacology, etc. Not just basic knowledge.

 

[Monty Python]

I have no intention to start a fight here but I need to clarify one thing:
Practicing regional anesthesia requires in depth understanding of several things:
1- Anatomy
2- Physiology of the nervous system
3- Pharmacodynamics and pharmacokinetics of local anesthetics and additives.
4- Ability to diagnose and treat immediate and delayed complications.

I have worked with CRNA's every day for many years, and still have to see a CRNA who has these abilities.
This is why regional anesthesia is beyond the capacity of CRNA's.
Unless we are talking about some form of super CRNA I haven't been privileged to meet yet.

Any military-trained CRNA knows those topics cold. They expected to - it's not unusual for a CRNA to be deployed as the sole provider in a location where GETA is the last resort. Regional is always the preferred style if appropriate.

Those were my working conditions and the Navy's expectations of me when I was the sole anesthesia provider on an aircraft carrier.

http://gw.ffc.navy.mil/

Military CRNA expectations: http://www.newswise.com/articles/view/529137/

Anesthesia is practiced in medical centers, in the field with Special Operations teams and ground forces, onboard ships, in the air, at overseas duty stations, and remote locations...... Independent practice and the ability to perform a wide variety of anesthetic techniques, including regional anesthesia, is expected.

 

[2ndyear]

I'm interested to know your thoughts on pain management by CRNA's (both chronic and acute). Say you place an epidural for a thoracic and abdominal case and round on it, do you bill post op rounds like a NP or PA?

I can see where moving into the pain clinic would be a stickier situation. Now, instead of having patients presenting for surgery, you have either an order from a referring provider for a procedure (ie ortho surgeon wants a trial of 3 LESI's before laminectomy) or patients presenting on their own with complaints. Not wanting to start a war, but thoughts from the CRNA's?

 

[Planktonmd]

Again I don't mean to start a fight, but I hope you guys are just saying these things for argument sake and don't really believe that your are qualified to safely administer regional anesthesia.
and by the way, I have worked with many previous military CRNA's and I am very well familiar with their level of knowledge and abilities.
I don't mean to insult anyone but just stating the facts.
Let's be realistic.

 

[rmh149]

I'm interested to know your thoughts on pain management by CRNA's (both chronic and acute). Say you place an epidural for a thoracic and abdominal case and round on it, do you bill post op rounds like a NP or PA?

I can see where moving into the pain clinic would be a stickier situation. Now, instead of having patients presenting for surgery, you have either an order from a referring provider for a procedure (ie ortho surgeon wants a trial of 3 LESI's before laminectomy) or patients presenting on their own with complaints. Not wanting to start a war, but thoughts from the CRNA's?

Good questions. We routinely place epidurals for abdominal cases for post op pain management. Our 1st call CRNA that stays in house 24hrs rounds on them. They also round on the patients that received an intrathecal dose of morphine. I know we bill for managing them...but I have no idea how much. I will look into it.

As far as my opinion of CRNA's moving into pain management as in practicing out of a pain clinic, your right it does get stickier. I can see where a physician can refer a patient to me for a procedure (although I cant see that occuring often enough to make a living). However, patients coming to me with complaints of chronic pain.....Nope. I wouldnt know what to do. I am not a physician and have had no training in diagnosing causes of chronic pain. I just do anesthesia. Sure we can do epidural steriod injections. But it is not up to me to decide whether someone would benefit from the procedure (not being related to an anesthetic).

Does this makes sense?

I have read a post somewhere about a CRNA (dont know the full details) opening a pain clinic somewhere up north. I dont see how they can do this without a physician partner supervising the overall patient care. I will look into it.

Just did a quick google on " CRNA Pain clinic" This is what I get. I am assuming these are two good examples of pain clinic setups. I would think that the physician is responsible for diagnosing and choosing a course of treatment. Also, it looks like one of the CRNA's is AAPN certified....I Have no idea what that means.

http://www.kishhospital.org/health_services/pain_management.html

http://www.vrh.org/medicalservices/rehab/pain-clinic.html

Any input from anyone with pain managment background?

 

[blackjack]

I have no intention to start a fight here but I need to clarify one thing:
Practicing regional anesthesia requires in depth understanding of several things:
1- Anatomy
2- Physiology of the nervous system
3- Pharmacodynamics and pharmacokinetics of local anesthetics and additives.
4- Ability to diagnose and treat immediate and delayed complications.

I have worked with CRNA's every day for many years, and still have to see a CRNA who has these abilities.
This is why regional anesthesia is beyond the capacity of CRNA's.
Unless we are talking about some form of super CRNA I haven't been privileged to meet yet.

And what part of this list is beyond the capabilites of a CRNA? How are these requirements for regional anesthesia different than for general anesthesia?

 

[Planktonmd]

And what part of this list is beyond the capabilites of a CRNA? How are these requirements for regional anesthesia different than for general anesthesia?

All four parts are beyond CRNA's capabilities because you simply don't learn them the way a physician does.
You might think that you know everything, and this is a common trend in the new CRNA's these days, they usually get over it after a few years when they realize how much they did not know.
You can learn to do the blocks, anyone can, but to do them safely, avoid complications, and know how to react when complications happen is purely the practice of medicine, and you can't practice medicine.
Again I don't mean to insult anyone, I think CRNA's are valuable practitioners but I am speaking from my hands on experience with CRNA's.

 

[rmh149]

Again I don't mean to start a fight, but I hope you guys are just saying these things for argument sake and don't really believe that your are qualified to safely administer regional anesthesia.
and by the way, I have worked with many previous military CRNA's and I am very well familiar with their level of knowledge and abilities.
I don't mean to insult anyone but just stating the facts.
Let's be realistic.

Plankton, I can see where CRNA's that don’t practice regional anesthesia lose their skills. Obviously, if you don’t use it, you lose it. I personally stick to spinals, epidurals, bier block and on a rare occasion axiallary blocks. I am out of practice with anything else. They military CRNA's that I worked with were damn good at doing all kinds of regional blocks.

I just couldn’t see the benefit (ACL repair for example) of sticking some poor shmuck in the groin, zapping them, injecting a crap load of drug, then sticking them in the a$$....and again zapping them, followed by injecting another crap load of drug...all this while providing heavy sedation with narcotics and benzodiazepines so they "hopefully" do not remember how horrible the experience was. I would feel much more comfortable with putting in an epidural and keeping them pain free for the next 24 hours. Regional anesthesia (other than epidural/spinals) is very time consuming for me. I can see where it is beneficial with an anesthesia care team. But when there are multiple cases scheduled for the day, doing a sciatic and femoral nerve block (for example) just isn’t worth it in my situation.

I dont even know where the insulated needles and nerve stimulators are at my hospital.

Plankton, what is your opinion on CRNA's performing intrathecal and epidural anesthesia?

 

[jetproppilot]

This is why regional anesthesia is beyond the capacity of CRNA's.
Unless we are talking about some form of super CRNA I haven't been privileged to meet yet.

My wife had a scheduled C section March 15, 2006.

I was the attending.

David K., CRNA, did the spinal.


Saying you want to prohibit CRNAs from doing regional is one thing.

Saying CRNAs that can perform regional don't exist is another....and it's dead wrong. David K. is more deft at spinals and epidurals than most MDs I know.


I understand your argument. You want to protect our specialty from what you perceive as a threat.

I don't think your argument about a CRNA's lack of knowledge in the things you cited is the right strategy, since it is entirely inaccurate.

Feel like you need to prohibit CRNAs from doing regional? Great. I respect that. But don't camoflage your real motive with a bunch of erroneous bulls hit.

Simple.

Doesnt matter what their job description is. Doesnt matter what the AANA says. Doesnt matter if the federal government eventually adjusts their billing to reflect them as independents.

Become active in the politics of the hospitals you practice at.

If an individual hospital says CRNAs cannot do regional anesthesia, CRNAs will not perform regional anesthesia. At that hospital.

In almost 11 years of private practice, I've yet to see CRNAs be a threat to MDs at an individual hospital where well-respected MDs practice.

Its all in individual hospital by-laws, folks.

If an individual hospital wants to tell a physician he can't do laparascopic procedures anymore (because of complication rate....yes....real story), said individual hospital can limit said-physician's practice.

If they can do it to a doctor, they can certainly do it to a nurse.

So hospitals hold the cards in what an individual can do.

Thats certainly enough ammo.

If you wanna fight, I think the most bang-for-your-buck exists at the individual-hospital level.

 

[Planktonmd]

Plankton, I can see where CRNA's that don’t practice regional anesthesia lose their skills. Obviously, if you don’t use it, you lose it. I personally stick to spinals, epidurals, bier block and on a rare occasion axiallary blocks. I am out of practice with anything else. They military CRNA's that I worked with were damn good at doing all kinds of regional blocks.

I just couldn’t see the benefit (ACL repair for example) of sticking some poor shmuck in the groin, zapping them, injecting a crap load of drug, then sticking them in the a$$....and again zapping them, followed by injecting another crap load of drug...all this while providing heavy sedation with narcotics and benzodiazepines so they "hopefully" do not remember how horrible the experience was. I would feel much more comfortable with putting in an epidural and keeping them pain free for the next 24 hours. Regional anesthesia (other than epidural/spinals) is very time consuming for me. I can see where it is beneficial with an anesthesia care team. But when there are multiple cases scheduled for the day, doing a sciatic and femoral nerve block (for example) just isn’t worth it in my situation.

I dont even know where the insulated needles and nerve stimulators are at my hospital.

Plankton, what is your opinion on CRNA's performing intrathecal and epidural anesthesia?

Many CRNA's I work with do Spinals and Epidural but I supervise them, and I take care of the patients post-op.
If you are working independently and doing basic regional techniques I hope for the sake of your patients that you try to understand at least the anatomy of where you are inserting your needles and have a broad understanding of what local anesthetics do.
Develop a plan of action for the common complications.
Remember also that all your patients deserve a good sterile technique.

 

[Planktonmd]

My wife had a scheduled C section March 15, 2006.

I was the attending.

David K., CRNA, did the spinal.


Saying you want to prohibit CRNAs from doing regional is one thing.

Saying CRNAs that can perform regional don't exist is another....and it's dead wrong. David K. is more deft at spinals and epidurals than most MDs I know.


I understand your argument. You want to protect our specialty from what you perceive as a threat.

I don't think your argument about a CRNA's lack of knowledge in the things you cited is the right strategy, since it is entirely inaccurate.

Feel like you need to prohibit CRNAs from doing regional? Great. I respect that. But don't camoflage your real motive with a bunch of erroneous bulls hit.

Simple.

Doesnt matter what their job description is. Doesnt matter what the AANA says. Doesnt matter if the federal government eventually adjusts their billing to reflect them as independents.

Become active in the politics of the hospitals you practice at.

If an individual hospital says CRNAs cannot do regional anesthesia, CRNAs will not perform regional anesthesia. At that hospital.

In almost 11 years of private practice, I've yet to see CRNAs be a threat to MDs at an individual hospital where well-respected MDs practice.

Its all in individual hospital by-laws, folks.

If an individual hospital wants to tell a physician he can't do laparascopic procedures anymore (because of complication rate....yes....real story), said individual hospital can limit said-physician's practice.

If they can do it to a doctor, they can certainly do it to a nurse.

So hospitals hold the cards in what an individual can do.

Thats certainly enough ammo.

If you wanna fight, I think the most bang-for-your-buck exists at the individual-hospital level.

I never said that CRNA's that can do regional don't exist, they do and some of them are very skilled at it, but for them to do the full spectrum of regional anesthesia unsupervised is a major threat to patient safety.
You said you were the attending when David K did your wife's spinal, he was not practicing solo.
Would you feel comfortable letting a CRNA practicing solo do your wife's spinal?
How about an inter-scalene for your shoulder surgery?
I am not camoflaging anything, just stating my personal observations on CRNA's doing regional anesthesia.

 

[jetproppilot]

I never said that CRNA's that can do regional don't exist, they do and some of them are very skilled at it, but for them to do the full spectrum of regional anesthesia unsupervised is a major threat to patient safety.
You said you were the attending when David K did your wife's spinal, he was not practicing solo.
Would you feel comfortable letting a CRNA practicing solo do your wife's spinal?
How about an inter-scalene for your shoulder surgery?
I am not camoflaging anything, just stating my personal observations on CRNA's doing regional anesthesia.

If you'll read your initial post again, there is nothing in it referring to supervised vs. unsupervised.

And yes, most posts referring to the lack of CRNA's ability on X or Y are camoflaged posts in an effort to protect domain.

Don't misinterpret my response. I'm not PRO-militant CRNA.

I am, though, pro team-approach.

There is alotta talk about protection of MDs from CRNAs on this forum.

I respect that.

I'm not convinced you are going about it the right way, though.

 

[jetproppilot]

I never said that CRNA's that can do regional don't exist,

Uhhhhhhhhhh, unless that last margarita-with-an-extra-Don Julio shot is speaking for me,

YES YOU DID.

 

[rmh149]

My wife had a scheduled C section March 15, 2006.


If an individual hospital says CRNAs cannot do regional anesthesia, CRNAs will not perform regional anesthesia. At that hospital.

In almost 11 years of private practice, I've yet to see CRNAs be a threat to MDs at an individual hospital where well-respected MDs practice.

Its all in individual hospital by-laws, folks.

If an individual hospital wants to tell a physician he can't do laparascopic procedures anymore (because of complication rate....yes....real story), said individual hospital can limit said-physician's practice.

If they can do it to a doctor, they can certainly do it to a nurse.

So hospitals hold the cards in what an individual can do.

Thats certainly enough ammo.

If you wanna fight, I think the most bang-for-your-buck exists at the individual-hospital level.

Jetproppilot,

I agree completely. In fact, our group of CRNA's practice at this hospital mainly because the anesthesiology group gave up OB. It was strictly (as I understand it) a business decision. The hospital found us to cover OB. We also provide anesthesia in the OR to the surgeons that choose us...mainly GYN and cardiology. We have a good relationship with the anesthesiologists. We help them and they help us when times are difficult. It was rocky in the beginning, but we made it clear that we had no desire to take over the hospital. We joke "we make a living off what you dont want to do".

Now, my brother works for another group that uses the anesthesia care team model. He prefers to work with this model because he gets to do big cool cases, such as neuro, thoracics, etc. Their hospitals bylaws state that they want the CRNA's to be supervised by anesthesiologists. He's perfectly happy....as I think I would be if I worked there. I just happen to like doing OB.

Regardless of the changes in the law, hospitals set their own bylaws. And their will be plenty of CRNA's that still prefer to do the big cases with anesthesiologists.

 

[Planktonmd]

Uhhhhhhhhhh, unless that last margarita-with-an-extra-Don Julio shot is speaking for me,

YES YOU DID.

Well, maybe it is my 21 year old Glenlivet that is speaking for me but that's not what I intended to say.
many CRNA's do basic regional but they should not do it unsupervised because the patient gets better care when a board certified anesthesiologist is involved.
Do you like that?

 

[rmh149]

Many CRNA's I work with do Spinals and Epidural but I supervise them, and I take care of the patients post-op.
If you are working independently and doing basic regional techniques I hope for the sake of your patients that you try to understand at least the anatomy of where you are inserting your needles and have a broad understanding of what local anesthetics do.
Develop a plan of action for the common complications.
Remember also that all your patients deserve a good sterile technique.

I cant convince you that I am safe. I can only go by the numbers. I promise you that I know the anatomy of where I am sticking my needle....and I have an in depth knowledge of local anesthetics. I have practically memorized Stoelting's Pharmacology and Physiology in Anesthetic Practice, Stoelting and Dierdorf Anesthesia and Coexisting Disease, and Morgan and Mikhail's clinical anesthesiology. Longnecker and Barash are good too....if you have a ton of time on your hands to sift through all the rat studies before you get to the meat. I guess what I am trying to say is I wouldnt be doing this if it wasnt safe.[/U]

 

[jetproppilot]

Well, maybe it is my 21 year old Glenlivet that is speaking for me but that's not what I intended to say.
many CRNA's do basic regional but they should not do it unsupervised because the patient gets better care when a board certified anesthesiologist is involved.
Do you like that?

Yes Sir. I do.

 

[CremeSickle]

Now there is a man i can respect.

well said, professional and correct.

My wife had a scheduled C section March 15, 2006.

I was the attending.

David K., CRNA, did the spinal.


Saying you want to prohibit CRNAs from doing regional is one thing.

Saying CRNAs that can perform regional don't exist is another....and it's dead wrong. David K. is more deft at spinals and epidurals than most MDs I know.


I understand your argument. You want to protect our specialty from what you perceive as a threat.

I don't think your argument about a CRNA's lack of knowledge in the things you cited is the right strategy, since it is entirely inaccurate.

Feel like you need to prohibit CRNAs from doing regional? Great. I respect that. But don't camoflage your real motive with a bunch of erroneous bulls hit.

Simple.

Doesnt matter what their job description is. Doesnt matter what the AANA says. Doesnt matter if the federal government eventually adjusts their billing to reflect them as independents.

Become active in the politics of the hospitals you practice at.

If an individual hospital says CRNAs cannot do regional anesthesia, CRNAs will not perform regional anesthesia. At that hospital.

In almost 11 years of private practice, I've yet to see CRNAs be a threat to MDs at an individual hospital where well-respected MDs practice.

Its all in individual hospital by-laws, folks.

If an individual hospital wants to tell a physician he can't do laparascopic procedures anymore (because of complication rate....yes....real story), said individual hospital can limit said-physician's practice.

If they can do it to a doctor, they can certainly do it to a nurse.

So hospitals hold the cards in what an individual can do.

Thats certainly enough ammo.

If you wanna fight, I think the most bang-for-your-buck exists at the individual-hospital level.

 

[nimbus]

Most CRNAs are smart people. There is no reason they cannot develop excellent regional skills if they have the desire.

Regional anesthesia is not what I consider one of the more challenging aspects of anesthesia practice. If they can take care of a 95 yo with a 15%EF and dead bowel in some small hospital in bumf*ck small town with no anesthesiologists, then they can learn to do simple interscalene and infraclavicular blocks.

 

[Planktonmd]

Most CRNAs are smart people. There is no reason they cannot develop excellent regional skills if they have the desire.

Regional anesthesia is not what I consider one of the more challenging aspects of anesthesia practice. If they can take care of a 95 yo with a 15%EF and dead bowel in some small hospital in bumf*ck small town with no anesthesiologists, then they can learn to do simple interscalene and infraclavicular blocks.

Sure they can learn the procedures, any one can be taught, but they need to be supervised by an anesthesiologist because it's not only about inserting the needle, it's about seeing the whole picture, understanding the science behind it and the possible complications.
The fact that they are practicing solo in areas where there is no anesthesiologists does not make it right, and does not make it good patient care.

 

[CremeSickle]

Plankton

Generally I agree with your posts.

What comes up over and over again are these 2 assumptions:

it's about seeing the whole picture, understanding the science behind it and the possible complications

Why do you think they dont? You didnt (really) before you did your residency. I know I didnt. I was taught. Why do you assume they arent? Sure some are clueless, but so too are some residents and attendings.

The fact that they are practicing solo in areas where there is no anesthesiologists does not make it right, and does not make it good patient care

Well again, why? Where is the proof that this isn't "good patient care"? Its just an opinion not a fact.

The largest problem with the arguments I see here is that none of them are substantiated. Its all just posturing and no facts. This doesn't exactly make us look good while from the other side of our mouths we are talking up EBM and research. People notice, especially the surgeons I work with.

Based on your assumptions we should also be inserting IVs and giving all IV drugs since RNs do not "see the whole picture". Certainly, this is true of most RNs yet we don't fight to 'retake' these skills. The difference is that CRNAs (the ones i have had contact with) DO seem to see the whole picture and are prepared to deal with the complications. More importantly, we wouldn't make money for the IV insertion and the IV drugs in the general admitted patient.

Why not just be honest (as a few others have been) and say that the reason we don't want CRNA independence is b/c we are protecting our income and professional turf. If it was about patient safety then where is the evidence? Even after decades of CRNAs working independently there isn't any. Everyone on the planet can understand protecting ones turf, noone will be sympathetic about us using "sticks and stones" tactics. It makes us look unprofessional and pompus.

 

[Planktonmd]

Plankton



Why do you think they dont? You didnt (really) before you did your residency. I know I didnt. I was taught. Why do you assume they arent? Sure some are clueless, but so too are some residents and attendings.

My opinion is based on my personal experience over the past 10 years with CRNA's of all kinds of backgrounds and seniority.
I have taught many of them to do blocks and watched many work, they can perform the procedures but they don't have the understanding.
Without a physician backing them up they don't have the ability to diagnose or treat complications.
They are not trained to diagnose anything.
I am not anti CRNA in anyway, but I state the facts based on personal observations.
I don't have studies showing a difference in outcome when regional anesthesia is performed by non supervised CRNA's but there are no studies showing they are safe either.
Is there a study showing that CRNA's administering regional anesthesia unsupervised have the same rate of complications as the supervised ones and as anesthesiologists? Provided they are doing the same kinds of procedures.

 

[CremeSickle]

Nicely said and fair enough!

No studies either way it seems. However, thats the problem I think. Until there is, there isnt an argument just an opinion....