How would you define the appropriate role and limitations of nurse anesthetists?

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I couldn't find a thread directly related to this topic. Is there a clearly defined role that is published somewhere? It seems like some of the variation is institution or state dependent.

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Legally they operate under the board of nursing. It's not up to us. They decide for themselves. But you're right that in reality it is locally determined in ACT practices. In independent practices in opt out states it's the Wild West.
 
It varies a huge amount by instition and coverage requirements.

During residency and at my (private practice) job I have for next year it’s been consistent - CRNAs can intubate, insert a-lines (radial only), and put in epidurals I’m the L&D floor (no spirals or CSEs). No regional, CVLs, or other more advanced stuff.

It’s the same at my fellowship, but I think at an affiliated hospital the CRNAs do a whole lot of regional.

Some on here have posted wildly different accounts. Just depends on what they are comfortable with. The presence of SRNAs and the competition for procedures or good cases should play a role in choosing a residency. Thankfully didn’t deal with that at all myself.
 
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CRNA's should not be doing regional when docs are in the practice. WTF. No US regional and no Echo.

Neuraxial may be an exception. Labor epidurals maybe but I don't like it.

A-lines maybe but what's the doc doing?? Step the fu.ck up and stop letting the fox guard the hen house. No central lines. I advocate keeping virtually all procedures to the docs. Yes, procedures can be taught to just about anyone, but I believe in a strong separation of duties.

This has been discussed ad nauseam.
 
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CRNA's should not be doing regional when docs are in the practice. WTF. No US regional and no Echo.

Neuraxial may be an exception. Labor epidurals maybe but I don't like it.

A-lines maybe but what's the doc doing?? Step the fu.ck up and stop letting the fox guard the hen house. No central lines. I advocate keeping virtually all procedures to the docs. Yes, procedures can be taught to just about anyone, but I believe in a strong separation of duties.

This has been discussed ad nauseam.
agree with you wholeheartedly; in my shop (Childrens Hospital) where I'm at most 2:1 and usually 1:1 , why do my colleagues let them put in A-lines and neuraxial (caudals, lumbar and thoracic epidural) and peripheral nerve blocks? I don't know! But it's more the norm and i'm an outsider and considered a poor team player for not letting them do anything. Those of us who put the patient safety first are relegated to MRI and other unappealing locations. The message is clear and loud at our shop. Aside from anesthetist satisfaction , what is the point of letting them do these procedures if you are right there. I have a hard time sitting back watching them flog a child...I think it's wrong to have someone more experienced sit back and not perform the procedure. Residents and fellows are a different situation, as they are training and they are the future. Even then, I have clear limits and step in, but what is the point with letting anesthetists do these procedures when you are right there? Please let me know how this is best for patient safety and our profession?
 
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Ghastly75, you need to speak up.
You can't be worried about a job that you are not pleased with. Speak up and make it right.
 
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agree with you wholeheartedly; in my shop (Childrens Hospital) where I'm at most 2:1 and usually 1:1 , why do my colleagues let them put in A-lines and neuraxial (caudals, lumbar and thoracic epidural) and peripheral nerve blocks? I don't know! But it's more the norm and i'm an outsider and considered a poor team player for not letting them do anything. Those of us who put the patient safety first are relegated to MRI and other unappealing locations. The message is clear and loud at our shop. Aside from anesthetist satisfaction , what is the point of letting them do these procedures if you are right there. I have a hard time sitting back watching them flog a child...I think it's wrong to have someone more experienced sit back and not perform the procedure. Residents and fellows are a different situation, as they are training and they are the future. Even then, I have clear limits and step in, but what is the point with letting anesthetists do these procedures when you are right there? Please let me know how this is best for patient safety and our profession?

I can see a shop without a residency or fellowship program, running hard, 4 CRNA rooms most of the time, deciding to hell with it. Gonna make hay while one can. Spread themselves so thin that they need the CRNA's to step in and get that stuff done in order to keep work flow going. I almost signed on to a place like that as partner track and am glad I didn't. To some extent these are the sell outs.....

As for your situation, it's leadership and at this point probably just cultural. But, f.ck it. I would buck that trend and start asking my colleagues some tough questions. What you describe is indefensible in my mind and I think you are spot on in resisting that. Perhaps you can influence a change but be patient as these things take time.

Hell, in my mostly ACT model I still (and will always) take intubations on a regular basis (like if I have a 5 ETT case room, I'll take 1-2). We have a mostly good crew (mostly) of NA's, and I hear "it's good to see you guys intubate now and again, makes me feel safer for when I get into trouble". I am serious when I say that. Also, it sends a message to the NA, and the entire room that (in an ACT model this is only an issue), the doc still has his flow.....

Other ways in ACT models (perhaps more applicable in smaller or mid-sized facilities) is to go in for a break while waking a patient up and say "hey, I'll wake the patient up, you go take lunch". Arrange for appropriate coverage with your physician colleagues and you are good to go. I say small to mid-size because often you can "tweak" your coverage easier that way.

Now, that's very different from the cultural shift of taking away procedures, but I would just start saying, "I'll get the A-line on this one". Or, "you push meds, and I tube?" (Make it sound like a question but you're really not asking. Works well and they get the point)

Best of luck. Tough situation but it can be changed..... I have done it and it's not bee too hard. Our folks place a very very rare A-line, no blocks, hardly any neuraxial but we have a few CRNA's who do cover overnight epidurals (don't like it and we should stay in house) along with docs (it's a mix but NA and Doc not on same night).
 
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