MDA vs. CRNA

[mark2climb]

This is a hot topic among the anesthesiologist and I'm not trying to start another fire....just interested in your perspectives. As a disclosure, I am a RN heading into a CRNA program.

I was wondering if you surgeons noticed a difference between the care provided by an anesthesiologist vs. a CRNA. I don't need actual studies or numbers as I know they are already out there but more along the lines of anecdotes or little things that you've noticed. For example, do you tend to feel more comfortable having an 'ologist do your anesthesia or do you not see much of a difference? Is it case dependent? Pt dependent?

Thanks.

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[core0]

This is a hot topic among the anesthesiologist and I'm not trying to start another fire....just interested in your perspectives. As a disclosure, I am a RN heading into a CRNA program.

I was wondering if you surgeons noticed a difference between the care provided by an anesthesiologist vs. a CRNA. I don't need actual studies or numbers as I know they are already out there but more along the lines of anecdotes or little things that you've noticed. For example, do you tend to feel more comfortable having an 'ologist do your anesthesia or do you not see much of a difference? Is it case dependent? Pt dependent?

Thanks.

I am not sure how to compare a CRNA with the Muscular Dystrophy Association. They have very little overlap.

 

[nonesuchgirl]

I am not sure how to compare a CRNA with the Muscular Dystrophy Association. They have very little overlap.

*snerk*
😴😴

 

[ESU_MD]

CRNA's are OK for the vast majority of cases. I have never really had much of any problems with the crna's.

The only difference would be the very rare, truly difficult airway when maybe someone who does alot of fiberoptics could make a difference.

 

[filter07]

.

 

[dr.evil]

Just like anything else, it's who's doing the anesthesia and not the initials behind the name. Anesthesia seems to really be a game of experience. I really believe at my current community hospital, the best anesthesia personnel is a CRNA. He's been doing it forever, has seen it all, and is the guy they call on for a difficult airway or an unstable patient. I have yet to see him need an anesthesiologist to help him.

Anesthesiologists are great for the medical aspect as they seem to have more background in the odd diseases states or difficulties (i.e. pheochromocytomas, or the sickle cell pts, or the malignant hyperthermia family member). But overall, it's just like surgeons. Some are better than others.

 

[Chronic Student]

Experience counts for a lot.

Where I'm at we have a good mix of MDs and CRNAs. This hospital started out with mostly CRNA's 20+ years ago and some of them are still around, then came the MD's.

Before the merger, which I will explain later you could get either a CRNA or MD and they were basically interchangeable. Everyone had a ton of experience and everyone was good. If I had to have surgery my wife had two names, one MD and one CRNA that I would prefer. Each provider kinda had their thing. Some you would see more often doing cerebral aneurysms, some with regional blocks and some were airway specialists and some were docs and some CRNAs who were the specialists. The docs did not supervise the CRNAs and everything seemed to work well.

More recently, the MD's negotiated with the hospital to get an exclusive contract and the old CRNAs had to join the group or they were SOL. They all signed on and then the docs brought in some newer CRNAs.

First let me preface my statement by saying that I think MD oversight of CRNAs is a good thing, just as I think a doc should be supervising me (a PA). However, I am really disturbed by a lot of things that are happening now.

1. I can't tell you the last time I saw an MD put someone to sleep. I mean, we have more providers and better coverage, but the MDs are supervising and not working.

2. I have real issues with a lot of the CRNAs that have been brought in. It may be just an experience difference, but I have noticed the new CRNAs do not pay as much attention to the case/patient.

I'm in neuro and we do a lot of extremely long cases and I routinely have to ask the circulator to check the urine output, as we can do a 10-hour case and the newbies may only check UO once. To me that is not acceptable. (I try and watch everything going on in the room so that my boss can pay more attention to the case)

I have seen them play with their iPhones when the patient needs pressors, gets light, etc. This is not acceptable either.

I routinely help with induction, insofar as masking (from the side when they are readying meds), making a good seal on the mask by pressing the cheek up on the side opposite their masking hand, cricoid, applying monitors, pushing tubes into their hands, getting the lip out of the way, jaw thrust of fiberoptics with myelopathy patients, etc.

I end up getting to know their skills and strengths and weaknesses quite well. They lack confidence, smoothness, are very rough/knock around in the airway and cause trauma, seem okay with letting the patient desat/get hypotensive, etc.

3. Breaks. I have no problem with someone running to the restroom with a stable patient, as long as the circulator is watching the monitors (and I trust that circulator). However, I am used to one anesthesia provider staying with a case until it is done. It is called continuity of care. It is not uncommon for us to have five or six different providers during a case now.

There is no one on this earth that is going to convince me that this is OK and I oppose it in the strongest terms. There is no way to convey everything that has happened during an 8-10 hour case in a 60 second report. Someone is going to forget to chart a medication, an antibiotic will be missed, a change in the patients breathing pattern will go unnoticed (change in rate, tidal volume, etco2, etc). Especially when someone comes in for a break and is then switched out to a person who did not put the patient to sleep and is going to finish the case. (Gets off of soapbox).

The short story is that I think experience is what counts. The difference in-between MDs and CRNAs is that most of what the CRNAs get is through OJT, whre the MD's have the theory and it may take a CRNA twenty years to equal (using this term very tongue-in-cheek) an MD with just a couple of years of experience.

Just my .02

 

[jetproppilot]

.

 

[jwk]

3. Breaks. I have no problem with someone running to the restroom with a stable patient, as long as the circulator is watching the monitors (and I trust that circulator). However, I am used to one anesthesia provider staying with a case until it is done. It is called continuity of care. It is not uncommon for us to have five or six different providers during a case now.

There is no one on this earth that is going to convince me that this is OK and I oppose it in the strongest terms. There is no way to convey everything that has happened during an 8-10 hour case in a 60 second report. Someone is going to forget to chart a medication, an antibiotic will be missed, a change in the patients breathing pattern will go unnoticed (change in rate, tidal volume, etco2, etc). Especially when someone comes in for a break and is then switched out to a person who did not put the patient to sleep and is going to finish the case. (Gets off of soapbox).

Whoa - you're friggin kidding me, right? You think it's acceptable for an anesthesia provider to LEAVE THE ROOM in the middle of a case and let the circulator watch the monitors? Yet you have a problem with having different providers during the case? Tell me the name of this hospital so I can make sure I NEVER have surgery there. Oh, and BTW - this would qualify as insurance/medicare fraud. And since you're aware of it, you're just as guilty.

Five or six providers during an 8 hr case might be a little unusual, but not unreasonable. Hell, we have surgeons swap out on 8 hr cases, ESPECIALLY neuro. It's far preferable for someone to get a break than be sitting in a case for hours on end. Getting a fresh perspective from another provider is often helpful as well - that person giving the break may catch something that the other person hasn't noticed, or maybe even something you haven't noticed, since you apparently can't keep your own mind on your part of the procedure.

And while we're at it - why is the neuro PA helping with inductions? Clearly not what you need to be doing. Are you a control freak or what? Isn't there enough neuro stuff for you to concentrate on without worrying about the anesthesia part of it as wel? Or is your anesthesia group really that bad?

 

[Noyac]

On a side note. It is crna's like yourself that will eventually ruin the good thing that we (anesthesia care team model) have going.

You are applying to crna school and you are already comparing yourself to DOCTORS. REALLY!

THis definitely defines the mentality of the current crna's entering and coming out of school. Trouble!

 

[SleepIsGood]

If you want to be a nurse...go to nursing school.

If you want to be a doctor....go to medical school.

If I ever needed an appendectomy, cholecystectomy, etc I wouldnt go to the surgeon's PA or a surgeon's surgical technician with 12 years of experience. I would want to go to the SURGEON (ie doctor) with the real knowledge and experience.

Sorry Ms. RN...I think us docs are going to stick together on this one...dont even try splitting us, I think we know what you are trying to do🙄

 

[Winged Scapula]

I have worked in all environments: academic hospitals with anesthesia residents, community hospitals with MD-As supervising CRNAs and my current practice which is in community centers with MDs only.

The biggest difference is experience. IMHO, the problem I have with CRNAs is the same I have with an CA-1 doing the case: inexperience. Most tend to keep the patient light and I am frequently having to say "if the patient is awake enough to ask me to change my music on the IPod, they are too light" or "the patient is trying to help, can you stop that please?" (I do a lot of cases under MAC).

This has almost never happened in places where its an MD-A attending providing my anesthesia. I don't have any horror stories about CRNAs but frankly for my ease of practice, I much prefer the pace and skills of the MD-A.

 

[Chronic Student]

First off, is it possible you are overreacting a little? I have been around surgery for over a decade now and have seen surgery practiced in >15 hospitals. We are not talking about my first rodeo and your reply is less than collegial. In fact, it borders on hostile.

Whoa - you're friggin kidding me, right? You think it's acceptable for an anesthesia provider to LEAVE THE ROOM in the middle of a case and let the circulator watch the monitors? Yet you have a problem with having different providers during the case? Tell me the name of this hospital so I can make sure I NEVER have surgery there. Oh, and BTW - this would qualify as insurance/medicare fraud. And since you're aware of it, you're just as guilty.

A 45-second pee break is very common on extremely long cases and the bathroom is 15 feet away. A stable patient, railroad tracks if you will, left alone for 45 seconds. I'm not saying that things don't go wrong, but it would probably go wrong anyway whether they are there or not.

Seriously, medicare fraud. That is pure hyperbole and does not contribute to a rational discussion.

I'm sure you've never seen a perfectly healthy gallbladder or appendix come out. I'm sure you have never started an A-line, IV or central line that maybe you didn't really need.

Lets not even talk about ASA grading.

Oh, that patient is really a 3 ASA with only mild hypertension. You are really coming off as high and mighty and as someone who has never done anything, even if it was for the good of the patient, that may be in a gray area.

No, I still don't have a problem with them taking a 45 second pee break. I was under the impression that nurses did monitoring on local and sedation cases, right? Is this supposed to be a threat or am I supposed to be scared? Lets have a rational discussion about the real world. I must say that I am very surprised at you. I have always known you to be rational and honestly, I can't think of a single one of your posts I have ever disagreed with and I've certainly never seen you act this way.

I would rather they take the pee break and monitor the patient while they are in the room, check the urine output and give a damn about the patient.

What I said was not an attack on mid-level anesthesia and I feel like you are taking it that away. I specifically said that those folks with experience can put me to sleep anytime. In fact, several of my good friends are CRNAs.

My entire point was about experience. I happened to pick on the new CRNAs, because they are exactly that, new. The older CRNAs are a joy to work with and there are MDs that don't check UO, don't pay attention, etc.

Five or six providers during an 8 hr case might be a little unusual, but not unreasonable. Hell, we have surgeons swap out on 8 hr cases, ESPECIALLY neuro. It's far preferable for someone to get a break than be sitting in a case for hours on end. Getting a fresh perspective from another provider is often helpful as well - that person giving the break may catch something that the other person hasn't noticed, or maybe even something you haven't noticed, since you apparently can't keep your own mind on your part of the procedure.

Fair enough, I had not considered it from that perspective.

I still am uncomfortable with that many different people behind the drapes. 2 or 3 I can see >4 worries me.

As far as keeping my mind on the procedure that is really not any of your business. In fact, that is what my boss has asked me to do so that he can pay more attention to what is going on in the operation. I know I should have blinders on, according to you. However, in the past I have caught airway leaks, people contaminating the field (including anesthesia), have caught when medicatiosn that we ask anesthesia to give have not been given, when a circulator has put an incorrect medication on the field, when instruments are not properly sterilized, etc, etc. Some of those things could have caused serious harm to patients.

Are you telling me that you are NOT paying attention to what is going on in the sterile field. We are all supposed to work as a team. I learned how to multitask a long time ago and am pretty successful.

And while we're at it - why is the neuro PA helping with inductions? Clearly not what you need to be doing. Are you a control freak or what? Isn't there enough neuro stuff for you to concentrate on without worrying about the anesthesia part of it as wel? Or is your anesthesia group really that bad?

My aren't we territorial.

Years ago, when I was in scrub tech school, we were actually taught a fair amount about anesthesia. We were taught that it is the anesthesiologists/anesthetists room until the patient was asleep. That you need to be quiet during induction and that the patient is the most important person in the room along with the more technical stuff.

I have continued to practice those things throughout my carrer. I do my best to help everybody in the room. That ultimately helps the patient and makes the cases go faster and smoother which makes my boss happy. I have been known to help mop floors while turning a room over, help open instruments and supplies, I have even set up cases when a tech was late. In addition, I have been known to put in foleys, put on TEDs and SCDs, etc.

Yes, I will admit to being a control freak. You're not?

You know its funny, you are so gung-ho about me minding my own business. I have never been told by an anesthesia provider to step back, that I was annoying them or that I was not helping. In fact, it is just the opposite. I routinely get thanked by a variety of providers for my help. It is also not uncommon for them to ask for my help. Whether it be to hold c-spine, do jaw thrust, assist with a central line, etc. Hell, my boss will put in central lines when we have a trauma so that it can free up anesthesia to do other stuff. Should I tell him to stop and that he is overstepping his bounds?

Are you seriously telling me that you would rather have a circulator, fresh out of school who has been in the OR for less than a month try and help you. We often don't have an anesthesia tech around because the hospital is too cheap to have more than one on a shift.

I'm not sitting there slobbering all worked up in a lather on every case. However, if there is no anesthesia tech around, if the circulator is busy or if I am asked for my help then I will. Do I try and make myself obnoxious and participate in every anesthetic? No. I would say I end up helping on around 50% of the cases. I'm usually just sitting there with my thumb up my butt, because I have everything else ready. If I can free up someone who is needed elsewhere or that needs to get stuff done in the room than why not. Are you really suggesting that I should not be helpful?

Would it not be better for you and the patient to have good help with induction and intubation. Someone who has been there done that, actually knows where the cricoid is and is helpful. Someone who has intubated patients before (OK not many, but >10) and knows what you are trying to accomplish.

I know you feel like I'm overstepping my bounds, but think about it from my perspective. Just as I am listening to yours.

If my post seems overly hostile it is only because I feel like you are attacking me.

In fact, if anyone else wants to comment. Should I go sit in the doctors lounge and twiddle my thumbs or does anyone appreciate a little help?

 

[stone123]

1. I can't tell you the last time I saw an MD put someone to sleep. I mean, we have more providers and better coverage, but the MDs are supervising and not working.

I agree. As an overall group, anesthesiologists are the best providers. But I believe the group of anesthesiologists who go to work every day doing their own cases will be far better practitioners 10 years after residency than the ones who go straight to a supervisory practice and spend their time in the lounges day in and day out going over their portfolio strategies. The experienced midlevels in these practices will end up being the ones you want doing your anesthetic.

 

[Leukocyte]

Who let "the dogs" out? Who? Who, who, who-who?

Really, who is the idiot who started giving diagnostic and therapeutic rights to non-physicians? I would like to slap him on the forehead like they do on the V-8 commercial. What an idiot. Greedy filthy idiot.😡

Oh well, too late now...the "dogs" are out now, and there is no way to stop them. The problem is that they are humping each other like crazy, producing more and more of their kind...

I have NO problem with the PA model. It is the "dogs", who can independantly practice, diagnose and treat without a MDs supervision that worry me. Today they maul- anesthesia. Tommorow they will maul medicine. The day after tommorow they maul surgery.

Buy the way, where is McGayver?

 

[Gern Blansten]

The problem is that they are humping each other like crazy, producing more and more of their kind...

 

[dara678]

If you want to be a nurse...go to nursing school.

If you want to be a doctor....go to medical school.

If I ever needed an appendectomy, cholecystectomy, etc I wouldnt go to the surgeon's PA or a surgeon's surgical technician with 12 years of experience. I would want to go to the SURGEON (ie doctor) with the real knowledge and experience.

Sorry Ms. RN...I think us docs are going to stick together on this one...dont even try splitting us, I think we know what you are trying to do🙄

THANK YOU!

btw ... isn't the OP a dude?

 

[Coastie]

This is a hot topic among the anesthesiologist and I'm not trying to start another fire....just interested in your perspectives. As a disclosure, I am a RN heading into a CRNA program.

I was wondering if you surgeons noticed a difference between the care provided by an anesthesiologist vs. a CRNA. I don't need actual studies or numbers as I know they are already out there but more along the lines of anecdotes or little things that you've noticed. For example, do you tend to feel more comfortable having an 'ologist do your anesthesia or do you not see much of a difference? Is it case dependent? Pt dependent?

Thanks.

🙄

People legislating authority they didn't earn and do not possess. Just another reason why American healthcare faces big troubles.

Wake up, surgeons! You're next!

 

[Faebinder]

Doing the case with a CRNA instead of a anesthesiologist in the room is like flying on autopilot... you hope to God the plane knows what it's doing.

 

[jwk]

First off, is it possible you are overreacting a little? I have been around surgery for over a decade now and have seen surgery practiced in >15 hospitals. We are not talking about my first rodeo and your reply is less than collegial. In fact, it borders on hostile.


You know its funny, you are so gung-ho about me minding my own business. I have never been told by an anesthesia provider to step back, that I was annoying them or that I was not helping. In fact, it is just the opposite. I routinely get thanked by a variety of providers for my help. It is also not uncommon for them to ask for my help. Whether it be to hold c-spine, do jaw thrust, assist with a central line, etc. Hell, my boss will put in central lines when we have a trauma so that it can free up anesthesia to do other stuff. Should I tell him to stop and that he is overstepping his bounds?

I'm not sitting there slobbering all worked up in a lather on every case. However, if there is no anesthesia tech around, if the circulator is busy or if I am asked for my help then I will. Do I try and make myself obnoxious and participate in every anesthetic? No. I would say I end up helping on around 50% of the cases. I'm usually just sitting there with my thumb up my butt, because I have everything else ready. If I can free up someone who is needed elsewhere or that needs to get stuff done in the room than why not. Are you really suggesting that I should not be helpful?

Would it not be better for you and the patient to have good help with induction and intubation. Someone who has been there done that, actually knows where the cricoid is and is helpful. Someone who has intubated patients before (OK not many, but >10) and knows what you are trying to accomplish.

OK - parts of your post struck a nerve - so I'll apologize for a little over-reaction, and explain where I'm coming from.

I'm actually much more concerned with the questionable anesthesia practices at your hospital than you helping them out. The whole idea behind the anesthesia care TEAM concept is that there are always two sets of hands when needed. We always have two people at induction - we work together to insure the best care for the patient (which is clearly what you want as well). You indicated that the anesthesiologists are supervising the CRNA's - then where are they, if not being around at induction, emergence, and other times when two pairs of hands are needed? Not that we all don't appreciate extra help when needed, but if your anesthesia folks routinely need/ask for help from the circulator/surgical PA/scrub etc., then to me, that's a problem.

I will stand by my assertion that an anesthesia provider leaving the room to go to the bathroom, leaving only the circulator watching the monitors, is clearly and definitely an unacceptable practice. Someone doing that in our group would be fired on the spot. I had assumed when you said break, you meant 10-15 minutes - but even that 1 minute bathroom break without an anesthesia provider in the room is unacceptable.

Every MD in my group still does cases on a rotating basis, including the chairman of the department, and our former ASA president. Anyone doing cases is offered breaks through the day. On all-day cases, they're going to get a morning, lunch, and afternoon break. There's no way to insure that the same person gives all three breaks in our high-volume practice. If the case runs after 3pm and the person doing the case is not scheduled late, they're going to be relieved. Keep running longer, and the person that came in at 3pm will be getting a dinner break around 6pm. However, each and every time someone comes in or out, a report is given covering the patient's history, progress of the procedure to that point, issues to watch for or be prepared for, drugs and fluids so far, yada, yada, yada. In most cases, that's easily done in less than a minute. Rarely do I find issues while I'm giving someone a break - but when I do, I point it out to them when they return. That fresh perspective on a long case can be very beneficial.

And although you may think Medicare fraud is a stretch of the imagination, it's not. Anesthesia charges are based, in part, on time. You can't bill for time you're not with the patient. If that were reported, trust me, it would be a big problem. We have to suffer through a Medicare compliance presentation every year - Medicare requires not only compliance with their regulations, they mandate reporting of violations of compliance with those regulations. In theory, as a Medicare vendor yourself, by not acting when you see potential Medicare fraud occur, you are complicit in that fraud. Now, is that likely? No. Is the potential there? Absolutely. I can tell you, we go to some extraordinary lengths with our record keeping and practice parameters to remain compliant to the absolute letter of the law.

Again, sorry if my other post came off heavy-handed.

 

[Chronic Student]

Fair enough. I actually appreciate getting another point-of-view, as there are things that I obviously had not considered.

I definately think there are some issues to be ironed out with our new anesthesia care team and I'm not naive enough to think they will all get solved overnight.

As for the medicare fraud, I see where you're coming from. However, I'm much more concerned about the care my patient gets than with the govmint. I'm sure that would change in a heartbeat if someone called us on it.

I will have to rethink my position on someone leaving the room for 45 seconds. I really had not given it all that much thought and obviously there are issues that need to be considered.

It does make me think about all the personal phone calls, reading magazines, etc. In fact, I guess you could take that ad absurdum and say that stepping into the sterile corridor to get meds your patient needs out of the pyxis is abandonement.

Once again, I'll have to think about it and no hard feelings.

 

[mark2climb]

Yes, the OP is a feller...thanks for correcting him. I hope he also doesn't still think that nurses wear dresses and caps or that women should stay home and be barefoot in the kitchen.

Thanks for those who have offered thoughtful replies. It was an honest question and I am in no way trying to compare myself to a physician. You guys suffer through all those years and countless hours in school and training, so I sure hope you know more than I do.

And for those of you who didn't offer thoughtful replies...well...your words speak for themselves. 😎

 

[s42brown]

The real question is who BLOCKS more, CRNAs or MD/DO?

I think they should have a special class in medical school for all the future surgeon titled "How to prevent the damn anesthesia provider from cancelling your case"

 

[mark2climb]

That's funny....I worked with an anesthesiologist who's last name was Cancel. The first few times we saw his name....you guessed it, we were tempted to erase the case from the board. He was terrible too!!

 

[deleted89854]

That's funny....I worked with an anesthesiologist who's last name was Cancel. The first few times we saw his name....you guessed it, we were tempted to erase the case from the board. He was terrible too!!

We refer to them as "The Department of Surgical Prevention"

 

[GIST]

My point would be, CRNA make way too much money for the little that they do. All the responsibility lies with the Anesthesiologist or Surgeon not the CRNA.

 

[Ale]

Shouldn't the patient decide?


I want to see a Hospital writing in their ads "Come here we don't have doctors giving you your anesthesia. Hey! The CRNAs are not even supervised, but we will charge you the same." Let’s see what happens.

As a patient I would never ever go to a PA for primary care and I would never get surgery with a CRNA. No mater how many "experience" years they have. It's like building over mud.

 

[2win]

I know this language - " anesthesia provider". It is intended for some people that work in this field having low qualification. Helllo - we are here MD-s. Do you know what that means? A little respect please. Like CRNA-s are MD-s. LOL

 

[2win]

Message uselles - how you can judge a DOCTOR when you don't have training? Oh- you know that Propofol is white. LOL

 

[2win]

again "provider"??? I bet that you had dreams to become a physician and you couldn't. Read some JAMA editorials about the use of this word in our field. Rarely you'll see and MD using. So, please reffer to MD-s with Doctor and the other ones with subordinates or whatever you like.

 

[SocialistMD]

1. I'm not quite sure why we are having this discussion in the surgery forums, other than because it has probably been beaten to death in the anesthesia forums (although, I would say most of the posts here have been by people who usually don't frequent this area...)

2. Knowing several CRNAs and having one I know recently "provide" my wife's anesthesia, I can say that he is qualified to do his job, does it well, and makes me (an MD) feel more comfortable than many residents do when I'm operating on a patient let alone how they would make me feel keeping my wife comfortable. Yes, in the more complex cases I admit I probably will want an anesthesiologist, but for much of the run-of-the-mill stuff (where the CRNA's usually work anyway), I think CRNA's do a fine job, and I wouldn't care if I had a CRNA should I need something like an inguinal hernia repair, lipoma excision, etc...

3. Just because I think they can provide good anesthesia most of the time doesn't mean I would ever hire them to provide my anesthesia should I go into private practice. I'm not assuming that liability. I don't know what they are supposed to be doing, so I am in no position to supervise.

 

[2win]

That's funny....I worked with an anesthesiologist who's last name was Cancel. The first few times we saw his name....you guessed it, we were tempted to erase the case from the board. He was terrible too!!

Wow! Where are you located doctor? Just to avoid that area...Please be aware of this fact: a lot of the "old" anesthesia md-s got in the residency really easy - just because nobody wanted to get there. Now thinks changed. We do have academic achievements and so on. So your community hospital wit CRNA-s make you feel a doctor? Happy there? Do you have an anesthesia plan for them? I bet NO. Most likely is - hey Doc, we an obese one with DM, airway looks OK, BP is a little high but OK, I think that I will intubate him. And you say - yes, go ahead, and stay in your office ( if you have one) and play solitaire. Of course at home, when you stay with your family, you're a Doctor.

 

[2win]

This is a hot topic among the anesthesiologist and I'm not trying to start another fire....just interested in your perspectives. As a disclosure, I am a RN heading into a CRNA program.

I was wondering if you surgeons noticed a difference between the care provided by an anesthesiologist vs. a CRNA. I don't need actual studies or numbers as I know they are already out there but more along the lines of anecdotes or little things that you've noticed. For example, do you tend to feel more comfortable having an 'ologist do your anesthesia or do you not see much of a difference? Is it case dependent? Pt dependent?

Thanks.

Wait for few more years - this job CRNA-s will be (or already is ) in rural areas. That one that you see it on country channels.

 

[2win]

1. I'm not quite sure why we are having this discussion in the surgery forums, other than because it has probably been beaten to death in the anesthesia forums (although, I would say most of the posts here have been by people who usually don't frequent this area...)

2. Knowing several CRNAs and having one I know recently "provide" my wife's anesthesia, I can say that he is qualified to do his job, does it well, and makes me (an MD) feel more comfortable than many residents do when I'm operating on a patient let alone how they would make me feel keeping my wife comfortable. Yes, in the more complex cases I admit I probably will want an anesthesiologist, but for much of the run-of-the-mill stuff (where the CRNA's usually work anyway), I think CRNA's do a fine job, and I wouldn't care if I had a CRNA should I need something like an inguinal hernia repair, lipoma excision, etc...

3. Just because I think they can provide good anesthesia most of the time doesn't mean I would ever hire them to provide my anesthesia should I go into private practice. I'm not assuming that liability. I don't know what they are supposed to be doing, so I am in no position to supervise.

Yep - me too sometimes I think that the PA-s are better than surgeons. Did you get this ideea yet? Did you have you CT rotation yet? Did you see a nurse reading TEE? Did you see a nurse reading ABG-s? Hmmmm - you're still in the hernia rotation. Please post when you have some experience.

 

[2win]

Experience counts for a lot.

Where I'm at we have a good mix of MDs and CRNAs. This hospital started out with mostly CRNA's 20+ years ago and some of them are still around, then came the MD's.

Before the merger, which I will explain later you could get either a CRNA or MD and they were basically interchangeable. Everyone had a ton of experience and everyone was good. If I had to have surgery my wife had two names, one MD and one CRNA that I would prefer. Each provider kinda had their thing. Some you would see more often doing cerebral aneurysms, some with regional blocks and some were airway specialists and some were docs and some CRNAs who were the specialists. The docs did not supervise the CRNAs and everything seemed to work well.

More recently, the MD's negotiated with the hospital to get an exclusive contract and the old CRNAs had to join the group or they were SOL. They all signed on and then the docs brought in some newer CRNAs.

First let me preface my statement by saying that I think MD oversight of CRNAs is a good thing, just as I think a doc should be supervising me (a PA). However, I am really disturbed by a lot of things that are happening now.

1. I can't tell you the last time I saw an MD put someone to sleep. I mean, we have more providers and better coverage, but the MDs are supervising and not working.

2. I have real issues with a lot of the CRNAs that have been brought in. It may be just an experience difference, but I have noticed the new CRNAs do not pay as much attention to the case/patient.

I'm in neuro and we do a lot of extremely long cases and I routinely have to ask the circulator to check the urine output, as we can do a 10-hour case and the newbies may only check UO once. To me that is not acceptable. (I try and watch everything going on in the room so that my boss can pay more attention to the case)

I have seen them play with their iPhones when the patient needs pressors, gets light, etc. This is not acceptable either.

I routinely help with induction, insofar as masking (from the side when they are readying meds), making a good seal on the mask by pressing the cheek up on the side opposite their masking hand, cricoid, applying monitors, pushing tubes into their hands, getting the lip out of the way, jaw thrust of fiberoptics with myelopathy patients, etc.

I end up getting to know their skills and strengths and weaknesses quite well. They lack confidence, smoothness, are very rough/knock around in the airway and cause trauma, seem okay with letting the patient desat/get hypotensive, etc.

3. Breaks. I have no problem with someone running to the restroom with a stable patient, as long as the circulator is watching the monitors (and I trust that circulator). However, I am used to one anesthesia provider staying with a case until it is done. It is called continuity of care. It is not uncommon for us to have five or six different providers during a case now.

There is no one on this earth that is going to convince me that this is OK and I oppose it in the strongest terms. There is no way to convey everything that has happened during an 8-10 hour case in a 60 second report. Someone is going to forget to chart a medication, an antibiotic will be missed, a change in the patients breathing pattern will go unnoticed (change in rate, tidal volume, etco2, etc). Especially when someone comes in for a break and is then switched out to a person who did not put the patient to sleep and is going to finish the case. (Gets off of soapbox).

The short story is that I think experience is what counts. The difference in-between MDs and CRNAs is that most of what the CRNAs get is through OJT, whre the MD's have the theory and it may take a CRNA twenty years to equal (using this term very tongue-in-cheek) an MD with just a couple of years of experience.

Just my .02

"they are supervising and not working"???? You buddy - did you hear about eICU? Do you know what that means? LOL

 

[2win]

The term collegial is wrong - they are subordinates. I hope that is clear for us, physicians. They try to have a converations but this is not possible. Is like a PA is surgery is telling to the surgeon that they are colleagues. Wake up doctors! They work for us ( what a mistake...).

 

[SocialistMD]

Yep - me too sometimes I think that the PA-s are better than surgeons. Did you get this ideea yet? Did you have you CT rotation yet? Did you see a nurse reading TEE? Did you see a nurse reading ABG-s? Hmmmm - you're still in the hernia rotation. Please post when you have some experience.

What are you talking about? Your "phrasiology" is very cryptic and difficult to read (not just in response to my post, but each of your 8 posts on this topic). Yes, I've rotated on CT. No, I haven't seen a nurse read a TEE, nor did I advocate for that. Honestly, I'm not sure your run-of-the-mill anesthesiologists could give an accurate read of a TEE unless they've been through CT or critical care graduate training. Yes, I've seen a nurse read an ABG, and those in the ICU (let alone those with graduate training) tend to know what to do about any derangements. No, I'm not still "in the hernia rotation." Please reread my post; I said that for the simple stuff (like hernias) CRNAs are fine, but that when it comes to the more advanced procedures, I would rather have an anesthesiologist than a CRNA (or even a junior level anesthesia resident).

I'm not sure what your regular SDN user name is, but your "post-bombing" of this thread is quite annoying and you really aren't adding anything intelligible with your incomplete thoughts and difficult to interpret prose. Please slow down, gather your opinions into one coherent idea and then post that rather than the mish-mash of random thoughts currently on display, as I'm getting a headache trying to decipher your point(s).

 

[Leukocyte]

This is truly a sad topic. A nurse is a nurse, and should be practicing nursing. A physician is a physician, and should be practicing medicine/surgery. There should be NO overlap, and NO profession should step on the other's foot. It is wrong. It is unfair. It is not ethical. I like the PA model. It is fair and ethical. A PA is a great asset in very remote communities, and they are at least practicing under some sort of MD supervision.

Are these nurses (NP, CRNAs) ALWAYS supervised by a MD? Do nurses in the so called "Opt-out states" practice on their own with no need for a MD supervision? If so, then this is truly messed up.

 

[Southpaw]

Shouldn't the patient decide?


I want to see a Hospital writing in their ads "Come here we don't have doctors giving you your anesthesia. Hey! The CRNAs are not even supervised, but we will charge you the same." Let's see what happens.

As a patient I would never ever go to a PA for primary care and I would never get surgery with a CRNA. No mater how many "experience" years they have. It's like building over mud.

If patients knew the difference then perhaps they could and should decide. Truth is, most assume whoever is treating them is qualified and the patient gives the benefit of the doubt. The problem as I see it is that nursing seems to constantly work to expand their scope for CRNAs and NPs, while physicians as a group (AMA) seem to just sit on their hands. We can complain about this all day, but I don't really see it changing anytime soon.

Leuk, if PAs and NPs are in fact supervised, then that is a very loose interpretation of the word. It's certainly not the same supervision that I get from residents as an MS3, and it's not the same supervision that residents get by attendings. You're right, it truly is a sad topic, but I see no end in sight as long as there is a money crunch and our country sees it fit that people other than physicians can provide care.

 

[Chronic Student]

The term collegial is wrong - they are subordinates. I hope that is clear for us, physicians. They try to have a converations but this is not possible. Is like a PA is surgery is telling to the surgeon that they are colleagues. Wake up doctors! They work for us ( what a mistake...).

If you would actually read DOCTOR, you know how to do that right. The person I was having the exchange with is an AA and we are most certainly colleagues. Do you just assume things about your patients as well.

Please and your trying to be condescending with me. You have just made yourself look like a fool.

 

[2win]

You revealed your anger and frustration with this post.Enough said -you had maybe once in you lifetime the oportunity to talk with a Doctor. Oh - you're also part of the new "patient satisfaction" doctrine, right? Do whatever do satisfy. I bet that you have a lot of frustration. Sorry - time is over, things are changing. Good luck with your PA and changing the face of anesthesia in US. LOL

 

[Ale]

If patients knew the difference then perhaps they could and should decide. Truth is, most assume whoever is treating them is qualified and the patient gives the benefit of the doubt...

You are completely right.
Once I went to the ER for a cut I received while doing a frozen. I thought the person treating me was the Resident. OK, I said. She started ordering crazy test and I respectfully declined. Unnecessary, I said. No need to X-ray my hand. Then she came up with the idea to debride my wound, major mistake. She put the anesthesia in the palm of my hand, as opposed to the webs, and pinched the nerve. I could not hold a thing for a year.

Afterwards she “cleaned” the wound with the tip of the needle. At that time I mentioned that irrigation would have been better in this situation. I knew what she was doing was wrong, but in my mind she was the ER resident. I was thinking: she must be the chief or one of the seniors because she never called the attending. She must know something I was not taught in my trauma rotation.

WRONG, she was a PA. She never said I am a PA. I found out later when I was asking for my MD and check why she had not ordered HIV and HBC testing for a work related injury.

My bill came and it was $600 and the attending never saw me.

Sucker!!!

 

[Southpaw]

You are completely right.
Once I went to the ER for a cut I received while doing a frozen. I thought the person treating me was the Resident. OK, I said. She started ordering crazy test and I respectfully declined. Unnecessary, I said. No need to X-ray my hand. Then she came up with the idea to debride my wound, major mistake. She put the anesthesia in the palm of my hand, as opposed to the webs, and pinched the nerve. I could not hold a thing for a year.

Afterwards she “cleaned” the wound with the tip of the needle. At that time I mentioned that irrigation would have been better in this situation. I knew what she was doing was wrong, but in my mind she was the ER resident. I was thinking: she must be the chief or one of the seniors because she never called the attending. She must know something I was not taught in my trauma rotation.

WRONG, she was a PA. She never said I am a PA. I found out later when I was asking for my MD and check why she had not ordered HIV and HBC testing for a work related injury.

My bill came and it was $600 and the attending never saw me.

Sucker!!!

The sad thing is, it's the physician's fault for allowing this PA to see patients independently. If a physician trains a PA for a bit, the PA gets to know the physicians style and what they like, and then next thing you know they're off on their own seeing patients. I can't blame the PA, because they don't know what they don't know. Physicians should know better. Shame on that physician for letting a midlevel screw up your lac repair so bad. Beyond the potential legal ramifications, it's substandard, poor care.

And shame on that PA for not introducing herself as a PA. That's disingenuous.

 

[fastosprintini]

could somebody please explain to me what business a wannabe crna has posting on a physician website , trying to divide medical specialties ??!? i am sick and tired to deal with people who don't know what they don't know, please go to allnurses .com

 

[Winged Scapula]

could somebody please explain to me what business a wannabe crna has posting on a physician website , trying to divide medical specialties ??!? i am sick and tired to deal with people who don't know what they don't know, please go to allnurses .com

Everyone is welcome to read, post on and learn from SDN. SDN is not a "physician website". Medical doctors are only one segment of our 9 defined communities, which encompasses all students and practitioners in those fields.

That said, while nurses/CRNAs are welcome here, bashing either profession is not welcome, so I will remind users to keep things civil and professional. If it ceases to be so, then the thread will be closed. I have no interest in this turning into the debacle seen in the Gas Forums.

 

[jetproppilot]

I have no interest in this turning into the debacle seen in the Gas Forums.

PAST TENSE DEBACLE.

You forgot that part, Sir/Ma'am.

We havent had a problem in a long time now.

 

[jetproppilot]

Are you sure about that?

not even if we all agree . . .

. . . to post in verse?

Or we mess with the font size?

Can I at least take a moment to mention how great I am? really, I am, I promise

.

 

[Winged Scapula]

PAST TENSE DEBACLE.

You forgot that part, Sir/Ma'am.

We havent had a problem in a long time now.

I says "seen"; was meant as past tense. "Long time" is relative though, as armygas was rearing his ugly little head there just a few days ago, as I recall. But anyway, you are right...the debacle was at its height months ago.

BTW, what's with the Sir? Do I need to tart it up a bit?😀

 

[filter07]

Nurses should do nursing.

Doctors should do doctoring.

 

[jetproppilot]

Why did you erase your post?

But for the record, I enjoy your posts, and read the gasforums frequently. I may disagree with your point of view, but your posts are always interesting and informative. Your style is quite different from most others here, which is why I engaged in a bit of parody.

Cheers.

Fair enough dude.

Sometimes I struggle with posting to a response vs not posting.

Thanks for your parody!