Nursing vs. Physician Mentality

[BLADEMDA]

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Sorry Blade, but I have to call you out on this one. Honestly, S*** like this thread is piling up on SDN and is painting physicians in a bad light. It makes me seriously question my continued association with this site.

You are making unsubstantiated claims about the current practice patterns and critical thinking skills of the majority of CRNAs based (apparently) on your online interaction with a few vocal individuals, and perhaps your personal interaction with a 20-80 or so CRNAs (if you are currently practicing in a ACT model). You are then contrasting that with what? Your opinion of what anesthesiologists are doing?


It may well be that CRNA's are unable to critically evaluate the scientific literature with the same discernment as a physician, but the illustration that you are using does not support the contention. Come up with GOOD examples of how CRNA and Anesthesiologist critical thinking differs.

You are painting physicians in a bad light by using non-scientific arguments and insults to criticize CRNA's for a lesser ability to understand and evaluate scientific argument. You are smarter than that. You can hopefully come up with better examples than this.

If this is all we have left to differentiate us from the CRNA, then I suppose the war really is lost.

- pod

http://www.nurse-anesthesia.org/sho...ies-insinuations-and-scare-tactics-....-again...



Go ahead and read the above link. Feel free to join their website.

 

[periopdoc]

1. You are totally MISSING the point here

No, you are missing the point here. I am not arguing against quantitative TOF or routine reversal of neuromuscular blockade. Nor am I arguing that this particular CRNA is right.

You are parading this particular argument with this particular CRNA as proof that the majority of CRNA's are less capable of critically evaluating and applying evidence, and are thus less safe providers. I am stating that you chose a particularly poor example to demonstrate your point with, and you are making physicians look foolish by parading it on public internet forums.

Exceptional claims require exceptional evidence. In order for this discussion to be the damning evidence of a lower standard of CRNA care, that you are claiming it to be, three conditions must be met.

1. The evidence in favor of quantitative TOF monitoring must be overwhelming.
2. The evidence must be accepted and acted on en masse by anesthesiologists.
3. The evidence must be rejected en masse by CRNAs.

So lets look at each condition a little more closely.

1. The evidence in favor of quantitative TOF monitoring must be overwhelming.​

This is the condition that is closest to being met. It is becoming increasingly clear that quantitative TOF is likely the safest way to manage long-acting and/or repeated intra-operative dosing of intermediate acting neuromuscular blockade to maintain paralysis for the duration of the case. Extensive randomized, outcomes-based studies are lacking, but the bulk of the evidence points toward quant TOF being the best practice.

There have been three studies that have examined the role of acceleromyographic monitoring in preventing or reducing residual block in this scenario. Two of them compared acceleromyographic monitoring to no monitoring one with pancuronium and one with repeated rocuronium dosing methods. Only one study directly compared acceleromyographic monitoring to traditional nerve stimulator monitoring. Murphy, Et Al. Anesthesiology. 109(3):389-398, September 2008.

In an accompanying editorial to this final study, Aaron Kopman, one of the most long-standing and vocal proponents of quantitative TOF monitoring, states

Although it is difficult to find fault with the authors' data and the results seem plausible and even confirm what common sense would predict, questions remain...

the authors' protocol may not have mimicked actual clinical practice. Clinicians were instructed to keep the TOF count at two or three responses. Therefore, incremental doses of rocuronium may have been administered when additional surgical relaxation was not necessary. If clinicians had not received specific protocol instructions, would the results of this study have been different? It is impossible to say. Finally, the study was limited to observations in the first 30 min after extubation. We do not know whether long-term morbidity was increased in the PNS group...

A case can perhaps be made that objective monitoring is not always necessary...

clinicians who opt not to use even conventional PNS units are practicing within official guidelines.

The data on single-dose, intermediate-acting neuromuscular blockade technique to achieve optimal intubating conditions followed by a multi hour surgical procedure with no redose of NMB (that the original CRNA is posting) is even less dramatic. The best study is the Debaene study that I posted MD PhD critiques of earlier in this thread.

2. The evidence must be accepted and acted on en masse by anesthesiologists.​

As I have briefly demonstrated above, there is only growing consensus, not established consensus, among physicians that quantitative TOF monitoring is optimal. There is no ASA guideline for even qualitative TOF monitoring with a traditional PNS. As far as I can tell, Blue Star Enterprises is not a public company so we have no metric to measure the effect of July's editorials on the uptake of the only practical, commercially available acceleromyographic monitoring device, the TOF-Watch. We have yet to see the letters to the editor for the July issue (currently the April issue letters are the latest published). Perhaps we will see a resounding hurrah for the editors, just as likely we will see the same sort of critiques that you are seeing on CRNA sites posited by physicians.

3. The evidence must be rejected en masse by CRNAs.​

I agree that you will have a better metric on this than I will. You and I have met, and I now understand that, through your continued contact with several of your previous resident colleagues throughout a specific region of the US, you have a significantly greater insight into the mentality of CRNA's in this one region. However, I will see you and raise you the best insight we have into the mentality of physicians across the country and into Europe. Namely, the Naguib's Survey Data. We have yet to see any metric of the effect of July's data/ editorials on physicians.

The CRNAs that you are quoting are practicing outside of their national organization's standards, which (assuming monitoring of neuromuscular blockade does indeed prove out to be safest) are a step ahead of ours, stating that the CRNA shall,

Monitor neuromuscular function and status when neuromuscular blocking agents are administered.

Further,

The omission of any monitoring standards shall be documented and the reason stated on the patient’s anesthesia record

So the best evidence we have of the CRNA standard is that they should be doing exactly what you argued that they should be doing.


_____________________________

So, we fail on all three counts to make a strong argument that the CRNA's are using a lower standard of care or are interpreting the literature in a less sophisticated manner than anesthesiologists. You can't hold them accountable for not adopting standards that we haven't even adopted or implemented. What will you say if their national organization beats us to the punch and adopts quant TOF as a standard before ASA does? You and I know that this is an easier process for their organization (to change their standards), but Joe Public will only see the end result of their organization parading a higher standard of care than ours, and your argument will be blown out of the water.

Blade, I want you to discover and expose evidence that CRNA standards and capabilities are lower than anesthesiologists. I believe that you are uniquely situated to do it. However, parading this type of argument around sets up a straw man that can be used by the CRNA's in the future to attack you when you finally have good evidence to utilize in this fight. Please focus your attention and your attacks on areas where significant differences are empirically demonstrable instead of blasting poorly considered shotgun style attacks that don't really help us in taking the fight to the next level of changing public perception.

- pod

 

[periopdoc]

A (hopefully) brief response to some other points to get caught up

Quantative monitors are NOT used in most ORs but low dose Neostigmine is READILY available and SHOULD be used for reversal.

If after reading the peer referenced literature and Editorials you still don't either reverse your patients or document a TOF of 0.9 or greater than you may be causing harm to patients.

That is not where the evidence is pointing, it is more subtle than that. It is pointing to tailored NMB reversal based on quantitative TOF monitoring. Choosing a reversal dose base on qualitative data or empiric opinion does not appear to be as safe as tailored dosing based on quantitative data, it appears to be safer than not using any reversal, but it is not benign.

So, after reading the extensive literature posted you would recommend avoiding "routine" reversal of NMBs? I doubt most Anesthesiologists would agree with you AFTER reading the material.

Kudos to the Editorial Board of the A and A for taking a tough, unpopular stand on an issue which may improve patient safety or, at the least, patient comfort in the PACU.

Now you are putting words in my mouth, and yes kudos to the A&A editorial board. Key word there may improve patient safety.

In fact, please give one example of an AANA standard of care which was adopted by the ASA? Please name one MODERN contribution to patient care by the AANA? You can't.

The ASA will continue to advance patient safety as it has done so in the past.
This means new standards will be adopted and followed first by Anesthesiologists then by the AANA/CRNAs.

Now that is a legitimate line of argument to follow in differentiating anesthesiologists from CRNAs. There is empirical data to support your contentions and demonstrable evidence to provide to the public. Why not spend more time developing this line of argument than one that is so easily discredited?

I also stand by my opinion that this particular CRNA and many others persist in the wrongly held belief that routine reversal of NMBs are not warranted in many situations.

So do many physicians... physician heal thyself?

I may be in the minority but I am looking forward towards an ASA standard in this area.

I look forward to a large-scale, randomized outcomes based study that will give us the necessary evidence to make this a standard. I hope that the impetus behind the July editorials was to initiate just such a study. I do not believe that the quality of evidence exists to survive the process of developing a new ASA standard as we require a very rigorous evidence base. I do believe that there is sufficient evidence to begin utilizing quantitative TOF at the individual practitioner level.

Oh and that CRNA who extubates without reversal only 1 hour after the 2x ED95 dose of Roc? That dude is way off the bell curve and it looks like even the CRNAs at allnurses were critical of that idea.

- pod

 

[BLADEMDA]

There is now a consensus that these low degrees of residual paralysis are relatively frequent, difficult to detect, and still potentially harmful. However, the appropriate dose of anticholinesterase for this situation has not yet been determined. This may be of clinical interest because several neostigmine side effects are dose dependent, and probably even more importantly in this context, overabundance of acetylcholine at the neuromuscular junction has the potential to increase muscle weakness rather than reverse residual neuromuscular block. Similar results were also reported by others. Indeed, Payne et al. observed that 2.5 mg of neostigmine given after neuromuscular recovery may lead to prolonged neuromuscular blockade. In vitro data from Bartkowski indicate that high concentrations of anticholinesterase led to randomly appearing hyperactivity with severe fade on stimulation. Goldhill et al. confirmed these findings, reporting that a second dose of neostigmine (2.5 mg) given after spontaneous recovery from nondepolarizing block may adversely affect neuromuscular function. Recent findings from Eikermann et al. suggest that the upper airway dilator muscles may be especially vulnerable to this paradoxical effect of neostigmine, showing a decrease in inspiratory upper airway volume caused by neostigmine-evoked weakness of upper airway dilator muscles. Moreover, Caldwell reported a decrease in TOF ratio in 8 of 30 patients who received 40 μg/kg of neostigmine 2, 3, or 4 h after a single bolus of 0.1 mg/kg of vecuronium; all these 8 patients had a TOF ratio of more than 0.9 before administration of neostigmine. No such paradoxical effect occurred when neostigmine was given in the presence of residual paralysis or when reduced doses of neostigmine were given (i.e., 20 μg/kg). These data suggest that neostigmine when given in relative excess compared with the degree of neuromuscular blockade may adversely affect neuromuscular recovery by leading to a curare-like effect; the data from Caldwell give convincing evidence that this phenomenon may already occur at current clinical doses of neostigmine. Indeed, it seems that high, but not low, doses of neostigmine given at a shallow level of neuromuscular block may produce neuromuscular weakness. However, the effectiveness of low neostigmine doses in antagonizing shallow block (i.e., TOF ratio 0.4–0.6) has not yet been evaluated when applying the current criteria of adequate neuromuscular recovery. Therefore, this study aimed to investigate the dose–effect relationship of neostigmine to antagonize residual paralysis corresponding to a TOF ratio of 0.4 and 0.6, respectively

 

[BLADEMDA]

There is now a consensus that these low degrees of residual paralysis are relatively frequent, difficult to detect, and still potentially harmful. However, the appropriate dose of anticholinesterase for this situation has not yet been determined. This may be of clinical interest because several neostigmine side effects are dose dependent, and probably even more importantly in this context, overabundance of acetylcholine at the neuromuscular junction has the potential to increase muscle weakness rather than reverse residual neuromuscular block. Similar results were also reported by others. Indeed, Payne et al. observed that 2.5 mg of neostigmine given after neuromuscular recovery may lead to prolonged neuromuscular blockade. In vitro data from Bartkowski indicate that high concentrations of anticholinesterase led to randomly appearing hyperactivity with severe fade on stimulation. Goldhill et al. confirmed these findings, reporting that a second dose of neostigmine (2.5 mg) given after spontaneous recovery from nondepolarizing block may adversely affect neuromuscular function. Recent findings from Eikermann et al. suggest that the upper airway dilator muscles may be especially vulnerable to this paradoxical effect of neostigmine, showing a decrease in inspiratory upper airway volume caused by neostigmine-evoked weakness of upper airway dilator muscles. Moreover, Caldwell reported a decrease in TOF ratio in 8 of 30 patients who received 40 μg/kg of neostigmine 2, 3, or 4 h after a single bolus of 0.1 mg/kg of vecuronium; all these 8 patients had a TOF ratio of more than 0.9 before administration of neostigmine. No such paradoxical effect occurred when neostigmine was given in the presence of residual paralysis or when reduced doses of neostigmine were given (i.e., 20 μg/kg). These data suggest that neostigmine when given in relative excess compared with the degree of neuromuscular blockade may adversely affect neuromuscular recovery by leading to a curare-like effect; the data from Caldwell give convincing evidence that this phenomenon may already occur at current clinical doses of neostigmine. Indeed, it seems that high, but not low, doses of neostigmine given at a shallow level of neuromuscular block may produce neuromuscular weakness. However, the effectiveness of low neostigmine doses in antagonizing shallow block (i.e., TOF ratio 0.4–0.6) has not yet been evaluated when applying the current criteria of adequate neuromuscular recovery. Therefore, this study aimed to investigate the dose–effect relationship of neostigmine to antagonize residual paralysis corresponding to a TOF ratio of 0.4 and 0.6, respectively

Here is what we know today about non depolarizing NMBs:


1. Residual weakness after a single dose of intermediate NMBS is highly likely even with TOF/Tetany without fade.

2. Administration of low dose neostigmine is UNLIKELY and never been shown to cause a significant problem in HUMANS after receiving a NMB.
High dose or "standard" reversal may pose an issue in patients with a TOF of 0.9 or greater but low dose is unlikely to cause weakness.

3. Quantitative measurement of TOF with a device like TOF-Watch may allow the avoidance of reversal agents completely if a TOF of 0.9 or greater can be documented.

4. Now here is the kicker and why I firmly believe this thread is warranted:
If all you have in the operating room is standard twitch monitor then administering low dose reversal agents to patient with a TOF and tetany without fade is warranted based on our current body of knowledge.


Hence, Ron Miller, MD stated in the July Edition of Anesthesia and Analgesia the following statement:

The 3 excellent conclusions in the Viby-Mogensen and Claudius editorial include routine monitoring. We would add a fourth recommendation—routine administration of neostigmine or sugammadex (if available).

 

[BLADEMDA]

"The CRNAs that you are quoting are practicing outside of their national organization's standards, which (assuming monitoring of neuromuscular blockade does indeed prove out to be safest) are a step ahead of ours, stating that the CRNA shall,

Quote:
Monitor neuromuscular function and status when neuromuscular blocking agents are administered.
Further,


Quote:
The omission of any monitoring standards shall be documented and the reason stated on the patient's anesthesia record
So the best evidence we have of the CRNA standard is that they should be doing exactly what you argued that they should be doing."

-----------------------------------------------------------------


So, the CRNAs are monitoring neruromuscular blockade on a routine basis.
The evidence clearly shows that providers (MD and CRNA) can't tell a TOF of 0.6 from 0.9 the majority of the time. Since the majority of CRNAs on that Forum don't routinely reverse their patients when TOF and Tetany without fade is present many patients will be "weak" in the PACU.

I appreciate your pointing out that their Union advocates "monitoring" NMB with a twitch monitor. But, If a person was drowning are you going to to give him a life raft/ inner tube or take a picture with your I Phone?

 

[BLADEMDA]

•

Abstaining from giving anticholinesterase

agents is acceptable only if the T4/T1 ratio
threshold is ​

​

≥0.9 and is documented by a measuring
device

François Donati PhD, MD


​

 

[periopdoc]

3. Quantitative measurement of TOF with a device like TOF-Watch may allow the avoidance of reversal agents completely if a TOF of 0.9 or greater can be documented.

Agreed.


Anesthesiologists have had a long history of rapid adoption of new techniques to improve safety. We also have a proud history of skepticism towards adoption of new technologies (ie BIS) until there is adequate data to support the efficacy of new technologies. We are on the cusp of a huge leap in bringing a traditional research technique with no practical applicability to daily practice into the realm of daily use. It is understandable that such a monumental shift in thinking, understanding, and practice will be met with a degree of reticence by both our physician and nursing colleagues. It is too early to castigate those who have not adopted this technology and the new understanding underpinning it for not "buying in." The data is neither particularly new nor completely convincing, but the push to broaden exposure to the data is and the stage is set for a definitive study that will provide strength of evidence to make this a new standard for safety within the ASA.

Ironically the AANA with its less rigorous demands for supporting data for their standards may in fact beat us to the punch in adopting this as a standard. It is also ironic that the most likely significant improvement in NMB safety (suggamadex) will almost certainly see wider initial acceptance by the CRNA's who have not lived through and been trained as thoroughly in the drugs who have been ultimately pulled from market after unexpected side effects led to their demise. Assuming it lives up to its promise, they will look very good. If it becomes the next aprotinin or rapacuronium, we will look better.

- pod

 

[Mman]

The fundamental problem with the majority of Nurses/APRNs/CRNAs is the way they view the practice of "Nursing" or what we call Medicine.

When I read the title of this thread, I thought of some other directions this was going.

For example, in the OR today with an extremely unstable patient the CRNA I was working with/supervising/telling what to do seemed to be more preoccupied with charting correctly than taking care of the patient. I mean is entering every value of the ABG correctly into the anesthesia record more important than giving the f'in bicarb and calcium and hurrying up to check some more blood like ASAP because the BP is in the toilet right now?!?! I'm pretty sure the lab results are time stamped in the hospital EMR. It's not like nobody will know what the pO2 was at a certain point in time.

As a bright anesthesiologist once told me..."a patient never died from lack of charting". My CRNA today seemed to believe that if we charted everything, the patient would be fine.


It's almost unfathomable to me what would happen if CRNAs practiced independently in the setting I work in. Postop MI and stroke rates would at least go up by a factor of 10. Intraop deaths would significantly increase as well. It would truly by tragic.


Don't get me wrong, I work with some great CRNAs and some could probably handle themselves without me helping out. But the day you let one go independent, you let them all. And the bad ones (and even mediocre ones) would struggle mightily.

 

[BLADEMDA]

When I read the title of this thread, I thought of some other directions this was going.

For example, in the OR today with an extremely unstable patient the CRNA I was working with/supervising/telling what to do seemed to be more preoccupied with charting correctly than taking care of the patient. I mean is entering every value of the ABG correctly into the anesthesia record more important than giving the f'in bicarb and calcium and hurrying up to check some more blood like ASAP because the BP is in the toilet right now?!?! I'm pretty sure the lab results are time stamped in the hospital EMR. It's not like nobody will know what the pO2 was at a certain point in time.

As a bright anesthesiologist once told me..."a patient never died from lack of charting". My CRNA today seemed to believe that if we charted everything, the patient would be fine.


It's almost unfathomable to me what would happen if CRNAs practiced independently in the setting I work in. Postop MI and stroke rates would at least go up by a factor of 10. Intraop deaths would significantly increase as well. It would truly by tragic.


Don't get me wrong, I work with some great CRNAs and some could probably handle themselves without me helping out. But the day you let one go independent, you let them all. And the bad ones (and even mediocre ones) would struggle mightily.

I agree with your post 100%. Allowing the bottom 10-25% of CRNAs to practice Solo is dangerous and unwarranted.

Feel free to change the direction of this thread.

 

[pgg]

Allowing the bottom 10-25% of CRNAs to practice Solo is dangerous and unwarranted.

I'm in an opt-out state. A couple nights ago I was the 3rd call MD behind 1st and 2nd call "independent" CRNAs. One of our orthopods had a BKA to do in a cardiopulmonary cripple with ESRD and 52 lousy uremia-insulted platelets. The patient was more-or-less optimized after dialysis, and needed his stinking rotting foot chopped off.

CRNA 1 & 2 weren't "comfortable" with GA in this patient (wasn't my first choice either, but it sure wasn't contraindicated!). The platelet count precluded a spinal, and neither one knew how to do peripheral nerve blocks, so they were stuck. Stuck as in unable to do a BKA! The surgeon called me and I did the case. Popliteal/saphenous block, a couple mg of midazolam, no big deal.

I do cases that shouldn't be mine on call all the time for "independent" CRNAs who are either uncomfortable or simply unable, or because the surgeon sees which bottle of weak sauce is on the schedule and preempts problems by requesting physician anesthesia.

Mind you, I'm not really complaining. I am happy to do those cases, because the patient deserves a safe anesthetic, and that's what I signed up to do. I get in the mindset that not-1st call means I still might do the 1st case, and when the phone rings, I'm usually done swearing within 1 or 2 rings.


Very few of these guys know how to put in lines, none of them know any regional anesthesia. The exception are the current or ex military CRNAs I work with, who did get that procedural training and are usually fairly good with the needle driving; some have excellent technical skills. But how can the rest of them ever be truly independent if their plan for every single case is MAC/local, MAC/spinal, or ETT/LMA?

I know I'm preaching to the choir here, but I think about that a lot when I'm doing their cases. It makes me feel better about our job security, because they really can't do our jobs, push come to shove.

 

[flashgordon]

I'm in an opt-out state. A couple nights ago I was the 3rd call MD behind 1st and 2nd call "independent" CRNAs. One of our orthopods had a BKA to do in a cardiopulmonary cripple with ESRD and 52 lousy uremia-insulted platelets. The patient was more-or-less optimized after dialysis, and needed his stinking rotting foot chopped off.

CRNA 1 & 2 weren't "comfortable" with GA in this patient (wasn't my first choice either, but it sure wasn't contraindicated!). The platelet count precluded a spinal, and neither one knew how to do peripheral nerve blocks, so they were stuck. Stuck as in unable to do a BKA! The surgeon called me and I did the case. Popliteal/saphenous block, a couple mg of midazolam, no big deal.

I do cases that shouldn't be mine on call all the time for "independent" CRNAs who are either uncomfortable or simply unable, or because the surgeon sees which bottle of weak sauce is on the schedule and preempts problems by requesting physician anesthesia.

Mind you, I'm not really complaining. I am happy to do those cases, because the patient deserves a safe anesthetic, and that's what I signed up to do. I get in the mindset that not-1st call means I still might do the 1st case, and when the phone rings, I'm usually done swearing within 1 or 2 rings.


Very few of these guys know how to put in lines, none of them know any regional anesthesia. The exception are the current or ex military CRNAs I work with, who did get that procedural training and are usually fairly good with the needle driving; some have excellent technical skills. But how can the rest of them ever be truly independent if their plan for every single case is MAC/local, MAC/spinal, or ETT/LMA?

I know I'm preaching to the choir here, but I think about that a lot when I'm doing their cases. It makes me feel better about our job security, because they really can't do our jobs, push come to shove.

Uhh... Sounds like it's a sweet deal for your "independent CRNAs 🙄" to have MDs as back-ups, but a crappy deal for you. These nurses shouldn't be taking call at all, for the patient's sake.

I think it's pretty obvious to everyone here how limited a CRNA's knowledge base is. However, they're trained to be NURSES, not physicians. Comparing them to anesthesiologists is like making fun of a handicapped person.

That being said, it amuses me whenever I take over or hand off a case to a CRNA . Even the very best CRNA (military included) has <10% of the knowledge & skills of an anesthesiologist. They are unable to tailor their plan to the patient's physiology because they don't understand the patient's physiology. Everyone pretty much gets prop/sux/tube/gas.

I learned early on as a medical student that there is absolutely no intellectual threat by these nurses, only political. Unfortunately we are getting our asses kicked...

 

[maceo]

I'm in an opt-out state. A couple nights ago I was the 3rd call MD behind 1st and 2nd call "independent" CRNAs. One of our orthopods had a BKA to do in a cardiopulmonary cripple with ESRD and 52 lousy uremia-insulted platelets. The patient was more-or-less optimized after dialysis, and needed his stinking rotting foot chopped off.

CRNA 1 & 2 weren't "comfortable" with GA in this patient (wasn't my first choice either, but it sure wasn't contraindicated!). The platelet count precluded a spinal, and neither one knew how to do peripheral nerve blocks, so they were stuck. Stuck as in unable to do a BKA! The surgeon called me and I did the case. Popliteal/saphenous block, a couple mg of midazolam, no big deal.

I do cases that shouldn't be mine on call all the time for "independent" CRNAs who are either uncomfortable or simply unable, or because the surgeon sees which bottle of weak sauce is on the schedule and preempts problems by requesting physician anesthesia.

Mind you, I'm not really complaining. I am happy to do those cases, because the patient deserves a safe anesthetic, and that's what I signed up to do. I get in the mindset that not-1st call means I still might do the 1st case, and when the phone rings, I'm usually done swearing within 1 or 2 rings.


Very few of these guys know how to put in lines, none of them know any regional anesthesia. The exception are the current or ex military CRNAs I work with, who did get that procedural training and are usually fairly good with the needle driving; some have excellent technical skills. But how can the rest of them ever be truly independent if their plan for every single case is MAC/local, MAC/spinal, or ETT/LMA?

I know I'm preaching to the choir here, but I think about that a lot when I'm doing their cases. It makes me feel better about our job security, because they really can't do our jobs, push come to shove.

I cant believe you accept that **** That is insane. If you areindependent you are independent. That means YOU DONT GET HELP. I DONT COME IN TO HELP unless i have a physician patient relationship at the very outset. That is what is called safe practice..

 

[Southpaw]

I know I'm preaching to the choir here, but I think about that a lot when I'm doing their cases. It makes me feel better about our job security, because they really can't do our jobs, push come to shove.

Maybe your hands are tied because you're still in the military, but in my mind your style of practice is dangerous and troublesome for our profession. It allows nurses to cherrypick cases at the outset (ASA 1s and 2s, insured patients, etc.) and dish the sick, uninsured, and other cases they're either not equipped to do or simply don't want to do. This is also the problem I have with CRNAs practicing independently within the same group as Anesthesiologists. Sure, it emphasizes the point that they can't work without us, but I still don't think it's a good thing for us. I believe we operate on a very slippery slope if we say some cases are good to go without our involvement.

Maybe your type of practice is what's coming...and if so, it ain't good.....

 

[wine thief]

I cant believe you accept that **** That is insane. If you areindependent you are independent. That means YOU DONT GET HELP. I DONT COME IN TO HELP unless i have a physician patient relationship at the very outset. That is what is called safe practice..

👍👍👍👍

that setup infuriates me. why do they get the low hanging fruit and you get the complications??? so they can do "outcome" studies with their ASA 1-2 patients?

 

[pgg]

Sure they can.

I challenge you to show me any data that shows that Etomidate, sux, tube a litlle fentanyl and supplemental inhalational agent is an inferior choice in this patient OR That these peripheral nerve blocks are EVER standard of care.

By the way there are thousands of anesthesiologists out there practicing who aren't trained in performing these blocks.

🙄 Come on Blade, surely you can admit that some patients are better served by one technique or another, even if it's safe and possible to do things another way. We make that judgment every day when we evaluate a patient and pick a technique or drug.

I specifically noted in my post that a careful GA would've been perfectly OK in that patient, and I never even even implied that a PNB was the standard of care in this or any other case.

Maybe your hands are tied because you're still in the military, but in my mind your style of practice is dangerous and troublesome for our profession. It allows nurses to cherrypick cases at the outset (ASA 1s and 2s, insured patients, etc.) and dish the sick, uninsured, and other cases they're either not equipped to do or simply don't want to do. This is also the problem I have with CRNAs practicing independently within the same group as Anesthesiologists. Sure, it emphasizes the point that they can't work without us, but I still don't think it's a good thing for us. I believe we operate on a very slippery slope if we say some cases are good to go without our involvement.

Maybe your type of practice is what's coming...and if so, it ain't good.....

This was at my civilian moonlighting gig. The military CRNA would've simply done the case.

Most often though it's not the (civilian) CRNA balking, but the surgeon requesting an anesthesiologist. Which is good; it's evidence that they understand the difference, and the surgeons are important allies to have in the hospital. I'm sure as hell not going to tell the surgeon "nah, the CRNA is up first, he can do just as good a job as me" ... I hope you agree that would be an even worse message to send and precedent to set.

Pay here is not an eat-what-you-kill arrangement for anyone, so there's no incentive to dodge uninsured patients. An anesthesiologist makes the schedule, so they can't cherrypick cases during the day. The only time this is an issue is at night and weekends ... and the first anesthesiologist on the list still gets paid for the call, even if he's listed behind one or more CRNAs.

I expect to get the sicker patients. It's better for the patients, and it's also better for me at a year out of training to do more hard cases.

 

[PICUPNP]

You sure love fighting a lost battle! You need a girlfriend or something to take up your extra time. Maybe publishing on reversal of NMBs? Hmm...

 

[Laryngophed]

You sure love fighting a lost battle! You need a girlfriend or something to take up your extra time. Maybe publishing on reversal of NMBs? Hmm...

 

[BLADEMDA]

Allowing all CRNAs to practice Independently means more deaths in the perioperative arena. Any organization or individual espousing such a belief must be opposed.

 

[BLADEMDA]

Quote from the "other" anesthesia forum:


"well the facts r the facts. outcome studies show that CRNA's are the same (in some cases, better outcomes, but not past the statistical significance so it is more fair to say equal). The Extra MDA knowledge is erroneous, it's cool to have, but has zero percent impact on the delivery of anesthesia. "

NURSE
​

 

[BLADEMDA]

You sure love fighting a lost battle! You need a girlfriend or something to take up your extra time. Maybe publishing on reversal of NMBs? Hmm...

You bet I do! As long as there is still a single STATE left which hasn't opted out I will continue to post. As long as there are hospitals and medical staffs which support MD or ACT Anesthesiology I will continue to post. I know patients will die if the AANA wins this war. Regardless of Obamacare Solo CRNAs across the USA means more dead ASA 3 and 4 patients.

 

[Denatured]

Quote from the "other" anesthesia forum:


"well the facts r the facts. outcome studies show that CRNA's are the same (in some cases, better outcomes, but not past the statistical significance so it is more fair to say equal). The Extra MDA knowledge is erroneous, it's cool to have, but has zero percent impact on the delivery of anesthesia. "

NURSE
​

That individual was banned. They did not believe it was an actual nurse.

 

[Southpaw]

You sure love fighting a lost battle! You need a girlfriend or something to take up your extra time. Maybe publishing on reversal of NMBs? Hmm...

Time to slam the ban hammer on this troll....

 

[Southpaw]

I hope you agree that would be an even worse message to send and precedent to set.

It's better for the patients, and it's also better for me at a year out of training to do more hard cases.

I completely agree. I see a lot of positive in your situation. Both patients and surgeons are completely aware that you're the gold standard and the safest option. But I see potential for abuse in that arrangement also.