What I've noticed about the midlevels with whom I practice is that the majority of them seem to be far more cavalier about the anesthetic they are giving. It reminds me, many times, of when I was a CA-1...
Early in my training, I used to do cases, put patients to sleep, wake them up, drop them off in the PACU, and nothing seemed to go wrong. My attending would come in and would point out what I needed to pay more attention to, and I would think to myself, "This d-bag. That **** ain't important." And, each day, I would reaffirm this with my limited experience doing cases in patients where there weren't many co-morbidities or when I would never see them again post-op.
Then, as I progressed through my training, I got more experience taking care of truly sick patients. I mean, taking patients to the OR who were at death's door. I started doing my advanced rotations in the ICU, and I got to see what the effects of a sub-optimal anesthetic had on the patient (acute kidney injury, need for prolonged resuscitation, inadequate analgesia, prolonged intubation, massive fluid shifts, etc.) in the immediate peri-operative period. My eyes were opened. And, I started to realize how important the little details that I wasn't previously aware of actually were. This is the result of knowledge AND experience, and what separates a practitioner from a consultant. That's the difference.
So, now I see this unspoken but clinically-evident bravado in my CRNA colleagues with whom I work, and I'm reminded of myself early in my training. But, when a truly, truly sick patient comes to the OR, they suddenly seem a little more quiet. They suddenly seem to have a little wider eyes and slightly more dilated pupils. You suddenly start to hear from them things like, "Hey, is there anything I'm missing here?" or "What do you think we should do next?"
Many of you have heard the saying: "There are no atheists in a foxhole." Sometimes in the OR we find ourselves, so to speak, in the foxhole with bombs dropping all around us and bullets whizzing over our heads. The spirit of this expression is far more evident in our daily clinical practice than most CRNAs are willing to admit. That would require them to let go of their tenacious grip on the attempted devaluation of the Anesthesia Care Team model, something - purely for political and financial reasons, not safety - they are vociferously unwilling to do.
-copro