Scope Creep

[Hork Bajir]

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I have never put in a baby line, nor would I ever want to.

If I had a kid who needed a line, though, I would be enraged to discover that the doctor was delegating that task to a less well-trained person. Nothing personal against @btbam or anyone else... Just think that the idea of allowing anyone other than a doctor to do a central line on a child (much less a baby) is insane.

@btbam not to knock your skills- especially since I don’t know you- but if you stick the carotid or cause a pneumo, are you going to fully own the management of that complication?

 

[deleted87051]

Another thing that’s hard to tell on the internet.

No harm, no foul.

In my experience, pediatric anesthesiologists don’t invite people to learn procedures on babies unless they think they can handle it so my hats off to you.

 

[chocomorsel]

Ah yes the internet, where people feel emboldened to say things they’d never say in real life.

You don’t know him. He’s a total straight shooter.
Some of us are quite sarcastic. I don’t think he is.
Edit: Late to the party again.

 

[chocomorsel]

No they are called resident registered nurse anesthetist, just the same as their resident physician cohorts ya know. This is in an academic place as well, one that has docs doing mixed supervision with residents and CRNAs, and own cases as well. I can't imagine how and why the docs accepted that the srna program would use this moniker instead... Horrible

Except that they are literally still in school and therefore students.
WTF?
Are residents in school?

 

[GassYous]

No harm, no foul.

In my experience, pediatric anesthesiologists don’t invite people to learn procedures on babies unless they think they can handle it so my hats off to you.

One of my best moments in residency was when one of the attendings let me put a line in a cardiac baby.

 

[Southpaw]

No harm, no foul.

In my experience, pediatric anesthesiologists don’t invite people to learn procedures on babies unless they think they can handle it so my hats off to you.

Agree. More than any other attendings in residency the peds folks were restrictive and checked in the room more frequently to make sure I wasn’t screwing it up. It was always appropriate.

 

[btbam]

I have never put in a baby line, nor would I ever want to.

If I had a kid who needed a line, though, I would be enraged to discover that the doctor was delegating that task to a less well-trained person. Nothing personal against @btbam or anyone else... Just think that the idea of allowing anyone other than a doctor to do a central line on a child (much less a baby) is insane.

@btbam not to knock your skills- especially since I don’t know you- but if you stick the carotid or cause a pneumo, are you going to fully own the management of that complication?

I mean you could say the same thing about the cardiac surgeon letting the PA close, or gen surg letting a med student run skin (which lest we forget is the only thing the parents will see when their kid comes back to them). Should they be getting permission from the patient's family for that?

I have stuck the carotid before, as I imagine most of you have as well. Never under US guidance, but with a 23g seeker needle by landmarks. Just hold pressure for 5 min and stick again. I have never (knowingly) caused a pneumo, but if we're doing cardiac surgery it doesn't really matter right? I'm not trying to sound cavalier, as there are obviously serious complications with CVL insertion (losing the wire comes to mind), but I don't think of those two as horrific.

You are correct though, I would not manage the post operative chest tube. Then again, would you? It's not like you'd take time out of your busy day to go sit in the ICU for that.

Not to try and sound like some badass, but US really makes most of these lines much easier. Even in an 3kg baby an IJ is still a damn big vessel on US.

 

[ToKingdomCome]

Is it common for CRNA’s to basically run the L and D floor? Like doing spinals and epidurals unsupervised ?

 

[AdmiralChz]

Is it common for CRNA’s to basically run the L and D floor? Like doing spinals and epidurals unsupervised ?

“Run” the floor is probably the wrong word to use. Is it common for them to do epidurals without direct one-on-one supervision at all times? Yes. Even spinals, in some places yes. These are largely easily-learned manual skills that CRNAs have done for many years.

Is it common for them to do these procedures without oversight from a physician? Probably not, in it estimation. You’ll at least need a doc at home who can come in for c-sections (think a low-volume floor).

 

[GassYous]

Is it common for CRNA’s to basically run the L and D floor? Like doing spinals and epidurals unsupervised ?

Don't think so. It doesn't make much sense to me for them to be doing the procedures, especially if you're standing right there. Including setup, a spinal takes maybe 5 minutes? That's including the prep and charting. An epidural should be less than 10 since you need to thread the catheter and check the level. I think their role is to be a helping hand in sections, to do things like topoffs, etc. Unfortunately doctors seem to be hell bent on giving up all their procedural abilities.

 

[dhb]

One of my best moments in residency was when one of the attendings let me put a line in a cardiac baby.

I want your life! 😉

 

[jwk]

Don't think so. It doesn't make much sense to me for them to be doing the procedures, especially if you're standing right there. Including setup, a spinal takes maybe 5 minutes? That's including the prep and charting. An epidural should be less than 10 since you need to thread the catheter and check the level. I think their role is to be a helping hand in sections, to do things like topoffs, etc. Unfortunately doctors seem to be hell bent on giving up all their procedural abilities.

Really? OB is one of the biggest problem areas where anesthesiologists have ceded their authority to the CRNAs. There are countless departments around the country where, even with plenty of anesthesiologists on staff, CRNAs run all of the OB cases, or else they run all the OB cases except for 7-3 Mon-Fri. The docs are in the street at 3pm.

 

[ToKingdomCome]

“Run” the floor is probably the wrong word to use. Is it common for them to do epidurals without direct one-on-one supervision at all times? Yes. Even spinals, in some places yes. These are largely easily-learned manual skills that CRNAs have done for many years.

Is it common for them to do these procedures without oversight from a physician? Probably not, in it estimation. You’ll at least need a doc at home who can come in for c-sections (think a low-volume floor).

At my residency it’s not uncommon to never see the attending on the OB floor unless there’s a resident Doing OB cases

 

[Endee]

Really? OB is one of the biggest problem areas where anesthesiologists have ceded their authority to the CRNAs. There are countless departments around the country where, even with plenty of anesthesiologists on staff, CRNAs run all of the OB cases, or else they run all the OB cases except for 7-3 Mon-Fri. The docs are in the street at 3pm.

This has been the case at both places I've worked over the last 10 years, each with large OB/L&D departments. Basically ceded to the CRNAs, although anesthesiologists are still responsible on paper and some of the better ones still make sure that they are properly involved. But some/many of them just let the CRNAs run amok and only respond in the event of an emergency. It's no wonder the CRNAs in these environments think they can practice independently. Some of the most militant CRNAs I've ever met have been ones that do OB exclusively. They think it's their domain.

 

[Southpaw]

This has been the case at both places I've worked over the last 10 years, each with large OB/L&D departments. Basically ceded to the CRNAs, although anesthesiologists are still responsible on paper and some of the better ones still make sure that they are properly involved. But some/many of them just let the CRNAs run amok and only respond in the event of an emergency. It's no wonder the CRNAs in these environments think they can practice independently. Some of the most militant CRNAs I've ever met have been ones that do OB exclusively. They think it's their domain.

Yep. Anesthesiologists will always, always be their own worst enemy. Scope of practice issues? Dudes, look in the mirror! Giving your OB floor to CRNAs Bc you don’t like it/they keep you from sleeping? Don’t act all high and mighty when CRNAs get mouthy and defend their territory. You gave it to them!

The anesthesiologists who don’t like what they see are here, trying to fight a fight worth having. But we are in the clear minority across the country.

 

[MirrorTodd]

Admittedly OB does tend to draw the worst personalities in medicine. I can understand why "militant" crnas would flock there.

 

[BLADEMDA]

I mean you could say the same thing about the cardiac surgeon letting the PA close, or gen surg letting a med student run skin (which lest we forget is the only thing the parents will see when their kid comes back to them). Should they be getting permission from the patient's family for that?

I have stuck the carotid before, as I imagine most of you have as well. Never under US guidance, but with a 23g seeker needle by landmarks. Just hold pressure for 5 min and stick again. I have never (knowingly) caused a pneumo, but if we're doing cardiac surgery it doesn't really matter right? I'm not trying to sound cavalier, as there are obviously serious complications with CVL insertion (losing the wire comes to mind), but I don't think of those two as horrific.

You are correct though, I would not manage the post operative chest tube. Then again, would you? It's not like you'd take time out of your busy day to go sit in the ICU for that.

Not to try and sound like some badass, but US really makes most of these lines much easier. Even in an 3kg baby an IJ is still a damn big vessel on US.

I’ve had one serious pneumo in my career years ago. I had to manage the pneumo myself for 2 hours until the surgeon arrived to assist me. So, yes you are responsible for dealing with those complications.

 

[Arch Guillotti]

I’ve had one serious pneumo in my career years ago. I had to manage the pneumo myself for 2 hours until the surgeon arrived to assist me. So, yes you are responsible for dealing with those complications.

What did you do?

 

[deleted500612]

We don’t get paid for thinking about it. We get paid for doing it. And even now the thought process is literally just: what does the algorithm say?

Not necessarily the case; if you are employed in an anesthesia care team model chances are most of the time you are getting paid for thinking about it while the CRNA is actually the one doing it. IMO it is a disservice to our specialty to undervalue the knowledge required in formulating an optimal anesthetic plan for a sick patient (aka "thinking about it") as being of secondary importance to doing procedures like intubating or putting in lines.

I agree with @chocomorsel, what primarily differentiates an anesthesiologist from a CRNA (nurse) is medical knowledge, not some unique ability to be a procedure monkey. Multiple different physician specialties and flavors of midlevel provider can all put in lines and intubate. That skill, while obviously crucial to have as an anesthesiologist, isn't what makes our specialty unique or indispensable. Good luck getting some in here to admit that a competent midlevel can actually put in a line just as well as an anesthesiologist (as though physicians are just naturally born with superior hand-eye coordination and dexterity compared to every midlevel). What makes our specialty indispensable is an unparalleled fund of knowledge in perioperative medicine, which is the result of a vast disparity in educational attainment. The pay check difference is not because of some inexplicably unique competency in threading a catheter into a radial artery that a midlevel just couldn't possibly achieve.

 

[IMGASMD]

Not necessarily the case; if you are employed in an anesthesia care team model chances are most of the time you are getting paid for thinking about it while the CRNA is actually the one doing it. IMO it is a disservice to our specialty to undervalue the knowledge required in formulating an optimal anesthetic plan for a sick patient (aka "thinking about it") as being of secondary importance to doing procedures like intubating or putting in lines.

I agree with @chocomorsel, what primarily differentiates an anesthesiologist from a CRNA (nurse) is medical knowledge, not some unique ability to be a procedure monkey. Multiple different physician specialties and flavors of midlevel provider can all put in lines and intubate. That skill, while obviously crucial to have as an anesthesiologist, isn't what makes our specialty unique or indispensable. Good luck getting some in here to admit that a competent midlevel can actually put in a line just as well as an anesthesiologist (as though physicians are just naturally born with superior hand-eye coordination and dexterity compared to every midlevel). What makes our specialty indispensable is an unparalleled fund of knowledge in perioperative medicine, which is the result of a vast disparity in educational attainment. The pay check difference is not because of some inexplicably unique competency in threading a catheter into a radial artery that a midlevel just couldn't possibly achieve.

Sure it’s nice to tell us who know that. Preaching to the choir.

It is NOT how medicine work in this country. We are getting paid to do not to think. Unless you can change that or even the “perception” of that. It’s a nice discussion, nothing more.

P. S. How about those who sits in ivory tower, direct nurses/residents but think all day. Can they practice? Do they deserve a better salary?

 

[Urzuz]

Not necessarily the case; if you are employed in an anesthesia care team model chances are most of the time you are getting paid for thinking about it while the CRNA is actually the one doing it. IMO it is a disservice to our specialty to undervalue the knowledge required in formulating an optimal anesthetic plan for a sick patient (aka "thinking about it") as being of secondary importance to doing procedures like intubating or putting in lines.

I agree with @chocomorsel, what primarily differentiates an anesthesiologist from a CRNA (nurse) is medical knowledge, not some unique ability to be a procedure monkey. Multiple different physician specialties and flavors of midlevel provider can all put in lines and intubate. That skill, while obviously crucial to have as an anesthesiologist, isn't what makes our specialty unique or indispensable. Good luck getting some in here to admit that a competent midlevel can actually put in a line just as well as an anesthesiologist (as though physicians are just naturally born with superior hand-eye coordination and dexterity compared to every midlevel). What makes our specialty indispensable is an unparalleled fund of knowledge in perioperative medicine, which is the result of a vast disparity in educational attainment. The pay check difference is not because of some inexplicably unique competency in threading a catheter into a radial artery that a midlevel just couldn't possibly achieve.

Though you are correct regarding medical knowledge being more important than procedural skills, the reality is that barring midlevels from doing procedural skills is the easiest way to protect your turf. You think the hospital administrators give a flying @#$% that you have a better grasp of medicine than a nurse? No. You are more expensive, and as long as the nurse can churn patients out just as well as you can (and do all associated procedures, including blocks, spinals, etc), the administrators will happily kick your overeducated, overtrained butt out to the curb. Keep in mind that measuring true outcome differences between nurses and anesthesiologists is exceedingly challenging since, 1) bad outcomes are extraordinarily rare given how safe anesthesia has become, and 2) less bad outcomes (swollen lips, N/V, worse pain scores, blocks not working, etc) don't matter to higher ups.

Letting nurses do procedures while you stroke yourself off knowing that you have a better fund of knowledge than they do is doing our specialty, your patients, and all future anesthesiologists a huge disservice.

 

[jw3600]

Not necessarily the case; if you are employed in an anesthesia care team model chances are most of the time you are getting paid for thinking about it while the CRNA is actually the one doing it. IMO it is a disservice to our specialty to undervalue the knowledge required in formulating an optimal anesthetic plan for a sick patient (aka "thinking about it") as being of secondary importance to doing procedures like intubating or putting in lines.

I agree with @chocomorsel, what primarily differentiates an anesthesiologist from a CRNA (nurse) is medical knowledge, not some unique ability to be a procedure monkey. Multiple different physician specialties and flavors of midlevel provider can all put in lines and intubate. That skill, while obviously crucial to have as an anesthesiologist, isn't what makes our specialty unique or indispensable. Good luck getting some in here to admit that a competent midlevel can actually put in a line just as well as an anesthesiologist (as though physicians are just naturally born with superior hand-eye coordination and dexterity compared to every midlevel). What makes our specialty indispensable is an unparalleled fund of knowledge in perioperative medicine, which is the result of a vast disparity in educational attainment. The pay check difference is not because of some inexplicably unique competency in threading a catheter into a radial artery that a midlevel just couldn't possibly achieve.

We all know this. Us being aware of this has not helped make other people aware of this. Unfortunately there are those who are aware of this who CHOOSE not to acknowledge it for rea$on$.

Edit: last 2 posters basically said the same thing.

 

[ProRealDoc]

Oh yeah, even one of the GI nurses who I guess just finished his nursing school, is in a nurse residency program in the GI suite, apparently working the job is the residency. It's ridiculous

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