So, I finally got to shadow an anesthesiologist, and I must say...

[VolatileAgent]

hey, in the spirit of trying to dispell "disinformation"... and, we were talking california, right?

a physician has to give you the green light in order for you to proceed...

2827. Anesthesia services; Approval; Permit

The utilization of a nurse anesthetist to provide anesthesia services in an acute care facility shall be approved by the acute care facility administration and the appropriate committee, and at the discretion of the physician, dentist or podiatrist. If a general anesthetic agent is administered in a dental office, the dentist shall hold a permit authorized by Section 1646

... and just so it's clear that you yourself are not practicing medicine...

2833.5. Practice not authority to practice medicine or surgery

Except as provided in Section 2725 and in this section, the practice of nurse anesthetist does not confer authority to practice medicine or surgery.

... and that you must be supervised by a physician...

2725. Legislative intent; Practice of nursing defined

(2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist, as defined by Section 1316.5 of the Health and Safety Code.

... and that you have no authority, unlike a physician, to designate someone to carry out any of your nursing responsibilities (i.e., you yourself can't delegate or supervise tasks)...

2725.3. Functions performed by unlicensed personnel

(a) A health facility licensed pursuant to subdivision (a), (b), or (f), of Section 1250 of the Health and Safety Code shall not assign unlicensed personnel to perform nursing functions in lieu of a registered nurse and may not allow unlicensed personnel to perform functions under the direct clinical supervision of a registered nurse that require a substantial amount of scientific knowledge and technical skills, including, but not limited to...

... that you have the legal obligation to abide by these regulations

2832. Applicant to comply with all provisions of article

Every applicant for a certificate to practice nurse anesthesia shall comply with all the provisions of this article in addition to the provisions of this chapter.

http://www.rn.ca.gov/npa/b-p.htm

so, the point is, the physician who runs the surgery center is in charge and directly responsible for the actions of that nurse anesthetist who works there. if this is not the case, then someone needs to report that institution to the california board of licensure, because they are violating the law.

this is far different than being an anesthesiologist, where no such limitations (as noted above) are placed on our scope of practice.

in other words, like it or not the crna always answers to a physician. it may not be another anesthesiologist, but don't try to suggest or in any other way imply that this is "independent" practice of anesthesiology.

furthermore, in this legal opinion, the following is held to be true:

California law does NOT permit Certified Registered Nurse Anesthetists (CRNAs) to administer anesthesia without supervision or direction by physicians or other practitioners (dentists and podiatrists) whose own lawful scope of practice specifically allows the administration of anesthesia.

that is, they need to have approval and licensure from the state in order to be in compliance with the law... a doctor can't just decide on his own to appoint any crna to provide anesthesia... and who do you think provides the lead opinion for which healthcare centers get such approval...

Hence, nurses, including CRNAs, have no independent ability to access anesthetic agents for any purpose.

Thus, it is unprofessional conduct for a CRNA to administer an anesthetic agent except "as directed by a physician". Unprofessional conduct is grounds for sanctions against the license to practice including revocation. This directly contradicts the assertion that CRNAs may administer anesthesia in California without physician direction.

http://www.csahq.org/pdf/prof/crna_scope_01_barnaby.pdf

so, you can try to use all the clever rhetoric you want to make everyone think you are independently practicing anesthesia, but you're not. it's like a lie you keep telling yourself enough times that soon you begin to believe it. and, if you're lucky enough, those to whom you're spouting this may be either equally "disinformed" or too lazy to actually get appropriately informed. and, then they may start to believe it too.

in summary and despite what you seem to believe you, if you are a crna in california you:

(1) cannot not legally administer anesthesia unsupervised.
(2) you must do it under the direction of a physician who is approved by the state to have anesthesia administered at his/her facility.
(3) are violating california law if you fail to do both those things.

just wanted to make sure that was clear.

---

Members don't see this ad.

 

[Conflicted]

Gee

Last i checked, surgeons were PHYSICIANS.

Oh and we know how much they understand anesthesia, yet somehow, the stats for saftey between the 2 groups are identicle. Wonder how that happens without an MD behind ones name?

Must be a miracle eh?

Oh and to clarify, anesthesia is the practice of NURSING and MEDICINE.

Also, the ownership of the practice can be anyone, including corporations who are clearly NOT physicians.

Se lets clarify again:

CRNA owns the surgery center.
CRNA provides ALL of the anesthesia at the center
CRNAs can provide anesthesia without ANY input from an anesthesiologist and do so everyday.
The law of supervision is met by having a DDS or MD in the room who knows nothing about anesthesia.

So, since all Operations are done by surgeons who are physicians and you cannot have anesthesia without the surgeon, they play as much apart in your anesthetic as they do mine. Thanks for comin out.

 

[johnnywad]

Now that is not to say that a CRNA that has been practicing for years is not experienced. But one who is fresh out of school is usually very green and has a big militant chip on their shoulder.

Just like a resident, huh?

 

[militarymd]

So, since all Operations are done by surgeons who are physicians and you cannot have anesthesia without the surgeon, they play as much apart in your anesthetic as they do mine. Thanks for comin out.

For the high and mighty anesthesiologists...who practice "independently".....allow me to humbly point out that NO ONE comes to the hospital to get an anesthetic....

They come for a surgical procedure.......Anesthesia is administered to facilitate the surgery....

At least that's how I understand it...

Then again...maybe there are such GREAT anesthesiologists out there that patients just come to have anesthesia alone....without the surgery...for those who are that great...I bow down to your superior skills.

 

[johnnywad]

I can vouch for the authenticity of what conflicted an rn29306 are saying.......and conflicted is not nitecap.......frankly nitecap seems to have disappeared from the anesthesia community at large.........he's mia, getting schooled or flunked.........nobody knows..........volatile.......looks like conflicted has your nads in his hands and is squeezing very hard.

 

[VolatileAgent]

Gee

Last i checked, surgeons were PHYSICIANS.

huh? yes, crna's must function under the legal supervision of a surgeon (who, yes, is a physician), or another physician, dentist, or podiatrist who is approved to administer anesthesia under their scope of practice.

Oh and we know how much they understand anesthesia,

huh? understand this: they wouldn't be allowed to supervise a crna if they didn't have medical authority from the state. you are bringing up a state board of medicine/training/cme issue. perhaps you need to tell me where you are aware that physicians don't have minimal competency on how to practice medicine, which is understanding pathophysiology and disease processes and their treatments, which may be resulting in the crna's who're working there unwittingly putting patients in danger. perhaps we should report these cases to the california state medical board, because likely in such instances they are violating the law.

...yet somehow, the stats for saftey between the 2 groups are identicle. Wonder how that happens without an MD behind ones name?

huh? source please.

Must be a miracle eh?

huh? i don't think you're "conflicted", i think you are very confused.

Oh and to clarify, anesthesia is the practice of NURSING and MEDICINE.

huh? this is not a clarification. this is your unsupported statement. anesthesiology is a medical discipline. nurse anesthesia is a nursing discipline. in the former, physicians have extensive medical training in the pathophysiology of disease, it's diagnosis, and treatment and are legally, ethically, and fiduciarily responsible for the evaluating, diagnosing, treating, and follow-up the patient's condition. in the latter, it is a nursing discipline which is geared towards the administration of anesthetic agents under the direction of a qualified physician.

i'm not making this up. this is the spirit of our separate professions. not only that, it is clearly defined in the law. this is the difference. you seem to have a very hard time understanding that.

Also, the ownership of the practice can be anyone, including corporations who are clearly NOT physicians.

so what? you can't practice anesthesia independently. keep saying that to yourself until you understand it.

Se lets clarify again:

nothing is clear about your misstatements.

CRNA owns the surgery center.

even if true, so what. i don't care whose name the surgicenter is in. provided that he/she is not referring patients (which he/she can't do anyway because he/she is not practicing medicine) to his/her own center and is not violating the cms rules addressing self-referrals, then there is nothing wrong with that. i don't see how this point has anything to do with the illegality of independent crna practice.

CRNA provides ALL of the anesthesia at the center

and, if he/she is not doing this under a physician's, dentist's, or podiatrist's supervision - who is also authorized to supervise the administration of anesthesia - he/she is violating california law. UNDERSTAND THAT POINT. it is PARAMOUNT.

CRNAs can provide anesthesia without ANY input from an anesthesiologist and do so everyday.

and, if he/she is not doing this under a physician's, dentist's, or podiatrist's supervision - who is also authorized to supervise the administration of anesthesia - he/she is violating california law. UNDERSTAND THAT POINT. it is PARAMOUNT.

The law of supervision is met by having a DDS or MD in the room who knows nothing about anesthesia.

huh? WRONG! and, i challenge you to show me any credible evidence to the contrary. you are the worst kind of advocate for your profession: not only are you poorly informed, you're trying to pass of "disinformation" as fact.

So, since all Operations are done by surgeons who are physicians and you cannot have anesthesia without the surgeon, they play as much apart in your anesthetic as they do mine. Thanks for comin out.

huh? your twisted logic is just... bizarre. read this one more time:

and, if any crna is giving anesthesia without a physician's, dentist's, or podiatrist's supervision - who is also authorized to supervise the administration of anesthesia - he/she is violating california law.

please do NOT post any more garbage responses until you can understand that point.

 

[Conflicted]

amazing

I have never seen someone so deluded as you Volatile. Ive read all of your posts on this board and it comes through on just about every one.

Lets review:

huh? understand this: they wouldn't be allowed to supervise a crna if they didn't have medical authority from the state. you are bringing up a state board of medicine/training/cme issue. perhaps you need to tell me where you are aware that physicians don't have minimal competency on how to practice medicine, which is understanding pathophysiology and disease processes and their treatments, which may be resulting in the crna's who're working there unwittingly putting patients in danger. perhaps we should report these cases to the california state medical board, because likely in such instances they are violating the law.

Have you actually worked with surgeons and asked them how much they know about anesthesia even AFTER taking a one day class to "certify" them? Your deluded AGAIN.

huh? source please.

[Pine, M, Holt, KD, Lou, YB. "Surgical Mortality and Type of Anesthesia Provider." AANA Journal. 2003;71:109-116.]

In the April 2003 AANA Journal, Dr. Michael Pine, a board-certified cardiologist widely recognized for his expertise in analyzing clinical data to evaluate healthcare outcomes, and a team of researchers published the results of a groundbreaking study titled "Surgical Mortality and Type of Anesthesia Provider." The study analyzed the effect of different types of anesthesia providers—specifically Certified Registered Nurse Anesthetists (CRNAs) and physician anesthesiologists—on the death rates of Medicare patients undergoing surgery

The results revealed that patients are just as safe receiving their anesthesia care from CRNAs or anesthesiologists working individually, or from CRNAs and anesthesiologists working together.



Now that thats done. Here is the thing bub. Having a physician in the room who keeps up their CMEs is supervision as defined by law. While they may have done the online CME for anesthesia, they know much less about it than any CRNA. So, who is making the decisions about anesthesia do you think? Thats right, the CRNA says "here is what im gonna do" the surgeon says "ok" and signs off on it and voila, supervision has occurred without any violation of any law. Since ive clearly been at this alot longer than you, (oh and your days as a paper pusher dont count) i know the law. I also know how it works in practice outside your experience (which is obviously limited).

Please, lets not continue to evidence your ignorance and inexperience.

 

[johnnywad]

huh? source please.

Pine Study

nothing is clear about your misstatements.

Very Clear

and, if he/she is not doing this under a physician's, dentist's, or podiatrist's supervision - who is also authorized to supervise the administration of anesthesia - he/she is violating california law. UNDERSTAND THAT POINT. it is PARAMOUNT.

The point YOU don't seem to get is that the "supervision" doesn't have to be by an anesthesiologist. Conflicted was right, when he said it could be a DDS or MD who doesn't know jack about anesthesia.....you gonna say that all MD's are omniscience and proficient in all medical specialties? You are a bizarre and argumentative little man/girl who seems to have a bad attitude in general. See what happens when you don't spank your children? They grow up to be like you.

 

[BeatrixKiddo]

What's a CRNA.

 

[BeatrixKiddo]

m about anthesiologist groups and a lot of general attitudes, anesthesiology no longer has any appeal to me. Despite the sacrifices needed, I really want to do surgery now.

Feel free to discuss. Sorry this post got so long.

So you want to do surgery because it's more exciting? Or because of a need to feel important and wanted?

I think you should do what... um... hm.. do what you're best at. Yeah and you'll always be important to me. <3

 

[markneil]

Pine Study











Very Clear












The point YOU don't seem to get is that the "supervision" doesn't have to be by an anesthesiologist. Conflicted was right, when he said it could be a DDS or MD who doesn't know jack about anesthesia.....you gonna say that all MD's are omniscience and proficient in all medical specialties? You are a bizarre and argumentative little man/girl who seems to have a bad attitude in general. See what happens when you don't spank your children? They grow up to be like you.

so who gets the blame when something messes up on the anesthesia side of things? the surgeon? or the surgicenter itself?

 

[Noyac]

i do sort of envy you crna's. You get to do all this Kool stuff without any responsiblity.

 

[salmonella]

CRNA stands for certified registered nurse anesthetist. There are currently lots of angry anethesiologists out there blaming CRNAs for taking their jobs...

 

[BeatrixKiddo]

CRNA stands for certified registered nurse anesthetist. There are currently lots of angry anethesiologists out there blaming CRNAs for taking their jobs...

Speaking of that, in certain third world countries they train highschool or even middle school drop outs to do menial/repetative hospital work that usually takes a bachelors or is done by doctors. Maybe they'll be replaced soon too.

 

[Conflicted]

Noy

Well thats sortof the trade off i think. Being a CRNA is a great profession, we do get to do some of the kool stuff without the rigors of medical school. I am well aware of how hard it is to become a physician. I did the pre reqs, did the MCAT and was accepted. That was hell. At the same time i was accepted to CRNA school. Really, it was an easy choice for me. Having many physician friends (including anesthesiologists i highly respect) saying med school wasn't worth it (and would get worse in the future) made it easier.

I dont want anyone to get the wrong impression. I dont (and most CRNAs dont) think they are physicians. We just get to do one small subset of what you all have to learn. So are CRNA = MD? Of course not. In only once place does a CRNA work as a functional equivalent and thats the OR. You guys get to do all the kool ICU stuff and the like. CRNAs can never do these things as they simply do not have the education or training necessary.

Its a collegiate relationship we share and, in actual practice, Anesthesiologists and CRNAs get along great going to each others kids birthdays and hanging out as good friends. SDN (and other sites of the ilk) are not at all true representations of the relationships and respect between the professions on a daily basis.

 

[VolatileAgent]

a lot of hot rhetoric...

[Pine, M, Holt, KD, Lou, YB. "Surgical Mortality and Type of Anesthesia Provider." AANA Journal. 2003;71:109-116.]

In the April 2003 AANA Journal, Dr. Michael Pine, a board-certified cardiologist widely recognized for his expertise in analyzing clinical data to evaluate healthcare outcomes, and a team of researchers published the results of a groundbreaking study titled "Surgical Mortality and Type of Anesthesia Provider." The study analyzed the effect of different types of anesthesia providers&#8212;specifically Certified Registered Nurse Anesthetists (CRNAs) and physician anesthesiologists&#8212;on the death rates of Medicare patients undergoing surgery

but...

RESULTS: Adjusted odds ratios for death and failure-to-rescue were greater when care was not directed by anesthesiologists (odds ratio for death = 1.08, P < 0.04; odds ratio for failure-to-rescue = 1.10, P < 0.01), whereas complications were not increased (odds ratio for complication = 1.00, P < 0.79). This corresponds to 2.5 excess deaths/1,000 patients and 6.9 excess failures-to-rescue (deaths) per 1,000 patients with complications. CONCLUSIONS: Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. These results suggest that surgical outcomes in Medicare patients are associated with anesthesiologist direction, and may provide insight regarding potential approaches for improving surgical outcomes.

http://www.ncbi.nlm.nih.gov/entrez/..._uids=10861159&query_hl=5&itool=pubmed_docsum

hmmm.... on the surface there seems to be some conflicting data. who am i supposed to believe? a publication from the nurse anesthetist's journal from a cardiologist?

still, all of your rhetoric doesn't change the law. the fact is, when there is trouble, there is a physician there to take responsibility and direct care. i've never said that it is mandated that that has to be an anesthesiologist.

you don't understand the law if you continue to argue. that's the only salient point. you cannot practice anesthesia independently. and, the data suggest that, when there are complications (get that important distinction straight), better outcomes occur when an anesthesiologist directs care. the state medical and nursing boards understand this. you apparently don't.

as someone on here said recently, any monkey can turn the dials on an anesthesia machine. that is not the same as the practice of medicine.

 

[BeatrixKiddo]

Noy

Well thats sortof the trade off i think. Being a CRNA is a great profession, we do get to do some of the kool stuff without the rigors of medical school. I am well aware of how hard it is to become a physician. I did the pre reqs, did the MCAT and was accepted. That was hell. At the same time i was accepted to CRNA school. Really, it was an easy choice for me. Having many physician friends (including anesthesiologists i highly respect) saying med school wasent worth it (and would get worse in the fuiture) made it easier.

I dont want anyone to get the wrong impession. I dont (and most CRNAs dont) think they are physicians. We just get to do one small subset of what you all have to learn. So are CRNA = MD? Of course not. In only once place does a CRNA work as a functional equivilant and thats the OR. You guys get to do all the kool ICU stuff and the like. CRNAs can never do these things as they simply do not have the education or training nessairy.

Its a collegiate relationship we share and, in actual pracitice, Anesthesiologists and CRNAs get along great going to each others kids birthdays and hanging out as good friends. SDN (and other sites of the ilk) are not at all true representations of the relationships and respect between the professions on a daily basis.

Lol awwwwwww that's touching! <3

 

[VolatileAgent]

In only once place does a CRNA work as a functional equivalent and thats the OR.

you are comparing apples and oranges. anesthesiologists are far more likely to be involved in more complex anesthetics on sicker patients. we're not talking about pushing propofol for an endoscopy.

 

[VolatileAgent]

The point YOU don't seem to get is that the "supervision" doesn't have to be by an anesthesiologist.

show me once ANYWHERE on this forum where i attempted to argue that or make such a statement. anywhere. understand what's in contention before you spout off.

as far as the rest of your ad hominem, it is undeserving of a response and belies your maturity level, not mine. i think your entire post speaks to your general lack of comprehension of the facts.

 

[VolatileAgent]

Its a collegiate relationship we share...

the word you were looking for is "collegial".

 

[Conflicted]

Awww

You think your so smart. So you want me to believe a study funded and done by the ASA.

Now, what you missed (since you didnt read it) was what the pine study showed:

It was a much larger and better designed study;

The researchers studied 404,194 Medicare cases that took place from 1995-1997 in 22 states. Only cases with clear documentation of type of anesthesia provider were studied, and adjustments were made for differences in case mix, clinical risk factors, hospital characteristics, and geographic location. The types of surgical procedures included carotid endarterectomies, cholecystectomies, herniorrhaphies, mastectomies, hysterectomies, laminectomies, prostatectomies, and knee replacements.

And with a larger study are better results.

Groundbreaking Results. The Pine study yielded the following important findings:

*
Mortality rates were similar for CRNAs and anesthesiologists working individually.

*
There was no statistically significant difference in the mortality rate for CRNAs and anesthesiologists working together versus CRNAs or anesthesiologists working individually.

*
There was no statistically significant difference in the mortality rate for hospitals without anesthesiologists versus hospitals where anesthesiologists provided or directed anesthesia care.

And WOW, they even mention your study, which is a joke

Pine et al. concluded the following:

*
That while their findings differed from those of Silber et al. (see analysis of Silber/Pennsylvania study, pp. 21-28 in this booklet), they were consistent with earlier research and with current data which estimate that anesthesia-related deaths today are as low as 1 in 200,000 to 300,000 cases. [To Err is Human: Building a Safer Health System. Kohn, LT, Corrigan, JM, Donaldson, MS. Washington, DC: National Academy Press. 1999.]

*
That based on the surgical procedures included in the study, inpatient surgical mortality is not affected by whether the anesthesia provider is a CRNA or an anesthesiologist.

Pine Versus Silber.

The Silber/Pennsylvania study (see analysis on pp. 21-28 in this booklet), which was published nearly three years before the Pine study, contained glaring methodological deficiencies that Pine et al. endeavored to avoid. Specifically, approximately two- thirds of the cases which Silber et al. classified as not involving an anesthesiologist in the patient care either A) actually did have an anesthesiologist involved in some, but not all, of a patient's procedures, or B) had no bill for the anesthesia care (making it impossible to confirm whether an anesthesiologist was or was not involved).

Further, cases in which anesthesiologists worked alone were not distinguished from those in which CRNAs and anesthesiologists worked together. Finally, only cases in one state—Pennsylvania—were included in the Silber study.

This failure by Silber et al. to more accurately quantify the cases in which anesthesiologists were involved led the researchers to conclude that there was an increase of 2.5 deaths per 1,000 patients when an anesthesiologist was not involved in the case. This inflated ratio was alarmingly out of sync with the Institute of Medicine's (IOM's) published report that anesthesia mortality rates today are approximately 1 death per 200,000 to 300,000 anesthetics administered, a ratio also routinely cited by the American Society of Anesthesiologists (ASA). [To Err is Human: Building a Safer Health System. Kohn, LT, Corrigan, JM, Donaldson, MS. Washington, DC: National Academy Press. 1999.] Had Silber et al. identified a more accurate (i.e., larger) number of cases as involving anesthesiologists, the ratio obviously would have been much different.

Pine et al. sought to avoid the limitations that marred the Silber study by taking the following steps:

*
Studying cases from 22 states, instead of just a single state.

*
Using only cases that clearly identified the type(s) of anesthesia provider involved in the patient care.

*
Distinguishing between care provided by CRNAs and anesthesiologists working together and care provided by anesthesiologists or CRNAs working individually.

The results of the efforts by Pine et al. to attribute anesthesia care to the correct providers) was twofold: 1) The researchers attained data that is more consistent with current overall anesthesia-related mortality rates cited by the IOM, the ASA, and the American Association of Nurse Anesthetists, and 2) they found no statistically significant difference in mortality rates when anesthesia is given by a CRNA working individually, an anesthesiologist working individually, or CRNAs and anesthesiologists working together.

Pine Rebuttal to ASA Comments on Pine Study. In May 2003, the "ASA Preliminary Comment on Pine Study" was released. In a gross misinterpretation of the Pine study results, the ASA claimed that Pine et al. found 38 deaths per 10,000 cases in hospitals where anesthesiologists administered or directed all anesthetics, and 45 deaths per 10,000 cases when an anesthesiologist was not involved. From this, ASA suggested that "the Pine study data support what most recent studies have found—that anesthesiologists improve anesthesia outcomes." [ASA Preliminary Comment on Pine Study. Lobbying day handout. May 2003.]

That same month, Dr. Pine wrote "Response to 'ASA Preliminary Comment.'" He stated that for the ASA to suggest that his study's data supports "the conclusion 'that anesthesiologists improve anesthesia outcomes'" is evidence of "either a woeful ignorance of the basics of data analysis or a cynical contempt for the intelligence of the intended audience." Defending his study, Dr. Pine wrote that his data actually found 34 deaths per 10,000 cases when CRNAs administered anesthesia while working together with anesthesiologists, and 45 deaths per 10,000 cases when anesthesiologists worked without a CRNA. He pointed out that this difference of 11 deaths per 10,000 cases was "even more impressive than the 7 deaths per 10,000 cases" difference cited by the ASA (see paragraph above), and that based on this data, "the AANA could claim that anesthesiologists should not be permitted to administer anesthesia unless a CRNA is present to prevent the excess mortality associated with physicians attempting to engage in the practice of nursing. However, unlike the ASA, the AANA has enough respect for its audience to avoid making such unwarranted claims."

Dr. Pine reiterated his study's findings that after risk adjustment there is no statistically significant difference between CRNAs working individually, anesthesiologists working individually, or CRNAs and anesthesiologists working together. He added that his study's data support the conclusion that even when there are two anesthesia providers working together, substituting an anesthesiologist for a CRNA does nothing to lower the mortality rate. [Pine, M. Response to "ASA Preliminary Comment."www.aana.com. May 2003.]

a lot of hot rhetoric...



but...



http://www.ncbi.nlm.nih.gov/entrez/..._uids=10861159&query_hl=5&itool=pubmed_docsum

hmmm.... on the surface there seems to be some conflicting data. who am i supposed to believe? a publication from the nurse anesthetist's journal from a cardiologist?

still, all of your rhetoric doesn't change the law. the fact is, when there is trouble, there is a physician there to take responsibility and direct care. i've never said that it is mandated that that has to be an anesthesiologist.

you don't understand the law if you continue to argue. that's the only salient point. you cannot practice anesthesia independently. and, the data suggest that, when there are complications (get that fact straight), better outcomes occur when an anesthesiologist directs care. the state medical and nursing boards understand this. you apparently don't.

as someone on here said recently, any monkey can turn the dials on an anesthesia machine. that is not the same as the practice of medicine.

Oh look, there you go evidencing your inexperience and ignorance again.

 

[VolatileAgent]

Originally Posted by Conflicted
The law of supervision is met by having a DDS or MD in the room who knows nothing about anesthesia.

huh? WRONG! and, i challenge you to show me any credible evidence to the contrary. you are the worst kind of advocate for your profession: not only are you poorly informed, you're trying to pass off "disinformation" as fact.

i'm still waiting...

 

[VolatileAgent]

Oh look, there you go evidencing your inexperience and ignorance again.

your childish ad hominem again duly noted. still, i guess two ill-conceived, "methodologically flawed" studies (one provided solely to juxtapose your's) are better than none...

Really, who can blame AANA for trying to produce a paper to counteract the earlier study of anesthesia provider differences and their impact on Medicare patient outcomes published by Silber et al.3 in Anesthesiology? Ironically, the current Pine study and the earlier Silber study validate three important observations, none of which serve the AANA's primary purpose for commissioning an epidemiologic investigation:

A knowledgeable physician is important when things go wrong. Both the Silber and Pine studies show that "two heads are better than one" when unexpected problems arise. In these studies, the anesthesia care team (defined as an anesthesiologist working with a nurse anesthetist) had lower failure-to-rescue and mortality rates. Anesthesiologists are vital in resolving medical emergencies and implementing life-saving medical care.

Medicare databases do not provide good enough information to use in outcome studies. Multiple studies have concluded that Medicare's billing and other administrative data do not provide valid information for outcome studies.2,4-6 Until the databases improve or, by a miracle, someone learns how to glean the wheat from the chaff within the data tapes, authors should be dissuaded from using this information for outcome studies.

Type of in-room anesthesia provider is an interesting but relatively unimportant issue. Please recall that ASA worked with the Centers for Disease Control (CDC) in the early and mid-1980s to develop a prospective study that would clarify the importance of anesthesia providers on the outcomes of surgical patients. Based on preliminary data, the definitive study was projected to be large and very expensive. Although the potential price tag dampened enthusiasm for the project, it was the advent of HTLV-III infection (later known as HIV, or AIDS) that diverted the CDC's attention to this more important and pressing issue.

...

The Pine study has provided little political clout to AANA in its attempt to provide "safety" data that support a rationale for eliminating physician supervision by state governor waiver from Medicare requirements. Given the apparent political impasse from the Pine and Silber studies, let us take a deep breath, re-evaluate the most important research needs of our specialty and vigorously pursue studies that will improve the care of our patients. Both the Foundation for Anesthesia Education and Research and the Anesthesia Patient Safety Foundation stand ready to help young investigators begin to address these questions and advance the science of anesthesiology.

http://www.asahq.org/Newsletters/2003/07_03/warner.html

hmmm... a mature, circumspect response from the ASA vs. a "this proves it", sophomoric one from the AANA's minions.... guess who my money's on in the long run?

then again, the AANA is well-known for putting forth crap arguments as "fact" to support their political agenda.

 

[TheMightyAngus]

Now that thats done. Here is the thing bub. Having a physician in the room who keeps up their CMEs is supervision as defined by law. While they may have done the online CME for anesthesia, they know much less about it than any CRNA. So, who is making the decisions about anesthesia do you think? Thats right, the CRNA says "here is what im gonna do" the surgeon says "ok" and signs off on it and voila, supervision has occurred without any violation of any law.

So what happens during surgery when the $hit hits the fan and the patient arrests? What does the surgeon and CRNA do if no anesthesiologist is present? [I'm not trying to be argumentative. This is a legitimate question of mine.]

 

[VolatileAgent]

So what happens during surgery when the $hit hits the fan and the patient arrests? What does the surgeon and CRNA do if no anesthesiologist is present? [I'm not trying to be argumentative. This is a legitimate question of mine.]

the crna tries to draw on their experience in order to save the patient's life... and hopefully calls for help (just like any well-trained anesthesiologist would).

 

[Noyac]

Noy

Well thats sortof the trade off i think. Being a CRNA is a great profession, we do get to do some of the kool stuff without the rigors of medical school. I am well aware of how hard it is to become a physician. I did the pre reqs, did the MCAT and was accepted. That was hell. At the same time i was accepted to CRNA school. Really, it was an easy choice for me. Having many physician friends (including anesthesiologists i highly respect) saying med school wasn't worth it (and would get worse in the future) made it easier.

I dont want anyone to get the wrong impression. I dont (and most CRNAs dont) think they are physicians. We just get to do one small subset of what you all have to learn. So are CRNA = MD? Of course not. In only once place does a CRNA work as a functional equivalent and thats the OR. You guys get to do all the kool ICU stuff and the like. CRNAs can never do these things as they simply do not have the education or training necessary.

Its a collegiate relationship we share and, in actual practice, Anesthesiologists and CRNAs get along great going to each others kids birthdays and hanging out as good friends. SDN (and other sites of the ilk) are not at all true representations of the relationships and respect between the professions on a daily basis.

Ok, so I have a few questions. What Med School were you accepted to? Why did you choose crna over med school? Functional equivalent? Well that is debatable and it has been debated adnauseum here. Yes you guys can do 95% of the cases out there. Does that make you the functinal equivalent? I agree that MD's and crna's get along great and attend each others childrens parties. I don't get what this has to do with anything. I have nurses, doctors, scub techs, administrators over all the time and at the same time. Does this make us all functional equivalents? It has nothing to do with our work duties.

If you have read my posts in the past you will know that I support crna's. I understand the need for them. But when they start claiming equivalence and boasting on a Doctor forum, I lose respect.

 

[VolatileAgent]

okay. here's your chance, conflicted. just say it. you think you can do just as good of a job as an anesthesiologist and should be able to practice independently. don't try to disingenuously couch your true feelings in some spurious "collegiate" atmosphere rhetoric. you are a run-of-the-mill whited sepulcher. it's clear to everyone reading these posts that you have an agenda. why try to hide it anymore? i'm just calling you out.

 

[VolatileAgent]

What Med School were you accepted to? Why did you choose crna over med school?

come on, noy. this is a bald-faced lie and everyone who read that knows it. and, this guy/gal supposedly has ANY credibility left?

 

[salmonella]

I am starting to think that "conflicted" is actually Nitecap.

 

[BIS]

I promise you this guy is not nitecap. Nitecap is younger, this guy is older.

It sure is funny to see how influential nitecap has been here. The chap hasnt posted here in over 6 months and you guys are still bringing up his name.

 

[Conflicted]

Hey Noy

I dont mind answering you, i have no use for the likes of volatile as his true colors now become clear. When presented with evidence that he cannot refute he attacks my character, typical high-school behavior. I wont bother to banter with him any longer.

What Med School were you accepted to?

I was accepted to UNECOM as well as Trinity medical school in Ireland. No, i did not apply to any MD schools as I was a more competitive applicant in DO schools.

Why did you choose crna over med school?

My feeling was that 8 years more in school just wasn't worth it. I was not interested in all of medicine just anesthesia. Being Canadian I thought the only route to this was med school, i didnt discover CRNA until i came to the US. Moreover, the majority of my physician friends (including relatives) dissuaded me from going as they felt it "wasn't what it was" and was "only going to get worse".

Yes you guys can do 95% of the cases out there. Does that make you the functional equivalent?

I think that CRNAs are trained to do 100% of the same cases. While you are absolutely correct that in large institutions its rare for a CRNA to do the "high risk complex" cases, it does occur and there has been no documented proof to suggest patients have worse outcomes. So my opinion is that in the OR, functional equivalents yes.

I agree that MD's and crna's get along great and attend each others childrens parties. I don't get what this has to do with anything.

Oh, just getting the point across that the fire seen here with people like volatile is not usual. Nor is the clear hostility seen on this forum vs CRNAs, in fact its just the opposite.

If you have read my posts in the past you will know that I support crna's. I understand the need for them. But when they start claiming equivalence and boasting on a Doctor forum, I lose respect

Well thats the thing. I dont think we are equivalent. As i mentioned, your ability to work in an ICU as well as other functions outside of the OR sets you apart. You are a physician and I am an RN, there is a real significant educational gap. My feeling, and the evidence to date, suggests that the extra training and knowledge just doesn't make a difference in regards to patient outcomes under anesthesia.

Ok, so I have a few questions. What Med School were you accepted to? Why did you choose crna over med school? Functional equivalent? Well that is debatable and it has been debated adnauseum here. Yes you guys can do 95% of the cases out there. Does that make you the functinal equivalent? I agree that MD's and crna's get along great and attend each others childrens parties. I don't get what this has to do with anything. I have nurses, doctors, scub techs, administrators over all the time and at the same time. Does this make us all functional equivalents? It has nothing to do with our work duties.

If you have read my posts in the past you will know that I support crna's. I understand the need for them. But when they start claiming equivalence and boasting on a Doctor forum, I lose respect.

 

[Conflicted]

I think the word you were looking for was "bold"

come on, noy. this is a bald-faced lie and everyone who read that knows it. and, this guy/gal supposedly has ANY credibility left?

conflicted: you're pwnd. get a life. or, at least go back to your nurse's forum where you can continue to live in your fantasy world.

 

[VolatileAgent]

I dont mind answering you, i have no use for the likes of volatile as his true colors now become clear. He cannot backup anything so he attacks my character, typical high-school behavior.

huh? i've backed-up everything i've said. you're accusing me of what you initiated and are continuing to do - engage in ad hominem and attack my character, which is the desperate ploy of someone who knows they've been bettered.

to this point, you've either ignored or tried to twist my statements, but as everyone else can see i've supported every assertion i've made - with sourced links! what's worse, you've confused yourself with me - now you're trying to say my "true colors" are showing when i've never hidden a thing. you're the one who's running scared. even worse still, you continue to try to paint the picture of someone who strives to maintain a "collegiate" environment, when everything else you've posted/stated is completely to the contrary. it is clear - even by this last post - that you feel the exact opposite, namely that your training - admittedly inferior from a medical standpoint - puts you on par with an anesthesiologist, a medical doctor. that only proves this: you don't really know what you don't really know.

... and, i'm still waiting for you to answer a few more questions. your evasion to this point has been clear to everyone here.

so, just start by pointing to exactly where in the california nursing or medical practice regulations it says a crna can be supervised by any physician.

 

[VolatileAgent]

I think the word you were looking for was "bold"

no, i've already mastered the english language, something you have yet to do.

 

[Conflicted]

heh

You mean this one?

The American Heritage® Dictionary of the English Language: Fourth Edition. 2000.

bold-faced

PRONUNCIATION: bldfst
ADJECTIVE: 1. Impudent; brazen: a bold-faced lie. 2. Printed in thick, heavy type.

no, i've already mastered the english language, something you have yet to do.

 

[johnnywad]

show me once ANYWHERE on this forum where i attempted to argue that or make such a statement. anywhere. understand what's in contention before you spout off.

Dude, you've been spewing that drivel everywhere, all the time. I'm not gonna do a forum search for you...you, I assume, can read it yourself. They way you are handling the stress here...........don't think I'd like to see you standing above me when I'm on an OR table.

 

[The_Sensei]

in summary and despite what you seem to believe you, if you are a crna in california you:

(1) cannot not legally administer anesthesia unsupervised.
(2) you must do it under the direction of a physician who is approved by the state to have anesthesia administered at his/her facility.
(3) are violating california law if you fail to do both those things.

just wanted to make sure that was clear.

Bravo!! Fantastic post.

 

[The_Sensei]

CRNA stands for certified registered nurse anesthetist. There are currently lots of angry anethesiologists out there blaming CRNAs for taking their jobs...

Not me. My job is, has been, and always will be secure. Those blaming nurses for taking their jobs are insecure.

 

[The_Sensei]

So.........I, and I'm sure many others will agree:

Volatile Agent=1, Conflicted=0

Conflicted.....you're a CRNA. You are NOT the functional equivalent of an anesthesiologist in the OR. To think so is delusional, reprehensible and downright insulting. But if that's what you need to keep telling yourself to get by, so be it.

 

[Conflicted]

Hmm

Well I have decided to defer to a friend of mine here (an anesthesiologist) and not bother to engage volatile anymore as ive already proven my point and he has repeatedly asked questions ive already answered. However, Sensei
You say this:

Conflicted.....you're a CRNA. You are NOT the functional equivalent of an anesthesiologist in the OR. To think so is delusional, reprehensible and downright insulting.

Please show me the evidence to backup this claim. I have shown you the pine study which is the evidence upon which my opinion is based. Volatile showed a very underpowered and glaringly flawed study which has since been debunked by pine. Then went on to post the ASA commentary about the study but neglected to read the Pine authors rebuttal which also debunks the ASA attempt to downplay the study. Truly, im not interested in baseless "opinion" which is all the ASA reply was. Show me the evidence. If you cannot, that means your reply here is simply opinion and therefore meaningless.

I am not anti-Anesthesiologist, im pro-evidence. I will gladly change my opinion if you can prove it incorrect. The burden of proof is now on you, not me.

 

[Planktonmd]

Hmm

Well I have decided to defer to a friend of mine here (an anesthesiologist) and not bother to engage volatile anymore as ive already proven my point and he has repeatedly asked questions ive already answered. However, Sensei
You say this:



Please show me the evidence to backup this claim. I have shown you the pine study which is the evidence upon which my opinion is based. Volatile showed a very underpowered and glaringly flawed study which has since been debunked by pine. Then went on to post the ASA commentary about the study but neglected to read the Pine authors rebuttal which also debunks the ASA attempt to downplay the study. Truly, im not interested in baseless "opinion" which is all the ASA reply was. Show me the evidence. If you cannot, that means your reply here is simply opinion and therefore meaningless.

I am not anti-Anesthesiologist, im pro-evidence. I will gladly change my opinion if you can prove it incorrect. The burden of proof is now on you, not me.

All these studies about mortality are meaningless.
Anesthesia is not about people not dying! this is a given I thought!
You can't say that because CRNA's are not killing more people than anesthesiologists they are equal!
Anesthesia is about quality of care and patient's overall experience.
Common sense says that the patient will benefit from a team approach to anesthesia rather than a one player type of thing ( I have no studies to support that).
And the patient will benefit of having a clinician that has a deeper understanding of medicine involved in their care ( this also is common sense and no, I don't have studies to support it).
That being said, I have nothing against CRNA's and I actually enjoy working with many of them.
We each have a role that's it!

 

[The_Sensei]

Show me the evidence. If you cannot, that means your reply here is simply opinion and therefore meaningless.

I am not anti-Anesthesiologist, im pro-evidence. I will gladly change my opinion if you can prove it incorrect. The burden of proof is now on you, not me.

Fine, so be it. I will not waste my time defending myself to a nurse, however. That is my final say on this non-issue.

 

[Frank Rizzo]

This isn't by any means a final decision, I won't let this one experience put me completely off. I'll likely do a gas rotation when the time comes (still a ways off) but it's just kind of sad that the way I imagined it didn't turn out to be very true (at least the day I was there.) Thanks for all your kind words, everyone. =)

xpinchx,

Sorry your thread got hi-jacked with the usual MD/CRNA bullshat. Don't let it get to you... many specialties are dealing with similar issues (think PA's, NP's, PT/OT), blah, blah blah. Gives me a headache.

It sounds like you're pretty early on in your training, and you've already shown the initiative to investigate certain specialties. Good work, keep doing it. You'll find something you like, and remember, your perception of what a certain specialty entails will change as you gain more experience and insight into medicine.

 

[domer621]

I'm really pretty depressed about it. In the reality of what I saw, the CRNAs did almost all of the work to speak of.

That's weird. I actually decided to shadow an anesthesiologist over break and I had the opposite experience. The guy did everything and pretty much worked alone. It made me really excited about the field. He loved his job and was very intelligent... the sitting around during surgery was good because I got a lot of time to talk with him.

Maybe you need to shadow a different guy.

 

[Arch Guillotti]

Thread, please die.

 

[blocks]

Another thread hijacked and torched by a bunch of insecure, uppity nurses. Nice.

 

[xpinchx]

Yeah, this thread turned out to be something totally different than what I wanted. Thanks to those who gave me advice. =)

 

[swpm]

I'm a resident. I respect the CRNAs and SRNAs at my institution, but I don't consider them the professional equals to the MD/DO attendings and residents.

I have no studies to cite here, just personal experience.

Residents are never paired with CRNAs at my institution, so I never see them in the OR, unless I take over a case at the end of a day when I'm on call. I frequently find myself asking myself just WTF they were thinking.

But here's what I've observed though during my time in the PACU. Patients dropped off by CRNAs and SRNAs consistently have far more difficulties with hypertension, tachycardia, poor pain control, big hits of Dilaudid that peak after they get to the PACU, cookie-cutter post op orders. They just seem to be sloppier and less precise than the anesthesiologists and residents.

Are the outcomes for their patients worse, in terms of deaths or other sentinel events? Not that I can see. Are their patients' operative experiences less smooth? Frequently.

I wish I'd kept track of # of patients delivered by CRNAs/anesthesiologists vs. # of times I was paged to manage some postop issue by the PACU staff.

I strive to produce a nice anesthetic every time. It's an expectation from my staff every time I take a patient to the OR. Smooth induction, uneventful case, calm comfortable emergence, comfortable transition in recovery. From my limited PACU window of observation it just seems that that happens a lot less often with a CRNA.

Maybe this is all atypical, and the CRNAs at my hospital just suck. I am a young grasshopper yet, but there seems to be more to the practice of anesthesia than avoiding sentinel events, which is all the studies comparing CRNAs to anesthesiologists seem to look at.

 

[salmonella]

During my surgery rotations, I would say at least half of cases I saw were done by CRNAs, and CRNAs actually taught and supervised anesthesiology residents at my institution. The attending anesthesiologist would just quickly stop by the OR once or twice during the case and asked if everything was OK.

CRNAs appear to be very knowledgeable and have good bedside manner; they taught residents and me pretty well. From what I have seen, they receive equal respect from patients and surgeons as their MDA colleagues. Everybody happily works in team and no one looks down on anybody.

 

[me454555]

During my surgery rotations, I would say at least half of cases I saw were done by CRNAs, and CRNAs actually taught and supervised anesthesiology residents at my institution. The attending anesthesiologist would just quickly stop by the OR once or twice during the case and asked if everything was OK.

CRNAs appear to be very knowledgeable and have good bedside manner; they taught residents and me pretty well. From what I have seen, they receive equal respect from patients and surgeons as their MDA colleagues. Everybody happily works in team and no one looks down on anybody.

Please tell me what institution this is so I can knock it off my list. Training residents under a CRNAs supervision is a farce and slap in the face. If it was a med student on an elective I can understand but a resident? Please, this is just plain bs or your program is VERY poor.