But what CAN'T CRNAs do UNSUPERVISED currently in states where they have the most practice rights? And what will they NEVER BE ABLE to do UNSUPERVISED. Like liver transplants, heart and lung transplants, TEE, patient resuscitation, diagnosis etc.
All i read about these days is how they can do more and more of what was once the realm of anesthesiologists. There as to be some level at which everyone even the CRNA agrees that an anesthesiologist MUST be present and managing the case, or doing the procedure...
Your thoughts??
I'm not sure where the hard and fast line is drawn. However, in general, the "bigger" and more complex the case, the more likely it will be done in either an ACT, all-MD or academic residency kind of setting. To my thinking, all major organ transplants would fit that category, as would major spine and neuro, complex laparoscopic procedures, and pediatric-only facility,etc. TEE, while being used by some CRNA's, is really an MD skill, and certification in TEE is not offered to non-physicians. And of course despite what the militant CRNA's think, chronic pain management is clearly a physician specialty, not nursing. Any CRNA who thinks they can compete on both a knowledge and clinical base with a pain fellowship trained physicians is simply lying through their teeth to themselves and the public.
Although CRNA's will claim they do "really big" cases on their own, in most places they simply don't unless it's on an emergent basis - like a ruptured AAA that appears at a hospital with a general surgeon but no anesthesiologist. Think about where "independent practice" is most likely. Small hospitals (sometimes mulitple small hospitals with a single CRNA), plastic surgery centers, GI clinics, eye clinics, etc. and any other outpatient facility more concerned with "cheap" than quality. Once the hospitals or outpatient facilities increase in size, and anesthesiologists are on the medical staff, surgeons will demand the involvement of an anesthesiologist at some level.
How much involvement is very much practice-dependent. There are hospitals with so-called "collaborative practice" where both CRNA's and MD's work in the same practice but in theory the CRNA's aren't directed or supervised by an anesthesiologist (not sure what happens when **** hits the fan). In many hospitals, there is some form of ACT practice, from a strict medical direction practice with no more than 4 anesthetists being supervised by an anesthesiologist (the type I practice in), to a more loosely "supervised" model with one or two docs covering perhaps 12-15 OR's, and then there's everything in between.
Big cases, high potential for big problems, secondary/tertiary referral centers, etc., are all places where you'll tend to find anesthesiologists involved and rarely CRNA-only.
