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Victory in Louisiana!!

Discussion in 'Anesthesiology' started by The_Sensei, May 5, 2007.

  1. The_Sensei

    The_Sensei Banned
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    From the ASA Newsletter:

    Scope of Practice
    The Louisiana Supreme Court denied the Louisiana State Board of Nursing's petition to review the lower court's decision. The lower court ruled that the board's statement was a rule, subject to the Louisiana Administrative Procedures Act, and issued a preliminary injunction against the nursing board and nurse anesthetist who sought the statement. The "statement" authorized nurse anesthetists to perform interventional pain management procedures (for background, see www.ASAhq.org/Newsletters/2007/02-07/stateBeat02_07.html). The Louisiana Society of Anesthesiologists (LSA) and ASA continue to monitor this lawsuit as there are several unresolved issues at the trial court level. Congratulations to LSA for its hard work!

    Keep fighting the good fight!!
     
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  3. BLADEMDA

    BLADEMDA ASA Member

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    Hopefully, the sign of many more victories to come against the AANA and its drive for 100% CRNA Independence.

    Blade
    ASA Member
    Federal and State PAC contributor
    Ready to donate to the P.R./letter campaign
    Fighting against the AANA
     
  4. toughlife

    toughlife Resident

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    how is it possible for a nursing board to issue statements expanding scope of practice to its constituency? Granted the state medical boards have the same power but they are at least assured that everyone who has a license to practice medicine has met a certain standard and passed exams to support that view.

    To just issue a statement and give a person the ability to play doctor is like forming the Amateurs Piper Cub Club and stating they can now start flying 747s.
     
  5. core0

    core0 Which way is the windmill

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    Not to be argumentative but here physicians have an unrestricted license to practice medicine. There is nothing to stop the FP physician from attending a 2 day course and practicing pain management for example. The BOM tends to be reactive instead of proactive in these cases. Now hospital credentialling comittees are a different matter.

    David Carpenter, PA-C
     
  6. Monty Python

    Monty Python Blissfully retired

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    The BON was asked to clarify, via a "practice opinion", what is and is not allowed by law in the nurse practice act vis-a-vis pain management. The BON said xyz was within the law and therefore was within the scope of practice. This was supported by the initial court ruling in response to ASA challenge.

    On appeal by the ASA, the lower court ruling was overturned by the Appeals Court. Not on the merits of the case itself, but on the technicality of how the BON failed to follow the state administrative code when issuing the original opinion.

    The BON then appealled this to the Supreme Court. The Supreme Court is charged with making sure the Constitution and proper court procedures are followed, not ruling on the merits of the case itself. The Supreme Court did not find any reason (based on violation of the Constitution or court procedures) to overturn the appeal's court opinion (which would have simply put the original issue back in the district court for re-trial).

    So we have the Supreme Court saying, by default, that the appeals court was correct in overturning the original court decision, caused by the BON failing to follow the state administrative code.

    This is how lawyers make money.
     
  7. Noyac

    Noyac ASA Member
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    Can you show me a 2 day course on pain management for FP?
     
  8. jetproppilot

    jetproppilot Turboprop Driver

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    Yeah, what a scary thought....and the lay public is misled by this...and yet it is a proliferating industry.

    I'm eleven years into this biz and can do run-of-the-mill pain stuff...but to market myself as a pain guy I'd either 1) go back and do a fellowship or 2)go into practice with an established pain guy and "apprentice" the practice until I felt comfortable...which would take a year or so.
     
  9. Taurus

    Taurus Paul Revere of Medicine

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    This is very good news.

    If CRNA's try to push for scope expansion into pain management in other states, other state courts will use this ruling as a precedent. CRNA's are gonna have a really tough time trying to getting into pain management anywhere. :thumbup:
     
  10. Taurus

    Taurus Paul Revere of Medicine

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    http://www.asahq.org/Newsletters/2007/03-07/stateBeat03_07.html

    Louisiana Nursing Board Challenges Ruling in Pain Management Lawsuit

    Lisa Percy, J.D., Manager
    State Legislative and Regulatory Affairs

    Last month’s “State Beat” reported that the Louisiana Court of Appeal held that the statement issued by the Louisiana nursing board was a rule, subject to the Louisiana Administrative Procedures Act. Additionally the court issued a preliminary injunction enjoining the nursing board from enforcing the statement and the nurse anesthetist who sought the statement from practicing any form of interventional pain management in reliance on the authority of the statement. The court’s decision relied on its analysis of Louisiana’s statutory definition of “rule” and relied on testimony that the statement would expand nurse anesthetist scope of practice.

    As anticipated the nursing board has asked the Louisiana Supreme Court to review the lower court’s ruling. First, the nursing board argues that it issued a declaratory order, which is excluded from the definition of a rule. Therefore the procedures applicable to declaratory orders differ from those that apply to rules. As such the procedures are less stringent because declaratory orders are nonbinding and without the effect of law.

    Second, the court erroneously interpreted the Nurse Practice Act (NPA) when it held that the nursing board’s statement expands nurse anesthetist scope of practice into an area in which they have not traditionally practiced. Because the NPA states that “CRNAs are trained and legally authorized to administer all types of anesthetics in all settings,” the board argues that the court placed a limitation on their scope that does not already exist. Additionally the declaratory order does not expand nurse anesthetist scope of practice as it simply opines the applicability of a statute governing the administration of anesthesia to the administration of anesthetics for pain management purposes.

    ASA and the Louisiana Society of Anesthesiologists will continue to monitor whether the Louisiana Supreme Court grants the nursing board’s petition to review the Court of Appeal’s decision.
     
  11. rmh149

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    Wow, they are really fighting over there in LA.

    I wouldnt have a CLUE on what to do in pain management...other than steroid epidurals requested by a physician.

    Did they define the requirements to practice, like felowships, certifications, etc.?
     
  12. core0

    core0 Which way is the windmill

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  13. Taurus

    Taurus Paul Revere of Medicine

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    I'm not so worried about a handful of FP's trying to do pain management. They understand the risk and liability of offering a new service which they don't have a pain fellowship to back up except a weekend course.

    Allowing 40k CRNA's into the field is a far scarier idea. You just know that there would have been a large invasion by CRNA's because they will always go after where there's more income.
     
  14. Disciple

    Disciple Senior Member

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    Their argument is ridiculous.

    So doing transforaminal ESIs under fluoro is "administering an anesthetic"?

    So implanting stims, Vertebroplasty and Radiofrequency denervation is "administering an anesthetic"?

    I believe ASIPP is also putting their money in to crush this.

    It's not just Louisiana, there is a well publicized CRNA pain clinic in New Hampshire offering the full scope of interventional pain procedures, including implants.
     
  15. Taurus

    Taurus Paul Revere of Medicine

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    It's funny how the nurses are trying to pull the wool over the courts' eyes. Unlike politicians, the courts are not so easily duped and can't be influenced. Call it what it is, nurses want to practice medicine without a medical license. Last time I checked, that's unlawful.
     
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  17. Camel

    Camel Senior Member

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    Makes it look like the AANA is made up of people who wanted to go to medical school and could not make it in or they went to nursing school and decided after the fact that they would have rather gone to medical school. Now, they want to practice medicine.

    There is NO question that the practice of nursing is essential to the success of medicine. There is no question that nurses are well-trained for the practice of nursing (my fiance is a nurse, I have the highest respect for what she has CHOSEN to do and what she is fulfilled by and loves to do). However, for the AANA to attempt what they are attempting is downright horrific. The longer they are allowed to do so, the more people will enter that track thinking that they will get to practice medicine w/o going to medical school.

    It may be "too late" (though I don't think it is ever to late to go back and get an education) for the AANA leadership to go to medical school, but everyone else who wants to practice medicine should do so. If they can't make it, then they shouldn't be permitted to practice through the guise of the CRNA position or the DNP position.

    We need a nice concise document outlining all of this and posted on the ASA site (there might be such a document, but I've never seen it referenced and I haven't searched for it yet, just recently got my ASA membership). This should be written to be understood by the layperson (politicians can't be expected to understand more than a layperson does about this problem except MAYBE in terms of the money issue). Thoughts?
     
  18. Noyac

    Noyac ASA Member
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  19. Disciple

    Disciple Senior Member

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    Check this out.

    http://www.cottagehospital.org/physician/physician_list.cfm?SpecialtyID=6

    One of the CRNA profiles lists a fellowship from the American Academy of Pain Mangement (a non-medical, non-physician organization that has nothing to do with interventional pain management).

    On the other hand, some of the fault lies with us, as several academic pain departments allow CRNAs to attend their cadaver courses.
     
  20. Mman

    Mman Senior Member

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    There is nothing to stop dishonest people from using bogus "degrees" to pad their resume. I could call myself a fellow of the Kazahkstani Interventional Pain Society and how much time would anybody try to waste disproving it? I could just throw in some facet blocks and use my Borat impersonation to impress the patients.
     
  21. The_Sensei

    The_Sensei Banned
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    Dude,

    This article predates the one I mentioned and is therefore irrelevant.
     
  22. MacGyver

    MacGyver Banned
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    The problem is that by state law, there are 2 separate boards, the board of nursing and the board of medicine. The board of medicine deals only with the practice of "medicine" and the board of nursing deals only with the practice of "nursing"

    The shrewd nurses saw that there was a loophole in this setup. The states give SOLE AUTHORITY to the BON and the BOM to define what "nursing" and medicine" constitutes, respectively. The means all hte BON has to do is define procedure X as the practice of "nursing" and voila they can expand scope to their membership.

    Technically, the BONs could even define surgery as the practice of "nursing" and instantly expand their scope to cover that. They wont do that because it would raise such a ruckus it would get defeated by the legislatures and courts, but theoretically there is NOTHING in the law to stop them from doing it at any time.
     
  23. Taurus

    Taurus Paul Revere of Medicine

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    Your article is from February 2007. Mine is from March 2007.

    Whatever. If it's over, I'm happy.
     
  24. Taurus

    Taurus Paul Revere of Medicine

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    From reading the case, it seems like if the nurses were trying to increase their scope using a backdoor. They probably knew that if they went through the appropriate rules changing process they would be soundly defeated. If it were that easy to change the rules, they would never have bothered to go all the way to the Louisiana Supreme Court. That's what is at the heart of this case. I bet that there's quite a bit of input from the medical side and legislature before the Board of Nursing can simply include pain management in their scope.

    A question is, who gets on the Board of Nursing? There was an earlier case this year where the Board of Pharmacy in Washington ruled that pharmacists had to honor Plan B emergency contraception prescriptions. The board initially ruled that pharmacists did not, but the governor threatened to replace them all if they didn't reverse themselves. So I'm guessing that something similar is in play with BON and BOM. If the BON started to abuse it's authority the BOM will alert everyone and the entire BON could be replaced by the governor. At that level, you have to play nice and follow tradition.
     
  25. Disciple

    Disciple Senior Member

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    Look like this is going on in Indiana too.

    Here's a cadaver course for CRNAs only teaching Discography, RF and Cervical ESIs

    http://www.ipge.com/PainManagement.htm

    Course director listed is Jackie Rowles, CRNA "Interventional Pain Specialist"

    How about this, their own Interventional Pain Society called NAPES

    http://www.napeseminars.com/pages/mission.html


    Nice little AANA endorsed mission statement they've got there:thumbdown:
     
  26. Taurus

    Taurus Paul Revere of Medicine

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    So the question is, how do we stop CRNA's from doing pain management in all 50 states? I'm hoping that the ASA is taking the lead on this. It seems like the nurses' greed is boundless. Next, they'll demand to do surgery solo.
     
  27. jetproppilot

    jetproppilot Turboprop Driver

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    It really does take alot to piss me off.

    And this misrepresentaion bulls hit really pisses me off.

    This is like a P.A. who has worked for a vascular group marketing himself as a heart surgeon.
     
  28. bigeyedfish

    bigeyedfish Member

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    It's only a matter of time. Unfortunately, if the current trend continues, within 10-20 years run of the mill lap chole's, hernias, cysts, lipomas, etc will be the "practice of nursing."
     
  29. The_Sensei

    The_Sensei Banned
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    Not to beat a dead horse, bro but you're wrong. The article at the start of this thread was cut and pasted from the MAY 2007 ASA Newsletter. The link contained within is indeed from February 2007. Check for yourself on the ASA website.
     
  30. rmh149

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    I was wondering when everyone here was going to realize that the board of nursing and the board of medicine are two completely different entities. The practice of medicine is what the BOM dictates physicians do...and the BON dictates what the practice of nursing is.

    When a CRNA does anesthesia it is called nursing. When a physician does anesthesia...exactly the same way, it is called medicine.

    I never thought CRNA's could do pain management independently. But I guess they are fighting for that too.
     
  31. toughlife

    toughlife Resident

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    Only in america are we stupid enough to even allow such a concept to exist.


    'When it is done by a physician it is called practicing medicine and when done by a CRNA nursing"? That is the most ridiculous concept that only a mentally challenged person would endorse.

    Are you telling me that an action which does not change in concept, form or design changes names depending on who's performing it?

    So if two people drive a car and one is a college graduate and the other is a high school graduate then the action (driving the car) should be called something different depending on who is doing it?

    What you and your organization are doing is PRACTICING MEDICINE. That is the societal norm and standard.
     
  32. Disciple

    Disciple Senior Member

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    So maybe the NPs working for Neurosurg groups should start evacuating subdurals and say it's "the practice of nursing".

    As you know, pain fellowships have become increasingly multidisciplinary, requiring training in Anesthesia, Neurology, PM&R and Psyche. There is no way the AANA can justify that the training CRNAs undergo even remotely resembles anything required of today's pain docs.

    So, the CRNA who learned some interventional techniques from another CRNA is now going to do H&Ps, formulate diagnoses, long-term management plans, decide whether or not someone needs cervical fusion, read their own spinal CTs/MRIs, prescribe high doses of PO opiates, understand the appropriate use of EMG/NCS, implant pumps/stims, admit these patients post-op to the surgical floor under their name and deal with the surgical complications of those procedures?

    More than a few Pain docs have seriously injured patient's with certain procedures. There are known complications and it happens. I know of very few physicians who think it's OK for CRNAs to do these procedures. Should enough CRNAs be allowed to do interventional pain management, it's only a matter of time before one of them paralyzes somebody or causes a stroke. When that happens there will be a line of expert witnesses a mile long chomping at the bit to crucify them in court.
     
  33. Taurus

    Taurus Paul Revere of Medicine

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    Remember that CRNA's were created with the idea of physician supervision. Midlevels like PA's in the OR can cut because they are under supervision by a surgeon. So, CRNA's are practicing medicine essentially. When AA's perform the same duties as you, it's still under the umbrella of medicine. CRNA's never want to admit to be practicing medicine because they don't want to fall under the state BOM's.

    I am of the opinion that there should be one over-arching health-related board at each state that covers medicine, nursing, pharm, etc.

    With one board, they can make sure that each provider has a specific role and there are no overlaps. This will prevent redundancies in the system and confusion by the public. Most importantly, it will prevent scope creep by some professional groups.
     
  34. Camel

    Camel Senior Member

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    Yeah, CRNAs practice medicine; they are just supposed to be doing so under the supervision of a physician trained in the medical model, etc. Essentially, the BON making decisions about the practice of medicine is like the FAA making rules about shipping lanes because they have some planes that land on ships periodically. I like analogies, sorry :) I hope that one made sense on some level.
     
  35. MacGyver

    MacGyver Banned
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    Absolutely right. The best way to end this nonsense is to have one board that controls both nursing and medicine. Teh problem I see with this is that the nurses will demand equivalent membership/leadership on this board. The rules would need to be set up such that it requires 75% or some other high percentage of board approval to change scope of practice regs. That way the nurses wont have a backdoor to use anymore and the only way they can add scope changes is if they have doctors supporting them at the board level.
     
  36. rmh149

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    I dont disagree with you. I dont know much about CRNA's practicing pain management. I cant really have an opinion on it due to my ignorance in the issue. However, my first impression was that it was not part of our scope.

    I agree with most of what you said except the first sentence. If a NP was able to evacuate subdurals then it would be the practice of nursing (very very very unlikely). Everything a nurse does has to follow under nursing....not medicine. They frequently overlap just as it does with CRNA's practicing nursing. The majority of what we do in the clinical setting is identical to the practice of medicine and would fall under the board of medicine.. BUT, we cant say it is practicing medicine. We are not physicians and we are not regulated by the board of medicine. My license comes from the board of nursing.

    I do believe that at one time CRNA's were asked to fall under the BOM and become members to the ASA. Does anyone know the history behind this?
     
  37. BLADEMDA

    BLADEMDA ASA Member

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    Perhaps,

    They will team up with a non-invasive Pain Doc Boarded by the American Academy of Pain Medicine. This way the CRNA can do the procedures and the Doctor can admit the patients. Since neither of these individuals can do the entire job alone they will work together as a team. CRNA's are very creative individuals and once the AANA creates a pain pathway (and they will) you can expect the BON's and many CRNA's to take it. I fully expect Pain Fellowships after the DNAP. It is the AANA's natural progression.

    Blade
     
  38. Taurus

    Taurus Paul Revere of Medicine

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    Going forward, anesthesiologists have to look at what's best for the profession, not their bottom line or how much free time they will have. This CRNA mess was created by such anesthesiologists.
     
  39. rmh149

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    Problem is who would be the head of the board? A doctor? Then all the nruses would be saying the head of the board is biased toward the physicians. What if the head of the board was a nurse? WHAT if it was ME :laugh: ?
     
  40. rmh149

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    Now that totally makes sense. I can see this happening.
     
  41. rmh149

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    I didnt say it made sense. Someone smarter than myself said it better:

    ....obviously CRNAs are not MDs and vice versa. Fortunately, the practice of anesthesia is the practice of medicine when performed by a physician, and the practice of nursing when done by a CRNA, so sayeth the courts.

    The practice of medicine is what physicians are legally entitled to do and the practice of nursing is what nurses are legally entitled to do. Lots of people give anesthesia -- nurses, physicians, dentists.

    The real issue is not whether something is the practice of medicine, but how and by whom it is to be practiced. Nurse anesthetists have made anesthesia a practice of nursing by more than 100 years.


    lawmed, Baltimore www.expertlaw.com 01-14-2007, 10:17 AM
    http://www.expertlaw.com/forums/showthread.php?t=19167
     
  42. Camel

    Camel Senior Member

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    I would submit that the aspect of anesthesia that is the practice of nursing was initially within the scope of being supervised by an anesthesiologist. The origin of this entire ordeal stems from the success of the AANA in effecting change in the law that allows them to practice medicine (or to practice nursing which was practicing medicine while supervised by an MD). No?

    And, as an aside, if I may: rmh149, your conduct and the manner in which you have interacted with those on this forum have both been exemplary. I applaud you.
     
  43. rmh149

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    Thank you, Camel. I try my best to be respectful as I realize I am more of a visitor (as a nurse) on this forum regardless of its public accessibility.
     
  44. johankriek

    johankriek Banned
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    physicians have made the specialty, the specialty it is for over 100 years. all of the strides that it has made is due to physicians..
     
  45. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved

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    Absolutely incorrect,
    Nurses administer anesthesia.
    Physicians practice Anesthesiology which is a medical specialty.
    What a nurse does is not the same thing a physician does.
     
  46. Taurus

    Taurus Paul Revere of Medicine

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    You put a lot of stock in his legal opinion. That's one person's opinion. I'm sure you can find a different opinion from a different lawyer.
     
  47. cfdavid

    cfdavid Banned
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    I agree, I know that rmh has exercised some unparalleled restraint a few times. I'm not even sure that could be expected of anyone. But, it shows professionalism. Again, my opinion, but this is the type of CRNA that I would think is not unwelome on this forum.

    Our fight is not going to be against individuals trying to make a living and learning etc. It's against an organization (surely supported by their constituents which gets murky, however).
     
  48. Monty Python

    Monty Python Blissfully retired

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    Various courts have weighed in on this issue. The general consensus is that anesthesia is the practice of medicine when performed by a physician, and is the practice of nursing when performed by a nurse anesthetist. Unlike other areas in medicine which are crystal clear and are obviously the sole practice of medicine, anesthesia has attributes of both medicine and nursing. Further muddying the waters is how anesthesia in America used to be relegated to the junior-most person in the OR (which was usually a nurse) while in other countries it was predominantly a physician specialty from the outset.

    The Missouri Supreme Court ruled that it was the legislature, not the "practice of medicine" which determined what nurses could do.

    The Kentucky Supreme Court .... Anesthesia is a proper nursing function; Frank v. South, 175 Ky. 416, 194 S.W. 375 (1917);

    The California Supreme Court, same as above, Chalmers-Francis v. Nelson, 6 Cal. 2d 402 (1936)
     
  49. BlackScorpion

    BlackScorpion Member

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    Well if the courts, with all it's great lawyers and omniscient judges say that anesthesia is the practice of nursing and medicine, then who are we mere physicians to argue?

    I just love it, when courts implement healthcare policy. Makes me feel good inside that our judges know so much about medicine.
     
  50. BLADEMDA

    BLADEMDA ASA Member

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    The State legislature along with the BON defines the limit on Nurse Anesthetist practice. There is NOTHING to prevent the legislators from requiring the direct supervision of a CRNA by a Board Certified Anesthesiologist. The AANA knows this is where the real battle is fought.

    Blade
     
  51. Taurus

    Taurus Paul Revere of Medicine

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    It's well established that CRNA's administer anesthesia. It is within their scope.

    The question in this case was could pain management be considered part of nursing anesthesia? If it were, then they didn't need to go through the formal rules changing process. The Louisiana Supreme Court established that it is not and therefore the CRNA's have to request it formally. This is a legislative change. The CRNA's probably realized that it is unlikely that the BON, with resistance from the BOM, could increase the scope of CRNA's to include pain management which is long considered part of medicine. That's like saying CRNA's wanting to do solo surgery. It ain't gonna happen. CRNA's can argue successfully that they are qualified to give anesthesia, but it's far different than being qualifed to do anything beyond that.

    I'll be interested to see if any state passes legislation that specifically allows CRNA's to do pain management.

    I'll be interested to see what the ASA does about shutting down these CRNA pain clinic in all 50 states too.
     
  52. Camel

    Camel Senior Member

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    Not exactly a new article, but I was taking some time to look at some other news sites and searching about anesthesiology and found this:

    http://search.ama-assn.org/Search/amnews/cs.html?charset=iso-8859-1&url=http%3A//www.ama-assn.org/amednews/2007/02/12/prl10212.htm&qt=category%3Acontent+||+anesthesia&col=amnews&n=5&la=en

    Is there any collaborative movement amongst the various physician groups dealing heavily with such issues to affect change? Taurus mentioned the ASA... what about the AMA?
     

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