what exactly does supervising crnas entail?

[captbadass]

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im starting med school in the fall and have only had the opportunity to see anesthesiologists in action a few times. all of these times were during open heart procedures. seeing how the gas doc kept everything under control and adapted to each and every change in vital sign made me very interested in the specialty.

recently, i started browsing through gaswork.com just to look at what some of the opportunities in the field are. i noticed in the job ads that the the amount of supervising of crnas ranges anywhere from 0% to 80% or more. what exactly is the gas doc doing when he/she is supervising? home many crnas can a gas doc supervise at one time? i'm a little confused about this aspect of the job. i cant really tell if this supervising role is a drawback or not. i know i definitely liked what the cardiac anesthesiologist did.

thank you in advance for answering my questions. also, best of luck to all you ms4's waiting to see where you match!

capt

 

[jcdoc107]

im starting med school in the fall and have only had the opportunity to see anesthesiologists in action a few times. all of these times were during open heart procedures. seeing how the gas doc kept everything under control and adapted to each and every change in vital sign made me very interested in the specialty.

recently, i started browsing through gaswork.com just to look at what some of the opportunities in the field are. i noticed in the job ads that the the amount of supervising of crnas ranges anywhere from 0% to 80% or more. what exactly is the gas doc doing when he/she is supervising? home many crnas can a gas doc supervise at one time? i'm a little confused about this aspect of the job. i cant really tell if this supervising role is a drawback or not. i know i definitely liked what the cardiac anesthesiologist did.

thank you in advance for answering my questions. also, best of luck to all you ms4's waiting to see where you match!

capt

I'm an MSII interested in anesthesiology and have found the same thing on gaswork.com. I think anesthesiology could be a good field for me, however, it is hard to imagine myself going through all that training only to supervise and not directly use my skills. At this point in my education I feel like I would want to be the one administering anesthesia and doing procedures 100% of the time. After looking through gaswork.com this seems to be almost nonexistent. I would like to know how some anesthesiologist feel about this. I'm sure this has been discussed before but this was the only thread my search returned.

 

[Gimlet]

I'll bet this thread gets no further than about 10 posts before it gets the "Fatty McFattypants" seal of approval (to borrow a phrase from the EM Forum).

 

[Pooh & Annie]

I believe that's "Fatty McButterpants", as we loyal King of Queens fans remember.

 

[MD Dreams]

I'm an MS III so I can't speak with authority, but here's what I think.

There are physician only groups out there that do all the cases themselves. I think these tend to be the more specialized type of anesthesia, like cards.

I believe, CRNA's can be very helpful when it comes to those long, relatively easy cases where one just needs to be there to monitor. Not every anesthesiologist wants to participate during this time.

I think one anesthesiologist can supervise upto four CRNA's, but I'm not positive.
This part is actually a real money-maker. While the anesthesiologist is supervising the CRNA's, he/she can bill for each case, although they may be going on at the same time.

Supervising CRNA's means you are there for induction and awakening (I don't know the technical word) and also if there are any emergencies/acute situations.

 

[jwk]

I'm an MS III so I can't speak with authority, but here's what I think.

I believe, CRNA's can be very helpful when it comes to those long, relatively easy cases where one just needs to be there to monitor. Not every anesthesiologist wants to participate during this time.

Ah, much to learn, grasshoppa...

Do a search - you'll find more than you want to know about MD's and anesthetists.

Hey, you knew someone was gonna say it OK, quick, shut it down.

 

[nitecap]

I have been in a latent phase for a few months now but this thread has slightly awoken a few cells so I will make a statement. And please this is not meant to start any crap. Im just gonna read right out of a book and notes I study in a class. Here goes.

If they are advertising that a certain amt of the time you said 80% requires of CRNA supervision then it is probrably a medically directed practice where both CRNA's and MDA's work. Here is how the Medical direction is set up per the Code of Federal Regulations, Title 42, public hlth, chp iv CMS, DHHS

Part 414. payment for medicare part B medical and other services

414.16 Additional Rules for payment for anesthesia services
Medical Direction
-only MDA's can bill for medical direction
-Max ratio 1:4 (crna, AA)
-SRNA max 1:2
-MD total = 50 units plus face time with pt. 1unit every 15min
-CRNA total = 50 units

Conditions for Payment of Medically directed Anesthesia services
TEFRA 7
MDA:
1- performs pre anesthetic assessment
2-prescribes anesthesia plan
3-participates in demanding portions ...induction
4-ensures procedures performed by qualified individual
5-monitors the coures of the anesthetic at freq intervals
6-remains physically present and able to treat emergencies
7-provides indicated post anesthesia care

MDA alone inclusively documents in medical record that the conditions set forth have been satisfied.

So really alot of the jargon you are seeing in reimburstment related. The CRNA that works for your group has signed their billing rights over to that group. So as long as the MD complies with the rules set forth for medical direction they can bill 100% for that pt though may only be involved in 15% of the actually anesthetic course. AKA its how you guys get rich.

Supervision in it self is an entire other thread not CMS reimburstment related really. We can get into it if you want but think that may flare up some dormant hemrroids on this forum so we better not. The bleeding may be to bad.

Im really suprised residents dont know more about these such important issues. I figured they would be pounding it into you guys like they do us.

 

[ear-ache]

Im really suprised residents dont know more about these such important issues. I figured they would be pounding it into you guys like they do us.

No anesthesia residents have posted on this thread... they know better.

 

[Pir8DeacDoc]

supervision doesn't require being present for induction and emergence. I think it's pretty much up to the MDA how little/much they want to be involved. Probably depends a fair amount about their confidence in the CRNA.

 

[jwk]

supervision doesn't require being present for induction and emergence. I think it's pretty much up to the MDA how little/much they want to be involved. Probably depends a fair amount about their confidence in the CRNA.

You better read Nitecap's post above.

 

[MacGyver]

MDAs skirt those rules all the time, with no consequences.

Its routine for MDAs to "supervise" CRNAs at distant hospital sites! All they have to do is make a cell phone call at induction and another 2 minute call after the surgery.

Not to mention the fact that many states have revoked all supervision rules for CRNAs, meaning they can practice totally independently and still get full reimbursement.

"Supervision" is a joke, and MDAs have gotten rich off it. Enjoy it while you can, because eventually Congress and/or state legislatures are going to crash on your little charade. They are going to have CRNAs testify that "supervision" is really nothing more than a 5 minute phone call from a hospital/office on the other side of the city. When that happens, these legislators are going to say "hmmmmmm.....why dont we cut out the middle man and just let CRNAs do everything, they obviously are just as good as the MDAs and dont need any supervision. That way I can stump to my citizens that I'm doing something to improve access to healthcare!"

When that happens, say goodbye to your nice little moneymaking scheme.

 

[VentdependenT]

Cap'n! This wessel is gettin difficult to control! I may heav to abort tit!

 

[militarymd]

I say....let it ride

 

[jetproppilot]

MDAs skirt those rules all the time, with no consequences.

Its routine for MDAs to "supervise" CRNAs at distant hospital sites! All they have to do is make a cell phone call at induction and another 2 minute call after the surgery.

Not to mention the fact that many states have revoked all supervision rules for CRNAs, meaning they can practice totally independently and still get full reimbursement.

"Supervision" is a joke, and MDAs have gotten rich off it. Enjoy it while you can, because eventually Congress and/or state legislatures are going to crash on your little charade. They are going to have CRNAs testify that "supervision" is really nothing more than a 5 minute phone call from a hospital/office on the other side of the city. When that happens, these legislators are going to say "hmmmmmm.....why dont we cut out the middle man and just let CRNAs do everything, they obviously are just as good as the MDAs and dont need any supervision. That way I can stump to my citizens that I'm doing something to improve access to healthcare!"

When that happens, say goodbye to your nice little moneymaking scheme.

Implying that your depicted scenerio is common is fraudulent prose, to say the least.

The team model is alive and well in the southeast. My partners and I are intricately involved in our cases, and the efficiency afforded by said approach allows us and our CRNA colleagues to cover all anesthetizing sites, prep patients in the holding area before the case so anesthesia in-the-OR-doing-stuff-before-the-operation is minimal, and cover OB.

MacGyver, what level are you, may I ask? Med student? Resident?

Your inference that all MDs that work in a team model are crooks, supervising cases from across town is insulting. Where is Trinity Alumnus? Ask the dude how much his MDs supervised from the cell phone.

I'm all for calling a spade a spade. I am also a team model advocate. That does not mean I'm against all MD groups...thought I was headed for one right outta residency, but things turned out differently and I stayed in the southeast instead of Vegas.

I'll call a spade a spade: you are ignorant. Not for being an all MD advocate, but for not recognising the efficacy/proven safety of an MD/CRNA combined model.

Am I pro-independent CRNAs? No.

Am I against inexperienced residents posting propeganda that MDs in a team-model are supervising over their cell phones?

Yes.

 

[jetproppilot]

Implying that your depicted scenerio is common is fraudulent prose, to say the least.

The team model is alive and well in the southeast. My partners and I are intricately involved in our cases, and the efficiency afforded by said approach allows us and our CRNA colleagues to cover all anesthetizing sites, prep patients in the holding area before the case so anesthesia in-the-OR-doing-stuff-before-the-operation is minimal, and cover OB.

MacGyver, what level are you, may I ask? Med student? Resident?

Your inference that all MDs that work in a team model are crooks, supervising cases from across town is insulting. Where is Trinity Alumnus? Ask the dude how much his MDs supervised from the cell phone.

I'm all for calling a spade a spade. I am also a team model advocate. That does not mean I'm against all MD groups...thought I was headed for one right outta residency, but things turned out differently and I stayed in the southeast instead of Vegas.

I'll call a spade a spade: you are ignorant. Not for being an all MD advocate, but for not recognising the efficacy/proven safety of an MD/CRNA combined model.

Am I pro-independent CRNAs? No.

Am I against inexperienced residents posting propeganda that MDs in a team-model are supervising over their cell phones?

Yes.

OK MacGyver,

just reread my post, and I've gotta apologize...it was a little over the top.

YOU are not ignorant. I dont know you. You could be Micheal Roizen for all I know. So I'll take the personal-level stuff out of it.

But by all means, your post was ignorant.

 

[militarymd]

Jet,

Read some of his posts, and then give us one of your famous FBI profiles.

 

[jetproppilot]

Jet,

Read some of his posts, and then give us one of your famous FBI profiles.

Jet FBI profiler is on the case...

 

[nitecap]

NOt another series:

CSI SDN, what night of the week will they fit this one on.

 

[Gimlet]

NOt another series:

CSI SDN, what night of the week will they fit this one on.

More importantly, which song by The Who will they use as its theme?

 

[jetproppilot]

Jet,

Read some of his posts, and then give us one of your famous FBI profiles.

CSI SDN STARRING FBI PROFILER JET

ok dudes/dudettes, this is a comedic post. All references made below are not applicable in the court of law. But, Jet has been accurate in profiles so far, identifying the anti -social milleau of our society....

Upon review of said poster, Jet has identified an interesting, incessant trend. Said poster is well read, knowledgable, and all knowing in EVERYTHING. Said poster elicits PhD-level knowledge on a plethora of topics, exceeding the brain-potential of Albert Einstein. Expert posts on anesthesia, New Orleans, the pharmaceutical industry, the-demise-of anesthesiologists, Texas Tech, Canadian physicians, and a variety of other subjects abound.

Said poster never posts inquisitively...never asks for the opinion of a colleague. Always knows the answer.

Based on the above investigation, Jet paints a profile of said poster...the dude is either The Lord God Himself, OR, and more likely, is a caucasian male, superior IQ, probably in the 135 range, and.....heres where Jet reaches an indecision in physically describing said poster. He is on the-extreme-one-side-or-the-other of physical attributes...he is either:

1) 5'6", 140 lbs, diminutive, receding hairline, big glasses, or,

2) 5'11"-6'1", 200-210 lbs, muscular, socialite, lady-killer

Emotionally, said poster has problems interacting secondary to I'm-right-100%-of-the-time attitude. If 1), he has no interaction with women. If 2) he is the wham-bam-thank-you-ma'am type.

Delving into the obvious inexperience portrayed by erroneous anesthesia-business posts, said poster is most likely in training, living in a modest apartment, close to a university hospital, and drives a 1997-1998 Honda, white in color if physical attributes meet 1) and black if 2).

Further contemplation and investigation will enable me to home in on which side of the physical spectrum said poster resides in.

 

[Gimlet]

drives a 1997-1998 Honda, white in color if physical attributes meet 1) and black if 2).

Damn, that is some pinpoint profiling, Jet. I'll keep my eyes peeled!

 

[aredoubleyou]

CSI SDN STARRING FBI PROFILER JET
.

That was freakin awesome....can you do me next? Is there a line or a sign up sheet? Do you charge? I can print it out an hang it on the wall like one of those cheesy "Wanted dead or alive" pinups you get at the ghost town amusement parks out west with your face on it...

 

[jwk]

Cap'n! This wessel is gettin difficult to control! I may heav to abort tit!

Steady Mr. Chekov 😀

 

[bigeyedfish]

1) 5'6", 140 lbs, diminutive, receding hairline, big glasses, or,

2) 5'11"-6'1", 200-210 lbs, muscular, socialite, lady-killer.

Those are two rather different possiblilities. You almost sound like a radiologist. Maybe you should add "needs clinical correlation and further studies."

 

[EastCoast]

ok, so i realize everyone is making fun of what macgyver said. and you guys who are out in residency/working know about this stuff a lot more than someone like me---so i have to ask---is there any truth to what macgyver says? i mean i can't get that lingering concern out of my head--about "cutting out the middle man"..

if everything is about the bottom line, than isn't it true in years to come that insurance companies/hospitals might just go for more crnas? wouldn't that make it hard for anesthesiologists to find jobs (even in the big cities?). i understand that crnas can't do that hard cases, etc....but these concepts worry me.

i also realize that i am totally falling into the trap that people like macgyver like to set, by freaking out about all this stuff after a post like that 🙄 🙄

 

[Gimlet]

ok, so i realize everyone is making fun of what macgyver said. and you guys who are out in residency/working know about this stuff a lot more than someone like me---so i have to ask---is there any truth to what macgyver says? i mean i can't get that lingering concern out of my head--about "cutting out the middle man"..

if everything is about the bottom line, than isn't it true in years to come that insurance companies/hospitals might just go for more crnas? wouldn't that make it hard for anesthesiologists to find jobs (even in the big cities?). i understand that crnas can't do that hard cases, etc....but these concepts worry me.

i also realize that i am totally falling into the trap that people like macgyver like to set, by freaking out about all this stuff after a post like that 🙄 🙄

EastCoast,

There are millions, perhaps even billions of threads on this forum where this issue has been hashed over and argued without ever reaching anything even resembling a conclusion. People are ignoring MacGyver's bait because they know that the argument will never be settled, and having discussions like that just breed a hateful feeling on this board. You don't have to do a search very far back to find a couple of these threads...check it out. 👍

 

[MacGyver]

You guys continue to stick your heads in the sand.

Whats the count on the number of states that have repealed all the regs requiring MDA supervision? I believe its at least in the teens, maybe 20 states or so by now.

In these states, there is no such thing as MDA supervision. They can work 100% independently. So maybe they arent trying to run lung-heart transplant cases by themselves YET, but you are foolish if you think they arent gradually going to push for more and more scope. Hell right now there is nothing in these state regulations to prevent them from running any case they want 100% solo from any MDA. The only thing holding them back is hospital policy (occassionally) and their own reluctance to do risky cases, trust me those things will fall away eventually. There are already some hospitals in these states that let CRNAs do whatever they want to.

Its not in every state yet, but for you in the "supervised" states to ignore it is stupid. What do you think the CRNAs are going to do next? You got it, they are going to use the state precedents to argue their cause for 100% independence in front of YOUR state legislature next.

 

[MacGyver]

ok, so i realize everyone is making fun of what macgyver said. and you guys who are out in residency/working know about this stuff a lot more than someone like me---so i have to ask---is there any truth to what macgyver says? i mean i can't get that lingering concern out of my head--about "cutting out the middle man"..

if everything is about the bottom line, than isn't it true in years to come that insurance companies/hospitals might just go for more crnas? wouldn't that make it hard for anesthesiologists to find jobs (even in the big cities?). i understand that crnas can't do that hard cases, etc....but these concepts worry me.

Its a state by state thing. All the people who are arguing against me work in states that still require MDA supervision. Their attitude is "well its not in my state so its not an issue." What they fail to realize is that every year more and more states repeal the regs that require MDA supervision and allow CRNAs to work 100% solo.

They are absolutely foolish because they dont understand that CRNAs will use prior state precedent and mortality/morbidity stats in those states that show CRNAs working 100% solo results in same morbidity/mortality stats as MDA-supervised states.

It will take awhile before every state switches over, and the process moves slowly enough so that it allows many gas docs to stick their head in the sand and outright profit from it during the transition period.

The MDAs (especially the older MDA attendings who will be retiring in the next 5-15 years) who exploit loopholes in supervision rules to double their income are the real problem. Secretly they know its hurting the profession, but they dont care because they are making a fortune and will already be retired by the time the CRNAs change the rules in their state to get 100% independence.

 

[threepeas]

this may be old news, but it wasnt to me.

http://www.ober.com/shared_resources/news/newsletters/HLA/HLA_wspr02_08.htm

 

[threepeas]

once again, obviously old news, but for those looking for some info to follow the previous link i posted. sorry if this is redundant posting, but i am relative new to the issue as is the original poster.

http://www.asahq.org/Washington/narules.htm

 

[toughlife]

this may be old news, but it wasnt to me.

http://www.ober.com/shared_resources/news/newsletters/HLA/HLA_wspr02_08.htm

That is correct but since then several states have removed the supervision requirement d/t lack of providers. I think the number of states that have abolished it is somewhere around 12-14.

 

[FJLA]

I was humbly wondering where the subspecialties within anesthesiology fall into this discussion. Specifically, pediatric anesthesia seems like a field that not many CRNAs gravitate toward, but I am not quite sure. Because peds is so highly specialized and typically requires one to work for a children's hospital in a big city, it would seem to me that most pediatric hospitals would prefer to hire only fellowship-trained peds anesthesiologists.

On a personal note: As a parent of 2 boys, my narcissistic (sp?) parenting style makes me prefer to have a pediatric anesthesiologist behind the curtain. Like most parents, I want my kids to be very well taken care of. I would imagine that a pediatric anesthesiologist could manage my kid the best of all.

I would love to hear what others think, especially Jet, Mil, and UT. All of you have insightful and professional answers which, I believe, help the rest of us figure out what we want to do with our lives. I am striving for the peds anesthesia route, and the CRNA question therefore applies to me, anyway.

Thanks.

 

[MedicinePowder]

I was humbly wondering where the subspecialties within anesthesiology fall into this discussion. Specifically, pediatric anesthesia seems like a field that not many CRNAs gravitate toward, but I am not quite sure. Because peds is so highly specialized and typically requires one to work for a children's hospital in a big city, it would seem to me that most pediatric hospitals would prefer to hire only fellowship-trained peds anesthesiologists.

On a personal note: As a parent of 2 boys, my narcissistic (sp?) parenting style makes me prefer to have a pediatric anesthesiologist behind the curtain. Like most parents, I want my kids to be very well taken care of. I would imagine that a pediatric anesthesiologist could manage my kid the best of all.

I would love to hear what others think, especially Jet, Mil, and UT. All of you have insightful and professional answers which, I believe, help the rest of us figure out what we want to do with our lives. I am striving for the peds anesthesia route, and the CRNA question therefore applies to me, anyway.

Thanks.

I would imagine cardiothoracic specialization in anesthesiology would be good insurance for the future as the crnas at the hospital i'm a student at, don't do any of those cases. i'm not sure if that's just the case in this department.

 

[nitecap]

I was humbly wondering where the subspecialties within anesthesiology fall into this discussion. Specifically, pediatric anesthesia seems like a field that not many CRNAs gravitate toward, but I am not quite sure. Because peds is so highly specialized and typically requires one to work for a children's hospital in a big city, it would seem to me that most pediatric hospitals would prefer to hire only fellowship-trained peds anesthesiologists.

On a personal note: As a parent of 2 boys, my narcissistic (sp?) parenting style makes me prefer to have a pediatric anesthesiologist behind the curtain. Like most parents, I want my kids to be very well taken care of. I would imagine that a pediatric anesthesiologist could manage my kid the best of all.

I would love to hear what others think, especially Jet, Mil, and UT. All of you have insightful and professional answers which, I believe, help the rest of us figure out what we want to do with our lives. I am striving for the peds anesthesia route, and the CRNA question therefore applies to me, anyway.

Thanks.

CRNA's may not be doing a ton of Peds and CT cases in large urban areas but believe me in suburban regional med centers with no MDA residency many crna's are doing both types of cases.

 

[militarymd]

CRNAs can and DO perform all manners of anesthetics...including CT and Peds.


Here is my view of supervising CRNAs.

They are nurses (highly specialized and trained nurses) who help me take care of more than one patient at a time.

Just like ICU nurses who take care of my ventilated patient with ARDS and necrotizing pancreatitis.

Just like the CCU nurse who takes care of a cardiologists ACS patient.

Just like the ward nurse who takes care of the COPD patient admitted with CAP.

Anesthesiologist presence in the OR is determined by the medical staff of the hospital. It doesn't matter what the supervision laws are in the state. What matters is what the medical staff wants....and their wants are ultimately dictated by what the patients want.

 

[kidmd44]

Well said, as usual Mil.

Here I sit, on-call in the NICU tonight, about 45 babies on the unit, fabulous nurses right at their bedside. Like other ICUs, the nurses are my eyes and ears tonight. They call when they're worried about something. I tweak vents, interpret gases, etc. If something goes wrong, I make my assessment and create a plan. They rely on me for that, and I rely on them for what they see moment to moment. It is a team effort, and the BEST teams are those with players who know their role and perform their role well. I am no "better" than the nurses are; I merely have a different role, one that has more responsibility, one that is more managerial. My depth of medical knowledge from my years of training thus far has afforded me that.

If it were only me here tonight, and every patient needed their own MD, then our ICU would have just one patient. Not very cost-effective, nor very realistic. As you said, Mil, nurses help us manage more than one patient at a time. Hasn't this been the medical model for centuries? Why is there such a disconnect from this model when it comes to the OR and the CRNA vs. MDA debate?

 

[Noyac]

The MDAs (especially the older MDA attendings who will be retiring in the next 5-15 years) who exploit loopholes in supervision rules to double their income are the real problem. Secretly they know its hurting the profession, but they dont care because they are making a fortune and will already be retired by the time the CRNAs change the rules in their state to get 100% independence.

You may very well be right, MAcGyver. However, I am somewhat optimistic. I worked with many of these "older" anesthesiologists as you describe and you are right about them to some degree. I had quite a few partners that never wanted to be in a room and who thought that the crna was the way to go strictly b/c of money. They never stuck their heads in the room unless called for problem management, which we had plenty of. The groups motto was turn out cases as fast as possible and it worked. Until, some of the surgeons started to have concerns. Mostly regarding unsupervised crna's.

I am on the fence here with regards to midlevels (all midlevels from nurse practictioners, to crna's, to PA's practicing independently). These guys in my group who were unconcerned, were ruining my specialty. They no longer were concerned with patient care. They just wanted to maintain their lifestyle. I think the midlevel is a valuable tool to underserved areas but in no way are they a substitue for a physician.

So MacGyver, your points are well taken here but a little too far fetched currently. Thats not to say that we as a specialty don't need to continue to make our voices heard cause we know the nurses are not going to stop. There are some bad seeds out there and we do need to impress upon them the importance of their actions (anesthesiologists that is). I can say more but out of time currently.

 

[rn29306]

Here I sit, on-call in the NICU tonight, about 45 babies on the unit, fabulous nurses right at their bedside. Like other ICUs, the nurses are my eyes and ears tonight. They call when they're worried about something. I tweak vents, interpret gases, etc. If something goes wrong, I make my assessment and create a plan. They rely on me for that, and I rely on them for what they see moment to moment.

Nice attempt at an analogy, but a bit off. Somehow the term 'nurse' and 'CRNA' on this board became interchangeable. The two are not interchangeable and CRNAs are not staff nurses.

I realize there are many models of supervision even within the team approach. I would assume that places where anesthesia residents train keep a very tight control over the CRNAs, just to keep the heirarchial chain enforced. I only wish to stress that there are places where CRNAs freely draw / interpret ABGs, start intra-op art lines, order and give blood / other products, make vent changes, and give pharmacologic agents without the anesthesia MD telling them to. Senior SRNAs run rooms with MD supervision at my facility and do the same above-mentioned. Not to say I don't keep my supervising MD in touch with what is going on, but nor do I call for permission for everything. All TERFA requirements are met at our facility and things run as smoothly and efficiently as I would imagine a university setting could hope to run. There is no cell phone supervision going on here.

To believe that such strict supervision is rampant or the norm where I have to call for even a vent change is a little ignorant and shortsighted. I realize I open myself to criticism here, but this is how the real world runs. I would hope you would appreciate a balanced viewpoint on this matter.

 

[Sodak]

Oops, repent.

 

[Sodak]

RN (above post) inadvertently pointed out what is perhaps the fundamental difference between MDs and CRNAs, nurses, and those in the midlevel fields: DEPTH OF KNOWLEDGE

You said in your post that you are able to "change vents, read ABGs, do A-lines," etc, really do everything that I would term "procedural."

As long as you have repetition, nothing that is "procedural" takes a really long time to learn, hence the length of your training.

And yes, you can probably make a damn good assessment here and there, too. But I bet your differential dx list is shorter than an MD. Just cuz there's tachycardia doesn't mean the patient is in pain and you shoot more Fent. (I've seen this way too many times...)

Remember that a carpenter from a tech school can build a damn good house; an architect from Princeton can build a city.

 

[kidmd44]

RN (above post) inadvertently pointed out what is perhaps the fundamental difference between MDs and CRNAs, nurses, and those in the midlevel fields: DEPTH OF KNOWLEDGE

You said in your post that you are able to "change vents, read ABGs, do A-lines," etc, really do everything that I would term "procedural."

As long as you have repetition, nothing that is "procedural" takes a really long time to learn, hence the length of your training.

And yes, you can probably make a damn good assessment here and there, too. But I bet your differential dx list is shorter than an MD. Just cuz there's tachycardia doesn't mean the patient is in pain and you shoot more Fent. (I've seen this way too many times...)

Remember that a carpenter from a tech school can build a damn good house; an architect from Princeton can build a city.

Ahh... whatever Sodak.

Anyway, I appreciate a balanced point of view, and I respect what you have written RN. I thought it was understood from previous posts that CRNAs are highly specialized in their field, having advanced training. THEIR training has afforded THEM the opportunity to perform said procedures and maneuvers. I don't believe that anyone argues this point, and certainly a CRNA's ability to do this without direct supervision by the MDA allows more rooms to run. Jet has said that his experience has led him to believe that the team approach is best. I predict that when I am finished with training, I will think the same way.

MacGyver seems to really dwell on the money issue. Noyac says that yes, there are bad seeds out there (MDs) who abuse the system. Hopefully, these "bad seeds" are few and far between, or they have retired from the field.

Question for MacGyver: Is the debate you bring and the animosity you tout really centered around money? CRNAs do pretty damn well too, right?

 

[MedicinePowder]

Nice attempt at an analogy, but a bit off. Somehow the term 'nurse' and 'CRNA' on this board became interchangeable. The two are not interchangeable and CRNAs are not staff nurses.

I realize there are many models of supervision even within the team approach. I would assume that places where anesthesia residents train keep a very tight control over the CRNAs, just to keep the heirarchial chain enforced. I only wish to stress that there are places where CRNAs freely draw / interpret ABGs, start intra-op art lines, order and give blood / other products, make vent changes, and give pharmacologic agents without the anesthesia MD telling them to. Senior SRNAs run rooms with MD supervision at my facility and do the same above-mentioned. Not to say I don't keep my supervising MD in touch with what is going on, but nor do I call for permission for everything. All TERFA requirements are met at our facility and things run as smoothly and efficiently as I would imagine a university setting could hope to run. There is no cell phone supervision going on here.

To believe that such strict supervision is rampant or the norm where I have to call for even a vent change is a little ignorant and shortsighted. I realize I open myself to criticism here, but this is how the real world runs. I would hope you would appreciate a balanced viewpoint on this matter.

This is when things go sour and CRNAs try to take too much credit or try to compare themselves to an MD. Bottomline, a CRNA is a nurse. Case closed.

 

[MacGyver]

This is when things go sour and CRNAs try to take too much credit or try to compare themselves to an MD. Bottomline, a CRNA is a nurse. Case closed.

I'm glad you brought that up. The state nursing boards use that logic as an excuse to have separate regulatory bodies, meaning that state medical boards cant say anything about the scope of practice of nurses because "we are nurses and they are doctors"

Nurses are using your logic against doctors to expand their scope. They argue that since "we are nurses and they are doctors" that ONLY the state nursing boards have the right to set the scope of practice. Conversely, if the state nursing boards want to expand the scope of practice, then state medical boards have no say.

Nurses are more cunning than you think

 

[toughlife]

I would imagine cardiothoracic specialization in anesthesiology would be good insurance for the future as the crnas at the hospital i'm a student at, don't do any of those cases. i'm not sure if that's just the case in this department.

Why not include critical care as another viable option?

 

[rn29306]

This is when things go sour and CRNAs try to take too much credit or try to compare themselves to an MD. Bottomline, a CRNA is a nurse. Case closed.

I didn't say I was a substitute or an equal provider as a SRNA or CRNA to an MD anesthesiologist, nor did I compare the two. Help me out and find that in my post for me sometime.

Bottom line - The team model runs quite well at my facility and I believe in it. And I don't call my MD for every damn thing I do in the OR either. Check my sig sometime - ATC.

 

[rn29306]

Ahh... whatever Sodak.

Anyway, I appreciate a balanced point of view, and I respect what you have written RN. I thought it was understood from previous posts that CRNAs are highly specialized in their field, having advanced training. THEIR training has afforded THEM the opportunity to perform said procedures and maneuvers. I don't believe that anyone argues this point, and certainly a CRNA's ability to do this without direct supervision by the MDA allows more rooms to run. Jet has said that his experience has led him to believe that the team approach is best. I predict that when I am finished with training, I will think the same way.

MacGyver seems to really dwell on the money issue. Noyac says that yes, there are bad seeds out there (MDs) who abuse the system. Hopefully, these "bad seeds" are few and far between, or they have retired from the field.

Question for MacGyver: Is the debate you bring and the animosity you tout really centered around money? CRNAs do pretty damn well too, right?

kidmd44,
Then I mis-read your post and I apologize for jumping the gun.

 

[militarymd]

They are nurses (highly specialized and trained nurses) who help me take care of more than one patient at a time.

Just like ICU nurses who take care of my ventilated patient with ARDS and necrotizing pancreatitis.

Just like the CCU nurse who takes care of a cardiologists ACS patient.

Just like the ward nurse who takes care of the COPD patient admitted with CAP.

.

Remember this:

Many ICU nurses can and do take care of many sick patients in the absence of physicians.

Many CCU nurses can and do know what to do with an ACS patients without orders.

Ward nurses will frequently know what antibiotics are needed for an admitted patient before the orders are written.

Physicians are responsible for the management of patient care, but don't your title and responsibility fool you into thinking that you're the only one who knows what needs to be done.

 

[cfdavid]

Anesthesiologist presence in the OR is determined by the medical staff of the hospital. It doesn't matter what the supervision laws are in the state. What matters is what the medical staff wants....and their wants are ultimately dictated by what the patients want.

I agree that we live in a consumer driven society. When I told my mom, for example, about the role that CRNA's play she was kind of suprised. She said, "I'd want the anesthesiologist there if I went into surgery". I'm certain that most people would prefer this.

That being said, with respect to possible over-the-top CRNA autonomy, we need to be careful not to discount a generally ignorant public. Also, should such legislative initiatives arise, the anesthesiologist's lobby should be ready to argue on behalf of their interests etc.

I also agree with the analogy that you made relative to CRNA's being a highly skilled nurse with specialty training that plays an integral role in the anesthesia care team. That's the way it needs to be promoted. (not saying it's not true reality)

Personally, it seems that MD/DOA's need to get behind AA's a bit more. Perhaps starting to request them more and more. From a pragmatic point of view, it makes a whole lot of sense.

 

[nitecap]

You guys need to wake up from your MD dominant dream one day and realize that CRNA's administer all types of anesthetics all over the country with no MD/MDA looking over their shoulder telling them what stick of drugs to push or what knob to turn. It is your faded and cloudy understanding about what we are really capable of doing clinically that advances the CRNA profession. You guys that have the old oh just another ICU nurse mentality are just a helping hand ect when that really is a large misestimate of a CRNA's capability. The more you underestimate the less robust you lobby, the less you think CRNA's can really get done. Which in turn leads you guys all to be shocked when another state opts out, or when we dont have your back on a CMS issue, or when we don't agree to kneel down to your rules. AS well all of the aurguments you use while in your dream are all illegitiment as far as a real study claiming who is the safest provider. So please guys, hold out your arms, allow another bolus of STP and enjoy the dream, eventually someone will wake you up, wont be me.

As far as the AA issue goes heres a little piece of advice. IT makes whole lot of sense for you guys to totally control the market, and thats about the only sense it makes b/c it does not make finacial sence b/c AA's are paid the same for the most part. It does not at all make for a safer anesthetic b/c their are no studies what so ever comparing MDA's to CRNA's to AA's. And as well if the AA profession grows pretty soon it will be like the PA profession and you will have little Johnny's 4th grade homeroom teacher putting little johnny to sleep with only 24 months of training beyond her elementary education degree. So sure it makes more sense to bow out of the batltle, take the passive aggressive approach b/c you guys are not any stronger the the body of CRNA's mentally, emotionally and passionately. Once Get you 30 thoussand AA's as you want and you will see malpractice increase, deaths rise, you name it. No offense JWK, you have a plethora of experience, the AA I met online the other nite at Emory has a civil engineering degree with never a hands on pt care experience ever in her life. Never even looked in to a pt's mouth, never did anything. The experience gap is huge, and of course can be filled with years of practice but hate to pt that pt during the first year.

 

[militarymd]

It's pretty funny how the most militant of CRNAs say that their training makes them same as a physician.....but an AA's training does not make them equal....I don't understand.