CRNA Induction Sequence List - page 2

CRNA's, Would you PLEASE list for me you're DETAILED SEQUENCE of actions during an induction (non-complicated patient). Just think about your actions from the very start and put them in a... Read More

  1. by   yoga crna
    Sorry Purple--I don't agree with you. I stopped using a precordial stethoscope about 6 years ago and I don't believe my practice is below the standard of care of the profession. I stopped because my hearing was slightly compromised and I simply couldn't hear the heart and breath sounds well with all of the external OR noise. I do have the audio up on the monitor and can tell the heart rate, oxygen sat on a beat by beat basis.

    I do agree that if I was teaching anesthesia, I would insist that the students use a stethoscope and become very comfortable with it.

    It is a good idea not to be so emphatic about standard of care issues. The standards are set by the profession by the use of expert witnesses, who are given more credibility than written institutional standards. The legal rationale for that is that the American jurisprudence system allows for cross-examination. An expert witness can be cross-examined, an institutional document cannot. However, the institutional document can be admitted into evidence. I know many CRNAs and anesthesiologists who moniitor patients the same way I do and would be happy to testify on my behalf that it is safe practic.

    Yoga
  2. by   air
    Just so we do not belabour the point. AANA has some standards for patient monitoring during anesthesia.
    The last revision for those standards was done in 2002.
    listed under scope and standards of nurse anesthesia practice.
  3. by   deepz
    Quote from air
    Just so we do not belabour the point. AANA has some standards for patient monitoring during anesthesia.....

    Yes, Standard V at:

    http://www.aana.com/crna/prof/scope.asp

    No specific mention of precordial.
  4. by   air
    Quote from deepz
    Yes, Standard V at:

    http://www.aana.com/crna/prof/scope.asp

    No specific mention of precordial.
    True
  5. by   traumasrna
    I am assumming that in this thread you all were talking about precordial or esophogeal stethoscopes. I have to stand by PurplFrawg's response regarding the AANA's basic standards and also by the recommendations of MGH. We have a moral, ethical and professional obligation to employ every step necessary to ensure quality patient anesthesia care. It will be just a matter of time before those who become complacent(?) to be served some humble pie, unfortunately it will come at the expense of the patient. I will not take that risk.
  6. by   jwk
    Quote from traumacrna
    I am assumming that in this thread you all were talking about precordial or esophogeal stethoscopes. I have to stand by PurplFrawg's response regarding the AANA's basic standards and also by the recommendations of MGH. We have a moral, ethical and professional obligation to employ every step necessary to ensure quality patient anesthesia care. It will be just a matter of time before those who become complacent(?) to be served some humble pie, unfortunately it will come at the expense of the patient. I will not take that risk.
    Using that logic, EVERY PATIENT should have an A-Line, PA Cath, foley with automated urine output monitor, BIS (even though it's worthless), full 12-lead EKG monitoring throughout the case....I'm sure I've missed something, but you get the drift.

    I looked again at the AANA standards. There is no mention of continuous monitoring of breath sounds with a precordial or esophageal. SaO2, EKG, BP, EtCO2 - all standards by pretty much everyone's professional associations. Continuous monitoring of precordial or esophageal? NOT a standard. I'm still waiting for the cite from the APSF. No one has provided it, but that's OK - they heard it was a standard.

    Don't mistake the fact that many providers do NOT use constant precordial monitoring for complacency. It's not the same thing. The way you make it sound - if someone is NOT monitoring a precordial/esophageal, they must not be monitoring their patient at all.

    This is the exact thing that gets anesthesia providers burned in lawsuits. A lot of you want to claim that something is a STANDARD when it simply isn't. It may be the way YOU do things at your institution. And it may be a WONDERFUL idea. And more than likely, it's something I have been doing every day on every patient for years. But hey - if they do it at Mass General (highly respected, I know) but they don't do it at Mayo (gee, I heard they were pretty good too) - which one sets the standard? NEITHER!!!!! Except for their own institution. If Mayo or MGH want to set a policy that all of their patients will receive X,Y, and Z monitors, fine. Does their institutional policy apply to me, just because they're at Mayo or MGH and they're highly respected, and I'm just a poor little southern boy way down here in Georgia and I think the Z monitor is marginal at best? NOPE.
    Last edit by jwk on Jan 27, '05
  7. by   Just a CRNA
    The idea that invasive monitors are a standard is patently absurd. Through the years, the personal standards that set nurse anesthetists apart and above other providers is constant vigilance. Precordials provide that input at no cost and without potential of failure from power loss, dead batteries, or even when the lights go out. They take little or no time to apply, and give immediate feedback after intubation. I would expect an argument against precordials from an AA, not a CRNA.
  8. by   jwk
    Quote from PurplFrawg
    The idea that invasive monitors are a standard is patently absurd. Through the years, the personal standards that set nurse anesthetists apart and above other providers is constant vigilance. Precordials provide that input at no cost and without potential of failure from power loss, dead batteries, or even when the lights go out. They take little or no time to apply, and give immediate feedback after intubation. I would expect an argument against precordials from an AA, not a CRNA.
    Give me a break:angryfire Can you not have a civil discussion without turning this into an AA vs CRNA thread? (there are plenty of those around, including a current one - do a search) It's a discussion about clinical issues, and like it or not, not everyone is going to agree with you, as you can see from this thread. Don't take it personally, and don't assume that YOUR way is the ONLY correct way of doing things.

    If you'll actually READ the post I was responding to a specific statement:

    "We have a moral, ethical and professional obligation to employ every step necessary to ensure quality patient anesthesia care"

    "Every step necessary" implies an awful lot, and I was simply trying to point out the pitfalls of that statement.

    My other point, which you keep continuing to miss in your efforts to flame AA's, is that MGH does not set standards for the country. You are the one who brought this up. I am simply challenging you on the facts. You have yet to provide the evidence to back up your statement that MGH and the APSF have a STANDARD that REQUIRES the continuous use of a precordial or esophageal stethoscope.

    You're supposedly a CRNA instructor. Excellent. You are obviously concerned about patient care. So am I. Excellent. We have a difference of opinion on how that is accomplished. It's OK to disagree - at least have the courtesy to be civil.
  9. by   traumasrna
    JWK, I hear what your saying. Let's not get angry and start being condescending to one another either, I'd like to keep it profession. I went back and read some of your other posts so your perspective and statements make more sense to me now. When reading your previous post re: precordials, I had the new grad CRNA in mind. I firmly believe in taking all the precautionary measures necessary simply because many of us lack the experience that will come with time. I also think you might have me confused with someone else because I am not an instructor.













    Quote from jwk
    Give me a break:angryfire Can you not have a civil discussion without turning this into an AA vs CRNA thread? (there are plenty of those around, including a current one - do a search) It's a discussion about clinical issues, and like it or not, not everyone is going to agree with you, as you can see from this thread. Don't take it personally, and don't assume that YOUR way is the ONLY correct way of doing things.

    If you'll actually READ the post I was responding to a specific statement:

    "We have a moral, ethical and professional obligation to employ every step necessary to ensure quality patient anesthesia care"

    "Every step necessary" implies an awful lot, and I was simply trying to point out the pitfalls of that statement.

    My other point, which you keep continuing to miss in your efforts to flame AA's, is that MGH does not set standards for the country. You are the one who brought this up. I am simply challenging you on the facts. You have yet to provide the evidence to back up your statement that MGH and the APSF have a STANDARD that REQUIRES the continuous use of a precordial or esophageal stethoscope.

    You're supposedly a CRNA instructor. Excellent. You are obviously concerned about patient care. So am I. Excellent. We have a difference of opinion on how that is accomplished. It's OK to disagree - at least have the courtesy to be civil.
  10. by   yoga crna
    I think the real standard is constant monitoring of the patient. Anything less is below standard. How that monitoring is done should be up to the practitioner and the surgical circumstances. Once we get too locked into recipe card anesthesia, we revert to being technicians and not professionals. I have no problems with precordial or esophageal stethoscope monitoring and have done it for most of my career. Now that I don't do it, I watch my patients as closely as I ever had.

    Yoga
  11. by   jwk
    Quote from yoga crna
    I think the real standard is constant monitoring of the patient. Anything less is below standard. How that monitoring is done should be up to the practitioner and the surgical circumstances. Once we get too locked into recipe card anesthesia, we revert to being technicians and not professionals. I have no problems with precordial or esophageal stethoscope monitoring and have done it for most of my career. Now that I don't do it, I watch my patients as closely as I ever had.

    Yoga
  12. by   snakebitten
    I'm with JWk..Well said
  13. by   Tenesma
    as a former MGH resident and attending, I can say that there is NO SUCH requirement.... I therefore disagree with Fawg and agree with everybody else... There are a set list of ASA required monitors for every case (just as I am sure the AANA has a list - probably the same) and precordial monitoring is not one of them. I think it is up to the provider to choose which monitors to use above and beyond the required monitors - patient/case specific.

    I personally can't stand precordial scopes and I think they are absolutely useless.... If i were working in a 3rd world country with minimal monitors, I would absolutely want one.

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