Here's what AAs really think of CRNAs

Specialties CRNA

Published

And this comes from the PRESIDENT of the American Society of Anesthesiologist Assistants

Again, assertions that AAs and CRNAs function at the same level -absolutely misleading.

And, what's with "anesthesia nurse"? If it sounds condescending in print, can you imagine how it would sound out of his mouth? What arrogance.

At least there is a phone number listed at the end of the article. Let's call Rob and let him know what we think of his little article!

Read carefully, SRNAs, this is a grim foreboding...

Licensed anesthesiologist assistants help access to medical care

By Rob Wagner

MY VIEW

Re: "Don't weaken the standards for anesthesia providers" (My View, April 11).

Maybe you or someone you know has had surgery delayed. Perhaps hospitals in your

area have closed operating rooms as they have in Miami, Jacksonville, Tampa and

elsewhere in Florida.

One reason for growing problems of this nature for patients is a shortage of

anesthesia providers. These are the assistants who help

physician-anesthesiologists perform the critical task of putting you to sleep

before surgery.

There is a common-sense solution rapidly making progress in the Florida

Legislature and around the country, which is to license anesthesiologist

assistants (called AAs). Key legislative action is expected today in Florida's

House Health Care Committee on HB 1381/SB 2332 and it is important that

lawmakers support it.

They need to be assured that this legislation will not weaken standards because

AAs are highly trained and perform the same function as anesthesia nurses. AAs

like myself serve patients in 16 states and have impeccable safety records. AAs

have worked with a high level of safety for 30 years in Georgia and Ohio.

AAs are required to have three times the hands-on, clinical training than are

most anesthesia nurses who currently assist anesthesiologists. Before we are

allowed to enter AA school, we must take the same courses physicians take as

pre-med students. Nurses do not do that. In fact, as the chief anesthetist at

St. Joseph's Hospital in Atlanta, I am in charge of both AAs and anesthesia

nurses.

If you are "going under," who would you rather have assisting the

anesthesiologist; someone trained to work directly with him or her, or a nurse?

We enjoy our professional relationships with our nursing colleagues. Yet nursing

organizations in Florida continue to misinform, even scare the public, calling

our profession "new" and "experimental."

Try telling that to the prestigious Emory University in Atlanta or Case Western

in Cleveland, which have been training AAs for more than three decades. Or try

to tell that to boards of medicine that oversee AAs in the states in which we

practice and whose members readily vouch for our safety record.

Try telling that to Medicare, the nation's largest health insurer, which

reimburses AAs and anesthesia nurses at the same rate. This means our skill

levels are viewed equally. And tell the insurance companies. They charge no

difference in fees between anesthesia nurses and AAs,

meaning our safety records are equal. Try telling that to the Florida Medical

Association, American Medical Association and American Society of

Anesthesiologists, whose members resoundingly support our working in Florida. In

the era of malpractice crisis, doctors are certainly not going to support

"experimental" health care providers.

Why, then, would the anesthesia nurses be opposed to this? In a word, money.

Because of nurse shortages, their salaries are artificially high, up to $150,000

in Florida. If you made that kind of living, wouldn't you try to keep the

competition out?

This nursing shortage is well documented on the Web sites of Florida schools

that train anesthesia nurses, the U.S. Department of Health and Human Services,

and yes, even on the anesthesia nurses' own Web site, http://www.aana.org, where the

shortage is called "serious" and "acute."

To help relieve the problem, two institutions, the University of Florida and

Nova Southeastern, are ready to open special schools for anesthesiologist

assistants in Florida. Would those schools offer programs if they didn't think

AAs are in great demand? Would they risk their reputations on an "experimental"

profession? Of course not.

One AA can mean five more patients per day will get their surgery. That's 1,200

patients per year treated with the help of only one AA. If you are or know one

of those patients, I'm sure you would be grateful to the Florida Legislature for

passing this common-sense legislation.

--------------------------------------------------------------------------------

Rob Wagner is chief anesthetist at St. Joseph's Hospital in Atlanta and

president of the American Academy of Anesthesiologist Assistants, PO Box 13978

Tallahassee, FL 32317 Phone: 656-8848.

Georgia AA, what 17 states can AA's practice in? My understanding was that AA's were only in Georgia, Ohio, and now Flordia.

I know they work in Alabama. I have worked with them before. I thought they did a great job from the limited scope of knowledge I know. The MD comes in at the beginning and at the end, but otherwise not seen much.

This is a bill passed in Ohio regarding AA's and what they can do:

Ohio Legislative Service Commission

123rd Senate Bill Analysis

In an individual's practice as an anesthesiologist assistant, the bill specifies that the assistant may do any of the following:

(1) Obtain a comprehensive patient history and present the history to the supervising anesthesiologist;

(2) Pretest and calibrate anesthesia delivery systems and monitors and obtain and interpret information from the systems and monitors;

(3) Assist the supervising anesthesiologist with the implementation of medically accepted monitoring techniques;

(4) Establish basic and advanced airway interventions, including intubation of the trachea and performing ventilatory support;

(5) Administer intermittent vasoactive drugs and start and adjust vasoactive infusions;

(6) Administer anesthetic drugs, adjuvant drugs, and accessory drugs;

(7) Assist the supervising anesthesiologist with the performance of epidural and spinal anesthetic procedures;

(8) Administer blood, blood products, and supportive fluids.

In addition to the activities specified above, the supervising anesthesiologist of an anesthesiologist assistant may authorize the assistant to do the following:

(1) Participate in administrative activities and clinical teaching activities;

(2) Participate in research activities by performing the anesthesia assistance procedures the bill authorizes;

(3) Provide assistance to a cardiopulmonary resuscitation team in response to a life-threatening situation.

At all times when an anesthesiologist assistant is providing direct patient care, the assistant is required by the bill to display in an appropriate manner the title "anesthesiologist assistant" as a means of identifying the individual's authority to practice under the bill.

Under the bill, an anesthesiologist assistant may practice only under the supervision of an anesthesiologist and only in a hospital

Sounds to me like AA's must be under direct supervision of an anesthesiologist at all times, meaning an MD must be in the room at all times.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

This is bound to make a lot of eyeballs roll back in a lot of heads, but ya gota understand the history of Nurses in anesthesia and MD's in anesthesia.

I'm sure anyone knows that early anesthesia was traditionally done by Nurses.. They were more "Vigilant" (attentive) than the residents and interns , then came the surplus MD situation.

It's a matter of control. CRNA's on a day to day basis "witness" the clinical skills of Anesthesiologists, (from now on MD-A for short)

These are the guys that are supposed to be our superiors.. and in many cases, they are good.. not superior, but at least equal.. Then there historically has been the Foreign Trained MD that chose Anesthesia, because they could not speak enough English to enter private practice. Their skill level might have been good, but their other skills lacked.

For years MD-A's were looked down upon by their surgeon colleagues for some of those reasons.

And at the other extreme is the MD that is not trained in anesthesia at all, possibly taking a rotation in anesthesia for a few months, then calling themselves an Anesthesiologist. They are still out there, maybe as a GP doing anesthesia ,to a lesser degree, but still mucking about. Then there are the ones that cannot pass their boards in anesthesia, but call themselves "board Eligible" and work as MD-A's.

Now this fussin has been going on for at least 40 years that I have been passing gas and longer between CRNA's , that usually come from the tops of their classes, are somewhat over achievers, and clinically excellent, in comparison with some of the older so called MD-A's that just squeezed through med school.

The issue now is about control of anesthesia provision and competition, by the MD-A's, that by law, and standard practice have no real control over CRNA practice. CRNA's are technically supervised by a surgeon, as part of a team effort in most states, but Surgeons do not know a lot about modern anesthesia . It's about all they can do to stay on top of their own Board requirements.

So the CRNA-AA fuss stems from the CRNA / MD-A control issue. They have been unsuccessful in legislating control over CRNA's, so they have created their own Newtech Anesthesia provider.. The Anesthesia Assistant. And these folks have put down their sliderules from engineering, Botany, Chemistry , etc degrees, and come into a patient care field without any background in human science (eg Nursing background-- remember all the hoops you all had to go through, taking care of patients? Enemas till clear. talking to the family of a child that just died, Psych and OB training, etc,wrestling with the drunk in ER, and worse as part of your nursing backgrounds? )

This is not a put down of Anesthesia assistants, they have just been sucked into the CRNA MD-A turf Battle... All proposed legislation to permit Anesthesia Assistants to work has required that they be SUPERVISED by an MD-A--- talk about built in control..

there is NO requirement in ANY state that a CRNA must be supervised by an MD-A , but MD-A's would love this requirement, and control.

There is an old saying among CRNA's , that we all get smarter at 3:30, when the MD-A's go home, and we are left there by ourselves, finishing the schedule, or being on call the rest of the night, with no supervision..

The Anesthesia Programs at Emory and other places, were started as a direct attempt by MD-As to gain control over anesthesia. Note, it was not mentioned that the MD-A's actually do the cases, Lord no.. that would make it difficult to sit in the lounge and watch the stock ticker and eat donuts..

I do not really have a problem with AA's, but again I do not personally know any. They may be the greatest people in the world, I don't know. I do know, that by law, their wings are Clipped,, they may not make independent decisions , insert invasive cardiovascular lines, do regional anesthesia in most situations (another facet of "Control")

God forbid the MD-A should be stuck in the bathroom or have an MI and they had to make a clinical judgments, that is not in their armamentarium.

When I have my next surgery, I want my anesthesia done by someone that can give me an emergency enema if needed, without calling an MD-A for advice.

Oh yea, someone made the comment about the US being the only place that uses CRNA's... Untrue, and it is being experimented with in England, Australia, Canada, and many other places that have traditionally had only MD-s Doing anesthesia.. they are beginning to see the light..

Many Anesthesia Assistants are trying to pass themselves off as Physician's Assistants. The Nation Physician Assistant Assn, states in no uncertain terms, that Anesthesia Assistants are NOT the equivalent of Physicians Assistants.

http://www.aapa.org/gandp/aas2.html

You can see Emory's evaluation of the 2 on their own web site

http://anesthesiology.emory.edu/PA_Program/whatis.html

As nurses you have seen the good and bad Physicians. And the control issues. This is what I all comes down to. Control and MONEY..

I'm done ....you can wake up now..

It might be me but I don't see all the hoorah about people thinking MD's being better at anesthesiology. This is in regards to a few previous posters comments. If it weren't for nurses, the art of anesthesia would not be where it is today. Look back at the late 1800's where they could not even get MD residents to perform the anesthesia because they were more interested in the actual surgery. There was also no money to be made in anesthesia at that time because the surgeons charged for anesthesia services and pocketed that money. It is not until around the 1920-1930's that MD's became more interested in anesthesia and found they could make money in it, so what better to do than to kick the "nurses" out and keep the money for themselves. CRNA's provide superior care and I would put it up against any MD.

AA's currently practice in 19 states. We just passed legislation in the biggest of them all - Florida. Florida was seen as the lynchpin in the national arena since it is historically the most difficult state to pass credentialling legislation. Other states will now follow in short order. A third program is set to open this summer.

Trust me - we are here to stay.

AA's practice in 19 states? According to this ASA document, it's 10. Eleven if you now include Florida.

http://www.asahq.org/asarc/AA-CRNA_Comparison.pdf :confused:

BTW, I checked on the situation in California, which is a pretty big state too. ;) No AA legislation here, at least not yet. It hasn't even been introduced, or so I'm told. Just FYI.

I'm not really pro or con either way. To me, the real question is, has anybody been able to prove that AA's actually endanger patient safety?

Maybe that's not possible to examine that question for a number of reasons, including the fact that there aren't many AA's to begin with. But I suspect that many of the CRNA arguments may fall on deaf ears, at least in the public arena, until somebody can prove for sure that this is a patient endangerment issue.

Arguing that they don't have enough training, even if it is true (and I'm not saying it is BTW), probably isn't enough until it can be proven that AA cases actually result in higher death rates, etc. Otherwise, it looks like a money/power/turf struggle.

I'm not saying that either side is right or wrong. I'm just talking about the realities of the public's perception of this kind of debate. Afterall, this may be the reason that Florida went ahead and passed AA legislation.

:coollook:

TEFRA requirements -- In supervising concurrent cases, the anesthesiologist must meet the so-called TEFRA (Tax Equity and Fiscal Responsibility Act) requirements, which are:

Perform a pre-anesthesia examination and evaluation;

Prescribe the anesthesia plan;

Personally participate in the most demanding procedures in the anesthesia plan, including induction and emergence; (this requirement gets a high percentage of 'medically directed' violations)

Ensure that any procedures in the anesthesia plan that the physician does not perform are performed by a qualified individual;

Monitor the course of anesthesia administration at frequent intervals;

Remain physically present and available for immediate diagnosis and treatment of emergencies; and

Provide indicated post-anesthesia care.

Quote Georgia-aa: As a senior anesthetist I am given free reign to manage my cases as I see fit. Very rarely does my attending dictate what the anesthetic should be. They may make a suggestion here or there like "work in a little Morphine towards the end" but I am not required to check with them about most decisions that come up during a case. New grads on the other hand (AA and CRNA) really are expected to communicate with their attendings a little more often. I commonly do extremely complicated cases from beginning to end with little to no involvement from my supervising MD. Italics added.

How does this meet the TEFRA requirements? And is billing for medical supervision or medical direction? My understanding (admittedly, limited) is that AA MUST be medically directed. Period. CRNAs, on the other hand, may be supervised by an anesthesiologist or physician and bill directly for their own services.

PG

I have not read all the threads in detail, but know the basic discussion. I live in southwest Kansas where most hospitals are run by CRNA's. I have yet to see an AA function independently as such. I beleive there are only 2-3 anesthesiologist in that region. The rest is CRNA's

Our MDAs check on the room at regular intervals and sign the chart when they do so. All perfectly legal and normal practice. Your statement that this is an issue with AA practice is misleading since they afford the same level of supervision to the CRNAs.

see - this is what i mean by blurring the lines of distinction...just because your MDA's "afford this level of supervision to the CNRA's" doesn't mean it is neccesary for them to do - in other words - THEY MUST DO THIS FOR AA'S - THEY NEEDN'T DO IT FOR CRNA'S because we are legally allowed to function independently...i am well aware that some institutions have the MDA's present for sentinal events (intubation and extubation) but that is institution dependent - NOT LEGALLY MANDATED where CRNA's are concerned. You are misleading in your statements by equating our scope of practice when it is in fact not equal - perhaps we do many of the same skills - but your practice MUST BE supervised by law - ours may be supervised but it is NOT A MUST....there is a signifigant difference which i think the AA movement clearly tries to hide in its quest.

perhaps i can give another example....Nursing Technicians do the almost all of the same functions a nurse can - they can place iv's, foleys, do ekgs, - and most are very adept at caring for a patient (some moreso than nurses...LOL) - however - they are not nurses and their scope of practice and what legal responsibility they carry differs much from nurses. - now i am not equating AA's to nursing techs - AA's have advanced training and advanced degrees - but...i am trying to show that just because you do some of the same functions DOES NOT mean the scope of practice is equal.

Just a few quick points/questions.

If AAs have been around for 30 years, has this argument been raging that entire time? Shouldn't the lobby power been used to stop AAs before they were established instead of now?

What have the AAs or the MDAs been doing to restrict our practice? How are we more limited now than thirty years ago before AAs were introduced? From the checking I have done, it looks like CRNAs have made inroads into traditional MDA areas and not the other way around.

If there are only 700 AAs and two schools, is there nothing more relevant that our money and lobby power should go to?

Has an independent group ever made a decisive study of the outcomes of the CRNAs vs. AAs?

I just do not understand why it is such a hot issue when it looks like almost everyone on this board has never worked with an AA. The arguments that I have read have been that AAs lower CRNA salaries, but GeorgiaAA's statement and looking on Gasworks does not appear to back this up. The second point that appears to be hot is that AAs are not properly trained to handle anesthesia, but if there was a string of dead patients behind the AAs I do not think anyone would be arguing this point.

If AAs have been around for 30 years, has this argument been raging that entire time?

A few years ago the ASA announced an initiative to focus on AAs and foster their growth and membership. Some believe the timing to be related to nurse anesthesia's attempt to remove supervision requirements from Medicare regulations (that led to the individual state opt-outs that are still in progress).

What have the AAs or the MDAs been doing to restrict our practice? How are we more limited now than thirty years ago before AAs were introduced? From the checking I have done, it looks like CRNAs have made inroads into traditional MDA areas and not the other way around.

This is a common misconception. Read Swumpgas post for a brief history of anesthesia delivery models in this country. Or better yet, read "Watchful Care" by Bankert.

If there are only 700 AAs and two schools, is there nothing more relevant that our money and lobby power should go to?

One of the biggest limiting factors in any anesthesia education (MD/CRNA/AA) is the availability of clinical experiences. Any wannabe who has been following this board has learned one of the things to look for in a program is the availability of clinical experiences, and the desirability of a program where nurse anesthesia student do not compete with anesthesia residents for clinical experiences. What will happen to our education programs when you add another type of student competing for cases? Will there be enough cases for everyone? Some individual programs might by adversely affected. That is significant to the future of our profession.

Has an independent group ever made a decisive study of the outcomes of the CRNAs vs. AAs?

Forget about it. It isn't practical, and the results wouldn't matter anyway. I don't agree with slinging mud onto AAs over safety. I don't like it when ASA does it to us, and I won't stoop to their level.

I just do not understand why it is such a hot issue when it looks like almost everyone on this board has never worked with an AA. The arguments that I have read have been that AAs lower CRNA salaries, but GeorgiaAA's statement and looking on Gasworks does not appear to back this up. The second point that appears to be hot is that AAs are not properly trained to handle anesthesia, but if there was a string of dead patients behind the AAs I do not think anyone would be arguing this point.

I know most of you are very new to these issues. But listen to those of us that have been around awhile. There is a history here, a pattern of behavior. This is part of a bigger picture.

loisane crna

This doesn't completely have to do with AA's, but for anyone thinking that the CRNA/MD fight is due to CRNA's, look at this thread, https://allnurses.com/forums/showthread.php?t=17140

Hope it works, it will give you a little insight on what the MD profession thinks of us

"lowly" CRNA's, one even calls us OR Scum. Sounds pretty professional to me.

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