Are you good at regional blocks?

[Bluebolt]

I should give some background to this question. I just finished cramming numerous hours for a massive exam on ultrasound guided regional nerve blocks. They included methods for blocks without ultrasound like nerve stim and landmark orientation. We are also doing a gross lab course where we dissect the human body with a heavy focus on the vasculature and nervous system.

We took the test today, pretty sure it took a few years off my overall lifespan to learn all the material.

I was talking to some of the professors and many of them mentioned that the anesthesiologists do the blocks at their facility. Then they told me that out of about 15 clinical sites we rotate between only about 5 encourage students to learn blocks. I was told that it's common in most locations for MDAs to be very territorial over blocks and won't allow CRNAs to do them. I actually looked up the ASAs stance on CRNAs doing blocks and their opinion is that they aren't trained or qualified to properly manage care with blocks.

My question to you out there practicing is, did I just spend all this time and energy learning the entire brachial plexus to stand back and watch an MDA do the procedure? All the while commenting that because I learned it in a program that wasn't called anesthesia residency I'm not safe performing them?

If you do get unsupervised independent practice with blocks, how did you go about doing that? Does anybody work in a practice with MDAs where there isn't this ego territory issue?

I'm looking for a way to practice the full scope of my training and licensure when I graduate without any condescending co-workers around insinuating I'm not qualified. I'm looking for a light at the end of the tunnel of this CRNA DNP.

[PresG33]

In hospital where I worked in the ICU the MDAs did all the blocks and OB regional, CRNAs did spirals/epidurals in the room for OR cases. The explanation was that the MDA does the block for the next patient while the CRNA is extubating and turning over the room so the flow is better. Not sure if I buy it... interestingly, at this facility the CRNAs do all the hearts including TEE/lines so they have a good scope in that respect. At the hospital across town the CRNAs do all their own blocks. Everything I've seen is that it is very group/facility dependent. Independent CRNA groups are obviously more likely to do their own regional from what I've seen/heard.

[Bluebolt]

Independent CRNA groups are obviously more likely to do their own regional from what I've seen/heard.

Right, we do rotations with two different CRNA only groups and they handle anything that comes thier way independently. I like the idea of a CRNA only group and would love to work in a practice setting like that after graduation. I'm aware that the majority of anesthesia practices out there are not CRNA only groups though and am wondering if the typical CRNA is getting good practice with blocks in their work setting.

I'm aware it can be a touchy subject with some CRNAs and don't mean to imply any shame if you don't get to practice blocks. There are many reasons people choose different work environments and if you have an awesome schedule/pay/retirement package you may not care if you're not allowed to practice to your full licensure and training.

[offlabel]

I don't do peripheral blocks because of the sub- specialty that I practice in. (CT/vascular). That said I do echo and lines. Should indy CRNA's feel less the anesthetists because they don't practice the way I do? No. The majority of anesthesiologists in the US don't do the things that I do.

Hanging your professional self worth on a procedure betrays a certain lack of awareness of the reality of doing anesthesia. I get the enthusiasm of the folks in training. That is great. And there are plenty of practices that accommodate any number of preferences. But it's kind of a Rubic's cube out here in the real world. Once you get one or two sides the way you want them, the other four or five might not match your ideal. Most folks have 30 or more years in the business and that is a long time to find just the right place for you.

One caveat, there are those that will always see greener pastures somewhere they're not. That is an awful way to build a retirement because it is very expensive to change practices every 5 years for something "better". And there is no guarantee that once you think you're in the right place, some anesthesiologist, CRNA, surgeon or hospital administrator comes in and messes the whole thing up.

[wtbcrna, MSN, DNP, CRNA]

With a lot of territorial issues in anesthesia you should follow the money. PNBs, especially USGPNB, are big money makers. You can bill a few hundred dollars for every USGPNB that you do. This also is another reasong for MDAs to state they need to be out of the OR doing "supervision/direction". I am USAF CRNA so I was trained to be independent and PNBs are a large part of my practice. I am credentialed to do PNBs at the Kaiser facility I work at, but the MDAs there do most of the blocks.

[Bluebolt]

We just had a lecture explaining how volatile anesthetics are contraindicated in cancer patients, that PNB and TIVA is better for the patient. It seems that a large percentage of facilities still use volatile anesthetics on cancer patients because they don't want the CRNAs doing the blocks. So at that point you're actually being told by your supervisor to provide a more harmful anesthetic to your patient even if you're trained and licenced to provide a safer one. That would be an impass for me.

It's looking more and more like CRNA only groups or collaborative practice will be the only option for me.

[wtbcrna, MSN, DNP, CRNA]

We just had a lecture explaining how volatile anesthetics are contraindicated in cancer patients, that PNB and TIVA is better for the patient. It seems that a large percentage of facilities still use volatile anesthetics on cancer patients because they don't want the CRNAs doing the blocks. So at that point you're actually being told by your supervisor to provide a more harmful anesthetic to your patient even if you're trained and licenced to provide a safer one. That would be an impass for me.

It's looking more and more like CRNA only groups or collaborative practice will be the only option for me.

There are military contractor jobs, Indian Health Service, USPHS, and VA jobs that some or all offer independent practice. Despite all the rhetoric around the VA there are VAs with independent CRNA practices and/or CRNA only practices. The US Army utilizes lots of CRNA contractors and the pay is decent.