CRNA Induction Sequence List

[miloisstinky]

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 list....such as O2, Induction agent, Mask Ventilate, SCAN, Muscle relaxant, intubate, tape eyes, check ETCO2, BBS, Close APL Valve.......Thank You, Thank You. I, OBVIOUSLY, am a student and am always missing something in my SEQUENCE. I would love to hear yours. Also, I am SOOOOO fearful of emerging my patient too soon, what are your words of wisdom. THANKS IN ADVANCE AS ALWAYS!!!

[snakebitten]

I have been doing this stuff probably as long as JWK and I agree with him/her. There is no standard for wearing a precordial stethescope and I still won't use them on adults. There are better monitors (for me), I just prefer not to use precordials. Adequate ventilation and heart rates can be monitored with pulse oximetry, ECG's, tidal volumes peak pressures etc....What are you gonna do if your have problems? Tear off the earpiece and check your monitors, and get your drugs out. What are the lawyers gonna say then? Their gonna say what is the standard of care or standard monitors--precodial stethescopes are an adjunct but NOT standard.

[snakebitten]

I have been doing this stuff probably as long as JWK and I agree with him/her. There is no standard for wearing a precordial stethescope and I still won't use them on adults. There are better monitors (for me), I just prefer not to use precordials. Adequate ventilation and heart rates can be monitored with pulse oximetry, ECG's, tidal volumes peak pressures etc....What are you gonna do if your have problems? Tear off the earpiece and check your monitors, and get your drugs out. What are the lawyers gonna say then? Their gonna say what is the standard of care or standard monitors--precodial stethescopes are an adjunct but NOT standard.

[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

[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

[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.

[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.

[deepz]

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.

[deepz]

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.

[air]

Yes, Standard V at:

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

No specific mention of precordial.

True

[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.

[jwk]

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.

[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.