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!!!
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.
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.
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.
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.
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.
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.
......standards that set nurse anesthetists apart and above other providers is constant vigilance. Precordials provide that input at no cost......
An observation on learning the fine points of clinical anesthesia -- in my own days as clinical instructor at Wayne State, I had one student doing an induction, his precordial on the patient's chest, as was mine also. While he bagged aggressively, sweating bullets, waiting for muscle relaxant onset, I asked, "Hear that, that squeaky gurgle? Ease up a bit. You're bagging air down the esophagus."
Being open to subtle changes is another part of vigilance.
I still have my original precordial stethescope from 1966, and I use it regularly, though I can't say I listen continuously every time I put it on. For long cases, once in a while you can hear a buildup of secretions that can be suctioned out before leading to problems. For little kids it's invaluable.
You make statements like you are a seasoned pro.......I just read your posting where you stated you were JUST accepted in March '04. You should consider changing your name.
The truth about the monitoring with a precordial stethoscope is that it is NOT considered a standard monitor as there has been litigation concerning tunneling of the esophageal stethoscope in the submucosa of the pharynx. Again it is NOT a standard monitor
I had stated in my response that I was inexperienced. So, there is no effrontery going on here. The traumacrna is my yahoo ID and email and it's what I'd like to do one day. I never thought I'd get so many people who would react to this statement. I kept it professional and only presented my perspective as many of you have. Good luck on your practice.
You make statements like you are a seasoned pro.......I just read your posting where you stated you were JUST accepted in March '04. You should consider changing your name.
The truth about the monitoring with a precordial stethoscope is that it is NOT considered a standard monitor as there has been litigation concerning tunneling of the esophageal stethoscope in the submucosa of the pharynx. Again it is NOT a standard monitor
jwk
1,102 Posts
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.