CRNA supervision by anesthia MD

TXCRNA · Aug 12, 2009

Im very sorry to hear about your experience and Im glad everything worked out ok (im assuming since you are posting here). Unfortunately, CRNAs dont have a monopoly on med errors. Ive seen med errors by both CRNAs & MD anesthesiologits over my years of experience. I myself have made a drug error--benign results. Anyone who tells you've they've never made an error is either lying or hasnt been practicing very long. Again--Vigilance is key. Its not that the CRNA wasnt educated enough. A person on the street knows dont give a med to a person if they are allergic to that med. It was lack of vigilance on his/her part. Obviously, human error occurs...look @ wrong site surgeries...those are docs. i just want to make the point that no matter what letters are after your name, MD or CRNA, you are human. I think you should discuss your concerns w/ your next anesthesia provider prior to the procedure. I myself just had a c-section 4 weeks ago and I was scared to death because I know all the poss problems that could occur. I wanted my anesthesia provider to be whoever did c-sections and spinals the most. If that was the doc thats who I wanted and vice versa for CRNAs. I didnt want someone who hadnt done OB in 10 years. So...just ask " Do the docs do their own anesthetics @ this facility?" if the answer is "no. we sit in a lounge and havnt done an anesthetic in years" then I wouldnt want that MD, Id rather have the provider who usually dose the anesthesia. I work @ a facility where our MDs do there own anesthetics all the time & are excellent, along w/ excellent CRNAs doing their own cases.

darne20 · Aug 14, 2009

Thanks for the replies; this is more complicated that I had originally thought. Since the re-do will be elbow/wrist surgery with a Bier Block and the "problems" arose from the "conscious sedation" I'm thinking that I'll just request the procedure without any sedation and that will eliminate the anesthesia issue except for the block. Do CRNA's do Bier Blocks? I have been checking out several facilities; one wants to schedule a CNRA and an anesthesiologist (block and sedation, which I'm now going to skip)..is using 2 providers normal? Thanks.

subee, MSN, CRNA · Aug 14, 2009

A Bier block can be provided by either and it is quite usual to have a CRNA and an MDA on the case. However, the MDA is not in the room for the case usually except for the very beginning. The real question is whether this procedure can be done with a Bier block at all. They are not suitable for long cases (over 45 - 60 minutes) because of the tourniquet. An alternative is an axillary block. My experience has been, however, that axillary blocks often require additional sedation if they have to chip bone. We're only talking a little zitz of propofol here - nothing more than that. Its unusual for anyone to be allergic to TWO anesthetic drugs. My sympathies on that one.

darne20 · Aug 17, 2009

I was wrong to think that I would be better off with the anesthesiologist rather than a CRNA. I just finished separate meetings with the anesthesiologist and the supervising CRNA to determine how to proceed. My surgeon's advice was poor. The anesthesia MD is a mere figurehead; the CRNA's are knowledgeable and a lot more honest.

TXCRNA · Aug 17, 2009

All depends on the facility. If thats the MDs role where you are having your surgery then you'd be better off to keep the status quo. Changing the way things are usually done is usually not the best. Im sure you are going to do great. If a bier block w/o sedation is poss Im sure they would be happy to provide that for you. Please let us know how everthing goes. good luck.

darne20 · Aug 20, 2009

Thanks TXCRNA-Due to a cancellation I was able to get the surgery done this morningn and I did go with the status qood (good suggestion). The only rough spot was when I reminded them that this was supposed to be a Bier Block without sedation (because of a really horrible previous experience with C/S); they basically ignored this until just before the surgery then mentioned as I was entering the O.R. that this may or may not be what they were going to do despite our previous discussion. That is until I mentioned I specified on the consent no sedation or GA bier block only; this resulted in a brief heated exchange (the MD who agreed to the no sedation part was not present)...to prevent cancelling the surgery, the anesthesiologist agreed to do the block without sedation but added that if I declined sedation that I couldn't get any painkiller (I agreed but it seemed a little one-sided to me)...after talking to my surgeon the anesthesiologist departed never to return (not sure why he left, but the CRNA said that the no sedation/no painkiller ultimatum was stupid) and she and the surgeon did the case (32 minutes). The bier block worked fairly well, but my heightened BP from the "preop discussion" prevented the block from being as effective as it could have been, but the surgery did get done. So the CRNA was an effective patient advocate (she offered fentanyl when I was less stoic about the cuff pain, but I survived without it). The anesthesiologist was not. When I have to have the other arm done, I'm asking for the same CRNA if possible. My only criticism is that despite resolving the sedation days in advance, the anesthesiologist tries a "power play" 5 minutes before surgery to change my mind. Fortunately I had 2 things on my side: I specified no sedation on the consent and a CRNA who had no problem with standing up to an anesthesiologist who was clearly trying to ignore my wishes. There is nothing like having a real patient advocate on your side and the CRNA was clearly mine.

subee, MSN, CRNA · Aug 20, 2009

Well, I'm glad you got through it, but as you saw, a Bier block alone is not very good anesthesia. Can we help you think through the problem you had with anesthesia in the past? I'm believing that you have needly put yourself through physical and emotional trauma because of a fear not based on actual events as THEY WERE EXPLAINED TO YOU. I find that patients who want to tough it out usually do, despite the red face and sweating. However, yesterday I had a patient who wanted to watch his entire colonoscopy but ending up required just a few cc. of propofol to get around a difficult curve and then he was able to wake up completely and watch ghe 2nd half of the procedure. However, he was miserable. I hope that this doesn't affect his zeal to get his next colonoscopy in 3 years (had polyps). I had a patient from Canada who eventually moved to states. Waited 19 years for follow-up colonoscopy for ulcerative colitiis because of pain she endured during first colonoscopy! 19 years with colitis! At would be helpful to you to decipher what happened to you before to make sure it was actually the drug administered or the circumstances under which it was administered. They can't take your appendix out with a Bier Block!

darne20 · Aug 20, 2009

thanks for the info-redface and sweating (SOAKED)

darne20 · Aug 20, 2009

thanks-redfaced and sweating was an accurate description, but the pain was preferable to getting so-called "conscious sedation" that I didn't consent to. Some patients like propofol; I hate it. I did my Ph.D. thesis on propofol, so I know a little about it...it's the creepiest most dysphoric sensation that I can imagine.........administered by someone whom you trust is one thing; when they try to administer a drug that you do not consent to-that's another...................

TXCRNA · Aug 20, 2009

Sounds like your surgery was stressful to say the least. Im sure you're glad it is behind you. Im glad your faith in CRNAs has been restored as well, although sounds like her job was easy since you didnt want any meds. As I told you, I recently had c-section. I had a spinal & not a drop of any sedation...it was stressful beyond words(although my spinal worked great). So...I understand your experience. Whenever I do a block I make sure the pt understands that it could fail or wear of prematurely thus making a general anesthetic neccassary. I explain that I cant guarantee no general anesthesia if this were to occur mid-procedure. There are also complications from the local anesthetic that rarely occur, which Im sure you're aware of, that require possible intubation, medication, etc.. So I would hesitate to write on the consent no sedation/general, but barring that, I would abide by your wishes if I was doing your case (although I would've prob tried to talk you out of it. LOL).

MoLee228 · Aug 21, 2009

Thanks for the replies. If the surgeon agrees that the anesthesia will be performed by an anesthesia MD (because of patient request), is this a problem if agreed to in advance?

Interestingly, I had an anesthesia fellow say to me that if he had to choose who did his anesthesia (if he was having surgery) he would always choose a CRNA over an MD. This is because we are at a large teaching hospital, and 9/10 MDs providing anesthesia are residents. They are still learning anesthesia, whereas a CRNA has mastered it. Interesting, don't you think?

darne20 · Nov 8, 2009

I wanted to reply to this old thread because I just got back from having my second ulnar nerve/trans CTR done and this time I was able to have the CRNA/MDA, no sedation, Bier Block only issues settled in advance. For the first operation, the MDA had a total hissy-fit when I told him that I didn't want sedation or GA and put this on the consent (my experience is that a verbal agreement means little); so my surgeon suggested skipping the MDA and going with the CRNA. Unlike the MDA, the CRNA had read my chart in advance and knew what I wanted and didn't want (sedation makes these procedures intolerable for me)......and we didn't have to argue about it, which would have raised my BP and made the block less effective. I though that the procedure went well; the CRNA mentioned that I must be uncomfortable since I was all sweaty, but that was by choice. In the RR, the surgeon ordered Toradol and before I could object, the CRNA said quite loudly: "no, he's not kidding about his allergies; the last time he got Toradol he ended up in the ER with a GI bleed and got IV H2-blockers"....I like that CRNA;I'm sending her a letter of appreciation, at least, even though she thinks that I'm nuts for declining the sedation.