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.

While I can understand the need to look at issues from a personal level, using specific/individual examples, I would like to ask that we step back and take a more global look at the CRNA vs. AA comparison.

Medicine is a profession. Physicians were the first to establish themselves as professionals in health care, and standardize their education and licensing.

Nursing is also a profession. We are younger, but we have a well established system of educational and licensing standards.

The practice of nurse anesthesia by CRNAs is accountable to the standards of the nursing and the governmental institutions that regulate nursing.

Who are AAs accountable to? My understanding is that they are not professionally accountable (GeorgiaAA of course, is welcome to comment on this). Since AAs are by definition assisting the physician, it is the physician who is professionally accountable for the AAs actions. (The AA may be personally accountable, but that is a different standard from professional accountability). They are truly physicain extenders. This is congruent with organized anesthesiology's position that all anesthesia is the practice of medicine. They believe the only role for non-physician anesthesia providers is to perform delegated medicine. The physician is always accountable, at the top of the pyramid.

So, the central issue as I see it (stay with me now)- is this a correct position? Is society best served by the physician always in charge model? Are other licensed health care providers incapable of safe, effective care without the direct supervision of a physician?

Our culture has a strong pro-physician bias. This often leads to the (erroneous in my opinion) view that CRNAs are a "second best". Everybody wants the best of care for themselves and their families, and we have been conditioned to believe that the only way to receive that is from a physician. Everyone else is second best. There was a time, when physicians were first establishing professional standards, that this was actually true. But I believe health care has evolved past that.

Nursing is a profession. Nurses have a legitimate role in patient care, separate from physicians. We are not physician extenders. Medicine does not control us. We have our own license, our own professional regulatory Board and our own professional standards.

Nursing stands on its own. I don't agree with the model that requires CRNAs to always be subordinate to the anesthesiolgist. But I am not looking to replace all of them with CRNAs. What is so wrong with wanting to work side by side as equals? Those in medicine who would like to see us subserviant need to know that we aren't their hand maidens, and we aren't going back to that. Nurse anesthesia is leading the way, and the rest of nursing will follow.

loisane crna

Thank you Loisane, very well stated.

Interested

Loisane, your post was excellent. Thank you for your insight. The distinction you make is clear - and also an angle that I hadn't considered.

And DeepZ, you always inject a bit of fire into the discussion! Thanks for the explanation of reimbursement.

Pnurse, the issue is far more complex than who is supervised and who works independently. Do a search on this board for the several recent threads.

LBhot, I hope you clearly see that there is more difference than job outlook. But since you asked, the last time I checked www.gaswork.com, there were 1138 jobs posted for CRNAs (obviously, some may be repeats, agency, etc). There were 3 AA postings. AAs are not PAs. They can practice in a limited role in a minority of states in this country.

Alansmith, I think we need to get you and DeepZ together for a beer at the National convention. Now THAT conversation would be a hoot!

User69, did you really mean to say "as long as they are not students"? Are you not just starting nursing school, not even an RN yet? Who are you going to practice on? Because let me tell you, starting an IV in an orange is not the same as a screaming, kicking meth-user who just arrived in your ICU pooping blood. And "anesthesia nurse" is meant to be condescending. There are nurses in endoscopy and special procedures that call themselves "anesthesia nurses". They are not CRNAs, and "anesthesia nurse" is a non-technical, made-up name. Few people in the public can even pronounce anesthetist, let alone grasp the scope of the job description.

Tenesma, the term anesthetist (pronounced ah-neeth-ta-test or ah-neese-tha-tist with some regional variation) is a common term for physician anesthesiologists across the British isles.

Athomas, how about "Anesthesia Diva?"

And seriously, Georgia_AA, I appreciate your thorough post. Your explanations were helpful and your description of the salary issue is true in the Atlanta metro area and surrounding towns, as I understand it.

By your own admission, though, you I should point out that if you are running your cases with no involvement from your supervising MD, s/he is committing billing fraud and you are practicing beyond the scope of your license. This illustrates beautifully one of the main issues regarding AA practice. You simply cannot argue that what is designed to be a supervisory role often lapses into one of independent practice with the "supervision" being applied only to allow four rooms staffed by CRNAs or AAs to be run by one MDA, and billed accordingly. Please do not take this as a personal attack. I understand well that this is a common phenomenon that is not at all unique to your department.

The other key issue at stake here is that the acceptance of this "anesthesia care team" model in which AAs and CRNAs function interchangeably serves as a springboard for the future restriction of CRNA scope of practice. AAs cannot rise to the current level of practice of CRNAs by virtue of their training and licensure, so the CRNA scope of practice is restricted to allow for equitable working conditions. This is not acceptable.

And let's be honest. Physician anesthesiologists are extremely concentrated in metro/suburban areas or those with a higher quality of life. The real shortage lies in the underserved, rural areas and those with less desirable working conditions. AAs cannot practice independently, AAs must have a supervising anesthesiologist, and anesthesiologists typically do not choose to work in areas with the greatest need, therefore AAs cannot be the solution to this country's anesthesia provider shortage, contrary to the attestation of your national organizations.

Many thanks to all for this dialogue...

Nicely stated!

Interested

First of all, I'm agreeing w/ you. I thought $76,000 sounded like a low salary to me also. Your might call this greed, but don't be blind to the business aspect of the profession. When I was in the ICU, I was making about $15,000/yr less than the salary offered to me if I were start work as a CRNA at that hospital. Their was a $20,000 educational rembursment offer to me. Sure, I had to stay for 3 years, but it was offered. So now we are up to $83,000/yr. This, of course, after I borrow $90,000 and quit work for 2 1/2 years. Sound greedy? I saw from your previous posts that your husband is an OB. Some of us don't have the luxury of a supplemental 6 figure income in the house. This is gonna be more than a hobby for me.

You have taken my reference to greed out of context. I was refering specifically to the issues between CRNAs and AAs. In Atlanta many CRNAs feel that the AAs have depressed the salaries. I'm not going to outline the whole thing for you here, you can read it if you want to, but you may have missed my point.

I think it's safe to say that this issue is interesting...seeing as I am signing on at post #244.

A little history....

Upon graduating with my BSN, I went directly into the SICU in Atlanta, Ga. I have always wanted to provide anesthesia. I had never heard of AAs until this move. They recovered several of my patients and seemed very professional in nature. I actually observed in the OR with an AA I met and was amazed. I went on to be trained as a CV nurse involved with balloon pumps and swan monitoring on a daily basis (who hasn't) to be more competative for anesthesia school. I also have done transplant unit nursing at Emory as well. There is an enormous degree of pathophysiological anatomy, a definite pharmacological understanding, and simply, refined acute assesment skills that a bedside RN brings to the table before anesthesia school. HOWEVER.....(those of you with experience...hold your tongue..), following my first day in the OR, my first month, sometimes even now, you would not have known me from a Walmart greeter. Yes, some prior knowledge was helpful , but fundamentaly, it's a whole new ball game. We leave the roll as nurses and take on the responsibilties as trained anesthesia providers to that of an MD-A.

Now for Georgia AA, I commend you for stepping into the field of battle. I am very familiar with Mr Rob Wagner (previous AA President article posted). My wife performs subspecialty surgery at St. Josephs and Rob is a friend of hers. I also very much understand that AAs and CRNAs get along very well while in the anesthesia setting but bash and clash each other (as seen in about 240 other postings) when the back is turned. Now don't get me wrong, I'm not selling out...I support my profession. It just seems to me that many of the postings are very similar to the current presidential election debates....lots of talk and jabbing about laws, lack of education, lack of acute experience, bla bla bla but no real support of any certain issue. In 240+ postings, few actually settled the difference between the two professions. I hope you have not signed off. I would like to acutally speak with you privately....I most likely will be returning to Atlanta.

Now the REAL TRUTH...it's not that AAs drive the market down in Atlanta...it's that the combination of the enormous amount of AAs there and also the CRNAs somewhat saturate the market in the metro area. Now for those of you that don't live in Atlanta, that comment did not pertain to you. I know that even as far away as www.gaswork.com, and check any state. And if you haven't heard, Georgia is to open it's second AA school in Savannah at South University starting 2005. Florida is posted to open new schools (2-3??) if legislation moves through...Georgia will continue to have less competative salaries as some other regions of the country currently offer.

For myself, I will be graduating with over $120,000 dollars in loans from undergrad and NA school. I've spoken with four major hospitals in Atlanta as of yet and the offers have ranged from $84000 to $93000 for a new grad. That does not include any stipend or sign on bonus. In fact, some places only offered a sign on bonus of $5000....very sad seeing as that's the same amount I recieved upon graduating with my BSN. In fact, one hospital is now offering $10,000 for RNs to sign on. Another fact...I worked agency most of my time in Atlanta. Each year I made over $75,000 with little effort. I DID NOT GO BACK TO SCHOOL AND GO INTO DEBT OVER 100 GRAND AS WELL AS SUFFER THE 2.5 HARDEST YEARS OF MY LIFE JUST TO RETURN FOR A COUPLE OF DOLLARS RAISE PER HOUR!!!!

That my loyal peers lies the truth of all of the battles you have read...the almighty green daddy...HOW MUCH AM I WORTH!!!! There is no question over training, skills, (or even EF%, on pump/off pump 15 vessel is you will) or whatever guns are to be pulled out here.

Georgia AA stated that he/she (not sure) has been working for over 14 years and is now a senior anesthetist with a base of $115 making approx $160 with lots of OT/Post Call, etc. Here in Carolina, new grads are starting out at over $145,000 in areas with populations of 100,000+ people with sign on bonuses of 20-40,000+. I know for a fact that a grad from 2003 made over $240,000 the first year out with call and post call. That's the premise for those of you who aren't yet in school or who are not familiar with the whole AA vs CRNA battle is sturring over.

Also, in ATLANTA...not everywhere, the majority of regional blocks, spinals, epidurals, etc are not performed by AAs or CRNAs. This comes strait from an Attending MD-A at Emory University (training site for AAs)..."Yes CRNAs are trained to perform the functions of regional anesthesia and central line placement as well as our AAs but we just don't have the time to sort out the professional anesmosity between you guys, we rather do it ourselves?????"

Nice.

Now for those of you with revolvers loaded and ready...please be civil...or not. I just am man enough to know the truth about why I personally have an issue here. It does not involve intelligence. And please, for the sake of sanity, don't quote me on the acute care experience RNs have before school and the lack thereof AAs possess because if fact be known, many of the current SRNAs across the nation have less than one year experience...including PACU or the ED...they have never seen a swan, obtained vent management skills, or much less know anything about titrating drips, hemo monitoring etc,....and yet we all graduate together...as far as some of them are concerned, TLC is a R & B group out of Atlanta.

And second of all, don't reply stating that I'm just wet behind the ears still or "green" d/t being an SRNA. It doesn't require a license to balance a check book.

Come on guys...it's about the intense training and intelectual competance we learn as we go...not Physician Supervised or not....yes it hurts the pocket...but I believe it will all come out okay in the wash.

And for you cowboys that just can't see me through...I hope your saddle rides out safely and you aren't cattle romped by some legal ramification just because you are independantly licensed and not supervised. Personnally, after observing the criminal mindset of the general public and their quick way to make a dollar by lawsuits as I have thus far, I feel I will enjoy not being the sole provider and responsibility of one's care but rather having and practicing with a "team" of providers that share some common liabilty. Although I will always have the opportunity to practice alone once graduated, it is a relief for now to have the team approach.

And so it begins....

As someone is is considering becoming a CRNA, I found this thread very interesting!

"In the 1960s, three anesthesiologists, Joachim S. Gravenstein, John E. Steinhaus, and Perry P. Volpitto, were concerned with the shortage of anesthesiologists in the country. After studying the educational pathway for anesthesiologists and nurse anesthetists (NAs), they created a new educational paradigm for a mid-level anesthesia practitioner that included a pre-med background in college. This person would perform the same job as the NA but would be readily able to go on to medical school if appropriate. This new professional, the anesthesiologist assistant, or AA, thus had the potential to alleviate the shortage of anesthesiologists."

(http://www.asahq.org/career/aa.htm#1)

I have an undergraduate degree in Biology from Duke (pre-med), and a MS in Molecular Biology. Why do people think a pre-med BS is much harder or "better" than a BSN?

Right now I am looking at entering an accelerated BSN course, and I don't find it easier by any means. Different, but not easier.

In fact, pre-med courses are great as a solid science base for medical school, but really have little practical application... The BSN seems to cover more practical applications of science. In my opinion, I think the BSN better prepares you for working in a clinical environment than a BS by many magnitudes!

I am not on either side, it is just strange how the literature for AA programs, etc seem to emphasize that AAs "are prepared to go to med school" (paraphrasing) at a moment's notice! To me, that doesn't mean that much, as I know I certainly wasn't prepared for anything after I got my BS degree (pre-med).

Now, the actual *training* AA receive in their program, and the *training* CRNAs receive in their program--that is what prepares both CRNAs and AAs for their jobs.

Specializes in Government.

I have found this thread fascinating. I never even heard of an AA before. I do have friends who are CRNAs and they make 3 to 4x what I make. They all have master's degrees and advanced credentialing.

O/T: makeup nurse? I'm an accelerated program BSN graduate. PM me if you have any questions.

Good observation!!!

as someone is is considering becoming a crna, i found this thread very interesting!

"in the 1960s, three anesthesiologists, joachim s. gravenstein, john e. steinhaus, and perry p. volpitto, were concerned with the shortage of anesthesiologists in the country. after studying the educational pathway for anesthesiologists and nurse anesthetists (nas), they created a new educational paradigm for a mid-level anesthesia practitioner that included a pre-med background in college. this person would perform the same job as the na but would be readily able to go on to medical school if appropriate. this new professional, the anesthesiologist assistant, or aa, thus had the potential to alleviate the shortage of anesthesiologists."

(http://www.asahq.org/career/aa.htm#1)

i have an undergraduate degree in biology from duke (pre-med), and a ms in molecular biology. why do people think a pre-med bs is much harder or "better" than a bsn?

right now i am looking at entering an accelerated bsn course, and i don't find it easier by any means. different, but not easier.

in fact, pre-med courses are great as a solid science base for medical school, but really have little practical application... the bsn seems to cover more practical applications of science. in my opinion, i think the bsn better prepares you for working in a clinical environment than a bs by many magnitudes!

i am not on either side, it is just strange how the literature for aa programs, etc seem to emphasize that aas "are prepared to go to med school" (paraphrasing) at a moment's notice! to me, that doesn't mean that much, as i know i certainly wasn't prepared for anything after i got my bs degree (pre-med).

now, the actual *training* aa receive in their program, and the *training* crnas receive in their program--that is what prepares both crnas and aas for their jobs.

i'm not sure about the bs/bsn comment you mentioned but a bsn is a bachelor of science in nursing. upon graduation, you can sit for your state board of nursing to be licensed as a registered nurse.

the bs, a bachelor of science degree, can cover any numerous majors in science, but yes, is great for applying to medical school. the bsn is required for crna school, as your bs,ms will most likely to let you walk into aa school as a competitive candidate.

We leave the roll as nurses and take on the responsibilties as physician trained anesthesia providers.....

I have to take issue with this characterization of nurse anesthesia. While physicians may be involved in our EDUCATION, their participation is not the principle defining factor of who we are. Professionals are educated. Training is for assistants. Your choice of words speaks volumes. I challenge you to examine your own personal philosophy of nurse anesthesia, and your professional role. If you are a senior student, then this is part of the transitional process toward graduate.

Personnally, after observing the criminal mindset of the general public and their quick way to make a dollar by lawsuits as I have thus far, I enjoy someone else having the ultimate liability while at the same time, I am under few restrictions to practice what I have been trained to do while existing under that liability.

No, working with anesthesiologists does NOT place the ultimate liability for your actions on them. This is a myth, perpetuated by non-CRNA friendly 'ologists, in part to scare surgeons into insisting on 'ologist involvement in their cases.

When you become a CRNA, the responsibility for your anesthetics lies with you. If you work with an 'ologist, they may share some of that responsibility, but it does not remove the responsibility from you. This is the difference between a professional and an assistant. What you say IS true of AAs, but not of CRNAs, even in anesthesia team care settings.

My friend, I fear you have been the recipient of some less than completely accurate appraisal of our profession. Maybe this will be addressed in your program at a later date. The issues are complex, and many of our own colleagues are confused about much of this. And consider the fact that it varies state by state, and it gets even more intricate. But you are early in your career, this is a great time to tackle the complexities involved. The AANA journal has an article every issue on the legal ramifications of our profession. These issues are addressed regularly. Include this as part of your education. The April issue had a good discussion about the ASA team standard.

In you education, never settle for "that's good enough for me, after all, I am always going to work with an anesthesiologist backing me up". Learn to practice as though you will be working solo. Then if you choose to always work ACT, fine you are just that much better at what you do. But if you decide later that you would like to "be a cowboy" (as you call it), you will not have closed a door and limited your options for your entire future, based on beliefs you hold right now.

loisane crna

I have to take issue with this characterization of nurse anesthesia. While physicians may be involved in our EDUCATION, their participation is not the principle defining factor of who we are. Professionals are educated. Training is for assistants. Your choice of words speaks volumes. I challenge you to examine your own personal philosophy of nurse anesthesia, and your professional role. If you are a senior student, then this is part of the transitional process toward graduate.

No, working with anesthesiologists does NOT place the ultimate liability for your actions on them. This is a myth, perpetuated by non-CRNA friendly 'ologists, in part to scare surgeons into insisting on 'ologist involvement in their cases.

When you become a CRNA, the responsibility for your anesthetics lies with you. If you work with an 'ologist, they may share some of that responsibility, but it does not remove the responsibility from you. This is the difference between a professional and an assistant. What you say IS true of AAs, but not of CRNAs, even in anesthesia team care settings.

My friend, I fear you have been the recipient of some less than completely accurate appraisal of our profession. Maybe this will be addressed in your program at a later date. The issues are complex, and many of our own colleagues are confused about much of this. And consider the fact that it varies state by state, and it gets even more intricate. But you are early in your career, this is a great time to tackle the complexities involved. The AANA journal has an article every issue on the legal ramifications of our profession. These issues are addressed regularly. Include this as part of your education. The April issue had a good discussion about the ASA team standard.

In you education, never settle for "that's good enough for me, after all, I am always going to work with an anesthesiologist backing me up". Learn to practice as though you will be working solo. Then if you choose to always work ACT, fine you are just that much better at what you do. But if you decide later that you would like to "be a cowboy" (as you call it), you will not have closed a door and limited your options for your entire future, based on beliefs you hold right now.

loisane crna

As for you first comment, I am unsure of your point. I greatly value my chosen field and profession and have no interests in redefining my "philosophy" in part to your interpretation of an email; not a valid conversation or debate. My purpose in that statement was to say completely that a CRNA is educated including highly specialized training (strait off the AANA website definition). We no longer have the roll of "call the doc and get an order," but a responsibility of assess, interpret, and take the appropriate action. It in no way was meant to be a "characterization" of NAs with a negative connotation.

For the second conundrum, I fully understand and accept the responsibilities of the profession I am studying as a professional. My clinical decisions will ultimately rest within the defined scope of practice set forth by the AANA and the State Board of Nursing and any variation of that set law falls on me, not my MD-A. My statement was in fact meant for the nurse anesthesia providers that continuously degrade AAs and ultimately feel flying "solo" is the only way to go and fear that AAs will strip them of their $$. In my home town, there is no MD-A. Both CRNAs have been fired recently d/t greed and being John Wayne as one poster put it. That's the direction my comment was manifested for. Don't ever think I would say a derogitory thing regarding my own chosen field. I am merely a realist. HOWEVER, this in fact is more based on a poor choice of wording in communication of my ideas rather than examples of inapt decision making by a student...I have revised my statements in the original posting.

Thank you for you comments! I will gladly speak with you for your advice any time.

In my home town, there is no MD-A. Both CRNAs have been fired recently d/t greed and being John Wayne as one poster put it.

I understand "John Wayne" type behavior, but how do you get fired due to greed? If your employer declines to meet your salary demands you can stay on at your current rate or you can leave, you don't get fired for asking (at least I hope not!). Unless there was bribery or some such dirtiness going on.

to Carolina SRNA:

I know the difference between a BS and a BSN... What struck me after reading this thread and reading up about AA programs is that AA association really emphasizes that AAs have a BS, they they are "pre-med", that they have "taken all the courses required to get into med school", that they could "apply to med school", etc. Whereas CRNAs have various backgrounds, some BSN, some RN with other BA degrees, etc.

I disagree that having a BS (and having taken the pre-med requirements) makes someone more qualified than someone with a BSN. The AA association seems to think it does--sort of a funny thing to dwell on and emphasize over and over again in my opinion.

I think it is "six of one, half dozen of the other" sort of situation... I don't think having a pre-med BS or a BSN will make you better or more qualified. AAs and CRNAs learn their profession while in AA school or CRNA school--that is what makes them highly skilled professionals.

This thread has been very informative, and I wish both the AAs and CRNAs the best of luck! :)

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