How do CRNAs/SRNAs benefit anesthesiology residents?

Hellllllo Nurse, BSN, RN · Jun 18, 2004

u-r-sleeepy,

I was interested in your views and what you had to say, until this point in your post:

democraps

loisane · Jun 18, 2004

but i cant say anything better than loisanne, i'm sure she will respond and clarify, and correct me. i just felt a need to respond to some of these questions.
d

Gaspassah has done a pretty good job.

I'm in a rush right now. TD has asked some thoughtful questions, that deserve some thoughtful answers. But I will be back to elaborate when I can, and see if anyone is still interested ;-)

loisane crna

susanna · Jun 18, 2004

This is perhaps the most absurd statement that I've seen written on this forum to date. How did all of these wonderful advances you mentioned happen?? Was it through the ground breaking research done by CRNAs?? No, these things are developed largely by anesthesiologists and other physicians working in consort with the companies that fund their research. Do you think a drug company just comes up with an idea, develops the drug on their own, gets FDA approval and then it just lands in your anesthesia cart so that you can continue your proud 100 year tradition of safe anesthesia care?
I work side by side everyday with an anesthesiologist responsible for most of the early animal studies on Fentanyl. Another on our faculty was instrumental in developing Milrinone. Another brilliant young cardiac anesthesiologist is fast becoming famous for ground breaking work he is doing in the area of coagulation issues during CPB. The BIS monitor was largely developed thru work done by another one of our attendings - and on and on and on....
How many discoveries that change the way we practice anesthesia everyday have come from the CRNA camp?? How many CRNAs have secured NIH grants for their research?? You get my point??

I'd like to know more about these things too if anyone can answer.

This is really an alarm to me because I thought anyone who was willing to do research and quality improvement, could.

It was my understanding that biochemists, pharmacists, chemists, and biomedical engineers were the ones who "invented" safer drugs, techniques, and machines with the collabortion of research-focused doctors and nurses and that teams of both nurses and doctors were involved with clinical studies and statistics of these medical inventions.

I guess this merits a whole 'nother thread on what nurse anesthetists can do in research or if they can even do research. But I thought that they were able to conduct research too? I mean, personally, I want to be a CRNA someday and if I see that a problem/question comes along in my work area that I think merits research, I think I'd like to be an active participant in solving that problem. I don't want to just sit on my *** and not do/say anything about something I know about. Does this mean that I can't?

zentuit · Jun 18, 2004

I'd like to know more about these things too if anyone can answer.
This is really an alarm to me because I thought anyone who was willing to do research and quality improvement, could.

according to AANA website CRNA's are involved in research. Go to that link and look for the Research sub-heading toward the bottom of the page.

tom

gaspassah · Jun 18, 2004

Do you think a drug company just comes up with an idea, develops the drug on their own, gets FDA approval and then it just lands in your anesthesia cart so that you can continue your proud 100 year tradition of safe anesthesia care?

well yeah i did. drug companies with and without input from physicians work everday to improve the safety and efficacy of the drugs they produce.

what i gather from your rather terse and somewhat inflamatory statement is that without anesthesiologists imput there would be no advance in anesthesia practice or drug safety. who is more absurd.

any company worth their stock price knows "if you make it they will come". make a better volatile agent and people will buy it. make a more stable safe narcotic and people will buy it. i'm sure there is plenty of research by chemist and pharmacologists that are trying to improve drug safety and efficacy without the tutelage of a mda.

That surgeries and anesthesia have become increasingly complex and that while yes, anesthesia is safer now than it has ever been, it is not because the anesthesia itself has gotten easier, but because we know so much more now than we ever have.

read loisannes post then the rest of td's reply.

this statement was in response to loisanns statement that crnas have been performing anesthesia for 100 years without mda supervision. td has made it clear that he believes that anesthesia is the practice of medicine and that crnas should be supervised. i took his statement to mean that as mdas they now believe and "know" that safe anesthesia is to be provided by mda supervised groups. which i disagree with. and that surgeries are more complex now requiring supervision by a mda.... again a statement i would disagree with. if i took this out of contex so be it i apologize. if not i stand by my statements. as absurd or wrong as you aa's believe them to be.

d

TejasDoc · Jun 18, 2004

this statement is right and wrong. the reason anesthesia became so safe had nothing to do with anesthesiologists and supervision, but advances in drugs used ie more cardiac stable meds, monitoring equipment etc. at one time there were no pulse oxs, no ekg, all you had was a blood pressure cuff, your finger to palpate the pulse, and you looked into the patients eyes to try and determine anesthesia plane by pupil size. please do not try to say anesthesiologists were the saving grace of safety in anesthesia care, it just aint so.

So I'm not really sure, what was wrong with that statement that made? I said absolutely nothing about anesthesiologists or supervision, not a thing. All the things you wrote about have to do with increased knowledge, which is exactly what I was talking about. BUT, since you brought it up. While I can't prove that anesthesiologists are not the reason why anesthesia is so much safer now than 100 years ago, I would be surprised if you can prove that is was NOT anesthesiologists. Like I said, I can't prove it, but I could put forth some arguments that would support the possibility. Anyway, I just had to chime in and say that you're putting words in my mouth or you're not reading my posts carefully enough. Either way, if you're going to call me out about something I've said, I should have said it.

only in the sense that someone has to "order" the anesthesia. these doctors are not responsible nor are they involved in the delivery or liability of the anesthesia care.

Why is the word 'order' here in quotes? Does someone actually have to put an order in the chart for anesthesia services to be provided in the states that require physician supervision? Is that the only involvement that they have? If they have to put an actual order in the chart, then I don't understand why 'order' would be in quotes. AND, if they have to put an order in the chart, then I don't understand how they're not liable if something goes wrong and it is determined that anesthesia was at fault. If I'm in the ICU, and I write an order for a dopamine drip, and it is later determined that the dopamine drip killed the patient, I'm screwed. And I wouldn't have administered the drip, the ICU nurse would have administered the drip, but I wrote the order ... sooooooo. But maybe it's a different kind of order, I don't know.

the surgeons have no liability related to anesthesia, this has been shown through countless lawsuits. they operate we anesthetize. they are the doctor of record only to the sense a physician had to "order" (for a lack of a better word) that someone anesthetize the patient. at least this is how it was explained to me.

I don't think we can throw around the word 'order' unless we're talking about a medical order from a physician, as we all know it. From our point of view as health care professionals, physician orders have a very specific meaning, if this isn't the right word, we need to find out what is the right word.

Countless lawsuits ... but not just lawsuits, countless lawsuits ... so, I need a lawsuit to use as a reference. Just one, something I look up, something that is a matter of record in a court of law here in the United States. What would be even better is the precedent setting case in this matter. But since there are countless numbers of them, any really juicy one will do, but I need a real point of reference.

see above 2 posts, i know it's hard to believe but states do not require your services. this is not meant to be ugly but true. the delivery of anesthesia does not have to involve mdas. i know what you THINK is important but law does not agree with you.

I'm glad you also find it hard to believe that all states do not require the services of an anesthesiologist for the provision of anesthesia care. Whew, I didn't think we'd agree on anything. :> Actually, I'm getting the distinct feeling you're not reading my posts. To be totally honest, I don't care. Read my posts, don't read my posts, save 'em, burn 'em, whatever. But if you're going to argue with me about issues that I've already commented on, at least make sure that you're quoting me properly. I didn't say that the states required anesthesiologist supervision, I said some states require PHYSICIAN supervision, and then asked if a physician is in a position to supervise anesthesia care, shouldn't that physician be an anesthesiologist. Now I've said it twice.

what priviledges are you taking about. the priviledge of practicing anesthesia. anesthesia again is not the sole domain of the anesthesiologist. law has shown it is the practice of both nursing and medicine.
again i think this whole argument boils down to a couple of things.
1 mdas think anesthesia belongs to them, no changing your mind you are what you are.
2. IF they have to work with CRNAs then they feel they must supervise.
again you cant change what dont want to be changed.
3. mdas feel a threat to loss income from crna competition, fair enough
4. crnas have and do practice safe anesthesia everyday without input from mdas and without bad outcomes.
5 crnas are not mda wannabees. if i had wanted to be a doctor i would have.
you can see the difference in care provided by each person. i'm not saying better just diff.
but i cant say anything better than loisanne, i'm sure she will respond and clarify, and correct me. i just felt a need to respond to some of these questions.

Ok, it's decided, you're not reading a thing I'm writing. I actually wrote out a list of things and said "Let's just call these 'practice priviledges' to make it easy." So why did you ask what I was talking about? I spelled out specifically what I was talking about and called the group of things I was talking about 'practice priviledges'.

So your post was really just jumping down my case about a bunch of things I didn't actually say. Please let me know if you find those cases, I think they'd make interesting reading.

Gaspassah has done a pretty good job.

Nope, he didn't, he actually did a very bad job. Loisane, you do such a good job posting, your comments are well thought out and well articulated. I'm going to agree with gaspassah on this one and say you've got him beat.

TD

gaspassah · Jun 19, 2004

i read your posts. i may read into your posts, for that i apologize. however i will attempt to justify my comments.

Originally Posted by Loisane

I don't think there is any disagreement that nurse anesthetists were the first health care professionals to specialize in anesthesia. So it follows logically that nurse anesthetists "did it all" without supervision. What we need to determine is when/if did this notion of "supervision" begin?

origninally posted by tejasdoc

You're right, as a group, nurses were the first to specialize in anesthesia. No arguments there. Anesthesiologists and supervisors of anesthesia care did come around later, leaving a gap where nurse anesthetists were not supervised. Having conceded this, will you concede that surgical / anesthesia care in the 21st century bares little resemblence to the surgical / anesthesia care provided during this period where there were very few anesthesiologists? That surgeries and anesthesia have become increasingly complex and that while yes, anesthesia is safer now than it has ever been, it is not because the anesthesia itself has gotten easier, but because we know so much more now than we ever have

i took this to mean that you think anesthesia i much different now in technique as well as delivery. included in this new delivery is the mda model. you have stated earlier that you think crnas should be supervised, i take this to mean that you feel this is a safer method. so when you state we know more now (mdas supervision delivers safer care, better drugs etc. as a whole.) that supervision is important because surgeries are more complex now. again i apologize if this was not the gist of your comment. and if it is not do you believe that a crna can provide quality safe anesthesia outside of the mda supervision model?

as for legal references:

Landmark decisions in Kentucky (1917) and California (1936) established that nurse anesthetists were practicing nursing, not illegally practicing medicine.

In Hughes v. St. Paul Fire and Marine Insurance Company (1981, Louisiana), a physician (who was not a surgeon) instructed a CRNA to attempt nasal intubation on a patient suffering a respiratory crisis. The court found that the doctor was not vicariously liable for the acts of the CRNA since (1) the CRNA was not employed by the doctor, and (2) the doctor did not actually supervise or control the acts of the CRNA.

In Kemalyan v. Henderson (1954, Washington), the court found that the surgeon was not responsible for the negligence of a nurse anesthetist in administering an anesthetic since the surgeon "did not exercise any supervision or control" over the nurse anesthetist.

In Sesselman v. Muhlenberg Hospital (1954, New Jersey), the court found that an obstetrician who gave instructions to a nurse anesthetist, did not become liable for the negligence of the nurse anesthetist.

In cases of this type, courts sometimes impose "primary liability" rather than "vicarious liability" upon the surgeon. The courts find that the surgeon fails to take appropriate action to remedy or minimize harm when there is an anesthesia accident without regard to his responsibility for the actions of a nurse anesthetist or anesthesiologist.

Thus, in Schneider vs. Albert Einstein Medical Center, noted above, (which involved an anesthesiologist) the court also found that the surgeon was negligent in fulfilling his obligation to monitor the patient "regardless of what the anesthesiologist is doing." The court noted that the doctor "could have and should have given orders to cancel the anesthesia attempts when it was apparent that the progress of these procedures was not satisfactory."

Although we do not claim to have read all of the cases, we have not yet come across a case in which a statutory requirement of supervision was the basis of imposing liability on a surgeon for the actions of a nurse anesthetist. In general, it seems that the courts take a "common sense" approach to the issue by finding liability where the surgeon caused or could have prevented the damage either because of his control or because he failed to take remedial measures.

in regard to the "order" reference, a crna is not going to walk into a patients room and put them under general anesthesia. if a dentist wants to use a crna he/she will contract a crna to do it and then ask that crna to perform anesthesia this is the order part. i did not mean that the surgeon orders anesthesia on an order sheet. i think the difference is when a nurse is performing an order in the icu it's a direct action based on the doctors order. anesthesia i guess is more of a consultation for service. i could be wrong, it's been known to happen.

as for rights and priviledges i read your posts and this is all i found:

And if you want to be a CRNA, with all the rights, priviledges, respect and recognition of a CRNA, by all means, good luck, it's a worthly and impressive goal also. But to me, it seems wrong, if you train to be a CRNA and then try to legislate your way to being treated like an anesthesiologist.

CRNAs want the 'practice priviledges' and pay of a anesthesiologist, but instead of going back to medical school and doing a residency, they lobby to have Medicare rules changed, and lobby changes in policy, such as those regarding office based anesthesia, like in Florida (I think).

so....yeah i need a list, spell it out, make it plain for me, or make it easy for yourself, give me the post number, i'm sorry just couldnt find it. if you mean coming up with differential diagnoses, interpreting labs etc, i dont think this is what crnas are out to do. if a patient in the icu desats the nurse should try to diagnose what's wrong before calling the md. ie mucous plug, migrated tube, worsening pulmonary function. there may be nursing interventions that can be made, if not then page the doc. i see this as it applies to anesthesia also.

there are a lot of times here when i feel sad that words do not show tone or inflection of voice. not once did i post anything in response to your comments that i felt was jumping on you, if you felt that way i'm truly sorry. i was just making point counter point.

as for the aa's i always feel like i get a little hostility, so sometimes i return it. that is immature on my part. i know that when you are in the minority in certain situations many things appear hostile. i will also agree there has been hostility in these threads and i for one will attempt to cease any hostile remarks. as adults i think we can have open frank discussions.

so formally, if anyone has taken any of my remarks prior to this point as hostile whether i meant them to be or not,

I apologize. please do not take this as a sign of weakness on my positions because it is not. however my grandmother would shame me for my manners at times.

so this is how i leave it for now. floor open for more discussion.

david student of anesthesia and of life.

:chuckle

susanna · Jun 19, 2004

Exactly what is everybody arguing about? I'd have to go back and read more carefully to get the jist of the argument here I guess but I'm too tired to do that.

Anyways, thanks for redirecting me, zentuit. I kind of posted right after I saw georgia aa's message without thinking because it immediately alarmed me. I forgot that this is a debate.

About the debate: I appreciate debates A LOT and arguements and like reading them. BUT, I hope we're all on the same page here that the best anesthesia provider is the person who strives to and who is able to provide the best anesthetic care, regardless of educational title? We're all in the same boat, even the same legal boat: Everyone in anesthesia is going to have to deal with lawsuits, no matter how good you are or what kind of education you received, this field and this country is just law-suit frenzy filled. That AAs, MDAs, and CRNAs all share the same love for the same field and for the anesthesia community? That we all contribute and sacrafuce equally to the field and that it is useless to say that someone gave more? That, no matter what field you're in, there are going to be people who trying to shove other people around and make other people feel unworthy but that the truly dedicated professionals don't engage in that kind of egotistic rivalry. I hope most people here share most of these perceptions. The personal attacks in some of these posts give me the bad feeling that we really do not.

FNP2B · Jun 19, 2004

i have some ? in regard to salary for CRNA's?

Home Health Columnist / Guide · Jun 19, 2004

personal attacks

our first priority is to the members that have come here because of the flame-free atmosphere we provide. there is a zero-tolerance policy here against personal attacks. we will not tolerate anyone insulting another individual's opinion nor name calling and will ban repeat offenders.

how to handle personal attacks or objectionable material is seen

if you are ever in a position where you feel you have been personally attacked, do not respond to that attack. please report the post using "report this post to a moderator" link found in right hand corner of each post. let us deal with the problem. if you respond to that attack, you may find yourself removed as well, and we don't want to see that happen.

ignore list

if a bb member posts causes you to loose your cool, go to your user profile, miscellaneous section and place their name on the ignore list. this will prevent their posts from being viewable to you. https://allnurses.com/forums/profile.php?do=editlist

giving all posters a chance to review tos and and rethink what they have posted on this thread. personal cleanup appreciated.

smk1, LPN · Jun 19, 2004

i have some ? in regard to salary for CRNA's?

go to http://www.salary.com it will give you a good idea of the salary range for a crna as it will differ the same as any job in different parts of the country.

loisane · Jun 19, 2004

Boy, I turn my back for a moment, and the moderators are in here giving us the "look"! LOL

TD, I too was a little surprised at your reaction to Gaspassah. I guess I made some of the same assumptions that Gasspassah explained in his subsequent response to you. I think most of us are doing a fairly good job of giving and receiving feedback during this discussion.

About history, I did take note of your early comments about putting it in perspective (sort of-yeah but what have you done lately, except you stated it much more professionally). While that was a little difficult for me to hear, I think it was constructive for me to be aware of. We do beat our chest a lot on that, and maybe we should evaluate if we are overdoing it in some instances. I brought history up in this particular discussion for a specific reason. To make a case that CRNAs have never been required to be supervised by anesthesiologists. So I thought it was useful to trace the development of how CRNAs and anesthesiologists first came to work together.

About liability, thank goodness Gasspassah posted a list of relevant court cases, so I didn't have to look them all up! To summarize, what the courts have determined is that liability for anesthesia rests with the anesthesia professional. The standard of care for anesthesia is the same regardless of the professional's licensure. So if there is anesthesia negligence, it is the CRNAs fault, not the surgeon. There is no such thing as "well, if this had been an anesthesiologist, it would be professional negligence, but since it is a CRNA, there is a different standard, and we cannot hold the CRNA responsible."

About safety, we all agree anesthesia is safer now than it used to be. Is it because of better drugs, better monitors, more anesthesiologist involvement, or some other unidentified factor? I agree with you, I don't think we can prove anything one way or the other.

About money, I would never imply in any way that you were motivated by money. But I think there was a particular time in the history of anesthesiology where greed got entirely out of hand, and that was what I was describing.

It may seem like we have gotten far off the original post, but what we are talking about is the function of the ACT, and that was at the heart of the original question. I am going to lay my cards on the table. I enjoy lofty discussions, but it is probably no surprise to anyone here that I have an agenda. My hope is to positively (in my view) influence the opinions of young professionals. Future CRNAs, and since you are here, future anesthesiologists. I think anesthesia in the country is in a heck of a mess. It needs fixed. You young people are our hope. You have to figure out a way to make things better.

Here is what I believe, and what I hope you will come to believe, or at least put in the back of your mind, and ponder on as you collect your own evidence through your professional evolution.

At one time anesthesiology was a noble profession. Those first anesthesiologists treated CRNAs with respect, and the work was amicable. Then money and greed got in the way. Far too many anesthesiologist got drunk on all the money to be made, and these miserable, greedy so-and-sos ruined anesthesiology. It is this greedy legacy that now has hold of ASA leadership, making decisions based purely on economics. They insist that an anesthesiologist be involved in every anesthetic. Completely unnecessary. They say regional anesthesia should only be done by physicians. Ridiculous. You guys need to vote these bums out. They are not leading anesthesiology down the right path. Get rid of them, and return anesthesiology to its noble roots.

You mentioned the term perioperative medicine awhile back. I really like that description. I might picture it differently than you do. Here is my idea of ACT functioning. CRNAs doing all the cases, under full scope of practice. That means they do the preop, do their own inductions, place their own blocks and lines, etc. Anesthesiologists are available for those times when a patient problem needs diagnosed and treated. Does every patient have need for (my view of) "perioperative medicine"? No, many cases could be done without the anesthesiologist ever interacting in any way. Are there cases done when patients have problems, and could benefit from the expertise of an anesthesiologist? Absolutely. Let the CRNAs do the cases, and get the ologist if there is a need. This is a way to make the best use of every team members talents and improve efficiency. It would probably solve the provider shortage.

And the amazing reality is that some ACT indeed function in this way. I have only witnessed it myself a time or two. But I hear repeatedly from CRNAs at meetings, on these forums, etc about how their teams function fine, and what is all the fuss about at the national level. Well, if these CRNA-friendly anesthesiologists would get involved in their professional organization, maybe its policies wouldn't be so out of line with reality.

I say it again, to you, and to anyone listening-VOTE THE BUMS OUT. Reclaim anesthesiology.

Ok, I guess I better get the flamesuit out. Others have taken heat, it is probably my turn. But if there is even one person out there listening, who might look back on this some day and say "You know, that crazy CRNA might have been on to something there", then it will have been worth it.

loisane crna