Can't our PR crews from AANA and state associations reach these people? If the subtitle of this article is true why then have we allowed states to opt out?
If you go on to read the article, it is not bad, it is the title that fires me up a little, especially when my relatives who get their health info from time magazine are asking me about it.
So, are we saying anyone receiving versed requires a CRNA or MD anesthesiologist to deliver it since it can cause apnea just as propofol can? If so, then most office procedures and all EGD/colonoscopies would require the presence of an anesthesia provider....can we really supply the manpower for such a requirement? And of course the cost of a simple procedure would now escalate significantly due to a requirement of anesthesia providers presence...
My points are 1. we cannot afford in the US to have CRNAs/MDAs present for every use of what we lovingly call "MAC" anesthesia or what medicare calls "moderate sedation: CPT 99144" 2. even if it were affordable, we cannot provide the manpower to do so 3. the use of artificially contrived divisions of what anesthetic drug is to be used for what purpose and by whom it may be used defies reality and represents an elitist protectionism of turf without any scientific evidence of improved safety. 4. if non certified anesthesia providers are to use sedation, then they do need to follow ASA guidelines, be ACLS certified, have all necessary resuscitation and support equipment immediately available, and have staff that are ACLS trained with knowledge of where resuscitation drugs and equipment are located.
We all want patients to be safe during procedures, but there has to be a balance between health economics, optimal use of certified providers where needed and the perceived torture of patients when no anesthesia is given due to excessively restrictive policies or positions.
I do agree with what you are saying. An RN with ACLS giving versed for a scope is one thing. I have personally been approached by surgeons asking how they could get by doing procedures in their offices, which traditionally have been done under GA or big MAC. Do we need to draw some lines in the sand? How much do we let the patient experience because the doc wants to do this in his office? It is perfectly acceptable to do a colonoscopy with no sedation. If the patient doesn't mind that is. The problem is that the procedures seem to be crossing the barrier.
For example.... A surgeon talked a woman into having a procedure normally done under GA, done under local. This was not a local procedure. The pt and doc both told me that they wanted no sedation. I educated the pt on the probable discomfort. Two minutes into the procedure she was yelling. I asked if I could intervene. The pt agreed. The surgeon protested. In a bit of a post conference with the MD, his motives were clear. He wanted to start doing these in his office, without sedation.
No it is not feasible to provide anesthesia for every colonscopy and wart removal. And an RN pushing some mid is ok too. But how long before its a med tech pushing diprivan for veins? Defining anesthetics drugs, and who can use them is far from elitist. It in fact is what we do. If we don't have a say in patient safety as pertains to the safety of pharma, then who does? I know surgeons who would let dietary sedate patients as long as the case went on time. Most HMO's would let a chimp do the anesthesia if it cost less.
Elitist turf protection in the eyes of people motivated by cash, possibly. Patient protection in the eyes of an anesthetist, always.
Once you start waving that flag, the interrogative corollary becomes "SHOW ME THE DATA". Since you have none (other than anecdotal case reports that lack any semblance of scientific significance), you are relegated to the role of a shrill protestor that appears to be more of an interloper than a clinician. This is the very conundrum that besets all of us that adopt a position rendered untenable through failure to prove our case. I actually agree with your sentiments, but point out in a rhetorical fashion the difficulties that exist when arguing in a vacuum. Our experience and training in these realms is less important than the science behind our assertions. EBM increasingly determines our modus operandi, including the appropriate venue for delivery of a specific anesthetic. The difficulty we face is anesthesia in the 21st century is just too damned safe to be able to gather statistical data on significant differences in outcomes. And frankly, given a physical therapist or chiropractor or hospital orderly the tools and minimal training needed to deliver an anesthetic, 99.9% of the time they would probably have outcomes equivalent to that of CRNAs or MDAs. It is because of the existence of the small fractions of a percent of uncertainty that the professions of CRNAs or MD anesthesiology can be justified. We live in a land where the null hypothesis cannot be proven, where the few times that patient vital signs spiral out of control are best handled by a seasoned professional, or where the few cases with special needs can be managed by those with exposure to thousands of challenging cases. Ours is a profession whose value is measured not by improvement of patient condition, but by maintenance. One of my mentors once said "Anesthesiology is a sobering profession. We can never make anyone better, we can only make them worse." And in general, he was correct.
So perhaps we should endeavor to demonstrate via other means the appropriate venue or use of anesthetics, since evidence based medicine is not the statistical friend of patient safety measurements in delivery of anesthesia.
Perhaps it is YOU who doesn't know how to properly bag a patient.
In the MIUC/SICU where I work, EVERYONE (MDs RNs, RTs) knows how to bag a patient. Are you for real?
What do you do for a living?
You think you know how to bag-mask ventilate, but you don't. Proper mask ventilation can be quite difficult. Most RNs and RTs I see are TERRIBLE at it in the ICU or anywhere. Anesthesia providers are the only people I know who can do this well.
Perhaps it is YOU who doesn't know how to properly bag a patient.
In the MIUC/SICU where I work, EVERYONE (MDs RNs, RTs) knows how to bag a patient. Are you for real?
What do you do for a living?
Hey Aquaphone,
I'm not questioning your own abilities here, but I think it's possible that there may be some confusion about 'bagging' and what jwk is suggesting.
He was referring to the use of a mask to bag a patient, not bagging via an ETT. Sc is right, it can be a difficult skill and some pt's are harder to mask ventilate than others. I just find it very hard to believe that all the RNs, RTs and MDs in you unit have an opportunity to MASK ventilate patients on a regular enough basis to be highly proficient at it. As a CRNA, I still run into patients who are a challenge to mask.
Feel free to correct me if I'm way off base here...
You think you know how to bag-mask ventilate, but you don't. Proper mask ventilation can be quite difficult. Most RNs and RTs I see are TERRIBLE at it in the ICU or anywhere. Anesthesia providers are the only people I know who can do this well.
Allright, I apologise. I think I was perceiving your comments insulting and therefore I missed your point.
Certainly most everyone in my ICU can keep a patient alive with a BVM. Wether or not we're properly ventilating is another matter.
It suprises me that you would say RTs tend to be terrible at it. After all, they're the ones who do it the most. I would think they would cover that subject quite extensively in their training. I wouldn't know.
Is manual ventilation emphasized to a great extent in anesthesia training?
I will discuss this with the anesthesiology residents who work in my unit. We don't have any nurse anesthetists in the SICU/MICU, so I can't ask them.
In the mean time, can you give any recommendations as far as how to properly bag a patient? Any websites/articles?
While you're at it, how would YOU define proper manual ventilation?
To answer a couple of your questions, yes manual ventilation is heavily emphasized in anesthesia training. It is an invaluable skill for all anesthestists. Once we induce patients, unless we're doing a rapid sequence intubation, everyone gets mask ventilated for at least 45 seconds and up to 3 minutes depending on which muscle relaxant we use. Some have shorter onset than others and we mask ventilate until the muscle relaxant takes effect, then we intubate.
It takes a lot of practice for most folks to get good at it. First, you have to get a good seal of the mask over the mouth and nose. Then you have to do a simultaneous chin lift-jaw thrust maneuver. It's the same skill they teach in ACLS exept its much different on a real patient. I was always taught to "pull" the patients face up into the mask, rather than smash the mask down onto the patients face. You can do this 1 handed or 2 handed. If you do the 2 handed technique, you need to have a 2nd person to do the bagging part.
With the one handed technique, your thumb and index finger of your left hand form a 'C' shape on the top of the mask and your middle and ring fingers are placed just under the patients mandible and your pinky is placed along the angle of the jaw near the TM joint. It feels really awkward the first few times you do it and your hand tires quickly. It can be a little more difficult for women to get used to b/c they tend to have smaller hands. At least, it was for me b/c I'm female.
Once the mask and patient are positioned, you bag them with your right hand. Like I said before, this skill is imperative in anesthesia. If you have a patient you can't intubate for some reason (difficult airway) but you can mask them, this will save their life until you either wake them up or try other advanced airway interventions.
I hope that helps a little! You should see about trying to get a chance to go hang out with a CRNA or MDA for a day and try to learn this technique if you're interested.
It never ceases to amaze me when I walk in on a code or a resp distress situation and find the RN or the RT standing at the side of the bed with the AMBU and mask on the pt's face. This is what we are talking about when we say most non anesthesia providers do not bag correctly. I fail to see how you can open the airway from the side of the bed. The RT hate it when we come and take over the bagging from them but our reason for doing it is that we can tell from a mile off that the pt is not being ventilated. It is one thing to place a mask on the pt, but another thing to see the chest going up and down.
paindoc
169 Posts
So, are we saying anyone receiving versed requires a CRNA or MD anesthesiologist to deliver it since it can cause apnea just as propofol can? If so, then most office procedures and all EGD/colonoscopies would require the presence of an anesthesia provider....can we really supply the manpower for such a requirement? And of course the cost of a simple procedure would now escalate significantly due to a requirement of anesthesia providers presence...
My points are 1. we cannot afford in the US to have CRNAs/MDAs present for every use of what we lovingly call "MAC" anesthesia or what medicare calls "moderate sedation: CPT 99144" 2. even if it were affordable, we cannot provide the manpower to do so 3. the use of artificially contrived divisions of what anesthetic drug is to be used for what purpose and by whom it may be used defies reality and represents an elitist protectionism of turf without any scientific evidence of improved safety. 4. if non certified anesthesia providers are to use sedation, then they do need to follow ASA guidelines, be ACLS certified, have all necessary resuscitation and support equipment immediately available, and have staff that are ACLS trained with knowledge of where resuscitation drugs and equipment are located.
We all want patients to be safe during procedures, but there has to be a balance between health economics, optimal use of certified providers where needed and the perceived torture of patients when no anesthesia is given due to excessively restrictive policies or positions.