Is the AA profession gaining ground?

deepz · Apr 4, 2006

....What is called into question is not the didactic education but the lack of clinical experience and hands on pt care before you are pushing dangerous drugs and shoving tubes and lines in people, and making critical descisions........

This is exactly on target, Nitecap, and is what escapes many. As is often said, the first two years of an orificethesiolgy residency are largely spent trying to teach the doctors to act like nurses.

http://www.gaspasser.com/unique.html

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georgia_aa · Apr 4, 2006

As is often said, the first two years of an orificethesiolgy residency are largely spent trying to teach the doctors to act like nurses.
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By whom - nurses??

lmdscd · Apr 4, 2006

Why not nurses sounds good. JWK you always site reports but how about the reports that say crna's are as safe as doc, and if so you are arguing then you are as safe as doc so go tell them you want to practice on your own . :idea:

EMS/ICU/SRNA · Apr 4, 2006

I have read all of the AA/CRNA debate threads with great interest as I will soon be entering anesthesia school and ultimately the profession of anesthesia. The big debate seems to be preparation and experience prior to entering anesthesia school whether CRNA or AA. I do not know how to not take the AAs' comments as insults. Are they saying that the nurses on this forum and the nurses that they hand their pt's over to in the ICU and PACU know nothing? Do you really believe that you learn everything that a CRNA does in two years? The CRNA has a minimum of 6 years of focused education learning how to care for pts. (excludes the requisite acute care experience) AA's have 2. And to address one more recurrent theme... AA students may have experience prior to entering AA school. The CRNA student must have experience. Maybe I am missing something in the AAs' arguments ...........................JMHO

jwk · Apr 4, 2006

I have read all of the AA/CRNA debate threads with great interest as I will soon be entering anesthesia school and ultimately the profession of anesthesia. The big debate seems to be preparation and experience prior to entering anesthesia school whether CRNA or AA. I do not know how to not take the AAs' comments as insults. Are they saying that the nurses on this forum and the nurses that they hand their pt's over to in the ICU and PACU know nothing? Do you really believe that you learn everything that a CRNA does in two years? The CRNA has a minimum of 6 years of focused education learning how to care for pts. (excludes the requisite acute care experience) AA's have 2. And to address one more recurrent theme... AA students may have experience prior to entering AA school. The CRNA student must have experience. Maybe I am missing something in the AAs' arguments ...........................JMHO

Let's not pretend that every course you take in nursing school relates to patient care, so this "6 years of focused education learning how to care for pts" is misleading at best.

We're not trying to insult anyone. If you take it that way, that's your problem, not mine. Do you see where I've made the statement that nurses don't know anything? Nope.

You don't see me trying to abolish the CRNA profession because 2/3 of the ones currently in practice have less education than I do. If you use the logic that nursing experience is required for anesthesia, you've already blown that argument since most MD's aren't nurses first. The debate about preparation and experience is within the CRNA group, not mine. We've already settled that debate. AA's have been in practice for 35 years - it's not like we're some brand new profession with no track record. We've demonstrated over those 35+ years that AA's are safe and competent providers. (let's count how many posts before someone brings up the CRNA's and 100 years argument - and BTW, Crawford Long and William Morton were not nurses - they were physicians - oops, there goes that "nurses were first and the MD's stole it from us" argument as well).

These arguments have been bantered about for years, and we see it every time we make a move to enter another state to practice. It's a money and competition issue. Always has been, always will be. The experience issue is a smokescreen. So is the education issue. So is the "there's no anesthesia provider shortage, we don't need AA's" vs. the "there's an anesthesia provider shortage and we need state/federal money for a CRNA school" issue. The same for the "no anesthesiologist in the county" (and no hospital either) argument. All of these are smokescreens for the real concern of CRNA's - money and competition. It really is that simple in the end.

georgia_aa · Apr 4, 2006

Do you really believe that you learn everything that a CRNA does in two years?

Absolutely I do. I know it for a fact because I did it.

Nitecap · Apr 4, 2006

And many AAs aren't nurses before beginning their anesthesia training and it doesn't seem to be affecting the level of care that THEY provide. So why are you right and I'm so wrong. OF COURSE, it's not the degree that makes the provider a great clinician. I actually agree with you on that point. Masters prepared or certificate, it's the persons intellect and work ethic that ultimately determines how they'll function in the stress filled and often fast paced environment of the OR.
Let me ask you this - where did you get your experience before you started taking care of patients in the ICU? I mean, surely you weren't pushing all of those dangerous drugs and titrating drips and taking care of those incredibly sick patients with no prior clinical experience were you? Maybe all ICU nurses should be nursing assistants first so that they will have clinical experience before entering the acute care environment of the ICU. Oh wait - you went to NURSING SCHOOL with didactic and clinical rotations BEFORE you entered the ICU as a bonafide licensed practitioner. AAs get 2 solid years of hands-on direct patient care proctored by practicing AAs and MDAs before they are ever left alone in the OR.
We've already proven that you don't have to have a nursing background to be an anesthetist. I think that it just galls you guys that there is a shorter path to the same goal. Just because you have to jump through all of those hoops that your nursing profession places in front of you, doesn't mean that I have to.
I maintain that each and every one of you great CRNAs would have been just fine had you entered CRNA school right out of nursing school. Maybe not right away, but ultimately - yes. I know it, and I think you know it too - you just can't say it.

You are right about a few things. Yes when I entered a large Cardiothoracic ICU fresh out of nursing school I was a bit clueless about many things. I felt like this and I even worked as a PCA in a PACU for about a 350 bed regional hospital. I had really just done simple things such as draw blood, hook pts up to monitors, zero lines ect but it did help some. So being that I had pushed narcotics and gave a ton of routine IV/PO/IM drugs in nursing school and worked in PACU for over a year I had a little exposure. Thats said when I started in a CT unit recovering fresh CABS and Valves straight out I was clueless at first. It required time and extra studying to get more proficient and yes eventually I did. Like I said an AA/CRNA of ten years are prob equal as far as their abilities and knowledge. Im just talking about students and new grads. I see the PA students at my program. They are just learning how to assess a pt. Just learing how to interpret ecg's, just learing medical terminology they have never titrated drugs, never titrated epidurals, never done even simple things like suction an ETT, never placed a stethoscope on a pt, never given any drug, never assessed lab values, never volume resuscitated a pt, never coded a pt. Though some of these skills may be more simple than others they all take practice which comes with experience and time.

Here is my solution to this debate so here me out.

We take Case Western which has both CRNA and AA programs, or gather any SRNA's/AA students based on a few variables. We review the students educational and clinical experience back grounds and place numeric values to both. We then take them to a pt simulator and let a neutral person, that as no idea whether you are a SRNA or AA, run the same scenario on each student. It has to be a simulator that has predetermined ranked priorities of the needed interventions and that grades the student on how they intervene so solve the problems with the case. Of course all students compared would have to be at equal levels within their respective programs.

We can then compare many things such as:

1-A SRNA with 1 month OR exp vs the AA at the same level

2-Senior SRNA's vs AA's

3-The AA with calc and organinc chem vs. a SRNA that doesnt

4-The SRNA with 5yrs of intense ICU experience vs the srna with 6months ICU exp vs the AA that was a 4th grade teacher and has no exp - could assess all diff levels 1st yr thru seniors within their programs using this variable.

Again each student would get the same cases. We could even tone the cases down to the students level of anesthesia experience giving maybe a less complicated case to the SRNA/AA with 1 month OR exp vs the SRNA/AA students that are about to graduate.

what do you think? Of course there would be many kinks to work out but it could theoretically work and if done on an adequate sample size could give some pretty good data being that the computer would generate the numbers and the priorities of interventions would be predetermined. This could prevent many of the biases that we here of other comparative studies from all sides on these issues. Sounds like a realistic study that could happen.

MmacFN · Apr 4, 2006

not to stir the pot but....

Here is the thing. From talking to many CRNAs and MDs over the past few months comming through my ACLS and PALS classes they all readily admitt that 99% of cases are straight forward and uneventful.

However, its the 1% of cases that you train for. That is where the RN background will be invaluable when the patient crashes and the **** hits the fan. Ive literally coded thousands of patients, managed multiple drips and titrated them to a fine balance in a crisis. AAs will never have this experience as it isnt something that can be taught in an educational setting. It is a skill and mindset, learned through YEARS of experience and patient management.

Will that matter in 99% of cases? Absolutely not. That easily explains the numbers you see in the study. What you want to do is take cases that went wrong when a crisis happened how each reacts and works. This is where you will see the difference that only experience can give.

georgia_aa · Apr 4, 2006

However, its the 1% of cases that you train for. That is where the RN background will be invaluable when the patient crashes and the **** hits the fan. Ive literally coded thousands of patients, managed multiple drips and titrated them to a fine balance in a crisis. AAs will never have this experience as it isnt something that can be taught in an educational setting. It is a skill and mindset, learned through YEARS of experience and patient management.

Mike - thank you for the kind words in your earlier post. That being said, I take issue with your statement that ""AAs will never have this experience.."

I, too, have coded many,many patients. I practice in a large academic city hospital where the acuity level is very high. I do primarily cardiac anesthesia and work with one of the pre-eminent off-pump heart surgeons in the world. Let me tell you, when you ligate the left main and try to sew a graft to it, very scary things can happen - ischemia, ectopy, full arrest. We commonly have to code our open heart patients right in the middle of their distals. Why is your experience more valuable than mine. Could I do it right out of school?? No, probably not. But now, with 16 years under my belt there isn't anything that you have seen that I haven't dealt with either - I promise you.

georgia_aa · Apr 4, 2006

Like I said an AA/CRNA of ten years are prob equal as far as their abilities and knowledge. Im just talking about students and new grads. I see the PA students at my program. They are just learning how to assess a pt. Just learing how to interpret ecg's, just learing medical terminology they have never titrated drugs, never titrated epidurals, never done even simple things like suction an ETT, never placed a stethoscope on a pt, never given any drug, never assessed lab values, never volume resuscitated a pt, never coded a pt. Though some of these skills may be more simple than others they all take practice which comes with experience and time.

You get no argument from me on this. I have stated numerous times that the CRNA right out of school probably has an advantage over the new AA grad. But after 5 years you would not be able to tell them apart. I'll take it one step further and say that if that new CRNA grad goes to a small outpatient center and does knee scopes all day and the AA grad goes to a major center and does cardiac and major vascular cases all day, that the AA will be superior in terms of skills, knowledge, and ability after those same 5 years.

Please understand that I am not making these statements out of sheer supposition like many of you on this board. I have worked with CRNAs for years and years. When we hire a CRNA who has worked in surgi-centers or other low-acuity settings, they are quite overwhelmed when they get here believe me. Some of them will gravitate to the outpatient surgery center and stay there while others will eventually get to where they are comfortable doing the bigger cases. We currently have 8 CRNAs in our group right now and not a single one of them does cardiac. Not because we won't let them - they simply don't want to do it.

EMS/ICU/SRNA · Apr 4, 2006

Absolutely I do. I know it for a fact because I did it.

You are an RN who went to CRNA school then went to AA school? If that were the case do you think that you would have an objective assessment of AA education having already been educated as a CRNA?

MmacFN · Apr 4, 2006

Hey Georgia

I agree. I think the largest gap is in the begging and then it totally depends on the kind of cases you decide to do (or are avalaible in your area) as an AA. If its all "bread and butter" cases, codes will be rare and the experience will never build. All falls back to experience, clearly you have gotten good experience. However, i wouldnt want my first code experience to be in the OR on my first solo case, know what i mean? I cut my teeth surrounded by VERY experienced RNs slowly integrating me into the high risk/critical stuff. I had backup as a new learner and then became others backups based on my clinical ability and experience. That isnt happening in the OR. Ive never met a surgeon who knew anything about codes or drugs in general. That leaves the onus on the guy/girl at the head of the bed to run the code and make the critical decisions.

I think we are on the same page :)

Mike - thank you for the kind words in your earlier post. That being said, I take issue with your statement that ""AAs will never have this experience.."
I, too, have coded many,many patients. I practice in a large academic city hospital where the acuity level is very high. I do primarily cardiac anesthesia and work with one of the pre-eminent off-pump heart surgeons in the world. Let me tell you, when you ligate the left main and try to sew a graft to it, very scary things can happen - ischemia, ectopy, full arrest. We commonly have to code our open heart patients right in the middle of their distals. Why is your experience more valuable than mine. Could I do it right out of school?? No, probably not. But now, with 16 years under my belt there isn't anything that you have seen that I haven't dealt with either - I promise you.