MD vs CRNA

See old post.

I believe the question is and should be are you a nurse or a dr? You have been trained as a nurse already. Do you identify with the patient advocate thing. Are you the one that puts the siderails up? Do you go toe to toe with the docs to get the right thing done? Or do you find yourself pining to wright orders and to go to classes on how to be a jerk? The other day I'm doing CABAGs with a resident. At the end of the case he said to me "thanks for all the good work, you really know your stuff, and how come you always have the right things ready for the job at hand/ You always have a marker/scissors/clamp/right drug ready. I replied it comes from 7 years of nursing and having to support docs that never took classes in chart finding. Also remember I have those years of sperience while he has sat in classes up to this point. Not better, just different. I believe docs are docs and nurses are nurses. CRNAs are not almost docs remember. The courts have consistently held you have as much right to admin anesthesia as Mds. The perscription for anesthesia is implied by the surgeon when it books the case. Now, decide if your soul/heart is in nursing or would you rather doctor.

Wow, great response, Dave. Couldn't have said it better myself!

this is in response to wntrmute2

1) do you identify with the patient advocate thing...

since when did nurses lasso in patient advocacy as their contribution to medicine? patient advocacy belongs to anybody who provides care to patients: that includes the transporter who makes sure that the patients arms don't bang into anything, to the nurse who removes restraints when they are no longer needed, to the doctor who tries to provide the best patient management possible

2) are you the one who puts the siderails up??? how does that define the difference between a nurse and a doctor? sure, there have been times where i have forgotten to put up the siderails... but there have also been times where a nurse bolused somebody with 50,000 units of heparin...mistakes do happen, some are worse than others, and as a team we provide the cross-coverage to minimize those accidents.

3) do you go toe to toe with a doctor to get the right thing done? if nurses always knew what the right thing is, then we wouldn't need medical school, residency, fellowships to provide appropriate medical care... now every once in a while, a nurse will be in a situation where he/she is working with a new intern or a new doctor or a medical student or an attending who just happens to be new to the hospital, and that new person may not be familiar with a few things... this is the nurses opportunity to assist in the learning process of the medical provider, and not an opportunity to go toe to toe... why are you so confrontational?

4) do you find yourself pining to write orders and go to classes on how to become a jerk?

you must have had some rotten experiences if you are surrounded by jerks... i find it hard to believe that patients will pay money to be treated by jerks... and by the way, doctors do more than write orders - in fact, in the past doctors didn't write orders at all as they usually performed the tasks for which orders are currently written. the reason we have the current system is because the case load of patients is vastly greater than in the past, and writing orders creates efficiency...

5) i have those years of "sperience" while he (doctor) sat in classes to this point...

hmmm i wonder how many nurses sit through classes to become a nurse? well surprise, the same goes for doctors... and then during internship/residency/fellowship the hospital becomes the classroom

6) the courts have consistently held that CRNAs can administer anesthesia... phew, finally wntrmute comes up with something coherent. yes, the courts (as do I) feel that CRNAs provide excellent anesthesia

7) the "prescription" for anesthesia is implied by the surgeon who books the case... wrong! if that were the case, we wouldn't need anesthesia consents.... The surgeon books the case based on surgical disease, the CRNA or the MDA will then decide if the patient is a candidate for surgery (only the CRNA/MDA can decide that - not the surgeon). CRNAs/MDAs are consultants in the hospital and as such we provide consultant anesthetic care, our service is never implied.

now in response to the earlier question MDA vs CRNA:

if you want to practice anesthesia from an advanced nursing point of view - become a CRNA, if you want to practice anesthesia from a medical point of view - become a MDA. two different trainings that allow for safe anesthesia... the big differences reside in length of training (or length of sacrifice - :) ), the broadness of knowledge base and critical care management.

good luck with your choice, and please don't go to wntrmute's hospital because you will end up having to go toe to toe with people who go to class on how to become a jerk and who can't remember to put up siderails

a patient advocate (or else i wouldn't have spent my twenties and half my thirties earning 6 bucks an hour, working 110 hours a week, getting a day off every 4 to 6 weeks just for the pleasure of providing medical care)

tenesmus

tenesmus

Actually, any nurse who has worked in an ICU spends quite a bit of time trying to get the appropriate orders for their patient. Not from residents and interns, but from the internists, family practice, (insert specialty here) docs, who admit patients to the ICU with no clue about how to manage a critically ill patient and, an ego to large to allow them to consult someone who does.

Granted, I have worked in a few facilities that required a consult for patients admitted to ICU's. Then and only then, did I not spend at least some part of everday trying to get appropriate care.

1)when did nurses lasso in patient advocacy as their contribution to medicine

One of the central tenents of nursing is defined as patient advocacy. It is considered part of the job. My experience of 8 years of nursing is that the nurse USUALLY is the one that insures pt safety, sees that families are cared for. Certainly not exculsivly. I didn't claim it but being a patient advocate is part of what nursing does.

2) are you the one who puts the siderails up??? how does that define the difference between a nurse and a doctor?

Metaphor possibly?

3)do you go toe to toe with a doctor to get the right thing done? if nurses always knew what the right thing is.

Well I'm talking about being strong enough to overcome that subservient role nurses are in in their relationship with docs. Occasionally one of us is convinced that a patient may be too unstable to travel, that the resident shouldn't attempt another line insertion after the first 3 failed etc. My point is that nurses are different than Drs and the questioner must decide who he or she is. I didn't claim that confrontation is desireable, just that a nurse needs to be confident and strong enough to stand up when needed.

4) i find it hard to believe that patients will pay money to be treated by jerks.

Happens all the time. Rude doctors are not unusual. I'm not sure that you know all the times families and patients complain about the Dr. that just walked out but excuse it because techincally he/she is good. The CV surgeons frequently throw stuff, yell at the staff, start cutting thru sternums with absolutly no notice. (it is possible I am attending to hypotension arrhytmias or something equally as important as DR S. just begins sawing). The other day a MDA struck a student, someone else went after someone with a PNS. I've been called "useless" or was that "worthless". I have been blamed for the loss of perfusion in the right arm as a different CV surgeon is pressing on the innominate artery during a mediastinoscopy. This isn't to say nurses are all sweet and kindness. But methinks most observers would agree with my position.

5) and then during internship/residency/fellowship the hospital becomes the classroom

Absolutely, that's my point. This resident had a much better knowledge base at this point but I had a better clinical base. I happened to experiece more, not know more. At this point I knew that what was causing the ST changes was air entering the RCA that was trapped in the heart during a MVR because I've seen it and it was only a concept he had read about up until this point.

6) We agree.

7) "prescription" for anesthesia is implied by the surgeon who books the case... wrong! if that were the case, we wouldn't need anesthesia consents.... The surgeon books the case based on surgical disease, the CRNA or the MDA will then decide if the patient is a candidate for surgery.

I believe that the consent is what allows you to procede. From a CRNA's POV, the surgeon is giving an "order" to a specialty trained nurse to administer an appropriate anesthesia. This is how the Assoc. of Nurse Anesthetists view it if i am reading their legal colums correctly. It also happens to be what protects the surgeon from being legally responsible in an adverse anesthesia outcome event. I think that we are deciding whether we will administer an anesthetic, not deciding whether the patient is a candidate for surgery as you claim. I believe as nurses we couldn't just put someone to sleep without a DR. needing to do surgery, run an uncomfortable test etc. Maybe Dr.s can.

On the essential question, decide if you are a nurse or a doctor, there is a difference that extendes further than training.

i see where you are coming from but i still have one point of contention left over...

i really, really hope that it isn't the policy of the AANA to follow surgeon's "orders" to provide anesthetic... surgeons are not trained to clear patients for surgery, they are not trained in

pre-oping a patient. If they plan on doing surgery, we as anesthetists (regardless of whether MDA or CRNA) have to certify this patient ok for surgery. Examples range from patient is a diabetic with a new bundle branch block in the past few days to the patient with a family history of an adverse reaction to anesthesia (but the patient is unsure of the cause of the adverse reaction) - for elective cases you as the anesthesia provider will end up in court if something happens in the OR... now of course, if the patient is set for an emergent surgical procedure, you are then dispelled of that liability and all you can do is provide the safest anesthesia possible (for the 1st example, use only drugs that are not cardiac depressants - induce with etomidate, run a nitrous anesthetic, etc... for the 2nd example, assume the relative had MH and use a volatile free cart and run TIVA, but be ready for anaphylaxis to any of the drugs given).... so there is never an order to perform surgery, and you will be on the safe side of the law if you tell the surgeon you won't provide anesthesia until all issues are cleared up...

i have an excellent example of a good CRNA doing just that: we had a patient who was coming in for a knee arthroscopy (pretty straightforward, right?), but with some odd symptoms (sounding like hyperthyroid) and with an undetectable level of TSH... she refused to provide the anesthesia, i backed her up and told the surgeon that we need this evaluated... the surgeon was upset, and decided to provide his own local anesthetic and forego any anesthetist in the room... guess what, the patient went asystolic in the recovery room... thank goodness she was brought back after 20 minutes of coding her... can you imagine the check the surgeon would have written to her family, especially if the lawyers got hold of anesthesia's charting regarding the non-viability of the case!!!!

and out of curiosity why are those doctors still allowed to work if they behave that way??? they can be charged with assault and battery, and kicked out of your hospital faster than anything... our hospital (a big academic center with a lot of big egos) doesn't tolerate any bad behavior....

I don't really know why this kind of behavior is tolerated. I guess it is left over from the old days. I will not be staying there once I graduate.

The other point regarding surgeons "ordering" the anesthetic is not an order for you to give an anesthetic. I agree we all have the obligation to evaluate/clear the patient for anesthesia. We frequently decide to postpone/cancel surgery for medical reasons. However, this is from the AANA's General Counsel:

>"Part of the confusion over whether the practice of nurse anesthesia is the practice of medicine is whether nurse anesthetists "prescribe" anesthetic agents. In most institutions, no one fills out a prescription blank for the anesthetics. Does this mean the CRNA is prescribing? The law governing the healthcare field is interpreted in such a way as to give great latitude to healthcare professionals to work out their own procedures. Since most surgery cannot be performed without anesthesia, scheduling a patient for surgery is generally equivalent to the prescription of anesthesia. This can only be done by a physician."

Remember, it is the nurses obligation to NOT follow orders they believe will cause harm to the patient. So despite a "prescription" to provide anesthesia. The CRNA may refuse to fill that prescription in the same way a MD would. This brings us back to the patient advocacy issue.

BTW, I have heard that the term MDA is considered by docs to be derogatory, have you heard of this? I happen to not use the term as I feel I'm being slightly insulting.

MDA isn't insulting/derogatory in any way....

tenesmus