passgasser

Uberman, just a thought. Quoting radio personalities, particularly when those personalities are as rabid as Savage, is not a particularly good way to get your point across.

I've been wanting to ask this, and this is a good post to lead in: Why this hatred for the wealthy? I'm not wealthy, though as a CRNA I make a pretty good living. Why the vitriol? In most cases, the wealthy became wealthy through their own hard work. They took advantage of opportunities that were presented, and often made their own opportunities. Why resent them for what they earn? Why the presumption that they somehow don't deserve what they earn?

Sorry, but I think you missed my point. This isn't a liberal versus conservative issue. Neither is it an issue of who we will or won't protect. It is an issue that nurses need to be concerned with, but from more than one angle. From a public health viewpoint, this vaccination could be a boon. However, from a freedom standpoint, making it mandatory is troubling. Whatever anyone's feelings about R v W, one thing it did clearly establish was that a woman's body and mind are her own. It made it clear, very correctly I think, that neither the state nor the church have the right to dictate what her beliefs should be, nor have they any right to dictate what she should do with her body. This is a very just and correct standard. I am concerned that by making this vaccination mandatory we would be taking a step back from this standard.

Mandatory. In theory I think this is a good idea. We already mandate certain vaccines for children in order for them to register for school, why not include this vaccine? However, let me play the devil's advocate for a moment. (This is not my argument, but a point made by a co-worker. Nonetheless I think its a very valid argument.) Suppose we require young girls to get this vaccine. Would that not fly in the face of the admitted gains of Roe vs Wade? The fundamental principle on which R v W was argued was that a woman's body was her own, and she was free to choose what to do with her body. Would requirement of this (or any) vaccine constitute government control over our most private concern, our own body? And if such a vaccine were required, could that not be used as an argument against R v W? No argument, just food for thought.

Mark Mostly, I agree with what you write, but would like you to be aware of a few things: 1. You are correct that the first full time anesthesia providers were nurses. But nothing there has been taken from us. A few statistics: In the US today, something like 60% of all anesthetics are administered by CRNA's. In rural areas, that number rises to 95 to 98%. Nurses provide anesthesia services safely, by themselves, all over the country every day. There is nothing new about Anesthesia Assistants. They have been around for at least 20 years, and they do not have the independence that CRNA's have. They must work under the supervision of a MD anesthesiologist. I am under no such restriction. Recent court cases have limited some of the anesthetic procedures they may perform. And they cannot practice in all 50 states. In fact, last time I looked, there were only 5 or 6 states where AA's were allowed to practice. And generally, they get paid about the same as CRNA's working at the same place. But they do not have the opportunity to go to the places that pay non-MD anesthesia providers higher salaries. I guarantee that there are no AA's today earning what I earn. 5. Nurses cannot place ET tubes because they are not trained to do so. It is a physical skill that requires training, experience, and finesse. Someone without adequate training stumbling around an airway can make a bad situation far worse. Not to say that nurses could not be trained on intubation, they can. But, like many skills, it is one that requires frequent use to stay competent. Most nurses simply won't get the necessary intubations to keep the skill current. I do it several times, every day. It ain't as easy as it looks.

But, as someone else pointed out in another thread, a national healthcare system would serve only to expand that which admittedly frustrates you.

OK, first of all, liability issues. Someone here claimed that liability insurance for healthcare providers would actually fall under a universal healthcare system, since people would be reluctant to sue the federal government. You might be correct, except that your fundamental premise is incorrect. Look at it this way: If you suffer damages from medical malpractice, do you sue your health care insurance provider? Of course not, you sue the health care provider that caused you harm. Without significant changes in liability laws, that would remain unchanged under any universal healthcare plan. So, my original argument stands. While reimbursement, and therefore salary for healthcare providers would fall, liability insurance would not. There are places, for example some counties in the South, where malpractice insurance has climbed so high for OB doctors, none practice there because they cannot hope to earn enough money just to cover their malpractice premiums. Since income for us will fall under a universal healthcare plan, there will be even more areas where it makes no financial sense for specialty practitioners to go. So, in the name of provision of health care for all, you just reduced the availability of health care to portions of our population. Next, I challenged anyone to name a federal bureaucracy that is efficiently managed. HM2Viking first listed the Social Security Administration. To begin with, the web site to which we were sent was a transcript of testimony before the Senate by a gentleman who was against the privatization of Social Security, so one cannot really consider the source to be at all unbiased. But, even if we take this testimony at face value, consider this. I am in my late 40's, and have been paying in to social security since I was 14. I hope to retire in about 20 years. Every report I have seen suggests that in my retirement planning, I would be foolish to consider any income from social security, since it will likely be bankrupt by then. Just how efficient can the administration of social security be when it is in such dire financial condition? As to Tricare or the VA, having had experience with both, I'd like to see some reference to indicate that either is well administered. Tricare was born out of a promise made then broken to our soldiers, sailors, airmen and marines. The promise was that in return for service to the country, service members would have free medical and dental care for both themselves and their families during their service. When the military medical services became overburdened, first CHAMPUS, then Tricare were born. Both were based on the model of the insurance industry, and both required co-payments. Hardly the free health care we were promised. As to the VA, it is notorious among veterans for inefficiency, rudeness, excessively long waits, and antiquated facilities and equipment. (Yes, there are facilities that are exceptions, but they are the exception, not the rule.) I've never yet been to a VA Regional Center that didn't have twice the number of administrative personnel over the number of health care providers. I also want to quickly address the constitutional provision about providing for the "general welfare." This term does not mean welfare as that word is commonly used today. In fact, welfare as it is defined today did not even exist at the time the document was written. What we now call "welfare" was then called "charity." In using the term "general welfare," constitutional authors had in mind the creation of a society with opportunities, unfettered by silly governmental interference, where one could make a living and prosper in accordance with just how hard one was willing to work. They most certainly did not mean that government had a responsibility to act as a safety net for those who did not wish to work as hard. And without a doubt, they did not intend to confer rights on one group of people at the expense of another group. Such a thought was anathema to those who sought to escape a government that would enrich itself on the backs of others.

Newman University, Wichita Kansas. All clinical sites in Wichita.

More later on other points, but did want to address this. I'd be more inclined to accept this argument if there was a strong nurses' union in the US. In many parts of the country, there are no nursing unions whatsoever, and the national organization that purports to represent us all, the ANA, has absolutely no "huevos" either. Yet US nurses clearly outearn their British counterparts.

Have not blown the discussion off. Lots of call in the last few days has reduced my online time. I'll be back.

One other point. I tend to think more in concrete terms, rather than the abstract. So, I do not view "redistribution of wealth" in the abstract of "leveling the playing field." I see it in the concrete "we are going to take money from you to give to others who don't make as much as you." I am a CRNA, and I earn quite a good living. I refuse to feel guilty for that, neither will I apologize for it. I worked VERY hard to get where I am, with the intent of being able to provide a certain life for both myself and my family. I take a dim view of those would tell me that my hard work means nothing, and that I should give up a significant portion of what I earn for "others." I often give of both my talent and my money. In so doing, I decide where that donation will go, where it will do the most good. I'll be damned if the government is going to force me to do so.

Most of this response will be directed at the comments made by Bluesky, though I will also include what others have written. Forgive the length of this post. You claim that most of my points are based on imagination. Not so. They are based on the examples of what has happened elsewhere (i.e. nursing salaries in Britian) and on the history of how the federal government (mis)manages every federal program. I do not make "extensive use of the European and Canadian systems as bases for what would be." I did point out that in every country where some kind of government supported universal health care program has been established, taxes have had to be raised to 50% and higher. Now, if you think our government can enact a federally mandated and supported health care program, costing multi-billions of dollars a year without raising our taxes, please enlighten me. We are already deficit spending. I also drew the comparison between nursing salaries in nations with universal health care and our nation. Again, if you can show me how our government can shoulder this burden without reducing health care workers salaries, I'm all ears. As to government management of the system, considering things like the welfare system (60% of every dollar received goes to maintaining the bureaucracy, while only 40% goes towards actual welfare payments), I think it safe to assume that a federal healthcare bureaucracy would do no better. I still challenge you to show me one federal bureaucracy that is efficiently run, that could be used as a model for a healthcare bureaucracy. By extension, it stands to reason that a monolithic health care bureaucracy would lead to the same kinds of red tape and frustration that every other federal program has. You need look no further than the posts of those who relate personal anecdotes of their frustration with the current system. In one case, a poster has been fighting the system for over a year and still does not have the federal assistance required. And you want to foist this system on ALL of us? Is net income a measure of quality of life? For some people it is, and for some people it isn't. But I do think it's safe to state that for everyone, net income is certainly a contributor to the overall quality of life. Therefore, an across the board reduction of net income would certainly have an impact on everyone's quality of life, don't you think? Especially in light of the fact that for the majority of us, what we are doing now is working, bringing me to a major point of my argument: Those who support the idea of a "universal healthcare program" point to the fact that 15% of the people in this nation do not have health care coverage. In citing that statistic, there are a couple of things they don't want you to notice. First, the statistic talks about those without health care coverage. That in no way equates to not having any healthcare whatsoever. More importantly, though, those who cite the statistic do not want you to do the simple math. If 15% are without healthcare coverage of any type, that means a whopping 85% of our nation has health care coverage of some kind or another. Name for me if you can any other system that to one degree or another meets the needs of 85% of our population, particularly one we consider to be a failure. I'm running out of time, but wanted to get to one quote of yours: "Simply, the justifiable crux of your argument is quite simple. You represent the opinion of a group of Americans who believe that sharing their own wealth in a systematic, organized way to alleviate the suffering of others is neither necessary nor American." You are correct. The "sharing of wealth" that you talk of is not "American." Neither is it constitutional. It is socialism, pure and simple. Socialism, on the scale of which you speak, is demonstrably harmful to the economy, and more to the point, it flies in the face of the principles of the US Constitution. If YOU want to trade YOUR BMW to help others, you are free to do so, and I laud you for it. However, neither you nor government has the right to force all of us to do so. The constitution forbids it.

whoever told you this was wrong. this patient was suffering from etoh withdrawal, not ropivacaine toxicity. overdoses of local anesthetics do not lead to this kind of behavior, they lead to cardiac arrhythmias and seizures. toxicity to local anesthetics is seen within seconds to minutes following the administration of the dose, not three days later. for more information, see http://www.manbit.com/oa/c4.htm. this patient was suffering from dt's.

Arguments (or lack thereof) before notwithstanding, consider what would possibly be the worst effects of creating a national healthcare program. Think of the federally administered programs now in existence. Now, try to come up with just one that has not become a bloated bureaucratic behemoth. Try to come up with one that does not spend more in administering itself than it spends in actual aid of whatever kind. You can't, because no such program exists. Now, try to think of one program that is rapidly responsive to the people it serves. Again, there is no such animal. Why not? Because programs administered by the federal government are truly accountable to no one. "You want what we have? You'll have to wait for it." At least insurance companies are accountable to two different populations. First, to their customers, in that if they are not responsive, the customers go elsewhere. Loss of business makes them have to answer to their second population, the investors. Who does the federal government respond to? The voters? Show me one federally funded program that has been changed significantly because of an election. Some in this thread have already posted about how difficult it is currently to get healthcare they are qualified for from the government. You want to turn all of healthcare into that nightmare? Finally, consider the bureaucratic red tape you would face from such a program. Again, name for me one federally administered program that does not involve reams of paperwork, all of which is rejected if just one "t" is not crossed. Make all the claims you want about a federally funded healthcare program. However, the federal government has proven time and again that it simply cannot administer any social program efficiently or effectively. You may look to the future with hope, but historically I see only despair.

Neither. Also a very poor debating tactic. You claim my arguments are erroneous, yet fail to demonstrate a single error. So, since you can't debate the points, you attack the one who made the points.

Who said anything about eliminating medicare? But your second post was more telling. You listed the salaries of CEO's in four major health insurance companies. Are those salaries exorbitant? Perhaps, but they are what the market will bear. More to the point though, is this: If you were to add up all the salaries of all the CEO's of all the health insurance companies, hospitals, and managed care companies, you would have a sum that would end up being a very small drop in the very large bucket of health care dollars spent in the US. So the point is ultimately moot. Moreover, you may feel that you (and all other nurses) are worth more than what they are being paid. I'd agree with you. However, so long as your solution to the problem is to cut CEO salaries, you are spinning your wheels. Organization and cohesion are the answers to that problem, things nurses are historically very bad at. All of which is very interesting. It is also irrelevant to the topic under discussion, which is whether we need universal health care. My contention is that we do not, and in fact a government run universal health care plan would be disasterous. Let me reask the questions I posed earlier: Are you willing to continue doing what you do now for 20 to 50% less than what you currently earn? Are you willing to see your taxes rise to take 50% of your earnings before you ever see a dime? If the answer to these two questions is yes, what lifestyle changes are you willing to make to make this happen? Are you willing to give up home ownership? How about giving up the newer car you may have? Are you willing to see the federal government grow yet again to encompass the needs of such a program? Are you willing to give up yet another bit of your privacy to the federal government in order to see such a program enacted? Are you willing to see more and more healthcare rationing? Are you willing to tell the family "Sorry, I know you love grandma, but federal regulations say that at 75, she is simply too old to warrant ICU care?"

One other issue: If you think I painted a bleak picture for nursing, consider the situation for physicians and nurse practitioners. We too will see a reduction in salary. On top of that, folks like John Edwards, who have made their fortune through malpractice law, are not about to allow that system to change. Therefore, while salaries will go down, malpractice premiums will continue unchanged. There are already places in this nation where the malpractice premiums for certain specialties are higher than what the provider can possibly earn in a year. That's only going to get worse. Add it all up, and I can easily forsee an exodus of health care workers to other professions. That will make our current (mythical) healthcare crisis look like gentle summer breeze next to a Kansas tornado.

OK, I have to weigh in on this. To paraphrase the manta of the conservatives during the Clinton administration, if universal health care is the answer, the question must have been exceedingly stupid, and for a number of reasons. To begin with, let's examine the question of nursing salaries. One poster stated that if we are to enact universal healthcare, that we (nurses) must be prepared to accept serious cuts in salary. Others asked that poster to back up that statement. I'll do so, happily. To begin with, as pointed out by Caroladybell, it is unreasonable to expect that reductions in reimbursement will affect everyone except nurses. We will ALL take a salary hit. I look no further than Great Britain, where universal health care is the norm, to demonstrate. One nurse that I work with came to the US from England. According to this gentleman, the average nurse's salary there is only marginally greater than the average salary paid to McDonald's employees. How many of you are willing to continue at your present jobs for anywhere from 20 to 50% less than what you are currently making? But it goes further. Since our federal government will be forced to pay for the health care of all citizens, it will have to raise our taxes. I believe that the average rate of taxation in countries that fulfill this mythical social contract is around 50%. So, not only will you see a reduction in salary, the government is going to take more of the smaller amount you make to pay for everyone else's health care. Think about that for a minute, and think about what you currently own. Will you be able, on that reduced salary, to make your current payments? Will you be able to continue to live the lifestyle to which you have become accustomed? Most nurses I know won't. They will have to sell homes, cars, furniture, whatever, in order to reduce their debt load. On top of that, they will have to accept living in smaller apartments, driving older cars, and bargain shopping for everything, which will probably be the best they can afford. And if you have student loans, well, you are just toast. Or are we as nurses being greedy in our expectations, and should we be willing to accept these cuts? Threads on salary seem to suggest this is not the case. But there are other problems with the idea of universal health care. Think every dollar collected for such a program will go to the provision of health care? Think again. Consider the behemoth that is our welfare system. For every tax dollar that is collected for welfare, only something like 40 cents goes out in actual aid. The other 60 cents goes towards maintaining the bureaucracy that has been set up to administer the programs. Universal health care will be no different. How many of you are concerned with the supposed loss of privacy you have endured under the present administration? That's going to get a lot worse. The federal government is not going to just pay for your health care without some knowledge of why the money is being spent. In other words, the federal government will maintain health care records on all of us. And those records will be available to any other federal agency, because we now have laws about records sharing between federal agencies. Just think. The FBI will be able to access your health record with nothing more than a memo, rather than the current warrant that is required. And we still have not discussed things like rationing of health care, which will occur. Neither have we discussed the waiting periods that will occur. The arguments against such a program just go on and on. No thank you, I'd just as soon the federal government stayed out of health care. Let me end by suggesting something really radical: Perhaps, just perhaps if uninsured=financial ruin, then maybe one should do what one must to maintain health insurance rather than expect the rest of us to carry the burden.

Absolutely correct. In fact, I work so little that I now have no stress in my life. I don't even need to sleep anymore. I don't lift patients, I don't run through the hospital to codes. Heck, most days I don't even move at all. Again, absolutely correct. I can't remember how many times as a staff RN in the ICU I gave drugs to induce unconsciousness in a patient, intubated the patient, then kept the patient alive while 20 different things were causing that patient's hemodynamic state to be in a constant state of flux. Of course, in the ICU as a staff RN, I was the one making the decisions about what drugs would best suit the patient, when the patient needed blood, and so forth. And I sure don't like to think of myself as a nurse. That's why I hide the initials RN between a "C" and an "A." Man, you really have us pegged. I've worked in hospitals without MDA's, and got paid a six figure salary to come in every day and discuss with the surgeon what kind of cases we would be doing that day if we just had an anesthesiologist. But, we didn't have one, so we of course couldn't do any surgery. So, after the discussion, usually at about 7:30, I'd go home and be on call. When something came in that needed emergent treatment, I'd go in and discuss with the physician what I'd do for the patient if there were an anesthesiologist on staff. Even now, when I work in a hospital with only one -ologist, the poor guy never gets to leave the hospital, cause I'm just a trained monkey, who can't induce anesthesia without him holding my hand. Can't do any epidurals either, unless he's standing right over me.

For those not quite as fast on the draw, this is exactly my point. Normally, I don't care about spelling mistakes. But, in the same vein, perhaps when a man says "we're pregnant," rather than being gritchy about the "we" aspect, perhaps we should just be grateful that there will be a child born with a daddy who claims them, and by all appearances will be there for them. So, "get over it." But perhaps not. Perhaps we should all just vent about our little pet peeves, ignoring the larger issues.

I would guess it would make you just a little less angry after working with me for one day on call. I do epidurals for pregnant women and girls every week for whom the only contribution to the pregnancy or raising of the child was the few cc's of semen they contributed at conception. Haven't been seen or heard from since. Mom's going to raise that baby with no emotional, financial, or any other kind of support from the "baby daddy." At least the men from the "we're pregnant" crowd are there and taking their responsibilities seriously. By the way, I've looked. I can't seem to find the definition for the word "diffinition." Any help?

While the article posted does seem to give a balanced perspective without taking sides, it also demonstrates exactly why I and other anesthesia providers know RN administered propofol sedation is such a bad idea: I don't know any anesthesia provider who would agree with such a blanket statement. The first question I would ask is why is the patient ASA III or IV? There are some patients, particularly cardiac patients, who will be ASA III or IV, for whom propofol at any clinically useful dose is a particularly bad idea. Making such a blanket statement is both foolish and dangerous. It all goes back to what I and others have said: When it comes to the administration of propofol, or any other anesthetic drug, you don't even know what you don't know.

Your first error is to assume that you may use propofol for "conscious sedation." In any clinically useful dose, propofol renders the patient unconscious and unresponsive, and therefore exceeds the boundaries of "conscious sedation." Your second error is to rely on what BON's have determined is acceptable. There are also multiple BON's who have stated that administration of propofol IV push on an unintubated patient exceeds the practice boundaries of the staff RN. Bottom line here is that you need to read the package insert for propofol. It doesn't much matter which manufacturer you choose, because they all say the same thing: Propofol, when administered IV to an unintubated patient, is safe only in the hands of an educated, experienced anesthesia provider. So, if you have a bad outcome with RN administered propofol, you have no defense. After all, the manufacturer has clearly stated that the practice you are following is unsafe. Your third (and perhaps most egregious) error is to point to the faster turnover times with propofol. In other words, I can get 'em in and get 'em out quicker, increasing volume, hence increasing profit. And by having an RN administer the drug rather than an anesthetist, I can further increase my profit by being able bill for the anesthesia services provided. Wonderful. You are sacrificing patient safety for the sake of money. Your fourth error is to tell us all that your are OK with doing this because patients are asking for it. Patients ask for a lot of things that may not be in their best interest. They ask for these things assuming that you will provide it safely. Next time you discuss this with a patient, allow me to recommend you be honest with that patient. Tell them this: "We do have RN’s who administer propofol, which will render you unconscious. However, the manufacturer does not recommend this practice, and recommends that propofol be given to patients like yourself by experienced anesthesia providers. If we proceed with this course of action, there is an increased risk to yourself, because the RN is neither trained or experienced in provision of anesthesia, and if you get into trouble, the RN may not be able or adept at getting you out of that trouble. Additionally, the RN won’t have the requisite rescue drugs and equipment readily at hand, as an anesthesia provider would. In short, because we choose to have RN’s give anesthesia rather than educated, experienced anesthesia providers, your risk for a bad outcome, including aspiration, prolonged ventilation, brain damage, and death, rise significantly." Given the facts, see just how many of these patients wish to proceed.

The simple answer to your question is yes, in many places Endo RN's are administering anesthesia. The fact is that any time you give propofol IV push to a non-intubated patient, you are administering anesthesiia. And if you are an RN who is not a CRNA, you are not qualified to do so, disclaimers about "annual competencies" and "ACLS certification" not withstanding. These RN's are taking an enormous risk with their licences, with their liability, and worst of all, with their patients' lives. So, why are they doing so? In the end, it isn't about patient comfort (though that may be the nurse's goal), nor is it about saving the patient money. It is about maximizing the profit for the GI doc, period. If he or she can convince the RN that they can safely give an anesthetic, they can charge for the sedation as well as for the procedure. Worse, I've never yet met a GI doc who was competent to administer an anesthetic, so if there is a severe problem, the doc won't have the slightest idea what to do. Leaving the RN, and worse, the patient, swinging in the breeze.

tntrn First of all, rational or not, your fears are real to you. As an anesthesia provider, I recognize that fact, and have dealt with this very situation several times. I would not dismiss your fears, neither would I ignore them. You have the right to an anesthesia provider who would, at the very least, sit and discuss your fears with you to try to relieve you of some of the stress you are experiencing. Though you would never elect to have a c-section, both of us know that there are times where a c-section, though neither emergent or urgent, is medically indicated. For example, if a woman has had a prior c-section, and is presented with all the facts regarding VBAC vs repeat c-section, it is perfectly valid for her, and medically sound for her OB doc, to decide not to take the risks associated with VBAC. I actually took care of such a woman, who because of the emergent nature of the situation with her first child, had to be put to sleep for that section. She presented for a repeat section, and she had many of the same fears you have regarding neuraxial anesthesia. In my interview with her, after taking her history, I told her we would be doing a spinal technique for her second section. She let her fears be known, and I had a long talk with her about the various kinds of anesthesia, and why general anesthesia for c-sections was reserved for only truly emergent cases. (This discussion lasted a good 30 minutes.) I answered all of her questions, and by the time we were done, she elected to have the section, with the spinal I recommended. The point of this little story is to let you know that I never dismiss a patient's fears out of hand, but I also never allow a patient to steer a clearly dangerous course, when safer options are available. That's why I went to school for such a long period of time. I would far rather deal with a patient's psych issues, both in the pre-operative interview, and during the section, than to deal with a woman who has aspirated, or worse got into a can't ventilate, can't intubate situation because I allowed her to dictate anesthetic technique over my better judgement.