foraneman

If the MD tells a patient that he is putting the patient to sleep and that a "nurse" will be "monitoring" them, and then fails to in fact administer the anesthetic in its entirety from induction to emergence, and/or the "nurse" is involved in the administration of the anesthesia beyond simple "monitoring", the MD has committed fraud and can be held liable for their misrepresentation to the patient. Should there be an untoward event the MDA will have no defense to a claim from the patient that he lied to the patient as to who would be substantially involved in the administration of the anesthetic. He would in fact likely take on the liability of the CRNA where no such responsibility would have existed before. From a liability standpoint such an approach is monumentally stupid. Not to mention unethical and void of any patient oriented reasoning.

I wholeheartedly endorse my alma mater, St. Elizabeth Health Center/Youngstown State Univ School of Anesthesia in Youngstown Ohio. Not until some years after graduating did I come to realize that there can be GREAT disparity in clinical experience between programs. At the Youngstown program all clinicals are at the same site, a Level 1 Trauma Center with high risk OB, pediatric, heart, transplant, neuro, ortho, vascular, chest, outpatient, etc., etc. all under the same roof. You will far exceed ALL minimum numbers for ALL procedures. There are NO anesthesia residents and CRNA class size is limited. You will do as many regional anesthetics, central lines, nerve blocks as your heart desires. Tuition and cost of living in Youngstown is as low as it gets as an added bonus.

"When you were done with school were you confident that you knew what you were doing?" YES

Individuals who are "mac Blade users" always find that they have to abandon their blade of choice in certain patients and grab the miller blade. "Miller blade users" NEVER find they have to abandon their preferred instrument in favor of a mac. I am a 'miller man' in the interest of full disclosure, so much so that it is beyond me why anyone ever uses a mac blade. I can still say objectively that a miller blade is a MUST when you have any of these situations: limited mouth opening, limited neck extension, small mouths relative to head size, overbites, poor Mallampati score, poor dentition with significant danger of knocking a tooth out on laryngoscopy. And "using a mac like a miller" to lift the epiglottis certainly is a valid technique but it will not change the result in most cases. Your solution? Use a miller blade....some of us use it 100% of the time.

I agree...unless you want to work in a large university academic center setting doing the most challenging of cases across many disciplines, using the most cutting edge technology, and be able to teach students, participate in research, etc. Then you are rather stuck with one form/severity of ACT or another.

Agree with all of the above and would add: A lack of peer review feedback. No immediate colleagues to review and discuss cases with.

Your CRNA practice can be as routine and mundane or as challenging and stimulating as you desire. Your choice of employment setting AND your personal initiative within that setting determine it. I have worked in a world renowned academic trauma specialty anesthesia department with arguably one of the most CRNA friendly and respecting collegiate Anesthesia Care Team practices possible, where the CRNA yielded great autonomy and decision making in every aspect of the anesthesia care of the most critically ill patient's imaginable. I have also worked in another well know academic department of anesthesia which had an oppressive Anesthesia Care Team practice where the anesthesiologist expected to be consulted before a CRNA administered pharmacology to lower a patient's blood pressure, or administered a unit of blood. In the second setting, which came along after years of practice in the first followed by more years of independent practice as a sole provider, there were 40 Anesthesia Assistants and 5 CRNAs. The ACT was clearly designed to fulfill the required-by-law direct supervision of AAs by anesthesiologists. Whether I continued employment in the department was not a worry of mine. I could take it or leave it and I was not going to allow myself to be "belittled" or micro managed if they wanted me to stay, which they did. On my second day I was 'floating' with the AA who was assigned to post-ops and carried the code/trauma/intubation pager. So I got my tour of the large inner city Level 1 Trauma Center as we did post ops (where I found a patient who had two broken tibias with external fixation, no BM for 7 days and abdominal pain, with a bed pan lying on her lap in great expectation...first 'let me help you treat this pt correctly' moment, not 8 am yet). Before the day was half over, how my CRNA practice would be defined for the remainder of my next two years there was made clear, by me, with two more events. The pager went off and we were called to the trauma OR for a patient coming from the ER as an emergency. I do not recall the mechanism of injury, only that it was either a chest or abdomen and the patient was clearly in hypovolemic shock. There was myself and two AAs in the room and the patient was intubated. While they were connecting the monitors and taking care of the usual transition to the OR/anesthesia machine stuff I took note of the need for better IV access the situation demanded and grabbed a Cordis Introducer, quickly prepped the groin knowing in minutes the drapes would prevent access to a large volume line site below the injury location, and inserted it into the femoral vein, tossed in a stitch, done in 2-3 min. I hear "What are you doing!!?" and look up to see sheer terror in the eyes of one of the AAs. "I put in a femoral Cordis." He desperately exclaims "We don't do that here!" "You don't use femoral Cordises here? Why not?", was my reply. "No, no. WE don't put them in! Only the attending can do that!" he gasped, looking around as if he feared that at any moment every anesthesiologist in the building would burst through the doors to drag us all out and arrest us. "Well THIS is gonna be interesting" I said to myself, my mask hiding the smile on my face. Attending comes in, drapes go up, myself and my AA tour guide go off to our nest assignment leaving the nerve wracked AA and attending with the case. A few hours later we answer a page for a head injury pt in the neuro ICU who has extubated himself. Due to swelling he has limited jaw opening and neck extension and it is clear he is not going to make it sans endotracheal tube, so we will reintubate. Must call the attending first. "OK, you call the attending and I will get everything ready so that we can get on with it when she walks in", says I. She arrives, tosses me an understandable "who the hell are you" glance as she scours my badge with a scowl. Not much is said as it is made clear that I am welcome to hush up while she and the AA handle things. The AA attempts the intubation a number of times unsucessfully. The attending calls down to the OR for the fiberoptic scope. As we wait I introduce myself to the attending and ask he if she would like me to take a look while we wait. The patient is stable and being bagged. "Nope". Another minute or two go by. "One of us might as well look. Who knows? A different blade or perspective and this could be over...couldn't hurt", I offer in a friendly, light tone. "No. We will wait for the fiberoptic." comes the 'I do the thinking' toned response. I roll my eyes and go sit in a chair in the corner of the room. "I may not stay until dinnertime" I point out to myself in inner dialogue. At the same time I am also in my "Well THIS is gonna be interesting" mode. Fiberoptic is brought up by an anesthesia tech. Wrong one, too short...not the tech, the fiberoptic. A Trauma surgery attending is now in the room and the anesthesia attending says to her let's prep for a trach. Now everyone is running about doing just that. "And THIS is exactly how and when bad shite is unnecessarily created" my inner alarm bell screams. So I get up and nonchalantly walk back to the head of the bed as gowns are hurriedly being put on and the betadine is hitting skin. "Seriously, let's have a second person take one more look before we cut this guys throat" I suggest, not with any suggestion of a mere friendly opinion. "No." comes the reply, without even a glance my way. Well, I think to myself, 'I didn't really care if I ever ate the cafeteria food here anyway', and I place my bare hand on the betadine prepped neck..a few gasps, and before the trauma surgeon can say a word I say to the attending "We cannot do a bedside trach on a patient who has only had the least experienced anesthesia person in the room attempt an intubation with the wrong laryngoscope blade. While they reprep let me look. If I cannot intubate this patient then I will immediately quit." Sounds bold, but the blade used was a MacIntosh, notoriously difficult for a limited jaw/neck mobility situation, and the patient simply was not one I would peg as a difficult intubation based on lots of experience intubation trauma patients....and at that point I had had it and really would have quit. "Fine, it's on you"..whatever that was supposed to mean, was the reply. Patient quickly intubated on first try, Miller blade. Surgeon thanks the attending. "Well IS gonna be interesting" I think, mask again hiding my smile. Attending turns to me and says "well I gotta go back downstairs, don't forget to write this up in the chart." "Not me", I reply, "I couldn't begin to explain in writing what just went on in here, and I guarantee you would prefer it if I did not." And out the door I went. The events of the day of course spread quickly within the department. Not one to wait for others to form the outcome of important things and then tell me about it, I took the dept MDA Chief aside in the hall a bit later and, ignoring the entire ICU incident since I figured "I DARE someone to criticize me on that", I asked, "Hey, what's this I hear about CRNAs no being allowed to insert central lines here?" Well, it's not that they are not allowed. No one has ever asked to before. Technically the AAs and CRNAs have privileges to do so, but only the AAs who do the hearts ever do them.", he replied. "I put a femoral Cordis in a trauma this morning, so you can add me to the list." "I bet THAT raised a few eyebrows." he chuckled, and that was that. From then on I treated the patients, without delay, as needed, and informed the attendings as soon as reasonably possible. Patient needs blood but not urgently? Sure, I'll give you a call if that is the sort of thing you want me to bother you with. But no, I will not delay urgent care trying to find you. Within a month or two it became clear each attending had their own version of the ACT, which became even another version specific to me...a 'what are you calling me for, get on with it version'. My point: If as a CRNA you are feeling marginalized, lacking respect, unappreciated, unchallenged, bored, etc., you generally have willingly placed yourself in that position and in the end have no one to blame but yourself. Even in the WORST of practice settings you play a part....though the fact that you are IN one of those settings is usually the first thing you can and should change. From everything you have said, I think that you would find being a CRNA a very rewarding career which, for you, would likely be a specialized one of your own making based on the challenges of the position you seek, rather than the paycheck from, say, an outpatient eye clinic. The only other career move that comes to mind which it sounds like you might enjoy is a critical care Nurse Practitioner in a setting where the NPs are used similar to residents in the ICU. These do exist.

I have never heard the term "MDA" used in anything even remotely approaching a derogatory or disrespectful connotation in 25+ years. It is simply a shortcut for saying anesthesiologist, and frankly it is used almost exclusively amongst CRNAs and MDAs, as well as some OR staff for just that reason. If we say it to other colleagues or patients they have no idea what we are talking about. So how and to whom using it would 'devalue' their education I have no idea.

I realize that I am a bit late to the conversation but hopefully this will still be helpful to someone when they read it. First a bit about the Florida Intervention Project For Nurses (IPN): The Intervention Project for Nurses (IPN) was established in 1983 through legislative action to ensure public health and safety through a program that provides close monitoring of nurses who are unsafe to practice due to impairment as a result of misuse or abuse of alcohol or drugs, or both, or due to a mental or physical condition which could affect the licensee's ability to practice with skill and safety. The IPN defines Impairment as the following: Impairment is a condition that results from the use of mind/mood altering substances, distorted thought processes found in the psychologically impaired or a physical condition that prevents the nurse from providing safe patient care. Impairment is characterized by the inability to carry out the professional duties and responsibilities in a reasonable manner consistent with nursing standards. The IPN does not itself provide evaluation or treatment of potentially impaired nurses. It DOES provide referrals to appropriate medical professionals once some one is reported to, or self reports to, the IPN. Some basic facts on the structure and policies/procedures of the IPN: 1. IPN is NOT part of the board of nursing and the board of nursing DOE NOT get access to your records at the IPN without your permission. 2. The IPN program is CONFIDENTIAL, is NOT a disciplinary program and CANNOT restrict, suspend, revoke or place on probation, your license. 3. Any person suspecting impairment of a nurse's ability to provide safe nursing care may report this nurse to IPN and/or the Dept of Health(Board of Nursing). Under Florida's Mandatory Reporting Law, all licensed nurses must report any suspected impairment in practice to IPN and/or the Dept of Health. The Board of Nursing is the most frequent 'person' or entity that makes referrals of nurses to the IPN. This serves two purposes. First, it often serves as a confidential, non-public, action in lieu of discipline, and second it results in the nurse undergoing a medical evaluation, treatment recommendations, and appropriate treatment of any mental of physical impairment they may have. 4. A nurse may self report to the IPN. Participation is ALWAYS voluntary regardless of who makes the report. HOWEVER, if you are reported to the IPN, are referred to the IPN by the Board, or you self report, and then you fail to follow the recommendations for evaluation and treatment the IPN gives you, you WILL BE REPORTED TO THE BOARD OF NURSING. Failure to comply with IPN recommendations is usually presumed to be a violation of the nurse practice act, by the Board, and you will now have to defend yourself at an administrative hearing before the Board of Nursing. Once you find yourself in a hearing before the Board regarding an issue of whether or not you are impaired in your practice of nursing, your license is at risk no matter how right you think you are. 5. If you have a physical or mental impairment which affects your ability to practice to the standard of care expected in nursing, your supervisors, colleagues, employer and patients can make a valid complaint to the Board of Nursing. They are not required to report you to the IPN instead of the BON. While most people reported for an impairment to the BON are then referred to the IPN, this is NOT mandatory. In other words, depending on the circumstances and the current mood of the Board, you may NOT be offered the confidential in lieu of discipline option of entering the IPN. And in THAT case you will have your issues held before the Board who may then choose one or more of the following: No action. A fine. Placing your license on probation. Suspending your license. Revoking your license. Requiring you to complete CEUs in a relevant area. Any action taken will be public record accessible by anyone with access to the internet and the BON website. 6. Participation in the IPN obfuscates the need for a disciplinary hearing, and takes the options for actions against your license off the table. It also guarantees confidentiality. 7. If you are in fact impaired in some way, your best choice is almost always to self report to the IPN if given the option. An employer MAY give you x number of days to self report to the IPN, advising you that should you fail to do so they will report you to the BON. NEVER self report an issue of impairment to the BON. ALWAYS report these issues ONLY to the IPN. What can you expect after self reporting to the IPN? A case manger will interview you and then recommend: 1. No further action necessary (highly unlikely). 2. Referral to an appropriate physician, by name, for an evaluation as to whether an impairment exists. #. The evaluating physician will them make a diagnosis if appropriate, and any appropriate recommendations for treatment (you may be given a clean bill of health with no further recommended actions). If a diagnosis of an impairment IS made, you MUST follow and complete the recommended treatment. failure to do so will result in your being reported to the BON for your failure to comply with the IPN. You will then find yourself in that disciplinary hearing. If you DO comply with the requirements and recommendations of the IPN your case is closed and the BON NEVER EVER sees the file or hears of your participation with the IPN. Hopefully this is not as confusing as I worry it may be. All of this is off the top of my head.

There is some information and perspective here that may help: KY 17th State To Opt Out CRNA Physician Supervision Requirement

"She was then asked to submit a urine test which came back positive for marijuana. This was because she smoked at a party a few weeks before." Actually, more like a few DAYS before.

PRO: Apparently eases your conscience or something since recertification is not dependent on membership. Giving something to the organization that "does a lot for our profession in general". Paying 50% of your already relatively low cost dues. CON: Living with yourself being cheap. Ignoring efforts by the AANA on behalf of military CRNAs, of which there are many. Pretending your profession in general and practice in the military are somehow separate.

Agreeing with everyone else. You never know how this might come back to bite you. I assume these classes would have been possible credit towards your BS? And that the school which granted you your degree would have accepted the credits had you passed and asked them to? If yes you should be honest and explain the situation. It should not hurt you. If NO, these were not credits taken towards your BS since your degree school would never had accepted them then in my view you do not have to report them....it would be similar to having taken a pottery class at the county extension center.

While I did not want to make a career out of the ICU, I did enjoy it...but ONLY when I had the sickest patients. But if you are not keen on doing ICU for a year I don't think anesthesia is for you. There is a HUGE bit of learning to do in the ICU before you are ready to be a CRNA and if you are not eating that up then anesthesia is not gonna strike you any better I am afraid.

There is almost NOTHING similar between an AA and a PA. PAs are FAR FAR better educated and clinically trained. They also have FAR more autonomy and responsibility.