neveragain

This state law still SAYS that anesthesia may be provided by "a CRNA who is UNDER THE DIRECTION of the operating practitioner or (UNDER THE DIRECTION) of a qualified physician who is immediately available if needed." Sorry for being so dense, but the phrase "under the direction" could be construed as "under the supervision" couldn't it? If I am "under the direction or supervision" of somebody higher up in the food chain than I am, it means they tell me what they want and I make it happen. I have some leeway in complying with their wishes, but I can't unilaterally decide that I am going to do something other than what they want. There is usually somebody nearby that makes sure that what I'm doing is satisfactory, and who can give me a hand if something goes wrong. I am not saying that the "director/supervisor Dr." is breathing down the neck of the CRNA, any more than my supervisor monitors every single thing *I* do. The language of either the federal regulation which I quote elsewhere or the state regulation quoted here by Paindoc, doesn't really lend itself to the interpretation that CRNA's are autonomous and beyond the purview of a Doctor... and that this is some kind of "billing" law. I don't really see anything in this law as it is written that specifies that this is only to be used for billing purposes. Maybe there is a difference in medical parlance as opposed to "the rest of us." That being said, I am choosing to read the law as written in the strictest interpretation, that it means EXACTLY what it says; that a CRNA, unless otherwise exempted, MUST be (federal) or IS (state) under the direction/supervision of a physician, whether an operating practitioner (MD of some kind, surgeon, OBGYN etc.) or another physician (MD) who is immediately available. What I quoted is a federal regulation pertaining to CRNA supervision. It is also the law in Indiana where Paindoc got the legislation pertaining to CRNA direction that appears here. I hope we are not going to argue what "is" is...:)

Wow, so this FEDERAL LAW has absolutely nothing to do with supervision as it states, only billing, which it says nothing about. So this LAW actually means that it is giving people permission to BILL for supervision without actually having to supervise? Call me crazy, but *I* believe the law says what it says and means exactly what it says. I will have to call my congressman in DC and get back to you... No wonder health care is so expensive. Billing for supervision when there isn't a supervisor is not right. Having a law which clearly states that CRNA's must be supervised but is merely a billing tool is bizarre in my mind.

42CFR (civil federal regulations) 485.639 - Condition of participation: Surgical services (2) In those cases in which a CRNA administers the anesthesia, the anesthetist must be under the supervision of the operating practitioner except as provided in paragraph (e) of this section. An anesthesiologist's assistant who administers anesthesia must be under the supervision of an anesthesiologist. (e) Standard: State exemption. (1) A CAH may be exempted from the requirement for physician supervision of CRNAs as described in paragraph ©(2) of this section, if the State in which the CAH is located submits a letter to CMS signed by the Governor, following consultation with the State's Boards of Medicine and Nursing, requesting exemption from physician supervision for CRNAs. The letter from the Governor must attest that he or she has consulted with the State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interests of the State's citizens to opt-out of the current physician supervision requirement, and that the opt-out is consistent with State law.

42CFR485.639 ©(2) In those cases in which a CRNA administers the anesthesia, the anesthetist must be under the supervision of the operating practitioner except as provided in paragraph (e) of this section. An anesthesiologist's assistant who administers anesthesia must be under the supervision of an anesthesiologist. (e) Standard: State exemption. (1) A CAH may be exempted from the requirement for physician supervision of CRNAs as described in paragraph ©(2) of this section, if the State in which the CAH is located submits a letter to CMS signed by the Governor, following consultation with the State's Boards of Medicine and Nursing, requesting exemption from physician supervision for CRNAs. The letter from the Governor must attest that he or she has consulted with the State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interests of the State's citizens to opt-out of the current physician supervision requirement, and that the opt-out is consistent with State law.

Right on cue hypocaffeinemia does exactly what I expected. Versed can be a very bad drug and is unilaterally used on unsuspecting patients to gain compliance. Villifying those poor souls who have a bad reaction to Midazolam is perplexing to say the least. The amount of subterfuge and aggression by some in the medical field regarding its use is shocking. I expected hypo to try to twist the most recent study on PTSD and the use of Midazolam. My dear you all seem to feel that Versed is the same as Valium, yet now we are going to split hairs as to which exact benzo is being used. Typical. I have read all the web sites that I can find about bad reactions to Versed. I don't find these outside the realm of possibility. Any drug which causes the changes in behavior and cognitive function has an endless possibility for detrimental side effects. Dismissing the side effects as anecdotal, narrowly focused or not possible is very narrow minded. This is an alarming trend in medical care these days. Patients have a right to know what is being put in their bodies and what it does. They have a right to say no. They have a right to be "control freaks" or any other thing. They have an absolute right to have their wishes heeded regardless of what the medical person, nurse, Doctor whatever IMAGINES is best for them. They are living beings with likes, dislikes and life experiences. They deserve to be treated with respect and dignity, not drugged into oblivion. Midazolam is a commonly used drug to bypass patient rights and autonomy. Midazolam causes extreme anxiety in any number of patients and these human beings are being treated like they are crazy and their concerns are being dismissed as "not Versed!" There are a LOT of people who are not going to get lifesaving medical treatment because of the Midazolam problem. Regardless of how YOU feel about it, patients are saying something else. Because of my experience with Versed I am in a unique position to help patients who have undergone a treatment, usually a colonoscopy or endoscopy in which the drug Versed was used and the effects of it were not revealed by their care givers. These people are nervous WRECKS! Is this what nursing is about? Forcing patients to take a drug and then if they object, quantify their pain or dismiss it entirely? Demand that they PROVE beyond a shadow of a doubt that it was Versed? Prove it isn't Versed. Please no anecdotal evidence or self serving studies designed to promote the use of Versed.

lolol benzodiazepines linked to post-icu depression here is just one. i didn't really want to get into a *war* of citations. i assume that you will pick apart any of the studies i bring up. you may also want to look at studies of brain activity in people with a high iq. their brains are different and this may be part of the problem with versed. just a thought, i am not a neuro doc, but neither are you... remember that midazolam is highly favored by health care workers. having a blindly obedient patient who can't question or stop the procedure, and usually has amnesia is a huge draw. it is also very expensive to get "conscious sedation." there are other studies as well. look how old some of the citations you give are! a lot of what you cite are studies comparing (midazolam with drug x) or (midazolam with drug y.) this isn't really asking patients if they want to be medical zombies or not. they are also from the perspective of the practitioner not the patient. as paindoc says, it's a matter of perpective. as with any drug there is a curve of efficacy. there are people who want the drug (sedation dentistry comes to mind) and people who don't want the drug or have a paradoxical or bizarre reaction to it. i am saying that midazolam does cause these problems in at least some patients, with or without disclosure. (you seem to admit that) i am saying that this drug should be an option with full disclosure, not be routinely administered without explanation and with disregard and disrespect for the patients rights, wishes and/or experience with anesthesia drugs. as more and more people have an anecdotal experience with this drug and talk about it, you will find that more and more patients exclude versed. i really hope that you in particular hypocaffeinemia are actually on a quest for knowledge that will make you a better nurse and not just wanting to squabble with me.

Yes, I surface on Midazolam discussions. I am a patient advocate with personal experience with Midazolam. It is not false to tell patients that Midazolam causes AMNESIA! It isn't false to tell the patient that under Midazolam they will be unable to stop the procedure whether or not they get amnesia! It isn't false to say that this drug is given so that you will be obedient. If a patient wishes to remain "awake and alert" it is unethical to give them Midazolam. I guess I would be one of those "tin hat" people who feel that because of the abuse associated with Midazolam that it should be banned. While I agree that some people prefer not to have any memory of a medical event, I strongly feel that this should be up to the patient with FULL disclosure. (actually this is the law, not just a strong feeling) Respect is also a two way street. I respect the fact that medical professionals have superior knowledge of general patient care. This does not apply to ALL patients ALL the time. What I do not understand is the vitriol expressed towards those patients who desire or need something different than "I know what's best and you are going to get whatever I want" type care. It is anecdotal to say that Versed is a good drug. Good for whom? Specific patients with phobias? Prove that Midazolam is good. Prove that patients are not suffering from this drug. By your own statement

Its very telling to see posts like hypocaffeinemia! To have patients concerns dismissed as "anecdotal" and

Thanks CrohnieToo! I have been worrying about having an endo without the Versed (or Propofol) The amnesia doesn't work for me with 9 mls of Versed but it does render me helpless. I just can't go in and have anything done with Versed. I would be totally aware "on red alert" and unable to move or speak while this was going on. I will stop worrying over this now. I just have to find an endo who is comfortable with outlier patients and can do this without turning me into a zombie and subjecting me to long term anxiety from the Versed.

I refused the procedure if I had to be sedated or knocked out. I told the doctor, called his office to remind him the day before surgery and told everybody that came in my room at the hospital that these things were out of the question. It didn't make any difference. They say I gave permission for the general anesthetic after I was heavily sedated (also against my stated desires) by "not objecting." Since I really couldn't move or speak at the time, this was very bad. Medical procedures are a necessary part of our lives, but be aware that patient rights are not written in stone and breaching them has no consequences. My Doctor and I did discuss this at length and I had to pay $250 to tell him all of this. He never said anything to the contrary. The people in the hospital never said anything to contradict what I told them, they just went right on ahead. The head nurse at the next hospital I went to to repair the damage from the first argued with me over the sedation. I had to tell her that it was a deal breaker to do my procedure with Versed or general anesthetic. I got the procedure done with Fentanyl (for the tourniquet pain), a beir block and nausuea meds. This is exactly how I wanted it done in the first place. I am not saying all this to be argumentative, but for information. I had a false sense of security when I went in the first time. Obviously I was on a different page than the first group. At no time was I informed that they had a completely different plan from the one I had accepted the risk for. Just be careful. Not everybody is a scrupulous as the people here.

In theory the patient is allowed to have some say over sedation drugs or anything else for that matter. In practice it's not true. My nurse never said a word even though she knew that I had declined the drugs and had not signed an informed consent for same. I think she was intimidated (?) by the CRNA and the Doctor.

There are a lot of people who have a bad reaction to Versed. Not just tin foil hat people either. I have noted that people who do not get the amnesia claim that they were immobile, that their blood pressure shot up and that they were NOT relaxed. Their muscles were flaccid, but it was traumatizing to be rendered compliant and incapable of resisting or having their pain addressed. Even people who did get the amneisa have problems with Versed after effects. There are scientific studies which show an INCREASE in implicit memory with Versed even though it pretty much knocks our the EXPLICIT memory. For some people whose brains have (incomplete?) access to implicit memory this drug does cause long term problems. It is just blamed on the patients' life experiences, previous trauma, other drugs etc.

Notice how it is patients who dislike this drug while the nurses love using it. Very peculiar. I hope some nurses read this, as it seems nobody in the medical field wants to discuss how bad this favorite drug is. For every person who likes having it there is one who hates it. So why do we all have to have it?

Versed merely blocks the memory of the pain. For me the idea that I may be in pain, screaming and writhing while my caregivers assume that I won't remember it is the stuff of nightmares. Babbling on about things that would absolutely humiliate me in my right mind is also disconcerting. Did you have this anxiety before this drug was ever used on you? I have major anxiety over medical stuff now, but not prior to getting Versed.

There are studies in dental phobia that show Versed, because of its amnesia effect is not good for alleviating the phobia. Since there is no memory 90% of the time, there is a continuing panic reaction to dentist visits. I also feel that the roughness because the patient "won't remember" could also exacerbate a phobia. My suggestion is a good nurse, one who will talk to you, hold your hand, explain every moment of what is being done. There are some absolutely fabulous ones out there who are more than happy to "talk you through it." Yes it *may* take more time than just administering Versed, but oddly once you have been through it, know what to expect, and have somebody who understands your problem you may find that it wasn't so bad after all, and will feel silly! Trust me I don't like being catheterized either. Its embarrassing, (I am super modest) and a little uncomfortable at first, but not painful. For me Fentanyl is best for pain relief and light calming effect without the rest of the problems with Versed. I am not sure that they would do this for a simple cath, but if they use Versed for it, Fentanyl looks tame by comparison. Demerol makes me combative and makes me hallucinate. Not a good combo for the nurses! A good nurse is better than all the Versed in the world.