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.

Take this with a grain of salt, as I am one of those who was traumatized (no drama) by Versed being used on me. Versed is not necessary for pre general anesthetic. Once you are knocked out that's it. The excuse is intraoperative awareness, but this has not been documented to be significant. There is no real reason to use Versed other than its benefit for the staff in most cases. Similar to sedation dentistry where only a few phobic patients actually require this medicine, most people would be just fine without it. This drug makes the patient easy to control, in that you will follow their orders without question. Apparently the amnesia isn't reliable as approximately 10% of patients actually do remember. I have read that the patients are "chatty and amusing" while under the influence. I have recall and in my case I was silent. I couldn't speak coherenly which was part of the trauma, so I shut up. I still wonder if this is why my CRNA kept on giving me more and more Versed even after I was immobilized. Maybe an OR nurse can answer that. Is being talkative a part of knowing whether the patient is properly sedated? Also this medicine is a cost driver in minor procedures. There is extra nursing care and extended PACU time involved with this drug. If more patients had recall more patients would be traumatized by the care they received while under the influence. I did not find this drug relaxing in the slightest bit, but it did make me obedient even while I objected to the slurs that were spoken about me and the administration of general anesthesia drugs which I had declined and for which there was no informed consent. My CRNA says that I gave consent after he gave me 9 mls of Versed. I consented by "not objecting." There was no attempt at patient "care" as they expected me to have amnesia. The exception was my OR nurse. She was so good that I called the head nurse at the hospital and said that this nurse should have been in charge of the whole operation. I just wish she had the authority to tell me what the CRNA was planning on doing! There is plenty of evidence out there about long term anxiety disorders directly attributed to Versed. These are being dismissed as anecdotal. I would suggest NEVER allowing Versed to be used on you UNLESS you are a medically phobic patient and feel you just can't handle the procedure. If you have a history of fighting anesthetics (I do) this drug is probably not for you. If you like knowing what is happening, if you want to be involved in your health care, and are concerned about the long term anxiety, just say no. Everybody is different. There is no excuse for assuming that everybody would welcome the amnesia, obedience, inablility to speak coherently, inability to stop the procedure, inability to sign out AMA if you don't want more intrusive procedures than you signed for etc. You will need to get a medic alert bracelet too so that EMT's don't give Versed to you.

There are a lot of patients on this forum. The reasons you share about why the patient should not be a part of their health care team are pretty much in line with what I have dicovered from my own "team." I am sorry that you are not interested in the patients' perspective, and imply that we are too uneducated to deserve any say in what drugs and procedures are used. The idea that we can't understand an informed consent is ludicrous. The purpose of informed consent is that we DO understand. We are supposed to sign to show that we understand and agree with the procedures and accept the risk. Maybe you should be up front with your own patients and allow them the luxury of leaving. Respect is a two way street. Allegedly. What I am doing is figuring out what the prevailing attitude is about informed consent and patient partnership. Why did this happen to me? Who better to explain than nurses? One of my best friends is a nurse, but not a CRNA. She won't allow Versed to be used on her or her family. I was considering a career change to nursing, but thankfully the list was too long and I discovered that my arm and hand will not be strong enough for nursing before I paid a bunch of money. Sorry to be so hard on you, but this is an open forum and it is an ethics question...

Hello again, haven't been here for a while... I have been having problems with my surgery and been told that due to the screws sticking out into the soft tissue from the reduction, that I could cut the tendons to my hand in two if I persist in using my hand. So, from beginning (Versed) to end this has been an experience. No nursing career for me, my hand is compromised. Yes I do think I need therapy for the "control" issue, which is nothing but a bad reaction to Versed. I don't want to control the world, just what happens to me! The new Doctor says that I can have IV anesthetic in my arm, with Fentanyl as the sedation agent. I didn't need Versed or a general at all. I am not the one who picked the axillery block in the first place. I wanted a regional block and no general. I like to know what is happening to me. My anesthesiologist picked the axcillery and an intrascalene block, apparently for pain relief AFTER surgery. Judging by the comments I heard while under the influence of Versed, I have good reason not to want it, not to mention the nasty and unpleasant side effects of Versed. I have been well informed (afterwards, and mostly on-line) that the axcillery block is sometimes insufficient ( depending a lot on the skill of the Doctor) and that most anesthesiologists in my area no longer use it. That being said, my arm was completely numb for almost 24 hours after release from the hospital to the point that I could have amputated it and felt nothing. So the Versed and general were for the OR staff, not me. I have such a profound distrust of anesthesiologists now that I am unwilling to take the risk of another surgery on my arm. If I could turn back the clock I would certainly have left that hospital and figured out another option. All of this could have been avoided if my anesthesiologist had presented an "informed consent" document to me, detailing what he had in mind, instead of deciding to do away with the informed consent in order to facilitate his own wishes. All of us would have been much happier!

Thank you all very much for an enlightening look at medical professional thinking. I was hoping that the problem I had was not a pervasive one. Perhaps I am missing the whole point of "informed consent." From a patient's point of view it means that the patient gets to decide what procedures, if any, the medical professionals get to do! When I get back to work I will look into it. Perhaps stronger legislation is in order. One does not need to have a complete medical education to decide what treatment is acceptable. The information to make this decision is a required part of "informed consent." That's the law, here at least. I had no idea there was such a deep resentment of this. Like I said, it's been very illuminating... Thanks again.

Boy I wish the CRNA HAD told me to take a hike! I would have been more than happy to sign out AMA! I expected to be allowed to do so... I would have been a lot better off without his ministrations. By the example of the aggressive posts on this subject, I believe there is a problem, and the problem is not mine. I am merely stating that I own this body and I don't care how much education you may or may not have, you are not me. I shouldn't have to be a paindoc in order to have some say so in my own treatment. I am astonished that a patient who objects to Versed being stealthily administered can create such animosity. Now I know why my own CRNA was so bad. He obviously felt that he was vastly superior to his patients and having a patient set bounderies made him ANGRY! FYI most of my nurse friends will not allow Versed to be used on them.

I think that this goes back to patient choice. I chose NOT to be incapacitated and I chose NOT to have the surgery if the block and pain meds was unsuccessful. I was very clear about it! To have the CRNA decide unilaterally to negate my choice is somewhat like rape. I said no. I and others feel violated when our choices are disregarded. There has been a great deal of talk about how arrogant the CRNA's can be, and mine is an example of how that works. The CRNA says that he knows what is best for his patients and apparently nothing can dissuade him. I don't think that this is how you would like to be treated, is it? I am sorry that disagreeing with a course of treatment causes some to think that the patient must have a mental problem. It is simply a matter of respect.

I gave permission for an axillary block and pain meds. Nothing else was to be used. I was very specific. I had reduced my own fracture before swelling started and the reduction I saw in the x rays was acceptable to me. Where I got into trouble was I allowed a surgeon to convince me that due to swelling that the reduction would collapse. I informed the surgeon in his office that general anesthesia was unacceptable for this surgery. I left a message with his office prior to surgery reminding him of this. I told the anesthesiologist and the CRNA that I was not to have general anesthesia and I further told them I was to remain "awake and alert." I guess I should have said "awake alert and oriented?" My idea of awake and alert is NOT what Versed does. In his (CRNA) notes he states that in the OR he told me he was going to give me a general anesthetic and that I did not object at that time. Of course at that time I was under the influence of Versed and COULDN'T object any more. I don't like general anesthetic and the fighting and the rest of it is so disturbing to me that I don't want it unless it's absolutely necessary to live. Now I can add that Versed is NOT TO BE USED UNDER ANY CIRCUMSTANCES, and I have an allergy medical bracelet stating same. I sure wish I had a different CRNA! (and anesthesiologist.) I would have signed myself out AMA if the CRNA had been honest about what he was doing. Conscious sedation was never mentioned, nor anything else really. No informed consent, nothing. Very bad. I have applied to nursing school...

I too have noticed a heated response to Versed. It's very odd. I had it used against me to gain compliance in an elective surgery. They didn't even attempt to have me sign an informed consent. (they knew that I would not sign anything that gave them permission to do a general anesthesia.) The CRNA who says he knows whats best, flagrantly violated me by using Versed to gain compliance. I told him I wanted to be "awake and alert" which has certain meaning to me and obviously something else entirely to a CRNA. I have a severe reaction to loss of consciousness and did not want it for a minor surgery! So, I get the "Vitamin V" with the explanation that it a muscle relaxant. It did not create the amnesia they wanted and I remember all of the pre general anesthesia up until they gave me the general anesthesia drugs, and plenty of them. I actually COOPERATED with the procedures even though I wanted to get up and run away. This is like a rape. I said no very loudly and constantly, yet I got exactly what I told them NOT to do. I have been called names, fear monger, stupid, insane to start with, and a whole host of other things by people who like Versed. No amount of complaining has budged these people or caused them to regret that they attacked me. No wonder people sue! I am in Pharmacy school now to insure that nobody EVER gives me drugs that I don't know all about! I have said this in another post and I will say it again, thank God for the OR nurses. The one in particular made sure that I was modestly covered as much as possible so that the hateful CRNA couldn't make any rude comments about my body at least. (He made crude comments about other things.) She also defended me when I woke up irate. I remember her saying "She told you she would wake up like this!" If SHE had been in control, I would never have gotten the treatment I got. I guess you can tell that I am passionate about Versed use. This is a dangerous psychotropic drug and should be treated as such!

This thread highlights one of the problems with CS. There are a lot of people who do not like a feeling of being out of control with memory loss attending. Yes, the PATIENT should be allowed to have access to this information regarding the effects of Versed in particular, and make a decision whether they WANT this type of med or not. Also the idea of having your loved one conversing with you about God knows what is disturbing to say the least. The fact that a health care professional would advise a spouse that the brain of the husband could be accessed without his consent or memory is extremely upsetting. I would be complaining long and loud about this. It is an issue of patient safety. We expect to have safety in the hospital. Obviously the nurse or whatever risked this person's well being in an egregious manner. It is unsafe for the patient to be grilled by anybody in a compromised state, and makes you wonder what else goes on after Versed is administered...

I had a bad experience with Versed as well. I was aware, but curiously unable to move unless the nurses told me to. They proceeded to give me a general anesthetic that I had told them would be completely unacceptable for my particular surgery. We had no talk ahead of time like it says for "informed consent." Since I had said no to the general and accepted the risk for an axillery block, I thought the subject was finished. How was I to know that the CRNA had a drug like Versed? Anyway, I had to listen to his (CRNA) crude comments about me, and actually PARTICIPATE in the general anesthesia prep, even though I wanted to jump off the table and RUN AWAY AS FAST AS I COULD! It was so upsetting, that months later I can't get a good night's sleep, have PTSD and am afraid to take the Prozac my gp wants me to take, etc. This was caused by VERSED, let alone awakening during the procedure paralyzed! I wanted to be awake and aware, and watch the operation, not be given a zombie drug, have a tailpipe shoved down my throat and a given a general! Not to mention the staggering hospital bill for all the procedures involving anesthesia! I want to have the sloppily installed hardware taken back OUT of my arm, but am too terrified to go back to a hospital. I swear if the things weren't screwed in I would get a scalpel and slice them out myself! The OR nurses were the only people that were kind and considerate to me even though they all thought that I would have amnesia. Without them I would be in a mental hospital. Big thank you to all of you OR nurses who are sweet to patients even if they believe the patient won't remember.