smiling_ru

Maybe we should add to the FAQ which programs have a lot of regional and line placement opportunities.

O.K. This is how it works. The order for anesthesia is given, a discussion with the person ordering the anesthesia occurs ie.. general/local/block/MAC. This does NOT mean that the person ordering the anesthesia needs to discuss every drug. No matter the practice environment anesthesiologist only/ team/ crna only, type of anesthetic is discussed. As far as physicial presence generally when you provide an anesthetic the surgeon is providing a surgical service. It appears that hospitals may opt to provide services in a wholly different manner per the last paragraph. But, I did not look those regs up. Anyway, I hope that answers your question. I looked at the SBN website, Illionois does have some very restrictivie language, especially in office based procedure. This is one of the areas the ASA has been pushing hard. Following is a cut and past. Section 1305.45 Delivery of Anesthesia Services by a Certified Registered Nurse Anesthetist a) A licensed certified registered nurse anesthetist may provide anesthesia services pursuant to the order of a licensed physician, licensed dentist, or licensed podiatrist in a licensed hospital, a licensed ambulatory surgical treatment center, or the office of a licensed physician, the office of a licensed dentist, or the office of a licensed podiatrist. For anesthesia services, an anesthesiologist, physician, dentist, or podiatrist shall participate through discussion of and agreement with the anesthesia plan and shall remain physically present and be available on the premises during the delivery of anesthesia services for diagnosis, consultation, and treatment of emergency medical conditions, unless hospital policy adopted pursuant to Section 10.7(3)(B) of the Hospital Licensing Act [210 ILCS 85/10.7(3)(B)] or ambulatory surgical treatment center policy adopted pursuant to Section 6.5(3)(B) of the Ambulatory Surgical Treatment Center Act [210 ILCS 5/6.5(3)(B)] provides otherwise. (Section 15‑25(a) of the Act) b) A certified registered nurse anesthetist who provides anesthesia services in a hospital shall do so in accordance with Section 10.7 of the Hospital Licensing Act and, in an ambulatory surgical treatment center, in accordance with Section 6.5 of the Ambulatory Surgical Treatment Center Act. (Section 15‑25(b) of the Act) c) A certified registered nurse anesthetist is not required to possess prescriptive authority or a written collaborative agreement meeting the requirements of Section 15‑15 of the Act to provide anesthesia services ordered by a licensed physician, dentist, or podiatrist. Certified registered nurse anesthetists are authorized to select, order, and administer drugs and apply the appropriate medical devices in the provision of anesthesia services under the anesthesia plan agreed with by the anesthesiologist or the physician in accordance with hospital alternative policy or the medical staff consulting committee policies of a licensed ambulatory surgical treatment center. In a physician's office, dentist's office, or podiatrist's office, the anesthesiologist, operating physician, operating dentist, or operating podiatrist shall agree with the anesthesia plan, in accordance with the written practice agreement. (Section 15‑25(d) of the Act) d) A certified registered nurse anesthetist may be delegated limited prescriptive authority under Section 15‑20 of the Act in a written collaborative agreement meeting the requirements of Section 15‑15 of the Act. (Section 15-25(e) of the Act) e) In a physician's office, the certified registered nurse anesthetist may only provide anesthesia services if the physician has training and experience in the delivery of anesthesia services to patients. The physician's training and experience shall be documented in the written practice agreement and the training and experience shall meet the requirements set forth in 68 Ill. Adm. Code 1285.340. f) In addition, in a physician's office, any certified registered nurse anesthetist and physician who enter into a practice agreement shall obtain ACLS certification by December 31, 2002, and shall thereafter maintain current Advanced Cardiac Life Support (ACLS) certification. g) In a dentist's office, the certified registered nurse anesthetist may only provide those services the dentist is authorized to provide pursuant to the Illinois Dental Practice Act [225 ILCS 25] and rules (68 Ill. Adm. Code 1220). Licensed dentists are required to hold permits to administer anesthesia pursuant to 68 Ill. Adm. Code 1220: Subpart D. h) In a podiatrist's office, the certified registered nurse anesthetist may only provide those services the podiatrist is authorized to provide pursuant to the Podiatric Medical Practice Act of 1987 [225 ILCS 100] and rules (68 Ill. Adm. Code 1360). Podiatrists may not administer general anesthetics. i) A CRNA providing anesthesia services in a physician, dental or podiatrist office shall do so with the active participation, approval, presence and availability of the physician, dentist or podiatrist as well as in accordance with Standards 1‑11 of the "Standards for Office Based Anesthesia Practice", American Association of Nurse Anesthestists, 222 South Prospect Avenue, Park Ridge, Illinois 60068 (1999), which are hereby incorporated by reference, with no later editions or amendments. If there is a conflict between the Nursing and Advanced Practice Nursing Act or this Part and the Standards for Office Based Anesthesia Practice of the American Association of Nurse Anesthetists, the Act and this Part shall prevail. (Source: Amended at 26 Ill. Reg. 7279, effective April 26, 2002)

If you feel that you are considered inferior because you are an LPN, then change it. I started out as an LPN, and dealt with some of the same issues you have. The only solution for me was to further my education.

You need to educate yourself in the practice of nurse anesthesia. We are not in a position where our actions are determined by anyone other than the patients needs. We do not need an order to administer a drug, we do not need an order for the type of anesthetic. All we need is an order for anesthesia or pain management from a physician. Just as any physician writes an order when another specialty is needed. The issue is not just symantics, rural patients would be without surgical/pain services if it were not for CRNA's. There are very few MDA's working in or anywhere near rural facilities. CRNA's currently bill directly, if we said oh....it is just symantics let them say we are supervised, then again there would be patients without reasonable access to services. I could go on ad-nauseum but I will stop now. The issues go beyond this message board.

loisane, Which school did you ultimately choose? I have looked at Case Western, Rush, VCU. I applied to UT Memphis, but the switch from DNSc to DNP concerns me. I am afraid that the DNP may limit my future choices as opposed to the DNSc, what do you think? Please tell me of any programs that you have seen with an anesthesia focus and limited on campus time. Thank you

Maintenance of adequate heart rate is the most important factor in ensuring adequate cardiac output. However, the dominance of the parasympathetic portion of the autonaumic nervous system tone makes neonates, infants, and young children particularly vulnerable to bradycardia when they are faced with physiologic stressors. http://66.102.7.104/search?q=cache:pXQEYkTGac8J:www.vh.org/pediatric/provider/anesthesia/proceduralsedation/pedscsa_p.html+physiology+bradycardia+children&hl=en So the answer is high vagal tone.

Ventilator injury; http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14508153 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12793874 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12793866 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12770853 Pulmonary edema; http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14729508 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12449188 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11719296 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11316656 As to HPV, whenever you decrease oxygenation to an area of the lung pulmonary vasoconstriction occurs. So if you are fluid overloading them, then you are also creating areas of HPV.

(IMHO) Antimicrobial accessiblity in these situations is going to be circulation dependent, increasing the pulmonary edema will only increase the shunting, decreasing antimicrobial availability. The other issue is that protiens leak along with the "fluid", these proteins are implicated in the exacerbation of injury. One example being PAI 1 which is associated with a higher incidence of fibrosis Sometimes none of those ventilator modes are effective. All ventilator strategies can cause ALI, the goal is to minimize that risk, by placing a patient in the position of needing inverse ratio ventilation you are certainly increasing their risk of ARDS etc,. I would say the list of potential complications is a whole lot longer than you state. In a later posting you stated that they were already performing this study. How did they ever convince an IRB much less a patient to agree to this. Must be in a county other than America because I can't imagine an IRB board approving it here. Please provide some references to the physiology you are proposing.

The anesthesia reference sheet that Cusick puts out has most of that information. I have never heard of MAC induction/ MAC intubation. But, I would assume MAC BAR would be intubation. If you don't already have this sheet, this link has an example of an older version. http://www.cusick.com/ars/AnesRef.pdf Look at the footnote in the inhalational section for the information you want. This site has the ordering information, the original forms are in color, this site shows examples, but you cannot read them. http://www.accrs.com/default.html

Quote: These arguments are great if your audience is mostly CRNAs, other nurses and medical professionals. That is the real problem for CRNA's. Because, while anyone working in US healthcare is familiar with what a nurse brings to the table, the public and legislators still have this picture of a person who only functions in the realm of what the physician orders. One of the many things that need to change....and it is getting better. The other point that I would like to make is that if this argument is " great if your audience is mostly CRNAs, other nurses and medical professionals." Then it obviously has merit, so why discount it just because John Q Public does not understand? These links are to the curriculum of both programs, I believe that they clearly demonstrate that upon graduation the AA's are ready to function as a technician. (Noun 1. technician - someone whose occupation involves training in a specific technical process). They are not learning about anything beyond anesthesia, and you should all know that most patients present with a myriad of issues which impact anesthesia. http://www.anesthesiaprogram.com/curriculum.html http://anesthesiology.emory.edu/PA_Program/coursework.html READ the curriculum THINK about what is NOT there and then read this statement. Georgia AA's statement "As a senior anesthetist I am given free reign to manage my cases as I see fit. Very rarely does my attending dictate what the anesthetic should be. They may make a suggestion here or there like "work in a little Morphine towards the end" but I am not required to check with them about most decisions that come up during a case. New grads on the other hand (AA and CRNA) really are expected to communicate with their attendings a little more often. I commonly do extremely complicated cases from beginning to end with little to no involvement from my supervising MD."

For those of you who can not discern a difference, and see this as a turf battle, I would like you to consider this. A nurse anesthesia student starts the program with a great deal of education and experience in the medical field. They all understand medical terminology, how to chart appropriately. Various disease processes, their effects, and treatment. Pharmacology, lab interpretation, EKG interpretaion, ventilator strategies, ACLS, PALS, CPR, sterile technique, this list could go on and on. On the other hand an AA student can walk in with very little of this knowledge. Consider that the AA programs are about the same length of time as the CRNA programs. That the AA has few if any of the aforementioned skills, and must also learn the art and science of anesthesia. Do you think there is enough time? Do you want that person providing your anesthetic?

I will be there.

Anesthesiologists working in an "anesthesia team" environment do NOT generally administer the anesthesia. This is why I laugh when a patient insists that an anesthesiologist provide theirs. They are basically asking for the person with the LEAST day to day experience in anesthesia administration. (One of our jokes is that their oral airway is an OETT), as they frequently roll into PACU with a patient that is still intubated, this is because they only perform cases to meet their certification requirements. Now before the flames start, I am not saying this is true of all MDA's but it is certainly true of MDA's in the "anesthesia care team". Which is the most common practice, especially in larger hospitals.

AA do not receive direct reimbursement, they must be supervised therefore, the anesthesiologist bills for supervised cases. This is in contrast to CRNA's who can bill directly.

Teeituptom, I am curious, why would you prefer an AA to a CRNA?