jwk

Thanks for making my point. I've done anesthesia for liposuction cases since the procedure was developed more than 3 decades ago. Most go well - but I've also seen the overly aggressive high-volume lipo with tumescent anesthesia where things have not gone well.

Sorry liponurse - the translation for your post is "lazy surgeon, more interested in money than patient safety". It doesn't matter how rare complications are in your hands. It only takes one and your career is gone. All that's being done here is maximizing the number of patients and $$$ for the surgeon. I'm sure you probably do a fine job - but why on earth would you take that risk?

You know as much about AA's as Jasy appears to know about CRNA's, which is ​nothing.

Of course it's sterile. And this isn't exactly rocket science chemistry. Many years ago when I ran a cellsaver service, we wanted to use the larger 3L bags to rinse the red blood cells which were then re-infused. Back then, I had a letter from the manufacturer of our fluid products stating that what was in the 3L bags of NS was exactly the same as what was in the 1L bags or smaller. Whether that's true now or holds or held true for all manufacturers I have no idea. We were also told that anything larger than a 1L bag could not be labeled for IV use - although clearly custom-mixed TPN infusions would be an exception to that.

My large group has never been subsidized. I know quite a few anesthesiologists what work in rural areas, despite the fact that CRNA's are subsidized by the federal government in critical access hospitals and anesthesiologists are not. Your generalizations are opinions not based in reality.

This C-collar thing seems to be a common paramedic thing, but it really doesn't do anything to secure a tube. You will not find a single patient in the ICU or OR with c-collar on to keep a tube from being dislodged. Tape it in properly or use a commercial tube-securing device. When you're moving the patient, best to D/C the circuit, but if you can't do that, make sure the person at the head has one hand on the patient's head and the other holding the tube. Tube's don't just come out on their own - they come out because people are careless.

My guess is there is a whole other side to this story that has not been talked about - what led the hospital to this point that they decided to move the anesthesia contract to a private company? I'll be the first to say I thought the original offer presented to the CRNA's left much to be desired as far as details. I wouldn't sign a contract either without knowing what I was agreeing to, so from that standpoint, I totally agree with them. But, by their own admission, they pretty much had free rein on the schedule and received a ton of overtime. Anesthesia, whether provided by hospitals or by a private group/management company, is still a business. Even non-profits can't lose money indefinitely. Somebody stepped up and offered the hospital an alternative that saved them money. Whether that's a good move long term or not remains to be seen, but by all accounts, everything has been running fine at these two hospitals since the new group took over. I have no idea if any of the "Michigan68" ended up working with the new group, but if they had no alternative employment options, it would not surprise me if some changed their minds at the last minute and went to work with the new group - they had that option available to them till the last day. For better or worse, and I hope it's not worse since my group was just acquired by a management company, this is the direction anesthesia is headed, at least until bundled payments to the hospitals becomes reality and the hospital controls who gets what piece of the pie for the whole hospitalization. I will thankfully be retired by that point.

A $10k difference is nothing, considering there is no state income tax in Florida and the cost of living, for the most part, is substantially less than NY. That being said - the main complaint for years has been that the Florida market is more than flooded with anesthetists. There are jobs to be had, but high supply compared to demand is what is keeping compensation down.

The main question in the US will be the cost. If it's cost-prohibitive, which it's rumored to be, it won't get much use.

I'm sorry - there is no such thing as a rural hospital with 200 beds in Georgia. There is no such thing as a rural hospital in Georgia doing hearts, etc. Any hospital within an hour of Atlanta is IN metro Atlanta. Rural is NOT Lagrange, Rome, Gainesville, or Valdosta. Rural is Blue Ridge, Toccoa. Americus, or Donalsonville.

Like the others indicated - death from anesthesia is extremely rare. Perioperative death due to the patient's presenting condition are much more likely, though also uncommon. Trauma, ruptured aneurysm, fulminant sepsis, and perhaps PE would be among the things we would see most often. Loss of airway, one of the things feared most often in anesthesia, is much less probable than it was even five years ago with the widespread use of video-laryngoscopes. The OP' statement - "I know that a lot of the times the death will fall back on the anesthesia team"- is not reality.

Scary thought. :)Ever hear that old saying about nurses eating their young? You're seeing a classic example in this thread. You're not even a nurse yet, and you're firmly established in a professional career, and yet you're treated as lower than pond scum because you don't bow down at the altar and show what is deemed to be appropriate humility even though you're asking perfectly reasonable questions. And although folks like wtbcrna and others would have you believe that only a tiny fraction of CRNA's are practicing in ACT practices and are not to be considered "true" CRNA's if they are, quite the opposite would be the case. BTW - AA's are not a dying profession, nor a new one. We've been around nearly 45 years now - I know, I know, it pales in comparison to 150 years of CRNA-dom, but then none of the CRNA's here are 150+ years old, so it's not like that makes any difference. Although small in numbers compared to CRNA's, our graduates as well as the number of states in which we practice, grows every year.

Although it's just semantics...an IJ catheter is, by definition, a central venous catheter, whether it's with a 3 inch 18ga catheter or a 9FR introducer and everything in between. Treat it as such. Also, it makes no sense to leave a catheter in the IJ (or other orifice for that matter) for four days if it's not being used or cared for appropriately. There's no reason an RN can't take it out using appropriate technique.

Correct me if I'm wrong, but there is no such thing as a CRNA in the UK. As I recall there are "anesthesia nurses" but their roll is pretty limited.

"Pre-nursing" and you're worried about CRNA vs MD compensation? Seriously?

I think the OP is talking about -triptans, not tristans. Probably the most well known is sumatriptan, or Imitrex. Methergine is an ergot alkaloid, some of which are indeed used in the treatment of migraines (the one I'm most familiar with is Cafergot, which contains caffeine and ergotamine). However, any OB nurse should be familiar with methergine and recognize that this is the drug we use immediately post-partum to help the uterus contract and control post-partum bleeding. Ergot alkaloids are contraindicated in pregnant patients.

So no propofol, benzo, or any other type of drug was given? The fact that he might use dilaudid for every induction isn't a problem, unless that is the ONLY drug he is using at induction - unless he's giving that and doing an inhalation induction on top of that with N2O and/or sevo. Like I said before - there's got to be more to this - something is not adding up. Even with high dose narcotics at induction, we would be likely to give additional drugs like midazolam.

Look at it from a different perspective - any hospital that doesn't have anesthesia services in-house 24/7 shouldn't be doing OB. You're not dealing in reality here. There are tiny hospitals all over the country that SHARE a single anesthesia provider because their volume can't support anyone full time. Yet those 20 bed critical access hospitals attempt to offer OB services, with a lot of those perhaps doing less than 100 deliveries a year.

I don't disagree, but in some hospitals, particularly smaller ones, that's not possible. EVERY OB doc should know how to do, or at least start, a C-Section under local. It isn't fun for anyone involved, but it can be lifesaving, and it's certainly possible and do-able.

Sorry, hit the wrong button too quickly.As already noted by two of us, nobody induces anesthesia with Dilaudid. There's more to your story. Patients don't have a "tolerance" to anesthesia. Some certainly require more (or less) agent or drugs than others, but one doesn't develop a "tolerance" to anesthesia in the way one might do so with narcotics or benzodiazepines or other drugs. WTB is right - a lot has changed since 1978. I have patients tell me all the time they're "hard to put to sleep". It doesn't matter - I always have enough of whatever I need to keep every patient adequately anesthetized. I joke with patients all the time that "I never lose". Is it possible you woke up in the middle of your procedure? Yes, but it's highly unlikely. Your description from 1978 sounds like it could just as easily have occurred at the completion of the procedure. When patients awaken, they are often disoriented for a few minutes. I always talk to my patients as they awaken and tell them "you're waking up - we're all done with your surgery". I don't know what to make of your second experience - the "induce with dilaudid" comment IMHO indicates you don't really know what happened or why.

??? Induced with dilaudid? Hmm, I don't think so.

In a perfect and total fantasy world, surgeons would be on time, cases wouldn't get delayed for slow surgeons or emergencies, and we could start antibiotics at the exact appropriate time for every case. In the imperfect real world, that just doesn't happen. Anesthesia reimbursement can get dinged for improper antibiotic timing, even though as far as we're concerned, that should be a nursing responsibility since antibiotics have absolutely nothing to do with the anesthetic, but guess who gets stuck with that problem? The best solution we've found for making sure antibiotics are given within the SCIP window is for anesthesia to be responsible for it, whether we like it or not. If the surgeon wants to wait for all of the antibiotic to be infused prior to incision or tourniquet inflation, he's welcome to wait it out - easy if it's cefazolin, and never gonna happen if it's vanco. Again - real world, AND, it's not required by the SCIP standard for the antibiotic to be infused prior to incision or tourniquet inflation. That's the problem with some of these stupid rules - they're really not based in reality, and certainly not written by people who actually provide hands-on patient care and deal with the logistical issues of a modern OR. They're written by people who sit behind desks and carry clipboards and only wear scrub clothes to give the appearance they work in the OR.

Not sure where the problem is here. Would it perhaps be better if the vanco was started earlier? Maybe, although I'll bet you'd be hard pressed to find data that says an hour or so prior to incision is any better than 10 minutes as far as outcomes. But as long as vanco is started anywhere within a 2 hr window prior to incision, the SCIP standard is satisfied.

Seriously?

But they have yet to release a statement saying that an anesthesiologist was present for the Joan Rivers case, and they certainly don't say they use an anesthesiologist for EVERY case. I thought they had changed their story about the vocal cord bx - regardless, tickling the cords with an endoscope is pretty easy to do. I frequently have to ask some of our GI docs NOT to go back down and suction of that little bit of snot they see down near the vocal cords as they're withdrawing their scope.