The Independence debate in Anesthesia

The independence debate in anesthesia. #anesthesiologist #physician @nmsahq @asahq Physician-led anesthesia care team provides patient safety, which is the #1 priority in patient care. #va #patientsafety #healthcare

The physician vs. crna debate has reared its ugly head…. yet again.  There have been multiple bills presented to suggest crna independence WITHOUT physician anesthesiologist oversight.  In 2017, proposals were made to the Veteran’s Affairs to replace physicians with crnas.  Here’s what they found when they looked at the VA databases to conclude that nurses will continue with physician oversight in anesthesia:

Current laws in 45 states and the District of Columbia all require physician involvement for anesthesia care and the VA in 2017 decided to maintain its physician-led, team-based model of care. The VA’s Quality Enhancement Research Initiative (QUERI) could not discern “whether more complex surgeries can be safely managed by CRNAs, particularly in small or isolated VA hospitals where preoperative and postoperative health system factors may be less than optimal.”

Here’s my evidence and reasons why I believe the care of the patient is best when it is physician-led.  After all, would you want a nurse or assistant doing your actual surgery?  The ultimate goal is patient safety.

Physician anesthesiologists have up to 14 years of post-graduate medical education and residency training, which includes 12,000-16,000 hours of clinical training, nearly seven times more training than nurse anesthetists.

From 2010:

From 2011:

From 2017:

 

Yet, here’s another debate that shows there’s no difference in an anesthesia care team setting with an anesthesia assistant and a crna:

Bottom line in my opinion:

  • Physicians endure years of grueling medical education that starts with the why, how, and treatment of disease. This is followed with years of residency training in anesthesia. There’s also further training in the form of a fellowship for specialized fields.
  • Getting into medical school is an extremely competitive process. You take the top 1% of college graduates and high MCAT scores to get into medical school.  The board certification for becoming certified in anesthesiology is quite complex and difficult in both the written and oral board exams.
  • I will continue to be FOR team-based physician-led anesthesia care.

Calm before the storm

March 5, 2010

People who have witnessed and/or survived crazy forces of Mother Nature often state that there’s a “calm before the storm”. I have experienced this with tornados growing up in west Texas.

But on OB?
Yep.

The OB anesthesia team was enjoying the fruits of the night team’s labor. All epidurals were in…. most of the ladies had delivered. Life was good! I even had time to prop my feet up and get some reading done. Not only that, we all enjoyed a rather relaxed lunch. It was WAY TOO CALM!!!

Anesthesia STAT was called overhead/paged to our beepers/called to the anesthesia room….

What appeared to be a normal vaginal delivery… turned into any OB’s worst nightmare. The cause wasn’t clearly revealed. We started multiple large bore IVs and sent off blood and raced to the OR. EBL 3L. Once in the OR, complete assessment of the bleeding by the OBs rendered a necessary hysterectomy. The patient was pale white.  Never before had I seen a human so pale, but alive and interacting with us. She didn’t flinch for a 14g PIV or the a-line. I wonder what she was thinking as she could probably feel her life fading away. Belmont, cardiac nurses, cell saver..dozens of people in an OB OR; all wanting to give this woman a chance to see her 5 kids.

PreOX, Cricoid, RSI–>GA. Quick prep. Intraop, a uterine rupture was noted. Hysterectomy completed. Still more bleeding!! Multiple uterine veins were found…just avulsed along the lateral walls of the abdomen. 2 more ob/gyn surgeons called stat for repair. Still no control of the bleeding. Partial aortic compression to help with hypotension. 2 vascular surgeons called. + Confirmation of control of bleeding. Belmont was running about 200ml/min x 120 min. Multiple blood product given (20-30U PRBC, 20-30U FFP, 24 plt, 10 cryo). pH 7.11–>7.38. UOP about 100ml/hr. At it’s lowest, Hb was 4.8 (the lowest I’ve ever seen!). Upon delivery to the unit, pH 7.38, Hb 10, Plt 127 (got as low as 84), PT/PTT slightly elevated, INR 1.2 (1.8 at its highest), fibrinogen 213 (65 at its lowest). She was mechanically ventilated based on the ARDSnet protocol (small tidal volumes, higher PEEP, fast frequency).

This is not something you see everyday…. much less something you see commonly on OB. The wonderful communication between the nurses, surgeons, staff, anesthesia…everyone truly made this a world-class effort. And because of this… a mother cheated death.

Lessons learned:
– Call for help early and clearly
– Practice effective communication
– Close the loop — verify if questions
– Don’t be afraid to get help — there’s many consultants at a hospital
– Debrief — because you’ll never know when you’ll need to be prepared for another “storm”