Talk:Anesthesia

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Contents

[edit] Distinction between anesthetics and other agents

Commented out succinylcholine and curare in list of agents because they aren't actually anesthetic in effect, even though they are commonly used with anesthetic agents. If they must remain in the section, it might be good to clearly distinguish between agents that actually produce anesthesia and those that do not produce anesthesia but are often used in conjunction with true anesthetic agents. — Agateller 14:57, 23 January 2006 (UTC)

[edit] Who's Halsted ?

Hi User:TwoOneTwo, in one of the edits, the following has come up: "... it was first used by Karl Koller in ophthalmic surgery in 1884. Halsted. Prior to that doctors had ...". What is Halsted, is it part of a line that was missed out ? Jay 00:24, 3 Jul 2004 (UTC)

I don't know about missed out... Halstead is, almost certainly, William Stewart Halsted - an early experimenter with cocaine, he became addicted and, I seem to recall, ended badly. What the sentence may have actually contained I don't know. TwoOneTwo 19:36, 3 Jul 2004 (UTC)
I've removed it anyways .. Jay 07:02, 9 Nov 2004 (UTC)

[edit] Safety of regional vs. GA

Although the BMJ article is interesting regarding the relative safety of regional anesthesia, the current thinking is that regional anesthesia and general anesthesia are equally safe for an otherwise healthy patient. There are certain patient groups for whom regional techniques are safer, and certain patient groups for whom GA is safer. For instance, the incidence of cardiac arrest in young healthy patients is about 4x higher for spinal anesthesia than for general anesthesia, while mortality for pregnant women having C-sections is one third when a spinal anesthetic is used when compared to a general anesthetic.

[edit] MAC definition out of context

I don't understand why the MAC definition should be there between the list of drugs of 20th century. So, I moved it to here -- Abinoam Jr. msg 02:31, 29 May 2005 (UTC)

--- *MAC (minimum alveolar concentration) is defined as the concentration in the alveolus (expressed as a percentage) of a potent inhaled anesthetic agent required to stop 50% of people moving to a surgical stimulus, when used as the sole anesthetic. That is, in the absence of nitrous oxide (an anesthetic gas) and an opioid. ---

[edit] Anesthesia in Soviet Union

There was a medical policy in Soviet Union to minimize usage of anesthesia. Because of this, many painful operations, including abortions and stomatology were performed without any kind (even local) of anesthesia. Very large percent of soviet children (including me) in 70-th and 80-th undergoned a surgery of tonsils or adenoid extraction. This operation was normally performed without any anesthesia as well. All of patients remember this episode of their life as a nightmare. Surgeons were encouraged to perform abdominal operations under local anesthesia only. It was a norm to perform appendectomy under local anesthesia, which was a painful operation. As a result of all this anesthesia was always subject for a bribe, making dentist a very profitable profession. In modern Russia things have changed to better, as well as payed medicine became available. But it is still quite natural to ask a bribe for anesthesia. "A patient fixed well does not need any anesthesia" - popular saying among soviet surgeons

Varnav 06:24, 20 Jun 2005 (UTC)


[edit] Anaesthesia section updates

I have added some additional information with regards to MAC, anaesthetic equipment and physics. Would appreciate some feedback and correction of any errors of the working princicples. Thanks! --koshime 10:56, September 4, 2005 (UTC)

I'd gladly do that, but concerning the MAC as of right now there's just a couple sentences with not too much info within it. I hope that's not the additional info you're referring to? (By the way, did some vital wikifying on the whole page in case you noticed:) Kreachure 22:09, 7 September 2005 (UTC)

Well - i added the MAC as a link, so that folks who wanted to know more about MAC could find a more detailed explanation. Propably help to add a few studies on MAC - historical and present --koshime 23:20, September 9, 2005 (UTC)

Hello Just revisinig for my UK FRCA Part 1 exams, thought I could jot a few bits down as I went. Will that be at an appropriate level?

[edit] gerationeous vapors???

What in all that is fromulous is a gerationeous vapour (see "Volatile agents")? We are the only place in the whole of Googledom to know of such a crompuloonity. --Slashme 16:13, 27 June 2006 (UTC)


[edit] Things to add

The history part seems to hit a brick wall at 1900...what happened after this? When did they stop using ether? What about intubation-when did this become a part of general anesthesia? What effects did the advent of anesthesia have on medicine?Mauvila 22:57, 7 October 2006 (UTC)

I am a practicing anesthesiologist physician and boarded in both the US and Canada. I am also boarded in Critcal Care Medicine. I have worked with different non-physician anesthesia providers and have also been involved in the education of these providers. From time to time, I will be editing and adding information to the page to make it more factual and neutral. -JBZIV

[edit] Anesthesia's longterm impact on developing brain cells?

http://whyfiles.org/251anesth_brain/index.php?g=1.txt

"Anesthesia is essential to surgery, but does it kill brain cells?"


Any suggestion about where this kind of research might best be found? 199.214.24.129 21:14, 19 January 2007 (UTC)

[edit] Stop removing links.

To the people who are removing links in the anesthesia links section to the AANA and other Nurse Anesthetist related site, stop. If it continues I will report you and your IP will be banned.

I have logged your IP and location.

Mmackinnon 13:24, 28 January 2007 (UTC)

[edit] Recent Rash of vandalism on anesthesia page

Hello

There are 3 of us who have been monitoring this page for vandalism Deepz, eclipse anesthesia and myself. We have noticed that user Uptowner also known as IP 68.11.82.15 has constantly removed links to, added DIS-information about and defamed Nurse Anesthetists for the last month orso. CRNAs are NOT techs and work independently in the USA up to the SAME scope as Anesthesiologists in the OR. The largest study done was the PINE study which has proven there is NO pt outcome difference b/t a CRNA or MDA (anesthesiologist). In the USA 65% of anesthetics are delivered by CRNAs. In fact CRNAs 32000 strong about the same number as the MDAs in the country. Constantly editing out these providers IS VANDALISM in the same way editing out nurses from history would be. Mmackinnon 02:50, 30 January 2007 (UTC)


OK, as an uninvolved party, I'm going to try and understand this edit dispute.

  1. Can I ask what makes these groups sufficiently notable to be included in the article? Can you prove this 65%b statistic? Are you suggesting the largest provider of anasthesia from all countries should be included?
  2. Please take a look at this dif. A lot of content seems to have been deleted over the course of this dispute. Should it be restored, or are there valid reasons for not including it? WJBscribe 03:02, 30 January 2007 (UTC)

--

Notable? 60% of the world's anesthetics, and 65% in the USA, are provided exclusively by nurse anesthetists. (Cf. AANA.com.) To 'disappear' nurse anesthetists from the entry on ANESTHESIA would seem a notable exclusion, vandalism, and probably a conflict of interest. Turf war is one description of American anesthesia.

Most of the current info is correct. deepz2

  • Yes, but was any of the old information which is no longer present incorrect? WJBscribe 03:31, 30 January 2007 (UTC)

The formatting of the discussion by the CRNA lobby is an attempt to confuse users not provide information. Paragraphs about anesthesiologists in different countries don't need to have mention of nurses mixed in. They can have their own paragraph if they like. Links to anesthesiology organizations don't need to be blended with links to nursing propaganda organizations. They can have their own section though I'd be better if they were listed under nursing in wikipedia. I have frequestly deleted a link that primarily provides misinformation and is ment to propagandize not inform the user. It is confusing enough to patients that anesthestist and anesthesiologists in the US have such similar names. The individuals above seek to exploit this confusion and blur the line between physician and nurse, not to educate the user. —The preceding unsigned comment was added by Uptowner (talk • contribs).

above unsigned

Anesthesia is anesthesia. Anesthetists are anesthetists. When provided by a physician, it is the practice of medicine; when by a CRNA, the practice of nursing. All the name-calling in the world won't change the fact that to delete all mention of CRNAs and their organizations is simply to be doctor-chauvinistic, and that deceives the public. We are all providers. We all belong on the ANESTHESIA page --deepz2

OK, why has this section been deleted?

The spinal canal is covered by the dura mater, through which the spinal needle enters. The spinal canal contains cerebrospinal fluid and the spinal cord. The sub arachnoid block is usually injected between the 4th and 5th lumbar vertebrae, because the spinal cord usually stops at the 1st lumbar vertebra, while the canal continues to the sacral vertebrae. It results in a loss of pain sensation and muscle strength, usually up to the level of the chest (nipple line or 4th thoracic dermatome).

It seems relevant. WJBscribe 03:59, 30 January 2007 (UTC)

Clarity. This is not a page to teach students or residents, but a page to inform the public. Right? Too much info makes the eyes glaze over. I teach patients (i.e. the Public) every day. As edited, this section is now more clear to a layman. deepzCRNA 04:15, 30 January 2007 (UTC)

  • In regards to 'unsigned' comments: This is absolutely untrue. The AANA is NOT a "nursing propaganda organizations" it is the national organization for Nurse Anesthetists. The Title of this article is ANESTHESIA not "Anesthesiologists". I could just as easily suggest you add your own information under that name. The links that are consistently deleted that I readd are AANA.COM and WWW.NURSE-ANESTHESIA.ORG, neither of which are 'propagandist' in nature. There is no confusion among patients as CRNAs introduce themselves as such and have been performing anesthesia longer than physicians in this country. There is no attempt at blurring the line between physician and nurse, the practice of anesthesia in the USA is BOTH the practice of medicine AND nursing by LAW. Edits have been made suggesting that Physician anesthesia is safer than CRNA when in fact the largest study produced (by an MD if you did not know) shows absolutely no difference between CRNA and MDA pt outcomes. Please show me where anything we have added has "misinformed" the user?

Here is a list of edits which I felt was vandalism by you, i assume.

  1. Removal of evidence about CRNAs and patient outcomes [[1]]
  1. Removal of various links to CRNAs [[2]]
  1. Removal of AANA website (one of MANY) [[3]]
  1. Removal of IOM data as well as outcome evidence [[4]]
  1. Changing history to reflect that physician anesthesia is better when the evidence suggests there is no difference (propaganda?)[[5]]
  1. Removal of IOM data as well as outcome evidence [6]]

They continue right until this was locked. Now within these edits many 'propagandist' things are said in regards to how physicians practice safer anesthesia (evidence from Pine study states there is no difference). You remove links to Nurse Anesthetist websites and delete pertinent information about them. We have not deleted a single thing about anyone else from the wiki, only kept in what is factual about CRNAs. You, on the other hand, have gone to great lengths to edit our info. Now who is trying to confuse the public exactly? Come now, if i wanted to confuse the public and "blur" the lines wouldnt i edit some of the physician related info (which i haven't)? Mmackinnon 04:20, 30 January 2007 (UTC)

Mmackinnon, there's little point in a blow-by-blow rehash of the dispute. Its in the edit history for all to see. I'd like to focus on reaching a concensus on how the article should read once it is unblocked. WJBscribe 04:26, 30 January 2007 (UTC)

[edit] Suggestion

OK, I'm starting to understand the nature of the disagreement. In principle, how would both sides feel about information about the article discussing provision of anesthesia in two sections:

  1. Provision of anasthesia by nurses
  2. Provision of anasthesia by physicians

That would seem to ensure the article covers both, but makes clear the difference... WJBscribe 04:26, 30 January 2007 (UTC)

  • Well therein lies the problem. There is no difference b/t what a physician does or a CRNA does in the provision of anesthesia. The way it currently reads is acceptable to us as it mentions us appropriately. What is at issue is how our information has been deleted, modified and vandalized. We did not do so to the physician information we only re added what was deleted.Mmackinnon 04:33, 30 January 2007 (UTC)
  • Anesthesia is anesthesia: one high standard of care, two major types of provider. The public is confused every time they access info from the ASA and there is NO MENTION of CRNAs. Wiki should be one place where we find a level playing field for informing the public, and where the public is not confused by self-serving claims of superiority based on unfounded presuppositions, and not backed up by science.

CRNAs don't need to be segregated into a nurses section. We are anesthetists, nurse anesthetists, yes, and proud to be called so. The heading of Anesthesia Providers is exactly right, as is. deepzCRNA 05:00, 30 January 2007 (UTC)

Uptowner

I wrote a very reasonable paragraph about how anesthesia is provided by doctors, nurses & assistants who are supervised by doctors, or nurses unsupervised and said that it is controversial whether one form is superior to another. This was deleted by mckinnon who wants to pick one faulty study that happened to fail to demonstrate a difference and present it as proof that there is no difference. There are no good studies of this because it would be unethical to submit patients to a blinded control trial. He is unwilling to have the public know that there is potentially a difference in the anesthesia provision they'll receive and that they may want to ask questions about it.

The AANA is a propaganda organization dedicated to lobbying to give nurses the right to practice medicine without attending medical school. As a physician and a member of a proud profession, this is offensive. If you want to link the AANA, it should be part of a section on nursing, not physician anesthesiology organizations. You shouldn't just blend the list of nursing and physician anesthesia organizations as if they are the same. They are not the same. Giving drugs according to orders written by a physician is the practice of nursing. This is the entirity of the practice of nurse anesthetics; anything more is the practice of medicine.

Medicine and nursing are not equivalent no matter how much nurses want them to be. Even if the CRNA propaganda organization is able to bribe it's way to increased legal rights of nurses to practice medicine, they will not be the same. Medicine is a profession available to only those who earn membership through attending medical school. It shouldn't and can't be a pseudo-profession that is open to the highest bidder.

Wikipedia users, many of whom will represent patients and their families, should be aware of who is providing their medical care. In the hospital, a large portion of CRNAs avoid letting patients know that they are nurses, though some do not, and right here, right now they seek to avoid letting the public be informed through wikipedia.

——————————————————————————————————————————

  • CRNAs are Midlevel providers and as such have the right to order tests, treat and prescribe anesthetic treatment. If you were not aware, ANESTHESIA is the practice of NURSING and MEDICINE in the USA, it is not the sole domain of medicine as you propagate.

As for the difference, there isn't any evidence of ANYKIND which shows physician only anesthesia is any better than CRNA anesthesia. The AANA link was placed under "Anesthesia Provider Associations" not "physician only anesthesia associations" which YOU edited in. In fact its original wording was Anesthesia associations i believe before you changed it and moved links around. Something YOU did not a CRNA. CRNAs do NOT give medication based on the orders of a physician just as NPs do not. CRNAs can practice anesthesia autonomously without any MDA present and you know it, your rewriting history and law.

Nursing has no interest in being medicine. However, anesthesia is the LEGAL practice of BOTH. Therefore we should and will be represented in an wiki on "ANESTHESIA". Moreover, the AANA should also be listed with the organizations as a national organization of ANESTHESIA providers in the USA. Lastly, you selectively mention some things here which are absolutely unreasonable. Your initial edits removed the link entirely as well as the mention of how CRNAs are trained including the years of experience. You also edited out CRNA resource sites entirely which were there previous to your vandalism. YOU are the one misleading the public by suggesting that "Doctors" are the only ones doing anesthesia in the USA independently and that they are safer (yes i saw that edit). Moreover, you lie here by ignoring the LAW which states that anesthesia is both the practice of medicine and nursing. CRNAs work in the OR to the SAME functional scope as the MDA. They do so in both ACT practices and 100% independent CRNA only anesthesia practices. YOU are the propaganda machine here both being the one editing the wiki to suit your personal agenda and changing the content to reflect your 'opinion'.

I would like to direct the moderators attention to the fact that CRNAs represent only FOUR lines on that entire document. Also we only have 3 links on the entire link section related to us. However, Uptown felt the need to edit that out or change it to suit his agenda. Only one person here is changing and removing parts of the document, thats Uptown. We have only reentered that which you have vandalized. Mmackinnon 23:04, 30 January 2007 (UTC)

  • By now the doctor's unreasonable stance should be obvious. Sic semper tyrannis. The dictatorial mindset that characterized Medicine into the middle of the 20th century has not died out yet, obviously, despite the modern focus on the PATIENT as the hub of the healthcare wheel, not the doctor. Anesthesia is unique, the only modality that does not aim to cure (see below), and anesthesia in America is the only specialty within which physician providers and nurse practitioners compete head-to-head, offering the same service to the public. The public needs to see the facts. Vandals would hide them.
  • For more info: http://www.gaspasser.com/unique.html

deepzCRNA 03:14, 31 January 2007 (UTC)

  • If I may insert a related question here, why does the Wikipedia link from ANESTHETIST take the viewer to ANESTHESIOLOGIST, where there is no mention of nurse anesthetists, only British anaesthetists? Seem to be the disappearing act for CRNAs again.  ??????

deepzCRNA 05:26, 31 January 2007 (UTC)

More heat than light is being generated by the above debate. I think a small subsidiary article entitled "Anaesthesia providers" or similar could neatly and concisely include:

  • doctors in the UK (etc.) who give anaesthesia ("anaesthetists")
  • the emerging technicians in the UK who give anaesthesia (current nomenclature "anaesthesia care practitioners" (ACPs), but this changes with the wind)
  • doctors who give anaesthesia in the US and Canada (etc.) ("anesthesiologists")
  • nurses who give anaesthesia in the US and Canada ("anesthetists" or "nurse anesthetists")
  • the situation in other countries, e.g. Sweden, which has nurse anaesthetists
  • the situation in the developing world, where a single practitioner may be responsible for both the anaesthetic and the surgery during the case, or some practitioners may at different times adopt the role of either surgeon or anaesthetist
  • the historical situation, where the anaesthetist was a co-opted lay person, bystander, medical student, or junior surgeon

I am not remotely interested in arguing over who does it better. Among both doctors and nurses, some will be excellent, some others dreadful. This type of argument (with insults and point-scoring) is disappointing and reflects badly on us- all of us- as a group of practitioners. Some above posters have a huge personal agenda to promote, for which Wikipedia is not the forum. Finally, this whole article is in a dreadful state and lacks a logical layout and a meaningful conceptual framework.Preacherdoc 13:27, 31 January 2007 (UTC) ___________________

Vandalism is the question, not who does what better.

deepzCRNA 13:49, 31 January 2007 (UTC)

Comment. Each side accusing the other of vandalism is not helping. I see no vandalism, only a content dispute. Continually refering to other users' good faith edits as vandalism is generally seen as a violation of WP:CIVIL. Lets confine ourselves to a discussion of what content belongs in this article and in what form. WJBscribe 13:52, 31 January 2007 (UTC)

____________________

Am I understanding you, WJB? -- you do not see the repeated deletion of all mention of CRNAs from the heading ANESTHESIA as vandalism?

deepzCRNA

____________________


Yes CRNAs have the legal right to order tests, treat and prescribe anesthetic treatment because their money and lobby has allowed them to chip away at the lagal boundaries surrounding the practice of medicine, not because those are nursing functions. At this point what matters is how the article goes forward. It should go forward with different groups separated, not blended together so that nurses can confuse the public and forward their political aims.

The practice of anesthesia is a nursing function (as defined by law) regardless of your personal feelings. Part of being a midlevel practitioner is prescriptive and diagnostic rights involved in the practice which are well recognized in the USA for CRNAs, Nurse Practitioners and even PAs, none of which are physicians (or want to be). Your antagonistic comments and clear attacks on the profession simply reveal your true intent, remove CRNAs from the article. The article isnt about 'doctors', the article is about Anesthesia of which CRNAs are a significant part in the USA. Mmackinnon 20:45, 31 January 2007 (UTC)

[edit] Article badly in need of organization

I propose the following:

  • Rename "Anesthetic equipment and physics" to "Anesthetic equipment" and move it to the end by "Anesthetic monitoring" since they are related
  • Move the first paragraph from "Local anaesthetics" into the History section because it's history
  • Move "Early opioids and hypnotics" into the History section for the same reason
  • Consolidate the section on "Volatile agents" to remove redundant information, and make it a part of "Current inhaled general anesthetic agents"
  • Reformat "Local anaesthetics" as a list, to match the format of the other types of anesthetics

Oanjao 19:32, 31 January 2007 (UTC)

[edit] Unprotected

The protection of this page from editing has now expired. I have changed the text to what appears to me a middle ground between the two camps, with full discussion of nurse anesthetists in a seperate section. Please discuss major changes here rather than returning to the edit warring of the past few days. If necessary, the page will be protected again. Remember that the article needs to reflect concensus and a NPOV. WJBscribe 19:35, 31 January 2007 (UTC)

Ok i propose a couple of changes.

Remove this line from the space on nurse anesthetists and I will edit that section to include what is appropriate.

"Anesthesiologist Assistants are another group who administer anesthetics. In the United Kingdom, personnel known as ODPs (operating department practitioner) or Anaesthetic nurses provide support to the anesthetist."

These people are not Nurse Anesthetists (CRNAs).

I also propose that the addition of www.nurse-anesthesia.org be placed back in "anesthesia resources" in order to give a place for CRNAs and Student CRNAs a place to go for support and resource.

Lastly, i propose that if either of these sections are defiled after the changes that the ppl responsible are quickly delt with.

Mmackinnon 20:35, 31 January 2007 (UTC)

  • Comment. I have created a further subsection about nurses as support staff to physician anesthetists- is that acceptable? Also, I see no problem with the edits by Deepz2. As to the links. OK, add it for now but I'm planning on reviewing all the external links. There are far too many and I think a number are going to have to go if they are brought in line with Wikipedia policy (WP:EL). WJBscribe 23:08, 31 January 2007 (UTC)

Sounds fair WJ. I would suggest just calling that section "Anesthesia Assistants" and it will pertain to the term Anesthesiologist (US) and Anesthetist (UK)

  • Done. WJBscribe 23:49, 31 January 2007 (UTC)

Looks good. I think right now everything does a fair job of representing Physican and Nurse Anesthetists. Thank you for your help.Mmackinnon 23:53, 31 January 2007 (UTC)


[edit] Edits to Anesthesia provider sections

I have edited a few points to increase the accuracy of the providers section and to represent AA's more positively. I'm not trying to restart the recent excessive editing problems. I changed the AA section title to anesthesiologist assistant since that is their name. Operating Department Practitioners are not CRNAs but neither are they AAs. They are at least nurses and therefore more similar to CRNAs than AAs. They should probably go in the CRNA section rather than the AA section, but I don't care if they don't.

Comment. I appreciate your efforts but I'm not sure you fully appreciated the intended nature of the sections you edited. The diea is to describe anesthesia provision worldwide, with examples from specific countries. Not focus on the US policy (though it should certainly be mentioned). Thus the three sections were intended to be:

  1. Physicians who provide anesthesia
  2. Nurses who provide anesthesia
  3. Nurses who assist physicians in providing anesthesia

The section should give an overwiew of how these groups might particate in the provision of anesthesia, with example of how this works in specific countries. Also comments about effectiveness/performance figures must be supported by impartial references from reliable sources. Please modify these sections to provide a less US-centric view or I will revert to the prior version by Oanjao. Thanks, WJBscribe 00:10, 3 February 2007 (UTC)

_____________________________________________

Your groups 2 and 3 should be one heading 'Nurses specializing in anesthesia' because it is the exception and not the rule for any nurses to provide anesthetics without the supervision of a physician. Anesthesiologist Assistants also provide anesthetics under the supervision of a physician but are not nurses and therefore require a separate section. I haven't made any attempt to make this US-centric, but information regarding anesthsia training in other countries is less available. I would broaden the discussion if I could, and I'd invite anyone with real knowledge of the practices in other countries to include it. The AA performance figures were derived from www.anesthesiaassistant.com, A four year study in Cleveland, Ohio's University Hospitals comparing Anesthesiologist Assistants and CRNA's safety records showed that the two professions were virtually identical. The Medical Center conducted the research study over four years (1999-2003) and studied more than 46,000 cases involving Anesthesiologist Assistants and CRNA's (23,0000 cases each). They concluded by saying, "Complication rates were no higher for Anesthesiologist Assistants than CRNAs."

The reason that there are two groups is to distinguish nurses who actually give the anasthesia themselves from those who support physicians who actually administer it, but are not authorised to do it themselves. The idea is to give a broad overview of who across the world might provide anesthesia and how. Then specific examples from countries (at the moment US and UK are the main one available) can be given. I deliberately went for titles that avoided the terms Anesthesiologist and Anesthetist because those vary from country to country, to convey a more neutral word perspective (i.e. who provides it, not what they call themselves). WJBscribe 00:51, 3 February 2007 (UTC)


_____________________________________________________________________ That's exactly the problem. It's not "who provides IT." They aren't two versions of the same thing that happened to have a different training pathway whether nurses practice independently (relatively rare) vs with supervision (the norm). They are superficially similar but actually quite different. To quote a prominent anesthesiologist, "In fact, my university is a training site for CRNA students and I work with them all the time. The training they get is good but it is not the same as MD residents. I am not aware of many CRNA only hospitals serving as training centers for CRNA students. They mostly train at MD residency programs and, unfortunate as it may sound, the more difficult cases are preferentially given to the MD residents. And while there are a relatively small percentage of CRNA's who are doing the most difficult cases, it is not fair to say that as a group they are doing the same thing as MDAs. That would be like saying that the Sous chef is the same as the head chef. They both cook but the Sous chef works under the eye of the head chef...CRNAs are not the same as MDAs despite outward appearances.' Ronald Levy, MD, Associate Professor of Anesthesiology, UTMB-Galveston

Ok

1st point Anesthesiologist Assistants

  • AAs and CRNAs are not the same or similar. AAs are only allowed to practice in a limited number if states in the USA and cannot practice independently as CRNAs can. They do practice VERY similarly to the UK nurses who 'assist' by sitting in the room monitoring the anesthesia. In anycase, there are less than 1000 AAs int he USA in practice so really, a separate category isnt needed. Neither the RNs who assist or AAs belong in the CRNA section, they are all entirely different.

2nd point about anon comment above

  • CRNAs DO anesthesia (and are trained and qualified)in ALL of the cases MDAs do. There are no cases that are only done by MDAs due to a difference in training. While I agree that it is not typical CRNAs will do these cases in large centers, i would argue this has more to do with where the MDA wants to live rather than training differences. CRNAs have to learn and do anesthesia in all the same types if cases as an MDA resident. Your "quote" is just more propaganda and opinion which is absolutely irrelevant to the Wiki.Mmackinnon 17:33, 3 February 2007 (UTC)

You only seem to care about legal rights and not the practice that takes place in the real world. In centers where AA's work, their function is identical to a CRNAs. While CRNA's have the 'right' to practice independently in some locations, the fact is that they function under supervision in the vast majority of actual cases. They should function under supervision in all cases, but that argument is beyong the scope of this article. Just as I am warry of nurses lobbying to practice medicine (no matter how some louzy judge defines nursing practice) and degrading my profession, you are warry of AA's practicing nursing and degrading yours. You are perfectly happy to assume that CRNA practice is equivalent to physician anesthesia practice just because it hasn't been proven to be false. Why don't you take the same view and assume that AA practice is equivalent to CRNA practice since that hasn't been proven to be false? Neither question will be studied adequately because the study would be unethical. Few if any patients would willingly and knowingly submit to nurse only care in a major case, and assigning patients to nurse only cases in a blinded study is unethical. The question about differences between providers is unanswered and is likely to remain so. PS. Good luck with your med school applications abroad. Maybe your view will change if/when you switch sides.

  • Comment. Sir, in response to the views you express- the article needs to focus on legal rights as these are verifiable. Practice in individual hospitals as to supervisions, or views as to whether this is necessary needs be ascertained by verifiable independent sources, which is problematic. As such the article is required to focus on the legal differences between different anesthesia providers. Your comment that you are "warry of nurses lobbying to practice medicine ... and degrading my profession" suggests you have a strong point of view here and would prefer the article not to reflect the fact that CRNA are authorised to provide anesthesia without supervision from physicians. AAs cannot. This appears to me as someone with no medical background to be a vital distinction. WJBscribe 04:13, 5 February 2007 (UTC)

Interesting assumptions. However, here is the thing, CRNAs DO practice to the same scope as MDAs (within the OR) and can do so independently. AAs cannot. In fact, AAs cannot practice as your proxy anywhere you are not or in the vast majority of states in the USA. We are NOT the same legally or functionally. P.S. I have no interest in med school I love what im doing now, thanks.Mmackinnon 03:30, 5 February 2007 (UTC)

WJBScribe

These people are back to editing in their opinions again. Please remove them. This should clearly prove their motivation.Mmackinnon 03:34, 5 February 2007 (UTC)

[edit] Concensus (elusive though it seems to be)

The present version of this article seems to provide a good balance of opinions mentioned. I do think a distinction between nurses who are authorised to apply anesthesia and those who are not is fundamental to classifying anesthesia providers. The issue of whether nurses should provide anesthesia themselves, as in the case in US, is interesting and topical. It seems right therefore to distinguish countries where this happens from those where it doesn't and to try (as best as possible) to compare like with like across different countries. I am particularly concerned by likening CRNAs to nurse that play only a supporting role in anesthesia provision, as this is likely to confuse a lay reader. They are clearly authorised to be the primary anesthesia provider and this needs to be recognised.

I would ask that major departures from the present contents be discussed here first so that consensus can be reached. WJBscribe 04:07, 5 February 2007 (UTC)

[edit] Sourcing

  1. The average CRNA student has 5-7 years of nursing experience before entering an anesthesia program. This seems to have become controversial. Can someone provide a link to a page on the relevant website that states this? WJBscribe 04:07, 5 February 2007 (UTC)

Added the reference for you. Was that correct format?Mmackinnon 04:42, 5 February 2007 (UTC)

Fixed format :-). WJBscribe 05:34, 5 February 2007 (UTC)

[edit] Compromise

Would there be any objections to an additions to the Nurses Anesthetists sections along the lines of: "Although licensed to provide anesthesia independently, CRNAs will not always do so and in many cases act under the supervision of physician anesthetists". Phrasing open to debate, but some mention of the fact that it appears CRNAs also act under supervision is probably needed to maintain the neutrality of the article. WJBscribe 04:16, 5 February 2007 (UTC)

I think it would be acceptable to say that "Nurse Anesthetists are licensed to practice anesthesia independently and as well within the Anesthesia Care Team." The ACT or anesthesia care team is defined in the USA as being a lead by a physician anesthetist. That helpful?Mmackinnon 04:46, 5 February 2007 (UTC)

Getting there, how about: "Nurse Anesthetists are licensed to practice anesthesia independently and as well within an Anesthesia Care Team, which are lead by a physician anesthetist" ? WJBscribe 05:24, 5 February 2007 (UTC)

That dosent sound bad to me.Mmackinnon 05:36, 5 February 2007 (UTC)

Done. That seems to address that little issue. Hopefully, things might calm down a bit now. WJBscribe 05:39, 5 February 2007 (UTC)


That CRNA part sounds pretty good. The description of Anesthesiologist Assistants should really tell what they do, not just be a speech about how they are not CRNAs though. I edited that paragraph so that the one about AAs is actually about AAs.

Comment. I see how the section does seem to be emphasising that they are not as good as CRNAs. I've reworded to use postiive langauge rather than emphasising that they are not CRNAs. What do people think? WJBscribe 00:53, 6 February 2007 (UTC)

______________________

Under patient information the link to "Information on Labor, Outpatient and Child Anesthesia" appears to nothing more than a Dallas TX physician group's advertisement. The site is still under construction anyway, judging by the non-link to info under "Perioperative Guidelines." Any objections to deleting that?

deepzCRNA 00:47, 6 February 2007 (UTC)


Actually, to say that AA's duties are identical to CRNA's is misleading in this respect: CRNAs do regional blocks, central lines, pain management and similar duties which AAs do not, by ASA policy. In some specific institutions, it might be the case that the job descriptions are similar; overall in the US, nationwide, it would be misleading to say they are identical.

deepzCRNA 01:29, 6 February 2007 (UTC)

Excuse my lay knowledge but are regional blocks not covered by the fact that they are not authorised to provide anesthesia? You may have to explain central lines to me.... WJBscribe 01:38, 6 February 2007 (UTC)

___________________

Yes, WJB, there are a number of functions within the full global practice of anesthesia which the ASA, by policy, has carved out as being in their view suitable only for physician providers. These functions include regional blocks such as spinal, epidural, and plexus nerve blocks (the instituting of the block per se; monitoring afterward may be freely delegated); insertion of central venous access 'lines' and pulmonary artery catheters; administration of epidural steroids for back pain; and certain other interventions. Besides independent practice, AAs also are not allowed to provide these services. These restrictions originate within the ASA. Though the ASA doctors would wish to control the practice of CRNAs, they do not. Our practice is our own to define. Regardless ASA policy, many CRNAs routinely perform these services as part of fulfilling their duties as full service anesthetists, and they have done so for generations. Therefore, AAs cannot be said to have the identical job description as CRNAs overall, only within those few specific institutions where AAs are allowed, and where those aforementioned restrictions apply equally to both AAs and CRNAs. Clear as mud? deepzCRNA 04:07, 6 February 2007 (UTC)

The article should avoid discussing the politics you mention above but thank you for clarifying. Perhaps you'd like to expand the description of CRNAs to more fully represent their anesthesia giving functions (as you do above though you may need to simplify a little given your audience)? It will presumably then be easier to explain that these functions are not performed by AAs. WJBscribe 04:17, 6 February 2007 (UTC)

_______________

Politics?? There politics involved?! I'm shocked -- shocked, I tell you.

I'll work on more clarifications. Thanks.

deepzCRNA 04:24, 6 February 2007 (UTC)

______________

Humbly request that whoever is deleting mention of CRNAs be banned.

deepzCRNA 03:51, 7 February 2007 (UTC)

Im noticing a trend here. We discuss with you WJB what we shall edit before doing it. However, the other grp does nothing but edit via anonymous IPs but they are clearly the same people who have been doing this since the beginning. Why not band the IP?Mmackinnon 04:04, 7 February 2007 (UTC)

Comment. Mmm, I wish that user would explain themselves more. Blocking users who edit by IPs only is a pretty major thing because many other people may edit from that address. I propose strengthening the apparently contentious statement.
Does anyone have access to statistics about how many countries in the world license nurses to perform anesthesia? It might be a good idea if a reference is cited for the statement that "In over 100 other countries... specially qualified nurse anesthetists also administer anesthes".
I shall look into the IP issue and see what steps can be taken if the unexplained deletions continue, the best option may be to semi-protect the page so anonymous IPs cannot edit it, thereby forcing the editor to register an account or bring their concerns here. WjBscribe 04:07, 7 February 2007 (UTC)

_________________

Semi-protecting the page would appear appropriate.

The source for over 100 nations is to be found on the IFNA link. 107 they say.

http://ifna-int.org/ifna/e107_files/downloads/Practice.pdf

deepzCRNA 14:03, 7 February 2007 (UTC)


[edit] Comment on recent edits

All statements are being converted to CRNA advertisements. If 5 countries are mentioned as having only physician anesthesia, countries that also happen to have the greatest saftey and satisfaction records, there is an addition that CRNAs practice in blah blah blah, no citation. The description os AAs was converted to a talk about how they aren't as good as crnas, so that needed to be edited. They repeatedly insert 'citation needed' into the discussion, delete the citation when provided, and insert many unsubstantiated claims in their own paragraph. A link to patient information for various types of anesthesia is deleted after a statement that they're going to do so in the discussion section while a so-called patient information link that is entirely an advertisement for crnas remains even though I pointed out last week that it is nt what it claims to be. A list of 'facts' about crnas doesn't belong in the patient information section. I can't discuss it in this discussion section because there is a group of nurses trying to make the article all about them, and there's only me trying to tell the truth about physicians and AAs. I deleted the first paragraph from the 'providers' section because it was redundant and an unnecessary paragraph. If you insist on talking about how many countries have nurse anesthetists, put it in the nurses section. Everything else was redundant. Maybe you guys should go into the agents section and change it to roc is used by crnas for..., propofol is used by crnas for..., etc. The lobbying effort of nurses needs to be limited.

I'd like to rewrite the nurses section to say that nurses, medical students, and lay people were historically the providers of anesthesia when there were few agents and no skill involved. Over time, knowledge of anesthesia grew and became a well developed medical specialty. As an historical error, nurses were slowly allowed to practice medicine in anesthesia due to it's primitive beginnings. They now not only take advantage of this historical error to practice medicine without actualy attending medical school, but they lobby the government in an constant effort to become doctors in all but name. Many feel that a physician is made through attendance at medical school, not in the halls of congress or by judicial activis. Nurses would disagree with this view, not because it is wrong, but because they benefit from the corruption of lobbying their way into a profession they haven't truely earned entrance to. It is much easier to buy lawyers and representatives than to return to school and get a medical degree (if they could even gain admittance which is unlikely since crna school has admissions criteria that pale beside those of medical school) to practice medicine. What's worse, they now want to invent a doctoral degree in nurseing so that they can mislead patients by passing themselves off as doctors. There own misguided sceme to bypass medical school yet practice medicine is of primary importance to many crnas and honesty can be sacrifice toward that goal.

I propose that the above paragraph replaces the crna section. What do you guys think?

Comment. I am a little concerned by the tone of your contributions. In your latest comments you say: "Nurses ... benefit from the corruption of lobbying their way into a profession they haven't truely earned entrance to". You seem to have a very strong view on this issue. The fact is that nurses are licensed to provide anesthesia in many counties, especially the US, I understand that you disagree with this. But an article on Wikipedia is not the place to argue against nurse being allowed to provide anesthesia. It can only report on what does occur. Is there anything factually incorrect about this article?
As to your comment re:AAs. I see no suggestion that they "aren't as good" as CRNAs, but it is the case that they do not perform the same range of functions as CRNAs and that only a limited number of states license them. Or do you disagree with this?
The links issue. I have stated before that there are too many links attached to this article, per WP:EL. However, I feel this is a secondary issue to ensuring that the text of the article can be agreed and remain stable. I ask everyone to bear with me here as I can only do one thing at once. If you would like to list links that you feel shouldn't be there (with reasons) on the talkpage, please do. That would be helpful.
Please understand that this article can never represent you opinion on the relative merits of physician and nurse anesthesists, it can only describe the functions each perform neutrally. WjBscribe 02:42, 8 February 2007 (UTC)

_______________________

The anon poster above has, if I understand correctly, received a final warning for vandalism before being blocked on 28 Jan 07, and has now deleted mention of nurse anesthetists again today.

What's the holdup in blocking him and semi-protecting the page to get rid of the anonymous vandals?

deepzCRNA 00:05, 8 February 2007 (UTC)

__________________________


What do 'you guys' think? I think this is the perfect place for your self-serving ANONYMOUS opinions, and not on the Wiki encyclopedia pages on ANESTHESIA. You have had your last warning from the Powers That Be; twice today now you have deleted mention of nurse anesthetists from the Providers section. How emblematic that action is, revealing your wish to 'disappear' us from public view.

Won't work.

deepzCRNA 00:22, 8 February 2007 (UTC)

He may be removing sections from the article, but he has provided viable reasons for doing so. Assume good faith and discuss the article with the user. He has come here to discuss the article, and branding him as a "vandal" is not going to help the situation. Nishkid64 01:20, 8 February 2007 (UTC)

____________________

Oh how I wish we could continue to assume good faith from this person, but he has proven not to deserve it, clearly. Did you not, Nishkid64, give him a last warning on the 28th of January? He has demonstrated repeatedly that his anonymous opinions are all that he will tolerate on the page, and so, he still continues to repeatedly remove whatever he wishes. Neutrality, please!

What justification -- what 'viable reason,' as you put it -- can he offer to delete GasPasser.com, a site plainly full of in-depth consumer information. Check it for yourself please. Because some authors there do not happen to agree with his doctor-centric views does not mean he can censor the site from public view, does it?

And to say now that anesthesiologists practice in every country in the world is so clearly silly (Mines bigger than yours is....), and such a typical response from ASA militants, who have been known to resort to gross hyperbole at the drop of a hat, even in sworn testimony before Congress. For your edification I include this link from the clearly-distinguished *editorial* side of the deleted consumer info site. [7]

300,000 cases, indeed!

deepzCRNA 02:05, 8 February 2007 (UTC)

Did you not see that after the warnings, the user came to the talk page and tried to discuss his edits with other users? I issued a warning nearly 10 days ago. That warning does not still apply 10 days later. I gave that warning because he was just removing text with no discussion. He has now made some edits to the page, but he has also gone to the talk page and tried to strike up discussion with other users. Discuss with the user. Wikipedia is not here to serve as a "consumer guide"; we're here as an encyclopedia. If the links are actually notable and relate to the article, then they should be kept. This particular link is notable, but it does not seem professional, in any sort. It seems like one person (or a few) decided to make a site on the subject. I'd rather see links to government or institutional websites. As I said, discuss instead of trying to get me to block the user. Nishkid64 02:16, 8 February 2007 (UTC)

Hi Nishkid64, I understand your position. However, it is hard to suggest this is anything less than vandalism after a MONTH of it occurring, WJB moderating until he is blue in the face with frustration and the ONLY people coming to the table to discuss anything is us. What else could it be? When the people editing didnt get their way they simply resorted to random/anon editing as it seems that is above punishment. So what I guess is confusing is why you seem to be chastising the only people who are following the rules? Why should I assume it's in good faith when it hasent been from the get go? What is there to discuss when it has been discussed her Ad Nauseam, a decision was made (as were compromises) then it is blatantly disregarded? Why not stop editing by people who are not logged in? Mmackinnon 02:21, 8 February 2007 (UTC)

________________________________________________

This would appear to be the crux of the matter with our anomalous friend: like many ASA militants, he does not accept anesthesia as a valid practice of nursing, despite numerous court rulings reaffirming CRNA practice in America over the past almost 100 years. This attitude is neither reasonable nor realistic.

Vandalism unpunished is compliance.

deepzCRNA 04:46, 8 February 2007 (UTC)

[edit] AA licensing

WJB, actually, as to states in which AAs are licensed to practice, this is what their site says:

"AAs currently work in sixteen states. The states in which AAs work by a license, regulation, and/or certification are: Alabama Florida Georgia Kentucky Missouri New Mexico (university hospital settings) Ohio South Carolina Vermont"

To post they are *licensed* in 16 States is incorrect. Perhaps our anonymous friend could tell us about what states, if any, actually LICENSE AAs?

deepzCRNA 19:30, 8 February 2007 (UTC)

Fair point, I've adjusted the statement to better fit the reference. Is it OK now? WjBscribe 19:44, 8 February 2007 (UTC)

Looks proper now. Thanks. deepzCRNA 20:44, 8 February 2007 (UTC)


_________________________________________________________________________

[edit] Response

I didn't write anything about AA liscensing. Someone else went back and added those few words to what I wrote about their practicing.

Parts of anesthesia are nursing, given meds according to a protocol or under the direction of a physician, charting, etc. Other parts of what you want to do are not nursing.

Why is that twilight anesthesia bs continually added. No argument has or can be made that it is a site dedicated to patient information. Neither is the new CRNA info sight. They aren't about patients, they're advertising for CRNAs. These should be removed.

It's easy for you to say I should be banned for changing things. Your insertions are more vandalsm than my editing. There are now at least four links providing basically the same information about CRNAs. How is that helpful?

The nurses don't want to accept AAs as a viable alternative, because the arguments in their favor are so strong. Their training is faster and cheaper while providing care that hasn't been shown to be any different, they don't worsen the nursing shortage by pulling many of the best nurses away from ICUs, and they don't seek to unethically mislead the public into thinking they are physicians with a cheap doctoral degree. We could all get PhDs online tonight, but calling ourselves doctors in the hospital afterward would be awful.

Why keep complaining about my anonymity? I'm no more anonymous than you except for McKinnon who I remember reading about when he was applying to medical schools in Europe. Even so, he and all of us are fairly anonymous. It has nothing to do with the article.

Reply. I'll try and address what you've said. I've been trying to address content inssues before dealing with the link section but I gather it is now a large part of the controversy, so I shall turn my attention to it now. The guiding policy on external links is: WP:EL, it would be great if everyone could read it. Please state which external link you object to and why. I have no idea what "that twilight anesthesia bs " refers to, so a more specific comment would be helpful.
Do you have any objection to the contents of the article. It now seems to factually represent what CRNAs and AAs do and fully details the states in which AAs can pratice.
"they don't seek to unethically mislead the public into thinking they are physicians with a cheap doctoral degree". I have no idea what relevance this has to the article, given that it clearly states that CRNAs are not physicians.
To conclude, I will look into the external links. There are too many at present. If anyone wishes to argue on this page that a praticular link is important/irrelavant please do so as clearly as possible so we can have a meaningful discussion. If there content of the article is still problematic please identify which part. Thanks, WjBscribe 00:51, 10 February 2007 (UTC)


"that twilight anesthesia bs " refers to the link in the patient information section though it doesn’t inform patients about anesthesia ** In-Depth Consumer Information About Anesthesia from Twilight Anesthesia Inc I linked a site describing different types of anesthesia and it was deleted by a 'vandal' and none of the united front of nurses called for each other to be banned as a result. There's quite a double standard in their arguments against my contributions. The following three links are to the same website. The first is in the patient info section and doesn’t provide info for patients. It provides ads for CRNAs which is better covered by the third appearance of the link, in the organizations section. ** Award-winning site on Anesthesia, Nursing, and Medicine ** The Unusual History of Ether** Resource Website for Student Nurse Anesthetists and CRNAs


As opposed to defaulting to the immature antics of our anonymous friend I will simply use facts to back up my points (as you notice he uses no facts). First, like it or not, anesthesia IS the practice of nursing INDEPENDENTLY and without the need for a Doctor. As with ALL midlevel providers, we can prescribe and diagnose, this isn't a new phenomenon and you wanting it not to be true does NOT make it so. Frankly, your entire arguments are insulting.

As for you knowing me, I dont know you, I have never applied to medical school and don't plan to. Again, you appear to rewrite history.

As for the links, it appears you are unable to tell one website from another. www.nurse-anesthesia.COM and www.nurse-anesthesia.ORG are entirely 2 different websites. One, the .com, does a full history of nurse anesthesia and anesthesia in the US in general. The .ORG one is a resource site for CRNAs and SRNAs as well as people interested in anesthesia. Both are important for different reasons. The .com shows the history of anesthesia in general but also CRNAs, the .Org refers to a website which allows people to talk with CRNAs and SRNAs along with a significant portion of anesthesia information.

All you are doing is proving what we have been saying with your rhetoric. You are clearly not interested in the truth but you own personal agenda. Nothing written in the CRNA section is incorrect or non-factual and references have been added. Again, you do not have to like it but it doesn't give you the right to edit in your 'opinions', which is all they are. I could argue the points with evidence but that is outside the scope of this discussion.Mmackinnon 03:02, 10 February 2007 (UTC)


__________________________________________________________

"As for you knowing me, I dont know you, I have never applied to medical school and don't plan to. Again, you appear to rewrite history." You have the same last name and first initial as a nurse I've come across before. If it's not you, I guess you are anonymous too.

Ok ok. Only two of the links are duplicates.

Linking a website doesn't establish anything as fact. We could link all kinds of websites stating a wide variety of nonsense. From your 'twilight' propaganda site,"...in anesthesia training, both groups receive education that is essentially equivalent, often attending class and clinical side by side. Both types bring their respective backgrounds to the specialty and both end up full-fledged independent anesthesia providers. They may work together, or they may choose to work solo. In the operating room environment, CRNAs and anesthesiologists are functional equivalents..." This is blatantly untrue. The training is not equivalent and the they are not functional equivalents. Just because you can link a site full of lies doesn't mean your section is actually true. I suspect that you know very well that we are not functional equivalents and that while frequently side by side, the training is not equivalent. Maybe you've heard these lies so many times that you even half believe them, but the majority of anesthesiologists and nurse anesthetists know that it isn't really true.

Ah the banter. Ok i'll indulge for JUST a moment. There is clearly a difference in that they dont teach you english (at least you) in medical school. Let me help you.

From Websters dictionary. Functional = Of or relating to a function Equivalent = corresponding in position, function or Having similar or identical effects.

So to help you, Functional Equivalent = People performing the same functions with the same outcomes.

What does an MDA do in the OR during anesthesia that a CRNA cannot do? Thats correct, CRNAs are licensed to preform all the same tasks (including meds and diagnostics) as an MDA is in the operating room. What are the outcome differences? None. If you dont like the USA stats then look at the UK. They have NO CRNAs yet have the same safety and outcome stats as we do for similar cases.

The anesthesia training CRNAs receive covers everything an MDA receives in ANESTHESIA. We are NOT doctors (nor claim to be YOU are the one inferring that) and so did not goto medical school. However, it is clear that medical school is not needed to perform safe, efficient and professional anesthesia care. Its like using a sledge hammer to drive a nail, overkill. Also, after a few years the vast majority of your medical training is lost due to neglect and disuse. Ask your attendings in New Orleans, LA about it. The only person deluded her about their own self-importance is you, my young friend. Mmackinnon 14:38, 10 February 2007 (UTC)


__________________________________________________________________________

Whether or not they are functional equivalents has not been established. It is claimed because it suits the author's aims, not because of the strength of the evidence. The vast majority of complicated anesthetics are performed or supervised by a physician. You make claims about the huge number of anesthetics administered by cras but choose to ignore and fail to quote the proportion that is supervised. You also ignore differences in the cases and patients seen. You are comparing apples and oranges. It's like saying a guy batting .400 on a AAA baseball team is the funtional equivalent of a guy batting .400 in the majors. Sure the outcomes are the same, but they aren't playing in the same league.

Your comparison of the training is also misleading. The subjects covered are the same, but the depth of coverage is greater in physician training. Just because we all study the same subjects doesn't mean our knowledge is the same.

You can call it overkill if you want, but unexpected complications occur. Real world patients want to best trained provider to be present or immediately available in that case. I doubt you would send your mother to a crna-only facility for a complicated case. At the end of the day, you know that the extra training might just come in handy and you probably wouldn't bet your mothers life on it, however rare a complication might be.

I think you are making assumptions. My mother had her Bypass anesthesia done by a CRNA. The public's choice of provider is not for you to dictate, they seems to have had no difficulty with CRNAs for over 100 years. You make claims here but none of which are substantiated. There ARE ORs where CRNAs are doing the Trauma call and hearts without MDAs. How is it we haven't seen the publications of massive lawsuits? You know very well the A$A would be all over that. Also you forget to mention that the A$A has never proven any difference at ALL in outcomes (not for lack of trying). So don't play all coy with me. The fact is we ARE functional equivalents and outcomes ARE the same. You say it hasn't been establish simply because no research available supports your personal claims. Im sure if you could Bill for IV insertions MDAs would be doing all of those as well b/c you are so much 'better trained'. Why don't you stop adding opinion here as it clearly cannot be backed up by any facts and is irrelevant to this Wiki article. This argument is nothing more than you protecting your 'lifestyle' specialty and bank account. Mmackinnon 23:36, 10 February 2007 (UTC)

_________________________________________________________________________

I didn't say a crna wouldn't be in the room for your mother's bypass. I said an md would be 'present or immediately available'. Was that incorrect?

"This argument is nothing more than you protecting your 'lifestyle' specialty and bank account." That's the pot calling the kettle black. You insert lines about how few states aa's can practice in, all the time supporting an organization that lobbies against aa's and is the reason they don't work in more states. crna's are functional equivalents to aa's and are potentially cheaper, so you nurses fight against them to protect your bank accounts.

Plus, the reason crna's practice indepedently in rural hospitals is crna lobbying against mda rural pass-through rights. You spread lies about how md's won't work in rural communities while fighting tooth and nail to prevent them from doing so.

YOUR additions are a combination of misinformation and spin and THEY have no place in this Wiki article.

[edit] Wikipedia is not a soapbox

These discussions are frankly getting out of control. This talkpage is for discussions of improvements to the anesthesia article, mot for debating the relative merits of various providers. I will from now on delete from this page all arguments not directed to the improvement of the anesthesia article, per WP:NOT. I propose the following:

  1. If anyone feels that information on the information is innacurate or biased, please list it here. Sources can then be found for it. If the information is sourced, either give a very good explanation for why the source is unnaceptable (sources from professional bodies are likely to be acceptable). If you believe there is a contrary view not being expressed, please write material expressing the contrary opinion, accompanied by a reliable source.
  2. I am going ruthlessly prune the external links section down to a minimum, disussion here can ensue as to what other sources should be present.

Lets try and improve this article rather than debate the politics of anesthesia provision. WjBscribe 01:07, 11 February 2007 (UTC)

Hi WJB

You really cannot use the ASA;'s refernece for the definition of Anesthesia Care Team. It states that it is the practice of medicine only which is incorrect.Mmackinnon 01:20, 11 February 2007 (UTC)

It confirms the sentence in question. Being used as a source is no endorsement of the entire document. It is used to say that ACT are lead by physicians. If replaced by a better source it can go, but ASA seems like a reliable sources to me in explaining the elements of the ACT. Its views as to the merits of ACTs are not what it is being used for. WjBscribe 01:27, 11 February 2007 (UTC)

[edit] WJB More editing by this anon. Time to ban.

Ok

Im done with the banter. After waiting a short time, this fellow has simply,y gone back to his old tricks and edited out what he didnt like (proof free). I have reversed it again. However, it IS TIME to ban his IP. Mmackinnon 00:56, 11 February 2007 (UTC)

I may have missed something but todays edits appear to add information, not remove it. Do you argue that it is incorrect? WjBscribe 01:00, 11 February 2007 (UTC)

Hello WJB

Yes, he has added the political policy of the ASA his national organization. I did not add any information related to AANA political policy simply facts. We mentioned that CRNAs sometimes work with anesthesiologists in a team model in the article. He added a whole paragraph which says anesthesia is the practice of medicine. It is incorrect in the USA and only represents his national organizations viewpoints (which are not the law). This: According to the ASA statement on the Anesthesia Care Team, anesthesia care personally performed or medically directed by an anesthesiologist constitutes the practice of medicine. is NOT the law in the USA but the aspirations of their national organization ONLY. Anesthesia is LEGALLY the practice of Nursing and Medicine.Mmackinnon 01:11, 11 February 2007 (UTC)

My point wasn't that the entire additon should stay, just that describing his or her actions as editing out wasn't accurate. In general I do have problems with a lot of the new material but I have kept the reference for the Anesthesia Care Team however, as it is a valid source for the Anesthesia Care Team being lead by a physician. I shall explain why I don't think the addition meats Wikipedia's neutral point of view policy:
  1. "According to the ASA statement on the Anesthesia Care Team, anesthesia care personally performed or medically directed by an anesthesiologist constitutes the practice of medicine." The view of one body as to what constitutes the practice of medicine does not amount to much, we cannot list the view of every body about what constitutes medicine. The reader must make up their own mind on such point.
    More acceptable might be a comment on: "Physicians are sometimes hostile the the use of nurses in providing anesthesia without supervision, feeling that this does not amount to the practice of medicine."
  2. "Certain aspects of anesthesia care may be delegated to other properly trained and credentialed professionals. These professionals, medically directed by the anesthesiologist, comprise the Anesthesia Care Team." This is already discussed later, but doesn't cover the fact that anesthesia can also be delivered outside the ACT.
  3. "According to the Care Team statement (last amended on October 17, 2001), “Such delegation and direction should be specifically defined by the anesthesiologist director of the Anesthesia Care Team and approved by the hospital medical staff. Although selected functions of overall anesthesia care may be delegated to appropriate members of the Anesthesia Care Team, responsibility and direction of the Anesthesia Care Team rest with the anesthesiologist.”" I do not think this is important enough to quote verbatum.
In general the addition would also give too much emphasis to anesthesia provision in the US when the article should be trying to give a worldview, with regional examples only. Perhaps an article should be started about Anesthesia Care Team, which can be linked to. I hope that clarifies why the addition did not appear unhelpful. WjBscribe 01:24, 11 February 2007 (UTC)

[edit] Editing and the like

Ok

I understand your situation WJB. I feel like I have been very cooperative. Why is it that there are no repercussions for the behavior of one anon.individual who is causing all these problems? Do i have to lodge an official complaint somewhere? Or do I have to continually check this entry everyday to make sure his IP isnt back editing without restriction at a whim?Mmackinnon 01:26, 11 February 2007 (UTC)

You could if you want report the matter at the appropriate administrator's noticeboard (WP:AN/I) but I think a block unlikely. Administrators are unlikely take sides in a content dispute. I would point out that as we have worked together to improve the material, it has ceased to be removed. The best response is to make the material less controversial- ensure it is balanced and support any controversial parts with references. I have already stated above that I will delete all further political debate of the merits of different anesthesia providers from this page. I hope for focused discussion from now on. I would regard the blocking of a likely contributor to such a debate counterproductive. WjBscribe 01:53, 11 February 2007 (UTC)

This would be a better reference for the anesthesia care team. I will defer to you to place it or not

http://www.durhamregional.org/healthlibrary/behind_the_scenes/20060518173014802Mmackinnon 01:42, 11 February 2007 (UTC)

I agree that this is a better reference. It is more focused on the sentence it is used as a source for. I have changed it accordingly. WjBscribe 01:57, 11 February 2007 (UTC)

[edit] External links

Well I did say that my interpretation of WP:EL would be fairly ruthless. If the are sites that its is felt provide information that should be linked to, please argue for them. I will say now that I see little reason for any national anesthesia website (for one thing because there are just far too many if all are to given equal weight). Websites for specific US anesthesia website belong in the articles about that organisation in question (e.g. CRNA website in article about CRNAs etc.). They might also have a place in an article about Anesthesia provision in the US but here priority should be given to international organisations. Images of surgery is a very good collection of copyright material that cannot be indorporated into the article. All opinions on candidates for links that should be added to the page obviously welcome. WjBscribe 01:53, 11 February 2007 (UTC)

Hey

Can't argue with your changes. I think it looks cleaner and avoids competition to place links.Mmackinnon 01:58, 11 February 2007 (UTC)

___________________________________________

Though I understand your reasoning, WJB, I'm sorry to see all the patient info links go, as it is mainly patients the world over I would assume, and not medicos, who seek out this page and benefit from it. Most patients could care less about our specific drugs or at what level the spinal cord might end; they care most about the anesthesia process, and links such as http://www.gaspasser.com/rap.html can give them the vital information they seek, as well as allay anxiety.

deepzCRNA 21:31, 11 February 2007 (UTC)


___________________________________________________________________________

I say good riddance to gasspasser.com, a site primarily dedicated to providing information to favor crnas rather than to inform patients. Do you guys have a financial interest in that particular site or something? Gees! There are plenty of good links that would provide patient information. If you choose to add one, I hope you chose one that is less partisan.

I think the site is much better now. There is appropriate information about different providers in their own sections (though OCPs and crnas belong in a united nursing section rather than split into crnas and other) and there isn't anything excessively devisive anywhere. It's not exactly what I think is an accurate description, but it's a good compromise on the whole.

__________________________________

Didn't read that link, did you Mr Anon. There is nothing remotely commercial there, just information.

Anesthesia is anesthesia, that's what you wish to hide from the public by banishing CRNAs to some Jim Crow segregation.

Proudly signing,

deepzCRNA 22:49, 11 February 2007 (UTC)


So now our anomalous friend has simply moved his vandalism to the page Anesthesia provision in the US

Don't you ever tire of your childish games, Mr Georgia AA?

Proudly sitgned,

deepzCRNA 02:04, 12 February 2007 (UTC)

[edit] Where is the evidence for this statement?

"Physician anesthesiologists delivery anesthetics in every country in the world."

Time to remove it as its simply not true.Mmackinnon 04:01, 14 February 2007 (UTC)

That's a difficult statement to reference. Perhaps you could find one country without physician anesthesiology. Do you really think it's false or you just like being a pain? Uptowner 22:17, 14 February 2007 (UTC)


Removed the external link which claimed to be International AAs. The AAAA is All-American. The hyperbole never ends.

deepzCRNA 23:00, 14 February 2007 (UTC)

______________________________

Mr Georgia AA, you inserted the statement that MDAs 'delivery' (sic) anesthetics in 'every country in the world.' Can you not back up your claim with evidence? Surely you're not just pulling those words out of your ... protocol?

deepzCRNA 00:07, 15 February 2007 (UTC)


Mr Georgia AA didn't put that in, I did. You know that it's true, too. Uptowner 19:08, 15 February 2007 (UTC)


He's cloning himself?

deepzCRNA 02:39, 16 February 2007 (UTC)

_________________________________________

Is it not evident by now that the ASA crowd is continuing to mess with the CRNA sections, while the CRNA crowd does nothing to tamper with the doctor/AAs' own self-glorified editing? Is that not plain?

deepzCRNA 02:47, 16 February 2007 (UTC)

Uptowner. Dont bother editing in inaccurate, unfounded and propagandist statements. We will delete them daily.Mmackinnon 03:19, 17 February 2007 (UTC)

[edit] sweeping edits

To whomever recently went in an edited a number of things. I reverted them. If you are going to make sweeping edits then discuss it here firstMmackinnon 14:52, 18 February 2007 (UTC)

Indeed. I would also like an explanation of the deletions by 12.164.102.129 on the 18th. They were correctly reverted. Without explanation, such blanket removal of content can only be seen as vandalism. WjBscribe 08:00, 20 February 2007 (UTC)


Hey wjb, again more edits that i had to reverse.Mmackinnon 01:06, 24 February 2007 (UTC)

Again, I agree and have warned the IP address concerned. Unexplained deletion of content without explanation is unnacpetable, especially where that content was arrived at through concensus in discussions on the talkpage. WjBscribe 01:24, 24 February 2007 (UTC)


Appreciate your efforts, WJB. The vandalism we confront here is also covered elsewhere: http://en.wikipedia.org/wiki/Fanaticism The Churchill quote is especially apt.

deepzCRNA 05:49, 24 February 2007 (UTC)


I made edits regarding CRNA's working under Physician supervision in the ACT model, and they were reverted. CRNA's do work under Physician supervision in the ACT model, and the reverts were unnecessary. Changing back...

Your editings suggest that CRNAs only work as part of the ACT model, when they are also licensed to provide anesthesia without physician supervision. A lot has work has gone into creating a neutral representation of these issues. Please discuss any concerns you have about the present text here fully, before making changes that don't seem to provide the full picture. WjBscribe 14:58, 22 March 2007 (UTC)


WJ, with all due respect, I made sure to note that CRNA's are licensed in "some" states, because they are not licensed in all 50 ( I believe only 16 ), to practice independently, and that under the ACT model they work under the direct supervision of a Phyisican Anesthesiologist. This is an important distinction when evaluating the overall role of CRNA's in anesthetic care. Many of the"27 million anesthetics" delivered are done so under a physician's supervision. To say that this is not the case is akin to a Physician's Assisstant claiming "1000 surgeries a year" while in reality, they were in the OR 1000 times, each time was as first assist to the attending surgeon. Thank you. 72.185.204.89 15:36, 22 March 2007 (UTC)


I think you are confusing CRNAs with AA's (who are only licensed in 16 States). The fact that under the ACT model they work under physician supervision is already explained in the article. And your edit did not say that many of the 27 million anesthetics were delivered under supervision, it implied that all were. WjBscribe 15:40, 22 March 2007 (UTC)
WJ, I take back what I said earlier. CRNA's are only allowed to work independently in the 14 states which the Governor's have signed a Medicare "opt-out" clause, which allows the state to "opt-out" of physician supervision. I added a link and explanation for clarification under the CRNA portion of the article, with the reference coming from the AANA website itself. This is an important addition, as it explans to Anesthesiologists around the world why America is the only industrialized nation to allow (albeit limited in quantity) CRNA independent practice: Limited access to patients in the states listed in the links. These opt-out clauses can be taken back at any time by a Governor. For more info, please see link. Thank you. 72.185.204.89 13:16, 23 March 2007 (UTC)
----------------

This is also inaccurate. CRNAs practice INDEPENDENT of anesthesiologists in all 50 states. There is no requirement anywhere in the USA for CRNAs to be supervised by an MDA. The safety stats in the UK are near identical to that of the USA national average (and the sole CRNA practice average)which clearly proves there is no difference in provider. The dictatorial role of medicine in other countries is irrelevant and certainly not evidence of anything. Mmackinnon 07:32, 24 March 2007 (UTC)

Please note I was referring to independant practice of CRNA's, which is not allowed in all 50 states. I believe the wording under the ACT model, which was a direct contrast to "independent practice", was not fully explained in the portion of the article. It was my goal to show that many of the 27 million were delievered under supervision, but not all. This goal is represented by the reality of anesthetic care. Perhaps we can alter the wording to reflect the emphasis on the ACT model being under Physician supervision and the fact that many of those 27 million are delivered under supervision? Thank you. 72.185.204.89 15:44, 22 March 2007 (UTC)
If you have a source to confirm what proportion of those procedures are performed under supervision that would be be a helpful addition to the article. Otherwise I suggest adding "either independently or under physician supervision" as the most neutral way of expressing that point. WjBscribe 15:57, 22 March 2007 (UTC)
As the nurse's section includes a statistic on anesthetics delivered from their professional organisation, I included statistics from the physician's section from their professional organization regarding how many anesthetics are delivered each year, and by whom. I believe this gives us an accurate picture of how great the ACT model plays a role in the delivery of anesthetics. 72.185.204.89 16:20, 22 March 2007 (UTC)

Additionally, CRNA's are not allowed to perform interventional pain procedures, only a licensed Pain Anesthesiologist or Pain Physiatrist can. These include facet joint injections, lumbar blocks, morphine pump placement, and spinal stimulators, all done with an OR setting under guidance of fluorsoscopy. When the claim is made that CRNA's are able to deliver "all types of anesthestic care", I believe that this is misleading, and the correction regarding interventional pain procedures should be made. Thank you. 72.185.204.89 15:39, 22 March 2007 (UTC)

If you wish to add information to the article to clarify points about what treatments CRNAs can perform please do so, but include independent reliable source to confirm your claims, as Wikipedia policy requires. I have no objection to your removing the protion you just did, but please ensure that your contributions to this article are balanced. WjBscribe 15:57, 22 March 2007 (UTC)

There are no laws in the USA which state CRNAs cannot perform pain procedures. If you actually read the Louisiana appellate court decision (which u clearly havent) it is merely an injunction in ONLY THAT STATE until the entire process is finished. At NO point (and the appellate court states this) are they inferring or making a decision on scope of practice in this current case. You might consider a "law blog" as a credible source but i dont.Mmackinnon 07:32, 24 March 2007 (UTC)

WJ, Thank you. Two references added regarding CRNA scope of practice not including interventional pain procedures, even under the supervision of a physician. Thank you. 72.185.204.89 16:06, 22 March 2007 (UTC)

The line "CRNAs may also practice in parallel with their physician colleagues in certain institutions, both types of provider caring for their own patients independently and consulting whenever collaboration is appropriate to patient outcome." was removed, because if an Anesthesiologist is present, the ACT model abounds. This does not take away from the CRNA's license to independently practice where no Anesthesiologists are found (usually in rural areas with vast shortages), nor does it denigrate their role in the ACT model. However, it does imply that in "certain institutions", CRNA's have an equal footing with Anesthesiologists in role of patient care. I would love to see a reference on this. Either the ACT model with both abound, or either one practices independently, but in my time in many academic institutions, I have yet to see this "parallel" practice. It reeks of propaganda, and we need to keep this article neutral for public consumption. Thank you 72.185.204.89 15:54, 22 March 2007 (UTC)

[edit] New Content Suggestion

In an effort to improve the education of the general population I would like to see additional content on potential anesthesia complications and anesthesia consent. It would be another tool which we could use when talking with patients and their family members before surgery. It could also be a reference that hospitals and surgeons could use to help inform patients before they are able to speak an anesthesia provider.

I plan to help create such a section and would like to either include it as a part of the anesthesia site or a link to it if people think that it is more appropriate. My big concern is that large edits to this page keep getting deleted by all the political in-fighters. Such major content restoration has really prevented the page from progressing into a more powerful tool. Tstan 14:34, 25 February 2007 (UTC)

I'm sure those additions will be fine. The dispute you refer to was concerned primary with discussions of the various providers of anesthesia and not edits to other sections. In any event it is now largely resolved as far as this article is concerned. Feel free to add details on the topics as you propose. WjBscribe 23:23, 25 February 2007 (UTC)

______________________________________________

As there has been no citation provided to explain or substantiate how it might be that MDAs 'delivery' (sic) anesthetics in 'every country in the world' I'll remove that.

deepzCRNA 15:52, 27 February 2007 (UTC)

Fair enough. It can be readded if sourced. I have however restored the 109 figure for nations in which nurses provide anesthesia. Saying "more than 100" seems unnecessary when an actual figure is available. WjBscribe 16:05, 27 February 2007 (UTC)

OK, I just doubt the true accuracy of the 109, based solely on the IFNA stats.

deepzCRNA 18:43, 27 February 2007 (UTC)

I think its fair to assume the International Federation of Nurse Anesthetists knows what its talking about unles there's evidence to the contrary. WjBscribe 18:46, 27 February 2007 (UTC)

Of course. Here's what they say: http://ifna-int.org/ifna/e107_files/downloads/Practice.pdf

deepzCRNA 18:49, 27 February 2007 (UTC)


[edit] CRNA and Interventional Pain

Whoever added the edit regarding nurses in rural areas and pain: Please provide a reference. I have provided two references which state otherwise, including a recent court decision in Louisiana striking down CRNA claims that they are able to perform these procedures, even in the "rural areas" of backcountry bayou Louisiana. I will remove your contribution unless you provide reference. Thank you. 72.185.204.89 13:05, 23 March 2007 (UTC)


Mr anonymous.


The court decision in Louisiana just proves your ignorance. Not only is it NOT a federal decision but its NOT a decision at all. This is simply a preliminary injunction will remain in effect until the trial court issues its final ruling. Essentially, NO decision.Mmackinnon 06:59, 24 March 2007 (UTC)

[edit] WJB

We have numerous times discussed what exactly IS vandalism.

Please see this link about what the "MDA Residents" are planning in regards to vandalism of this wiki entry. http://gasforums.studentdoctor.net/showthread.php?t=383702

thanksMmackinnon 06:40, 24 March 2007 (UTC)


The sweeping edits you put in place, including removing documented evidence regarding CRNA scope of practice, including links from the AANA website, are atrocious. I will immediately revert. This sort of "re-writing" of history is pretty ridiculous. With regards to the link you posted above, I saw it, and it seemed like those guys probably just wanted to keep the wiki article in check because of folks on both sides who are getting a little heated. Let us keep all this within wikipedia guidelines, and the truth will prevail. Thank You. ICUDocMD 15:30, 24 March 2007 (UTC)


Just so you KNOW ICUDocMD these EDITS were long approved before your arrival and attack on this article. The consensus was months ago. YOU are clearly the one coming in here writing revisionist history and disrupting the homeostasis. DO NOT edit the CRNA section, we have NEVER edited the MDA section. Again, in case you are unable to digest legal documents, the "LA pain decision" makes no statement on CRNA practice in regards to pain but only holds it until the entire decision is rendered. They state that right in the actual LEGAL document from the court (as opposed to your "law blog"). Please get your facts straight.Mmackinnon 15:50, 24 March 2007 (UTC)
Mmackinnon, please refrain from the CAPS, as yelling isn't appropriate. I can read exactly what you are saying. With regards to the edits I put in place, WJBscribe and I discussed them (see above under sweeping edits), and references were placed. I believe this better allows us to understand all of these statistics thrown around, as well as the delivery of anesthesia, not to mention the scope of each provider's roles in patient healthcare. I would appreciate discussions here before sweeping edits are put into place, which I will only re-instate due to the vandalisitic, or even fanatic, manner in which the sweeping edits were included. Thank You. ICUDocMD 15:57, 24 March 2007 (UTC)
ICUdocMD, please review the history of the wiki for the last 6 months. These edits have been established and you are the one now making mass changes. Your discussion with the moderator is not the decision upon which revisionist history becomes true. Your references were both incorrect and lackluster. We have been compromising for quite some time, it is your side which has decided to edit the CRNA section to fit your idea of it. To suggest that your statistics from your organization are any more valid than those from the AANA is laughable. BTW, i replied in that section (which i started BTW) to your points over 24 hours ago.Mmackinnon 16:05, 24 March 2007 (UTC)
I reviewed it, and saw that both sides were putting up things which were not documented, making sweeping edits of each other's material, and overall not acting within wiki rules. I appreciate the order which was brought about by WJBscribe and a few others in this fight. With regards to the most recent changes, I fail to see why you are deleting links under the CRNA section which come from the parent organisation of the CRNA's, the AANA, itself, regarding the medicare opt-out rules and the CRNA scope of practice. Furthermore, in order to keep this article fair and balanced, I believe it is necessary to discuss each issue you have with material which has already been discussed and hashed out between WJB and I, before you make sweeping deletions of documented material. I look forward to future discussions in which we can view the facts objectively, and take it from there. Thank You. ICUDocMD 16:10, 24 March 2007 (UTC)

[edit] Quick thoughts

I don't have time to look in on the disputes about this page's content right now, though I will try and find time later. I encourage contributors to discuss how this page should read here and try and reach a compromise as to how to neutrally represent the situation. Content on Wikipedia is never set in stone and often has to be reconsidered when new participants arrive. I hope you will all engage in productive discussions. Please remember to include reliable sources for any information that may be controversial. I will will take a look at the discussions page once I am able. WjBscribe 15:54, 24 March 2007 (UTC)

[edit] Richard Stiles edits.

These need to be put in check. He adds personal ideas to fit his own agenda. these comments he continues to add "under the supervision of an licensed physician" and "It is important to note that when cases are complicated, most CRNAs rely on their physician counterparts for help." are simply incorrect and personal opinion. This is nothing less than revisionist history to fit his national organizations political agenda, not facts.Mmackinnon 16:10, 24 March 2007 (UTC)

I completely agree, and think his recent edits are examples of what NOT to do in this discussion. ICUDocMD 16:11, 24 March 2007 (UTC)
Edits by this user do appear to have been rather unproductive. I have warned them accordingly. WjBscribe 22:14, 25 March 2007 (UTC)

[edit] ICUdocMD

Hey there


Well it seems apparent you are interested in a good discussion and i also would like that. Lets go through everything one by one maybe im not being fair either. Could you present the info here about what you would want to change and ill discuss it. Lets not edit till we have come to agreements. Fair?Mmackinnon 16:27, 24 March 2007 (UTC)

you mention the opt out in relation to independent practice. This is where it gets a bit incorrect. The opt out only relates to medicare patients and actually has nothing to do with anesthesiologists or independent practice. All it says is that in these states CRNAs can charge directly for anesthesia services to medicare. CRNAs in states which havent "opted out" can still work independent of an anesthesiologist and charge medicare as the surgeon just signs it off. As well, any case where the payor isnt medicare there is no requirement for any sign off. It is really not about independent practice but only medicare payments. See what i mean?Mmackinnon 16:32, 24 March 2007 (UTC)


Sure thing. I'm glad you made this extra edit. Let's talk about things one by one.

A) Interventional Pain Procedures. This is a hotly debated topic amongst healthcare providers, but it seems that according to the ASIPP and the Louisiana Courts, nurses are not able to perform these procedures, and only thought they were able to due to a "recommendation" by the Louisiana Nursing Board. If you could please provide how these procedures are within the scope of CRNA practice, I'd be much obliged. Evidence must be shown to allow these procedures, not the negative thereof. If that was the case, you could say, for example: CRNA's can perform cardiac stents. I would deny this, and you would ask for a case showing where they were not allowed to do so. The onus is on you to show that precedent allows them to in fact perform such procedures. CRNA's perform within the nursing scope of healthcare, while physicians perform within the medical scope. Would you say that Interventional Pain Procedures are within the nursing scope? Furthermore, if so, where does this nursing scope end? I look forward to your response.

I agree it is hotly debated. From my understanding a CRNA can only do a limited number of pain procedures and they relate to the direct order from a referring physician (which makes sense). I do not believe that CRNAs do the placing of any sortof devices which are common to pain practice. I believe this is a physician only practice. I will look for specific information as to the reality. Personally, i think pain medicine is typically medically directed when done by a CRNA. Good points, ill see what i can find and if nothing, we remove it!

B) Anesthesia Care Teams: Led by an Anesthesiologist, not "physician anesthetist". ACT's are found only within the United States, and as such, physicians are referred to as Anesthesiologists within the United States, while anesthetists outside the United States are physicians. I would appreciate having the phrase "led by an Anesthesiologist" with the appropriate wiki link inserted : Anesthesiologist in order not to confuse those perusing wikipedia.

I agree. Anytime the term "anesthesia care team" is used it is always in conjunction with an anesthesiologist (man that is so much longer than MDA to write!). Good point and appropriate edit!

C) I understand the medicare opt-out with regards to billing. Medicare, the largest provider of healthcare in the United States, has a policy of physician supervision of nurse anesthetists, except in those 14 states. In otherwords, Medicare doesn't allow "solo CRNA's without physician supervision" in more than 14 states. It should be noted that physician supervision is required. Please provide reference to the private insurances not requiring a physician signature. If this was the case, then what is the fight all about? Furthermore, why is only 10% of Anesthesia care CRNA only? Come on now. :)


I think we are just mis communicating here. In states which have chosen to opt out the wording in the CMS ruling would consider the relationship between a CRNA and the dentist, physician, podiatrist etc as a collaborative. In states where there isnt an opt out it is a supervision situation when that person would have to co-sign with the CRNA. The info can be found here: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2001_register&docid=01-28439-filed.pdf. As for independent practice, well I would say 10% is a little high to be honest. The fact is the vast majority of the places without anesthesiologists are rural areas where they would never be (regardless of the passthrough argument). Even tho these CRNA only practices exist, it is likely they wont have the same pt subset as that of the large teaching institution where ACT practices are the only option. I have no idea why the argument is so big but both sides make a big deal out of something i see as simple. Politics... sad.


D) "practice in parallel to physician colleagues...collaborating where necessary". Please add a reference to this, otherwise, it's an undocumented statement with regards to scope and details of CRNA practice. It implies parity amongnst the parties in training and scope of practice. This article needs to be clear with regards to scope of practice of each healthcare provider. ICUDocMD 16:56, 24 March 2007 (UTC)

II have to tell you, im not sure where that came from as i didnt write it. When a CRNA works with an anesthesiologist (with the exception of the military setting) it is always in the anesthesia care team. The time this would be true is when the CRNA is working with a physician or other authorized person in an opt out state, it then would be collaboration. In the non- opt out states i would also say it is collaboration when not with an anesthesiologist as the expert in anesthesia would always be the CRNA relative to the dentist or non-anesthesiologist physician. As im sure you know, we always work in collaboration as anesthesiologist and CRNA but the final reality is that the anesthesiologist is the supervisor of the anesthesia care team. Does that make sense?Mmackinnon 19:47, 24 March 2007 (UTC)

[edit] Comment

It seems you are working well towards agreeing improvements to this text, a couple of thoughts occur agree to me:

  1. Detail. The more detailed account should be at Anesthesia provision in the US. As far as possible this article should stick to providing a brief (but accurate summary) of the position in the US, to comply with Wikipedia's policy on providing a worldview of topics. Readers can be directed towards the fuller article if they are interest in further details of US anesthesia provision.
  2. Physician supervision. It appears to me that one are in which confusion has occured previously is the difference between a CRNA acting in a team headed by a physician (without an anesthesia specialism) and under the direct supervision of an anestheologist. Am I correct in observing a distinction here?

Please highlight if there are any areas on which you have difficulty reaching agreement and wish an outside opinion on... WjBscribe 22:23, 25 March 2007 (UTC)

Hey WJB The physician supervision issue is a complicated one. CRNAs work in one of 3 ways.

- As a part of the Anesthesia Care Team with a lead anesthesiologist.

- As an anesthesia provider working with a physician non-anesthesiologist. Their function and the anesthesia function are seperate (surgeon vs anesthesia) where they may or may not be required to sign off on everything for "Billing" reasons.

- As an anesthesia provider with a NON-Physician such as a dentist, podiatrist etc. where they may or may not be required to sign off on everything for "Billing" reasons.


In states where the "opt out" is mentioned the "collaboration" statement would be correct. The CRNA would do the anesthesia and bill for it without input or signature of the collaborating individual (physician or otherwise). Its all very confusing.Mmackinnon 23:52, 25 March 2007 (UTC)


Hey everyone. I will look over the content placed by my friend Mmackinnon. However, something has come up in my personal life, and I may not be able to reach it within a week or so. See you then. Thank you! ICUDocMD 03:30, 26 March 2007 (UTC)
hey ICUDocMD. No problem bud. I wont be making any real Mmackinnon 04:04, 26 March 2007 (UTC)changes until we have talked them through.

[edit] To the person who added another link

Hello


This link, along with MANY others were deleted in an effort to avoid CRNAs & MDAs competing with adding links. The 4 left are all that has been decided acceptable. For that reason i removed yours.Mmackinnon 18:34, 28 March 2007 (UTC)

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