Talk:Anesthesia/Archive 1

Distinction between anesthetics and other agents
Commented ouut 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. &mdash; Agateller 14:57, 23 January 2006 (UTC)

i was thinking about entering into this field. i am a young women only 19 and about to start school so i can become one of the greats. i have many differnt people telling me that i cant and never will be able to make it. how old was everybody else when they thought about doing this. i just would like some feedback. thank you for taking the time to stop and read this. have a good day. —Preceding unsigned comment added by 206.207.225.21 (talk) 07:31, 28 January 2008 (UTC)

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)

Hello, Halstead was a surgeon in New York who used cocaine as a local anesthetic. Specifically he perfected the technique of mandibular nerve block that is most commonly used in dental practice to this day. 124.169.226.19 (talk) 15:21, 20 March 2008 (UTC) Dr A. J. Lepere DDS, FADSA, JP  124.169.226.19 (talk) 15:21, 20 March 2008 (UTC)

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.

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. ---

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)

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?

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)

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

While trying to add things the the List of medical abbreviations I have been looking for PACU and cannot find it. I also then went to look for Recovery and found a bunch of things in the disambiguation, but no mention of a post anaesthetic care area. How do I go about requesting a page on PACU or Recovery? Cheers! 139.168.206.220 22:32, 20 April 2007 (UTC)

Please add discuss regarding anesthesia and Alzheimers. There is a link between use of isoflurane in particular. Many scientific articles support this and there is a wealth of anecdotal evidence.

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)

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)

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) Removal of various links to CRNAs []


 * 1) Removal of AANA website (one of MANY) []


 * 1) Removal of IOM data as well as outcome evidence []


 * 1) Changing history to reflect that physician anesthesia is better when the evidence suggests there is no difference (propaganda?)[]


 * 1) Removal of IOM data as well as outcome evidence ]

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)

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: That would seem to ensure the article covers both, but makes clear the difference... WJBscribe 04:26, 30 January 2007 (UTC)
 * 1) Provision of anasthesia by nurses
 * 2) Provision of anasthesia by physicians


 * 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)

---

deepzCRNA 05:26, 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.                       ??????

---

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: 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) ___________________
 * 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

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)

Article badly in need of organization
I propose the following: Oanjao 19:32, 31 January 2007 (UTC)
 * 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

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)

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: 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)
 * 1) Physicians who provide anesthesia
 * 2) Nurses who provide anesthesia
 * 3) Nurses who assist physicians in providing anesthesia

_____________________________________________

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)

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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)

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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)

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)

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)

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)

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.  Nish kid 64  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. 

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.  Nish kid 64  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)

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)

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.

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

-- 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)

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:
 * "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."
 * "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.
 * "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)

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)

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)

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)

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)

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)

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)

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)

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)

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)

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


 * 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.

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)

To 150.216.218.103 who keeps changing Nurse Practitioners to "Advanced practice nurses"
All CRNAs ARE Nurse Practitioners. Advanced practice nurse is not the correct term.Mmackinnon 20:56, 19 April 2007 (UTC)

Please stop editing without discussing here first.
Any edits (such as those recently) will be reverted if no discussion occurs.Mmackinnon 00:13, 15 May 2007 (UTC)

Nikolay Ivanovich Pirogov was a pioneer in ether as Anasthesia
that's what this article says Nikolay Ivanovich Pirogov

Recent edits to section under the "Types" heading and "Anesthetic agents" heading
I made several edits to the Types section. This section previously contained no distinction between local/regional anesthesia techniques using amide/ester anesthetics and sedation/general anesthesia using centrally-acting agents. Also, this section contained an imprecise definition of general anesthesia I replaced using a definition adopted by the ASA. I also added information about other types of anesthesia care that fall alongside general anesthesia in the continuum of depth of anesthesia.

I also made several edits to the Agents section. I added descriptions of various anesthetic agents that did not exist before. Also, I removed obsolete agents (curare) that are not used in modern anesthesia (these agents are discussed in the history section). I also mentioned that halothane is not used in modern anesthesia practice often. I split the opioids section into short-acting agents frequently used perioperatively (fentanyl and its derivatives) and longer-acting agents mostly used for postoperative analgesia. I also removed codeine because it is almost never used intravenously and didn't fit with the others. Because pain relief is a part of anesthesiology, perhaps we should add a section about non-intravenous drugs used for pain relief more generally. I added a section on reversal agents and re-organized the list of muscle relaxants.

I believe that all or nearly all of the statements I have added are correctly documented, but please let me know if there is any other problem with these edits.

Depstein 06:46, 1 July 2007 (UTC)

Hypnosis link
Please do not link hypnosis to the Wikipedia article on hypnosis. The Wikipedia article on hypnosis refers to the process by which "critical thinking faculties of the mind are bypassed and a type of selective thinking and perception is established." This definition of hypnosis is not the same as the hypnosis we are talking about with general anesthesia, where the patient experiences no thinking or perception because he has been given a hypnotic or sleep-inducing agent.

Depstein 07:00, 17 July 2007 (UTC)

Anesthesia Providers
These comments will pale in significance to what you're working on--and have worked through--already. They're just a few observations from my brief encounter with this article. Rather than make the one edit that I could do without further knowledge of the subject, I'll just leave these notes for someone who can make all of the appropriate changes.


 * Unless "Anesthesia Providers" is a proper noun, and the article doesn't seem to say that it is, this section heading should have a lower-case "p".
 * The first sentence of this section is almost identical to the first paragraph of the section following it. It would be an improvement to eliminate the redundancy by removing it from this section.
 * Someone should spell-out the meaning of "ACT".
 * It appears that perhaps the sections that follow this one and describe specific groups of anesthesia providers should be subordinate to this one, rather than at the same "level" in the article's structure.

My 2¢ worth. --rich

Please do not add links in the external link section
It has already been discussed and decided that the external link section would not include non-international associations or country specific organizations of anykind. This is to avoid an "editing war" for everyone to add their own politically or economically motivated links.

Thanks ~

IP 71.196.45.16: Stop editing in non-international association links.
There isnt an AANA, ASA or AAAA link there because we long ago decided to have NO US only association links. International only. If you cannot abide by the rules be prepared to have a complaint lodged and your IP restricted.~

Anesthesia safety statistics
In the US, up until about 1980 anesthesia was a significant risk, with at least one death per 10,000 times administered. After becoming something of a public scandal, a careful effort was made to understand the causes and improve the results. It is generally believed that anesthesia is now at least ten times safer than it was then.  However, there is some controversy about this.  In the US, the data is not made public (in fact, the data is not even collected), so the truth is uncertain.  The rate for dental anesthesia is reported to be one out of 350,000.

See also:
 * http://www.apsf.org/resource_center/newsletter/1995/fall/gravenstein.html
 * 

Please add safety statistics to this main article. Please link to some appropriate article containing detailed safety statistics by country, discussion of change over history, causes of such changes, etc. -69.87.200.24 21:50, 28 August 2007 (UTC)

Truth or Myth?
I heard rumours saying that anaesthetics may affect one's ability to remember things negatively (like short-term memory loss). I myself has gone through an operation before which had me totally unconscious for the whole surgery. I don't know if I'm just scaring myself but I think my memory is getting weaker in the way that I can forget things much more easily after that operation.

Any expert to verify this rumour? Any replies will be very much welcomed, thanks. — Yurei-eggtart 14:35, 10 September 2007 (UTC)

Anesthesia monitoring versus Anesthesia record
I am new to wiki and wanted to add the article "Anesthesia record". Right after posting, the article would disappear and instead the keywords "anesthesia record" would be redirected to "anesthesia monitoring". There must be either a misunderstanding or insufficient level of description of this matter. "Anesthesia monitoring" refers to the observation of the patient either directly by the anesthesia provider or by the use of devices (e.g. ECG, pulse oximetry, etc). However, the "Anesthesia record" (or anesthetic record) refers to "The Anesthesia Record is the medical and legal documentation of events during an anesthetic. It reflects a detailed and continuous account of drugs, fluids, and blood products administered and procedures undertaken, and also includes the observation of cardiovascular responses, estimated blood loss, urinary body fluids and data from physiologic monitors (e.g. SpO2, ECG, body temperature, end-tidal CO2, invasive blood pressures, etc.) during the course of an anesthetic." Reference: Stoelting RK, Miller RD: "Basics of Anesthesia", 3rd ed. 1994, Churchill Livingstone. Please add the section "Anesthesia record" and I would love to provide my input for this. Cbeh —Preceding unsigned comment added by Cbeh (talk • contribs) 03:17, 11 September 2007 (UTC)

How does it work?
There does not seem to be anything in this article about how anesthesia works in a biochemical sense. Additional material or a link should be added or if the mechanism is not understood this should be stated. Xxanthippe 11:50, 27 October 2007 (UTC).
 * I agree. This is just what I was thinking when I looked through the article. ::Travis Evans (talk) 19:46, 5 December 2007 (UTC)

Vandal 75.58.184.58
A request has been sent to the admins to either ban you or protect the page. Vandals are not tolerated here and your attempts to defame the Nurse Anesthesia Profession will not be either. If this is how "Doctors" act then I feel bad for patients. (you notice the CRNAs have never edited your sections)Mmackinnon 23:12, 28 October 2007 (UTC)

No unconsciousness
You write "Hypnosis: produces unconsciousness without analgesia" Even deep hypnosis is NOT unconsciousness. The person is very aware of inviroment and responds to suggestions. Analgesia may be the purpose of the particular session or even surgery. jmak (talk) 07:00, 9 April 2008 (UTC)

20th Century Poem by Ferdowsi?
The "history" part mentions 20th century poem by Ferdowsi, where anesthesia is described. Ferdowsi died somewhen around 1020, so he obviously could not write anything in 20th century. I think this ought to be corrected. 194.44.31.194 (talk) 14:04, 2 June 2008 (UTC)

Number of years of pre-CRNA school experience
The following statement was made in the anesthesia provider section: "The average CRNA student has 5-7 years of nursing experience before entering a 27-36 month masters level anesthesia program.[13]" The citation given points to a study published in the Journal of the AANA titled "Television conferencing: Is it as effective as "in person" lectures for nurse anesthesia education?"

1) Convenience Sample: the authors of the cited paper state that "a group of 36 nurse anesthesia students were selected as a convenience sample of students from the same class. . ." on page 20 under the methods section. A convenience sample is defined as "A sample for which cases are selected only on the basis of feasibility or ease of data collection. This type of sample is rarely useful in evaluation and is usually hazardous."  http://www.epa.gov/evaluate/glossary/c-esd.htm  Another definition reads: '''"A convenience sample is a sample where the patients are selected, in part or in whole, at the convenience of the researcher. The researcher makes no attempt, or only a limited attempt, to insure that this sample is an accurate representation of some larger group or population."  http://www.childrensmercy.org/stats/definitions/convenience.htm Out of convenience of testing, the authors of the paper used two groups of participants who were selected for their entry-level requirements. Out of convenience, the authors of that paper took a group of students and matched individual characteristics to remove any other factors' bias in the results, namely the effect of televised lectures on examination performance. Especially because the data are not affected by the variable of lecture location, namely the number of years of experience prior to CRNA school entry and because the data were derived from a convenience sample, it would be scientifically inappropriate and blatatently statistically false to make that assumption. 2) Others have noted that the original article's purposes is to discuss television conferencing and not the average number of years of experience prior to entry into CRNA school. This is another reason why the citation given is inappropriate for the claim in the sentence of the Wikipedia article.  3) The final paragraph of the results section includes the statement "Having documented that both groups entered the program with comparable entry level qualifications, with the only difference in treatment of the respective groups being the mode of transmission of didactic material. . ." which supports the assertions regarding the convenience sample herein. 4) Finally, the authors of the paper make no claim, not even a casual one at that, to quantifying the trend of experience of SRNA students prior to entering school.

You must refrain from citing articles which do not support the assertion made in the text. Failure to do so is a violation of the citation guidelines of Wikipedia, namely requiring accurate citations 'to improve the credibility of Wikipedia". This conflict is settled.  Any further edit knowingly using inappropriate citations will be viewed as a breach of the standards of Wikipedia and will be dealt with accordingly.

If you find a research article which properly asseses the education background of CRNAs nationwide in an appropriately randomized, properly controlled, multi-location study, please include the citation to that article. Until you find such evidence, please refrain from making unsubstantiated statements or inappropriate citations. --Healthpolicy (talk) 00:19, 8 July 2008 (UTC)

If we are following stringent research standards.
I would suggest then that all of the research posted be reviewed? Some of it is little more than opinion paper. Should i list them here?Mmackinnon (talk) 00:58, 8 July 2008 (UTC)

Definitions
In the opening paragraph is the following statement Anesthesia differs from analgesia in blocking all sensation, not only pain.

Am I the only one to find the obvious fault? Consider local anaesthesia, such as used in suturing, gross sensation is present, only pain sensation is inhibited. Dlegros (talk) 01:53, 15 September 2008 (UTC)

Stop editing the Nurse Anesthesia section to reflect personal politics. Thanks.
If you have a disagreement post it here. Otherwise, i suggest you (whomever) stop editing the Nurse Anesthesia section to reflect how you want it to read when you are CLEARLY not a CRNA. Thanks. Mmackinnon (talk) 21:31, 2 January 2009 (UTC)

This is an encyclopedia entry, not a propaganda page.
We can and should discuss what nurse anesthetists do. If we are going to discuss the law, we should make that as accurate as possible. It is technically true - but quite misleading- to claim that CRNAs don't require anesthesiologist supervision in any state. This is because they require the supervision or direction of a physician or dentist trained in anesthesia in most states. A few states are more permissive. At any rate, this is not a place for political talking points. Riffington (talk) 20:25, 20 February 2009 (UTC)

ANSWER:

Read closely so I can explain "the law" to you. CRNAs can work in every state in the union INDEPENDENTLY. What you are referring to is "Medical Direction" and "supervision" which are CMS billing terms and NOT a document on practice scope, rule or dependence. The requirement for Medical direction was put in place (1:4 MDA:CRNA) to FORCE MDAs who were committing billing fraud to meet SOME obligation for billing 50% per case. This is found in the CMS billing rules and is what the 7 TEFRA rules are for MDA billing. If an MDA does NOT MEET these 7 rules the CRNA can still do the case ALONE in any state in the union and bill 100%. So, get your facts straight. Now, the "supervision' term is yet another CMS billing term and NOT about practice rights. This is requires that the dentist, podiatrist or physician sign the chart so that the CRNA can bill CMS 100%. Nothing more nothing less. There is NO REQUIREMENT in ANY STATE that these people must have any anesthesia training of any type. Moreover, they hold exactly ZERO liability for the anesthetic which a solo CRNA provide. This is obvious in case law where CRNAs have been found liable and the surgeon was dropped. The law is clear, unless the surgeon takes control of the anesthetic they are not liable for the CRNA. This, BTW also holds true with MDAs. So, now thati have taught you what the actual laws are, you understand that you are incorrect. Please, do NOT BS me about political taking points as you paste references from the ASA absolutely blurring the law. Mmackinnon (talk) 20:59, 20 February 2009 (UTC)

No. Medical supervision is not a mere billing term. CRNAs require actual supervision in many states, which a surgeon cannot provide while simultaneously operating. Reread the reference which describes the law, state by state. Riffington (talk) 21:21, 20 February 2009 (UTC)

ANSWER:

The ASAs (a political organization which promotes anesthesiologists views in politics) "Interpretation" of law is not a fact. The terms medical direction and supervision are, indeed, CMS laws. The state laws you suggest exist are simply extensions of the federal CMS regs. CRNAs can and do practice in all states independent of anesthesiologists. What i wrote IN THE NURSE ANESTHETIST section is absolutely and completely correct.

Mmackinnon (talk) 22:08, 20 February 2009 (UTC)

The AANA is a political organization which solely promotes nurse anesthetists' views in politics. The ASA is an educational organization with far less political bias. It includes and incorporates anesthesiologists and nurse anesthetists at meetings. State laws are not mere extensions of Federal regulations - they include additional requirements. You gloss over these. CRNAs have much more limited scopes of practice in some states than in others. Riffington (talk) 22:26, 20 February 2009 (UTC)

ANSWER:

I have since submitted this to the admins as a dispute. I have been monitoring this section for over a year and managing these edits. An agreement was made during the last "debate" with an ASA member who felt the need to post ASA politics as fact and this was the result. You now come doing the same thing. Im sure it will be decided the same way again.Mmackinnon (talk) 23:33, 20 February 2009 (UTC)

I don't understand how you can criticize me for posting politics as fact, when that is what you seem to be doing. Nurse anesthetists have very different scopes of practice depending on state. Since you happen to work in Philadelphia, let's look at Pennsylvania law. Pennsylvania requires CRNAs to be supervised by physicians. You tried in 2007 to change this law to allow nurse anesthetists to administer anesthesia "in collaboration" with a physician or dentist. This bill would have opened the door to CRNA independent practice; it failed.

Now, it would be entirely reasonable for an encyclopedia entry to leave out these kinds of subtle legal issues, and merely state that nurse anesthetists participate in 55% of surgeries in the US. That's a fact, and it's helpful. It would not be reasonable for the entry to imply nurse anesthetists can practice independently in all states - they can't. Alternatively, we could include the number of states that require direction and the number that require supervision.Riffington (talk) 12:36, 21 February 2009 (UTC)

ANSWER:

Again you seem to not understand the law. Yes, the CRNA is 'supervised' but can be done by the operating practitioner. Which IS the case in PA since there are MANY independent CRNA ONLY practices here where there are no "anesthesiologists". In fact, CRNAs can work here with podiatrists and dentists who both act as the 'supervising' physician. You simply do not understand how these laws work and have been so busy trying to "interpret" them via the ASA talking points you have clearly no actual understanding of them. Practice has not changed in PA since or before that bill. CRNAs here practice independently with the operating practitioner signing the chart 'ordering' anesthesia. They hold ZERO liability for the CRNA anymore than they do for the MDA. This is codified in case law. When was the last time that an MDA didnt work with an operating practitioner? Never. So the CRNA has them sign the chart, thats it.Mmackinnon (talk) 13:54, 21 February 2009 (UTC)

---

You're right that it didn't change since that bill, because HB 1256 was killed in committee. Heck, listen to how your Pennsylvania Association of Nurse Anesthetists described the bill: "The Governor of Pennsylvania has proposed independent practice for CRNAs in certain circumstances to increase access to quality health care. This is a monumental development for our profession – IF THE LEGISLATURE APPROVES HIS PLAN." Supervision is an active process, not a mere formality; PANA didn't get that worked up just to avoid a signature. Also, MD anesthesiologists do sometimes work without an operating practitioner, and so do CRNAs (typically with anesthesiologist supervision).

Side note: if you abbreviate MD anesthesiologist as MDA, what do you call anesthesiologists who have a DO?

ANSWER:

It didnt change because there are STILL CRNA only grps (as there were before) working with the 'supervising' operating practitioner. This is independent practice. They do not determine or direct the anesthetic. I use the term MDA the same way stoelting did, as a shorter acronym for the long term. There is nothing derogatory about it just as there is nothing derogatory about CRNA instead of the long term. Mmackinnon (talk) 15:06, 21 February 2009 (UTC)

___ Why are you continuing to put supervising in quotations? If the quotation marks were warranted, those supervisors would be negligent. Who decides which lab tests are needed for the anesthetic? Who diagnoses problems that occur during and after the anesthetic? Who runs the postoperative unit? Any physician responsible for these tasks needs to be well-trained in anesthesia, and the vast majority of such physicians are anesthesiologists. Any nurse responsible for them needs to be practicing in a state other than Pennsylvania, or needs to be a physician. Riffington (talk) 01:48, 2 March 2009 (UTC)

ANSWER:

In practices where there are no MDAs CRNAs make ALL of these decisions and the dentist, surgeon and/or podiatrist do NOT. You are ignorant of what the term "supervision" means. It means ONE thing, a billing term for CMS. There is no requirement for direct supervision of CRNAs... anywhere. You simply do not know the laws whatsoever and keep simply rattling off ASA talking points which are incorrect. I submit that in practices without MDAs, CRNAs make all these decisions in every state in the country. This also happens in places where there ARE MDAs who are there only for consulting (supervision vs medical direction practices... BOTH CMS terms again). It has been that way since 1984 when CMS started TEFRA.Mmackinnon (talk) 00:05, 8 March 2009 (UTC)

If the CRNAs are making these medical decisions, they cannot legally do so in the many states requiring medical supervision. Please name a single truly independent CRNA practice in PA (your own state) that legally performs all functions. They cannot; those functions must be performed by the supervising physician. Additionally, you are misstating the definition of supervision. It is not a billing issue, it is a patient safety issue. Finally, states have not been permitted to allow independent practice as early as 1984: they were permitted only in 2001. —Preceding unsigned comment added by Riffington (talk • contribs) 14:44, 11 March 2009 (UTC)

ANSWER:

Again you dont understand the law. There is NO law that does not allow CRNA independent practice in EVERY state in the union. The 2001 thing you refer to is OPT OUT which has NOTHING to do with independent practice but ONLY relates to billing medicare. You need to learn the laws before you come here and tell me what MY practice allows. I am well aware of the laws, you are well aware of the ASA political talking points, which, BTW are NOT the laws.Mmackinnon (talk) 00:52, 12 March 2009 (UTC)

You, sir, are the one who is only promoting talking points of the AANA. Please stop that, and stop accusing me of what you are the one doing. What nurse anesthetist anywhere in your state do you know who has the legal right to practice without supervision? Who may run a postop unit? Who may order diagnostic tests needed for the preoperative care of the surgical patient? These are important parts of the practice of anesthesia. You are focusing only on the administration of anesthesia under another supervising physician's orders, which is not the same as independent practice. Your PA nurse anesthetist organizations tried and failed to introduce a bill to allow independent practice, and you pretend the bill was meaningless. Why would they put so much political capital into a meaningless bill? And stop pretending that patient safety laws are "just for billing".Riffington (talk) 16:27, 13 March 2009 (UTC)

ANSWER:

Sigh...

There are 6 CRNA only groups that currently exist in PA. They run their entire ORs without MDAs. They write and order PACU orders and take care of their own patients. This is the pervue of all APNs to order diagnostic tests and medications as needed, as it has ALWAYS been. The ONLY time a CRNA requires a surgeon to "sign" the chart is when it is a medicare case as clearly explained in the CMS literature. Again, yes, supervision is ONLY for billing with CMS patients and, as it is also clearly explained in the CMS rules and case law, the definition of "supervision" is only as a billing term and, in NO way results in liability for the surgeon for the CRNAs actions orders or anesthetic. It is obvious you are clueless about these laws, they are NOT about patient safety or practice and that is ALSO clearly stated in the CMS rules, again which you have not read. The evidence is clear, there is NO DIFFERENCE. It is too bad you are too full of yourself to understand that and actually do the research yourself. Oh, and that bill, did not give independent practice as CRNAs already have it here in PA as evidenced by the CRNA only practices in the state.Mmackinnon (talk) 01:42, 14 March 2009 (UTC)

Dude, now you are making things up even beyond the AANA talking points you were previously espousing. In PA, CRNAs aren't advanced practice nurses at all. They can't order PACU orders, they can't order medications, and the issue isn't "signing" charts, it's supervision. These laws are exactly about patient safety. The CMS allows an optout - not for economic reasons - but so that in areas where anesthesiologists are in shortage patients still get access to anesthetic care.70.12.239.120 (talk) 02:18, 14 March 2009 (UTC)

ANSWER:

Ok, then show me the law that shows CRNAs cannot order anything, there is not one. CRNAs are not listed as APNs in PA but this is intentionally vague in order to allow practice to continue as it has always been. BTW, all the CRNAs in these practice do their own pacu orders. Again, as for the CMS opt out you should consider actually reading it. There is no "independent" practice in the opt out only the non-requirement for the surgeon to sign the chart so the CRNA can bill CMS 100% of the physician fee structure. This has NOTHING to do with "safety" and there is no evidence to support such a statement. Show me your evidence (since i know none exists) for any of your allegations here. BTW, living in minn. certainly does not make you an expert of PA (or apparently even familiar with federal) law.Mmackinnon (talk) 02:58, 14 March 2009 (UTC)

The Pennsylvania Code defines what nurse anesthetists may do:"(1) Induce anesthesia. (2)  Maintain anesthesia at required levels.  (3)  Support life functions during the period in which anesthesia is being administered, including induction and intubation procedures. (4)  Recognize and take appropriate corrective action, including the requesting of consultation, when necessary, for abnormal patient responses to the anesthesia or to an adjunctive medication or other form of therapy.  (5)  Provide professional observation and resuscitative care, including the requesting of consultation, when necessary, until the patient has regained control of his vital functions. "

The various States have their own laws related to anesthetic practice, in addition to CMS rules. In opting out of CMS requirements for physician supervision of nurse anesthetists, they must show that doing so is in the interests of their citizens. It is absurd to suggest that the Federal government wants states to decide whether a mere billing rule is in the interests of the State's citizens. Indeed, all the states that have considered opting out have looked at a conflict between the increased safety of a physician-led anesthetic team vs the potential for difficulty of access in areas where anesthesiologists are in particularly short supply. Look at any of their debates. They used a variety of correct and incorrect information in making their respective decisions, but that question of access vs quality is central to all the states's debates. The states with the greatest anesthesiologist shortages are thus the ones that have been most likely to opt out of the Federal rule, and also to allow greater scope of practice within their State bylaws. Riffington (talk) 17:21, 14 March 2009 (UTC)

Please cite that reference for me and how it restricts CRNAs from ordering labs, medication etc in the OR and out of the PACU (BTW it does not). You do not know your history about the CMS TEFRA rules clearly. Before 1984 there were SO MANY cases of fraud being committed by MDAs who were "supervising" CRNAs from the golf course and home that CMS developed the 7 TEFRA rules. These rules are the requirements that MUST be met for an MDA "medically directing" up to 4 CRNAs at a time and so they can bill 50% of each case. RIGHT in this same document (goto the CMS website and look it up), it explains that this is not a dictation of scope or practice but a billing term (as is "supervision") when used in regards to CMS billing and specifically in regards to MDAs. "Supervision" which is what the opt out is 100% about is 100% related to CMS billing only. That is clear. In fact it is highly likely that there will be a national opt out within the next 4 years. This has nothing to do with the "number" of MDAs but had to do with the access to care. You keep saying lots of great ASA talking points, unfortunately, none of them are grounded in the legislation and practice laws for CRNAs (which are decided by the BON and legislation).Mmackinnon (talk) 20:07, 14 March 2009 (UTC)

You still seem quite interested in talking about 1984. I'll explain to you the current law.

http://www.pacode.com/secure/data/028/chapter123/chap123toc.html It describes CRNAs scope of practice, as well as the requirements for anesthesia. The very first requirement in fact describes something that a CRNA cannot do independently: "1) Every patient requiring anesthesia shall have a preanesthesia evaluation by a physician or by a qualified person under the supervision of a physician, with appropriate documentation of pertinent information regarding the choice of anesthesia. This examination and recording of the findings from it shall take place within 48 hours prior to surgery. "

Also re the CMS http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=391&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date "The new Medicare rule changes the physician supervision requirement for CRNAs furnishing anesthesia services in hospitals. The rule removes a federal requirement that a physician supervise every case of anesthesia administration by a nurse anesthetist and allows states to determine whether such supervision is needed. The rule would allow CRNAs to practice in hospitals without physician supervision where state law and hospital policy permits. Similarly, the rule would require that CRNAs be supervised by physicians where such oversight is required by state law and hospital policy. And any hospital can establish stricter standards than required by state law.

The final rule recognizes the states' traditional domain in establishing professional licensure and scope-of-practice laws. It does not prohibit, limit, or restrict in any way the practice of medicine or prevent anesthesiologists from administering anesthesia or supervising another professional."

Obviously, each state is different. And accordingly, some States with physician shortages have allowed CRNAs to practice independently. Those 14 States are primarily rural ones with anesthesiologist shortages: Iowa, Nebraska, Idaho, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, South Dakota, Wisconsin and Montana. I'm not sure where you derive the claim that all 50 are likely to follow suit, though this is of course plausible.Riffington (talk) 02:54, 15 March 2009 (UTC)

ANSWER:

Ok lets break this down shall we?

This line you stated:

"The very first requirement in fact describes something that a CRNA cannot do independently: "1) Every patient requiring anesthesia shall have a preanesthesia evaluation by a physician or by a qualified person under the supervision of a physician, with appropriate documentation of pertinent information regarding the choice of anesthesia"

In no way says a CRNA cannot and does not do this. As stated under the supervision of the surgeon. Yes and in this state a CRNA can perform all of these tasks. The surgeon supervision is extremely loose and not defined in any documents. It is clear to me that even the documents you provided (which i already read) in no way hamper the CRNAs ability to work independently. As you are aware, there is a surgeon with EVERY case so just because they have to sign the chart does not change the CRNAs ability to perform all the care needed to get the patient into, through and out of the PACU. Your assertions that CRNAs cannot write orders isnt correct and not backed up by this document (or the CMS one).

It is nice to see you left out the rest of that document. Let me add it from the same CMS link:

"There is no evidence that CRNA independent practice would cause adverse outcomes. There also is no evidence that states are any less concerned with ensuring the quality of care and safety of their citizens than is the federal government -- or that states have been unsuccessful in overseeing other health care professional practice. Critics of the proposed rule have cited findings of researchers at the University of Pennsylvania that anesthesia outcomes are better when anesthesiologists are involved in furnishing anesthesia care. However, this study is not relevant to the issue involved in this rule. It did not compare CRNA practice with non-anesthesiologist physician supervision to CRNA practice without physician supervision. It does not provide sound and compelling evidence to support maintaining federal preemption of state law.

Full Deliberation

This change was first proposed in 1997, when HCFA proposed changes to its hospital conditions of participation and stated its desire to move toward standards that are patient-centered, evidence-based, and outcome-oriented. HCFA proposed eliminating many outdated federal requirements and deferring to states unless there was compelling and sound evidence to support an across-the-board federal requirement for the supervision of one state-licensed health professional by another. After three years of deliberation and comment from the public and the health care community, HCFA believes its new rule allows the appropriate level of regulatory flexibility without compromising patient health or safety."

Clearly, the federal government did NOT mention "access" to MDAs bud. Sorry, but that was not and never has been the impetus for opt out. You, again, dont know your history but like the ASA are excellent at cherry picking documents. Fortunately, I already have read them all. This document only further proves my point that outcomes and saftey are NOT impacted by CRNA only Independent anesthesia. Which, like it or not, IS legal in PA. You are trying to suggest that because a surgeon has to sign the order for "anesthesia" (which is their ownly requirement), that this somehow changes the practice. However, it does not and there is no law which states or codifies that it is. The surgeon must merely sign and in doing so takes no responsibility for the anesthetic which the CRNA delivers. The captain of the ship doctrine is long dead and that is very clear in case law.

This editing started by you FOR political reasons and nothing more. This wiki has been as is for over a year without issue and after much work between myself and some MDAs. I take care of the CRNA section they take care of the MDA section. You, however, just decided to espouse all of your wisdom and change things without any evidence to do so. Since the start there has been alot of bouncing around in topics here in your attempt to somehow prove that CRNAs cannot work independently. You have not proven that, CRNAs do, in fact, work independently in PA. The supervision in PA involves nothing more than the surgeon signing the chart to order the anesthesia. There are no rules which state the CRNA cannot order diagnostics and drugs in the holding area, OR or PACU. This is, in fact, done everyday. You are hanging your whole argument that the need for the surgeon to sign something in SOME WAY makes an MDA "better" and it does not.

Oh and BTW, anesthesia is the practice of NURSING and medicine. That is an indisputable fact since the nelson dagmar case.

Mmackinnon (talk) 14:53, 15 March 2009 (UTC)

Finally we agree that a CRNA can do it under the supervision of the surgeon. That requires a surgeon capable of supervising it, which in turn requires knowledge of anesthesia on his/her part beyond that of the average surgeon.

As to the safety part, read it again. It says that the evidence showing the increased safety of anesthesiologist-supervised anesthetic teams does not imply that non-anesthesiologist physician supervision necessarily provides the same benefit. Since the minimum standards are simply physician supervision rather than anesthesiologist supervision, that means that in hospitals where physician supervision would not be anesthesiologists, there would be little safety increase. However, 90% of anesthetics that CRNAs perform are supervised by anesthesiologists. Hence in most locations, there is a proven safety benefit.

Supervision is not and has never been a mere signature. That would be malpractice. Supervision is a much more active process, and your attempts to claim otherwise are ridiculous. I am sure you have browbeat anesthesiologists on this forum before, but that doesn't make you correct. You are placing propaganda where it does not belong. Why not agree to make the CRNA section a little more neutral and leave out the AANA talking points? Riffington (talk) 00:17, 16 March 2009 (UTC)

hehe. No, most states do not (i dont know of any) require the surgeon to have any special training in anesthesia to supervise. Which, BTW it does not look like PA does. Oh and what you are quoting IS NOT what CMS says but that absolutely flawed study by silber (who says it does not show significance). Also, CMS even invalidates it with this sentence: "Critics of the proposed rule have cited findings of researchers at the University of Pennsylvania that anesthesia outcomes are better when anesthesiologists are involved in furnishing anesthesia care. However, this study is not relevant to the issue involved in this rule. It did not compare CRNA practice with non-anesthesiologist physician supervision to CRNA practice without physician supervision. It does not provide sound and compelling evidence to support maintaining federal preemption of state law.'''

You twisted it to sound as tho CMS was saying that MDAs were needed, it does not and in fact states that the silber study is irrelevant. There is no "proven safety benefit of MDAs". There is only proven safety benefit of having extra hands. Which could be a CRNA or an MDA. Moreover, the studies which have been done on solo practitioners (pine) shows that solo MDA and solo CRNA have similar outcomes for similar cases. To me (and the government) that clearly suggests equal safety records (which is true).

Show me where supervision is an active process.

You suggest I 'browbeat' these MDAs. Of course not, we actually came to an agreement. I would not edit their section (which i never have) and they would not edit mine. Everything written is referenced correctly. You dont have to like it but that is how it is. You even here reference the 90% MDA supervised stuff, which is funny thats an ASA stat. Look, you will never convince me to change the CRNA section because you want it to follow along with YOUR politics. It is as neutral as it needs to be and is as 100% accurate and correct. YOU do not get to dictate/define my profession, sorry.

in fact let me add some evidence for you: Anesthesia Provider Model, Hospital Resources, and Maternal Outcomes Jack Needleman 2 and Ann F. Minnick 1 * 1 School of Nursing, Vanderbilt University, 461 21st Avenue South, Nashville, TN 37240 and 2 Department of Health Services, UCLA School of Public Health, Los Angeles, CA Objective. Determine the ability of anesthesia provider model and hospital resources to explain maternal outcome variation. Data Source/Study Setting. 1,141,641 obstetrical patients from 369 hospitals that reported at least one live birth in 2002 in six representative states. Conclusion. Hospitals that use only CRNAs, or a combination of CRNAs and anesthesiologists, do not have systematically poorer maternal outcomes compared with hospitals using anesthesiologist-only models.

Centers for Disease Control

In 1990, the federal Centers for Disease Control (CDC) considered undertaking a multimillion-dollar study regarding anesthesia outcomes. Following a review of anesthesia data from a pilot study issued by the CDC and the Battelle Human Affairs Research Centers, however, the CDC concluded that morbidity and mortality in anesthesia was too low to warrant a broader study. The pilot study, published on December 1, 1988, was entitled, "Investigation Of Mortality and Severe Morbidity Associated With Anesthesia: Pilot Study." The pilot study stated that:

To obtain regional estimates of rates of mortality and severe morbidity totally associated with anesthesia with a precision of about 35% a nationwide study consisting of 290 hospitals should be selected. This size study would cost approximately 15 million dollars spread over a 5-year period.

Minnesota Department of Health Study In 1994, the Minnesota Department of Health (DOH), as mandated by the state Legislature, studied the provision of anesthesia services by CRNAs and anesthesiologists. The department reached four conclusions, including the following:

There are no studies, either national in scope or Minnesota-specific, which conclusively show a difference in patient outcomes based on type of anesthesia provider. [page 23, DOH study.] [emphasis added]

Forrest Study [Forrest, WH. "Outcome - The Effect of the Provider." In: Hirsh, R, Forrest, WH, et al., eds. Health Care Delivery in Anesthesia. Philadelphia: George F. Stickley Company. Chapter 15.1980:137-142.] It was surprising that the stage of training of the anesthesiologist or administration of an anesthetic by a nurse anesthetist or anesthesiologist seemed to affect risk very little.... [page 220] Dr. Forrest's very carefully done study showed no difference in outcome whether the provider was a nurse anesthetist or an anesthesiologist.... If we had to accept the data that there are no differences in outcome between anesthetics administered by anesthesiologists compared to nurse anesthetists, the consequences would be truly extraordinary. It would mean that we would have to question our very careers; we would have to question the value of anesthesia residency training programs; we would have to question organization in hospitals; we would have to question and reexamine projections for manpower needs in the future; we would have to question medical economics as they are projected right now. With some of the data presented to us [during the full symposium] we were very comfortable because they matched expectations... Now in the study comparing nurse anesthetists and anesthesiologists, we do not have this comfort. [pages 223-224]

National Academy of Sciences Study

This study was mandated by the U.S. Congress and performed by the National Academy of Sciences, National Research Council. The report to Congress stated:

"There was no association of complications of anesthesia with the qualifications of the anesthetist or with the type of anesthesia." [House Committee Print No. 36, Health Care for American Veterans, page 156, dated June 7,1977.1

Bechtoldt Study [Bechtoldt, Jr, AA. "Committee On Anesthesia Study. Anesthetic-Related Deaths: 1969-1976." North Carolina Medical Journal. 1981;42:253-259.] Bechtoldt reported that the ASC:

... found that the incidence among the three major groups (the CRNA, the anesthesiologist, and the combination of CRNA and anesthesiologist) to be rather similar. Although the CRNA working alone accounted for about half of the anesthetic-related deaths, the CRNA working alone also accounted for about half of the anesthetics administered. [page 2571] [emphasis added]

Bechtoldt stated that the ASC's study included patients representing all risk categories. The study did not, however, address whether particular types of anesthesia providers (i.e., anesthesiologists or CRNAs) tended to encounter patients having particular risk factors. Because CRNAs working alone provided approximately half of the nearly two million anesthetics administered in the state during the period of the study, it is reasonable to believe CRNAs provided care to patients covering the full spectrum of physical status and anesthetic risk.

Pine study After adjustment for differences in case mix, clinical risk factors, hospital characteristics, and geographic location, the current study found similar riskadjusted mortality rates whether anesthesiologists or CRNAs worked alone. Furthermore, hospitals without anesthesiologists had results similar to those of hospitals in which anesthesiologists provided or directed anesthesia care. Anesthesia care teams had a slightly lower risk-adjusted mortality rate than did practitioners working alone, but the difference was not statistically significant. Although these findings differ from those of Silber et al,7 they are more consistent with the earlier research cited and with current data on overall anesthesia-related mortality.1 They indicate that for the surgical procedures included in this study, the type of anesthesia provider does not affect inpatient surgical mortality.

Dr. Pine reiterated his study's findings that after risk adjustment there is no statistically significant difference between CRNAs working individually, anesthesiologists working individually, or CRNAs and anesthesiologists working together. He added that his study's data support the conclusion that even when there are two anesthesia providers working together, substituting an anesthesiologist for a CRNA does nothing to lower the mortality rate. [Pine, M. Response to "ASA Preliminary Comment

Comments on the Silber study Further supporting the argument that other studies do not agree with the purported findings of Silber and his fellow researchers is the following objective, third-party opinion offered by HCFA/CMS in the Federal Register on January 18, 2001: Our decision to change the Federal requirement for supervision of CRNAs applicable in all situations is, in part, the result of our review of the scientific literature which shows no overarching need for a Federal regulation mandating any model of anesthesia practice, or limiting the practice of any licensed professional." (p. 4685-4686) D. HCFA/CMS Affirms that Study Not About CRNA Practice In the anesthesia rule published in the January 18, 2001, Federal Register by HCFA/CMS, the administration dismissed all claims by ASA and the Pennsylvania study research team that the study examined CRNA practice and was relevant to the supervision issue. HCFA/CMS stated the following:

* "We have also reviewed a more recently published article by Dr. Silber (July 2000) and colleagues from the University of Pennsylvania. This article also is not relevant to the policy determination at hand because it did not study CRNA practice with and without physician supervision, again the issue of this rule. Moreover, it does not present evidence of any inadequacy of State oversight of health professional practice laws, and does not provide sound and compelling evidence to maintain the current Federal preemption of State law." (p. 4677) * "One cannot use this analysis to make conclusions about CRNA performance with or without physician supervision." (p. 4677) * "Even if the recent Silber study did not have methodological problems, we disagree with its apparent policy conclusion that an anesthesiologist should be involved in every case, either personally performing anesthesia or providing medical direction of CRNAs." (p. 4677)

Although the January 18 rule was rescinded on November 13, 2001, with the publication of a new rule that allows state governors to write to CMS and opt out of the federal physician supervision requirement after meeting certain conditions, the January rule's extensive comments supportive of nurse anesthetists and dismissing the relevancy of the Pennsylvania study to the supervision issue have in no way been repudiated by CMS and still remain part of the public record.

E. Conclusions

The following conclusions can be drawn from a careful examination of the study "Anesthesiologist Direction and Patient Outcomes":

* The study described has nothing to do with the quality of care provided by nurse anesthetists. * The study examines postoperative physician care, not anesthesia care. * The researchers so much as admit that the study does not prove anything with regard to the effect of anesthesiologist involvement in patient care. * The timing of the publication in the ASA's own journal was politically motivated. * HCFA/CMS finds no credence in ASA and Dr. Silber's assertions regarding the results of the Pennsylvania study. Mmackinnon (talk) 01:34, 16 March 2009 (UTC)

--

Of course, PA doesn't list what training a surgeon must have to supervise nurse anesthetists, any more than it lists what training he/she must have to read an MRI. RN scope of practice is dictated by law (somehow citing the law that spells out CRNA scope of practice in PA is cherry picking?) to a much larger extent than MD scope of practice. But not every surgeon knows how to read an MRI, and not every surgeon knows how to supervise a nurse anesthetist. Supervision always holds the potential to become an active process, so to supervise someone you need to know a fair bit about what they do.

"Your" CRNA section is not neutral. A neutral section would not include sentences like "CRNAs do not require Anesthesiologist supervision in any state and only require surgeon/dentist/podiatrists to sign the chart for medicare billing in all but 16 states." Neutrality would look like "the specific laws related to independent practice vary state by state", or "CRNAs typically work as part of an anesthesia care team, although in certain states they may practice independently". Additionally, you are mistaken when you say you've never edited the anesthesiologist section. You added the sentence "It is not required to be board certified in the USA in order to practice anesthesiology" in a location where it did not fit logically or grammatically.

Fundamentally, you don't want a neutral section. You want to create conflict between CRNAs and anesthesiologists in order to drum up more business for your nurse anesthetist resource center. You personally profit from friction, and so you try to create it.

Also: you are correct that in-hospital mortality has not been shown to be different. Silber looked at a longer period (30 days), which therefore has much higher mortality rates. In that setting (which is indeed relevant to overall patient care), there is a statistically significant difference in mortality rates. The safest anesthesia setting is, probably not coincidentally, the most common anesthesia setting: CRNAs with anesthesiologist supervision.

Riffington (talk) 23:20, 19 March 2009 (UTC)

So, when you dont have evidence to back up what you say I should simply take your word for it? Let me answer some of what you stated.

"Of course, PA doesn't list what training a surgeon must have to supervise nurse anesthetists, any more than it lists what training he/she must have to read an MRI."

That is because there are no requirements in PA for a surgeon, dentist or podiatrist to have special training to 'supervise'.

"CRNAs do not require Anesthesiologist supervision in any state" = True

"only require surgeon/dentist/podiatrists to sign the chart for medicare billing in all but 16 states" = True.

What you wrote favors your political views, nothing more nothing less.

"the specific laws related to independent practice vary state by state" = Not exactly correct. When it comes to billing medicare they do not. States do not regulate the practice outside of billing rules for medicare. Supervision be it medicare of in the state law, at no point suggests OR implies that the operating individual must have some special training to supervise. Moreover, there is absolutely no 'assumed' liability for the CRNA which even the ASA has admitted.

"CRNAs typically work as part of an anesthesia care team, although in certain states they may practice independently" = You WANT to be this way. In reality what I wrote is legally and technically correct.

"It is not required to be board certified in the USA in order to practice anesthesiology" I forgot about this, although it is absolutely correct per the ABA.

"Fundamentally, you don't want a neutral section. You want to create conflict between CRNAs and anesthesiologists in order to drum up more business for your nurse anesthetist resource center.  You personally profit from friction, and so you try to create it."

I dont even know what you are talking about here. I dont own a 'resource center' nor do I profit from anything but anesthesia. I added evidence, you simply attempt to skew it without any to back you up.

"Silber looked at a longer period (30 days), which therefore has much higher mortality rates. In that setting (which is indeed relevant to overall patient care), there is a statistically significant difference in mortality rates.  The safest anesthesia setting is, probably not coincidentally, the most common anesthesia setting: CRNAs with anesthesiologist supervision."

You clearly dont understand research. let me help you. Besides what i posted debunking it (BTW that was the federal government who debunked it), here is some more information.

on January 18, 2001, the Health Care Financing Administration (HCFA, which became the Centers for Medicare & Medicaid Services, or CMS, in June 2001) published a 14-page anesthesia rule in the Federal Register (Vol. 66, No. 12, pp. 4674-87) that affirmed, in no uncertain terms, AANA's contention that the Pennsylvania study is not relevant to the issue of physician supervision of nurse anesthetists. (The January 18 rule was rescinded on November 13, 2001, with the publication of a new rule that allows state governors to write to CMS and opt out of the federal physician supervision requirement after meeting certain conditions. The January 18 rule's extensive comments supportive of nurse anesthetists and dismissing the relevancy of the Pennsylvania study to the supervision issue, however, have in no way been repudiated by CMS and still remain part of the public record.)

On its surface, the study suggests that patient outcomes are better when nurse anesthetists are directed by anesthesiologists. However, a closer examination clearly reveals that the study

''' * is not about anesthesia care provided by nurse anesthetists * actually examines post-operative physician care.'''

A. Background

The study was conducted using data obtained from Health Care Financing Administration (HCFA) claims records. The study group consisted of 217,440 Medicare patients distributed across 245 hospitals in Pennsylvania who underwent general surgical or orthopedic procedures between 1991-94. '''Dr. Silber headed a research team that included three anesthesiologists. B. Study Does Not "Compare Anesthesiologists Versus Nurse Anesthetists"'''

According to Dr. Longnecker, one of the anesthesiologist researchers: "The study ... does not explore the role of (nurse anesthetists) in anesthesia practice, nor does it compare anesthesiologists versus nurse anesthetists. Rather, it explores whether anesthesiologists provide value to the delivery of anesthesia care." (Source: Memorandum from Dr. Longnecker to Certified Registered Nurse Anesthetists in University of Pennsylvania Health System's Department of Anesthesia, October 5, 1998)

Why, then, was such a misleading title ("Do Nurse Anesthetists Need Medical Direction by Anesthesiologists?") chosen for the abstract? The answer: for political reasons. Consider these facts:

* The abstract was published in the midst of the controversy between anesthesiologists and nurse anesthetists over HCFA's proposal to remove the physician supervision requirement for nurse anesthetists in Medicare cases. * The study was funded in part by a grant from the American Board of Anesthesiology, which is affiliated with the ASA. ASA vehemently opposes HCFA's proposal.

Why was the name of the abstract changed prior to publication of the paper in the July 2000 issue of Anesthesiology? Most likely for the following reasons:

'''   * As Dr. Longnecker stated in his memorandum, the study was not intended to examine the question posed by the abstract's title. * The study clearly could not and did not answer the question posed by the abstract's title. * Pressure from AANA in the form of statements to the media and commentary published on the Internet forced the researchers and ASA to rename the paper for publication.'''

C. Problems with the Data

Careful examination of the "findings" reported in the paper reveal numerous problems.

Glaring Admissions. '''In the next to last paragraph of the paper, the researchers conclude that, "Future work will also be needed to determine whether the mortality differences in this report were caused by differences in the quality of direction among providers, the presence or absence of direction itself, or a combination of these effects." Boiled down, this clearly is an admission by the researchers that the study does not, in fact, prove anything about the effect—positive or negative—of anesthesiologist involvement in a patient's overall care, let alone the patient's anesthesia care!'''

This statement appears in a section titled "Discussion," which is devoted primarily to explaining away the limitations of the billing data used (HCFA's claims records comprise a retrospective database intended for billing purposes, not quality measurement) and the myriad adjustments for variables which the data required the researchers to make. According to the researchers, among other adjustments were those made for severity of illness and the effect of hospital characteristics.

The researchers, however, admit the following:

''' * "The accuracy of our definitions for anesthesiologist direction (or no direction) is only as reliable as the bills (or lack of bills) submitted by the caregivers." * "We cannot rule out the possibility that unobserved factors leading to undirected cases were associated with poor hospital support for the undirected anesthetist and patient." * "...if anesthesiologists had a tendency not to submit bills for patients who died within 30 days of admission, our results could be skewed in favor of directed cases."'''

These admissions by the researchers seriously limit the application of the data. They are also proof that ASA's use of data from this study, in advertising campaigns and lobbying efforts to discredit nurse anesthetists and frighten seniors, has been opportunistic, misleading, and ethically reprehensible at best. Time Frame. Nurse anesthetists do not diagnose or treat nonanesthesia postoperative complications -- they administer anesthesia. '''According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), anesthesia mishaps usually occur within 48 hours of surgery. The study, however, evaluated death, complication, and failure to rescue rates within 30 days of admission, encompassing not only the time period of the actual surgical procedures, but also a substantial period of postoperative care as well. Therefore, it is impossible to know from the data how many or what percentages of deaths, complications, and failures to rescue occurred within that 48-hour window and were directly attributable to anesthesia care. However, if one considered the study's sample size (217,440) in relation to the widely accepted anesthesia mortality rate of one death in approximately 240,000 anesthetics given, which is recognized by ASA, AANA and cited in the Institute of Medicine report, To Err is Human: Building a Safer Health System (Kohn LT, Corrigan JM, Donaldson MS. Washington, DC: National Academy Press. 1999.), logic would dictate that less than a single individual in the entire database is likely to have died as the direct result of an anesthesia mishap!'''

What that leaves is this: Based on the 30-day time frame, it is clear that the study actually evaluates postoperative physician care, not anesthesia care.Italic text

Death Rates. The Pennsylvania study cites death rates that were many times more than the anesthesia-related death rates commonly reported in recent years, again leading one to conclude that the increase was almost certainly due to nonanesthesia factors.

In a June 2000 press release about the Pennsylvania study, the ASA stated "that patient safety has greatly improved from one [death] in 10,000 anesthetics to one in 250,000 anesthetics." (This amounts to four deaths in one million.) In the same press release, the ASA stated that, "Dr. Silber's findings show that for every 10,000 patients who had surgery, there were 25 more deaths if an anesthesiologist did not direct the anesthesia care." Through a complex series of calculations, the difference translates to 8,000 deaths in one million. Thus, the difference in mortality rates that the ASA cited is 2,000 times the mortality rate ever attributed (including by the ASA) in the last decade to the administration of anesthesia.''' To attribute a difference of this magnitude solely to the supervision of CRNAs is ridiculous. In actuality, the large differences in mortality and failure-to-rescue are due to differences unrelated to the administration of anesthesia and outside the scope of practice of CRNAs, whether unsupervised, supervised by anesthesiologists, or supervised by other physicians.'''

Further, it has been noted by Dr. Michael Pine, a board-certified cardiologist widely recognized for his expertise in analyzing clinical data to evaluate healthcare outcomes, that after adjusting the death rates for case mix and severity, the patients whose nurse anesthetists were supervised by nonanesthesiologist physicians were about 15% more severely ill than the patients whose nurse anesthetists were supervised by anesthesiologists. The paper provides no information to explain why the anesthesiologist-supervised cases involved less severely ill patients.

Dr. Pine's analysis of the study also reveals the following:

1. 7,665 patients (3.5%) died within 30 days of surgery. 2. Although the study found 258 more deaths of patients who may not have had an anesthesiologist involved in their case, the researchers' adjustments for differences among patients and institutions reduced the number by 78% (to 58 deaths). 3. The 58 "excess" deaths could be due to numerous, equally plausible factors, for example:

A. Faulty design of the study B. Inaccurate or incomplete billing data (e.g., most of the 23,010 "undirected" cases used had no bill for anesthesia care) C. Unrecognized differences among patients (e.g., medical information on patients' bills was insufficient to permit complete adjustment for their initial risks) D. Unrecognized differences in institutional support (e.g., information about hospital characteristics was inadequate to permit full assessment) E. Medical care unrelated to anesthesia administration (e.g., post- operative medical care provided by anesthesiologists or by other medical specialists who are more likely to be at hospitals in communities where anesthesiologists are plentiful)

The end result is a statistically insignificant difference in negative outcomes between anesthesiologist-directed and nonanesthesiologist-directed cases.

Complication Rates. After adjusting for case mix and severity, the study found no statistically significant difference in complication rates when nurse anesthetists were supervised by anesthesiologists or other physicians. Dr. Pine noted that poor anesthesia care is far more likely to result in significant increases in complication rates than in significant increases in death rates. Therefore, Dr. Pine concluded that this finding strongly suggests that medical direction by anesthesiologists did not improve anesthesia outcomes.

Failure to Rescue. For the most part, failure to rescue occurs when a physician is unable to save a patient who develops nonanesthesia complications following surgery. Therefore, it is not a relevant measure of the quality of anesthesia care provided by nurse anesthetists. It is a relevant measure of postoperative physician care, however.

Patients Involved in More than One Procedure. For reasons not explained in the abstract, patients involved in more than one procedure were assigned to the nonanesthesiologist physician group if for any of the procedures the nurse anesthetist was supervised by a physician other than an anesthesiologist. It is impossible to measure the impact of this decision by the researchers on the death, complication, and failure to rescue rates presented in the abstract.

To emphasize the importance of this, consider the following hypothetical scenario: A patient is admitted for hip replacement surgery. A nurse anesthetist, supervised by the surgeon, provides the anesthesia. The surgery is completed successfully. Three days later the patient suffers a heart attack while still in the hospital and is rushed into surgery. This time the nurse anesthetist is supervised by an anesthesiologist. An hour after surgery, and for reasons unrelated to the anesthesia care, the patient dies in recovery. According to the researchers, a case such as this would have been assigned to the nonanesthesiologist group!

Patients Who Were Not Billed for Anesthesia Services. As noted in the discussion on death rates, most of the "undirected" cases had no bill for anesthesia care. The actual figure is 14,137 patients, or 61% of the 23,010 patients defined as undirected. The researchers 'flimsy rationale for lumping all nonbilled cases in the undirected category is as follows: "The 'no-bill' cases were defined as undirected because there was no evidence of anesthesiologist direction, despite a strong financial incentive for an anesthesiologist to bill Medicare if a billable service had been performed' (emphasis added). Of course, one might ask how many of those cases were not billed because an anesthesiologist had a bad patient outcome.

Referenced Studies. and The researchers claim that their research "results were consistent with other large studies of anesthesia outcomes." Interestingly, the two studies cited were by BechtoldtForrest. As indicated below, neither of these studies agrees with the conclusions reached by Dr. Silber and his team of researchers on the Pennsylvania study:

* Bechtoldt reported that the Anesthesia Study Committee (ASC) of the North Carolina Medical Society "...found that the incidence among the three major groups (the CRNA, the anesthesiologist, and the combination of the CRNA and anesthesiologist) to be rather similar. Although the CRNA working alone accounted for about half of the anesthetic-related deaths, the CRNA working alone also accounted for about half of the anesthetics administered." * After applying statistical tests to the results of research conducted by the Stanford Center for Health Care Research, Forrest stated: "Thus, using conservative statistical methods, we concluded that there were no significant differences in the outcomes between the two groups of hospitals defined by type of anesthesia provider. Different methods of defining outcome changed the direction of differences for two weighted morbidity measures."

Further supporting the argument that other studies do not agree with the purported findings of Silber and his fellow researchers is the following objective, third-party opinion offered by HCFA/CMS in the Federal Register on January 18, 2001: Our decision to change the Federal requirement for supervision of CRNAs applicable in all situations is, in part, the result of our review of the scientific literature which shows no overarching need for a Federal regulation mandating any model of anesthesia practice, or limiting the practice of any licensed professional." (p. 4685-4686) D. HCFA/CMS Affirms that Study Not About CRNA Practice In the anesthesia rule published in the January 18, 2001, Federal Register by HCFA/CMS, the administration dismissed all claims by ASA and the Pennsylvania study research team that the study examined CRNA practice and was relevant to the supervision issue. HCFA/CMS stated the following:

* "We have also reviewed a more recently published article by Dr. Silber (July 2000) and colleagues from the University of Pennsylvania. This article also is not relevant to the policy determination at hand because it did not study CRNA practice with and without physician supervision, again the issue of this rule. Moreover, it does not present evidence of any inadequacy of State oversight of health professional practice laws, and does not provide sound and compelling evidence to maintain the current Federal preemption of State law." (p. 4677) * "One cannot use this analysis to make conclusions about CRNA performance with or without physician supervision." (p. 4677) * "Even if the recent Silber study did not have methodological problems, we disagree with its apparent policy conclusion that an anesthesiologist should be involved in every case, either personally performing anesthesia or providing medical direction of CRNAs." (p. 4677)

Although the January 18 rule was rescinded on November 13, 2001, with the publication of a new rule that allows state governors to write to CMS and opt out of the federal physician supervision requirement after meeting certain conditions, the January rule's extensive comments supportive of nurse anesthetists and dismissing the relevancy of the Pennsylvania study to the supervision issue have in no way been repudiated by CMS and still remain part of the public record.

E. Conclusions

The following conclusions can be drawn from a careful examination of the study "Anesthesiologist Direction and Patient Outcomes":

* The study described has nothing to do with the quality of care provided by nurse anesthetists. * The study examines postoperative physician care, not anesthesia care. * The researchers so much as admit that the study does not prove anything with regard to the effect of anesthesiologist involvement in patient care. * The timing of the publication in the ASA's own journal was politically motivated. * HCFA/CMS finds no credence in ASA and Dr. Silber's assertions regarding the results of the Pennsylvania study.

AND

Pine Versus Silber.

The Silber/Pennsylvania study, which was published nearly three years before the Pine study, contained glaring methodological deficiencies that Pine et al. endeavored to avoid. Specifically, approximately two- thirds of the cases which Silber et al. classified as not involving an anesthesiologist in the patient care either A) actually did have an anesthesiologist involved in some, but not all, of a patient's procedures, or B) had no bill for the anesthesia care (making it impossible to confirm whether an anesthesiologist was or was not involved).

Further, cases in which anesthesiologists worked alone were not distinguished from those in which CRNAs and anesthesiologists worked together. Finally, only cases in one state—Pennsylvania—were included in the Silber study.

This failure by Silber et al. to more accurately quantify the cases in which anesthesiologists were involved led the researchers to conclude that there was an increase of 2.5 deaths per 1,000 patients when an anesthesiologist was not involved in the case. This inflated ratio was alarmingly out of sync with the Institute of Medicine's (IOM's) published report that anesthesia mortality rates today are approximately 1 death per 200,000 to 300,000 anesthetics administered, a ratio also routinely cited by the American Society of Anesthesiologists (ASA). [To Err is Human: Building a Safer Health System. Kohn, LT, Corrigan, JM, Donaldson, MS. Washington, DC: National Academy Press. 1999.] Had Silber et al. identified a more accurate (i.e., larger) number of cases as involving anesthesiologists, the ratio obviously would have been much different.

Pine et al. sought to avoid the limitations that marred the Silber study by taking the following steps:

* Studying cases from 22 states, instead of just a single state. * Using only cases that clearly identified the type(s) of anesthesia provider involved in the patient care. * Distinguishing between care provided by CRNAs and anesthesiologists working together and care provided by anesthesiologists or CRNAs working individually.

The results of the efforts by Pine et al. to attribute anesthesia care to the correct providers) was twofold: 1) The researchers attained data that is more consistent with current overall anesthesia-related mortality rates cited by the IOM, the ASA, and the American Association of Nurse Anesthetists, and 2) they found no statistically significant difference in mortality rates when anesthesia is given by a CRNA working individually, an anesthesiologist working individually, or CRNAs and anesthesiologists working together.

AND

Pine Rebuttal to ASA Comments on Pine Study.

In May 2003, the "ASA Preliminary Comment on Pine Study" was released. In a gross misinterpretation of the Pine study results, the ASA claimed that Pine et al. found 38 deaths per 10,000 cases in hospitals where anesthesiologists administered or directed all anesthetics, and 45 deaths per 10,000 cases when an anesthesiologist was not involved. From this, ASA suggested that "the Pine study data support what most recent studies have found—that anesthesiologists improve anesthesia outcomes." [ASA Preliminary Comment on Pine Study. Lobbying day handout. May 2003.]

That same month, Dr. Pine wrote "Response to 'ASA Preliminary Comment.'" He stated that for the ASA to suggest that his study's data supports "the conclusion 'that anesthesiologists improve anesthesia outcomes'" is evidence of "either a woeful ignorance of the basics of data analysis or a cynical contempt for the intelligence of the intended audience." Defending his study, Dr. Pine wrote that his data actually found 34 deaths per 10,000 cases when CRNAs administered anesthesia while working together with anesthesiologists, and 45 deaths per 10,000 cases when anesthesiologists worked without a CRNA. He pointed out that this difference of 11 deaths per 10,000 cases was "even more impressive than the 7 deaths per 10,000 cases" difference cited by the ASA (see paragraph above), and that based on this data, "the AANA could claim that anesthesiologists should not be permitted to administer anesthesia unless a CRNA is present to prevent the excess mortality associated with physicians attempting to engage in the practice of nursing. However, unlike the ASA, the AANA has enough respect for its audience to avoid making such unwarranted claims."

Dr. Pine reiterated his study's findings that after risk adjustment there is no statistically significant difference between CRNAs working individually, anesthesiologists working individually, or CRNAs and anesthesiologists working together. He added that his study's data support the conclusion that even when there are two anesthesia providers working together, substituting an anesthesiologist for a CRNA does nothing to lower the mortality rate. [Pine, M. Response to "ASA Preliminary Comment

Sorry, again your arguments are not back up by facts and when i debunk them one by one you try and deflect. Why dont you do us both a favor. Stop quoting me ASA propaganda, take care of the section you are an expert on and I will do the same. Oddly, you seem to think you have some ability to define MY practice and the laws... however, that is not the reality. I hope your residency is going well.Mmackinnon (talk) 02:53, 20 March 2009 (UTC)

I am 100% wrong and Mmackinnon is 100% right. In fact, I am going inactive with my account.

Riffington (talk) 23:17, 23 March 2009 (UTC)

Requested changes (nothing to do with anesthesiologists vs. CNRAs)
I would like to make several edits to this page.

1) Add a citation after the statement: "Today, the term general anesthesia in its most general form can include:". This should reference the Miller, Ronald 2005 text already in the Notes section. (This definition of general anesthesia is described in this text in the opening paragraph of Chapter 3 – Basic Principles of Pharmacology Related to Anesthesia).

2) The link to Hypnosis (hypnosis is in the bulleted list at the top of the page) refers to another Wikipedia page which describes a "state of focused attention and heightened suggestibility," which is a different entity than the hypnosis referred to in this article. We are speaking about the production of sleep or unconsciousness through use of sedative-hypnotic drugs like propofol or barbiturates. So the link should instead direct to "Hypnotic" which more accurately describes what we are talking about. Similarly, the text to the right of this link is incorrect: many hypnotic drugs, such as benzodiazepines, produce no analgesia or even produce increased sensation of pain, while drugs like NSAIDs or local anesthetics can produce analgesia without depressing consciousness. (The Miller's Anesthesia text mentioned above writes, in the summary to Chap. 31: "profound degrees of hypnosis in the absence of analgesia will not prevent the hemodynamic responses to profoundly noxious stimuli"). Instead, the text should say something like "producing unconsciousness."

3) The text for "Relaxation" in the same bulleted list should instead say "Paralysis" (though the link should remain the same). Relaxation is a confusing term, as it could describe relief of anxiety, which is really a function subsumed by sedative-hypnotic drugs (described under the link of hypnosis in the same bulleted list). Here we are referring to neuromuscular paralysis, so to avoid confusion the text should say paralysis instead.

4) Remove the "[citation needed]" text next to "Minimal sedation or anxiolysis". There is already a reference at the end of the definition (it is #2). There is no need to put a duplicate reference both at the end of the term and then again at the end of the definition of the term 30 words later.

Depstein (talk) 20:06, 22 February 2009 (UTC)


 * I don't think this has anything to do with controversial topics Riffington (talk) 01:39, 2 March 2009 (UTC)
 * ✅. Thanks for your contributions. Martinmsgj 11:04, 2 March 2009 (UTC)

Dear Admin(s),...
I have just redirected 'put to sleep' to this article. Since I can't edit the page to show this, could you kindly do it, thank you. Mod.torrentrealm (talk) 15:41, 21 March 2009 (UTC)
 * What would be the purpose of showing this on the article? &mdash; Martin (MSGJ · talk) 16:24, 21 March 2009 (UTC)