CRNA vs MDA

we can all pull out antecdotes, such as the recent difficult airway, the MD attempted to vizulize cords could not then got glide scope, good call so far, saw cords but could not intubate due to angle so tried for 20 min and bloodied up the airway would not try anything else finally CRNA tubes patient with bougie and MIL 2.
Classic case of just to little knowldge and dangerous.

Just transferred to the east coast and saw this thread. One simple way to end this problem is to include the credentials/status (or lack thereof) of the actual person/persons who will be performing the actual anesthesia right on the anesthesia consnet. 1. Your case will be done my a physician anesthesiologist. or 2. Your case will be done by an unsupervised nurse (crna). or 3. Your case will be done by a combo of the above, spelled out. Let the patient decide. Some people want a physician; others are o.k. with a nurse.

newtoeastcoast wrote:

Just transferred to the east coast and saw this thread. One simple way to end this problem is to include the credentials/status (or lack thereof) of the actual person/persons who will be performing the actual anesthesia right on the anesthesia consnet. 1. Your case will be done my a physician anesthesiologist. or 2. Your case will be done by an unsupervised nurse (crna). or 3. Your case will be done by a combo of the above, spelled out. Let the patient decide. Some people want a physician; others are o.k. with a nurse.

One simple way is to read the consent, pa's and first assists perform large parts of surgery this covered by the consent as" others that may be designated" or similar language.

On your anesthesia consent be sure to add: "I'm consenting to a board-certified anesthesiologist performing or managing my case without supersising other cases". Have him/her sign (they will) and that way you won't have an unsupervised nurse doing your anesthesia.

They don't make them like they used to. Nurses.

I was pleasantly surprized when I had outpatient surgery recently since I was able to have an anesthesiologist do (not supervise) my case instead of a nurse. I had expected some vitrolic comments from the CRNA on staff; just the opposite. One of more experienced CRNA told me that she totally prefers to work under the ACT or ACTS(?) model whereby where is supervised by an anesthesiologist and that she would not want anything less for her own surgery. I think that the CRNA have an important support role; just not one as indep. practitioners and I don't care what the state regulations may say (as a consumer that's my call). The anesthesiologist was totally supportive of my desire not to have a nurse do my anesthesia for my surgery; furthermore she's going to personally do the sedation for my upcoming endoscopy, which I wasn't even questioning since many patients at the endo center seem to do o.k with a CRNA supervised by an anesthesiologist. But, it's certianly safer to have an anesthesiologist doing my case than having a nurse do it and her being merely supervised by an anesthesiologist (also supervising 3 other cases). Stick to your rights and request an anesthesiologist if you want one, schedule it in advance and they will take care of you. No need to demean the nurses, the CRNA have an important supporting role.

There seem to be a number of comments on here from CRNA's claiming that they do just as good of a job and they are just as competent as anesthesiologists.

Historically, delivering anesthetics to facilitate surgery has been around for over a century, and CRNA's have been doing it for most of that time. Over the many decades, they have fought ongoing legal battles to attempt to practice independently and have been fairly successful. The newest thing is that they wish to have CRNA programs at a doctoral level. This would enable one to technically introduce themselves as 'doctor' so-and-so; this says nothing of the ethical implications of doing such.

For CRNA's to state that their capabilities are equivalent to that of an anesthesiologist is deceptive. Yes, they are able to do most of the same things (regional, central line placement, specialty anesthesia), but that is not a function of their equal ability, but rather their legal efforts in pursuing anonymity. Anybody can be trained to do medical procedures. During open-heart surgery, often PA's will enter the chest, dissect the LIMA and saphenous vein grafts, and close the patient at the end of surgery. The CT surgeon is only in the room to evaluate the patency of the graft and sew it into place, a process that often is less than 30 minutes. The real difference in the training between the two is the decision-making process to get to that point in the OR, including presurgical eval of risks/benefits, and application of such. It is no different with anesthesiologists and CRNA's. A decent anesthesiologist will be able to better evaluate your medical condition and think through issues before they surface. If a complication does occur, they are more suited to manage it postoperatively based on their education and the idea drilled into them from med school and internship that patient ownership extends beyond perioperative care.

The body of literature and research used by both CRNAs and anesthesiologists is indeed, as you might suppose, created by anesthesiologists.

Anesthesiologists may do fellowships specialized in certain areas, including pain, critical care, and subspecialties such as peds, cardiothoracic, etc. CRNA's attempt many of the same things. As a chronic pain-trained anesthesiologist who spends most of his time in the clinic, I shake my head at that prospect.

The bar to get into medical school is very high and the coursework is sufficiently rigorous, as is the competition to enter an anesthesiology residency these days, that is usually ensures that the substrate of an individual (intelligence, capability, etc) is pretty solid. I, again, shake my head frequently at the decision-making processes applied time and time again by my military CRNA colleages, who have trained at one of the top CRNA schools in the nation--presumably this means they are better than most in their specialty.

When I was a medical student and an intern, I couldn't tell the difference between an anesthesiologist and a CRNA. Now as a dual-board certified anesthesiologist, it is quite obvious. There are good CRNA's and bad anesthesiologists to be sure. A good way of viewing this is that the providers in each specialty are represented via ability by a bell curve. This 'ability' bell curve for anesthesiology and CRNA does overlap somewhat, with the best CRNA's overshadowing the poorest anesthesiologists at the ends; but in no way, shape, or form are the abilities of the average practicioner in each specialty equal; the anesthesiologist is better prepared.

In my military institution where the CRNA's are 'independent practioners', they must seek an anesthesiologist's consultation for sicker patients, and when things go wrong, will look to the anesthesiologist to bail them out. If they do not, the surgeon will demand it. That speaks volumes.

I wrote this to attempt to illustrate the differences so that anybody interested in pursuing one of the two specialties might be better informed.

Oops, I don't know why it says I'm in Indonesia lol. I trained and practice in the U.S.

One more thing: MDA is a term that CRNA's use to describe anesthesiologists. We don't use it to describe our own profession, at least to my knowledge.

While I appreciate the tone and spirit that this has been posted there are several misrepresentations in this post.
1. Yes, they are able to do most of the same things (regional, central line placement, specialty anesthesia), but that is not a function of their equal ability, but rather their legal efforts in pursuing anonymity

This is untrue it is due to the equel abilities period, the laws would most certainly restrict these procedures if CRNA's did not have a long record of performing these procedures safely.

2. If a complication does occur, they are more suited to manage it postoperatively based on their education and the idea drilled into them from med school and internship that patient ownership extends beyond perioperative care.

If this were truly the case then then it would be common to see anesthesiologists managing patients on the floor, or ICU's. The vast majority do not I have yet to see an anesthesiologist manage a patient outside of the PACU the usual cry is call for the hospitilist.

3. This 'ability' bell curve for anesthesiology and CRNA does overlap somewhat, with the best CRNA's overshadowing the poorest anesthesiologists at the ends;
This is no more then opinion without any evidence of anykind, there is far more evidence of comprable outcomes then not, multiple studies have shown equel outcomes many not funded by the AANA, the BJA performed a meta analysis of studies involving outcomes and came to the conclusion that no study had shown a difference in outcome.

4. In my military institution where the CRNA's are 'independent practioners', they must seek an anesthesiologist's consultation for sicker patients, and when things go wrong, will look to the anesthesiologist to bail them out. If they do not, the surgeon will demand it. That speaks volumes

Just because a regulation states that a consult needs to be made does not mean it is either nesssecarry or useful (look at tefra), and in my case there is no anesthesiologist to "bail me out" Now THAT speaks volumes.

All being said I appreciate the respectful tone of the post and appreciate it very much.

Respectfully disagree with you on your responses. Without going into detail, I'll hit a couple of high points. The first is that there is research to suggest that ASA IV patients do better w/ anesthesiologists. The second is that I think you misrepresented my comments on postoperative care. Although I believe it is true that most -ologists do follow their patients postoperatively for a time, and could provide better consultation if required, I specifically was referring to complications related to anesthesia or procedures related to patient care in the perioperative period.

I think there is a role for CRNA's and an equal role for Anesthesiology Assistants, and that is part of the team paradigm, where the most medically-qualified individual is at the top.

One thing I left out of my initial comments is another advantage to an anesthesiologist. I believe they can better serve as patient advocates as they are on an equal 'physician' basis w/ the surgeons, and therefore can better stand their ground. Although anecdotal, I hear many CRNA's explain to me that the reason they are doing something is because surgeon so-and-so wanted it, even though the situation could place the overall health of the patient in detriment. Either they did not understand that, or simply wanted to appease the surgeon.

Thanks and good discussion.

If you would please produce this research I would be greatly surprised, as for advococy I have seen many anesthesiologists aquiece to surgeons demands time and time again, this advococy of yours is not a product of education but one of integrity, a quality that varies from individual to individual regardless of the degree, unless of course you really believe as you imply having an MD somehow makes gives you this integrity.

Setting aside the comments about what CRNA can do because of regulation (misguided or not). some things are clear: anesthesiologists bail out crna every day..because of this fact I want an anesthesiologist doing my case not a crna. even when crna are supervised, the delay in having the crna realize that the patient is in trouble beyond her nursing/anesthetist skills then calling the anesthesiologist (how may or may not be busy elsewhere) can be deadly. I want a real MD/DO anesthesiologist at my table actually doing the anesthesia and I'll tell you a secret: tell you surgeon that you want anesthesiologist-only care, write this on the consent and tell them it's a deal-breaker otherwise and you will get your wish every time. I'm not anti-nurse or crna; one of my best friends is a NP and she does most of my primary care.

I forgot to add: I had surgery last week at a University Medical center and told them in advance that I wanted an anesthesiologist to do my case 1:1 without supervising other cases. It's a teaching hospital where I did a residency (long ago; I'm not in the anesthesia field). I made my desires know on the consent, everyone co-signed and an anesthesiologist did my case. I assumed that the myriad of crna present watching this drama would hate me for eliminating them from participating in my care..not so. One CRNA told me that she has a chronically ill son who gets frequent surgeries and she demands an anesthesiologist for his care (not a crna) every time. That's honesty and professionalism.

stanley wrote:

This anxiety of yours seems to be well out of proportion to the supposed complication, I would sincerely suggest some form of therapy. It is exceptionally unusual to OBSESS over an anesthetic.
This RESISTANCE of yours to "anesthesia drugs" and refusal for sedation or GA ( as if being awake and aware of procedure is soothing) leads me to believe one of two things.
1. You are some physician eager to scream about CRNA's
2. You would be dissatisfied with ANY level of service, but have decided to hop on this bandwagon.

Stanley, my anxiety is not out of proportion to the supposed complication at all. Is this what you tell your patients when they have a bad time? While I agree that obsessing over an anesthetic is fairly unusual, it's not unheard of in regards to Versed. Obsession is a common reaction to this particular drug.
Being awake and aware of procedure IS preferable to me. Where you get the "soothing" part is beyond me. Sadly this must be part of your own mental process.
To answer you 1) No I'm not a physician. If I were my crew would have done what I wanted. If I were a physician I would NOT have had an omnipotent, know-it-all creep of a crna doing my anesthesia either. Use your head. 2)I have been very pleased with levels of service from ANESTHESIOLOGISTS! How would I be able to compare the level of care between a crna and an MD otherwise? Your vitriol is clouding your common sense.

I reecntly witnessed an experienced crna fumble with a simple patient-care problem; she didn't understand why the meds that she pushed (she's a nurse, after all?) didn't work as expected...she has been a crna for 25 years....anyway, she didn't understand that ephedrine and epi aren't the same. this is the same nurse who almost killed an OB patient by botching the simple intubation. solo crna practice? sure, pay up your life insurance and kiss your loved one goodbye. Isn't it sickening how these crna nurses "demand" some sort of parity with physicians? never happen.

crna are techs wrote:

I reecntly witnessed an experienced crna fumble with a simple patient-care problem; she didn't understand why the meds that she pushed (she's a nurse, after all?) didn't work as expected...she has been a crna for 25 years....anyway, she didn't understand that ephedrine and epi aren't the same. this is the same nurse who almost killed an OB patient by botching the simple intubation. solo crna practice? sure, pay up your life insurance and kiss your loved one goodbye. Isn't it sickening how these crna nurses "demand" some sort of parity with physicians? never happen.

I know multiple physicians that fall into this same category (surgeons, primary care, anesthesia, gyno). Your one example of a bad CRNA proves absolutely nothing!

safety wrote:

Setting aside the comments about what CRNA can do because of regulation (misguided or not). some things are clear: anesthesiologists bail out crna every day..because of this fact I want an anesthesiologist doing my case not a crna. even when crna are supervised, the delay in having the crna realize that the patient is in trouble beyond her nursing/anesthetist skills then calling the anesthesiologist (how may or may not be busy elsewhere) can be deadly. I want a real MD/DO anesthesiologist at my table actually doing the anesthesia and I'll tell you a secret: tell you surgeon that you want anesthesiologist-only care, write this on the consent and tell them it's a deal-breaker otherwise and you will get your wish every time. I'm not anti-nurse or crna; one of my best friends is a NP and she does most of my primary care.

You are ignorant.

Scared Patient wrote:

I want a DOCTOR, not a NURSE doing the most important thing during my surgery: anesthesia!
Why would I want a bed pan nurse doing the job of a highly trained scientific and intelligent DOCTOR?
You people who think nurses = doctors are crazy and stupid, and the nurses on here who claim to be the same as doctors are delusional!
I have seen CRNA salaries, what a theft and crock! No wonder healthcare costs are so high, we are paying poorly trained nurses more than regular doctors!
No thanks!

You need to get out of old ages and enter the new age. There are no bed pans, We are not equal to doctor practices but we are better because we add compassion and care in what we do. It is not the money you should read on what it takes to anesthetize someone and wake them up. Sorry there are people like you who talk without researching the subject.

Alright folks here is a little insight into the MDA Vs. CRNA controversy. My father is an anesthesiologist and I have a grandfather, uncle, and aunt who are nurse anesthetists. The major difference is in the training and not in the delivery of anesthesia. Nurse anesthetists spend four years in college obtaining a BSN. The next step is working in an ICU for a minimum of 18 months to 2 years before one can be accepted into an anesthesia school. Anesthesia programs range from 27-36 months. Then the graduate is eligible to take boards and practice independently as an anesthesia provider. Anesthesiologist spend four years in college, four years in medical school, and four years in residency. The time difference is about 3 years longer to become an MDA versus a CRNA. I am a nursing student and have spent many hours inside the OR learning about anesthesia delivery regardless of CRNA or MDA administering. What I've learned is that CRNA's give anesthesia exactly the same as MDA's. I feel that CRNA's are just as capable of delivering anesthesia as safely as MDA's in most circumstances. With that said I do feel that in certain very complex cases an MDA would probably be more suited for the task due to the extensive medical background. Based on my knowledge of anesthesia and what my family members tell me CRNA's are perfectly capable of functioning independently in the delivery of anesthesia. In fact, the majority of rural USA anesthesia providers are only CRNA's. One can say that rural areas handle easier cases and to some extent this is true some of the time, but when severe traumas or just plain difficult cases present anesthetists are there to manage the case and stabilize the patient so they can make it to a larger facility to receive the necessary treatment. As with any profession people have varying degrees of competence and skill, just because nurse anesthetists aren't doctors doesn't mean they are stupid or unqualified for the job. Personally I haven't decided whether to go to anesthesia school or head to medical school yet, but I do have knowledge of what it takes to succeed in either case. To be honest the only reason I'm debating going to medical school is because of the difference in pay. Yeah Yeah, call it what you want, but money influences everyone and I'm no exception. I can assure you that I've told the truth to the best of my knowledge and hope people will cut the shit on these forums.

I wonder if anyone can answer this question. Why would a hospital that has a great anesthesia department that took years to build, got rid of all the locums, brought in a school, everyone got along and things fell into place, then suddenly bring in a new group, get rid of the director that worked so hard to make it happen and now wants to have the CRNAS rotate shifts with the lack of many of the employees that are parents and can't work 24 hours or take call 7 days in a row. Where is the sense in this move?? providers will leave, the hospital will once again have to hire locums that will cost more money than they were originally paying to their permanent staff. Answer anyone??