Nurse anesthetists "without doctor supervision"

The August issue of Health Affairs published a study indicating that there is no difference in complications or death following surgery between nurse anesthetists (CRNAs) working alone and anesthetists working under an anesthesiologists's (MD's) supervision. Currently, to receive Medicare reimbursement, your anesthetists need to be supervised. However, states can petition CMS to allow unsupervised anesthetists, and the number of "opt-out" states and number of "unsupervised" cases has grown. In the interim there's been apparently no increase in the number of problems.

I'm not too surprised because as far as I've heard from physicians and anesthetists, being a "supervising physician" amounts to having CRNAs as employees of your practice and covering them with your malpractice insurance. Not, you know, actually supervising every individual case.

The study authors indicate that this means we should be opting for cheaper anesthetists rather than more expensive anesthesiologists. CRNAs cost, by informal estimates I've heard, about 10 times less than an MD. However, I thought part of the reason CRNAs are less costly is because they don't have to buy their own malpractice insurance, but are rather sheltered under the anesthesiologists they work for. I'm not sure how this works in "unsupervised" cases; are the anesthetists employees of the hospital and covered under the hospital's insurance?

The study authors also speculate that anesthesiologists are taking on more of the higher-paying cases, e.g. privately insured cases and more technically involved or higher acuity cases, leaving the lower-paying cases, e.g. Medicare-insured and simpler cases to the lowly CRNAs. As bad as that sounds (yet it's probably true, because it makes economic sense), it could have skewed the results. A study which examined similar acuity of care among CRNAs and MDs might be better. Not that I balk at the idea of taxpayer-subsidized surgeries being performed by lower-cost but equitable professionals, while the people who can pay for their own insurance can go to higher-paid professionals if they want; but I doubt that the consumer is making the choices here!

Funnily enough the only comment to this on the Health Affairs blog is by the American Medical Association, which decries the study and says it's fully funded by a CRNA lobbying agency. But isn't the AMA the largest physician lobbying agency?

Should I force my kids to be nurses?

I know, doesn't that sound awful? But really, back in the days when I didn't know what I wanted to do with my life, and I was pursuing a "dream job" in graphic that I didn't even really want, at least not enough to work hard for, and I wasn't even really good at, and the job market was terrible...I wish someone had forced me into nursing or some other career which had a short-term educational requirement but a high-yield pay reward.

Think about it. You can be twenty years old and a nicely-paid professional.  And unlike most professions, you'd still have time to do whatever you want.

When my kids say they don't know what career they want to enter, they're definitely going to community college for the first two years of general education. I'm not paying $500 a credit hour for gen-ed's when they don't have a goal in mind, and I won't let them pay that much either.

But what's wrong with getting a job in nursing and then trying to pursue your dream career? Imagine living cheap and single and paying out the nose for university, but making a nurse's income instead of working at Starbucks. Imagine paying for school instead of racking up educational loans. Some of my coworkers are experienced nurses in their early 20's. They still live with their parents, so they're just bankin' the ca$h money. And some are pursuing higher educational degrees and are able to pay for it with minimal to no loans.

So what do you plan to do with your kids? Or what did you do? Did you encourage them to work and make money, or just focus on school? Did you push them toward something practical or let them take as long as they want to find their dream job?

I probably won't force the issue. Nursing school was two years of UTTER ANGUISH AND TORMENT. But what about mechanic school? Air conditioning and heating? There are plenty of trades with short educational requirements, say two years or under, which you could easily nab before you're 20 years old, and then work at while deciding what you "really" want to do. And if you decide you really want to do that trade, you're already set.

Disclaimer: I'm not slighting the idea that nursing is this divine calling. I love being a nurse. It's an art and a science. Everybody says you shouldn't go into nursing for the money. But face it: if you're a caring individual, you could be a nurse for five years and put yourself through, say, photography school. There is absolutely nothing wrong with changing careers or using helping other people and making decent money at it as a stepping-stone. I don't know any volunteer nurses, so we're all in it for the paycheck to some degree.

Nurses: Would you ever own a motorcycle?

The allnurses.com forum has an interesting poll:

Nurses: Would you ever own a motorcycle?

There are 13 pages full of comments from RNs about this. Many not only had patients with broken pelvises, brain bleeds, lung contusions, etc, but loved ones as well. There's still a lot of yes's, though!

My take? I wouldn't unilaterally be against owning one, but I'd only use it on side streets and cruise slow. Anything else is asking for death, or a trach and peg tube—helmet or no helmet. So I guess I'm really talking about a Vespa or a scooter.

Or this seems relatively safe:

Too Big For MRI

Just sitting here pondering why MRI machines were only made for the 350-pound-or-less crowd...and by 350 pounds, we really mean a certain GIRTH, because my patient's not 350! And he takes up the entire hole. They're nudging him this way and that, in and out on the conveyor belt to make him fit.

This is like a cartoon where they're shoving the big person through a small hole before the bad guys come. I'm waiting for them to grab a plunger or a stick to shove the poor guy in.

I just heard one of the techs say "Tell us if we're hurting you..."  Ouch.

Now they're asking if he can hold his arms above his head. Seriously? Dude has sleep apnea like crazy and is huffing and puffing already.....Okay, they stopped.

Disclaimer: I don't normally blog while at work. However, sitting with a patient during an hour-long MRI (or a 45 minute long squishing contest) means I'm just sitting here. And sitting here. And continuing to sit here, watching a heart rate and standing by in case anything "bad" happens. I can't enter the MRI room, I can only demand that they bring my patient out if he codes or something. Ho hum.

Posted my server by email, edited and published later on my day off. Can you tell I still feel guilty about it?

Cha-Ching - Financial incentives affect surgical decisions

This was on our hospital's intranet website today:

Financial incentives affect surgical decisions
Last Updated: 2010-08-18 14:41:10 -0400 (Reuters Health)
NEW YORK (Reuters Health) - Your odds of going under the knife may depend on whether or not your orthopedic surgeon has a financial stake in your treatment center, suggests a new study. Patients receiving care for their wrist, rotator cuff or knee from a provider with ownership in the facility were up to twice as likely to have surgery compared to those treated by non-owners.

I'm certain you could do this kind of study for surgeries and interventions in other high-income fields, like cardiology, oncology,  obstetrics (YOU KNEW THAT WAS COMING!), etc.

It's a shame, because while some paranoid people treat their doctors like car mechanics (i.e. maybe good but probably out to get your money), most people think doctors are above that sort of thing.

HERE HAVE SOME SUGAR!!!

A family member of mine fainted after a fasting blood draw and got sent in an ambulance to the ER. He's been complaining about how expensive the whole process was, especially since he saw the whole bill since his insurance company rejected all the costs at first*. 

No offense to ER nurses, but I think it's a little crazy that he got D₅₀ shoved in his vein while he was fully awake. His blood sugar tested low but he was conscious and walking. You use juice for your patients who can drink and reserve the fat gun of thick intravenous 50% dextrose solution for your patients who are in a low blood sugar coma. Geez.  

So the length of his vein up his arm hurt for several days and it cost a lot of money. I mean, at first I thought it was just silly, but it's really stupid. I hate to say it, but most ERs seem based around shutting up the problem (or the patient) ASAP without regard to applicability or cost. Eventually hospitals are going to have to catch up with the fact that insurance companies are not just writing a blank check for their customers anymore.

*When I took my son to the ER, they paid the hospital but refused to pay the ER physician (a separate bill). Then when finally paid, the ER physician continued to bill me. When I called about that, the physician's office said it was a mistake, and the insurance company said offices "accidentally" double-bill all the time because they only stand to benefit if someone pays. It's kind of weird anyway because most insurances pay for any emergency visits, so why would they immediately reject it? 

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How to juggle hospice and critical care at the same time, or: No one's going to read this big block of text!

My past two nights in a nutshell. Accepted a "withdraw", a patient we're going to withdraw treatment on. I hate saying "withdraw treatment," because we're still going to treat their needs, but that's the terminology. Anyway, they'd been in the ICU for months, went into multi-system organ failure, needed emergency dialysis but then went into cardiopulmonary arrest within an hour of the treatment (dialysis tends to drop your blood pressure). The power of attorney, one of the patient's kids, signed the documents to withdraw the emergency life support measures, e.g. the ventilator and IV pressor agents, and went home because they couldn't handle the situation. They left their spouse, a child-in-law, here to be with the patient and (get this) "decide" when we were going to extubate. I mean, of course we let the family decide when these things are going to proceed, but this person took it as if they were deciding to make the patient die. It was a grown man bawling in my room, crying over the patient (who he was evidently very close with), asking aloud why it had to be him to make the decision, why it had to be today, that he wanted a miracle. I tried to reassure him that the decision was already made, but he insisted that his spouse "only gave consent" and he was the one who had to decide.  Mostly I had to leave him in the room with a young priest who wasn't really helping AT ALL, just sitting there looking lost.

Finally he came out and said he was ready.  I gave her a touch of morphine and Versed and then suctioned and extubated her. The patient died later that night and the son-in-law was visibly shaking. I told him I didn't want him to think this was "his decision," or anybody's decision really. We would need to do emergency dialysis that night, or the patient would die in the next day or two; but dialysis would kill them.

Within hours a rapid response is called on the floor and I'm assigned to take the patient when they transfer to ICU. I get report from a floor RN who isn't in the room and has no idea what's going on, just that the patient's lethargic and their blood pressure's in the toilet. Also she's suffering from advanced metastatic cancer and kidney failure and it sounds like septic shock. They come with the patient and she's awake, knows her name, where she is, what day it is, etc. Just when I'm thinking this is an overreaction by the floor and she's not that sick, I plug her into the monitor and she's in full-on SVT, heart rate 200's, blood pressure 50's over whatever. So she's awake now but maybe not for long? She's accompanied by the resident who was at the rapid response; I say "accompanied" but I mean he was at a computer trying to write his note and get out of there. I ask what we're doing about the heart rate and BP and I get an order for an EKG. Because that'll save this patient. I and the other RNs ask if I can give adenosine, or amiodarone, or cardiovert her, but the resident says she might need her heart rate this high so she can maintain cardiac output. SHE HAS NO CARDIAC OUTPUT BECAUSE HER HEART RATE IS SO HIGH! The resident high-tails it out of there while I ask aloud if we can just cardiovert her anyway since that is part of the advanced cardiac life support protocol (meaning RNs are legally allowed to do it to save a life without a specific doctor's order); but in a teaching hospital you have to rely on your residents and can't really disregard their orders without talking to their supervisor unless it's really life or death. She was still talking so it wasn't life or death yet. I finally get a sensible physician involved and he lets me give her metoprolol to slow her heart rate, which IMMEDIATELY brings her blood pressure up to tolerable levels, although she was still maxed on pressors.

Meanwhile the family arrives and apparently they were already talking about palliative care for incurable cancer, but hadn't made any decisions. It's probably too late for that, but I at least got the ball rolling to make her a do-not-resuscitate, which means we're not going to do chest compressions or put her on a ventilator if she goes into arrest, but we'll do everything possible to keep that from happening. And trust me, that was a lot of work, because she was extremely precarious. Thankfully the charge nurse took my other patient who I had no time for!

Then I go home, sleep an insufficient number of hours in the daytime, and go back to my shift. In the interval the patient had decided to stop everything and request comfort care. I'm learning that being an ICU nurse sometimes means being a hospice nurse for one patient and an ICU nurse for another patient. In one room I'm managing drips, nasotracheal suctioning out epic amounts of mucus from someone's lungs (which is not for the faint of stomach), and doing frequent neuro assessments to make sure their brain bleed isn't evolving; while in the other room I'm tiptoeing around sleeping family members, silencing alarms, moistening a mouth, and doing anything else I can to make sure the patient is comfortable.