CRNA fixes parosmia with Stellate block!?!

[cowboydoc]

Teen gets most of her smell back after 'rebooting' nerve system through series of shots

Republic Pain Specialists - Pain Management Bryan, College Station & Madisonville, Texas > About > Our Team

People travel across the country to have a nurse do a stellate…for post-Covid parosmia.

There is an MD associated with this practice, kind of, based on the web site. So many questions/issues here.

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[cowboydoc]

The MD is a retired neurosurgeon.

Rudy Briner - MD

 

[Agast]

now make it a PRP stellate ganglion block

 

[soxman]

Thank God "Dr Gaskin" explains how Stellate ganglion blocks work

 

[chibadriver]

• Texas BON complaint filing: Texas Board of Nursing - Discipline & Complaints - Policies & Guidelines.
• Peer review report form: https://www.bon.texas.gov/pdfs/complaint form_NPRC.pdf

 

[thecentral09]

But in all seriousness has anyone done this with success?
Does insurance cover?
I have an asked about it outside of work three times in the last week

 

[MitchLevi]

This is utterly fraudulent and a great way to ruin another effective pain procedure.

Cash or not, I don't care.

Stellates carry significant medical risk.

 

[Asclepius186]

Stellate ganglion block reduces symptoms of Long COVID: A case series - PubMed

After recovering from COVID-19, a significant proportion of symptomatic and asymptomatic individuals develop Long COVID. Fatigue, orthostatic intolerance, brain fog, anosmia, and ageusia/dysgeusia in Long COVID resemble "sickness behavior," the autonomic nervous system response to...

pubmed.ncbi.nlm.nih.gov

Case series; n=2. Bilateral stellate blocks one day apart. Good results. Not sure if this counts as evidence, but it’s something. The background makes it sound somewhat plausible.

 

[hyperalgesia]

I thought ketamine was the new sgb...

 

[lobelsteve]

Luke Liu, MD | Neuroversion

Meet Dr. Luke Liu, MD.

www.neuroversion.com

These are not my patients.

Long Haul COVID-19 Post-Treatment | Neuroversion

Treatment for COVID-19

www.neuroversion.com

These should not be your doctors.

 

[Agast]

Eh, if I were suffering from long covid I would probably try this with a friend. Any improvement in feeling like crud all the time would be a plus.

 

[Ducttape]

Stellate ganglion block reduces symptoms of Long COVID: A case series - PubMed

After recovering from COVID-19, a significant proportion of symptomatic and asymptomatic individuals develop Long COVID. Fatigue, orthostatic intolerance, brain fog, anosmia, and ageusia/dysgeusia in Long COVID resemble "sickness behavior," the autonomic nervous system response to...

pubmed.ncbi.nlm.nih.gov

Case series; n=2. Bilateral stellate blocks one day apart. Good results. Not sure if this counts as evidence, but it’s something. The background makes it sound somewhat plausible.

case series is level IV evidence. N=2 doesnt count as a "case" series. thats just 2 cases.

please perform a randomized blinded study to justify use of this modality.

how is the background making it sound plausible?

i personally am not seeing the link of a unilateral sympathetic chain to innervation to the entire body and immune system.


Agast - that sounds like a placebo effect you are talking about. and that may be powerful, but entails risk.

 

[buddababa]

I literally just got a call from a random person asking about stellate for loss of taste and smell.... news/articles like this spread like wildfire

 

[geauxg8rs]

Four calls this week

 

[Agast]

case series is level IV evidence. N=2 doesnt count as a "case" series. thats just 2 cases.

please perform a randomized blinded study to justify use of this modality.

how is the background making it sound plausible?

i personally am not seeing the link of a unilateral sympathetic chain to innervation to the entire body and immune system.


Agast - that sounds like a placebo effect you are talking about. and that may be powerful, but entails risk.

Laugh now, but when the stellate works and I’m cured with a cervical spine stimulator you’re going to wish you thought of it

 

[Orin]

Insurance may authorize it, but it depends on the carrier. The CPT code isn't limited to a diagnosis of CRPS.

While I'm not sure how you're doing it that it's a high risk procedure, I agree this sounds like a placebo response until someone does a high-quality RCT.

 

[Ligament]

Followup on this issue. I am posting for the sake of public safety.

His name is David Gaskin, CRNA. He is in Texas.

Here is his web page:

Republic Pain Specialists - Pain Management Bryan, College Station & Madisonville, Texas > About > Our Team

One of his patients, a 30 y/o female seeking treatment for parosmia, video recorded her SGB procedure with him on March 4th. This is done to treat parosmia. She records him doing the following, all on the same day, in this sequence:

1. Right SGB
2. Right SGB
3. LEFT SGB
4. Right SGB

She has very evident Horner's syndrome's on each side.

For those of you unaware, bilateral SGB on the same day can block the bilateral recurrent laryngeal nerves and create a surgical airway emergency.

She also reports in her video that:

1. He will perform the SGB on pregnant patients "If your are past your first trimester"
2. Children "as long as they are able to sit still"

Here is her youtube video showing David Gaskin doing the procedure bilaterally on the same day. Time/date stamps can be seen on the ultrasound unit to confirm this is all the same day.



This patient seems to be a very kind and sincere person trying to get relief from parosmia, and help others with it. Of course, do not direct any negative comments toward her or her youtube channel.

In case it is taken down, I have downloaded it, and encourage you to do the same if you see the need.

​

 

[powermd]

I've been doing stellate blocks for PTSD and anxiety for a while. The patients do well and are very, very happy. I would go so far as to say these are some of the most satisfied patients I've ever had. I really enjoy working with these patients and don't mind spending extra time chatting in recovery, or answering questions over email. They seem to require a bit more hand holding than old guys with facet syndrome.

I started getting calls about COVID-19, and now anosmia/parosmia. One had an appointment with the CRNA in Texas, but upon hearing about me cancelled that trip.

I've done one patient for parosmia two days ago, and have another on deck. No immediate effect in the first patient. She wants a second block on the left side, so we're doing that tomorrow. I'll play along for a while, operating within the bounds of patient safety. I've made it utterly clear that there is no science to guide using the procedure for this purpose. But since living with these symptoms must absolutely suck, I'm happy to do it for her. If we don't see any improvement after two weeks, I'll counsel her against additional blocks.

I think there is some rational basis for doing this in hyperarousal syndromes, and the positive results are very hard to deny. I still make it clear to everyone that these are off label uses for the procedure, and no particular result can be guaranteed. They all get the full list of potential complications.

I charge cash only, $575 + the consult, which insurance usually pays.

I had a patient from out of state on Monday. She's a hairdresser that paid $2500 to "Stella" in NYC for two blocks. She did super well and wanted to keep up the progress, so now she's coming to me... and trying to talk her husband into getting one.

Here is what one of my patients wrote to me on day 8 since her first block (for anxiety):

"I woke up today with such a peace within my soul. I feel calm and comfortable in my own skin. Another exciting thing is my reynauds disease symptoms have stopped, I read that blocks are used to treat that as well and I can tell you that it's working. My fingers and toes typically turn blue when they're cold. They've been a healthy bright color for days. I believe the block helped. My mindset is peaceful, my intentions are set, I'm excited to see what other things will improve since I've had the block. Such a fascinating treatment, I'm excited to learn more as I progress."

 

[Agast]

I’ve done stellate ganglion blocks for Reynaud’s in fellowship and more recently PTSD for one person (50% improved). But I’d prefer post covid blocks to be done by an academic center that can publish results for the rest of us to look at.

 

[RoloTomassi]

What's the protocol for PTSD? How many if series, laterality, days apart, frequency of repeat series, etc?

 

[powermd]

What's the protocol for PTSD? How many if series, laterality, days apart, frequency of repeat series, etc?

For PTSD in studies, doctors are doing them on the right. You would have to look in pubmed to see if any protocols have been devised.

I just do a single right side block and follow up with the patient in two weeks. If they want a second, we can do that. I put them on a little meditation and hand warming biofeedback program too. Some patients return every three months for a top up, others when the symptoms return.

 

[soccrwz]

Mulvaney has some good info on this, works in SD with vets, Right Sided SGB with 25G; much easier than U/S, often found you have to go very deep on U/S to avoid IJ or transvessel on U/S (same as CVC), fluoro easier to see spread, test block with lido 2% 2 mL, watch for lack of seizures, then 4-6mL of dexa with 0.25% marc, used fluoro technique at C6, its helpful to have a psych/therapist on board before and after, PCL 5 before--during consult-- and after block on f/u to document objective relief repeat as needed in a few weeks/months; I've had several with good benefit on refractory patients. He only does Right SGB something to do with right side controls mood vs left? BL is a no no unless intubated every anesthesia person knows this...

 

[Orin]

Mulvaney has some good info on this, works in SD with vets, Right Sided SGB with 25G; much easier than U/S, often found you have to go very deep on U/S to avoid IJ or transvessel on U/S (same as CVC), fluoro easier to see spread, test block with lido 2% 2 mL, watch for lack of seizures, then 4-6mL of dexa with 0.25% marc, used fluoro technique at C6, its helpful to have a psych/therapist on board before and after, PCL 5 before--during consult-- and after block on f/u to document objective relief repeat as needed in a few weeks/months; I've had several with good benefit on refractory patients. He only does Right SGB something to do with right side controls mood vs left? BL is a no no unless intubated every anesthesia person knows this...

Bilateral staggered is fine. The risk is less than 1% for bilateral RLN blockade.
Ultrasound is simplest and safer.

Happy to do the study for COVID, but unsure what the best metrics are

 

[Ligament]

Bilateral staggered is fine. The risk is less than 1% for bilateral RLN blockade.
Ultrasound is simplest and safer.

Happy to do the study for COVID, but unsure what the best metrics are

Do you have a reference of less than 1% for bilateral RLN blockade? How do you define "staggered"?

 

[powermd]

Insurance may authorize it, but it depends on the carrier. The CPT code isn't limited to a diagnosis of CRPS.

While I'm not sure how you're doing it that it's a high risk procedure, I agree this sounds like a placebo response until someone does a high-quality RCT.

Not interested in doing this at MDC rates. Not a chance. I'll do a cervical epidural for chump change as a loss leader, but totally elective off label cervical sympathetic blocks? No freakin' way. $500 minimum.

 

[MitchLevi]

Followup on this issue. I am posting for the sake of public safety.

His name is David Gaskin, CRNA. He is in Texas.

Here is his web page:

Republic Pain Specialists - Pain Management Bryan, College Station & Madisonville, Texas > About > Our Team

One of his patients, a 30 y/o female seeking treatment for parosmia, video recorded her SGB procedure with him on March 4th. This is done to treat parosmia. She records him doing the following, all on the same day, in this sequence:

1. Right SGB
2. Right SGB
3. LEFT SGB
4. Right SGB

She has very evident Horner's syndrome's on each side.

For those of you unaware, bilateral SGB on the same day can block the bilateral recurrent laryngeal nerves and create a surgical airway emergency.

She also reports in her video that:

1. He will perform the SGB on pregnant patients "If your are past your first trimester"
2. Children "as long as they are able to sit still"

Here is her youtube video showing David Gaskin doing the procedure bilaterally on the same day. Time/date stamps can be seen on the ultrasound unit to confirm this is all the same day.



This patient seems to be a very kind and sincere person trying to get relief from parosmia, and help others with it. Of course, do not direct any negative comments toward her or her youtube channel.

In case it is taken down, I have downloaded it, and encourage you to do the same if you see the need.

​

Halfway through video and I refuse to watch any more of this.

If he was any good at his job he wouldn't have needed repeats.

I don't know how much medicine he's injecting, but a stellate at C6 requires a good amount of volume to reach all the way to the proximal thoracic ganglion at T1. Maybe less depending on any number of things. That isn't a huge pt, so 8cc would probably do it guess.

Did this mofo inject 30 to 40 total cc in her neck that day?

Bilateral stellates are a huge no-no. As Ligament said, the RLN on both sides FFS. Do enough of these and you'll catch an occasional RLN and the pt will say they had a horse voice for a day.

This is highly alarming and the Texas Medical Board should be notified.

 

[chibadriver]

Halfway through video and I refuse to watch any more of this.

If he was any good at his job he wouldn't have needed repeats.

I don't know how much medicine he's injecting, but a stellate at C6 requires a good amount of volume to reach all the way to the proximal thoracic ganglion at T1. Maybe less depending on any number of things. That isn't a huge pt, so 8cc would probably do it guess.

Did this mofo inject 30 to 40 total cc in her neck that day?

Bilateral stellates are a huge no-no. As Ligament said, the RLN on both sides FFS. Do enough of these and you'll catch an occasional RLN and the pt will say they had a horse voice for a day.

This is highly alarming and the Texas Medical Board should be notified.

Can’t be handled by BOM, nurses are their own discipline, contact Texas BON.

 

[Ligament]

Halfway through video and I refuse to watch any more of this.

If he was any good at his job he wouldn't have needed repeats.

I don't know how much medicine he's injecting, but a stellate at C6 requires a good amount of volume to reach all the way to the proximal thoracic ganglion at T1. Maybe less depending on any number of things. That isn't a huge pt, so 8cc would probably do it guess.

Did this mofo inject 30 to 40 total cc in her neck that day?

Bilateral stellates are a huge no-no. As Ligament said, the RLN on both sides FFS. Do enough of these and you'll catch an occasional RLN and the pt will say they had a horse voice for a day.

This is highly alarming and the Texas Medical Board should be notified.

You can see the syringes on the video. They appear to have around 8cc of local in them. The patient mentions he is injecting lidocaine and decadron. No way to tell if that is accurate, nor the concentration of the local, and therefore the total dose.

 

[powermd]

I had a request to do this block on a 12 year old who lives in Mass. Parosmia. I drew a line there and suggested they talk to Boston Children's.

 

[Orin]

Do you have a reference of less than 1% for bilateral RLN blockade? How do you define "staggered"?

Here's an example of bilateral blocks for pain indications

Multiple bilateral ultrasound-guided stellate ganglion blocks to treat acute vasculitis in a recently diagnosed patient of systemic lupus erythematosus

Medical management along with stellate ganglion block is frequently given to prevent the vasculitis of fingers in patients of systemic lupus erythematosus (SLE). Bilateral stellate ganglion block is rarely given due to the concern of phrenic and recurrent ...

www.ncbi.nlm.nih.gov

Here's an example of bilateral blocks for cardiac arrhythmias

Stellate Ganglion Blockade for the Treatment of Refractory Ventricular Arrhythmias - PubMed

Minimally invasive, ultrasound-guided bilateral SGB appears safe and provides substantial reduction in VA burden with approximately 1 in 2 patients exhibiting complete suppression of VT or VF for 48 h.

pubmed.ncbi.nlm.nih.gov

The 1% risk of bilateral RLN number comes from multiple studies that show a rate of about 10% for a RLN issues.
For example: The optimal volume of 0.2% ropivacaine required for an ultrasound-guided stellate ganglion block
Assuming these are independent events, for you to knock out both, that is 0.1*0.1=0.01 or 1%

Staggered by 20 - 30' between needle in/out for the contralateral aspect.

In reality, the left side is probably more likely than the right, so I normally do the right first, and then come back to do the left later, using lower volumes if I'm at all scared.

 

[Ducttape]

Here's an example of bilateral blocks for pain indications

Multiple bilateral ultrasound-guided stellate ganglion blocks to treat acute vasculitis in a recently diagnosed patient of systemic lupus erythematosus

Medical management along with stellate ganglion block is frequently given to prevent the vasculitis of fingers in patients of systemic lupus erythematosus (SLE). Bilateral stellate ganglion block is rarely given due to the concern of phrenic and recurrent ...

www.ncbi.nlm.nih.gov

Here's an example of bilateral blocks for cardiac arrhythmias

Stellate Ganglion Blockade for the Treatment of Refractory Ventricular Arrhythmias - PubMed

Minimally invasive, ultrasound-guided bilateral SGB appears safe and provides substantial reduction in VA burden with approximately 1 in 2 patients exhibiting complete suppression of VT or VF for 48 h.

pubmed.ncbi.nlm.nih.gov

The 1% risk of bilateral RLN number comes from multiple studies that show a rate of about 10% for a RLN issues.
For example: The optimal volume of 0.2% ropivacaine required for an ultrasound-guided stellate ganglion block
Assuming these are independent events, for you to knock out both, that is 0.1*0.1=0.01 or 1%

Staggered by 20 - 30' between needle in/out for the contralateral aspect.

In reality, the left side is probably more likely than the right, so I normally do the right first, and then come back to do the left later, using lower volumes if I'm at all scared.

interesting but i would really be circumspect about quoting a rate of 1%. those are kind of tenuous grounds to determine 1% risk of a sentinel event.

the article you posted was a case study, and they had significant safety measures in place. they waited an hour between blocks, and that seems much more reasonable because of how bupivacaine works.

im still unclear of mechanism of action for a mechanism that is centrally acting. the use of stellates for intractable arrhythmias was previously discussed (by me) on this forum. i can understand that mechanism as you are blocking sympathetics downstream (in the heart).

 

[MitchLevi]

interesting but i would really be circumspect about quoting a rate of 1%. those are kind of tenuous grounds to determine 1% risk of a sentinel event.

the article you posted was a case study, and they had significant safety measures in place. they waited an hour between blocks, and that seems much more reasonable because of how bupivacaine works.

im still unclear of mechanism of action for a mechanism that is centrally acting. the use of stellates for intractable arrhythmias was previously discussed (by me) on this forum. i can understand that mechanism as you are blocking sympathetics downstream (in the heart).

Not EVERYONE carries the same risk of adverse events doing these. Some ppl are simply better at them than others.

Ever gotten records from other pain doctors and they were stupid enough to send procedure pics and you can't tell WTH actually took place on the routine L4-5 TFESI?

 

[Ducttape]

but why should society as a whole allow anyone to do these injections?

with regards to your question - the multiple injections are for 2 reasons - 1. he missed the first, second or third try 2. he bills more for each extra attempt.


also, remember that bad things can happen to good people.

at least, thats what i try to convince myself when some crazy driver cuts me off and then goes 30 in a 45 zone.

which happens at least daily.

 

[MitchLevi]

but why should society as a whole allow anyone to do these injections?

with regards to your question - the multiple injections are for 2 reasons - 1. he missed the first, second or third try 2. he bills more for each extra attempt.


also, remember that bad things can happen to good people.

at least, thats what i try to convince myself when some crazy driver cuts me off and then goes 30 in a 45 zone.

which happens at least daily.

I agree with all of this.

He clearly missed and had to keep trying.

Doing these with US alone isn't as reliable as combined US + XRAY (the way I do it).

I have on several occasions injected contrast under US and checked with fluoro. Despite what looks like meticulous US technique, the contrast isn't always great.

You may be perfectly placed at C6, but you've still got to anesthetize C7 and T1 for it to truly work. That requires a certain dispersal pattern and just bc you're seemingly great at C6 doesn't mean it will do what you want and neatly cover C7 and T1. The proximal thoracic ganglia needs to be anesthetized.

I would encourage each of you to do the following for the next 5 stellates you do and see if I'm correct:

Have XRAY get an AP shot and mark C6 on the skin. XRAY then pulls out about 2 feet to get out of the way. Put the US probe on your skin mark and ensure you're at C6.

Do your US-guided stellate, but inject contrast 2cc instead. Have XRAY come back and shoot a pic.

You'll find very often you're not deep enough and your contrast is a little more lateral than you'd perhaps like to see.

This guy in the video simply missed and kept trying. I wouldn't. If I screwed that up you'd have to come back another day.

Seems the stellate is the ESI of the 80s and 90s - Just shoot the medicine in there and it will fix everything.

 

[Ducttape]

you dont have to pull the C arm out of the way.

the tech comes in from superolateral, so the c arm is not in my way. the tech can rotate the image

i image, mark C7 with a straight line extending laterally. i then place the probe directly on this marked line and scan parallel to this line.

once i place the needle, aspirate, image needle only, and then inject if it looks good.

 

[MitchLevi]

Putting some contrast and shooting it again to watch the spread is very eye opening. Try it out sometime.

The better the spread the better the Horner's. Perfect spread is a blood shot eye, ptosis and pupillary changes immediately.

I usually do a mixture of lidocaine, bupi and dexamethasone. I know ppl who also do toradol and clonidine.

 

[nvrsumr]

Did these blind bedside inpatient as a fellow. Havent done one in 5 years now.

 

[MitchLevi]

Did these blind bedside inpatient as a fellow. Havent done one in 5 years now.

?

What you mean? That's impossible.

 

[RoloTomassi]

?

What you mean? That's impossible.

"Do me a favor, squint your right eye for the video"

 

[nvrsumr]

Im PMR but learned in my gas fellowship that volume fixes almost anything. Fun to do under anothers license.

Did hanging drop CESIs in VA exam rooms with crash cart god knows where... Hey turn Vet turn ur seat around and lay your forehead on the counter. This wont hurt a bit.

 

[MitchLevi]

I catch someone doing that to my mother and we have a big problem.

 

[MitchLevi]

Im PMR but learned in my gas fellowship that volume fixes almost anything

15cc down the esophagus doesn't result in Horner's...It results in potential sepsis. Palpate the artery and go medial I'd guess.

 

[Ferrismonk]

No matter how likely or unlikely, closed bilateral cords is an absolute emergency requiring you push through and damage the cords to intubate or perform a cricothyroidotomy. All for a purely elective procedure. Ridiculous.

Play stupid games, get stupid prizes.

 

[chibadriver]

Can’t be handled by BOM, nurses are their own discipline, contact Texas BON.

If the subject of this thread bothers you, I encourage you to ACTUALLY report this to the Texas BON. Support your arguments with a few articles and what has been discussed here. Takes as much time as it does to come up with something worthwhile to post on this forum.

 

[nvrsumr]

Im not a proponent. This was pre bedside US. Inpatient and probably not able to reasonably get to the OR. Not certain as to the reasoning. Maybe just roundsmanship. Was a baller indian attending who had trained there and then did residency and fellowship here. He knew some cool tricks and was super smart. Did a few a few of them. Same patient.

 

[Ligament]

Here's an example of bilateral blocks for pain indications

Multiple bilateral ultrasound-guided stellate ganglion blocks to treat acute vasculitis in a recently diagnosed patient of systemic lupus erythematosus

Medical management along with stellate ganglion block is frequently given to prevent the vasculitis of fingers in patients of systemic lupus erythematosus (SLE). Bilateral stellate ganglion block is rarely given due to the concern of phrenic and recurrent ...

www.ncbi.nlm.nih.gov

Here's an example of bilateral blocks for cardiac arrhythmias

Stellate Ganglion Blockade for the Treatment of Refractory Ventricular Arrhythmias - PubMed

Minimally invasive, ultrasound-guided bilateral SGB appears safe and provides substantial reduction in VA burden with approximately 1 in 2 patients exhibiting complete suppression of VT or VF for 48 h.

pubmed.ncbi.nlm.nih.gov

The 1% risk of bilateral RLN number comes from multiple studies that show a rate of about 10% for a RLN issues.
For example: The optimal volume of 0.2% ropivacaine required for an ultrasound-guided stellate ganglion block
Assuming these are independent events, for you to knock out both, that is 0.1*0.1=0.01 or 1%

Staggered by 20 - 30' between needle in/out for the contralateral aspect.

In reality, the left side is probably more likely than the right, so I normally do the right first, and then come back to do the left later, using lower volumes if I'm at all scared.

The first example was for an inpatient with four limb gangrene being treated with 64 SGBs(!!!) plus continuous tunneled SGB block over 35 days to save limbs.

The second paper "At the time of SGB, 10 (50%) were on inotropic support and 9 (45%) were on mechanical circulatory support."

I'd be very cautious in applying the population in these studies to an entirely outpatient population getting a procedure for a debilitating but very benign condition such as parosmia.

 

[Agast]

If the subject of this thread bothers you, I encourage you to ACTUALLY report this to the Texas BON. Support your arguments with a few articles and what has been discussed here. Takes as much time as it does to come up with something worthwhile to post on this forum.

I reported an NP to the Texas BON for their prescribing habits. They actually did start an investigation and it’s not a nurse who does it. I’m not sure what the outcome was, if any, but it did serve to let the NP know that they don’t prescribe in a vacuum.

 

[hyperalgesia]

This is a tangent but I saw an ophthalmologist for a routine visit and was planning on seeing him regularly. Suddenly he pawns me off to his optometrist to help build other aspects of the practice (passive income). Very annoying but this is what docs do to themselves by empowering midlevels.

 

[Ligament]

"Do me a favor, squint your right eye for the video"

SGB is a 100 year old procedure (seriously).

It is has been done this way for the vast majority of that time.

 

[Agast]

This is a tangent but I saw an ophthalmologist for a routine visit and was planning on seeing him regularly. Suddenly he pawns me off to his optometrist to help build other aspects of the practice (passive income). Very annoying but this is what docs do to themselves by empowering midlevels.

Not to be nitpicky, but optometrists aren't midlevels. Their training is completely separate and in many states they are barred from treating specific conditions or prescribing certain medications (not controlled substances - I'm talking eye drops). Whereas an NP/PA could probably prescribe the same eye drops without threatening their license. Sort of like a chiropractor would not be a midlevel for a physiatrist, minus the Woo training.