CRNA: We are the Answer - WTF????

[sevoflurane]

My quotes show why I believe (and studies support) an ACT model is perfectly safe, I am unsure why you are "confused" about that. I have never argued that physician only care is less safe, I just believe it is undoubtedly less efficient. I fully support docs that are happy working in that model to do so. I would not personally enjoy doing so.

Less efficient? You can’t start 4 rooms at the same time can you?
For MD only, It depends on staffing and “ability” of your anesthesiologists.
Harder on anesthesiologists? Yes. Less efficient? Not necessarily.
What I find complete lack of physician ownership of anesthesia services are the groups that staff 2 cardiac rooms and 1-2 more “simple rooms” with a single anesthesiologist.
Ridiculous.
Care IS affected in that circumstance weather you believe or not.

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[sevoflurane]

ACT and cardiac is just greed.

 

[Echo33]

ACT and cardiac is just greed.

Have you ever practiced ACT with cardiac? Curious to hear your thoughts on why you feel this way.

 

[MoMoGesiologist]

CRNAs doing cardiac cases blows my mind. Those cases seemed so challenging during residency...

 

[sevoflurane]

Have you ever practiced ACT with cardiac? Curious to hear your thoughts on why you feel this way.

I’ve never practiced ACT in PP... besides witnessing it during med school and playing ACT during residency. But I have plenty of colleagues that “have to” practice that way. They hate it.

Sometimes you’re just too busy coming off pump in one room and the other just has to do it with a CRNA.

F’up in my opinion.

Guess who gets to play with the probe then and make suggestions? Inotrope, balloon placement, antiarrhytmics, blood products, inability to separate, ECMO, go back on or not.... you do what you like but I would never put my loved one in that situation.

It’s f’n heart surgery not a lipoma excision.

CRNAs do not belong in high risk peds or cardiac unless 1:1.

 

[mmag]

As a patient my out of pocket/copay is the same for unsupervised CRNA, ACT, or solo anesthesiologist. Not sure given the choice, why I wouldn't want an anesthesiologist take care of just me in the OR full time. I'm only an ASA 1 until something weird comes up intraop. Sure the chance is like <0.01% but when it happens to me, that quickly becomes 100%.
Some people like a nice Subaru and others a Corvette. Both will get you to work every day but I see a lot of sports car in the hospital lot everyday.

 

[sevoflurane]

Case:

Mitral clip for 4+ MR in a very frail ASA4 patient.

Systolic blunting at baseline.
Ant/post leaflets adequately grasped under echo guidance.
Mitral clip deployed.
PVF not significantly changed with one clip and minimally reduced MR.

“Insisted on a second clip”

Second clip deployed under echo guidance.
PVF normalized.
Mean gradient 4 mmhg.
Mild/1+ regurg post 2nd clip.

Did the right thing.

One patient at a time.

She will do very well with this procedure.

Wouldn’t do this unless solo or 1:1 ACT (expensive).

 

[Echo33]

I’ve never practiced ACT in PP... besides witnessing it during med school and playing ACT during residency. But I have plenty of colleagues that “have to” practice that way. They hate it.

Sometimes you’re just too busy coming off pump in one room and the other just has to do it with a CRNA.

F’up in my opinion.

Guess who gets to play with the probe then and make suggestions? Inotrope, balloon placement, antiarrhytmics, blood products, inability to separate, ECMO, go back on or not.... you do what you like but I would never put my loved one in that situation.

It’s f’n heart surgery not a lipoma excision.

CRNAs do not belong in high risk peds or cardiac unless 1:1.

Very valid points .

Wish every day I could be solo for cardiac. Would make my job so much easier. Just not happening at my joint. I’m one of those that covers 2 cardiac rooms plus a third. This is pretty normal in my area.

We have a small CT surgery team but extremely tightly run, experienced. Excellent outcomes. I’ve never been not present during bypass wean. Never in 4 years. All lines and echo are done by the MD. CRNAs do not touch the probe. Decisions on drugs are decided by me and the surgeon, we get the plan together during bypass based on preop and bypass situation. The rooms are right next to each other, connected, so I’m just flipping back fourth. I know what’s going on most times but you are right, it can never match the intimacy of being hands on.

We don’t do echo intense cath lab cases like mitraclip.

 

[Mman]

Less efficient? You can’t start 4 rooms at the same time can you?
For MD only, It depends on staffing and “ability” of your anesthesiologists.
Harder on anesthesiologists? Yes. Less efficient? Not necessarily.
What I find complete lack of physician ownership of anesthesia services are the groups that staff 2 cardiac rooms and 1-2 more “simple rooms” with a single anesthesiologist.
Ridiculous.
Care IS affected in that circumstance weather you believe or not.

who on earth starts 4 rooms at the same time? I might have anywhere from 1-3 rooms to start the day with depending on acuity of cases and patients. When we do hearts, we do 1 heart and maybe a toe amp in the vascular room next door.

You keep daydreaming some scenario where 1 doc is always supervising 4 rooms and those 4 rooms might all be disasters. We don't function that way.

And when I talk about "efficiency", I'm not talking about working with fewer docs. I'm talking about getting more things accomplished in less time. If a patient needs an epidural for their case, I can put it in before the previous case is even out of the room. If blocks need to be done preop or postop, I can do them while the anesthetist is dropping off in PACU or getting ready to roll next case back. If a patient needs a CVP and an art line after they go to sleep, we can do them at the exact same time.

Now does this save hours for each room during the day? Of course not. But it saves minutes here and minutes there and lets more cases get done in rooms in less time and helps the hospital spend less OT for rooms running late and get more things done during normal hours.


Now if you want to argue that it is possible to be lazy and run an ACT practice in an unsafe manner, of course it is. But I've also seen some unsafe stuff from physicians doing their own cases so that's more of a function of the person (people) and not the model of care. You admit you've never even seen ACT model in PP. It can be done quite well.

 

[MoMoGesiologist]

Guess who gets to play with the probe then and make suggestions? Inotrope, balloon placement, antiarrhytmics, blood products, inability to separate, ECMO, go back on or not.... you do what you like but I would never put my loved one in that situation.

There’s no way a CRNA is telling a cardiac surgeon what drips to go on, placing IABP, product or ECMO decisions, etc... right!?

 

[IMGASMD]

There’s no way a CRNA is telling a cardiac surgeon what drips to go on, placing IABP, product or ECMO decisions, etc... right!?

Wasn’t there a discussion recently with a crna run cardiac service trying to hire a collaborating anesthesiologists?

 

[sevoflurane]

Wasn’t there a discussion recently with a crna run cardiac service trying to hire a collaborating anesthesiologists?

Exactly.

 

[Man o War]

There’s no way a CRNA is telling a cardiac surgeon what drips to go on, placing IABP, product or ECMO decisions, etc... right!?

No. They’re taking orders from the surgeon instead of the anesthesiologist. Basically they’re walked through the anesthetic.

 

[Man o War]

I’ve never practiced ACT in PP... besides witnessing it during med school and playing ACT during residency. But I have plenty of colleagues that “have to” practice that way. They hate it.

Sometimes you’re just too busy coming off pump in one room and the other just has to do it with a CRNA.

F’up in my opinion.

Guess who gets to play with the probe then and make suggestions? Inotrope, balloon placement, antiarrhytmics, blood products, inability to separate, ECMO, go back on or not.... you do what you like but I would never put my loved one in that situation.

It’s f’n heart surgery not a lipoma excision.

CRNAs do not belong in high risk peds or cardiac unless 1:1.

Our cardiac surgeons would refuse to operate with a CRNA in the room. They’ve been very vocal about that. Many of them have been there done that either in training or other hospitals and will not accept it.

 

[dannyboy1]

Our cardiac surgeons would refuse to operate with a CRNA in the room. They’ve been very vocal about that. Many of them have been there done that either in training or other hospitals and will not accept it.

They won’t operate with non “cardiac” MD’s either. The CRNA threat is that they can do all of the other cases.

 

[Man o War]

They won’t operate with non “cardiac” MD’s either. The CRNA threat is that they can do all of the other cases.

Hospital requires advanced TEE cert for credentialing. Our surgeons wouldn’t care about that, as long as the doc is proficient with TEE.
Most CRNAs can’t function independently at a proficient level, so I’m not sure they are a “threat”

 

[T-burglar]

CArdiac is probably the only subsecialty of anesthesia where CRNAs aren’t a threat and never will be. As old heart surgeons retire and new school surgeons arrive, the demand for consultant level subspecialty MD expertise will increase, compounded further by the growth of TEE guided structural.

Where I work the cardiologists and surgeons would never agree to have anything but ACTA anesthesia . Cardiovascular intervention continues to become more and more complex.

 

[deleted162650]

who on earth starts 4 rooms at the same time? I might have anywhere from 1-3 rooms to start the day with depending on acuity of cases and patients. When we do hearts, we do 1 heart and maybe a toe amp in the vascular room next door.

You keep daydreaming some scenario where 1 doc is always supervising 4 rooms and those 4 rooms might all be disasters. We don't function that way.

And when I talk about "efficiency", I'm not talking about working with fewer docs. I'm talking about getting more things accomplished in less time. If a patient needs an epidural for their case, I can put it in before the previous case is even out of the room. If blocks need to be done preop or postop, I can do them while the anesthetist is dropping off in PACU or getting ready to roll next case back. If a patient needs a CVP and an art line after they go to sleep, we can do them at the exact same time.

Now does this save hours for each room during the day? Of course not. But it saves minutes here and minutes there and lets more cases get done in rooms in less time and helps the hospital spend less OT for rooms running late and get more things done during normal hours.


Now if you want to argue that it is possible to be lazy and run an ACT practice in an unsafe manner, of course it is. But I've also seen some unsafe stuff from physicians doing their own cases so that's more of a function of the person (people) and not the model of care. You admit you've never even seen ACT model in PP. It can be done quite well.

Legitimate question:

Let’s say you have 20 ORs to cover for 0700 start time. Do you stagger the starts so each MD can start multiple rooms, or do you start with 20 MD’s and quickly wean down?

If staggered, doesn’t that somewhat negate the efficiency gains you tout?

 

[Mman]

Legitimate question:

Let’s say you have 20 ORs to cover for 0700 start time. Do you stagger the starts so each MD can start multiple rooms, or do you start with 20 MD’s and quickly wean down?

If staggered, doesn’t that somewhat negate the efficiency gains you tout?

ORs never all roll in at 715 on the dot. Literally never. There is always a surgeon not yet marking the patient or a room waiting on a piece of equipment. And all the rooms are not GA cases. There are also some cases done under block or sedation. We also don't have "weaning down" of rooms until at least 3 or 4 PM.

 

[deleted162650]

ORs never all roll in at 715 on the dot. Literally never. There is always a surgeon not yet marking the patient or a room waiting on a piece of equipment. And all the rooms are not GA cases. There are also some cases done under block or sedation. We also don't have "weaning down" of rooms until at least 3 or 4 PM.

So are all cases scheduled to start at 0715 and just fingers crossed other people are the rate limiting step, or are the start times scheduled staggered?

 

[Endee]

I am an AA. At my first position it was a large all ACT practice and we did a lot of cardiac. The cardiac cases were restricted to a small group of AAs and CRNAs. We had two cardiac rooms and also did advanced echo guided cath and EP lab procedures.

Usually there was a different anesthesiologist for each cardiac room. Those rooms were usually max 1:2. If it was the same anesthesiologist in both it was definitely 1:2. AAs and CRNAs didn’t even manipulate or read the probe unless I just wanted to get a simple view to check volume status or contractility and the physician wasn’t in the room. We never came off pump or went on pump without the anesthesiologist present. It was very tightly run and the surgeons were happy. There were probably less than 10 of the anesthetists that did the open hearts.

My second job was at a children’s hospital where I did exclusively cardiac. We had one open heart room and two cath lab rooms plus we covered cardiac MRI and any general case that a cardiac patient was having. In the cardiac room we were always 1:1 and the physician was again always present for all critical points. The cath labs were covered 1:2 or 1:1 depending on how busy we were and both rooms were connected with the control room so the anesthesiologist could hang out there and be available for both rooms, although their office was 10 feet away anyway.

I get people’s sentiments about the ACT model in cardiac and high risk cases but I just wanted to share that it can be done in an appropriate way. I was proud about how tight we ran things and how smooth it all worked out. The anesthesiologists all seemed happy and had a lot of trust in us that we would very readily inform them of any deviation from what was expected, which we did.

Just wanted to share my experience. Doing extensive cardiac had been one of my favorite experiences as an AA.

 

[Mman]

So are all cases scheduled to start at 0715 and just fingers crossed other people are the rate limiting step, or are the start times scheduled staggered?

everything scheduled for 715. Everything usually ends up starting by 730.

 

[sevoflurane]

Is it economically efficient to run 1:1 or 1:2?

 

[GravelRider]

So are all cases scheduled to start at 0715 and just fingers crossed other people are the rate limiting step, or are the start times scheduled staggered?

When I supervise, which is usually 1:3 and very rarely 1:4, I get 2 ortho flip rooms, which are obviously staggered, and another normal room. Ortho gets 7:00 start times and everyone else gets 7:30 start times. Maybe once or twice a year induction takes a little longer because of a hairy airway and another induction gets delayed by a few minutes. I doubt there is much difference in efficiency between MD only or ACT. I also doubt there is much difference in outcomes either. The biggest difference is in job satisfaction. As someone who does both, I much prefer days where I am flying solo and not dealing with whiney CRNAs complaining that I didn’t give them enough breaks.

 

[Endee]

Is it economically efficient to run 1:1 or 1:2?

Generally no. Other parts of the business subsidize that. In the case of my peds job, the hospital wanted coverage availability for more concurrent cardiac cases (OR+2cath+MRI+General OR) so that’s why the three cardiac anesthesiologists hired two AAs. There was a subsidy from the hospital to pay for that. One physician was call, one post call, and the third supervised the AAs if we ran two other rooms outside the open heart room.

 

[deleted162650]

Is it economically efficient to run 1:1 or 1:2?

1:1 is a money loser. 1:2 technically should be equivalent to MD only assuming the CRNA's 1/2 of the bill is enough to pay for their salary + benefits.

 

[caligas]

1:1 is a money loser. 1:2 technically should be equivalent to MD only assuming the CRNA's 1/2 of the bill is enough to pay for their salary + benefits.

It’s not enough. 1:3 is maybe a small bump over MD only.

 

[deleted162650]

It’s not enough. 1:3 is maybe a small bump over MD only.

Which begs the question: Is it worth it?

While 1:2 sound like it'd be chill, 1:3 and especially 1:4 sounds miserable to me. Do many groups run a strict 1:4 all the time to really cash in on the potential anyways or is that not practical/doable?

 

[Man o War]

It’s not enough. 1:3 is maybe a small bump over MD only.

1:4 is really the only way ACT makes sense financially when you consider the bump in call burden for the docs.
That, or if you’re in an area where you literally can’t hire enough docs to be MD only.
I cannot understand why anyone would be 1:1 for any case- makes no sense at all.

 

[Endee]

Which begs the question: Is it worth it?

While 1:2 sound like it'd be chill, 1:3 and especially 1:4 sounds miserable to me. Do many groups run a strict 1:4 all the time to really cash in on the potential anyways or is that not practical/doable?

I have never worked in an ACT practice that routinely runs 1:4. In my experience 1:4 is reserved for later afternoon, evenings, busy days with addons causing new rooms to open, or days where people called in sick. 1:3 is the most typical other times with 1:2 used if things are slower until people start to get sent home. The board runner usually isn’t supervising or is at a low ratio.

From my observation, 1:4 is exhausting. 4 patients in the OR, several patients in pre-op, several patients in recovery. Not worth it.

 

[sevoflurane]

It’s not enough. 1:3 is maybe a small bump over MD only.

1:3 is a wash... maybe some upside.
1:4 is where you actually can benefit economically... but you will loose mentally.

This is an underlying issue for me.

Adding the malignant AANA propaganda just has me jaded on ACT all together.

I’m sure there are good groups that make it work and are not militant.

That is NOT what the AANA wants though. They want your job by undermining our education.

Plain and simple.

I support AAs.

 

[sevoflurane]

Which begs the question: Is it worth it?

No

 

[deleted162650]

A lot of what's written here contradicts the claims that MD only is an economically unviable option for many groups.

Now I don't know what to believe.

Black is left, Up is white, Nothing is as it seems!!

 

[sevoflurane]

Not enough of us to go around unfortunately.

Ok... rant over. I’m off this thread.

 

[Endee]

1:3 is a wash... maybe some upside.
1:4 is where you actually can benefit economically... but you will loose mentally.

This is an underlying issue for me.

Adding the malignant AANA propaganda just has me jaded on ACT all together.

I’m sure there are good groups that make it work and are not militant.

That is NOT what the AANA wants though. They want your job by undermining our education.

Plain and simple.

I support AAs.

And unfortunately this is leading to “ACT” groups going 1:8 billing all QZ with a token anesthesiologist around just for emergencies.

This is de facto independent practice. It’s what happened in Charlotte and some other places. It doesn’t matter if the state is opt out or not, or independent practice or not. Every state can have CRNAs do an unlimited ratio billing QZ. Hopefully ASA can get a handle on it.

 

[GravelRider]

It has nothing to do with economics. It’s honestly a matter of limited resources. There are just not enough anesthesiologists to fill the roles...even in highly populated, desirable areas. Plus the speed at which hospitals are expanding services or ASCs are opening makes is really impractical to staff with only docs. There just aren’t enough good docs. I’ll take a CRNA or care team over some of the bad anesthesiologists out there.

Having a hybrid system is the way to go, in my opinion. It gives you flexibility, but also gives you plenty of presence in the ORs and time to do your own cases. Lets say you have 4 docs supervising 1:3. Now they call for an MRI under anesthesia or an add-on somewhere else. You go
1:4 and send a doc off to do that add on case. That’s not as easy in MD only without calling someone in from home or delaying the case.

It seems extremely short sighted to me to make these overarching claims that every practice should be doctor only (I wish). It ignores many of the realities of modern medical practice. Remember, modern medicine is less about what is right, and more about what makes good business sense.

 

[deleted162650]

It has nothing to do with economics. It’s honestly a matter of limited resources.

I realize that is a separate and very real issue. I was referring specifically to another thread where the claim was made that many practices would financially collapse if they were MD only.

 

[Man o War]

And unfortunately this is leading to “ACT” groups going 1:8 billing all QZ with a token anesthesiologist around just for emergencies.

This is de facto independent practice. It’s what happened in Charlotte and some other places. It doesn’t matter if the state is opt out or not, or independent practice or not. Every state can have CRNAs do an unlimited ratio billing QZ. Hopefully ASA can get a handle on it.

Fortunately this is somewhat self limiting because of call. In any decent sized hospital, CRNAs can’t take call because they’re simply not able to handle any/every that rolls through the doors on their own, so the docs are stuck taking all the call.

 

[Direct Laryngoscopy]

They don’t even realize it, pushing for “independence” will ultimately lead to their downfall. Who would choose a CRNA over a physician? Do they really think they are fooling the public? ‍♂️

 

[deleted941485]

1:3 is a wash... maybe some upside.
1:4 is where you actually can benefit economically... but you will loose mentally.

This is an underlying issue for me.

Adding the malignant AANA propaganda just has me jaded on ACT all together.

I’m sure there are good groups that make it work and are not militant.

That is NOT what the AANA wants though. They want your job by undermining our education.

Plain and simple.

I support AAs.

There’s a private shop at my hospital. I’ve seen 1:3 and 1:4 at the hospital I work at and it’s a disgrace. Crnas literally looking at me what to do. Anesthesiologist covering crnas in OR and down where I am in the basement with the Nextel phones “ready for induction”. Patients constantly waking up mid procedure slowing me down. We had a radioactive source in a patient and mid treatment lifted her whole pelvis off the table and tried to pull the tube out. It was a medical event for us not to mention unnecessary exposure to the staff. Crna acts like nothing happend and by the time the anesthesiologist gets there **** had already hit the fan.

 

[sevoflurane]

There’s a private shop at my hospital. I’ve seen 1:3 and 1:4 at the hospital I work at and it’s a disgrace. Crnas literally looking at me what to do. Anesthesiologist covering crnas in OR and down where I am in the basement with the Nextel phones “ready for induction”. Patients constantly waking up mid procedure slowing me down. We had a radioactive source in a patient and mid treatment lifted her whole pelvis off the table and tried to pull the tube out. It was a medical event for us not to mention unnecessary exposure to the staff. Crna acts like nothing happend and by the time the anesthesiologist gets there **** had already hit the fan.

I am very sorry you have to deal with that type of dangerous nonsense.

If your anesthesiologists are being lazy and are not present for induction and extubation (at the least)... then there needs to be corrective action.

Advocate for an MD only model so you get the best care possible.

Again... sorry you have to deal with your current situation.

It should never be that way.

 

[jwk]

Fortunately this is somewhat self limiting because of call. In any decent sized hospital, CRNAs can’t take call because they’re simply not able to handle any/every that rolls through the doors on their own, so the docs are stuck taking all the call.

There are a surprising number of "ACT" practices that cede their OB, evening, night, and weekend work to CRNAs while the docs are gone after 5pm. Sucks.

 

[GravelRider]

There are a surprising number of "ACT" practices that cede their OB, evening, night, and weekend work to CRNAs while the docs are gone after 5pm. Sucks.

Now that is a practice I can get behind. I will personally contribute to the AANA if their slogan was “We want independence so we can do all the evening, weekend, holiday, and OB work.”

 

[Mman]

Is it economically efficient to run 1:1 or 1:2?

we staff based on safety, not economics. Peds heart? You will be 1:1. Big case and/or very sick patient, you will not be more than 1:2 and that other room will be easy. 1:3 more normal. 1:4 if you take over something from someone else that just requires baby sitting.

 

[Mman]

It’s not enough. 1:3 is maybe a small bump over MD only.

that is only true if you have low contract rates

 

[skypilot]

1:4 is really the only way ACT makes sense financially when you consider the bump in call burden for the docs.
That, or if you’re in an area where you literally can’t hire enough docs to be MD only.
I cannot understand why anyone would be 1:1 for any case- makes no sense at all.

Adding one CRNA to an all MD group frees up a doctor to serve as a float. The doc can supervise the room at 1:1 and do blocks, epidurals, breaks, preops, consults, and help with problems all while supervising the room.

 

[skypilot]

I realize that is a separate and very real issue. I was referring specifically to another thread where the claim was made that many practices would financially collapse if they were MD only.

Won't collapse if the docs take a pay cut. ;(

Hoya's practice:
For my practice at 40 rooms we have 10 docs and 40 CRNAs. 10 X 500k (total MD package) + 40 x 250k (total CRNA package) = 15 million

Budget of 15 million could hire 40 docs at $375. Or 30 full time call taking docs with higher salaries and 10 mommy track docs with lower salaries.

Or 25 docs and 22 CRNAS and create a hybrid system with the docs doing all the intense cases, and the supervised CRNAs doing the bread and butter.

The CRNAs should never outnumber the Physicians. Numbers equal power.

 

[Modanq]

CArdiac is probably the only subsecialty of anesthesia where CRNAs aren’t a threat and never will be. As old heart surgeons retire and new school surgeons arrive, the demand for consultant level subspecialty MD expertise will increase, compounded further by the growth of TEE guided structural.

Where I work the cardiologists and surgeons would never agree to have anything but ACTA anesthesia . Cardiovascular intervention continues to become more and more complex.

One of the other major points to stress is that the current crop of cardiac surgeons and interventional cardiologists are actually playing fair in the sandbox. There are heart teams, structural teams and according to all the society guidelines, SCAI, AHA, ACC, STS, SCA Anesthesiologists have to be on this team. There is never mention of the CRNA. This is mandatory and guideline driven.
The younger surgeons and proceduralists are actually really happy we are there.
As an MD you are on equal footing as any of the proceduralists and really should make that space if that doesn't currently exist in your work setting.

So that being said. I don't mind the anesthesia nurse checking blood or untangling lines in a complex case but there needs to be role clarification and delineation. So when it comes to the procedures: Lines, Intubations, Inductions, art lines, ECMO, Device management, going on and off pump, TEE, TTE, Structural intervention...its on us. And some of the newer bleeding edge topics ECMO Cannulation, ICE, etc. we own this space. But if you want to run the ACT/TEG machine sure..have at it.

What needs to happens is not necessarily define anesthetics based on the presence of a sedative medication (which is basically a continuous level of anesthetic depth) but improve our risk stratification from the current simplistic ASA 1,2,3,4 score.
The ASA needs to improve risk stratification if it really wants the ACT model. So...Instead of some random number put down on the preoperative note, there should be a calculator of 50 variables. Heck we can even feed it a database of 100000 anesthetics which will then help guide anesthesiology coverage schemes.
25 yo healthy gallbladder, Sleeve, and lipoma sure CRNA 1:3.
75 year old triple valve with EF of 15% yeah 1:1.
And sure optho rooms might be usually started 1:3 coverage but every so often the optho room may need 1:2 or 1:1.

The ASA needs to come out and declare the exact things that we do. Not just say hey we do Anesthesia...What the hell does that even mean.
It needs to clearly define everything we should do and things CRNAs should not do. Otherwise, there will always be whack job sell out MDs out there teaching the next anesthesia nurse that walks by how to do a ISB just so they can feel good about themselves and sell the patient and the profession short.

 

[sevoflurane]

we staff based on safety, not economics.

So do we.

 

[Mman]

So do we.

which I fully support!